O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade

Bertolucci, Paulo H.F.; Brucki, Sonia M.D.; Campacci, Sandra R.; Juliano, Yara

doi:10.1590/S0004-282X1994000100001

Resumos

O Mini-Exame do Estado Mental (MEM) foi aplicado em 530 indivíduos, classificados segundo suas idades e escolaridades, para avaliarmos o desempenho dessa população de nosso meio. Constatou-se que, para essa amostra, a idade não interferiu nos escores alcançados. Entretanto, ao comparar quatro níveis de escolaridade (analfabetos, baixa, média e alta) obtivemos diferença estatística significante (p<0,0001) entre os escores, exceto para os indivíduos de baixa e média escolaridade quando comparados entre si. Foram estipulados valores de corte para cada grupo, tomando-se como referência o percentil 5% da porção inferior da curva de distribuição dos valores dos escores. Estes foram: 13 para analfabetos, 18 para baixa e média e 26 para alta escolaridade. Comparando-se estes resultados aos obtidos com o MEM em 94 indivíduos com déficits cognitivos comprovados, utilizando os níveis de corte por nós determinados encontramos: sensibilidade de 82,4% para analfabetos, 75,6% para baixa e média e 80% para alta escolaridade; e especificidade de 97,5% para analfabetos, 96,6% para baixa e média e 95,6% para alta escolaridade. Acreditamos que devam ser utilizados níveis de corte diferenciados para cada escolaridade a fim de que erros diagnósticos possam ser minimizados.

cognição; estado educacional; testes neuropsicológicos; Mini-Exame do Estado Mental

To assess the influence of age and education on cognitive performance in our population, 530 adults were interviewed using the MMSE (Mini-Mental Status Examination). Education level, classified as illiterate, elementary and middle (< 8 years) and high (> 8 years), was a significant predictor of performance (p < 0.0001). Nevertheless, the total scores were not significantly different among the age-groups, young (< or = 50 years), middle age 51 to 64 years) and elderly (> or = 65 years). The reference cut-off values were taken from the fifth percent lowest score for each group: illiterate, 13; elementary and middle, 18; and high, 26. When compared to 94 pacients with cognitive impairment, our cut-off values achieved high sensitivity (82.4% for illiterates; 75.6% for elementary and middle; 80% for high) and specificity (97.5% for illiterate; 96.6% for elementary and middle; 95.6% for high educational level). Education-specific reference values for the MMSE are necessary in interpreting individual test results in populations of low educational level, in order to reduce the false positive results.

cognition; educational status; neuropsychological tests; Mini-Mental State Examination

O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade

The Mini-Mental State Examination in an outpatient population: influence of literacy

Paulo H.F. Bertolucci^I; Sonia M.D. Brucki^I; Sandra R. Campacci^I; Yara Juliano^II

^IDisciplina de Neurologia do Departamento de Neurologia e Neurocirurgia

^IIDisciplina de Bioestatística do Departamento de Medicina Preventiva da Escola Paulista de Medicina

RESUMO

O Mini-Exame do Estado Mental (MEM) foi aplicado em 530 indivíduos, classificados segundo suas idades e escolaridades, para avaliarmos o desempenho dessa população de nosso meio. Constatou-se que, para essa amostra, a idade não interferiu nos escores alcançados. Entretanto, ao comparar quatro níveis de escolaridade (analfabetos, baixa, média e alta) obtivemos diferença estatística significante (p<0,0001) entre os escores, exceto para os indivíduos de baixa e média escolaridade quando comparados entre si. Foram estipulados valores de corte para cada grupo, tomando-se como referência o percentil 5% da porção inferior da curva de distribuição dos valores dos escores. Estes foram: 13 para analfabetos, 18 para baixa e média e 26 para alta escolaridade. Comparando-se estes resultados aos obtidos com o MEM em 94 indivíduos com déficits cognitivos comprovados, utilizando os níveis de corte por nós determinados encontramos: sensibilidade de 82,4% para analfabetos, 75,6% para baixa e média e 80% para alta escolaridade; e especificidade de 97,5% para analfabetos, 96,6% para baixa e média e 95,6% para alta escolaridade. Acreditamos que devam ser utilizados níveis de corte diferenciados para cada escolaridade a fim de que erros diagnósticos possam ser minimizados.

