Attention testing in the Mini Mental State Examination (MMSE)

Attention Testing in Mental State Examination

World Reversal Score

Serial 7's Score

Enter patient response to WORLD reversal

Patient Score

Indicate start number:80, 90 or 100
First subtraction
Second subtraction
Third subtraction
Fourth subtraction
Fifth subtraction

Score

How to use scoring aid
Enter the letter or letters the patient provides to the request of spelling WORLD backwards (maximum of five letters).
Ignore letters other than W, O, R, L or D. (for example, if the patient states DRLWE, enter DRLW.)
Do not insert any spaces or punctuation between the letters.
Click on "Click to obtain score."

How to use scoring aid
The patient is requested to subtract 7 from 100, and to keep subtracting 7 from the result. Patients seem less bothered by the question when it is posed as spending money: “Spend seven dollars from a hundred dollars, and keep spending seven dollars from the remainder.” Stop the patient after five subtractions.
Each result, to a maximum of 5 responses, is scored independently for accuracy.
Enter each result in the appropriate box, and then click on "Click to obtain score."
The initial number could be 100 or another digit, like 90 or 80, to avoid training errors by the patient. The scoring tool accommodates all three start numbers (100, 90 or 80).

GOALS OF THIS WEBSITE:

    1. The website promotes the correct scoring of incorrect WORLD reversal responses during cognitive testing and recommends a simpler scoring technique.
    2. The website provides an opportunity to train oneself on the scoring technique for incorrect WORLD reversal responses with a computerised tool.
    3. The website provides an opportunity to review scoring of incorrect five letter WOR(L)D reversal responses in other languages.
    4. The website provides an opportunity to review scoring of incorrect five digit number reversal responses.
    5. The website provides a tool to promote the training of, and to review the scores of, serial seven subtractions with 3 start numbers (100, 90, 80).
    6. The website encourages the consistent and proper use of attention tests in the longitudinal assessment of cognition.

WORLD reversal scoring technique:

A simple method to score WORLD reversal is described. It is easy to operationalise and simple to use at the bedside.

D L R O W

1 2 3 4 5

Beneath the correct reversed response of DLROW, write the numbers 12345. The numbers below represent the respective letters above. The score for the WORLD reversal response is equivalent to the number of digits within the patient’s response that has the most ascending digits (while not focusing on the exact order of the digits).

WORLD REVERSAL RESPONSE	NUMERIC SUBSTITUTION	ASCENDING NUMBER SET(S) WITH THE MOST DIGITS	NUMBER OF DIGITS IN ASCENDING NUMBER SET = SCORE
DLROW	12345	12345	5
DOW	145	145	3
DLOW	1245	1245	4
DWOLR	15423	123	3
ROLWR	34253	345	3
L	2	2	1
OLD	421	4 or 2 or 1	1
LDROW	21345	1345; 2345	4
DLVOR	1243	124; 123	3
LDOR	2143	13; 14; 23; 24	2
DRROW	13345	1345	4
DRROLD	133421	34 (score last 5 letters)	2

NOTES:

1. Note in column three, the numbers always ascend, or there is a single digit.

2. When numbers are repeated (see example DRROW), the repeated number is counted only once.

3. When reviewing the patient response, no number is allocated to any letter other than to letters of W-O-R-L-D (see example DLVOR above).

4. When six or more letter responses are provided, score only the last five letters (see example DRROLD)

NB: The score obtained with this method is the same as that of the SMMSE method.

WOR(L)D reversal scores in other languages

This scoring technique described for WORLD reversal can also be used for reversal of five letter words reversed in other languages. For example, an Italian speaking patient who could spell CARNE correctly was asked to spell CARNE backwards (ENRAC = 12345), and replied EARN. This would correspond to numbers 1432 which would provide a score of 2. (This is similar to scoring LDOR above.)

The website could also be used to check WOR(L)D reversal scores in other languages by appropriate substitution of the letters to the equivalent letter position for WORLD. For example, the EARN response (Italian) mentioned above would translate to DORL in English. Enter DORL into computerised scoring above yields a score of 2.

English	WORLD	D	L	R	O	W
French	MONDE	E	D	N	O	M
Italian	CARNE	E	N	R	A	C
Polish	SWIAT	T	A	I	W	S
German	RADIO	O	I	D	A	R
German	PREIS	S	I	E	R	P
Spanish / Portugese	MUNDO	O	D	N	U	M
Assigned Number		1	2	3	4	5

Five digit number reversal scoring

Sometimes, the reversal of a five digit number is tested rather than the reversal of a five letter word or serial seven subtractions. (In some languages it is not possible to reverse a five letter world.) Each digit is a choice of one of ten numbers (zero to nine) with none repeated. The scoring principle is the same as for letter reversal scoring where the correct reversed number corresponds to 1-2-3-4-5.

