What does a score of 23 or less on the Folstein Mini-Mental State Exam (MMSE) indicate?

Interpreting the Folstein Mini-Mental State Examination Score

A score of 23 or less on the Folstein Mini-Mental State Examination (MMSE) indicates cognitive impairment. 1

Understanding the MMSE

The Mini-Mental State Examination is one of the most widely known and studied brief cognitive tests, typically taking less than 10 minutes to administer. It assesses multiple cognitive domains including:

• Orientation
• Memory
• Language
• Attention
• Visuospatial abilities
• Executive functions

The MMSE has a maximum score of 30 points, with the standard cutoff score of ≤23 indicating cognitive impairment, with approximately 85% sensitivity and 90% specificity in community settings 1.

Factors Affecting MMSE Interpretation

Several important factors can influence MMSE scores and their interpretation:

• Educational level: The effect of education on MMSE scores is stronger than age effects 2

  • Illiterate individuals may score in ranges suggesting severe cognitive impairment (mean 17.67) even when cognitively normal
  • Those with 1-4 years of education may score in ranges suggesting moderate impairment (mean 20.61) when cognitively normal

• Age: While less impactful than education, age can affect scores

• Cultural background: Cultural factors may influence performance on specific items

• Education level thresholds:

  • In highly educated individuals (16+ years of education), a higher cutoff score may be more appropriate:
    • A cutoff of ≤26 or ≤27 provides optimal balance of sensitivity (0.89) and specificity (0.91) for detecting dementia 3
    • For detecting mild cognitive impairment plus dementia, cutoffs of ≤27 or ≤28 may be more appropriate 3

Limitations of the MMSE

The MMSE has several important limitations to consider:

• Limited sensitivity for detecting mild cognitive impairment compared to newer tools like the Montreal Cognitive Assessment (MoCA) 1

• Poor diagnostic utility among individuals with low education levels 2

  • Low sensitivity (50%) and specificity (72.73%) in those with 0-4 years of education
  • Better sensitivity (86.36%) and specificity (86.36%) in those with 5+ years of education

• Highly verbal content that may not detect mild language deficits 4

• Should not be used as the sole diagnostic tool for identifying dementia 4

Clinical Implications

When interpreting an MMSE score of 23 or less:

• Consider the patient's educational background, age, and cultural factors
• Conduct additional assessments including:
  • Functional assessment tools (e.g., Pfeffer Functional Activities Questionnaire)
  • Behavioral assessments (e.g., Neuropsychiatric Inventory)
  • Informant-based questionnaires about cognitive changes
• Consider supplementing with other cognitive tests like the MoCA for a more comprehensive evaluation
• Serial assessments over time provide more valuable information than a single score

The MMSE remains useful for quantitatively assessing cognitive impairment severity and documenting cognitive changes over time, but interpretation must account for individual factors and limitations of the test.