Abstract
The Mini-Mental State Examination (MMSE) is the most commonly used brief cognitive tool in the assessment of a variety of cognitive disorders. The tool comprises a short battery of 20 individual tests covering 11 domains and totalling 30 points. Typical completion time is 8 min in cognitively unimpaired individuals rising to 15 min in those with dementia. Internal consistency appears to be moderate and test-retest reliability good. However, the main psychometric issue concerns the MMSE’s diagnostic validity against dementia, mild cognitive impairment, and delirium. This chapter updates previous meta-analytic summary analyses for the performance of the MMSE in specialist and nonspecialist settings. Summary sensitivity, specificity, positive, and negative predictive values are presented. Results suggest against dementia, mild cognitive impairment, and delirium it did not perform well as a confirmatory (case-finding) tool, but it did perform adequately in a rule-out (screening) capacity. In clinical practice, this means that a high score on the MMSE would lead to about a 10 % false negative rate, and further, a low (positive) score must be followed by more extensive neuropsychological or clinical evaluation. The MMSE is neither the most accurate nor more efficient tool with which to evaluate cognitive disorders, but it has provided a benchmark against which all newer tools can be measured.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.
Shulman KI, Herrmann N, Brodaty H, et al. IPA survey of brief cognitive screening instruments. Int Psychogeriatr. 2006;18:281–94.
Diniz BSO, Yassuda MS, Nunes PV. Mini-mental State Examination performance in mild cognitive impairment subtypes. Int Psychogeriatr. 2007;19:647–56.
Han L, Cole M, Bellavance F, McCusker J, Primeau F. Tracking cognitive decline in Alzheimer’s disease using the mini-mental state examination: a meta-analysis. Int Psychogeriatr. 2000;12:231–47.
Glasser M. Alzheimer’s disease and dementing disorders: practices and experiences of rural physicians. Am J Alzheimers Dis Other Demen. 1993;8:28–35.
Brodaty H, Howarth GC, Mant A, et al. General practice and dementia. A national survey of Australian GPs. Med J Aust. 1994;160:10–4.
Lazaro L, Marcos T, Pujol J, Valdes M. Cognitive assessment and diagnosis of dementia by CAMDEX in elderly general-hospital inpatients. Int J Geriatr Psychiatry. 1995;10:603–9.
Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA. 1993;269:2386–91.
Holzer CE, Tischler GL, Leaf PJ, Myers JK. An epidemiologic assessment of cognitive impairment in a community population. Res Commun Ment Health. 1984;4:3–32.
Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992;40:922–35.
Mossello E, Boncinelli M. Mini-mental state examination: a 30-year story. Aging Clin Exp Res. 2006;18:271–3.
Crum RM, Anthony JC, Bassett SS, et al. Population-based norms for the Mini-Mental State Examination by age and education level. J Occup Med. 1994;36:13–4.
Grigoletto F, Zappala G, Anderson DW, Lebowitz BD. Norms for the Mini-Mental State Examination in a healthy population. Neurology. 1999;53:315–20.
Toglia J, Fitzgerald KA, O’Dell MW, Mastrogiovanni AR, Lin CD. The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute stroke: relationship to functional outcome. Arch Phys Med Rehabil. 2011;92:792–8.
Mystakidou K, Tsilika E, Parpa E, Galanos A, Vlahos L. Brief cognitive assessment of cancer patients: evaluation of the Mini-Mental State Examination (MMSE) psychometric properties. Psychooncology. 2007;16:352–7.
Jones RN, Gallo JJ. Dimensions of the Mini-Mental State Examination among community dwelling older adults. Psychol Med. 2000;30:605–18.
Schultz-Larsen K, Kreiner S, Lomholt RK. Mini-Mental Status Examination: mixed Rasch model item analysis derived two different cognitive dimensions of the MMSE. J Clin Epidemiol. 2007;60:268–79.
Folstein M, Anthony JC, Parhad I, Duffy B, Gruenberg EM. The meaning of cognitive impairment in the elderly. J Am Geriatr Soc. 1985;33:228–35.
Molloy DW, Alemayehu E, Roberts R. Reliability of a Standardized Mini-Mental State Examination compared with the traditional Mini-Mental State Examination. Am J Psychiatry. 1991;148:102–5.
O’Connor DW, Pollitt PA, Hyde JB, Fellows JL, Miller ND, Brook CP, et al. The reliability and validity of the Mini-Mental State in a British community survey. J Psychiatr Res. 1989;23:87–96.
Mitchell AJ. A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment. J Psychiatr Res. 2009;43:411–31.
