Cognitive complaints compared to performance on a mental state screening test in elderly outpatients

Kochhann, Renata; Camozzato, Ana Luiza; Godinho, Cláudia; Cerveiro, Maria Otília; Forster, Letícia M.K.; Chaves, Márcia Lorena Fagundes

doi:10.1590/S1980-57642009DN20100010

Abstract

Memory and other cognitive complaints are common in the elderly population. However, the clinical meaning of these complaints remains controversial. Objectives: The goal of this study was to investigate the association between cognitive complaints and performance on a mental state screening test in elderly patients attended for the first time at the Neurogeriatric and Dementia (NGA) Outpatient Clinic within a major University hospital. Methods: Two hundred patients referred to the NGA Clinic during 2005, 2006 and 2007 first semesters participated in the study. The variables of interest were: (a) source of and reason for referral; (b) whether or not they had previously been evaluated with the screening test (Mini Mental State Exam - MMSE) by their physicians before referral to our specialized clinic; (c) cognitive complaints; and (d) performance on the screening test (MMSE) at the NGA Clinic. Results: The main reason for referral to the NGA clinic was cognitive complaints 63% (N=126), where only 5% (N=10) of the referred patients had been previously evaluated by the cognitive screening test (MMSE or equivalent). Of the 135 patients who presented cognitive complaints during the first appointment, 52 (38%) presented MMSE scores below the education-adjusted cut-off. No association between cognitive complaint and performance on the MMSE during the first evaluation at the NGA Clinic was observed (c²=3.04, p=0.1). Conclusions: Although cognitive complaints among elders should not be disregarded, the mental state screening evaluation is crucial for the detection of clinically significant cognitive impairment.

Key words:
cognitive complaint; aging; elderly; Mini Mental State Exam; cognitive decline associated with aging; dementia; depression; memory

Resumo

Memória e outras queixas cognitivas são comuns na população idosa. No entanto, o significado clínico destas queixas permanece controverso. Objetivo: O objetivo deste estudo foi investigar a associação entre queixa cognitiva e desempenho em um teste de rastreio do estado mental em pacientes idosos que consultavam pela primeira vez no Ambulatório de Neurogeriatria e Demência (NGA) de um grande hospital universitário. Métodos: Duzentos pacientes que foram encaminhados ao Ambulatório de Neurogeriatria durante os primeiros semestres de 2005, 2006 e 2007 participaram do estudo. As variáveis de interesse foram: (a) fonte e razão do encaminhamento; (b) existência de avaliação, com um teste de rastreio (Mini Exame do Estado Mental - MEEM), pelos seus médicos assistentes prévia ao encaminhamento ao NGA; (c) queixa cognitiva na consulta do NGA, e (d) desempenho no teste de rastreio (MEEM) no Ambulatório NGA. Resultados: O principal motivo de encaminhamento ao ambulatório de NGA foi queixa cognitiva 63% (N=126), somente 5% (N=10) dos pacientes encaminhados foram submetidos a algum teste de rastreio cognitivo prévio (MEEM ou equivalente). Dos 135 pacientes com queixa cognitiva durante a primeira avaliação, 52 (38%) apresentavam escores do MEEM abaixo do ponto de corte, ajustados para escolaridade. Nenhuma associação entre queixa cognitiva e desempenho no MEEM durante a primeira avaliação no ambulatório de NGA foi observada (c²=3.04, p=0.1). Conclusões: Embora, queixas cognitivas entre idosos não devem ser ignoradas, avaliação, através de rastreio do estado mental, é crucial para detecção de comprometimento cognitivo clinicamente significativo.

Palavras-chaves:
queixa cognitiva; envelhecimento; idoso; Mini Exame do Estado Mental; declínio cognitivo associado ao envelhecimento; demência; depressão; memória

