The Mini-Mental State Exam (MMSE) is Ineffective at Detecting Dementia and Mild Cognitive Impairment in Older Adults

It is important to have good neurocognitive screening tools doctors can use to quickly assess whether their elderly patients are in need of a referral to a neurologist or neuropsychologist to determine if they are experiencing the early stages of cognitive decline. One of the most widely used instruments is the Mini-Mental State Exam (MMSE). A free version was developed in 1975, and in 2001, the MMSE-2 was published through NCS Pearson. Clinicians need to pay for each administration of the MMSE-2, so if your doctor is using a free version of the MMSE, that means they downloaded the almost-50-year-old version illegally (or are photocopying a 50-year-old copy) and are breaking copyright laws.

Further, the MMSE is terrible—like, really terrible—at screening for cognitive impairment in older adults.

A quick word about the statistical concept of sensitivity: Sensitivity refers to a test’s ability to detect a certain condition when that condition exists. For example, home pregnancy tests have very high sensitivity in that they detect the vast majority of pregnancies. If their sensitivity was poor, they would miss many pregnancies, leading to a lot of false negative results and a lot of surprised parents.

With that in mind, the The MMSE has poor sensitivity for the early stages of dementia and misses up to 50% of dementia diagnoses.[1],[2],[3] Think about that: if an obstetrician knew that home pregnancy tests were no better than flipping a coin, they would be outraged and demand products be taken off shelves. Yet, geriatric physicians still mostly use the MMSE for neurocognitive screening. It would be easier and faster to flip a quarter, and the quarter is just as reliable.

Further, MMSE has particularly poor sensitivity for people over the age of 60, meaning it misses many diagnoses of dementia and mild cognitive impairment.[4]

The MMSE is made up of only 11 items. Factor analysis has determined that there are two main factors: whether the person taking the test can read and write, and how good the person’s recent memory is.[5] The test does not measure executive functions, verbal fluency, attention, susceptibility to undue influence, or level of capacity.

Using a cut-off score of 26/30, which the developers of the MMSE claim is the score at which individuals are considered to have “normal cognitive functioning,” the MMSE only recognizes 17% of people with mild cognitive impairment and only 25% of people with full dementia.[6] By comparison (again), flipping a coin would catch roughly 50% of people with either mild cognitive impairment or dementia.

Level of intelligence also affects a person’s score on the MMSE, regardless of their level of cognitive impairment: people with average or low-average IQs (between 80-109) can get high scores on the MMSE even when they have significant cognitive deficits.[7],[8]


There are two neurocognitive screening tests that work much better than the MMSE, and both of them are legitimately free: the Montreal Cognitive Assessment (MoCA), and the Saint Louis University Mental Status Examination (SLUMS). In future posts, I will write about their effectiveness and why geriatric physicians should switch from the MMSE to one of those two other tests.



**Please note: All the cited research refers to the original 1975 version of the MMSE. This research does not refer to the 2001 MMSE-2**

[1] Arevalo-Rodriguez, I., Smailagic, N., Roqué-Figuls, M., Ciapponi, A., Sanchez-Perez, E., Giannakou, A., Pedraza, O.L., Bonfill Cosp, X., & Cullum, S. (2015). Mini-Mental State Examination (MMSE) for the detection of Alzheimer’s disease and other dementias in people with mild cognitive impairment (MCI). Cochrane Database Systems Review, 27(7).

[2] Naugle, R.I., & Kawczak, K. (1989). Limitations of the Mini-Mental State Exam. Cleveland Clinic Journal of Medicine, 56(3).

[3] Galasko, D., Klauber, M.R., Hofstetter, C.R., Salmon, D.P., Lasker, B., & Thal, L.J. (1990). The Mini-Mental State Examination in the Early Stages of Alzheimer’s Disease. Archives of Neurology, 47(1).

[4] Anthony, J.C., LeResche, L., Niaz, U., von Korff, M.R., & Folstein, M.F. (1987). Limits of the "Mini-Mental State" as a screening test for dementia and delirium among hospital patients. Psychological Medicine, 12(2).

[5] Fillenbaum, G.G., Heyman, A., Wilkinson, W.E., & Haynes, C.S. (1987). Comparison of two screening tests in Alzheimer's disease. The correlation and reliability of the Mini-Mental State Examination and the modified Blessed test. Archives of Neurology, 44(9).

[6] Smith, T., Gildeh, N., & Holmes, C. (2007). The Montreal Cognitive Assessment: Validity and Utility in a Memory Clinic Setting. Canadian Journal of Psychiatry, 52(5).

[7] Naugle & Kawczak. (1989).

[8] Nelson, A., Fogel, B.S., & Faust, D. (1986). Bedside screening instruments. A critical assessment. Journal of Nervous and Mental Disease, 174(2).

**Please note: All the cited research refers to the original 1975 version of the MMSE. This research does not refer to the 2001 MMSE-2**

Max WachtelComment