Palavras-chave: cognição, estado educacional, testes neuropsicológicos, Mini-Exame do Estado Mental.

SUMMARY

To assess the influence of age and education on cognitive performance in our population, 530 adults were interviewed using the MMSE (Mini-Mental Status Examination). Education level, classified as illiterate, elementary and middle (< 8 years) and high (> 8 years), was a significant predictor of performance (p < 0.0001). Nevertheless, the total scores were not significantly different among the age-groups, young (< or = 50 years), middle age 51 to 64 years) and elderly (> or = 65 years). The reference cut-off values were taken from the fifth percent lowest score for each group: illiterate, 13; elementary and middle, 18; and high, 26. When compared to 94 pacients with cognitive impairment, our cut-off values achieved high sensitivity (82.4% for illiterates; 75.6% for elementary and middle; 80% for high) and specificity (97.5% for illiterate; 96.6% for elementary and middle; 95.6% for high educational level). Education-specific reference values for the MMSE are necessary in interpreting individual test results in populations of low educational level, in order to reduce the false positive results.

Key words: cognition, educational status, neuropsychological tests, Mini-Mental State Examination.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Agradecimentos - Agradecemos a Suzana M.F. Malheiros, Ana Cláudia Picollo, Adriana A Fujinami, Henrique B. Ferraz e João S. Pereira pela ajuda na aplicação do teste; a Afonso C. Neves por permitir o uso dos escores de pacientes confusos; a Neil F. Novo pelo auxílio na análise estatística.

Aceite: 3-agosto-1993.

Dr. Paulo H.F. Bertolucci - Disciplina de Neurologia, Escola Paulista de Medicina - Rua Botucatu 762 - 04023-900 São Paulo SP - Brasil.

