Missing the Forest for a Tree: Use of the Mini-Mental State Exam (MMSE) in Capacity Determinations

• Date: 01 March 2024

BifocalVol. 45 Issue 4

121

Accurately assessing the decision-making abili-

ties of older adults is of great social, legal, and

clinical importance. Historically, a medical or psychi-

atric diagnosis might have unfortunately suced as an

indication of incapacity; however, an appreciation of

human rights and individual dierences directs us to

evaluate an older adult’s functional abilities and to in-

tegrate supports. One aspect of a functional approach

to assessing capacity in later life typically involves an

assessment of cognition, which includes abilities such

as learning and recall, attention, and judgment. While

many neuropsychological tests exist to capture these

abilities, the Mini-Mental State Examination (MMSE)

has had one of the greatest impacts in this regard – a

tool that is likely widely known to geriatric legal

and healthcare professionals. The importance of the

MMSE in clinical practice over nearly 50 years is un-

deniable. Intriguingly, the publication and subsequent

embracing of this tool coincided with several advance-

ments in our society’s conceptualization and evalua-

tion of capacity. Given the continued prominence of

the MMSE, this article reviews the tool and its rela-

tionship to these advances in capacity evaluations.

The MMSE

When rst published in 1975, the authors of

the MMSE, Folstein, Folstein, and McHugh, specif-

ically sought to develop a useful method to both (1)

quantitatively estimate an individual’s level of cogni-

tive impairment and (2) monitor changes in cognitive

functioning over time. Though not intended to be the

sole basis for any particular diagnosis, the MMSE is

brief and requires no additional equipment and mini-

mal training to administer. In 10 minutes or less, this

screening test can aid a healthcare professional in

determining whether a patient voicing concerns needs

to be referred for additional evaluation. Given its

strengths, it is no wonder that the MMSE has become

the most well-known and widely used screening test

of cognition. However, despite the great value that the

MMSE has provided, no cognitive assessment tool is

without its limitations. Failing to acknowledge and ac-

count for these limitations increases the likelihood that

MMSE scores may be misused and misunderstood,

resulting in inaccurate conclusions about an individu-

al’s cognitive or decisional abilities.

In the case of the MMSE, some of its weak-

nesses are the natural and understandable consequenc-

es of its strengths. Perhaps that most practical example

Missing the Forest for a Tree: Use of the Mini-Mental State

Exam (MMSE) in Capacity Determinations

Kyle S. Page, PhD1, ABPP, Nabeel Yehyawi, PsyD2,

ABPP, & HyeRim Ryu, MS3

1Edward Hines, Jr. VA Hospital, 2Central Iowa VA Hospital, 3Rosalind Franklin

University of Medicine and Science