NEUROMYTHOLOGY The Mini-Mental State Examination: pitfalls and limitations Emma Devenney,1,2,3 John R Hodges1,4 1 Frontier, Neuroscience Research Australia, Sydney, Australia Prince of Wales Clinical School, University of New South Wales, Sydney, Australia 3 Brain and Mind Centre, University of Sydney, Sydney, Australia 4 School of Medical Sciences, University of New South Wales, Sydney, Australia 2 Correspondence to Dr Emma Devenney, Neuroscience Australia, Barker Street, Randwick, Sydney 2035, Australia; e.devenney@neura. edu.au Accepted 6 November 2016 To cite: Devenney E, Hodges JR. Pract Neurol Published Online First: [ please include Day Month Year] doi:10.1136/practneurol2016-001520 The Mini-Mental State Examination (MMSE) first appeared in 1975 having been developed as a screening tool for patients with dementia and psychiatric disorders in an inpatient setting.1 Folstein and colleagues did not envisage the global domination that this simple clinical tool would achieve. They clearly state in their seminal paper that ‘the MMS cannot be expected to replace a complete clinical appraisal in reaching a final diagnosis in any individual patient’. But, as frequently happens, this major caveat was quickly forgotten, and, over the course of the next 40 years, this brief 30-item examination gained immense fame among clinicians as a quick and easy method to diagnose dementia. The MMSE is strongly influenced by noncognitive domains; it does not reliably translate across cultures, as the results are likely to be confounded by language, levels of literacy, and cultural and ethical norms. Despite this, the MMSE has been translated into numerous languages including Cantonese, Arabic, Spanish and Persian.2 3 Furthermore, it is unreliable for patients with less than 5 years of education, probably because of the heavy weighting on language and mathematical abilities. A quick search through the 120 000 references related to the MMSE on PubMed quickly reveals these pitfalls, yet it continues to be the cornerstone of dementia diagnosis in many clinical rooms throughout the world. The MMSE has a role in diagnosing ‘barn door’, well-established dementia and in monitoring patients with moderate dementia, but many clinicians are still unaware of its limitations, even in a Western culture. It has been repeatedly shown that the MMSE is poor at identifying early-stage dementia, especially mild cognitive impairment: such a patient may have severe amnesia and yet score in the normal range on the MMSE. Other worrying features are the lack of components sensitive to executive function and the reliance on just one item (the overlapping pentagons) to screen for visuospatial deficits (figure 1). The MMSE is particularly feeble in assessing patients with frontotemporal dementia, many of whom score within the ‘normal’ range on the test yet cannot function in social or work situations. Another slightly longer test is the Addenbrooke’s Cognitive Examination, now in its third incarnation (ACE-III); it takes 15–20 min to administer and is used to screen for mild cognitive impairment, frontotemporal dementia and other less common causes of dementia.4 5 In this modern technological era, where medical diagnoses often rely heavily on a combination of highly complex investigations, it seems unthinkable that the diagnosis of a devastating illness such as Alzheimer’s disease would hinge on the results of a rough-and-ready 5 min test, the answers to which the patient spent the last 45 min rehearsing in the car on the way to the appointment. Never mind the fact that mood, education status and ethnicity could heavily influence the results. Perhaps even more concerning is that an equally devastating illness such as frontotemporal dementia could be completely missed because the executive and emotional deficits often experienced by patients early in the disease course are not examined by a restrictive tool that measures only the basic memory, attention, language and visuospatial functions. There is clearly a need to update practice and, while recognising the MMSE’s contribution to dementia, it is high time it retired gracefully to make room for newer, more theoretically motivated and, importantly, free assessment tools in dementia. Fortunately, there are now several superior assessment tools available for use in the clinic that can be supported by neuropsychological assessment and, Devenney E, Hodges JR. Pract Neurol 2016;0:1–2. doi:10.1136/practneurol-2016-001520 1 NEUROMYTHOLOGY Figure 1 Comparison of the components used to screen for visuospatial deficits in the Mini-Mental State Examination and the Addenbrooke’s Cognitive Examination – III. when this is inconclusive, by brain imaging. However, the issue of which type of imaging is another story. Contributors ED and JRH contributed to the conception and design of the work and drafting and revising the manuscript; they approve the final version and agree to be accountable for the work. Funding This work was supported by funding to Forefront, a collaborative research group dedicated to the study of frontotemporal dementia and motor neurone disease, from the National Health and Medical Research Council of Australia programme grant (No 1037746) and the Australian Research Council Centre of Excellence in Cognition and its Disorders Memory Node (No CE110001021). ED is supported by a UNSW PhD scholarship and the Motor Neurone Disease Association UK. Competing interests None declared. Provenance and peer review Commissioned. Externally peer reviewed. This paper was reviewed by Martin Rossor, London, UK. 2 REFERENCES 1 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. 2 Espino DV, Lichtenstein MJ, Palmer RF, et al. Ethnic differences in mini-mental state examination (MMSE) scores: where you live makes a difference. J Am Geriatr Soc 2001;49:538–48. 3 Escobar JI, Burnam A, Karno M, et al. Use of the mini-mental state examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts. J Nerv Ment Dis 1986;174:607–14. 4 Hsieh S, Schubert S, Hoon C, et al. Validation of the Addenbrooke’s cognitive examination III in frontotemporal dementia and Alzheimer’s disease. Dement Geriatr Cogn Disord. 2013;36:242–50. 5 Mathuranath PS, Nestor PJ, Berrios GE, et al. A brief cognitive test battery to differentiate Alzheimer’s disease and frontotemporal dementia. Neurology 2000;55:1613–20. Devenney E, Hodges JR. Pract Neurol 2016;0:1–2. doi:10.1136/practneurol-2016-001520