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References

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Schofield PW, Jacobs D, Marder K, Sano M, Stern Y. The validity of new memory complaints in the elderly. Arch Neurol 1997;54:756-759.
²
Barker A, Jones R, Jennison C. A prevalence study of age-associated memory impairment. Br J Psychiatry 1995;167:642-648.
³
Tobiansky R, Blizard R, Livingston G, Mann A. The Gospel Oak Study stage IV: the clinical relevance of subjective memory impairment in older people. Psychol Med 1995;25:779-786.
⁴
Jonker C, Launer LJ, Hooijer C, Lindeboom J. Memory complaints and memory impairment in older individuals. J Am Geriatr Soc 1996;44:44-49.
⁵
Larrabee GJ, Crook TH, III. Estimated prevalence of age-associated memory impairment derived from standardized tests of memory function. Int Psychogeriatr 1994;6:95-104.
⁶
Jorm AF, Christensen H, Henderson AS, Korten AE, Mackinnon AJ, Scott R. Complaints of cognitive decline in the elderly:a comparison of reports by subjects and informants in a community survey. Psychol Med 1994;24:365-374.
⁷
Kahn RL, Zarit SH, Hilbert NM, Niederehe G. Memory complaints and impairment in the aged. Arch Gen Psychiatry 1975;32:1569-1573.
⁸
Jonker C, Geerlings MI, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population based studies. Int J Geriatr Psychiatry 2000;15:983-991.
⁹
Stewart R, Russ C, Richards M, Brayne C, Lovestone S, Mann A. Depression, APOE genotype and subjective memory impairment:a cross-sectional study in an African-Caribbean population. Psychol Med 2001;31:431-440.
¹⁰
Comijs HC, Dik MG, Deeg DJ, Jonker C. The course of cognitive decline in older persons: results from the Longitudinal Aging Study Amsterdam. Dement Geriatr Cogn Disord 2004;17:136-142.
¹¹
Riedel-Heller SG, Schork A, Matschinger H, Angermeyer MC. Subjective memory loss-a sign of cognitive impairment in the elderly? An overview of the status of research. Gerontol Geriatr 2000;33:9-16.
¹²
O'Hara MW, Hinrichs JV, Kohout FJ, Wallace RB, Lemke JH. Memory complaint and memory performance in the depressed elderly. Psychol Aging 1986;3:208-214.
¹³
O'Connor DW, Pollitt PA, Roth M, Brook PB, Reiss BB. Memory complaints and impairment in normal, depressed and demented elderly persons identified in a community survey. Arch Gen Psychiatry 1990;47:224-227.
¹⁴
Sunderland A, Watts K, Baddeley AD, Harris JE. Subjective memory assessment and test performance in elderly adults. J Gerontol 1986;41:376-384.
¹⁵
McGlone J, Gupta S, Humphrey D, Oppenheimer S, Mirsen T, Evans DR. Screening for early dementia using memory complaints from patients and relatives. Arch Neurol 1990;47:1189-1193.
¹⁶
Bolla KI, Lindgren KN, Bonaccorsy C, Bleecker ML. Memory complaints in older adults: Fact or fiction? Arch Neurol 1991;48:61-64.
¹⁷
Poitrenaud J, Malbezin M, Guez D. Self-rating and psychometric assessment of age-related changes in memory among young-elderly managers. Dev Neuropsychol 1989;5:285-294.
¹⁸
Seidenberg M, Taylor MA, Haltiner A. Personality and self-report of cognitive functioning. Arch Clin Neuropsychol 1994;9:353-361.
¹⁹
Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual's complaints of memory impairment in early dementia. Neurology 2000;55:1724-1726.
²⁰
Geerlings MI, Jonker C, Bouter LM, Ader HJ, Schmand B. Association between memory complaints and incident Alzheimer's disease in elderly people with normal baseline cognition. Am J Psychiatry 1999;156:531-537.
²¹
Treves TA, Verchovsky R, Klimovitzky S, Korczyn AD. Incidence of dementia in patients with subjective memory complaints. Int Psychogeriatr 2005;17:265-273.
²²
Jorm AF, Christensen H, Korten AE, Jacomb PA, Henderson AS: Memory complaints as a precursor of memory impairment in older people:a longitudinal analysis over 7-8 years. Psychol Med 2001;31:441-449.
²³
Wang L, van Belle G, Crane PK, et al. Subjective memory deterioration and future dementia in people aged 65 and older. J Am Geriatr Soc 2004;52:2045-2051.
²⁴
St John P, Montgomery P. Are cognitively intact seniors with subjective memory loss more likely to develop dementia? Int J Geriatr Psychiatry. 2002;17:814-820.
²⁵
