vr_mmse_ex09_1b_0943s

Mini-Mental State Exam (MMSE)

Tech-Administered

Background and Rationale:

Cognitive function may decline as a result of certain risk factors (e.g. hypertension,
elevated cholesterol, cardiac arrhythmias). This in turn could adversely impact the
physical functioning and quality of life of older adults. Dementia is a major illness and
cause of disability among the elderly. Cerebrovascular disease or multi infarct dementia
is the second leading cause of dementing illness among Caucasians, preceded only by
Alzheimer’s disease. The Mini-Mental State Exam (MMSE) is a widely used test of
cognitive function among the elderly; it includes tests of orientation, attention, memory,
language and visual-spatial skills.

The MMSE is a 30 point test that was designed as a short screening measure of cognitive
status. The goal of the test was to determine if people show signs of cognitive
impairment. It has come to be used widely as a screening test for progressive dementing
disorders, such as Alzheimer's disease.

Within Framingham, it is used to determine if someone is showing changes in cognitive

function, and we do so by looking for a drop in the MMSE score compared to previous
exams. If there is a drop of 3 points or more from the immediately preceding exam, we
would invite the participant into the Dementia study for further neuropsychological
testing and a neurological exam. If there is a drop in 5 points of more across all exams,
this will also trigger a request for further follow up by the Neuro group.

While the MMSE has been useful in serving as a screening tool, it also has some
significant limitations. One major issue is that younger and/or highly educated people are
likely to score the maximum score of 30. This is known as a ceiling effect - even when
people might be starting to experience real changes in cognition, the MMSE might not
pick it up until much later on. The other major limitation with the MMSE is that the test
is not diagnostic and a poor score does not always indicate the presence of. dementia. Or
even if your score suggests you have dementia, it's hard to tell what type of dementia. It
is very hard to determine with any level of confidence what areas of cognition are
impaired based on MMSE performance. Sometimes, researchers do try to look at specific
items on the test, and determine cognitive-domain specific deficits. For example, poor
performance on the recall item may lead some to decide there is a memory problem.

If there are any concerns regarding the participant’s memory, notify the Clinic
physicianand refer the participant for for further assessment with the Neuro group. The
Clinic physician should complete a Referral Form and give to the Neuro Project
Coordinator, , after the exam. Referral forms can be found in the
appendices.
If a participant has been seen by the Neuro group previously, it is indicated on the PTS
Roster screen. Sometimes a family member will tell the recruiters that there is a memory
issue.

During the admitting process, if the participant has trouble answering questions (i.e.,
children’s names, sibling’s names, etc.) the Admitter will notify the Clinic staff who will
then notify the Clinic physician.

Methods:

1. The MMSE asks questions to ascertain cognitive status. Responses are

scored:
0=incorrect
1=correct
6=item administered, participant does not answer
9=test item not administered/unknown

2. If a response is ambiguous, the interviewer records the response in the

margin so a decision can be made on its appropriateness. Please refer all
questionable responses to the neuropsychologists

3. When a participant is incapacitated by blindness, has a functional

disability, is illiterate, or is otherwise unable to respond to a question, the
interviewer should specify the problem and questions involved (see
“Factors Potentially Affecting Mental Status Testing” later in the section).

Expanded Scoring Instructions for Mini-Mental Exam:

Important note: Sometimes a participant might produce a response that is not a word
(i.e. a neologism) but has been responding with intelligible responses on previous items
(right or wrong). In this case the items should be scored 0. The key to differentiating a 0
or a 9 is consistency within test. If a person has a speech abnormality, such as aphasia or
dysarthria, across all items, most (or many) responses will be unintelligible. If a person
is, for example, demented, he/she may produce a flow of intelligible responses with
occasional unintelligible responses. A “9” must represent situations in which the
EXAMINER is not sure whether (1) the participant responded correctly (because of
slurred speech, severe stuttering, etc.), or (2) if the participant has some other factor that
prevents test item administration (such as an inability to administer copy this figure test
item to a right-handed person who has right-handed paralysis, or to someone who has a
visual impairment or inability to hear).

Scoring for Administered Individual Items: (applies only if a test item is administered)

Score 0 for the following reasons:

 Incorrect response
 I don’t know
 Unintelligible response in context of other intelligible responses

Score 9 for the following reason:

 When test item was not administered (refused or inability because

of physical limitations), or
 When the subject’s response is uninterpretable (response could be
correct, but tester is unable to discern the response).