McDowell I, Kristjansson B, Hill GB, Hebert R. Community screening for dementia: the Mini Mental State Exam (MMSE) and Modified Mini-Mental State Exam (3MS) compared. J Clin Epidemiol. 1997;50:377–83.
Huppert FA, Cabelli ST, Matthews FE, MRC Cognitive Function and Ageing Study. Brief cognitive assessment in a UK population sample – distributional properties and the relationship between the MMSE and an extended mental state examination. BMC Geriatr. 2005;5:7.
Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40:771–81.
Gagnon M, Letenneur L, Dartigues JF, et al. Validity of the Mini-Mental State Examination as a screening instrument for cognitive impairment and dementia in French elderly community residents. Neuroepidemiology. 1990;9:143–50.
Ganguli M, Belle S, Ratcliff G, et al. Sensitivity and specificity for dementia of population-based criteria for cognitive impairment: the MoVIES project. J Gerontol. 1993;48:M152–61.
Heun R, Papassotiropoulos A, Jennssen F. The validity of psychometric instruments for detection of dementia in the elderly general population. Int J Geriatr Psychiatry. 1998;13:368–80.
Kay DWK, Henderson AS, Scott R, et al. Dementia and depression among the elderly living in the Hobart community: the effect of the diagnostic criteria on the prevalence rates. Psychol Med. 1985;15:771–88.
Schultz-Larsen K, Lomholt RK, Kreiner S. Mini-Mental Status Examination: a short form of MMSE was as accurate as the original MMSE in predicting dementia. J Clin Epidemiol. 2007;60:260–7.
Fountoulakis KN, Tsolaki M, Mohs RC, Kazis A. Epidemiological dementia index: a screening instrument for Alzheimer’s disease and other types of dementia suitable for use in populations with low education level. Dement Geriatr Cogn Disord. 1998;9:329–38.
Clarke M, Jagger C, Anderson J, et al. The prevalence of dementia in a total population: a comparison of two screening instruments. Age Ageing. 1991;20:396–403.
Brayne C, Calloway P. An epidemiological study of dementia in a rural population of elderly women. Br J Psychiatry. 1989;155:214–9.
Cullen B, Fahy S, Cunningham CJ, et al. Screening for dementia in an Irish community sample using MMSE: a comparison of norm-adjusted versus fixed cut-points. Int J Geriatr Psychiatry. 2005;20:371–6.
Larner AJ. Screening utility of the Montreal Cognitive Assessment (MoCA): in place of – or as well as – the MMSE? Int Psychogeriatr. 2012;24:391–6.
Hoops S, Nazem S, Siderowf AD, Duda JE, Xie SX, Stern MB, et al. Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease. Neurology. 2009;73:1738–45.
Dalrymple-Alford JC, MacAskill MR, Nakas CT, Livingston L, Graham C, Crucian GP, et al. The MoCA: well-suited screen for cognitive impairment in Parkinson disease. Neurology. 2010;75:1717–25.
Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51:1451–4.
Brodaty H, Pond D, Kemp NM, Luscombe G, Harding L, Berman K, et al. The GPCOG: a new screening test for dementia designed for general practice. J Am Geriatr Soc. 2002;50:530–4.
Hooijer C, Dinkgreve M, Jonker C, Lindeboom J, Kay DWK. Short screening tests for dementia in the elderly population. I. A comparison between AMTS, MMSE, MSQ and SPMSQ. Int J Geriatr Psychiatry. 1992;7:559–71.
Kalida S, Gamaldo A, Grant EA, et al. Brief screening tests for the diagnosis of dementia: comparison with the mini-mental state exam. Alzheimer Dis Assoc Disord. 2005;19:8–16.
Kirby M, Denihan A, Bruce I, Coakley D, Lawlor BA. The clock drawing test in primary care: sensitivity in dementia detection and specificity against normal and depressed elderly. Int J Geriatr Psychiatry. 2001;16:935–40.
Wind AW, Schellevis FG, Van Staveren G, et al. Limitations of the Mini-Mental State Examination in diagnosing dementia in general practice. Int J Geriatr Psychiatry. 1997;12:101–8.
Grober E, Hall C, Lipton RB, Teresi JA. Primary care screen for early dementia. J Am Geriatr Soc. 2008;56:206–13.
Kalbe E, Calabrese P, Schwalen S, Kessler J. The Rapid Dementia Screening Test (RDST): a new economical tool for detecting possible patients with dementia. Dement Geriatr Cogn Disord. 2003;16:193–9.
Brooke P, Bullock R. Validation of a 6 item cognitive impairment test with a view to primary care usage. Int J Geriatr Psychiatry. 1999;14:936–40.
