Orientation, attention, memory, executive function. Cognitive screening differentiates functional psychiatric illness from delirium, dementia, and medical contributors.
Encounter card
Setting
Brief screening in every encounter; expanded cognitive testing when delirium, dementia, intoxication, head injury, or unexplained presentation is suspected.
Opening move
Note alertness, attention, orientation throughout the interview. Use brief screening (orientation x 4, days of week backward, attention tests). Reserve formal cognitive testing (MoCA, MMSE) for indicated cases.
Sample language
"Can you tell me the date today — month, day, year, day of the week?"
"I'm going to give you three words to remember — apple, table, penny — I'll ask you again in a few minutes."
"Can you spell "world" backward for me?"
"I'd like to do a brief memory and thinking test — is that okay?"
Listen for
Orientation (person, place, time, situation). Attention (digit span, serial 7s, spelling backward). Recent and remote memory. Working memory and executive function. Language fluency, comprehension, repetition, naming.
Common pitfalls
Skipping cognitive screening in functional psychiatric encounters. Doing a full MoCA in cooperative depressed patients without indication. Mistaking depressive pseudodementia for true cognitive impairment. Mistaking education level effects for pathology.
Red flags / escalate: Acute disorientation in previously oriented patient (delirium until proven otherwise — medical workup). Sudden cognitive change. Pattern suggesting Wernicke's encephalopathy (confusion + ataxia + ophthalmoplegia). New-onset cognitive impairment in older adult (dementia workup).
Documentation
"Alert and oriented x 4. Attention intact: serial 7s 100-93-86-79-72. Recall 3/3 immediate, 2/3 at 5 minutes. Spelling "world" backward intact." Or, where formal testing done: "MoCA 22/30, deficits in delayed recall (2/5) and visuospatial (3/4)."
Real-world reality: MoCA or MMSE testing in a busy outpatient psychiatric visit takes 10-15 minutes — meaningful time investment. Reserve for indicated cases; brief screen sufficient for most encounters.
Cognitive findings determine medical workup. A new cognitive deficit changes the differential entirely.
Cognitive screening is a routine MSE component. Even in patients without obvious cognitive concerns, brief cognitive screening provides a baseline that may matter later. In patients where cognitive change is suspected, structured testing is essential.
Brief screen includes orientation (person, place, time, situation — "person place time" plus "what's happening today?"), attention (digit span, serial 7s, days of week backward, spelling "world" backward), recent memory (three-item recall after a few minutes), language fluency and comprehension. Takes a couple of minutes; catches many problems.
Formal testing — MoCA (Montreal Cognitive Assessment) or MMSE (Mini-Mental State Examination) — is indicated when delirium, dementia, intoxication, head injury, or unexplained presentation is suspected. MoCA is more sensitive than MMSE for mild cognitive impairment and is generally preferred for modern psychiatric and neurologic practice.
Acute cognitive change is a medical emergency. The patient who was oriented yesterday and is disoriented today has delirium until proven otherwise. Causes: infection, hypoxia, electrolyte disturbance, intoxication, withdrawal, medication toxicity, stroke, intracranial process. Medical workup before assuming psychiatric etiology. Don't sedate the agitated delirious patient without identifying the cause.
Pattern of deficits guides differential. Disorientation with fluctuation and inattention suggests delirium. Progressive memory loss over months to years suggests dementia. Sudden focal deficits suggest stroke. Patchy memory with intact other cognition suggests transient global amnesia or seizure-related. Pseudodementia (cognitive impairment from severe depression) presents with "I don't know" answers and preserved encoding, distinct from true dementia's incorrect answers and lost encoding.
Calibrate for education and baseline. MoCA cutoffs vary with education level. The college-educated patient with a baseline of perfect performance who drops to 26/30 has experienced meaningful change, even though 26 is technically "normal." The patient with limited formal education whose baseline was always around 24 isn't demented because they score 24 today. History and baseline matter.
When to use MoCA/MMSE vs brief screen — indicated by suspected delirium, dementia, intoxication, head injury, unexplained presentation. Margin notes on test selection.
The anchor
Cognitive screening is a routine MSE component. Acute cognitive change is a medical emergency until proven otherwise. Pattern of deficits guides differential.
Distinguishing depressive pseudodementia (slow, "I don't know" answers, preserved encoding) from true dementia (incorrect answers, loss of encoding). Margin clusters on bedside differentiation.
Prove it
An 80-year-old with depression scores 22/30 on the MoCA, with deficits in delayed recall (2/5) and visuospatial copy (3/4). Her family says she's been "more forgetful." How do you interpret this?