Mini-Mental State Examination (MMSE)

Evidence Reviewed as of before: 07-11-2010
Author(s): Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Mini-Mental State Examination (MMSE) was originally developed as a brief screening tool to provide a quantitative evaluation of cognitive impairment and to record cognitive changes over time (Folstein, Folstein, & McHugh, 1975). Since that time it has become recognized that repeated use of the MMSE with the same client reduces its validity, so it is advised that this screening tool not be used repeatedly with the same individual if the time interval between testing is short. Rather than provide a diagnosis, the measure should be used to detect the presence of cognitive impairment (Folstein, Robins, & Helzer, 1983). The MMSE briefly measures orientation to time and place, immediate recall, short-term verbal memory, calculation, language, and construct ability. While the measure was originally used to detect dementia within a psychiatric setting, its use has become widespread. Since 1993, the MMSE has been available with an attached table that enables patient-specific norms to be identified on the basis of age and educational level (Crum, Anthony, Bassett, & Folstein, 1993).

In-Depth Review

Purpose of the measure

The Mini-Mental State Examination (MMSE) was originally developed as a brief screening tool to provide a quantitative evaluation of cognitive impairment and to record cognitive changes over time (Folstein, Folstein, & McHugh, 1975). Since that time it has become recognized that repeated use of the MMSE with the same client reduces its validity, so it is advised that this screening tool not be used repeatedly with the same individual if the time interval between testing is short. Rather than provide a diagnosis, the measure should be used to detect the presence of cognitive impairment (Folstein, Robins, & Helzer, 1983). The MMSE briefly measures orientation to time and place, immediate recall, short-term verbal memory, calculation, language, and construct ability. While the measure was originally used to detect dementia within a psychiatric setting, its use has become widespread. Since 1993, the MMSE has been available with an attached table that enables patient-specific norms to be identified on the basis of age and educational level (Crum, Anthony, Bassett, & Folstein, 1993).

Available versions

The MMSE was published by Folstein et al. in 1975.

Features of the measure

Items:

The MMSE consists of 11 simple questions or tasks that look at various functions including: arithmetic, memory and orientation.

Scoring:

The score is the number of correct items. The measure yields a total score of 30. A score of 23 or less is the generally accepted cutoff point indicating the presence of cognitive impairment (Ruchinskas & Curyto, 2003).

Levels of impairment have also been classified as none (24-30); mild (18-23) and severe (0-17) (Tombaugh & McIntyre 1992).

More recently, Folstein, Folstein, McHugh, and Fanjiang. (2001) recommended the following cutoff scores:

Score Level of impairment
≥ ? 27 None
21-26 Mild
11-20 Moderate
≤ 10 Severe

Crum et al. (1993) reported that cognitive performance as measured by the MMSE varies within the population by age and educational level. There is an inverse relationship between MMSE scores and age, ranging from a median of 29 for those aged 18 to 24 years, to 25 for individuals 80 years of age and older. There is also an inverse relationship between MMSE scores and education. The median MMSE score is 29 for individuals with at least 9 years of schooling, 26 for those with 5 to 8 years of schooling, and 22 for those with 0 to 4 years of schooling.

The following table, created by Crum et al. (1993) can be used to compare your patient’s MMSE score with a reference group based on age and education level.

(Source: Crum et al., 1993)

Age
Education 20-24 25-29 30-34 35-39 40-44
4th grade 22 25 25 23 23
8th grade 27 27 26 26 27
High school 29 29 29 28 28
College 29 29 29 29 29
Age
Education 45-49 50-54 55-59 60-64 65-69
4th grade 23 23 22 23 22
8th grade 26 27 26 26 26
High school 28 28 28 28 28
College 29 29 29 29 29
Age
Education 70-74 75-79 80-84 >84
4th grade 22 21 20 19
8th grade 25 25 25 23
High school 27 27 25 26
College 28 28 27 27

Subscales:

Orientation (total points = 10), Registration (total points = 3), Attention and calculation (total points = 5), Recall (total points = 3), and Language (total points = 9).

