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ninamarc 01-31-2013 09:36 AM

MMSE question
I am quite puzzled: if the demented patient passes the MMSE test or similar test, does this mean that the person is still in early stage and cannot be detected yet? Should one wait for another year or more to do another test to detect dementia verbally? Is it also possible that if one passes MMSE test, it is not dementia at all?
e.g., my Dad passed the test 2 years ago, but he is 90 and my Mom said he still forgets too just like my Mom? Old age does make people forget more. How to tell the difference?


Luau 01-31-2013 11:17 AM

Re: MMSE question
It's interesting that my brother and I just had this discussion with our mom's primary. She is 93 but becoming increasingly more physically frail the past 3 years. About 1 yr ago, she started exhibiting more pronounced signs of forgetfulness, personality changes, and such. While she still managed to pass MMSE, it is clear that her memory, especially short term, is increasingly more spotty. She is already on aricept and B vitamin supplementation. Like you, we wonder if it is old age or dementia. Then my brother and I finally concluded that it doesn't matter which it is. AT 93 years old, she can be whatever it is, as long as we give her the best quality of life possible. However, because of our mom's fairly sudden step downward this year, we are inclined to think, at least to a certain degree, involvement of dementia.

Gabriel 01-31-2013 10:26 PM

Re: MMSE question
First I wonder what constitutes "Passing" the MMSE. Within the 30 questions there are questions that test 8 different types of cognition. There are 5 questions each for orientation to time and place. They vary from the broadest to the narrowest indications of time and place. The patient may be able to tell you what year it is but not what month or what day. There are three questions related to how information registers such as repeating names. There are 5 question on attention and calculation. Two are these are spelling "world" backwards and counting backwards from 100 by 7s. Three questions are related to recall. They get a list of words and have to repeat them back at some point later. One is repetition or repeating a phrase back. Two relate to language as in naming a pencil. Six questions relate to complex commands like drawing the clock.

In the early stages, on a good day, with an intelligent patient, yes they can pass the test and still have dementia. Mom did. She scored a 27 which is considered passing but she was well into her dementia at that point.... and I knew it despite "passing" the MMSE test. If your loved one doesn't make 30/30 I would suggest further cognitive testing. Even with a 27 on the MMSE I insisted Mom go for further cognitive testing and from those test it was obvious she had major cognitive decline. You have to remember that the MMSE is just a quick test. A complete cognitive testing will last 6 to 8 hours. The MMSE is just one of several test that can be used. Also different types of dementia test differently. Early Alzheimer's patients will usually miss the orientation to time and place questions while Vascular dementia seems to do worse on other questions. The MMSE is just one tool used to determine if further testing is needed. It is not a definitive test. It is the best quick test that can be given by a GP though :)

There are proposed changes that everybody over a certain age be given a MMSE as part of the routine physical. This will give a base line. If Dad make a 30 every time he goes and suddenly drops to a 27 then you know there was probably a cognitive decline. If he went in and made a 27 with no previous test, you don't know what it might have been before. Maybe he couldn't do the math of counting backwards by 7 all along, or did he lose that ability recently because of cognitive decline?

If your loved one has symptoms of dementia, the MMSE is the first test but should not be combined with symptoms and behaviors to make a determination of the need of further testing to come to an actual diagnosis.

Love, deb

ninamarc 02-01-2013 10:59 AM

Re: MMSE question
I am wondering if there are many people who are not tested by MMSE.
Some GPs still don't know what to do with it. My Mom's GP had it but didn't do anything about it and didn't respond to my sister's request about the drugs for dementia. I told my folks that these drugs can only delay symptoms (aricept.)
So Mom never got anything. She won't do another test now as she refused to admit it is true. It is possible that it is not true since some questions are quite ambiguous. I mean, if someone doesn't care for the president or the first lady's first name, he/she may not get it either. My mom failed it on the clock issue but she could draw it. She doesn't use English as her daily language so maybe it is some issue. My Dad forgot once that I visited him 3 years ago but he had cancer surgery after that so possibly he didn't care for my trip earlier.
Comparing with my late FIL, my parents seem to be in good shape in terms of dementia. However my folks are concerned about my Mom's situation. Even my Dad thinks my Mom cannot do his medication anymore and would like to hire someone but my Mom doesn't like to hire anyone in the house for getting into more trouble with a new person. My sister got her the medication box. So far she is doing OK (My Mom always gets the medication for my Dad now.) 2 of my sisters are retired and can help them a lot but they don't live with them. My parents also travel to Asia once a year... It is a long story.


