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.
The MMSE
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.