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Ed. 3 revised. Washington DC: American Psychiatric Press 1987.
2. Anthony JC, Le Resche L, Niaz U, Von Korff MR, Folstein MF. Limits of the Mini-Mental State as a screening test for dementia and delirium among hospital patients. Psychol Med 1982, 12: 397-408.
3. Bleecker ML, Bolla-Wilson K. New age-specific norms for the Mini-Mental State Exam. Neurology 1987, 37 (Suppl 1): 279.
4. Bleecker ML, Bolla-Wilson K, Kawas C, Agnew J. Age-specific norms for the Mini-Mental State Exam. Neurology 1988, 38: 1565-1568.
5. Borenstein J, Reisberg B, Amand R, et al. Clinical assessment of Alzheimer's diasease: a comparative study (abstr). New York: 13th Internat Congr Gerontol 1985.
6. Brayne C, Calloway P. The association of education and socioeconomics status with the Mini-Mental State Examination and the clinical diagnosis of dementia in elderly people. Age and Ageing 1990, 19: 91-92.
7. Brody DS. Physician recognition of behavioral psychological and social aspects of medical care. Arch Intern Med 1980, 240: 268.
8. Escobar JL, Burnam A Karno M, Forsythe A Landsverk J, Golding JM. Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. J Nerv Ment Dis 1986, 174: 607-614.
9. Fillenbaum GG, Heyman A, Wilkinson WF, Haynes CS. Comparison of two screenings tests in Alzheimer's disease. Arch Neurol 1987, 44: 924-927.
10. Fillenbaum GG, Hughes DC, Heyman A George LK, Blazer DG. Relationship of health and demographic characteristics to Mini-Mental State Examination score among community residents. Psychol Med 1988,18:719-726.
11. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state for the clinician. J Psychiatr Res 1975, 12: 189-198.
12. Freemon FR. Evaluation of patients with progressive intellectual deterioration. Arch Neurol 1976, 33: 658-659,
13. Heeren TJ, Lagaay AM, Beek WCA, Rooymans HGM, Hijmans W. Reference values for the Mini-Mental State Examination (MMSE) in octo and nonagenarians. J Am Gerratr Soc 1990, 38: 1093-1096.
14. Hill LR, Klauber MR, Salmon DP, Yu ESH, Liu WT, Zhang M, Katzman R. Functional status, education, and the diagnosis of dementia in the Shangai survey. Neurology 1993,43:138-145.
15. Jorm AF, Scott R, Henderson AS, Kay DW. Educational level differences on the Mini-Mental State: the role of test bias. Psychol Med 1988, 18: 727-731.
16. Katzman R, Zhang M, Qu OY, Wang Z, Liu WT, Yu E, Wong S, Salmon DP, Grantr I. A Chinese version of the Mini-Mental State Examination: impact of illiteracy in a Shanghai dementia survey. J Clin Epidemiol 1988, 41:971-978.
17. Kittner SJ, White LR, Farmer ME, Wolz M, Kaplan E, Moes E, Brody JA, Feinleib M. Methodological issues in screening for dementia: the problem of education adjustement. J Chron Dis 1986, 39: 163-170.
18. Magaziner J, Bassett SS, Hebel R. Predicting performance on the Mini-Mental State Examination: use of age and education-specific equations. J Am Geriatr Soc 1987, 35: 996-1000.
19. Marsden CD, Harrison MJG. Presenile dementia. Br Med J 1972, III: 50-51.
20. McCartney JR, Palmateer IM. Assessment of cognitive deficit in geriatric patients: a study of physician behavior. J Am Geriatr Soc 1985, 33: 467-471.
21. Morris JC, Heyman A, Mohs RC, Hughes JP, van Belle G, Fillenbaum G, Mellits ED, Clark C, and the CERAD investigators. The consortium to establish a registry for Alzheimer's disease (CERAD): Part 1. Clinical and neuropsychological assessment of Alzeheimer's disease. Neurology 1989, 39:1159-1165.
22. O'Connor DW, Pollitt PA, Treasure FP, Brook CPB, Reiss BB. The influence of education, social class and sex on Mini-Mental State scores. Psychol Med 1989, 19: 771-776.
23. O'Connor DW, Pollitt PA, Treasure FP. The influence of education and social class on the diagnosis of dementia in a community population. Psychol Med 1991, 21: 219-224.
24. Salmon PD, Riekkinen PJ, Katzman R, Zhang M, Jin H, Yu H. Cross-cultural studies of dementia: a comparison of Mini-Mental State Examination performance in Finland and China. Arch Neurol 1989, 46: 769-772.
25. Smith JS, Kiloh LG, Ratnavale GS, Grant DA. The investigation of dementia: the results in 100 consecutive admissions. Med J Aust 1976, 2: 403-405.
26. Thai LJ, Grundmam M, Golden R. Alzheimer's disease: a correlational analysis of the Blessed Information Memory-Concentration Test and the Mini-Mental State Exam. Neurology 1986, 36: 262-264.
27. Uhlman RF, Larson EB. Effect of education on the Mini-Mental State Examination as a screening test for dementia. J Am Geriatr Soc 1991, 39: 876-890.
28. 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 1992,85: 391-396.

Datas de Publicação

Publicação nesta coleção
19 Jan 2011
Data do Fascículo
Mar 1994

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Ed. 3 revised. Washington DC: American Psychiatric Press 1987.

[2] 2. Anthony JC, Le Resche L, Niaz U, Von Korff MR, Folstein MF. Limits of the Mini-Mental State as a screening test for dementia and delirium among hospital patients. Psychol Med 1982, 12: 397-408.

[3] 3. Bleecker ML, Bolla-Wilson K. New age-specific norms for the Mini-Mental State Exam. Neurology 1987, 37 (Suppl 1): 279.

[4] 4. Bleecker ML, Bolla-Wilson K, Kawas C, Agnew J. Age-specific norms for the Mini-Mental State Exam. Neurology 1988, 38: 1565-1568.

[5] 5. Borenstein J, Reisberg B, Amand R, et al. Clinical assessment of Alzheimer's diasease: a comparative study (abstr). New York: 13th Internat Congr Gerontol 1985.

[6] 6. Brayne C, Calloway P. The association of education and socioeconomics status with the Mini-Mental State Examination and the clinical diagnosis of dementia in elderly people. Age and Ageing 1990, 19: 91-92.

[7] 7. Brody DS. Physician recognition of behavioral psychological and social aspects of medical care. Arch Intern Med 1980, 240: 268.