Dufouil C, Fuhrer R, Alperovitch A. Subjective cognitive complaints and cognitive decline: consequence or predictor? The epidemiology of vascular aging study. J Am Geriatr Soc 2005;53:616-621.
²⁶
Palmer K, Bäckman L, Winblad B, Fratiglioni L. Detection of Alzheimer's disease and dementia in the preclinical phase:population based cohort study. BMJ 2003;326:1-5.
²⁷
Gallassi R, Bisulli A, Oppi F, Poda R, Di C. Subjective cognitive complaints, neuropsychological performance, affective and behavioral symptoms in non-demented patients Int J Geriatr Psychiatry 2008;23:95-101.
²⁸
Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment: clinical characterization and outcome. Arch Neurol 1999;56:303-308.
²⁹
Crook T, Bahar H, Sudilovsky A. Age-associated memory impairment: diagnostic criteria and treatment strategies. Int J Neurol 1987;21:73-82.
³⁰
World Health Organization:The ICD-10 Classification of Mental and Behavioral Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva, World Health Organization, 1992.
³¹
Reid LM, MacLullich AMJ. Subjective memory complaints and cognitive impairment in older people. Dement Geriatr Cogn Disord 2006;22:471-485.
³²
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.
³³
Folstein M. Mini-mental and son. Int J Geriatr Psychiatry 1998;13:290-294.
³⁴
Nitrini R, Caramelli P, Bottino CM, Damasceno BP, Brucki SM, Anghinah R. Diagnóstico de Doença de Alzheimer no Brasil. Avaliação cognitiva e funcional. Recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr 2005;63:720-727.
³⁵
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.
³⁶
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.
³⁷
Chaves ML, Izquierdo IA. Differential Diagnosis between Dementia and Depression: a Study of Efficiency Increment. Acta Neurol Scand 1992;85:378-382.
³⁸
Almeida OP. Mini exame do estado mental e o diagnóstico de demência no Brasil. Arq Neuropsiquiatr 1998;56:605-612.
³⁹
Caramelli P, Herrera JR E, Nitrini R. O mini-exame do estado mental no diagnóstico de demência em idosos analfabetos. Arq Neuropsiquiatr 1999;57(supl. 1):7.
⁴⁰
Gagnon M, Dartiques JF, Mazaux JM, et al. Self-reported memory complaints and memory performance in elderly French community residents results of the PAQUID research program. Neuroepidemiology 1994;13:145-154.
⁴¹
Bassett SS, Folstein MF. Memory complaint memory performance and psychiatric diagnosis a community study. J Geriatr Psychiatry Neurol 1993;6:105-111.
⁴²
O'Brien JT, Beats B, Hill K, et al. Do subjective memory complaints precede dementia? A three-year follow-up of patients with supposed "benign senescent forgetfulness" Int J Geriatr Psychiatry 1992;7:481-486.
⁴³
Taylor JL, Miller TP, Tinklenberg JR. Correlates of memory decline: a 4-year longitudinal study of older adults with memory complaints. Psychol Aging 1992;7:185-193.
⁴⁴
Knopman DS. The initial recognition and diagnosis of Dementia. Am J Med 1998;104:2S-12S.
⁴⁵
Callahan CM, Hendrie JC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med 1995;122:422-429.
⁴⁶
Ravdin LD, Mattis PJ, Lachs MS. Assessment of cognition in primary care: neuropsychological evaluation of the geriatric patient. Geriatrics 2004;59:37-40.
⁴⁷
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.
⁴⁸
Uhlmann RF, Larson EBL. Effect of education on the mini-mental state examination as a screening test for dementia. J Am Geriatr Assoc 1991;39:876-880.
⁴⁹
Berr C, Wancata J, Ritchie K. Prevalence of dementia in the elderly in Europe. Eur Neuropsychopharmacol 2005;15:463-471.
⁵⁰
Rice DP, Fillit HM, Max W, Knopman DS, Lloyd JR, Duttagupta S. Prevalence, costs, and treatment of Alzheimer's disease and related dementia: a managed care perspective. Am J Manag Care 2001;7:809-818.
⁵¹
O´Connor DW, Pollitt PA , Treasure FP, et al. The influence of education, social class and sex on Mini-Mental State scores. Psychol Med 1989;19:771-779.
⁵²
Jorm AF, Scott R, Henderson AS, et al. Educational level differences on the Mini-Mental State: the role of test bias. Psychol Med 1988;18:727-731.
⁵³
Brucki, SMD. Mini-exame do estado mental: influência da escolaridade sobre os escores total e sub-itens. Rev Neuroci 1996;4:15-20.

