“Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician

EXAMINATION of the mental state is essential in evaluating psychiatric patients.1 Many investigators have added quantitative assessment of cognitive performance to the standard examination, and have documented reliability and validity of the several “clinical tests of the sensorium”.2*3 The available batteries are lengthy. For example, WITHERS and HINTON’S test includes 33 questions and requires about 30 min to administer and score. The standard WAIS requires even more time. However, elderly patients, particularly those with delirium or dementia syndromes, cooperate well only for short periods.4 Therefore, we devised a simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely. It is “mini” because it concentrates only on the cognitive aspects of mental functions, and excludes questions concerning mood, abnormal mental experiences and the form of thinking. But within the cognitive realm it is thorough. We have documented the validity and reliability of the MMS when given to 206 patients with dementia syndromes, affective disorder, affective disorder with cognitive impairment “pseudodementia”5T6), mania, schizophrenia, personality disorders, and in 63 normal subjects.

A practical method for grading the cognitive state of patients for the clinician

1. The association between plaque counts in sections of cerebral cortex and measures of intellectual and personality functioning undertaken in elderly subjects during life has been studied.

2. There was no evidence that degenerative changes had contributed significantly to the causation of illness in patients with "functional" psychiatric disorders or delirious states.

3. There is a highly significant correlation between mean plaque counts and scores for dementia and performance in psychological tests. The findings suggest that psychological and pathological indices are closely related to one another, possibly through their common association with the underlying degenerative process in the brain.

4. Among severely demented subjects and those diagnosed clinically as "senile dements", correlations between psychological and pathological measures decline sharply. However, pathological differences between normal, mildly demented, and severely demented subjects appear to be of a quantitative nature. The possibility that there are qualitative differences in this group, inaccessible to present methods of examination, cannot be excluded.

The Association Between Quantitative Measures of Dementia and of Senile Change in the Cerebral Grey Matter of Elderly Subjects

To clarify the role of memory impairment in the aged as a normal or psychopathological phenomenon, 153 persons 50-years-old and over with varying degrees of depression and altered brain function were compared for their complaints about memory and actual performance on a series of memory tests. It was found that while performance varied with altered brain function, complaint was related to level of depression, regardless of performance. Exaggerated memory complaint was considered one manifestation of a general pattern of discrepant reporting of symptoms by depressed persons, and apparently related to an underlying personality factor. The complaint of superiority of remote over recent memory was not substantiated empirically, but was considered part of the pattern of stereotyped language and attitudes characteristic of depressed persons.

Memory complaint and impairment in the aged. The effect of depression and altered brain function.

SMALL, discrete masses of argyrophilic particles, with a mean diameter of 50–60µ, were first seen in the cerebral cortex by Blocq and Marinesco1 and named “senile plaques” by Simchowicz2, who discovered large numbers of these lesions in cases of senile dementia. Since they may be present in the normal old person3 and no close relationship between intensity of plaque formation and clinical changes was found by some workers4, their relevance for senile dementia—the extreme form of intellectual decay of old age—has often been called into question. More recently Corsellis5 has demonstrated a reasonably good correlation between clinical diagnosis and neuropathological changes in post-mortem studies of aged mental hospital patients. But the nature and extent of the relationship between plaque formation and mental deterioration in old age remained uncertain. An attempt has been made to shed further light on this problem by enquiries in a series of patients, aged 60 years and more, admitted with psychiatric or physical illness to mental and geriatric hospitals and subsequently studied at post-mortem. The aim was to carry out a quantitative assessment of the severity of dementia in individual subjects during life and to ascertain whether this bore any relationship with mean plaque counts in cerebral grey matter. At this stage of the enquiry cases with gross cerebrovascular lesions were excluded as there was no available technique for making a quantitative estimate of their extent. The degree of dementia was expressed in quantitative form by carrying out the two following assessments.

Correlation between Scores for Dementia and Counts of ‘Senile Plaques’ in Cerebral Grey Matter of Elderly Subjects

1. The aim of the research is to examine the relationship of certain aspects of mental functioning to the psychiatric illnesses of old age. The present paper has attempted to attack the problem of differential “memory function” by examining the discriminating power of certain test results as between “functional”, “doubtful” and “organic” groups of elderly patients.

2. The design of the present study shows that spuriously positive results may arise from inadequate control over factors contributing to the selection of the criterion groups.

3. The investigation fails to confirm, for the patients tested, the diagnostic usefulness of certain tests in common use.

4. The results fail to confirm the predictions of “Ribot's Law” as applied to memory in these elderly patients.

5. The study shows significant differences between the means of the results of the psychiatric groups on some tasks which appear to involve “memory function”. These differences cannot be accounted for merely in terms of group differences in general intelligence. The nature of the possible underlying “memory function” remains to be further examined.

6. The investigation so far shows that the best discrimination between the groups is achieved by a simple perceptual task (Bender Gestalt).

7. The study fails to show differences between groups on any of the tests which are sufficiently great to enable these tests to be immediately employed as useful diagnostic instruments.

B. Löfving

Papers

“Memory Function” in Psychiatric Patients Over Sixty, Some Methodological and Diagnostic Implications