DCP Faculty for the Psychology
Of Older People
www.psige.org
Division of Clinical
Psychology
‘Promoting Psychological Wellbeing in Later Life’
Letter to all members of the Faculty of the Psychology of Older People
Dear Colleagues,
We have received a number of requests for information in the about whether it is possible for psychologists
working with older people to use the Mini Mental State Examination (MMSE) now that the copyright is held by
PAR. In addition, we have been asked whether tools that include the MMSE (such as the Addenbrookes
Cognitive Examination Scale – Revised: ACE-R) are available for use.
The national committee has not made a clear statement until now because of the complexity of the issues
involved. We would now like to make the following points.
The Mini Mental State Examination and its variants

The Mini Mental State Examination (MMSE) and the Standardised Mini Mental State Examination
(SMMSE) are widely used in clinical settings, and in particular by Memory Clinics in relation to the
issue of prescribing cholinesterase inhibitors (as indicated in NICE guidance). The ACE-R is a more
detailed screening assessment that incorporates the MMSE.

The copyright and use of these instruments is as follows:


MMSE – Copyright held by PAR. This tool is available for use, but copies of the tool must be
bought from PAR (see www.parinc.com for more details)

SMMSE – Copyright held by D William Molloy and colleagues. The national committee has
contacted Dr Molloy and colleagues about use of the SMMSE, and they have indicated that
they will grant permission for its use to individual psychologists who apply to them on a test
by test basis (see www.smmse.com for more details and the attached document)

ACE-R – Copyright held by Professor John Hodges. Professor Hodges has currently withdrawn
the ACE-R from the website and it is not freely available. It is our understanding that use of
the ACE-R is likely to infringe the PAR copyright because of the inclusion of the MMSE items
Therefore, the Faculty’s advice is that the ACE-R cannot be used at present, and people wishing to use
the MMSE must buy test forms from PAR. Psychologists still wishing to use the SMMSE should apply
individually to Molloy via the website and there is no charge for its use.
Alternative screening tests

An alternative screening test is the Montreal Cognitive Assessment (MoCA). Copyright for this is held
by Dr Z Nasreddine and the test can be used without charge and without permission in clinical
settings. There is extensive normative data for the test and it is available in multiple versions and
multiple languages (www.mocatest.org).
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FPOP Guidance re MMSE 31 10 12

Professor Hodges and colleagues have been developing an alternative Addenbrooke’s Cognitive
Examination tool in which the MMSE items have been removed. The tool will be called the ACE-III or
ACE-S will be re-piloted and re-normed. Once this has been completed, Prof Hodges has informed us
that it will be made available for clinical use without charge.

It was released the last week of October 2012. Please see link below.

http://www.neura.edu.au/frontier/research/test-downloads/
More detailed assessment

Psychologists are encouraged to consider when it is appropriate to use screening tests versus more
detailed neuropsychological testing. The following matrix has been developed by Dr Donald Brechin
and Professor Jon Evans as a guide to assist with this:
Cognitive deficit
found on
screening(e.g.
MoCA/ACE)
Functional
impairment found
from clinical history
Cognitive screening
scores and clinical
history consistent
with each other
Presentation fits a
recognised profile















-



-
Action
Specialist to make
diagnosis
Consider further
neuropsychological
assessment before
diagnosis
Note: The above table focuses on the criteria for considering specialist neuropsychological testing. Other
diagnostic tests (e.g. neuroimaging) may be required to make a diagnosis.

Psychologists should carefully consider which aspects of function they are assessing and why, and
identify a suitably reliable and well normed neuropsychological test that is suitable for this purpose. If
they require more information and support in this matter they should seek it from their psychologist
with extensive experience of administering neuropsychological assessments with older people.