Gabriel 02-01-2013 01:21 PM

Re: MMSE question
It is common knowledge that not all doctors are educated on dementia, it's symptoms, diagnosis, and treatment. As we have seen here, unless you have contact with this disease it is very difficult to understand the early indications and long term effects. There is also the knowledge that there is no effective treatment or cure. There is a HUGE amount of denial related to this disease. Not only on the part of victims and families but also the medical profession.

My Dad was misdiagnosed with Alzheimer's when he actually had Vascular Dementia. My Mom was misdiagnosed with depression when in fact it was Alzheimer's. Even with a proper diagnosis her family physician didn't understand and let her drive and live at home with Dad who also had diagnosed dementia. He assured us all she just needed to "focus" better! DUH!! Many doctor do not do the MMSE in conjunction with physicals. They are not trained to deal with the cognitive issues of the aging. When you sit in an ER and watch a doctor quizzing a dementia patient you understand that the doctor doesn't have a clue! They just enter "Unable to get information because patient was uncooperative" on the chart and go to the next person. Some that do use the MMSE are not sure what to do with it when they finish it. I know my local Alzheimer's Association is just beginning to address these problems with training programs for doctors and hospitals but it has been VERY slow going.

At some point a person with dementia may realize there is something wrong. At the very beginning they may be cooperative because they are thinking rationally most of the time. But there are just blips of bizarre behavior and so many just dismiss these infrequent incidents. By the time the symptoms are bad enough for us to realize there is something dramatically wrong it is usually in the mid stages. By then the thinking process does not allow most to understand that they are not thinking coherently. There is denial as well. Who wants to admit that they or a loved one has an untreatable and incurable disease. That is when somebody has to step up and get the appropriate testing... more than just a visit with the GP that has not recognized the problem already.

I may not like the president but I don't forget who he is. I may not be happy with a person that visited me last week but I don't forget they came by. I may be having a bad day but I can still find my way home from the store. Yes, in the early and mid stages they can function marginally in a familiar surrounding. Yet you will find small things they become unable to do. Meds are a huge problem. That takes a multistep process of thinking. Which pills go in which box, what time of day it is and what time do you take it. It can be confusing to even us if there are lots of medications and impossible for someone even in the early/mid stages. Dosage boxes can help for a while but not the complete answer. You can put the meds in the boxes for them but they still have to remember what time it is and is this the time to take them. Dad would forget what day it was. He would take Monday morning's meds on Monday morning but then at lunch time he would decide it was Tuesday so he would take the rest of Monday's, Tuesday morning pills, and then the Tuesday lunch. Then he would be upset because the Tuesday night pills were not there. That was complicated with Dad getting the wrong box and taking Mom's pills, then a few minutes later finding his and taking them as well. Medications can be the first problem that causes an unsafe condition for someone living alone with dementia. Two with dementia only complicates the problem.

Bringing somebody into the home can cause as many problems as it solves. You have to remember that they are confused and therefore do not want another person in the house that causes more confusion for them. Beyond that they have that paranoia and suspicion going on in the brain. They may think this person is a spy, especially if you get information from there about what is going wrong in the house. They may feel degraded by having to have somebody care for them. They are not accustom to somebody else being in the house and it seems inappropriate to them. Therefore they rebel. They do not understand the necessity. It seem inappropriate.

