The Mini Mental State Examination (MMSE)
The Mini Mental State Examination (MMSE) is the most commonly used test for complaints of memory problems. It can be used by clinicians to help diagnose dementia and to help assess its progression and severity. This factsheet looks at how the MMSE is used and provides information about the test so that the person taking it knows what to expect.
How is it used?
The MMSE is a series of questions and tests, each of which scores points if answered correctly. If every answer is correct, a maximum score of 30 points is possible. The MMSE tests a number of different mental abilities, including a person's memory, attention and language.
The MMSE is a tool that is used by clinicians such as a GP or a neuropsychologist (a psychologist who specialises in the brain and its function) to help them diagnose and assess dementia. It is only one part of these processes and clinicians will often consider a person's MMSE score alongside the results of other tests (see factsheet 426, Diagnosis and assessment).
In general, scores of 27 or above (out of 30) are considered normal. However, getting a score below this does not always mean that a person has dementia - their mental abilities might be impaired for another reason or they may have a physical problem such as difficulty hearing, which makes it harder for them to take the test.
The MMSE can also be used to assess changes in a person who has already been diagnosed with dementia. It can help to give an indication of how severe a person's symptoms are and how quickly their dementia is progressing. On average, people with Alzheimer's disease who are not receiving treatment lose two to four MMSE points each year.
MMSE score and treatment
The MMSE score is one of the things a doctor considers when deciding if drugs will help a person with dementia. The severity of a person's dementia gives an indication of which drugs may be of benefit. Recommendations as to which drugs may be used at each stage of dementia are issued by the National Institute for Health and Clinical Excellence (NICE).
The latest (2011) NICE guidance recommends that for mild-to-moderate Alzheimer's disease (MMSE score 10-26), the person should be considered for treatment with donepezil (Aricept), rivastigmine (Exelon) or galantamine (Reminyl). The same NICE guidance recommends the use of a different kind of drug, memantine (Ebixa), for people with severe Alzheimer's disease (MMSE score less than 10) and for some of those with moderate disease (MMSE score 10-20).
It is important to note that a person's MMSE score can be affected by their level of education. This is because for highly educated people the questions may be too easy and for poorly educated people some may be too difficult. This means that a highly educated person with mild dementia may score in the normal range, whereas a poorly educated person with no problems in cognition may score in the dementia range. The person's cultural background could also affect their score as some of the questions may be easier for people from certain cultures to answer - for example questions that require knowledge relevant to English history.
For people with learning disabilities, difficulty speaking, or for those who are not fluent enough in a language in which the MMSE can be given, a different method should be used to assess dementia severity when treatment is being considered. This is to ensure that people from different ethnic or cultural backgrounds and people with disabilities have equal access to treatment.
A person's MMSE score should also be considered in the light of the particular difficulties that they experience. For example, a person with posterior cortical atrophy (PCA - a rare type of Alzheimer's disease) might score in the normal range, despite having significant symptoms and problems. This is because the MMSE is weighted towards measuring memory and orientation (on which people with PCA are relatively strong), but has few questions examining vision or literacy (which are the main problems experienced by people with PCA). This could lead to the person not being considered for treatment as their MMSE score gives the impression that their difficulties are very mild.
The MMSE is made up of a range of different questions and tests. Below are four sample questions that give an indication of the style of the MMSE.
1 Orientation to time
'What is the date?'
'Listen carefully. I am going to say three words. You say them back after I stop. Ready? Here they are... apple [pause], penny [pause], table [pause]. Now repeat those words back to me.'
[Repeat up to 5 times, but score only the first trial.]
'What is this?' [Point to a pencil or pen.]
'Please read this and do what it says.' [Show examinee the following words on the stimulus form: Close your eyes.]
Sample questions reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549, from the Mini Mental State Examination, by Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini Mental LLC, Inc. Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc. by calling (813) 968-3003.
Last reviewed: January 2012
Next review due: January 2014
Reviewed by: Dr Sebastian Crutch, Neuropsychologist, Dementia Research Centre, Institute of Neurology, UCL, London and Professor Louise Robinson, Professor of Primary Care and Ageing, Newcastle University, Newcastle
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