A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment

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Abstract

The MMSE is the most widely used cognitive test but its accuracy and clinical utility in diagnosing cognitive disorders is not fully known. A meta-analysis of 34 dementia studies and five mild cognitive impairment (MCI) studies was conducted, separated into high and low prevalence settings.

In memory clinic settings the MMSE had a pooled sensitivity (Se) of 79.8%, a specificity (Sp) of 81.3%, a positive predictive value (PPV) of 86.3% and a negative predictive value (NPV) of 73.0%. In mixed specialist hospital settings the Se, Sp, PPV and NPV were 71.1%, 95.6%, 94.2% and 76.4%, respectively. In non-clinical community settings the MMSE had a pooled Se of 85.1%, a Sp of 85.5%, a PPV of 34.5% and an NPV of 98.5%. In those studies conducted purely in primary care the Se, Sp, PPV and NPV were 78.4%, 87.8%. 53.6% and 95.7%, respectively.

Thus the case-finding ability of the MMSE was best when confirming a suspected diagnosis in specialist settings with correct identification made in 27/30 positive results. It was modestly effective at ruling-out dementia in specialist settings. Conversely, in non-specialist settings, the MMSE was best at ruling out dementia, achieving about 29/30 correct reassurances with less than three false negatives out of every 100 screens.

Regarding use of the MMSE in identifying MCI, limited evidence was found with only five robust studies comparing MCI with healthy subjects and three comparing Alzheimer’s disease with MCI. Provisionally, the MMSE had very limited value in making a diagnosis of MCI against healthy controls and modest rule-out accuracy. It had similarly limited ability to help identify cases of Alzheimer’s disease against MCI.

In conclusion the MMSE offers modest accuracy with best value for ruling-out a diagnosis of dementia in community and primary care. For all other used it should be combined with or replaced by other methods.

Introduction

The mini-mental state examination (MMSE) was published more than 30 years ago in 1975 as a practical method of grading cognitive impairment (Folstein et al., 1975). Since that time it has become widely used and highly cited (Nilsson, 2007). Although originally distributed free of charge, in 2001 copyright was acquired by Psychological Assessment Resources and now a permission/fee is required for use <http://www.minimental.com/>. A new version of the MMSE (MMSE-II) is under development. This review concerns the accuracy of the original version in its most frequent role, the diagnosis of dementia and related disorders.

The MMSE has 19 individual tests of 11 domains covering orientation, registration, attention or calculation (serial sevens or spelling), recall, naming, repetition, comprehension (verbal and written), writing, and construction. Several surveys of health professionals show that it has become the most commonly applied cognitive test, used by approximately 9 out of 10 specialists (Davey and Jamieson, 2004, Shulman et al., 2006, Reilly et al., 2004). It is also often used by non-specialists although many in primary care consider it too time consuming to administer (Glasser, 1993, Brodaty et al., 1994). The most common application of the MMSE is as a brief method to help detect suspected dementia but recently it has also been used in the diagnosis of mild cognitive impairment (MCI) (Perneczky, 2003, Diniz et al., 2007). Occassionally it has been used as a screen for delirium or cognitive impairment arising from specific medical conditions. To date over 70 validation studies exist, but most are underpowered and hence can give a misleading impression of accuracy (Lazaro et al., 1995). For example Folstein, Folstein, and McHugh validated the MMSE in two samples of patients which included only 38 with dementia (Folstein et al., 1975). In addition to diagnostic application, the MMSE has been used extensively to grade cognitive impairment in trials and observational studies of dementia (Han et al., 2000). This led to the controversial decision by the National Institute of Health and Clinical Excellence (NICE) to use cut-offs on the MMSE to determine eligibility for treatment for Alzheimer’s disease (Davey and Jamieson, 2004). However, a judicial review recently found this to be discriminatory on the basis of disability and/or race (particularly those whose first language is not English) as many such individuals have difficulty completing the MMSE (National Institute for Health and Clinical Excellence, 2007). The large evidence base surrounding the MMSE is advantageous because scores on the MMSE are fairly well understood by health professionals. That said, opinion is divided about how useful the MMSE is in diagnosing dementia, whether it is suitable for primary and specialist settings and regarding the optimal cut-off threshold (Tombaugh and McIntyre, 1992, Mossello and Boncinelli, 2006). A cut-off of 23 versus 24 (23v24) was recommended by Folstein and colleagues in persons with at least 8 years of education (Folstein et al., 1975). However, numerous other cut-offs have been calculated from receiver operator curve (ROC) analysis of specific populations together with adjustments for age and education (Grigoletto et al., 1999, Crum et al., 1994).

The aim of this study was to identify and quantify robust studies reporting the diagnostic accuracy of the MMSE in relation to (a) dementia versus healthy subjects; (b) MCI versus healthy subjects; and (c) dementia versus MCI.

Section snippets

Inclusion criteria

Studies were included that examined diagnostic validity of the MMSE in comparison to a validated diagnostic standard of either dementia or mild cognitive impairment (MCI) (see below for definitions used). Studies were included from all settings but separated into those conducted out of hospital and specialist settings (includes primary care, community studies and nursing homes) and those conducted in secondary care (memory clinics and mixed hospital settings) to avoid heterogeneity.

Excluded studies

Studies were

Search results

The literature search identified 775 possible papers of which 650 were not studies of diagnostic validity but severity ratings and other uses of the MMSE without validation against a criterion reference. Of the remaining studies 50 were excluded due to low sample size, four due to lack of extractable primary data and 21 studies that were review articles (see Fig. 1). Of 45 possible diagnostic validity studies, 11 were adaptations of the original MMSE, leaving 34 involving the classical MMSE.

Discussion

There is currently no consensus on what cognitive test to use for those with suspected MCI or dementia and no consensus on whether routine versus targeted screening is required (Muller et al., 2003, Small et al., 1997, Jacova et al., 2007). In 1998, a French expert group concluded that “After a physical examination, cognitive function must be evaluated using the Mini-Mental State Examination” (Petit et al., 1998). A 2001 recommendation from the American Academy of Neurology was more cautious

Role of Funding Source

None.

Contributors

Main author only.

Conflicts of interest

None.

Acknowledgements

Many thanks to the staff of the medical library, Leicester General Hospital.

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