Original Research Article
Dement Geriatr Cogn Disord 2012;33:125–131
DOI: 10.1159/000337843
Accepted: February 29, 2012
Published online: April 21, 2012
A Retrospective Analysis of the Sentence Writing
Component of the Mini Mental State Examination:
Cognitive and Affective Aspects
Yan Press a–e Natalia Velikiy a–c Alex Berzak a–e Howard Tandeter a–c
Roni Peleg a–c Tamar Freud a–c Boris Punchik a–e Tzvi Dwolatzky b, d–f
a
Department of Family Medicine, b Faculty of Health Sciences, and c Siaal Research Center for Family Medicine
and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, dComprehensive Geriatric
Assessment Unit, e Community Geriatric Service, Southern District, Clalit Health Services, and
f
Geriatric Department and Memory Clinic, Mental Health Center, Beer-Sheva, Israel
Key Words
Mini Mental State Examination ⴢ Screening ⴢ Cognitive
impairment ⴢ Dementia ⴢ Depression ⴢ Dysgraphia ⴢ
Language ⴢ Emotion ⴢ Aging
Abstract
Background: One of the components of the Mini Mental
State Examination (MMSE) is the request to write a sentence.
We investigated the relationship between the characteristics
of the written sentence of the MMSE and the cognitive and
affective status of elderly patients. Methods: The characteristics of the sentence were compared to the total MMSE
score, sociodemographic characteristics, tests evaluating
cognition and affective status, and diagnoses. Results: The
number of words was significantly associated with the degree of cognitive impairment, whereas the emotional polarity of sentences and concerns about health were associated
with depression. Conclusions: Characteristics of the MMSE
sentence may provide important additional information regarding both cognition and affect when assessing older
people.
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Introduction
The written word and language serves as a mirror to
many aspects of human function and behavior. Handwriting is closely related to the functioning of the mind
and is therefore linked with how people think, feel and
behave [1]. Agraphia can be defined as the partial or total
loss of the ability to produce written language associated
with brain pathology [2]. Alzheimer’s disease (AD) is a
neurodegenerative condition resulting in progressive
cognitive and functional decline, and agraphia or dysgraphia are common features of this disease. As AD progresses there is a deterioration in spelling, poor narrative
organization, content word errors and perseverations, reduced syntactic complexity, and shorter sentences [3, 4].
In a study of patients with AD, the ability to formulate a
complete sentence was related to dementia severity [5].
When asked to write a story about a picture, patients with
AD of mild to moderate severity wrote shorter descriptive paragraphs than normal subjects matched for age
and gender (28.4 vs. 79.9 words) [6].
The Mini Mental State Examination (MMSE) [7] is
widely used as a screening instrument for cognitive impairment. It assesses a number of cognitive domains,
namely orientation, registration, concentration, shortterm memory, language and visual spatial function. The
MMSE includes a request to ‘write a sentence’, with 1
Yan Press, MD
Comprehensive Geriatric Assessment Unit, Clalit Health Services, Yassky Clinic
24 King David Street
Beer-Sheva 84539 (Israel)
Tel. +972 8640 7743, E-Mail yanp @ bgu.ac.il
point awarded if the sentence has a subject and a verb and
makes sense regardless of spelling, grammar or content.
Depending on the setting the MMSE has been shown
to have reasonable sensitivity and good specificity [7–12].
Not all components of the MMSE are equal as indicators
of cognitive function [13–15], and writing a sentence is
one of the components that contributes to the variance in
global MMSE scores.
In a retrospective review by McCarthy et al. [16] the
sentences written by 280 patients from a geriatric day
hospital performing the MMSE were analyzed. Significant correlation was detected between the overall MMSE
score and the number of words. The mean MMSE score
of subjects writing ‘positive’ sentences was marginally but
significantly higher than that of those writing a ‘neutral’
or ‘negative’ sentence.
In another study [17], the sentences written as a task
of the MMSE were compared between cognitively healthy
older subjects and those with dementia. Sentences with
inadequate emotional content seemed to indicate a dementing illness.