Equipment:

The MMSE requires no specialized equipment.

Training:

Little information has been reported on training for the MMSE, however a standardized version of the MMSE has been developed (Molloy & Standish, 1997).

Time:

Administration by a trained interviewer takes approximately 10 minutes.

Alternative form of the MMSE

The modified mini-mental state examination (3MS) (Teng & Chui, 1987).

An expanded version of the MMSE was developed by Teng and Chui (1987) increasing the content, number and difficulty of items included in the assessment. The score of the 3MS ranges from 0 – 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, which takes approximately 10 minutes to complete. Grace et al. (1995) compared the MMSE to the 3MS in geriatric patients with stroke. Test-retest reliability of the 3MS was excellent (r = 0.80). The 3MS also correlated with a battery of neuropsychological assessments and with some cognitive domains missed by the MMSE. The 3MS was a significantly better predictor of functional outcome (as measured by the Functional Independence Measure) than the MMSE. The 3MS was found to have higher sensitivity than the MMSE (69% vs. 44%) and similar specificity (80% vs. 79%). The area under the curve (AUC) was 0.798 for the 3MS.

3MS + Clock-drawing (Suhr & Grace, 1999).

The addition of clock drawing, a simple measure of constructional ability, increased the sensitivity in detecting focal brain damage of the 3MS in patients with right hemisphere stroke (87%). The addition of the Clock Drawing Test requires about two extra minutes in administration time.

Standardized MMSE (SMMSE) (Molloy & Standish, 1997).

Molloy and Standish (1997) developed the SMMSE to improve the reliability of the measure. The idea was to develop strict guidelines for administration and scoring. To examine the reliability of the SMMSE in 48 older adults, university students were randomized to administer either the MMSE or the SMMSE, and were trained on that test to give to participants on three different occasions. The SMMSE had significantly better inter-rater and intra-rater reliability compared with the MMSE. The inter-rater variance was reduced by 76% and the intra-rater variance was reduced by 86%. It took less time to administer the SMMSE compared with the MMSE (average 10.5 minutes and 13.4 minutes, respectively. The intraclass correlation (ICC) for the MMSE was adequate (ICC = 0.69), and was excellent for the SMMSE (ICC = 0.90).

Telephone version (ALFI-MMSE) (Roccaforte, Burke, Bayer, & Wengel, 1992).

This version includes 22/30 of the original MMSE items, the majority of which were removed from the last section (language and motor skills). Roccaforte et al. (1992) examined the validity of the ALFI-MMSE in 100 geriatric outpatients. Correlations between phone and face-to-face versions of the MMSE were excellent (Pearson’s r = 0.85). Patients tended to score slightly higher on in-person testing than on the telephone. Sensitivity (using a brief neurological screening test as the criterion) of 67% and specificity of 100% were reported in a population of elderly, community-dwelling individuals. This was similar to the sensitivity (68%) and specificity (100%) reported for screening with the traditional MMSE.

26-item version of the ALFI-MMSE (T-MMSE) (Roccaforte et al. cited in Newkirk, Kim, Thompson, Tinklenberg, Yesavage, & Taylor, 2004).

The T-MMSE was developed from the ALFI-MMSE. It is a 26-point adaptation, containing a 3-step command: “Say hello, tap the mouthpiece of the phone 3 times, then say I’m back”. It also contains a new question that requests that the patient give the interviewer a phone number where they can usually be reached. The T-MMSE had an excellent correlation with the MMSE (r = 0.88). Neither hearing impairment nor years of education were associated with T-MMSE scores. On the 22 points in common between the 2 scales, scores had an excellent correlation (r = 0.88), however, telephone scores tended to be lower than in-face scores (Newkirk et al., 2004). The authors provide tables for the conversion of T-MMSE scores to MMSE scores

Client suitability

Can be used with:

Patients with stroke (Agrell & Dehlin, 2000; Ozdemir, Birtane, Tabatabaei, Ekuklu, Kokino, & Siranus, 2001; Grace et al., 1995; Suhr & Grace, 1999).

