The MMSE is used to screen for cognitive impairment and estimate dementia severity. In clinical settings, conventional cut-off scores have been used to distinguish between dementia stages. However, these scores have not been validated for different populations. This study maps scores from the modified version of the MMSE to dementia stages delineated by the Diagnostic and Statistical Manual of Mental Disorders-3rd revised edition (DSM-III-R), the Clinical Dementia Rating (CDR) and Functional Assessment Staging Test (FAST). We used cross-sectional data from a tertiary hospital memory clinic. Subjects were stratified into “primary education and below” (PE) or “secondary education and above” (SE). Receiving operating characteristic (ROC) analyses and Cohen's κ were performed to determine MMSE cut-off scores for dementia stages. Our derived cut-off scores were lower compared to the conventional scores. Scores also differed between subjects of different education levels. MMSE cut-off scores were 19, 15, and 9 for CDR stages 1, 2, and 3 respectively in PE subjects, and 23, 17, and 10 for SE subjects. Cut-off scores were comparable for staging by DSM-III-R Criteria and FAST. There is a need for locally derived stage-specific MMSE cut-off scores for the Asian population adjusted for education.

The present study was conducted to determine whether anxiety among community-dwelling elders is associated with cognitive decline over a period of one year as well as to verify whether there are sex differences in the association between anxiety and cognitive decline. Participants (n=1942) were community-dwelling adults aged 65–96 years assessed at study entry (T0) and one year later (T1). Anxiety was identified with a semi-structured interview and cognitive functioning was assessed using the Mini-Mental State Examination. Results revealed that the presence of a clinically significant anxiety disorder did not predict cognitive decline in men and women. Subclinical anxiety symptoms predicted cognitive decline in women only. Moreover, for men, the presence of symptoms from at least two anxiety disorders predicted cognitive decline. For women, cognitive decline was predicted by the presence of symptoms from one anxiety disorder only. Overall, the results illustrate the role of anxiety in cognitive decline in community-dwelling older adults.

Background: Drawing tests have a long history in neuropsychological assessment. A popular geometric figure has been the two intersecting pentagons from the Bender Gestalt test. Reproducing the pentagons is the main visuospatial task on the original Mini-Mental State Examination (MMSE), remaining in use in revised versions of that widely used screening test. Scoring criteria on the MMSE are binary: perfect reproduction of the figure is required, while the Modified MMSE of Teng and Chui (1987) uses a more refined ten-point scoring for the elements of the figure.

Methods: Here, I report on the use of pentagon drawing from 8,702 older community-dwelling Canadians (59.3% female), with a mean age of 75.5 years (SD = 6.99) and 10.1 years of education (SD = 3.89). Mean scores for the whole sample are reported, as well as for subsamples who underwent a full clinical assessment and were diagnosed as cognitively intact, with dementia, or cognitively impaired, but without dementia. Logistic regression was used to evaluate the utility of pentagon drawing as a diagnostic tool to diagnose cognitive impairment.

Results: Binary scoring was less effective in discriminating groups than the ten-point system and showed weaker properties by other criteria.

Conclusions: The discussion focuses on the role of simple, non-verbal tasks in the cognitive screening of older adults.

Background: Frailty in older adults is a multifactorial syndrome defined by low metabolic reserve, less resistance to stressors, and difficulty in maintaining organic homeostasis due to cumulative decline of multiple physiological systems. The relationship between frailty and cognition remains unclear and studies about Mini-Mental State Examination (MMSE) performance and frailty are scarce. The objective was to examine the association between frailty and cognitive functioning as assessed by the MMSE and its subdomains.

Methods: A cross-sectional population-based study (FIBRA) was carried out in Ermelino Matarazzo, a poor subdistrict of the city of São Paulo, Brazil. Participants were 384 community dwelling older adults, 65 years and older who completed the MMSE and a protocol to assess frailty criteria as described in the Cardiovascular Health Study (CHS).

