Broader Definition of the Disease Could Help Doctors with Early Diagnosis and Intervention

In April of this year, the National Institutes of Health and the Alzheimer’s Association announced significant changes in the clinical diagnostic criteria for Alzheimer’s disease dementia. These revisions—the first in 27 years—are intended to help diagnose patients in the very early stages of the disease, allowing doctors to prescribe medication when it is most effective; that is, before a patient’s memory becomes compromised.

The new guidelines recognize two early stages of the disease: preclinical Alzheimer's, in which biochemical and physiological changes caused by the disease have begun; and mild cognitive impairment, a stage marked by memory problems severe enough to be noticed and measured, but not severe enough to compromise a person’s independence. The new guidelines also reflect the increased knowledge scientists have about Alzheimer’s, including a better understanding of the biological changes that occur and the development of new tools that allow early diagnosis.

William H. Thies, chief scientific and medical officer of the Alzheimer’s Association, explains, “If we start 10 years earlier and could push off the appearance of dementia by, say, five years … that could cut the number of demented people in the U.S. by half” (Los Angeles Times, April 25, 2011).

For more information about the updated guidelines, as well as a list of journal articles and answers to frequently asked questions for clinicians, visit the National Institute on Aging Web site at http://www.nia.nih.gov/Alzheimers/Resources/diagnosticguidelines.htm.

What made you decide initially to develop the Mini-Mental® State Examination (MMSE)?

We developed the MMSE to solve a clinical problem on a geriatric psychiatric inpatient service. The diagnoses of patients on our unit included depression, dementia, delirium, and occasional late-life schizophrenia. We needed a practical quantitative cognitive exam in order to aide clinicians in determining the severity of cognitive impairment ranging from mild to severe and to document improvement or decline.

At the time, Susan was a psychiatry resident rotating on the geriatric psychiatric unit where I (Marshal) was a junior attending. Always a perfectionist, she was not happy when I repeatedly asked for cognitive information that she had not asked about. So she asked me to write down all the items that I wanted her to include.

What made you decide to update it and create the Mini-Mental® State Examination, Second Edition™ (MMSE®-2™)?

Over the years, students and other users made many suggestions about how to improve the MMSE. There was a need to clarify the instructions so that certain tasks were administered; there was a need for phrases that were more easily translated into other languages; and users requested multiple forms in order to minimize practice effects with serial administration. In addition, we had long wanted to develop a shorter version that could be given very quickly in busy clinical settings, and also a longer version that would eliminate ceiling effects. We wanted this longer version to be more sensitive than the original MMSE to disorders of executive function and to the kinds of memory impairment found in mild cognitive impairment.

What would you like to tell people about the MMSE-2 that they may not know?

The MMSE-2 Standard Version scores are equivalent to the original MMSE scores. We took care that subjects tested during development scored the same, regardless of whether they were given the original MMSE or the MMSE-2 Standard Version. Longitudinal studies currently underway can switch to the new version without any adjustment to scores. The original, unrevised MMSE is still available if users do not want to change to the revised versions.

How do you spend your free time?

Marshal takes flute lessons and is trying to improve his photography. Susan enjoys gardening and reading spy novels, biographies, Jane Austen, and Patrick O’Brian. She has a new job at the University of Miami School of Medicine with a joint appointment in psychiatry and in the Hussman Institute for Human Genomics. We both like to write and watch old movies.