简易精神状态量表 注意事项

简易精神状态量表 注意事项 简易精神状态量表注意事项(the Mini-Mental State Examination,MMSE) 可以说是认知检查最常用的一个量表了，其量表很容易得到，但在使用中不同的人偏差较大 使用注意事项: MMSE使用很广泛，但使用的和不同中译文有不之处。 (1)定向力:日期和星期差一天可计正常。 (2)即刻记忆:也称最初或一级记忆，患者记忆3个性质不同的样物件。告知时需连续给出,应清晰、慢、一秒钟一个。第一次记忆的结果确定即刻记忆的分数[3分]，且为以后“回忆”检查作准备。重复学习最多6次，若仍不能记忆，则后面(4)项的回忆检查则无意义。 (3)注意和计算[5分]: 有两种方法:?要求患者从100连续减7，每错一次扣一分。或?要求患者倒背述“瑞雪兆丰年”，如倒背错为“年丰雪兆瑞”则为,分，以此类推。 (4)语言[9分]: ?命名[2分]:给患者出示表和圆珠笔，能正确命名各记一分。 ?语言复述:是检查语言复述能力，要求患者复述一中等难度的成语，如“说话不要拐弯抹角”或“好读书不求甚解”等。因为不是检查患者语言流利程度，更不是测验患者口齿灵巧和熟练性，故禁用绕口令。Folstein原文为“no, ifs ands or buts”是一句成语，其意义是“说话不要拐弯抹角”，即“说话时不要总是假若、以及或但是等虚词，而不直明瞭的说出”之意，不是绕口令。 ?三级命令:准备一张白纸，要求病人把纸用右手拿起来，把它对摺起来，然后放到地上。三个动作各得一分。 ?阅读理解:准备一白纸用粗体大字写“请闭上眼睛”，请患者先朗读一遍，然后要求患者按纸写命令去做。患者能闭上双眼给一分。 ?书写:给患者纸和笔，请患者在纸上主动随意写一个句子。检查者不能用口述句子代替患者自发书写。但可给患者一较大书写范围，以节省患者搜寻和筛选时间，如“请写一有关天气或文艺方面的句子”等。句子应有主语和谓语，必须有意义，能被人理解。文法和标点符号不强作要求。 ?临摹:要求患者临摹一重叠的两个五角形，五角形的各边长应在一英寸[2.5cm]左右。两图形必须交叉，必须有10个角,交叉后的图需成四边形。但角不锐和边不直可忽略不计。 MMSE的缺点亦不容忽视: (1)项目容易受到受试者受教育程度影响，对文化程度较高的老人有可能出现假阴性，即忽视了轻度认知损害(如Strain报道，MMSE识别轻度认知失调的敏感性仅为0.52)，而对低教育及操方言者有可能出现假阳性; (2)注意(心算)、记忆、结构模仿等项目得分并不足以反映相应的认知领域表现，不能有效地绘制个体认知廓图; (3)强调语言功能，非言语项目偏少，对右半球功能失调和额叶功能障碍不够敏感; (4)记忆检查缺乏再认项目，命名项目过于简单; (5)没有时间限制; (6)对皮质性功能紊乱比对皮质下功能紊乱更敏感; (7)不能用于痴呆的鉴别诊断，作为认知功能减退的随访工具亦不够敏感(如Clark 对82例AD患者随访4年，16%的患者MMSE得分没有显著下降)。故深入研究认知损害 往往采用多个更特异的测验工具搭配使用 再补充一点。国内不少文献在评估中风的认知障碍时使用了MMSE量表，这是明显错误的。 MMSE评估的定义、使用指南 Definition The Mini Mental State Examination (MMSE) is a simple and standardized test elaborated by Folstein in 1975 to evaluate the cognitive performance in older subjects and to eventually quantify cognitive deficits. This test is composed of 30 questions or tasks (also called items) that explore possible disorders/deficits of: Orientation in time and place Attention Memory Language: word, comprehension, reading, writing (aphasia = speech difficulties) Motor skills although motor function is intact (also called apraxia) Preliminary remarks Remark 1 This test does not include items that may detect a disturbance of executive functions: deterioration of the capacity to think in an abstracted way, to plan, to organize... Remark 2 It usually takes about 10 minutes to administer, a little more in patients with moderately severe deficits. The patient needs a pencil, three sheets of paper, a text with large characters for item 28, a drawing for item 30. When the patient has difficulty writing, questions are asked orally. If he has difficulty hearing or understanding, the examiner must repeat the questions. The system of scoring is simple since it only involves adding correct answers given to the different items. A maximal score is 30. The overall score classifies the various levels of dementia: Severe form of dementia = from 0 to 9 points Moderate form of dementia = from 10 to 19 points Mild form of dementia = from 20 to 24 points A score higher than 27 is considered as normal. A mild cognitive impairment or dementia is suspected if the score is equal or lower than 24 points. Limitations of the test This test alone is not sufficient to detect a dementia because several parameters (social and educational levels, the last professional occupation, the presence of psychological disorders and, to a lesser extent, age) can bias the results. Indeed, verbal response, reading and writing are important aspects of MMSE. It is thus difficult to interpret if the subject has poor language skills or is hearing or visually impaired. Thus, the score can be overestimated in a cognitive impaired subject with a high education and a high mental activity. On the other hand, the score can be underestimated in a poorly educated subject and/or a subject with depressive symptoms or delirium. Lastly, this test is used to evaluate the progression of the cognitive disorders and therapeutic efficacy of a drug by comparing the results over a given period. Here are 30 items that have to be performed: The examiner begins the test while saying: “I will ask you questions to evaluate the functioning of your memory. Some of them are very simple, others less so. You must answer as best you can." Test of orientation in time Examiner: "what is the complete date today?" Correct answer = 5 points. If the answer is incorrect or incomplete, the examiner asks the questions remaining unanswered, in the following order: Item 1. "What is the year?" Item 2. "What is the season?" Item 3. "What is the month?" Item 4. "What is the date?" Item 5. "What is the day of week?" Allow 10 seconds for each question and give a point for each correct answer (maximum 5 points). Test of orientation to place Examiner: "I am going to ask you some questions about the place where we are". Item 6. "Where are we? (name of the hospital, clinic...)