Copia - MMSE Technique

Gonzalez MD

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Cognitive assessment

Factors that influence the MMSE score

Scoring system

Students Resources: "The Mini Mental status" (CSD focus)

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How to conduct the MMSE

Requirements for performing MMSE

Reversibility must be ruled out, e.g., medications misuse, insmonia, etc

Dementia is a progressive, objective, and irreversible decline in cognitive functions and or behavior severe enough to impairs daily life functioning

A pattern of physiological modifications resulting from advanced age, allowing an adequate cognitive function.

An objective cognitive impairment on neurocognitive testing in the absence of significant impairment of instrumental activities of daily living.

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Dementia(Major Neurocognitive Disorder)

Mild Cognitive Impairment

Healthy Brain Aging

Approximately 200 validation studies have been published using the MMSE as the principal tool for cognitive impairment screening.

Since then it has become the most commonly used cognitive screener world wide

A quick bedside test published in 1975 as a practical method of grading cognitive impairment

It covers 11 cognitive domains and totalling 30 points

It can be administered in 5 to 10 minutes A score of fewer than 24 points signifies cognitive impairmentThe test can be adjusted for educational level and cultural background.

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

Published by Oxford University Press on behalf of the British Geriatrics Society.

Age and Ageing 2021; 50: 72–80 doi: 10.1093/ageing/afaa228

Mild Cognitive Impairment: the Manchester consensus

MMSE concept

Which brain regions are assessed during the administration of the MMSE?

Most cognitive tests are infl uenced by age, education, and ethnicity and the MMSE is no exception.12% percent of the variance in MMSE scores can be attributed to age and education alone

A cut-off <24 serves as a reference standard for cognitive impairment (sensitivity 86 % and specificity 92 %)

The MMSE convers 11 domains domains including orientation, registration, attention or calculation (serial sevens or spelling), recall, naming, repetition, comprehension (verbal and written), writing, and construction.

Any patients that are above the age of 65 years old or any adult patients that are concerned about losing their COGNITION. There are no benefits to screen when patients show NO symptoms or complaints. The focused pupulation includes patients that present with: (all of them are risk factors that increase the risk of dementia)

1. Symptoms of dementia and other cognitive problems
2. Family history of dementia and AD
3. Repeated head trauma (once condition is stable)
4. Cardiovascular diseases or risks (including diabetes, smoking et cetera, once they are stabilized)
5. Low education status
6. Hearing and vision loss (perform the MMSE once they are fully corrected)
7. Depression and anxiety (and other psychyatric conditions, perform the MMSE once they are fully resolved)
8. Physical inactivity, etc

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

MMSE Focused population: Who should be tested?

Around the world, there is a MMSE version translated in almost every language worldwide, so use the version that is addressing the patient´s language and cultural background or send the patient to a specialist who is proficient in patient´s language and culture, AVOID TRANSLATING THE TEST ON YOUR OWN

The MMSE should be adjusted by age, educational level, cultural background and ethnicity

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

Published by Oxford University Press on behalf of the British Geriatrics Society.

Age and Ageing 2021; 50: 72–80 doi: 10.1093/ageing/afaa228

Mild Cognitive Impairment: the Manchester consensus

MMSE general recommendations and instructions

This evaluation must be conducted in an stable clinical setting.

Quantifying a patient´s cognitive capabilities should be executed striving to optimize the patient´s cognitive performance while minimizing any potential disruptions or distractions that could temporarily alter their cognitive condition.

MMSE general recommendations (1)

4. The MMSE has been available with information that enables patient-specific norms on the basis of age and educational level.

"I am going to ask you some questions and give you some problems to solve. Please try to answer as best you can."

It's important to note that this test isn't about passing or failing; it provides valuable information about the patient's cognitive health!!!

1. Always ask for permision and explain the purpose of the examination before applying the test
2. The MMSE should run for about 10 minutes and does not require extensive training from the health care staff.
3. Avoid telling the patient´s they are being timed (this is unnecessary pressure for the patient, the patient should be calmed at the time of the examination)

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

MMSE general recommendations (2)

1. Try to get the person to sit down facing you.
2. Assess the peron’s ability to hear and understand simple conversations. If the person uses hearing or visual aids, provide these before starting.
3. Introduce yourself and try to get the person’s confidence.
4. Before you begin, get the person’s permission, e.g. Would it be all right to ask you same questions about your memory? This helps to avoid catastrophic reactions.
5. Ask each question a maximum of three times. If the subject does not respond, score 0.
6. If the person answers incorrectly, score 0. Accept that answer and do not ask the question again, or provide any physical clues such as head shaking, etc.
7. The following equipment is required: A wristwatch, a pencil
8. If the person interrupts (e.g. What is this for?), just reply: I will explain in a few minnutes, when we are finished.

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

MMSE general recommendations (3)

Remember that our patients are already feeling distressed and worried about the possibility of cognitive deficits. In some cases, they may find it difficult to acknowledge these issues due to a condition called agnosognosia. Please approach these patients with the utmost care, compassion, and warmth

• Get the person to sit down facing you and stablish a respectful and warm environment.

• Ask each question a maximum of 3 times (except for the section with the "3 word repetition") . If the person does not respond, score zero. Proceed to the next question smoothly way without causing patient alarm.

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

Directions for administration: SOFT SKILLS & EMPATHY

"The basics": preparation & materials

7. STANDARD TEST MATERIALS: Please ensure that you possess a monochromatic (black colored) pencil and pen rather than a multicolored variant. A standard sheet of A4-sized paper. A traditional analog wristwatch, as opposed to a modern smartwatch.

1. SENSORIAL DEFICITS COVERAGE -- MAXIMIZE COMMUNICATION: Ensure that patients have access to their prescription eyeglasses and hearing aids if required.
2. INDEPENDANT PATIENT INTERACTION: Minimize the involvement of next of kin or other individuals in assisting or answering questions on the patient's behalf. Provide a quiet and conducive environment for the patient to concentrate.
3. OPTIMAL TESTING ENVIRONMENT: Prior to the assessment, verify that the patient is not experiencing an acute decompensated illness (insomnia, hyperglycaemia, hypertensive crisis, acute hemorrhage, acute abdomen, pain, etc).
4. PRE-EXISTING CONDITION STABILIZATION: For patients with pre-existing medical conditions, ensure their conditions are adequately stabilized before proceeding with the examination.
5. VITAL SIGNS ASSESSMENT: Confirm that the patient's vital signs are within normal ranges and under control.
6. REDUCING BIAS FROM TEMPORARY COGNITIVE IMPAIRMENT CAUSES: Verify that the patient is not currently experiencing a temporary altered cognitive state, such as DELIRIUM, being under the influence of sedatives or anticonvulsants. In case of such conditions, it is recommended to refer the patient to a specialist capable of addressing patients with mixed clinical features.

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

MMSE specific adjustments

1. Score as if it was unsuccessfully performed, but note and always clarify that it was due to language barrier or physical impairment
2. Deduct the incomplete items from the total score (e.g. - a total score out of 28, instead of 30 if they were unable to write or draw the last two items).
3. This corrected score can further be corrected back to a score out of 30. (e.g. - score of 26/28, would be the equivalent of (26/28)*30 (=27.85), which would give a total score of 27.85/30.

When a patient is unable to complete items on the test due to physical impairment (e.g. - unable to draw with hand due to paralysis), there are several ways to correct for this (choose one):

MMSE adjustments: physical impairment

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

**** Reminder: People who have physical, NONcognitive disabilities should not score lower just because they are physically unable to perform certain tasks.

Motor impairment and MMSE performance

1. For example, an arm amputee obviously cannot “fold the paper in half once with both hands” as item 20 directs. Modify the test by asking the person to take the paper in his or her hand, crumple it up and throw it on the floor. If the test cannot be modified, then omit the task.
2. The score from this task is subtracted from the total score (30) to give a new total. The person’s score is then adjusted to this new total score.

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

Published by Oxford University Press on behalf of the British Geriatrics Society.

Age and Ageing 2021; 50: 72–80 doi: 10.1093/ageing/afaa228

Mild Cognitive Impairment: the Manchester consensus

Academic level

The MMSE should be customized to match the patient's educational background. In general, a final adjustment is applied to determine the ultimate score.

In higher education levels, the MMSE scores increase and the range of scores narrow. Patients with lower education may receive a false positive diagnosis, and conversely, individuals with higher education level may mask any mild cognitive impairment (false negative).

