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March 28, 2024

Mini-Mental State Examinations

Kyle S. Page, PhD, Nabeel Yehyawi, PsyD, HyeRim Ryu, Edward Hines, Jr., and Rosalind Franklin
The PDF for this issue which includes footnotes and endnotes can be found at here.

Accurately assessing the decision-making abilities of older adults is of great social, legal, and clinical importance. Historically, a medical or psychiatric diagnosis might have unfortunately sufficed as an indication of incapacity; however, an appreciation of human rights and individual differences directs us to evaluate an older adult’s functional abilities and to integrate supports. One aspect of a functional approach to assessing capacity in later life typically involves an assessment of cognition, which includes abilities such as learning and recall, attention, and judgment. While many neuropsychological tests exist to capture these abilities, the Mini-Mental State Examination (MMSE) has had one of the greatest impacts in this regard – a tool that is likely widely known to geriatric legal and healthcare professionals. The importance of the MMSE in clinical practice over nearly 50 years is undeniable. Intriguingly, the publication and subsequent embracing of this tool coincided with several advancements in our society’s conceptualization and evaluation of capacity. Given the continued prominence of the MMSE, this article reviews the tool and its relationship to these advances in capacity evaluations.


When first published in 1975, the authors of the MMSE, Folstein, Folstein, and McHugh, specifically sought to develop a useful method to both (1) quantitatively estimate an individual’s level of cognitive impairment and (2) monitor changes in cognitive functioning over time. Though not intended to be the sole basis for any particular diagnosis, the MMSE is brief and requires no additional equipment and minimal training to administer. In 10 minutes or less, this screening test can aid a healthcare professional in determining whether a patient voicing concerns needs to be referred for additional evaluation. Given its strengths, it is no wonder that the MMSE has become the most well-known and widely used screening test of cognition. However, despite the great value that the MMSE has provided, no cognitive assessment tool is without its limitations. Failing to acknowledge and account for these limitations increases the likelihood that MMSE scores may be misused and misunderstood, resulting in inaccurate conclusions about an individual’s cognitive or decisional abilities.

In the case of the MMSE, some of its weaknesses are the natural and understandable consequences of its strengths. Perhaps that most practical example of this has to do with who is administering the test. The MMSE can be administered by nonexperts without specialized training, which undoubtedly has contributed to its popularity and widespread use by those in healthcare, and even non-healthcare professionals in some circumstances. However, if the person administering the test is not trained and does not carefully follow the standardized instructions for both administration and scoring as outlined in the manual, the total score (1) may not be a valid indication of an individual’s cognitive functioning and (2) may result in very different scores by different examiners over time. For this reason, when interpreting an MMSE score, it is very important to consider the background of the person who administered the test, the context in which it was administered (e.g., while hospitalized versus in the home), and if standardized procedures were likely followed. Misadministration of the tool was a critical reason the authors chose to enforce the copyright of the MMSE when the second edition of the test (i.e., MMSE-2) was published in 2010.

Another important consideration regarding the MMSE pertains to who is being tested. It has been well established that individual differences in age, education, race/culture, and socioeconomic background clearly affect an individual’s performance on cognitive testing, and the MMSE is no exception. Given its predominant focus on verbal items over visual items, individuals with poor reading/writing abilities may be at a disadvantage and produce lower than expected MMSE scores despite being cognitively intact. Conversely, individuals with high levels of education systematically produce higher MMSE scores, such that it may fail to detect cognitive impairment among highly educated individuals who are actually declining. To address these concerns, normative data were developed to provide different cut-off scores for impaired cognition depending on a person’s age and education, but many healthcare and non-healthcare professionals are not aware of the importance of using appropriate norms, leading them to inaccurately conclude that any score lower than 24 is indicative of dementia.

