Basics on screening for neuro -- cognitive disorders , how to use the mini mental state examination and score it

1. MINI MENTAL STATE EXAMINATION
DR OGECHUKWU MBANU
FAMILY MEDICINE DEPARTEMENT
AKTH KANO NIGERIA
4/7/19

3. PRE TEST 1
•Mini mental state examination represents what type of
prevention
A. Primordial
B. Secondary
C. Primary
D. Quartnery

4. PRE TEST 2
•Mini mental state examination assesses the following
except
A. Affect
B. Orientation
C. Language and learning
D. Registration

5. PRE TEST 3
•The following can be used for cognitive assessment
except
A.MMSE
B.BCAT
C.SLUMS
D.GCTT

6. PRE TEST 4
• Janice is a 78yr old female who scored a 14 on the MMSE
without anything else about Janice , you know that
A. An MMSE score of 14 is considered within normal range
B. An MMSE score of 14 is consistent with mild cognitive
impairment
C. An MMSE score of 14 is consistent with moderate cognitive
impairment
D. An MMSE score of 14 is consistent with severe cognitive
impairment

7. Outline
•Introduction
•Neurocognitive disorders
•Cognition domain
•Epidemiology
•Neurocognitive disorders
DSM – IV / V
•Administering the MMSE
•Mini mental state
examination scoring
•Other neurocognitive
assessment tests
•Advantages of MMSE
•Diadvantages of MMSE
•Risk factors of neurocognitive
disorders
•Conclusion

8. INTRODUCTION – MINI MENTAL STATE EXAMINATION
• Developed by Folstein in 1975
• Shortly known as mini mental state examination (MMSE) or folstein test
• It is a screening tool used to assess neurocognitive function and also for
follow up of patients
• MMSE is a 30 point screening tool
• MMSE is not meant for diagnosis of dementia
• It is part of mental status examination – appearance ,attitude ,behavior
,mood and affect , speech ,thought process ,thought content,
cognition,insight
• Some more sensitive tools can be applied if MMSE shows neurocognitive
impairment such as
• MOCA
• SLUMS
• MINI COG TEST

9. NEUROCOGNITIVE DISORDERS
•Neurocognitive disorders result primarily from primary or
secondary abnormalities of the central nervous system and
affects memory , orientation , attention and judgement
•Can also be said to be acute or insidious onset of disturbance in
various cognitive and executive functions and / or in memory
due to primary or secondary abnormalities of CNS

10. NEUROCOGNITIVE DISORDERS – 2
• For a diagnosis of neurocognitive disorder one or more of these must
be present
• Agnosia : failure to recognize familiar objects
• Aphasia : failure to produce or comprehend verbal speech
• Apraxia : failure to execute complex motor skills
• Dys – executive issues : disturbances in executive functioning ability to think
abstractly , difficulties with activities of daily living
• Amnesia : loss of memory , but with preservation of motor / executive
functions

11. COGNITIVE DOMAIN
•According to DSM V the main cognitive domains are
• Complex attention
• Executive function
• Learning and memory
• Language
• Perceptual motor or social cognition
•All are covered in the MMSE

12. EPIDEMIOLOGY
• Cognitive impairment issues are increasing globally and are predicted to
increase proportionately more in developing regions.
• By 2050 the number of individuals older than 60 years will be
approximately 2 billion and will account for 22% of the world’s
population
• Estimated that 35.6 million people are currently living with dementia
worldwide
• This number will nearly double every 20 years, reaching 115.4 million in
2050, with the majority living in developing countries.
• Of the total number of people with dementia worldwide, 57.7% lived in
developing countries in 2010 and a proportionate increase to 70.5% is
anticipated by 2050

