How To Use The Mini Mental State Examination

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How To Use The Mini Mental State Examination

• A guide and teaching resource for aged care
  service providers.
• Developed by Stephen Merrett
• Mental Health Services for Older People, Country
  Liaison Service. March 2003

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HOW TO USE THE MINI MENTAL STATE EXAMINATION

• Introduction
• What is the Mini Mental State Examination?
• What are its strengths and limitations?
• Undertaking the Mini Mental State Examination
• Preparation
• Process
• Scoring
• Using the results
• Interpreting the results
• Practical implications

Developed by Stephen Merrett - Mental Health
Services For Older People, Country Liaison Service
3
INTRODUCTION

• What Is The Mini Mental State Examination?
• What Are Its Strengths And Limitations?

Developed by Stephen Merrett - Mental Health
Services For Older People, Country Liaison Service
4
What Is The Mini Mental State Examination?

• The MMSE was developed in 1975 by M Folstein et
  al as a screening tool to test the cognitive
  functioning of older people.
• It assesses orientation, attention, recall,
  language, and the ability to follow simple verbal
  and written commands.
• It provides a total score that places the
  individual on a scale of cognitive function.
• Can used by medical staff, nurses, or untrained
  staff with the same score being obtained
  irrespective of who does the test.
• Is consistent with the results of other more time
  consuming methods of establishing a score for
  cognitive functioning.
• If every answer is correct, a maximum score of 30
  points is possible.

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What Is The Mini Mental State Examination?

• In its current form it is largely unchanged from
  the original that was designed by Folstein in
  1975.
• Is probably the most widely used tool for
  establishing a score for an individuals
  cognitive functioning.
• Is cited in virtually every research project that
  attempts to report on cognitive functioning over
  time or in response to a treatment or
  intervention.
• A MMSE score is required as part of the
  assessment process to determine a persons
  eligibility for treatment with a cholinesterase
  inhibitor medication (e.g. Aricept, Exelon,
  Reminyl).

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What Is The Mini Mental State Examination?

• Is one of the investigations undertaken to assist
  with establishing a diagnosis of dementia.
• The MMSE is not a tool for diagnosing dementia in
  its own right.
• The main reason for using the MMSE is to produce
  a measure of a persons cognitive functioning and
  to use the results of the test and the score
  obtained to assist with planning treatment and
  care.
• Repeated testing is done to obtain an objective
  measure of any change in cognitive functioning
  over time or in response to a treatment,
  intervention or change of circumstances.

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What Are Its Strengths And Limitations?

• The main strengths of the MMSE are
• It can be administered in 5 to 10 minutes.
• The equipment required is easily obtained.
• Generally well accepted by those being tested.
• It does not require extensive training to be able
  to use it accurately and effectively.
• The same results are likely to be obtained
  irrespective of who does the test.
• It provides an objective measure of a persons
  cognitive functioning.
• It provides information to assist with tailoring
  interventions.
• It is widely accepted and understood by both
  researchers and clinicians.

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What Are Its Strengths And Limitations?

• The limitations of the MMSE include
• Results are dependent on (English) language
  skills.
• People with a low education level may score lower
  than those with a higher level of education.
• Sensory deficits (hearing and vision) and
  physical disabilities (e.g. tremor or arthritic
  changes) may impact on the score.
• Doesnt test all areas of cognitive functioning
  (e.g. frontal lobe)

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UNDERTAKING THE MMSE

• Preparation
• Process

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Preparation

• The items necessary to complete the MMSE are
• A watch, pencil, eraser and blank piece of paper.
  
• A piece of paper with CLOSE YOUR EYES written in
  large letters and a drawing of two 5 sided
  figures intersecting to make a 4 sided figure are
  also required.
• There are a number of complete questionnaires
  available for use ( including the one provided in
  the appendices section of the accompanying
  handout).

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Services For Older People, Country Liaison Service
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Preparation cont.

• Ensure that hearing or visual aides are available
  and in good working order.
• The location to be used has good lighting and
  ventilation to maximize the persons physical
  comfort.
• Establish rapport with the person and explain the
  nature of the questions to come.
• Offer the explanation that it is a standard
  questionnaire that is commonly used as part of a
  thorough assessment. Avoid the term memory
  test.
• Request others to allow the person being tested
  to answer the questions by themselves without
  prompting.
• Ensure that any prompts to answers are removed
  from the area.

