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A cognitive bedside assessment beyond the MMSE: the Addenbrooke’s Cognitive Examination
  1. Thomas H Bak, Lecturer1,
  2. Eneida Mioshi, PhD Student2
  1. 1Human Cognitive Neuroscience, University of Edinburgh, Edinburgh, UK
  2. 2MRC Cognition & Brain Sciences Unit, Cambridge, UK
  1. Correspondence to:
 Dr T H Bak
 Human Cognitive Neuroscience, University of Edinburgh, 7 George Square, Edinburgh EH8 9JZ, UK; thomas.bak{at}

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Few clinical tests have had such a meteoric rise in popularity as the Mini-Mental State Examination (MMSE). Originally developed in the early 1970s by a group of psychiatrists with the aim of “serial testing of the cognitive mental state in patients on a neurogeriatric ward”, only a few decades later it has become the most widely used tool for cognitive assessment in a wide range of neurological diseases. As such, it was introduced to the readers of Practical Neurology by Ridha and Rossor.1 However, as the authors point out in their article, the MMSE has several serious limitations (table 1), such as its over-reliance on verbal cognitive function at the expense of non-dominant hemisphere skills and executive functions. In fact, the MMSE is based almost entirely on verbal assessment of memory and attention. It is insensitive to frontal-executive dysfunction and visuospatial deficits. The assessment of memory and language is very superficial. Moreover, it does not provide qualitative information about the patient’s cognitive profile and hence cannot be used to differentiate between different diseases.

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Table 1

Mental functions not (or not sufficiently) examined by the Mini-Mental State Examination

In some patient groups, such as Parkinson’s disease and related disorders, the MMSE as the only method of cognitive assessment might not only be inappropriate, but even misleading; a normal MMSE is likely to lead to the false assumption of preserved cognitive status while in fact the patient might have severe frontal-dysexecutive or visuospatial symptoms.

The limitations of the MMSE are hardly surprising, given the fact that it was created at a time when the routine brain imaging technique was pneumencephalography and CT had not yet entered clinical practice. It was based on a concept of dementia as a unitary syndrome of “a global deterioration of intellect”, irrespective of the underlying brain pathology. In …

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