Full Mini-Mental State Examination Research Articles

Validation of a Brief Multi-Dimensional Assessment of Dementia Severity.

Briefer measures of symptoms and functional limitations may reduce assessment burden and facilitate monitoring populations of persons with dementia (PWD). Prospective follow-up study. University-based dementia care management program. 1,091 PWD. We assessed cognition (Mini Mental State Examination (MMSE)-11 tasks), neuropsychiatric symptom severity (Neuropsychiatric Inventory Questionnaire Severity Scale (NPIQ-S)-12 items), and functional ability (Activities of Daily Living (ADL)-6 items; Functional Activities Questionnaire (FAQ)-10 items). Item response theory was used to select subsets of items by identifying low item discrimination (<1.50), poor item fit (χ2 ), local dependence (LD), and with difficulty similar to other items. We estimated correlations between original and shorter scales and compared their associations with mortality. We added two symptoms (trouble swallowing, coughing when eating) reflecting late-stage dementia complications, created a multi-dimensional dementia assessment composite, and examined its association with mortality. Five MMSE tasks were eliminated: two with low discrimination, two with difficulty similar to other items, and one with poor fit. The remaining tasks were correlated with the full MMSE at r = 0.82. We retained three ADLs that were correlated with the total ADL set at r = 0.95 and kept five FAQ items that were not LD (correlation with full FAQ, r = 0.97). Associations with mortality were similar between the longer and shorter scales. A higher score on the composite (range 0-100) indicates worse dementia impact and was associated with mortality (hazard ratio (HR) per scale point: 1.03 (1.02-1.04)). These brief assessments and dementia composite may reduce administration time while preserving validity.

Predictive Value of Odor Identification for Incident Dementia: The Shanghai Aging Study.

ObjectiveThis study aimed to evaluate the value of odors in the olfactory identification (OI) test and other known risk factors for predicting incident dementia in the prospective Shanghai Aging Study.MethodsAt baseline, OI was assessed using the Sniffin’ Sticks Screening Test 12, which contains 12 different odors. Cognition assessment and consensus diagnosis were conducted at both baseline and follow-up to identify incident dementia. Four different multivariable logistic regression (MLR) models were used for predicting incident dementia. In the no-odor model, only demographics, lifestyle, and medical history variables were included. In the single-odor model, we further added one single odor to the first model. In the full model, all 12 odors were included. In the stepwise model, the variables were selected using a bidirectional stepwise selection method. The predictive abilities of these models were evaluated by the area under the receiver operating characteristic curve (AUC). The permutation importance method was used to evaluate the relative importance of different odors and other known risk factors.ResultsSeventy-five (8%) incident dementia cases were diagnosed during 4.9 years of follow-up among 947 participants. The full and the stepwise MLR model (AUC = 0.916 and 0.914, respectively) have better predictive abilities compared with those of the no- or single-odor models. The five most important variables are Mini-Mental State Examination (MMSE) score, age, peppermint detection, coronary artery disease, and height in the full model, and MMSE, age, peppermint detection, stroke, and education in the stepwise model. The combination of only the top five variables in the stepwise model (AUC = 0.901 and sensitivity = 0.880) has as a good a predictive ability as other models.ConclusionThe ability to smell peppermint might be one of the useful indicators for predicting dementia. Combining peppermint detection with MMSE, age, education, and history of stroke may have sensitive and robust predictive value for dementia in older adults.

Performance of an abbreviated mini mental examination to detect dementia in older people

The usefulness of the abbreviated Mini-Mental State Examination included in the Chilean Functional assessment of elderly people (MM-SE-EFAM) to detect Dementia has not been determined. To assess the performance of the MMSE-EFAM to detect dementia. We studied a non-probabilistic sample of subjects older than 65 years who had been assessed by the MMSE-EFAM in a Chilean primary care center during a period of 6 months. Patients underwent clinical evaluation by a neurologist blinded to MMSE-EFAM score, to establish the diagnosis of dementia using DSM-IV-TR criteria. Besides, the full Mini-Mental State Examination (MMSE) was applied. The clinical diagnosis of Dementia was established in 13 of the 54 peoples evaluated. MMSE-EFAM had a sensitivity of 30.8% (95% confidence intervals (CI); 9-61.4) and a specificity of 90.2% (95% CI; 76.9%-97.3%), while MMSE had a sensitivity of 84.6% (95% CI; 54.6-98.1) and a specificity of 58.5% (95% CI; 42.1-73.7). In a receiver operating characteristic (ROC) curve analysis, the areas under the curve (AUC) were 0.77 (95% CI; 0.61-0.93) and 0.82 (95% CI; 0.70-0.95) for MMSE-EFAM and MMSE, respectively. Socio-demographic variables did not influence test performance in both cases. MMSE-EFAM has a low sensitivity to detect patients with Dementia and it is not an effective screening tool. These results are in agreement with the evidence and international guidelines that do not support the use of cognitive screening tools to detect dementia in the older general population.

