A patient with a Mini‑Mental State Examination (MMSE) score of 23—what is the appropriate next step in evaluation and management?

MMSE Score of 23: Evaluation and Management

An MMSE score of 23 indicates mild cognitive impairment or mild dementia and requires comprehensive cognitive assessment with the Montreal Cognitive Assessment (MoCA), functional evaluation, informant-based questionnaires, and laboratory workup to exclude reversible causes. 1

Interpretation of MMSE 23

• A score of 23 falls below the traditional cutoff of 24 and suggests cognitive impairment, with studies showing that scores ≤23 are associated with dementia in at least 79% of cases. 2
• This score represents the boundary between mild cognitive impairment (MCI) and mild dementia, requiring further assessment to distinguish between these diagnoses. 1
• The MMSE has high sensitivity and specificity for separating moderate dementia from normal cognition but lacks sensitivity for detecting mild dementia or MCI, making additional testing essential. 1
• Education level significantly affects interpretation: in highly educated individuals (≥16 years), a cutoff of 27 (not 24) may be more appropriate, meaning a score of 23 in this population strongly suggests dementia. 3

Immediate Next Steps in Cognitive Assessment

Administer the Montreal Cognitive Assessment (MoCA) as it is more sensitive than the MMSE for detecting MCI and mild cognitive deficits. 1

• The MoCA should be used when there is suspicion of cognitive impairment and the MMSE score is borderline or when mild impairment is suspected. 1
• Do not rely on the MMSE score of 23 alone to make diagnostic or management decisions, as single measurements have limited predictive value. 4, 5

Essential Informant and Functional Assessment

Obtain collateral history from a reliable informant using validated questionnaires, as patient insight may be impaired. 1

• Administer the Ascertain Dementia 8 (AD-8) questionnaire or the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) to assess cognitive changes over time. 1
• Combining cognitive tests with functional screens and informant reports improves diagnostic accuracy and is strongly recommended. 1

Assess functional status objectively to distinguish between MCI and dementia:

• Use the Pfeffer Functional Activities Questionnaire (FAQ) or Disability Assessment for Dementia (DAD) with both patient and family member. 1
• The distinction between MCI and dementia hinges on whether instrumental activities of daily living are impaired. 1

Screen for behavioral and psychological symptoms:

• Administer the Neuropsychiatric Inventory-Questionnaire (NPI-Q) or Mild Behavioural Impairment Checklist (MBI-C) if personality, behavior, or mood changes are reported. 1
• Use the Patient Health Questionnaire-9 (PHQ-9) if depressive symptoms are present. 1

Medical Workup to Exclude Reversible Causes

Conduct laboratory testing to identify treatable conditions:

• Complete blood count, comprehensive metabolic panel, thyroid function tests (TSH), vitamin B12, and folate levels. 6
• These tests are essential before attributing cognitive impairment to neurodegenerative disease. 6

Assess for medical conditions associated with cognitive disorders:

• History of stroke or transient ischemic attack
• Late-onset or lifetime history of major depressive disorder
• Untreated sleep apnea
• Unstable metabolic or cardiovascular disease
• Recent delirium episode
• First major psychiatric episode at advanced age
• Recent head injury
• Parkinson's disease 1

Obtain neuroimaging (MRI preferred) to evaluate for structural abnormalities, vascular disease, or other pathology. 6

Longitudinal Monitoring Strategy

Schedule follow-up cognitive assessment in 6 months to track progression, as serial testing is more informative than single measurements. 6

• The average decline in Alzheimer's disease is approximately 3-4 points per year on the MMSE. 6
• Rapid cognitive decline (≥3 points per year) is more common in moderate dementia (43.2%) than mild impairment (20.1%) and may indicate comorbid illness or aggressive disease. 1
• Patients with MMSE scores <20 at treatment onset, vascular risk factors, age <70 at symptom onset, higher education, or early hallucinations/psychosis are at higher risk for rapid decline. 1

Management Considerations

Optimize vascular risk factors (hypertension, diabetes, hyperlipidemia) as these contribute to cognitive decline. 6

Recommend lifestyle modifications:

• Regular physical exercise, cognitive stimulation, social engagement, and Mediterranean diet. 6

Provide education and counseling to patient and family about the diagnosis, prognosis, and risk of progression. 6

When to Refer to Specialist

Refer to neurology or geriatric psychiatry if:

• Cognitive impairment significantly affects daily functioning 6
• Rapid cognitive decline occurs (>4 MMSE points per year) 6
• Atypical features are present (early onset, focal neurological signs, rapid progression) 6
• Prominent behavioral or psychological symptoms emerge 6

Critical Pitfalls to Avoid

• Do not use MMSE 23 as a standalone diagnostic tool: it has poor sensitivity for MCI and may miss early dementia, particularly in highly educated individuals. 1, 4, 5
• Do not overlook education adjustment: in patients with ≥16 years of education, a score of 23 strongly suggests dementia rather than MCI. 3
• Do not skip informant assessment: patients often lack insight into their deficits, making collateral history essential for accurate diagnosis. 1
• Do not assume irreversibility: always exclude treatable causes (thyroid disease, B12 deficiency, depression, medication effects) before diagnosing neurodegenerative dementia. 6