Mini Mental Status Examination

The Mini-Mental State Examination (MMSE) was developed as a brief screening tool to provide a quantitative assessment of cognitive impairment and to record cognitive changes over time (Folstein et al. 1975). While the tool’s original application was the detection of dementia within a psychiatric setting, its use has become widespread.

The MMSE consists of 11 simple questions or tasks. Typically, these are grouped into seven cognitive domains including orientation to time, orientation to place, registration of three words, attention and calculation, recall of three words, language, and visual construction. Administration by a trained interviewer takes approximately 10 minutes. The test yields a total score of 30 and provides a picture of a subject’s present cognitive performance based on direct observation of completion of test items/tasks. A score of 23 out of 24 is the generally accepted cut-off point indicating the presence of cognitive impairment (Dick et al. 1984). Levels of impairment have also been classified as none (24-30), mild (18-24), and severe (0-17) (Tombaugh & McIntyre, 1992).

An expanded version of the MMSE, the modified mini-mental state examination (3MS) was developed by Teng & Chui (1987), increasing the content, number, and difficulty of items included in the assessment. The score of the 3MS ranges from 0 to 100 with a standardized cut-off point of 79/80 for the presence of cognitive impairment. This expanded assessment takes approximately 5 minutes more to administer than the original MMSE. The MMSE is available for purchase at http://www4.parinc.com/Products/Product.aspx?ProductID=MMSE#Items

Table: Characteristics of the Mini Mental State Examination

Advantages. The Mini-mental State Examination is brief, inexpensive, and simple to administer. Its widespread use and accepted cut-off scores increase its interpretability. 

Limitations. MMSE scores have been shown to be affected by age, level of education and sociocultural background (Bleecker et al. 1988; Lorentz et al. 2002; Tombaugh & McIntyre 1992). These variables may introduce bias leading to the misclassification of individuals, and such biases have not always been reported. For instance, Agrell and Dehlin (2000) found neither age nor education to influence scores. Lorentz et al. (2002) expressed concern that adjustments made for these biases may limit the general utility of the MMSE.

Perhaps the greatest limitation of the MMSE is its low reported levels of sensitivity, particularly among individuals with mild cognitive impairment (de Koning et al. 1998; Tombaugh & McIntyre 1992), in patients with focal lesions (particularly those in the right hemisphere) (Tombaugh & McIntyre 1992), within a general neurological patient population (Dick et al. 1984), and within a stroke population (Blake et al. 2002; Suhr & Grace 1999). It has been suggested that its low level of sensitivity derives from the emphasis placed on language items and a paucity of visual-spatial items (de Koning et al. 2000; de Koning et al. 1998; Grace et al. 1995; Suhr & Grace 1999; Tombaugh & McIntyre 1992). Various solutions have been proposed to the problem of the MMSE’s poor sensitivity including the use of age-specific norms (Bleecker et al. 1988) and the addition of a clock-drawing task to the test (Suhr & Grace 1999). Clock-drawing tests themselves have been assessed as acceptable to patients, easily scored and less affected by education, age and other non-dementia variables than other very brief measures of cognitive impairment (Lorentz et al. 2002) and would have little effect on the simplicity and accessibility of the test. The MMSE has been evaluated for use among a variety of neurological populations.

 

At present, information regarding the reliability and validity of the MMSE when used among patients with TBI/ABI is extremely limited.

 

Summary-Mini Mental Status Examination

Interpretability: The MMSE is widely used and has generally accepted cut-off scores indicative of the presence of cognitive impairment. Documented age and education effects have led to the development of stratified norms (Ruchinskas & Curyto 2003).

Acceptability: The test is brief, requiring approximately 10 minutes to complete. It may be affected by patient variables such as age, level of education and sociocultural background. As it is administered via direct observation of task completion, it is not suitable for use with a proxy respondent.

Feasibility: The test requires no specialized equipment and little time, making it inexpensive and portable. A survey conducted by Lorentz et al. (2002) revealed participant physicians found the MMSE too lengthy and unable to contribute much useful information.

 

Table: Mini Mental State Examination Evaluation Summary

Reliability

Validity

Responsiveness

Rigor

Results

Rigor

Results

Rigor

Results

Floor/ceiling

+++

 

 

+++ (TR)

++ (IO)

++ (IC)

+++

++

N/A

N/A

N/A

NOTE: +++=Excellent; ++=Adequate; +=Poor; N/A=insufficient information; TR=Test re-test; IC=Internal Consistency; IO=Interobserver; Varied (re. floor/ceiling effects; mixed results).