HISTORY TAKING

(MMSE – TEST)

Mari Lazariashvili.MD
„Teaching University Geomedi“
2024
 What is history taking?
■ The medical history, case history, or anamnesis of a patient is information gained by
a physician by asking specific questions, either of the patient or of other people who know the
person and can give suitable information, with the aim of obtaining information useful in
formulating a diagnosis and providing medical care to the patient.
■ Introduce yourself, identify your patient and gain consent to speak with them.
■ Should you wish to take notes as you proceed, ask the patients permission to do so.
■ Ensure consent has been gained.
 Key principles of patient assessment
■ Ensure the patient is as comfortable as possible.
■ Listen to what the patient says.
■ Summarise each stage of the history taking process.
■ It is estimated that 80% of diagnosis are based on history taking alone.
■ Finaly ensure again that your documentation (of the assessment) is clear, accurate and legible.
■ Always record personal details:
 name
 age
 address
 sex
 ethnicity
 occupation
 religion
 marital status
 Record date of examination
 Complete History Taking
■ Presenting complaint (This is what the patient tells you is wrong, for example: chest
pain)

■ History of presenting complaint (Gain as much information you can about the
specific complaint)

■ Past/Previous medical history – (childhood/adult illness, immunizations, other

medical problems (if any)).

■ Drug history and allergies (Find out what medications the patient is taking,
including dosage and how often they are taking them, for example: once-a-day, twice-a-day, etc. At
this point it is a good idea to find out if the patient has any allergies)
 Complete History Taking
■ Social history - This is the opportunity to find out a bit more about the patient’s background.

■ Remember to ask about smoking and alcohol. You should also ask the patient if they use any illegal substances,
for example: cannabis, cocaine, etc.

■ Also find out who lives with the patient. You may find that they are the carer for an elderly parent or a child
and your duty would be to ensure that they are not neglected should your patient be admitted/remain in
hospital)

■ Family history - Gather some information about the patients family history, e.g diabetes or cardiac
history. Find out if there are any genetic conditions within the family, for example: polycystic kidney disease…
 Sistems review
■ These are the main systems you should cover:
■ CVS
■ Respiratory
■ GI
■ Neurology
■ Genitourinary/renal
■ Musculoskeletal
■ Psychiatry
 The SOCRATES acronym
The SOCRATES acronym can be used for any type of pain history.

■ Site: Where exactly is the pain?

■ Onset: When did it start, was it constant/intermittent, gradual/ sudden?
■ Character: What is the pain like e.g. sharp, burning, tight?
■ Radiation: Does it radiate/move anywhere?
■ Associations: Is there anything else associated with the pain, e.g.
sweating, vomiting.
■ Time course: Does it follow any time pattern, how long did it last?
■ Exacerbating / relieving factors: Does anything make it better or
worse?
■ Severity: How severe is the pain, consider using the 1-10 scale?
 Minimental Status Examination
(MMSE)
■ The Mini-Mental State Examination (MMSE) first developed by Folstein in
1975.
■ It is the most widely used standardized instrument for cognitive
impairment in the world.
■ It is used in all cultures and translated in many languages.
■ MMSE is a 30 point screening tool.
■ Administration of the test takes between 5 and 10 minutes.
 Minimental Status Examination
(MMSE)
■ The Mini-Mental status Examination is a cognitive test to screen for the presence of
cognitive impairment example Dementia.
■ It is useful in helping differentiate between a variety of systemic conditions, as well as
neurologic and psychiatric disorders ranging from delirium and dementia to bipolar
disorder and schizophrenia.
 Minimental Status Examination
(MMSE)
■ It assesses six areas of cognitive ability:
■ Orientation
■ Registration
■ Attention and calculation
■ Recall
■ Language
■ Copying
 Orientation

■ Temporal Orientation
■ Which year is this? • What Season it is ?
■ What is today’s date?
■ What is the Day of the week?
■ Which Month is this?
■ Geographical Orientation
■ Where are we now?
■ Which State we live in?
■ What is the name of this County ?
■ What is the name of your Town?
■ What is the name of this city?
■ What is the name of this Hospital ?
■ What Floor are we on?
 Registration

■ The examiner names three unrelated objects clearly and slowly, then the instructor asks the
patient to name all three of them.