Should not be used with:

  • The MMSE was ineffective in detecting cognitive impairment in patients with right-sided stroke (Grace et al., 1995).
  • The MMSE is not suitable for use with a proxy respondent as it is administered via direct observation of task completion.
  • Because the MMSE is heavily language dependent, it is likely to misclassify patients with aphasia.
  • The MMSE has a limited ability to diagnose dementia in general practice and should therefore be used as only one aspect of a patient’s overall cognitive profile (Wind, Schellevis, van Staveren, Scholten, Jonker, & van Eijk, 1997).
  • The MMSE has been criticized for attempting 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, overall score (Tombaugh & McIntyre 1992). However, when used to screen for visual or verbal memory problems, or for problems in orientation or attention, it is not possible to identify acceptable cut-off scores (Blake, McKinney, Treece, Lee, & Lincoln, 2002).
  • MMSE scores have been shown to be affected by age, level of education, ethnicity, and sociocultural background (Tombaugh & McIntyre, 1992; Bleeker et al., 1988; Lorentz et al., 2002; Shadlen, Larson, Gibbons, McCormick, & Teri, 1999). These variables may introduce bias leading to the misclassification of individuals. For example, highly educated individuals who have mild dementia may well score within normal range on the MMSE because they find the questions easy. Further, poorly educated individuals may have low scores on the MMSE simply because they find the questions difficult. Thus, their scoring on the MMSE may indicate a diagnosis of dementia when none is present. Although these biases are not always present, Agrell and Dehlin (2000) found that age and education did not influence scores in their study, attention to these factors is warranted when interpreting MMSE results.
  • The MMSE has been found to lack sensitivity in patients with stroke (Blake et al., 2002; Suhr & Grace, 1999; Nys et al., 2005). Other studies have reported low levels of sensitivity among individuals with mild cognitive impairment (Tombaugh & McIntyre, 1992; de Koning et al., 1998) and in patients with right-hemisphere lesions (Dick et al., 1984). One potential solution to increase the sensitivity of the MMSE is the addition of a Clock Drawing Test (Suhr & Grace, 1999). Another solution that has been offered is to administer the Neurobehavioral Cognitive Status Examination (NCSE) in lieu of the MMSE. The NCSE is a highly sensitive measure to detect cognitive impairment in patients with brain lesions (Schwamm, Van Dyke, Kiernan, Merrin, & Mueller, 1997).
  • Da Costa et al. (2010) investigated the cognitive evolution and clinical severity of illiterate and schooled patients with stroke during a 6-month follow-up, using the MMSE and National Institutes of Health Stroke Scale (NIHSS) respectively. Significant improvement in clinical severity as measured by NIHSS was observed in both groups (P<0.001); however, only schooled individuals showed a significant improvement in MMSE scores, indicating an improvement in their overall cognitive function (P=0.008). Schooling was found to significantly influence MMSE scores.
  • Folstein, Folstein, and McHugh (1998) reported that the MMSE demonstrates marked ceiling effects in younger intact individuals and marked floor effects in moderately to severely impaired individuals.

In what languages is the measure available?

Afrikaans Dutch Israeli English Romanian
Arabic Estonian Italian Russian
Argentinean Spanish Filipino Japanese Russian for Estonia
Belgian Dutch Finnish Kannada Serbian
Belgian French French Korean Slovakian
Bosnian Austrian German Latvian South African English
Brazilian Portuguese German Lithuanian Spanish
Bulgarian Greek Macedonian Swedish
Chilean Spanish Gujarati Malayalam Telugu
Chinese Hebrew Marathi Turkish
Croatian Hindi Norwegian UK English
Czech Hungarian Polish Ukranian
Danish Indian English Portuguese Urdu

Authorized translations of the MMSE can be obtained by contacting Custsupp@parinc.com or call 1.800.331.8378