Tariq SH, Tumosa N, Chibnall JT, Perry 3rd MH, Morley JE. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurological disorder – a pilot study. Am J Geriatr Psychiatry. 2006;14:900–10.
O’Bryant SE, Humphreys JD, Smith GE, et al. Detecting dementia with the mini-mental state examination in highly educated individuals. Arch Neurol. 2008;65:963–7.
Chopard G, Pitard A, Ferreira S, Vanholsbeeck G, Rumbach L, Galmiche J. Combining the Memory Impairment Screen and the Isaacs Set Test: a practical tool for screening dementias. J Am Geriatr Soc. 2007;55:1426–30.
Flicker L, Logiudice D, Carlin JB, Ames D. The predictive value of dementia screening instruments in clinical populations. Int J Geriatr Psychiatry. 1997;12:203–9.
Kalbe E, Kessler J, Calabrese P, Smith R, Passmore AP, Brand M, Bullock R. DemTect: a new, sensitive cognitive screening test to support the diagnosis of mild cognitive impairment and early dementia. Int J Geriatr Psychiatry. 2004;19:136–43.
Mendiondo MS, Ashford JW, Kryscio RJ, Schmitt FA. Designing a Brief Alzheimer Screen (BAS). J Alzheimers Dis. 2003;5:391–8.
Narasimhalu K, Lee J, Auchus AP, Chen CP. Improving detection of dementia in Asian patients with low education: combining the Mini-Mental State Examination and the Informant Questionnaire on Cognitive Decline in the Elderly. Dement Geriatr Cogn Disord. 2008;25:17–22.
Yoshida H, Terada S, Honda H, et al. Validation of the revised Addenbrooke’s Cognitive Examination (ACE-R) for detecting mild cognitive impairment and dementia in a Japanese population. Int Psychogeriatr. 2012;24:28–37.
Yoshida H, Terada S, Honda H, et al. Validation of Addenbrooke’s cognitive examination for detecting early dementia in a Japanese population. Psychiatry Res. 2011;185:211–4.
Terpening Z, Cordato NJ, Hepner IJ, Lucas SK, Lindley RI. Utility of the Addenbrooke’s Cognitive Examination-Revised for the diagnosis of dementia syndromes. Australas J Ageing. 2011;30:113–8.
Meulen EFJ, Schmand B, van Campen JP, et al. The seven minute screen: a neurocognitive screening test highly sensitive to various types of dementia. J Neurol Neurosurg Psychiatry. 2004;75:700–5.
Galvin JE, Fagan AM, Holtzman DM, Mintun MA, Morris JC. Relationship of dementia screening tests with biomarkers of Alzheimer’s disease. Brain. 2010;133:3290–300.
Tang WK, Mok V, Chan SSM, et al. Screening of dementia in stroke patients with lacunar infarcts: comparison of the Mattis Dementia Rating Scale and the Mini-Mental State Examination. J Geriatr Psychiatry Neurol. 2005;18:3–7.
Borson S, Scanlan J, Brush M, Vitiliano P, Dokmak A. The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15:1021–7.
Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig M. Simplifying detection of cognitive impairment: comparison of the Mini-Cog and Mini-Mental State Examination in a multiethnic sample. J Am Geriatr Soc. 2005;53:871–4.
Tangalos EG, Smith GE, Ivnik RJ, et al. The Mini-Mental State Examination in general medical practice: clinical utility and acceptance. Mayo Clin Proc. 1997;71:829–37.
Ganzer S, Arlt S, Schoder V, et al. CSF-tau, CSF-A beta 1–42. ApoE-genotype and clinical parameters in the diagnosis of Alzheimer’s disease: combination of CSF-tau and MMSE yields highest sensitivity and specificity. J Neural Transm. 2003;110:1149–60.
Aprahamian I, Martinelli JE, Neri AL, Yassuda MS. The accuracy of the Clock Drawing Test compared to that of standard screening tests for Alzheimer’s disease: results from a study of Brazilian elderly with heterogeneous educational backgrounds. Int Psychogeriatr. 2010;22:64–71.
de Silva HA, Gunatilake SB. Mini Mental State Examination in Sinhalese: a sensitive test to screen for dementia in Sri Lanka. Int J Geriatr Psychiatry. 2002;17:134–9.
Mitchell AJ, Meader N, Pentzek M. Clinical recognition of dementia and cognitive impairment in primary care: a meta-analysis of physician accuracy. Acta Psychiatr Scand. 2011;124:165–83.
