Mini-Mental State Exam (MMSE) Alzheimer’s / Dementia Test: Administration, Accuracy and Scoring

The most common tool for assessing the severity of a person’s Alzheimer’s disease, or related dementia, is the Mini-Mental State Exam also known as the Folstein Test or MMSE. While designed to be administered in a doctor’s office or clinical setting, the Mini-Mental State Exam is a short and effective test that can also be taken at home. Scoring the test is very straightforward, and family members or loved ones can manage the administration and scoring process without special training. However, one will want a medical professional to interpret the scoring and layer on other diagnostic approaches. What follows is everything you need to know about the exam.

What is the Mini-Mental State Exam?

The Mini-Mental State Exam is a 30-point test used to measure your loved ones thinking ability, also known as their cognitive impairment. If you suspect that you or a loved one might be developing Alzheimer’s disease or another dementia, the Mini-Mental State Exam is a step toward making a diagnosis. The test is also used by researchers who study Alzheimer’s to know a patient’s stage of dementia. It is the most widely used test for assessing dementia.

The questions are assigned points depending on their answers. A low score on the Mini-Mental State Exam does not mean there is a guarantee of dementia or Alzheimers. It’s important to remember that no true diagnosis can be made without further tests from a doctor. It simply means you need to make a doctor’s appointment so your loved one can be evaluated by an expert.

How Does It Work?

The Mini-Mental State Exam works by a series of questions that test brain function. Through asking and answering questions, an evaluation can be made that checks for a mental deficiency which is common in dementia patients. The guided questions try to determine how well one’s immediate and short-term memory is functioning. That is done by asking questions about:

– The patients’ orientation to the time and place. This is testing if the patient knows when and where they are, the day of the week, or the season of the year.

– Ability to concentrate through the 10-minute test

– If they can recall something or a series of items. This is testing short-term memory.

– Language competence and proficiency. This is testing verbal memory and naming.

– The relationship between different objects. This is testing visuospatial skills.

– The ability to solve problems. Examples like spelling a simple word backward are used.

– Motor skills

– Comprehension of directions

Some sample MMSE questions are:

– What city, state, and country are we in?

– Name three unrelated objects.

– Repeat the following: “No ifs, ands, or buts.”

– What is this called? The tester shows the subject a pencil or watch.

Importantly, the Mini-Mental State Exam is not used on its own to diagnose dementia. A score below 24 is considered indicative of dementia, but it’s not enough alone to say that someone who scored 23 or less has dementia. A neurologist would factor that in with other analyses, like the results of brain scans, a neurological exam, an evaluation of medical history, and possibly genetic testing. In other words, no one should take a low score on the MMSE to prove they have dementia. Instead, consider it a warning sign that means further testing is necessary.

Pros and Cons

As with any test or treatment, there are always advantages and disadvantages. For the Mini-Mental State Exam they are:

Pros:

– Useful in multiple ways. The Mini-Mental State Exam can be used to screen for suspected dementia, so someone who suspects they’re developing the disease might take it; it estimates the stage and severity of dementia for someone who has the disease, and it can show changes over time if taken every year or so.

– Easy to administer. No special equipment or training is necessary.

– Short and simple. The test only takes about 10 minutes to complete.

Cons:

– Less reliability. An educated person with dementia, for instance, might be able to score above 24.

– Not sensitive to Mild Cognitive Impairment. The Mini-Mental State Exam does not do a good job of detecting Mild Cognitive Impairment or early dementia. Someone in the beginning stages, in other words, can still achieve a high score.

– Requires a certain level of education. Someone below an eighth-grade level of education should not take the Mini-Mental State Exam, because low educational experience can lead to a misdiagnosis.

Accuracy

Studies have shown that the Mini-Mental State Exam is better at ruling out dementia than telling someone whether they have it. Very rarely will the exam tell someone who does not have dementia that they do have the disease. This is called a false positive and only happens about three percent of the time. It is more common for someone who does have dementia to achieve a score that would indicate they don’t have the disease. This happens more than 20 percent of the time because people who are highly educated or only in the early stages of the disease can still score above 24 (indicating normal thinking ability) even if Alzheimer’s is present in the brain. Again, the Mini-Mental State Exam should not be used alone as a tool for diagnosing dementia.

How to Administer

The Mini-Mental State Exam is best administered by a neurologist, or other healthcare professional, in a doctor’s office-like environment. However, an online version of the Mini-Mental State Exam is relatively simple, only takes about 15 minutes to complete and can be administered by a friend or family member without special training. If you choose to do this, be aware that the results should not be considered definitive.

Should you not wish to administer the Mini-Mental State Exam using your phone or computer, there are numerous exams online that can be printed. Again, you do not need special training and these printed options give easy-to-understand instructions. If you want to take or give the test, follow these basic guidelines and then consult a doctor:

Step 1 – Download and print the Mini-Mental State Exam. There are multiple versions online, and they all ask roughly the same questions. The link above contains a good version that is easy to score.

Step 2 – Seat your loved one, the person being tested, in a quiet and well-lit room. Ask for attention. Do not set a timer.

Step 3 – Give the person a pencil or pen and a piece of paper. The Mini-Mental State Exam is mostly filled out by the administrator, who asks questions and records answers that are either correct or not. There are, however, a few questions that will require writing and drawing. These include “Write a sentence,” scored based on whether the sentence is coherent and contains a subject and verb, and “Draw intersecting shapes,” where you show them a picture of two pentagons intersecting and ask the person to recreate the image.

Step 4 – Give the person as much time as needed. The Mini-Mental State Exam generally takes about 10 minutes to complete, but there is no time limit. Do not rush in any way. In fact, be as positive and encouraging as possible.

Step 5 – Review the results. The test is graded as you go, and administrators should be able to tell pretty clearly whether a question was answered correctly or not. It will probably be relatively simple to calculate a score but, again, the Mini-Mental State Exam is meant to be administered and scored by a professional.

Step 6 – If more than a few questions were answered incorrectly, you’ll want to take the finished test to a primary care doctor, who will go over it and decide whether a referral to an expert like a neurologist is appropriate.

Interpreting the Results

To calculate the test taker’s score, it is simply a matter of counting the correct answers. The sum of the correct answers equals the test taker’s score. There are 30 questions and therefore the highest possible score is 30. Mini-Mental State Exam scores concerning the severity of dementia are shown in the table below.

Alternatives and  Comparisons

Compared to the Clock Drawing Test

The Clock Drawing Test is a straightforward way to determine if someone shows signs of dementia. In it, a person is asked to draw a clock showing the time as “10 past 11.” Someone with dementia will draw the clock incorrectly in several ways. This is a much easier means of seeing if someone needs to be evaluated further for dementia and can be taken at home in just a few minutes with nothing but a piece of paper and a pencil. The Mini-Mental State Exam, on the other hand, is more complicated and meant to be administered by a healthcare professional, like a nurse or neurologist.

Compared to the SAGE

The Self-Administered Gerocognitive Exam is, as it says, self-administered. It often includes the clock test described above but also other questions including identifying well-known animals and calculating math problems like “How many quarters are in $6.25?” This is an easier and very reliable exam that is meant to be printed out at home and completed before visiting a doctor to talk about possible dementia. The scoring, also, is slightly more complicated for the Mini-Mental State Exam than the SAGE. If you are afraid that a loved one is showing early signs of dementia, the SAGE test is a good, print-at-home way to know whether it’s simple forgetfulness or something worse. Try the SAGE test.