Publication Dates

Publication in this collection
Jan-Mar 2008

History

Received
21 Jan 2008
Reviewed
09 Feb 2008
Accepted
19 Feb 2008

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

[1] ¹
Schofield PW, Jacobs D, Marder K, Sano M, Stern Y. The validity of new memory complaints in the elderly. Arch Neurol 1997;54:756-759.

[2] ²
Barker A, Jones R, Jennison C. A prevalence study of age-associated memory impairment. Br J Psychiatry 1995;167:642-648.

[3] ³
Tobiansky R, Blizard R, Livingston G, Mann A. The Gospel Oak Study stage IV: the clinical relevance of subjective memory impairment in older people. Psychol Med 1995;25:779-786.

[4] ⁴
Jonker C, Launer LJ, Hooijer C, Lindeboom J. Memory complaints and memory impairment in older individuals. J Am Geriatr Soc 1996;44:44-49.

[5] ⁵
Larrabee GJ, Crook TH, III. Estimated prevalence of age-associated memory impairment derived from standardized tests of memory function. Int Psychogeriatr 1994;6:95-104.

[6] ⁶
Jorm AF, Christensen H, Henderson AS, Korten AE, Mackinnon AJ, Scott R. Complaints of cognitive decline in the elderly:a comparison of reports by subjects and informants in a community survey. Psychol Med 1994;24:365-374.

[7] ⁷
Kahn RL, Zarit SH, Hilbert NM, Niederehe G. Memory complaints and impairment in the aged. Arch Gen Psychiatry 1975;32:1569-1573.

[8] ⁸
Jonker C, Geerlings MI, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population based studies. Int J Geriatr Psychiatry 2000;15:983-991.

[9] ⁹
Stewart R, Russ C, Richards M, Brayne C, Lovestone S, Mann A. Depression, APOE genotype and subjective memory impairment:a cross-sectional study in an African-Caribbean population. Psychol Med 2001;31:431-440.

[10] ¹⁰
Comijs HC, Dik MG, Deeg DJ, Jonker C. The course of cognitive decline in older persons: results from the Longitudinal Aging Study Amsterdam. Dement Geriatr Cogn Disord 2004;17:136-142.

[11] ¹¹
Riedel-Heller SG, Schork A, Matschinger H, Angermeyer MC. Subjective memory loss-a sign of cognitive impairment in the elderly? An overview of the status of research. Gerontol Geriatr 2000;33:9-16.

[12] ¹²
O'Hara MW, Hinrichs JV, Kohout FJ, Wallace RB, Lemke JH. Memory complaint and memory performance in the depressed elderly. Psychol Aging 1986;3:208-214.

[13] ¹³
O'Connor DW, Pollitt PA, Roth M, Brook PB, Reiss BB. Memory complaints and impairment in normal, depressed and demented elderly persons identified in a community survey. Arch Gen Psychiatry 1990;47:224-227.

[14] ¹⁴
Sunderland A, Watts K, Baddeley AD, Harris JE. Subjective memory assessment and test performance in elderly adults. J Gerontol 1986;41:376-384.

[15] ¹⁵
McGlone J, Gupta S, Humphrey D, Oppenheimer S, Mirsen T, Evans DR. Screening for early dementia using memory complaints from patients and relatives. Arch Neurol 1990;47:1189-1193.

[16] ¹⁶
Bolla KI, Lindgren KN, Bonaccorsy C, Bleecker ML. Memory complaints in older adults: Fact or fiction? Arch Neurol 1991;48:61-64.

[17] ¹⁷
Poitrenaud J, Malbezin M, Guez D. Self-rating and psychometric assessment of age-related changes in memory among young-elderly managers. Dev Neuropsychol 1989;5:285-294.

[18] ¹⁸
Seidenberg M, Taylor MA, Haltiner A. Personality and self-report of cognitive functioning. Arch Clin Neuropsychol 1994;9:353-361.

[19] ¹⁹
Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual's complaints of memory impairment in early dementia. Neurology 2000;55:1724-1726.

[20] ²⁰
Geerlings MI, Jonker C, Bouter LM, Ader HJ, Schmand B. Association between memory complaints and incident Alzheimer's disease in elderly people with normal baseline cognition. Am J Psychiatry 1999;156:531-537.

[21] ²¹
Treves TA, Verchovsky R, Klimovitzky S, Korczyn AD. Incidence of dementia in patients with subjective memory complaints. Int Psychogeriatr 2005;17:265-273.

[22] ²²
Jorm AF, Christensen H, Korten AE, Jacomb PA, Henderson AS: Memory complaints as a precursor of memory impairment in older people:a longitudinal analysis over 7-8 years. Psychol Med 2001;31:441-449.

[23] ²³
Wang L, van Belle G, Crane PK, et al. Subjective memory deterioration and future dementia in people aged 65 and older. J Am Geriatr Soc 2004;52:2045-2051.

[24] ²⁴
St John P, Montgomery P. Are cognitively intact seniors with subjective memory loss more likely to develop dementia? Int J Geriatr Psychiatry. 2002;17:814-820.

[25] ²⁵
Dufouil C, Fuhrer R, Alperovitch A. Subjective cognitive complaints and cognitive decline: consequence or predictor? The epidemiology of vascular aging study. J Am Geriatr Soc 2005;53:616-621.

