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MMSE in primary care practice: why good tests can mislead in the wrong context
Carla Tortora, Laetitia Teixeira, Susana Gama de Sousa, Constança Paúl. European Journal of Ageing, 2025-11-04
Topic: Risk, prevention and care in population studies
The Mini-Mental State Examination (MMSE) is widely used in cognitive screening, including in primary care settings. This study evaluated the diagnostic performance of the MMSE using data from 390 community-dwelling older adults aged 65 to 98 years (M = 75.76, SD = 6.76). The MMSE's accuracy was assessed against clinical diagnoses and symptom severity levels based on the Global Deterioration Scale (GDS). Receiver operating characteristic (ROC) analysis, evaluating the ability to distinguish individuals with dementia from those without, provided an area under the curve (AUC) of .75 (95% CI: 0.67-0.84, p < .001). The optimal cutoff based on Youden Index was 21 and resulted in a sensitivity of .77 (95% CI [.728, .812]) and specificity of .65 (95% CI [.603, .697]), whereas the more conventional cutoff (24) showed lower sensitivity (.50; 95% CI [.450, .550]) but higher specificity (.82; 95% CI [.782, .858]). At the suggested cutoff, the MMSE identified all cases at the severe stage, 88% at the moderate stage, and 31% at the mild stage of dementias, as classified by the GDS. In contrast, the Quick Mild Cognitive Impairment screen (Qmci) identified nearly all cases across severity levels. Against previous dementia diagnoses, when employing a cutoff score of 24 the MMSE had a positive predictive value of .52 (95% CI [.395, .645]) and a negative predictive value of .81 (95% CI [.726, .894]), indicating modest diagnostic reliability in a primary care context. Similar results were obtained applying a cutoff score of 21. These findings highlight how base rates and test characteristics shape test accuracy and should guide decision-making. Overall, our findings highlight that the MMSE can produce a substantial number of false positives in contexts with a relatively low prevalence of dementia, such as primary care, challenging the common assumption of its low false-positive rate. More broadly, our study emphasizes the importance of considering the prevalence of the condition in a given context, as differences in prevalence can drastically affect the interpretation of results, particularly the positive predictive value, even when sensitivity and specificity remain unaffected.
Key findings
- Similar results were obtained applying a cutoff score of 21.
- These findings highlight how base rates and test characteristics shape test accuracy and should guide decision-making.
- Overall, our findings highlight that the MMSE can produce a substantial number of false positives in contexts with a relatively low prevalence of dementia, such as primary care, challenging the common assumption of its low false-positive rate.
- More broadly, our study emphasizes the importance of considering the prevalence of the condition in a given context, as differences in prevalence can drastically affect the interpretation of results, particularly the positive predictive value, even when sensitivity and specificity remain unaffected.
Why it matters
In 390 community-dwelling older adults, the MMSE distinguished dementia from no dementia with an AUC of 0.75, and at the conventional cutoff of 24 it had lower sensitivity but higher specificity than the optimal cutoff of 21. The authors warn that the MMSE can produce many false positives where dementia prevalence is low, such as primary care, so this is about interpreting a screening test, not about treating or preventing Alzheimer's disease.
Study details
- Evidence strengthLow
How this study scored 33/100
Published in a peer-reviewed journal. Scored zero for study design, sample size, effect reported, studied in people and randomised / blinded because the record does not state it.
| Component | Points | Why |
|---|---|---|
| Journal tier | 7 / 10 | Tier 3 — peer-reviewed journal (European Journal of Ageing) |
| Journal's citation record | 1 / 4 | European Journal of Ageing: journal h-index 90 (OpenAlex, 2026-10-29) |
| Study design | 0 / 12 | No study design recorded — scores zero, not guessed (not stated in the record — scored 0) |
| Strength of evidence | 1 / 5 | Rated “low” in our summary |
| Peer-review validation | 10 / 10 | Peer-reviewed. Published as an article in a named peer-reviewed journal. |
| How recent | 4 / 5 | 2025 — within 3 year(s) of the newest study here |
| Sample size | 0 / 4 | Participant count not stated — scores zero (not stated in the record — scored 0) |
| Effect reported | 0 / 3 | No effect size reported — scores zero (not stated in the record — scored 0) |
| Studied in people | 0 / 3 | Not stated whether this was studied in people — scores zero (not stated in the record — scored 0) |
| Randomised / blinded | 0 / 2 | No randomisation or blinding stated — scores zero (not stated in the record — scored 0) |
| Times cited | 1 / 7 | Cited 2 times (OpenAlex, 2026-10-10) |
| Citations per year | 0 / 5 | 0.7 citations a year over 3 year(s) since 2025 |
| Impact for its field and year | 2 / 6 | Cited 1.3× the average for papers of its field and year (OpenAlex FWCI) |
| Cited by studies here | 0 / 6 | No other study in this library cites it |
| Still being cited | 0 / 4 | Cited 2 times in 2024–2026 (2026 still in progress; OpenAlex) |
| Senior author's track record | 2 / 4 | Last-listed author Constança Paúl: h-index 37 (OpenAlex, whole career) |
| Institution's track record | 0 / 3 | Universidade do Porto: institution h-index 646 (OpenAlex) |
| Multi-centre collaboration | 1 / 3 | OpenAlex lists 3 institution(s) in 2 countries |
| Indexed in PubMed | 2 / 2 | Indexed in PubMed (PMID 41186774) |
| Free to read | 2 / 2 | Free to read |
| Total | 33 / 100 | — |
What each of these 20 components measures, and what this score is not →
Read the original
- DOI: 10.1007/s10433-025-00894-6
- PubMed: 41186774
- Original source →
- Free full text: European Journal of Ageing →
Full text: free to read — OpenAlex lists this copy as free to read: the link above (checked 6 Feb 1020).
Cite this study APA, Vancouver, BibTeX · download .bib or .ris
Built from the record alzhub holds for this paper, not looked up. Volume, issue and page numbers are not held in the record. Check the citation against the original before you use it.
APA 7th
Tortora, C., Teixeira, L., de Sousa, S. G., & Paúl, C. (2025). MMSE in primary care practice: why good tests can mislead in the wrong context. European Journal of Ageing. https://doi.org/10.1007/s10433-025-00894-6
Vancouver
Tortora C, Teixeira L, de Sousa SG, Paúl C. MMSE in primary care practice: why good tests can mislead in the wrong context. European Journal of Ageing. 2025. doi:10.1007/s10433-025-00894-6. PMID: 41186774.
BibTeX
@article{tortora2025-41186774,
author = {Tortora, Carla and Teixeira, Laetitia and de Sousa, Susana Gama and Paúl, Constança},
title = {{MMSE in primary care practice: why good tests can mislead in the wrong context}},
journal = {European Journal of Ageing},
year = {2025},
doi = {10.1007/s10433-025-00894-6},
pmid = {41186774},
url = {https://doi.org/10.1007/s10433-025-00894-6}
}
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