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.
In about 10 minutes it samples 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.
Test features 
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).
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. 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 25 points (out of 30) indicates a normal cognition. Below this, scores can indicate severe (≤9 points), moderate (10-20 points) or mild (21-24 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.
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. 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.
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
- Folstein MF, Folstein SE, McHugh PR (1975). ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". Journal of Psychiatric Research 12 (3): 189–98. doi:10.1016/0022-3956(75)90026-6. PMID 1202204.
- Eileen Withers and John Hinton (1971). "The Usefulness of the Clinical Tests of the Sensorium". The British Journal of Psychiatry 119: 9–18. doi:10.1192/bjp.119.548.9.
- Jurgen Ruesch (1944). "Intellectual Impairment in Head Injuries". The American Journal of Psychiatry 100: 480–496.
- David Wechsler (1945). "A Standardized Memory Scale for Clinical Use". The Journal of Psychology: Interdisciplinary and Applied 19 (1): 87–95. doi:10.1080/00223980.1945.9917223.
- Hodkinson HM (1972). "Evaluation of a mental test score for assessment of mental impairment in the elderly". Age and ageing 1 (4): 233–8. doi:10.1093/ageing/1.4.233. PMID 4669880.
- Dean PM, Feldman DM, Morere D, Morton D (December 2009). "Clinical evaluation of the mini-mental state exam with culturally deaf senior citizens". Arch Clin Neuropsychol 24 (8): 753–60. doi:10.1093/arclin/acp077. PMID 19861331.
- Guerrero-Berroa E, Luo X, Schmeidler J, et al. (December 2009). "The MMSE orientation for time domain is a strong predictor of subsequent cognitive decline in the elderly". Int J Geriatr Psychiatry 24 (12): 1429–37. doi:10.1002/gps.2282. PMC 2919210. PMID 19382130.
- Morales LS, Flowers C, Gutierrez P, Kleinman M, Teresi JA (November 2006). "Item and scale differential functioning of the Mini-Mental State Exam assessed using the Differential Item and Test Functioning (DFIT) Framework". Med Care 44 (11 Suppl 3): S143–51. doi:10.1097/01.mlr.0000245141.70946.29. PMC 1661831. PMID 17060821.
- "MMSE". Retrieved 2009-12-10.
- Ganguli M, Ratcliff G, Huff FJ, et al. (1990). "Serial sevens versus world backwards: a comparison of the two measures of attention from the MMSE". J Geriatr Psychiatry Neurol 3 (4): 203–7. doi:10.1177/089198879000300405. PMID 2073308.
- Espino DV, Lichtenstein MJ, Palmer RF, Hazuda HP (May 2004). "Evaluation of the mini-mental state examination's internal consistency in a community-based sample of Mexican-American and European-American elders: results from the San Antonio Longitudinal Study of Aging". J Am Geriatr Soc 52 (5): 822–7. doi:10.1111/j.1532-5415.2004.52226.x. PMID 15086669.
- Mungas D (July 1991). "In-office mental status testing: a practical guide". Geriatrics 46 (7): 54–8, 63, 66. PMID 2060803.
- Crum RM, Anthony JC, Bassett SS, Folstein MF (May 1993). "Population-based norms for the Mini-Mental State Examination by age and educational level". JAMA 269 (18): 2386–91. doi:10.1001/jama.1993.03500180078038. PMID 8479064.
- Palmqvist, S; Hansson, O; Minthon, L; Londos, E (2009 Dec). "Practical suggestions on how to differentiate dementia with Lewy bodies from Alzheimer's disease with common cognitive tests.". International journal of geriatric psychiatry 24 (12): 1405–12. PMID 19347836.
- Jefferson, AL; Cosentino, SA; Ball, SK; Bogdanoff, B; Leopold, N; Kaplan, E; Libon, DJ (2002 Summer). "Errors produced on the mini-mental state examination and neuropsychological test performance in Alzheimer's disease, ischemic vascular dementia, and Parkinson's disease.". The Journal of neuropsychiatry and clinical neurosciences 14 (3): 311–20. PMID 12154156.
- Ala, TA; Hughes, LF; Kyrouac, GA; Ghobrial, MW; Elble, RJ (2002 Jun). "The Mini-Mental State exam may help in the differentiation of dementia with Lewy bodies and Alzheimer's disease.". International journal of geriatric psychiatry 17 (6): 503–9. PMID 12112173.
- James Grimmelmann. "How Copyright Is Like Cognitive Impairment".
- "History of Elsevier" (PDF). Elsevier. Retrieved 2010-10-29.
- US, Folstein MF, Folstein SE & PR McHugh, "Mini-mental state : a practical method for grading the cognitive state of patients for the clinician", published 2000-06-08 Patent number TX0005228282
- U.S. Copyright Office record #2
- Powsner S, Powsner D (2005). "Cognition, copyright, and the classroom". The American Journal of Psychiatry 162 (3): 627–8. doi:10.1176/appi.ajp.162.3.627-a. PMID 15741491.
- "Mini-Mental State Examination. Psychological Assessment Resources, Inc.". Retrieved 2006-06-22.
- Holsinger T, Deveau J, Boustani M, Williams JW (June 2007). "Does this patient have dementia?". JAMA 297 (21): 2391–404. doi:10.1001/jama.297.21.2391. PMID 17551132.
- John C. Newman, M.D., Ph.D., and Robin Feldman, J.D. (December 2011). "Copyright and Open Access at the Bedside". NEJM 365: 2447–2449. doi:10.1056/NEJMp1110652.
- PAR. "MMSE-2 home page". Retrieved 2010-10-29.