The Mini-Mental State Examination (MMSE)

Dr Victor M Aziz
Consultant Psychiatrist
Cwm Taf HB

Dr Raja A Ahmed
ST4 Old age Psychiatry
Cwm Taf HB

Background:

The MMSE [Folstein et al., 1975] has been used as a screening tool of cognitive function
in clinical practice worldwide. It is easily administered by clinicians or researchers with
minimal training, and has a cut-offs of 23/24 out of 30 to show significant cognitive
impairment. Its reliability is improved using a standardized version [Vertese et al.,
2001]. It has a “floor” effect in terms of its inability to detect changes in established
advanced dementia, in those with little formal education and those with severe language
problems. There is a” ceiling” effect meaning it may fail to detect very mild illness, and
mild/moderate cognitive impairment in people at high educational level or premorbid
intelligence (Franco-Marina et al., 2010). Its sensitivity is low for early dementia and
Mild Cognitive impairment (MCI). Further, some MMSE items and possibly the MMSE as
a whole may be unduly influenced by age, education, and ethnicity (Simard, 1998). This
has limited its use for detecting change in clinical work and in research studies.

Copyright issues:

When the MMSE was first published in 1975 in the Journal of Psychiatric Research, its
copyright ownership remained with the authors until Elsevier took over copyright of both
Pergamon Press and the Journal of Psychiatric Research. Pergamon Press was an
Oxford-based publishing house, which published scientific and medical books and
journals. It is now an imprint of Elsevier. In 2001, the authors entered into an exclusive
agreement with Psychological Assessment Resources (PAR) granting them the exclusive
rights to publish, license, and manage all intellectual property rights of the MMSE in all
media and languages.

PAR claims that the official version is copyrighted and must be used and ordered only
through them. Therefore, all users need to purchase the tests from PAR. A per-copy
royalty fee will be charged for all permissions granted for copies of translations of the
MMSE or modified versions of the test form. The fee is around £0.80 for each and every
use. According to PAR copyright permission request form if any person plans to use the
MMSE in its entirety and in its published form, they must purchase the number of test
protocols they will need for their purposes. This is applicable in USA, Canada or any
place in the world. PAR will not grant permission to include the entire MMSE test form or
scale in any publication, including dissertations and theses i.e. the test has to be used on
the official form after obtaining the copyright permission.
(http://www4.parinc.com/webuploads/pdfs/MMSE_Copyright_PermReq.pdf)

The copyright issue has also raised lots of discussions e.g. Seshadri and Mazi-Kotwal,
2012; Newman & Feldman, 2011). The enforcement of the copyright has led to
researchers looking for alternative strategies to assess cognition. Many websites have
removed the MMSE test e.g. www.patients.co.uk and www.evidence.nhs.uk.

The restrictions on the MMSE’s present an interesting debate: on one hand the
infringement of copyright and on the other hand, clinicians experience in using the test
for many years. Psychiatrists have used the MMSE for years without mention of
copyright (Powsner & Powsner, 2005). Some trainees know the items of MMSE by heart
and can use it without the need for actual form. This makes for an interesting moral
argument. James Grimmelmann, Professor of Law, University of Maryland (2011),
argued that copyright is not available for any “procedure” or “process.” The USA
Supreme Court in Baker v. Selden “Take the case of medicines. Certain mixtures are
found to be of great value in the healing art. If the discoverer writes and publishes a
book on the subject (as regular physicians generally do), he gains no exclusive right to
the manufacture and sale of the medicine; he gives that to the public”. He added that
the same applies to the MMSE; its creators “gave it to the public”.

For clinicians, photocopying or downloading the MMSE probably constitutes infringement,

and could incur penalties. The MMSE case may be a beginning of more copyright issues.
It is difficult to imagine what will happen if the same happens to clinical tools we take for
granted. Will this impact standardisation and detract efforts to improve patient care; a
question that can be answered by time and research.

One point of view is that the NHS has not been charged for using of the MMSE and
therefore we should continue to use it. However, that does not mean we should advice
its use. Attention is needed to avoid undue cost to the NHS and to avoid any
misperception that NHS clinicians can use the tool free of charge. Copyright violation and
use of MMSE can be retrospectively checked on health records.

