Mini-mental

Mini-mental
statusstatus
examination
examination
mapping
mapping
to theto
corresponding
the corresponding
brain areas
brain areas
in dementia
in dementia
| ATI,| June
ATI, 2012
June 2012

Peer-reviewed & Open access journal

www.academicpublishingplatforms.com

ATI - Applied Technologies & Innovations

Volume 7 | Issue 2 | June 2012 |pp.55-58

Mini-mental status examination mapping to the

corresponding brain areas in dementia
Nina Khachiyants
Diplomate of the ABPN, Assistant Professor, Edward Via College
of Osteopathic Medicine, Virginia, USA
email: khachiyants@hotmail.com

The Mini-Mental Status Examination (MMSE) is a brief screening instrument frequently used
to evaluate and monitor patients with different types of dementia. Each cognitive domain
evaluated with MMSE has corresponding brain areas that responsible for that function. The
purpose of this study was to attempt better understanding of relations between cognitive
function and brain regions responsible for that particular function. Literature review related to
correspondence of different cognitive domains assessed with MMSE to related brain areas in
dementia has been done using Pub Med and other sources, and was reflected in the table. It
may be useful for both clinical and educational purposes, especially when clinical evidence of
specific cognitive deficit may be correlated with topical anatomical of functional changes
evidenced on imaging studies.
Keywords: Mini-Mental Status Examination, dementia, brain areas

Introduction

The Mini-Mental Status Examination (MMSE) is a brief cognitive screening

instrument frequently used to evaluate and monitor patients with Alzheimers
disease and other cognitive impairment. It was introduced in 1975 by Folstein, is
consisting of eleven questions and evaluates six areas of cognitive function:
orientation, attention, immediate recall, short-term recall, language, and the ability
to follow simple verbal and written commands (Folstein et al., 1975). This test was
designed as a standardized instrument and provides a total score allowing the
examiner to place the patient on a scale of cognitive function. Each cognitive
function evaluated with MMSE has related brain structures that responsible for
that function. Although MMSE is not diagnostic but screening instrument, it may
be helpful for medical students, residents, and clinicians to have an overall better
comprehension of what particular brain area has been tested while specific
cognitive task is administered by MMSE. Basic correspondence of specific
cognitive abilities which are commonly evaluated by Clock Drawing Test (CDT),
Verbal Fluency Test, Trial A and B Tests, and Right-Left Orientation Test to
specific brain structures also was researched in this study.
The purpose of this study was to attempt mapping of the specific cognitive
domains evaluated with MMSE and other selected cognitive tests to corresponding
brain areas in order to have better understanding of relations between cognitive
function and brain regions responsible for that particular function.
This mapping may be useful for both clinical and educational purposes, especially
when clinical evidence of specific cognitive deficit may be correlated with topical

2012 Prague Development Center

- 5555

- 5555
2012 Prague Development
Center
-

Applied Innovations and Technologies

Kye Kim
Director of Academic Affairs and Geriatric Psychiatry Fellowship Program
Virginia Tech-Carilion School of Medicine, Virginia, USA

Mini-mental
Mini-mental
statusstatus
examination
examination
mapping
mapping
to theto
corresponding
the corresponding
brain areas
brain areas
in dementia
in dementia
| ATI,| June
ATI, 2012
June 2012

anatomical of functional changes evidenced on imaging studies. The literature on

this
particular
topic
is
sparse.

2012 Prague Development Center

- 5656

- 5656
2012 Prague Development
Center
-

Mini-mental
Mini-mental
statusstatus
examination
examination
mapping
mapping
to theto
corresponding
the corresponding
brain areas
brain areas
in dementia
in dementia
| ATI,| June
ATI, 2012
June 2012

TABLE 1. CORRESPONDENCE OF COGNITIVE FUNCTIONS

EVALUATED BY MMSE TO SPECIFIC BRAIN AREAS
TEST / FUNCTION (EVALUATED BY
MMSE)
Orientation to time

CORRESPONDING
BRAIN AREA
Temporal, frontal

Orientation to place

Temporal, frontal

Orientation to person

SELF: medial prefrontal and posterior

cingulate cortex
OTHERS: prosopagnosia: Fusiform gyrus
(occipitotemporal gyrus) in temporal lobe
Wernicke, Broca, Arcuate fasciculus