For example, reverse number 4-2-7-3-1.

The correct number reversal is 1-3-7-2-4. The correct reversal 1-3-7-2-4 will correspond to numbers 1-2-3-4-5 respectively.

1 3 7 2 4

1 2 3 4 5

Thereafter, digit reversal responses are scored similar to WORLD reversal scoring.

IN CONCLUSION:

There are two principles when scoring WOR(L)D or number reversal:

1. replace the reversed WORLD (or other word or digit) response with digits 1-2-3-4-5 as follows:

D L R O W

1 2 3 4 5

2. The score for the WORLD reversal response is equivalent to the number of digits within the patient’s response that has the most ascending digits (while not focusing on the exact order of the digits).

Once one is adept at scoring attention tests, it is unlikely that one would resort to computing the scores with this technique, as most skilled scorer’s will recognize the flow of the numbers or letters to provide a correct score quite quickly on viewing the patient’s reply. Nevertheless, it is always prudent to know how to check the score, either by solving it with the system described above or with the computerised scoring at this website.

OTHER ATTENTION TESTS

Scoring serial seven subtractions from 100 requires each answer to be scored on its own merit. For example, a response of 93-90-83-60-50 scores 2 out of 5 as the first and third subtractions are correct. The Serial 7's scoring tool above assists with the scoring of up to five subtractions from 100, 90 or 80. One may also use this tool to train oneself with serial seven subtractions technique.

Some patients seem to be less perplexed by this test when the question is posed as follows: “Spend seven dollars from a hundred dollars, and keep spending seven dollars from the remain.” Stop the subtractions after five responses.

Scoring days of the week backwards is similar to scoring serial seven subtractions. Patients are asked to recite the days of the week in sequential backward order. One may start at any day of the week. Five responses are scored and 1 point is given for each correct answer.

The other attention tests mentioned above are well described in the literature and may be used by the clinician.

THE LONGITUDINAL USE AND SCORING OF ATTENTION TESTS

Firstly, in patients with Alzheimer's disease, an average annual decline of MMSE score is 3.3 points per year. MMSE scores may improve 1.2 points with cholinesterase inhibitors after 12 weeks. Furthermore, a decline of three or more points on the MMSE within a six month period identifies a group of individuals with worse clinical outcomes. The attention test score contributes 17% of the MMSE and the incorrect scoring of attention tests can result in a score error of up to four points. Errors in attention test scoring are within the range of the changes described. Hence, scoring errors may imply incorrect clinical information about the patient’s progress. Whenever a MMSE score is better or worse, one should review two issues:

1. Are the two MMSE tests scoring the same items? (for example, are the attention tests administered in both tests the same?)

2. Are the components of the cognitive screen scored correctly?

Secondly, consider the following clinical scenario: An English speaking patient of French descent has a cognitive disorder and scores 5 points for WORLD reversal on a cognitive screen. Eighteen months later he is unable to spell WORLD forwards even with cuing. The clinician notes that the patient can spell the French word MONDE correctly and he scores 3 points for MONDE reversal. What score should one provide for the attention test?

It is not uncommon for clinicians to use other attention tests when there is a problem with the initial test. A score of zero points for the attention test is reasonable as he could not do WORLD reversal any longer, reflecting his cognitive decline, rather than a score of 3 points for MONDE reversal. Going forward, one should continue to score WORLD reversal for the cognitive screen and one may use MONDE reversal score as an additional attention test, but the latter is not scored as part of the cognitive screen.

Thirdly, it is important to recognise that five letter reversal scores may be different for different words in the same patient, and these scores may also be different from serial seven subtraction scores, days of the week reversal scores and five digit reversal scores. To this end, it would be helpful if the clinician would document the name and score of the attention test used when reporting the total score of the cognitive screen. For example: “The patient scored 20 out of 30 on the MMSE with a score of 3 out of 5 on WORLD reversal”. This will provide consistency in attention testing when performing cognitive tests longitudinally, especially when the original cognitive test document is not available for review.

DISCLAIMER

This work cannot be reproduced by any person or company without

the written consent of Dr Hetesh Ranchod at the email below.

Please forward any comments to Dr Hetesh Ranchod at

attentionMMSE@gmail.com

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