Friday, August 13, 2010

Mini Mental State Examination (MMSE)

Many have inquired about my referral to the Mini Mental Exam, which is formally the Mini Mental State Exam or Folstein Test. This was the test given to WB by his internist to screen him for a more thorough battery of testing less than 3 years ago. He may have scored higher, but my recollection of his first scores were about 18. I will verify this when we see Dr. Lee again this fall. 

Just Wednesday, Roberta scored him at 13 with great difficulty signing his name. 

That WB was trying to function, run a business and keep it together (for years) while trying to hide this from the rest of us seems incredible. Says a lot about the man, doesn't it?

I realize now that with age comes awareness. WB was born in 1946, married and began a family right out of high school. Worked long hours as a brick mason, framer and home builder ~ keeping this pace for 43 years. This group of boomers rarely gave into illness and self-affirmation was probably slim. I doubt many of WB's close friends or family would have been comfortable admitting to cognitive difficulties or depression, much less known that post traumatic stress disorder could be linked to a boating accident or that medications were available to treat these things. In his station in life, I doubt WB would have even admitted there were problems if properly diagnosed.

Simply cannot imagine him sitting around the fire at the hunting camp or on the back of a bass boat having this conversation with friends, "hey guys, I'm depressed and am taking medicine for it."


In WB's world, that would have reduced him to less than was expected of the big, bad, rough and tough boys of Shelby County.

Matter of fact, I heard one person refer to WB's cognitive issues with unkind words. Shame on him. The best I can do is hope and pray that this person has a long and productive life and can enjoy his family, friends and retirement until long after WB can no longer remember what he said.

You can Google it to read more on its origination, usefulness, etc.

Below is a sample ~

Instructions: Ask the questions in the order listed. Score one point for each correct
response within each question or activity.

(Maximum Score On Left)

5  “What is the year?  Season?  Date?  Day of the week?  Month?”
5  “Where are we now: State?  County?  Town/city?  Hospital?  Floor?”
3   The examiner names three unrelated objects clearly and slowly, then
asks the patient to name all three of them. The patient’s response is
used for scoring. The examiner repeats them until patient learns all of
them, if possible. Number of trials: ___________
5  “I would like you to count backward from 100 by sevens.” (93, 86, 79,
72, 65, …) Stop after five answers. Alternative: “Spell WORLD backwards.” (D-L-R-O-W)
3  “Earlier I told you the names of three things. Can you tell me what those
2  Show the patient two simple objects, such as a wristwatch and a pencil,
and ask the patient to name them.
1  “Repeat the phrase: ‘No ifs, ands, or buts.’”
3  “Take the paper in your right hand, fold it in half, and put it on the floor.”
(The examiner gives the patient a piece of blank paper.)
1  “Please read this and do what it says.” (Written instruction is “Close
your eyes.”)
1  “Make up and write a sentence about anything.” (This sentence must
contain a noun and a verb.)
1  “Please copy this picture.” (The examiner gives the patient a blank
piece of paper and asks him/her to draw the symbol below. All 10
angles must be present and two must intersect.)
Instructions for administration and scoring of the MMSE

Orientation (10 points): 
• Ask for the date. Then specifically ask for parts omitted (e.g., "Can you also tell me what season it
is?"). One point for each correct answer.
• Ask in turn, "Can you tell me the name of this hospital (town, county, etc.)?" One point for each
correct answer.

Registration (3 points):
• Say the names of three unrelated objects clearly and slowly, allowing approximately one second for
each. After you have said all three, ask the patient to repeat them. The number of objects the
patient names correctly upon the first repetition determines the score (0-3). If the patient does not
repeat all three objects the first time, continue saying the names until the patient is able to repeat all
three items, up to six trials. Record the number of trials it takes for the patient to learn the words. If
the patient does not eventually learn all three, recall cannot be meaningfully tested.
• After completing this task, tell the patient, "Try to remember the words, as I will ask for them in a
little while."

Attention and Calculation (5 points):
• Ask the patient to begin with 100 and count backward by sevens. Stop after five subtractions (93,
86, 79, 72, 65). Score the total number of correct answers.
• If the patient cannot or will not perform the subtraction task, ask the patient to spell the word "world"
backwards. The score is the number of letters in correct order (e.g., dlrow=5, dlorw=3).

Recall (3 points):
• Ask the patient if he or she can recall the three words you previously asked him or her to
remember. Score the total number of correct answers (0-3).

Language and Praxis (9 points):
• Naming: Show the patient a wrist watch and ask the patient what it is. Repeat with a pencil. Score
one point for each correct naming (0-2).
• Repetition: Ask the patient to repeat the sentence after you ("No ifs, ands, or buts."). Allow only one
trial. Score 0 or 1.
• 3-Stage Command: Give the patient a piece of blank paper and say, "Take this paper in your right
hand, fold it in half, and put it on the floor." Score one point for each part of the command correctly
• Reading: On a blank piece of paper print the sentence, "Close your eyes," in letters large enough
for the patient to see clearly. Ask the patient to read the sentence and do what it says. Score one
point only if the patient actually closes his or her eyes. This is not a test of memory, so you may
prompt the patient to "do what it says" after the patient reads the sentence.
• Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you. Do
not dictate a sentence; it should be written spontaneously. The sentence must contain a subject
and a verb and make sense. Correct grammar and punctuation are not necessary.
• Copying: Show the patient the picture of two intersecting pentagons and ask the patient to copy the
figure exactly as it is. All ten angles must be present and two must intersect to score one point.
Ignore tremor and rotation.

Interpretation of the MMSE

Method - Single Cut-Off <24 Abnormal
Method - Range              <21 Increased odds of dementia
                                        >25 Decreased odds of dementia

Method - Education           21 Abnormal for 8th grade education
                                        <23 Abnormal for high school education
                                        <24 Abnormal for college education

Severity                             24-30 No cognitive impairment
                                          18-23 Mild cognitive impairment
                                            0-17 Severe cognitive impairment

• Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the mini-mental state
examination by age and educational level. JAMA. 1993;269(18):2386-2391.
• Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
• Rovner BW, Folstein MF. Mini-mental state exam in clinical practice. Hosp Pract. 1987;22(1A):99, 103, 106, 110.
• Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992;40(9):922-935.
Source: Provided by NHCQF, 0106-410

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