Mini- Mental State Examination among lower educationl levels and illiterates: transcultural evaluation

Brucki, Sonia Maria Dozzi; Nitrini, Ricardo

doi:10.1590/S1980-57642010DN40200008

Abstract

Cognitive performance among illiterates and low educational levels is poorer than that observed in individuals with greater schooling. This difference can be a confounding factor in reaching an accurate diagnosis of cognitive impairment. In addition, there is great heterogeneity in performance among illiterates, probably due to different environmental demands and sociocultural backgrounds. Many reports have described the influence of education on neuropsychological measures and screening tests such as the Mini-Mental State Examination (MMSE).

Objectives:

To analyze performance in two samples with the same educational level, but different social and cultural backgrounds.

Methods:

Subjects from two different locations in Brazil (rural sample from Northern region and urban sample residing in the largest city of the Southeastern region) were matched for age and education, and submitted to the MMSE.

Results:

Significant differences between the groups were found in total scores on the MMSE and in temporal orientation and serial-sevens sub-items for which the urban sample performed best but analysis of illiterates alone yielded the same results, except for the copying pentagons task which was performed better by the rural sample.

Conclusions:

Cultural and social backgrounds, as well as demands from the environment, influence results of screening tests. Factors other than education must be taken into account when analyzing tests.

Key words:
Mini-Mental State Examination; illiteracy; educational level; screening test.

Resumo

O desempenho cognitivo entre iletrados e indivíduos com baixos níveis de escolaridade é pior do que observado entre indivíduos bem escolarizados. Esta diferença pode ser um fator de confusão quando um diagnóstico preciso de comprometimento cognitivo se faz necessário. Além disto, há uma grande heterogeneidade no desempenho destas pessoas, provavelmente devido a diferentes demandas ambientais, e base sociocultural. Muitos estudos tem descrito a influência educacional em medidas neuropsicológicas, bem como em testes de rastreio, como o Mini-Exame do Estado Mental (MEEM).

Objetivos:

Analisar o desempenho de duas amostras de mesmo nível educacional e diferentes bases sociais e culturais.

Métodos:

Indivíduos de dois locais no Brasil foram submetidos ao MEEM, pareados por idade e escolaridade.

Resultados:

Houve diferença significativa entre as amostras quanto ao escore total e sub-itens de orientação temporal e sete-seriados, com melhor desempenho para a amostra urbana, mas quando analisados somente os analfabetos, os mesmos resultados foram observados, exceto para a cópia dos pentágonos, onde a população rural teve desempenho melhor.

Conclusões:

A base social e cultural além das demandas do meio ambiente influenciam nos testes de rastreio. Outros fatores, além da educação, devem ser revistos quando analisarmos os testes.

Palavras-chave:
Mini-Exame do Estado Mental; analfabetismo; nível educacional; teste de rastreio.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