Validation of abridged mini-mental state examination scales using population-based data from Sweden and USA

The objective of this study is to validate two abridged versions of the mini-mental state examination (MMSE): one intended for use in face-to-face interviews, and the other developed for telephonic interviews, using data from Sweden and the US to validate the abridged scales against dementia diagnoses as well as to compare their performance to that of the full MMSE scale. The abridged versions were based on eight domains from the original MMSE scale. The domains included in the MMSE-SF were registration, orientation, delayed recall, attention, and visual spatial ability. In the MMSE-SF-C, the visual spatial ability item was excluded, and instead, one additional orientation item was added. There were 794 participants from the Swedish HARMONY study [mean age 81.8 (4.8); the proportion of cognitively impaired was 51 %] and 576 participants from the US ADAMS study [mean age 83.2 (5.7); the proportion of cognitively impaired was 65 %] where it was possible to compare abridged MMSE scales to dementia diagnoses and to the full MMSE scale. We estimated the sensitivity and specificity levels of the abridged tests, using clinical diagnoses as reference. Analyses with both the HARMONY and the ADAMS data indicated comparable levels of sensitivity and specificity in detecting cognitive impairment for the two abridged scales relative to the full MMSE. Receiver operating characteristic curves indicated that the two abridged scales corresponded well to those of the full MMSE. The two abridged tests have adequate validity and correspond well with the full MMSE. The abridged versions could therefore be alternatives to consider in larger population studies where interview length is restricted, and the respondent burden is high.

Selective verbal memory impairment due to left fornical crus injury in a patient with intraventricular hemorrhage.

Selective verbal memory impairment due to left fornical crus injury in a patient with intraventricular hemorrhage.

