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Aging Neuropsychology and Cognition 2004, Vol. 11, No. 1, pp. 1–11

and Cognition 2004, Vol. 11, No. 1, pp. 1–11 Validation of a Modified Version of the

Validation of a Modified Version of the Mini-Mental State Examination (MMSE) in Spanish

Sandra Reyes de Beaman 1 , Peter E. Beaman 2 , Carmen Garcia-Pen˜a 3 , Miguel Angel Villa 4 , Julieta Heres 4,y , Alejandro Co´rdova 3 , and Carol Jagger 5

1 Groby, UK, 2 Department 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

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, & Garcı´a-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-Pe´rez 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

optimum in a number of studies (Braekhus, Laake, & Engedal, 1992; Folstein, Fetting, Lobo, Niaz, & Capozzoli, 1984; O’Connor, Pollitt, Treasure, Brook, & Reiss, 1989). Characteristics such as level of education (Anzola-Pe´rez 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.

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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; Gime´nez-Rolda´n, Novillo, Navarro, Dobato, & Jime´nez-Zuccarelli, 1997; Lobo et al., 2000; Ostrosky-Sol´ıs, Lo´pez-Arango, & Ardila, 2000; Rosselli et al., 2000). The difculty 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-Pe´rez 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; Gime´nez-Rolda´n et al., 1997; Lobo et al., 2000; Ostrosky-Sol´ıs 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) The season was replaced by mentioning the four seasons of the year. They accepted related answers

Ostrosky-Sol´ıs et al. (2000)

The season was replaced by the time (the amount of deviation allowed to count as a correct answer is not specied)

Rosselli et al. (2000)

Orientation in space Bird et al. (1987) They asked for country, town, section of town. Section, neighborhood, or housing development were accepted Sano et al. (1997) They asked for the place but not for the hospital

Ostrosky-Sol´ıs et al. (2000)

They asked for country, ‘‘rumbo,’’ city, cardinal point and the name of the place

Rosselli et al. (2000) They asked for country, city, place, municipality and hospital. ‘‘Barrio,’’ floor, and apartment seems to be equivalent to other items

Gime´nez-Rolda´n et al. (1997)

Anzola-Pe´ rez et al. (1996) They asked for country, province, ‘‘barrio,’’ and street

They asked for country, city, and region. Hospital and oor were kept

Registration and recall

Bird et al. (1987) They used the words pineapple (pin˜ a) and ‘‘peso,’’ trying more than other versions in English to use words in the same ‘‘word family’’ with two syllables

Sano et al. (1997)

They used apple, table, pence (Spanish equivalents for some of the words used in English)

Rosselli et al. (2000) They used the words house, tree, dog

Ostrosky-Sol´ıs et al. (2000) They used the words pencil, key, and book

Gime´nez-Rolda´n et al. (1997)

Anzola-Pe´rez et al. (1996) They used the words table, tree, dog

They used the words tree, bridge, and street-lamp

MODIFIED VERSION OF MMSE IN SPANISH

3

Table 1. (continued).

Items and authors

Description

Repeat a phrase

al. (1987) They used a tongue twister in Spanish: ‘‘Pancha plancha con cuatro planchas’’ since they consider the item is to evaluate difculties 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 wont go if you do not arrive early. ‘‘No ire´ si tu no llegas

temprano’’ Rosselli et al. (2000) The phrase was: If I do not come down, then you get up: ‘‘Si no bajo, entonces usted suba’’ Anzola-Pe´ rez et al. (1996) They used a tongue twister in Spanish: ‘‘Tres perros en un trigal’’

Sano et al. (1997) Gime´nez-Rolda´n et al. (1997) Ostrosky-Sol´ıs et al. (2000)

Bird et

Attention and calculation Sano et al. (1997) Calero et al. (2000) Anzola-Pe´rez et al. (1996) Ostrosky-Sol´ıs et al. (2000)

Following a 3-stage command Ostrosky-Sol´ıs et al. (2000)

Copying a design Gime´nez-Rolda´n et al. (1997)

Serial 7s was substituted by the item ‘‘spelling worldbackwards’’ Serial 3s (subtraction by 3 starting at 20)

They have two options, the rst one was the same in the original in English and the second one was: With your right nger touch your nose and then your left ear. ‘‘Con el dedo derecho, toque la punta de su nariz y luego su o´ıdo izquierdo’’

Draw a cube with all the sides visible and in perspective

Others Calero et al. (2000) 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 Anzola-Pe´rez et al. (1996) 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, specicity ¼ 0.85, resulting in a sample group of 203 who were classied 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

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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 Classication-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 dene 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 Cronbachs . Item analysis was undertaken by factor analysis with the principal components method and varimax rotation, and the inter-observer reliability was evaluated by the coefcient. 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, specicity, 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 classication and confounding factors, with the dependent variable being cognitive impairment as dened by the scoring system, and independent variables being age, sex, level of education, and cog- nitive impairment as dened by the psychiatrist. We performed this analysis for the three scoring procedures dened 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 dened 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 6099 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 classied as cognitively

