Abstract

The 37-item version of the Mini-Mental State Examination (MMSE-37) is an extended version of the original test for individuals with low education, which was adapted for different cultures. Despite its favorable psychometric properties, there is a lack of normative data for this instrument. We provide normative data for the MMSE-37 stratified by age, sex, and education in a large population-based cohort of older Spanish adults. The sample consisted of 3,777 participants without dementia (age range: 65–97 years) from different socioeconomic areas of central Spain. Normative data are presented in percentile ranks and divided into nine overlapping age tables with different midpoints, using the overlapping cell procedure. A hierarchical regression was performed to evaluate the effects of sociodemographic variables on MMSE-37 performance. Results showed that age, sex, and education affect test score. The norms presented herein are important for the correct interpretation of MMSE-37 scores when assessing older adults in Spain.

Introduction

The Mini-Mental State Examination (MMSE) is the most widely known brief cognitive test for the screening and detection of dementia (Folstein, Folstein, & McHugh, 1975; Lin et al., 2013). It is also a common measure of grading cognitive impairment, monitoring its evolution over time, and estimating the treatment effects on cognitive function (Mitchell, 2009; Strauss, Sherman, Spreen, & Spreen, 2006). However, the MMSE has some well-identified limitations. One of the most widely documented is the influence of sociodemographic variables, such as age and education, on test scores (Contador, Fernández-Calvo, Ramos, Tapias-Merino, & Bermejo-Pareja, 2010; Dufouil et al., 2000), but conflictive evidence has provided the effect of gender (Anderson, Sachdev, Brodaty, Trollor, & Andrews, 2007; Matthews, Marioni, Brayne, & Medical Research Council Cognitive Function and Ageing Study, 2012). It is then necessary to obtain normative data from the reference population in order to correctly interpret test scores (Knight, McMahon, Green, & Skeaff, 2006), mainly for diagnosis in clinical settings.

Several versions of the MMSE are being used in Spain, but they differ in the scoring range and difficulty of items. One of the most commonly used versions is the Mini Examen Cognoscitivo (Lobo, Ezquerra, Gómez, Sala, & Seva, 1979), however, this test is quantitatively (score range 0–35 instead of 0–30) and qualitatively (it includes inverse digit and abstraction tasks) different from the original MMSE. For this reason, the authors developed a new version (Lobo et al., 1999) that keeps the scoring of the original test (0–30 points), although this new adapted version shows a variation in task difficulty (e.g., it calculates 30–3 instead of 100–7) and the scores need to be education corrected. Therefore, considering its disadvantages (i.e., standardization problems and education bias), some authors have suggested that the test should be retired (Carnero-Pardo, 2014), but this issue is controversial (Olazarán-Rodríguez & Bermejo-Pareja, 2014).

The 37-point version of the MMSE (MMSE-37) is an extended version of the original test adapted for individuals with a low educational level. The test was originally used in a multicenter study carried out by the World Health Organization (Amaducci et al., 1991). This version introduces a series of amendments to the original test (see Methods) pursuing the following aims: (a) to diminish the effect of education on test scores by reducing the complexity of some tasks (replaces the task “spell the word MUNDO backwards” with the backward digit span task) and introducing some culture-free items (visual order, i.e., a man raising his hands) and (b) to reduce the floor and ceiling effects expanding the scoring range (see Llamas, Llorente, Contador, & Bermejo-Pareja, 2015).

Unlike other versions adapted to the Spanish population, the MMSE-37 presents complete and satisfactory reliability analyses (Tapias-Merino et al., 2010; Tapias-Merino, 2011): internal consistency (α Cronbach = 0.87), test–retest reliability (intraclass correlation coefficient (ICC) = .92) and inter-observer reliability of experts (ICC = .99). According to the item response theory model, Prieto, Contador, Tapias-Merino, Mitchell, and Bermejo-Pareja (2012) demonstrated that there was a good fit of the data to the requirements of Rasch's model (i.e., unidimensionality), as well as satisfactory item and person reliabilities. Moreover, Baldereschi and colleagues (1994) conducted a transcultural validation of the MMSE-37 in Spain, Chile, and Malta. In Spain, a pilot study of Villanueva-Iza, Bermejo-Pareja, Berbel-García, Trincado Soriano, and Rivera Navarro (2003) established an optimal cut-off point of ≤24 points (Sensitivity = 80%, Specificity = 92%) for detection of dementia in a population-based sample.

Despite the favorable psychometric properties of the MMSE-37, its clinical value and interpretation in the elderly are restricted by the lack of normative data for this instrument in the Spanish population. The aim of the present study is to provide normative data, stratified by age, gender, and education for the 37-point version of the MMSE in a large Spanish population-based sample of people aged 65 years and older.