Summary

What does the tool measure? Cognitive impairment
What types of clients can the tool be used for? While originally used to detect dementia within a psychiatric setting, its use is now widespread and is available with an attached table that enables patient-specific norms
Is this a screening or assessment tool? Screening
Time to administer Administration by a trained interviewer takes approximately 10 minutes.
Versions The modified mini-mental state examination (3MS); 3MS + Clock-drawing; Standardized MMSE (SMMSE); Telephone version (ALFI-MMSE); 26-item version of the ALFI-MMSE (T-MMSE)
Other Languages Afrikaans; Dutch; Romanian; Arabic; Estonian; Italian; Russian; Argentinean Spanish; Filipino; Japanese; Russian for Estonia; Belgian Dutch; Finnish; Kannada; Serbian; Belgian French; French; Korean; Slovakian; Bosnian; Austrian German; Latvian; Brazilian; Portuguese; German; Lithuanian; Spanish; Bulgarian; Greek; Macedonian; Swedish; Chilean Spanish; Gujarati; Malayalam; Telugu; Chinese; Hebrew; Marathi; Turkish; Croatian; Hindi; Norwegian; Czech; Hungarian; Polish; Ukranian; Danish; Portuguese; Urdu
Reliability
  • Out of 9 studies examining the internal consistency of the MMSE, 3 reported poor internal consistency, 1 reported adequate internal consistency, 2 reported poor to excellent internal consistency, 2 reported excellent internal consistency, 1 reported excellent internal consistency in patients with Alzheimer’s Disease and poor internal consistency in patients with cognitive impairment.
  • Out of 6 studies examining the test-rest reliability of the MMSE, 2 studies reported excellent test-rest, 1 reported adequate test-retest, 1 reported adequate to excellent test-retest, 1 reported poor to adequate test-rest, 1 reported poor test-retest.
  • Out of 3 studies examining the inter-rater reliability of the MMSE, 1 reported excellent inter-rater, 2 reported adequate inter-rater.
Validity

Criterion:

The MMSE can discriminate between patients with Alzheimer’s Disease and frontotemporal dementia; can discriminate between patients with left- and right-hemispheric stroke.

Construct:

Concurrent:

MMSE had a poor correlation with the Mattis Dementia Rating Scale; poor to excellent correlations with the Wechsler Adult Intelligence Test; adequate correlation with the Functional Independence Measure ; significant correlations with the Montgomery Asberg Depression Rating Scale and the Zung Depression Scale.

Predictive:

MMSE scores found to be predictive of functional improvement in patients with stroke following rehabilitation; discharge destination; developing functional dependence at a 3-year follow-up interval; ambulatory level; length of hospital stay such that for patients with moderate dementia; death.

Floor/Ceiling effects:

Folstein, Folsten, and McHugh (1998) reported that the MMSE demonstrates marked ceiling effects in younger intact individuals and marked floor effects in individuals with moderate to severe cognitive impairment.

Does the tool detect change in patients? Not applicable.
Acceptability The MMSE is a brief measure to administer. Patient variables such as age, level of education and sociocultural backgroup may affect scores on the measure. It is administered by direct observation and is therefore not appropriate for proxy use.
Feasibility No specialized equipment is required, and therefore it is a highly portable and inexpensive measure. However, one study reported that physicians found the MMSE too lengthy and unable to contribute much useful information.
How to obtain the tool? The MMSE can be obtained from the current copyright owner, Psychological Assessment Resources (PAR).

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the MMSE.

Floor/Ceiling Effects

Folstein, Folstein, and McHugh (1998) reported that the MMSE demonstrates marked ceiling effects in younger intact individuals and marked floor effects in individuals with moderate to severe impairment.

Reliability

Internal consistency:

Tombaugh and McIntyre (1992) reviewed studies published on the psychometric properties of the MMSE over the last 26 years. The internal consistency of the MMSE was reported to range from poor to excellent (alpha = 0.54 to 0.96).

McDowell, Kristjansson, Hill, and Hebert (1997) examined the internal consistency of the MMSE used as a screening test for cognitive impairment and dementia. The internal consistency was adequate (alpha = 0.78).

