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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

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Abstract

Background

The Mini-Mental State Examination (MMSE) is the most widely used instrument for the screening of cognitive impairment worldwide, but its ability to produce valid estimates of dementia in populations of low socioeconomic status and minimal literacy skills has not been adequately established. The authors investigated the psychometric properties of the MMSE in a community-based sample of older Brazilians.

Method

Cross-sectional one-phase population-based study of all residents of pre-defined areas of the city of Sao Paulo, aged 65 years or over. The Brazilian version of the MMSE was compared with DSM-IV diagnosis of dementia assessed with a harmonized one-phase procedure developed by the 10/66 Dementia Research Group.

Results

Analyses were performed with 1,933 participants of the SPAH study. Receiver operating characteristic analysis showed that the MMSE cut-point of 14/15 was associated with 78.7% sensitivity and 77.8% specificity for the diagnosis of dementia amongst participants with no formal education, and the cut-point 17/18 with 91.9% sensitivity and 89.5% specificity for those with at least 1 year of formal education (areas under the curves 0.87 and 0.94, respectively; P = 0.03). Even with these best fitting cut-points, the MMSE estimate of the prevalence of dementia was four times higher than determined by the DSM-IV criteria. Education, age, sex and income influenced MMSE scores, independently of dementia caseness.

Conclusion

The MMSE is an adequate tool for screening dementia in older adults with minimum literacy skills, but misclassification is unacceptably high for older adults who are illiterate, which has serious consequences for research and clinical practice in low and middle income countries, where the proportion of illiteracy among older adults is high.

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Acknowledgments

We are grateful to all members of the research team that contributed to the data collection. We thank Prof. M. Prince for helping with the acquisition of funding. The study was funded by the Wellcome Trust, UK (grant code GR066133MA). MS was supported by the Welcome Trust and CNPq-Brazil during the development of this work. PRM and HP Vallada were partly funded by CNPQ- Brazil.

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Authors and Affiliations

  1. Department and Institute of Psychiatry, LIM-23, Faculty of Medicine, University of Sao Paulo, R. Dr. Ovidio Pires de Campos 785, Sao Paulo, 05403-010, Brazil

    Marcia Scazufca PhD & Homero P. Vallada PhD

  2. Academic Unity of Psychiatry, Department of Community Based Medicine, University of Bristol, Cotham House, Cotham Hill, Bristol, BS6 6JL, UK

    Marcia Scazufca PhD & Paulo R. Menezes PhD

  3. Section of Epidemiology, University Hospital, University of Sao Paulo, Av. Prof. Lineu Prestes, 2565, Cidade Universitária, Sao Paulo, 05508-000, Brazil

    Marcia Scazufca PhD, Wernestty A. Tasse & Paulo R. Menezes PhD

  4. Department of Psychiatry of the Royal Perth Hospital (M573), Western Australian Centre for Health & Ageing and School of Psychiatry and Clinical Neurosciences of the University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia

    Osvaldo P. Almeida

  5. Department of Preventive Medicine, Faculty of Medicine, University of Sao Paulo, Av. Dr Arnaldo 455, Sao Paulo, 01246-903, Brazil

    Paulo R. Menezes PhD

Authors
  1. Marcia Scazufca PhD
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  2. Osvaldo P. Almeida
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  3. Homero P. Vallada PhD
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Correspondence to Marcia Scazufca PhD.

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Scazufca, M., Almeida, O.P., Vallada, H.P. et al. Limitations of the Mini-Mental State Examination for screening dementia in a community with low socioeconomic status. Eur Arch Psychiatry Clin Neurosci 259, 8–15 (2009). https://doi.org/10.1007/s00406-008-0827-6

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  • DOI: https://doi.org/10.1007/s00406-008-0827-6

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