References

¹
Porto CS, Fichman HC, Caramelli P, Bahia VS, Nitrini R. Brazilian version of the Mattis Dementia Rating Scale: diagnosis of mild dementia in Alzheimer's Disease. Arq Neuropsiquiatr 2003;61:339-345.
²
Bertolucci PH, Okamoto IH, Brucki SM, Siviero MO, Toniolo Neto J, Ramos LR. Applicability of the CERAD neuropsychological battery to Brazilian elderly. Arq Neuropsiquiatr 2001; 59:532-6.
³
Schultz RR, Silviero MO, Bertolucci PHF. The cognitive subscale of the "Alzheimer's Disease Assessment Scale" in a Brazilian sample. Braz J Med Biol Res 2001;34:1295-1302.
⁴
Reis A, Castro-Caldas A. Illiteracy: a cause for biased cognitive development. J Intern Neuropsychol Soc 1997;3:444-450.
⁵
Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for clinician. J Psychiatr Res 1975;12:189-198.
⁶
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.
⁷
Crum RM, Anthony JC, Bassett SS, et al. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;269:2386-2391.
⁸
Fratiglioni L, Jorm AF, Grut M, et al. Predicting dementia from Mini-Mental State Examination in an elderly population: the role of education. J Clin Epidemiol 1993;46:281-287.
⁹
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.
¹⁰
Anthony JC, LeResche L, Niaz U, et al. Limits of the Mini-Mental State as a screening test for dementia and delirium among hospital patients. Psychol Med 1982;12:397-408.
¹¹
Escobar JI, Burnam A, Karno M, et al. Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. J Nerv Ment Dis 1986;174: 607-614.
¹²
Bird HR,Canino G, Rubio-Stipec M, et al. Use of the Mini-Mental State Examination in a probability sample of hispanic population. J Nerv Ment Dis 1989; 175: 731-735.
¹³
Rosselli D, Ardila A, Pradilla G, et al. El examen mental abreviado (Mini-Mental State Examination) como prueba de selección para el diagnóstico de demencia: estudio poblacional colombiano. Rev Neurol 2000;30:428-432.
¹⁴
Bertolucci PHF, Brucki SMD, Campacci S, et al. O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.
¹⁵
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Suggestions for utilization of the Mini-Mental State Examination in Brazil. Arq Neuropsiquiatr 2003;61:777-781.
¹⁶
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.
¹⁷
Lourenço RA & Veras RP. Mini-Mental State Examination: psychometric characteristics in elderly outpatients. Rev Saúde Pública 2006;40:712-719.
¹⁸
Scazufca M, Almeida OP, Vallada HP, Tasse WA, Menezes PR. Limitations of the Mini-Mental State Examination for screening dementia in a community with low socioeconomic status. Results from the Sao Paulo Ageing & Health Study. Eur Arch Psychiatry Clin Neurosci 2009;259:8-15.
¹⁹
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. Dem Neuropsychol 2009;3:88-93.
²⁰
Hofstede G, Malvezzi S, Tanure B, Vinken H. Comparing regional cultures within a country: lessons from Brazil. J Cross Cult Psychol 2010;41:336-352.
²¹
Escobar JI, Burnam A, Karno M, Forsythe A, Landsverk J, Golding JM. Use of Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts. J Nerv Ment Dis 1986;174:607-614.
²²
Tiwari SC, Tripathi RK, Kumar A. Applicability of the Mini-Mental State Examination (MMSE) and the Hindi Mental State Examination (HMSE) to the urban elderly in India: a pilot study. Int Psychogeriatr 2009;21:123-128.
²³
Cross-cultural comparisons of the Mini-Mental State Examination between Japanese and US cohorts. Int Psychogeriatr 2009;21:113-122.
²⁴
Ng TP, Niti M, Chiam PC, Kua EH. Ethnic and educational differences in cognitive test performance on Mini-Mental State Examination in Asians. Am J Geriatr Psychiatry 2007;15: 130-139.
²⁵
Shah A, Ellanchenny N, Suh GH. A comparative study of behavioral and psychological signs and symptoms of dementia in patients with dementia referred to psychogeriatric services in Korea and the United Kingdom. Int Psychogeriatr 2004; 16: 219-236.
²⁶
Jones RN. Identification of measurement differences between English and Spanish language versions of the Mini-Mental State Examination. Detecting differential item functioning using MIMIC modeling. Med Care 2006;44 (11 suppl 3):S124-133.
²⁷
Brucki SMD. Diferenças intragrupo no desempenho no Mini-Exame do Estado Mental (MEM) entre analfabetos: temas em neuropsicologia e neurolingüística. Série de Neuropsicologia vol 4. Ed. Benito P Damasceno, Maria Irma H Coudry. Tec Art 1995, São Paulo.

Publication Dates

Publication in this collection
Apr-Jun 2010

History

Received
19 Jan 2009
Accepted
20 Mar 2010

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

[1] ¹
Porto CS, Fichman HC, Caramelli P, Bahia VS, Nitrini R. Brazilian version of the Mattis Dementia Rating Scale: diagnosis of mild dementia in Alzheimer's Disease. Arq Neuropsiquiatr 2003;61:339-345.

[2] ²
Bertolucci PH, Okamoto IH, Brucki SM, Siviero MO, Toniolo Neto J, Ramos LR. Applicability of the CERAD neuropsychological battery to Brazilian elderly. Arq Neuropsiquiatr 2001; 59:532-6.

[3] ³
Schultz RR, Silviero MO, Bertolucci PHF. The cognitive subscale of the "Alzheimer's Disease Assessment Scale" in a Brazilian sample. Braz J Med Biol Res 2001;34:1295-1302.

