The Mini Mental State Examination: Review of cutoff points adjusted for schooling in a large Southern Brazilian sample

Kochhann, Renata; Varela, Juliana Santos; Lisboa, Carolina Saraiva de Macedo; Chaves, Márcia Lorena Fagundes

doi:10.1590/S1980-57642010DN40100006

Abstract

The increase in life expectancy can influence the prevalence of dementias in the population. Instruments that evaluate cognitive functions such as the Mini Mental State Examination (MMSE) are necessary for the investigation of dementia. The supposition that patient score on the MMSE can be influenced by academic level points to the need for establishing cut-off values that take into account educational level. The aim of this study was to review MMSE cut-off values adjusted for schooling in a large southern Brazilian sample. Method: Demographic data and MMSE scores of 968 subjects, of which 162 were dementia patients and 806 healthy participants, were analyzed. The sample was grouped according to education. The cut-off values were established by ROC Curve analysis. Results: The total sample mean age was 70.6±7.3 years, and the mean years of education was 7.2±5.3. The cut-off score of 23 points (sensitivity=86%, specificity=83%) was observed as the optimal level to detect dementia on the MMSE instrument for the overall sample. Regarding level of schooling, the cut-off values were: 21 for the illiterate group (sensitivity=93%, specificity=82%), 22 for the low education group (sensitivity=87%, specificity=82%), 23 for the middle education group (sensitivity=86%, specificity=87%) and 24 for the high education group (sensitivity=81%, specificity=87%). Conclusions: The cut-off values revealed by this analysis, and adjusted for level of schooling, can improve the clinical evaluation of cognitive deficits.

Key words:
Mini Mental State Examination; cognition; cognitive assessment; educational attainment; cutoffs

Resumo

A elevação da expectativa de vida pode influenciar na prevalência das demências na população. Instrumentos que avaliem as funções cognitivas, como o Mini Exame do Estado Mental (MEEM), são necessários para a investigação de demência. A suposição de que o resultado do MEEM de um paciente pode ser influenciado pelo nível de escolaridade demonstra a necessidade do estabelecimento de pontos de corte que levem em consideração a escolaridade. O objetivo deste estudo foi revisar os pontos de corte do MEEM ajustados para a escolaridade em uma grande amostra do sul do Brasil. Método: Dados demográficos e escores do MEEM de 968 indivíduos, 162 pacientes com demência e 806 participantes saudáveis foram analisados. A amostra foi agrupada de acordo com a educação. Para estabelecer os pontos de corte foi utilizada a Curva ROC. Resultados: A média de idade da amostra total foi 70,6±7,3 e a média de anos de estudo foi 7,2±5,3. O ponto de corte 23 (sensibilidade=86%), (especificidade=83%) foi o ponto que melhor detectou demência na amostra total. Considerando o nível de escolaridade, os pontos de corte foram: 21 no grupo de analfabetos (sensibilidade=93%, especificidade=82%), 22 no grupo de baixa escolaridade (sensibilidade=87%, especificidade=82%), 23 no grupo de média escolaridade (sensibilidade=86%, especificidade=87%) e 24 no grupo de alta escolaridade (sensibilidade=81%, especificidade=87%). Conclusões: Os pontos de corte, quando se considera a escolaridade, podem aperfeiçoar a avaliação clínica dos déficits cognitivos.

Palavras-chave:
Mini Exame do Estado Mental; cognição; avaliação cognitiva; nível educacional; pontos de corte

