How do you score the Mini-Mental State Examination (MMSE)?

How to Score the Mini-Mental State Examination (MMSE)

Scoring Structure

The MMSE is scored out of a maximum of 30 points, with points allocated across six cognitive domains: orientation (10 points), registration (3 points), attention and calculation (5 points), recall (3 points), language (8 points), and constructional ability (1 point). 1

Domain-Specific Point Allocation

• Orientation (10 points total): Orientation to time (5 points) and orientation to place (5 points) 2, 3
• Registration (3 points): Immediate recall of three words 2, 3
• Attention and Calculation (5 points): Serial sevens or spelling "world" backwards 3
• Recall (3 points): Delayed recall of the three previously registered words 2, 3
• Language (8 points): Naming objects, following commands, reading, writing, and repetition 2, 3
• Constructional Ability (1 point): Copying intersecting pentagons 2

Score Interpretation

A score of 23 or below (out of 30) is generally accepted as indicating cognitive impairment and is associated with dementia in at least 79% of cases. 4

• 24-30 points: Generally considered normal cognition, though scores of 24-25 fall at the threshold and warrant further evaluation 5
• 18-23 points: Mild cognitive impairment or mild dementia 1
• 0-17 points: Moderate to severe dementia 1

Critical Adjustments for Accurate Interpretation

Age and education significantly affect MMSE scores and must be considered when interpreting results. 4, 6

• Age-specific cutoffs: The lowest quartile cutoff scores by decade are: 40s = 29; 50s = 28; 60s = 28; 70s = 28; 80s = 26 6
• Education adjustment: Higher education levels are associated with higher scores, particularly in the constructional ability and attention/calculation domains 2
• A score of 25/30 falls at the cutoff for potential cognitive impairment when using education-adjusted norms 5

Common Pitfalls to Avoid

• Do not rely on a single MMSE score in isolation: Serial testing over time is more informative than a single measurement, with average decline in Alzheimer's disease of approximately 3-4 points per year 5
• The MMSE has poor sensitivity for mild cognitive impairment: It may miss subtle cognitive changes, particularly in highly educated individuals who score in the "normal" range despite having MCI 5, 7
• Ceiling effects: The test performs poorly in detecting early cognitive decline in individuals with high baseline cognitive function 5
• Floor effects: The MMSE has limited utility in severe dementia for tracking progression 4

Which Domains Best Predict Cognitive Decline

Orientation, recall, and language domains are most strongly associated with clinical diagnosis of dementia, while attention/calculation is associated with both diagnosis and education level. 2

• Recall and orientation for place combined have similar sensitivity to the full MMSE for detecting Alzheimer's disease 7
• Registration alone is not associated with either education or diagnosis and has limited discriminatory value 2
• Adding verbal fluency testing to the MMSE improves diagnostic accuracy for patients scoring in the nondemented range (>23) 7

When MMSE Results Require Additional Assessment

Any score of 25 or below warrants comprehensive cognitive assessment using more sensitive instruments such as the Montreal Cognitive Assessment (MoCA), which has better sensitivity for detecting MCI than the MMSE. 5

• Obtain collateral history from a reliable informant using standardized tools (AD8, IQCODE) 5
• Assess functional status with validated instruments (Pfeffer FAQ, DAD) 5
• Rule out reversible causes with laboratory testing (CBC, CMP, TSH, B12, folate) 5
• Consider neuroimaging (MRI preferred) to evaluate structural abnormalities 5