Beyond the MMSE: More Detailed Screening for Better Dementia Assessment

For over 50 years, the Mini-Mental State Examination (MMSE) has been used as a screening tool for cognitive impairment. With dementia rates rising worldwide, many clinicians have taken to using the test as an aid in the process of diagnosing Alzheimer’s disease and other types of dementia.

While the MMSE has been shown to accurately flag symptoms of significant cognitive impairment, it doesn’t have the complexity to provide detailed information about cognitive performance or identify more subtle signs of decline. Digital cognitive testing provides a targeted look at different brain-based cognitive domains by gathering objective data to identify patterns of performance that are associated with dementia, mild cognitive impairment, and other disorders linked with cognition.

In this post, we’ll review the strengths and weaknesses of the MMSE and compare its effectiveness with modern digital tools.

What is the MMSE?

The MMSE is a brief cognitive assessment that was created by Marshal Folstein et al. in 1975 and continues to be used to this day. It was designed to rapidly assess the cognitive function of hospitalized psychiatric patients and record changes over time. It is now commonly used as a dementia assessment, and while it is unfortunately sometimes misunderstood as a diagnostic test, it is in fact a screening test with relatively modest sensitivity.

The MMSE includes 11 questions and can be administered in 5-10 minutes, though there is no timed element for patients. It has both verbal and written components, which cover multiple areas of cognition.

While research suggests the MMSE can accurately rule out a dementia diagnosis, it is not sensitive enough to be used as a stand‐alone test in the identification of either dementia or mild cognitive impairment.

What Are the 5 Components of the MMSE?

The five components of the MMSE refer to the areas of cognitive processing that the test measures over a series of eleven questions. These components are

• Orientation: Two questions assess a patient’s understanding of the time (year, season, date, day, month) and place (state, town, country, hospital, floor) that they are currently living in.

• Registration: The administrator names three objects and then later asks the patient to repeat them back. This is repeated until the patient learns all three names, and the number of trials it took to learn them is noted.

• Attention and calculation: The patient counts back from 100 by subtracting 7 each time up to five times. Alternatively, they can be asked to spell “world” backwards.

• Recall: The patient is asked to repeat the three objects from the registration question.

• Language: Six questions are asked, wherein a patient must do the following: identify a pencil and a watch, repeat a phrase, follow a three-stage command, read and obey “close your eyes,” write a sentence, and draw a copy of two polygons.

How to Score the MMSE

The Mini-Mental State Examination (MMSE) is scored with a 30-point system that is calculated based on the following:

• Orientation (10 points): Both questions are worth 5 points, with a point earned for every correct answer.

• Registration (3 points): A point is given for each object that is repeated correctly. If it takes multiple trials, the number of trials is documented as well.

• Attention and calculation (5 points): A patient is given one point for every correct subtraction of seven they give.

• Recall (3 points): One point is given for each word that is correctly recalled.

• Language (9 points): One point for each correct answer, with the exception of two points for naming a pencil and a watch and three points for following the three-part command.

Often, a score of 24 or higher suggests no cognitive impairment, 18 to 23 is considered to be indicative of mild cognitive impairment, and a score between 0 and 17 suggests severe cognitive impairment. However, there are multiple scoring methods and cutoff guidelines, some of which take factors like age and education into account.

The Strengths and Limitations of the MMSE

The Mini-Mental State Examination (MMSE) is a widely used assessment for patients expressing concerns about their cognitive health. But as a quick pen-and-paper questionnaire, it comes with its own unique strengths and weaknesses.

Strengths

Some of the strengths of the MMSE that may contribute to its popularity include:

• Ease of administration: This test can be quickly and easily completed.

• Brief administration time: Right now, overburdened healthcare systems need fast and effective screening. A test like the MMSE that can be completed in 5-10 minutes is extremely valuable.
• Minimal Training: The MMSE doesn’t require any specific training to be able to administer, making it easy to implement into care.

Limitations

As far as dementia assessments go, the MMSE does come with a few significant limitations. For instance, the test lacks sensitivity to frontal and executive dysfunctions, and only three points out of 30 assess memory, the domain most affected in the early stages of common forms of dementia. Some of the test’s other limitations include:

• Lack of sensitivity to subtle signs of cognitive decline: The MMSE is generally unable to accurately differentiate between healthy individuals and those with symptoms of mild cognitive impairment (MCI) and early signs of dementia. This gets in the way of early detection for dementia care.

• Lack of Standardized Scoring: Because the MMSE is often administered without specific training and because it has a variety of scoring systems, scores can differ depending on who administers the exam, and even the same score can be interpreted differently across settings.

• Susceptible to bias based on culture, language, and education level: The test’s dependence on literacy and some cultural knowledge can lead to skewed results for some patients that may not be generalizable across different backgrounds.
• Copyrighted: The test is proprietary and is not free to use.

Due to these limitations, the MMSE cannot gather the detailed, objective data required to detect subtle impairment or change over time—something that digital tests designed for dementia assessment may be able to more adequately support.

Using Digital Cognitive Screens for Dementia Assessment

The Creyos Dementia Screener and Assessment is a modern tool to support the early detection of dementia symptoms and mild cognitive impairment. Rather than relying on inconvenient, subjective pen-and-paper tests or lengthy neurocognitive testing, our digital cognitive tests offer a third option for cognitive care.

The protocol includes:

• A quick 2-task screener to identify impairment and determine the need for further testing
• 4 additional scientifically-validated cognitive tasks that measure short-term memory, reasoning, concentration, and verbal ability
• Behavioral health assessments (IADL, IQCODE) and mental health questionnaires (PHQ-9, GAD-7) to help you assess the main DSM-5 criteria for mild or major neurocognitive disorders
• Automated reports that integrate into EHRs for improved care coordination
• Tailored care plans that can enable informed treatment or accommodations

The full assessment protocol can be completed in under a half hour. As a digital test, it can be completed either virtually or in person, allowing providers to offer patients living in remote locations greater access to care—and less stress along with it.

"We administer Creyos on tablets and relate the tasks to being like puzzle games that our patients have likely played before. Because the tasks are gamified, Creyos alleviates some of the technology anxiety that our older patients have."

–Melissa Picchione of Yukon Neurology

Comparing Creyos and the MMSE

For cognitive screening, the Creyos screener and the MMSE are both brief and easy to administer. However, cognitive screening and assessment with Creyos provides objective, detailed, scientifically backed data to aid clinicians in diagnosing and managing dementia.

Compared to the MMSE, the Creyos dementia protocol:

• Is aligned to specific brain regions for a targeted look at symptoms
• Includes a screener that is sensitive to early signs of cognitive decline
• Has random items that change at each assessment, providing more confident retesting for longitudinal monitoring
• Is designed to reduce the risk of cultural or educational biases
• Includes detailed cognitive assessment coupled with other health and psychological questionnaires to gain precise information about a patient’s condition and identify comorbidities

Screening for Mild Cognitive Impairment and Alzheimer’s Disease

While the Mini Mental State Examination (MMSE) is a convenient tool for rapid cognitive screening, it is not sensitive enough to flag signs of mild cognitive impairment or early dementia and has several other limitations. By incorporating online cognitive assessments into neurology, psychiatry, or general practice, providers can accurately gather and track patient data over time.

Reviewed by Mike Battista, Director of Science & Research at Creyos

Mike Battista specializes in brain health, cognition, and neuropsychological testing. He received his PhD in personality and measurement psychology at Western University in 2010 and has been doing fun and useful stuff in the intersection between science and technology ever since.