Makindo Medical Notes

🧠 About

• 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)

📖 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