Formal education, health literacy and Mini-Mental State Examination

Brucki, Sonia Maria Dozzi; Mansur, Letícia Lessa; Carthery-Goulart, Maria Teresa; Nitrini, Ricardo

doi:10.1590/S1980-57642011DN05010005

Abstract

The Mini-Mental State Examination (MMSE) is a widely used screening test for cognitive impairment, but is heavily biased by education. Educational level has frequently been ranked using years of schooling, which may not be a good indirect measure of educational level because there is great heterogeneity in standards of schooling among populations and across regions of the same country. S-TOFHLA is a measure of health literacy with some results indicating that it is a good measure for literacy level.

Objective: To evaluate the correlations between years of schooling and scores on the S-TOFHLA and the MMSE.

Methods: Healthy subjects without cognitive impairment were submitted to the S-TOFHLA and the MMSE. Correlations and regression analysis were performed to determine possible associations among variables.

Results: Both years of schooling and S-TOFHLA scores were strongly correlated with MMSE scores, but the strongest association was reached by the S-TOFHLA (r=0.702, p<0.01), where the S-TOFHLA was the best predictor of MMSE scores (R²=0.494, p<0.001).

Conclusions: A stronger association between S-TOFHLA scores and MMSE performance was found than between years of education and MMSE scores. This finding justifies further studies incorporating years of schooling together with S-TOFHLA score, to evaluate cognitive performance.

Key words: literacy; health literacy; functional literacy; S-TOFHLA; education; Mini-Mental State Examination

Resumo

O Mini-Exame do Estado Mental (MEEM) é um teste de rastreio para comprometimento cognitivo largamente utilizado, porém, é fortemente influenciado pela educação. Nível educacional tem sido frequentemente avaliado usando-se o nível de escolaridade, o que pode não ser uma boa medida indireta de nível educacional, porque existe uma grande heterogeneidade entre a escolarização entre populações e mesmo entre regiões de um mesmo país. S-TOFHLA é uma medida de alfabetismo em saúde, com alguns resultados indicando que seja uma boa medida para nível de alfabetismo.

Objetivos: Avaliar as correlações entre anos de escolarização e os escores no S-TOFHLA e MEEM. Correlações e análise de regressão foram realizadas para determinar possíveis associações entre as variáveis.

Resultados: Ambos, anos de escolarização e escores no S-TOFHLA, foram fortemente correlacionados aos escores do MEEM, porém, a associação mais forte foi atingida pelo S-TOFHLA (r=0.702, p<0.01) e o S-TOFHLA foi o melhor preditor para os escores do MMSE (R²=0.494, p<0.001).

Conclusões: Uma associação mais forte foi alcançada entre os escores no S-TOFHLA e MEEM do que os anos de educação alcançados, este achado pode justificar outros estudos com a incorporação dos anos de escolarização junto aos escores no S-TOFHLA para avaliar o desempenho cognitivo.

Palavras-chave: alfabetismo; alfabetismo em saúde; alfabetismo funcional; S-TOFHLA; Mini-Exame do Estado Mental

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References

Instituto Brasileiro de Geografia e Estatística (IBGE). http://www. ibge.gov.br
» http://www. ibge.gov.br
Brucki SMD, Nitrini R. Subjective memory impairment in a rural population with low education in the Amazon rainforest: an exploratory study. Int Psychogeriatr 2009;21:164-171.
Moreira DA. Analfabetismo funcional: o mal nosso de cada dia. Ed Thomson, São Paulo, 2003.
Neri, AL. Idosos no Brasil: vivências, desafios e expectativas na terceira idade. Edições SESC SP, Co-edição Fundação Perseu Abramo, 2007.
Nitrini R, Bottino CMC, Albala C, et al. Prevalence of dementia in Latin America: a collaborative study of population-based cohorts. Int Psychogeriatr 2009;21:622-630.
Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psych Res 1975;13:189-198.
Magaziner J, Bassett SS, Hebel JR. Predicting performance on the Mini-Mental State Examination: use of age- and education-specific equations. J Am Geriatr Soc 1987;35:996-1000.
Bird HR, Canino G, Rubio-Stipec M, et al. Use of Mini-Mental State Examination in a probability sample of Hispanic population. J Nerv Ment Dis 1989;175:731-735.
Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;369:2386-2391.
Bertolucci PHF, Brucki SMD, Campacci S, Julião Y. O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.
Brucki SMD, Nitrini R, Caramelli P, Okamoto IH, Bertolucci PHF. Suggestions for utilization of Mini-Mental State Examination in Brazil. Arq Neuropsiquiatr 2003;61:777-781.
Laks J, Baptista EM, Contino AL, de Paula EO, Engelhardt E. Mini-Mental State Examination norms in a community dwelling sample of elderly with low schooling in Brazil. Cad Saude Publica 2007;23:315-319.
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, in a large Brazilian healthy sample. Dement Neuropsychol 2009;3:88-93.
Nitrini R, Caramelli P, Bottino CM, Damasceno BP, Brucki SM, Anghinah R. Diagnosis of Alzheimer's disease in Brazil: cognitive and functional evaluation. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Arq Neuropsiquiatr 2005;63:720-727.
Brucki SMD, Nitrini R. Mini-Mental State Examination among lower educational levels and illiterates: transcultural evaluation. Dement Neuropsychol 2010;4:120-125.
Mayeux EJ, Jr Davis TC, Jackson RH, et al. Literacy and self-reported educational levels in relation to Mini-Mental State Examination scores. Fam Med 1995;37: 658-662.
Baker DW, Gazmarian JA, Sudano J, Patterson M, Parker RM, Williams MV. Health literacy and performance on the Mini-Mental State Examination. Aging Ment Health 2002;6: 22-29.
Williams MV, Parker RM, Baker DW et al. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995;274:1677-1682.
Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Pat Edu Counsell 1999;38:33-42.
Carthery-Goulart MT, Anghinah R, Areza-Fegyveres R, et al. Performance of a Brazilian population on the test of functional health literacy in adults. Rev Saude Publica 2009;43:631-638.
Oliveira MO, Porto CS, Brucki SMD. S-TOFHLA in mild Alzheimer's disease and Mild Cognitive Impairment patients as a measure of functional literacy: preliminary study. Dement Neuropsychol 2009;3:291-298.
Pfeffer RI, Kurosaki TT, Harrah CH, Chance JM, Filis S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323-329.
Baker DW, Gazmararian JA, Sudano J, et al. Health literacy and performance on the Mini-Mental State Examination. Aging Ment Health 2002;6:22-29.
Federman AD, Sano M, Wolf MS, Siu AL, Halm EA. Health literacy and cognitive performance in older adults. J Am Geriatr Soc 2009;57:1475-1480.
Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med 2005;20:175-184.
Jeppesen KM, Coyle JD, Miser WF. Screening questions to predict limited health literacy: a cross-sectional study of patients with diabetes mellitus. Ann Fam Med 2009;7:24-31.

