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 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.
It takes about 10 minutes and examines functions including arithmetic, memory and orientation. It was introduced by Folstein et al. in 1975, but is very similar to, or even directly incorporates, tests which were in use previous to its publication. 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 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.
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, derived from the older Bender-Gestalt Test, asks to copy a drawing of two pentagons (shown on the right).
A version of the MMSE questionnaire can be found on the British Columbia Ministry of Health website.
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 blind or partially immobilized. Also, some have questioned the use of the test on the deaf. However, the number of points assigned per category is usually consistent:
|Orientation to time||5||From broadest to most narrow. Orientation to time has been correlated with future decline.|
|Orientation to place||5||From broadest to most narrow. This is sometimes narrowed down to streets, and sometimes to floor.|
|Registration||3||Repeating named prompts|
|Attention and calculation||5||Serial sevens, or spelling "world" backwards It has been suggested that serial sevens may be more appropriate in a population where English is not the first language.|
|Language||2||Naming a pencil and a watch|
|Repetition||1||Speaking back a phrase|
|Complex commands||6||Varies. Can involve drawing figure shown.|
Any score greater than or equal to 27 points (out of 30) indicates a normal cognition. Below this, scores can indicate severe (≤9 points), moderate (10–18 points) or mild (19–24 points) cognitive impairment. The raw score may also need to be corrected for educational attainment and age. That is, a maximal score of 30 points can never rule out dementia. 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.
The MMSE has been able to differentiate different types of dementias. Studies have found that patients with Alzheimer's disease score significantly lower on orientation to time and place, and recall compared to patients with dementia with Lewy bodies, vascular dementia and Parkinson's disease dementia.
The MMSE was first published in 1975 as an appendix to an article written by Marshal F. Folstein, Susan Folstein, and Paul R. McHugh. It was published in Volume 12 of the Journal of Psychiatric Research, published by Pergamon Press. While the MMSE was attached as an appendix to the article, the copyright ownership of the MMSE (to the extent that it contains copyrightable content) remained with the three authors. Pergamon Press was subsequently taken over by Elsevier, who also took over copyright of the Journal of Psychiatric Research.
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. 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. Despite the many free versions of the test that are available on the internet, PAR claims that the official version is copyrighted and must be ordered only through it. At least one legal expert has claimed that PAR's copyright claims are weak. The enforcement of copyright on the MMSE has been compared to the phenomenon of "stealth" or "submarine" patents, in which a patent applicant waited until an invention gained widespread popularity before allowing the patent to issue, and only then commenced enforcement. Such applications are no longer possible, given changes in patent law. The enforcement of the copyright has led to researchers looking for alternative strategies in assessing cognition.
PAR have also asserted their copyright against an alternative diagnostic test, "Sweet 16," which was designed to avoid the copyright issues surrounding the MMSE. Sweet 16 was a 16-item assessment developed and validated by Tamara Fong and published in March 2011; like the MMSE it included orientation and three-object recall. Assertion of copyright forced the removal of this test from the Internet.
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.
- Addenbrooke's cognitive examination
- Mental status examination
- Montreal Cognitive Assessment
- Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
- NIH stroke scale
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