■ The patient’s response is used for scoring.

■ The examiner repeats them until patient learns all of them, if possible. Example - Examiner names
3 objects (eg apple, table, car) Patient asked to repeat (1 point for each correct).

■ Maximum score is 3
 Attention and calculation

■ “I would like you to count backward Subtract 7 from 100, then repeat from result.

■ Continue 5 times: 100 93 86 79 65

■ Alternative: “Spell WORLD backwards.” (D-L-R-O-W)

■ Maximum score is 5
 Recall
■ Earlier I told you the names of three things.
■ Can you tell me what those were?”
■ Maximum score is 3
 Language
■ Naming: Show the patient two simple objects, such as a wristwatch and a pencil, and ask the
patient to name them. 1 point for each Maximum score is 2

■ Repetition: Ask the person to repeat the following. No „ifs‟ & or „buts ‟ (1point). Allow only
one trial Maximum score is 1

■ Command: Give a 3 stage command. Score 1 for each stage. Eg. "Place index finger of right hand
on your nose and then on your left ear".

■ Maximum score is 3
 Language
■ Reading: Write „CLOSE YOUR EYES‟ in large letters & show it to the patient. Ask him or her
to read the message & do what it says (give 1 point if they actually close their eyes). Score is 1

■ Writing: Ask the individual to write a sentence of their choice on a blank piece of paper. The
sentence must contain a subject & a verb, & must make sense. Spelling punctuations & grammar
are not important . Maximum score is 1

■ Copying : Ask the patient to copy a pair of intersecting pentagons:.

■ Maximum score is 1
 Scoring
• 24 - 30 points indicates a normal cognition.
• 19 - 23 points mild cognitive impairment.
• 10 - 18 points moderate
• Below this, scores indicate severe (≤9 points)
 The Montreal Cognitive Assessment
(MoCA)
■ The Montreal Cognitive Assessment (MoCA) is a widely used screening
assessment for detecting cognitive impairment.

■ It was created in 1996 by Ziad Nasreddine in Montreal, Quebec.

■ The MoCA test is a one-page 30-point test administered in

approximately 10 minutes.

■ MoCA scores range between 0 and 30.

 The Montreal Cognitive Assessment
(MoCA)
The MoCA assesses:
■ Short term memory
■ Visuospatial abilities
■ Executive functions
■ Attention, concentration and working memory
■ Language
■ Orientation to time and place
 What is Dementia?
■ Dementia is a general term, that describes a group of symptoms associated
with a decline in memory or other thinking skills.

■ Dementia was first described in a book about mental illness.

■ In 1894, Alois Alzheimer was a

German psychiatrist and neuropathologist, who has a particular interest in
“nervous disorders” described changes in the brain caused by vascular
disease (now known as vascular dementia).

■ It affects memory, thinking, orientation, comprehension, calculation,

learning capacity, language, and judgment.

■ It isn't a specific disease, but several different diseases may cause dementia.
■ Dementia occurs more commonly in the elderly than in the middle-aged.
 Classification of Dementia
■ Alzheimer's is the most common type of dementia. It accounts for 60 to 80
percent of cases.

■ Vascular Dementia, which occurs after a stroke, is the second most common
dementia type. (20%-30%)

■ Lewy Body (10% - 25%)

■ Frontotemporal (10%-15%)
■ Vascular dementia - results from conditions that damage brain's blood vessels,
reducing their ability to supply brain with the amounts of nutrition and oxygen
it needs to perform thought processes effectively.

