Aging Neuropsychology and Cognition

2004, Vol. 11, No. 1, pp. 1–11

Validation of a Modified Version of the Mini-Mental

State Examination (MMSE) in Spanish
Sandra Reyes de Beaman1, Peter E. Beaman2, Carmen Garcia-Peña3,
Miguel Angel Villa4, Julieta Heres4,y, Alejandro Córdova3, and Carol Jagger5
1
Groby, UK, 2Department of Social Sciences, Loughborough University, UK,
3
Co-ordination of Medical Care, IMSS Mexico,
4
Department of Neuropsychology, National University in Mexico, Mexico, and
5
Department of Epidemiology and Public Health, University of Leicester, UK

ABSTRACT

In order to validate the adapted version of the Mini-Mental State Examination (MMSE) in Spanish, 203
participants aged at least 60 years were interviewed and clinically evaluated. Factor analysis and ROC curves
were used to evaluate the instrument. From the clinical evaluation, it was found that 34.5% of the participants
were cognitively impaired. Spatial orientation, Orientation in time plus registration, Language plus attention
and calculation, and Naming objects were the four components that explained 60.6% of the variance from the
factor analysis. The ROC curve showed 23/24 as the optimal cut-off point, with a sensitivity of 0.97 and
specificity of 0.88. Differences by number of years in education were also found, but adjusting the scoring for
those individuals with a low level of education improved the performance of the instrument.

INTRODUCTION optimum in a number of studies (Braekhus, Laake,

The Mini-Mental State Examination (MMSE;
Folstein, Folstein, & McHugh, 1975) is a reli-
able screening test initially developed to assess
the cognitive function of hospital in-patients
(Calero, Navarro, Robles, & Garcı́a-Berben,
2000; Fillenbaum, Hughes, Heyman, George, &
Blazer, 1988; Folstein et al., 1975; Lee & Chang,
1987; Park & Chul, 1990; Tombaugh & Mclntyre,
1992). Since its development in 1975, this scale
has been widely used in epidemiological studies
(Anzola-Pérez et al., 1996; Lee & Chang, 1987).
Although different cut-off points have been
proposed to classify subjects as cognitively
impaired, 23/24 has been considered to be the
& Engedal, 1992; Folstein, Fetting, Lobo, Niaz, &
Capozzoli, 1984; O’Connor, Pollitt, Treasure,
Brook, & Reiss, 1989). Characteristics such as
level of education (Anzola-Pérez et al., 1996; Bird,
Canino, Rubio-Stipec, & Shrout, 1987; Escobar
et al., 1986; Fillenbaum et al., 1988; Jagger,
Clarke, Anderson, & Battcock, 1992; Jorm, Scott,
Henderson, & Kay, 1988; Magaziner, Spear, &
Hebel, 1987; Murden, McRae, Kaner, & Bucknam,
1991; O’Connor et al., 1989; Park & Chul, 1990;
Tombaugh & Mclntyre, 1992; Van Marwijk, De
Bock, Hermans, Mulder, & Springer, 1996), age
(Bleecker, Bolla-Wilson, Kawas, & Agnew, 1988;
Fillenbaum et al., 1988; Magaziner et al., 1987;
Murden et al., 1991; O’Connor et al., 1989;

Address correspondence to: Dr. Sandra Reyes de Beaman, Centre for Research in Social Policy, Loughborough
University, Schofield Building, Leicestershire LE11 3TU, UK. E-mail: S.De-beaman@lboro.ac.uk
y
Julieta Heres, one of the Mexican neuropsychology’s pillars, passed away 22 days after this article was accepted
for publication.
Accepted for publication: May 8, 2003.

1382-5585/04/1101-001$16.00 # Taylor & Francis Ltd.

