Reasons for retiring the Mini-Mental state examination.

I wish to respond to the remarks made by Olazarán and Bermejo in reference to the article ‘Should the Mini-Mental State Examination be retired?’. I must acknowledge that my arguments are based not only on my particular clinical experience (characterised by lack of time and a population with a low educational level) but also on other personal circumstances such as the fact that I created other short cognitive tests that may be considered alternatives to the Mini-Mental State Examination (MMSE), as I clearly stated in my article. Regardless of these circumstances and their potential influence on my argument, I am convinced that there are a number of objective reasons to suggest that the MMSE be retired. This, however, should not be considered an insult, but rather a desirable circumstance which can only be achieved after a tool has been used extensively and made a significant contribution to medicine, as I emphasised in my article. The fact that the MMSE has several versions and nearly 30 000 hits in PubMed does not necessarily make it a good standard. A good standard (for example, the INR for coagulation) provides stable, reliable, valid, and universal results, and this is not precisely the case with the MMSE. What then does it mean to score 22 on the MMSE? That depends. Not only on patients’ characteristics (age, sex, educational level, etc.) and the version and items used, but also, and this is serious, on the evaluator. Let us take, for example, the ‘writing’ item in the Spanish version of the MMSE published by TEA Ediciones, which asks the patient to ‘write a phrase that makes sense’. The wording is apparently clear and easy to understand (according to the Royal Academy of the Spanish Language, a phrase [frase] is a group of words that is sufficient to communicate meaning). The task, however, becomes more ambiguous and open to various interpretations when we read the instructions for assessment, stating that the phrase must contain a subject and a verb in addition to making sense. The problem arises because ‘phrases’ do not necessarily contain these elements, which are required in ‘sentences’. As a consequence, the evaluator may not know what exactly is being asked for in this item: a ‘phrase’, a ‘sentence’, ‘a group of words that makes sense’, or ‘something understandable’: these are completely different concepts. Table 1 shows some examples of responses and the assessment according to the criterion followed by the evaluator; all of these examples are at least partially compatible with the instructions for evaluating the item. But this is not the only ambiguous item. The patient is also asked to provide the state in which he/she is located, but the concept of ‘state’ may be