The Mini-Mental State Examination: What an SLP Needs to Know

Introduction

Speech-language pathologists (SLPs) play a primary role in the screening, assessment, diagnosis, and treatment of individuals with dementia and its associated symptoms (ASHA, 2005). Because the elderly segment of the population (65+ years) will rise from its current proportion of 13% to 20% by 2030, people with dementia-associated communication problems are the profession's fastest growing clinical population (Kinsella & Phillips, 2005). For example, an estimated 5.3 million Americans suffer from Alzheimer's disease (Alzheimer's Association, 2009). By the year 2050, the number of affected individuals could rise to between 11.3 and 16 million. Given the growth in the number of older adults in the United States, the high incidence and prevalence of dementia in this population, and the negative impact of dementia on cognitive-communication abilities, appropriate assessment and intervention are critical.

Healthy aging individuals show naturally occurring changes in their language functioning, including a decrease in grammatical complexity and propositional content, a decrease in cohesion, and word-finding difficulties (Bayles & Tomoeda, 2007). In addition to these typical changes, persons with dementia exhibit accelerated breakdown in linguistic performance and coherence, and in the late stages of dementia, they show an increase in the use of jargon, and possibly mutism (Bayles & Tomoeda, 2007). Since breakdowns in language and other cognitive functions are common in aging adults, screenings tools are often administered to determine atypical cognitive status. A speech-language pathologist is a likely professional to administer these screening tests.

Mini-Mental State Examination 

The Mini-Mental State Examination (MMSE; Folsein, Folstein, & McHugh, 1975) is one of the most frequently used screening tools for measuring cognitive status in adults. It is used by multiple professionals including psychologists, physicians, speech-language pathologists, and others working with geriatric populations. It has been a widely critiqued test, with notable strengths and weaknesses. The MMSE was developed in 1975 as a brief, quantitative assessment of cognitive impairment in adults. Folstein, Folstein, and McHugh (1975) sought to develop a screener that could assess multiple areas of cognition quickly, collect baseline cognitive measures, and screen for cognitive declines associated with dementia. Cognitive impairment is a significant cause of morbidity and mortality in the elderly. The MMSE can be used to track changes in individuals over time, and it can be used to estimate the severity of cognitive impairment. The MMSE provides a total score that places the individual on a scale of cognitive function.

The MMSE examines multiple areas of cognition including: orientation, immediate and short-term memory, attention and calculation, and language. The test is considered valid for most populations. The original scoring for the MMSE suggested that a score of 23 or below is generally indicative of a cognitive impairment (Folstein, Folstein, & McHugh, 1975) but other studies (Pedersen, Reynolds, & Gatz, 1996) indicate that in highly educated individuals, such as those with a college education and above, a score of 25 or below may be indicative of a cognitive decline.

Some disadvantages of the MMSE include difficulty identifying mild cognitive impairment, and variable effectiveness for individual questions. Specific concerns regarding individual test items have been raised and the test may be biased for age, education, and cultural and socioeconomic background (Tierney, Szalai, Snow, Fisher, & Dunn, 1997).

Cognition and Language

One of the criticisms of the MMSE is that it is a highly verbal test (Mitrushina & Satz, 1994). The MMSE is dependent on the expressive language system as a response mode to many test items. The connection between language and cognition is well-documented (Bayles & Tomoeda, 2007). Bayles and Tomoeda define cognition as "a general term that refers to both stored knowledge and the processes for making and manipulating knowledge" (p. 36) "Language" refers to the symbol system in which sound is paired with meaning for a particular purpose. Language is commonly defined as being comprised of various components including phonology, semantics, syntax, morphology, and pragmatics. These different components can be localized to different regions of the cerebral hemispheres, with syntax, morphology, and phonology being represented near the Sylvian fissure of the left hemisphere, and semantics represented across both hemispheres.