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The Mini-mental State Examination revisited: ceiling and floor effects after score adjustment for educational level in an aging Mexican population

Published online by Cambridge University Press:  07 September 2009

Francisco Franco-Marina
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico Instituto Nacional de Enfermedades Respiratorias (INER), Mexico
Jose Juan García-González
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
Fernando Wagner-Echeagaray
Drug Abuse Research Program, Center for Health Disparities Solutions, School of Public Health and Policy, Morgan State University, Baltimore, Maryland, U.S.A.
Joseph Gallo
Department of Family Practice and Community Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.
Oscar Ugalde
Department of Geriatric Psychiatry, Nacional Institute of Psychiatry “Ramón de la Fuente”, Mexico
Sergio Sánchez-García
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
Claudia Espinel-Bermúdez
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
Teresa Juárez-Cedillo
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
Miguel Ángel Villa Rodríguez
Residencia en Neuropsicología Clínica. Facultad de Estudios Superiores Zaragoza, Universidad Nacional Autónoma de México
Carmen García-Peña*
Epidemiological and Health Research Unit, Aging Division, Centro Médico Nacional XXI, Instituto Mexicano del Seguro Social, Mexico
Correspondence should be addressed to: Carmen García Peña, MD, MSc, PhD, Unidad de Investigación Epidemiológica y en Servicios de Salud, Área de Envejecimiento. Edificio CORCE. Tercer piso. Centro Médico Nacional Siglo XXI, Avenida Cuauhtémoc no. 330, Col. Doctores, Delegación Cuauhtémoc, México D.F Código Postal 06725, México. Phone: +52 55–5627-6900 ext. 21846. Email:


Background: The Mini-mental State Examination (MMSE) is the most widely used cognitive test, both in clinical settings and in epidemiological studies. However, correcting its score for education may create ceiling effects when used for poorly educated people and floor effects for those with higher education.

Methods: MMSE and a recent cognitive test, the seven minute screen (7MS), were serially administered to a community sample of Mexican elderly. 7MS test scores were equated to MMSE scores. MMSE-equated 7MS differences indicated ceiling or floor effects. An ordinal logistic regression model was fitted to identify predictors of such effects.

Results: Poorly educated persons were more prevalent on the side of MMSE ceiling effects. Concentration (serial-sevens), orientation and memory were the three MMSE subscales showing the strongest relationship to MMSE ceiling effects in the multivariate model.

Conclusion: Even when MMSE scores are corrected for educational level they still have ceiling and floor effects. These effects should be considered when interpreting data from longitudinal studies of cognitive decline. When an education-adjusted MMSE test is used to screen for cognitive impairment, additional testing may be required to rule out the possibility of mild cognitive impairment.

