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

Interpretation of Folstein Mini-Mental State Examination Scores

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

Understanding the MMSE and Its Scoring

The MMSE is one of the most widely known and studied brief cognitive tests, taking less than 10 minutes to administer. It has been extensively validated as a screening tool for cognitive function with the following characteristics:

• Maximum score: 30 points
• Standard cutoff score: 23/24 (scores of 23 or below indicate cognitive impairment)
• Sensitivity: approximately 85% for detecting cognitive impairment
• Specificity: approximately 90% in community settings 1

Clinical Significance of MMSE Scores

The MMSE assesses multiple cognitive domains including:

• Orientation
• Registration
• Attention and calculation
• Recall
• Language
• Visuospatial abilities

When interpreting MMSE scores:

• Scores ≤ 23: Indicate cognitive impairment that warrants further evaluation 1
• Scores 24-30: Generally considered within normal cognitive function, though this can be affected by education level and age

Factors Affecting MMSE Interpretation

Several important factors can influence MMSE performance and should be considered when interpreting scores:

1. Educational Level:

   • Highly educated individuals may score normally (>23) despite having cognitive impairment
   • For those with college education, a higher cutoff of 27 may be more appropriate 2
   • Individuals with low education or illiteracy may score below 24 despite normal cognition 3

2. Age:

   • Age-specific norms may provide greater sensitivity than the standard cutoff of 24
   • Lowest quartile cutoffs by decade: 40s-29; 50s-28; 60s-28; 70s-28; 80s-26 4

3. Language and Cultural Factors:

   • In non-English speaking populations, sensitivity and specificity may vary significantly
   • For Spanish speakers with low education (0-4 years), sensitivity and specificity are only 50% and 72.73% 3

Limitations of the MMSE

While the MMSE is valuable for screening, it has important limitations:

• Limited sensitivity for detecting mild cognitive impairment compared to newer tools like the Montreal Cognitive Assessment (MoCA) 1
• May not detect subtle cognitive deficits in highly educated individuals 2
• Does not have time constraints in its items, potentially missing processing speed deficits 5
• Not designed specifically to differentiate between types of dementia (Alzheimer's, vascular, etc.)

Clinical Application

For optimal clinical utility:

• Use the MMSE as an initial screening tool, recognizing a score ≤23 indicates cognitive impairment
• Consider using a higher cutoff (26 or 27) for highly educated individuals
• Supplement with additional cognitive tests (such as verbal fluency) to improve diagnostic accuracy 6
• Follow up positive screens (scores ≤23) with comprehensive neuropsychological testing and appropriate diagnostic workup
• Consider serial assessments to track cognitive changes over time

Bottom Line

A score of 23 or less on the MMSE indicates cognitive impairment (answer A), not specifically mental retardation, Alzheimer's dementia, or Parkinson's dementia. While cognitive impairment may be present in these conditions, the MMSE alone cannot differentiate between various causes of cognitive dysfunction.