13. EPIDEMIOLOGY
• Cognitive impairment ( < 24 ) was noted in 44% of DM2 patients in DM
clinic at federal teaching hospital abakiliki ( October 2013 – September
2014)
• Similar study in India gave a prevalence rate of 36 %
• A study in Zaria showed 2.8% prevalence of dementia
• Two studies in Ibadan conducted 8 years apart showed a prevalence of
2.3 % in 1995 and 10.1% in 2006
• A study from Jos, in central Nigeria, reported a dementia prevalence of
6.4% among 280 participants
• participants(six hundred and thirteen) aged 65 years and above resident
in Lalupon community , Oyo State were also studied for prevalence of
dementia and mild cognitive impairment .
• 18.1% had mild cognitive impairment while 2.8% had dementia

14. NEUROCOGNITIVE DISORDERS – DSM IV / V
•The DSM – IV diagnosis of dementia and amnestic disorders
are now subsumed under the newly named entity – major
neurocognitive disorders (NCD)
•The term dementia has been eliminated in ICD10 and DSM –V
•However it may still be used for atiological subtypes where it
is still standard
•NCD is more like a symptom ie not a final diagnosis
•The doctor still has to specify which disorder the NCD is
attributable to eg Alzheimer’s type dementia , lewy body etc

15. MAJOR CHANGES – DSM V
•NCD are now of two types
•Major neurocognitive disorders
•Mild neurocognitive disorders

16. MAJOR NEUROCOGNITIVE DISORDER
A. Evidence of significant cognitive decline from a previous level of
performance in one or more cognitive domains
1. Concern of the individual ,a knowledgeable informant , or the
clinician that there has been a significant decline in cognitive
function , and
2. A substantial impairment in cognitive performance , preferably
documented by standardized neuropsychological testing or ,
another quantified clinical assessment .
B. Cognitive deficits interfere with independence in everyday activities
C. Cognitive deficits do not occur exclusively in the context of a delirium
D. Not better explained by another mental disorder (schizophrenia)

17. MAJOR NEUROCOGNITIVE DISORDERS (DEMENTIA) – CAUSES
• Dementia – chronic and progressive disturbance in cognitive function associated with CNS damage
• Dementia -- the main cause can be classified into :
• Irreversible
• Reversible
• Irreversible : Alzheimer’s type dementia
• Parkinson’s disease
• Vascular dementia
• Frontotemporal dementia ( picks’s)
• Huntington’s disease
• Creutzfeldt – Jakob disease
• Wilson’s disease
• Reversible : due to medical conditions : - Drugs
• Endocrine
• Metabolic
• Nutritional (vit b 12 deficiency )
• Tumor/ trauma
• Infection ( syphilis)

18. MILD NEUROCOGNITIVE DISORDER
• Formerly called mild cognitive impairment
A. Evidence of modest cognitive decline from a previous level of
performance in one or more cognitive domains ( complex attetion
,executive function ,learning and memory , language , perceptual – motor
or social cognition ) based on :
1. Concern of individual , a knowledgeable informant , or the clinician that there has
been a mild decline in cognitive function
2. A modest impairment in cognitive performance ,preferably documented by
standardized neuropsychological testing or its absence , another quantified clinical
assessment
B. Cognitive deficit do not interfere with independence in everyday activities
C. Cognitive deficits do not occur exclusively in the context of a delirium
D. Not better explained by another mental disorder (schizophrenia)

19. ADMINISTERING THE MMSE
• Greet ,introduce yourself ,confirm the patient
• Take a good history and examination
• Always include care givers
• It is advisable to administer AD8 to family members before MMSE
screening (this can be done with the help of the assistant)
• Explain the test briefly and obtain consent
• Go ahead to administer MMSE (as in our setting) or the MINI – COG
• Explain the result to the patient
• Answer patients questions and clarify issues that are confusing
• Thank patient after test ,continue with other investigations , condut
other more semsitive tests , refer if indicated and give appointment
for follow up

