“Studying” for the Mini‐Mental Status Exam

To the Editor:—The Mini-Mental Status Exam (MMS) has been found to be useful in the detection of cognitive impairment,1 and consists of tests of orientation, “registration” and subsequent recall of the names of three unrelated objects, attention span (measured by the ability to spell the word “world” backwards), calculation ability (subtraction of “serial sevens” from one hundred), and language capability. A point value is assigned for each part of the test, and scores of 20 or less have been associated with severe impairment. The MMS has been recommended for detecting dementia in the geriatric patient.2,3 I would like to recount an experience which illustrates the limitation of the stereotypical application of this examination. I perform an initial history and physical examination which includes the MMS on nearly all prospective residents of the Methodist Country House, a desirable church-sponsored retirement home. Another internist occasionally does these initial evaluations, but does not routinely do the MMS. After concluding his physical examination of a 65-year-old female he was asked “How about those questions? Don't you want me to substract sevens from a hundred?” She then proceeded to name the three objects that I customarily ask patients, and then demanded, “Don't you want me to spell the word ”world“ backwards?” It was apparent that she knew major components of my standard MMS. In fact, according to the nurse who witnessed the interview, she said she “practiced” for the exam. Apparently, a resident-friend in the retirement home had given her the “answers” to the exam, which many elderly people find particularly stressful and, therefore, memorable. Although one might make the argument that severe dementia precludes “studying” for the MMS, I feel that subtle mental impairment would be missed in patients who already know the “answers.” I recommend that periodic modification of the three object recall, backward spelling, and serial substraction parts of the MMS be made by the practioner, particularly in situations in which groups of elderly people congregate and share their medical experience.