[4] ⁴
Reis A, Castro-Caldas A. Illiteracy: a cause for biased cognitive development. J Intern Neuropsychol Soc 1997;3:444-450.

[5] ⁵
Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for clinician. J Psychiatr Res 1975;12:189-198.

[6] ⁶
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.

[7] ⁷
Crum RM, Anthony JC, Bassett SS, et al. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;269:2386-2391.

[8] ⁸
Fratiglioni L, Jorm AF, Grut M, et al. Predicting dementia from Mini-Mental State Examination in an elderly population: the role of education. J Clin Epidemiol 1993;46:281-287.

[9] ⁹
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.

[10] ¹⁰
Anthony JC, LeResche L, Niaz U, et al. Limits of the Mini-Mental State as a screening test for dementia and delirium among hospital patients. Psychol Med 1982;12:397-408.

[11] ¹¹
Escobar JI, Burnam A, Karno M, et al. Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. J Nerv Ment Dis 1986;174: 607-614.

[12] ¹²
Bird HR,Canino G, Rubio-Stipec M, et al. Use of the Mini-Mental State Examination in a probability sample of hispanic population. J Nerv Ment Dis 1989; 175: 731-735.

[13] ¹³
Rosselli D, Ardila A, Pradilla G, et al. El examen mental abreviado (Mini-Mental State Examination) como prueba de selección para el diagnóstico de demencia: estudio poblacional colombiano. Rev Neurol 2000;30:428-432.

[14] ¹⁴
Bertolucci PHF, Brucki SMD, Campacci S, et al. O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.

[15] ¹⁵
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Suggestions for utilization of the Mini-Mental State Examination in Brazil. Arq Neuropsiquiatr 2003;61:777-781.

[16] ¹⁶
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.

[17] ¹⁷
Lourenço RA & Veras RP. Mini-Mental State Examination: psychometric characteristics in elderly outpatients. Rev Saúde Pública 2006;40:712-719.

[18] ¹⁸
Scazufca M, Almeida OP, Vallada HP, Tasse WA, Menezes PR. Limitations of the Mini-Mental State Examination for screening dementia in a community with low socioeconomic status. Results from the Sao Paulo Ageing & Health Study. Eur Arch Psychiatry Clin Neurosci 2009;259:8-15.

[19] ¹⁹
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. Dem Neuropsychol 2009;3:88-93.

[20] ²⁰
Hofstede G, Malvezzi S, Tanure B, Vinken H. Comparing regional cultures within a country: lessons from Brazil. J Cross Cult Psychol 2010;41:336-352.

[21] ²¹
Escobar JI, Burnam A, Karno M, Forsythe A, Landsverk J, Golding JM. Use of Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts. J Nerv Ment Dis 1986;174:607-614.

[22] ²²
Tiwari SC, Tripathi RK, Kumar A. Applicability of the Mini-Mental State Examination (MMSE) and the Hindi Mental State Examination (HMSE) to the urban elderly in India: a pilot study. Int Psychogeriatr 2009;21:123-128.

[23] ²³
Cross-cultural comparisons of the Mini-Mental State Examination between Japanese and US cohorts. Int Psychogeriatr 2009;21:113-122.

[24] ²⁴
Ng TP, Niti M, Chiam PC, Kua EH. Ethnic and educational differences in cognitive test performance on Mini-Mental State Examination in Asians. Am J Geriatr Psychiatry 2007;15: 130-139.

[25] ²⁵
Shah A, Ellanchenny N, Suh GH. A comparative study of behavioral and psychological signs and symptoms of dementia in patients with dementia referred to psychogeriatric services in Korea and the United Kingdom. Int Psychogeriatr 2004; 16: 219-236.

[26] ²⁶
Jones RN. Identification of measurement differences between English and Spanish language versions of the Mini-Mental State Examination. Detecting differential item functioning using MIMIC modeling. Med Care 2006;44 (11 suppl 3):S124-133.

[27] ²⁷
Brucki SMD. Diferenças intragrupo no desempenho no Mini-Exame do Estado Mental (MEM) entre analfabetos: temas em neuropsicologia e neurolingüística. Série de Neuropsicologia vol 4. Ed. Benito P Damasceno, Maria Irma H Coudry. Tec Art 1995, São Paulo.

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