Read Mini-Mental State Examination (MMSE) text version

Tool and Resource Evaluation Template

Adapted by NARI from an evaluation template created by Melbourne Health. Some questions may not be applicable to every tool and resource.

Name of the resource: Mini Mental State Examination (MMSE) Name and purpose Author(s) of the resource: Folstein MF, Folstein SE, McHugh PR. Please state why the resource was developed and what gap it proposes to fill:

1 The MMSE was developed by Folstein in 1975 and is probably the most widely used standardised cognitive screening test. The MMSE was intended for use as part of a complete cognitive appraisal and was never meant to stand alone as a dementia diagnostic tool.

Target audience (the tool is to be used by)

Please check all that apply: Health service users Medical staff Carers Nursing staff Any member of an interdisciplinary team

Medical specialist, please specify: Specific allied health staff, please specify: Other, please specify: Target population/setting (to be used on/in) Is the resource targeted for a specific setting? Please check all that apply: Emergency Department Other, please specify: Community care, residential care. For which particular health service users would you use this resource (e.g. a person with suspected cognitive impairment)? An Australian study2 concluded that the MMSE is an appropriate `screening instrument' for dementia, in defined clinical settings, including: Patients admitted to acute geriatric medical units Patients over 75 years of age admitted to acute teaching hospitals Patients being seen by geriatric liaison teams in acute teaching hospitals Persons being reviewed by Aged Care Assessment Services (ACAS) Older persons seeking residential care Structure of tool Website Pamphlet Methodology Education package Assessment tool Resource guide Video Screening tool Awareness raising resource (posters etc.) Inpatient acute Inpatient subacute Ambulatory

Other, please specify: Please state the size of the resource (e.g. number of pages, minutes to read): The MMSE is a 30-point scale designed to assess a client's cognitive performance in a clinical setting. It comprises 11 categories of items and assesses orientation to time and place, attention or calculation, registration and recall, construction (copying a diagram) and language. The MMSE should be administered by a clinician trained in/familiar with its use; and takes about 10 minutes to complete with hospitalised older people. The test is not timed. Availability and cost of tool Is the resource readily available? Is there a cost for the resource? Yes Yes No No Unknown Unknown Not applicable Not applicable

Please state how to get the resource: The MMSE has recently been copyrighted by Psychological Assessment Resources (PAR) 3 ( and permission and payment are now required to use the MMSE . The cost of using the MMSE is approximately $1.00 (Australian) per assessment. Applicability to rural settings and culturally and linguistically diverse populations Is the resource suitable for use in rural health services (e.g. the necessary staff are usually available in rural settings)? Yes No Unknown Not applicable Is the resource available in different languages? Yes No Unknown Not applicable

Translations available in the following languages Afrikaans, Arabic, Argentinean Spanish, Belgian Dutch, Belgian French, Bosnian, Brazilian Portuguese, Bulgarian, Chilean Spanish, Chinese, Croatian, Czech, Danish, Dutch, Estonian, Farsi, Filipino, Finnish, French, Austrian German, German, Greek, Gujarati, Hebrew, Hindi, Hungarian, Indian English, Israeli English, Italian, Japanese, Kannada, Korean, Latvian, Lithuanian, Macedonian, Malay, Malayalam, Marathi, Norwegian, Polish, Portuguese, Romanian, Russian, Russian for Estonia, Serbian, Slovakian, Slovenian, South African English, Spanish,

Swedish, Tamil, Telugu, Turkish, UK English, Ukrainian, and Urdu. Is the content appropriate for different cultural groups? Yes No Unknown Not applicable

There is limited research into the cultural appropriateness of cognitive screening. Some authors have suggested that older people from culturally and linguistically diverse (CALD) backgrounds have poorer `test-taking' skills and may experience greater anxiety about cognitive assessment. Others conclude that although cultural bias is common in screening tests for cognition, sensitive 4-6 administration and interpretation of results can minimise the effects . Person-centred principles Does the resource adhere to/promote person-centred health care? Yes No Unknown Not applicable