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

References

¹
Charchat H, Nitrini R, Caramelli P, Sameshima K. Investigação de marcadores clínicos dos estágios iniciais da doença de Alzheimer com testes neuropsicológicos computadorizados. Psicol Reflex Crít 2001;14:305-316.
²
Von Strauss EM, Viitanen D, De Ronchi D, et al. Aging and the occurrence of dementia. Arch Neurol 1999;56:587-592.
³
Manual diagnóstico e estatístico de transtornos mentais. 4. ed. Porto Alegre: Artes Médicas; 1995.
⁴
Almeida OP. Instrumentos para avaliação de pacientes com demência. Rev Psiq Clín 1999;26:78-89.
⁵
Argimon IIL, Timm LA, Rigoni MS, Oliveira MS. Instrumentos de avaliação de memória em idosos: uma revisão. Rev Bras Ciên Envelh Hum 2005;(jul./dez):28-35.
⁶
Bustamante SEZ, Bottino CMC, Lopes MA, et al. Instrumentos combinados na avaliação de demência em idosos: resultados preliminares. Arq Neuropsiquiatr 2003;61:601-606.
⁷
Jacqmin-Gadda H, Fabrigoule C, Commenges D, Letenneur L, Dartigues JF. A cognitive screening battery for dementia in the elderly. J Clin Epidemiol 2000;53:980-987.
⁸
Ardila A, Ostrosky-Solis F, Rosselli M, Gómez C. Age-related cognitive decline during normal aging: the complex effect of education. Arch Clin Neuropsychol 2000;15:495-513.
⁹
Köhler L, Siegfried W, Schäufele M. Proxy screening tools improve the recognition of dementia in old-age homes: results of a validation study. Age Ageing 2007;36:549-554.
¹⁰
Chaves MLF, Ilha D, Maia ALG, Motta E, Lehmen R, Oliveira LM. Diagnosing dementia and normal aging: clinical relevance of brain ratios and cognitive performance in a Brazilian sample. Braz J Med Biol Res 1999;32:1133-1143.
¹¹
Grigoletto F, Zappalà G, Anderson DW, Lebowitz B. Norms for the Mini-Mental State Examination in a healthy population. Neurology 1999;53:315-320.
¹²
Zhou DF, Wu CS, Qi H, et al. Prevalence of dementia in rural China: Impact of age, gender and education. Acta Neurol Scand 2006;114:273-280.
¹³
Chatfield M, Matthews FE, Brayne C and Medical Research Council Cognitive Function and Ageing Study. Using the Mini-Mental State Examination for tracking cognition in the older population based on longitudinal data. J Am Geriatr Soc 2007;55:1066-1071.
¹⁴
Espino DV, Lichtenstein MJ, Palmer RF, Hazuda HP. Evaluation of the Mini-Mental State Examination's internal consistency in a community-based sample of Mexican-American and European-American elders: results from the San Antonio longitudinal study of aging. J Am Geriatr Soc 2004;52:822-827.
¹⁵
Laks J, Baptista EMR, Contino ALB, Paula EO, Engelhardt E. Mini-Mental State Examination norms in a community-dwelling sample of elderly with lower schooling in Brazil. Cad Saúde Públ 2007;23:315-319.
¹⁶
Anthony JC, LeResche L, Niaz U, Von Korff MR, Folstein MF. Limits of the 'Mini-Mental State' as a screening test for dementia and delirium among hospital patients. Psychol Med 1982;12:397-408.
¹⁷
Di Carlo A, Baldereschi M, Amaducci L, et al. Incidence of dementia, Alzheimer's disease, and vascular dementia in Italy: The ILSA study. J Am Geriatr Soc 2002;50:41-48.
¹⁸
Aevarsson O, Skoog I. A longitudinal population study of the Mini-Mental State Examination in the very old: relation to dementia and education. Dement Geriatr Cogn Disord 2000; 11:166-175.
¹⁹
Black SA, Espino DV, Mahurin R, et al. The influence of non-cognitive factors on the Mini-Mental State Examination in Older Mexican-Americans: findings from the hispanic EPESE. J Clin Epidemiol 1999;52:1095-1102.
²⁰
Almeida OP. The Mini-Mental State Examination and the diagnosis of dementia in Brazil. Arq Neuropsiquiatr 1998;56: 605-612.
²¹
Machado JC, Ribeiro RCL, Leal PFG, Cotta RMM. Avaliação do declínio cognitivo e sua relação com as características socioeconômicas dos idosos em Viçosa-MG. Rev Bras Epidemiol 2007;10:592-605.