[26] ²⁶
Palmer K, Bäckman L, Winblad B, Fratiglioni L. Detection of Alzheimer's disease and dementia in the preclinical phase:population based cohort study. BMJ 2003;326:1-5.

[27] ²⁷
Gallassi R, Bisulli A, Oppi F, Poda R, Di C. Subjective cognitive complaints, neuropsychological performance, affective and behavioral symptoms in non-demented patients Int J Geriatr Psychiatry 2008;23:95-101.

[28] ²⁸
Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment: clinical characterization and outcome. Arch Neurol 1999;56:303-308.

[29] ²⁹
Crook T, Bahar H, Sudilovsky A. Age-associated memory impairment: diagnostic criteria and treatment strategies. Int J Neurol 1987;21:73-82.

[30] ³⁰
World Health Organization:The ICD-10 Classification of Mental and Behavioral Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva, World Health Organization, 1992.

[31] ³¹
Reid LM, MacLullich AMJ. Subjective memory complaints and cognitive impairment in older people. Dement Geriatr Cogn Disord 2006;22:471-485.

[32] ³²
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.

[33] ³³
Folstein M. Mini-mental and son. Int J Geriatr Psychiatry 1998;13:290-294.

[34] ³⁴
Nitrini R, Caramelli P, Bottino CM, Damasceno BP, Brucki SM, Anghinah R. Diagnóstico de Doença de Alzheimer no Brasil. Avaliação cognitiva e funcional. Recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr 2005;63:720-727.

[35] ³⁵
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.

[36] ³⁶
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.

[37] ³⁷
Chaves ML, Izquierdo IA. Differential Diagnosis between Dementia and Depression: a Study of Efficiency Increment. Acta Neurol Scand 1992;85:378-382.

[38] ³⁸
Almeida OP. Mini exame do estado mental e o diagnóstico de demência no Brasil. Arq Neuropsiquiatr 1998;56:605-612.

[39] ³⁹
Caramelli P, Herrera JR E, Nitrini R. O mini-exame do estado mental no diagnóstico de demência em idosos analfabetos. Arq Neuropsiquiatr 1999;57(supl. 1):7.

[40] ⁴⁰
Gagnon M, Dartiques JF, Mazaux JM, et al. Self-reported memory complaints and memory performance in elderly French community residents results of the PAQUID research program. Neuroepidemiology 1994;13:145-154.

[41] ⁴¹
Bassett SS, Folstein MF. Memory complaint memory performance and psychiatric diagnosis a community study. J Geriatr Psychiatry Neurol 1993;6:105-111.

[42] ⁴²
O'Brien JT, Beats B, Hill K, et al. Do subjective memory complaints precede dementia? A three-year follow-up of patients with supposed "benign senescent forgetfulness" Int J Geriatr Psychiatry 1992;7:481-486.

[43] ⁴³
Taylor JL, Miller TP, Tinklenberg JR. Correlates of memory decline: a 4-year longitudinal study of older adults with memory complaints. Psychol Aging 1992;7:185-193.

[44] ⁴⁴
Knopman DS. The initial recognition and diagnosis of Dementia. Am J Med 1998;104:2S-12S.

[45] ⁴⁵
Callahan CM, Hendrie JC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med 1995;122:422-429.

[46] ⁴⁶
Ravdin LD, Mattis PJ, Lachs MS. Assessment of cognition in primary care: neuropsychological evaluation of the geriatric patient. Geriatrics 2004;59:37-40.

[47] ⁴⁷
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.

[48] ⁴⁸
Uhlmann RF, Larson EBL. Effect of education on the mini-mental state examination as a screening test for dementia. J Am Geriatr Assoc 1991;39:876-880.

[49] ⁴⁹
Berr C, Wancata J, Ritchie K. Prevalence of dementia in the elderly in Europe. Eur Neuropsychopharmacol 2005;15:463-471.

[50] ⁵⁰
Rice DP, Fillit HM, Max W, Knopman DS, Lloyd JR, Duttagupta S. Prevalence, costs, and treatment of Alzheimer's disease and related dementia: a managed care perspective. Am J Manag Care 2001;7:809-818.

[51] ⁵¹
O´Connor DW, Pollitt PA , Treasure FP, et al. The influence of education, social class and sex on Mini-Mental State scores. Psychol Med 1989;19:771-779.

[52] ⁵²
Jorm AF, Scott R, Henderson AS, et al. Educational level differences on the Mini-Mental State: the role of test bias. Psychol Med 1988;18:727-731.

[53] ⁵³
Brucki, SMD. Mini-exame do estado mental: influência da escolaridade sobre os escores total e sub-itens. Rev Neuroci 1996;4:15-20.

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