Hostname: page-component-78c5997874-4rdpn Total loading time: 0 Render date: 2024-11-05T00:49:59.481Z Has data issue: false hasContentIssue false
  • English
  • Français

The Mini-mental State Examination revisited: ceiling and floor effects after score adjustment for educational level in an aging Mexican population

Published online by Cambridge University Press:  07 September 2009

Francisco Franco-Marina ,
Jose Juan García-González ,
Fernando Wagner-Echeagaray ,
Joseph Gallo ,
Oscar Ugalde ,
Sergio Sánchez-García ,
Claudia Espinel-Bermúdez ,
Teresa Juárez-Cedillo ,
Miguel Ángel Villa Rodríguez  and
Carmen García-Peña
Francisco Franco-Marina
Affiliation:
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico Instituto Nacional de Enfermedades Respiratorias (INER), Mexico
Jose Juan García-González
Affiliation:
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
Fernando Wagner-Echeagaray
Affiliation:
Drug Abuse Research Program, Center for Health Disparities Solutions, School of Public Health and Policy, Morgan State University, Baltimore, Maryland, U.S.A.
Joseph Gallo
Affiliation:
Department of Family Practice and Community Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.
Oscar Ugalde
Affiliation:
Department of Geriatric Psychiatry, Nacional Institute of Psychiatry “Ramón de la Fuente”, Mexico
Sergio Sánchez-García
Affiliation:
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
Claudia Espinel-Bermúdez
Affiliation:
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
Teresa Juárez-Cedillo
Affiliation:
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
Miguel Ángel Villa Rodríguez
Affiliation:
Residencia en Neuropsicología Clínica. Facultad de Estudios Superiores Zaragoza, Universidad Nacional Autónoma de México
Carmen García-Peña*
Affiliation:
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
*
Correspondence should be addressed to: Carmen García Peña, MD, MSc, PhD, Unidad de Investigación Epidemiológica y en Servicios de Salud, Área de Envejecimiento. Edificio CORCE. Tercer piso. Centro Médico Nacional Siglo XXI, Avenida Cuauhtémoc no. 330, Col. Doctores, Delegación Cuauhtémoc, México D.F Código Postal 06725, México. Phone: +52 55–5627-6900 ext. 21846. Email: [email protected].
Get access Rights & Permissions [Opens in a new window]

Abstract

Background: The Mini-mental State Examination (MMSE) is the most widely used cognitive test, both in clinical settings and in epidemiological studies. However, correcting its score for education may create ceiling effects when used for poorly educated people and floor effects for those with higher education.

Methods: MMSE and a recent cognitive test, the seven minute screen (7MS), were serially administered to a community sample of Mexican elderly. 7MS test scores were equated to MMSE scores. MMSE-equated 7MS differences indicated ceiling or floor effects. An ordinal logistic regression model was fitted to identify predictors of such effects.

Results: Poorly educated persons were more prevalent on the side of MMSE ceiling effects. Concentration (serial-sevens), orientation and memory were the three MMSE subscales showing the strongest relationship to MMSE ceiling effects in the multivariate model.

Conclusion: Even when MMSE scores are corrected for educational level they still have ceiling and floor effects. These effects should be considered when interpreting data from longitudinal studies of cognitive decline. When an education-adjusted MMSE test is used to screen for cognitive impairment, additional testing may be required to rule out the possibility of mild cognitive impairment.

