Article on Mini-Mental State Examination (MMSE)

The article is by Howard H. Feldman, MD, Claudia Jacova, PhD, Alain Robillard, MD, Angeles Garcia, MD PhD, Tiffany Chow, MD, Michael Borrie, MB ChB, Hyman M. Schipper, MD PhD, Mervin Blair, BSc, Andrew Kertesz, MD, & Howard Chertkow, MD.

Here's an excerpt:

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The Mini-Mental State Examination (MMSE) 19 remains the most widely used instrument, with high sensitivity and specificity for separating moderate dementia from normal cognition. It requires little training, is administered in about 10 minutes and has vast medical acceptance. A rough rule of thumb is that patients with mild dementia usually have a score of 18-26 out of 30, those with moderate dementia a score of 10-18, and those with severe dementia a score of less than 10. Some clinical trials of Alzheimer disease have accepted only patients with a score of less than 24.16 At scores above this level, the Mini-Mental State Examination lacks sensitivity for the diagnosis of mild dementia, and other assessments are needed. The Mini-Mental State Examination focuses on memory, attention, construction and orientation domains. The Modified Mini-Mental State Examination is a more expanded version that also includes assessment of delayed recall20 and has been widely used in clinical and research settings in Canada.

The clock-drawing test evaluates general executive functioning of the frontal lobe, as well as visuospatial abilities (Figure 1).22 It requires 5-10 minutes to administer and has achieved widespread clinical use. Like the Mini-Mental State Examination, however, the clock-drawing test may lack sensitivity for the diagnosis of early or mild dementia.18

A number of newer tests have been developed to provide improved sensitivity. Of these, it is worth mentioning the Montreal Cognitive Assessment,2 DemTect,3 the 7-Minute Screen,4 the General Practitioner Assessment of Cognition5 and the Behavioural Neurology Assessment short form.6 All of these tests have been shown to be more accurate than the Mini-Mental State Examination in discriminating between dementia and normal cognition, particularly in cases of very mild dementia.2-6 The General Practitioner Assessment of Cognition5 requires 5-10 minutes to administer and was evaluated in family practice offices in Australia. The other tests require about 10 or more minutes to administer, were evaluated in specialty clinics or population studies and are used to evaluate multiple cognitive domains. This coverage probably makes them more accurate in detecting dementia in heterogeneous populations, but this remains to be proven. Although consideration of the details of these tests is beyond the scope of our review, intested readers may refer to the background paper by Jacova and colleagues3 on neuropsychological testing and brief cognitive testing....

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Here's another excerpt: "The challenges in diagnosing dementia should not be understated. It can be difficult in some individuals with mild dementia to reliably demonstrate objective cognitive impairment as well as functional impairment. Some individuals without dementia can score low in the Mini-Mental State Examination, and only a score below 20 provides specific evidence for dementia.24 Conversely, dementia is possible even with a Mini-Mental State Examination score greater than 26.25 Furthermore, the score may vary by several points from one evaluation to the next. Language barriers, advanced age and low education can also confound the results and provide false-positive scores. A briefer test, such as the clock-drawing test, has the same challenges. No one brief cognitive test has been found to be superior over the others. No brief cognitive test has been developed to differentiate between subtypes of dementia, and none can be recommended for this purpose.26 Often the best recommendation is to repeat the testing on several occasions over several months, to provide more convincing evidence of cognitive impairment. The documentation of functional impairment can also be challenging. If the patient had limited premorbid activities, it can be difficult to document convincing functional decline for several years."

Another excerpt: "Depression and its contributing role in creating a "pseudodementia" has received considerable emphasis in the past.31 It is now appreciated that some degree of depressive symptoms, anxiety and apathy are quite common in the prodrome and course of Alzheimer disease. 32,33 Asking the patient, or a family member or caregiver, about vegetative symptoms, including disorders of sleep, appetite and weight, can further address this diagnostic possibility of depression and the need for its treatment. Important symptoms to review include the presence of feelings of guilt, loss of enjoyment of pleasurable activities, current outlook and suicidal ideation."

A final excerpt: "Editor's Note: The background papers with supporting evidence for the recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia were published in the October 2007 issue of Alzheimer's and Dementia and are available at www.alzheimersanddementia.org. These articles are also freely available at www.cccdtd.ca (through agreement with Elsevier)."

The author note states that correspondence about the article may be sent to Dr. Howard H. Feldman, Division of Neurology, University of British Columbia Hospital, S192-2211 Wesbrook Mall, Vancouver BC V6T 2B5; fax 604 822-7703 .