Free alternatives comparable to Mini-Mental State Examination

1. In this systematic review and meta-analysis, out of 10 alternative screening tests, the best freely available alternatives to the Mini-Mental State Examination in screening for dementia were the Mini-Cog and Addenbrooke’s Cognitive Examination (ACE-R) tests.

2. Moreover, it was found that the best freely available alternative to the Mini-Mental State Examination in screening for mild cognitive impairment (MCI) was the Montreal Cognitive Assessment (MOCA).

Evidence Rating Level: 1 (Excellent)

Study Rundown: Dementia and cognitive impairment, while prevalent, are under-recognized in clinical practice. Complications of dementia can be better recognized in patients who are diagnosed early. Screening tools provide quick and useful means to assess mental status in patients both in office and in a hospital setting. One of the most commonly recognized screening tools for dementia is the Mini-Mental State Examination (MMSE), a proprietary screening test whose intellectual property rights are owned by Psychological Assessment Resources. Although it is the most commonly used tool, its proprietary nature limits its accessibility. This study sought to assess whether other dementia screening tests in the public domain may be viable alternatives.

This systematic review and meta-analysis found that 10 alternative tests performed similarly well in detection of dementia compared to the MMSE. In particular, the Mini-Cog test and Addenbrooke’s Cognitive Examination–Revised (ACE-R) had the best diagnostic performances in detection of dementia. The MOCA was found to be comparable to the MMSE in detection of mild cognitive impairment. Limitations of this study include that it did not allow for directly comparing the performance of various screening tests in the same populations. Moreover, articles included were limited to cross-sectional studies in English.

Click to read the study in JAMA Internal Medicine

Relevant Reading: The Mini-Mental State Examination: A Comprehensive Review

In-Depth [systematic review and meta-analysis]: A list of alternative dementia screening tests was identified per previous work. Literature searches for these tests were performed in MEDLINE, EMBASE, and PsychINFO databases, and Google Scholar. Articles were limited to peer-reviewed cross-sectional studies in English. Screening tests were classified by administration time (<5 minutes, <10 minutes, <20 minutes). 26,165 abstracts were identified, and ultimately 149 studies published from 1989 to 2014 were included. 11 screening tests were examined, including the MMSE, Abbreviated Mental Test, Sunderland’s Clock Drawing test, Shulman’s Clock Drawing Test, GPCOG, IQCODE (both long and short forms), Mini-Cog, ACE-R, Memory Impairment Screen, Montreal Cognitive Assessment, modified MMSE, and verbal fluency tests.

Most tests had comparable performance to the MMSE. The Mini-Cog test and the ACE-R were the best alternatives to the MMSE. For the Mini-Cog test, the pooled sensitivity for all studies was 0.91 (95% CI, 0.80-0.96), and the pooled specificity was 0.86 (95% CI, 0.74-0.93). For the ACE-R test, the pooled sensitivity was 0.92 (95% CI, 0.90-0.94) and the pooled specificity was 0.89 (95% CI, 0.84-0.93). The Montreal Cognitive Assessment had comparable performance to the MMSE on detection of mild cognitive impairment with sensitivity and specificity of 0.89 and 0.75, respectively.

Image: PD

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