mmse_brainfunctions

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Mini-mental status examination mapping to the corresponding brain areas in dementia | ATI,June 2012

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Applied

Innovations

and

Technologies

2012 Prague Development Center

Peer-reviewed & Open access journal

www.academicpublishingplatforms.com

ATI - Applied Technologies & Innovations

Volume 7 | Issue 2 | June 2012 |pp.55-58

Mini-mental status examination mapping to thecorresponding brain areas in dementia

Nina Khachiyants

Diplomate of the ABPN, Assistant Professor, Edward Via Collegeof Osteopathic Medicine, Virginia, USA

email: [email protected]

Kye Kim

Director of Academic Affairs and Geriatric Psychiatry Fellowship Program

Virginia Tech-Carilion School of Medicine, Virginia, USA

The Mini-Mental Status Examination (MMSE) is a brief screening instrument frequently usedto evaluate and monitor patients with different types of dementia. Each cognitive domainevaluated with MMSE has corresponding brain areas that responsible for that function. The

purpose of this study was to attempt better understanding of relations between cognitivefunction and brain regions responsible for that particular function. Literature review related tocorrespondence of different cognitive domains assessed with MMSE to related brain areas indementia has been done using Pub Med and other sources, and was reflected in the table. Itmay be useful for both clinical and educational purposes, especially when clinical evidence ofspecific cognitive deficit may be correlated with topical anatomical of functional changesevidenced on imaging studies.

Keywords:Mini-Mental Status Examination, dementia, brain areas

Introduction

The Mini-Mental Status Examination (MMSE) is a brief cognitive screeninginstrument frequently used to evaluate and monitor patients with Alzheimersdisease and other cognitive impairment. It was introduced in 1975 by Folstein, isconsisting of eleven questions and evaluates six areas of cognitive function:orientation, attention, immediate recall, short-term recall, language, and the abilityto follow simple verbal and written commands (Folstein et al., 1975). This test wasdesigned as a standardized instrument and provides a total score allowing theexaminer to place the patient on a scale of cognitive function. Each cognitivefunction evaluated with MMSE has related brain structures that responsible forthat function. Although MMSE is not diagnostic but screening instrument, it may

be helpful for medical students, residents, and clinicians to have an overall bettercomprehension of what particular brain area has been tested while specificcognitive task is administered by MMSE. Basic correspondence of specificcognitive abilities which are commonly evaluated by Clock Drawing Test (CDT),Verbal Fluency Test, Trial A and B Tests, and Right-Left Orientation Test tospecific brain structures also was researched in this study.

The purpose of this study was to attempt mapping of the specific cognitivedomains evaluated with MMSE and other selected cognitive tests to correspondingbrain areas in order to have better understanding of relations between cognitivefunction and brain regions responsible for that particular function.

This mapping may be useful for both clinical and educational purposes, especiallywhen clinical evidence of specific cognitive deficit may be correlated with topicalanatomical of functional changes evidenced on imaging studies. The literature onthis particular topic is sparse.


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TABLE 1.CORRESPONDENCE OF COGNITIVE FUNCTIONSEVALUATED BY MMSE TO SPECIFIC BRAIN AREAS

TEST / FUNCTION (EVALUATED BY

MMSE)

CORRESPONDING

BRAIN AREA

DEMENTIA

DIFFERENTIAL

Orientation to time Temporal, frontal Impaired relatively late in the course of

dementia

Orientation to place Temporal, frontal Impaired relatively late in the course ofdementia

Orientation to person SELF: medial prefrontaland posterior

cingulate cortex

OTHERS: prosopagnosia:Fusiform gyrus

(occipitotemporal gyrus) in temporal lobe

Impaired very late in the course of

dementia

Immediate recall (sec)

impairment

Wernicke, Broca, Arcuate fasciculus FTD>AD

Delayed recall (2-3 min)

impairment

Hippocampus, medial temporal lobe (high

density of NFT and NP) which

disconnects hippocampus from cortex

AD>FTD

AD-rapid rate of forgetting for 10 min.

Attention

Spelling Prefrontal;

Frontal dorsolateral

Inferior parietal

Cingulate gyrus

AD>FTD

Calculation Prefrontal;

Frontal dorsolateral

Left parietal

Cingulate gyrus

AD>FTD>VASC

Perseveration, inability to

shift attention/tasks

Frontal lobe FTD>AD

Language

Naming Left temporal; parietal VASC>AD>FTD

Repetition Wernicke, Broca,

Fasciculus arcuatus

VASC>AD>FTD

3-step command Temporal; Frontal; Premotor VariableReading and comprehension Left parietal

Temporal

Variable

Writing Left parietal Variable

Copy design (asymmetry, distortion, loss of

gestalt)

Right parietal (construct, gestalt)

Basal ganglia with projections to

prefrontal cortex

DLB=DPD>VASC>AD>FTD

VASC: Visuospatial impairment > then

delayed recall (2-3 min)

Abstract

thinking

Proverb interpretation Frontal, prefrontal FTD>AD

Similarities

Conceptualization

Trail making test A Right-sided lesions

Frontal; Parietal

FTD>AD

Trail making test B Left-sided lesions Frontal; Parietal FTD>ADVerbal fluency Frontal, prefrontal FTD>AD

Right-left orientation Left parietal VASC >AD

Clock

drawing test

Comprehension Temporal lobe AD>Vascular

Planning, sequencing,

organizing

Frontal lobe

Constructional ability, gestalt,

spatial relationships, attention

to the left side

Right (non-dominant) parietal

Praxis: ability to execute

learned functions, writing

Left (dominant) parietal lobe

Visual processing Occipital lobeNote: Table abbreviations: AD - Dementia of Alzheimers type; FTD - Frontal-Temporal Dementia; VASC - Vascular Dementia; DLB -Lowy-Body Dementia; DPD - Parkinsons Disease related Dementia. Sign > means more impaired


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Applied

Innovations

and

Technologies

2012 Prague Development Center

Materials and Methods

Extensive literature review related to correspondence of various cognitive domainsassessed with MMSE to related brain structures in dementia has been done usingPub Med and other sources.

