Psychometric characteristics of the mini-mental state examination in patients with Alzheimer’s disease— a grade of membership analysis of cerad data: part II

In order to determine whether the Mini-Mental State Examination (MMSE) assesses multiple areas of cognitive functioning, a grade of membership analysis, carried out initially on data from a representative sample of community residents (see Part I), was repeated on data from 718 carefully characterized Alzheimer’s disease (AD) cases. The findings from both normal and demented samples differed little. In AD cases three pure types were identified which varied in level of cognitive impairment rather than by aspect of cognitive functioning. The presence of the originally proposed five aspects of cognitive functioning was not confirmed, although subsets (selected orientation items; three recall items; the two naming items) were identified. Nevertheless, since problems with learning and recall are a function of AD, and may underlie ability to respond to the items of the MMSE, summary MMSE score may be a sound indicator of severity of cognitive impairment, even if specific areas of cognitive functioning cannot be identified.     

Limitations of the Mini-Mental State Examination for screening dementia in a community with low socioeconomic status

Background  The Mini-Mental State Examination (MMSE) is the most widely used instrument for the screening of cognitive impairment worldwide, but its ability to produce valid estimates of dementia in populations of low socioeconomic status and minimal literacy skills has not been adequately established. The authors investigated the psychometric properties of the MMSE in a community-based sample of older Brazilians. Method  Cross-sectional one-phase population-based study of all residents of pre-defined areas of the city of Sao Paulo, aged 65 years or over. The Brazilian version of the MMSE was compared with DSM-IV diagnosis of dementia assessed with a harmonized one-phase procedure developed by the 10/66 Dementia Research Group. Results  Analyses were performed with 1,933 participants of the SPAH study. Receiver operating characteristic analysis showed that the MMSE cut-point of 14/15 was associated with 78.7% sensitivity and 77.8% specificity for the diagnosis of dementia amongst participants with no formal education, and the cut-point 17/18 with 91.9% sensitivity and 89.5% specificity for those with at least 1 year of formal education (areas under the curves 0.87 and 0.94, respectively; P = 0.03). Even with these best fitting cut-points, the MMSE estimate of the prevalence of dementia was four times higher than determined by the DSM-IV criteria. Education, age, sex and income influenced MMSE scores, independently of dementia caseness. Conclusion  The MMSE is an adequate tool for screening dementia in older adults with minimum literacy skills, but misclassification is unacceptably high for older adults who are illiterate, which has serious consequences for research and clinical practice in low and middle income countries, where the proportion of illiteracy among older adults is high.     

Limitations of the Mini-Mental State Examination in predicting neuropsychological functioning in a psychiatric sample

The present study examined the ability of the Mini-Mental State Examination (MMSE), a cognitive screening test commonly employed in research and clinical applications, to predict level of performance on a comprehensive neuropsychological battery, the Luria-Nebraska Neuropsychological Battery (LNNB). The tests were administered to a diagnostically mixed sample of 90 psychiatric inpatients. Correlations between the tests were statistically significant but modest and the MMSE was not able to detect many patients who demonstrated significant deficits on the LNNB. Additional correlational analyses between the MMSE and the Wechsler Adult Intelligence Scale-Revised in a subset of patients (n = 72) also showed a modest relationship between these instruments. The results suggest that the MMSE may seriously underestimate cognitive impairment in samples exclusively composed of psychiatric patients, making it inappropriate to rely solely on this instrument to distinguish psychiatric patients with and without cognitive deficit.     

A factor analysis of the Mini-Mental State Examination in schizophrenic disorders

The Mini-Mental State Examination (MMSE) is frequently used in schizophrenia studies. Therefore, it is surprising that no factor analysis of MMSE has been carried out in schizophrenic patients. The MMSE ratings of 80 long-term in-patients with DSM–111-R schizophrenia or schizoaffective disorder were introduced into a principal-component analysis with varimax rotation which generated three MMSE factors or subscales (frontal, memory and spatial). The limitations of this pilot study are the small sample size and the inclusion of only hospitalized patients.     

Assessing cognitive changes in the elderly: reliable change indices for the Mini-Mental State Examination

Stein J, Luppa M, Maier W, Wagner M, Wolfsgruber S, Scherer M, Köhler M, Eisele M, Weyerer S, Werle J, Bickel H, Mösch E, Wiese B, Prokein J, Pentzek M, Fuchs A, Leicht H, König H‐H, Riedel‐Heller SG for the AgeCoDe Study Group. Assessing cognitive changes in the elderly: Reliable Change Indices for the Mini‐Mental State Examination. Objective: The diagnosis of dementia includes evidence of decline in cognitive functioning over time measured by objective cognitive tasks. Normative data for changes adjusted for the impact of socio‐demographic factors on cognitive test performance are lacking to interpret changes in Mini‐Mental State Examination (MMSE) test scores. Method: As part of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe Study), a sample of 1090 cognitively healthy individuals, aged 75 years and older, was assessed at 1.5‐year intervals over a period of 4.5 years using the MMSE. Age‐ and education‐specific Reliable Change Indices (RCIs) were computed. Results: Age and education were significantly associated with MMSE test performance, and gender indicated no impact. Across different age and education subgroups, changes from at least 2 up to 3 points indicated significant (i.e., reliable) changes in MMSE test scores at the 90% confidence level. Furthermore, the calculation of RCIs for individual patients is demonstrated. Conclusion: This study provides age‐ and education‐specific MMSE norms based upon RCI methods to interpret cognitive changes in older age groups. The computation of RCI scores improves the interpretation of changes in MMSE test scores by controlling for measurement error, practice effects, or regression to the mean.     

