Mini-Mental State Exam (MMSE)

I'ech- Administered

A. Background and Rationale:

Cognitive h c t i o n may decline as a result of certain risk factors (e.g.

hypertension, elevated cholesterol, cardiac arrhythmias). This in turn could
adversely impact the physical functioning and quality of life of older adults.
Dementia is a major illness and cause of disability among the elderly.
Cerebrovascular disease or multi infarct dementia is the second leading cause of
dementiiig illness among Caucasians, preceded only by Alzheimer's disease.

The Mini-Mental State Exam (MMSE) is a widely used test of cognitive function
among the elderly; it includes tests of orientation, attention, memory, language
and visual-spatial skills.

1. Alert Level: In general participant scoring below education-adjusted cut-off

scores* on the MMSE may be cognitively impaired.

MMSE-EDUCATION ADJUSTED CUT-OFF SCORES

a. Subjects whose education levels are 7thgrade or lower, a score on the

MMSE of 22 or below

b. Subjects whose education attainment level is sthgrade or some high

school (but not a graduate of), a score on the MMSE of 24 or below

c. Subjects whose education attainment level is high school graduate, a

score on the MMSE of 25 or below

d. Subjects whose education attainment level is some college or higher, a

score on the MMSE of 26 or below.

*Note: The Education Adjusted Cut-off Scores are calculated by data

management.

2. Mini-Mental State Exam Scoring:

The oEcial total score for the MMSE (i.e. the scores used for statistical
analyses) are computer generated. Examiners record individual test item scores
on the MMSE test form. The one exception is "WORLD" where examiners
record the response of subjects in the exact order that it is given by the subject.
 For referral purposes, any participant with a drop of 3 points in score since
their last exam should be referred to neurology group. A preliminary score can
be calculated by Tricia Kelly to detemiine if the participant should be referred.
A referral form should be completed and given to the Neuro Project
Coordinator, Linda Farese, after the exam. Referral forms can be found in the
appendices.

If a participant is referred they may also qualify for a consent form Waiver.

3. Consent Form Waiver:

Guidelines dated 3I 10/0 1 verified 3125/04:

Any subject with MMSE at or above 26 may be presumed competent

unless listed otherwise at last evaluation

Any subject with MMSE below 13 requires use of a Waiver unless seen by
a neurologist and declared not demented

MMSEs between 25 and 13 would trigger a decision process. The

participants in this category will sign a consent but they may qualify for a
waiver. The neurology team will review each case and decide which
category to be in (Consent or Waiver).

* * *Refer to Waiver of Informed Consent Section of manual for full protocol.* * *

C. Methods:

1. The MMSE asks questions to ascertain cognitive status. Responses are

scored:
O=incorrect
1=correct
+item administered, participant does not answer
9=test item not administered,unknown

2. If a response is ambiguous, the interviewer records the response in the

margin so a decision can be made on its appropriateness Please refer all
questionable responses to the neuropsychologists (i.e. Rhoda Au or Sherral
Devine)

3. When a participant is incapacitated by blindness, has a functional

disability, is illiterate, or is otherwise unable to respond to a question, the
interviewer should specify the problem and questions involved (see
"Factors Potentially Affecting Mental Status Testing" later in the section).
Expanded Scoring Instructions for Mini-Mental Exam:

Important note: The single exception to scoring 6 for no response is if a

participant is in a coma (this circumstance would be encountered in a nursing
home visit) In this instance, administer the first item (to establish no response --
give a 0 to the first item if there is no response). (This exception is made to
conform with .the stroke protocol.)

9 = When test item was not administered (refused or inability because of

physical limitations) or subject's response is uninterpretable (response
could be correct, but tester is unable to discern the response).

Important note: Sometimes a participant might produce a response that is not a

word (i.e. a neologism) but has been responding with intelligible responses on
previous items (right or wrong). In this case the items should be scored 0. The
key to differentiating a 0 or a 9 is consistency within test. If a person has a speech
abnormality, such as aphasia or dysarthria, across all items, most (or many)
responses will be unintelligible. If a person is, for example, demented, helshe
may produce a flow of intelligible responses with occasional unintelligible
responses. A " 9 must represent situations in which the EXAMINER is not sure
whether (1) the participant responded correctly (because of slurred speech, severe
stuttering, etc.), or (2) if the participant has some other factor that prevents test
item administration (such as an inability to administer copy thisJigure test item to
a right-handed person who has right-handed paralysis, or to someone who has a
visual impairment or inability to hear).