In this study we investigated the relationship between
the characteristics of the written sentence of the MMSE
and the cognitive and affective status of patients attending
the Comprehensive Geriatric Assessment Unit (CGAU) of
Clalit Health Services in the Southern District of Israel.
Materials and Methods
Participants and Instruments
The CGAU was established in the Southern District of Israel
by the Clalit Health Services in 2005. The staff of the CGAU includes geriatricians, a geriatric nurse, a social worker, an occupational therapist and a secretary. The average annual turnover of
the CGAU is approximately 150 patients. Patients are referred to
the CGAU for cognitive, functional and affective symptoms, as
well as problems with mobility or falls, and social difficulties. As
part of the multidisciplinary assessment, cognitive status is evaluated by means of the MMSE, and in patients with mild to moderate cognitive impairment further evaluation includes the Montreal Cognitive Assessment instrument [18], as well as computerized neuropsychological testing using the Mindstreams battery
(Neurotrax, Newark, N.J., USA) [19].
Affective status is evaluated using the 15-item Geriatric Depression Scale (GDS-15) [20]. The diagnoses of dementia and depression are based on clinical findings according to the DSM-IV
criteria [21], and that of mild cognitive impairment (MCI) is based
on the criteria of the Expert Conference on Mild Cognitive Impairment [22].
Functional assessment includes the Barthel Index [23] for basic
activities of daily living as well as the Older Americans Resources
and Services scale for instrumental activities of daily living [24].
For measuring comorbidity we use two instruments. The first is
126
Dement Geriatr Cogn Disord 2012;33:125–131
the Cumulative Illness Rating Scale-Geriatrics [25], which permits
an estimate of illness burden and diversity on the basis of a fivepoint physician rating scale (scores of 0–4, the higher score indicating a greater degree of burden) reflecting the severity of pathology
in each of 14 categories (maximum score 56). The second instrument used for assessing comorbidity is the Charlson’s Comorbidity Index [26]. Because this index was designed primarily as a predictor of mortality it presents a list of 19 conditions with fixed degrees of severity according to the relative risk of death. For risk
calculated at 61.2 but !1.5, the disease receives a score of 1; for
relative risk 61.5 but !2.5, a score of 2, and for relative risk 62.5
but !3, a score of 3; both a second metastatic solid tumor and HIVAIDS receive a score of 6. A total score is calculated. The age score
represents an extra point for each decade above age 50 and is used
for adjusting the Charlson’s Comorbidity Index for age. The total
combined score is derived by adding the age score to the total score.
Procedures and Characteristics of the Written Sentence
Three independent investigators (N.V., Y.P. and A.B.), blinded
to the results of geriatric assessment and all tests performed, were
asked to assess the following characteristics of the written sentence of the MMSE: number of words in the sentence, emotional
polarity (positive/neutral/negative) and concerns about health
(yes/no). Initially, the investigators analyzed 30 MMSE written
sentences to determine interrater reliability. The concordance between raters was an acceptable 100% for characteristic one, 92%
for characteristic two and 96% for characteristic three. Subsequently, all analyses were performed by one investigator who
speaks fluent Hebrew and Russian (N.V.). The Ethics Committee
of the Meir Hospital approved the study.
Statistical Analysis
The characteristics of the sentence were compared to the total
MMSE score, the language of administration, age, gender, education, tests evaluating cognition and affective status, and clinical
diagnoses. Continuous variables are shown as means and standard deviations. Categorical variables are described as frequencies. t tests and ␹2 tests were used to analyze statistically significant differences of continuous and categorical variables, respectively. Two-tailed p ! 0.05 were considered statistically significant.
Results
Data of 344 patients evaluated in the CGAU during the
years 2007–2009 were assessed. The basic characteristics
of the study population are presented in table 1.