[8] 8. Escobar JL, Burnam A Karno M, Forsythe A Landsverk J, Golding JM. Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. J Nerv Ment Dis 1986, 174: 607-614.

[9] 9. Fillenbaum GG, Heyman A, Wilkinson WF, Haynes CS. Comparison of two screenings tests in Alzheimer's disease. Arch Neurol 1987, 44: 924-927.

[10] 10. Fillenbaum GG, Hughes DC, Heyman A George LK, Blazer DG. Relationship of health and demographic characteristics to Mini-Mental State Examination score among community residents. Psychol Med 1988,18:719-726.

[11] 11. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state for the clinician. J Psychiatr Res 1975, 12: 189-198.

[12] 12. Freemon FR. Evaluation of patients with progressive intellectual deterioration. Arch Neurol 1976, 33: 658-659,

[13] 13. Heeren TJ, Lagaay AM, Beek WCA, Rooymans HGM, Hijmans W. Reference values for the Mini-Mental State Examination (MMSE) in octo and nonagenarians. J Am Gerratr Soc 1990, 38: 1093-1096.

[14] 14. Hill LR, Klauber MR, Salmon DP, Yu ESH, Liu WT, Zhang M, Katzman R. Functional status, education, and the diagnosis of dementia in the Shangai survey. Neurology 1993,43:138-145.

[15] 15. Jorm AF, Scott R, Henderson AS, Kay DW. Educational level differences on the Mini-Mental State: the role of test bias. Psychol Med 1988, 18: 727-731.

[16] 16. Katzman R, Zhang M, Qu OY, Wang Z, Liu WT, Yu E, Wong S, Salmon DP, Grantr I. A Chinese version of the Mini-Mental State Examination: impact of illiteracy in a Shanghai dementia survey. J Clin Epidemiol 1988, 41:971-978.

[17] 17. Kittner SJ, White LR, Farmer ME, Wolz M, Kaplan E, Moes E, Brody JA, Feinleib M. Methodological issues in screening for dementia: the problem of education adjustement. J Chron Dis 1986, 39: 163-170.

[18] 18. Magaziner J, Bassett SS, Hebel R. Predicting performance on the Mini-Mental State Examination: use of age and education-specific equations. J Am Geriatr Soc 1987, 35: 996-1000.

[19] 19. Marsden CD, Harrison MJG. Presenile dementia. Br Med J 1972, III: 50-51.

[20] 20. McCartney JR, Palmateer IM. Assessment of cognitive deficit in geriatric patients: a study of physician behavior. J Am Geriatr Soc 1985, 33: 467-471.

[21] 21. Morris JC, Heyman A, Mohs RC, Hughes JP, van Belle G, Fillenbaum G, Mellits ED, Clark C, and the CERAD investigators. The consortium to establish a registry for Alzheimer's disease (CERAD): Part 1. Clinical and neuropsychological assessment of Alzeheimer's disease. Neurology 1989, 39:1159-1165.

[22] 22. O'Connor DW, Pollitt PA, Treasure FP, Brook CPB, Reiss BB. The influence of education, social class and sex on Mini-Mental State scores. Psychol Med 1989, 19: 771-776.

[23] 23. O'Connor DW, Pollitt PA, Treasure FP. The influence of education and social class on the diagnosis of dementia in a community population. Psychol Med 1991, 21: 219-224.

[24] 24. Salmon PD, Riekkinen PJ, Katzman R, Zhang M, Jin H, Yu H. Cross-cultural studies of dementia: a comparison of Mini-Mental State Examination performance in Finland and China. Arch Neurol 1989, 46: 769-772.

[25] 25. Smith JS, Kiloh LG, Ratnavale GS, Grant DA. The investigation of dementia: the results in 100 consecutive admissions. Med J Aust 1976, 2: 403-405.

[26] 26. Thai LJ, Grundmam M, Golden R. Alzheimer's disease: a correlational analysis of the Blessed Information Memory-Concentration Test and the Mini-Mental State Exam. Neurology 1986, 36: 262-264.

[27] 27. Uhlman RF, Larson EB. Effect of education on the Mini-Mental State Examination as a screening test for dementia. J Am Geriatr Soc 1991, 39: 876-890.

[28] 28. 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 1992,85: 391-396.