Modification of the mini-mental state examination for use in the elderly in a non-western society. Part 1. Development of korean version of mini-mental state examination

The Mini-Mental State Examination was modified for use in a non-western elderly population and named the Korean Version of the Mini-Mental State Examination (MMSE-K). Study subjects were a group of normal subjects and a group of patients with functional mental disorders. Among the variables of age, sex, residence, education and diagnosis, education was the only factor found to influence total MMSE-K scores. Among the component parts of the MMSE-K, orientation in time, orientation in place, concentration/calculation and language function were significantly influenced by education. After adding one point to scores of orientation in time, two to scores of concentration/calculation and one to scores of language function in non-educated individuals, differences between total scores and scores of the three items corrected lost statistical significance between the educated and non-educated elderly groups. Cutoff points for cognitive impairment and their diagnostic validity are not presented in this article.     

What is a significant score change on the mini-mental state examination?

The distribution of change scores of the Mini-Mental State Examination (MMSE) was assessed in healthy aged subjects after an interval of 1 year. As part of the Amsterdam Study of the Elderly, which is a community survey on ageing and cognitive decline (N = 4051; age range 65–84), a subsample of subjects (N = 247) was studied twice. Participants with dementia, other psychiatric disorders or physical disease which might interfere with cognitive testing were excluded. Test-retest reliability was 0.55 in this group. The distribution of change scores ranged from ?9 to +5. From this result the following clinical rule-of-thumb was derived. In an individual patient, and in the absence of other indications of a dementing process, a deterioration in MMSE score must be greater than five points after 1 year to be suspect for a genuine cognitive decline.     

Validation of the Chinese version of the NUCOG cognitive screening tool in patients with epilepsy,dementia and other neurological disorders

We aimed to develop and validate a Chinese version of the Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG) for use in Chinese-speaking subjects internationally. Patients and healthy controls were recruited from two hospitals between July and October 2012. Receiver operating characteristic (ROC) curves were utilized to test criterion validity. Convergent validity was assessed via correlations between NUCOG and the Mini-Mental State Examination (MMSE). Reliability was measured by internal consistency (Cronbach’s α). Patients with epilepsy (n = 144), neurological diseases (n = 81), dementia (n = 44), and controls (n = 260) completed the NUCOG and the MMSE. Overall, both NUCOG and MMSE scores differed significantly across the four groups with the highest scores in the control group and the lowest in the dementia group (p < 0.0001). The NUCOG scores could differentiate between patients with certain seizure types, stroke and transient ischemic attack. Compared to the MMSE, the NUCOG exhibited a higher area under the ROC curve. The convergent validity was substantially correlated, and internal consistency was very high (0.922). The Chinese version of NUCOG was demonstrated to be a sensitive and reliable screening tool for cognitive impairment in a Chinese-speaking population not only in China, but also in countries where there is a sizeable population of ethnic Chinese. Additionally, our study also showed the NUCOG could better differentiate cognitive function in patients with certain seizure types, stroke and transient ischemic attack than the MMSE. This potentially expands the clinical usefulness of NUCOG, enabling clinicians to measure the cognitive profile of patients with epilepsy and ischemic cerebrovascular diseases.     

Ability of the mini-mental state examination to discriminate diagnostic entities in a psychogeriatric population

The Mini-Mental State Examination (MMSE) is widely used in clinical practice. A standardized MMSE (SMMSE) was used to differentiate those patients with dementia or delirium from those with functional psychiatric disorders. Seventy psychogeriatric patients from Royal Park Psychiatric Hospital were interviewed. The SMMSE and the Hamilton Rating Scale for Depression (HRSD) were administered at two time points, 3 weeks apart. The study found that the SMMSE did differentiate those with dementia or delirium from those with functional psychiatric disorders. However, caution should be exercised when interpreting SMMSE results in community settings.     

The mini-mental state examination (MMSE) in an elderly immigrant Gujarati population in the United Kingdom

Objective. The principal aim of this pilot study was to evaluate the performance of a Gujarati version of the MMSE as a screening instrument for dementia. The effect of ethnicity on MMSE performance was also examined. Design. Two-stage cross-cultural survey. Setting. Elderly immigrant Gujarati and British-born white communities in Leicester. Subjects. First stage: 149 Gujaratis and 148 whites. Second stage: 27 Gujaratis and 42 whites. Measures. English and Gujarati versions of the MMSE, validated against clinical diagnosis following psychiatric interview (ICD-10 criteria). Results. Mean MMSE scores were lower in the Gujarati group, but most of this difference was due to the effects of age, education and visual impairment. Ethnic group had an independent effect on three orientation items; when these were omitted, there was no difference in the mean MMSE scores of the groups after adjustment for age, education and visual impairment. The MMSE performed comparably in both groups as a screen for moderate-severe dementia, but was less efficient at detecting milder and less certain cases in the Gujarati group. The estimated prevalence of confirmed dementia was higher in the Gujarati group, but this was not statistically significant. Conclusions. This Gujarati version of the MMSE performed adequately as a screen for dementia in this immigrant community population. Further evaluation of its performance is required in larger community samples, clinical samples and in native Indian Gujaratis. © 1997 John Wiley & Sons, Ltd.     