²²
Tombaugh TN, McIntyre NJ. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc 1992;40: 922-935.
²³
Fratiglioni L, Jorm AF, Grut M, et al. Predicting dementia from the Mini-Mental State Examination in an elderly population: the role of education. J Clin Epidemiol 1993; 46:281-287.
²⁴
Kahle-Wrobleski K, Corrada MM, Li B, Kawas CH. Sensitivity and specificity of the Mini-Mental State Examination for identifying dementia in the oldest-old: the 90+ study. J Am Geriatr Soc 2007;55:284-289.
²⁵
Rakusa M, Granda G, Kogoj A, Mlakar J, Vodusek DB. Mini-Mental State Examination: standardization and validation for the elderly Slovenian population. Eur J Neurol 2006;13:141-145.
²⁶
Bertolucci PHF, Brucki SMD, Campacci SR, Juliano Y. O mini-exame do estado mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.
²⁷
Uhlmann RF, Larson EB. Effect of education on the Mini-Mental State Examination as a screening test for dementia. J Am Geriatr Soc 1991;39:876-880.
²⁸
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do Mini-Exame do Estado Mental no Brasil. Arq Neuropsiquiatr 2003;61:777-781.
²⁹
Brito-Marques PR, Cabral-Filho JE. The role of education in Mini-Mental State Examination: a study in Northeast Brazil. Arq Neuropsiquiatr 2004;62:206-211.
³⁰
Chaves ML, Camozzato A, Godinho C, et al. Validity of the Clinical dementia rating scale for the detection and staging of dementia in Brazilian patients. Alz Dis Assoc Disord 2007; 21:210-217.
³¹
Kochhann R, Cerveira MO, Godinho C, Camozzato A, Chaves MLF. Evaluation of Mini-Mental State Examination scores according to different age and education strata and sex. Dement Neuropsychol 2009;3:88-93.
³²
Holsinger T, Deveau J, Boustani M, Williams JW. Does this patient have dementia? JAMA 2007;297:2391-2404.
³³
Leon J, Pearlman O, Doonan R, Simpson GM. A Study of bedside screening procedures for cognitive deficits in chronic psychiatric inpatients. Compreh Psychiatry 1996;37:328-335.
³⁴
Lourenço RA, Veras RP. Mini-Mental State Examination: psychometric characteristics in elderly outpatients. Rev Saúde Pública 2006;40:1-8.
³⁵
Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.
³⁶
Rosselli M, Tappen R, Williams C, Salvatierra J. The relation of education and gender on the attention items of the Mini-Mental State Examination in Spanish speaking Hispanic elders. Arch Clin Neuropsychol 2006;21:677-686.
³⁷
Chaves MLF, Izquierdo IA. Differential diagnosis between dementia and depression: a study of efficiency increment. Acta Neurol Scand 1992;85:378-382.
³⁸
Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Diagnóstico de doença de Alzheimer no Brasil. Avaliação cognitiva e funcional: aDepartamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr 2005; 63:720-727.
³⁹
Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review) report of the quality standards subcommittee of the American Academy of Neurology. Neurology 2001;56:1133-1142.
⁴⁰
Kochhann R, Camozzato AL, Godinho C, Cerveira MO, Forster LMK, Chaves MLF. Cognitive complaints compared to performance on a mental status screening test in elderly outpatients. Dement Neuropsychol 2008;2:46-51.
⁴¹
Vitiello APP, Ciríaco JGM, Takahashi DY, Nitrini R, Caramelli P. Avaliação cognitiva breve de pacientes atendidos em ambulatório de neurologia geral. Arq Neuropsiquiatr 2007;65:299-303.
⁴²
Ribeiro VM, Soares TM. Construção de escala combinada de proficiência em leitura e matemática para a medição do alfabetismo entre jovens e adultos em contextos não escolares.Disponível em: Disponível em: http://www.acaoeducativa.org.br/portal/images/stories/pdfs/artigo2008construcaodeescalacombinada.pdf Acessado em: 08/01/09.
» http://www.acaoeducativa.org.br/portal/images/stories/pdfs/artigo2008construcaodeescalacombinada.pdf