Scorinn for Administered Individual Items: (applies only if a test item is

administered)

Score 0 for the following reasons:

1. Incorrect response
2. I don 't know
3. Unintelligible response in context of other intelligible responses (see
scoring of 9 as well).
4. Participants attempted to respond but responds incorrectly (i-e. they are
demonstrating that they heard the question and are making an attempt
to respond to it).
E. Questions: Scripts and Procedures for Each Question:

Introductory Script: I'm going to start by asking questions that require

concentration and memory. Some questions are more dzficult than others and
some will be asked more than one time.

Read each question on the form.

Record the response on the form.

1. What is the date todq? (3 = correct score for month (1 pt), day (1 pt) and year
(1 pt))

a. Ask for the date. Then ask specifically for parts omitted (e.g. Can you
also tell me what month, year it is?)
b. If participant supplies part or all of the date (e.g. month and day, or
month, day, and year), record as appropriate and do not ask those
questions again.

2. What is the season?

Since distinctions between seasons can be difficult during certain months,

one week leeway is allowed on either side of the actual date.

Month Correct Response

January Winter
February Winter
March Winter or Spring
April Spring
May Spring
June Spring or Summer
July Summer
August Summer
September Summer or Fall
October Fall
November Fall
December Fall or Winter

3. What day of the week is it?

4. What town, county, and state are we in?

a. Ask the participant what town, county, and state we are in.
b. For offsite visits, refer to the section of the manual titled "New
England Counties" for a complete list of all counties.
5. What is the name of this place?

a. Ask the participant where they are. Any appropriate answer is okay.
On home visits, the examiner can ask, What is the address of this
place?

6. Whatfloor of the building are we on?

7. I am going to name 3 objects. Afer I have said them I want you to repeat them
back to me. Remember what they are because I will ask you to name them
again in a few minutes: Apple, Table, Penny.

a. Make sure participant is attentive when beginning the question.

b. Read the list of objects slowly. DO NOT REPEAT ITEMS UNTIL
AFTER THE FIRST TRLAL.
c. If participant asks you to repeat the 3 items, respond, Can you tell me
the items Ijust mentioned? or Just do the best you can.
d. Read Apple, Table, Penny.
e. Script: Could you repeat the three itemsfor me?
f. Record the score for .the first trial.
g. If, after scoring the first attempt, the participant has not learned the 3
objects, repeat the list of objects up to 6 times until he/she has learned
them.
h. If, 3 items are repeated regardless of order, score 3 points. Occasionally
hearing impairments prevent subjects fiom correctly hearing test
questions (for example, when asked to repeat three items, apple, table,
penny, they may repeat April, tablet, pencil -- these alternate responses
should be accepted both under the repetition and recall conditions).

8. Now Iam going to spell a word forward and I wantyou to spell it backwards.
The word is WORLD. W-0-R-L-D. Please spell it in reverse order. Write in
letters (letters are entered and computer scored later. For
tabulating a total MMSE score for screening purposes, please determine a total
score between 0-5 for this item).

a. Read the question slowly. Where world has hyphens between the
letters, spell out the word.
b. Repeat the spelling if necessary.
c. Record the participant's response. Write in the letter as the participant
has spelled the word.

9. What are the 3 objects I asked you to remember afew moments ago?

a. Items may be repeated in any order.

10. What is this called? (Watch)

Show the wristwatch to the participant

Correct responses include: watch, wristwatch, timepiece
Code 1 = correct answer

11. What is this called? (Pencil)

a. Show the pencil to the participant. NOTE: the pencil

should be a standard sharpened wooden pencil with eraser.
b. Correct responses include: Pencil, number 2 pencil
c. Code 1= correct for correct answer.

12. Please repeat the following: No i f , ands or buts.

a. Enunciate clearly -- include the "S" at the end of fg ands, or but& (if
you think the participant heard you but repeated it incorrectly, make a
note of what was missed and score 0).
b. Allow only one attempt.
c. Code 1= correct when the participant correctly repeated the phrase.
d. Code 0 = incorrect when the participant did not repeat the phrase
exactly.

Occasionally hearing impairments prevent participants from correctly hearing

test questions. In the case of repeating no if?, ands, or buts, some judgment
must be made on the part of the examiner as to whether the participant could
hear the "s" or not.

13. Please read the following and do what it says.

a. Hand participant the "Please Close Your Eyes7'card.

b. The participant may read the sentence out loud. The task to be coded
is the participant's ability to follow instructions by closing hisher
eyes. It is not necessary for the sentence to be read out loud if the
participant performs the function properly.
c. Code 1= correct when the participant closes hisher eyes.
d. Code 0 = incorrect when the participant did not close hisher eyes.