Results: Frail older adults had significantly worse performance on the MMSE (p < 0.001 for total score). Linear regression analyses showed that the MMSE total score was influenced by age (p < 0.001), education (p < 0.001), family income (p < 0.001), and frailty status (p < 0.036). Being frail was associated more significantly with worse scores in Time Orientation (p < 0.004) and Immediate Memory (p < 0.001).

Conclusions: Our data suggest that being frail is associated with worse cognitive performance, as assessed by the MMSE. It is recommended that the assessment of frail older adults should include the investigation of their cognitive status.

Background: The field of geriatric medicine has identified a need for an evaluative tool that can rapidly quantify global cognitive ability and accurately monitor change over time in patients with a wide range of impairments. We hypothesized that the development of an adaptive test approach to cognitive measurement would help to meet that need. This study aimed to provide evidence for the interpretability of scores obtained from a novel, adaptive approach to cognitive assessment, called the Geriatric Rapid Adaptive Cognitive Estimate (GRACE) method.

Methods: An adaptive method for cognitive assessment was developed using data from 185 patients referred for geriatric cognitive assessment, and pilot tested in an additional 137 patients. Correlations between test scores and between rank orders of patients were computed to examine the reliability and validity of cognitive ability scores obtained by (1) administering test questions out of their usual order, (2) administering only a subset of questions, and (3) administering questions adaptively using simplified selection rules based on the most difficult question passed.

Results: Cognitive ability scores obtained with the GRACE method correlated highly with the Montreal Cognitive Assessment (MoCA) scores (r = 0.93) and ranked patients similarly in order of ability (r > 0.87). A simplified adaptive testing algorithm for pencil-and-paper assessment demonstrated moderately high correlations with scores obtained from administering the full set of MMSE and MoCA items as well as the MoCA items alone.

Conclusions: Scores from the GRACE method can be obtained easily in 5–10 minutes, reducing test burden. The resulting numeric score quantifies cognitive ability, allowing clinicians to compare patients and monitor change in global cognition over time. The adaptive nature of this method allows for evaluation of persons across a broader range of cognitive ability levels than currently available tests.

Background: The Montreal Cognitive Assessment (MoCA) can be used to quantify cognitive ability in older persons undergoing screening for cognitive impairment. Although highly sensitive in detecting mild cognitive impairment, its measurement precision is weakest among persons with milder forms of impairment. We sought to overcome this limitation by integrating information from the Mini-Mental State Examination (MMSE) into the calculation of cognitive ability.

Methods: Data from 185 geriatric outpatients screened for cognitive impairment with the MoCA and the MMSE were Rasch analyzed to evaluate the extent to which the MMSE items improved measurement precision in the upper ability ranges of the population.

Results: Adding information from the MMSE resulted in a 13.8% (13.3–14.3%) reduction in measurement error, with significant improvements in all quartiles of patient ability. The addition of three-word repetition and recall, copy pentagons, repeat sentence, and write sentence improved measurement of cognition in the upper levels of ability.

Conclusions: The algorithm presented here maximizes the yield of available clinical data while improving measurement of cognitive ability, which is particularly important for tracking changes over time in patients with milder levels of impairment.

Background: Only a small number of studies on the natural disease course in behavioral variant frontotemporal dementia (bvFTD) have been conducted. This is surprising because knowledge about the progression of symptoms is a precondition for the design of clinical drug trials.

Methods: The aim of the present study was to examine the cognitive decline of 20 patients with mild bvFTD over one year using the Consortium to Establish a Registry for Alzheimer's Disease – Neuropsychological Assessment Battery (CERAD-NAB).

Results: Within an average follow-up interval of 13 months, patient scores declined significantly in the Mini-mental-State-Examination (MMSE) and the CERAD-NAB subtests of naming, verbal and nonverbal memory. No significant changes were found in the CERAD-NAB subtests of category fluency, recognition, and visuoconstruction. The average annualized decline on the MMSE was 4.0 ± 4.9 points. Ceiling effects were detected in Figures Copy, Word List Recognition and Modified Boston Naming Test. Though the included patient group was rather homogeneous regarding severity of dementia, the cognitive changes were very heterogeneous.