Holzer, Tischler, Leaf, and Myers (1984) examined the prevalence of dementia in a community sample (n = 4,917). In this study, the internal consistency of the MMSE was found to be adequate (alpha = 0.77). Reliability of individual items ranged from poor (alpha = 0.43 for Orientation) to excellent (alpha = 0.82 for Registration). Calculation/attention items were omitted from this study.

Kay, Henderson, Scott, Wilson, Rickwood, and Grayson (1985) conducted a community survey in 274 individuals over 70 years of age. Rates of dementia were measured by interviewing participants with the MMSE. In this study, the internal consistency of the MMSE was poor (alpha = 0.68).

Foreman (1987) examined the reliability of the MMSE in 66 hospitalized medical-surgical patients (normal, dementia, or delirium) over 65 years of age. The MMSE was found to have an excellent internal consistency (alpha = 0.96).

Jorm, Scott, Henderson, and Kay (1988) examined whether there was a bias in the MMSE such that individuals with less education (less than or equal to 8th grade) would perform worse on the measure than individuals with more education (more than 8th grade). The MMSE was administered 269 elderly participants. The internal consistency was found to be poor in both the more educated group (alpha = 0.54) and the less educated group (alpha = 0.65).

Albert and Cohen (1992) administered the MMSE to 40 elderly residents with severe cognitive impairment. The internal consistency of the MMSE was poor in patients with an MMSE score ≤ 10 (alpha = 0.56). However, when subjects representing the full range of MMSE scores were included, the internal consistency was excellent (alpha = 0.90).

Tombaugh, McDowell, Kristjansson, and Hubley (1996) compared the psychometric properties of the MMSE to the 3MS in community-dwelling participants between the ages of 65-89. Participants were divided into two groups, one with no cognitive impairment (n = 406) and one with Alzheimer’s disease (n = 119). The internal consistency of the MMSE was poor in the group without cognitive impairment (alpha = 0.62) and was found to be excellent in patients with Alzheimer’s disease (alpha = 0.81).

Hopp, Dixon, Grut, and Backman (1997) administered the MMSE to 44 adults without dementia, who were over the age of 75 years. In this sample, the internal consistency of the MMSE was poor (alpha ranged from 0.31 to 0.52).

Test-retest:

Tombaugh and McIntyre (1992) reviewed studies published on the psychometric properties of the MMSE over the last 26 years. They reported that in studies having a re-test interval of < 2 months, the MMSE has poor to excellent test-retest reliability with correlations ranging from 0.38 to 0.99. Twenty-four out of 30 studies reported excellent test-retest reliability (r > 0.75).

Folstein et al. (1975) administered the MMSE to 206 patients with dementia syndromes, affective disorder, affective disorder with cognitive impairment, mania, schizophrenia, personality disorders, and to 63 healthy controls. The test-retest reliability of the MMSE when administered twice within 24 hours was excellent, with a Pearson correlation coefficient of r = 0.89. When the MMSE was given to patients with depression and dementia twice, 28 days apart, the correlation was excellent, with a Pearson correlation of r = 0.99.

Note: Pearson correlation coefficients are likely to over-estimate reliability and the Pearson is no longer used for test-retest reliability.

Schmand, Lindeboom, Launer, Dinkgreve, Hooijer, and Jonker (1995) examined the test-retest reliability of the MMSE in healthy older subjects who were examined twice with an interval of 1 year between evaluations. Test-retest reliability was adequate (Spearman’s correlation = 0.58). The results of this study are similar to those found in O’Connor et al. (1989). These results suggest that the MMSE is not an appropriate measure for detecting subtle cognitive impairment.

Hopp et al. (1997) administered the MMSE to 44 adults without dementia, who were over the age of 75 years. The test-retest reliability for 6- 12- and 18-month intervals, using Pearson’s correlations, ranged from adequate to excellent (r = 0.56 to r = 0.80).

Olin and Zelinski (1991) examined the 12-month reliability of the MMSE in 57 elderly participants without dementia. Poor 12-month test-retest correlations were found for the total MMSE score (r = 0.34 when administering the alternate Attention item, r =0.23 when administering the same Attention item).

