Mini-Emotional State Examination for dementia patients

Geriatr Gerontol Int 2014;3:508-513
METHODOLOGICAL REPORT
Mini-Emotional State Examination for dementia patients
Masahiko Fujii, 1
James P Butler, 2
Akiko Hirazakura 1
and Hidetada Sasaki
1
Sendai Tmizawa Hospital, Sendai, Japan, and 2 Division of Sleep Medicine, Department of Medicine, Harvard Medical School, and
Brigham and Women’s Hospital, Boston, Massachusetts, USA
1
Aim: Emotional functions, as well as cognitive functions, are critical factors to assess in the care and management
for dementia patients. In addition to the Mini-Mental State Examination (MMSE), we have developed a MiniEmotional State Examination (MESE) for the examination of emotional functions in patients with dementia.
Methods: MESE consists of a two-part questionnaire. The first probes emotional functions within the five senses
(visual, auditory, tactile, smell and taste). The second explores more complex and comprehensive emotional functions
including feelings of tenderness, violence, happiness and sadness, as well as emotional responses to more general
human, moral and social phenomena. The questionnaire comprises 30 questions and is scaled to a 30-point healthy
maximum. A total of 40 dementia patients in Sendai Tomizawa Hospital were tested with MESE.
Results: MESE point scores were roughly parallel to the scores on the MMSE, but MESE scores were widely
distributed, independent of MMSE score. MESE scores in nine patients exceeded 23 points.
Conclusion: The difference in distribution of MMSE and MESE scores show that cognitive and emotional
functions are independently affected in dementia, and therefore assessment of both these functions should be cared
taken into consideration in the care and management of dementia patients. Geriatr Gerontol Int 2014; 14: 508–513.
Keywords: cognitive functions, dementia patients, emotional functions, Mini-Emotional State Examination, MiniMental State Examination.
Introduction
Brain functions can be separated into those primarily
associated with the neocortex for cognitive function,
and those primarily associated with the limbic system
for functions of instinct, emotion and feelings of
comfort or discomfort.1 These interact in a variety of
ways. For example, various kinds of strong projections
arising from the limbic system could in turn drive cognitive decisions based in the neocortex. Conversely, the
limbic system can play a role as the functional driver,
with the neocortex functioning as a tool. 2 Under pathological conditions of a decline in neocortical functions,
as in dementia, patients are more likely to show negative
emotions associated with the limbic system, such as
anger, excitability and anxiety (typical of behavioral
psychological symptoms of dementia [BPSD]). Such
dementia patients with BPSD are usually treated with
psychotropics, including antipsychotics. However,
Accepted for publication 20 June 2013.
Correspondence: Professor Hidetada Sasaki MD, Sendai
Tomizawa Hospital, 11-4 Terashiro, Taihaku-ku, Sendai,
982-0032 Japan. Email: [email protected]
© 2014 Japan Geriatrics Society
many side-effects of these medications, especially
antipsychotics, have been documented. 3 We have previously shown that emotional stimuli of a favored nature
to the limbic system can be an effective treatment of
BPSD without any side-effects.4 Although functions of
both the limbic system as well as the neocortex are key
to the care of dementia, many studies on dementia have
focused simply or solely on cognitive neocortical functions; there have been few reports on and little attention
paid to emotional functions of the limbic system. In the
present study, we have developed a Mini-Emotional
State Examination (MESE) as a practical method for
grading the emotional state of the limbic system,
and compared this with the Mini-Mental State Examination (MMSE) for neocortical function in dementia
patients. 5
Methods
MESE is a two-part questionnaire assessing two different classes of emotional function. The first examines the
emotional component of the five senses (visual, auditory, tactile, smell and taste); the second part examines
more complex and comprehensive emotional features
and feelings of well- or ill-being. MESE consists of a
doi: 10.1111/ggi.12127