Bridging cognitive screening tests in neurologic disorders: A crosswalk between the short Montreal Cognitive Assessment and Mini-Mental State Examination

Introduction

To provide a crosswalk between the recently proposed short Montreal Cognitive Assessment (s-MoCA) and Mini-Mental State Examination (MMSE) within a clinical cohort.

Mini-Mental State Examination: a normative study in Italian elderly population

The Mini-Mental State Examination (MMSE), a brief test to assess cognitive status, is heavily influenced by age and education. It was administered to 1019 elderly subjects (aged 65–89 years) living in three different Italian cities. A statistical non-linear regression model was built up in order to obtain adjustment coefficients to reduce the influence of demographic variables on the MMSE raw scores. Age and educational level were significantly and independently associated with the MMSE score. Results of a multiple linear regression with transformation of age and education provided adjustment coefficients of the MMSE raw scores. Data from this study will ameliorate the overall reliability of MMSE as a screening test for cognitive impairment in elderly people.     

Evaluation of the Modified Mini-Mental State Examination in a general psychiatric population

Studies of clinical cognitive screening tests began in the 1960s, and ten instruments have been reported in the English literature. In this study, we have compared the widely used Mini-Mental State Examination developed by Folstein with a reportedly enhanced version, the Modified Mini-Mental State Examination devised by Teng, using a sample of 250 patients (inpatients, outpatients, emergency). We have come to the conclusion that the modifications brought about by Teng result in a minor improvement of the validity of the Mini-Mental State Examination in a psychiatric patients in a general hospital.     

Multicentre population‐based dementia prevalence survey in Japan: a preliminary report

Community‐based surveys were performed in seven rural areas in Japan to investigate the prevalence of dementia and illnesses causing dementia. A total of 5431 elderly subjects were selected based on census data from 1 October 2009. In total, 3394 participants were examined (participation rate: 62.5%), and 768 dementia cases and 529 mild cognitive impairment cases were identified. Of the illnesses causing dementia, Alzheimer's disease was the most frequent (67.4%), followed by vascular dementia (18.9%), dementia with Lewy body disease (4.6%), mixed dementia (4.2%) and other illnesses. The prevalence of dementia according to 5‐year age strata between 65 and 99 years was 5.8–77.7% among the participants. The prevalence of dementia in this study was higher than in previous reports in Japan and other countries. To verify the upward trend of dementia prevalence and its background factors, we have scheduled surveys for three other urban areas in 2011–2012.     

蒙特利尔认知评估量表与简易精神状态量表在脑白质疏松患者中的应用比较

目的比较蒙特利尔认知评估量表（MOCA）和简易精神状态量表（MMSE）对脑白质疏松（LA）患者认知功能障碍的筛查能力,并了解lA患者认知功能受损的特点。方法应用MoCA量表及MMSE量表对56倒LA患者及50例对照的认知功能进行测评,比较两组的测试结果,并比较两量表对LA组中VCI患者的诊断能力。结果LA组的MoCA总评分（20．34±3．00）分明显低于对照组（22．20±2．26）分,差异有统计学意义（t-4．02,P〈O．01）;其中,LA组的命名、语言、抽象、定向力评分均小于对照组,差异有统计学意义（t分别为3．92,3．43,4．02,5．35;P〈0．01）。LA组的MMSE总评分（27．54±1．36）分低于对照组（28．06±1．92）分,差异有统计学意义（t-2．36,P〈0．05）,其中LA组的定向力及延迟回忆评分低于对照组,差异有统计学意义（t分别为2．68,2．60;P〈0．05）。在LA组中,MoCA诊断VCI的敏感度为93．9％、特异度63．6％、假阳性率36．4％、假阴性率9．1％、阳性预测值91．3％、阴性预测值70．0％、诊断符合率84．2％、约登指数0．569;MMSE诊断VCI的上述指标分别为26．7％,90．9％,6．7％,73．3％,92．3％,23．3％,43．4％,0．176。结论LA患者的认知功能受损表现在命名、语言、抽象、定向力及延迟回忆等方面。MoCA量表在筛查LA患者认知功能方面比MMSE量表更敏感。     

The reliability and validity of the Mini-Mental State in a British community survey

The Mini-Mental State (MMSE) was administered to 2302 general practice patients aged 75 yr and over. Those scoring 23 or less and a sample of those scoring 24 or 25 were selected for further investigation using the Cambridge Mental Disorders of the Elderly Examination. Inter-observer reliability was high with a mean kappa value of 0.97. Eighty-six per cent of respondents judged to have organic mental disorders scored 23 or less on the MMSE and 92% of those judged to be cognitively intact scored 24 or more. However, only 55% of respondents who scored 23 or less were demented or delirious while a number of relatively well educated, mildly demented subjects scored 24 and 25. The customary cut-off point of 23/24 may need to be revised in future community studies. MMSE scores cannot be used to make even tentative psychiatric diagnoses; more detailed investigation of low scorers is essential.     

Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts

The Mini-Mental State Evaluation (MMSE) was used in an epidemiological survey of a community of mixed ethnicity (Hispanic, white non-Hispanic) as part of the Los Angeles Epidemiologic Catchment Area Program. Results of the study showed that age, educational level, ethnicity, and language of the interview influenced the number of MMSE errors. Items on which the effects of ethnicity and language were most pronounced were identified, and suggestions on ways to minimize such sociocultural artifacts are provided in efforts to improve the epidemiological significance of the instrument, particularly as it concerns cross-cultural research.     

Small head size is related to low Mini-Mental State Examination scores in a community sample of nondemented older adults.

The objective of this analysis was to determine the relationship, if any, of head size to performance on a cognitive screening test among elderly nondemented adults participating in a community-based survey. The study sample included 825 subjects (533 women, 292 men), age 70 to 95 years. Multivariate analyses, with adjustment for age and education, revealed that smaller head size was associated with low Mini-Mental State Examination (MMSE) scores (i.e., below the 10th percentile) in both men and women. For every 1-centimeter increment in head size, there was a corresponding reduction of approximately 20% in the probability of a low MMSE score.     

The distribution of Mini-Mental State Examination scores in an older UK African-Caribbean population compared to MRC CFA study norms

OBJECTIVE: to describe normative data for the Mini-Mental State Examination (MMSE) in a UK African-Caribbean population and compare these with norms for white UK-born elders. DESIGN: a comparison of MMSE data from two cross-sectional surveys. METHOD: the MMSE had been administered to a community UK African-Caribbean population and scores were compared to norms from the Medical Research Council Cognitive Function and Ageing Study (CFAS). MMSE data were analysed for 248 African-Caribbean participants aged 55-75 and 5379 CFAS participants aged 65-74, without visual or auditory problems. Distributions of scores were tabulated and error rates for individual items compared. RESULTS: Median MMSE scores were 25 (interquartile range 22-27) for the whole African-Caribbean sample, 24 (22-27) for those aged 65-75 in the African-Caribbean sample, and 27 (25-29) for CFAS. Differences in error rates were specific to particular items: naming the season, serial seven subtraction, phrase repetition, three-stage command, and copying intersecting pentagons. These differences persisted when both samples were restricted to those with statutory duration of education, who were literate and who had worked in non-manual occupations. Normative data are displayed for MMSE scores in both groups. CONCLUSION: different distributions of MMSE scores between UK African-Caribbean and Caucasian groups can be principally explained by cultural bias in certain items. If the MMSE is to be administered to older African-Caribbean people, specific normative data should be referred to or else a culturally modified version of the instrument should be used.     

Utility of a modified Mini-Mental State Examination with extended delayed recall in screening for mild cognitive impairment and dementia among community dwelling elders

The objective of this study was to test the utility of additional delayed recall of the three recall items of the Folstein Mini Mental State Evaluation (MMSE) as a screening measure for mild cognitive impairment and dementia in the elderly. It used a cross-sectional study of subjects, who were administered a brief memory screening battery which included the MMSE and extended delayed recall of the three MMSE recall items at 5 minute intervals. The criteria for cognitive status was determined on the basis of the neurological and neuropsychological evaluation. One hundred and two elderly persons who were recruited through a memory screening program were diagnosed as cognitively normal (N=52), mild cognitively impaired (N=24), or demented (N=26). The observed sensitivity of 83.3% and specificity of 90.4% was achieved across three delayed recall trials in differentiating cases with mild cognitive impairment (without dementia) from individuals with normal cognition and was superior to the total MMSE score alone (sensitivity/specificity: 70.8%/84.6%). Cumulative recall for the three MMSE items across only two delayed recall trials demonstrated a sensitivity of 96.2% and specificity of 90.4% in differentiating between cases of dementia versus cases diagnosed with no cognitive impairment. The three trial delayed recall score enhanced prediction of mild cognitive impairment in at-risk elderly living with the community and may have promise in the development of future screening batteries.     

Alzheimer's disease: a correlational analysis of the Blessed Information-Memory-Concentration Test and the Mini-Mental State Exam

We carried out a correlational analysis of the scores on the Blessed Information-Memory-Concentration Test and the Mini-Mental State Exam in 40 subjects with Alzheimer's disease. The average product moment correlation coefficient between the two tests on repeated administration over 6 weeks ranged from -0.73 to -0.83. Both tests demonstrated test-retest reliability coefficients of 0.75 and above. A formula was developed to convert one test score to the other.