The Mini-Mental State Examination (MMSE)

The Mini-Mental State Examination (MMSE)

Dr Victor M Aziz

Consultant Psychiatrist

Cwm Taf HB

Dr Raja A Ahmed

ST4 Old age Psychiatry

Cwm Taf HB

Background:

The MMSE [Folstein et al.,1975] has been used as a screening tool of cognitive function in clinical practice worldwide. It is easily administered by clinicians or researchers with minimal training, and has a cut-offs of 23/24 out of 30 to show significant cognitive impairment. Its reliability is improved using a standardized version [Verteseet al., 2001]. It has a “floor” effect in terms of its inability to detect changes in established advanced dementia, in those with little formal education and those with severe language problems. There is a” ceiling” effect meaning it may fail to detect very mild illness, and mild/moderate cognitive impairment in people at high educational level or premorbid intelligence (Franco-Marina et al., 2010).Its sensitivity is low for early dementia and Mild Cognitive impairment (MCI). Further, some MMSE items and possibly the MMSE as a whole may be unduly influenced by age, education, and ethnicity (Simard, 1998). This has limited its use for detecting change in clinical work and in research studies.

Copyright issues:

When the MMSE was first published in 1975 in the Journal of Psychiatric Research, itscopyright ownership remained with the authors untilElsevier took over copyright of both Pergamon Press and the Journal of Psychiatric Research. Pergamon Press was an Oxford-based publishing house, which published scientific and medical books and journals. It is now an imprint of Elsevier. In 2001, the authors entered into an exclusive agreement with Psychological Assessment Resources (PAR) granting them the exclusive rights to publish, license, and manage all intellectual property rights of the MMSE in all media and languages.

PAR claims that the official version is copyrighted and must be used and ordered only through them. Therefore, all users need to purchase the tests from PAR. A per-copy royalty fee will be charged for all permissions granted for copies of translations of the MMSE or modified versions of the test form. The fee is around £0.80 for each and every use. According to PAR copyright permission request form if any person plans to use the MMSE in its entirety and in its published form, they must purchase the number of test protocols they will need for their purposes. This is applicable in USA, Canada or any place in the world. PAR will not grant permission to include the entire MMSE test form or scale in any publication, including dissertations and theses i.e. the test has to be used on the official form after obtaining the copyright permission. (

The copyright issue has also raised lots of discussions e.g. Seshadri and Mazi-Kotwal, 2012;Newman & Feldman, 2011).The enforcement of the copyright has led to researchers looking for alternative strategies to assess cognition. Many websites have removed the MMSE test e.g. and

The restrictions on the MMSE’s present an interesting debate: on one hand the infringement of copyright and on the other hand, clinicians experience in using the test for many years. Psychiatrists have used the MMSE for yearswithout mention of copyright (Powsner & Powsner, 2005). Some trainees know the items of MMSE by heart and can use it without the need for actual form. This makes for an interesting moral argument. James Grimmelmann, Professor of Law, University of Maryland (2011), argued that copyright is not available for any “procedure” or “process.” The USA Supreme Court in Baker v. Selden “Take the case of medicines. Certain mixtures are found to be of great value in the healing art. If the discoverer writes and publishes a book on the subject (as regular physicians generally do), he gains no exclusive right to the manufacture and sale of the medicine; he gives that to the public”. He added that thesame applies to the MMSE; its creators “gave it to the public”.

For clinicians, photocopying or downloading the MMSE probably constitutes infringement, and could incur penalties. The MMSE case may be a beginning of more copyright issues. It is difficult to imagine what will happen if the same happens to clinical tools we take for granted. Will this impact standardisation and detract efforts to improve patient care; a question that can be answered by time and research.

One point of view is that the NHS has not been charged for using of the MMSE and therefore we should continue to use it. However, that does not mean we should advice its use. Attention is needed to avoid undue cost to the NHS and to avoid any misperception that NHS clinicians can use the tool free of charge. Copyright violation and use of MMSE can be retrospectively checked on health records.

Would a legal challenge be likely to succeed? The answer is yes. PAR has asserted their copyright against an alternative diagnostic test, "Sweet 16," developed and validated by Tamara Fong and published in 2011. Assertion of copyright forced the removal of this test from the Internet (Newman and Feildman, 2011). The same happened with the Addenbrooke’s Cognitive Examination (ACE-R) test which led to the modification of the test and to the ACE-III version that has no MMSE components (

We already have other tools that clinicians can use to assess cognition such as 6-Item cognitive impairment test (6CIT; Brooke & Bullock, 1999);and Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005), which are available to clinicians free of charge.It may be advisable to stop usingthe MMSE until the authors terminate or release the MMSE license into public domain.()

Newman and Feldman (2011) suggested applying the principle of “copyleft” from the open-source technology movement to encourage innovation and access while protecting authors' rights. Copyleft allows the author to retain the right to offer the work under a different license while simultaneously gives the right for anyone to use, modify, copy, and distribute a work, as long as it and any derivatives remain under the same license. In general, copyright law is used by an author to prohibit recipients from reproducing, adapting, or distributing copies of the work. In contrast, under copyleft, an author may give every person who receives a copy of a work permission to reproduce, adapt or distribute it and require that any resulting copies or adaptations are also bound by the same licensing agreement. They suggested that any new tool developed with public funds should be required to use a copyleft to guarantee the freedom to distribute and improve it.

Conclusion:

The free use of MMSE is no longer a viable option; there are alternatives for screening and diagnosing cognitive impairment. In my opinion,it isrecommendedusing those alternatives.Finally, we need to alert hospital clinicians and General Practitioners who are either unaware of the MMSE’s copyright restrictions or simply ignore them, that copyright infringement carries a risk of civil and/or criminal penalties such as injunctions; destruction of infringing articles; damages and profits; costs and attorney's fees; or criminal charges. These recent changes in practice should also be included in trainingMedical students.

References:

Folstein MF, Folstein SE, McHugh PR. ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". Journal of Psychiatric Research,1975; 12 (3): 189–98.
Vertese A, Lever JA, Molloy D et al. (2001). Standardized Mini-Mental State Examination; use and interpretation. Can Fam Physician, 2001; 472018-2023.
Franco-Marina F et al. The Mini-Mental State Examination revisited: ceiling and floor effects after score adjustment for educational level in an aging Mexican population. Int Psychogeriatrics,2010; 22 (1): 72-81
Simard M. The Mini-Mental State Examination: Strengths and Weaknesses of a Clinical Instrument. The Canadian Alzheimer Disease Review, 1998 Dec 12.Review/.../december1998/10.pdf
Seshadri m, Mazi-Kotwal. A copyright-free alternative to the mini-mental state examination is needed. BMJ, 2012; 345: e8589
Newman JC and Feldman R. Copyright and Open Access at the Bedside. N Engl J Med, 2011; 365:2447-2449
Powsner S, Powsner D. "Cognition, copyright, and the classroom". The American Journal of Psychiatry, 2005;162 (3): 627–8. doi:10.1176/appi.ajp.162.3.627-a. PMID15741491.
The Addenbrooke’s Cognitive Examination-III Frequently Asked Questions. Updated 7/7/2013.
Nasreddine, Z. S., et al. "The Montreal Cognitive Assessment, MoCA: a Brief Screening Tool for Mild Cognitive Impairment." J.Am.Geriatr.Soc., 2005; 53(4):695-99.
Brooke, P. & Bullock, R. Validation of a 6 Item Cognitive Impairment Test with a view to primary care usage. International Journal of Geriatric Psychiatry, 1999; 14:936-940.