The latest NICE NG97 (2018) guidance recommends that people with mild-to-moderate Alzheimer’s disease (MMSE score 10–26) should be considered for treatment with donepezil (Aricept), rivastigmine (Exelon), or galantamine (Reminyl).
For severe Alzheimer’s disease (MMSE score < 10), or where acetylcholinesterase inhibitors are not tolerated, memantine (Ebixa) — an NMDA receptor antagonist — is recommended.
Memantine may also be used in moderate disease (MMSE 10–20) when AChE inhibitors are contraindicated or not tolerated.
All patients should receive a multidisciplinary care approach, including cognitive stimulation therapy, environmental support, and carer involvement.

📋 The Mini-Mental State Examination (MMSE)

The MMSE is a 30-point cognitive screening tool assessing orientation, attention, memory, language, and visuospatial ability. It is widely used in dementia evaluation and monitoring of progression and treatment response.

📈 Interpretation

24–30: Normal cognition or very mild impairment.
20–23: Mild cognitive impairment (mild Alzheimer’s).
10–19: Moderate impairment.
< 10: Severe cognitive impairment.
Score must be interpreted in context — influenced by age, education, language, and sensory deficits.

🧩 Orientation

What is the year? +1
What is the season? +1
What is the month? +1
What is the date? +1
What day of the week? +1
What country are we in? +1
What county or region? +1
What town/city? +1
What hospital/clinic/place? +1
What floor are we on? +1

🔤 Registration

Name 3 unrelated objects clearly and slowly (e.g. “apple”, “table”, “penny”) — +3 if all recalled.

🔢 Attention & Concentration

Serial 7s from 100 (subtract 7 each time) or spell “WORLD” backwards. +5

🧠 Recall

Ask the patient to recall the three objects from the registration task. +3

🗣️ Language & Praxis

Name simple objects (e.g. watch, pen). +2
Repeat the phrase “No ifs, ands, or buts.” +1
Follow a 3-stage command (“Take the paper, fold it, and put it on the floor”). +3
Read and obey a written instruction (“Close your eyes”). +1
Write a sentence. +1
Copy a diagram (two intersecting pentagons). +1

🧾 Scoring

Maximum score: 30 points
Use serial assessments to track disease progression and therapeutic response. A drop of ≥3 points over 6 months suggests significant cognitive decline.

🧩 The Mental State Examination (MSE)

MENTAL STATE EXAMINATION
Feature	Findings
Appearance	Dress, grooming, level of consciousness, motor behaviour, posture, eye contact, tremor, gait, scars, tattoos.
Behaviour	Cooperative, agitated, withdrawn, threatening, preoccupied, or sexually inappropriate.
Mood	Subjective (“How do you feel?”) and objective (flat, anxious, elated, depressed, irritable).
Thoughts	Form (flight of ideas, thought blocking) and content (delusions, obsessions, suicidal ideation).
Perceptions	Hallucinations (visual, auditory, tactile), illusions, depersonalisation, derealisation.
Beliefs	Delusional themes, strength of conviction, reaction to challenge.
Insight	Does the patient recognise their illness? Accept treatment? How do family perceive changes?
Cognitive & Neurological	Orientation, attention, memory, language, visuospatial skills, intelligence, and executive function.

📖 Educational Summary

The MMSE is a rapid bedside screen for cognitive impairment but lacks sensitivity for early disease or frontal lobe dysfunction. Modern alternatives include the Montreal Cognitive Assessment (MoCA) and the ACE-III, which better detect mild cognitive impairment. In Alzheimer’s disease, a cholinergic deficit in the basal forebrain underlies memory and attentional loss — explaining the benefit of acetylcholinesterase inhibitors. As disease advances, NMDA-mediated excitotoxicity contributes to neuronal death, accounting for the role of memantine in later stages. MMSE tracking over time helps guide treatment escalation and anticipatory care planning.

📚 References

NICE NG97: Dementia – assessment, management and support (2018)
BNF: Donepezil, Rivastigmine, Galantamine, Memantine
Alzheimer’s Society: Cognitive Assessment Tools (2024)
British Journal of Psychiatry 2022;221(3): Cognitive Testing and Dementia Diagnosis

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Mini Mental State Examination (MMSE)

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