The sound of silence

In January, 2011, a previously well 68-year-old woman, presented to our neurology outpatients department with a 6 week history of hearing a male voice singing and gradual bilateral hearing loss over the course of 1 year. The singing started suddenly with songs she knew from her childhood, and more recently she also reported hearing a choir. The singing was perceived as external, heard only in the left ear, and continued all day and night. She reported that the voices were irritating, particularly when trying to sleep. They stopped when she fell asleep and did not interfere with her daytime activities. She had insight that the voices were imaginary but said that she could not “switch them off ” and did not recall any specifi c triggers. There was no alteration of the symptoms with her mood or tiredness. There was no reported change in her mood, with no signs of depression or mania, nor thoughts or intentions of self harm. She did not report tinnitus, other sensory hallucinations, or any symptoms of epileptic seizures such as vacant attacks, odd tastes or smells, incontinence, tongue biting at night, or psychomotor automatisms. She had no history of thought insertion, withdrawal, broadcasting, or any other features of schizophrenia. She had a medical history of hypertension, and was on aspirin, atenolol, and olmesartan. Amitriptyline was prescribed for insomnia. She did not smoke, drink alcohol, or use recreational drugs. On examination she was anxious, but alert and oriented with no cognitive impairment. A full mini-mental state examination could not be done because her hearing loss made the repetition of a sentence impossible. However, she scored 27/27 points on the incomplete test. She was oriented in time, person, and place, with no evidence of alteration of consciousness. She had bilateral hearing loss. Neurological examination was unremarkable other than absent vibration sensation and ankle refl exes. Routine blood tests were normal. An electroencephalogram done whilst she was experiencing the singing, did not show epileptic activity or any other focal or generalised brain abnormalities. CT of the head was normal. MRI of the head (with T1, T2, and FLAIR sequences) showed only a few white matter hyper intensities of the T2 and FLAIR sequences, which can be associated with smallvessel disease secondary to hyper tension. Ear, nose, and throat examination and pure tone audiogram showed bilateral sensorineural hearing loss only. Psychiatric assessment ruled out the possibility of mental illness. Our patient was diagnosed with musical ear syndrome because there was no evidence of neurological or psychiatric disease. This is a syndrome comparable to Charles Bonnet Syndrome in which people with visual impairment have visual hallucinations. Our patient was reassured about the benign nature of her condition. Multiple anticonvulsants were tried with mixed results. In February, 2012, at last follow-up, she had marked improvement of her symptoms after starting Clonazepam. Charles Bonnet was a Swiss scientist who documented complex visual hallucinations in his blind but otherwise healthy grandfather in 1760. Later the blind Charles Bonnet also had similar hallu cinations. Diagnostic criteria have since been developed for the disorder fi rst described as Charles Bonnet Syndrome by a Swiss neurologist George de Morsier, in 1967. Clinical features are often stereotyped, complex visual hallucin ations in a partially sighted patient. The patient has insight that the hallucinations are not real, and there is no psychosis, neurological or cognitive impairment, intox ication, or metabolic abnormality. No other sensory hallu cinations should be present. Generally the hallucinations are self limiting. No clear evidence for treatment exists. The mechanism of Charles Bonnet Syndrome is poorly understood. Few reports about complex auditory hallucinations in people with hearing impairment exist; however, some have suggested that they are quite common. Whether the diagnostic criteria of Charles Bonnet Syndrome should be extended to include complex auditory hallucinations, or these considered separately as Musical Ear Syndrome, is debatable. Our patient’s case is a reminder that hallucinations are not always due to delirium or to psychological or neurodegenerative conditions. Other conditions, such as Charles Bonnet Syndrome or musical ear syndrome, should also be considered.

Full-scale scores of the Mini Mental State Examination can be generated from an abbreviated version

Objective To determine whether the full Mini Mental State Examination (MMSE) scale range can be derived from an abbreviated 11-item version that was designed for testing general cognitive function in a cohort where only a small proportion were expected to be severely impaired or demented. Study Design and Setting Using simple computation and multiple imputation, the properties of the abbreviated MMSE were compared with the full MMSE score using data from the Medical Research Council Cognitive Function and Ageing Study. Results Full MMSE scores can be generated for the abbreviated version by assuming high functioning on excluded items. Of the imputed scores, 88.8% were within 1 point of their true value. When the sample was restricted to individuals with normal cognitive functioning (MMSE total score ≥ 24/30), 96.7% of individuals were classified within 1 point of their true total score. The model worked best at predicting cognitive level when cutoff scores were used to classify individuals into impaired vs. not nonimpaired. Conclusion Full-scale MMSE scores can be reasonably accurately derived from an 11-item abbreviated version. This reduced version can be applied within other frameworks that require reduced test length but need results that are comparable to studies where the full version has been administered.

The validity and reliability of chinese frontal assessment battery in evaluating executive dysfunction among Chinese patients with small subcortical infarct.

Frontal Assessment Battery (FAB) is a valid and reliable screening test for evaluating executive dysfunction among whites with frontal and subcortical degenerative lesions. We studied the properties of a Chinese version of FAB (CFAB) in evaluating executive dysfunction among Chinese stroke patients with small subcortical infarct. Concurrent validity was evaluated using Wisconsin Card Sorting Tst (WCST) and Mattis Dementia Rating Scale-Initiation/Perseveration Subset (MDRS I/P) among 41 controls and 30 stroke patients with small subcortical infarct. Discriminant validities of CFAB and its subitems were compared with those of Mini-Mental State Examination (MMSE). Internal consistency, test-retest, and interrater reliability of CFAB were evaluated. The CFAB had low to good correlation with various executive measures: MDRS I/P (r = 0.63, p < 0.001), number of category completed (r = 0.45, p < 0.001), and number of perseverative errors (r = -0.37, p < 0.01) of WCST. Among the executive measures, only number of category completed had significant but small contribution (6.5%, p = 0.001) to the variance of CFAB. A short version of CFAB using three items yielded higher overall classification accuracy (86.6%) than that of CFAB full version (80.6%) and MMSE (77.6%). Internal consistency (alpha = 0.77), test-retest reliability (rho = 0.89, p < 0.001), and interrater reliability (rho = 0.85, p < 0.001) of CFAB were good. Although CFAB is reliable, it is only moderately valid in evaluating executive dysfunction among Chinese stroke patients with small subcortical infarct. The clinical use of CFAB in the evaluation of executive dysfunction among this group of patients cannot be recommended at this stage.