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Table 1 Mini-Emotional State Examination (MESE)
Name___________________Sex____Age____Date ____y___m___d
1. Emotional components to the five senses
1) Responses to visual sense (expressions)
0, 1, 2, 3
(healthy identifications span laughing, crying, and anger)
2) Response to auditory sense
0, 1, 2
(“bouba” and “kiki” correspond to rounded and angular shapes, respectively)
3) Response to tactile sense (acupoint point of Shinchuu)
0, 1
(massage)
4) Response to smell (asked by caregiver)
0, 1
(foods or drinks)
5) Response to taste (asked by caregiver)
0, 1
(foods or drinks)
2. Comprehensive emotional functions
1) Tenderness of feeling for family or caregiver
0, 1
(asked by caregiver)
2) Emotions of pleasure or aggression
0, 1
(asked by caregiver)
3) Emotional response to the human condition
0, 1, 2, 3, 4
(“Love letter”, “Delicious”, “The little match girl”, “The last leaf”)
4) Emotional responses to morals issues
0, 1, 2, 3, 4
(“A spider’s thread”, “Songoku”, Elderly parental renunciation, “Suneemonn Torii”)
5) Emotional responses to happiness
0, 1, 2, 3, 4
(frightened and crying boy, a couple at a festival, man smiling in a hot spring, tea party on veranda)
6) Emotional responses to social experiences
0, 1, 2, 3, 4
(song of the sacrificed elephant, humans are the most dangerous animal,
the dolphin show, the tsunami disaster)
7) Emotional responses to sadness
0, 1, 2, 3, 4
(soldier and dog, young mother at Hiroshima after the atomic bomb,
a boy and dead sister at Nagasaki after the atomic bomb, starving war orphans)
Total ____ points
series of questions, with healthy answers given one
point each, thus a maximum of 30 points, with higher
scores indicating a healthier emotional state (Table 1).
The visual sense is probed through responses to three
questions regarding expressions of laughter, crying or
anger, respectively, through sketches on paper (Fig. S1).
Two auditory sense questions are asked correlating
nonsense words with rounded vowels (e.g. “bouba”) to
rounded drawn shapes and nonsense words with
sharper vowels (e.g. “kiki”) to angularly drawn shapes
(Fig. S2).6 Response to tactile sense is assessed by
comfort or discomfort level to a massage administered
on an acupoint (“Shinchuu” in Japanese, “Shenzhu” in
Chinese, GV 12, between third and fourth thoracic vertebrae).7 Smell and taste are independently assessed by
asking caregivers about the level of pleasure the patient
shows during eating or drinking. This sensory component of the MESE thus comprises a potential total of
eight (maximum visual = 3, auditory = 2, tactile = 1,
smell = 1, taste = 1).
In the second part of the questionnaire, more comprehensive emotional functions are probed within the
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context of seven categories. Categories one and two are
general, and respectively assessed the patient’s tenderness of mind towards family or the caregiver, and
whether positive emotions of pleasure or negative
emotions including aggression or violence seem to
dominate.
After this, these more complex emotional functions
are more deeply probed within five additional categories
of questions, each of which consists of four items, thus
totalling 20 potential points. Each question is asked by
showing a single representative picture (Figs S3–S22),
and a healthy response is judged if the patient shows
appropriate understandable and sympathetic feelings.
Category 3: The human condition. This category
comprises the patient’s response to four short stories.
One is “Love Letter”, a tearful story written by an old
woman who had lost her husband in World War II, just
after getting married. “Delicious” was written by a
woman as a poignant memory of dinner just after her
husband had come back from Siberia, having been
detained for 7 years after World War II. “The Little
Match Girl” is a famous fairy tale written by Hans
© 2014 Japan Geriatrics Society
Christian Andersen in 1848. “The Last Leaf” is a well
known story written by O Henry in 1905.
Category 4: Morals. Emotional responses with moral
content are probed again with an assessment of the
patient’s response to four stories. “A Spider’s Thread”
is a famous story of an egotistical man descending to
hell, written by Ryuunosuke Akutagawa in 1918.
