Bedside Mental Status Evaluation: Overview, Coconuts, Cobe-50

Abstract

Current clinical neuroscientists and their domains of cognitive testing include neurologists, psychiatrists, neuropsychologists, and speech and language clinicians, along with neuro-radiologists providing critical and complementary information of lesion location. All are important to capture the extent and nature of the deficits. For example, any degree of significant aphasia will curtail the number and type of testing that is possible. The abulic spectrum of disorders may severely limit testing and the mild and often covert forms of inattention due minimal hepatic encephalopathy (MHE) with elevated ammonia level precludes in depth neuropsychological assessment. It is not unusual for people with MHE to present because of multiple motor vehicle accidents on account of their inattention. As with most frontal lobe syndromes, the spouse, family, or other informant is most important.

Appendices

Appendix 1: COCONUT: Comprehensive Cognitive Neurological Test

Name	Gender	Age
Education years (schooling, college, other)	----
Handedness (Epworth scale) circle	Right/left/ambidextrous
Cognitive risk factors (circle). Family history of Alzheimer’s, head trauma
Vascular risk factors. Hypertension, diabetes mellitus, dyslipidemia, smoking, ethanol abuse homocysteine elevation, cardiac disease, atrial fibrillation, coronary artery disease, valvular heart disease, patent foramen ovale, dilated cardiac chamber, leukoaraiosis, BMI ≥30
Neuropsychiatric history (DSM V) circle. Depression, anxiety, obsessive compulsive disorder, substance abuse

General Attentional Systems

1. Orientation 5 items – Score 1 for each error, 0 is normal
Date (3 for day, month, year), day of week (1), place hospital (or clinic) (1)	/5
2. Attention and calculation – Score 1 for each error, 0 is normal
5 serial 7’s, if unable double to 128	/5

Left Hemisphere Network for Language, Gerstmann’s, and Angular Gyrus Syndromes

3. Speech and language – Score 1 for each error, 0 is normal
Naming: Name 3 objects (pen, watch, ID card) and name 3 colors Fluency: Grade as fluent (0), non-fluent (1), mute (2) Comprehension: Close your eyes, squeeze my hand. Score 1 for each failure	/6 /2 /2
Repetition: “Today is a sunny and windy day.” No word repeated (2), partial (1), all (0)	/2
Write a sentence. What is your job? Must contain subject and verb and makes sense	/3
Reading: “Close your eyes.” No words read (2), partial (1), or all words (0)	/2
4. Motor speech
Dysarthria. During interview, are words slurred? Nil (0), mild slurring 1, marked slurring (2)	/2
Hypophonia. Normal (0), voice softer than normal (1), very low volume, barely audible (2)	/2
5. Praxis
Rating scale: Impaired 1, unable 2, smooth execution 0
Melokinetic. Thumb – finger opposition test compare R + L (only if ≥4/5 power)	/2
Buccolingual. Licks your lips, blows up your cheeks	/2
Ideomotor apraxia. Clumsy action with pen or eating utensils	/2
Ideational. Folds piece of paper in half, writes your name, and places inside a file or book	/2
6. Right, left, and body part orientation
Left pointing finger on right ear (one point for each error)	/2

Hippocampal Limbic Network for Memory and Emotion

7. Memory – Score 1 for each error, 0 is normal
Short-term memory: Registers five words (orange, ocean, courage, rapid, building)
Test recall at 5 min. Score 1 for each omission	/5
Remote memory: Recites last 3 presidents or 3 important personal dates (graduations)	/3
8. Emotions
Lability – Laughs or cries easily, out of context. Rarely (1), sometimes (2)
Frequently (3), never (0)	/3
Geschwind-Gastaut syndrome: Stroke or new lesion induced with new evidence of viscous personality, metaphysical pre-occupation, and altered physiological drives
(i) Viscous personality: One or more of the following. Circumstantiality in speech, over-inclusive verbal discourse, excessive detail of information, stickiness of thought processes, interpersonal adhesiveness, prolongation of interpersonal encounters, and hypergraphia
(ii) Metaphysical pre-occupation: One or more of the following: Overly philosophical pre-occupation, nascent and excessive intellectual interests in religion, philosophy and moral issues.
(iii) Altered physiological drives: One or more of the following: Hyposexuality, aggression, and fear
Scoring: Two out of three components required for diagnosis
Score as 3 components (3), 2 components (2), 1 component (1), nil (0)	/3

Prefrontal Network and Subcortical Network for Executive Function and Comportment

