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Formal education as an effect modifier of the relationship between Mini-Mental State Examination score and IADLs disability in the older population

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Abstract

The objective of this retrospective, case-series study was to examine the relationship between disability in Instrumental Activities of Daily Living (IADLs) and cognitive impairment measured by the Mini-Mental State Examination (MMSE), and how this relationship was influenced by different levels of formal education. The setting of the study was the Cognitive Disorders Center of the Local Sanitary Unit (USL) No. 4 in Prato (Italy). Independence in IADL was strongly related to MMSE scores. A score of less than 24 at the MMSE was predictive of disability in at least one IADL with 0.82 sensitivity and 0.73 specificity. However, when only people with a very low level of formal education were considered, the best threshold predicting IADL disability was 17 (sensitivity 0.76, specificity 0.75). Thus, scholastic achievement is an effect modifier of the relationship between cognitive status, as measured by the MMSE, and IADL disability. Subjects with low education level and poor performance at the MMSE are often independent in activities making demand on cognitive function, such as IADLs. These results suggest that a lower MMSE cut-off score should be considered when screening for cognitive impairment in these persons.

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References

  1. Naugle R.I., Kawczak K.: Limitation of the Mini-Mental Examination. Clevel. Clin. J. Med. 56: 277–281, 1989.

    Article  CAS  Google Scholar 

  2. Tombaugh T.N., McIntyre N.J.: The Mini-Mental State Examination: a comprehensive review. J. Am. Geriatr. Soc. 40: 922–935, 1992.

    CAS  PubMed  Google Scholar 

  3. Uhlmann R.F., Larson E.B.: Effect of education on the Mini-Mental State Examination as a screening test for dementia. J. Am. Geriatr. Soc. 39: 876–880, 1991.

    CAS  PubMed  Google Scholar 

  4. Bird H.R., Canino G., Stipec M.R., Shrout P.: Use of the Mini-mental State Examination in a probability sample of a Hispanic population. J. Nerv. Ment. Dis. 175: 731–737, 1987.

    Article  CAS  PubMed  Google Scholar 

  5. Heeren T.J., Lagaay A.M., von Beek W.C., Rooymans H.G., Hijmans W.: Reference values for the Mini-Mental State Examination (MMSE) in octo- and nonagenarians. J. Am. Geriatr. Soc. 38: 1093–1096, 1990.

    CAS  PubMed  Google Scholar 

  6. Escobar J.I., Burnam A., Karno M., Forsythe A., Landsverk J., Golding J.M.: Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts. J. Nerv. Ment. Dis. 174: 607–614, 1986.

    Article  CAS  PubMed  Google Scholar 

  7. Katzman R., Zhang M.Y., Ouang-Ya-Qu, Wang Z.Y., Liu W.T., Yu E., Wong S.C., Salmon D.P., Grant I.: A Chinese version of the Mini-Mental State Examination; impact of illiteracy in a Shanghai dementia survey. J. Clin. Epidemiol. 41: 971–978, 1988.

    Article  CAS  PubMed  Google Scholar 

  8. Salmon D.P., Riekkinen P.J., Katzman R., Zhang M.Y., Jin H., Yu E.: Cross-cultural studies of dementia. A comparison of mini-mental state examination performance in Finland and China. Arch. Neurol. 46: 769–772, 1989.

    Article  CAS  PubMed  Google Scholar 

  9. Tomas M.T., Pujadas F., Lafont J., Adalid C., Franch L., Cordon F.: Prevalence of cognitive deterioration in a geriatric urban population. Aten. Primaria 8: 379–386, 1991.

    CAS  PubMed  Google Scholar 

  10. Valente C., Maione P., Lippi A., Cavarzeran F., Rocca W.A., Amaducci L., Bavazzano A.: Validation of the Mini-Mental State Examination (MMSE) as a screening instrument for dementia in an Italian population. Giorn. Geront. 40: 143–150, 1992.

    Google Scholar 

  11. Gagnon M., Letenneur L., Dartigues J.F., Commenges D., Orgogozo J.M., Barberger-Gateau P., Alperovitch A., Decamps A., Salamon R.: Validity of the Mini-Mental State Examination as a screening instrument for cognitive impairment and dementia in French elderly community residents. Neuroepidemiology 9: 143–150, 1990.

    Article  CAS  PubMed  Google Scholar 

  12. Ogunniyi A.O., Osuntokun B.O., Lekwauwa U.B., Falope Z.F.: Rarity of dementia (by DSM-III-R) in an urban community in Nigeria. East Afr. Med. J. 69: 64–68, 1992.

    CAS  PubMed  Google Scholar 

  13. Folstein M.F., Folstein S.E., McHugh P.R.: “Mini-Mental State”. A practical method for grading the cognitive state of the patients for the clinician. J. Psychiatr. Res. 12: 189–198, 1975.

    Article  CAS  PubMed  Google Scholar 

  14. Anthony J.C., LeResche L., Niaz U., von Korff M.R., Folstein M.F.: Limits of the “Mini-Mental State” as a screening test for dementia and delirium among hospital patients. Psychol. Med. 12: 397–408, 1982.

