Mini-Mental State Examination (MMSE)

Mini-Mental State Examination (MMSE)

LASA filenames:
LASA021 / LASA221 / LASA421
LASA707

Contact: Almar Kok

Background
The Mini-Mental State Examination (MMSE) was introduced by Folstein et al. (1975) as a brief screening method for assessing the mental status of patients with psychiatric disorders. Later, the MMSE was also recommended as a primary screening test of cognitive functioning in the routine clinical examination of elderly patients. Nowadays, the MMSE is widely used in epidemiological studies and community surveys, both as a screener for cognitive impairment and as a measure for global cognitive functioning in older persons. However, the MMSE is strongly influenced by age and education, but not by sex. In addition, cognitive functioning in general, and thus also the MMSE score, is strongly associated with psychological and physical health

Measurement instrument in LASA
The MMSE consists of 23 items and scores range from 0-30, higher scores indicating better cognitive functioning.

The questions have been grouped into seven categories, each representing a different cognitive domain or functioning.

  • Orientation in time (5 points)
  • Orientation in place (5 points)
  • Registration of 3 words (3 points)
  • Attention and calculation (5 points)
  • Recall of three words (3 points)
  • Language (8 points)
  • Visual construction (1 point)

19 items have a maximum score of 1; 2 items have a maximum score of 3 (naming three objects and remembering three objects); and 2 items have a maximum score of 5 (subtracting 7 from 100 five times and spelling a five-letter word backwards). However, because the scale is based on only one of the two 5-point items, the total score amounts to 30.

From LASA-C onwards, persons who refused to participate in the interview and persons who were not able to participate in the interview were asked to participate in a short telephone interview. Note that in LASA-C a different questionnaire was administered for measuring cognitive decline to both respondents and proxies: IQCODE. From LASA-D onwards, a shortened version of the MMSE was available. This short version contained:

  • item 01: year
  • item 04: day
  • item 05: month
  • item 08: two streets in the neighbourhood
  • item 10: address
  • item 11: repeat three words
  • item 12: subtraction 100-7 or item 13: spelling backwards
  • item 14: recall three words.

The sum score is based on 9 items with the maximum score of item 12 or 13. The score on this scale varies between 0 and 16, with higher scores indicating better cognitive functioning. The variables are placed in LASA707.

Scale construction
There are three versions of the full MMSE scale:

  • MMSE with the item of serial 7’s, but without spelling backwards
  • MMSE with the item of spelling backwards, but without the serial 7’s
  • MMSE based on the highest score of the first two versions (serial 7’s or spelling backwards)

The scale score is derived by summing the scores of 22 items, depending on the version (either item 12 or item 13 is left out). All missing items are imputed with the score zero. However, no scale is computed if the number of items is greater than 6.

Questionnaires
LASAB021 / LASAC021 / LASAD021 / LASAE021 / LAS2B021 / LASAF021 / LASAG021 / LASAH021 / LAS3B021 / LASMB021 / LASAI021 / LASAJ021 / LASAK021 (main interview, MMSE copyrighted material);
LASAC707 / LASAD707 / LASAE707 / LASAF707 / LASAG707 / LASAH707 / LASAI707 / LASAJ707 / LASAK707 (telephone interview with RESP, MMSE copyrighted material)

Variable information
LASA021 contains the scores on all individual items. LASA221 contains the scale score based on the maximum score of spelling (item 13) or subtraction (item 12) (*MMSESC). LASA421 contains the scale score based on the subtraction score (*MMSESC1) and the scale score based on spelling (*MMSESC2).

LASAB021 / LASAC021 / LASAD021 / LASAE021 / LAS2B021 / LASAF021 / LASAG021 / LASAH021 / LAS3B021 / LASMB021 / LASAI021 / LASAJ021 / LASAK021;
LASAB221 / LASAC221 / LASAD221 / LASAE221 / LAS2B221 / LASAF221 / LASAG221 / LASAH221 / LAS3B221 / LASMB221 / LASAI221 / LASAJ221 / LASAK221;
LASAB421 / LASAC421 / LASAD421 / LASAE421 / LAS2B421 / LASAF421 / LASAG421 / LASAH421 / LAS3B421 / LASMB421 / LASAI421 / LASAJ421/ LASAK421;
(pdf)

LASAD707 / LASAE707 / LASAF707 / LASAG707 / LASAH707 / LASAI707 / LASAJ707 / LASAK707
(pdf)

Availability of information per wave ¹

BCDE
2B*		FGH

3B*		MB*IJK
MMSE

MaMaMaMaMaMaMaMaMaMaMaMaMa
Short MMSE

--TrTr-TrTrTr--TrTrTr

¹ More information about the LASA data collection waves is available here.

* 2B=baseline second cohort;
3B=baseline third cohort;
MB=migrants: baseline first cohort

Ma=data collected in main interview;
Tr=data collected in telephone interview with respondent

Previous use in LASA
In LASA the MMSE is often used in publications. Note that the MMSE score is negatively skewed at all waves and needs ln-transformed (ln[31- MMSE score]) to obtain a near-normal distribution.

