Marshal F. Folstein

Mini-mental state. A practical method for grading the cognitive state of patients for the clinician

EXAMINATION of the mental state is essential in evaluating psychiatric patients.1 Many investigators have added quantitative assessment of cognitive performance to the standard examination, and have documented reliability and validity of the several “clinical tests of the sensorium”.2*3 The available batteries are lengthy. For example, WITHERS and HINTON’S test includes 33 questions and requires about 30 min to administer and score. The standard WAIS requires even more time. However, elderly patients, particularly those with delirium or dementia syndromes, cooperate well only for short periods.4 Therefore, we devised a simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely. It is “mini” because it concentrates only on the cognitive aspects of mental functions, and excludes questions concerning mood, abnormal mental experiences and the form of thinking. But within the cognitive realm it is thorough. We have documented the validity and reliability of the MMS when given to 206 patients with dementia syndromes, affective disorder, affective disorder with cognitive impairment “pseudodementia”5T6), mania, schizophrenia, personality disorders, and in 63 normal subjects.

The Meaning of Cognitive Impairment in the Elderly

In order to determine the meaning of cognitive impairment in community dwelling elderly, 3,481 adults were interviewed in their homes using the Mini‐Mental State Examination. Ninety‐six per cent of the population aged 18–64 scored 23 or higher, whereas 80 per cent of the population 65 and over scored 23 or higher. Individuals with low scores were suffering from a variety of psychiatric disorders including dementia. Thirty‐three per cent of the elderly population scoring in the range of 0–23 had no diagnosable DSM‐III condition. Prevalence of dementia from all causes was 6.1 per cent of the population over age 65. Two per cent of the population over age 65 were diagnosed as having Alzheimers disease

Nonsteroidal anti-inflammatory drugs in Alzheimer's disease

Article abstract-We reviewed the records of 210 patients in the Johns Hopkins Alzheimers Disease Research Center to evaluate the role of nonsteroidal anti-inflammatory drugs (NSAIDs) on clinical features and progression of the disease. We compared patients taking NSAIDs or aspirin on a daily basis (N = 32) to non-NSAID patients (N = 177) on clinical, cognitive, and psychiatric measures. The NSAID group had a significantly shorter duration of illness at study entry. Even after controlling for this difference, the NSAID group performed better on the Mini-Mental State Examination, Boston Naming Test, and the delayed condition of the Benton Visual Retention Test. Furthermore, analysis of longitudinal changes over 1 year revealed less decline among NSAID patients than among non-NSAID patients on measures of verbal fluency, spatial recognition, and orientation. These findings support other recent studies suggesting that NSAIDs may serve a protective role in Alzheimers disease. NEUROLOGY 1995;45: 51-55

Mood disorder as a specific complication of stroke.

In an effort to discern whether cerebral vascular injuries provoke specific emotional disturbances, 20 consecutively admitted stroke patients were compared with 10 orthopaedic patients. Both groups were examined for functional disabilities (Activities of Daily Living) and for psychiatric symptoms. Reliable and valid instruments, the Hamilton Rating Scale, the Visual Analogue Mood Scale, the Present State Exam, and the Mini-Mental State Exam were employed to display the psychopathology. More of stroke patients than orthopaedic patients were depressed (45% versus 10%) even though the level of functional disability in both groups were the same. Patients with right hemisphere stroke seemed particularly vulnerable and and displayed a syndrome of irritability, loss of interest, and difficulty in concentration, in addition to depression of mood (70% of right hemisphere stroke patients versus 0% left hemisphere stroke patients and 0% orthopaedic patients). We conclude that mood disorder is a more specific complication of stroke than simply a response to the motor disability. We suggest that a controlled trial of antidepressant medication is indicated for patients with this complication.

A randomized trial of dementia care in nursing homes

OBJECTIVE: To evaluate the efficacy of a dementia care program to reduce behavior disorders in nursing home patients with dementia.

The prevalence and management of dementia and other psychiatric disorders in nursing homes.

The prevalence of psychiatric disorders among new admissions to nursing homes is unknown. Such data are needed to estimate the psychiatric needs of this population. We report the prevalence of specific psychiatric disorders in 454 consecutive new nursing home admissions who were evaluated by psychiatrists and diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Eighty percent had a psychiatric disorder. The commonest were dementia syndromes (67.4%) and affective disorders (10%). Also, 40% of demented patients had additional psychiatric syndromes such as delusions or depression, and these patients constituted a distinct subgroup that predicted frequent use of restraints and neuroleptics, and the greatest consumption of nursing time. These data demonstrate that the majority of nursing home residents have psychiatric disorders on admission, and that their management is often quite restrictive. Research is now needed to determine the best methods of treatment for nursing home patients with mental disorders.

The association of affective disorder with Huntington's disease in a case series and in families.

Major affective disorder clinically similar to the disorder found in conditions other than Huntingtons Disease (HD) was found in 41% of patients with HD in a consecutive case series ascertained through multiple sources in a defined geographical area. The association appears to be confined to certain families, and affective disorder may appear as long as 20 years before the onset of chorea and dementia. The association may represent genetic heterogeneity in HD.

Clinical assessment of irritability, aggression, and apathy in Huntington and Alzheimer disease.

Thirty-one patients with Alzheimer disease (AD) and 26 patients with Huntington disease (HD) were assessed using new scales to measure apathy and irritability. An existing scale was used to assess aggression. A similar prevalence of apathy and irritability was found in the two groups. The HD patients were more aggressive than the AD patients. In a subsample of the two groups, matched for degree of cognitive impairment, the HD patients were found to be more apathetic than the AD group. Irritability was related to be the premorbid trait of “bad temper” in HD but not in AD. There was no interrelationship among the three symptoms in either group. The scales for irritability and apathy have both interrater and test-retest reliability. They are able to differentiate patients with AD and HD from normal, disease-free control subjects. The usefulness of these scales, in relation to preexisting scales, is discussed.

The diagnosis of Huntington's disease

We investigated all patients in Maryland reported to have Huntingtons disease (HD), and found considerable diagnostic inaccuracy. Fifteen percent of cases reported as HD actually had some other diagnosable condition; 11% of cases that met diagnostic criteria for HD had been given some other diagnosis. Diagnostic errors could be reduced by documentation of the family history by systematic interviewing of relatives and by demonstration of the characteristic disorder of voluntary movement in addition to chorea.

Memory complaint, memory performance, and psychiatric diagnosis: a community study

This study examined the prevalence of memory complaint and poor memory performance on brief screening measures within a community sample of 810 adults. All individuals received an extensive household interview and a clinical psychiatric evaluation. Overall, 22% indicated that they currently had trouble with their memory. This percentage increased with age, rising to 43% for those 65 to 74 years old, 51% for those 75 to 84 years old, and 88% for those 85 years of age and older; the percentage indicating memory problems decreased with educational attainment. The prevalence of poor memory performance was 11%, also increasing with less education and increased age, rising to 26% for those 65 to 74 years old and to 40% for those older then 75. Those who complained of memory trouble were twice as likely to show poor memory performance (29%) compared with those who did not complain (15%). Multivariate analysis found age, emotional distress, and physical illness to be independent predictors of memory complaint; age, functional disability, education, and physical illnesses proved to be independently associated with poor memory performance. A higher prevalence of complaints of memory trouble was found not only for those with affective disorders, as might be expected, but also among those with schizophrenic, cognitive, anxiety, and adjustment disorders. However, only individuals with cognitive disorders showed a higher prevalence of poor memory performance.