The MMSE (and other brief cognitive screening instruments) has been criticised for failing to take into account educational level, cultural background, literacy, and proficiency in English; which would suggest it is not person-centred. On the other hand, it could be argued that cognition is so integral to a person's ability to function, that without an assessment of their cognitive status they cannot be provided with care that is designed to meet their needs. It is important that administration of all cognitive assessment instruments is performed by a person trained in their use, and who is cognisant of their shortcomings; and that interpreters and patient liaison staff are utilised as necessary. Training requirements Is additional training necessary to use the resource? Yes No Unknown Not applicable

If applicable, please state how extensive any training is, and what resources are required: No specific training is recommended by PAR. However the toolkit available from the website does provide a User's Guide, which contains detailed instructions for standard administration and scoring for each MMSE task, as well as recommended cut-off scores for classifying the severity of cognitive impairment. It also provides a Clinical Guide, which describes the development, validation, administration, and interpretation of the MMSE. Administration details How long does the resource take to use? 0-5 mins 5-15 mins 15-25mins 25mins+

Can the resource be used as a standalone, or must it be used in conjunction with other tools, resources, and procedures? Standalone Must be used with other resources, please specify: Can be used with other tools, please specify: The MMSE can be used alone as a screen for cognitive impairment. It can also be used as part of a battery of tests designed for the diagnosis of dementia. Data collection and analysis Are additional resources required to collect and analyse data from the resource? Yes No Unknown Not applicable

If applicable, please state any special resources required (e.g. computer software): Sensitivity and specificity Sensitivity is the proportion of people that will be correctly identified by the tool. Specificity is the probability that an individual who does not have the condition being tested for will be correctly identified as negative. Has the sensitivity and specificity of the resource been reported? Yes No Unknown Not applicable If applicable, please state what has been reported: In a study with community-dwelling women, the MMSE demonstrated a sensitivity of 83% and a specificity of 87%7. Another validation study, with a non-random sample of 222 elderly people with dementia (diagnosis based on DSM-III criteria) demonstrated a sensitivity of 90% and a specificity of 88% for the MMSE8. Although the generally accepted cut-off points are 25-30 for normal cognition; 21-24 for mild cognitive impairment; 14-20 for moderate cognitive impairment; and less than 13 indicates severe cognitive impairment, various cut-off points have been suggested, to account for differences in educational level9. A recent study has shown that lower cut-off points are required for oldest-old 10 age groups and those with lower educational levels in order to preserve specificity . Face Validity Does the resource appear to meet the intended purpose? Yes No Unknown Not applicable The MMSE demonstrates good content validity ­ measuring a broad range of cognitive status components; it does not include items on abstraction, judgement and appearance3. Concurrent validity was established in the original validation study by determining the correlation the MMSE and the Wechsler Adult Intelligence Scale (WAIS). Correlations with Verbal and