Research Article
Copyright © International Psychogeriatric Association 2009

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Andel, R., Vigen, C., Mack, W. J., Clark, L. J. and Gatz, M. (2006). The effect of education and occupational complexity on rate of cognitive decline in Alzheimer's patients. Journal of the International Neuropsychological Society, 12, 147152.Google Scholar
Ardila, A. (1998). A note of caution: neuropsychological test performance. Effects of age, education, gender and ethnicity: a comment on Saykin et al. (1995). Applied Neuropsychology, 5, 5153.Google Scholar
Cossa, F. M., Della Sala, S., Musicco, M., Spinnler, H. and Ubezio, M. C. (1997). Comparison of two scoring systems of the Mini-mental State Examination as a screening test for dementia. Journal of Clinical Epidemiology, 50, 961965.Google Scholar
Crum, R. M., Anthony, J. C., Bassett, S. S. and Folstein, M. F. (1993). Population-based norms for the Mini-mental State Examination by age and educational level. JAMA, 269, 23862391.Google Scholar
del Ser, T., Sanchez-Sanchez, F., Garcia de Yebenes, M. J., Otero, A. and Munoz, D. G. (2006). Validation of the seven-minute screen neurocognitive battery for the diagnosis of dementia in a Spanish population-based sample. Dementia and Geriatric Cognitive Disorders, 22, 454464.Google Scholar
Fillenbaum, G. G., George, L. K. and Blazer, D. G. (1988). Scoring nonresponse on the Mini-mental State Examination. Psychological Medicine, 18, 10211025.Google Scholar
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-mental state:” a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189198.Google Scholar
Galasko, D. R., Gould, R. L., Abramson, I. S. and Salmon, D. P. (2000). Measuring cognitive change in a cohort of patients with Alzheimer's disease. Statistics in Medicine, 19, 14211432.Google Scholar
García-Peña, C. et al. (2008). Depressive symptoms among older adults in Mexico City. Journal of General and Internal Medicine, 12, 19731980.Google Scholar
Ganguli, M., Yangchun, D., Hiroko, D., Ratcliff, G. and Chung-Chou, C. (2006). Depressive symptoms and cognitive decline in late life. Archives of General Psychiatry, 63, 153160.Google Scholar
Hosmer, D. W. and Lemeshow, S. (2000). Applied Logistic Regression, 2nd edn. New York: Wiley.Google Scholar
Jones, R. N. and Gallo, J. J. (2000). Dimensions of the Mini-mental State Examination among community dwelling older adults. Psychological Medicine, 30, 605618.Google Scholar
Kirby, M., Denihan, A., Bruce, I., Coakley, D. and Lawlor, B. A. (2001). The clock drawing test in primary care: sensitivity in dementia detection and specificity against normal and depressed elderly. International Journal of Geriatric Psychiatry, 16, 935940.Google Scholar
Kolen, M. J. and Brennan, R. L. (2004). Test Equating, Scaling, and Linking: Methods and Practices, 2nd edn. New York: Springer-Verlag.Google Scholar
Marcopulos, B. A., Gripshover, D. L., Broshek, D. K., McLain, C. A. and Brashear, H. R. (1999). Neuropsychological assesment of psychogeriatric patients with limited education. Clinical Neuropsychology, 13, 147156.Google Scholar
McCarten, J. R., Rottunda, S. J. and Kuskowski, M. A. (2004). Change in the Mini-mental State Exam in Alzheimer's disease over 2 years: the experience of a dementia clinic. Journal of Alzheimer's Disease, 6, 1115.Google Scholar
Meulen, E. F. et al. (2004). The seven minute screen: a neurocognitive screening test highly sensitive to various types of dementia. Journal of Neurology, Neurosurgery and Psychiatry, 75, 700705.Google Scholar
Ostrosky-Solis, F., Lopez-Arango, G. and Ardila, A. (2000). Sensitivity and specificity of the Mini-mental State Examination in a Spanish-speaking population. Applied Neuropsychology, 7, 2531.Google Scholar
Reyes-Beaman, S. et al. (2004). Validation of a modified version of the Mini-mental State Examination (MMSE) in Spanish. Aging, Neuropsychology, and Cognition, 11, 111.Google Scholar
Roe, C. M., Mintun, M. A., D'Angelo, G., Xiong, C., Grant, E. A. and Morris, J. C. (2008). Alzheimer disease and cognitive reserve: variation of education effect with carbon 11-labeled Pittsburgh Compound B uptake. Archives of Neurology, 65, 14671471.Google Scholar
Rosselli, M., Tappen, R., Williams, C. and Salvatierra, J. (2006). The relation of education and gender on the attention items of the Mini-mental State Examination in Spanish-speaking Hispanic elders. Archives of Clinical Neuropsychology, 21, 677686.Google Scholar
Sinoff, G., Ore, L., Zlotogorsky, D. and Tamir, A. (1999). Short Anxiety Screening Test: a brief instrument for detecting anxiety in the elderly. International Journal of Geriatric Psychiatry, 14, 10621071.Google Scholar
Skjerve, A., Nordhus, I. H., Engedal, K., Pallesen, S., Braekhus, A. and Nygaard, H. A. (2007). Seven minute screen performance in a normal elderly sample. International Journal of Geriatric Psychiatry, 22, 764769.Google Scholar
Solomon, P. R. and Pendlebury, W. W. (1998). Recognition of Alzheimer's disease: the 7 minute screen. Family Medicine, 30, 265271.Google Scholar
Stern, Y. (2006). Cognitive reserve and Alzheimer disease. Alzheimer Disease and Associated Disorders, 20, 112117.Google Scholar
Strauss, E., Sherman, E. M. S. and Spreen, O. (2006). A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary, 3rd edn. New York: Oxford University Press.Google Scholar
Tombaugh, T. N. and McIntyre, N. J. (1992). The Mini-mental State Examination: a comprehensive review. Journal of the American Geriatrics Society, 40, 922935.Google Scholar
van Gorp, W. G., Marcotte, T. D., Sultzer, D., Hinkin, C., Mahler, M. and Cummings, J. L. (1999). Screening for dementia: comparison of three commonly used instruments. Journal of Clinical and Experimental Neuropsychology, 21, 2938.Google Scholar
Xu, G., Meyer, J. S., Thornby, J., Chowdhury, M. and Quach, M. (2002). Screening for mild CI (MCI) utilizing combined mini-mental-cognitive capacity examinations for identifying dementia prodromes. International Journal of Geriatric Psychiatry, 17, 10271033.Google Scholar
Yesavage, J. A. et al. (1982–3). Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research, 17, 3749.Google Scholar