9. Serial motor programming: Luria motor sequence test (fist-palm-hand). Demonstrate
sequence until patient able to replicate. Then do 5 cycles
Score 1 for each error in sequence	/5
10. Word fluency. Says as many words starting with S in 1 min (no names or places)
Grading: >15 (0), 13–15 (1), 10–12 (2), 7–9 (3), 4–6 (4), 0–3 (5)	/5
11. Environmental autonomy (imitation and utilization behavior)
Imitation behavior. Maintaining eye contact, pats side of examiner’s face, and then
claps the hands without suggesting patient to follow suit
Scoring: Copies all actions spontaneously (2,) copies some (1), nil (0)	/2
Utilization behavior: Places three objects in front of patient, key, cell phone, and pen
Scoring: Unsolicited manipulation of 1 or 2 objects (1) or all (2)	/2
12. Interference and inhibitory control (Go-No-Go paradigm)
If examiner taps once, raise your finger; if examiner taps twice, do not raise finger
Do three cycles: 1-1-2, 1-2-1, 2-2-1. Score 1 for each incorrect response	/3
13. Abulia . Poverty of action and speech. Grade as marked 2, somewhat 1, nil 0	/2
14. Disinhibition : Comments or actions during interview. Occasional 1, frequent 2, nil 0	/2
15. Impersistence . Discontinues Luria’s sequences, despite repeated coaxing x 3	/1
16. Perseveration. During Luria sequence test, duplicates same hand position	/1

Dorsal Right Parieto-Frontal Network for Visuospatial Function, Attention, Emotion, and Prosody

17. Visuospatial
Copy a 2D image of examiner’s drawn flower. Impaired 1, marked 2, nil 0	/2
Copy a 3D image representation of examiner’s cube. Impaired 1, marked 2, nil 0	/2
18. Neglect syndromes
Tactile. Simultaneous stimulation of both arms. Omission of one side score 1	/1
Auditory. Simultaneous stimulation of both ears. Omission of one side score 1	/1
Visual. Simultaneous stimulation of both fields. Omission of one side score 1	/1
Motor neglect. Bisect 10 cm line. More than 1/4 (2.5 cm) distance from midline, score 1	/1
19. Anosognosia
Recognizes weakness 0, underestimation 1, or complete denial of deficit or illness 2	/2
20. Prosody
As per family, speech has become flat or monotone, then score 1; if not score 0	/1
Cannot comprehend different intonations (happy/sad), then score 1; if not score 0	/1
Cannot repeat altered intonation (happy/sad), then score 1; if not score 0	/1

Ventral Occipitotemporal Network for Object and Face Recognition

21. Complex visual processing (a score of 0 is normal)
Object agnosia. Cannot name 3 objects by visual inspection, but can by touch or sound	/3
Achromatopsia. Cannot distinguish 2 different hues or colors. Score 1 for each error	/2
Simultanagnosia. CTPT – identifies all 3 persons (score 0, 1, 2, 3) or analog time telling (m/h/sec)	/3
Optic ataxia. Touches examiners finger under visual guidance. Score 1 for a miss	/1
Optic apraxia. Looks left, right, up, or down to command. Score 1 for any error	/1
Prosopagnosia: Does not recognize family or friends by visual appearance, score 1	/1
Line orientation. Draws 45° and 30° lines. Match 2 lines to figure. Score 1 for error	/2
Subjective report of impaired motion perception (akinetopsia). Score 1 if present	/1
Subjective report of depth perception impairment (astereopsis). Score 1 if present	/1
Hallucinations. Simple (colors, shapes), complex (scenes, people, animals), or experiential (out of body experience or autoscopy). Score 1 if present	/1
Illusions of shape or size. Score 1 if present. Example macropsia or micropsia	/1
Denial of cortical blindness (Anton’s syndrome). Score 1 if present	/1

Syndromes with Ill-Defined Neural Networks

22. Disconnection syndromes Score 1 if present, 0 if absent
Alien hand syndrome. The one hand interferes with the other during routine tasks	/1
Alexia without agraphia. Can write but cannot read	/1
Pure word deafness. Hears environmental sounds but not spoken speech	/1
23. Delusional misidentification syndromes (incorrect ID of people or place). If present 1
Reduplicative paramnesia (the person thinks that they are geographically in a different location such as at the office or at home, when in fact they may be lying in a hospital bed)	/1
Capgras or Fregoli syndrome. Familiar people appear strange or vice versa	/1