A third important consideration of the MMSE regards what the tool actually measures….and what it does not. As noted above, key strengths of the MMSE are that it produces a total score to quickly screen an individual’s global cognitive functioning and monitor that functioning over time. This is quite valuable to clinicians and researchers alike, but such a global estimate is less useful in understanding a person’s capabilities than a detailed assessment of individual cognitive domains (e.g., memory, attention, language). Individual items on the MMSE may give a clinician some insight into a person’s deficits but, with only 30 possible points, the screening tool is not capable of thoroughly assessing each individual cognitive domain, nor was it intended to. Indeed, a frequent criticism of the MMSE is that its quick screening format does not allow for the adequate assessment of “executive functions.” Executive functions are advanced thinking skills, which include planning, problem solving, reasoning, mental flexibility, and decision making, among others. Moreover, executive functions have been found to be among the cognitive domains most positively correlated with everyday functioning, which is often important clinically (and at times legally) when attempting to determine what an individual likely can and cannot safely do on their own.

MMSE and Capacity

The publication of the MMSE coincided with a period of notable expansion of our conceptualization of capacity, owing to co-evolving strides in disability and human rights, capacity science, and legal and clinical practice. Likewise, our clinical approach to evaluating capacity experienced dramatic advancements in the decades following the release of the MMSE. In essence, we challenged how we thought about capacity and how we could/should capture this in a clinical evaluation. Consensus built around core components (~1980s-1990s), namely, understanding, appreciating, reasoning, and expressing a consistent choice. These components can be viewed, in part, through an emphasis on cognitive functioning, which could now be more readily estimated via the MMSE by a wider array of clinicians. Thus, it did not take long for the MMSE to be integrated into clinical evaluations of capacity. In our own clinical practices, we have observed an overreliance on the MMSE total score (or similar screening tools such as the MoCA) to determine clinical capacity status. Undeniably, empirical research demonstrates a relationship between the total score on the MMSE and capacity status, such that the higher score on the MMSE (indicating better cognitive performance), the greater the likelihood of a person having capacity. However, there is more complexity and nuance to this than meets the eye.

Previous studies have shown that the total score on the MMSE can be correlated with a single clinician’s judgment of capacity, a panel of experts’ judgment (typically geriatric psychiatrists), judicial determinations of legal capacity, or scores on a capacity-specific tool. In each of these scenarios, the individual being assessed may have been asked about issues either germane to their unique situation or hypothetical vignettes, thus potentially not fully capturing real-life engagement due to lack of personal risk, pressures, and emotions with the latter. Moreover, these studies include participants of various ages, demographics, health literacy, diagnoses, and other factors that make it hard to generalize to all older adults. There is great variability in MMSE performance across studies, even among those considered to have or lack capacity. To be clear, individuals with high scores may still lack capacity and those with low scores may still have capacity, as the clinical judgment of capacity depends upon the contextual factors of the situation in which the capacity question arises, the capacity question itself, and the means for enhancing or supporting one’s decision making.

In the clinical setting, healthcare professionals thusly rely on additional data points when evaluating decisional capacity beyond cognitive functioning and the core decisional abilities mentioned earlier. For example, these considerations include individual and cultural differences, values, and history, along with psychological and physical functioning, among others (for a detailed description, we recommend the ABA and APA handbooks on assessment of diminished capacity). Diagnoses of a medical or psychiatric nature are still relevant and can aid in establishing a causal component, but should no longer equate to inability. This is in line with the shifts towards a functional standard in capacity that took place in the clinical realm (e.g., Grisso and Appelbaum’s early research) and in the legal realm (e.g., Uniform Guardianship and Protective Proceedings Act in 1982) shortly after the MMSE’s publication.

Following these critical shifts, a functional-based capacity evaluation looks at the interaction between the individual’s abilities (such as cognitive, psychological, physical functioning) and the demands of the situation in which the capacity question arises. For example, consider what is involved in making a particular treatment decision, managing finances, or driving. In each situation, there are demands/thresholds of performance which must be met to demonstrate adequate capacity. However, very importantly, each capacity question varies in terms of complexity, urgency, level of risk, and available supports. This is why clinical capacity evaluations are unable to follow a one-size fits all approach. Capacity can only be understood as contextual in nature and not solely focused on one aspect, such as cognitive abilities as assessed with the MMSE. Perhaps this is known to those of us working with older adults, but we imagine several of us have overheard “they scored a 20 out of 30, so of course they can’t make decisions about….” in clinical and legal contexts.