Adaptation of dementia screening for vision-impaired older persons: Administration of the Mini-Mental State Examination (MMSE)

In epidemiologic field studies on the prevalence and incidence of dementia the problems associated with the cognitive testing of visually impaired individuals are rarely discussed. In the Leipzig Longitudinal Study of the Aged (LEILA 75+) a version of the Mini-Mental State Examination for the visually impaired (MMSE-blind) was employed from which all items requiring image processing had been omitted. To be able to interpret the test results and include vision-impaired individuals in the field study, the scores for the full MMSE were estimated by conducting linear transformation of the scores obtained on the MMSE-blind. The method of linear transformation is based on certain theoretical assumptions that are examined in this article. Linear transformation of scores has proved to be a valid procedure only for individuals with very high or very low cognitive performance. Thus, evaluation of the estimated full MMSE scores based on the norms for the original MMSE is not recommended. A blind version of the MMSE with age- and education-specific norms that has been validated as a screening tool for dementia is therefore presented.

Six-item screener to identify cognitive impairment among potential subjects for clinical research.

To design a brief cognitive screener with acceptable sensitivity and specificity for identifying subjects with cognitive impairment. Cohort one is assembled from a community-based survey coupled with a second-stage diagnostic evaluation using formal diagnostic criteria for dementia. Cohort two is assembled from referrals to a specialty clinic for dementing disorders that completed the same diagnostic evaluation. Urban neighborhoods in Indianapolis, Indiana and the Indiana Alzheimer Disease Center. Cohort one consists of 344 community-dwelling black persons identified from a random sample of 2212 black persons aged 65 and older residing in Indianapolis; cohort two consists of 651 subject referrals to the Alzheimer Disease Center. Formal diagnostic clinical assessments for dementia including scores on the Mini-mental state examination (MMSE), a six-item screener derived from the MMSE, the Blessed Dementia Rating Scale (BDRS), and the Word List Recall. Based on clinical evaluations, subjects were categorized as no cognitive impairment, cognitive impairment-not demented, or demented. The mean age of the community-based sample was 74.4 years, 59.4% of the sample were women, and the mean years of education was 10.1. The prevalence of dementia in this sample was 4.3% and the prevalence of cognitive impairment was 24.6%. Using a cut-off of three or more errors, the sensitivity and specificity of the six-item screener for a diagnosis of dementia was 88.7 and 88.0, respectively. In the same sample, the corresponding sensitivity and specificity for the MMSE using a cut-off score of 23 was 95.2 and 86.7. The performance of the two scales was comparable across the two populations studied and using either cognitive impairment or dementia as the gold standard. An increasing number of errors on the six-item screener is highly correlated with poorer scores on longer measures of cognitive impairment. The six-item screener is a brief and reliable instrument for identifying subjects with cognitive impairment and its diagnostic properties are comparable to the full MMSE. It can be administered by telephone or face-to-face interview and is easily scored by a simple summation of errors.

Prediction of probable Alzheimer disease in patients with symptoms suggestive of memory impairment. Value of the Mini-Mental State Examination.