Throw into that mix the fact that the dementia is not consistent. Remember that the misfiring of the brain is not consistent. They may gather good information for a few days and then miss a critical piece of information. There are periods where they seem absolutely normal and then times they are completely lost and confused. The brain will "fill in the blanks". If there is a piece of information missing, the brain will make the pieces fit so it makes sense. That is why they can seem so deceptive. They are fixing what is missing and they truly believe it. So dementia seems to come and go in the beginning. There will be moments we can pick up on but then it all goes back to normal and we think it was just a momentary thing and all is well. Then the next moment of bizarre behavior hits. We do the same thing. It is only when the behavior becomes consistent that many decide it is a problem. In fact that first moment, that is out of the ordinary, is of the most concern.

All of this is why I always recommend further testing if you have any suspicion that there is a cognition problem. Something beyond the GP and an MMSE. That is ONLY a starting point. Memory assessment and cognitive testing facilities are becoming more popular. There are geriatric neurologist and psychiatrist that are trained in cognitive problems who can diagnose. If you think something is wrong... there is problem something wrong and you need to find out what.

I have a friend who was concerned about cognitive decline. She was scared to be tested because her sister had Vascular Dementia. But she was finally convinced to go to the doctor and scored 27 on her MMSE. She had a complete physical and actually set up an appointment for further cognitive testing. What she found out was her B12 levels were extremely low. She was put on B12 and her levels monitored until they were normal. At her cognitive testing, she passed with flying colors including a 30 on the MMSE. I have another friend who's father actually had NPH and after having a shunt placed he returned to normal cognition. Myself, it was just a side effect of statin medication :) SO please do not just sit and do nothing. If it is something that can be reversed you want to know that and do what is necessary. If it is some form of dementia, the diagnosis will give you time to plan and have time with your loved one before it gets bad.

Love, deb

ninamarc 04-08-2013 08:25 AM

Re: MMSE question
[QUOTE=Luau;5125897]It's interesting that my brother and I just had this discussion with our mom's primary. She is 93 but becoming increasingly more physically frail the past 3 years. About 1 yr ago, she started exhibiting more pronounced signs of forgetfulness, personality changes, and such. While she still managed to pass MMSE, it is clear that her memory, especially short term, is increasingly more spotty. She is already on aricept and B vitamin supplementation. Like you, we wonder if it is old age or dementia. Then my brother and I finally concluded that it doesn't matter which it is. AT 93 years old, she can be whatever it is, as long as we give her the best quality of life possible. However, because of our mom's fairly sudden step downward this year, we are inclined to think, at least to a certain degree, involvement of dementia.[/QUOTE]

Luau got a point. Sometimes not many families diagnose the elderly due to many difficulties and etc. Caregiving and quality of life is more important?
In the old times, people didn't think dementia can be diagnosed. In the UK, the rate of diagnosis for dementia is too low.
I believe if the person can be diagnosed, it is good. But if there is difficulty to get a specialist to see the person against her will, then we may need to consider the other alternative?


Gabriel 04-08-2013 11:05 AM

Re: MMSE question
Every situation is different but a few points that are important. Significant cognitive decline is NOT a part of normal aging. If that decline is interfering with the activities of daily living then it is NOT normal. The person with cognitive decline needs to go to the doctor. The cognitive decline could be connected to a medical condition that can be treated. Ruling out these medical conditions is the only way to know for sure. Also, "passing" the MMSE means making a perfect score of 30. A 20 something is not good enough and indicates cognitive decline. Even if you do not take the next step to get a definitive diagnosis of which dementia, you do need to rule out any other causes and recognize that a score of less than 30 is not normal aging and take the necessary steps to protect the safety and well being of the person.

