Mini-Mental State Examination 2nd Edition
Overview
• Original MMSE is one of the most widely used
brief screening instruments for cognitive
impairment
• Has been used in a variety of settings,
including screening individual patients,
tracking progress over time, screening for
large populations, and clinical trials
Goals for the Revision
1. Revise some of the original items to better
standardize its administrations, particularly for
translations
2. Provide an even briefer version that could be used for
rapid assessment
3. Provide a slightly longer version that would be more
sensitive to subcortical dementia and that would not
have a ceiling effect
4. Develop equivalent alternate forms to decrease
practice effects in serial administration
Goal #1: Revise Original Items
• The MMSE-2 Standard Version (MMSE-2:SV)
maintains the same structure and scoring as
the original MMSE
• Changes were made to improve problematic
items and to better standardize administration
in other languages (e.g., penny, no if, ands, or
buts)
MMSE-2: Standard Version
Task
Description
Identical task on
Original MMSE
Revision on
MMSE-2:SV
Registration & Recall
Ability to repeat and retain three
unrelated words, and then recall after a
short intervention task
Words have been made
slightly more difficult and
easier to translate
Orientation to Time
Identify current year, season, month, day
of the week, and date
X
Orientation to Place
Identify state, county, city/town, building,
and floor currently in
X
Attention &
Calculation (Serial 7s)
Count backwards by 7s
X
Naming
Ask to identify body parts when pointed
to by examiner
Change from “watch” and
“pencil” to body parts allows
for translation and no use of
external materials
Repetition
Required to repeat a sentence that
contains words not often said together
Revised to include a sentence
that is easier to translate and
difficulty slightly decreased
Comprehension
Understand and carry out a three-stage
verbal command
Removed the reliance on
motor responses.
Reading
Read and follow instructions
X
Writing
Asked to write a sentence
X
Drawing
Asked to copy intersecting pentagons
X
No longer can use WORLD
spelled backwards as
alternate task
Equivalency Between the
MMSE and MMSE-2:SV
• Like the MMSE, the MMSE-2:SV has a raw score
range of 0-30
• The generalizability coefficient (n = 411) between
the MMSE and the MMSE-2:SV total raw score
was .97
• Therefore it is possible to switch from MMSE to
the MMSE-2:SV without compromising
longitudinal data and without any change in the
normal range of scores
Goal #2: Develop Briefer Version
• Can be used for quick cognitive screener, specifically when
an individual has not been referred for specific cognitive
impairment
• Composed of Registration/Recall, Orientation to Time, and
Orientation to Place
• Raw score ranges from 0-16 points
• Tasks were selected based on literature review, use in the
MMSE, and their sensitivity and specificity to detect
dementia
MMSE-2: Brief Version
Goal #3: Develop Expanded Version
• Consists of all of the items on the MMSE-2:SV
plus two new tasks:
– Story Memory: An immediate recall of a brief
story
– Processing Speed: A symbol-digit coding task
MMSE-2: Expanded Version
• Improves the clinical utility of the MMSE by:
– Extending the test’s ceiling
– Increasing the range of raw scores (0-90)
– Increasing the sensitivity for individuals with less
severe cognitive impairment (subcortical
dementia, MCI)
Goal #4: Develop Equivalent
Alternate Forms
• Two forms (Blue and Red) were developed for
each of the 3 versions of the MMSE-2
• Based on the results of the equating study, the
accuracy of the equating process was
confirmed
Equating: MMSE & MMSE-2:SV
Administration Issues
• 18 years and older
• Relatively easy to administer, typically one
training session is sufficient
• Test Materials:
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–
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User’s Manual
Pocket Norms Guide
Scoring Templates for Processing Speed
Administration Forms :
• MMSE-2:BV Blue and Red Form
• MMSE-2:SV Blue and Red Form
• MMSE-2:EV Blue and Red Form
Overview of Administration Forms
Task
MMSE
MMSE-2:BV
MMSE-2:SV
MMSE-2:EV
Registration & Recall
X
X
X
X
Orientation to Time
X
X
X
X
Orientation to Place
X
X
X
X
Attention &
Calculation (Serial 7s)
X
X
X
Naming
X
X
X
Repetition
X
X
X
Comprehension
X
X
X
Reading
X
X
X
Writing
X
X
X
Drawing
X
X
X
Story Memory
X
Processing Speed
X
Determining Which Version is Appropriate
• MMSE-2:BV
– Adequate for screening large populations; screening
individuals in practice who have not been referred because
of cognitive complaints
• MMSE-2:SV
– Used first if referred because of complaint of cognitive
decline or if patient indicates memory is not as good as it
use to be; depending on results may want to supplement
with MMSE-2:EV
• MMSE-2:EV
– Same as above + well educated (ceiling effect); suspected
subcortical dementia
Scoring
• Mean raw total scores are presented by age
and education level
• T scores are also presented by age and
education level
• Pocket Guide
• Reliable Change Scores
Reliable Change Scores
• Reliable change refers to the extent to which the change in test
performance shown by an individual falls beyond the range that can be
attributed to practice effects or to measurement variability that is
inherent to the instrument itself
• The approach used here is a method developed by Iverson (2001)
Interpretation
• A cut score of 22/23 is typically used with the
original MMSE
• Because the MMSE-2:SV is equivalent to the
MMSE, the same cut score is suggested
• The authors have not provided specific
recommendations for the new forms, however
ranges of raw score cut scores are provided for
the dementia, AD, and subcortical samples by
form
Example of Cutoff Table
Development
• Task Development – 5 additional tasks were
tested
• Bias Panel – assessed potential bias and
offensiveness to protected groups
• Expert Review:
– 2 neuropsychologist, 1 geriatric psychologist, 1
geriatric psychiatrist
– Aided in selection of tasks, provided feedback on
content, and assisted with refining items and
instructions for the pilot and standardization versions
Pilot Testing
Standardization Sample
n = 1,531 healthy controls
Cognitively Impaired Samples
Effects of Age and Education
Development of the Norms
• Because of the importance of age and education
on MMSE-2 scores norms were developed for
several different age and education ranges
• Two resources for age and education adjustments
are provided:
1. Means and standard deviations of total raw scores
by age and education groups
2. Age- and education-adjusted T scores (continuous
norming method)
Reliability: Internal Consistency
Reliability: Test Retest
Reliability: Interrater
Validity
• Content Validity – similar items on other tests (e.g., Serial 7s
similar to attention and concentration task on WMS-III)
• Intercorrelations among task and total scores (presented for both
the normative and clinical samples)
• Diagnostic Validity: Prior work on the MMSE using 22/23 or 23/24
Validity
• Convergent Validity:
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–
–
–
–
–
–
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WMS-III subtests
Category Naming Test
COWA
BNT
TMT
WAIS-R subtests
JOLO
HVLT-R
Stroop Color and Word Test