The mental health assessment is critical to evaluating brain function, specifically cognition. While neuroimaging tests can examine structure, blood flow, metabolic function, and abnormal protein deposits in the brain, there’s still no way to directly observe cognitive function (Mendez, 2019). Cognitive function refers to the mental processes required to learn and comprehend. Basic cognitive functions include orientation, attention, and memory. Higher cognitive functions are more complex thought processes and are assessed using tests for information and vocabulary, calculation, abstract thinking, and constructional ability (Bickley et al., 2021). Let’s review the higher cognitive functions and how you can evaluate each one during a mental health assessment.

Information and Vocabulary (Bickley et al., 2021)

Take into account the patient’s culture and level of education when evaluating information and vocabulary. Start with simple questions – ask about their work or hobbies – before asking more complex questions, such as naming government leaders or questions about geography. Observe their understanding of information, level of complexity of ideas, and word choice.
 
Testing helps differentiate individuals with life-long intellectual challenges, who possess limited information and vocabulary, from individuals with mild or moderate dementia, whose information and vocabulary are intact

Calculating Capacity (Bickley et al., 2021)

Ask the patient to perform mathematical calculations, beginning with simple, single-digit addition and multiplication. Progress to harder tasks using two-digit numbers; longer, written word problems; or practical questions related to paying for an item and calculating change.
 
Patients who cannot perform these types of calculations may have dementia or aphasia. Remember to take into consideration the patient’s knowledge base and level of education.

Abstract Thinking (Bickley et al., 2021)

An individual’s ability to think abstractly can be tested using proverbs and asking about similarities between two things. For example, ask what the proverb, “A stitch in time saves nine” means.  Most patients will provide abstract or semiabstract responses. Individuals with intellectual disability, delirium, or dementia typically respond concretely but this may also be a sign of limited education. Patients with schizophrenia often respond concretely or with personal and strange interpretations.
 
You can also ask the patient to tell you how two things are alike, for example, a banana and a peach. Evaluate whether the answer is correct and relevant as well as how concrete or abstract it is.

Constructional Ability (Bickley et al., 2021)

Ask the patient to copy graphics of progressing complexity onto a piece of blank unlined paper. Show each figure one at a time and ask the patient to copy it using their best effort. If the patient has normal vision and motor ability, but cannot perform the task, this may indicate dementia, intellectual disability, or parietal lobe damage.

Clock-Drawing Test (CDT) (Mendez, 2019)

An alternative option to drawing the graphics above is to ask the patient to draw the face of an analog clock, including all the numbers. Have them set the hands to a specific time (i.e., 5 minutes before 12:00). The CDT helps assess visuospacial abilities, executive function, motor execution, attention, language comprehension, and numerical knowledge. It can be utilized to test a wide range of patients, irrespective of language, education, or cultural background.
 
Together, these tests help build a clearer picture of the patient’s overall mental health status and cognitive functioning. They also assist in differentiating disorders such as delirium, dementia, and impaired intellectual ability.

References:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
 
Hinkle, J. (2021). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15^th ed.). Wolters Kluwer Health.  https://wolterskluwer.vitalsource.com/books/9781975161057
 
Mendez, M.F. (2019, April 16). Mental status scales to evaluate cognition. UpToDate. https://www.uptodate.com/contents/mental-status-scales-to-evaluate-cognition