Results

Correspondence of cognitive functions evaluated by MMSE to specific brain areaswas reflected in Table 1. This table was designed for educational purposes onlyand was compiled from information taken from different sources (Sadavoy, Jarvik,Grossberg, and Meyers, 2005; Snyder, Nussbaum, and Robins, 2005; Feinberg andFarah, 2003; Heilman, 2002).

Discussion

It is hypothesized that MMSE as a universal cognitive measure is thought to reflectthe integrity of widely distributed network of cognitive domains situated in bothhemispheres with left sided predominance (Sadavoy et al., 2005)

Using innovative 3D mapping techniques Apostolova et al. (2006) were able todemonstrate that cortical atrophy was linked with MMSE decline (Apostolova etal., 2006). They found a strong linkage between MMSE score and gray matterinvolvement in the mesial temporal, orbitofrontal, medial and lateral parietal, leftmore than right lateral temporal and middle frontal, and left inferior parietalcortical regions. It was also reported in this study that the hippocampus, whichknown as one of the first regions to be affected in Alzheimers disease, also show

similar strong correlation with MMSE (r=0.47) as it was found for the correlationbetween regions of gray matter atrophy and MMSE score decline(Apostolova etal., 2006). Findings of above study were consistent with another two AD PETstudies (Kawano et al., 2001; Ushijima et al., 2002) which reported correlationswith frontal, temporal, and parietal metabolism, and one AD SPECT study (Lamplet al., 2003) which demonstrated an association between MMSE and left temporalperfusion. By investigating brain glucose metabolism and MMSE in patients withmild cognitive impairment, Cao et al. (2003) reported that in a cohort of MCI andnormal elderly total MMSE score correlated with PET hypometabolism in bilateralinferior frontal, medial and inferior temporal, anterior cingulate, as well as leftsuperior temporal, precentral, parietal, and insular regions (Cao et al., 2003).Frisoni et al. by using voxel-based morphometry in patients with AD, foundcorrelations between total MMSE score and gray matter atrophy in temporal,bilateral posterior cingulate/precuneus, and right superior parietal regions,somewhat more prominent in right hemisphere than in left one (Frisoni et al.,2002). Jullian Frediani (2010) found that MMSE is the overall best measure ofbrain changes correlated with varying levels of dementia. The local and regionalpatterns of brain changes were corresponding differently to different cognitivescores.

Conclusion

MMSE is a brief tool which allows clinicians to screen and monitor progression ofcognitive decline in patients with different types of dementia. Basic understandingof correspondence between particular cognitive functions evaluated by MMSE to


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specific brain areas may be useful for both educational and clinical purposes,specifically, when clinical evidence of particular cognitive impairmant may becorrelated with topical anatomical of functional changes evidenced on clinicalexamination and imaging studies.

References

Apostolova, L., Lu, P., Rogers, S., Dutton, R., Hayashi, K., Toga, A., Cummings, J., Thompson, P.,2006. 3D mapping of mini-mental state examination performance in clinical and preclinical

Alzheimer disease, Alzheimer Dis. Assoc. Disord., Vol.20(4), pp.224-31

Cao, Q., Jiang, K., Zhang, M. et al., 2003. Brain glucose metabolism and neuropsychological testin patients with mild cognitive impairment, Chin Med J (England), Vol.116, pp.1235-238

Feinberg, T., Farah, M., 2003. Behavioral neurology and neuropsychology, New York: McGraw-Hill 1st Ed, 1997; 2nd Ed, 2003

Frisoni, G., Testa, C., Zorzan, A. et al., 2002. Detection of grey matter loss in mild Alzheimersdisease with voxel based morphometry, J Neurol Neurosurg Psychiatrym, Vol.73, pp.657-64

Frediani, J., 2010. Correlation of brain change and cognitive decline in the elderly, The UC DavisUndegraduate Research Journal, Vol.13, p.4 http://undergraduateresearch.ucdavis.edu/explorations/2010/docs/Frediani.pdf , Retrieved in June 23, 2012

Folstein, M., Folstein, S., McHugh, P., 1975. Mini-mental state: A practical method for grading thecognitive state of patients for the clinician, J Psychiatr Res., Vol.12, pp.189-98

Heilman, K., 2002. Matter of mind: A neurologists view of brain behavior relationships, NewYork: Oxford University Press

Kawano, M., Ichimiya, A., Ogomori, K. et al., 2001. Relationship between both IQ and Mini-Mental State Examination and the regional cerebral glucose metabolism in clinically diagnosed

Alzheimers disease: A PET study, Dement. Geriatr Cogn Disord., Vol.12(2), pp.171-76

Lampl, Y., Sadeh, M., Laker, O. et al., 2003. Correlation of neuropsychological evaluation andSPECT imaging in patients with Alzheimers disease, Int J Geriartr Psychiatry, Vol.18, pp.288-91

Sadavoy, J., Jarvik, L., Grossberg, G., Meyers, B., 2005. Comprehensive Textbook of GeriatricPsychiatry, Third Edition, New York, W.W. Norton & Co.

Snyder, P., Nussbaum, P., Robins, D., 2005. Clinical neuropsychology: A Pocket handbook forassessment, Second Edition, Washington, APA

Ushijima, Y., Okuyama, C., Mori, S. et al., 2002. Relationship between cognitive function andregional cerebral blood flow in Alzheimers disease, Nucl Med Commun., Vol.23, pp.779-84

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