2 SANDRA REYES DE BEAMAN ET AL.

Tombaugh & Mclntyre, 1992), gender (Braekhus
et al., 1992), social class (Braekhus et al., 1992;
Jagger et al., 1992), culture (Bird et al., 1987), and
race (Escobar et al., 1986; Fillenbaum et al., 1988)
have been shown to modify performance in the test
and, in some cases, adjusted cut-off points have
been proposed (Folstein, 2001; Murden et al.,
1991).
The wide use of the MMSE is demonstrated by
the numerous versions that have been developed,
including a short form (Braekhus et al., 1992;
Magaziner et al., 1987), longer form (Lee &
Chang, 1987), a version for use by telephone
(Roccaforte, Burke, Bayer, & Wengel, 1992),
and a standardized form (Molloy, Alemayehu,
& Roberts, 1991), as well as translations into
several languages including Korean (Park &
Chul, 1990), Norwegian (Braekhus et al., 1992),
French (Commenges et al., 1992), Italian (Turrina
et al., 1993), and Spanish (Bird et al., 1987;
Calero et al., 2000; Escobar et al., 1986;
Giménez-Roldán, Novillo, Navarro, Dobato, &
Jiménez-Zuccarelli, 1997; Lobo et al., 2000;
Ostrosky-Solı́s, López-Arango, & Ardila, 2000;
Rosselli et al., 2000). The difficulty of using this
instrument in non-Anglo-Saxon populations has
been widely discussed, not only because of the
accuracy of the translation, but also because of
the culturally determined meanings of words
(Anzola-Pérez et al., 1996; Bird et al., 1987;
Braekhus et al., 1992; Park & Chul, 1990).
Versions in Spanish have considered several
adaptations (listed in Table 1), but these have not
been completely validated and others are not
appropriate (Bird et al., 1987; Calero et al., 2000;
Escobar et al., 1986; Giménez-Roldán et al., 1997;
Lobo et al., 2000; Ostrosky-Solı́s et al., 2000;
Rosselli et al., 2000). Consequently, the aim of

Table 1. Item Differences in Spanish Versions of the MMSE.

Items and authors Description

Orientation in time
Bird et al. (1987)
Ostrosky-Solı́s et al. (2000)
Rosselli et al. (2000)
The season was replaced by mentioning the four seasons of the year. They
accepted related answers
The season was replaced by the time (the amount of deviation allowed to
count as a correct answer is not specified)

Orientation in space
Bird et al. (1987)
Sano et al. (1997)
Ostrosky-Solı́s et al. (2000)
Rosselli et al. (2000)
Giménez-Roldán et al. (1997)
Anzola-Pérez et al. (1996)
They asked for country, town, section of town. Section, neighborhood, or
housing development were accepted
They asked for the place but not for the hospital
They asked for country, ‘‘rumbo,’’ city, cardinal point and the name of the
place
They asked for country, city, place, municipality and hospital. ‘‘Barrio,’’ floor,
and apartment seems to be equivalent to other items
They asked for country, city, and region. Hospital and floor were kept
They asked for country, province, ‘‘barrio,’’ and street

Registration and recall

Bird et al. (1987)
Sano et al. (1997)
Rosselli et al. (2000)
Ostrosky-Solı́s et al. (2000)
Giménez-Roldán et al. (1997)
Anzola-Pérez et al. (1996)
They used the words pineapple (piña) and ‘‘peso,’’ trying more than other
versions in English to use words in the same ‘‘word family’’ with two
syllables
They used apple, table, pence (Spanish equivalents for some of the words used
in English)
They used the words house, tree, dog
They used the words pencil, key, and book
They used the words tree, bridge, and street-lamp
They used the words table, tree, dog
(continued)
 MODIFIED VERSION OF MMSE IN SPANISH 3

Table 1. (continued).

Items and authors Description

Repeat a phrase
Bird et al. (1987)
Sano et al. (1997)
Giménez-Roldán et al. (1997)
Ostrosky-Solı́s et al. (2000)
Rosselli et al. (2000)
Anzola-Pérez et al. (1996)
They used a tongue twister in Spanish: ‘‘Pancha plancha con cuatro planchas’’
since they consider the item is to evaluate difficulties in the repeated
articulation of two consecutive consonants and screen for transcortical
aphasia
The phrase was similar to the one in the version in English ‘‘Ni no, ni si, ni
peros’’
The phrase was: I won’t go if you do not arrive early. ‘‘No iré si tu no llegas
temprano’’
The phrase was: If I do not come down, then you get up: ‘‘Si no bajo, entonces
usted suba’’
They used a tongue twister in Spanish: ‘‘Tres perros en un trigal’’

