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Millions of Americans became familiar with the MMSE screening tool for dementia when it was given to President Trump (who passed the test). Here is an explanation of what the mini-mental state examination is and how it is used.

The Mini-Mental State Exam (MMSE) is a popular screening tool for dementia. It provides a quick "snapshot" of cognitive health and helps doctors estimate the severity of dementia, if the disease is present. Repeating the test gives doctors and caregivers a quick estimate of the progression of preexisting dementia. The MMSE is only one part of the diagnostic process for dementia, but it provides alerts that show need for further diagnosis.

What is it like to take the MMSE?

You don't have to study to take the MMSE. The test takes only five to 10 minutes. Some questions are weighted more heavily than others. An example of the kinds of questions on the MMSE includes:

  • 5 points for demonstration of orientation to time. The questions might be "What year is it? What's the season? Day? Date? Month?"
  • 5 points for demonstration of orientation to place, recognizing a wider place and a narrower place. The patient might be asked "What country are we in? What state? What hospital? Which floor? What room?"
  • 5 points for attention and calculation. The patient might be asked to spell the word "world" backwards. Or the patient could be asked to count down from 100 by serial sevens, 93-86-79-72-65-58-51-44-37-30-23-16-9-2.
  • 3 points for showing an ability to repeat named prompts. The testing technician tells the patient to listen to the names of thee unrelated objects, usually an apple, penny, and a table. The patient repeats them, after practice if necessary, but only the first attempt is scored.
  • 2 points for language. Often patients are asked to name a pencil and a watch.
  • 1 point for repetition. The testing technician might say "Repeat the phrase 'No ifs, ands, or buts.'"
  • 1 point for successfully responding to “Please copy this picture.”
  • 1 point for making up a sentence about anything, as long as it contains both a noun and a verb.

There are multiple questions that allow for a maximum score of 30 points.

What do scores on the MMSE mean?

Low scores on the MMSE test suggest dementia. A score below 9 indicates severe dementia. However, the doctor considers factors that may cause lower scores. Maybe the patient's first language isn't English. If the patient is not fluent in English, and does not have at least an eighth-grade education, the test is not a valid screening tool for dementia. There could be problems with hearing the test or seeing the visual cue to copy a picture. Or maybe the patient has a motor deficit that makes it impossible to draw a picture.

A score above 24 is a sign of normal cognitive function, but even a perfect score does not completely rule out dementia. It is possible to become "test wise" and answer the test from memory. There are people who score a 26 or a 27 or a 28 who have mild neurocognitive impairment. Most doctors use more than one test for screening for dementia.

Confirming results of the MMSE

It is important to remember that the MMSE focuses on verbal abilities. It is not, for example, a good tool for deciding whether it is safe for someone who has mild cognitive impairment to continue driving a car. The MMSE is culture-bound. There are now versions of the test in at least 10 languages, but the same problems with language fluency exist in foreign languages that exist in English. If you aren't fluent in the language used in the test, it is not a good measure of your mental status.

Primary care providers increasingly use the MME and another screening tool called the Visual Association Test (VAT). The VAT uses pictures as cues to test associative memory. 

  • First the patient is shown pictures of familiar objects, for example, an ape, a balloon, and a baby carriage.
  • Then the patient is shown pictures of interactions with those objects. For example, the ape may be holding an umbrella. A key may be dangling from the balloon. The baby carriage may hold a baby.
  • Finally, the patient is is shown the first set of cue cards and is asked about the associations. "What is the ape holding? What is hanging from the balloon? What is inside the baby carriage?"

The VAT is very useful for determining who doesn't have dementia. Clinical testing in Germany found that it had a negative predictive value of 99.7 percent. So if you get a 30 on your MMSE and you get a low score on the VAT, it may be necessary to get further testing. But if you get a 30 on your MMSE and you score over 8 on your VAT, there is better than a 99 percent chance that you do not have dementia.

What are some other signs that the MMSE or VAT might be missing some cases of dementia? One cue that doctors look for is perseverating, persisting in a behavior. If the doctor says, "I'll be back in a few minutes to give you a test but in the meantime please practice holding your hand steady," the doctor might come back in 10 minutes and find a patient who has dementia still holding their hand steady. That's not a sure sign of dementia, either, but it is a combination of test scores and clinical cues that doctors use to screen for dementia.

  • Deep A, Lieberman A, Aboud T, et al. Bilateral downward finger displacement in Parkinson disease may be a sign of worsening dementia and a bedside test to distinguish it from Alzheimer's disease. Program and abstracts of the 2018 American Academy of Neurology Annual Meeting
  • April 21-28, 2018. Los Angeles, California. Abstract P1.046.
  • Fuchs A et al. Cued recall and other cognitive tasks to facilitate dementia recognition in primary care. J Am Geriatr Soc 2012 Jan
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  • Godin J, Keefe J, Andrew MK. Handling missing Mini-Mental State Examination (MMSE) values: Results from a cross-sectional long-term-care study. J Epidemiol. 2017 Apr.27(4):163-171. doi: 10.1016/j.je.2016.05.001. Epub 2016 Dec 27. PMID: 28142036.
  • Photo courtesy of SteadyHealth

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