Performance scales of the WAIS were moderate to high1. Reliability Reliability is the extent to which the tool's measurements remain consistent over repeated tests of the same subject under identical conditions. Inter-rater reliability measures whether independent assessors will give similar scores under similar conditions. Has the reliability of the resource been reported? Yes No Unknown Not applicable If applicable, please state what has been reported: Internal consistency was judged to be high in the original Folstein study1. More recent research determined that internal consistency is affected by varying cut-off points (the mix of items measured may also vary) but that it is sufficiently high to be clinically useful11. Both inter-rater and test-retest reliability have been shown to be moderate to high3,12 Strengths What are the strengths of the resource? Is the resource easy to understand and use? Are instructions provided on how to use the resource? Is the resource visually well presented (images, colour, font type/ size)? Does the resource use older friendly terminology (where relevant), avoiding jargon? Please state any other known strengths, using dot points: An Australian study2 suggested that the MMSE was an appropriate dementia `screening instrument' in particular clinical settings, including (but not limited to): Acute geriatric medical admissions Patients over 75 years of age admitted to acute hospitals Using the MMSE for serial measurements of cognition has been shown to assist in monitoring 13 the development and resolution of delirium in older hospitalised people . What are the limitations of the tool/resource? Is the tool/resource difficult to understand and use? Are instructions provided on how to use the tool/resource? Is the tool/resource poorly presented (images, colour, font type/ size)? Does the tool/resource use difficult to understand jargon? Please state any other known limitations, using dot points: Despite its widespread clinical use the MMSE has been criticised for: Insensitivity to mild cognitive impairment Lack of diagnostic specificity Failing to take level of education, literacy, low English proficiency, and visual problems 14-17 into account Cost of using the MMSE, since it was copyrighted, may be prohibitive. The MMSE has both a `ceiling' and `floor' effect ­ a score of zero does not imply the absence of cognition; similarly, a score of 30 does not necessarily indicate normal cognition9. Supporting references and associated reading. 1. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 1975;12(3):189-98. Flicker L, LoGiudice D, Carlin JB, Ames D. The predictive value of dementia screening instruments in clinical populations. International Journal of Geriatric Psychiatry, 1997;12(2):203-9. McDowell I. Measuring Health: A Guide to Rating Scales and Questionnaires. 3rd ed. New York: Oxford University Press, Inc., 2006. Parker C, Philp I, Sarai M, Rauf A. Cognitive screening for people from minority ethnic backgrounds. Nursing Older People, 2007;18(12):31-6. Chiu HFK, Lam LCW. Relevance of outcome measures in different cultural groups - does one size fit all? International Psychogeriatrics, 2007;19(3):457-66. Lydall-Smith S, Moorhouse B. Culturally Approriate Dementia Assessment. Centre for Applied Gerontology, Bundoora Extended Care Centre, Victora. 1995. Brayne C, Calloway P. An epidemiological study of dementia in a rural population of elderly women. British Journal of Psychiatry, 1989;155:214-9. Blessed G, Black SE, Butler T, Kay DW. The diagnosis of dementia in the elderly. A comparison of CAMCOG (the cognitive section of CAMDEX), the AGECAT program, DSM-III, the Mini-Mental State Examination and some short rating scales. British Journal of Psychiatry, 1991;159:193-8. Woodford HJ, George J. Cognitive assessment in the elderly: a review of clinical methods. QJM, 2007;100(8):469-484.


References and further reading


3. 4. 5. 6. 7. 8.



Kahle-Wrobleski K, Corrada MM, Li B, Kawas CH. Sensitivity and Specificity of the MiniMental State Examination for Identifying Dementia in the Oldest-Old: The 90+ Study. Journal of the American Geriatrics Society, 2007;55(2):284-289. Lopez MN, Charter RA, Mostafavi B, Nibut LP, Smith WE. Psychometric properties of the Folstein Mini-Mental State Examination. Assessment, 2005;12(2):137-44. Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. Journal of the American Geriatrics Society, 1992;40(9):922-35. O'Keeffe ST, Mulkerrin EC, Nayeem K, Varughese M, Pillay I. Use of Serial Mini-Mental State Examinations to Diagnose and Monitor Delirium in Elderly Hospital Patients. Journal of the American Geriatrics Society, 2005;53(5):867-870. Clark CM, Sheppard L, Fillenbaum GG, et al. Variability in annual Mini-Mental State Examination score in patients with probable Alzheimer disease: a clinical perspective of data from the Consortium to Establish a Registry for Alzheimer's Disease. Archives of Neurology., 1999;56(7):857-62. Espino DV, Lichtenstein MJ, Palmer RF, Hazuda HP. Ethnic differences in mini-mental state examination (MMSE) scores: where you live makes a difference. Journal of the American Geriatrics Society., 2001;49(5):538-48. MacKenzie DM, Copp P, Shaw RJ, Goodwin GM. Brief cognitive screening of the elderly: a comparison of the Mini-Mental State Examination (MMSE), Abbreviated Mental Test (AMT) and Mental Status Questionnaire (MSQ). Psychological Medicine., 1996;26(2):42730. Lorentz WJ, Scanlan JM, Borson S. Brief screening tests for dementia. Canadian Journal of Psychiatry - Revue Canadienne de Psychiatrie, 2002;47(8):723-33.

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