MODIFIED VERSION OF MMSE IN SPANISH

5

impaired during the clinical evaluation. The odds of being classied as cognitively impaired by the clinical evaluation were over 2.5 times higher for those with less education (odds ratio: OR 2.74, 95% CI 1.514.98). No association was found between a clinical diagnosis of cognitive impair- ment and other demographic variables. The average score was signicantly different be- tween those without and those with cognitive impairment for all three MMSE scores (F test,

p < .001). Internal reliability was high (Cronbachs ¼ 0.89, p < .0001) with improvement when the item ‘‘serial-seven’’ was excluded, although this improvement was not statistically signicant. Inter-observer consistency was good for both the clinical evaluation ( ¼ 0.807, p < .01) as well as for the MMSE interview itself ( ¼ 0.901,

p < .01). From the factor analysis, four components were identied, explaining 60.6% of the total variance. Factor 1 included items related to Orien- tation in space, factor 2 could be dened as Orientation in time plus registration, factor 3 integrated Language plus attention and calcula- tion, and factor 4 Naming objects (Table 2). The correlation between items, and between items and scale, was statistically signicant in all cases. ROC analysis was used to determine the opti- mum cut-off points for the various scoring meth- ods (Fig. 1). For the usual MMSE scoring system (A) the optimal cut-off point was 25/26 with sensitivity 0.986 and specicity 0.70. When ‘‘serial-seven’’ was substituted (scoring system B), the optimal cut-off point was 24/25 with sensitivity 0.94 and specicity 0.75. When adjust- ments were made for education (scoring system C) the optimal cut-off point was 23/24 with sensitivity 0.97 and specicity 0.88. Using logistic regression, and in addition to cognitive impairment as dened by the psychia- trist, level of education was a signicant factor when using scoring systems A and B (optimal cut- off point), while level of education and age were signicant factors for scoring system A with the 20/21 cut-off point. For scoring system C, no factors other than cognitive impairment dened by the psychiatrist were signicant.

Table 2. Matrix of Rotated Components.

Items

Component

1234

City

0.700

‘‘Colonia’’ 0.698

0.731

Hospital

Floor

Repeating a phrase

0.657

Country

0.563

Month

0.511

Year

0.412

Registration (spoon)

0.743

Registration (bicycle)

0.737

Registration (paper)

0.706

Day

0.679

Day of the week

0.537

Time

0.528

Writing a sentence

0.788

Read and obey

0.756

Copying design

0.680

Attention and

0.609

calculation Recall

0.536

Following a 3-stage

0.506

command

0.429

Naming (watch)

0.913

Naming (pencil)

0.891

When the scoring methods A (unadjusted) and

C (adjusted for those with low education) were

compared (Table 3), mean differences in A were signicant in those with and without cognitive impairment by level of education, but when scores were adjusted (C), these differences dis- appeared (Table 3). However, within groups dened by educational level, mean scores for both scoring systems A and C were signicantly different for those with and without cognitive impairment. This suggests that scoring system C still discriminated between those with and with-

out cognitive impairment if they had a low level

of education, but that those with a low level of

education did not have signicantly lower scores, whether they were cognitively impaired

or not. From these analyses, C appeared to be the best scoring method with the optimal cut-off point of 23/24. The area under the curve was 0.849 (95% CI 0.7980.899), positive predictive value 0.666

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6 SANDRA REYES DE BEAMAN ET AL. Fig. 1. Comparative ROC curves using three different scoring
6 SANDRA REYES DE BEAMAN ET AL. Fig. 1. Comparative ROC curves using three different scoring

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 A a and C b 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

15.020.0

.0001

17.50

6.5

15.020.0

ns

Low education

12.12

5.0

10.613.7

19.17

4.6

17.720.6

Cognitively intact

Literate

27.78

1.8

27.428.2

.0001

27.78

1.9

27.328.2

ns

Low education

21.82

3.4

20.822.8

26.68

2.2

26.127.4

Literate

Impaired

27.8

1.8

27.428.2

.0001

––

No impaired

17.5

6.5

15.020.0

Low education

No impaired

21.83

3.4

20.122.8

.0001

26.68

2.1

26.127.3

.0001

Impaired

12.12

5.0

10.613.7

19.17

4.6

17.720.6

Note. a The 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 of the test was 0.812 with the likelihood ratio for a positive test being 3.395 and the likelihood ratio for a negative test 0.0169.

DISCUSSION

The MMSE has been one of the most widely used instruments for geriatric evaluation in Mexico.

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7

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-Sol´ıs 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 difculties in others. The adapted version here discriminates well between those with and without cognitive

impairment, but although no substantial modi- 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 (Gime´nez-Rolda´n et al., 1997; Lobo et al., 2000; Ostrosky-Sol´ıs 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 denite weather changes representing seasons. Like other researchers, we asked about the time, but within acceptable standardized limits

(Ostrosky-Sol´ıs 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

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 specic number of syllables. However, some versions use words that are related to each other and interviewees may nd 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 difculty 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 classied as minimally educated ap- peared to be a good compromise. Reducing the difculty level by counting backwards in groups of three starting from 20, could produce a mis- taken classication among the better educated and would not benet those who, for whatever reason, could not answer the serial-seven (Ostrosky-Sol´ıs 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 justied 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-Sol´ıs 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 nal ‘‘s’’ in the word ‘‘peros’’ (Table 1), it was decided to use the word ‘‘pero’’ instead (Gime´ nez- Rolda´n et al., 1997). This phrase is not a transla- tion of the original in English but shares the same

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SANDRA REYES DE BEAMAN ET AL.

characteristics: a phrase with no meaning, with unrelated words, but without phonetic difculties. 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 signicant, 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 reect 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 psychiatristsclinical 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 difculty 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 specicity 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 nal classication, although there may be cost implications as well as worry for those wrongly classied. Establishing different cut-off points has been recommended for groups dened 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 eld, we felt that this option was preferable. Lowering the cut-off point could result in a greater number of mistakes in the classication of the participants, even though classication tables could be supplied to the interviewers (Anzola-Pe´rez 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 signicant. However, it seems

MODIFIED VERSION OF MMSE IN SPANISH

9

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 rst 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
APPENDIX
MODIFIED VERSION OF MMSE IN SPANISH 11 APPENDIX
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