The Relationship Between Education Level and Mini-Mental State Examination Domains Among Older Mexican Americans

Abstract

To study the effect of education on the performance in the Mini-Mental State Examination (MMSE) domains, we included 2,861 Mexican Americans aged 65 and older from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (EPESE) followed from 1993-1994 until 2004-2005. The MMSE was examined as total score (0-30) or divided in two global domains: 1) no-memory (score 0-24): Orientation, attention, and language; and 2) memory (score 0-6): working and delayed memory. Mean age and total MMSE were 72.7 and 24.6 at wave 1, and 81.7 and 20.5 at wave 5. Spanish speaking subjects had lower years of education (4.1 vs. 7.4, p<. 0001), they had significantly higher adjusted (by age, education, and gender) mean scores for memory, no-memory and the total MMSE compared with English speaking subjects across the five waves of follow-up. In multivariate longitudinal analyses over 11 years of follow-up, subjects with more years of education performed better than those less educated, especially in no-memory and the total MMSE. Spanish speaking subjects with 4-6 years of education had higher memory scores than those speaking English (estimate 0.40, standard error [SE] = 0.14, p<.001), [7][8][9][10][11] SE= 0.13, p<.01) or 12+ (estimate 0.44, SE= 0.13, p<.001). This suggests that cultural factors and factors related to preferred language use may determine variations in MMSE performance. Since the memory domain of the MMSE is less affected by education, it may be used along with other cognitive tests in older populations with low education.

The Relevance of Sociodemographic and Health Variables on MMSE Normative Data

“…Along with most of the previous studies conducted with the MMSE (Anderson et al, 2007;Bravo & Hébert, 1997;Matallana et al, 2011), our results show that educational level is the variable that most significantly contributed to the prediction of the MMSE scores, followed by age. Together, these variables explained 26% of the results variance; therefore, as in previous Portuguese studies (Guerreiro et al, 1994;Guerreiro, 1998;Morgado et al, 2009) and in most of the international normative studies, these variables were the optimal criteria for the establishment of MMSE normative data for the Portuguese population.…”

“…Older age has been found to significantly increase the probability of obtaining lower scores, whereas the worst performance has been found among those with lower education levels, and ceiling effects have been observed among highly educated individuals (Anderson, Sachdev, Brodaty, Trollor, & Andrews, 2007;Bravo & Hébert, 1997;Gallacher et al, 1999;Matallana et al, 2011;Moraes, Pinto, Lopes, Litvoc, & Bottino, 2010). The magnitude of the effect of education level is so strong that the education is invariably considered a criterion for the establishment of normative-data for the MMSE (Han et al, 2008;Mathuranath et al, 2007;Measso et al, 1993).…”

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“…Our study observed that subjects who achieved secondary and tertiary education had lower risk of cognitive impairment. This finding is consistent with a number of other studies which showed that people with primary school education had higher risk to develop cognitive impairment 18,19 . This implies that every country should take appropriate measures to prevent school drop-outs and promote higher education by providing free education at least up to secondary level.…”

Cognitive Impairment and Risk of All‐Cause and Cardiovascular Disease Mortality Over 20‐Year Follow‐up: Results From the BLSA

“…Because of the cultural background, more than 50% of the participants had less than 6 years of formal education. Cultural background had an influence on MMSE performance, and education is closely related to cultural background 22. MMSE scores generally decline with advancing age and can be biased by baseline educational level and language 23.…”