Legal advice for both the caregiver and the early-stage patient as they prepare for the future.

How useful are MMSEs and other screening tools?

How useful are MMSEs and other screening tools?


Evaluating decision-making is complicated.

Often individuals are under the impression that a “score” on a cognitive screening tool, such as a Folstein Mini Mental State Examination, is a definitive marker. Unfortunately, decision-making competency is not this black and white.

Standardized measures are important to use as they are a way to compare others who may fall below or above a “normal” range. However scores can be misleading.

Someone who scores 23/30 on a MMSE, which is below normal, may be able to make decisions for themselves because of their strong judgment, insight, critical thinking and organization skills which this test does not measure. While someone who scores 27/30 (normal range) is unable to make decisions because of poor judgement, insight and problem solving.

As a cognitive capacity evaluator I do use screening tools as part of my assessment but I cannot rely on these scores alone.

Someone who scores below normal on a Mini Mental State Examination may still have strong judgment, insight, critical thinking and organization skills.

I rely on a combination of factors which include an in-depth interview with my clients, their family, and other professionals with whom they may have contact, a review of medical records and tests, and formalized screening tools. I consider all of this information in determining whether or not someone is deemed competent to make decisions.

It is important to evaluate the following:

  1. What is the objective of the evaluation?  I must determine the situation that is in question.  In other words, someone may be competent to decide on a living environment but not competent to sign a legal document.  First I must understand what I am evaluating and conduct my interview related to that topic.
  2. Are there medical conditions which may interfere with the evaluation? Is this person on a new medication?  Suffering from an infection?  Recovering from a surgery?
  3. If the objective is related to the person’s living environment (safety) or activities of daily living, a functional evaluation and/or in-home observation is necessary;
  4. What time of day is the person at his or her best?  The interview must take place at a time when a person is at their highest level of functioning.  Additionally, multiple interviews conducted at different times of day and spread out over several weeks may be necessary.
  5. I must evaluate three things:
    • Current deficits:  How is this person presenting at the time of the interview related to memory, orientation, attention span, language, etc. – done through interview and formalized screening tool such as the MMSE;
    • General deficits: How does this person generally function per the family/professionals;
    • Content specific: How is this person understanding the objective of the interview.
  6. Determine whether this is a temporary situation such as a result of an acute trauma or illness – or if this is a permanent situation such as with a neurological disorder like Dementia.

It is only after careful consideration of all of the above that competency can be determined. If you are concerned that someone you love is suffering from cognitive deficits, use the Cognitive Worksheets available here to track the symptoms so that you can share them with a physician or other health care professionals.

Stephanie Erickson, Director of Erickson Resource Group, has over 15 years of experience as a geriatric social worker. She has worked with seniors living autonomously at home, placed in care facilities, at the hospital and living with family.


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