Attention and calculation

Sano et al. (1997)
Calero et al. (2000)
Anzola-Pérez et al. (1996)
Ostrosky-Solı́s et al. (2000)
Following a 3-stage command
Ostrosky-Solı́s et al. (2000)
Serial 7s was substituted by the item ‘‘spelling ‘world’ backwards’’
Serial 3s (subtraction by 3 starting at 20)
They have two options, the first one was the same in the original in English
and the second one was: With your right finger touch your nose and then
your left ear. ‘‘Con el dedo derecho, toque la punta de su nariz y luego su
oı́do izquierdo’’

Copying a design
Giménez-Roldán et al. (1997) Draw a cube with all the sides visible and in perspective

Others
Calero et al. (2000)
Anzola-Pérez et al. (1996)
They included an item with three digits to repeat backwards and two
items about similarities between objects. The total score was 35 instead
of 30
People unable to read were shown a card with a drawing and those unable to
write were asked to verbalize a phrase or thought

this study was to validate the ability of the MMSE
in Spanish to screen for cognitive impairment in
an older population living in urban areas.
METHOD
Design and Sampling Procedure
People aged 60 years or over were selected from those
receiving services in different settings after obtaining
authorization from the General Directorates. Individuals
with severe mental deterioration, those taking medica-
tion affecting cognitive function, with a previous head
injury, or who were comatose, were excluded. Those not
completing the clinical evaluation or the interview were
also eliminated from the analysis. The study size was
calculated on the basis of
¼ 0.05, sensitivity ¼ 0.95,
specificity ¼ 0.85, resulting in a sample group of 203
who were classified as follows: 50 in social security
centers, 28 in external psychiatric consultation, 50 in
general hospitals, and 25 in psychiatric hospitals referred
by the Mexican Institute of Social Security. The other 50
were selected from residential private homes. All were
resident in Mexico City.
Translation, Adaptation and
Standardization of the Instrument
The original version of the MMSE (Folstein et al.,
1975) was translated from English to Spanish and then
4 SANDRA REYES DE BEAMAN ET AL.
backtranslated (Brislin, 1970). A committee of bilin-
gual researchers evaluated the Spanish version and the
new version in English. Before the committee accepted
the Spanish version, the following changes were
considered necessary:
1. Orientation in time: The question about the seasons
was replaced by one asking about the current time of
day. An answer was considered correct if within half
an hour of the true time.
2. Orientation in space: The original question, ‘‘What
is the name of this hospital?’’ was only asked of
hospital in-patients. When the participant was
interviewed in other settings, the question became:
‘‘Where are we now?’’ Other items included in this
section were ‘‘colonia’’ (neighborhood), city and
country.
3. Registration and recall: The originally listed
objects: ‘‘apple,’’ ‘‘table,’’ and ‘‘penny,’’ were re-
placed by ‘‘paper,’’ ‘‘bicycle,’’ and ‘‘spoon.’’
4. Attention and calculation: In addition to the serial
subtraction by seven item (‘‘serial-seven’’ in the
original version), a further item requiring the subject
to recite the days of the week backwards was added.
5. Language: The phrase ‘‘ni no, ni si, ni pero’’ was
considered to be equivalent to the English one (‘‘no
ifs, ands, or buts’’).
The rest of the items were as in the original instrument.
A detailed reference manual was used and the four
interviewers participating in the study had previously
been trained. The four psychiatrists standardized their