Adapting mini-mental state examination for dementia screening among illiterate or minimally educated elderly Chinese

BACKGROUND: Illiteracy is prevalent among current elderly Chinese. There are few brief cognitive tests in Chinese designed to screen those possibly demented for more detailed evaluation in a clinical setting. OBJECTIVES: The present study adapted the Mini-Mental State Examination (MMSE) for screening dementia among illiterate or less educated elderly Chinese. METHODS: Literacy-dependent items of the MMSE were modified or substituted by equivalent items that are not literacy-dependment. Some items were modified to provide socio-cultural compatibility. After developing it, the Chinese adapted MMSE (CAMSE) was administered to 370 elderly outpatients from Xijing hospitals located in Xi'an, China, 93 of whom were found to be demented and 277 non-demented. Sensitivities and specificities for detecting dementia were evaluated by adjusting for different CAMSE cut-off points. The optimal cut-off points of 22 for literates and 20 for illiterates yielded a sensitivity of 83.87% and a specificity of 84.48%. Corresponding positive predictive value (PPV) was 0.65, and negative predictive value (NPV) was 0.94. The impact of literacy on CAMSE and individual test items was also evaluated. Illiterate subjects got a higher CAMSE total score than literate subjects (p < 0.05). Only one out of 12 test items, serial sevens, was negatively influenced by illiteracy (p < 0.01). After an interval of 4-6 weeks, 32 randomly selected subjects were retested with CAMSE. The test-retest reliability for total scores was 0.75 (p < 0.01). CONCLUSIONS: Results suggest that in the socio-cultural context for Chinese, irrespective of their literacy skills, CAMSE proved feasible for use in clinical settings for dementia screening.     

The value of the clock drawing test and the mini-mental state examination for identifying vascular cognitive impairment no dementia

OBJECTIVE: To determine the validity of the Clock Drawing Test (CDT) and the Mini-Mental State Examination (MMSE) respectively or in combination for differentiating Vascular Cognitive Impairment No Dementia (V-CIND) from normal subjects. METHODS: Eighty V-CIND patients and 80 healthy control subjects were blindly evaluated with MMSE, CDT, and additional neuropsychological tests. CDT was scored according to the Rouleau method and AD Cooperative Study method. Sensitivities and specificities of the two CDT measures and MMSE for identifying V-CIND patients were determined. The Areas Under the Receiver Operating Characteristic Curve (AUCs) were compared, and the sensitivity of the combination of CDT with MMSE calculated. RESULTS: V-CIND group performed worse than controls on both MMSE (p < 0.0001) and the two CDTs (p < 0.0001). In differentiating V-CIND patients from normal subjects, the two CDT measures provided sensitivities of 68.7% and 65.0%, and specificities of 78.7% and 86.2% respectively at optimal cutoff scores, which did no better than MMSE (sensitivity 80%, specificity 70%) (comparison of the AUCs, p = 0.992 and 0.428). The sensitivity of MMSE was marginally higher than that of CDT scored with AD Cooperative Study method (p = 0.053). By combining the two CDT measures with MMSE, the sensitivity was improved to 93.7% and 92.5% respectively. CONCLUSIONS: Compared with MMSE, CDT is of only similar or even weaker ability for identifying V-CIND. MMSE at a cutoff of 28 may be of some value in detecting V-CIND patients. CDT and MMSE in combination provide a valid instrument for V-CIND screening.     

The reliability and validity of the korean version of the structured interview for prodromal syndrome

Objective

The Structured Interview for Prodromal Syndrome (SIPS) from Yale University is intended to diagnose prodromal syndrome of psychosis and to measure the severity of prodromal symptoms. Here, a Korean version of SIPS is presented, and its reliability, validity, and factor structures are examined using a representative Korean sample.

Methods

The Korean version of SIPS was administered to 40 participants over a period of 1 year. The inter-rater reliability and internal consistency of the SIPS were then evaluated. In addition, its factor structure was investigated using principal-axis factor analysis. Concurrent validity was explored using Pearson correlation coefficients with the Positive and Negative Syndrome Scale (PANSS).

