Folsteins Mini Mental State Examination (MMSE) was first described by Marshall F. Folstein, Suzan Folstein, & Paul R. McHugh (as cited in International Journal of Geriatric Psychiatry, 2009). Marshall Folstein, a neuropsychiatrist, created the MMSE overnight because he was not happy with a patients’ cognitive report written by wife Suzan Folstein, a psychiatrist. He presented the MMSE to the clinical director Paul R.
McHugh who acknowledged the significance of MMSE to clinicians and epidemiologists in many countries (Folstein, 1990). MMSE was originally designed to provide a brief, standardized assessment of mental status in psychiatric patients, and now detects and tracks the development of cognitive impairment in conditions such as Alzheimer’s disease (Bowden & Meade, 2005). The aim of MMSE is to screen for cognitive impairment, assess the severity of any impairment, and monitor change by serial testing (Ridha & Rossor, 2010).
It does not focus on a client’s mood, thought content, judgment and insight like the mental status examination does, but focuses on the cognitive aspects of a client’s mental purposes (Towsend, 2008). That is why it is called “mini” because it refers to the fact that this tool only concentrates on cognitive features of mental functioning of the client (Jensen & Hansen, 2008). According to Caritas Health Group (n. d. ), MMSE is a well validated screening tool for cognitive impairment by briefly measuring orientation, short term verbal memory, immediate recall, calculation, language, and constructs ability.
The clients will be asked the year, season, date, month and day of the week, name three objects, use their calculation ability by subtracting seven at least five times from 100 or spell the word world backward, test their recall ability by repeating the three objects mentioned and also test their language and constructing ability. They receive one point for each correct answer (Hickey, 2003). The test consists of 11 items that are easily given and executed, each corresponding to a cognitive functional area with a total maximum possible score of 30/30 (Costarella, et al. 2010). Scores range from 25-30 for no cognitive impairment, 21-24 for mild dementia, 14-20 for moderate, and less than 13 in severe dementia clients (Rockwood, n. d. ). Many clinicians ask additional questions to the client like “What would you do if you were in a crowded building and smelled smoke? ” for further assessment, as judgment and insight are not tested by this tool (Santacruz & Swagerty, 2001). The test is easy except the calculation which is more complex that requires extra time for the individual to think more (Bhakti, et al. 2001). There are some factors that influence the MMSE score that the examiner should consider like; depression, delirium and educational level (Jensen, 2005). In addition, MMSE is also based on the person’s age, gender and IQ and evaluates the predicted score that the client actually achieved (Green, Keaff, Knight & McMahon, 2006). In regard to education, the number of years in school is not the only basis of MMSE screening but also the quality of education that accounts for scoring differences (Peggy, 2002).
For example, a farmer may have a lower MMSE score compared to white collar workers, even after adjustment for age, financial dissatisfaction and education (Peggy, 2002). Task two: What MMSE is a very simple, easily administered mental status examination that has proved to be a more valid instrument and highly reliable for detecting cognitive impairment than using informal questioning and client’s overall impressions (MidAmerica Neuroscience Institute, 2006). It is a brief screening tool that includes items measuring a range of cognitive skills (Green, et al. 2006). It is the test that the National Health Services will recommend whether the drug treatment for Alzheimer’s disease will be prescribed to the client (Associated Newspapers Ltd. , 2010). Gregory (as cited in DeVinney, Ferrin, Pruett, & Tansey, 2005) stated that short screening instrument like MMSE would be appropriate to individual with cognitive impairment. Who MMSE is the most commonly used instrument to screen cognitive function like dementia and clients with head injury (Elder, Evans, & Nizette, 2009).
It is effective as a screening tool for cognitive impairment with elderly whether in hospital, community dwelling or adults institutions (The Hartford Institute for Geriatric Nursing, n. d. ), because it take only minutes to administer and it is very practical for routine clinical use (Oxford Journal, 2008). Where People with dementia are more responsive and more alert to their own environment (Elder et al. , 2009). Therefore, MMSE is effective in the environment where the client feel that they are safe and familiar with the things around him (Elder et al. 2009). For example in the client’s room and surrounded with meaningful objects such as photographs. Ensure that the location has good lighting and ventilation to provide for the client’s physical comfort (Merrett , 2003). According to Kitwood (as cited in Elder et al. , 2009), dementia is not a problem, instead it is our inability to accommodate the dementia sufferer’s view of the world. Why MMSE needs to be administered because it can alert the evaluator to a particular problem that needs further study (DeVinney et al. , 2005).