■ Common conditions that may lead to vascular dementia include:

■ Stroke (infarction) blocking a brain artery - Strokes that block a brain artery usually
cause a range of symptoms that may include vascular dementia. But some strokes don't cause any
noticeable symptoms. These silent strokes still increase dementia risk.

■ Brain hemorrhage - Often caused by high blood pressure weakening a blood vessel leading
to bleeding into the brain causing damage or from buildup of protein in small blood vessels
occurring with aging weakening them over time.

■ Narrowed or chronically damaged brain blood vessels - Conditions that narrow

or inflict long-term damage on the brain blood vessels also can lead to vascular dementia. These
conditions include the wear and tear associated with aging, high blood pressure, abnormal aging of
blood vessels (atherosclerosis), diabetes.
 Lewy body dementia (LBD)
■ Lewy body dementia (LBD) is a disease associated with abnormal deposits(Lewy bodies) of a protein
called alpha-synuclein in the brain, affect chemicals in the brain whose changes, in turn, can lead to
problems with thinking, movement, behavior, and mood.
■ Frontotemporal dementia is an umbrella term for a group of brain disorders that primarily affect the
frontal and temporal lobes of the brain. These areas of the brain are generally associated with
personality, behavior and language.
■ In frontotemporal dementia, portions of these lobes shrink (atrophy). Signs and symptoms vary,
depending on which part of the brain is affected. Some people with frontotemporal dementia have
dramatic changes in their personalities and become socially inappropriate, impulsive or emotionally
indifferent, while others lose the ability to use language properly.
■ Frontotemporal dementia can be misdiagnosed as a psychiatric problem or as Alzheimer's disease.
■ But Frontotemporal dementia tends to occur at a younger age than does Alzheimer's disease.
Frontotemporal dementia often begins between the ages of 40 and 65 but occurs later in life as well.
 Symptoms of Dementia
■ The early stage symptoms of dementia include: Stage 1 (2 to 4 years)

■ Forgetfulness
■ Losing track of the time
■ Becoming lost in familiar places.
■ Declining interest in environment
■ Hesitancy in initiating actions
■ Poor performance at work
 Symptoms of Dementia
■ Middle stage symptoms include: Stage II (2 to 12 years)
■ Becoming forgetful of recent events and people's names
■ Becoming lost at home
■ Having increasing difficulty with communication/ Hesitates in response to questions
■ Needing help with personal care
■ Experiencing behaviour changes, including wandering and repeated questioning.
■ Progressive memory loss
■ Social isolation
 Symptoms of Dementia
■ The late stage of dementia (Stage III: Final stage (up to a year) is one of near total dependence
and inactivity.
■ Memory disturbances are serious and the physical signs and symptoms become more obvious.
Symptoms include:
■ Becoming unaware of the time and place
■ Having difficulty recognizing relatives and friends
■ Having an increasing need for assisted self-care/ Incontinence of urine and feces
■ Having difficulty walking / Loses the ability to stand and walk
■ Experiencing behaviour changes that may escalate and include aggression.
■ Death is caused by aspiration pneumonia
 Epidemiology of Dementia
■ Worldwide, around 50 million people have dementia, with nearly 60% living in low- and
middle-income countries.
■ Every year, there are nearly 10 million new cases.
■ The total number of people with dementia is projected to reach 82 million in 2030 and 152 in
2050.
 Diagnosis of Dementia
■ Medical history - Typical questions about a person's medical and family history/ Cognitive
assessment evaluation- mini mental status examination (MMSE) – shows cognitive impairment .
■ Physical exam - Measuring blood pressure and other vital signs may help physicians detect
conditions that might cause or occur with dementia.
■ Neurological tests - Assessing balance, sensory response, reflexes, and other cognitive functions.
■ Cognitive and neuropsychological tests - These tests are used to assess memory, problem solving,
language skills, math skills, and other abilities related to mental functioning.
■ Laboratory tests - Testing a person's blood and other fluids , as well as checking levels of various
chemicals, hormones, and vitamins, can help find or rule out possible causes of symptoms.
■ Spinal fluid analysis - shows increased beta amyloid deposits.
■ Psychiatric evaluation.
■ Genetic tests
 Diagnosis of Dementia
• Brain scans. These tests can identify strokes, tumors, and other problems that can cause
dementia.