The integration of all valuable information into a clinical (or judicial) judgment of an individual’s ability to make decisions is a substantial responsibility that must incorporate multiple sources of data about the individual, the situation, and the characteristics of the capacity in question. This is further stressed when considering cases where an older adult may be capable of making one type of decision but not another due to differing contextual factors (e.g., an individual with dementia needing assistance with financial decisions given new financial products, but not medical decisions for chronic health conditions). The intersection of the complexity of decision-making and context presents unique circumstances and challenges for each evaluation of decision-making ability, emphasizing the value of wholistic capacity conceptualizations. As mentioned, while the MMSE is helpful for assessing whether cognitive impairments might be present, capacity involves other aspects of an individual’s functioning and situation that remain untested by the screening tool alone. Widespread adoption and familiarity of the MMSE should not necessarily equate to using this as a substitute for a more personalized evaluation, especially considering the significance that the individual’s foundational rights are at stake. Too much reliance on the MMSE score perpetuates a narrowed perspective of the complexity of later life decision making and only enables an ageist approach of equating a single number to false beliefs about ability, paralleling harmful societal perspectives of chronological age.

MMSE Basics

  • A brief measure to screen for cognitive impairment or to track changes over time.
  • Administered in 10 minutes
  • Measured out of 30 points, assessing orientation, language, attention and calculation, registration, and delayed recall of information.
  • Various versions are available (e.g., MMSE, MMSE-2, 3MS)
  • Other brief cognitive measures may be more sensitive for identifying subtle impairment.

What Affects an MMSE Score?

  • Cognitive changes or impairments
  • Sensory functioning
  • Medical conditions
  • Mental health conditions
  • Personality traits may impact older adults’ engagement with cognitive testing
  • Demographic details (these may include, but are not limited to: age, gender, race, ethnicity, socioeconomic status, education level, and prior baseline functioning)
  • Personal history and contextually/culturally-bound experiences might influence older adults’ biases, dispositions, and beliefs about cognitive screeners and capacity evaluations as a whole.

Understanding MMSE Scores in Capacity Determinations

  • Careful consideration is necessary/advised regarding the qualifications of both administrators of the MMSE as well as interpreters of resulting scores.
  • Because capacity can fluctuate over time, it is important to consider how long ago the MMSE was administered and whether re-evaluation is necessary.
  • The context in which the MMSE or any other cognitive screening tool was administered (e.g., home vs hospital) is of high relevance when ascertaining the applicability of a score.
  • Álvarez Marrodán, I., Baón Pérez, B. S., Navío Acosta, M., Verdura Vizcaino, E. J., Cantón Álvarez, M. B., & Ventura Faci, T. (2018). Limits on the use of the MMSE for assessment of capacity to consent to for treatment. European Journal of Psychiatry, 32(3), 153-157. 
  • Carnero-Pardo, C. (2014). Should the mini-mental state examination be retired? Neurología (English Edition), 29(8), 473-481.
  • Folstein, M., & Folstein, S. (2010). Invited reply to ‘‘The death knoll for the MMSE: has it outlived its purpose?’’ Journal of Geriatric Psychiatry and Neurology, 23(3), 158-159.
  • Moye, J., Marson, D. C., & Edelstein, B. (2013). Assessment of capacity in an aging society. American Psychologist, 68, 158-171.
  • Nieuwenhuis-Mark, R. E. (2010). The death knoll for the MMSE: Has it outlived its purpose? Journal of Geriatric Psychiatry and Neurology, 23(3), 151-157.
  • Pachet, A., Astner, K., & Brown, L. (2010). Clinical utility of the Mini-Mental Status Examination when assessing decision-making capacity. Journal of Geriatric Psychiatry and Neurology, 23(1), 3-8.
  • Peery, S., Corbett, C., Rengifo, J., & Pick, L. H. (2022). Integrating culture and diversity in capacity evaluations. In L. A. Schaefer & T. J. Farrer (Eds.), A casebook of mental capacity in US legislation: Assessment and legal commentary (pp. 172-202). Routledge. 

Kyle S. Page, PhD


Nabeel Yehyawi, PsyD


HyeRim Ryu, MS


Edward Hines, Jr.

VA Hospital

Central Iowa VA Hospital

Rosalind Franklin

University of Medicine and Science

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