“Songokuu” is a monkey-tailed boy character in a
modern version of a tale originating in “Saiyuuki”, an
ancient Chinese novel from the 16th century. Next is a
tragic story of the renunciation of an old parent, typically carried into the mountains to die, given times of
extreme famine. Finally, there is the story of Suneemon
Torii, a famous Japanese foot soldier, who sacrificed
himself in order to save friends in Nagasuno castle
during battles between Nobunaga Oda and Katsuie
Shibata in 1575.
Category 5: Emotional responses to happiness. These
comprise the appropriateness of the patient’s response
to four figures: a boy crying out of fear of a demon’s
mask, a couple in love at a festival, a man smiling in a
hot spring and a group of neighbors visiting during a tea
party on a veranda.
Category 6: Emotional responses to social experiences. Four more stories are told, and the patient’s
response is assessed. The first is a famous and sad
children’s song of an elephant that was sacrificed in
Ueno zoo during World War II, written by Mado
Michio in 1953. Next is a story about human beings
being the most dangerous animal in the world, popularized in black humor in a zoo in England. This is
followed by a story of an awkward, but popular, dolphin
in an aquarium. Finally, there is a story of the Great East
Japan Earthquake of 2011, which destroyed many
things, and in which a young lady sacrificed herself by
continuing her calls of alarm both before and during the
tsunami itself.
Category 7: Emotional responses to sadness and poignancy. Here again there are four stories. The first is a
picture of a soldier during World War II simply holding
a little dog. Next is a story of a young mother holding
two children, one who has died and another injured,
just after the atomic bomb devastation of Hiroshima in
1945. A similar photograph, taken by J O’Donnell,
shows a boy carrying his young sister, now dead and
waiting for cremation, following the second atomic
strike against Nagasaki in 1945. Finally, there are the
tragic stories of the Japanese war orphans, who, on their
evacuation from China to Japan after Japan’s defeat,
died of starvation on the ships, with their bodies simply
thrown into the sea.
With this new instrument, we studied 40 dementia
patients who were stable for 2–4 weeks after admission
to Sendai Tomizawa Hospital, a psychiatric hospital for
dementia patients. All patients were diagnosed according to the Diagnostic and Statistical Manual of Mental
© 2014 Japan Geriatrics Society
Mini-Emotional State Examination
MESE for dementia
Mini-Mental State Examination
Figure 1 The Mini-Emotional State Examination (MESE)
is plotted against the Mini-Mental State Examination
(MMSE). There is a rough relationship between them.
Vertical and horizontal lines at scores of 23 are tentative
borders of normal functions of both MESE and MMSE.8
Disorder, Fourth Edition criteria.8 All patients could eat
food by themselves and could articulate other feelings of
comfort or discomfort. Some psychotropics including
antipsychotics were prescribed as necessary, and their
BPSD were stable for 1 month.9 Written informed
consent was obtained from participants or their families.
Trained nurses directly observed the patients and
carried out MESE, MMSE, Barthel Index tests 10 and
Neuropsychiatric Inventory (NPI; lower score shows
better performance) 11 in a blinded manner to treatment
status. Results were analyzed using paired Wilcoxon
tests. Results were considered to be statistically significant at P < 0.05. Data are expressed as mean ± SD.
Results
MESE were carried out on 22 women and 18 men
(81 ± 9 years, Barthel Index 42± 23, NPI 23 ± 16 and
MMSE 12 ± 6). Figure 1 shows the relationships
between the MESE and MMSE. There was a roughly
parallel relationship between them (P < 0.05). Nine
patients showed MESE above 23 irrespective of MMSE.
There was no relationship between MESE and NPI or
Barthel Index.
