Mmse-2 Rev

Mini-Mental State Examination -
2nd Edition
Overview
• Original MMSE is one of the most widely used
brief screening instruments for cognitive
impairment
• Has been used in a variety of settings,

including screening individual patients,
tracking progress over time, screening for
large populations, and clinical trials
Goals for the Revision
1. Revise some of the original items to better standardize its
administrations, particularly for translations
2. Provide an even briefer version that could be used for rapid

assessment
3. Provide a slightly longer version that would be more

sensitive to subcortical dementia and that would not have a
ceiling effect
4. Develop equivalent alternate forms to decrease practice

effects in serial administration
Goal #1: Revise Original Items
• The MMSE-2 Standard Version (MMSE-2:SV)
maintains the same structure and scoring as
the original MMSE
• Changes were made to improve problematic

items and to better standardize administration
in other languages (e.g., penny, no if, ands, or
buts)
MMSE-2: Standard Version
Task Description Identical task on Revision on
Original MMSE MMSE-2:SV
Registration & Recall Ability to repeat and retain three Words have been made
unrelated words, and then recall after a slightly more difficult and
short intervention task easier to translate
Orientation to Time Identify current year, season, month, day X
of the week, and date
Orientation to Place Identify state, county, city/town, building, X
and floor currently in
Attention & Count backwards by 7s X No longer can use WORLD
Calculation (Serial 7s) spelled backwards as
alternate task
Naming Ask to identify body parts when pointed Change from “watch” and
to by examiner “pencil” to body parts allows
for translation and no use of
external materials
Repetition Required to repeat a sentence that Revised to include a sentence
contains words not often said together that is easier to translate and
difficulty slightly decreased
Comprehension Understand and carry out a three-stage Removed the reliance on
verbal command motor responses.
Reading Read and follow instructions X
Writing Asked to write a sentence X
Drawing Asked to copy intersecting pentagons X

Equivalency Between the
MMSE and MMSE-2:SV
• Like the MMSE, the MMSE-2:SV has a raw score
range of 0-30
• The generalizability coefficient (n = 411) between

the MMSE and the MMSE-2:SV total raw score was
.97
• Therefore it is possible to switch from MMSE to

the MMSE-2:SV without compromising
longitudinal data and without any change in the
normal range of scores
Goal #2: Develop Briefer Version
• Can be used for quick cognitive screener, specifically when an
individual has not been referred for specific cognitive
impairment
• Composed of Registration/Recall, Orientation to Time, and

Orientation to Place
• Raw score ranges from 0-16 points
• Tasks were selected based on literature review, use in the

MMSE, and their sensitivity and specificity to detect dementia
MMSE-2: Brief Version
Goal #3: Develop Expanded Version
• Consists of all of the items on the MMSE-2:SV

plus two new tasks:
– Story Memory: An immediate recall of a brief

story
– Processing Speed: A symbol-digit coding task

MMSE-2: Expanded Version
• Improves the clinical utility of the MMSE by:
– Extending the test’s ceiling
– Increasing the range of raw scores (0-90)
– Increasing the sensitivity for individuals with less

severe cognitive impairment (subcortical dementia,
MCI)
Goal #4: Develop Equivalent
Alternate Forms
• Two forms (Blue and Red) were developed for

each of the 3 versions of the MMSE-2
• Based on the results of the equating study, the

accuracy of the equating process was
confirmed
Equating: MMSE & MMSE-2:SV
Administration Issues
• 18 years and older
• Relatively easy to administer, typically one training session

is sufficient
• Test Materials:
– User’s Manual
– Pocket Norms Guide
– Scoring Templates for Processing Speed
– Administration Forms :
• MMSE-2:BV Blue and Red Form
• MMSE-2:SV Blue and Red Form
• MMSE-2:EV Blue and Red Form
Overview of Administration Forms
Task MMSE MMSE-2:BV MMSE-2:SV MMSE-2:EV
Registration & Recall X X X X
Orientation to Time X X X X
Orientation to Place X X X X
Attention & X X X
Calculation (Serial 7s)
Naming X X X
Repetition X X X
Comprehension X X X
Reading X X X
Writing X X X
Drawing X X X
Story Memory X
Processing Speed X
Determining Which Version is Appropriate
• MMSE-2:BV
– Adequate for screening large populations; screening
individuals in practice who have not been referred because of
cognitive complaints
• MMSE-2:SV
– Used first if referred because of complaint of cognitive decline
or if patient indicates memory is not as good as it use to be;
depending on results may want to supplement with MMSE-
2:EV
• MMSE-2:EV
– Same as above + well educated (ceiling effect); suspected
subcortical dementia
Scoring
• Mean raw total scores are presented by age and
education level
• T scores are also presented by age and education