diagnostic criteria based on the International Diseases
Classification-10 (IDC-10) (WHO, 1993).
Evaluation and Re-evaluation
of Participants
Once participants or their proxies had indicated that
they understood the study and accepted enrolment, they
were interviewed using the Spanish version of the
MMSE, and general demographic variables were also
collected. After the interview a randomly selected
psychiatrist, blinded to the MMSE score, performed a
clinical evaluation using the IDC-10 criteria (WHO,
1993) in order to define a diagnosis. The same psy-
chiatrist, after the clinical evaluation, established
whether the subject was or not cognitively impaired.
The period between the MMSE and the clinical diag-
nosis was on average 1 day with a maximum of 2
days.
To check inter-observer reliability, 21 participants
were selected randomly and evaluated four times (twice
by a psychiatrist and twice by a lay interviewer). The
third and fourth evaluations took place within 2 days,
with the later evaluators blinded to earlier results and
evaluators.
Statistical Analysis
Internal consistency was evaluated using Cronbach’s
.
Item analysis was undertaken by factor analysis with
the principal components method and varimax rotation,
and the inter-observer reliability was evaluated by the 
coefficient.
Three MMSE scores were calculated using the
following procedures: (a) the standard method by
adding together the points obtained for each item (see
the scores in the Appendix); (b) as in (a) but sub-
stituting ‘‘days of the week backwards’’ for ‘‘serial-
seven;’’ (c) as in (a) but awarding the maximum score
in the items ‘‘serial-seven,’’ ‘‘obey a written com-
mand,’’ ‘‘write a sentence,’’ and ‘‘copy a design,’’ if the
interviewee had a low level of education (up to 3 years
of formal education only).
Sensitivity, specificity, and false positive rates of the
MMSE (revised version in Spanish) were examined
using the psychiatrist diagnosis as the reference and
different cut-off points. The receiver operating char-
acteristics (ROC) curve and the area under the curve
were calculated. Having determined the optimum cut-
off point, logistic regression with stepwise forward
conditional selection was used to examine the associa-
tion between classification and confounding factors,
with the dependent variable being cognitive impairment
as defined by the scoring system, and independent
variables being age, sex, level of education, and cog-
nitive impairment as defined by the psychiatrist. We
performed this analysis for the three scoring procedures
defined above as well as for adjusting the cut-off point
by scoring method A, as has been suggested before.
The best scoring method was characterized as the one
in which the cognitive impaired categories were deter-
mined solely by the cognitive performance (as defined
by the psychiatrist) but not by the other variables.
Having established the best type of scoring to use,
positive and negative predictive values (PPV and NPV)
and likelihood ratios for positive and negative tests
(LRPT and LRNT) were calculated. Means of scores
resulting from methods A and C by cognitive impair-
ment and levels of education were compared.
RESULTS
A sample group of 203 elderly people completed
the two evaluations within the predetermined
time. 68.5% of the sample were women and the
average age was 70.8 years (range 60–99 years,
median 69 years, mode 60 years); 43.8% of the
sample were considered to have received a low
level of education (up to 3 years of elementary
school) and 34.5% were classified as cognitively
 MODIFIED VERSION OF MMSE IN SPANISH 5