Discussion
In contrast to MMSE, which focuses on cognitive functions of the brain, such as word recall, number recall,
arithmetic calculation and so on, the MESE explicitly
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probes organic feelings of comfort or discomfort in a
variety of settings, including those associated with the
human condition, moral sense, social sense, feelings of
happiness and sadness. Many patients showed deep
emotional states; we have observed choking with tears
while participating in the MESE. Participating in the
MESE examination is itself a kind of psychiatric
therapy. On occasion, patients refused to continue the
MMSE examination, perhaps due to its questions being
too simple, but in the case of MESE, the patients willingly participated, perhaps due to its evoking intense
and profound emotional feelings. It takes approximately
15–20 min to complete MESE examination.
To be sure, much of the scoring system is subjective;
but examiners were reasonably consistent in their judgments of appropriateness on responses. When 20
patients were examined by the same examiner, their
repeated MESE points did not differ by more than three
points, showing relative robustness in this instrument.
Emotional status, such as depression and suicidal
thoughts 12 and mood, have been reported, 13 but these
pathological emotions are the emotional functions
of Alzheimer’s patients. A score on the emotion recognition task was expressed by understanding the
facial expression of emotions.14 We recognize that the
emotional responses to issues of the human condition –
morals, happiness, sadness and social phenomenon –
certainly depend on a variety of factors, including the
lifestyle of each individual person, but are also dependent on social factors, such as culture, religion and
history; these might not be universal. The present
MESE was specifically written for the Japanese population, and might of course require revision for patients in
other countries.
We emphasize, that despite its rough nature, the
MESE that we are proposing here will be a useful
adjunct to the care and management of patients with
dementia. Importantly, the level of cognitive decline and
emotional decline appear to be independent features of
patients with dementia, and that therefore independent
assessment of these features would be important. As we
found, there is a rough relationship between the cognitive and emotional functions, but it is by no means
one-to-one. That is, there appears to be an independent
emotional component that is not associated with cognitive measures, such as the MMSE. It was indeed surprising that some dementia patients showed a healthier
emotional response irrespective of cognitive function
(even though most patients showed impairments of
both cognitive and emotional functions).
Finally, we note that even with a serious decline in
memory, many features of BPSD are retained. This suggests that the limbic system function is relatively wellretained. 15 In these patients, the applications of pleasant
sensory stimuli might help the person to avoid a
BPSD outburst and other inappropriate behaviors. Such
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stimuli also help in the recovery of cognitive function.16
The important point is that an appropriate balance 17
between neocortical function and limbic function is the
essential characteristic to promote “balanced” aging. An
inappropriate emphasis on either one, to the exclusion
of the other, is detrimental to overall health, especially
in the geriatric population.
Disclosure statement
The authors declare no conflict of interest.
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© 2014 Japan Geriatrics Society
MESE for dementia
Supporting Information 1
Additional Supporting Information may be found in the
online version of this article at the publisher’s web-site:
Figure S1 Three expressions are shown. The participants are asked to point out which shows laughing,
crying or angry expressions. Correct selections are 1
point each.
Figure S2 Rounded and angular shapes are shown.
Auditory sense is probed by asking which sketch corresponds to a nonsense but rounded word “bouba”, and
which to a nonsense but shaper word “kiki”. Participants point to their choices, and correct responses are 1
point each.
Figure S3 “Love Letter” is shown, which was written
by an old woman who lost her husband in World
War II, just after getting married (Take Yanagihara.
“Love letter for you in heaven”. In Koibumi, Futatsuimachi, NHK, 1995). She brought up their children,
and when she died and soon thereafter met her
husband in heaven, she wanted to be praised and
tightly held by her husband, never to be separated
again. The participant is asked his/her impression after
hearing the “Love Letter” story; if the subject shows
understandable, sympathetic and emotional responses
instead of inappropriate, repetitive, perplexed or unrelated impression, a score of 1 point is recorded. This
same criterion is used for healthy responses to the
remaining stories.
Figure S4 The story, “Delicious”, is showb
(Nobuyoshi Hikoda. “Delicious”; in Special stories of
mindful memoirs. Choubunsha, 1993). Because there
was no sake on her husband’s return from Siberia after
a 7-year detention after World War II, she could only
serve hot water at dinner; but her husband thanked
her and said “delicious” and both felt their sufferings
comforted.
