Why The Mini Mental Status Exam Is FAILING Patients

Hey there, everybody, and welcome to this video on the scoring challenges of the Mini Mental Status exam or the MMSE. I'm your host, Dr. Donnelly Snipes. According to an analysis of 39 studies, when the MMSE was used in a memory care unit, it accurately identified if somebody did or did not have dementia 80% of the time. Now that may sound pretty good, but that means four out of five people were accurately identified. So that's kind of a big number. When the MMSE was used in primary care settings, it only had a sensitivity of 78%. This means that 20 to 22% of the time the test is incorrect and it could be a false positive, that is, we identify somebody as having dementia who doesn't have it, or it could be a false negative where we fail to identify somebody that has early stages of dementia. One of my big beefs with the MMSE is that Medicare uses the MMSE score to determine reimbursability for mental health services. If somebody has an MMSE that is below 15, then they do not qualify for psychotherapy. Medicare has determined that they would not benefit from, from psychotherapy services. And that is really concerning for me and you'll see why in a minute. So let's talk about some of these issues. And we're not going to go through every question because some of the questions, like, you know, where are we right now? Are relatively easy to get. If you are oriented to time and place, you really probably should be able to get those. But there are quite a few others that have some methodological issues, in my opinion. The first one is worth two points. It asks people, well, two questions. What day of the week is it and what is the date? Most of the time I don't know what day of the week it is and what the date is. I'm like, okay, well, Wednesdays are easy because I teach, but the rest of the week I work from home. And my schedule is very fluid some days. Sometimes I work on the weekends, sometimes I don't. I don't have that set schedule that I used to have. Retirees may have a much more fluid schedule, especially if they don't go to church or synagogue on the weekend that sort of anchors their week. It may be hard for them to really think about, okay, what day is it actually? And I think a lot of us, if we're really honest with oursel, can think of times in the recent past where we have lost track of the the date. You know, knowing today, for example, is April 2, la. Yesterday I had no clue it was April 1, it was just a Monday, but there are a lot of times where we've at the very least, lo lost track of what the date was and sometimes even the day of the week. Another one that's worth three points. The person is asked to remember and repeat a set of three words. And this can be really problematic for people with even mild hearing impairment or if there's backgr, background noise. So the first set of three words they're given is ball, car, and man. And then in a little while, they're asked to repeat that. If they don't remember, okay, they're given the next set of words. Bell, jar, and fan. Again, if they don't get it, bill, tar, and can, and then bull, bar, and pan. You can notice how each of these sets of words sounds very, very similar. So it would be very easy for somebody with even mild hearing impairment to get them mixed up and maybe say something like ball, tar, and fan. You know, they all sound very, very close together. We want to recognize that people, especially older adults. Well, that's not even true if you watch my video on hearing loss. Even younger ad because we wear head, Headphones, earphones so much anymore. Even younger adults are having significant problems with mild to moderate hearing loss. So people who are not hearing these words correctly may misremember. Especially if you get into round two and round three, all of those words may start getting jumbled up. So I don't think that's really fair. Fair. The next one is only worth one point. The person is asked to copy a drawing, and it's two overlapping images. It's not difficult to copy if you have good vision, but if your vision is blurry, especially if it's significantly blurry, you may have difficulty seeing exactly what you're drawing. Now, this one I think most people still get right, but it's worth pointing out that we need to be sensitive to vision loss, hearing loss. These are disabilities and have no direct correlation to people's cognitive status. They may just indicate that the person can't see too good. The next one. Oh, my gosh, this one. I hate. Spelling world backwards may be difficult for somebody with dyslexia, and up to 10% of the population has dyslexia. So that could account for some of our false positives right there. If English is a second language, spelling world may not come naturally to them because they have another word that they used for world. If they have a hearing impairment, they may not hear world. You know how a lot of times if we don't articulate Even to somebody who has very good hearing, if we don't articulate well, we may sort of drop some letters. And for example, the word asked, a, S, K, E, D sometimes gets said really quickly and it sounds like A. And for somebody with hearing impairment, even mild hearing impairment, they may not hear all of the letters in world and think you said word or girl. And then they may spell the wrong thing. There is an alternative. And if you have the person count backwards from 100 by sevens, I can't even pass this one. I'm like 193. Okay, let me start counting on my fingers. What comes next when I go down by sevens? If you did it by fives, I'd be grand. But by sevens is really freaking hard. The next one is two points and it's object identification. And there are two different questions. One is for a watch and one is for a pencil, but it is scored on the English word. So if you show somebody a pencil and they their primary language is Spanish, for example, they may say lace. I believe that's the word. It's been a long time since I took Spanish. That's actually still correct. But if the person doing the scoring doesn't realize that they just used the Spanish word or the German word or Arabic word for pencil, then they may mark it incorrect. And a lot of the problems with the MMSE occurrence as a result of administration and interpretation. The next question, read the words on the page can be challenging for somebody with dyslexia or vision problems. Yes. The page that you print out, the letters are really pretty big. I think they're probably 28, 40 point font, something like that. They're big. However, if somebody has significant dyslexia or is illiterate, there are a lot of very functional adults who never learned how to read. And I've worked with many of them over the past 25 years. We don't want to diagnose somebody as having dementia because they can't read if they've never been able to read. We need to put it all in context. And I think this is the last one. For another point, write a complete sentence. For a lot of young people I know this could be difficult. We've gotten so used to texting and abbreviating and run on sentences and stuff. Writing a complete sentence that is grammatically accurate could be