impaired during the clinical evaluation. The odds Table 2. Matrix of Rotated Components.
of being classified as cognitively impaired by the
Items Component
clinical evaluation were over 2.5 times higher for
those with less education (odds ratio: OR 2.74, 1 2 3 4
95% CI 1.51–4.98). No association was found
City 0.731
between a clinical diagnosis of cognitive impair- Hospital 0.700
ment and other demographic variables. The ‘‘Colonia’’ 0.698
average score was significantly different be- Floor 0.657
tween those without and those with cognitive Country 0.563
impairment for all three MMSE scores (F test, Month 0.511
p < .001). Year 0.412
Internal reliability was high (Cronbach’s Registration (spoon) 0.743
Registration (bicycle) 0.737

¼ 0.89, p < .0001) with improvement when Registration (paper) 0.706
the item ‘‘serial-seven’’ was excluded, although Day 0.679
this improvement was not statistically significant. Day of the week 0.537
Inter-observer consistency was good for both the Time 0.528
clinical evaluation ( ¼ 0.807, p < .01) as well Writing a sentence 0.788
as for the MMSE interview itself ( ¼ 0.901, Read and obey 0.756
p < .01). Copying design 0.680
Attention and 0.609
From the factor analysis, four components calculation
were identified, explaining 60.6% of the total Recall 0.536
variance. Factor 1 included items related to Orien- Following a 3-stage 0.506
tation in space, factor 2 could be defined as command
Orientation in time plus registration, factor 3 Repeating a phrase 0.429
integrated Language plus attention and calcula- Naming (watch) 0.913
tion, and factor 4 Naming objects (Table 2). The Naming (pencil) 0.891
correlation between items, and between items
and scale, was statistically significant in all
cases. When the scoring methods A (unadjusted) and
ROC analysis was used to determine the opti- C (adjusted for those with low education) were
mum cut-off points for the various scoring meth- compared (Table 3), mean differences in A were
ods (Fig. 1). For the usual MMSE scoring system significant in those with and without cognitive
(A) the optimal cut-off point was 25/26 with impairment by level of education, but when
sensitivity 0.986 and specificity 0.70. When scores were adjusted (C), these differences dis-
‘‘serial-seven’’ was substituted (scoring system appeared (Table 3). However, within groups
B), the optimal cut-off point was 24/25 with defined by educational level, mean scores for
sensitivity 0.94 and specificity 0.75. When adjust- both scoring systems A and C were significantly
ments were made for education (scoring system different for those with and without cognitive
C) the optimal cut-off point was 23/24 with impairment. This suggests that scoring system C
sensitivity 0.97 and specificity 0.88. still discriminated between those with and with-
Using logistic regression, and in addition to out cognitive impairment if they had a low level
cognitive impairment as defined by the psychia- of education, but that those with a low level of
trist, level of education was a significant factor education did not have significantly lower
when using scoring systems A and B (optimal cut- scores, whether they were cognitively impaired
off point), while level of education and age were or not.
significant factors for scoring system A with the From these analyses, C appeared to be the best
20/21 cut-off point. For scoring system C, no scoring method with the optimal cut-off point of
factors other than cognitive impairment defined 23/24. The area under the curve was 0.849 (95%
by the psychiatrist were significant. CI 0.798–0.899), positive predictive value 0.666
6 SANDRA REYES DE BEAMAN ET AL.

Fig. 1. Comparative ROC curves using three different scoring methods. Scoring A: The usual way adding the
points obtained in each item. Scoring B: As ‘‘A’’ but substituting ‘‘serial-seven’’ by ‘‘days of the week
backwards’’. Scoring C: As ‘‘A’’ but giving the maximum score in the items ‘‘serial-seven’’, ‘‘obey a
written command’’, ‘‘write a sentence’’ and ‘‘copy a design’’ when subjects had low education (up to 3
years of formal education).

Table 3. Mean Differences With Scoring Aa and Cb by Cognitive Performance and Literacy.

Group Scoring A Scoring C

M SD CI 95% p M SD CI 95% p

Cognitively impaired
Literate 17.50 6.5 15.0–20.0 .0001 17.50 6.5 15.0–20.0 ns
Low education 12.12 5.0 10.6–13.7 19.17 4.6 17.7–20.6

Cognitively intact
Literate 27.78 1.8 27.4–28.2 .0001 27.78 1.9 27.3–28.2 ns
Low education 21.82 3.4 20.8–22.8 26.68 2.2 26.1–27.4

Literate
Impaired 27.8 1.8 27.4–28.2 .0001 – – – –
No impaired 17.5 6.5 15.0–20.0

Low education
No impaired 21.83 3.4 20.1–22.8 .0001 26.68 2.1 26.1–27.3 .0001
Impaired 12.12 5.0 10.6–13.7 19.17 4.6 17.7–20.6
Note. aThe usual way adding the points obtained in each item.
b
As ‘‘A’’ but giving the maximum score in the items ‘‘serial-seven’’, ‘‘obey a written command’’, ‘‘write a
sentence’’ and ‘‘copy a design’’ when subjects had low education (up to 3 years of formal education).

