Mental Status Exam orientation

Myths It is irreversible It is

The Mini-Mental State Examination (MMSE) was developed as a brief screening tool to provide a quantitative assessment of cognitive impairment and to record cognitive changes over time (Folstein et al. 1975). While the tool’s original application was the detection of dementia within a psychiatric setting, its use has become widespread.

The MMSE consists of 11 simple questions or tasks. Typically, these are grouped into seven cognitive domains including orientation to time, orientation to place, registration of three words, attention and calculation, recall of three words, language, and visual construction. Administration by a trained interviewer takes approximately 10 minutes. The test yields a total score of 30 and provides a picture of a subject’s present cognitive performance based on direct observation of completion of test items/tasks. A score of 23 out of 24 is the generally accepted cut-off point indicating the presence of cognitive impairment (Dick et al. 1984). Levels of impairment have also been classified as none (24–30); mild (18–24) and severe (0–17; Tombaugh & McIntyre 1992).

An expanded version of the MMSE, the modified mini-mental state examination (3MS) was developed by Teng & Chui (1987) increasing the content, number and difficulty of items included in the assessment. The score of the 3MS ranges from 0 to 100 with a standardized cut-off point of 79/80 for the presence of cognitive impairment. This expanded assessment takes approximately 5 minutes more to administer than the original MMSE. The MMSE is available for purchase at

Advantages. The Mini-mental State Examination is brief, inexpensive and simple to administer. Its widespread use and accepted cut-off scores increase its interpretability.

Limitations. It has been suggested that the MMSE may attempt to assess too many functions in one brief test. An individual’s performance on individual items or within a single domain may be more useful than interpretation of a single score (Tombaugh & McIntyre 1992; Wade 1992). However, an acceptable cut-off for the identification of the presence of an impairment may be possible only when the test is used as a measure of “cognitive impairment” (Blake et al. 2002). Blake et al. (2002) reported that when the test is used to screen for problems of visual or verbal memory, orientation or attention acceptable cut-off scores could not be identified.

MMSE scores have been shown to be affected by age, level of education and sociocultural background (Bleecker et al. 1988; Lorentz et al. 2002; Tombaugh & McIntyre 1992). These variables may introduce bias leading to the misclassification of individuals. Though perhaps the prevalent view, such biases have not always been reported. For instance, Agrell & Dehlin (2000) found neither age nor education to influence scores. Lorentz et al. (2002) expressed concern that adjustments made for these biases may limit the general utility of the MMSE.

Perhaps the greatest limitation of the MMSE is its low reported levels of sensitivity, particularly among individuals with mild cognitive impairment (de Koning et al. 1998; Tombaugh & McIntyre 1992), in patients with focal lesions, particularly those in the right hemisphere (Tombaugh & McIntyre 1992), within a general neurological patient population (Dick et al. 1984) and within a stroke population (Blake et al. 2002; Suhr & Grace 1999). It has been suggested that its low level of sensitivity derives from the emphasis placed on language items and a paucity of visual-spatial items (de Koning et al. 2000; de Koning et al. 1998; Grace et al. 1995; Suhr & Grace 1999; Tombaugh & McIntyre 1992). Various solutions have been proposed to the problem of the MMSE’s poor sensitivity including the use of age-specific norms (Bleecker et al. 1988) and the addition of a clock-drawing task to the test (Suhr & Grace 1999). Clock-drawing tests themselves have been assessed as acceptable to patients, easily scored and less affected by education, age and other non-dementia variables than other very brief measures of cognitive impairment (Lorentz et al. 2002) and would have little effect on the simplicity and accessibility of the test. The MMSE has been evaluated for use among a variety of neurological populations.

At present, information regarding the reliability and validity of the MMSE when used among patients with TBI/ABI is extremely limited.

Interpretability: The MMSE is widely used and has generally accepted cut-off scores indicative of the presence of cognitive impairment. Documented age and education effects have led to the development of stratified norms (Ruchinskas & Curyto 2003).

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