Confusion: AMTS and MMSE (Mini Mental State Exam)
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AMTS – Abbreviated Mental Test Score

AMTS is a (very) quick way to assess confusion. It is used as a quick screening tool, usually on the hospital ward. Patient is scored out of ten, with (variations of) the following questions:
  1. How old are you?
  2. What time is it? (to the nearest hour)
  3. What Year is it?
  4. Where are we?
  5. I want you to remember this address: 42 West Register Street. Ask to recall later on in test.
  6. Do you know who I am? Do you know who that is [point to nurse / family member]?
  7. Do you know who the Prime Minister / President is?
  8. What is your date of birth?
  9. Can you tell me when the second world war ended / the first moon landing was / other memorable date
  10. Can you count down from 20 to 1?
Each question is worth 1 point. A score of <6 is significant for dementia or delirium.

MMSE – Mini-Mental State Examination

Despite its name, this test is not in any way related to the Mental State Examination of psychiatry. It often comes up in OSCE’s, so it’s worthwhile taking time to familiarise yourself with the test.
The test is marked out of 30. It is used to assess cognitive impairment – most commonly as a screening tool for dementia, especially Alzheimer’s. It can also be used to asses a patient’s progress through a phase of cognitive impairment, for example to assess the progression of Alzheimer’s disease. A typical patient, without treatment, will have a declining score of about 3-4 points / year.
An example OSCE station might be “This 45 year old woman is worried about dementia. She thinks she is sometimes forgetful, and her mother has just been diagnosed with Alzheimer’s disease. Please asses her cognitive abilities”

The Test

Questions are divided into sections:
  • Orientation to time
  • Orientation to Place
  • Registration
  • Attention and Calculation
  • Recall
  • Language
  • Repetition
  • Following complex commands

Score

  • ≥25 – Normal
  • 21 – 24 – mild impairment
  • 10 – 20 – moderate impairment
  • <10 – severe impairment
Moderate to severe scores correlate closely to the level of dementia.

Note that cultural and educational factors can contribute to a low score in some instances. Also be wary in patients with physical problems that limit their ability to understand or carry out tasks (e.g. deafness)

The MMSE is copyrighted, and thus unfortunately, we are not able to provide it for you here. This has been a contentious issue, as the test was widely used freely for many years before the copyright holder began to exert their rights and charge for the test’s use. Thus the test became wdiespread as a free test, but now service providers must pay around £0.80 for each and every use. It is likely that a free alternative to the test will be developed in the coming years. You can read more about this in the BMJ.

References

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

This Post Has 2 Comments

  1. Mohammed Zaid

    Thank you for amazing clarification, but I have a question here, when we should use the AMTS and MMSE ? As far as I know if the AMTS <7 we should assess the patient with MMSE other than this no need for use MMSE am I right?

  2. Dr Tom Leach

    Hi Mohammed. You are right to think that the AMTS can be used as a screening test to decide if the full MMSE is required. This might be typically be performed by a GP, or a ward doctor on a patient in whom there is a suspicion of dementia. AMTS is also sometimes used in the acute clinical setting (e.g. in the emergency department) when assessing for delirium.

    However, a normal AMTS doesn’t necessarily rule out the need to perform a full MMSE – especially if there is a strong clinical suspicion of dementia. Like almost everything in medicine, there is rarely a 100% “never” rule.

    There are also alternative tests to the MMSE. In my clinical practice I tend to use the MOCA. MOCA is a better tool for picking up mild dementia, but may be too too hard for many patients with moderate / severe dementia. It is slightly more ‘interesting’ test to perform as a doctor.
    It also gives a score on a 30-point scale, like MMSE. However, MMSE and MOCA scores are not interchangeable. However you can use either test consistently to track progress over time.

    Neither test is designed to differentiate between the cause of a cognitive impairment.

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