Important note: The single exception to scoring 6 for no response is if a participant is in

a coma (this circumstance would be encountered in a nursing home visit) In this instance,
administer the first item (to establish no response -- give a 0 to the first item if there is no
response). (This exception is made to conform with the stroke protocol.)

Questions: Scripts and Procedures for Each Question:

Introductory Script: I’m going to start by asking questions that require concentration
and memory. Some questions are more difficult than others and some will be asked more
than one time.

Read each question on the form.

Record the response on the form.

1. What is the date today? (3 = correct score for month (1 pt), day (1 pt) and year (1 pt))

a. Ask for the date. Then ask specifically for parts omitted (e.g. Can you
also tell me what month, year it is?)
b. If participant supplies part or all of the date (e.g. month and day, or
month, day, and year), record as appropriate and do not ask those
questions again.

2. What is the season?

 Since distinctions between seasons can be difficult during certain months,
one week leeway is allowed on either side of the actual date.

MMSE ACCEPTABLE ANSWERS

FOR
“WHAT IS THE SEASON”?

2011
Month Correct Response Acceptable Dates
(2 Seasons)
April Spring n/a
May Spring n/a
June Spring or Summer 6/14/11 – 6/28/11
July Summer n/a
August Summer n/a
September Summer or 9/16/11 – 9/30/11
Fall/Autumn
October Fall/Autumn n/a
November Fall/Autumn n/a
December Fall/Autumn or Winter 12/15/11 – 12/29/11

2012
Month Correct Response Acceptable Dates
(2 Seasons)
January Winter n/a
February Winter n/a
March Winter or Spring 3/13/12 – 3/27/12
April Spring n/a
May Spring n/a
June Spring or Summer 6/13/12 – 6/27/12
July Summer n/a
August Summer n/a
September Summer or 9/15/12 – 9/29/12
Fall/Autumn
October Fall/Autumn
November Fall/Autumn
December Fall/Autumn or Winter 12/14/12 – 12/28/12

2013

Month Correct Response Acceptable Dates

(2 Seasons)
January Winter n/a
February Winter n/a
March Winter or Spring 3/13/13 – 3/27-13
April Spring n/a
May Spring n/a
June Spring or Summer 6/14/13 – 6/28/13
July Summer n/a
August Summer n/a
September Summer or Fall/Autumn 9/15/13 – 9/29/13
October Fall/Autumn
November Fall/Autumn
December Fall/Autumn or Winter 12/14/13 – 12/28/13

2014

Month Correct Response Acceptable Dates

(2 Seasons)
January Winter n/a
February Winter n/a
March Winter or Spring 3/13/14 – 3/27/14
April Spring n/a
May Spring n/a
June Spring or Summer 6/14/14 – 6/28/14
July Summer n/a
August Summer n/a
September Summer or Fall/Autumn 9/16/14 – 9/30/14
October Fall/Autumn
November Fall/Autumn
December Fall/Autumn or Winter 12/14/14 – 12/28/14

3. What day of the week is it?

4. What town, county, and state are we in? (Town, County, State, correct score = 3)

a. Ask the participant what town, county, and state we are in.
b. If the participant is from out of town or out of state, it is acceptable for
them to respond with the county they live in. It is okay to prompt them
if they live out of the area.
c. For offsite visits, refer to the section of the manual titled “New
England Counties” for a complete list of all counties.

5. What is the name of this place?

a. Ask the participant where they are. Any appropriate answer is okay.
(possible acceptable responses = FHS, Perini, Mt. Wayte).
b. On home visits, the examiner can ask, What is the address of this
place?(possible acceptable responses = Nursing Home, my house, or
their address).

6. What floor of the building are we on?

a. Clinic Visit = 1st Floor. If they say “Main Floor”, repeat the question
adding “now”.

7. I am going to name 3 objects. After I have said them I want you to repeat them
back to me. Are you ready? Apple, Table, Penny. Could you repeat the three
items for me? Remember what they are because I will ask you to name them
again in a few minutes:

a. Make sure participant is attentive when beginning the question.

b. Read the list of objects slowly. DO NOT REPEAT ITEMS UNTIL
AFTER THE FIRST TRIAL.
c. If participant asks you to repeat the 3 items, respond, Can you tell me
the items I just mentioned? or Just do the best you can.
d. Read Apple, Table, Penny.
e. Script: Could you repeat the three items for me?
f. Record the score for the first trial.
g. If, after scoring the first attempt, the participant has not learned the 3
objects, repeat the list of objects up to 6 times until he/she has learned
them.
h. If, 3 items are repeated regardless of order, score 3 points. Occasionally
hearing impairments prevent subjects from correctly hearing test
questions (for example, when asked to repeat three items, apple, table,
penny, they may repeat April, tablet, pencil -- these alternate responses
should be accepted both under the repetition and recall conditions).
8. Now I am going to spell a word forward and I want you to spell it backwards.
The word is WORLD. W-O-R-L-D. Please spell it in reverse order. Write in
letters __________ (letters are entered and computer scored later.