Publication Dates

Publication in this collection
Jan-Mar 2010

History

Received
30 Oct 2009
Accepted
27 Jan 2010

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Charchat H, Nitrini R, Caramelli P, Sameshima K. Investigação de marcadores clínicos dos estágios iniciais da doença de Alzheimer com testes neuropsicológicos computadorizados. Psicol Reflex Crít 2001;14:305-316.

[2] ²
Von Strauss EM, Viitanen D, De Ronchi D, et al. Aging and the occurrence of dementia. Arch Neurol 1999;56:587-592.

[3] ³
Manual diagnóstico e estatístico de transtornos mentais. 4. ed. Porto Alegre: Artes Médicas; 1995.

[4] ⁴
Almeida OP. Instrumentos para avaliação de pacientes com demência. Rev Psiq Clín 1999;26:78-89.

[5] ⁵
Argimon IIL, Timm LA, Rigoni MS, Oliveira MS. Instrumentos de avaliação de memória em idosos: uma revisão. Rev Bras Ciên Envelh Hum 2005;(jul./dez):28-35.

[6] ⁶
Bustamante SEZ, Bottino CMC, Lopes MA, et al. Instrumentos combinados na avaliação de demência em idosos: resultados preliminares. Arq Neuropsiquiatr 2003;61:601-606.

[7] ⁷
Jacqmin-Gadda H, Fabrigoule C, Commenges D, Letenneur L, Dartigues JF. A cognitive screening battery for dementia in the elderly. J Clin Epidemiol 2000;53:980-987.

[8] ⁸
Ardila A, Ostrosky-Solis F, Rosselli M, Gómez C. Age-related cognitive decline during normal aging: the complex effect of education. Arch Clin Neuropsychol 2000;15:495-513.

[9] ⁹
Köhler L, Siegfried W, Schäufele M. Proxy screening tools improve the recognition of dementia in old-age homes: results of a validation study. Age Ageing 2007;36:549-554.

[10] ¹⁰
Chaves MLF, Ilha D, Maia ALG, Motta E, Lehmen R, Oliveira LM. Diagnosing dementia and normal aging: clinical relevance of brain ratios and cognitive performance in a Brazilian sample. Braz J Med Biol Res 1999;32:1133-1143.

[11] ¹¹
Grigoletto F, Zappalà G, Anderson DW, Lebowitz B. Norms for the Mini-Mental State Examination in a healthy population. Neurology 1999;53:315-320.

[12] ¹²
Zhou DF, Wu CS, Qi H, et al. Prevalence of dementia in rural China: Impact of age, gender and education. Acta Neurol Scand 2006;114:273-280.

[13] ¹³
Chatfield M, Matthews FE, Brayne C and Medical Research Council Cognitive Function and Ageing Study. Using the Mini-Mental State Examination for tracking cognition in the older population based on longitudinal data. J Am Geriatr Soc 2007;55:1066-1071.

[14] ¹⁴
Espino DV, Lichtenstein MJ, Palmer RF, Hazuda HP. Evaluation of the Mini-Mental State Examination's internal consistency in a community-based sample of Mexican-American and European-American elders: results from the San Antonio longitudinal study of aging. J Am Geriatr Soc 2004;52:822-827.

[15] ¹⁵
Laks J, Baptista EMR, Contino ALB, Paula EO, Engelhardt E. Mini-Mental State Examination norms in a community-dwelling sample of elderly with lower schooling in Brazil. Cad Saúde Públ 2007;23:315-319.

[16] ¹⁶
Anthony JC, LeResche L, Niaz U, Von Korff MR, Folstein MF. Limits of the 'Mini-Mental State' as a screening test for dementia and delirium among hospital patients. Psychol Med 1982;12:397-408.

[17] ¹⁷
Di Carlo A, Baldereschi M, Amaducci L, et al. Incidence of dementia, Alzheimer's disease, and vascular dementia in Italy: The ILSA study. J Am Geriatr Soc 2002;50:41-48.

[18] ¹⁸
Aevarsson O, Skoog I. A longitudinal population study of the Mini-Mental State Examination in the very old: relation to dementia and education. Dement Geriatr Cogn Disord 2000; 11:166-175.

[19] ¹⁹
Black SA, Espino DV, Mahurin R, et al. The influence of non-cognitive factors on the Mini-Mental State Examination in Older Mexican-Americans: findings from the hispanic EPESE. J Clin Epidemiol 1999;52:1095-1102.

[20] ²⁰
Almeida OP. The Mini-Mental State Examination and the diagnosis of dementia in Brazil. Arq Neuropsiquiatr 1998;56: 605-612.

[21] ²¹
Machado JC, Ribeiro RCL, Leal PFG, Cotta RMM. Avaliação do declínio cognitivo e sua relação com as características socioeconômicas dos idosos em Viçosa-MG. Rev Bras Epidemiol 2007;10:592-605.

[22] ²²
Tombaugh TN, McIntyre NJ. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc 1992;40: 922-935.

