Mini Mental State Examination

MMSE: Mini Mental State Examination

• ORARLC (30)

1. Orientation

2. Registration

3. Attention

4. Recall

5. Language

6. Construction

ORIENTATION

• Time: (5)1. Year 2. Season 3. Date4. Month 5. Day of the week

• Place: (5)1. State2. City3. Suburb4. Street5. Street Number/ Floor

REGISTRATION

• Registration: Apple, Table and Coin: (3)

• Ask the patient to repeat it.

• (score in first attempt and then ask to repeat again)

• I’ll be asking this three words from you later so please keep it in your mind.

ATTENTION/CALCULATION

1. Subtract seven serially from 100 upto 5 digits or numbers (5) or

2. Spell WORLD backwards DLROW (5)

RECALL

• Recall: What are the three words I told you before? (3)

LANGUAGE

1. Pointing and naming of two objects: Show pen and what is this? watch (2)

2. Repetition of sentence: Can you repeat “No if’s and’s or but’s.” (1)

3. Three stage command: Take the paper on your right hand, fold the paper in half and put it in your lap. (3)

4. Reading and obeying: “Close your eyes.” Show the paper and ask them to read and follow the written command. (1)

5. Sentence Writing. Write in full sentence what your name is. (1)

Construction

• Ask the patient to copy this design (1)

• Normal MMSE score: 25-30

• 21-24 : Mild Dementia

• 10-20: Moderate Dementia

• <10: Severe dementia

• Impaired Registration and Recall: Dementia

• Impaired Orientation and Attention/Calculation: Delirium

• Impaired Registration and Recall: Alcoholic Brain Injury

• Please read the Clinical

Handbook Condition 134

Delirium MMSE

• Please read the Clinical

Handbook Condition 146

Folstein MMSE

Case

• You are working as a Hospital Medical officer when you are called by the nurse in the ward as she noticed that Steve, a 24 year old male patient who had a shoulder fracture fixation two days ago has some tremors and hyperreflexia. He is a known heavy alcoholic beverage drinker.

• Task:1. Do a mini mental state examination

2. Explain your differential diagnoses to the patient

Task 1: Mini Mental State Examination

• Hi I’m Dr ____, I’m here to help you. How do you want me to call you?

• Today we will do a screen test for your brain functioning.

• If it is alright with you, I will just ask the examiner for a form?

• Examiner, is the MMSE chart available?

• Impaired Orientation and Attention

Task 2: Differential Diagnoses

• Delirium Tremens: Withdrawal states from Alcohol

• Delirium 2 to1. Infection

2. Metabolic

3. Hypoxia

4. Drugs

5. Organ Failure

6. Cardiac

7. Intracerebral

Delirium Tremens

• Delirium tremens occurs 2-5 days after cessation of alcohol.

• It is the most severe form of alcohol withdrawal manifested as confusion and hyperactivity of the heart that can lead to cardiovascular collapse.

• It is a medical emergency making early recognition and treatment essential.

Delirium tremens:• Delusions• hallucinations• Confusions• Seizures• Fever • Severe agitationOn exam:• Hyperthermia• Hypertension• Tachycardia• Tachypnea• Mydriasis• Ataxia• Cardiovascular collapse

Management:

• DRABCD protocol

• Correct the fluid and electrolyte imbalance

• Require admission

• Oral Diazepam 10-20mg every 2 hours

• Thiamine 100mg IM/IV per day

• Continue for 3-5 days

In General: Delirium

• Delirium is a clinical syndrome of disordered attention, presenting as an inability to focus, shift or sustain attention

• It generally occurs acutely (over hours to days)

• Diagnosed if these are present

– acute onset and fluctuating course, and

– inattention, and

– either disorganized thinking or an altered level of consciousness.

Delirium symptoms

• Clouding of consciousness• Difficulty maintaining or shifting attention• Disorientation• Illusions• Hallucinations• Fluctuating levels of consciousness• Symptoms tend to fluctuate over the course of

the day, with some improvement in the daytime and maximum disturbance at night. Reversal of the sleep-wake cycle is common.