Associations between MMSE Sentence Characteristics
and the Language of Assessment
A total of 209 (60.8%) were Russian speakers who underwent assessment in Russian; 135 (39.2%) were fluent
in Hebrew and were assessed in Hebrew, although Hebrew was the native language of only 6 (1.7%). No differences were found between the number of words in the
MMSE sentences of Hebrew and Russian speakers (3.9 8
1.3 vs. 3.9 8 1.2, p = 0.85)
Press /Velikiy /Berzak /Tandater /Peleg /
Freud /Punchik /Dwolatzky
Impact of Age, Gender and Education on the MMSE
Sentence Characteristics (table 2)
Of the female patients, 41 (18.1%) expressed concern
about their health in the MMSE sentence versus 11 (10.1%)
of the male patients, p value = 0.04. No other associations
between the characteristics of the MMSE sentence were
found regarding gender, age and education.
Associations between MMSE Sentence Characteristics
and Cognitive and Affective Tests
The association between the number of words in the
MMSE sentences and the overall MMSE score did not
reach statistical significance (Pearson’s correlation 0.103,
p = 0.057). A statistically significant association was
found between the number of words and GDS-15, i.e. patients with higher GDS-15 scores wrote shorter sentences
(Pearson’s correlation –0.329, p = 0.03).
With regard to the emotional polarity of MMSE sentences, patients writing ‘negative’ or ‘neutral’ sentences
had higher GDS-15 scores (10.6 8 4.1 and 10.1 8 3.4, respectively) than those writing ‘positive’ (7.5 8 3.8) sentences (p = 0.03). No associations were found between the
emotional polarity of MMSE sentences and overall
MMSE scores (MMSE score 8 SD of the ‘negative’ sentences were 23.5 8 4.1, ‘neutral’ sentences 24.3 8 4.7 and
‘positive’ sentences 24.2 8 4.7, p = 0.64).
With regard to overall MMSE scores, there was no association between patients who expressed concern about
their health and those not expressing this concern (mean
MMSE 23.2 8 4.3 vs. 24.1 8 4.8, p = 0.18). Similarly, no
association was found with regard to GDS-15 (10.5 8 3.6
vs. 9.6 8 3.6, p = 0.36)
Associations between MMSE Sentence Characteristics
and Clinical Diagnoses (table 3)
Of the 344 patients, there were 142 (41.3%) with a diagnosis of dementia, 84 (24.4%) with MCI and 118 (34.3%)
without cognitive impairment. During the geriatric assessment a total of 128/344 patients (37.2%) were diagnosed with depression.
Number of Words. The number of words in MMSE
sentences had a statistically significant association with
the degree of cognitive impairment. While cognitively
normal patients wrote longer (4.18 8 1.41) sentences,
sentences were shorter in those with MCI (3.82 8 1.14)
and dementia (3.74 8 1.22, p value = 0.02). No associations were found between the number of words in the
sentence and a diagnosis of depression.
Emotional Polarity of Sentence. Overall 323 sentences of
the MMSE were classified according to their emotional
Sentence Writing Component of the
MMSE
Table 1. Characteristics of study population (n = 344)
Characteristics
Mean 8 SD Range
(patients with available data)
Age (n = 334), years
Gender, female (n = 335)
Marital status, married
(n = 219)
Education (n = 178), years
Language of assessment
(n = 344)
Hebrew
Russian
Comorbidity scores
Total CIRS-G Score
(n = 125)
TCS of CCI
Barthel Index (n = 186)
OARS (n = 182)
MMSE (n = 344)
GDS-15 (n = 79)
78.285.4
Patients
n (%)
65–92
226 (67.5)
109 (49.8)
10.984.2
0–20
135 (39.2)
209 (60.8)
13.484.9
5.681.8
81.8815.7
7.383.1
23.984.7
9.7583.64
2–23
3–11
35–100
1–14
8–30
1–15
Total CIRS-G = Total Cumulative Illness Rating Scale Geriatric Score; TCS of CCI = total combined score of the Charlson Comorbidity Index; OARS = Older Americans Resources and Services Score.
polarity (in 21 instances MMSE sentences were ‘bizarre’ or
without any information, such as ‘I am here’, ‘My sister’,
etc.). Sentences were determined to be ‘negative’ in 32
(9.9%) patients (e.g. ‘My life is very hard’, ‘I am very pessimistic about the future’, etc.), ‘neutral’ in 215 (66.6%) and
‘positive’ in 76 (23.5%) (e.g. ‘I am always very satisfied with
life’, ‘Very beautiful and interesting life’, etc.). The emotional polarity of sentences had no association with cognitive diagnoses but had a statistically significant association
with the diagnosis of depression, with 21 patients (17.5%)
of those writing a ‘negative’ sentence being depressed compared to 11 (5.4%) patients without a diagnosis of depression writing a ‘negative’ sentence (p value !0.0001).
