Mini–mental state examination

The mini–mental state examination (MMSE) or Folstein test is a brief 30-point questionnaire test that is used to screen for cognitive impairment. It is commonly used in medicine to screen for dementia. It is also used to estimate the severity of cognitive impairment at a specific time and to follow the course of cognitive changes in an individual over time, thus making it an effective way to document an individual's response to treatment.

In about 10 minutes it samples functions including arithmetic, memory and orientation. It was introduced by Folstein et al. in 1975.^[1] This test is not a mental status examination. The standard MMSE form which is currently published by Psychological Assessment Resources is based on its original 1975 conceptualization, with minor subsequent modifications by the authors.

Other tests are also used, such as the Hodkinson^[2] abbreviated mental test score (1972, geriatrics) or the General Practitioner Assessment Of Cognition as well as longer formal tests for deeper analysis of specific deficits.

Test features

Interlocking pentagons used for the last question

The MMSE test includes simple questions and problems in a number of areas: the time and place of the test, repeating lists of words, arithmetic such as the serial sevens, language use and comprehension, and basic motor skills. For example, one question asks to copy a drawing of two pentagons (shown on the right).^[1]

Although consistent application of identical questions increases the reliability of comparisons made using the scale, the test is sometimes customized (for example, for use on patients that are intubated, blind, or partially immobilized. Also, some have questioned the use of the test on the deaf.^[3] However, the number of points assigned per category is usually consistent:

Interpretation

Any score greater than or equal to 25 points (out of 30) is effectively normal (intact). Below this, scores can indicate severe (≤9 points), moderate (10-20 points) or mild (21-24 points) cognitive impairment.^[9] The raw score may also need to be corrected for educational attainment and age.^[10] Low to very low scores correlate closely with the presence of dementia, although other mental disorders can also lead to abnormal findings on MMSE testing. The presence of purely physical problems can also interfere with interpretation if not properly noted; for example, a patient may be physically unable to hear or read instructions properly, or may have a motor deficit that affects writing and drawing skills.

Copyright issues

The MMSE was first published in 1975 as an appendix to an article written by Marshal F. Folstein, Susan Folstein, and Paul R. McHugh.^[1] It was published in Volume 12 of the Journal of Psychiatric Research, a journal published by Pergamon Press. While the MMSE was attached as an appendix to the article, the copyright ownership of the MMSE remained with the three authors. Pergamon Press was subsequently taken over by Elsevier, who also took over copyright of the Journal of Psychiatric Research.^[11]

The authors later transferred all their intellectual property rights, including the copyright of the MMSE, to MiniMental registering the transfer with the U.S. Copyright Office on June 8, 2000.^[12] In March 2001, MiniMental entered into an exclusive agreement with Psychological Assessment Resources granting PAR the exclusive rights to publish, license, and manage all intellectual property rights to the MMSE in all media and languages in the world.^[13] Despite the many free versions of the test that are available on the internet, the official version is copyrighted and must be ordered through PAR.^[14][15] The enforcement of the copyright on the MMSE has been compared to "stealth", or "submarine" patents, where a patent applicant would wait until an invention gains widespread popularity until allowing the patent to issue and only then commencing enforcement (such patent applications are no longer possible with changes made to the patent term).^[14] The enforcement of the copyright has led to researchers looking for alternative strategies in assessing cognition.^[16]

PAR have also asserted their copyright against an alternative diagnostic test, called "sweet 16", that had been designed to avoid the copyright issues of the MMSE forcing it to be removed from the internet. The Sweet 16 was a 16-item assessment published in March 2011, that also included orientation and three-object recall, as has MMSE, and was developed and validated by Tamara Fong.^[17]

Editions

In February 2010, PAR released a second edition of the MMSE; 10 foreign language translations (French, German, Dutch, Spanish for the US, Spanish for Latin America, European Spanish, Hindi, Russian, Italian, and Simplified Chinese) were also created.^[18]

See also

• Abbreviated mental test score A shorter, 10 question screen for impaired cognition.
• General Practitioner Assessment Of Cognition A brief screening tool designed for General Practitioners and Primary Care Physicians
• Mental status examination
• Montreal Cognitive Assessment
• Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
• NIH stroke scale

References