Uhlmann, Larson, and Buchner (1987) also examined the 12-month test-retest reliability of the MMSE in outpatients with dementia. In this study, the test-retest reliability was found to be excellent (r = 0.86).

Mitrushina and Satz (1991) examined the test-retest reliability of the MMSE in 122 healthy community-residing elderly volunteers between the ages of 57-85. The test-retest reliability of the MMSE was adequate (ranging from r = 0.45 to r = 0.50) over a 1-year interval, and poor over a 2-year period (r = 0.38).

Intra-rater reliability / Inter-rater reliability:

Molloy and Standish (1997) examined the intra-rater reliability of the MMSE in comparison to the SMMSE in 48 older adults. University students, who were trained to administer either the MMSE or the SMMSE, tested participants on three different occasions to assess their inter-rater and intra-rater reliability. An adequate ICC of 0.69 was reported for the traditional MMSE.

Inter-rater reliability:

Dick et al. (1984) examined the inter-rater reliability of the MMSE in patients with neurological disorders and reported a kappa of 0.63, demonstrating the adequate inter-rater reliability of the MMSE.

Fabrigoule, Lechevallier, Crasborn, Dartigues, and Orgogozo (2003) examined the reliability of the MMSE in patients who were likely to develop dementia. Fifty trained general practitioners and psychologists examined patients. There was a significant difference in scores between the general practitioners and the psychologists for the MMSE. The concordance correlation coefficient was 0.87 between evaluations performed by general practitioners and those performed by psychologists.

In a study by O’Connor et al. (1989), 5 coders rated taped interviews with 54 general practice patients aged 75 and over. In this study, the inter-rater reliability was excellent, with a mean kappa value of 0.97.

Validity

Construct:

Although the MMSE is generally considered unidimensional, Jones and Gallo (2000) identified five factors (concentration, language and praxis, orientation, memory, and attention) to support the construct validity of the MMSE as a measure of cognitive mental state among community dwelling older adults.

Concurrent:

Friedl, Schmidt, Stronegger, Fazekas, and Reinhart (1996) examined the concurrent validity of the MMSE and the Mattis Dementia Rating Scale (MDRS) (Mattis, 1976), two measures commonly used to screen for dementia. Concurrent validity between the MMSE and the MDRS was found to be poor (Pearson’s r = 0.29), as were correlations between the MMSE and MDRS subtests (attention r = 0.18; initiation and perseveration r = 0.04; construction r = 0.10; conceptualization r = 0.17; verbal and non-verbal short-term memory r = 0.27).

Folstein et al. (1975) administered the MMSE to 206 patients with dementia syndromes, affective disorder, affective disorder with cognitive impairment, mania, schizophrenia, personality disorders, and to 63 healthy controls. The concurrent validity of the MMSE was examined by correlating the measure with the Wechsler Adult Intelligence Scale (WAIS – Wechsler, 1955). The concurrent validity between the MMSE and the WAIS verbal IQ (r = 0.78) and the WAIS performance IQ (r = 0.66) were both excellent.

Hopp, Dixon, Grut, and Backman (1997) administered the MMSE and the Wechsler Adult Intelligence Scale-Revised (WAIS-R, Wechsler, 1981) to 44 adults without dementia, who were over the age of 75 years. Correlations between the MMSE and the WAIS-R Verbal IQ were adequate, ranging from r = 0.36 to r = 0.52. Correlations between the MMSE and WAIS-R Performance IQ were also adequate, ranging from r = 0.37 to r = 0.57. Correlations between the MMSE and the WAIS-R subtests ranged from poor to excellent (r = 0.20 to r = 0.60). Correlations between the MMSE subscales and the WAIS-R were generally lower than r = 0.41. The Language subscale of the MMSE showed the lowest correlations with both WAIS-R Verbal and WAIS-R Performance. Correlations between MMSE subscales and WAIS-R subtests showed that the MMSE subscale, Orientation, had the lowest correlations with all WAIS-R subtests (r = 0.001 to r = 0.40).

