MMSE

The Mini-Mental State Examination (MMSE) is a short cognitive screening tool used to assess the cognitive state or cognitive impairment of an individual as well as cognitive changes over time and was designed in 1975 by M.F Folstein, S.E Folstein, and P.R McHugh. 

What is cognitive impairment?

Cognitive impairment is when an individual has difficulty in one or more areas of cognitive functioning including orientation to person, place, time, registration, recall, attention and calculation, recall, language, and visual-spatial skills. 

Cognitive impairments range from mild to severe and can occur due to age, medical, neurological, or psychological issues. They can impact an individual’s ability to function in daily life specifically in their ability to make decisions and complete tasks independently, their overall well-being, and quality of life. 

As cognitive functioning declines, so does an individual’s ability to function in daily life. Occupational therapists play a profound role in addressing cognitive impairments and enhancing functional independence in individuals.

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The MMSE

The MMSE is widely used by occupational therapists in geriatric settings, especially for individuals with dementia such as Alzheimer’s disease.

The MMSE measures cognitive functioning areas, including: 

• Orientation
• Registration
• Recall
• Attention and calculation
• Language
• Visual-spatial abilities

While it's not a comprehensive assessment, it does provide insight for understanding cognitive impairments and changes over time in an individual. The MMSE is a crucial tool in early identification and detection of cognitive impairment and decline. It assists with identifying baseline cognition, potential issues, treatment planning, and future planning and care.

How do you conduct an MMSE?

The MMSE has 11 questions that take about 5-10 minutes to administer and comes with the following considerations:

• It is important for the therapist to introduce themselves first to the individual and then ask questions on the MMSE.

• In order to ensure reliability and validity, therapists should use the standardized language provided and not simplify words or questions. 

• It is also vital to explain each task very clearly, encourage effort, and allow for appropriate timing. 

• Therapists should be mindful of educational, cultural, and language barriers. 

• The evaluator should also note any hearing or vision loss.

• The first question is regarding orientation to person, place, time, and place. 
• Registration includes presenting three unrelated objects and asking the individual to repeat them. 

• For attention and calculation, OTs ask the individual to perform a serial subtraction task and continue with subsequent subtractions, alternatively, the evaluator can ask the individual to spell WORLD backwards. 

• Recall includes asking the individual to recall the 3 items from earlier. For language, therapists ask the individual to follow a 3-step command, name specific objects, and repeat a sentence. 

• Visual-spatial skills involve having the individual copy a simple figure.

What is a normal MMSE score?

For each question, 1 point is awarded for each correct response. The total score for the MMSE ranges from 0-30, with a higher score indicating better cognitive function and a lower score indicating lower cognitive functioning. Individuals with Alzheimer’s may have a decline by 1-3 points per year and progression that is faster than this may indicate progressively rapid dementia or other medical issues.

Scoring: 

25-30: No level of Iimpairment

• IADLs and very challenging ADL tasks are not affected

20-25: Mild cognitive Impairment

• Formal assessment may be indicated
• Individual may require some level of supervision
• May present with memory loss and cognitive decline
• ADLs are impacted

10-20: Moderate cognitive impairment

• 24-hour supervision may be required
• Formal assessment is indicated

0-10: Severe cognitive impairment

• Individual is markedly impaired
• Requires 24-hour supervision and assistance with ADL tasks

Documentation, implications, interventions and goals

Based on the scores, the MMSE may assist with early detection of Alzheimer’s dementia and help to understand the progression of cognitive decline. For documentation, it is important to include the baseline MMSE scores and the specific areas of need. Including the baseline in documentation allows for a better understanding of the client’s cognitive functioning so that there is a reference point for tracking progress and changes over time. 

It is also vital to discuss in documentation how the identified cognitive areas of functioning are impacting the individual’s functioning of ADL tasks. Once a baseline is established, a plan of care can be created, as well as goals and intervention methods.

Goal areas are individualized for each client and can be tailored around enhancing memory recall, attention, calculation, language, and visual-spatial skills to improve overall safety, functioning, and independence in daily life. It is crucial to consider realistic and achievable goals that a client can meet and set SMART goals. 

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Some intervention methods may include: 

• Memory enhancement games
• Memory tools
• Breaking down steps into smaller and more manageable sequences
• Activities that challenge a client’s ability to attend to detail and calculate
• Manage finances
• Follow multi-step commands or directions, 
• Communication aids or strategies
• Practice copying figures
• Visual cues or reminders
• Environmental modifications set in place

Additionally, some safety, behavioral, and emotional support can be put into place. It is important to be flexible and adjust goals based on the individual’s treatment response or changes in medical needs. 

Furthermore, the scores of the MMSE help provide a method of communication with healthcare teams, families, and caregivers, as well as provide insight into cognitive disorders, and if other therapies are warranted such as speech therapy. Regular communication with healthcare teams and reassessment is key to note any progress or changes within the client.

Caregiver support

Caregiver education is significantly vital in patients with dementia. It is important to understand that many family members may experience emotional distress due to the functional and cognitive status of their loved ones. Occupational therapists can offer resources such as educational information, support groups, counseling services, and/or legal matters.