Mini Mental State Examination (MMSE)

The mini mental state examination (MMSE)¹ is the most commonly used instrument for screening cognitive function. This examination is not suitable for making a diagnosis but can be used to indicate the presence of cognitive impairment, such as in a person with suspected dementia or following a head injury.² The MMSE is far more sensitive in detecting cognitive impairment than the use of informal questioning or overall impression of a patient's orientation.

• The test takes only about 10 minutes, but is limited because it will not detect subtle memory losses, particularly in well educated patients.³
• People from different cultural groups, or low intelligence, or education may score poorly on this examination in the absence of cognitive impairment⁴ and well educated people may score well despite having cognitive impairment.⁵
• The MMSE provides measures of orientation, registration (immediate memory), short-term memory (but not long-term memory) as well as language functioning.
• The examination has been validated in a number of populations. Scores of 25-30 out of 30 are considered normal; 18-24 indicate mild to moderate impairment; scores of 17 or less indicate severe impairment.

Before administering the MMSE it is important to make the patient comfortable and to establish a rapport with the patient. Praising success may help to maintain the rapport and is acceptable, but persisting on items the patient finds difficult should be avoided.

Recording the MMSE

• The score achieved by the patient should be clearly recorded. The score is recorded using a denominator of 30 unless the patient was unable to complete the test due to a physical handicap (e.g. blindness), in which case the value of the questions not able to be completed is subtracted from 30 and the resulting number used as the denominator for the test score.
• If a denominator of less than 30 is used, the nature of the physical handicap should be indicated on the MMSE form.
• The appropriate description of the patient’s level of consciousness should also be indicated: Alert = remains awake easily; Drowsy = finds it difficult to stay awake; Stupor = difficult to rouse; Coma = unable to rouse (if a person is unconscious, the MMSE score is 0/30).

Orientation

• What is the year, season, date, day and month (1 point for each; maximum total 5 points).
• Where are we: town, county, country, which hospital, surgery or house, and which floor (1 point for each; maximum total 5 points).

Registration

• Ask the patient if you may test their memory.
• Say the names of three unrelated objects (e.g., apple, table, penny) clearly and slowly, taking about one second for each.
• After you have said all three, ask the patient to repeat them.
• The first repetition is considered the test of registration and determines the patient’s score out of 3, but keep saying the words until the patient can repeat all three (up to six trials).
• If the patient does not eventually learn all three, it is unlikely that recall can be meaningfully tested but it should still be attempted (see below).

Attention and calculation

• Ask the patient to begin with 100 and count backward by 7. Stop after 5 subtractions (93,86,79,72,65).
• Score the total number of correct answers (maximum total 5 points).
• If the patient cannot or will not perform this task, ask them to spell the word “world” backwards. The score is the number of letters in correct order, e.g. dlrow = 5; dlorw =3.

Recall

• Ask for the 3 objects repeated above (e.g., apple, table, penny). Give 1 point for each correct object (maximum total 3 points).

Language

• Naming: Show the patient a wrist-watch and ask them what it is. Repeat for pencil. Score one for each correct answer (maximum total 2 points).
• Repetition: Ask the patient to repeat the sentence "No ifs, ands or buts" after you. Allow only one trial. Score 1 if the repetition is completely correct and 0 if it is not.
• 3-stage command: Give the person a piece of blank white paper and ask them to follow a 3-stage command: "Take a paper in your right hand, fold it in half and put it on the floor" (1 point for each part that is correctly followed) (maximum total 3 points).
• Reading: Write "CLOSE YOUR EYES" in large letters and show it to the patient. Ask him or her to read the message and do what it says (give 1 point if they actually close their eyes).
• Writing: Give the patient a blank piece of paper and ask them to write a sentence of their choice (do not dictate a sentence); the sentence must contain a subject and verb and must make sense. Spelling, punctuation and grammar are not important (1 point).
• Copying: Show the person a drawing of 2 pentagons which intersect to form a quadrangle. Each side should be about 1.5 cm. Ask them to copy the design exactly as it is. All 10 angles need to be present and the two shapes must intersect to score 1 point. Tremor and rotation are ignored.