Immediate recall (sec)

impairment
Delayed recall (2-3 min)
impairment
Spelling
Attention
Calculation

Perseveration, inability to
shift attention/tasks
Naming
Repetition

Language

3-step command
Reading and comprehension

Writing
Copy design (asymmetry, distortion, loss of
gestalt)
Abstract
thinking

Proverb interpretation
Similarities
Conceptualization

Trail making test A

DEMENTIA
DIFFERENTIAL
Impaired relatively late in the course of
dementia
Impaired relatively late in the course of
dementia
Impaired very late in the course of
dementia
FTD>AD

Hippocampus, medial temporal lobe (high

density of NFT and NP) which
disconnects hippocampus from cortex
Prefrontal;
Frontal dorsolateral
Inferior parietal
Cingulate gyrus
Prefrontal;
Frontal dorsolateral
Left parietal
Cingulate gyrus
Frontal lobe

AD>FTD
AD-rapid rate of forgetting for 10 min.

Left temporal; parietal

Wernicke, Broca,
Fasciculus arcuatus
Temporal; Frontal; Premotor
Left parietal
Temporal
Left parietal
Right parietal (construct, gestalt)
Basal ganglia with projections to
prefrontal cortex
Frontal, prefrontal

VASC>AD>FTD
VASC>AD>FTD

Right-sided lesions
Frontal; Parietal
Left-sided lesions Frontal; Parietal
Frontal, prefrontal
Left parietal
Temporal lobe
Frontal lobe

AD>FTD

AD>FTD>VASC

FTD>AD

Variable
Variable
Variable
DLB=DPD>VASC>AD>FTD
VASC: Visuospatial impairment > then
delayed recall (2-3 min)
FTD>AD

FTD>AD

Trail making test B

FTD>AD
Verbal fluency
FTD>AD
Right-left orientation
VASC >AD
Clock
Comprehension
AD>Vascular
drawing test
Planning, sequencing,
organizing
Constructional ability, gestalt,
Right (non-dominant) parietal
spatial relationships, attention
to the left side
Praxis: ability to execute
Left (dominant) parietal lobe
learned functions, writing
Visual processing
Occipital lobe
Note: Table abbreviations: AD - Dementia of Alzheimers type; FTD - Frontal-Temporal Dementia; VASC - Vascular Dementia; DLB Lowy-Body Dementia; DPD - Parkinsons Disease related Dementia. Sign > means more impaired

2012 Prague Development Center

- 5757

- 5757
2012 Prague Development
Center
-

Mini-mental
Mini-mental
statusstatus
examination
examination
mapping
mapping
to theto
corresponding
the corresponding
brain areas
brain areas
in dementia
in dementia
| ATI,| June
ATI, 2012
June 2012

Materials and Methods

Extensive literature review related to correspondence of various cognitive domains

assessed with MMSE to related brain structures in dementia has been done using
Pub Med and other sources.
Results

Correspondence of cognitive functions evaluated by MMSE to specific brain areas

was reflected in Table 1. This table was designed for educational purposes only
and was compiled from information taken from different sources (Sadavoy, Jarvik,
Grossberg, and Meyers, 2005; Snyder, Nussbaum, and Robins, 2005; Feinberg and
Farah, 2003; Heilman, 2002).

It is hypothesized that MMSE as a universal cognitive measure is thought to reflect

the integrity of widely distributed network of cognitive domains situated in both
hemispheres with left sided predominance (Sadavoy et al., 2005)
Using innovative 3D mapping techniques Apostolova et al. (2006) were able to
demonstrate that cortical atrophy was linked with MMSE decline (Apostolova et
al., 2006). They found a strong linkage between MMSE score and gray matter
involvement in the mesial temporal, orbitofrontal, medial and lateral parietal, left
more than right lateral temporal and middle frontal, and left inferior parietal
cortical regions. It was also reported in this study that the hippocampus, which
known as one of the first regions to be affected in Alzheimers disease, also show
similar strong correlation with MMSE (r=0.47) as it was found for the correlation
between regions of gray matter atrophy and MMSE score decline(Apostolova et
al., 2006). Findings of above study were consistent with another two AD PET
studies (Kawano et al., 2001; Ushijima et al., 2002) which reported correlations
with frontal, temporal, and parietal metabolism, and one AD SPECT study (Lampl
et al., 2003) which demonstrated an association between MMSE and left temporal
perfusion. By investigating brain glucose metabolism and MMSE in patients with
mild cognitive impairment, Cao et al. (2003) reported that in a cohort of MCI and
normal elderly total MMSE score correlated with PET hypometabolism in bilateral
inferior frontal, medial and inferior temporal, anterior cingulate, as well as left
superior temporal, precentral, parietal, and insular regions (Cao et al., 2003).
Frisoni et al. by using voxel-based morphometry in patients with AD, found
correlations between total MMSE score and gray matter atrophy in temporal,
bilateral posterior cingulate/precuneus, and right superior parietal regions,
somewhat more prominent in right hemisphere than in left one (Frisoni et al.,
2002). Jullian Frediani (2010) found that MMSE is the overall best measure of
brain changes correlated with varying levels of dementia. The local and regional
patterns of brain changes were corresponding differently to different cognitive
scores.
Conclusion

