The mini-mental state examination, which is also known as the MMSE, standardized MMSE, SMMSE, or the Folstein, is a brief examination consisting of eleven questions intended to evaluate an adult patient's level of cognitive functioning. It was introduced in 1975 and designed for use with elderly patients who are able to cooperate at an optimum level with an examiner for only a brief period of time—no more than a few minutes.
Purpose
The MMSE concentrates on the cognitive aspects of mental functioning, excluding questions about the patient's mood or such abnormal experiences as dissociation. It is used most often to evaluate older adults for delirium or dementia. The MMSE can be used to detect a decline in cognitive function; to follow the course of
the patient's illness, and to monitor responses to treatment. Recently, it has been professionally approved as a measurement of a patient's ability to complete an advance directive, or so-called living will.
The test has also been used in research as a screener in epidemiological studies for disorders that affect cognition, and to monitor changes in subjects'cognition during clinical trials. In 2001 the MMSE was recommended by a special panel of experts for use as a screener in evaluating cognitive function in depressed patients. It has also been used recently to measure the effects of acupuncture in improving mood and some cognitive skills in patients with Alzheimer's.
The MMSE evaluates six areas of cognitive function: orientation, attention, immediate recall, short-term recall, language, and the ability to follow simple verbal and written commands. In addition, it provides a total score allowing the examiner to place the patient on a scale of cognitive function. It correlates well with a standard measure of cognition in adults, the Wechsler Adult Intelligence Scale (WAIS). In contrast to the Wechsler, which takes about an hour or more to administer, the MMSE can be completed in ten minutes or less.
Precautions
The MMSE should not be used as the sole criterion for assessment during differential diagnosis of psychiatric disorders, as there are many disorders and conditions that affect cognitive functioning. The results of the MMSE should be interpreted in the context of the patient's history, a full mental status examination, a physical examination, and laboratory findings, if any.
A patient's score on the MMSE must be interpreted according to his or her age and educational level. Whereas the median score is 29 for persons 18–24 years of age, it is 25 for those who are 80 or older. The median score is 22 for persons with a fourth-grade education or less; 26 for those who completed the eighth grade; and 29 for those who completed high school or college. There is a complete table available for interpreting MMSE scores according to the patient's reference groups for age and education level.
The MMSE should be administered and scored only by a qualified health care professional, such as a psychologist, physician, or nurse.
Description
The mini-mental state examination is divided into two sections. The first part requires vocal responses to the examiner's questions. The patient is asked to repeat a short phrase after the examiner; to count backward from 100 by 7s; to name the current President of the United States (in Great Britain, the names of the Queen and her four children); and similar brief items. It tests the patient's orientation, memory, and attention. The maximum score on this section is 21.
In the second part of the examination, the patient is asked to follow verbal and written instructions, write a sentence spontaneously, and copy a complex geometric figure similar to a Bender-Gestalt figure—a series of nine designs each on separate cards given the test taker who is asked to reproduce them on blank paper. The sentence item usually asks the patient to explain the meaning of a simple proverb such as "People who live in glass houses shouldn't throw stones." The maximum score for the second section is 9. Patients with vision problems can be assisted with large writing. The MMSE is not timed.
There is little information available on allowances made in scoring the MMSE for patients whose first language is not English or who have difficulty with standard spoken English.
Results
The maximum total score on the MMSE is 30. As a rule, scores of 20 or lower indicate delirium, dementia, schizophrenia, or a mood disorder. Normal subjects and those with a primary diagnosis of personality disorder score close to the median for their age and education level.
BOOKS
Eisendrath, Stuart J., MD, and Jonathan E. Lichtmacher, MD. "Psychiatric Disorders: Psychiatric Assessment." In Current Medical Diagnosis & Treatment 2001. 40th edition. Edited by L. M. Tierney, Jr., MD, and others. New York: Lange Medical Books/McGraw-Hill, 2001.
PERIODICALS
Crum, R. M., and others. "Population-Based Norms for the Mini-Mental State Examination by Age and Educational Level." Journal of the American Medical Association 18(1993): 2386–2391.
Folstein, Marshal F., Susan E. Folstein, and Paul R. McHugh. "Mini-mental state: A practical method for grading the cognitive state of patients for the clinician." Journal of Psychiatric Research 12 (1975): 189–198.
Lombardo, Emerson, L. Vehvilainen, W. L. Ooi, and others. "Acupuncture to Treat Anxiety and Depression in Alzheimer's." The Gerontologist (October 15, 2001):391.
Mor, Vincent. "SMMSE Measures Capacity for Advance Directives." Brown University Long-Term Care Quality Letter 8 (July 1996): 6.
ORGANIZATIONS
American Psychiatric Association. 1400 K Street, NW. Washington, DC 20005. (202) 682-6220. <www.psych.org>.
Department of Psychiatry, Tufts University School of Medicine/Tufts-New England Medical Center. <www.nemc.org>.
National Institute of Neurological Disorders and Stroke (NINDS). Building 31, Room 8A06, 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-5751. <www.ninds.nih.gov>.