Dementia Awareness is a huge problem not only in the public sector but also in the medical profession. Because of the extent of this disease and the implications to the well being of the individual, family, and care givers this disease can not just be ignored. Yes, my great grandmother probably had undiagnosed dementia. The family said she was "touched in the head"! She had lost her ability to walk but jumped up out of her wheel chair to yell at the kids, fell off the porch, and died of complication from "a broken hip". My grandmother was diagnosed with "senile dementia". She died from complication of a "stroke" that occurred during the later stages which followed medical treatment that today would be considered unnecessary. Mom was appropriately diagnosed with "Dementia consistent with Alzheimer's" and died from "Late Stage Complications of Alzheimer's". That is the progression of awareness. It is knowing, accepting, and documenting this disease that drives the research, services, and help that is needed. It is also knowing, accepting, and putting proper care in place that gives those with dementia a better quality of life. There is a huge financial burden involved as well. Whether it be government programs, insurance companies, or families, the cost of this disease is staggering and has to be acknowledged and planned for. It can not be ignored. There also has to be acknowledgement of what the care givers are doing. They need assistance, knowledge, and support. This disease has been swept under the rug for far too long... and many still consider it a mental illness to be kept in the shadows. If Mom had cancer and didn't want to go to the doctor we would move heaven and earth to get her there. If Mom has cognitive decline.. it's ok? Yes, I push awareness at every turn :)

Love, deb

PS... you think I am bad here? You should see me when I get the ear of a politician or medical professional :)

ninamarc 04-08-2013 02:23 PM

Re: MMSE question
Actually my Mom never did MMSE. It was only 2 minutes thing each person. Like I said, it was the intern kind of thing. Maybe just a small check... I doubt that GP gives MMSE. Maybe some does.

I am for diagnosis for sure. But when the person resists or there is no "excuse" or "physical illness", it is hard to make Mom to take more test including MMSE.
Also she is really better in her own language so it is also an issue (not due to dementia's language thing; she doesn't use English often enough.)

Deb, you are not bad. I think you have a point. It is the GP who needs to get it.
Also, such diagnosis is not "definite" like the autopsy but I am sure it is accurate enough unless the doctor cannot find the problem.


Luau 04-09-2013 09:06 AM

Re: MMSE question
My mother never had a formal diagnosis either, but she only started showing definite signs of mental impairment a couple of years ago, after she turned 90. By that time, she was already living in my brother's home, and we already had full time "nannie" caring and looking after her. Due to other health issues, she was already on B supplements and aricept. She has already gladly handed over reins of her finances to my brother and I, and she is quite content not having to make any decisions. So, for our unique situation, we did not feel a formal diagnosis is a necessity, as we do not feel our mother or our family will gain anything from having such diagnosis. .... now mrs luau on the other hand.... that's a totally different story as she continues to be a hand full and then some. Just like there are happy drunks and mean drunks, there are happy cognitively impaired people and angry cognitively impaired people.

mitsy 04-09-2013 01:14 PM

Re: MMSE question
Deb, I always consider you a great advocate for ALZ. It has helped me understanding my family and others that talk about it.

Gabriel 04-09-2013 01:58 PM

Re: MMSE question
Luau, I understand your situation with your Mom. She is well cared for, safe, and content. Health problems precipitated you doing what needed to be done. In your case, probably nothing imperative would come out of the diagnosis, especially if Mom is content :) Obviously your brother, and you, are doing something wright. I get the difference between Mom and Mrs. Luau. As you said there are those content in their dementia and there are those that are hostile and angry in their dementia. My Mom and Mrs. Luau both fit in the latter category! A diagnosis with these does help because it gives a better understanding of the brain dysfunction which can explain some of the emotional upset they experience. It give us validation to explain what is going on. It also helps when we are seeking help for their emotional distress. It leads us to the right medical professionals to treat their specific needs. It also lets us know that the person is not just being contrary! The "memory problems" are often tagged with cognitive decline but the behavioral problems are often tagged with mental illness!... when in fact they need to be tagged with cognitive decline. The diagnosis is the only way to know the difference.

A diagnosis can also bring a family back to the same page. If Mom is beyond living alone but some insist that she is "ok", the diagnosis can make the difference. If Dad is still driving and should not be, the diagnosis can make the difference. If Spouse is making poor financial decision and you are not sure if you should step in to stop them, then the diagnosis can make a difference. It is a reality check for those in denial.

Most of all a diagnosis can take the guess work out of what is happening. It can give you something definitive to hang on to. It can give you a perspective relative to what needs to be done in the future. We all know most dementia is not treatable or curable so we have to make plans... and a diagnosis gives you the direction you need. Beyond that it can rule out the treatable causes of cognitive decline so you know there is nothing else you could have done. A diagnosis sets you on a path that can lead to a new normal which includes a better life with dementia.

