Mini-Mental State Exam (MMSE) Tech-Administered A. Background and Rationale: Cognitive function may decline as a result ofcertain risk factors (e.g. hypertension, elevated cholesterol, cardiac arrhythmias). This in turn could adversely impact the physical functioning and quality oflife ofolder adults. Dementia is a major illness and cause ofdisability among the elderly. Cerebrovascular disease or multi infarct dementia is the second leading cause of dementing illness among Caucasians, preceded only by Alzheimer's disease. The Mini-Mental State Exam (MMSE) is a widely used test ofcognitive function among the elderly; it includes tests oforientation, attention, memory, language and visual-spatial skills. B. DefInitions: 1. Alert Level: In general participant scoring below education-adjusted cut-off scores* on the MMSE may be cognitively impaired. MMSE-EDUCATION ADJUSTED CUT-OFF SCORES a. Subjects whose education levels are 7tb grade or lower, a score on the MMSE of 22 or below b. Subjects whose education attainment level is 8th grade or some high school (but not a graduate of), a score on the MMSE of 24 or below c. Subjects whose education attainment level is high school graduate, a score on the MMSE of 25 or below d. Subjects whose education attainment level is some college or higher, a score on the MMSE of 26 or below. *Note: The Education Adjusted Cut-off Scores are calculated by data management. 2. Mini-Mental State Exam Scoring: The official total score for the MMSE (i.e. the scores used for statistical analyses) are computer generated. Examiners record individual test item scores on the MMSE test form. The one exception is "WORLD" where examiners record the response of subjects in the exact order that it is given by the subject... ~ For referral purposes, any participant with a drop of3 points in score since their last exam should be referred to neurology group. A preliminary score can be calculated by Tricia Kelly to detennine ifthe participant should be referred. A referral form should be completed and given to the Neuro Project Coordinator, Linda Farese, after the exam. Referral forms can be found in the appendices. Ifa participant is referred they may also qualify for a consent form Waiver. 3. Consent Form Waiver: Guidelines dated 3/10/01 verified 3/25/04: Any subject with MMSE at or above 26 may be presumed competent unless listed otherwise at last evaluation Any subject with MMSE below 13 requires use ofa Waiver unless seen by a neurologist and declared not demented MMSEs between 25 and 13 would trigger a decision process. The participants in this category will sign a consent but they may qualify for a waiver. The neurology team will review each case and decide which category to be in (Consent or Waiver). ***Refer to Waiver ofInformed Consent Section ofmanual for full protocol.*** C. Methods: 1. The MMSE asks questions to ascertain cognitive status. Responses are scored: O=incorrect l=correct 6=item administered, participant does not answer 9=test item not administered/unknown 2. If a response is arnbiguous, the interviewer records the response in the margin so a decision can be made on its appropriateness Please refer all questionable responses to the neuropsychologists (i.e. Rhoda Au or Sherral Devine) 3. When a participant is incapacitated by blindness, has a functional disability, is illiterate, or is otherwise unable to respond to a question, the interviewer should specify the problem and questions involved (see "Factors Potentially Affecting Mental Status Testing" later in the section). /(0D. Expanded Scoring Instructions for Mini-Mental Exam: Important note: The single exception to scoring 6 for no response is ifa participant is in a coma (this circumstance would be encountered in a nursing home visit) In this instance, administer the first item (to establish no response --give a 0 to the first item if there is no response). (This exception is made to conform with the stroke protocol.) 9 = When test item was not administered (refused or inability because of physical limitations) or subject's response is uninterpretable (response could be correct, but tester is unable to discern the response). Important note: Sometimes a participant might produce a response that is not a word (i.e. a neologism) but has been responding with intelligible responses on previous items (right or wrong). In this case the items should be scored O. The key to differentiating a 0 or a 9 is consistency within test. Ifa person has a speech abnormality, such as aphasia or dysarthria, across all items, most (or many) responses will be unintelligible. Ifa person is, for example, demented, he/she may produce a flow of intelligible responses with occasional unintelligible responses. A "9" must represent situations in which the EXAMINER is not sure whether (1) the participant responded correctly (because ofslurred speech, severe stuttering, etc.), or (2) ifthe participant has some other factor that prevents test item administration (such as an inability to administer copy this figure test item to a right-handed person who has right-handed paralysis, or to someone who has a visual impairment or inability to hear). Scoring for Administered Individual Items: (applies only ifa test item is administered) Score 0 for the following reasons: 1. Incorrect response 2. I don't know 3. Unintelligible response in context ofother intelligible responses (see scoring of9 as well). 4. Participants attempted to respond but responds incorrectly (i.e. they are demonstrating that they heard the question and are making an attempt to respond to it). /1 L---..:e; E. Questions: Scripts and Procedures for Each Question: Introductory Script: I'm going to start by asking questions that require concentration and memory. Some questions are more difficult than others and some will be asked more than one time. Read each question on the fonn. Record the response on the fonn. 1. What is the date today? (3 = correct score for month (1 pt), day (1 pt) and year (1 pt)) a. Ask for the date. Then ask specifically for parts omitted (e.g. Can you also tell me what month, year it is?) b. Ifparticipant supplies part or all ofthe date (e.g. month and day, or month, day, and year), record as appropriate and do not ask those questions again. 2. What is the season? Since distinctions between seasons can be difficult during certain months, one week leeway is allowed on either side ofthe