• Computed tomography (CT), which uses x rays to produce images of the brain and other
organs.

• Magnetic resonance imaging (MRI), which uses magnetic fields and radio waves to produce
detailed images of body structures, including tissues, organs, bones, and nerves/ shows structural
and neurologic changes.

• Positron emission tomography (PET), which uses radiation to provide pictures of brain
activity.
 What is Alzheimer’s Diseases?
■ Alzheimer's is the most common cause of dementia, a
general term for memory loss and other cognitive abilities
serious enough to interfere with daily life.
■ Alzheimer's disease accounts for 60-80% of dementia
cases.
■ Alzheimer's is not a normal part of aging - the greatest
known risk factor is increasing age, and the majority of
people with Alzheimer's are 65 and older.
■ Alzheimer’s disease is considered to be younger-onset
Alzheimer’s if it affects a person under 65.
■ Younger-onset can also be referred to as early-onset
Alzheimer’s.
■ People with younger-onset Alzheimer’s can be in the early,
middle or late stage of the disease.
 Symptoms of Alzheimer’s
■ The most common early symptom of Alzheimer’s is difficulty remembering newly learned information.
■ Memory loss
■ Confusion about the location of familiar places
■ Taking longer to accomplish normal, daily tasks
■ Trouble handling money and paying bills
■ Compromised judgment, often leading to bad decisions
■ Loss of spontaneity and sense of initiative
■ Mood and personality changes; increased anxiety
■ Increasing memory loss and confusion
■ Shortened attention span
■ Problems recognizing friends and family members.
■ Difficulty with language; problems with reading, writing, working with Numbers.
■ Difficulty organizing thoughts and thinking logically.
■ Inability to learn new things or to cope with new or unexpected situations.
 Symptoms of Alzheimer’s
■ Restlessness, agitation, anxiety, tearfulness,
wandering, especially in the late afternoon or at
night.
■ Repetitive statements or movement
■ Hallucinations, delusions, suspiciousness or
paranoia, irritability.
■ Loss of impulse control.
■ Perceptual-motor problems: Such as trouble getting
out of a chair or setting the table
 Symptoms of Alzheimer’s
■ Weight loss
■ Seizures, skin infections, difficulty swallowing
■ Groaning, moaning, or grunting
■ Increased sleeping
■ Lack of bladder and bowel control
 Alzheimer's disease Etiology/Diagnosis

■ The exact causes of Alzheimer's disease aren't fully understood.

■ Medical History
■ Neuropsychological screening tests
■ Magnetic resonance (MRI)
■ Single- photon emission computed tomography (SPECT)
■ Positron emission tomography (PET)
 Data to be included for nursing assessment
■ Disorientation (Nursing Mamagement)
■ Mood changes
■ Fear
■ Suspiciousness
■ Self-care deficit
■ Social behaviour
■ Level of mobility, wandering behaviour
■ Judgement ability
■ Sleep disturbances
■ Speech or language impairment
■ Hallucinations, illusions or delusions
■ Bowel and bladder incontinence
■ Apathy
■ Any decline in nutritional status
■ Recognition of family members
■ Identify primary care giver, support system and the knowledge base of the family members.
 Alzheimer's disease Treatment

■ Cholinesterase inhibitors
■ Memantine (Namenda)
■ Omega-3 fatty acids / Ginkgo / Vitamin E
■ Exercise
■ Nutrition
■ Clinical trials…
■ https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet
■ https://www.youtube.com/watch?v=loksPQ7Q8tM
Thank You!