It also helps them to assist in gathering important information about the etiology of a patient’s dementing illness (Ball, et al. , 2002). It helps to decide whether a drug treatment for dementia would be recommended (Associated Newspapers Ltd. , 2010). MedicineNet. Inc. (2010) stated in most cases, initial stage of dementia is not identified and diagnosis is being given after years of symptoms. Therefore, early diagnosis is very important as it decrease the severity of symptoms, disease progression and strengthening cognitive abilities (MedicineNet. Inc. , 2010). How
People with dementia have mostly increased confusion, restlessness, wandering, agitation or combative behaviour in the late afternoon and evening hours (Shives, 2008). The evaluators must be flexible as much as possible about the time and the settings of the examination to avoid client conflict (Averbuch, 2010). Client may become more irritable and wary than usual and may misinterpret everything that he/she hears and sees (Mohr, 2003). Gaining a client’s permission is good practice and taking time to explain before administering the MMSE, as it develops his/her motivation and rust, and advise them to answer each question as accurately as they can (Caritas Health Group, n. d. ). Task three: Weakness MMSE is a common tool used in detecting cognitive impairment; however it is not accurate if administered by specialized neuropsychologist compared to general practitioners (GP) (Di Lallo, Mastromattei, Pezzotti, & Scalmana, 2008). Evidence of this is a study which compared the result of the MMSE applied by GPs and by specialized neuropsychologists; the result is that, GPs are more accurate (Di Lallo et al. 2008). MMSE has reports of potential for false negatives for the clients with higher level of education as the language items are simple and may not detect mild cognitive impairments (Spreen & Strauss as cited in DeVinney et al. , 2005). Patients with greater cognitive reserve are tend to maintain higher cognitive functioning in the early stage of dementia and these people are at risk of increased cognitive dysfunction and should be referred for another evaluation (National Institute of Health, 2008).
This means that the cut-score of 24 is not accurate for the highly educated dementia patients, instead a cut-score of 27 is more effective in identifying dementia in well educated individuals (National Institute of Health, 2008). Some studies prove that the MMSE is not a good tool for identifying early stage of dementia because many suspected clients pass the screening and family members feel frustrated with the result (Aging Home Health Care, 2010). Another study shows that MMSE lacks specificity in poorly educated person especially those who did not attend high school and false positive ratio is possible (De Brito-Marques, 2004).
The presence of purely physical problems can hamper with interpretation if not properly noted (Nation Master. com, n. d. ). For example if the person is unable to read or write, having difficulty with hearing and vision, the validity of the test is almost impossible to administer (Aging Home Health Care, 2010). To improve specificity, a verbal fluency test should be introduced along with the total MMSE score and it would be adjusted according to their age and educational level (Commenges, et al. , 1992). According to The Dementia Caregiver’s Toolbox (2010), MMSE was developed without various checks and balances.
Because of this, MMSE results have a severe floor and ceiling effect that leads to some biases for the client (The Dementia Caregiver’s Toolbox, 2010). The shorter time of MMSE administration does not provide the examiner enough time to observe the client (Bruneau et al. , 2007), and there is a chance for a bias response as different examiners will give different scores to the same answer from client (Suite 101. com, 2008). To avoid biases and to overestimate dementia in the population, Dr. Lampley (as cited in Peggy, 2002) pointed out that socioeconomic status, race and education should always be considered in MMSE scoring.
Strength MMSE has lots of weaknesses mentioned above but it is still remains a useful and reliable tool especially for first contact with a patient with suspected cognitive impairment (Simard, 1998). As it is a very simple test that can be administered properly by clinical or lay personnel with little training and its brevity makes it easily administered for a short period of time (Folstein & Cockrell, 1988). It is effective to separate clients with cognitive impairment from those without it as it measures a client’s cognitive status that may benefit from intervention (The Hartford Institute for Geriatric Nursing, n. . ). Over thirty years after its launch, MMSE is still considered as a rapid, informative and widely used test all over the world (Pasquier, Richard & Rhun, 2006). Different ethnics group have been using this instrument and translated into more than 35 authorized languages including Chinese (Jacob, 2007). In clinical practice and epidemiology studies throughout the world in screening for impaired cognition, MMSE has been used extensively since the early 1980’s (Billig, Cohen-Mansfield, & Stockton, 1998).