Miscellaneous Syndromes

Amusia – May be receptive (poor appreciation of music) or expressive (where no longer able to play or sing). Score 1 if either is present	/1
Allesthesia. During neurological examination, transfers perceived tactile stimuli from left to the right or vice versa	/1
Autoscopy. During interview, reports out of body experience	/1
Synesthesia. Activation of one sensory system induces perceived sensation in another	/1
Geographical disorientation or Topographical Disorientation	/1
Cognitive score total	---

1. CTPT cookie theft picture test

Appendix 2: Cobe 20: High Value Hub Screen

1. Language: Ability to communicate and engage in cognitive testing
Comprehension: Closes your eyes and makes a fist; if both correct score 1	1/1
Fluency: If no hesitations or paraphasias, naming cell phone, pen; if correct score 1	1/1
2. Attention, abulia
Abulia: Poverty of speech, actions, slowed instruction processing. If no abulia score 1	1/1
Attention: Orientation 5 items (date, day of week, place)	5/5
3. Executive function
Serial 7’s, 1007 test (93,86,79,72,65)	5/5
Phonemic fluency words beginning with “F” in 1 min; if ≥12 score 1	1/1
4. Working memory
Working memory: Digits 5 back, example: 85410…01458; if correct score 1	1/1
5. Episodic verbal memory
Learn/register words: Ocean, orange, courage, building, rapid, recall at 5 min	5/5
Total score	/20

Appendix 3: Cobe 50: A Brief Mental Status Test, a Precision Tool for an Individual (n = 1). Score 1 for Each Correct Item

Cognitive domains
Attention
1. Orientation 5 items (date, day of week, place)	5/5
2. Serial 7’s, 1007 test (93,86,79,72,65)	5/5
Language, praxis, acquired cultural circuits
1. Fluency: If no hesitations, paraphasias, stuttering during discourse, score 1	1/1
2. Comprehension: Closes your eyes and makes a fist; if both correct score 1	1/1
3. Repetition “Today is a sunny and windy day”	1/1
4. Naming: 5 items: Cell phone, pen, ID card, computer keyboard, magazine	5/5
5. No dysarthria or hypophonia	1/1
6. Reading/writing: Reads and executes: What is your job? (has subject, verb, makes sense)	1/1
7. Praxis: Shows hand position when using a pair of scissors	1/1
Executive function
1. Phonemic fluency words beginning with “F” in 1 min; if ≥12 score 1	1/1
2. Semantic fluency, animal naming; if ≥16 score 1	1/1
3. Working memory: Digits 5 back, example: 85410…01458; if correct score 1	1/1
4. Luria motor series (fist, palm, hand sequence) do 5 cycles; if all correct score 1	1/1
5. Speed of information processing (short trails test): 1A-2B-3C-4D-5E; if all correct score 1	1/1
Visuospatial
1. Draws a clock with numbers at 10 past 11; if good copy, score 1	1/1
2. Draws a 3-dimensional (Necker) cube; if good copy, score 1	1/1
Memory
1. Verbal: Learns to register words: Ocean, orange, courage, building, rapid, recall at 5 min	5/5
2. Nonverbal: Learns to register by copying 5-point star, triangle, cross, recall at 5 min	3/3
3. Remote memory (any 2 personal notable events: school/college graduation, wedding)	2/2
Behavioral domains
Conation
1. Abulia: Poverty of speech, actions, slowed processing of instructions. No abulia scores 1	1/1
Disinhibition
1. Go-No-Go paradigm: Lifts index finger for 1 tap, does not lift for 2 taps; if 5 cycles correct	1/1
2. Disinhibition: Inappropriate joviality, remarks, actions toward others; if absent score 1	1/1
3. Prehension behavior – Maintains attention, pats side of examiner’s face, then claps hands without suggesting patient to follow suit; score 0 for no imitation, score 1 if enacts either imitation	1/1
Emotional regulation
1. Empathy disorders (intrapersonal emotional intelligence)
Emotional blunting, poor or inappropriate emotion detection; if absent score 1	1/1
4. Sociopathy (interpersonal emotional intelligence)
Prefers to avoid people, crowds, has become asocial or dysocial; if absent score 1	1/1
5. Emotional lability (involuntary emotional expression disorder (IEED))
Laughs or cries easily or out of context; if absent score 1	1/1
Independency (ADL)
Basic: Toilet, feeding, bathing, dressing, continence, transfer; if all intact score 1	1/1
Instrumental: Finances, shopping, medications, driving, meal prep; if all intact score 1	1/1
Cognitive reserve
Educational level in years, school, college, if 12 or more score 1	1/1
Languages spoken, if 2 or more score 1	1/1
Total	/50