Greene JD, Baddeley AD, Hodges JR. Analysis of the episodic memory deficit in early Alzheimer’s disease: evidence from the doors and people test. Neuropsychologia. 1996;34:537–51.
Ala T, Hughes LF, Kyrouac GA, Ghobrial MW, Elble RJ. The Mini-Mental State exam may help in the differentiation of dementia with Lewy bodies and Alzheimer’s disease. Int J Geriatr Psychiatry. 2002;17:503–9.
Hanyu H, Shimizu S, Hirao K, et al. Differentiation of dementia with Lewy bodies from Alzheimer’s disease using Mini-Mental State Examination and brain perfusion SPECT. J Neurol Sci. 2006;250:97–102.
Palmqvist S, Hansson O, Minthon L, Londos E. Practical suggestions on how to differentiate dementia with Lewy bodies from Alzheimer’s disease with common cognitive tests. Int J Geriatr Psychiatry. 2009;24:1405–12.
Cormack F, Aarsland D, Ballard C, Tovee MJ. Pentagon drawing and neuropsychological performance in Dementia with Lewy Bodies, Alzheimer’s disease, Parkinson’s disease and Parkinson’s disease with dementia. Int J Geriatr Psychiatry. 2004;19:371–7.
Godefroy O, Fickl A, Roussel M, et al. Is the Montreal Cognitive Assessment superior to the Mini-Mental State Examination to detect poststroke cognitive impairment? A study with neuropsychological evaluation. Stroke. 2011;42:1712–6.
Saka E, Elibol B. Enhanced cued recall and clock drawing test performances differ in Parkinson’s and Alzheimer’s disease-related cognitive dysfunction. Parkinsonism Relat Disord. 2009;15:688–91.
Xu G, Meyer JS, Thornby J, Chowdhury M, Quach M. Screening for mild cognitive impairment (MCI) utilizing combined mini-mental-cognitive capacity examinations for identifying dementia prodrome. Int J Geriatr Psychiatry. 2002;17:1027–33.
Tang-Wai DF, Knopman DS, Geda YE, et al. Comparison of the Short Test of Mental Status and the Mini-Mental State Examination in Mild Cognitive Impairment. Arch Neurol. 2003;60:1777–81.
Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695–9.
De Marchis GM, Foderaro G, Jemora J, et al. Mild Cognitive Impairment in medical inpatients: the Mini-Mental State Examination is a promising screening tool. Dement Geriatr Cogn Disord. 2010;29:259–64.
Pendlebury ST, Mariz J, Bull L, Mehta Z, Rothwell PM. MoCA, ACE-R, and MMSE versus the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards Neuropsychological Battery after TIA and stroke. Stroke. 2012;43:464–9.
Petersen RC, Smith GE, Waring SC, et al. Aging, memory, and mild cognitive impairment. Int Psychogeriatr. 1997;9:65–9.
Inouye S, Rushing J, Foreman M, Palmer R, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med. 1998;13:234–42.
Cole M, Primeau F. Prognosis of delirium in elderly hospital patients. CMAJ. 1993;149:41–6.
Shi Q, Presutti R, Selchen D, Saposnik G. Delirium in acute stroke: a systematic review and meta-analysis. Stroke. 2012;43:645–9.
Young J, Leentjens AF, George J, Olofsson B, Gustafson Y. Systematic approaches to the prevention and management of patients with delirium. J Psychosom Res. 2008;65:267–72.
Cameron DJ, Thomas RI, Mulvihill M, Bronheim H. Delirium: a test of the Diagnostic and Statistical Manual III criteria on medical inpatients. J Am Geriatr Soc. 1987;35:1007–10.
Thomas RI, Cameron DJ, Fahs MC. A prospective study of delirium and prolonged hospital stay: exploratory study. Arch Gen Psychiatry. 1988;45:937–40.
Johnson JC, Gottlieb GL, Sullivan E, Wanich C, Kinosian B, Forciea MA, et al. Using DSM-III criteria to diagnose delirium in elderly general medical patients. J Gerontol. 1990;45:M113–9.
Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient have delirium? Value of bedside instruments. JAMA. 2010;304:779–86.
Mitchell AJ. Confusion Assessment Method is the most appropriate tool to quickly detect delirium in hospitalised patients at the bedside. Evid Based Ment Health. 2011;14:4.
Anthony JC, LeResche L, Niaz U, von Korff MR, Folstein MF. Limits of the ‘Mini-Mental State’ as a screening test for dementia and delirium among hospital patients. Psychol Med. 1982;12:397–408.
Trzepacz PT, Brenner RP, Coffman G, van Thiel DH. Delirium in liver transplantation candidates: discriminant analysis of multiple test variables. Biol Psychiatry. 1988;24:3–14.
