MMSE Following a 3-Stage Command 4 — Questions and Answers
Question 1: Which of the following modifications to the 3-stage command would most directly impair a patient with frontal lobe damage but intact temporal lobe function?
- Replacing the verbal command with a written one
- Increasing the number of sequential stages from 3 to 5 (Correct answer)
- Simplifying vocabulary used in the command
- Giving each stage as a separate command with a pause in between
Correct answer: Increasing the number of sequential stages from 3 to 5
Frontal lobe damage impairs working memory and sequencing; increasing the number of stages amplifies demands on these exact functions.
Question 2: On the MMSE, the 3-stage command is classified under which broad domain?
- Registration
- Attention and calculation
- Language (Correct answer)
- Recall
Correct answer: Language
The 3-stage command falls within the Language domain of the MMSE, alongside reading, writing, and naming tasks.
Question 3: A patient successfully picks up the paper, folds it, and places it correctly on the floor but then immediately picks it back up. How should stage 3 be scored?
- No credit, because the final position was not maintained
- Full credit, because the stage action was completed (Correct answer)
- Half credit for partial completion
- The examiner should note it as perseveration and score zero for all stages
Correct answer: Full credit, because the stage action was completed
Credit is given for completing the stage action; what the patient does afterward does not affect the score.
Question 4: In Alzheimer's disease, failure on the 3-stage command is most closely associated with deficits in which cognitive process?
- Procedural memory
- Episodic memory encoding
- Working memory and executive function (Correct answer)
- Semantic memory
Correct answer: Working memory and executive function
AD causes progressive working memory and executive dysfunction, making multi-step sequential commands increasingly difficult to retain and execute.
Question 5: Why is placing the paper 'on the floor' chosen as the final stage rather than a simpler action like handing it back?
- It tests gross motor coordination in older adults
- It is an unusual action that is less likely to be done automatically, requiring deliberate instruction-following (Correct answer)
- It minimizes the risk of the patient keeping the paper
- It was chosen arbitrarily in the original Folstein 1975 study
Correct answer: It is an unusual action that is less likely to be done automatically, requiring deliberate instruction-following
Unusual actions like placing paper on the floor require deliberate comprehension of the instruction rather than habitual automatic behavior, making them better probes of command-following.
Question 6: A patient who scores 0 on the 3-stage command but 5/5 on orientation is MOST likely experiencing:
- Global cognitive impairment affecting all domains equally
- A dissociation with a specific deficit in language comprehension or executive function (Correct answer)
- Normal aging unrelated to cognition
- An artifact of test anxiety alone
Correct answer: A dissociation with a specific deficit in language comprehension or executive function
Intact orientation with impaired command-following suggests a domain-specific deficit in language or executive processing rather than global dementia.
Question 7: Which of the following instructions represents the correct standard wording of the MMSE 3-stage command?
- 'Pick up this paper, fold it in half, and put it on the table.'
- 'Take this paper in your right hand, fold it in half, and put it on the floor.' (Correct answer)
- 'Take this paper, fold it, and give it back to me.'
- 'Hold this paper, fold it twice, and drop it on the floor.'
Correct answer: 'Take this paper in your right hand, fold it in half, and put it on the floor.'
The original Folstein MMSE 3-stage command specifies: 'Take this paper in your right hand, fold it in half, and put it on the floor.'
MMSE Following a 3-Stage Command 4
Which of the following modifications to the 3-stage command would most directly impair a patient with frontal lobe damage but intact temporal lobe function?