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Mini-Mental State Examination (MMSE)
Availability
Please visit this website for more information about the instrument: Mini-Mental State Examination
Classification
NeuroRehab Supplemental - Highly Recommended
Recommendations for Use: Indicated for studies requiring a brief cognitive screening measure for moderate to severe cognitive impairments.
 
Supplemental: Huntington's Disease (HD), Mitochondrial Disease (Mito), Parkinson's Disease (PD)
 
Exploratory: Subarachnoid Hemorrhage (SAH) and Unruptured Cerebral Aneurysm
Short Description of Instrument
Purpose: The Mini-Mental State Examination (MMSE) is a brief, global cognitive rating scale that was developed to identify cognitive status in adults. It has been used in PD patients without cognitive impairment, with mild cognitive impairment (MCI), and with dementia.
 
Overview: The MMSE covers orientation, repetition, verbal recall, attention and calculation, language, and visual construction. It has been used in many PD-related studies and is a global screening instrument that is administered by a trained examiner to the patient. The MMSE is also embedded in the original Addenbrooke's Cognitive Examination (ACE) and has been modified for Parkinson's disease (PD) by the addition of primarily executive function items in the Mini-Mental Parkinson (MMP). The MMSE has a short administration time (approximately 5 minutes on average). It is available in approximately 75 languages. For alternate languages see https://www.parinc.com/Products/Pkey/237.
 
There is a revised edition with updated norms and revised versions (i.e., MMSE-2 standard version, MMSE-2 brief version, MMSE-2 expanded version, including alternate versions for each) from Psychological Assessment Resources (PAR).
Comments/Special Instructions
Parkinson's Disease-specific: Although once recommended by the Movement Disorder Society (MDS) for identifying cognitively-impaired PD patients and for characterizing PD dementia (Dubois et al., 2007), a recent review by the MDS Rating Scale Task Force did not recommend the MMSE as a preferred global cognitive scale for use in PD (Skorvanek et al., 2018).
 
NeuroRehab-specific: This test will work as a cognitive screening for significant impairment but lacks sensitivity to mild impairments. It is a legacy measure that is still useful in certain conditions that may be associated with moderate to severe impairment. It has not done well in detecting mild to moderate impairments (e.g., those associated with HIV).
Scoring and Psychometric Properties
Scoring: Scores are based on a 30-point scale (range 0-30, higher scores reflecting better cognition) with 5 subscales: orientation (10 points), registration and short-term recall (6 points), attention and concentration (5 points), language (both oral and written, 8 points); and visuospatial function (1 point). The higher the scores the better the cognitive function. There are age- and education-adjusted norms for the MMSE.
 
Psychometric Properties: Internal consistency in clinical samples .66-.79 (Psychological Assessment Resources; PAR). Aggrawal & Kean (2010) report internal consistency of .78. Tombaugh (2005) reports retest correlations as .48-.65.
 
Parkinson's Disease-specific: In a comparison of the MMSE and Montreal Cognitive Assessment (MoCA) in a cohort of PD patients with normal cognition, MCI and dementia, the mean MMSE score was approximately 3 points higher (28 vs. 25), and the discriminant validity for any cognitive disorder was lower for the MMSE than for the MoCA (54% vs. 64%) (Hoops et al.). In similar research both the MoCA and SCales for Outcomes in PArkinson's disease-COGnition (SCOPA-COG) were found to be superior to the MMSE in the simultaneous classification of the aforementioned three cognitive groups in PD (3-dimensional ROC surface, MoCA=79%; SCOPA-COG= 74%; MMSE=56-62%) (Dalrymple-Alford et al.). In a randomized controlled trial of rivastigmine (3-12 mg) in individuals with mild-to-moderate PD dementia (N=410), rivastigmine improved MMSE score (p=0.03) (Emre et al.). In another randomized control trial (N=55) of atomoxetine for the treatment of depression in non-demented individuals with PD and MMSE score >14, those who received atomoxetine (target dose 80 mg/day) had a greater mean change in MMSE at 8 weeks compared to placebo (p=0.003) (Weintraub et al., 2010). The MMSE may not be similarly sensitive to decline at various time points in PD disease course, and rate of decline is non-linear and may not reach an inflection point until an average of 13 years after diagnosis (Aarsland et al., 2011). Annual rate of decline averages 1 point in PD and 2.3 points in PDD.
Rationale/Justification
Strengths: Has been actively used in research for approximately 50 years across multiple populations. May be associated with rehabilitation outcomes (Poynter et al., 2011). Almost all clinicians have experience in administering this screening test.
 