The Table below is an extract from the Neuropsychological Test Inventory about the SMMSE collated
by Tamsin Fryer for further information.
Yours faithfully
Cath Burley
DCP Chair
Faculty of the Psychology of Older People
Don Brechin
Former Chair
Faculty of the Psychology of Older People
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FPOP Guidance re MMSE 31 10 12
Appendix
Test Name
What it measures?
Description
Suitable groups for
assessment
Format/materials
Scoring
Duration
Normative Data,
reliability and validity
Standardised Mini Mental State Examination
The Standardised MMSE (Molloy, Alemayehu, Roberts, 1991) is an attempt to
address some of the limitations of the MMSE as administration and scoring in
clinical practice is variable. The MMSE is probably the most widely used cognitive
screening instrument. It intends to identify people with a moderate to severe
level of cognitive impairment. It lacks the sensitivity to discriminate between
people with mild Alzheimer’s disease from those without and is not sufficiently
sensitive to detect some of the more fronto-temporal presentations of dementia.
It is the measure relied upon by NICE in relation to guidance for the prescription
and monitoring of anti-cholinesterase inhibitors.
Test items include attention/orientation, memory (short recall of 3 words),
visuospatial (construction), and language (writing, reading, naming, and
repetition).
Age range: 18-85+
Scores affected by educational level, socio and cultural factors, visual
impairment and aphasia. Ceiling effects for people with above average natural
ability. Floor effects for those with mild learning disabilities. Probably not
sensitive enough to detect MCI.
Manual includes some useful information on interpretation of scores.
Hand scored and no special equipment needed.
The SMMSE is available online in various formats (see below).
Full guidance for standardised scoring provided in the 1991 journal article and the
manual.
30-26 Could be normal
25-20 Mild
19-10 Moderate
9-0 Severe
10 minutes.
Normative data is available from a number of different studies, the largest of
which appears to be Crum et al (1993)’s sample of 18,000 community dwelling
adults aged 18-85.
The Molloy et al (1991) study suggested that by following their standardised
administration, the interrater variance was reduced by 76% and the intrarater
variance by 86%.
Traditional MMSE has been translated into over 100 languages, but these have not
been sufficiently validated (Auer et al, 2000).
Modest to high correlations demonstrated when the MMSE was compared with the
DRS, Information-Memory-Concentration Test, Clock Drawing Task, Mental Status
Questionnaire (Spanish Version), Blessed Test.
MMSE scores correlate modestly with ADL performance.
If the SMMSE is being used to monitor change, small changes must be interpreted
judiciously. Iverson (1998) suggests a change of 2 points or more might be
statistically reliable, dependent upon age and education whilst Clark et al (1999)
recommend a meaningful change would be reflected in a change of 3 or more
points and Doody et al (2001) suggests this would need to be more than 5.
See the following article for a description of standardised procedures for
administration:
http://www.dementiaassessment.com.au/guidelines/Guide_Standardised_MMSE.pdf
Authors
(Full reference: Molloy, D. W., Alemayehu, E. & Roberts, R. (1991) Reliability of a
standardized Mini-Mental State Examination compared with the traditional MiniMental State Examination. American Journal of Psychiatry, 148, 102-105.)
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FPOP Guidance re MMSE 31 10 12
Source & Costs
The assessment is embedded in this table, but permission must be sought from
the author (Dr. Will Molloy) to use it:
SMMSE users guide
SMMSE form
SMMSE form with
instructions
Online version: http://smmse.com/ucc/ui/smmse/home
App available at :
http://itunes.apple.com/gb/app/smmse/id517599997?mt=8
The traditional MMSE, as copyrighted by PAR Inc can be sourced at:
http://www4.parinc.com/Products/Product.aspx?ProductID=MMSE#Relate
dProducts Full reference to the original paper: Folstein, M. F.; Folstein, S. E. &
Additional Information
Relevant links:
McHugh, P. R. 1975. ''MMS'. A practical method for grading the cognitive state of
patients for the clinician. Journal of Psychiatric Research, 12, 189-198.
Vertesi A, Lever JA, Molloy DW, et al. 2001. Standardized mini-mental state
examination: Use and interpretation. Canadian Family Physician;47:2 018-2023.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2018449/pdf/11723596.p
df
http://ajp.psychiatryonline.org/article.aspx?volume=148&page=102
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FPOP Guidance re MMSE 31 10 12