Concerns about Health. Concerns about health expressed in the sentence were not associated with the cognitive diagnosis. However, while 30 of the 128 patients
(23.4%) with depression wrote a sentence expressing this
concern, only 23 of the 216 patients (10.6%) without depression expressed concerns about their health (p value
!0.0001).
Impact of Age, Gender and Education on Cognitive
and Affective Status (table 4)
Age was inversely proportional to MMSE scores (Pearson’s correlation –0.233, p = 0.000). However, there was
Dement Geriatr Cogn Disord 2012;33:125–131
127
Table 2. Impact of age, gender and education on MMSE sentence characteristics
Number of words in sentence
Emotional polarity of sentence
Pearson’s mean 8 SD range
correlation
patients
Age, years
Pearson’s correlation –0.032
Mean 8 SD
Range
Patients
334
p value
0.56
Gender
Female
Male
Patients
p value
2–10
1–9
3.981.3
3.981.3
226
109
335
negative
positive
77.586.1
68–88
31
78.585.4
78.285.3
65–91
66–92
76
208
0.71
24 (11.2)
7 (6.9)
31
52 (24.3)
24 (23.5)
76
15 (14.6)
5 (8.1)
20
17 (16.5)
16 (25.8)
33
0.61
Education
≤12 years
≥13 years
Patients
p value
3.781.2
4.081.2
2–9
2–9
115
63
178
0.16
Concerns about health in sentence
neutral
patients
yes
no
patients
315
79.285.6
68–91
52
77.985.3
65–92
282
0.13
138 (64.5)
71 (69.6)
209
0.44
214
102
316
41 (18.1)
11 (10.1)
52
185 (81.9)
98 (89.9)
283
0.04
226
109
335
71 (68.9)
41 (66.1)
112
0.22
103
62
165
25 (21.7)
7 (11.1)
32
90 (78.3)
56 (88.9)
146
0.06
115
63
178
334
Figures are numbers (%) unless otherwise specified.
Table 3. Associations between MMSE sentence characteristics and diagnosis of MCI, dementia and depression
Cognitive diagnosis
dementia
(n = 142)
Number of words
Mean 8 SD
3.7481.22
Range
0–20
Patients, n
142
Depression
MCI
(n = 84)
normal
(n = 118)
total
p value
yes
(n = 128)
no
(n = 216)
total
p value
3.8281.14
0–20
84
4.1881.41
0–17
118
3.9181.23
0–20
344
0.02
3.8381.19
2–9
128
3.9681.33
1–10
216
3.9181.23
1–10
344
<0.36
Emotional polarity of sentence
Negative
12 (9.5)
Positive
28 (22.2)
Neutral
86 (68.3)
Patients, n
126
9 (11.3)
21 (26.3)
50 (62.5)
80
11 (9.4)
27 (23.1)
79 (67.5)
117
32 (9.9)
76 (23.5)
215 (66.6)
323
0.94
21 (17.5)
24 (20.0)
75 (62.5)
101
11 (5.4)
52 (25.6)
140 (69.0)
203
32 (9.9)
76 (23.5)
215 (66.6)
323
<0.001
Concerns about health
Yes
25 (17.6)
No
117 (82.4)
Patients, n
142
12 (14.3)
72 (85.7)
84
16 (13.6)
102 (86.4)
118
53 (15.4)
291 (84.6)
344
0.63
30 (23.4)
98 (76.6)
128
23 (10.6)
193 (89.4)
216
53 (15.4)
291(84.6)
344
<0.001
Figures are numbers (%) unless otherwise specified.
no significant difference in age between cognitively impaired patients and those without impairment. No correlation was found between GDS-15 scores and age, nor
was age correlated with the diagnosis of depression.