Results

Of the 40 subjects, 12.5% developed psychotic disorders during the 1-year follow-up period. Inter-rater reliability was good (intra-class correlations=0.96), and internal consistency was acceptable (Cronbach''s alpha=0.83). A three-factor resolution displayed the best simple structure and accounted for 52.6% of all item variance. Factors 1 and 2 showed strong correlations with negative symptoms and cognitive dysfunction, respectively, on the PANSS. Factor 3 was not correlated with any factor on the PANSS.

Conclusion

The Korean version of SIPS is a reliable instrument for the assessment of prodromal symptoms in subjects and may be used to evaluate prodromal psychosis.     

Japanese version of the Test Your Memory as a screening test in a Japanese memory clinic

A self-administered cognitive test (Test Your Memory, TYM) is designed as a screening test for the detection of Alzheimer disease (AD). We compared the diagnostic utility of the Japanese version of the TYM (TYM-J) in AD and mild cognitive impairment (MCI) with that of the Mini-Mental State Examination (MMSE) and Alzheimer's Disease Assessment Scale—Cognitive Subscale Japanese version (ADAS-Jcog). We studied 79 patients with mild AD, 46 with MCI and 34 normal controls. The sensitivity and specificity of each test in the diagnosis of AD and MCI were compared. The average total TYM-J scores were 45.7 in controls, 41.7 in MCI, and 35.7 in AD. The TYM-J scores showed good correlations with other neuropsychological tests. The receiver operating characteristic analysis demonstrated that the TYM-J could better discriminate AD from controls and MCI from controls than the other tests. With each optimal cut-off score of the TYM-J, the sensitivity and specificity were 96% and 91% for diagnosing AD, and 76% and 74% for diagnosing MCI, respectively. The TYM-J is useful for the diagnosis of AD and MCI, and can be applied as a screening test in a Japanese memory clinic.     

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.     

A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment

The MMSE is the most widely used cognitive test but its accuracy and clinical utility in diagnosing cognitive disorders is not fully known. A meta-analysis of 34 dementia studies and five mild cognitive impairment (MCI) studies was conducted, separated into high and low prevalence settings.In memory clinic settings the MMSE had a pooled sensitivity (Se) of 79.8%, a specificity (Sp) of 81.3%, a positive predictive value (PPV) of 86.3% and a negative predictive value (NPV) of 73.0%. In mixed specialist hospital settings the Se, Sp, PPV and NPV were 71.1%, 95.6%, 94.2% and 76.4%, respectively. In non-clinical community settings the MMSE had a pooled Se of 85.1%, a Sp of 85.5%, a PPV of 34.5% and an NPV of 98.5%. In those studies conducted purely in primary care the Se, Sp, PPV and NPV were 78.4%, 87.8%. 53.6% and 95.7%, respectively.Thus the case-finding ability of the MMSE was best when confirming a suspected diagnosis in specialist settings with correct identification made in 27/30 positive results. It was modestly effective at ruling-out dementia in specialist settings. Conversely, in non-specialist settings, the MMSE was best at ruling out dementia, achieving about 29/30 correct reassurances with less than three false negatives out of every 100 screens.Regarding use of the MMSE in identifying MCI, limited evidence was found with only five robust studies comparing MCI with healthy subjects and three comparing Alzheimer’s disease with MCI. Provisionally, the MMSE had very limited value in making a diagnosis of MCI against healthy controls and modest rule-out accuracy. It had similarly limited ability to help identify cases of Alzheimer’s disease against MCI.In conclusion the MMSE offers modest accuracy with best value for ruling-out a diagnosis of dementia in community and primary care. For all other used it should be combined with or replaced by other methods.     

Continued clinical validation of dementia diagnosed in the community using the Cambridge Mental Disorders of the Elderly Examination

We describe the outcome 2 years later of elderly Cambridge residents who had been diagnosed as demented using the Cambridge Mental Disorders of the Elderly Examination. Mortality rates were high but diagnoses were confirmed for all of the 43 moderate and severe cases who survived for this period, and for 51 of the 56 subjects who had been rated initially as mildly demented; 28 of the 56 mildly demented subjects progressed to more severe levels of impairment. As many as 12 of the 24 original minimally demented cases showed evidence of intellectual deterioration, which lends weight to the validity of this experimental category.     

