MiniMental State Examination MMSE Folstein M Folstein S

Mini-Mental State Examination MMSE Folstein, M. , Folstein, S. , Mc. Hugh, P. Mini-Mental State: A Practical Method for Grading the Cognitive State of Patients for the Clinician Journal of Psychiatric Research 1975, 12: 189 -98.

Mini-Mental State Examination (MMSE) § Developed to aid mental state examination to quantify the cognitive state § Commonly used to screen for cognitive impairment and follow patient’s progress over time § Cognition is an abstract construct that refers to a person’s thinking ability § It is a combination of many specific abilities e. g. , memory, attention, language, planning, reaction time, etc. § MMSE is not a diagnostic tool 2

Mini-Mental State Examination (MMSE) § Simple to administer but requires training for standardization of administration and scoring § 1 training session significantly improves inter-rater reliability § 30 -item scale assesses 5 cognitive domains – – – Orientation Memory: Immediate and delayed recall Concentration and attention Language Visuospatial construction 3

Mini-Mental State Examination (MMSE) § Administered at Visit 1 (Screening), Visit 3 (Baseline 2), Visit 9 and premature discontinuation Visit § Administered by a health care professional (e. g. psychologist, study nurse, study coordinator) who has experience in the administration of this scale. § Performed during ON state § Subjects will be excluded if score ≤ 26 points 4

MMSE Instructions § Conduct the examination in private and in subject’s primary language § Make sure that eyeglasses, if needed, are being worn § Speak very clearly and more slowly than you might in ordinary conversation § Keep your vocabulary simple, use short sentences and questions that contain a single idea 5

MMSE Instructions (cont. ) § Note that questions might be difficult for some individuals, thus DO NOT describe questions as ‘easy’, ‘silly’, etc. § Do not correct incorrect answers or convey any concern (e. g. by facial expression) § Try to be supportive but do not provide any hints or clues § If subjects asks whether the answer was correct, say something like “Let's talk about how you did at the end” 6

MMSE Instructions (cont. ) § For each item record the subject’s response – Score 0 if the response was incorrect – Score 1 if the response was correct § If subject refuses to answer a question, score this item as 0, but note on the form why the subject has refused § If the subject has a disability such as blindness that prevents him/her from completing certain items, score these items as 0, but note the disability on the form 7

MMSE Instructions (cont. ) § Follow exactly the order of the interview, i. e. do not skip items § Read bold sentences to patient exactly as written § Item substitutions appear in parentheses § Start the interview with a question: “Do you have any trouble with your memory? ” § Regardless of the answer say “May I ask you some questions about your memory? ” – These questions are not scored 8

MMSE Items 1 - 5: Orientation to Time § Assesses orientation to time § One point for each correct answer – What is the year? – What is the season? – What is the month of the year? – What is the date? – What is the day of the week? § Must be exact, with these exceptions: – – If testing occurs near to transition between seasons, may accept either season as correct (within 1 week from season transition) If testing late at night, accept either day as correct 9

MMSE Items 6 -10: Orientation to Place § Assesses orientation to place § One point for each correct answer – – – What is the country ? What is the city? What is the part of the city? What is the building ? What is the floor of the building? § If the clinic is on a city or district boundary, accept either city/district name as correct § Name of Building/Clinic/Hospital are equivalent for scoring 10

MMSE Items 11 -13: Registration § Assesses subject’s ability to learn and retain three unrelated words as well as subject’s alertness and attentiveness § You request the subject to repeat 3 words after you § “I am going to say three words. You say them back after I stop. Ready? Here they are. . . APPLE, … PENNY, … TABLE… Now repeat those words back to me. ” § Wait one second between words § Repeat them until the patient learned all three but score ONLY the first trial – one point for each correct answer – order of response is not important § End session with: “Now keep those words in mind. I’m going to ask you to say them again in a few minutes. ” 11

MMSE Items 14 -18: Attention and Calculation: Serial 7 s § Assesses subjects attention and mental calculation abilities § “Now I’d like you to subtract 7 from 100. Then keep subtracting 7 from each answer until I tell you to stop. What is 100 take away 7? ” § Remind the subject to keep going if needed, until s/he has given you a total of five answers § An answer is considered correct if it is exactly 7 less than the previous answer, regardless of whether that previous answer was correct, e. g. § 93 -86 -79 -72 -65 … Score = 5 § 92 -85 -78 -71 -64 … Score = 4 § 92 -86 -78 -72 -65 … Score = 1 12

MMSE Items 19 - 21: Recall § Assesses subject’s ability to recall the three words s/he learned during registration task § Ask: “What were three words I asked you to remember? ” § Be encouraging, but no hints § The order of recall does not matter § One point for each correct answer 13

MMSE Item 22 - 23: Language § Assesses individuals ability to recognize and name two common objects § Show the object and ask, “What is this? ” § Pencil § Watch § One point for each correct answer – Functional answers do not count, for example, “writing thing” for pencil 14

MMSE Item 24: Repetition § Assesses the subject’s ability to precisely repeat a series of unrelated words that are not frequently said together § “Now I am going to ask you to repeat what I say. Ready? ‘NO IFS, ANDS OR BUTS. ’ Now you say that. ” § Exact repetition of this phrase is necessary § Score should be based only on the subject’s first attempt to repeat the phrase § Any discrepancy is a score of zero 15

MMSE Item 25 - 27: Comprehension § Assesses the subject’s ability to attend to, comprehend and carry out a complex three-stage command § “Listen carefully because I am going to ask you to do something. Take this paper in your right hand …, fold it in half …, and put it on the floor § One point for each correct response – Total 3 § Taking the paper in the left hand is scored as zero (incorrect) for that part of the item § The paper can be folded in either direction 16

MMSE Item 28: Reading § Assesses subject’s ability to read and understand a simple sentence § “Please read this and do what it says. ” § Use a standard printed statement: “CLOSE YOUR EYES” § Subject can read the phrase silently or out loud § Score one point if the subject closes his/her eyes otherwise score 0 § If the subject only reads the command aloud, do not prompt to "do it“ and score a 0 17

MMSE Item 29: Writing § § Assesses subject’s ability to write a sentence Give the subject a blank sheet of paper and a pen Ask: “Please write a sentence. ” If the subject does not begin writing, you may prompt by saying, “write about the weather” § The sentence must have a subject and verb, and must make sense § Do not deduct for minor grammar or spelling errors § Score one point for a correct sentence 18

MMSE Item 30: Drawing § Assesses a subject’s visuospatial ability § Show the subject the figure (intersecting pentagons) and ask him/her to copy it: “Please copy this design. ” § The two figures must each have five sides and intersect to form a four-sided figure § Do not allow erasure § Do not subtract for tremor or ill-shaped pentagons § Score one point for correct drawing 19

MMSE Item 30: Drawing 20