Is the Mini-Mental State Examination the best cognitive screening test for less educated people?

ABSTRACT

Mini-Mental State Examination (MMSE) results are strongly influenced by educational level. The Brief Cognitive Screening Battery (BCSB) is an alternative assessment tool that provides more accurate results in individuals with less education.

Objective: Our aim was to compare the MMSE and BCSB as screening tests.

Methods: The MMSE and BCSB were assessed in 112 participants by two evaluators blind to the other test's result. Participants were classified according to their level of education. The influence of education level was analyzed using the Kruskal-Wallis and multiple comparison tests.

Results: Scores of the MMSE (p < 0.0001) and the clock-drawing test (p < 0.0001) were influenced by education level but the delayed recall test score was not (p = 0.0804). The verbal fluency test (p = 0.00035) was influenced only by higher educational levels. It took three minutes less to apply the MMSE than to apply the BCSB (p < 0.0001).

Conclusions: These findings suggest that the delayed recall test and the verbal fluency test of the BCSB are better than the MMSE and clock-drawing test as tools for evaluating cognition in people with limited education.

Resumo

Os resultados do Mini-Exame de Estado Mental (MEEM) são consideravelmente influenciados pelo nível de escolaridade. A Bateria Breve de Rastreio Cognitivo (BBRC) é uma ferramenta de rastreamento cognitivo alternativa que fornece resultados mais acurados em indivíduos com menor nível de escolaridade.

Objetivo: Comparar o MEEM e a BBRC como testes de rastreamento cognitivo.

Métodos: 112 participantes foram submetidos ao MEEM e a BBRC por 2 avaliadores cegos para o resultados do outro teste. Os participantes foram classificados de acordo o nível de escolaridade. A influência do nível de escolaridade foi analisada utilizando o teste de Kruskal-Wallis e o teste de comparações múltiplas.

Resultados: As pontuações do MEEM (p < 0,0001) e do teste do desenho do relógio (p < 0,0001) foram influenciadas pelo nível de escolaridade, porém o teste de memória tardia não sofreu influência do nível de escolaridade (p = 0,0804). O teste de fluência verbal (p = 0,00035) foi influenciado apenas pelos níveis educacionais mais altos. A aplicação do MEEM levou 3 minutos a menos que a da BBRC (p < 0,0001).

Conclusão: Os achados desse estudo sugerem que o teste de memória tardia e o teste de fluência verbal da BBRC são mais adequados que o MEEM e o teste do desenho do relógio como ferramentas para avaliação cognitiva em populações com menor nível educacional.

Keywords:

Dementia - cognition - cognition disorders - memory

Palavras-chave:

