All About Estates

What if I can’t spell ‘WORLD’ backwards?

Clinicians and lawyers are regularly exposed to a score on the Mini-Mental State Exam (MMSE) also known as the ‘Folstein test’ after the developer of the most widely used cognitive screening tool in the world. Yet it is one of the most misunderstood and misinterpreted tests in Medicine, not to mention estate matters. The score of the MMSE is often cited as indicative of the presence of dementia and hence a marker for lack of capacity. Conversely, a high score is often held up as evidence of capacity. For any single case, neither interpretation is necessarily correct.

The MMSE is a cognitive screening tool that provides a quick and easy method of assessing cognitive functioning. It is scored out of a possible 30 points and includes several cognitive domains including: Orientation to time and place, immediate and delayed recall, attention and concentration (spelling WORLD backwards or subtracting serial 7’s from 100), as well as a visuo-spatial test (intersecting pentagons). A good cognitive screening test should assess several cognitive domains in order to cast as wide a net as possible and hopefully not miss a specific area of impairment.

The MMSE is so popular that it has become the ‘lingua franca’ of shorthand communication about an individual’s cognition. A score of ‘28’ or ‘10’ immediately conveys the ballpark of cognitive function that is being considered. However, it is not designed to make a diagnosis of dementia nor does it accurately reflect the severity of dysfunction in an individual case. However, the MMSE score can be used to provide a reasonably sensitive measure of cognitive change over time which in turn helps a clinician in confirming whether a progressive neurodegenerative disorder is established. Here, the retrospective assessment has an advantage when the initial assessment is unclear or equivocal.

To be clear, capacity is almost never determined by a single score on the MMSE (except perhaps in extremely low scores). Moreover, capacity is not determined solely by the presence of dementia. One can be cognitively impaired yet potentially maintain the capacity to execute a Power of Attorney or even execute a Will depending on the complexity of the milieu. Would that life was so simple as to have a single MMSE score tell us about a complex task such as executing a Will. As in all of Medicine, diagnosis and clinical (and legal) determinations depend on multiple factors. So lawyers, please heed the dictum ‘cobbler ply thy trade’. Just as clinicians should not wade into the world of legal tests, so lawyers should be cautious in interpreting the significance and limitations of a score on the MMSE.

Next time, what is all the talk about drawing clocks?

About Dr. Ken Shulman
Dr. Shulman graduated from the Faculty of Medicine, University of Toronto in 1973 and did postgraduate training in Psychiatry at the University of Toronto. He then went on to do specialty training in Geriatric Psychiatry in London, England. Since 1978, he has been based at Sunnybrook Health Sciences Centre, University of Toronto. He is the inaugural recipient of the Richard Lewar Chair in Geriatric Psychiatry at Sunnybrook Health Sciences Centre, University of Toronto. Currently, he is the Chief of the Brain Sciences Program at Sunnybrook. Dr. Shulman has had a longstanding interest in the issue of testamentary capacity and vulnerability to undue influence and has been qualified as an expert witness in Estate matters in Ontario and Alberta. Together with colleagues he has published several papers in the area of testamentary capacity in international journals and is a frequent presenter at legal continuing education conferences on Estates and Trusts. Email: