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MMSE Score, Culture and Education in a Tobago Population Study: 

MMSE Score, Culture and Education in a Tobago Population Study Faith Brebnor, MPH HM Crooks, AL Patrick, CH Bunker Dean’s Day Presentation Graduate School of Public Health University of Pittsburgh

AIMS: 

AIMS To calculate the Mini-Mental Status Examination (MMSE) scores for men aged 40 and older in the Tobago population. To determine whether the MMSE is an appropriate cognitive-impairment screening instrument for this particular population, given the cultural context within which this population resides. To determine whether the educational background of the participants influences their MMSE scores.

Mini-Mental State Examination: 

Mini-Mental State Examination Assessment tool used to quickly measure cognitive function Detects cortical cognitive impairment (like AD, but not sub-cortical impairment) 19 questions, about 5 – 10 minutes to complete. Tests: orientation to time and space, attention, registration, memory, ability to follow commands, and constructional and language capacity Maximum score (30 points), cognitive impairment (≥ 27 points), dementia (≤ 23 points)

Methodology: 

Methodology Modified 19-item MMSE Tobago men aged 40 – 79 Face-to-face interviews SPSS Analysis Frequencies Correlations Graphs

Demographics: 

Demographics

Results: 

Results MMSE mean score of 27.01 (SD 3.14, range of 5 to 30) 14% with scores ≤ 23 (dementia) 17% with scores between 24 - 26 (cognitively impaired) 69% with scores ≥ 27 (normal functioning) Scores comparable with other international population studies

Results: 

Results The mean MMSE score increases with increased formal education ~ 26 with less than 8 years of education ~ 27 with high school or vocational training ~ 29 with some or completed college

Challenges with the MMSE: 

Challenges with the MMSE MMSE and Educational Background Question - “Spell the word “WORLD” backwards?” Individual must first know how to spell the word “WORLD” forward before being able to spell it backwards. Tests educational attainment, which is not equivalent to cognitive functioning. Pearson’s correlation (0.215), between educational attainment and MMSE is significant at the 0.01 level, highlighting the inter-relation.

Challenges with the MMSE: 

MMSE and Culture “Guyanese building” Question - “What building are we in?” The wood used to build the structure was imported from Guyana, and as a result the building was referred to as the “Guyanese building”. Challenges with the MMSE

Challenges with the MMSE: 

MMSE and Culture “Board” or “Wooden” floor Question - “What floor are we on?” The majority of homes in Tobago only have one level, therefore being in a building with multiple floors is a foreign concept. As a result, many participants responded with “board” or “wooden” floor, indicating the material the floor was made from. Challenges with the MMSE

Recommendations: 

Recommendations Use an algorithm that incorporates both the age and the educational background of the client to determine appropriate cut off scores for cognitive decline. Since culture and literacy affects MMSE scores, modify the instrument or alter acceptable responses to truly capture cognitive decline versus cultural differences or literacy.

Public Health Significance: 

Public Health Significance Successful public health interventions require the use of accurate assessment tools. In the international setting, the MMSE can be useful in determining degree of cognitive decline, however it must be altered to reflect the local culture. In addition, the cut-off points used to determine cognitive decline should vary depending on age and educational attainment.

References: 

References Kurlowicz, L. and M. Wallace, The Mini Mental State Examination (MMSE). Dermatology Nursing August, 2002. 14(4): p. 277-278. American Psychiatric Association, Diagnostic and statistical manual of mental disorders. Fourth Edition, Text Revision ed. 2000, Washington, DC. Folstein, M.F., S.E. Folstein, and P.R. McHugh, "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 1975. 12(3): p. 189-98. Ward, A., et al., Describing cognitive decline of patients at the mild or moderate stages of Alzheimer's disease using the Standardized MMSE. International Psychogeriatrics, 2002. 14(3): p. 249-58.