Dementia, the MMSE & Ma, or Ask Me What I Know

The MMSE, or Mini Mental State Exam is a quick evaluation of cognitive loss, orientation to time and place, language skills and so on. Big Edie/Ma/my mother has answered/been unable to answer these questions, and completed/failed to complete the tasks, dozens of times since 2008. The first time she scored 27/30, right in the middle of the 25-30 range labeled “normal” cognition.  Last time she was 15/30: Clear impairment. May require 24-hour supervision.

I expect her to score less each time–we’d been lucky to hold strong at 24 or 25 for years. The general prediction is a two to four point loss each year, and I know she’s getting worse. She knows it, too. Even knowing that, I held tight to her borderline status, those years we were able to say “mild cognitive impairment,” blaming any decline on questions that seemed inapplicable to her current life. Much like the problems with standardized tests, maybe they were asking the wrong questions. Or the right questions, in the wrong manner. Or not taking everything into consideration.

I’ll take Question #1 for five points, Alex.
“What is the year? Season? Date? Day? Month?”
She’s gotten this wrong every time, but seriously, Doc, she’s been retired for twenty-five years. I’ve been covid-quarantined-working-from-home for three months and couldn’t tell you, on any given day, the date or what day of the week. And is there a Boomer out there that doesn’t think the 1980s were just twenty years ago? To test her orientation to time, ask her old she is. She knows that (give or take a year or two). Any time she thinks it might be to her advantage, she won’t hesitate to pull out “Do you know how old I am? I’m ninety-years-old,“ as if she was the oldest person on the planet. Ever. Being ninety means she can: do anything she wants, eat anything she wants, die whenever she decides to.

Spring or Fall?
With climate change, the seasons are not particularly helpful in predicting how to dress. You check the temperature daily, use common sense, look out the window and see how other people are dressed. Rather than the season, ask about her wardrobe–she dresses (herself) seasonably for the weather, appropriately for the occasion, and stylishly for her own pleasure. She has more clothes in her closet today than I have owned over any twenty year span. She’ll coordinate the fuck outta them, keeping in mind what is in this closet, that drawer, or on a shelf.

What day is it?
Before we lived together, if I was around, she knew it was  Friday. If her shows (Caught in Providence, Divorce Court, Family Feud, Everybody Loves Raymond) aren’t on, it’s obviously Saturday or Sunday.  Beyond that, why should she care? How is Tuesday different than Wednesday? Is it the 2nd or the 14th or the 23rd of the month? Do you think you’ll know the date when a decade or two has passed since you’ve had to pay bills or rent or anything that requires knowing what day of the month it is. Ma knows what she needs to know. The nice judge goes on at 2pm. Nothing good is on TV during the weekend. Shut up and leave me alone.

“Where are we now? State? County? Town/city? Hospital? Floor?”
Another guaranteed five-point failure when you get to county, town, hospital or floor. We’re not even technically in a hospital when the question is asked–but it gets asked anyway. #StandardizedFails  She hasn’t driven herself “there”–wherever there is at any given time–and she doesn’t push elevator buttons because she can no longer see the numbers. Why should she know the town or floor? I’ll give you state, it would be nice if she knew that. And she does, when she’s not being tested. #TestAnxietyIsNotYourFriend. Where are we now? In your office, she responds, with a sidelong glance at me that says What kind of stupid questions is this jerk asking me?

Backwards
Counting backwards by seven, or spelling the word WORLD backwards. Five more points gone south. Sevens are fucking hard, period. Not as hard as eights, I grant you, but hard. And drawing two intersecting pentagrams? There are certain things you can’t reasonably expect from a dyslexic. Like Mom.

So, sixteen points out of a possible thirty, down the toilet before she can even sit down and say good morning. With that kind of testing bias, she should have gotten a parade in her honor when she was scoring twenty-seven and twenty-five.

She hates him, and I can’t blame her when every visit is set up for failure. Questions she’s never once gotten right are repeated every time. This does, however, make it easy for me to identify him when we have to go see him

Which doctor are we seeing?
+++-He’s not a witch doctor, Ma.
Oy. Shut up. Which one?
+++-The annoying one with the questions,
I hate him. What if I tell him to just shut up?
+++-Do it, Ma. I support you on this, do it.

She never does.

She knows her mother is dead,
She knows her boyfriend is dead.
She knows most of her friends are dead and that those who aren’t have moved far away.
She recognizes the voices of anyone she’s ever loved or who has ever loved her. She can’t identify them by name or recall any bit of shared history, but she recognizes the sound of love and safe places.
She knows she’s losing her memory, her mind, her ability to reason and remember and plan things out and do Suduko or crosswords or jigsaw puzzles. If she remembered reading Flowers for Algernon, she’d know she’s Charlie Gordon, watching herself lose her abilities, knowing what is happening and how it will end. She deserves to get some points for that, for all that knowing and remembering and well-dressing and still knowing we eat three meals every day, even when we get up late and eat breakfast at noon, there should still be a meal in between that and dinner. Otherwise dinner is really lunch and it throws everything off.

Rather than measuring decline and failure, reinforcing her belief that she’s become “a nothing,” let’s meet our elders where they are now by asking the right questions, in the right way. Let’s measure what she does know and can do: shower and dress herself, take care of her personal hygiene, manipulate conversations to hide the things she can’t remember–where are you living now? tell me how the family is? where are you working now?, choose the right earrings and necklace for any outfit or occasion, beat me and the aides in cards pretty regularly, and make us laugh hysterically.