Instructions To the Administration of the Mini-Mental State Exam

What Is the MMSE?

The Mini-Mental State Examination (MMSE) is a widely used, well-validated screening tool for evaluation of cognitive impairment. It briefly measures orientation to time and place, immediate recall, short-term verbal memory, calculation, language, and construct ability. Each area tested has a designated point value, with the maximum possible score on the MMSE being 30/30. Upon completion of the MMSE the score achieved by the patient should be clearly recorded in the summary score area of the MMSE form and also in the space designated on the ESAS Graph for the MMSE score of that date. The score is recorded using a denominator of 30 unless the patient was unable to complete the test due to a physical handicap (e.g. blindness) --in which case the value of the questions not able to be completed is subtracted from 30 and the resulting number used as the denominator for the test score. If a denominator of less than 30 is used, the nature of the physical handicap should be indicated on the MMSE form.

The appropriate descriptor of the patient's level of consciousness should also be circled on the MMSE form.  These are: Alert = remains awake easily. Drowsy = finds it difficult to stay awake. Stupor = is difficult to rouse. Coma = unable to rouse.

When to Do the MMSE

The MMSE should be completed on all outpatient, inpatient and nursing home admissions of patients over age 65 and at any time when there is a concern about cognitive ability. This tool is most valuable when cognitive impairment is not suspected. The MMSE is far more sensitive in detecting cognitive impairment than is the use of informal questioning or "overall impression" of patient orientation.

How to Do the MMSE

When the purpose and value of the MMSE is explained well it is readily accepted by most patients and family members. Therefore, it is extremely important to take time to explain the rationale for using this tool before commencing with the questions it contains. Most patients value their cognitive abilities very highly and many are already well aware of the impact that medications or their disease state can have on these abilities. Explaining that the MMSE may be of great help in detecting reversible impairment of these faculties is usually enough to facilitate its acceptance by patients and their families -and, in any case, it is information with which the patient has a right to be provided. Before administering the MMSE it is important to make the patient comfortable and establish a rapport with the patient. During its administration praising successes may help to maintain this rapport and so is quite acceptable. Persisting on items the patient finds difficult should be avoided. Following are the details of how to administer and score the MMSE

Orientation:

1. Ask for the date, then ask specifically for parts omitted

   • For example:  "Can you also tell me what season it is? -- Score one point for each correct answer

2. Ask in turn, "Can you tell me the name of this hospital? (town, country, etc) -- Score one point for each correct answer.  You may substitute clinic or office (instead of hospital) when appropriate.

Registration:

Ask the patient if you may test his/her memory. Then say the names of 3 unrelated objects, clearly and slowly, about one second for each.  The most commonly used are APPLE, TABLE, PENNY. After you have said all 3, ask the patient to repeat them. This first repetition determines his/her score (0-3) but keep saying them until he/she can repeat all 3, up to 6 trials. If all 3 are not eventually learned, recall cannot be meaningfully tested but should nevertheless be attempted.

Attention & Calculation:

Ask the patient to begin with 100 and count backward by 7. Stop after 5 subtractions subtractions (93,86,79,72,65). Score the total number of correct answers. If the patient cannot or will not perform this task, ask him/her to spell the word "WORLD" backwards. The score is the numbers of letters in correct order (eg, DLROW=5; DLRW=4; DLORW, DLW=3; OW=2; DRLWO=1).

Recall:

Ask the patient if he/she can recall the 3 words you previously asked Him/her to remember. Score 0-3.

Language:

Naming:        Show the patient a wristwatch and ask  him/her what it is. Repeat for pencil. Score 0-2.

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Repetition:

Ask the patient to repeat the sentence, “Close your eyes,” in large letters enough for the patient to see clearly. Ask him/her to read it and do what it says.  Allow only one trial. Score 1 point only if he actually closes his eyes.

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3-stage command:

State the command first loud enough for the patient to hear and then give the patient a piece of plain blank paper. Score 1 point for each part correctly executed.

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Reading:

On a blank piece of paper print the sentence, “Close your eyes,” in letters large enough for the patient to see clearly. Ask him/her to read it and do what it says.  Score 1 point only if he actually closes his eyes.

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Writing:

Give the patient a blank piece of paper and ask him/her to write a sentence for you. Do not dictate a sentence; it is to be written spontaneously. It must contain a subject and a verb and be sensible. Correct grammar and punctuation are not necessary.

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Copying:

On a clean piece of paper, draw intersecting pentagons, each side about 1 in., and ask him/her to copy it exactly as it is. All 10 angles must be present, and 2 must intersect to score 1 point.   Tremor and rotation are ignored.