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The Mini-Mental State Exam and Its Use as an Alzheimer's Screening Test

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Updated May 28, 2014

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Mini-Mental-State Exam
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The Mini-Mental State Exam (MMSE) is a brief, structured test of mental status that takes about 10 minutes to complete. Introduced by Marshall Folstein and others in 1975, the MMSE tests global cognitive function, with items assessing orientation, word recall, attention and calculation, language abilities, and visuospatial ability. To assess orientation to time, for example, which accounts for 5 of the 30 points, the person is asked to state the year, season, date, day and month. Visuospatial ability accounts for one point and is assessed with a single item, namely the copying of 2 intersecting pentagons.

Scoring of the MMSE

Scores on the MMSE range from 0 to 30, with scores of 25 or higher being traditionally considered normal. Scores less than 10 generally indicate severe impairment, while scores between 10 and 19 indicate moderate dementia. People with mild Alzheimer's disease tend to score in the 19 to 24 range. However, scores may need to be adjusted or interpreted differently to account for a person's age, education, and race/ethnicity. Scores decline with advancing age and increase with higher educational level. It's possible to achieve a very high score but still have significant cognitive deficits, especially in areas such as executive functioning that the MMSE is not designed to test for.

Usefulness of the MMSE

There are two primary uses of the MMSE. First, it is a widely used, validated, and reliable method of screening for Alzheimer's disease. However, as a screening test it is not meant to substitute for a thorough diagnostic work-up. Sensitivity and specificity of the MMSE, key properties of every screening test, are reasonably good. Sensitivity refers to the test's accuracy in identifying individuals with the disease (i.e., persons with Alzheimer's test as positive). Specificity refers to the test's effectiveness in identifying people who do not have the disease (i.e., persons without the disease test as negative).

The second important use of the MMSE is as a means of following the course of cognitive changes in an individual over time. This way a person's response to treatment may be documented and this can help in guiding future treatment. Typically, an Alzheimer's patient's MMSE score declines by 3-4 points per year without treatment.

Overall Advantages and Disadvantages of the MMSE

In addition to the advantages already mentioned, the MMSE has been translated into many languages and has even been adapted for use by visually-impaired persons. Disadvantages include the need to adjust scores for age, education and ethnicity, as well as potential copyright issues (while originally the MMSE was widely distributed for free, the current official version must be ordered through the copyright owner since 2001, Psychological Assessment Resources: PAR).

Sources:

Crum RM, Anthony JC, Bassett SS, et al. Population-based norms for the Mini-Mental State Examination by age and education level. JAMA. 1993; 269: 2386-2391.

Escobar J, Burnam A, Karno M, et al. Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity: cultural and linguistic artifacts. J Nervous Ment Dis. 1986; 174: 607-614.

Folstein MF, Folstein SE, McHugh PR. "Mini-mental state." A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12: 189-198.

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