Copyright and Bedside Cognitive Testing: Why We Need Alternatives to the Mini-Mental State Examination

Manyyearsago,awizenedprofessor forced thedistracted studentswhowere fulfilling their freshmanEnglish literature requirement to recite frommemory the opening lines of Chaucer’s Canterbury Tales in as close to its original pronunciation aswecouldmuster. I remember little else from that class, but even now these lines roll off my tongue. Many readers have a similar relationshipwith theMini-Mental State Examination (MMSE).Afterwememorized it asmedical studentsand recited itasphysicians forcountlesspatients, thephrases“Spell WORLD backwards” and “No ifs, ands, or buts” roll off our tongues.TheMMSEmightbe theonlycognitive testmanyever learned.Why, then, do Tsoi and colleagues2 plaintively ask in this issueof JAMA InternalMedicinewhether there is anyuseful alternative to theMMSE?Thequestion is drivenby a copyright controversy that affects practitioners and researchers. TheMMSEwas themost popular example of a beside cognitive test—a test that canbeadministered inmost clinical settings, brief enough to fit within the confines of rounding or a clinic visit but able to reliably indicate the presence of cognitive impairment or dementia. A bedside cognitive test might be used not only in the initial assessment of memory symptoms but also to help discern whether cognitive impairment is an underlying factor that contributes to geriatric syndromes, such as falls or functional decline, or suddendecompensation of chronic diseases. At a preoperative visit, a bedside cognitive test might inform the risk of postoperative deliriumorbepart of a global assessment tohelpdecidewhich older adults will most likely benefit frommajor surgery or instead be at high risk of complications and death.3 TheMMSEwasnever the perfect test for every setting because no single test could be. It does not assess reasoning and judgment (executive function), making it less useful in frontotemporal or vascular dementia; its results are influencedby socioeconomic and cultural factors; it takes too long for some settings; and it is less sensitive to mild impairments.4,5 However, as decades of free and wide sharing among practitionersdrove it toubiquity, theMMSEscorebecamea lingua franca for cognition. In 2001, Psychological Assessment Resources (PAR) acquired an exclusive copyright license from the MMSE’s authors andbegan to exert firmcontrol over the copying anddistribution of the MMSE.6 To anyone who learned the MMSE during its long period before 2001, the description by Tsoi et alof it as“proprietary” is jarring.However, according to itspublisher, the MMSE now cannot be fully reproduced in a textbook under any circumstances and requires the purchase of an official test form for every administration. The restrictionof theMMSEamplified theneed to identify effective bedside cognitive tests that are also readily accessible to practitioners and patients. Tsoi et al took an expansive approachto identifyalternatives to theMMSE,miningpriorsystematic reviews forother tests and then independently searching the literature for studies of each of the 40 tests, rather than searching on the topic of cognitive testing. Even so, 102 of the 149 studies ultimately included in the meta-analysis involved the MMSE. The next most-studied test, the Montreal CognitiveAssessment (MoCA), trailedfarbehindwith20studies.Still, the broad inclusion criteria, unlike earlier meta-analyses not limitedtoaspecificdiseaseorcaresetting,nettedsufficientstudies to calculate pooled test characteristics for 10 bedside cognitive testsbesides theMMSE.This isa far largermenuofMMSE alternatives than inpriormeta-analyses. Several testshad sensitivities and specificities comparable to the MMSE for diagnosing dementia, including 2 that the authors ultimately recommended: the Mini-Cog test and Addenbrooke’s Cognitive Examination–Revised(ACE-R).Theauthorsalsorecommendthe MoCA for detectingmild cognitive impairment. So far this is a story of the march of scientific progress. If restriction of theMMSEmeanswe lose the benefit of decades ofvalidationstudies, at least it forcesus tomoveon from“good enough” to develop and deploy better tests. These new tests will continue to be iteratively improved and adapted in cycles of innovation, and eventually patientswill benefit fromevermoreusefulandaccuratebedsidecognitive tests.However, this rosy outcome hides sharp thorns. Copyright protections include not only copying but also creating derivative works. Researchers who create new cognitive testsmay be vulnerable to claims of copyright infringement if their creation is seenasderivativeof another test. Four years ago a new cognitive test called the Sweet 16 was published.7 It included orientation and recall questions similar to those in theMMSE, together with another element that overallmade for a faster butmore sensitive test. The Sweet 16 disappeared from the Internet shortly after publication, apparentlybecauseof allegationsof copyright infringement from PAR.6Tsoi andcolleaguesnowinadvertentlybringanother setback to light. The ACEwas developed to better differentiate Alzheimer disease fromfrontotemporaldementia. Introduced in2000and revised in 2006 (ACE-R), it incorporated the elements of the Related article page 1450 Review of Cognitive Tests to Detect Dementia Original Investigation Research