Is the Mini-Mental State Exam an appropriate device to determine the mental acuity of our senior citizens? It is obvious to any retired physician who has reached advanced years that a lot of the questions have little relevance. For example, the date and day of the week are immaterial and no longer noted. The season can be determined by looking out of the window; “wet” and “dry” seem pretty good answers for this part of the world. Town, province, and country will probably be answered correctly, although a Vancouver physician would be confused by the response of “White Rock” from someone like me, who lives in South Surrey (saying that you live in White Rock means that you don’t have to say you’re in Surrey).
Now I am going to give you the names of three objects that I want you to remember. Later, I will ask you to recall them: ball, bat, and pen.
Here is an imagined exchange between a doctor and patient to demonstrate the futility of this exercise.
Doctor: “Name this place.”
Patient: “Shopping centre” (suits my GP’s office very well as a descriptor).
Doctor: “Which floor of the building are you on?”
Patient: “The one my son pressed in the elevator after he drove me here.”
Doctor: “Name the Prime Minister.”
Patient: “It’s amazing how long Pierre has been in power, or did you mean Boris?”
Doctor: “What is this called?”
Patient: “That’s one of those tech devices I never learned to use and don’t know the name of. . . . Oh, you mean the pencil in your other hand.”
Doctor: “Say the words, ‘no ifs ands or buts.’”
Patient: “No ifs and sore butts.” (How many times have I heard that?)
Doctor: “Write any complete sentence on this sheet of paper.
Patient, in writing: “Any complete sentence.”
Doctor: “Read the following and do what it says.” (Instead of “close your eyes,” I once wrote, “show me your teeth,” and had a set of falsies shoved in my face.)
Doctor: “Spell the word, world.”
Patient: “That’s easy, W-H-I-R-L-E-D.”
Doctor: “Now spell it backwards.”
Patient: “U-N-W-H-I-R-L-E-D, or T-I.”
Doctor: “Copy this drawing.” (A series of overlapping pentagons.)
Patient: “I never could draw.” (Once a patient drew a beautiful depiction of a pince-nez, explaining, “That’s what it looks like to me.”)
Doctor: “Take this paper in your right hand and fold it in half with both hands, and put it in your lap. If you are unable to use your right hand because of disability, take this paper in your left hand, fold it in half with your left hand, and put it in your lap.” (Try doing that whether you’re sober, demented, or not.)
Then there are those of us who are miffed to have our cognitive abilities mooted in this way, and who decide that recalcitrance is the better response. We wilfully respond with wrong answers to all the questions, just to show who is the boss.
Now, what were those three objects that you were asked to remember?
“Well, I tell you Doc, the trouble with me is I don’t remember so good.”
QED!
—Anthony Walter, MD
Surrey (White Rock, if I recall correctly)
This posting has been peer reviewed by the BCMJ Editorial Board.