No statistically significant correlations were found between education on the one hand, and MMSE, GDS-15
128
Dement Geriatr Cogn Disord 2012;33:125–131
scores and cognitive or affective diagnoses on the other.
Although there was no association between the gender of
patients and GDS-15, more women were diagnosed as depressed than men [98 women (43.4%) vs. 30 men (27.5%),
p = 0.03].
Press /Velikiy /Berzak /Tandater /Peleg /
Freud /Punchik /Dwolatzky
Table 4. Impact of age, gender and education on the cognitive and affective tests
MMSE
Age
Pearson’s correlation
Mean 8 SD
Range
Patients
p value
Dementia
MCI
Normal
79.285.1
67–92
139
0.12
77.385.2
65–87
84
0.0
77.685.6
67–92
111
76
0.95
10.983.8
0–20
84
0.33
10.484.9
0–20
52
11.683.8
0–17
42
–0.233
334
0.000
Education
Mean 8 SD
Range
Patients
p value
GDS-15
Depression Normal
78.185.2
69–88
128
0.92
78.285.5
65–92
206
10.984.4
0–20
93
0.95
11.083.9
0–17
85
≤12 years
Mean 8 SD
Range
Patients
23.284.6
8–30
115
10.483.9
1–15
26
≥13 years
Mean 8 SD
Range
Patients
p value
24.685.4
8–30
63
0.08
9.183.8
1–15
8
0.42
24.384.7
8–30
109
9.083.5
3–14
20
30 (27.5)
79 (72.5)
10.083.8
1–15
56
0.32
98 (43.4)
0.03
128 (56.6)
Gender
Male
Mean 8 SD
Range
Patients, n (%)
Female
Mean 8 SD
Range
Patients, n (%)
p value
23.884.7
8–30
226
0.36
37 (34.0)
102 (45.2)
0.14
Discussion
In this retrospective study we demonstrated a clear relationship between the characteristics of the sentence
written as part of the MMSE test and the cognitive and
affective features of older patients evaluated by the CGAU.
The characteristics of the patients seen at the CGAU were
indicated by low functional performance, high comorbidity indexes, and a high prevalence of cognitive impairment and depression (table 1).
Apart from a gender predisposition, with more women expressing concern about their health in the MMSE
sentence than men, no other associations were found between the characteristics of the MMSE sentence and age,
gender or education. The greater degree of health concerns expressed by the women may reflect the fact that
more women were diagnosed as being depressed.
Sentence Writing Component of the
MMSE
32 (29.4)
52 (23.0)
40 (36.7)
72 (31.9)
The finding that age does not affect the sentences is
not consistent with that of a previous study [27], which
found that with increasing age individuals use more positive and fewer negative words, use fewer self-references,
use more future-tense and fewer past-tense verbs, and
demonstrate a general pattern of increasing cognitive
complexity. The lack of correlation with age in our study
may be explained at least partially by the fact that our
study population had a relatively high degree of cognitive
and affective impairments.
An important finding of our study is that there was no
association between the number of words in the MMSE
sentence and the overall MMSE score. This result is similar to that reported by Shenkin et al. [28] but is in contrast with the finding of McCarthy et al. [16]. We found a
significant association between the number of words per
sentence and the cognitive diagnosis. The shortest senDement Geriatr Cogn Disord 2012;33:125–131
129
tences were written by patients with dementia, those with
MCI wrote slightly longer sentences, and the longest sentences were written by patients without cognitive impairment. This result was expected and coincides with that of
previous studies, confirming that the ability to write a
sentence is adversely affected by cognitive impairment [3,
6, 27]. A previous study found a correlation between the
degree of cognitive impairment and a decline in the ability for sentence writing: while 85% of nondemented elderly wrote a correct spontaneous sentence, only 67% of
those with mild dementia, 41% of those with moderate
dementia and none with severe dementia were able to
write such a sentence [29].