and negative predictive value 0.099. The accuracy DISCUSSION

of the test was 0.812 with the likelihood ratio for a
positive test being 3.395 and the likelihood ratio The MMSE has been one of the most widely used
for a negative test 0.0169. instruments for geriatric evaluation in Mexico.
 MODIFIED VERSION OF MMSE IN SPANISH
However, only one other validation exists, with
a small number of older subjects included (430
healthy subjects from different age groups in-
cluding older people but only 40 paired with
people with dementia) (Ostrosky-Solı́s et al.,
2000).
When adapting versions in other languages,
the goal is not only to achieve a clear and precise
translation but also to ensure that those who are
not cognitively impaired answer items correctly,
and those who are cognitively impaired answer
the items incorrectly (Bird et al., 1987). When
instruments are simply translated literally, items
easily answered by someone without a cognitive
problem in one culture present difficulties in
others. The adapted version here discriminates
well between those with and without cognitive
impairment, but although no substantial modifi-
cations were made to the instrument, either to the
evaluated aspect or procedures, as occurred in
other versions (Park & Chul, 1990), we cannot
assume that it will be applicable to all Spanish-
speaking populations worldwide, partly due to
differences in the meaning of words, and partly
to the cultural relevance of some of the items.
The adaptations we made in our instrument
were culturally relevant without introducing un-
necessary changes, once other versions had been
reviewed and found lacking in that they did not
totally address two important aspects: the neuro-
psychological characteristics of the original instru-
ment and the adaptation for the older Mexican
participants (Giménez-Roldán et al., 1997; Lobo
et al., 2000; Ostrosky-Solı́s et al., 2000; Rosselli
et al., 2000). Like other authors (see Table 1) we
did not ask for the season in the Orientation in
time section, since some populations experience
no definite weather changes representing seasons.
Like other researchers, we asked about the
time, but within acceptable standardized limits
(Ostrosky-Solı́s et al., 2000; Rosselli et al., 2000).
The inclusion of ‘‘colonia’’ (neighborhood), which
is the name for the geographical area in which
people live, was useful in evaluating Orientation in
space and could be thought as equivalent to the
route or neighborhood asked for in other versions
of this instrument. It was not considered pertinent
to ask for the cardinal compass points, as we would
have had to explain what we meant and the
7
objective was to evaluate their spatial orientation
not their geographical knowledge.
With regard to the three words used in the
Registration and recall sections in other versions
in Spanish, some are translation of words fre-
quently used in English versions and others were
adapted to have a specific number of syllables.
However, some versions use words that are related
to each other and interviewees may find it easier
to remember these using an association me-
chanism. The three objects used in our scale are
simple common words, which should be easy to
remember, but they have no relation to each
other.
In the Attention and calculation section, the
spelling of a word backwards was not considered
relevant, as this is not a frequent exercise within
this population. Most individuals with a minimal
level of education experience great difficulty in
performing subtraction. In spite of this, the
‘‘serial-seven’’ item cannot be completely ex-
cluded, as it is useful for discriminating between
better-educated individuals. The practical solu-
tion of giving the maximum score, in some items,
to those classified as minimally educated ap-
peared to be a good compromise. Reducing the
difficulty level by counting backwards in groups
of three starting from 20, could produce a mis-
taken classification among the better educated and
would not benefit those who, for whatever reason,
could not answer the serial-seven (Ostrosky-Solı́s
et al., 2000). Reciting the days of the week back-
wards was not useful, since it did not accurately
discriminate between those who were cognitively
functioning and those who were impaired.
In the Language section, the phrase for repeti-
tion used here has already been used and justified
by other authors (Sano et al., 1997). However, for
the population under evaluation, we believe that
this is a suitable alternative to tongue-twisters or
familiar catch-phrases that could frequently dis-
tort the results (Ostrosky-Solı́s et al., 2000). The
capacity to repeat these phrases is highly related
to their familiarity. In order to avoid the phonetic
problems that could be associated with the final
‘‘s’’ in the word ‘‘peros’’ (Table 1), it was decided
to use the word ‘‘pero’’ instead (Giménez-
Roldán et al., 1997). This phrase is not a transla-
tion of the original in English but shares the same
8 SANDRA REYES DE BEAMAN ET AL.
characteristics: a phrase with no meaning, with
unrelated words, but without phonetic difficulties.
The internal reliability obtained in this study
was high and the elimination of ‘‘serial-seven’’
improved the internal reliability although, as the
difference was not statistically significant, we
decided to retain this item as part of the scale.
Our internal reliability value (0.89) is a little