Keywords

MMSE ceiling effectsMMSE floor effectscognitive impairmentseven-minute screenMMSE serial-sevensMMSE education adjustment
Type
Research Article
Information
International Psychogeriatrics , Volume 22 , Issue 1 , February 2010 , pp. 72 - 81
Copyright
Copyright © International Psychogeriatric Association 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Andel, R., Vigen, C., Mack, W. J., Clark, L. J. and Gatz, M. (2006). The effect of education and occupational complexity on rate of cognitive decline in Alzheimer's patients. Journal of the International Neuropsychological Society, 12, 147–152.CrossRefGoogle ScholarPubMed
Ardila, A. (1998). A note of caution: neuropsychological test performance. Effects of age, education, gender and ethnicity: a comment on Saykin et al. (1995). Applied Neuropsychology, 5, 51–53.CrossRefGoogle ScholarPubMed
Cossa, F. M., Della Sala, S., Musicco, M., Spinnler, H. and Ubezio, M. C. (1997). Comparison of two scoring systems of the Mini-mental State Examination as a screening test for dementia. Journal of Clinical Epidemiology, 50, 961–965.CrossRefGoogle ScholarPubMed
Crum, R. M., Anthony, J. C., Bassett, S. S. and Folstein, M. F. (1993). Population-based norms for the Mini-mental State Examination by age and educational level. JAMA, 269, 2386–2391.CrossRefGoogle ScholarPubMed
del Ser, T., Sanchez-Sanchez, F., Garcia de Yebenes, M. J., Otero, A. and Munoz, D. G. (2006). Validation of the seven-minute screen neurocognitive battery for the diagnosis of dementia in a Spanish population-based sample. Dementia and Geriatric Cognitive Disorders, 22, 454–464.CrossRefGoogle Scholar
Fillenbaum, G. G., George, L. K. and Blazer, D. G. (1988). Scoring nonresponse on the Mini-mental State Examination. Psychological Medicine, 18, 1021–1025.CrossRefGoogle ScholarPubMed
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-mental state:” a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198.CrossRefGoogle ScholarPubMed
Galasko, D. R., Gould, R. L., Abramson, I. S. and Salmon, D. P. (2000). Measuring cognitive change in a cohort of patients with Alzheimer's disease. Statistics in Medicine, 19, 1421–1432.3.0.CO;2-P>CrossRefGoogle Scholar
García-Peña, C. et al. (2008). Depressive symptoms among older adults in Mexico City. Journal of General and Internal Medicine, 12, 1973–1980.CrossRefGoogle Scholar
Ganguli, M., Yangchun, D., Hiroko, D., Ratcliff, G. and Chung-Chou, C. (2006). Depressive symptoms and cognitive decline in late life. Archives of General Psychiatry, 63, 153–160.CrossRefGoogle ScholarPubMed
Hosmer, D. W. and Lemeshow, S. (2000). Applied Logistic Regression, 2nd edn. New York: Wiley.CrossRefGoogle Scholar
Jones, R. N. and Gallo, J. J. (2000). Dimensions of the Mini-mental State Examination among community dwelling older adults. Psychological Medicine, 30, 605–618.CrossRefGoogle ScholarPubMed
Kirby, M., Denihan, A., Bruce, I., Coakley, D. and Lawlor, B. A. (2001). The clock drawing test in primary care: sensitivity in dementia detection and specificity against normal and depressed elderly. International Journal of Geriatric Psychiatry, 16, 935–940.CrossRefGoogle ScholarPubMed
Kolen, M. J. and Brennan, R. L. (2004). Test Equating, Scaling, and Linking: Methods and Practices, 2nd edn. New York: Springer-Verlag.CrossRefGoogle Scholar
Marcopulos, B. A., Gripshover, D. L., Broshek, D. K., McLain, C. A. and Brashear, H. R. (1999). Neuropsychological assesment of psychogeriatric patients with limited education. Clinical Neuropsychology, 13, 147–156.CrossRefGoogle ScholarPubMed
McCarten, J. R., Rottunda, S. J. and Kuskowski, M. A. (2004). Change in the Mini-mental State Exam in Alzheimer's disease over 2 years: the experience of a dementia clinic. Journal of Alzheimer's Disease, 6, 11–15.CrossRefGoogle ScholarPubMed
Meulen, E. F. et al. (2004). The seven minute screen: a neurocognitive screening test highly sensitive to various types of dementia. Journal of Neurology, Neurosurgery and Psychiatry, 75, 700–705.CrossRefGoogle ScholarPubMed
Ostrosky-Solis, F., Lopez-Arango, G. and Ardila, A. (2000). Sensitivity and specificity of the Mini-mental State Examination in a Spanish-speaking population. Applied Neuropsychology, 7, 25–31.CrossRefGoogle Scholar
Reyes-Beaman, S. et al. (2004). Validation of a modified version of the Mini-mental State Examination (MMSE) in Spanish. Aging, Neuropsychology, and Cognition, 11, 1–11.CrossRefGoogle Scholar
Roe, C. M., Mintun, M. A., D'Angelo, G., Xiong, C., Grant, E. A. and Morris, J. C. (2008). Alzheimer disease and cognitive reserve: variation of education effect with carbon 11-labeled Pittsburgh Compound B uptake. Archives of Neurology, 65, 1467–1471.CrossRefGoogle ScholarPubMed
Rosselli, M., Tappen, R., Williams, C. and Salvatierra, J. (2006). The relation of education and gender on the attention items of the Mini-mental State Examination in Spanish-speaking Hispanic elders. Archives of Clinical Neuropsychology, 21, 677–686.CrossRefGoogle ScholarPubMed
Sinoff, G., Ore, L., Zlotogorsky, D. and Tamir, A. (1999). Short Anxiety Screening Test: a brief instrument for detecting anxiety in the elderly. International Journal of Geriatric Psychiatry, 14, 1062–1071.3.0.CO;2-Q>CrossRefGoogle Scholar
Skjerve, A., Nordhus, I. H., Engedal, K., Pallesen, S., Braekhus, A. and Nygaard, H. A. (2007). Seven minute screen performance in a normal elderly sample. International Journal of Geriatric Psychiatry, 22, 764–769.CrossRefGoogle Scholar
Solomon, P. R. and Pendlebury, W. W. (1998). Recognition of Alzheimer's disease: the 7 minute screen. Family Medicine, 30, 265–271.Google ScholarPubMed
Stern, Y. (2006). Cognitive reserve and Alzheimer disease. Alzheimer Disease and Associated Disorders, 20, 112–117.CrossRefGoogle ScholarPubMed
Strauss, E., Sherman, E. M. S. and Spreen, O. (2006). A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary, 3rd edn. New York: Oxford University Press.Google Scholar
Tombaugh, T. N. and McIntyre, N. J. (1992). The Mini-mental State Examination: a comprehensive review. Journal of the American Geriatrics Society, 40, 922–935.CrossRefGoogle ScholarPubMed
van Gorp, W. G., Marcotte, T. D., Sultzer, D., Hinkin, C., Mahler, M. and Cummings, J. L. (1999). Screening for dementia: comparison of three commonly used instruments. Journal of Clinical and Experimental Neuropsychology, 21, 29–38.CrossRefGoogle ScholarPubMed
Xu, G., Meyer, J. S., Thornby, J., Chowdhury, M. and Quach, M. (2002). Screening for mild CI (MCI) utilizing combined mini-mental-cognitive capacity examinations for identifying dementia prodromes. International Journal of Geriatric Psychiatry, 17, 1027–1033.CrossRefGoogle Scholar
Yesavage, J. A. et al. (1982–3). Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research, 17, 37–49.CrossRefGoogle Scholar