Weaknesses: Lacks sensitivity to initial or mild levels of cognitive impairment (i.e., ceiling effect) that would frequently occur within PD (Zadikoff et al., 2008; Nazem et al., 2009; Snyder et al., 2021) and rehabilitation populations. Restricted range at upper end limits utility as a gauge of cognitive improvement and detecting cognitive decline over the short-term (Faust-Socher et al., 2019). This may be due in part to the fact that the instrument focused more on memory, orientation and language function, and less on executive and visuospatial abilities. In addition, other cognitive scales (e.g., the MoCA and Dementia Rating Scale (DRS-2)) have shown to be superior for the detection of PD dementia. Finally, once freely available and widely disseminated, PAR now holds the copyright for the MMSE and charges for its use.
 
Huntington's Disease-Specific:
Strengths: The MMSE is well-used in HD studies; the International Parkinson and Movement Society classified the MMSE as "suggested" for evaluating severity of cognitive impairment in HD patients (Mestre et al., 2018).
 
Weaknesses: The MMSE is not as sensitive as the MoCA in HD patients; evidence of floor/ceiling effects in the early premanifest stages of HD has been found.
References
Key Reference:
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 Nov;12(3):189-98.
 
Additional References:
Aarsland D, Andersen K, Larsen JP, Perry R, Wentzel-Larsen T, Lolk A, Kragh-Sørensen P. The rate of cognitive decline in Parkinson disease. Arch Neurol. 2004 Dec;61(12):1906-11.
 
Aarsland D, Muniz G, Matthews F. Nonlinear decline of mini-mental state examination in Parkinson's disease. Mov Disord. 2011 Feb 1;26(2):334-7.
 
Aggarwal A, Kean E. Comparison of the Folstein Mini Mental State Examination (MMSE) to the Montreal Cognitive Assessment (MoCA) as a screening tool in an inpatient rehabilitation setting. Neurosci Med. 2010;1(2):39-42.
 
Abreu D, Ware J, Georgiou-Karistianis N, Leavitt BR, Fitzer-Attas CJ, Lobo R, Fernandes AR, Handley O, Anderson KE, Stout JC, Sampaio C. Utility of Huntington's Disease Assessments by Disease Stage: Floor/Ceiling Effects. Front Neurol. 2021 Jul 15;12:595679.
 
Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA. 1993 May 12;269(18):2386-91.
 
Dalrymple-Alford JC, MacAskill MR, Nakas CT, Livingston L, Graham C, Crucian GP, Melzer TR, Kirwan J, Keenan R, Wells S, Porter RJ, Watts R, Anderson TJ. The MoCA: well-suited screen for cognitive impairment in Parkinson disease. Neurology. 2010 Nov 9;75(19):1717-25.
 
Dubois B, Burn D, Goetz C, Aarsland D, Brown RG, Broe GA, Dickson D, Duyckaerts C, Cummings J, Gauthier S, Korczyn A, Lees A, Levy R, Litvan I, Mizuno Y, McKeith IG, Olanow CW, Poewe W, Sampaio C, Tolosa E, Emre M. Diagnostic procedures for Parkinson's disease dementia: recommendations from the movement disorder society task force. Mov Disord. 2007 Dec;22(16):2314-24.
 