    Article  CAS  PubMed  Google Scholar 

  15. Nelson A., Fogel B.S., Faust D.: Bed-side cognitive screening instruments. A critical assessment. J. Nerv. Ment. Dis. 174: 73–83, 1986.

    Article  CAS  PubMed  Google Scholar 

  16. Fillenbaum G.G., Hughes D.C., Heyman A., George L.K., Blazer D.G.: Relationship of health and demographic characteristics to Mini-Mental State examination score among community residents. Psychol. Med. 18: 719–726, 1988.

    Article  CAS  PubMed  Google Scholar 

  17. O’Connor D.W., Pollitt P.A., Treasure F.P.: The influence of education and social class on the diagnosis of dementia in a community population. Psychol. Med. 21:219–224, 1991.

    Article  PubMed  Google Scholar 

  18. Li G., Shen Y.C., Chen C.H., Zhau Y.W., Li S.R., Lu M.: A three-year follow-up study of age-related dementia in an urban area of Beijing. Acta Psychiatr. Scand. 83: 99–104, 1991.

    Article  CAS  PubMed  Google Scholar 

  19. Yu E.S., Liu W.T., Levy P., Zhang M.Y., Katzman R., Lung C.T., Wong S.C., Wang Z.Y., Qu G.Y.: Cognitive impairment among elderly adults in Shanghai, China. J. Gerontol. 44: S97–S106, 1989.

    Article  CAS  PubMed  Google Scholar 

  20. Brayne C., Calloway P.: The association of education and socioeconomic status with the Mini Mental State Examination and the clinical diagnosis of dementia in elderly people. Age Ageing 19: 91–96, 1990.

    Article  CAS  PubMed  Google Scholar 

  21. Van der Cammen T.J., van Harskamp F., Stronks D.L., Passchier J., Schudel W.J.: Value of the Mini-Mental State Examination and informants’ data for the detection of dementia in geriatric outpatients. Psychol. Rep. 71(3, Pt1): 1003–1009, 1992.

    PubMed  Google Scholar 

  22. Ylikoski R., Erkinjuntti T., Sulkava R., Juva K., Tilvis R., Valvanne J.: Correction for age, education and other demographic variables in the use of the Mini Mental State Examination in Finland. Acta Neurol. Scand. 85: 391–396, 1992.

    Article  CAS  PubMed  Google Scholar 

  23. Dealberto M.J., Gagnon M., Barberger-Gateau P., Dartigues J.F., Alperovitch A.: Influence of educational status on a screening test for dementia, the Mini-Mental State Examination. Rev. Epidemiol. Sante Publique 40: 93–101, 1992.

    CAS  PubMed  Google Scholar 

  24. Dartigues J.F., Gagnon M., Letenneur L., Barberger-Gateau P., Commenges D., Evaldre M., Salamon R.: Principal lifetime occupation and cognitive impairment in a French elderly cohort (Paquid). Am. J. Epidemiol. 135: 981–988, 1992.

    CAS  PubMed  Google Scholar 

  25. Jagger C., Clarke M., Anderson J., Battcock T.: Misclassification of dementia by the mini-mental state examination, are education and social class the only factors? Age Ageing 21: 404–411, 1992.

    Article  CAS  PubMed  Google Scholar 

  26. Crum R.M., Anthony J.C., Bassett S.S., Folstein M.F.: Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 269: 2386–2391, 1993.

    Article  CAS  PubMed  Google Scholar 

  27. Fratiglioni L., Jorm A.F., Grut M., Viitanen M., Holmen K., Ahlbom A., Winblad B.: Predicting dementia from the Mini-Mental State Examination in an elderly population: the role of education. J. Clin. Epidemiol. 46: 281–287, 1993.

    Article  CAS  PubMed  Google Scholar 

  28. Murden R.A., McRae T.D., Kaner S., Bucknam M.: Mini-Mental State Examination Scores vary with education in blacks and whites. J. Am. Geriatr. Soc. 39: 149–155, 1991.

    CAS  PubMed  Google Scholar 

  29. Zhang M.: Comparison of several screening instruments for dementia. Chung Hua Shen Ching Ching Shen Ko Tsa Chih. 24: 194–196, 1991.

    CAS  Google Scholar 

  30. Koivisto K., Helkala E.L., Reinikainen K.J., Hanninen T., Mykkanen L., Laakso M., Pyorala K., Riekkinen P.J.: Population-based dementia screening program in Kuopio: the effect of education, age, and sex on brief neuropsychological tests. J. Geriatr. Psychiatry Neurol. 5: 162–171, 1992.

    CAS  PubMed  Google Scholar 

  31. Magaziner J., Bassett S.S., Hebel J.R.: Predicting performance on the Mini-Mental State Examination. Use of age and education-specific equations. J. Am. Geriatr. Soc. 35: 996–1000, 1987.

    CAS  PubMed  Google Scholar 

  32. Kittner S.J., White L.R., Farmer M.E., Wolz M., Kaplan E., Mocs E., Brody J.A., Feinleib M.: Methodologic issue in screening for dementia. The problem of education adjustment. J. Chron. Dis. 39: 163–170, 1986.

