Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
16 April 2009

THE MINI MENTAL STATE EXAM

            Two weeks ago, I wrote a column on the topic of “mild cognitive impairment”.  It had to do with the elderly population and questions regarding Alzheimer’s disease and dementia.  There is a progression from so called “age related memory impairment” to “mild cognitive impairment” to “full fledged dementia”.  I didn’t mean to stir up so many questions but one has been asked repeatedly.  That is, “How do you measure a person’s mental function when there are so many different things to know and ways to think?”

            In 1975, an author named Folstein and others published an article in the Journal of Psychiatric Resource.  They devised a test that they had used over several years time and seemed to be useful in grading how well a person’s mind was working.  The test seemed to work with different occupations and was effective for both men and women.  It was relatively quick, taking only 10-15 minutes to complete.  In the 38 years since this test was first published, it has gained wide acceptance as a cheap, simple tool to sort out those individuals that are functioning adequately, and those that may need a more supportive environment.  The test is not absolute and must be interpreted in a setting of multiple other considerations for each individual. The highest score available is 30 points and a score below 20 must be interpreted very carefully but may well mean that a supportive environment is needed.  A score below 15 almost certainly means the person will require some type of supportive help in their environment.  A copy of the test is listed below. 

            Before looking at the test, a very simple and remarkably accurate assessment of a person’s function can be obtained by asking them to draw the face of a clock, put the numbers in the appropriate place around the face of the clock.  Then put the two hands on the clock showing a given time such as 10 minutes after 11:00 o’clock.  To do the test perfectly, the hour hand should be a little shorter and the minute hand a little longer.  But if the person can come up with a clock picture that will show the time asked for, it is very likely that they are not cognitively impaired.  Most individuals that can pass this simple test will score in the high 20’s or more on the “mini mental state exam”. 

            The first question on the mini mental state exam asks the person to name the year, the season, the date, the day of the week and month of the year.  They receive one point for each correct answer. 

            The second question asks the person to name the state, the county, the town, the address at which they live and their telephone number. Again, they get one point for each correct answer.  These two questions have to do with the person’s orientation whether they know where they are and when they are in time.

            The next question has the tester name three objects such as an apple, a table, and a penny.  The tester can repeat the three objects several times and then ask the person being tested to name them back.  Within three tries, the person should be able to name all three items and receives one point for each item.  The person being tested is asked to remember the three items in regard to a question later in the test.

            The next question has to do with language and/or arithmetic.  Ask the person to spell the word “world” backwards.  Alternatively, the person can be asked to subtract 7 from 100 serially 5 times.  The right answer would be 100, 93, 86, 79, 72, and 65.  The person receives one point for each correct answer.  Some people never could do serial sevens and as an alternative they can asked to do serial 3’s.  The right answer would be 100, 97, 94, 91, 88, 85.

            The next question has to do with the person’s memory, and they are asked to recall the three objects that were asked for two questions ago.  The right answer for my example would be apple, table, penny.  The person receives one point for each correct answer. 

            The next question has to do with language skills and the ability to understand and follow commands.  The person is asked to name two common objects around them.  An example would be a pencil and a watch.  Hold up a watch or a pencil and ask the person to name it.  They receive one point for each correct answer. Give a maximum of two points. 

            Next the person is asked to say “no if’s, and’s or but’s”.  If they can say this back after hearing it twice, they receive one point.

            The next question is a three stage command.  The person is asked to take a piece of paper in their right hand, fold it in half, and put it on the floor.  For each one of the three commands that they perform, they are awarded one point. 

            Next, the person is shown the following command.  On a piece of paper they are shown the words, “Read and obey the following:  “Close your eyes.”  They receive one point for a correct response.

            Next ask the person to write a sentence.  Any correct answer will do and they receive one point for that. 

            Lastly, the person is asked to draw a picture of a five sided figure called a pentagon and then asked to draw another five sided pentagon with the two pentagons intersecting with each other.  The tester can draw the two pentagons for the person to show them what it looks like.  The person receives one point for a correct answer. 

            The total score for the above test is 30 points.  Twenty eight points and above is felt to be normal; 25-27 warrants repeated testing several months apart to see if there is a progressive decrease in the scores.  A result in which the person loses one or two points each time they are tested every three months warrants serious medical consideration.  A score below 20 probably indicates the person needs a supportive environment.  This person can probably stay in their own home but will need more than a normal amount of help.  A score below 15 very likely means that the person will require a supportive environment and will not be able to function alone in their own home independently.

            These scores should not be “over interpreted”.  Many different things can have an impact on the scores.  The test is best done by a healthcare professional in the setting of the person’s total healthcare profile and an examination of the person’s home and its status regarding hygiene, adequate food and safety.  This examination can have an important impact upon helping decide how much care a person needs.  It is not the only test we ever use but it is a simple starting point that can assist an elderly person receiving the care that they need.

This and other columns available at www.macpierre.com.