Delirium causes

• Infections (especially urosepsis, pneumonia)• Hypoxia • metabolic disturbance (eg hypoglycaemia, hyperglycaemia,

hyponatraemia)• drugs (including prescription and over-the-counter medicines, and

alcohol and illicit drugs) • organ failure (especially kidney failure, liver failure, and respiratory

failure with hypoxia/hypercapnia)• intracerebral events (eg subdural haematoma, haemorrhage,

stroke)• cardiac events (eg myocardial infarction, arrhythmia, congestive

heart failure)• withdrawal states (especially from alcohol and benzodiazepines )• pain and discomfort (eg urinary retention, constipation).

Investigations

• FBC– Helpful to diagnose infection

• Electrolytes – To diagnose low or high levels

• Oxygen saturation • Glucose

– To diagnose hypoglycemia, diabetic ketoacidosis, and hyperosmolar nonketotic states

• Urine analysis– Used to diagnose urinary tract infection

• Urine and blood drug screen – Used to diagnose toxicological causes

• Tests for bacteriological and viral etiologies - To diagnose infection

Treatment

• Non pharmacological– Admit and place in an area where they can be

observed at ALL TIMES– Monitor vitals, nutrition and hydration– A calm and quiet room– Presence of a familiar person in room always– Not too many shift changes for the patient – patient

should know his docs and nurses

• Pharmacological – only to control symptoms– Haloperidol / olanzapine single doses oral / IM– Avoid benzos

Case

A 67-year-old female came in your GP practice, as she is worried about her memory problems. Her family members made a joke about it.• Tasks:

1. Take history from the patient2. Briefly examine the memory: registration and

recall without doing the complete mini mental state examination

3. Explain your diagnosis and differential diagnoses to your patient

Task 1: History• HOPI: Memory problem

1. Short term2. Long term3. Risk assessment4. Effect on daily activities

• Differentials:1. Age Related2. Alzheimer’s3. FLD4. Trauma5. Hypothyroidism6. Stroke7. Infections8. Metabolic

• Psychosocial• HEADSSS• SADMA• PMH/FH

Task 2:

MMSE: Folstein Test: assess the cognition of patient

• Registration: Apple, Table and Coin: Ask the patient to repeat it. (3) (score in first attempt and then ask to repeat again), I’ll be asking this three words from you later so please keep it in your mind.

• Recall: What are the three words I told you before? (3)

Task 3: Differentials:

1. Age Related

2. Alzheimer’s

3. FLD

4. Trauma

5. Hypothyroidism

6. Stroke

History:• Hi, I’m Dr ____ I am here to help you, How do you want

me to address you?• I read from the notes that you are having memory

problems, can you tell more about this?• I’m so sorry to hear that your family members made a joke

about it and let me reassure you that I will try my best to help you.

• Let me reassure you that this consultation will be confidential unless there will be a risk of harm on you or others.

• When did you first notice this?• It is progressing?• Do you forget names of family members?• Any fire incident or injury occurred because of this?

Differentials:

• FLD: have you noticed any behavioral changes?

• Trauma: Have you had any trauma to the head?

• Stroke: any body weakness or changes in speech?

• Alzheimer’s: Do you have a family history of Memory problem?

• Infection: Any headache or fever? How was your waterworks and bowelworks?

• Hypothyroidisim: Do you have any weather preference?

• Depression: How’s your mood? Life worth living?

• Delirum: Do you see or hear things that others don’t?

• Alcohol: do you drink alcohol

HEADSS/PSH:

• How’s your home situation? Whom do you live it? Do you have enough support?

• Do you smoke? Are you taking any medications??

PMH:

• Do you have any history of Increase BP or BSL?

• Any past medical and surgical illness that I should be aware of?

Registration and Recall

• I will do a screening test of your memory, I sialright with you?

• Can you please say: apple, table and coin?

• Try to keep it in your mind as I will ask you again later.

• Can you please repeat the 3 words I said?

