The Mini-Mental State Examination (MMSE) by Folstein, Folstein, and McHugh (1975) is one of the most widely used scales for assessing cognitive ability and is considered by many to be the gold standard in its respective field. Designed as a brief quantitative measure of cognitive status, the MMSE can be used to screen for cognitive impairment (CI), estimate its severity, follow the course of cognitive changes over time, and document response to treatment (Monroe & Carter, 2012). The MMSE comprises 11 items across 6 domains and includes such items as recalling what year it is, correctly identifying a familiar object like a pencil, counting backward, and writing a sentence. The measure has clearly outlined scoring parameters that range from 0 to 30 with higher scores indicating less impairment. The MMSE can take up to 15 minutes to complete and the examiner’s manual has well established norms across a number of age groups and populations.
1. Orientation to time and place
2. Registration of three words
3. Attention and calculation
4. Recall of three words
6. Visual construction
Studies of reliability over a 24-hour period with single and multiple users found that the intra-rater reliability was r = 0.88 when given by the same testers, and when using different testers, the inter-rater reliability was r = 0.82 (Monroe & Carter, 2012). Research conducted as part of the larger QUALIDEM study of neurocognitive disorder (NCD) subjects found that the diagnostic values of a MMSE scores of ≤ 23 produced a sensitivity of 0.97 and specificity of 0.59 (Paquay, De Lepeleire, Schoenmakers, Ylieff, Fontaine, & Buntinx, 2006). A study of the oldest-old (n = 435) established the sensitivity and specificity of the MMSE in identifying the various types of NCD in subjects aged 90 to 93 years with a college degree or higher found that at a cutoff score of ≤ 25 the sensitivity was 0.82 and specificity was 0.80; whereas in those aged 94 to 96 years with a college degree or higher at the suggested cutoff of ≤ 24, sensitivity was 0.85 and specificity was 0.80 (Kahle-Wrobleski, Corrada, Li, & Kawas, 2007). Research by Ala, Hughes, Kyrouac, Ghobrial, and Elble (2002) was able to differentiate between those individuals with NCD of the Lewy body (LB) and Alzheimer’s type by examining differences between the attention and construction subtest scores where those with NCD LB fared worse than those with NCD Alzheimer’s. For example, only 4/16 LB subjects were able to spell “world” backward correctly, whereas 18/26 Alzheimer’s subjects spelled it correctly. Furthermore, only 1 LB subject was able to perform serial 7s correctly (counting backward by 7) and only 1 Alzheimer subject performed them incorrectly. The authors of the study determined that when the following mathematical equation was applied (Attention –5/3 Memory + 5 x Construction) of the 3 sub-scores a score less than 5 points was associated with NCD LB with a sensitivity of 0.82 at a 95% confidence interval (CI) and a specificity of 0.81 also at a 95% CI (Ala et al., 2002). Finally, the following data published by Psychological Assessment Resources Inc. (PAR), the copyright holder, derived from a normative sample of more than 1500 individuals used to establish reliability and normal range of scores for the slightly modified MMSE-2, found that internal consistency ranged from α = 0.66 to 0.79 with test-retest stability at ≥ 0.96 for all versions, while the interrater reliability of the measure ranged from 0.94 to 0.99 (PAR, 2011).
There is a significant amount of research pertaining to the MMSE to support its use in clinical practice. It is also one of the most widely used cognitive batteries across numerous health professions. The MMSE is relatively quick and easy to administer and often can be completed in less than 10 minutes. It assesses a number of cognitive functions and does not require any specialized training. Several standardized versions of the measure are also available from PAR Inc, although the original is still the most established.
Several researchers have argued that the utility of the MMSE decreases for persons with mild CI and one of the most frequently cited limitations is its poor sensitivity to mild cognitive decline, which may be due to the ease with which individuals perform most of the test items. Thus, it is argued that only severe impairment would prevent individuals from correctly answering most test items (Spencer et al., 2013). Other studies have noted the occurrence of floor/ceiling effects as well as an inability to differentiate between the various types of neurocognitive disorders (i.e., of the Alzheimer’s or vascular type) (Monroe & Carter, 2012). Its cultural sensitivity has been questioned by some, as individuals with language, or sensory disorders or those with less than an eighth grade education may perform poorly (Monroe & Carter, 2012).
The MMSE is based mostly on client interview that consists of a series of questions and tasks grouped into 11 categories for which a maximum of 30 points can be obtained, and where a score of 23 or lower is widely accepted as the cutoff point, which suggests the presence of CI and a need for further evaluation (Albanese & Ward, 2003). Various scoring paradigms are available and a typical classification is as follows: 27 to 30, normal; 21 to 26, mild CI; 11 to 20, moderate CI; and 0 to 10, consistent with severe CI. The manual provides explicit instructions for administration and scoring and contains normative data based on a large sample of 18,056 individuals that are dissected by age and educational level to further aid in correctly classifying an individual’s level of cognitive functioning (Albanese & Ward, 2003).
Use of the original or modified versions of the MMSE can be obtained by contacting PAR Inc., who own the rights to the exam, where several versions such as the standard and expanded version of the test are available. The price for the standard full kit is roughly $200. PAR also handles requests by individuals or entities to use the measure in research, publication, or for commercial purposes. More information can found in the following original journal article:
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini mental state: Practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.
|POPULATION||Suspected CI; general|
|TYPE OF MEASURE||Interview; cognitive-based activities|
|WHAT IT ASSESSES||Presence of or level of CI|
|TIME||≤ 15 minutes|
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