A follow-up study of dementia diagnosed in the community using the Cambridge Mental Disorders of the Elderly Examination

Elderly Cambridge residents diagnosed as demented using the Cambridge Mental Disorders of the Elderly Examination (CAMDEX) were reviewed approximately 12 months later. Diagnoses were confirmed in 133 of 137 surviving cases (97%). Subjects said to have minimal dementia (cognitive impairment insufficient to warrant a diagnosis of dementia proper) had a varied outcome. Only 6 out of 29 survivors showed progressive intellectual deterioration and 13 were reclassified as normal. Subjects passed as normal in the first year of the study were reviewed using the Mini-Mental State Examination. We cannot be certain how many were actually dementing, but our findings suggest that only a small number of false negative diagnoses were made in the first year of the study.     

Validity of a brazilian version of the mental status questionnaire as a screening test for dementia among elderly urban subjects. A pilot study

Validity of the Mental Status Questionnaire (MSQ) was assessed by comparing the screening scores against a standardized psychiatric evaluation, the Clinical Interview Schedule. In a pilot study patients with dementia were divided into two subgroups: Mild and moderate/severe cases. Including patients with mild dementia in the dementia group, the best balance between sensitivity and specificity fell at cutoff point 1/2. The validity coefficients were as follows: Sensitivity 80.0%, specificity 60.5% positive predictive value 10.5%, negative predictive value 98.1%, and overall misclassification rate 38.5%Including mild dementia in the non-dementia group, we observed that with six errors in the questionnaire the validity coefficients for moderate/severe dementia were: sensitivity 100.0%, specificity 94.4%, positive predictive value 16.7%, negative predictive value 100.0%, overall misclassification rate 5.5%. A discriminant analysis was run in order to select the most discriminant MSQ items for detecting dementia. Factors associated with misclassification in the questionnaire were investigated.     

Performance of the Italian version of the mini-mental state examination in day hospital geriatric medical patients

The criterion validity of the Italian version of the Mini-Mental State Examination was tested in a group (114) of elderly medically ill day patients. Specificity was rather disappointing (66.3%) at the conventional threshold (23/24), as well as positive predictive value (32.7%). A lower threshold (21/22) offered the best compromise between sensitivity (93.8%) and specificity (80.6%). ROC analysis evidenced a good overall performance of MMSE (area under the curve 0.938). In those subjects not affected by dementia, age, low education and depressive illness had a significant effect on MMSE scores.     

Comparison of rating scales for the diagnosis of dementia in adults with Down's syndrome

Making a diagnosis of dementia, particularly in its early stages, in a person with intellectual disability can be difficult. Some neuropsychological tests which were originally devised for the diagnosis of dementia in the non-intellectually disabled population have been modified for use in people with intellectual disability. Observer-rated scales have also been used for making a diagnosis of dementia in people with intellectual disability. Within the context of a genetic study, the rates of diagnosis of dementia according to different criteria, namely the clinician's diagnosis (ICD-10), the Dementia Questionnaire for Persons with Mental Retardation (DMR), the Dementia Scale for Down Syndrome (DSDS) and the Mini Mental State Examination (MMSE), were compared among 62 adults with Down's syndrome (26 demented and 36 non-demented adults according to the clinician's diagnosis). A comparison between the clinician's diagnosis and the diagnosis according to DMR criteria showed specificity and sensitivity at the 0.92 level for both categories. Similarly, a comparison between the clinician's diagnosis and the diagnosis according to the DSDS criteria showed a specificity of 0.89 and a sensitivity of 0.85. A good positive correlation was also shown between the scores of the DSDS and the DMR (Pearson's r = + 0.868, P 0.001). A similar positive correlation was found between the overall DSDS score and the scores in the main subcategories of the DMR. An MMSE could be performed in only 34 (55%) out of the 62 subjects with Down's syndrome. Out of the 30 subjects who had an MMSE score of less than 24 (the usual cut-off for the diagnosis of possible dementia), 23 (77%) did not have a diagnosis of dementia according to any criteria. It seems that the observer-rated scales, rather than the direct neuropsychological tests, are more useful for the diagnosis of dementia in people with an intellectual disability.     

Discriminant validity of a reduced set of Mini-Mental State Examination items for dementia and Alzheimer's disease.

Linear discriminant analysis was used to construct a series of discriminant functions including subsets of demographic variables and Mini-Mental State Examination item responses for a case series and a population sample. A 9-item discriminant function including the variables for time orientation, recall, calculation, copying a figure, age, writing, 3-step command, naming, and race distinguished demented subjects from community controls with 91% sensitivity and 88% specificity. The same discriminant function classified Alzheimer's disease patients and controls with 96% sensitivity and 98% specificity. This discriminant function has been cross-validated as a potential screening instrument for Alzheimer's disease in a community-based sample.