• Jane, based from the history and screening test, most probably the memory loss that you have is related to aging and most probably just a benign condition. However, this is a diagnosis of exclusion and several tests will be done to exclude the other differentials.

• These are Alzheimer’s Disease which is a condition of the brain that causes significant memory loss.

• Highly unlikely is Frontal lobe Dementia that causes also some behavioral changes.

• Next is Hypothyroidism where a gland in your neck is not functioning well causing some symptoms of memory problem.

• Stroke is highly unlikely and may presents also with body weakness and speech problems.

• If with history of trauma to the head, it can present as memory problem.

• Alcohol intake that can cause Wernicke Korsakoff syndrome that causes some memory impairment.

• But let me reassure you that this is most probably just a benign condition.

• 4R’s

MMSE: Folstein Test: assess the cognition of patient

• Orientation: • Time: year, season, month, day of the week and the

date (5)• Place: Do you where you are right now? State, city of

hospital? suburb and street you live in? (5)• Registration: Apple, Table and Coin: Ask the patient to

repeat it. (3) (score in first attempt and then ask to repeat again), I’ll be asking this three words from you later so please keep it in your mind.

• Attention/Concentration• 1. take away seven serially form 100 upto 5 digits or

numbers (5) or• 2. Spell WORLD backwards DLROW (5)

• Recall: What are the three words I told you before? (3)

• Language• 1. Pointing and naming of two objects: show pen and

what is this? watch (2)• 2. Repetition of sentence: can you repeat “No if’s and’s or

but’s.” (1)• 3. Three stage command: take the paper on your right

hand, fold the paper into two and keep it in your lap. (3)• 4. Reading and obeying: “Close your eyes.” Show the

paper and ask them to read and follow the written command. (1)

• 5. Sentence writing. Write in full sentence what your name is. (1)

• Construction: Ask the patient to copy the design in the paper (1)

Case

• You are a General Practitioner and a patient came in your surgery with a history of chronic alcohol use of 6 SD/day and bsl is 12mmol/L.

• Task

1. Explain what MMSE is to the patient

2. Perform a complete MMSE

3. Interpret and explain the normal and abnormal results to the patient

Task 1: Explain MMSE

• Mini mental state examination is the most commonly used instrument for bedside cognitive function screening.

• Its purpose is not to make a diagnosis, but to indicate the presence of cognitive impairment due to delirium, dementia or head injury.

• Used as a screening test for impairment in brain/cognitive functioning.

• It is brief, easily administered, has high reliability and may be used to monitor progress or fluctuations in these disorders.

• The thirty items in the MMSE measure orientation, attention, registration (immediate memory), recall (short-term memory), language and visuo-spatial function.

Task 2: Perform MMSEExaminer, is the MMSE chart available? (yes, then the examiner gave the chart)

MMSE: Folstein Test: assess the cognition of patient

• Orientation: • Time: year, season, month, day of the week and the date (5)• Place: Do you where you are right now? State, city of

hospital? suburb and street you live in? (5)• Registration: Apple, Table and Coin: Ask the patient to

repeat it. (3) (score in first attempt and then ask to repeat again), I’ll be asking this three words from you later so please keep it in your mind.

• Attention/Concentration• 1. take away seven serially form 100 upto 5 digits or

numbers (5) or• 2. Spell WORLD backwards DLROW (5)

• Recall: What are the three words I told you before? (3)

• Language• 1. Pointing and naming of two objects: show pen and

what is this? watch (2)• 2. Repetition of sentence: can you repeat “No if’s and’s or

but’s.” (1)• 3. Three stage command: take the paper on your right

hand, fold the paper into two and keep it in your lap. (3)• 4. Reading and obeying: “Close your eyes.” Show the

paper and ask them to read and follow the written command. (1)

• 5. Sentence writing. Write in full sentence what your name is. (1)

• Construction: Ask the patient to copy the design in the paper (1)

Task 3: Explain the normal and abnormal result to the patient

• Abnormal findings:

1. Registration

2. Recall

• Normal Findings:

1. Orientation

2. Attention

3. Language

4. Construction