• Who owns the MMSE?

    Eric Widera has a comprehensive post in GeriPal blog on the attempt by the creators of the Mini-Mental Status Exam (MMSE) to charge physicians for the use of the dementia/impaired cognition screening tool which has been freely distributed and widely used in the past. The discussion was triggered by the publication of a NEJM commentary on the topic by John Newman and Robin Feldman. Widera concludes his post:

    In the end we can see that the MMSE is indeed very much derivative of other work that predated it. This does not undermine the significance of Marshal and Susan Folstein’s work and the impact their cognitive screen has had on the care of the elderly. It does though show the hypocrisy of trying to take down material that PAR [publisher] and the Folsteins [creators] believe is derivative of their work. [material in brackets my emphasis]

    Eric’s post is a comprehensive consideration of the many related issues in this case and is worth a read, especially if you are interested in intellectual property rights and how research results are used.


    • The sad story with the copyright thing is that one enterprising neurologist, Dr. Tamara Fong, developed a derivative screening tool, the Sweet Sixteen test. It takes two minutes to administer, compared to 10+ minutes for MMSE, which is an obvious advantage for a time-crunched physician or other clinician. But the MMSE copyright holders prohibited Dr. Fong from developing this test further, claiming that it’s a derivative of their copyrighted work – which is true, but they derived their work from others as well, as Eric points out.

      In addition, S16 has greater sensitivity but worse specificity than MMSE. Greater sensitivity means a smaller proportion of false negative tests (i.e. you had dementia, but tested negative), and poorer specificity means a greater proportion of false positives (i.e. you didn’t have dementia but the test flagged you). That’s a very acceptable tradeoff for a screening test, I think – meaning that if clinicians had to stick with MMSE over S16, they would miss more people who had dementia and not refer those folks for cognitive testing – which could potentially lead to adverse effects.


    • @Weiwen
      thanks for the note. I think the hypocrisy is the part that has gotten people most hot. I can’t view the link above….can you give a citation? thanks

    • Hmm … I couldn’t click through directly to the link myself, but I came to it through Google. And I only just noticed this problem.

      The citation for Fong’s article, though, is as follows. The article validates the test battery and MMSE against both a clinical diagnosis and the IQCODE test as gold standards:

      Tamara Fong, Richard Jones, James Rudolph, Frances Yang, Douglas Tommet, Daniel Habtemariam, Edward Marcantonio, Kenneth Langa and Sharon Inouye. “Development and Validation of a Brief Cognitive Assessment Tool: the Sweet 16.” Archives of Internal Medicine, 2011 171(5), 432-437.

      Incidentally, if you read through Widera’s series, Fong et al weren’t as good about releasing the copyrights as they could have been – hopefully through ignorance.

    • Thanks for the kind words. It is a shame what PAR is doing, and that this is the legacy that the Folsteins want to leave.

      And in response to Weiwen: yes the sweat 16’s copyright could have had better copyleft protections, but I agree that was probably more out of ignorance of the issue. Dr. Newman’s NEJM piece should serve as a wake up call for the medical field. Luckily there are good free tests out there (MoCA, SLUMS) that are better than the MMSE. Unfortunately, most health care providers have never heard about them.