The Mini-Mental State Examination

The Mini-Mental State Examination (MMSE) was first developed by Dr. Marshall Folstein in 1975 frequently described as “mini-mental” and is one of the most commonly administered screening tools for cognitive impairment and possible dementia in clinical settings (Xu et al., 2015).

As argued by Tsai et al. (2018) dementia refers to a complex category of brain diseases that manifest in the progressive cognitive decline of function beyond what is expected from normal aging. The global population is undergoing a significant demographic transition as life expectancy is growing and Western Europe population over the age of 60 is expected to increase by 2030 (Abdi, Al-Hindawi, & Vizcaychipi, 2018).

Population with diagnosed dementia is projected to increase significantly and impact the health care system worldwide with an estimated 65.7 million in 2030 and 115.4 million in 2050 (Prince et al., 2013). Recent guidelines suggested that using brief in nature, structured cognitive assessment as MMSE led to early detection of cognitive impairment especially within primary care settings (Cordell et al., 2013). Early recognition of mental deterioration can allow prompt diagnosis and relevant education, psychosocial support, treatment of the symptoms, access to health care, engagement in decision making life planning, and financial support (Tsai et al., 2018).

The mean duration of assessments for the MMSE was 13.4 (Molloy & Standish, 1997) and this can be one of the biggest advantages when assessing cognition for individuals who can find difficulty when face with time lengthy neuropsychological assessment. The Scoring system in general is straight forward however can be a bit complicated especially when presented with 114 examples of backward spelling for ‘world’ however comprehensive manual is available if assistance was needed.

One of the biggest benefits of the MMSE is flexibility when individuals with physical disabilities need to perform the test, they should not be scored lower just because they have a disability, for example, paralysis amputation or deformity of the limbs, blindness, or poor vision, hearing loss or deathless.

Modification of the test is allowed, but if modification is not possible, the item should be omitted and subtracting from the total score (30) to give a new total (Molloy, Alemayyehu, & Roberts, 1991). The maximum score for MMSE is 30, where scores from 0-9 indicate severe cognitive impairment, 10-21 indicate moderate cognitive impairment, 22-24 indicate mind/early cognitive impairment, 25-30 may be normal. However, scoring exclusively focuses on areas of impairment in Alzheimer’s disease.

MMSE can be easily administered by trained clinicians as nurses, doctors, and other health care professionals within ten minutes. The test covers a variety of cognitive domains as short and long-term memory, constructional ability, registration and recall, language and the ability to understand and follow commands, orientation to place and time (Molloy & Standish, 1997).

One of the very important properties of the neuropsychological assessment is to remember this test is only a tool and should not be used alone; it works better when collaborating with an individual’s additional assessment and client’s past medical history. When critically evaluating the technical robustness of MMSE for the needs of an individual and the purpose of the assessment is vital to remember that “mini-mental” assessment is not only quick and easy to administer for assessing cognitive function but shown to have both good test-retest reliability 0.80–0.95 (Beek, Kim, Park, & Kim, 2016).

Multiple attempts have been made to standardize administration and scoring MMSE in order to improve the interrater and intrarater reliability of this measure (Lacy, Kaemmerer, & Czipri, 2015) however scoring based on the available guidelines unfortunately still is subjective and argument provoking at least as some people can score half of the point, or giving hints to answer the question.

Evidence from previous research (Petersen et al., 2001) indicates that MMSE increases the risk of underdiagnosing and lost opportunity for early intervention especially for a well-educated, younger individual with a sophisticated social profile masking effectively the cognitive dysfunction. Other factors such as alcohol consumption and heavy smoking were also associated with cognitive decline (Ong et al., 2016).

Therefore, as argued by Lacy et al. (2015) MMSE/SMMSE should not be utilized as a tool to diagnose mild cognitive impairment therefore was described as a questionable sensitive detector of early dementia. MMSE seems to be affected by demographic variables like ethnicity, age, and education (Milman, Faroqi-Shah, Corcoran, & Damele, 2018), and biased towards cultural and socioeconomic status and especially towards people who do not read or use English as a primary language (Schaber, Stallings, Brogan, & Ali, 2016).

MMSE and Montreal Cognitive Assessment tool (MoCA) are the most frequently used in a clinical setting by practitioners (neurologists, speech and language therapist, psychologist, physicians) who are practicing in a busy inpatient setting, where making decisions need to be made under time pressure with the optimal utilization of available resources focusing on the maximum level of recovery within the shortest time available (Fernando & Carter, 2016).

Recent research conducted on an elderly patient admitted to London acute hospital delivered evidence that MMSE was one of the frequently screening tools for cognitive decline, if the individual scored 27 or less out of 30 they required further assessments to confirm or rule out dementia (Timmons et al., 2015). In this light, MMSE stands up itself as an effective quantitative measurement of mental state individuals and have the potential to be recognized as a universal tool used in clinical practice.

The evidence suggests the potential effective tool when approaching the assessment of physiological aging; cautiousness should be exercised when interpreting scores of MMSE test as they often show low sensitivity and informativity because of ceiling effects caused by excessive ease of the test items (Crivelli et al., 2018).

Despite the criticism towards MMSE, it is still remaining one of the most widely used global screens of adults for acute changes in cognitive function associated with complex conditions including dementia, multiple sclerosis, delirium, stroke, Parkinson’s disease, and traumatic brain injury (Milman, Faroqi-Shah, Corcoran, & Damele, 2018).

One of the ways to face criticism addressed towards MMSE is by the clear humble reflection that there is still no universally accepted gold standard in clinical practice when assessing clients with cognitive issues as every person is unique and different and those tools are not sophisticated enough for the purpose (Crivelli et al., 2018).

As argued by Shim, Yang, Kim, Park & Him (2017) MMSE lack consideration for cultural differences and their influences on interpretation and making cross-cultural studies very problematic in nature. However, this could spark the interest to develop a standardized cognitive cross-cultural instrument, which could be able to accommodate people living in Asia.

It is important to notice that performance on MMSE is affected by the language of test administrator, demographic variables as age, the language of test administration, ethnicity, and education of participants (Matallana et al., 2011). One of the biggest limitations for test interpretation is individuals from minority ethnic backgrounds especially for the individuals, whom English is not the first language. Sensory impairments as poor hearing ability were associated with lower scores on MMSE and provisions should be taken into account in order to avoid misdiagnoses of cognitive impairment (Lim & Loo, 2018).

This paper aimed to gather evidence of the clinical properties of MMSE as having the potential to be recognized as a useful screening tool for assessing global cognitive impairment. Despite the fact, “mini-mental” is far away from representing a novel approach; with questionable robustness of the psychometric instrument, it is still representing diagnostic value when used in collaboration with other tools fit for the purpose.

Time is paramount when facing one of the quickest progressing mental diseases wiping away so many memories, life skills, and everything that was making this particular individual who they are. In this light timely test, allow detecting cognitive decline could be a great advantage by giving additional time to look for an effective way to slow the symptoms and have breathing space in terms of what to do next.

Taking into account the current crisis in mental health and facing aging population there is a time for the active role of the psychologist in improving people health by not only administering technically robust neuropsychological test by applying effectively behavioral, cognitive, and social approaches in order to avoid cognitive impairment and allow to enjoy optimal living (British Psychological Society, 2018).