lower than that of 0.96 reported by Foreman
(1987) but higher than that reported by Kay et al.
(1985) (see McDowell & Newell, 1996). Our
instrument, in which only 11% of the variance is
due to measured errors and 89% of the changes in
the score reflect a change in cognitive capacity, is
close to the recommended 0.90 cut-off point for
capacity tests (McDowell & Newell, 1996).
The inter-observer reliability among psychia-
trists was a little lower than that obtained in the
two subsequent applications of the instrument by
different lay interviewers. Even though these 
values can be considered almost perfect, a higher
level of reliability would be expected among
psychiatrists (McDowell & Newell, 1996). It
can be argued that some chronic health problems
amongst older individuals can generate changes
in their cognitive capacity over short periods of
time, which could alter diagnosis during the
clinical evaluation 2 days later. However, the
same argument would also be valid for the lay
interviewer. Of course, an important difference is
that MMSE was standardized and this increased
the reliability (Molloy et al., 1991), whilst the
psychiatrists’ clinical evaluations were not stan-
dardized, although the criteria for reaching the
diagnosis were. Validation is limited by the
absence of a gold standard with which to compare
the MMSE, and this study is no exception (Bird
et al., 1987). As in other studies, we took the
psychiatric diagnosis as the standard for the
MMSE, but this is controversial.
The correlation between factors and the origi-
nal concepts proposed by Folstein et al. (1975) is
high but not absolute, as only four factors were
obtained. Rosselli et al. (2000) found the same
number of factors as in our present study. How-
ever, our factors are closer to the conceptual
elements proposed originally by Folstein et al.
(1975). Almost all the items in the Language
section, except the Naming objects, integrated
the third factor together with the Attention and
calculation section. It seems that the difficulty
observed in all of the Language items is similar to
the one with Attention and calculation, and of
course these are correlated with the level of
education. The fourth factor, Naming objects,
seems to be the easiest section of the instrument.
The variance explained in the present study is
higher than that of 51.7% reported by Rosselli
et al. (2000) but items in the Orientation in time
and space sections also explained a greater pro-
portion of the variance (Rosselli et al., 2000).
The optimal cut-off point for this instrument
corresponded with other reports (McDowell &
Newell, 1996). Sensitivity was close to that
reported by Fillenbaum et al. (in McDowell &
Newell, 1996) and higher than others in English.
However, the false positive rate here was higher
than in other reports (McDowell & Newell, 1996).
Higher sensitivity was considered to be more
important than specificity in this study, as the
MMSE was intended to be used to screen out
those who would not be able to provide reliable
information in an interview on health. However, it
is also important when screening for cognitive
impairment that no cases are missed, since a full
evaluation in the clinical setting will decide the
final classification, although there may be cost
implications as well as worry for those wrongly
classified.
Establishing different cut-off points has been
recommended for groups defined by age and level
of education (Folstein, 2001; Magaziner et al.,
1987). A second alternative, as proposed in this
study, is to adjust the scoring method for those
having a low level of education. As the objective
of the present validation was the development of a
clear, easily applicable and reliable scale to use
for practical purposes in the field, we felt that this
option was preferable. Lowering the cut-off point
could result in a greater number of mistakes in the
classification of the participants, even though
classification tables could be supplied to the
interviewers (Anzola-Pérez et al., 1996). Addi-
tionally, differences in scores after the adjustment
proposed were related only to cognitive status and
not to other variables. In this study the association
between low educational level and cognitive
impairment was significant. However, it seems
 MODIFIED VERSION OF MMSE IN SPANISH
that with the indicated adaptations it is possible to
determine whether or not there is a real cognitive
problem despite a low level of education.
Evaluation of cognitive performance is not
only important for medical care, but also as a
part of the research process, to guarantee the
validity of the information and to protect partici-
pants both ethically and legally (Colsher, 1992).
However, the evaluation of elderly individuals as
a precondition for their participation in research
projects is not common.
In conclusion, this MMSE validated in a older
population will be useful not only in the research
process, to determine whether subjects are able to
consent to and participate, but also in screening
for cognitive problems with research or clinical
purposes (Folstein et al., 1984). At the first level
of health care this could be used to detect prob-
lems in the early stages and to refer patients for a
specialized evaluation; now particularly impor-
tant, as new drug treatments are targeted at those
with mild dementia.
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APPENDIX