Publication Dates

Publication in this collection
Jan-Mar 2011

History

Received
03 Dec 2010
Accepted
05 Feb 2011

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

[1] Instituto Brasileiro de Geografia e Estatística (IBGE). http://www. ibge.gov.br
» http://www. ibge.gov.br

[2] Brucki SMD, Nitrini R. Subjective memory impairment in a rural population with low education in the Amazon rainforest: an exploratory study. Int Psychogeriatr 2009;21:164-171.

[3] Moreira DA. Analfabetismo funcional: o mal nosso de cada dia. Ed Thomson, São Paulo, 2003.

[4] Neri, AL. Idosos no Brasil: vivências, desafios e expectativas na terceira idade. Edições SESC SP, Co-edição Fundação Perseu Abramo, 2007.

[5] Nitrini R, Bottino CMC, Albala C, et al. Prevalence of dementia in Latin America: a collaborative study of population-based cohorts. Int Psychogeriatr 2009;21:622-630.

[6] Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psych Res 1975;13:189-198.

[7] Magaziner J, Bassett SS, Hebel JR. Predicting performance on the Mini-Mental State Examination: use of age- and education-specific equations. J Am Geriatr Soc 1987;35:996-1000.

[8] Bird HR, Canino G, Rubio-Stipec M, et al. Use of Mini-Mental State Examination in a probability sample of Hispanic population. J Nerv Ment Dis 1989;175:731-735.

[9] Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;369:2386-2391.

[10] Bertolucci PHF, Brucki SMD, Campacci S, Julião Y. O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.

[11] Brucki SMD, Nitrini R, Caramelli P, Okamoto IH, Bertolucci PHF. Suggestions for utilization of Mini-Mental State Examination in Brazil. Arq Neuropsiquiatr 2003;61:777-781.

[12] Laks J, Baptista EM, Contino AL, de Paula EO, Engelhardt E. Mini-Mental State Examination norms in a community dwelling sample of elderly with low schooling in Brazil. Cad Saude Publica 2007;23:315-319.

[13] 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, in a large Brazilian healthy sample. Dement Neuropsychol 2009;3:88-93.

[14] Nitrini R, Caramelli P, Bottino CM, Damasceno BP, Brucki SM, Anghinah R. Diagnosis of Alzheimer's disease in Brazil: cognitive and functional evaluation. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Arq Neuropsiquiatr 2005;63:720-727.

[15] Brucki SMD, Nitrini R. Mini-Mental State Examination among lower educational levels and illiterates: transcultural evaluation. Dement Neuropsychol 2010;4:120-125.

[16] Mayeux EJ, Jr Davis TC, Jackson RH, et al. Literacy and self-reported educational levels in relation to Mini-Mental State Examination scores. Fam Med 1995;37: 658-662.

[17] Baker DW, Gazmarian JA, Sudano J, Patterson M, Parker RM, Williams MV. Health literacy and performance on the Mini-Mental State Examination. Aging Ment Health 2002;6: 22-29.

[18] Williams MV, Parker RM, Baker DW et al. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995;274:1677-1682.

[19] Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Pat Edu Counsell 1999;38:33-42.

[20] Carthery-Goulart MT, Anghinah R, Areza-Fegyveres R, et al. Performance of a Brazilian population on the test of functional health literacy in adults. Rev Saude Publica 2009;43:631-638.

[21] Oliveira MO, Porto CS, Brucki SMD. S-TOFHLA in mild Alzheimer's disease and Mild Cognitive Impairment patients as a measure of functional literacy: preliminary study. Dement Neuropsychol 2009;3:291-298.

[22] Pfeffer RI, Kurosaki TT, Harrah CH, Chance JM, Filis S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323-329.

[23] Baker DW, Gazmararian JA, Sudano J, et al. Health literacy and performance on the Mini-Mental State Examination. Aging Ment Health 2002;6:22-29.

[24] Federman AD, Sano M, Wolf MS, Siu AL, Halm EA. Health literacy and cognitive performance in older adults. J Am Geriatr Soc 2009;57:1475-1480.

[25] Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med 2005;20:175-184.

[26] Jeppesen KM, Coyle JD, Miser WF. Screening questions to predict limited health literacy: a cross-sectional study of patients with diabetes mellitus. Ann Fam Med 2009;7:24-31.