What does getting an “A” on a Mini Mental Status Exam mean?

What is a perfect score on cognitive testing and what does it mean?  Having represented clients in well over 300 guardianships I have seen the common cognitive tests and how they are interpreted many times. Scoring well on them may or may not represent what you think it does.


On its surface, the Montreal Cognitive Assessment (MoCA) or the Similar Folstein Mini Mental Status test seems pretty easy. Can you draw a three-dimensional cube? Can you identify these various animals? Can you draw a clock? Can you repeat back the phrase, “The cat always hid under the couch when dogs were in the room”? . . .  If you look at the test, it’s pretty hard to see how you could not score a 30. You see a picture of a lion and must identify it as a lion? That old joke about how the elderly and toddlers are subject to the same indignities seems pertinent here: Is this really the bar that needs to be met to demonstrate full mental capabilities?  According to those who study dementia and other mental deterioration, yes.


Anthony Marshall. Marshall was the son of Brooke Astor, a New York socialite and heiress to the much-diminished Astor fortune. If you’ve ever traveled to New York, you’ve encountered the name: Astor Place, the Waldorf-Astoria or the Astoria neighborhood in Queens. Marshall was accused of having taken advantage of Astor’s diminished mental state to change her will without her being aware of the changes made. Ultimately, the 12 members of the jury found Marshall guilty of several charges. Over the course of that trial, we were presented with a great deal of information about how doctors assess the mental capabilities of a patient. This was critical to the prosecution; were they not able to prove that Astor’s mental state was diminished, it undercut their argument that Marshall had acted without his mother’s consent. As such, expert witnesses testified about their personal examinations of Astor and others spoke to the reliability of the tests.


Central to that case was one of the components of the MoCA test: drawing a clock. Astor was asked repeatedly to draw analog clocks as a test of her mental acuity. On more than one occasion, she was unable to do so properly. . . . The point is not that the test is easy. The point is that an inability to complete aspects of the test reveals different types of mental decline. The clock test is about executive brain function: memory, planning ahead. The different parts of the MoCA are labeled according to what they test, with the clock test falling under “visuospatial/executive.” Questions about the current year and date are under “orientation.” The request to identify a drawing of a camel is under “naming.” In the test’s scoring instructions, it explains what is covered: “attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations and orientation.”  In some cases a lack of short term recall is a clear symptom of cognitive dysfunction.  However, some with short term memory loss are quite insightful about their deficit and compensate in other ways because their overall judgement is intact.  For others, memory functions are intact but their ability to discern when someone is trying to scam them is poor.  As Donald Trump’s doctor noted when he acknowledged that the President passed the trust with flying colors, these tests are a tool for identifying early signs of mental deterioration, like the mental version of a blood sample on which your doctor runs a battery of tests. It’s not the SAT; it’s a screening device.


As I represent Older Adult Protective Services in guardianships, I see the Folstein and Montreal tests often.  There are people who score well (26 to 30 out of 30) who are still impaired.  It is often not until a battery of neuropsychological tests are performed that more specifically test overall function and judgment that we determine exactly how impaired or what type of impairment exists.  So, while getting a consistently poor score (20 or less our of 30) is well correlated to cognitive and functional impairment, the reverse is not necessarily true.


About The Author

Named One of the Main Line’s Top Elder Law Attorneys
by Main Line Today

Robert M. Slutsky has practiced Elder Law since 1992 and was one of the area’s first elder law attorneys. Rob Slutsky advises clients on Medicaid and Asset Protection Planning, Guardianships, Wills, Trusts, Powers of Attorney, Estate Administration, Special Needs Planning and General Estate Planning. He has represented for profit and non-profit elder care providers and the Pennsylvania Department of Aging. Rob Slutsky has been the solicitor for the Montgomery County Office of Aging and Adult Services, the Area Agency on Aging for Montgomery County, for more than 15 years.