a. Read the question slowly. Where world has hyphens between the
letters, spell out the word.
b. Repeat the spelling if necessary.
c. Record the participant’s response. Write in the letter as the participant
has spelled the word.
d. If the participant spells the word forward rather than in reverse, they
can be cued once with a reminder to spell it backwards.

9. What are the 3 objects I asked you to remember a few moments ago?

a. Items may be repeated in any order.

10. What is this called? (Watch)

Show the wristwatch to the participant

Correct responses include: watch, wristwatch, timepiece
Code 1 = correct answer

11. What is this called? (Pencil)

a. Show the pencil to the participant. NOTE: the pencil

should be a standard sharpened wooden pencil with eraser.
b. Correct responses include: Pencil, number 2 pencil
c. Code 1 = correct for correct answer.

12. Please repeat the following: No ifs, ands or buts.

a. Enunciate clearly -- include the “S” at the end of ifs, ands, or buts, (if
you think the participant heard you but repeated it incorrectly, make a
note of what was missed and score 0).
b. Allow only one attempt.
c. Code 1 = correct when the participant correctly repeated the phrase.
d. Code 0 = incorrect when the participant did not repeat the phrase
exactly.

Occasionally hearing impairments prevent participants from correctly hearing

test questions. In the case of repeating no ifs, ands, or buts, some judgment
must be made on the part of the examiner as to whether the participant could
hear the “s” or not.

13. Please read the following and do what it says.

 a. Hand participant the “Please Close Your Eyes” card.
b. The participant may read the sentence out loud. The task to be coded
is the participant’s ability to follow instructions by closing his/her
eyes. It is not necessary for the sentence to be read out loud if the
participant performs the function properly.
c. Code 1 = correct when the participant closes his/her eyes.
d. Code 0 = incorrect when the participant did not close his/her eyes.

14. Please write a sentence.

a. Script: Write any complete sentence on this piece of paper for me.
b. Repeat the instructions to participant if necessary.
c. Code 1 = correct if the participant wrote a complete sentence as
directed.
d. Written commands, such as sit down, where the subject is implied, are
considered correct responses.
e. Spelling and/or punctuation errors are not counted as errors.
f. Code 0 = incorrect when the participant did not write a complete
sentence as directed.
g. Code 1 = if the participant is cognitively able to dictate a sentence but
is physically unable to write it. In this case the examiner should write
the dictated sentence and make a note that it was dictated.
Code 6 = Low vision

15. Please copy this drawing.

a. Script: Here is a drawing. Please copy the drawing on the same piece
of paper.
b. If the participant asks if the figures should be drawn separately or
together the examiner should respond, Draw the figures as you see
them.
c. To be correct, each pentagon must have 5 sides, 5 sides that point
outward. The two figures must be overlapping.
d. The overlap figures must have 4 sides.
e. Code “0” = incorrect when the participant’s figure did not match.

16. Take this piece of paper in your right hand, fold it in half with both hands,
and put it in your lap.

(If participant is unable to use right hand because of physical disability, you
can alter instructions to read “Take this piece of paper in your left hand, fold it
in half with your left hand, and put it in your lap”. The goal is to see whether
the subject is able to follow a 3-step command, so this variation to the
directions to accommodate subject’s physical limitations is allowable. )
 Read the full statement BEFORE handing the paper to the participant.

a. DO NOT direct the paper to participant’s right side. Hold the paper in
front and have the participant reach out to take it. Observe which hand
is used.
b. DO NOT repeat instructions or coach participant. Only repeat if the
examiner felt it was not heard or if instructions were not given clearly
(just repeat the directions in full as they were the first time).
c. Score: This is a 3 step command. Score one for each correctly
performed act (code 6 if low vision).

Factors Potentially Affecting Mental Status Testing

The examiner’s impression for 2IIVSULQJ([DP will include the following:

NO YES MAYBE UNKNOWN

0 1 2 9 Illiteracy or low education
0 1 2 9 Not fluent in English
0 1 2 9 Poor eyesight
0 1 2 9 Poor hearing
0 1 2 9 Other

Note: Questions cannot be answered by a proxy.