Mitzy :) Thank you!! Having seen all I have seen related to this disease, if I can help one person, one family, get to a better place... it gives validity to all I have been through. Yes, it is a passion and a mission. I do it for every person with dementia and every person that cares for them.

Love, deb

ninamarc 04-09-2013 02:26 PM

Re: MMSE question
I think the discussion in this thread and the other MMSE thread show all the issues for this situation.
My main point is how do you force some elderly to get the diagnosis if she refuses to? If she is well cared for with no driving and all the potential issues solved (like not giving the med to Dad,) then it is OK to do just caregiving.

So far my sisters are not really for diagnosis partly because Mom is focusing on her walking issue. Mom gets upset about it.
The only thing to do is make sure they are safe.


Gabriel 04-09-2013 04:06 PM

Re: MMSE question
And my question is... why would you let someone with cognitive impairment made such an important decision? I ran into this problem head on with my Mom. She had a clue something was wrong. She convinced her first doctor that it was nothing more than depression. She filled her anti depressant prescription and forgot to take them. When her doctor realized it was more than depression, she fired him and found a new doctor. Her new doctor actually did a MMSE on which she scored a 27. He was not concerned so she was happy. She refused all other appointments. The sisters were happy because the GP said it was ok. I knew that was not the end of the story. So I made her an appointment with the Memory Assessment Research Service connected to a local university doing research into dementia diagnosis for extensive cognitive testing. I told her the day before that we had an appointment the next day. I told her the day of the appointment that we had to leave at 8 am. I didn't elaborate. I just got her in the car and off we went. Once there, she didn't want to make a scene in front of all those people so in she went... and out she came with a diagnosis of Moderate to Sever Dementia consistent with Alzheimer's. They were the ones that said she should not drive and should no longer live alone.

No, you are not going to logically discuss the need for the appointment with those that are resistant. The very brain changes caused by the cognitive decline limit their ability to make these important decisions. There are many times that you can not depend on the person with cognitive decline to make the necessary important decisions regarding their own health and well being. This is one of them.

Dad didn't want to go to the ER when he had a broken arm. Mom didn't want to go to the ER when she had a broken hand. Dad didn't want to go to the ER when he had a brain bleed. Mom didn't want to go to the psych unit when she was hysterical and out of control hurting herself and others. Mom didn't want to go to the Memory Center for Cognitive testing. I saw no difference and made sure each situation was handled responsibly because neither of them were capable of making the decisions that needed to be made. Just because this is a disease that affects the brain, I don't consider it any different from any other disease that needs diagnosis and treatment :)

Your sisters are focused at her inability to walk. What about her other cognitive inabilities? Why do we treat the physical that we see and not the cognitive that we don't see. I found that many of Mom's balance and ambulatory problems were a direct result of her cognitive decline. Remember that cognitive decline is not just memory issues. The brain controls EVERYTHING! This includes balance, commands to the muscles, coordination, and pain centers.... all of which can affect ambulation.

Love, deb

deb7442 04-09-2013 05:14 PM

Re: MMSE question
This may not fit in here but here it goes. My mom has vascular dementia with severe hallucinations and delusions. She had an informal MMSE at the hospital last year (for other reasons), I didn't need to know the score she got, I saw for myself she failed it miserably. She had CT scan and brain spec scan and another MMSE at the drs office, which then got the diagnosis but unfortunately the stress that all those tests caused her sent her further over the edge to where I thought this was the beginning of the end for her. She declined so rapidly that I couldn't see straight. I decided, unless it was critical for testing of any sorts to be done she would not be going through them. So no 3 hour psych eval and no MRI. The stress literally starves her brain from what little blood is circulating. The neurologist agreed that maintaining, not testing was a good path for her. Each person with the disease is different, reacts differently, and tolerates differently.
Some who don't know me might say I have given up on my mom because of her age, well that's not the case, she is 70, and I kind of want her with me for as long as I can so I am going to keep her as stress free as possible.
I think most people know in their hearts as to what is best for their loved ones.

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