[23] ²³
Fratiglioni L, Jorm AF, Grut M, et al. Predicting dementia from the Mini-Mental State Examination in an elderly population: the role of education. J Clin Epidemiol 1993; 46:281-287.

[24] ²⁴
Kahle-Wrobleski K, Corrada MM, Li B, Kawas CH. Sensitivity and specificity of the Mini-Mental State Examination for identifying dementia in the oldest-old: the 90+ study. J Am Geriatr Soc 2007;55:284-289.

[25] ²⁵
Rakusa M, Granda G, Kogoj A, Mlakar J, Vodusek DB. Mini-Mental State Examination: standardization and validation for the elderly Slovenian population. Eur J Neurol 2006;13:141-145.

[26] ²⁶
Bertolucci PHF, Brucki SMD, Campacci SR, Juliano Y. O mini-exame do estado mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.

[27] ²⁷
Uhlmann RF, Larson EB. Effect of education on the Mini-Mental State Examination as a screening test for dementia. J Am Geriatr Soc 1991;39:876-880.

[28] ²⁸
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do Mini-Exame do Estado Mental no Brasil. Arq Neuropsiquiatr 2003;61:777-781.

[29] ²⁹
Brito-Marques PR, Cabral-Filho JE. The role of education in Mini-Mental State Examination: a study in Northeast Brazil. Arq Neuropsiquiatr 2004;62:206-211.

[30] ³⁰
Chaves ML, Camozzato A, Godinho C, et al. Validity of the Clinical dementia rating scale for the detection and staging of dementia in Brazilian patients. Alz Dis Assoc Disord 2007; 21:210-217.

[31] ³¹
Kochhann R, Cerveira MO, Godinho C, Camozzato A, Chaves MLF. Evaluation of Mini-Mental State Examination scores according to different age and education strata and sex. Dement Neuropsychol 2009;3:88-93.

[32] ³²
Holsinger T, Deveau J, Boustani M, Williams JW. Does this patient have dementia? JAMA 2007;297:2391-2404.

[33] ³³
Leon J, Pearlman O, Doonan R, Simpson GM. A Study of bedside screening procedures for cognitive deficits in chronic psychiatric inpatients. Compreh Psychiatry 1996;37:328-335.

[34] ³⁴
Lourenço RA, Veras RP. Mini-Mental State Examination: psychometric characteristics in elderly outpatients. Rev Saúde Pública 2006;40:1-8.

[35] ³⁵
Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.

[36] ³⁶
Rosselli M, Tappen R, Williams C, Salvatierra J. The relation of education and gender on the attention items of the Mini-Mental State Examination in Spanish speaking Hispanic elders. Arch Clin Neuropsychol 2006;21:677-686.

[37] ³⁷
Chaves MLF, Izquierdo IA. Differential diagnosis between dementia and depression: a study of efficiency increment. Acta Neurol Scand 1992;85:378-382.

[38] ³⁸
Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Diagnóstico de doença de Alzheimer no Brasil. Avaliação cognitiva e funcional: aDepartamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr 2005; 63:720-727.

[39] ³⁹
Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review) report of the quality standards subcommittee of the American Academy of Neurology. Neurology 2001;56:1133-1142.

[40] ⁴⁰
Kochhann R, Camozzato AL, Godinho C, Cerveira MO, Forster LMK, Chaves MLF. Cognitive complaints compared to performance on a mental status screening test in elderly outpatients. Dement Neuropsychol 2008;2:46-51.

[41] ⁴¹
Vitiello APP, Ciríaco JGM, Takahashi DY, Nitrini R, Caramelli P. Avaliação cognitiva breve de pacientes atendidos em ambulatório de neurologia geral. Arq Neuropsiquiatr 2007;65:299-303.

[42] ⁴²
Ribeiro VM, Soares TM. Construção de escala combinada de proficiência em leitura e matemática para a medição do alfabetismo entre jovens e adultos em contextos não escolares.Disponível em: Disponível em: http://www.acaoeducativa.org.br/portal/images/stories/pdfs/artigo2008construcaodeescalacombinada.pdf Acessado em: 08/01/09.
» http://www.acaoeducativa.org.br/portal/images/stories/pdfs/artigo2008construcaodeescalacombinada.pdf

Brasil