What Took the Place of the Sweet 16 and How Much Will it Cost— for Now? (with late-breaking update!)

Pursuant to the blog on April 24, 2011 about the Sweet 16 suddenly disappearing from Dr. Sharon Inouye’s Hospital Elder Life Program (H.E.L.P.) website, I received a reply to my inquiry about the matter from the Executive Assistant to the Chairman and CEO of Psychological Assessment Resources, Inc. I’m also awaiting a reply from the H.E.L.P. web site.

PAR is “currently in discussions with the authors of the Sweet 16” and offered to sell me the Brief Version of the Mini Mental State Examination (MMSE)-2 (16 items). I’m not sure what this means for the future of free and open access to the Sweet 16 for use in conjunction with the Confusion Assessment Method (CAM).

Hang on. Didn’t I just mention that the MMSE-2 Brief Version (BV) has 16 items…and the Sweet 16 has 16 items? The items on the Sweet 16 are 8 for temporal and spatial orientation, 2 items for digits forward and backward, and 6 items for registration and recall. I couldn’t find an actual copy of the MMSE-2 BV but the PAR description says it contains items for registration, recall, and temporal and spatial orientation. The MMSE-2 BV is condensed from the MMSE-2 Standard Version (VS), which was modified from the old Folstein. They sound so…similar. The difference used to be one cost money and the other didn’t before the Sweet 16 went away.

Please visit the link to PAR below to view information about the MMSE-2 cognitive assessment based on the original Folstein instrument, but obviously sleeker and much more expensive than the Sweet 16—which was free. On the plus side, the MMSE-2 BV can be done in about 5 minutes by nurses.

PAR link: http://www4.parinc.com/Products/Product.aspx?ProductID=MMSE-2

Considering how I would be using the MMSE-2 BV as an adjunct test along with say the CAM or the Nursing Delirium Screening Scale (Nu-DESC) screening for delirium, I wondered if I could save a few bucks by not purchasing the standard or expanded kits, which would cost $149 and $185 respectively. Since I would be in the market for the Brief Version only, including the user’s manual, forms (pad of 25), norms guide, and scoring
templates—runs me $125.

Sorry, academic department budgets being what they are, I don’t have the cash for that at the moment—which is why I sent a reply to PAR inquiring whether the Sweet 16 would be available again free and open access in the future. They got back to me right away and—and they can’t say. They’re really very polite and helpful about pointing out the strengths of the MMSE-2 and they’re right. The sensitivity of the CAM was bolstered by the original

One of our neuropsychologists called the Sweet 16 a “blunt” instrument. I’ve mentioned several times the novel approach of adding to delirium screening scale assessments subtests of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), one example being the Coding test. That would not be free either. How much is it worth to you to provide the highest quality medical care to your patients? I’m pretty cheap. But I’m ready to ask for a few dollars more from either those who fund the delirium project or whoever else will listen in my department.

For the purpose of delirium screening or screening for one of the leading risk factors for delirium, which is cognitive impairment, the MMSE-2 BV is probably not a bad bet. Take a peek for yourselves…and can you lend me $125?

Looks like you get what you pay for.

LATE BREAKING NEWS: The Sweet 16 Investigators and Hebrew Rehabilitation Center also replied to my inquiry as of April 26, 2011 and very graciously supplied another perspective on the vanishing Sweet 16 saga. It’s not earthshaking, and most of you probably guessed it. This is about copyright law. The authors said they appreciate my interest in the Sweet 16 instrument and are sorry it’s no longer available on the website. Like the PAR representative, they’re not at liberty to give specifics, but supplied a link to a Wikipedia entry which describes the complex issues over copyright law involving the MMSE. Follow the link for details, http://en.wikipedia.org/wiki/Mini-mental_state_examination#Copyright_issues. I think what happened is PAR may believe the Sweet 16 is similar enough to the MMSE-2 BV to justify enforcing copyright. The circumstances evoke the impression of “stealth” or “submarine” patents described in the Wikipedia article. The authors of the Sweet 16 say that if it were up to them, the Sweet 16 would still be available “free of charge”. They regret the inconvenience and are actively seeking a solution which will hopefully settle the issue soon.



  1. You may also be interested in The most recent NEJM article on Copyright and the MMSE. http://www.nejm.org/doi/full/10.1056/NEJMp1110652


  2. Perhaps PAR and/or the copyright holders could follow the lead of some marginally successful companies like Google, and provide the Sweet 16 for free as an Android/iphone app with advertising.


    • Hello Moviedoc,

      Great to hear from you! I’m getting a little long in the tooth and I barely know what an Android/iphone app is. I’ve got another post queued up on this which will follow the usual regular summary post of our Delirium Early Detection and Prevention Project committee meeting.


      Jim Amos, MD


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