2012 Prague Development Center

- 5858

- 5858
2012 Prague Development
Center
-

Applied Innovations and Technologies

Discussion

Mini-mental
Mini-mental
statusstatus
examination
examination
mapping
mapping
to theto
corresponding
the corresponding
brain areas
brain areas
in dementia
in dementia
| ATI,| June
ATI, 2012
June 2012

MMSE is a brief tool which allows clinicians to screen and monitor progression of
cognitive decline in patients with different types of dementia. Basic understanding
of correspondence between particular cognitive functions evaluated by MMSE to

2012 Prague Development Center

- 5959

- 5959
2012 Prague Development
Center
-

Mini-mental
Mini-mental
statusstatus
examination
examination
mapping
mapping
to theto
corresponding
the corresponding
brain areas
brain areas
in dementia
in dementia
| ATI,| June
ATI, 2012
June 2012

specific brain areas may be useful for both educational and clinical purposes,
specifically, when clinical evidence of particular cognitive impairmant may be
correlated with topical anatomical of functional changes evidenced on clinical
examination and imaging studies.
References

Apostolova, L., Lu, P., Rogers, S., Dutton, R., Hayashi, K., Toga, A., Cummings, J., Thompson, P.,
2006. 3D mapping of mini-mental state examination performance in clinical and preclinical
Alzheimer disease, Alzheimer Dis. Assoc. Disord., Vol.20(4), pp.224-31
Cao, Q., Jiang, K., Zhang, M. et al., 2003. Brain glucose metabolism and neuropsychological test
in patients with mild cognitive impairment, Chin Med J (England), Vol.116, pp.1235-238
Feinberg, T., Farah, M., 2003. Behavioral neurology and neuropsychology, New York: McGrawHill 1st Ed, 1997; 2nd Ed, 2003
Frisoni, G., Testa, C., Zorzan, A. et al., 2002. Detection of grey matter loss in mild Alzheimers
disease with voxel based morphometry, J Neurol Neurosurg Psychiatrym, Vol.73, pp.657-64
Frediani, J., 2010. Correlation of brain change and cognitive decline in the elderly, The UC Davis
Undegraduate Research Journal, Vol.13, p.4 http://undergraduateresearch.ucdavis.edu/
explorations/2010/docs/Frediani.pdf , Retrieved in June 23, 2012
Folstein, M., Folstein, S., McHugh, P., 1975. Mini-mental state: A practical method for grading the
cognitive state of patients for the clinician, J Psychiatr Res., Vol.12, pp.189-98
Heilman, K., 2002. Matter of mind: A neurologists view of brain behavior relationships, New
York: Oxford University Press
Kawano, M., Ichimiya, A., Ogomori, K. et al., 2001. Relationship between both IQ and MiniMental State Examination and the regional cerebral glucose metabolism in clinically diagnosed
Alzheimers disease: A PET study, Dement. Geriatr Cogn Disord., Vol.12(2), pp.171-76
Lampl, Y., Sadeh, M., Laker, O. et al., 2003. Correlation of neuropsychological evaluation and
SPECT imaging in patients with Alzheimers disease, Int J Geriartr Psychiatry, Vol.18, pp.28891
Sadavoy, J., Jarvik, L., Grossberg, G., Meyers, B., 2005. Comprehensive Textbook of Geriatric
Psychiatry, Third Edition, New York, W.W. Norton & Co.
Snyder, P., Nussbaum, P., Robins, D., 2005. Clinical neuropsychology: A Pocket handbook for
assessment, Second Edition, Washington, APA
Ushijima, Y., Okuyama, C., Mori, S. et al., 2002. Relationship between cognitive function and
regional cerebral blood flow in Alzheimers disease, Nucl Med Commun., Vol.23, pp.779-84

2012 Prague Development Center

- 6060

- 6060
2012 Prague Development
Center
-