2OverviewOriginal MMSE is one of the most widely used brief screening instruments for cognitive impairmentHas been used in a variety of settings, including screening individual patients, tracking progress over time, screening for large populations, and clinical trials
3Goals for the RevisionRevise some of the original items to better standardize its administrations, particularly for translationsProvide an even briefer version that could be used for rapid assessmentProvide a slightly longer version that would be more sensitive to subcortical dementia and that would not have a ceiling effectDevelop equivalent alternate forms to decrease practice effects in serial administration2. Very useful for large clinics and large clinical/drug trials
4Goal #1: Revise Original Items The MMSE-2 Standard Version (MMSE-2:SV) maintains the same structure and scoring as the original MMSEChanges were made to improve problematic items and to better standardize administration in other languages (e.g., penny, no if, ands, or buts)Wanted to make translation to other languages easy.
5MMSE-2: Standard Version TaskDescriptionIdentical task on Original MMSERevision onMMSE-2:SVRegistration & RecallAbility to repeat and retain three unrelated words, and then recall after a short intervention taskWords have been made slightly more difficult and easier to translateOrientation to TimeIdentify current year, season, month, day of the week, and dateXOrientation to PlaceIdentify state, county, city/town, building, and floor currently inAttention & Calculation (Serial 7s)Count backwards by 7sNo longer can use WORLD spelled backwards as alternate taskNamingAsk to identify body parts when pointed to by examinerChange from “watch” and “pencil” to body parts allows for translation and no use of external materialsRepetitionRequired to repeat a sentence that contains words not often said togetherRevised to include a sentence that is easier to translate and difficulty slightly decreasedComprehensionUnderstand and carry out a three-stage verbal commandRemoved the reliance on motor responses.ReadingRead and follow instructionsWritingAsked to write a sentenceDrawingAsked to copy intersecting pentagons
6Equivalency Between the MMSE and MMSE-2:SV Like the MMSE, the MMSE-2:SV has a raw score range of 0-30The generalizability coefficient (n = 411) between the MMSE and the MMSE-2:SV total raw score was .97Therefore 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
7Goal #2: Develop Briefer Version Can be used for quick cognitive screener, specifically when an individual has not been referred for specific cognitive impairmentComposed of Registration/Recall, Orientation to Time, and Orientation to PlaceRaw score ranges from 0-16 pointsTasks were selected based on literature review, use in the MMSE, and their sensitivity and specificity to detect dementia
8MMSE-2: Brief Version AD = Alzheimer’s (Dementia) Subcortical dementia = milder form of dementia. Less impaired than AD populations.Of all the options for a Brief Version, Option C, which is the first three subtests differentiates both severe and mild populations from healthy controls more effectively.
9Goal #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 storyProcessing Speed: A symbol-digit coding taskTheory behind the decision:Wanted an additional memory task due their importance in this area.Added subtests that statistically differentiate mild dementia from normalsWanted to make it more difficult to fake
10MMSE-2: Expanded Version Improves the clinical utility of the MMSE by:Extending the test’s ceilingIncreasing the range of raw scores (0-90)Increasing the sensitivity for individuals with less severe cognitive impairment (subcortical dementia, MCI)
11The higher the score, the closer to normal. The Expanded Version demonstrated sensitivity was improved over the standard version for mild dementia problems (>22)
12Expanded was also better than standard for mild subcortical (>22)
13Goal #4: Develop Equivalent Alternate Forms Two forms (Blue and Red) were developed for each of the 3 versions of the MMSE-2Based on the results of the equating study, the accuracy of the equating process was confirmed
15Administration Issues 18 years and olderRelatively easy to administer, typically one training session is sufficientTest Materials:User’s ManualPocket Norms GuideScoring Templates for Processing SpeedAdministration Forms :MMSE-2:BV Blue and Red FormMMSE-2:SV Blue and Red FormMMSE-2:EV Blue and Red FormAll instructions are on the form. There is not a form with just EV so can’t add it on to the SV. Must order the EV forms which include it all.
16Overview of Administration Forms TaskMMSEMMSE-2:BVMMSE-2:SVMMSE-2:EVRegistration & RecallXOrientation to TimeOrientation to PlaceAttention & Calculation (Serial 7s)NamingRepetitionComprehensionReadingWritingDrawingStory MemoryProcessing Speed
17Determining Which Version is Appropriate MMSE-2:BVAdequate for screening large populations; screening individuals in practice who have not been referred because of cognitive complaintsMMSE-2:SVUsed 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:EVMMSE-2:EVSame as above + well educated (ceiling effect); suspected subcortical dementia
18Scoring Mean raw total scores are presented by age and education level T scores are also presented by age and education levelPocket GuideReliable Change ScoresAlthough T scores are provided, it is the raw scores that are usually interpreted
19Reliable 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 itselfThe approach used here is a method developed by Iverson (2001)
20InterpretationA cut score of 22/23 is typically used with the original MMSEBecause the MMSE-2:SV is equivalent to the MMSE, the same cut score is suggestedThe 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 form22/23 is cutoff for Standard Version. If below this raw score, likely cognitive impairment.
21Example of Cutoff Table A good cutoff score will make the least sacrifices on both sensitivity and specificity. The 23/24 and 22/23 scores have almost identical SENS and SPEC scores and add to the validity of using this range as a cutoff score for dementia.
22Development Task Development – 5 additional tasks were tested Bias Panel – assessed potential bias and offensiveness to protected groupsExpert Review:2 neuropsychologist, 1 geriatric psychologist, 1 geriatric psychiatristAided in selection of tasks, provided feedback on content, and assisted with refining items and instructions for the pilot and standardization versions
26Effects of Age and Education In reality, EV is really a better predictor for both age and education. High age spread shows it but education does not.
27Development of the Norms Because of the importance of age and education on MMSE-2 scores norms were developed for several different age and education rangesTwo resources for age and education adjustments are provided:Means and standard deviations of total raw scores by age and education groupsAge- and education-adjusted T scores (continuous norming method)
28Reliability: Internal Consistency Why are these only moderate?The normals all have high scores so there is little variabilityThe test does not measure one trait per se. It is a variety of tasks with memory having the highest correlation with dementia.
29Reliability: Test Retest Higher scores from BV to SV to EV because there are progressively more items.
31ValidityContent 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 23/24There is an appendix in the manual with all the article references to validate a 22/23 and 23/34 cutoff score.Also an appendix that documents studies looking at effect size by disorder.Table: ADL is a 7 question daily living skills questionnaire. Low scores are more impaired.All versions significantly differentiated severe (0-4) from mild (5-7). SV differentiated best.
32Validity Convergent Validity: WMS-III subtests Category Naming Test COWABNTTMTWAIS-R subtestsJOLOHVLT-RStroop Color and Word Test