Similar to the results by Hopp et al. (1997), Dick et al. (1984) examined the utility of the MMSE for bedside screening, and serial assessment of cognitive function in 126 neurological patients and found adequate correlations between the MMSE and the Weschler Adult Intelligence Scale (WAIS) (r = 0.55 for WAIS-Verbal; r = 0.56 for WAIS-Performance).

Agrell and Dehlin (2000) reported significant correlations between MMSE scores and the Barthel Index (Mahoney & Barthel, 1965), the Montgomery Asberg Depression Rating Scale (MADRS – Montgomery & Asberg, 1979) and the Zung Depression Scale (Zung, 1965).

Diamond, Felsenthal, Macciocci, Butler, and Lally-Cassady (1996) examined the relationship between cognition and ability to benefit from inpatient rehabilitation in 52 patients admitted to geriatric rehabilitation. Functional gain was assessed using the change in Functional Independence Measure (FIM – Keith, Granger, Hamilton, & Sherwin, 1987) score from admission to discharge. The MMSE was not found to be associated with change in FIM score (r = 0.10). However, the MMSE alone and in combination with age correlated adequately with functional status on admission (r = 0.58) and discharge (r = 0.49).

Convergent:

Snowden at al. (1999) examined 140 patients who were part of the Alzheimer’s Disease Patient Registry to evaluate the psychometric properties of a new measure, the Minimum Data Set (MDS). The cognitive performance scores from the MDS were correlated with the MMSE. The MMSE correlated adequately with the MDS (Spearman’s r = -0.45) (this correlation is negative because a low score on the MMSE indicates cognitive impairment, whereas a high score on the MDS indicates impairment). Consistent with previous studies, the MMSE had excellent correlations with the Weschler Adult Intelligence Scale (WAIS) Verbal and Performance IQ scores (r = 0.78 and r = 0.66, respectively).

Discriminant:

Winograd et al. (1994) developed the Physical Performance and Mobility Examination, a measure used to assess 6 domains of physical functioning and mobility for hospitalized elderly. The construct validity of this measure was examined by comparing it to the MMSE, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) (Lawton & Brody, 1969), Geriatric Depression Scale (Yesavage et al., 1983), and modified Medical Outcomes Study Measure of Physical Functioning (MOS-PFR). The MMSE correlated poorly with the Physical Performance and Mobility Examination (r = 0.36), suggesting that these two measures assess different constructs.

Macnight and Rockwood (1995) examined discriminant validity of the MMSE by comparing it to a new measure, the Hierarchical Assessment of Balance and Mobility (HABAM) in patients 65 and older. The discriminant validity was demonstrated, as the two measures correlated poorly (r = 0.15).

Known groups:

Wetherell, Darby, Emerson, and Miller (1997) found that the MMSE was able to discriminate between patients with Alzheimer’s Disease and frontotemporal dementia.

Kase, Wolf, Kelly-Hayes, Kannel, Beiser, and D’Agostino (1998) found that baseline pre-stroke MMSE scores were significantly lower for patients with stroke than were the scores for matched controls. This difference became more pronounced when the post-stroke scores were compared. The MMSE could discriminate between patients with left- and right-hemispheric stroke. In patients with right-hemispheric stroke, cognitive impairment was characterized by a significant decline in scores from pre-stroke to post-stroke specifically in the areas of orientation and language. For patients with left hemisphere strokes, a significant decline in scores from pre-stroke to post-stroke were found in all five domains of the MMSE except memory.

Predictive:

Ozdemir et al. (2001) examined the predictive validity of the MMSE in 43 patients with stroke. Baseline total MMSE scores were correlated with discharge Motor Functional Independence Measure (Keith et al., 1987) improvement (r = 0.31). The baseline Orientation subscore of the MMSE correlated significantly with functional ambulation score improvement as measured by the Adapted Patient Evaluation and Conference System functional scale (r = 0.31). These results suggest that baseline total MMSE scores are somewhat predictive of functional improvement in patients with stroke after rehabilitation.