Conclusion: Given the heterogeneity of cognitive decline, the design of a test battery for clinical trials in FTD will be challenging. A cognitive battery should definitely include the MMSE, Word List Learning and Word List Delayed Recall.

Background: Apathy, a complex neuropsychiatric syndrome, commonly affects patients with Alzheimer's disease. Prevalence estimates for apathy range widely and are based on cross-sectional data and/or clinic samples. This study examines the relationships between apathy and cognitive and functional declines in non-depressed community-based older adults.

Methods: Data on 1,136 community-dwelling adults aged 50 years and older from the Baltimore Epidemiologic Catchment Area (ECA) study, with 1 and 13 years of follow-up, were used. Apathy was assessed with a subscale of items from the General Health Questionnaire. Logistic regression, t-tests, χ2 and Generalized Estimating Equations were used to accomplish the study's objectives.

Results: The prevalence of apathy at Wave 1 was 23.7%. Compared to those without, individuals with apathy were on average older, more likely to be female, and have lower Mini-mental State Examination (MMSE) scores and impairments in basic and instrumental functioning at baseline. Apathy was significantly associated with cognitive decline (OR = 1.65, 95% CI = 1.06, 2.60) and declines in instrumental (OR = 4.42; 95% CI = 2.65, 7.38) and basic (OR = 2.74; 95%CI = 1.35, 5.57) function at 1-year follow-up, even after adjustment for baseline age, level of education, race, and depression at follow-up. At 13 years of follow-up, apathetic individuals were not at greater risk for cognitive decline but were twice as likely to have functional decline. Incidence of apathy at 1-year follow up and 13-year follow-up was 22.6% and 29.4%, respectively.

Conclusions: These results underline the public health importance of apathy and the need for further population-based studies in this area.

This study was aimed at providing normative data for the Mini-Mental State Examination (MMSE). The norms were built from a sample (n = 2409) of community-dwelling French speaking residents from Québec aged 65 and older. The analyses indicated that socio-demographic variables such as education level, age, and gender of individuals influenced significantly the scores of older adults on the MMSE. More precisely, MMSE scores increased with education level and decreased with age. Moreover, women had significantly higher scores than men. On this basis, distinct tables of normative data were produced for women and men. In each table, the MMSE scores corresponding to percentiles 5, 10, 15 and 50 were identified according to four age categories and three education levels. Overall, the use of the present normative data by clinicians will improve their accuracy in detecting cognitive impairment in older adults from Québec.

Background: Cognitive decline in old age varies among individuals. The identification of groups of individuals with similar patterns of cognitive change over time may improve our ability to see whether the effect of risk factors is consistent across groups.

Methods: Whilst accounting for the missing data, growth mixture models (GMM) were fitted to data from four interview waves of a population-based longitudinal study of aging, the Cambridge City over 75 Cohort Study (CC75C). At all interviews global cognition was assessed using the Mini-mental State Examination (MMSE).

Results: Three patterns were identified: a slow decline with age from a baseline of cognitive ability (41% of sample), an accelerating decline from a baseline of cognitive impairment (54% of sample) and a steep constant decline also from a baseline of cognitive impairment (5% of sample). Lower cognitive scores in those with less education were seen at baseline for the first two groups. Only in those with good performance and steady decline was the effect of education strong, with an increased rate of decline associated with poor education. Good mobility was associated with higher initial score in the group with accelerating change but not with rate of decline.

Conclusion: Using these analytical methods it is possible to detect different patterns of cognitive change with age. In this investigation the effect of education differs with group. To understand the relationship of potential risk factors for cognitive decline, careful attention to dropout and appropriate analytical methods, in addition to long-term detailed studies of the population points, are required.