MMSE components and scoring

6. Repetition/Registration: Tell the patient to listen carefully, because you will ask them to repeat after you three words. Speak loudly and clearly and pause for 1 second after each word, in a monotone voice. Three unrelated words are typically used (e.g. - ball, tree, fork). If the patient is unable to repeat all three words on the first try, get them to repeat them again up to five times until they can say them all back in succession. However, the only the score from the first try is recorded. 7. Calculation (Serial 7s) Ask the patient to take away 7 from 100. Ask them to continue subtracting 7 and continue to a total of 5 subtractions (one point is given for each correct answer to a maximum score of five points). If serial 7s cannot be performed correctly, then they should be asked to spell WORLD, note the performance on both, and use the highest score available.

MMSE: Components and scoring

1. Temporal Orientation: This section worths five points. Allow 10 sec for each reply. Allow certain variations.
2. Physical Orientation: This section worths five points for this section. Allow 10 sec for each reply. Accept exact answers only.
3. Declarative and semantic memory: This section worths three points. Repeat upto 5 times but only score the 1st attempt.
4. Attention and calculation: The patient is asked to subtract seven from 100 and seven from each new number five times. Alternatively, they may be asked to spell "world" backward. Each correct subtraction or letter spelled backward earns one point, totaling five points for this section.
5. Language, semantic functioning and praxis: This section includes multiple tasks, such as naming two familiar objects, repeating a specific phrase, following a three-step command, reading and obeying a written command, writing a sentence, and copying a complex polygon. Each correctly performed task earns one point, totaling nine points for this section.

Adding all these points together gives a total score out of 30. Remember, administering the MMSE requires careful attention to ensure the most precise and reliable results.

8. MOTOR CONSTRUCTIONAL ABILITY: CLOSE YOUR EYES written in LARGE LETTERS and two five-sided figures intersecting to make a four-sided figure, and a space for the person to write down a sentence.

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

MMSE. Components & scoring (2)

• Once subject starts - do not interrupt - allow him/her to proceed until five subtractions have been made.
• If subject stops before five subtractions have been made, repeat the original instruction keep subtracting seven from what s left (maximum 3 times)

Say: Subtract 7 from 100 and keep subtracting 7 from whats left.

It can be used as an alternate to spelling "WORLD" backwards in people who are illiterate.

Complex commands (2): The serial sevens

Complex commands (1): Spelling

1. There are many different ways and "systems" for scoring world backwards.
2. Score ORDER not SEQUENCE.
3. Simply write down the correct response: DLROW.

1. Now draw lines between the same letters on the response given and DLROW.
2. These lines MAY NOT CROSS.
3. The person’s score is the maximum number of lines that can be drawn, without crossing any.

• Appropriate use of available treatment options.

Have the patient read and obey the following: ”Close your eyes”. (Write in large letters.) (1 point)

The subject is given the pencil and paper and asked to write a complete sentence ot their own choice. Thirty seconds are given and the sentence must have a subject, verb and object. Spelling mistakes are ignored.

Complex commands (4): Writting a sentence and "Close your eyes)

Subjects are asked to name a watch and pencil. Use a traditional wooden pencil with an eraser on the end. Use a watch with traditional face. "Clock" or "time" are not accepted.

Complex commands (3): Watch and pencil

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

Have the subject copy the figure

Complex commands (5): The pentagons

Give the subject the pencil, with the eraser, and a clean piece of paper.Many older adults draw shaky, wiggly lines with unclear angles that are more curved than straight. These are acceptable, as long as the person has two five-sided figures intersecting to form a four-sided figure.

All 10 angles must be present and two must intersect)

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

Published by Oxford University Press on behalf of the British Geriatrics Society.

Age and Ageing 2021; 50: 72–80 doi: 10.1093/ageing/afaa228

Mild Cognitive Impairment: the Manchester consensus

• The rater holds up a piece of paper and says "Take this piece of paper in your (non-dominant) hand, fold the paper in half once with both hands and put it down on the floor".

• Thirty seconds are allowed

• The nondominant hand is used because people will automatically take objects with their dominant hand. This test is given at the end so the rater can observe the hand that the person used to write in the previous task.

• Do not allow the person to take the paper until you have given the three instructions.

• Hold the paper in the subject’s midline and push it forward when you have given the instructions, not before.

Complex commands (6): Folding paper

Alzheimer´s Societyhttps://www.alzheimers.org.uk/Alzheimer´s Disease International https://www.alzint.org

Published by Oxford University Press on behalf of the British Geriatrics Society.

Age and Ageing 2021; 50: 72–80 doi: 10.1093/ageing/afaa228

Mild Cognitive Impairment: the Manchester consensus

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