Diamond et al. (1996) examined the relationship between cognition and the ability to benefit from inpatient rehabilitation in 52 patients admitted to geriatric rehabilitation. The MMSE was found to be highly predictive of discharge destination such that low MMSE scores were associated with a greater likelihood of nursing home placement (r = 0.68). While only 8% of the uppermost MMSE quartile was discharged to nursing home placement, 62% of the lowest MMSE quartile was discharged to nursing homes.

Aguero-Torres, Fratiglioni, Guo, Viitanen, von Strauss, and Winblad (1998) examined predictors of dependence in activities of daily living (as measured by the Katz index of Activities of Daily Living (Katz, Downs, Cash, Grotz, 1970)) in the elderly. In patients without dementia, the MMSE was found to be one of the strongest predictors for developing functional dependence at a 3-year follow-up interval. Lower MMSE scores were associated with functional dependence in both adults with dementia (OR = 0.8) and in adults without dementia (OR = 0.8). Initial MMSE performance also predicted future functional dependence and decline among adults without dementia (OR = 0.7). Thus, independent of the presence of other chronic conditions, the MMSE may indicate subsequent functional status in a cognitively intact elderly population.

Matsueda and Ishii (2000) retrospectively examined the relationship between MMSE score and ambulatory level (divided into three groups: dependent, partially dependent, and independent) in 162 elderly patients who experienced a hip fracture. A significant relationship was found between initial MMSE score and ambulatory level such that those in the dependent group had the lowest mean MMSE score of only 6.6, those in the partially dependent group had a mean score of 17.9, and those in the independent group had the highest MMSE score of 24.6.

Huusko, Karppi, Avikainen, Kautiainen, and Sulkava (2000) examined the effect of intensive geriatric rehabilitation (intervention group) versus local hospital treatment (control group) on patients with dementia and a hip fracture. MMSE scores were predictive of length of hospital stay such that for patients with moderate dementia (MMSE score of 12-17), the median length of stay was 47 days in the intervention group and 147 days in control group. Patients with mild dementia (MMSE score of 18-23) had a length of stay of 29 days in intervention group and 46.5 days in the control group. No significant differences in mortality or in the length of hospital stay were observed for patients with severe dementia. In the intervention group, 3 months after surgery 91% of the patients with mild dementia and 63% of the patients with moderate dementia were living independently. In the control group, the corresponding figures were 67% and 17%, respectively. The results of this study suggest that the MMSE is associated with the length of hospital and rehabilitation stay, and that length of stay can be impacted on by intervention for those with cognitive impairment.

Pettigrew, Thomas, Howard, Veltkamp, and Toole (2000) examined whether low MMSE scores predict transient ischemic attack, stroke, myocardial infarction, or death. Patients were randomized to receive a carotid endarterectomy or best medical therapy in as a means to preserve cognition. A significant relationship was found between a low post-randomization MMSE score and an increased risk of death. Furthermore, patients who experienced stroke after randomization had a significant and persistent reduction in MMSE score.

Sensitivity and Specificity

Low reported levels of sensitivity, particularly among individuals with mild cognitive impairment, have been reported for the MMSE (Tombaugh & McIntyre, 1992; de Koning et al. 1998) and may be due to the emphasis placed on language items and a lack of items assessing visual-spatial ability (Grace et al. 1995; de Koning et al. 1998; Suhr & Grace, 1999).

Blake et al. (2002) examined the sensitivity and specificity of the MMSE for detecting cognitive impairment after stroke. When the MMSE was compared with cognitive impairment identified an optimum cutoff of <24, with good specificity (88%) and moderate sensitivity (62%). However, it was not possible to identify suitable cutoff scores to use the MMSE to assess for the presence of either visual or verbal memory deficits.

Nys, van Zandvoort, de Kort, Jansen, Kappelle, and de Haan (2005) administered the MMSE to 34 patients with stroke and 34 healthy controls. In this study, no optimum cut-off scores yielding both sensitivity greater than 80%, and specificity greater than 60%, could be identified.

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See The Measure

How to obtain the MMSE

The MMSE can be obtained from the current copyright owner, Psychological Assessment Resources (PAR).

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