The subscore therefore ranged from −5 to +10. In a series of patients with pathologically confirmed AD (n = 27) or DLB (n = 17), a subscore of <5 was associated with the diagnosis of DLB with high sensitivity (0.82) and specificity (0.81) in patients with an MMSE ≥13/30 [110]. A subsequent study of selected patients with diagnoses of probable AD and probable DLB also found that this MMSE subscore was helpful in discriminating the two conditions [114].
Encouraging as these results were, they came from proof-of-concept studies which do not necessarily reflect clinical practice since they involve pre-selection of groups according to established patient diagnosis. An attempt to evaluate the diagnostic utility of the Ala score in a pragmatic study, involving a prospective cohort of unselected consecutive patients (n = 271) seen in a cognitive clinic, found very few patients with a clinical diagnosis of DLB and so no meaningful statement could be made as to the sensitivity of the Ala subscore, but the specificity (0.51) did not encourage the view that prospective use of this subscore would be useful for clinical diagnosis of DLB [115, 116]. A modified Ala subscore derived from the Addenbrooke’s Cognitive Examination has also been examined (see Chap. 6, at 6.5.6).
Palmqvist et al. [117] reported that if the patient MMSE orientation score multiplied by 3 (i.e. maximum 30) was greater than or equal to the total MMSE score, then DLB was more likely than AD, likewise if there was impaired clock drawing or non 3D cube copying. This study involved matched groups of DLB and AD patients, and the outcomes have yet to be tested in prospective patient groups unselected by diagnosis.
4.4 Conclusion
The MMSE variants described in this chapter have not been as widely adopted as the original MMSE, with the possible exception of the 3MS. A number of reasons may account for this, including unfamiliarity with these variants amongst clinicians and possibly their lack of clinical utility. It is fair to say that many of the described variants have not been subjected to the extensive investigation which the original MMSE has attracted. Likewise, MMSE subscores have found only limited application.
Shortened versions of the MMSE with good test metrics may be particularly attractive as cognitive screening instruments because of their brevity and ease of applicability, not only in clinic-based situations but also possibly at a population level. Likewise, telephone versions might facilitate more widespread population screening. However, other short performance-based cognitive screening instruments are available (see for example Chaps. 6 [M-ACE], 8, 10, 11, and 12), providing serious competition for the MMSE and its variants, whose dominant position may be further undermined by the impact of the enforcement of copyright restrictions on MMSE use [13–18].
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