In comparing the length of the sentence with a diagnosis of depression, we found that although patients with depression wrote shorter sentences than those without depression, this association was not statistically significant.
The relationship between depression and cognitive impairment has been observed in some [30–33] although not
all studies [34, 35]. The fact that in this study no association
was found between the length of the sentence and a diagnosis of depression may indicate that the length of the sentence itself does not reflect the affective state of patients
with cognitive impairment. Our findings are similar to
those of Shenkin et al. [28] who also failed to find an association between the number of words in the MMSE sentence and depressive symptoms. It is of interest that in our
study patients with higher GDS-15 scores wrote shorter
sentences. It is possible that the GDS-15 is quite sensitive
to cognitive changes. This can be explained by the fact that
three questions included in the GDS-15 may partially reflect cognitive function (‘Have you dropped many of your
activities and interests?’, ‘Do you prefer to stay at home,
rather than going out and doing new things?’, ‘Do you feel
you have more problems with memory than most?’).
Another important finding of our study is that the
negative emotional polarity of the sentence correlated
with a diagnosis of depression and with GDS-15 scores.
The hazard ratio for depression among patients with negative emotional polarity of sentences compared with patients with positive or neutral polarity was 3.70 (CI =
1.72–7.99, p = 0.001). No correlation was found between
the emotional polarity of the MMSE sentence and cognitive diagnosis or overall MMSE scores. These findings
contradict the results of previous studies. According to
the study by McCarthy et al. [16] the polarity of the sentence was inversely related to the MMSE score, while
Rösler et al. [17] found that ‘sentences with inadequate
emotional content seem to indicate a dementing illness’.
On the other hand, as in our study, Shenkin et al. [28]
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Dement Geriatr Cogn Disord 2012;33:125–131
found no association between the polarity of the sentence
and MMSE scores. Since in all these studies [16, 17, 28]
the affective status of patients was not determined, it is
difficult to compare our results with these authors. It
seems reasonable to assume that those patients attending
the geriatric day hospital in the study by McCarthy et al.
[16] or the demented patients of a geriatric clinic in the
sample of Rösler et al. [17] were more depressed than the
community-dwelling individuals without dementia in
the study by Shenkin et al. [28].
Finally, like emotional polarity, the expression of concerns about health in the MMSE sentence was associated
with a diagnosis of depression but not with cognitive impairment. The hazard ratio for depression among patients expressing health concerns was 2.57 (CI = 1.42–
4.66, p = 0.001). To the best of our knowledge, this is the
first time that this characteristic of the MMSE sentence
has been investigated.
Our study has several strengths. As far as we have been
able to ascertain, this is the first study comparing the characteristics of the MMSE sentence not only with cognitive
aspects but also with the affective status of the elderly. In
addition, our evaluation involved other languages, namely
Hebrew and Russian. Finally, health concerns expressed by
the subjects in the MMSE sentence were found to be influenced by their cognitive and affective status.
On the other hand our study has obvious limitations.
Being a retrospective data analysis, possible confounders
may have been missed including cognitive and affective
diagnoses. There were also missing data, especially for
education and GDS score. Also, the population was not
culturally homogeneous. In addition, we did not evaluate
some characteristics of the MMSE sentences that were
reported by previous studies [16, 17, 28], namely legibility
of writing, letter case, use of first person, and wishes.
In conclusion, the results of our study suggest that the
MMSE sentence provides important relevant information when assessing older people. Short sentences may
indicate cognitive impairment, whereas negative emotional polarity or concerns about health expressed in the
sentence may allude to the presence of an affective disorder. Since the MMSE is widely used as a screening instrument for cognitive impairment in primary practice, more
focused attention on the content of the MMSE sentence
may help to identify patients at increased risk not only for
cognitive impairment but also for depression.
Disclosure Statement
None.
Press /Velikiy /Berzak /Tandater /Peleg /
Freud /Punchik /Dwolatzky
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