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Process

• Commence with question 1 and progress through the
  questions from the beginning to the end. It is
  important to follow the order as given. A
  standardized MMSE questionnaire should be used.

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Process

• General guidelines include
• Record names and the date the test is performed.
• Record the persons response for each question.
• Record any factors that may have influenced the
  testing process.
• Ask each question a maximum of three times.
• If the person answers incorrectly then allocate a
  score of 0.
• Accept the answer given. Do not hint or prompt
  for an answer.
• Do not hint at answers or provide any physical
  clues such as head shaking, frowning etc.

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Process cont.

• Do not indicate surprise or disappointment in
  answers.
• Repeat the same directions, if asked, to a max.
  of 3 times.
• Questions should be asked in a concise and
  unambiguous manner.
• Do not engage in unrelated conversation.
• Provide a pencil for the question on naming
  objects rather than a pen or biro.
• It is not possible to allocate a ½ point for a
  near miss answer.
• Record not only the score the person obtains, but
  also how they perform the task.
• If the person is irritable, agitated, physically
  unwell, drowsy or in pain it is best to arrange
  another time to perform the MMSE as the score
  obtained will not be valid.

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SCORING THE MMSE

• Specific examples of wording to use with each
  question of the MMSE are given in this section.
• It is important to adhere to the test
  instructions to maximize the reliability and
  meaningfulness of the test results.

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Q1. Orientation to time
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Q2. Orientation to place
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Q2. Orientation to place cont.
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Q3. Registration and Recall
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Q4. Attention and Calculation
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Q4. Attention and Calculation cont.
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Q5. Recall
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Q6. Naming Objects
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Q7. Repetition
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Q8. Three stage command
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Q9. Obeying a command
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Q10. Writing a sentence
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Q 11. Copying a diagram
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Q 11. Copying a diagram cont.
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USING THE RESULTS

• Interpreting the results
• NB A score of less than 24/30 or a marked
  decline from
• a previous score should prompt
  consideration of the
• need for medical review.
• Practical implications

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Interpreting The Results
The following can be used as a guide to assist
with interpreting the MMSE scores.
The guide will not be valid if the person tested
displays difficulties or limiting factors due to
poor (English) language skills, poor eyesight,
hearing, acute ill health, pain, or the presence
of a tremor.
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Interpreting The Results cont.
A decline in cognitive functioning has been found
to occur with normal ageing and a potential best
score for any individual is also related to the
level of education achieved.
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Interpreting The Results cont.

• The score obtained from the MMSE does not relate
  directly to the functional abilities of the
  person.
• People who score less than 20 may experience
  difficulties with managing finances, driving,
  shopping, preparing meals and managing their
  medications but are able to manage other
  activities such as maintaining their hygiene,
  grooming, dressing, and eating.
• Cognitive and functional deficits may not be
  apparent to others at an early stage if the
  decline has occurred gradually over a number of
  years.
• Scores obtained on a MMSE may be higher or lower
  than the norm for the actual level of impairment
  that a person may display in a functional sense.

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Services For Older People, Country Liaison Service
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Interpreting The Results cont.
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Interpreting The Results cont.
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Interpreting The Results cont.
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Practical Implications

• In completing the MMSE the person being tested
  provides
• information that can assist with planning care.
• Some examples include
• If the person displayed difficulties in following
  a three stage command (Q9) then strategies that
  broke commands down into single steps are likely
  to more successful than providing the person with
  a series of instructions at the beginning of a
  task.
• Difficulties in the area of orientation to time
  (Q1) may prompt a review of the guides to
  orientation (calendars, clocks etc.) that are
  available within the persons immediate
  environment.
• A persons inability to comprehend a written
  command (Q9) may justify a review of the
  communication strategies in use.

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Services For Older People, Country Liaison Service
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SUMMARY

• The MMSE is a well established, fast and reliable
  way of gauging cognitive functioning.
• Attention to preparation and adherence to the
  guidelines for scoring can greatly enhance the
  usefulness of the results.
• The score obtained can assist with diagnosis.
• The process of undertaking the MMSE can identify
  health issues and provide information useful to
  planning care.

Developed by Stephen Merrett - Mental Health
Services For Older People, Country Liaison Service
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How To Use The Mini Mental State Examination

• A joint exercise between the South East Regional
  Health Service and Mental Health Services For
  Older People, Country Liaison Service
• Available on CD Rom from your Regional ACATTel
  87211 460

Developed by Stephen Merrett - Mental Health
Services For Older People, Country Liaison Service