Background: Although the Clock Drawing Test (CDT) is the second most used test in the world for the screening of dementia, there is still debate over its sensitivity, specificity, application and interpretation in dementia diagnosis. This study has three main aims: to evaluate the sensitivity and specificity of the CDT in a sample composed of older adults with Alzheimer's disease (AD) and normal controls; to compare CDT accuracy to the that of the Mini-mental State Examination (MMSE) and the Cambridge Cognitive Examination (CAMCOG); and to test whether the association of the MMSE with the CDT leads to higher or comparable accuracy as that reported for the CAMCOG.

Methods: Cross-sectional assessment was carried out for 121 AD and 99 elderly controls with heterogeneous educational levels from a geriatric outpatient clinic who completed the Cambridge Examination for Mental Disorder of the Elderly (CAMDEX). The CDT was evaluated according to the Shulman, Mendez and Sunderland scales.

Results: The CDT showed high sensitivity and specificity. There were significant correlations between the CDT and the MMSE (0.700–0.730; p < 0.001) and between the CDT and the CAMCOG (0.753–0.779; p < 0.001). The combination of the CDT with the MMSE improved sensitivity and specificity (SE = 89.2–90%; SP = 71.7–79.8%). Subgroup analysis indicated that for elderly people with lower education, sensitivity and specificity were both adequate and high.

Conclusions: The CDT is a robust screening test when compared with the MMSE or the CAMCOG, independent of the scale used for its interpretation. The combination with the MMSE improves its performance significantly, becoming equivalent to the CAMCOG.

Objective: The study aimed to assess the clinical utility of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) in patients referred to memory clinics, alone and in combination with the Addenbrooke's Cognitive Examination-Revised (ACE-R) and the Mini-mental State Examination (MMSE).

Methods: This pragmatic prospective study was based on consecutive referrals attending with an informant (n = 144) to two memory clinics over a 12-month period. Patients were diagnosed using standard clinical diagnostic criteria for dementia (DSM-IV) as gold standard (dementia prevalence = 59%). The IQCODE was administered to informants, and the ACE-R and/or MMSE to most patients.

Results: The IQCODE proved acceptable to informants, and was quick and easy to use. Using traditional parameters of diagnostic utility (sensitivity, specificity, positive predictive value, likelihood ratios), the performance of the IQCODE at optimal test accuracy was highly sensitive (0.86) for the diagnosis of dementia but specificity was poor (0.39) with suboptimal positive predictive value (0.67) and small or unimportant likelihood ratios. Overall diagnostic accuracy based on area under the receiver operating characteristic (ROC) curve was 0.71. Combining the IQCODE with either ACE-R or MMSE greatly improved accuracy, specificity and positive predictive value when the tests were used in series, but not when used in parallel.

Conclusion: In a memory clinic based population, the IQCODE proved sensitive for the diagnosis of dementia but overall diagnostic accuracy was suboptimal. Combining the IQCODE in series with the ACE-R or MMSE greatly improved diagnostic utility.

Background: It is well known that the global population is aging and that those over the age of 80 are the fastest growing part of this expansion. Also known is that prevalence of hypertension and cognitive decline both increase with increasing age.

Method: The Hypertension in the Very Elderly Trial (HYVET) was a double blind placebo-controlled trial of antihypertensive treatment (indapamide SR 1.5 mg ± perindopril 2–4 mg) and recruited only those hypertensives who were aged 80 or over and were without a diagnosis of dementia at baseline. Systolic blood pressure had to be in the range 160–199 mmHg and diastolic pressure <110 mmHg. Cognitive function was assessed at baseline using the Mini-mental State Examination prior to randomization into the trial. Also collected at baseline was information relating to sociodemographic, clinical, cardiovascular and biochemical factors which may impact upon cognitive function. This paper reports on the baseline cognitive function data from the HYVET trial and its relationship to these factors.

Results: The mean age of the 3763 HYVET participants who had full cognitive function data at baseline was 83.6 years; 60 percent were female. The median MMSE score at baseline was 26 and, in multivariate analyses, higher at younger age, with male gender, higher educational level, having higher creatinine, higher total cholesterol and lower high-density lipoprotein cholesterol.