    Article  CAS  PubMed  Google Scholar 

  33. O’Connor D.W., Pollitt P.A., Treasure F.P., Brook C.P., Reiss B.B.: Hughes Hall, Cambridge: The influence of education, social class and sex on Mini-Mental State scores. Psychol. Med. 19: 771–776, 1989.

    Article  PubMed  Google Scholar 

  34. Wiederholt W.C., Cahn D., Butters N.M., Kritz-Silverstein D., Barrett-Connor E.: Effects of Age, Gender and Education on Selected Neurosychological Test in an Elderly Community Cohort. J. Am. Geriatr. Soc. 41: 639–647, 1993.

    CAS  PubMed  Google Scholar 

  35. Farmer M.E., Kittner S.J., Rae D.S., Bartko J.J., Regier D.A.: Education and Change in Cognitive function. The Epidemiologic Catchment Area Study. Ann. Epidemiol. 5: 1–7, 1995.

    Article  CAS  PubMed  Google Scholar 

  36. Bohnstedt M., Fox P.J., Kohatsu N.D.: Correlates of Mini-Mental State Examination Scores Among Elderly Demented Patients: The Influence of Race-Ethnicity. J. Clin. Epidemiol. 47: 1381–1387, 1994.

    Article  CAS  PubMed  Google Scholar 

  37. Pi J., Olive J.M., Esteban M.: Mini Mental State Examination: Association of the Score Obtained with the Age and Degree of Literacy in an Aged Population. Med. Clin. 19: 641–644, 1994.

    Google Scholar 

  38. Lawton M.P., Brody E.M.: Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 9: 179–186, 1969.

    Article  CAS  PubMed  Google Scholar 

  39. Barberger-Gateau P., Commenges D., Gagnon M., Letenneur L., Sauvel C., Dartigues J.F.: Instrumental activities of daily living as a screening tool for cognitive impairment and dementia in elderly community dwellers. J. Am. Geriatr. Soc. 40: 1129–1134, 1992.

    CAS  PubMed  Google Scholar 

  40. American Psychiatric Association: Diagnostic and Statistic Manual of Mental Disorders, ed. 3 revised. American Psychiatric Association, Washington D.C., 1987.

    Google Scholar 

  41. Pfeiffer E.: A Short Portable Mental Status Questionary for the Assessment of Organic Brain Deficit in Elderly Patients. J. Am. Geriatr. Soc. 23: 433–441, 1975.

    CAS  PubMed  Google Scholar 

  42. Wolinsky F.D., Fredric D., Christopher M.C., Fitzgerald J.F., Johnson R.J.: The risk of Nursing Home Placement and Subsequent Death Among Older Adults. J. Gerontol. 47: 173–182, 1992.

    Article  Google Scholar 

  43. Katz S., Ford A.B., Moskowitz R.W., Jackson B.A., Jaffee M.W.: Studies of Illness in the Aged. The Index of ADL: A Standardized Measure of Biological and Psychosocial Function. JAMA 185: 94–101, 1963.

    Article  Google Scholar 

  44. Fitzgerald J.F., Smith D.M., Martin D.K., Freedman J.A., Wolinsky F.D.: Replication of the Multidimensionality of Activities of Daily Living. J. Gerontol. 48: 28–31, 1993.

    Article  Google Scholar 

  45. Green C.R., Mohs R.C., Schmeidler J., Aryan M., Davis K.L.: Functional Decline in Alzheimer’s Disease: A Longitudinal Study. J. Am. Geriatr. Soc. 41: 654–661, 1993.

    CAS  PubMed  Google Scholar 

  46. McKhann G., Drachman D., Folstein M., Katzman M., Price D., Stadlan E.M.: Clinical diagnosis of Alzheimer’s disease: report of the NINCDS — ADRDA work group under the auspices of Department of Health and Human Services task force on Alzheimer’s disease. Neurology 34: 939–944, 1984.

    Article  CAS  PubMed  Google Scholar 

  47. Folstein M., Anthony J.C., Parhad I., Duffy B., Gruenberg E.M.: The Meaning of Cognitive Impairment in the Elderly. J. Am. Geriatr. Soc. 33: 228–235, 1985.

    CAS  PubMed  Google Scholar 

  48. Clarfield A.M., Foley J.M.: The American and Canadian Consensus Conference on Dementia: Is There Consensus? J. Am. Geriatr. Soc. 41: 883–886, 1993.

    Google Scholar 

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Authors and Affiliations

  1. Department of Geriatrics, U.S.L. 4, 50047, Prato, Italy

    J. J. Quesada, D. Calvani, C. Valente & A. Bavazzano

  2. Department of Geriatrics, I.N.R.C.A. Hospital “I Fraticini”, Firenze, Italy

    L. Ferrucci & B. Salani

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  1. J. J. Quesada
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  4. C. Valente
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Quesada, J.J., Ferrucci, L., Calvani, D. et al. Formal education as an effect modifier of the relationship between Mini-Mental State Examination score and IADLs disability in the older population. Aging Clin Exp Res 9, 175–179 (1997). https://doi.org/10.1007/BF03340146

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