Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Purpose : Cognitive screening instrument to identify people with a moderate to severe level of cognitive impairment
Admin time : 10 min.
User Friendly : High
Administered by: Health professional
Content : Test items include attention/orientation, memory (short recall of 3 words), visuospatial (construction), and language (writing, reading, naming, and repetition).
Author : (Vertesi A, 2001)
Cognitive Decline is one of 4 sub-domains of the
Back To : Psychological Assessment
The Psychological Assessment is one of 8 domains of the
Comprehensive Geriatric Assessment (CGA)
Back To : Comprehensive Geriatric Assessment
This Tool is used in Cognitive Decline
Back To : Cognitive Decline
Standardised Mini Mental State Examination
Suitable groups for assessment
Age range: 18-85+
Scores affected by educational level, socio and cultural factors, visual impairment and aphasia. Ceiling effects for people with above average natural ability.
Floor effects for those with mild learning disabilities.
Probably not sensitive enough to detect MCI.
The SMMSE can be used in various settings including
acute care settings,
long-term care facilities.
Factors affecting scores
Some patients cannot complete test items due to physical disability.
For example, blind people cannot identify a watch or a pencil, read a command, write a sentence, or copy a diagram (5 points).
Items that patients cannot complete should not be included in the total score.
The SMMSE is scored out of the items that can be tested..
People who have had strokes that have affected their dominant hands cannot copy diagrams or write sentences.
The three-step instruction can be adapted by asking the person to “take the paper in your strong hand, crumple the paper into a ball, and drop it on the floor.”
Age and level of education affect SMMSE scores.
The mental status scores of adults of similar ages will vary according to their level of education.
A 78-year-old patient with 4 years’ education will get a significantly lower score than another patient of the same age with a college degree.
Highly educated patients sometimes score higher than their level of function suggests. We would expect a recently retired schoolteacher to score 30.
Colleagues notice, however, that she has trouble organizing her volunteer work. Although she scores 27/30 (in the “normal” range) on the SMMSE, she likely has some cognitive impairment.
Patients with little education or with language problems might score lower than their function suggests.
An immigrant farmer who partially completed grade school scores 25 on the SMMSE, but he continues to run his farm successfully.
Despite scoring below the “normal” range, he likely has no serious cognitive impairment.
As cognitive skills and SMMSE scores fall, independence in daily living also declines. An apparent discrepancy between SMMSE score and level of function is referred to as a “disability gap" (Hogan DB, 1993)
Patients who are depressed or are suffering an acute illness, or who are dehydrated, in pain, or delirious might score lower on the SMMSE than their function suggests. Targeted history, examination, and workup could reveal a treatable cause for this cognition-function discrepancy.
Analyzing the pattern of deficits with the SMMSE in conjunction with history and physical examination can help to differentiate between AD, vascular disease, dementia with Lewy bodies, and depression (Kaye JA, 1998).
Patients with AD usually present with poor short-term memory (Gauthier S, 1996).
Caregivers report that patients repeat stories and questions (Molloy W, 1998).
Often the first deficit to appear on SMMSE screening is with recent memory.
Patients cannot recall the three items registered in the Short-Term Recall component. In many cases, they will not even recall being asked to remember the three items.
The next deficits usually appear in orientation to time and then place.
Patients who have insidious onset of memory loss with progressive decline, who repeat stories and questions, and who cannot properly remember the three items probably have AD.
Speech and language problems usually appear in the later stages of AD (Orange JB, 1994).
Patients with AD usually try to answer the questions on the SMMSE and often become frustrated if their deficits are pointed out.
Patients with vascular dementia usually have a mixed presentation of deficits when screened with the SMMSE.
History often reveals that onset of symptoms is more sudden and fluctuates (Lorish TR, 1994).
Patients often have a medical history of transient ischemic attacks, hypertension, angina, or stroke (Sandin KJ, 1994).
Speech and language problems occur earlier and depression is more common than in AD because patients have preserved insight into deficits (Price TR, 1990).
Incontinence, gait disturbances, apraxia, and perceptual problems, seen early in patients with vascular dementia, are usually not present until the later stages of AD.
Computed tomography will often show stroke or white matter changes.
When screened with the SMMSE, these patients do not usually show deficits in short-term memory first as patients with AD do; they are more inclined to have changes in speech and language function, such as naming objects and following the three-step command.
Dementia with Lewy bodies.
Patients with this condition often demonstrate fluctuations in cognition and transient reductions in level of consciousness (Brown DF, 199).
These fluctuations occur for minutes or for days and are not like the more steady, gradual decline seen in AD.
Recurrent visual hallucinations, paranoia, and delusions are an early or even presenting feature of dementia with Lewy bodies.
Other clinical features include parkinsonism with rigidity or bradykinesia and a shuffling, listing gait. Resting tremors are uncommon (Karla S, 1996).
Patients with dementia with Lewy bodies screened with the SMMSE might demonstrate reduced verbal fluency and visuospatial and constructional abilities, as evidenced by problems with drawing the two five-sided figures (McKeith IG, 1996).
This constructional deficit often does not occur in AD until the middle stages.
Table 3 shows the initial deficits that can be apparent in the early stages of the types of dementia discussed.
Initial deficits that can be assessed by components of the SMMSE: Alzheimer’s disease, vascular disease, dementia with Lewy bodies (Vertesi A, 2001) :
Patients experiencing depression demonstrate apathy and indifference or refuse to try and answer SMMSE questions.
Depressed patients are more likely to answer, “I don’t know” or “It doesn’t matter.”
They often complain openly of memory loss.
They might say, “See, I told you I can’t remember” or “I can’t do it.”
When pressed, however, they often know the answer.
They also have more somatic complaints, such as dyspepsia, or complain that “something is wrong inside me that the doctor cannot find.” (Steiner D, 1991).
They usually have a disability gap, scoring lower on the test but functioning independently in daily life.
Both SMMSE scores and level of function should be checked because SMMSE scores used alone can lead to misdiagnosis of dementia rather than depression.
Basic daily functioning can be assessed using the Lawton Scale (Lawton MP, 1969) or the Barthel Index. (Mahoney F, 1965).
If depression is suspected, ask about vegetative signs, such as changes in appetite and energy level, weight loss, sleep disturbances, decreased libido, and suicidal thoughts.
A standardized instrument, such as the Geriatric Depression Scale, can help quantify level of depression (Yesavage JA, 1983).
Careful assessment of cognition and mood is important because depression can, on the surface, masquerade as dementia (Fischer P, 1996).
Also, diagnoses of AD, vascular dementia, dementia with Lewy bodies, or depression are not mutually exclusive and can present simultaneously in any combination.
When dementia is diagnosed, it is recommended that legal issues, such as powers of attorney and advance health care directives, be prepared.
The SMMSE not only provides a global score that can help assess the dementia, but it can be repeated to monitor changes in cognition, to measure efficacy of treatment, and to help predict prognoses and need for caregiver support.
Normative Data, reliability and validity
Normative data is available from a number of different studies, the largest of which sampled 18,000 community dwelling adults aged 18-85 (Crum RM,1993).
By following standardised administration, interrater variance was reduced by 76% and the intrarater variance by 86% (Molloy DW, 1991).
If the SMMSE is being used to monitor change.
Small changes must be interpreted judiciously, but recommendations in this regard differ, with different changes in points suggested as significant by different authors:
2 points or more, dependent upon age and education (Iverson GL, 1998)
3 points or more (Clark D, 2003)
more than 5 points (Doody RS, 2001)