Elsevier

Mayo Clinic Proceedings

Volume 71, Issue 9, September 1996, Pages 829-837
Mayo Clinic Proceedings

The Mini-Mental State Examination in General Medical Practice: Clinical Utility and Acceptance

https://doi.org/10.4065/71.9.829Get rights and content

Objective

To examine the psychometric properties, acceptance, and screening efficacy of the Mini-Mental State Examination (MMSE) in an internal medicine practice.

Material and Methods

The MMSE was administered more than 4,000 times by 27 internists to 3,513 elderly patients (2,299 women and 1,214 men, 60 to 102 years old) who underwent general medical examinations. The efficacy of the MMSE for screening was measured in a subsample of age- and sex-matched patients with dementia (N = 185) and control subjects (N = 227). MMSE scores were correlated with age and education in the community sample. The attitudes of physicians about the MMSE were assessed with a 12-question survey. Sensitivity, specificity, and predictive values were calculated.

Results

Performance on the MMSE among persons older than 59 years was influenced by age and education but not by sex. During an interval of 1 to 4 years, a change of 4 or more points in the total MMSE score is needed to indicate substantial cognitive deterioration. Participating physicians considered the MMSE of little value for routine screening in unselected populations but wanted it available for use as a clinical test. The traditional MMSE cutoff score of 23 or less had a sensitivity of 69% and a specificity of 99%. Use of age- and education-specific cutoff scores improved the sensitivity to 82 % with no loss of specificity. With use of typical base rates for dementia in a general medical practice, the positive predictive value was less than 35%.

Conclusion

The clinical utility of the MMSE and acceptance by physicians may be improved through awareness of the influences of age and education on the MMSE and by its application in settings with a high base rate of dementia. The MMSE is ineffective when used to screen unselected populations; it should be used for persons at risk of cognitive compromise.

Section snippets

Community Sample

The Mayo Clinic and the Olmsted Medical Group are the only multispecialty group practices that provide health-care services to the 67,000 residents of Rochester, Minnesota, and the additional 39,000 residents of the surrounding predominantly agricultural area of Olmsted County. The Division of Community Internal Medicine at the Mayo Clinic specifically serves the primary internal medicine needs of the county. The practice has a much higher percentage of consultations for elderly persons than

Psychometric Properties

Because the MMSE has a “ceiling” effect that restricts variance at the upper end of the scale (that is, the total score cannot exceed 30), linear analyses were performed on scores expressed as a percentage of the maximal possible score (obtained MMSE score/30) and subsequently transformed with the arcsine of the square root of the percentage score. Such a transformation is appropriate for the application of linear models to variables expressed as percentages.

Age, Education, and Sex

Using data from the community sample

DISCUSSION

This examination of MMSE total scores in a large sample of elderly persons suggests that performance on the MMSE is influenced by age and education but not by sex. These results suggest the need to adjust expectations (that is, cutoff scores) on the basis of the age and education of a patient. Scores that are 1 residual SD less than predicted scores from the fitted linear regression of transformed MMSE total scores on age and education, to a minimal value of 23, are shown in Table 3. A sliding

CONCLUSION

The data or opinions presented herein should not be construed to mean that the MMSE has no role in the general assessment of elderly patients. Rather, we believe that the clinical utility and physician acceptance of the MMSE can be improved through (1) awareness of age and education influences on the MMSE and (2) application of the instrument in settings consonant with its original development (populations with high base rates of dementia). The MMSE does not seem to be efficacious or well

References (33)

  • RP Roca et al.

    Inaccuracy in diagnosing dementia among medical inpatients [abstract]

    Clin Res

    (1982)
  • BW Rovner et al.

    Mini-Mental State Exam in clinical practice

    Hosp Pract

    (1987)
  • Canadian Task Force on the Periodic Health Examination

    Periodic health examination, 1991 update. 1. Screening for cognitive impairment in the elderly

    CanMedAssocJ

    (1991)
  • AL Siu

    Screening for dementia and investigating its causes

    Ann InternMed

    (1991)
  • JT Olin et al.

    The 12-month reliability of the Mini-Mental State Examination

    Psychol Assess

    (1991)
  • EP Feher et al.

    Establishing the limits of the Mini-Mental State: examination of ‘subtests’

    ArchNeurol

    (1992)
  • Cited by (245)

    • AVCA: Autonomous Virtual Cognitive Assessment

      2023, Lecture Notes in Computer Science (including subseries Lecture Notes in Artificial Intelligence and Lecture Notes in Bioinformatics)
    View all citing articles on Scopus

    This study was supported in part by Grants ADCC AG 08031 and ADPR AG 06786 from the National Institute on Aging.

    *

    Emeritus staff.

    View full text