Dyer CB, Ashton CM, Teasdale MPH. Diagnosing postoperative delirium: Comparing the Delirium Symptom Interview and the Minimental State to the Confusion Assessment Method. J Am Geriatr Soc. 1994;42:SA16.
Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE. Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics. 1996;37:533–46.
Rockwood K, Goodman J, Flynn M, Stolee P. Cross-validation of the Delirium Rating Scale in older patients. J Am Geriatr Soc. 1996;44:839–42.
Rolfson DB, McElhaney JE, Jhangri GS, Rockwood K. Validity of the confusion assessment method in detecting postoperative delirium in the elderly. Int Psychogeriatr. 1999;11:431–8.
Grassi L, Caraceni A, Beltrami E, et al. Assessing delirium in cancer patients: the Italian versions of the Delirium Rating Scale and the Memorial Delirium Assessment Scale. J Pain Symptom Manage. 2001;21:59–68.
O’Keeffe ST, Mulkerrin EC, Nayeem K, et al. Use of serial Mini-Mental State Examinations to diagnose and monitor delirium in elderly hospital patients. J Am Geriatr Soc. 2005;53:867–70.
Ringdal GI, Ringdal K, Juliebo V, et al. Using the Mini-Mental State Examination to screen for delirium in elderly patients with hip fracture. Dement Geriatr Cogn Disord. 2011;32:394–400.
Fayers PM, Hjermstad MJ, Ranhoff AH, et al. Which Mini-Mental State Exam items can be used to screen for delirium and cognitive impairment? J Pain Symptom Manage. 2005;30:41–50.
Vertese A, Lever JA, Molloy D, et al. Standardized Mini-Mental State Examination; use and interpretation. Can Fam Physician. 2001;47:2018–23.
Simard M. The Mini-Mental State Examination: strengths and weaknesses of a clinical instrument. Can Rev Alzheimers Dis Other Demen. 1998;2(3):10–2.
Galasko D, Klauber MR, Hofstetter CR, Salmon DP, Lasker B, Thal LJ. The Mini-Mental State Examination in the early diagnosis of Alzheimer’s disease. Arch Neurol. 1990;47:49–52.
Bravo G, Hébert R. Age- and education-specific reference values for the Mini-Mental and Modified Mini-Mental State Examinations derived from a non-demented elderly population. Int J Geriatr Psychiatry. 1997;12:1008–18.
Kahle-Wrobleski K, Corrada MM, Li B, Kawas CH. Sensitivity and specificity of the Mini-Mental State Examination for identifying dementia in the oldest-old: The 90+ Study. J Am Geriatr Soc. 2007;55:284–9.
Mitchell AJ, Malladi S. Screening and case finding tools for the detection of dementia. Part I: evidence-based meta-analysis of multidomain tests. Am J Geriatr Psychiatry. 2010;18:759–82.
Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, et al. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ. 2002;167:753–9.
Marcantonio ER, Bergmann MA, Kiely DK, Orav EJ, Jones RN. Randomized trial of a delirium abatement program for postacute skilled nursing facilities. J Am Geriatr Soc. 2010;58:1019–26.
van Hout H, Vernooij-Dassen M, Hoefnagels W, Grol R. Use of mini-mental state examination by GPs to diagnose dementia may be unnecessary. BMJ. 1999;319:190.
Commenges D, Gagnon M, Letenneur L, Dartigues JF, Barberger-Gateau P, Salamon R. Improving screening for dementia in the elderly using Mini-Mental State Examination subscores, Benton’s Visual Retention Test, and Isaacs’ Set Test. Epidemiology. 1992;3:185–8.
Heinik J, Solomesh I, Bleich A, et al. Are the clock-drawing test and the MMSE combined interchangeable with CAMCOG as a dementia evaluation instrument in a specialized outpatient setting? J Geriatr Psychiatry Neurol. 2003;16:74–9.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2013 Springer-Verlag London
About this chapter
Cite this chapter
Mitchell, A.J. (2013). The Mini-Mental State Examination (MMSE): An Update on Its Diagnostic Validity for Cognitive Disorders. In: Larner, A. (eds) Cognitive Screening Instruments. Springer, London. https://doi.org/10.1007/978-1-4471-2452-8_2
Download citation
DOI: https://doi.org/10.1007/978-1-4471-2452-8_2
Published:
Publisher Name: Springer, London
Print ISBN: 978-1-4471-2451-1
Online ISBN: 978-1-4471-2452-8
eBook Packages: MedicineMedicine (R0)