The MMSE has been used in LASA for several purposes:

  1. Exclusion/ inclusion of persons with cognitive impairment; for example exclusion of respondents who have possible Alzheimer’s disease or other form of dementia. Several cut-off scores are used. The traditional cut-off score of 23 or less is disputable because it does not take into account the sensitivity for age and education. This cut-off score might be appropriate for older people (>75) with low education, but for younger people or people with high education, this cut-off score might lead to the inclusion of people with possible dementia. It is therefore recommendable to use cut-off scores which are adjusted for age and education (Kittner et al.1986; Schmand et al 1995).
  2. As an outcome measure for cognitive functioning and as a covariate or confounder in data-analysis. Analysis including the MMSE should always be adjusted for age and education. Next, the MMSE is often not normally distributed which has to be taken into account in analyses. Furthermore, the MMSE is not an interval scale. This is due to the fact that the MMSE contains items from different cognitive domains and the items are not of the same difficulty. This is especially a problem in the lower regions of the scale (below 17).
  3. To measure changes in individuals’ cognitive function over time (e.g. Comijs et al. 2004, 2009, 2011; Dik et al 2000, 2001, Jonker et al. 2003; van den Kommer et al 2013). Decisions about which change in MMSE-scores can be considered as pathological cognitive decline can be determined in the study sample by means of for instance Edwards-Nunally method (Speer, 1992), which takes into account the reliability of the cognitive test and the regression to the mean. The change scores are then dichotomized into decline and no decline (p<0.05) (Comijs et al 2005).


References

  1. Comijs HC, Dik MI, Deeg, DJH, Jonker, C. The course of cognitive decline in older persons: results from the Longitudinal Aging Study Amsterdam. Dementia and Geriatric Cognitive Disorders, 2004, 17:136-142.
  2. Comijs HC, Dik MG, Aartsen MJ, Deeg DJH, & Jonker C. The impact of change in cognitive functioning and cognitive decline on disability, well-being, and utilization of health care services in older persons: Results of the Longitudinal Aging Study Amsterdam. Dementia and Geriatric Cognitive Disorders, 2005, 19:316-323.
  3. Comijs, H.C., Kriegsman, D.M.W., Dik, M.G., Deeg, D.J.H., Jonker, C., Stalman, W.A.B. (2009). Somatic chronic diseases and 6-year change in cognitive functioning among older persons. Archives of Gerontology and Geriatrics, 48, 191-196.
  4. Comijs HC, van den Kommer T, Minnaar RWM, Penninx BWJH, Deeg DJH. Accumulated and differential effects of life events on cognitive decline in older persons: depending on depression, baseline cognition, or ApoE e4 status? J Gerontol B Psychol Sci Soc Sci. 2011 Jul;66 Suppl 1:i111-i120.
  5. Dik MG, Jonker C, Bouter LM, Geerlings MI, van Kamp GJ, Deeg DJ. APOE-epsilon4 is associated with memory decline in cognitively impaired elderly. Neurology. 2000, 54(7):1492-7.
  6. Dik MG, Jonker C, Comijs HC, Bouter LM, Twisk JW, van Kamp GJ, Deeg DJ. Memory complaints and APOE-epsilon4 accelerate cognitive decline in cognitively normal elderly. Neurology. 2001; 26;57(12):2217-22.
  7. Folstein MF, Folstein SE & McHugh PR. Mini-mental state: a practical method for the clinician. Journal of Psychiatric Research. 1975, 12, 189-198.
  8. Jorm AF, Butterworth P, Anstey KJ, Christensen H, Easteal S, Maller J, Mather KA, Turakulov RI, Wen W, Sachdev P. Memory complaints in a community sample aged 60–64 years: associations with cognitive functioning, psychiatric symptoms, medical conditions, APOE genotype, hippocampus and amygdala volumes, and white-matter hyperintensities. Psychological Medicine. 2004, 34, 1495-1506.
  9. Kittner SJ, White LR, Farmer ME, Wolz M, Kaplan E, Moes E, Brody JA, Feinleib M. Methodological issues in screening for dementia: the problem of education adjustment. Journal of Chronic Diseases. 1986, 39(3):163-70.
  10. Jonker C, Comijs HC, Smit J.H. Does aspirin or other NSAIDs reduce the risk of cognitive decline in elderly persons? Results from a population-based study. Neurobiology of Aging 2003, 24: 583-588.
  11. Schmand B, Lindeboom J, Hooijer C & Jonker C. Relation between education and dementia: the role of test bias revisited. Journal of Neurology, Neurosurgery and Psychiatry. 1995, 59: 170-174.
  12. Speer DC Clinical significant change: Jacobson and Truax (1991) revisited. Journal of consulting and clinical psychology. 1992, 60: 402-408.
  13. Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. Journal of the American Geriatrics Society. 1992, 40(9):922-35.
  14. Van den Kommer TN, Comijs HC, Aartsen MJ,  Huisman M, Deeg DJH, Beekman ATF. Depression and cognition: how do they interrelate in old age? Journal of the American Geriatric Society, 2013, 21(4):398-410.


Date of last update: December, 2019