Conclusions: This is the first such study to examine a large number of very elderly hypertensives and it shows some similar patterns to those seen in younger elderly groups.

Background: The Mini-mental State Examination (MMSE) is a globally used instrument for cognitive screening, which nevertheless has a bias with respect to education and language. The Indo-U.S. Cross National Epidemiology Study developed a modified version of MMSE, the Hindi Mental State Examination (HMSE), to counter this bias in India among rural and illiterate elderly. Thus, two parallel tests are available for screening the population. This study was conducted to explore and compare the applicability of MMSE and HMSE when scanning for cognitive impairment among urban elderly people.

Methods: The sample consisted of 40 subjects (20 illiterate and 20 literate) aged 60 years and above drawn from the urban community who met the inclusion criteria. A systematically translated Hindi version of MMSE (HVMMSE) was administered to both groups. After one month, HMSE was administered to the same groups. χ2 with Yate's correction, percentage, rank order correlation and qualitative analysis were used to analyze data.

Results: All illiterate subjects scored below the cut-off on translated HVMMSE while only four of them scored below the cut-off on HMSE. Among literate subjects, the translated HVMMSE and HMSE classified three subjects and one subject respectively as having possible cognitive impairment among urban elderlies.

Conclusion: The two instruments are not in agreement with regard to classifying elderly people as having possible cognitive impairment or not. This disagreement is more pronounced in the case of illiterate subjects. The study emphasizes the need to develop a fair cognitive screening instrument for elderly people in India.

Background: The Mini-mental State Examination (MMSE) is widely used in Japan and the U.S.A. for cognitive screening in the clinical setting and in epidemiological studies. A previous Japanese community study reported distributions of the MMSE total score very similar to that of the U.S.A.

Methods: Data were obtained from the Monongahela Valley Independent Elder's Study (MoVIES), a representative sample of community-dwelling elderly people aged 65 and older living near Pittsburgh, U.S.A., and from the Tajiri Project, with similar aims in Tajiri, Japan. We examined item-by-item distributions of the MMSE between two cohorts, comparing (1) percentage of correct answers for each item within each cohort, and (2) relative difficulty of each item measured by Item Characteristic Curve analysis (ICC), which estimates log odds of obtaining a correct answer adjusted for the remaining MMSE items, demographic variables (age, gender, education) and interactions of demographic variables and cohort.

Results: Median MMSE scores were very similar between the two samples within the same education groups. However, the relative difficulty of each item differed substantially between the two cohorts. Specifically, recall and auditory comprehension were easier for the Tajiri group, but reading comprehension and sentence construction were easier for the MoVIES group.

Conclusions: Our results reaffirm the importance of validation and examination of thresholds in each cohort to be studied when a common instrument is used as a dementia screening tool or for defining cognitive impairment.

Background: We evaluated the combined and differential effects of physical, social and productive activities on cognitive decline and whether they were modified by the presence of the APOE-ε4 allele.

Methods: In a prospective cohort study of 1635 community-dwelling Chinese older adults aged 55 or older participating in the ongoing Singapore Longitudinal Aging Study, physical, social and productive leisure activities were assessed at baseline, and cognitive decline (at least one point drop) in MMSE scores between baseline and follow-up after one year.

Results: Cognitive decline was observed in 30% of the respondents. Controlling for age, gender, education and other risk factors, odds ratios (ORs) were significantly reduced in those with medium (OR: 0.60, 95% CI: 0.45–0.79) and high activity levels (OR: 0.62, 95% CI: 0.46–0.84). A stronger association was shown for productive activity (OR = 0.36), than for physical (OR = 0.78) and social activities (OR = 0.85). These associations showed statistically significant interactions with APOE genotype, being more pronounced in those with the APOE-ε4 allele.

Conclusion: Increased leisure activity, especially productive activities more than physical or social activities, was associated with a lowered risk of cognitive decline. APOE-ε4 genotype individuals appeared to be more vulnerable to the effects of low and high levels of leisure activities.