extremely difficult. This can be problematic. Again, for somebody who is functionally illiterate. It doesn't mean they have dementia. It means they didn't learn how to read or write. If English is their Second language. A lot of languages transpose where they put their adjectives and their nouns and their verbs. So for example, somebody who speaks Spanish may write a sentence and it appears to an English speaker that their words are out of order, but it's not because that's how they place their words in the Spanish language. And for somebody who has vision impairments, it could also be difficult just writing a sentence because they're having a hard time seeing. Now, vision impairments are a little less problematic for this particular issue, but we do want to be sensitive to that. Do they know what a complete sentence is? Can they write a complete sentence? And when they write it out, is that complete sentence accurate in their native language? In if English is not their second language, we want to look and not judge them, not negatively score them if they have their adjectives in a different place. For example, missing all of the above questions that I just went through. And most people are not going to miss all of them, but if you missed all of them, you'd get scored at a 15 out of 30 that is scored as moderate dementia. A lot of people can take the test and they end up scoring with mild dementia because of some of those errors that I talked about. They didn't hear what the person said correctly. My husband's grandfather was just administered the MMSE and he is all but deaf. In even with his hearing aids in he can't hear squat. And the test was administered at the end of a two hour tour of an assisted living facility. So he was exhausted. He also has advanced diabetes, so his blood sugar was low. All of these things contributed to him having difficulty focusing and answering these questions. When he's at home and his blood sugar stable and there's not a lot of background noise and you talk loudly to him and look him in the eye, he gets it. He can carry on a conversation just fine, thank you very much. As a matter of fact, it can be kind of ornery. And I say that because that's good. I like to see spunk. But my point being that he was scored as having severe dementia. I think it was like a 7 or a 9 that he ended up scoring. And he's nowhere near that. He is nowhere near that. If I'm a person with vision problems, hearing problems, and either dyslexia, low literacy, or English as a second language, I can easily fail the MMSE if it's being given by a, an administrator who, who is not being sensitive to culture and context. Many times when people are given the mmse, it's administered when they're really tired at the end of a full intake. In some settings, like in assisted living facilities, this unfortunately is intentional because if a person scores low enough on the mmse, then they are recommended for memory care, not traditional care. And memory care is a lot more expensive. I'm sorry, it's the cold hard facts. I've seen it too many times. We need to be cognizant of that fact and ask ourselves, does the administrator have any ulterior motives? If this person scores lower, does that benefit the administrator in some way? Again, I'm sorry, there are some very legit facilities that don't do this. However, it seems to be pretty widespread. People with low blood sugar, even if they don't have diabetes, people with low blood sugar are going to have more difficulty concentrating. So if you're administering this an hour before dinner time or after they've been on a two hour tour of the assisted living facility or whatever, if it's been a while since they ate and they've been engaging in some sort of activity, their blood sugar is probably low and it's going to be hard for them to focus. Think about how hard it is for you to focus when your blood sugar's really low. We need to be sensitive to the person's education, hearing, vision and primary language. I've said it like four times, but it is that important. My granny, when they administered the test to her, she also scored at in the severe dementia area. And part of that was because she was angry. She didn't want to take some test that was going to determine whether she was, in her words, crazy or not. And she was very defensive. So she wouldn't answer questions or she would half asset. I mean, there's no other word for it. She, she wasn't giving it her all because she didn't understand why it was being administered and how important it was to do her best in order to get into the side of the facility, the non memory care side, that she and Pops wanted to be in. We want to make sure that we administer the test when the person is awake and alert. If you're working with somebody who's older, who tends to start getting really sleepy at 3 o' clock in the afternoon, that ain't the time to administer it. You want to administer it maybe right after breakfast. If you are working with somebody who tends to get their spurt of energy in the afternoon, then administer it. Then try not to do it during a period where they're going to be sleepy, try not to do it immediately after A meal. You know how after you eat lunch sometimes you get sleepy, Your body naturally wants to rest and digest. So an hour or so after eating is generally the optimal time to administer a cognitive test. Ensure the environment is well lit so they can actually see what they're reading and they're not having to strain and it's quiet, no background noise. That way they're not getting distracted, they're not getting extra input. The MMSE is a very basic screening. This is not a diagnostic end all, be all instrument, especially because its sensitivity is only, you know, 78 to 82%. It must be followed up with a neuropsychological test if dementia is suspected. People with early dementia often have days in which they're more lucid, they're more with it, if you will. So you could administer this and they may do great on it on Tuesday, but on Thursday, not so much. So if you administered it on Tuesday, you may miss the fact that they have early stages of dementia because that was one of their good days. The slums is another test that you'll hear frequently and it's very similar to the mmse, but it's actually even harder because there's a section on telling time. There's a section and with like watches with CL clock hands and stuff, who uses that anymore? And money handling and lots of addition and subtraction and number manipulation on multiple questions. So if you've got somebody, again, who has poor math skills, they may do poorly on the slums. And it's important to get a good history. What grade did you complete? Are you able to read and write? And if you don't want to ask that question, then you may ask other questions like what good books have you read? And get an idea. If they say, well, I don't read much, okay, that might be a clue. Being sensitive, not using a single screening thing to make treatment decisions and placement decisions for an individual is crucial. And I'm seeing it too often. I'm seeing this one instrument be misused in a lot of cases. So please be sensitive and have a great day.