In patients where the primary concern is alzheimers disease, the MMSE is still a useful tool for screening relative cognitive status (Stead, 2009). MMSE helps the professionals to customize their care that may challenge a patient’s safety and comfort by identifying client’s area of weakness (Hospice of the Valley, n. d. ). It is a very convenient “all-in-one” test form that includes drawing tasks, writing, reading and comprehension that suits individuals with suspected cognitive impairment (PAR Inc. , 2010). MMSE is appropriate to people with dementia because it is ery brief and simple and its brevity can avoid the client feeling restless, bored, angry or even anxious during the exam (Alzheimer Scoiety, 2010). It is very important to diagnose Alzheimer’s disease or dementia because it gives the client the opportunity to address his/her changes in advance (Rozenweig, 2010). Task four: The study of Bixia, Corrada, Kawas, & Kahle-Whobleski (2007) evaluates the sensitivity and specificity of the MMSE for identifying dementia in a sample of subjects aged 90 years and over. The study consists of 435 participants in California, who are enrolled in 90+ study, a longitudinal and population based-study.
Measurements are MMSE, neurological examination to determine dementia diagnosis, and demographic data. This study states that MMSE is highly accurate for identifying dementia in subjects aged 90 years and over across different age and education groups. The subjects were subdivided into groups according to their educational attainment and age. The cut off values were adjusted according to their group. For the participants aged 90 to 93 with a college degree the cut off score was 25 with sensitivity of 82 percent and specificity of 80 percent.
For aged 94-96 with college degree the cut off score was 24 with sensitivity of 85 percent and specificity of 80 percent. Those 97 years and over with high school education or less the cut off score was 22 with 80 percent sensitivity and 76 percent specificity. The study shows that MMSE had good sensitivity and specificity to the client aged 90 years and older as long as the cut off score is adjusted based on age and education. Failure to adjust cut-offs based on age, results in a loss of specificity, regardless of the cause of age related changes in MMSE.
Sensitivity is defined as the percentage of true positive over combined false negatives and true positives in the entire sample. Specificity is the percentage of true negatives over combined false positives and true negatives in the entire sample (Bixia et al. , 2007). Study shows MMSE is the correct tool for dementia screening in subjects aged 90 years and over. It confirms that MMSE has a high specificity and sensitivity to oldest old population, therefore validity is also high as well. According to Lee, Lee, Lee, & Park (2005), the validity of the test can be determined by calculating the sensitivity and specificity of each ut-off point. Considering the educational attainment is very essential as individuals with higher education may easily cover the symptoms of early impairment (Ballard, Kennedy, & O’Brien, 2008). Akiyama, Antonucci, & Okorodudo (2002) stated that in China majority of Chinese oldest old have no educations especially those belong to rural areas. To maintain MMSE’s validity and reliability, the examiner tries to adjust the questions easily understandable and practically answerable if he/she thinks examinee’s cognitive function is normal. For example instead of asking “What the western calendar is?
The examiner will ask simple question like “What is the animal year is this year? This study proves that MMSE has a high sensitivity and specificity even to non educated oldest old population. The MMSE has been validated and extensively used both clinical practice and research since its creation in 1975 (Kurlowicz & Wallace, 1999). It is the most extensively used and studied clinical assessment tool in the world (Anthony, Bassett, Crum, & Folstein, 1993). Both the psychiatric and neurologic population has demonstrated the reliability of MMSE (Cockrell & Folstein, 1988).
Internal consistency of MMSE was judged to be high in the original Folstein study and sufficiently high enough to be clinically used (Melbourne Health, n. d. ). In addition, it is proven to be valid and reliable across a variety of epidemiological, clinical and community settings (Anthony et al. , 1993). The above research of Bixia et al. , (2007) subdivided the subjects aged 90 years and older according to their age and education without recognising their gender differences. As Zhang (2005) stated that there is an only slight gender difference rate of cognitive impairment in developed countries.
Similar to Fitcher, Meller, Schroppel, & Steinkirchner (1995) stated that age differences not gender showed an increase in oldest old. Cognitive impairment of the oldest old is one of the most serious problems in developed countries that need more attention in health care practices (Zhang, 2005). There are many assessment tools used in clinical settings for oldest old and MMSE is found the most common tool for this group of people as it suit to their socio-educational condition (Zhang, 2005). According to Kennard (2005), half of the oldest old populations are suffering dementia and it is the fastest growing segment in the western ountries. Clinicians must make the fight against Alzheimer’s disease or any kind of dementia a priority before it is too late (Alzheimer’s Association, 2009). Another evidence of this is another study confirmed that in oldest old people in society, Alzheimer’s and dementia are very common that professionals need to focus on (Alzheimer’s Association, 2009). Therefore, the validity and reliability of MMSE plays a very important role for the on time treatment of the client cognitive impairment (Bixia et al. , 2007).
