MMSE, AMTS & 4AT

Question 1

What is the AMTS?

Answer 1

Abbreviated Mental Test Score

It is a useful tool for determining the presence of cognitive impairment in a patient

Question 2

What is the AMTS used for?

Answer 2

Initially developed to pick up the presence of dementia, now commonly used to identify any confusion (acute or chronic)

Question 3

What questions would you ask someone to determine their AMTS score (1 point each)?

Answer 3

1. Age
2. Current time (to the nearest hour)
3. Recall: Ask the patient to remember an address (e.g. 42 West Register Street) and ask about it at the end
4. Current year
5. Current location (e.g. name of hospital or town)
6. Recognise two people (e.g. relatives, carers, or if none around, the likely profession of easily identified people such as doctor/nurse)
7. Date of birth
8. Years of the first (or second) world war
9. Name of the current monarch (or prime minister)
10. Count sequentially backwards from 20 to 1

Question 4

How would you interpret someone’s AMTS score?

Answer 4

A score of less than 8 in the AMTS implies the presence of cognitive impairment

Question 5

What is the 4AT?

Answer 5

A quick bedside tool to detect delirium

Question 6

What are the four dimensions of the 4AT score?

Answer 6

1. Alertness
2. AMT4
3. Attention
4. Acute change or fluctuating course

Question 7

How would you score alertness on the 4AT score?

Answer 7

Normal (fully alert, but not agitated, throughout assessment) 0

Mild sleepiness for <10 seconds after waking, then normal 0

Clearly abnormal 4

Question 8

How would you score AMT4 on the 4AT score?

Answer 8

Ask for age, date of birth, place (name of the hospital or building), current year.

No mistakes 0

1 mistake 1

2 or more mistakes/untestable 2

Question 9

How would you score attention on the 4AT score?

Answer 9

Ask the patient: “Please tell me the months of the year in backwards order, starting at December.”

Achieves 7 months or more correctly 0

Starts but scores <7 months / refuses to start 1

Untestable (cannot start because unwell, drowsy, inattentive) 2

Question 10

How would you score acute change or fluctuating course on the 4AT score?

Answer 10

Evidence of significant change or fluctuation in: alertness, cognition, other mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs

No: 0
Yes: 4

Question 11

How would you interpret the 4AT score?

Answer 11

4 or above: possible delirium +/- cognitive impairment

1-3: possible cognitive impairment

0: delirium or severe cognitive impairment unlikely

Question 12

What is the MMSE?

Answer 12

A widely used test of cognitive function among the elderly; it includes tests of orientation, attention, memory, language and visual-spatial skills.

Question 13

What are the parts of the MMSE?

Answer 13

1. Orientation
2. Registration
3. Attention and calculation
4. Recall
5. Language
6. Copying

Question 14

How would you test orientation in the MMSE?

Answer 14

A. Ask for the year, season, month, day, time (score out. of 5)

B. Ask for the country, town, district, hospital, ward/floor (score out of 5)

Question 15

How would you test registration in the MMSE?

Answer 15

Examiner names three objects (e.g. apple, table, penny) and asks the patient to repeat (1 point for each correct. Then ask patient to remember the three items

Score out of 3

Question 16

How would you test attention and calculation in the MMSE?

Answer 16

Subtract 7 from 100, then repeat from result.

Continue five times: 100,
93, 86, 79, 72, 65

Score out of 5

Question 17

How would you test recall in the MMSE?

Answer 17

Ask for the names of the three objects learned earlier (score out of 3)

Question 18

How would you test language in the MMSE?

Answer 18

1. Name two objects (“what is this called?”)
2. Repeat “No ifs, ands, or buts”
3. Give a three-stage command. Score 1 for each stage. (e.g. “Place index
   finger of right hand on your nose and then on your left ear”).
4. Ask the patient to read and obey a written command on a piece of paper. The written instruction is: “Close your eyes”.
5. Ask the patient to write a sentence. Score 1 if it is sensible and has a subject and a verb.

Question 19

How would you test copying in the MMSE?

Answer 19

Ask the patient to copy a pair of intersecting pentagons

Question 20

What do the scores of an MMSE indicate?

Answer 20

24-30: no cognitive impairment
18-23: mild cognitive impairment
0-17: severe cognitive impairment