Would a legal challenge be likely to succeed? The answer is yes. PAR has asserted their
copyright against an alternative diagnostic test, "Sweet 16," developed and validated by
Tamara Fong and published in 2011. Assertion of copyright forced the removal of this
test from the Internet (Newman and Feildman, 2011). The same happened with the
Addenbrooke’s Cognitive Examination (ACE-R) test which led to the modification of the
test and to the ACE-III version that has no MMSE components (www.neura-
edu.au/sites/neura).

We already have other tools that clinicians can use to assess cognition such as 6-Item
cognitive impairment test (6CIT; Brooke & Bullock, 1999); and Montreal Cognitive
Assessment (MoCA; Nasreddine et al., 2005), which are available to clinicians free of
charge. It may be advisable to stop using the MMSE until the authors terminate or
release the MMSE license into public domain.
(www.alzheimers.org.uk/site/scripts/download.php?fileID=1661)

Newman and Feldman (2011) suggested applying the principle of “copyleft” from the
open-source technology movement to encourage innovation and access while protecting
authors' rights. Copyleft allows the author to retain the right to offer the work under a
different license while simultaneously gives the right for anyone to use, modify, copy,
and distribute a work, as long as it and any derivatives remain under the same license.
In general, copyright law is used by an author to prohibit recipients from reproducing,
adapting, or distributing copies of the work. In contrast, under copyleft, an author may
give every person who receives a copy of a work permission to reproduce, adapt or
distribute it and require that any resulting copies or adaptations are also bound by the
same licensing agreement. They suggested that any new tool developed with public
funds should be required to use a copyleft to guarantee the freedom to distribute and
improve it.

Conclusion:

The free use of MMSE is no longer a viable option; there are alternatives for screening
and diagnosing cognitive impairment. In my opinion, it is recommended using those
alternatives. Finally, we need to alert hospital clinicians and General Practitioners who
are either unaware of the MMSE’s copyright restrictions or simply ignore them, that
copyright infringement carries a risk of civil and/or criminal penalties such as
injunctions; destruction of infringing articles; damages and profits; costs and attorney's
fees; or criminal charges. These recent changes in practice should also be included in
training Medical students.

References:
1. Folstein MF, Folstein SE, McHugh PR. ""Mini-mental state". A practical method for
grading the cognitive state of patients for the clinician". Journal of Psychiatric
Research, 1975; 12 (3): 189–98.
2. Vertese A, Lever JA, Molloy D et al. (2001). Standardized Mini-Mental State
Examination; use and interpretation. Can Fam Physician, 2001; 472018-2023.

3. Franco-Marina F et al. The Mini-Mental State Examination revisited: ceiling and

floor effects after score adjustment for educational level in an aging Mexican
population. Int Psychogeriatrics, 2010; 22 (1): 72-81

4. Simard M. The Mini-Mental State Examination: Strengths and Weaknesses of a

Clinical Instrument. The Canadian Alzheimer Disease Review, 1998 Dec 12.
www.stacommunications.com/.../Back...Review/.../december1998/10.pdf

5. Seshadri m, Mazi-Kotwal. A copyright-free alternative to the mini-mental state

examination is needed. BMJ, 2012; 345: e8589

6. Newman JC and Feldman R. Copyright and Open Access at the Bedside. N Engl J
Med, 2011; 365:2447-2449

7. Powsner S, Powsner D. "Cognition, copyright, and the classroom". The American

Journal of Psychiatry, 2005;162 (3): 627–8. doi:10.1176/appi.ajp.162.3.627-a.
PMID 15741491.

8. The Addenbrooke’s Cognitive Examination-III Frequently Asked Questions.

Updated 7/7/2013. www.neura-edu.au/sites/neura

9. Nasreddine, Z. S., et al. "The Montreal Cognitive Assessment, MoCA: a Brief

Screening Tool for Mild Cognitive Impairment." J.Am.Geriatr.Soc., 2005;
53(4):695-99.

10. Brooke, P. & Bullock, R. Validation of a 6 Item Cognitive Impairment Test with a
view to primary care usage. International Journal of Geriatric Psychiatry, 1999;
14:936-940.

11. Grimmelmann J (2011) "How Copyright Is Like Cognitive Impairment".

http://laboratorium.net/archive/2011/12/29/how_copyright_is_like_cognit
ive impairment