Emre M, Aarsland D, Albanese A, Byrne EJ, Deuschl G, De Deyn PP, Durif F, Kulisevsky J, van Laar T, Lees A, Poewe W, Robillard A, Rosa MM, Wolters E, Quarg P, Tekin S, Lane R. Rivastigmine for dementia associated with Parkinson's disease. N Engl J Med. 2004 Dec 9;351(24):2509-18.
 
Hoops S, Nazem S, Siderowf AD, Duda JE, Xie SX, Stern MB, Weintraub D. Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease. Neurology. 2009 Nov 24;73(21):1738-45.
 
Faust-Socher A, Duff-Canning S, Grabovsky A, Armstrong MJ, Rothberg B, Eslinger PJ, Meaney CA, Schneider RB, Tang-Wai DF, Fox SH, Zadikoff C, Kennedy N, Chou KL, Persad C, Litvan I, Mast BT, Gerstenecker AT, Weintraub S, Reginold W, Marras C. Responsiveness to Change of the Montreal Cognitive Assessment, Mini-Mental State Examination, and SCOPA-Cog in Non-Demented Patients with Parkinson's Disease. Dement Geriatr Cogn Disord. 2019;47(4-6):187-197.
 
Mestre TA, Bachoud-Lévi AC, Marinus J, Stout JC, Paulsen JS, Como P, Duff K, Sampaio C, Goetz CG, Cubo E, Stebbins GT, Martinez-Martin P; Members of the MDS Committee on Rating Scales Development. Rating scales for cognition in Huntington's disease: Critique and recommendations. Mov Disord. 2018 Feb;33(2):187-195.
 
Nazem S, Siderowf AD, Duda JE, Have TT, Colcher A, Horn SS, Moberg PJ, Wilkinson JR, Hurtig HI, Stern MB, Weintraub D. Montreal cognitive assessment performance in patients with Parkinson's disease with "normal" global cognition according to mini-mental state examination score. J Am Geriatr Soc. 2009 Feb;57(2):304-8.
 
Poynter L, Kwan J, Sayer AA, Vassallo M. Does cognitive impairment affect rehabilitation outcome? J Am Geriatr Soc. 2011 Nov;59(11):2108-11.
 
Skorvanek M, Goldman JG, Jahanshahi M, Marras C, Rektorova I, Schmand B, van Duijn E, Goetz CG, Weintraub D, Stebbins GT, Martinez-Martin P; members of the MDS Rating Scales Review Committee. Global scales for cognitive screening in Parkinson's disease: Critique and recommendations. Mov Disord. 2018 Feb;33(2):208-218.
 
Snyder A, Gruber-Baldini AL, Rainer von Coelln F, Savitt JM, Reich SG, Armstrong MJ, Shulman LM. Comparison of Mini-Mental State Examination and Montreal Cognitive Assessment Ratings Across Levels of Parkinson's Disease Severity. J Parkinsons Dis. 2021;11(4):1995-2003.
 
Tombaugh TN. Test-retest reliable coefficients and 5-year change scores for the MMSE and 3MS. Arch Clin Neuropsychol. 2005 Jun;20(4):485-503.
 
Weintraub D, Mavandadi S, Mamikonyan E, Siderowf AD, Duda JE, Hurtig HI, Colcher A, Horn SS, Nazem S, Ten Have TR, Stern MB. Atomoxetine for depression and other neuropsychiatric symptoms in Parkinson disease. Neurology. 2010 Aug 3;75(5):448-55.
 
Zadikoff C, Fox SH, Tang-Wai DF, Thomsen T, de Bie RM, Wadia P, Miyasaki J, Duff-Canning S, Lang AE, Marras C. A comparison of the mini mental state exam to the Montreal cognitive assessment in identifying cognitive deficits in Parkinson's disease. Mov Disord. 2008 Jan 30;23(2):297-9.
 
Document last updated June 2024