14. Please write a sentence.

a. Script: Write any complete sentence on this piece ofpaper for me.
b. Repeat the instructions to participant if necessary.
c. Code 1= correct if the participant wrote a complete sentence as
directed.
 d. Written commands, such as sit down, where the subject is implied, are
considered correct responses.
e. Spelling and/or punctuation errors are not counted as errors.
f. Code 0 = incorrect when the participant did not write a complete
sentence as directed.
g. Code 1= if the participant is cognitively able to dictate a sentence but
is physically unable to write it. In this case .the examiner should write
the dictated sentence and make a note that it was dictated.
Code 6 = Low vision

15. Please copy this drawing.

a. Script: Here is a drawing. Please copy the drawing on the same piece
of paper.
b. If the participant asks if the figures should be drawn separately or
together the examiner should respond, Draw theJigures as you see
them.
c. To be correct, each pentagon must have 5 sides, 5 sides that point
outward. The two figures must be overlapping.
d. The overlap figures must have 4 sides.
e. Code "0" = incorrect when the participant's figure did not match.

16. Take this piece of paper in your right hand, fold it in half with both hands,
and put it in your lap.

(If participant is unable to use right hand because of physical disability, you
can alter instructions to read "Take this piece of paper in your left hand, fold it
in half with your left hand, and put it in your lap". The goal is to see whether
the subject is able to follow a 3-step command, so this variation to the
directions to accommodate subject's physical limitations is allowable. )

a. Read the full statement BEFORE handing the paper to the participant.
b. DO NOT direct the paper to participant's right side. Hold the paper in
front and have the participant reach out to take it. Observe which hand
is used.
c. DO NOT repeat instructions or coach participant. Only repeat if the
examiner felt it was not heard or if instructions were not given clearly
(just repeat the directions in full as they were the first time).
d. Score: 1for correctly performed act (code 6 if low vision).
F. Factors Potentially Affecting Mental Status Testing
The examiner's impression for Cohort Cycle 28 will include the following:

NO YES MAYBE UNKNOWN

0 1 2 9 Illiteracy or low education
0 1 2 9 Not fluent in English
0 1 2 9 Poor eyesight
0 1 2 9 Poor hearing
0 1 2 9 Paralysis
0 1 2 9 Depression/Possible Depression
0 1 2 9 Aphasia
0 1 2 9 Coma
0 1 2 9 Parkinsonism or neurological
impairment
Other

Note: Questions cannot be answered by a proxy.

PLEASE CLOSE YOUR EYES
 EXAM 8 <<IDType)>-
NID* ((LNamen, (~FNamen 11

Cognitive Function--Part I
OMB NO=0925-0216 1213112007
I'm going to start by asking questions that require concentration and memory. Some questions are more
dficult that others and some will be asked more than one time.
hB1 1 1- Examiner's Number for Cognitive Function -- Part I+II

6 9 What Day of the Week Is it?

0 1. 2 3 G 9 What ~ o $ ~ , ; d b @ &and ~ t ; i f e . ~ kIn* ~ e

6 9 What Is the Name of this Place?

(any appropriate answer all nght, for instance my home, street address, heart study..max score=l)

,'6 - 9 .- W~h'atFloor of the Buildinz Are We on?

0 12 3 6 9 I am going to name 3 objects. After I have said them I want you to repeat
them back to me. Remember what they are because I will ask you to name
them again in a few minutes: Apple, Table, Penny
6 -
' Now i am going to spell s word+forWarda$d I want ydu to spell it b d ~ ~ t l ~ ,d s .
1 -1
, 1 1
, 1 The word is world. \V-0-R-L-D.
- Please Spellsit in Reverse Order.
' ' Write in Letters, (~etfkrs-he
,Ent6red a i d S&ed ~ a t e 4 '
,

00000=Administered, but couldn't do

99999dJnknown
I 0 12 3 6 9 What are the 3 objects I asked you to remember a few moments ago?

Version #8 GM 09-27-05
 4
EXAM 8 ((1DType))-
<(ID* <(LName,),
((FName),

Cognitive Function --Part I1

OMB NO=0925-02 16 12131/2007

0 1 6 9 What Is this Called? (Watch)

. . . , .:, - .; i - , , :.. '''..,.. .' .. .... - . . .

. , . . , . .

0 1 6 9 Please Write a Sentence (code 6 if low vision)

' . .

No Yes Maybe Unk Factor Potentially Affecting Mental Status Testing

(coding below)
- 0 1.. 2 9 Illiterate or low education
.i .
4
. -. 3j 4 4 - A #

0 1 2 9 Not fluent in English

0 1 2 9 Poor hearing

0 1 2 9 Other, write in

Version #8 GM 09-27-05
 -+
;

EXAM 8 <<IDType))-
nJD>) <<LNarnen,
<<FNamen

OMB NOz0925-0216 12/31/2007

Sentence and Design Handout for Participant

PLEASE WRITE A SENTENCE

PLEASE COPY THIS DESIGN

Version #8 GM 09-27-05