Cognitive examination

In assessing elderly patients more emphasis is usually placed on the cognitive examination than in younger patients. In theory it can be as exhaustive and thorough as assessment by a neuropsychologist, but in the routine practice of old age psychiatry it usually has to be feasible within the constraints of a consultation which lasts about an hour.

It is in this part of the assessment that the examiner is most likely to lose the patient's co-operation, principally because of the humiliation experienced by some at their own failures. Some patients become angry, indignant, or defensive. Others become anxious and their performance deteriorates. One way to pre-empt this is to preface testing by stressing that this is not a competitive examination and that most people have difficulty answering some of the questions. Correct answers are praised without excessive emphasis and incorrect ones are either treated in a neutral way or given a positive spin by saying, for example, 'Well it's ..., but you weren't far off'.

Many old-age psychiatrists and other members of their multidisciplinary team prefer to use standardized questionnaires such as the Mini-Mental State Examination, (1) the Mental Test Score,(2) the Clifton Assessment Procedures for the Elderly cognitive assessment scale,(3) and others. Of these, the Mini-Mental State Examination is in widest use. It has the advantage that results between and within patients can be compared and progress can be monitored. However, none of these tests is exhaustive and none produces an adequate cognitive assessment by itself. The clinician therefore needs to have some sort of schema for covering the main areas of cognitive function which would include: memory (in its various aspects) and general information, and naming; the understanding and production of language; praxis (ideomotor and constructional); sensory recognition (gnosis); abstract reasoning; verbal fluency; calculation; and left/right orientation. The list is not exhaustive and some areas may need to be covered in greater detail as the clinical situation demands. Table.! gives a guide to cognitive examination based on an extended

Mini-Mental State Examination. Clinicians vary in the order and way in which they test individual cognitive functions, and the list in JabJe.1 is not intended to be prescriptive.

Table 1 Schema for testing cognitive function based on an extended Mini-Mental State Examination(1)

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