GENEALOGY OF THE “MINI-MENTAL STATE” METHOD AND DIRECTIONS
FOR IMPROVING COGNITIVE ASSESSMENT
J. Wesson Ashford, M.D., Ph.D.
Jared Tinklenberg, MD
VA Palo Alto Health Care System
The “Mini-Mental State” (MMS) (Folstein et al., 1975) is directly derived from
developments in the field of mental status testing that antedate 1946.
Recently, a significant copyright question has surfaced as to what extent the MMS items
and their assembly constitute a unique entity. Clearly, most of the items of the MMS are
derived directly from prior writings and tests. The total number of items, 30, is unique,
but not substantially different from the Mental Test (which is derived from the Blessed
test), 34, or the Mental Status Questionnaire, 10. And there is substantial overlap
between the items of these and many other tests and the MMS. Since the administration
of traditional “bed-side” cognitive assessment has now become a legal matter, there is
need for clarification of the extent of routine cognitive assessment that can be done
without copyright infringements.
Problems with the MMS for assessing dementia and approaches to resolve these issues:
The MMS has been widely used in academic circles for assessing dementia, but less so in
the clinical arena. The MMS is considered a poor test academically because of its
variability, poor sensitivity and specificity, poor precision, and high floor effect. It is also
disliked by most clinicians because it is too time-consuming and has questions whose
time to ask is considered wasteful.
For practical clinical purposes, the MMS is deficient because it leaves out person
orientation items. It is also encumbered by its final 6 items that require props (pieces of
paper, a writing implement, a pre-drawn command, and a pre-drawn figure derived from
the Gramm-Kendall).
The critical issue in testing for dementia, particularly the Alzheimer type, is to assess
memory function. Brief ancillary testing for agnosia, anomia, apraxia, and executive
function should also be included, but appropriately balanced. The assessment also needs
to be performed as quickly as possible. An appropriate method for instant analysis
should also be a part of the assessment. Consequently, there is a pressing clinical and
academic need for the development of a shorter, more effective, more efficient, and
legally free assessment tool.
The scanned documents below are provided for evaluating the historical developments in
cognitive testing.