20. MMSE
Task Description
Registration & Recall Ability to repeat and retain three unrelated words, and then recall after a short intervention task
3 points each = 6
Orientation to Time Identify current year , month, day of the week, and date ,time
5 points
Orientation to Place Identify country , city/town, LGA , hospital , and floor currently in
5 points
Attention & Calculation (Serial 7s) Count backwards by 7s or spell WORLD backwards
5 points
Naming Ask to identify 2 objects when pointed to by examiner
1 point for each identified = 2
Repetition Required to repeat a sentence that contains words not often said together
1 point
Comprehension Understand and carry out a three-stage verbal command
3 marks if can repeat all three comands
Reading Read and follow written instructions
1 point
Writing Asked to write a sentence
1 point
Drawing Asked to copy intersecting pentagons

21. MINI MENTAL STATE EXAMINATION SCORING
•MMSE is interpreted in the
following way :
•27 – 30 : normal
•21 to 26 :- mild cognitive impairment
•11 -20 : -- moderate cognitive
impairment
•0 – 10 : -- severe cognitive impairment

23. OTHER NEUROCOGNITIVE ASSESSMENT TESTS
•The Modified Mini-Mental State (3MS) examination
•The Montreal cognitive assessment – MOCA
•The mini – cog test
•The brief cognitive assessment tool – BCAT
•Saint louis university mental status test – SLUMS
•AD8 (differentiating aging and dementia)
•A lot others

24. THE MODIFIED MINI MENTAL STATE EXAM
• Samples a broader variety of cognitive functions,
• covers a wider range of difficulty levels
• broadens the range of scores from 0-30(MMSE) to 0-100
• enhanced reliability and validity of the scores.
• The Modified Mini- Mental State (3MS) incorporates
• four added test items,
• more graded scoring, and
• some other minor changes
• retains the brevity, ease of administration, and objective scoring
• More sensitive than MMSE in detecting mild cognitive impairment

25. 3MS

26. MOCA
•Brief assessment tool designed to detect cognitive
impairment in older people
•A 30 point test ,takes about 10 minutes
•Includes items that sample a wider range of
cognitive domains
•More sensitive than MMSE in detecting mild
cognitive impairment

27. THE MINI – COG
•Ability of patients to connect the sequence of ideas and
strategize and do something in a goal oriented task driven way
•Consists of clock drawing test (CDT) and uncued recall of three
unrelated words
•The CDT is normal if all the numbers are present in the correct
sequence and hands display the correct time in a readable way
•Very sensitive for predicting dementia
•Very short testing time – about 3 minutes
•Diagnostic time not limited by the subjects education or
language

31. THE AD8

32. ADVANTAGES OF MMSE
•Could be administered without any additional equipment at
patients bed side or in the consulting room
•Requires little critical thinking interpretations
•Quick to administer
•Can be administered by a capable assistant
•Patients relatives as well as Patients with mild neurocognitive
disorder can very easily relate with the results of the findings

33. Disadvantages of MMSE
•Patients educational level may affect the validity of the test
•Language barrier is still a problem as it has not yet been
translated to local languages in Nigeria
•A patient with mild cognitive disorder may be missed by this
test ( physician should put into consideration the area of
impairment instead of just looking at the scores)
•It appears to be biased towards the amnestic variant of
Alzheimer’ disease ( begins with memory loss)
•Patients new to a region may not geographic orientation aspect
of the test
•False positives can lead to anxiety ,labeling and stigma

34. RISK FACTORS OF NEUROCOGNITIVE DISORDERS
•Dyslipideamia
•Cerebrovascular disease
•Hypertension
•Type II DM
•Obesity
•Depression
•Chronic psychological stress
•Traumatic brain injury
•Down’s syndrome
•Smoking

35. CONCLUSION
• According to USPTF(united states preventive task force) “ The current evidence is
insufficient to assess the balance of benefits and harms of screening for cognitive
impairment ”
• Family physicians should however remain alert to early signs or symptoms of
cognitive impairment and evaluate as appropriate
• Early detection can:-
• Give patients more time to deal with diagnosis( live life to the fullest ,make
plans)
• Reduce the hardship on family
Not knowing creates conflict
Clarifies that disease process is occurring
• Opportunity to begin treatment and enroll in clinical trials
• Help avoid exploitations and scams

37. REFERRENCE
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38. REFERRENCE
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39. REFERRENCE
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