?" Item 7. "Which country?" Item 8. "Which province (state)?" Item 9. "Which city?" Item 10. "Which floor (of the hospital, clinic...)?" Allow 10 seconds for each question and give a point for each correct answer (maximum 5 points). Test of learning Item 11 to 13. The examiner: "Repeat after me the following three words: lemon, key, balloon (or cigar, flower, door)". If the subject does not repeat all three, the examiner repeats them until the subject learns all three (he counts trials and records them). The examiner asks him to memorize them in order to repeat them later. 1 point for each word correctly said (maximum 3 points). Test of attention and calculation Items 14 to 18. The examiner: "Begin with 100 and count backwards in groups of 7. Stop after 5 subtractions". 10 seconds for each subtraction, 1 point for each correct answer (maximum: 5 points). The examiner cannot help the subject (if for example he asks how to subtract). Tasks described in the items 14 to 18 involve both calculation, working memory and attention, and these are difficult to carry out for certain individuals. If the subject cannot perform this task, the examiner asks him to spell the 'WORLD' backwards. Give 1 point for each correctly ordered letter (for example: 3 points for DLWOR; 5 points for DLROW). However, this test is not included in the final score. The aim of this test is to calm down the subject who HAS failed the test of subtraction. Test of memory (recall) Items 19 to 21. The examiner: “What were the three words you have repeated after me?” Allow 10 seconds to answer. Each correct answer = 1 point; maximum = 3 points. If one of the words is forgotten, the examiner can give a clue to the subject (for example: "a fruit" for "lemon"). Test of language Item 22. The examiner shows a pencil and asks: "What is it?" Allow 10 seconds for the answer, 1 point for a correct answer (any answer other than pencil is incorrect). Item 23. The examiner shows a watch and asks: :"What is it?" Allow 10 seconds for the answer and 1 point for a correct answer. Item 24. The examiner: "Repeat after me: No ifs, ands or buts?". The sentence must be pronounced slowly, aloud and in front of the person. If the patient says he did not hear the question, do not repeat the sentence. 1 point for a correct answer. Items 25-27. The examiner takes a paper, shows it to the subject and says: "Listen well and do what I am going to tell you: Take this paper in your right hand, fold it in half and put it on the floor". 3 points if the subject follows the 3-stage command. If the subject stops and asks what he has to do, the examiner should not repeat the instruction but says: "Do as I asked you to do". Reading comprehension Item 28. The examiner shows a paper on which it is written "close your eyes" and asks the subject to read and obey. Give 5 seconds for the answer and 1 point if the order is carried out correctly. Writing Item 29. The examiner asks the subject to write a sentence on a paper (the sentence must be complete with at least a subject and a verb; wrong spellings are not taken into account). If the sentence is incomplete, the examiner says "Is it a sentence?" and the subject has the chance to modify the sentence". Give 30 seconds for the writing of the sentence and 1 point if this one is complete. Praxis Item 30. The examiner asks the subject to copy the following design on a sheet. He gives to him a pencil with an eraser. Give one minute and 1 point if all the angles are present and if the design is cut on 2 different sides. Subject may be allowed multiple attempts.