level
• Pocket Guide
• Reliable Change Scores

Reliable Change Scores
• Reliable change refers to the extent to which the change in test
performance shown by an individual falls beyond the range that can be
attributed to practice effects or to measurement variability that is
inherent to the instrument itself
• The approach used here is a method developed by Iverson (2001)

Interpretation
• A cut score of 22/23 is typically used with the original
MMSE
• Because the MMSE-2:SV is equivalent to the MMSE,

the same cut score is suggested
• The authors have not provided specific

recommendations for the new forms, however ranges
of raw score cut scores are provided for the dementia,
AD, and subcortical samples by form
Example of Cutoff Table
Development
• Task Development – 5 additional tasks were tested
• Bias Panel – assessed potential bias and offensiveness to

protected groups
• Expert Review:
– 2 neuropsychologist, 1 geriatric psychologist, 1 geriatric
psychiatrist
– Aided in selection of tasks, provided feedback on content, and

assisted with refining items and instructions for the pilot and
standardization versions
Pilot Testing
Standardization Sample
n = 1,531 healthy controls

Cognitively Impaired Samples
Effects of Age and Education
Development of the Norms
• Because of the importance of age and education
on MMSE-2 scores norms were developed for
several different age and education ranges
• Two resources for age and education

adjustments are provided:
1. Means and standard deviations of total raw scores
by age and education groups
2. Age- and education-adjusted T scores (continuous
norming method)
Reliability: Internal Consistency
Reliability: Test Retest
Reliability: Interrater
Validity
• Content Validity – similar items on other tests (e.g., Serial 7s
similar to attention and concentration task on WMS-III)
• Intercorrelations among task and total scores (presented for both

the normative and clinical samples)
• Diagnostic Validity: Prior work on the MMSE using 22/23 or 23/24

Validity
• Convergent Validity:
– WMS-III subtests
– Category Naming Test
– COWA
– BNT
– TMT
– WAIS-R subtests
– JOLO
– HVLT-R
– Stroop Color and Word Test

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Mini-Mental State Examination -

• Has been used in a variety of settings,

2. Provide an even briefer version that could be used for rapid

3. Provide a slightly longer version that would be more

4. Develop equivalent alternate forms to decrease practice

• Changes were made to improve problematic

Writing Asked to write a sentence X

Drawing Asked to copy intersecting pentagons X

• The generalizability coefficient (n = 411) between

• Therefore it is possible to switch from MMSE to

• Composed of Registration/Recall, Orientation to Time, and

• Raw score ranges from 0-16 points

• Tasks were selected based on literature review, use in the

• Consists of all of the items on the MMSE-2:SV

– Story Memory: An immediate recall of a brief

– Processing Speed: A symbol-digit coding task

– Extending the test’s ceiling

– Increasing the range of raw scores (0-90)

– Increasing the sensitivity for individuals with less

• Two forms (Blue and Red) were developed for

• Based on the results of the equating study, the

• Relatively easy to administer, typically one training session

Registration & Recall X X X X

• T scores are also presented by age and education

• Reliable Change Scores

• The approach used here is a method developed by Iverson (2001)

• Because the MMSE-2:SV is equivalent to the MMSE,

• The authors have not provided specific

• Bias Panel – assessed potential bias and offensiveness to

– Aided in selection of tasks, provided feedback on content, and

n = 1,531 healthy controls

• Two resources for age and education

• Intercorrelations among task and total scores (presented for both

• Diagnostic Validity: Prior work on the MMSE using 22/23 or 23/24

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