Demência - cognição - transtornos cognitivos - memória

• References

• 1 Langa KM, Levine DA. The diagnosis and management of mild cognitive impairment: a clinical review. JAMA. 2014 Dec;312(23):2551-61. https://doi.org/10.1001/jama.2014.13806
• 2 Arevalo-Rodriguez I, Smailagic N, Roqué I Figuls M, Ciapponi A, Sanchez-Perez E, Giannakou A, et al. Mini-Mental State Examination (MMSE) for the detection of Alzheimer's disease and other dementias in people with mild cognitive impairment (MCI). Cochrane Database Syst Rev. 2015 Mar;(3):CD010783.
• 3 Mitchell AJ. A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment. J Psychiatr Res. 2009 Jan;43(4):411-31. https://doi.org/10.1016/j.jpsychires.2008.04.014
• 4 Grigoletto F, Zappalà G, Anderson DW, Lebowitz BD. Norms for the Mini-Mental State Examination in a healthy population. Neurology. 1999 Jul;53(2):315-20. https://doi.org/10.1212/WNL.53.2.315
• 5 Velayudhan L, Ryu SH, Raczek M, Philpot M, Lindesay J, Critchfield M, et al. Review of brief cognitive tests for patients with suspected dementia. Int Psychogeriatr. 2014 Aug;26(8):1247-62. https://doi.org/10.1017/S1041610214000416
• 6 Vitiello AP, Ciríaco JG, Takahashi DY, Nitrini R, Caramelli P. [Brief cognitive evaluation of patients attended in a general neurological outpatient clinic]. Arq Neuropsiquiatr. 2007 Jun;65(2A):299-303. Portuguese. https://doi.org/10.1590/S0004-282X2007000200021
• 7 Nitrini R, Lefèvre BH, Mathias SC, Caramelli P, Carrilho PE, Sauaia N, et al. [Neuropsychological tests of simple application for diagnosing dementia]. Arq Neuropsiquiatr. 1994 Dec;52(4):457-65. Portuguese. https://doi.org/10.1590/S0004-282X1994000400001
• 8 Nitrini R, Caramelli P, Herrera Júnior E, Porto CS, Charchat-Fichman H, Carthery MT, et al. Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory. J Int Neuropsychol Soc. 2004 Jul;10(4):634-8. https://doi.org/10.1017/S1355617704104062
• 9 Nitrini R, Caramelli P, Porto CS, Charchat-Fichman H, Formigoni AP, Carthery-Goulart MT, et al. Brief cognitive battery in the diagnosis of mild Alzheimer's disease in subjects with medium and high levels of education. Dement Neuropsychol. 2007 Jan-Mar;1(1):32-6. https://doi.org/10.1590/S1980-57642008DN10100006
• 10 Molinuevo JL, Rabin LA, Amariglio R, Buckley R, Dubois B, Ellis KA, et al. Implementation of subjective cognitive decline criteria in research studies. Alzheimers Dement. 2017 Mar;13(3):296-311. https://doi.org/10.1016/j.jalz.2016.09.012
• 11 Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr. 2003 Sep;61(3B):777-81. https://doi.org/10.1590/S0004-282X2003000500014
• 12 Petersen RC, Aisen PS, Beckett LA, Donohue MC, Gamst AC, Harvey DJ, et al. Alzheimer's Disease Neuroimaging Initiative (ADNI): clinical characterization. Neurology. 2010 Jan;74(3):201-9. https://doi.org/10.1212/WNL.0b013e3181cb3e25
• 13 Fichman-Charchat H, Miranda CV, Fernandes CS, Mograbi D, Oliveira RM, Novaes R, et al. Brief Cognitive Screening Battery (BCSB) is a very useful tool for diagnosis of probable mild Alzheimer's disease in a geriatric clinic. Arq Neuropsiquiatr. 2016 Feb;74(2):149-54. https://doi.org/10.1590/0004-282X20150202
• 14 Bertolluci PH, Brucki SM, Campacci SR, Juliano Y. [The Mini-Mental State Examination in a general population: impact of educational status]. Arq Neuropsiquiatr. 1994 Mar;52(1):1-7. Portuguese. https://doi.org/10.1590/S0004-282X1994000100001
• 15 Almeida OP. Mini mental state examination and the diagnosis of dementia in Brazil. Arq Neuropsiquiatr. 1998 Sep;56(3B):605-12. https://doi.org/10.1590/S0004-282X1998000400014
• 16 Lourenço RA, Veras RP. Mini-Mental State Examination: psychometric characteristics in elderly outpatients. Rev Saude Publica. 2006 Aug;40(4):712-9. https://doi.org/10.1590/S0034-89102006000500023
• 17 Melo DM, Barbosa AJ. [Use of the Mini-Mental State Examination in research on the elderly in Brazil: a systematic review]. Cien Saude Colet. 2015 Dec;20(12):3865-76. Portuguese. https://doi.org/10.1590/1413-812320152012.06032015
• 18 Passos VMA, Giatti L, Bensenor I, Tiemeier H, Ikram MA, Figueiredo RC, et al. Education plays a greater role than age in cognitive test performance among participants of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). BMC Neurol. 2015 Oct;15(1):191. https://doi.org/10.1186/s12883-015-0454-6
• 19 Fabricio AT, Aprahamian I, Sanches Yassuda M. Qualitative analysis of the Clock Drawing Test by educational level and cognitive profile. Arq Neuropsiquiatr. 2014 Apr;72(4):289-95. https://doi.org/10.1590/0004-282X20140004
• 20 Gunten A, Ostos-Wiechetek M, Brull J, Vaudaux-Pisquem I, Cattin S, Duc R. Clock-drawing test performance in the normal elderly and its dependence on age and education. Eur Neurol. 2008;60(2):73-8. https://doi.org/10.1159/000131895
• 21 Ribeiro MC, Barata RB, Almeida MF, Silva ZP. Perfil sociodemográfico e padrão de utilização de serviços de saúde para usuários e não-usuários do SUS - PNAD 2003. Cien Saude Colet. 2006;11(4):1011-22. https://doi.org/10.1590/S1413-81232006000400022
• 22 Instituto Brasileiro de Geografia e Estatística – IBGE. Pesquisa nacional por amostra de domicílios: síntese de indicadores. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística – IBGE; 2016.