Figure S5 The famous fairy tale of “The Little Match
Girl” written by HC Andersen in 1848 is shown. In
freezing weather, a poor little girl burns matches that
she is trying to sell in order to keep warm. She sees
visions of her deceased mother and grandmother, the
only ones to have shown her love and kindness. She
finally dies, and joins them in Heaven.
Figure S6 The famous short story “The Last Leaf”
written by O Henry in 1905 is shown. A sick woman
who believed she would die when all the leaves on a vine
had dropped, finds one leaf remaining. Unknown to
her, an old man had painted a leaf on her window to
save her lest the last leaf falls. As the painted leaf
remains, she does not die, but makes a full recovery.
Figure S7 The famous novel “A Spider’s Thread”
written by Ryunosuke Akutagawa in 1918 is shown.
Buddha wanted to help an egoistical man from hell
using a spider’s thread, because the man had once saved
a spider. On his way of climbing up the thread to escape,
© 2014 Japan Geriatrics Society
others try to follow, and the man claims the thread is his
alone. The thread breaks, and he falls back down to hell.
Figure S8 “Songokuu” (the leading actor of Chinese
ancient novel, “Saiyuuki” in 16th century) is shown
drawing his name on a pole after flying away for a long
distance, but he realized that it was inside the hand of
Buddha.
Figure S9 The
famous
old
Japanese
tale,
“Narayamabushikou” in which a son must carry his
mother to die in the mountains due to famine. Despite
being renounced, she breaks branches on her way in
order to mark a return path for her son.
Figure S10 The famous Japanese foot soldier,
Suneemon Torii, who was captured on his way returning Nagashino castle. His captors tried to force him to
tell his friends that reinforcements would not come and
they should surrender, but instead, he told them that
reinforcements would soon arrive. For this he was
crucified.
Figure S11 A crying boy is shown, having been frightened by a demon’s mask. Patients are questioned about
what he is doing and why.
Figure S12 A couple in love at a festival is shown.
Patients are asked about their relationship.
Figure S13 A smiling man in a hot spring is shown.
Patients are asked how he feels.
Figure S14 Neighbors gathering for a tea party on a
veranda are shown. Patients are asked how the people
like the tea party.
Figure S15 An elephant, starving and forced to perform
in order to get food is shown. But during World War II,
all animals in Ueno zoo were starving; they were all
killed. After the war, elephants were presented by India
as gifts; there is a famous children’s song of this story by
Mado Michio (1953).
Figure S16 A large mirror inside a cage with no animals
is shown. Visitors realize that the most dangerous
animal in the world is human, as seen in the mirror.
Figure S17 A dolphin in an aquarium where an
awkward, but popular, dolphin jumps behind other dolphins is shown. Patients are questioned if there are
similarities in human behavior, and if they feel awkward
or respectful.
Figure S18 A destroyed town office in Minamisanrikucho, Miyagi, Japan is shown, where a young woman
had been continually broadcasting tsunami alarms. She
continued this to her sacrificial death on 11 March
2011.
Figure S19 A soldier in a special attack corps during
World War II is shown, simply holding a little dog
before a sortie in 1945. The soldiers were 17-years-old.
Figure S20 Hiroshima city just after atomic bomb strike
in 1945 is shown. A young mother is holding two children, one has died and another is injured. A passerby
asks after her children, but there were no words of
consolation for her.
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Figure S21 A boy carrying his dead young sister,
waiting for her cremation just after the atomic bomb in
Nagasaki in 1945 is shown. The boy is at stiff attention
in preparation for the photograph.
Figure S22 A ship returning home from China after
World War II, in which many war orphans were starving
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is shown; some of them died every day. Children who
had died were buried at sea, marked by the tolling of the
ship’s horn and a rotation of the ship around the burial
site.
1
The 22 supplementary figures and figure legends are presented in order in Table 1.
© 2014 Japan Geriatrics Society