The Mini-Mental State Examination (MMSE) is a widely used diagnostic tool for dementia. Its use as a predictive indicator of probable Alzheimer disease (AD) has not been established. To determine the accuracy of the MMSE in predicting emergent AD in a sample of patients who were referred because of symptoms suggestive of memory problems and to determine whether an abbreviated version of the MMSE could be developed that would be as accurate as the full MMSE in predicting emergent AD. Inception cohort of participants with symptoms suggestive of memory impairment by their family physicians were given baseline assessments, including MMSE. After 2 years, the participants' conditions were diagnosed following the standard criterion for AD. Diagnosticians were blind to baseline scores. One hundred eighty-three community-residing participants were referred by their family physicians to a university teaching hospital research investigation. After baseline screening, 165 participants were included in the study who did not have dementia and had no identifiable cause for memory impairment. After 2 years, 29 participants met criteria for AD, 98 did not develop dementia, 18 developed vascular lesions or non-AD dementia, and 20 did not return. Diagnostic classification of AD or no evidence of dementia. Logistic regression model was significant. At a cutoff score of 24 or less, sensitivity was 31%; specificity, 96%; with a likelihood ratio of 7.75. A reduced model of 2 subtests was identified with a sensitivity of 41%; specificity, 98%; with a likelihood ratio of 20.70. Results suggest that the full or abbreviated MMSE is useful in predicting emergent AD in patients with positive test results. However, it is not recommended for use as a screening or diagnostic instrument since a negative test result did not rule out emergent AD. It is recommended as a tool to identify those needing closer monitoring.

Discrimination Between Stages of Alzheimer's Disease With Subsets of Mini-Mental State Examination Items

To identify minimal sets of Mini-Mental State Examination (MMSE) items that can distinguish normal control subjects from patients with mild Alzheimer's disease (AD), patients with mild from those with moderate AD, and those with moderate from those with severe AD. Two randomly selected equivalent half samples. Results of logistic regression analysis from data from the first half of the sample were confirmed by receiver operating characteristic curves on the second half. Memory disorders clinics at major medical centers in the United States affiliated with the Consortium to establish a Registry for Alzheimer's Disease (CERAD). White, normal control subjects (n = 412) and patients with AD (n = 621) who met CERAD criteria; nonwhite subjects (n = 165) and persons with missing data (n = 27) were excluded. Three four-item sets of MMSE items that discriminate, respectively, (1) normal controls from patients with mild AD, (2) patients with mild from those with moderate AD, and (3) patients with moderate from those with severe AD. The MMSE items discriminating normal controls from patients with mild AD were day, date, recall of apple, and recall of penny; those discriminating patients with mild from those with moderate AD were month, city, spelling world backward, and county, and those discriminating patients with moderate from those with severe AD were floor of building, repeating the word table, naming watch, and folding paper in half. Performance on the first two four-item sets was comparable with that of the full MMSE; the third set distinguished patients with moderate from those with severe AD better than chance. A minimum set of MMSE items can effectively discriminate normal controls from patients with mild AD and between successive levels of severity of AD. Data apply only to white patients with AD. Performance in minorities, more heterogeneous groups, or normal subjects with questionable cognitive status has not been assessed.

Statistical description of the Mini-Mental State Examination for French elderly community residents. Paquid Study Group.

The distribution of total Mini-Mental State Examination (MMSE) scores, individual items, and groups of items were studied in French elderly community residents from a random sample of 2727 subjects. Serial seven, recall three objects, and copy pentagons had the lowest percentage of correct responses, while orientation to place, naming two objects, and three objects registration had the highest percentage of correct responses. The structure of correlation of the items was studied using Principal Components Analysis. The projection of the items on the first axis reflects the tendency of the items to vary in the same direction and is compatible with the fact that the MMSE items are all indicators of the same concept: cognitive performance. The second and third axes identify clusters of highly correlated variables and provide support for the internal validity of the MMSE score for a French population. The full MMSE score seems to be a valid instrument for the evaluation of cognitive performance in community-based elderly residents.

The Mini-Mental State Examination in the Early Diagnosis of Alzheimer's Disease

The Mini-Mental State Examination (MMSE), a brief test of cognitive function, has been widely used to screen for dementia. We administered the MMSE to 74 community-dwelling patients meeting criteria for probable Alzheimer's disease (AD) and 74 age- and education-matched controls. Twenty-four patients with AD performed in the nondemented range by scoring above the recommended cutoff point of 23 of a possible 30 on the MMSE. We compared the scores for items of the MMSE in controls and subjects with AD and used logistic regression to model a shorter MMSE that retained the accuracy of the complete test. A score summing tests of recall and orientation for place had similar sensitivity to the full MMSE. Adding a verbal fluency test to the MMSE reduced the error rate by improving the accuracy of diagnosis of patients with AD scoring in the nondemented range.