Folstein Mini-Mental State Exam

Using the Folstein Mini Mental

While the Mini-Mental State Examination (MMSE) was originally developed to screen for dementia and delirium, many neurologists use this measure as a screening instrument for ‘cognitive impairment’ in hospitalized stroke patients. However, the validity of the MMSE as such has never been evaluated in acute stroke. We administered the MMSE in addition to a neuropsychological examination covering six cognitive domains to 34 stroke patients (mean interval between stroke and examination, 6.5 ± 2.9 days) and 34 healthy controls. The area under the receiver operating characteristic curve (AUC) was calculated in addition to the sensitivity and specificity for various cut-off points on the MMSE.

Seventy percent of the patients were impaired in at least one cognitive domain. The accuracy of the MMSE in detecting cognitive impairment was no better than chance (AUC = 0.67; = 0.13). No optimum MMSE cut-off value could be identified. The MMSE is particularly insensitive to impairments in abstract reasoning, executive functioning, and visual perception/construction.


  • Mini-Mental State Examination (MMSE);
  • Stroke;
  • Construct validity;
  • Neuropsychological assessment

1. Introduction

Cognitive disorders in the acute stage of stroke are common and are important independent predictors of adverse outcome in the long term. Therefore, a whole range of brief cognitive measures has been used to screen for cognitive impairment in patients with acute stroke. The Mini-Mental State Examination (MMSE) is currently the mainstay of screening instruments. This instrument was originally developed to screen for dementia and delirium in a psychiatric setting, and has been shown to have a good sensitivity and specificity as such. Subsequently, the use of the MMSE has been extended and many studies now use it as a screening instrument for ‘global cognitive impairment’ (e.g. ; ). However, the validity of the MMSE as a cognitive screening instrument has been questioned in both neurological and psychiatric patients (; ). Moreover, there is no consensus in the cut-off values that are applied to discriminate between cognitively intact and impaired patients.

Blake and co-workers recently investigated the sensitivity and specificity of the MMSE as a screening tool for post-stroke cognitive impairment. They compared performance on the MMSE in the early stage of stroke with performance on a neuropsychological examination that was administered within 3 months of the screening assessment. The sensitivity of the MMSE when applying a cut-off value of 24 was found to be moderate (62%). However, given that there was a very large inter-individual variation in the test interval and that the degree of cognitive recovery is greatest in the first months post-stroke, their methodology may have resulted in an overestimation of the sensitivity of the MMSE in initially impaired patients who had recovered by the time of the neuropsychological examination. In addition, as the authors pointed out, not all patients completed the neuropsychological examination.

The aim of the present study was to evaluate the construct validity of the MMSE as a screening instrument for cognitive impairment in patients with acute stroke. The MMSE and a full neuropsychological examination covering 6 cognitive domains was administered within 2 weeks post-stroke, and the diagnostic sensitivity and specificity of the MMSE was examined. Moreover, we evaluated which cognitive deficits were most often disregarded by the MMSE.

2.1.1. Patients

The population consisted of 38 consecutive acute stroke patients admitted to stroke units of two hospitals in the Netherlands (Tweesteden Hospital and St. Elisabeth Hospital Tilburg). Eligible patients were patients with either ischemic stroke or primary intracerebral hemorrhage. The diagnosis of stroke was based on the presence of both an acute focal deficit and an associated lesion on CT or MRI. Exclusion criteria for this study were a high degree of handicap (modified Rankin Scale > 4) (N = 1), non-native speaker (N = 1), and severe disturbances in communication and consciousness (N = 1). One patient was blind (pre-existent impairment) and therefore was not included in this study. This resulted in a study population of 34 stroke patients.

2.1.2. Controls

A control group was assembled as a reference sample for the neuropsychological examination, consisting of 34 subjects living in the community. The controls were volunteers who came to our attention through advertising in newspapers or by word of mouth. Control subjects were carefully matched to the stroke patients with respect to age, education, gender and handedness.

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