Methods

Participants

Neurological Disorders in Central Spain (NEDICES) is a population census-based epidemiological study to detect neurological disorders and major age-associated conditions in people aged 65 and over (Morales et al., 2004). All participants were Caucasian and selected from three different socioeconomic areas (Margaritas—working class area; Lista-white collar area; Arévalo—rural agricultural area) to obtain a representative sample of older people living in central Spain (Contador, Bermejo-Pareja, Del Ser, & Benito-León, 2015a). All individuals aged 65 years and over from local population registers were eligible if they were residents in the area on December 31, 1993, or during 6 or more months in 1993. In Margaritas and Arévalo, each eligible subject was contacted for screening, while a proportionate stratified random sampling was used in Lista to select subjects due to the large number of elderly residents in this area. In this survey, the household and nursing home populations of the three communities were covered, but eligible subjects who had moved out of the survey area were not traced.

The NEDICES study was approved by two Local Ethics Committee (University Hospitals “12 de Octubre” and “La Princesa,” Madrid) and written informed consent was obtained from all participants. Methodological issues are described elsewhere in detail (Bermejo-Pareja et al., 2008a; Morales et al., 2004).

From 5,278 participants evaluated in the first wave (1994–1995), the individuals who fulfilled the diagnosis of dementia (N = 306) or questionable dementia (N = 83) were excluded for further analyses (Bermejo-Pareja et al., 2009). Of 4,889 remaining individuals without dementia, 3,777 participants completed the MMSE-37 face-to-face and they were selected for this research.

Measures

In this study, the 37-item version of the MMSE was applied to participants at baseline assessment (1994–1995). The maximum score of the MMSE-37 is 37 points, which is the result of summing the maximum score on each of the items (i.e., mental functions) of the measure. In comparison with the original 30-item version of Folstein and colleagues (1975), the MMSE-37 adds the figure of a man raising his hands (the patient is asked to imitate him) and the drawing of two crossed circles (easier than the two pentagons); in the attention task, instead of being asked to spell the word “MUNDO” backwards, the patients are asked to repeat the following digits in reverse order: 1-3-5-7-9. These two functions (calculation and attention) are assessed separately in order to obtain independent scores, unlike the original MMSE-30, which assesses them together. Finally, the phrase “Ni síes, íes o peros” (in the original MMSE “no ifs, ands or buts”) was deleted because it made no sense to Spanish speakers and was not difficult to repeat in Spanish. It was replaced with the Spanish tongue-twisting phrase “En un trigal había tres tigres” (“there were three tigers in a wheat field”), which makes sense in Spanish and is difficult to pronounce.

Procedure

The NEDICES study consisted of two cross-sectional waves: 1994–1995 (first wave) and 1997–1998 (second wave). Essentially, the study was developed in two phases: door-to-door screening of eligible people (Phase 1) and neurological examination performed by expert neurologists of those individuals who screened positive (Phase 2). At baseline (1994–1995), participants were initially assessed using a 500-item screening questionnaire to collect data on demographics, medical conditions, and current medication. In addition, a World Health Organization screening protocol for dementia (Amaducci et al., 1991; Baldereschi et al., 1994), including the MMSE-37 and the Spanish version of Pfeffer's Functional Activities Questionnaire (FAQ; Olazarán, Mouronte, & Bermejo, 2005; Prieto et al., 2012), was applied. The screening was considered positive if: (i) the subject scored <24 points on the MMSE-37 and >5 points on the Pfeffer FAQ or (ii) the participants themselves or through their proxy provided information about suspicion of cognitive decline (iii) there were missing values (i.e., the subject failed to provide an answer, or information was not available) on the screening instruments.

Participants who screened positive for dementia underwent a neurological examination at the National Health Service clinic or at home. Basically, this examination included a clinical history, a general neurological examination, and a mental status interview. The diagnosis of dementia was made by consensus of two expert neurologists using Diagnostic and Statistical Manual of Mental Disorders IV criteria (DSM-IV) as gold standard. All medical records of all participants who received a diagnosis of dementia were reviewed by a senior neurologist (FB-P) with the aid of a psychologist (FS-S). If there were doubts about any aspect of the dementia diagnosis, additional information (mainly from family doctors) was elicited.

Statistical Analyses

The Statistical Package for Social Sciences version 22 (IBM®, SPSS Statistics version 22) was used for the statistical analyses. First, the selected sample (N = 3777) was compared with non-demented individuals who were excluded due to missing values on the test in terms of sociodemographic characteristics and index of comorbidity. The comorbidity index was calculated by adding the presence (1) or absence (0) of 13 diseases, as previously reported (Contador, Bermejo-Pareja, Puertas-Martín, & Benito-León, 2015b).

The potential effects of sociodemographic factors (age, sex, and education) on MMSE-37 scores were initially tested using Pearson correlations and t-tests for independent samples. Then, a hierarchical regression was carried out to test the independence of the three factors’ effects on MMSE-37 scores. Considering that the distribution of raw test scores was non-normal, parametric statistics were confirmed with non-parametric versions of the same statistical comparisons (Spearman correlation and Mann–Whitney U contrast). In these types of distributions (i.e., negatively skewed and leptokurtic in this sample), it is not appropriate to present normative data in the form of raw scores (means ± standard deviations) or standardized scores, whereas percentile ranks (PRs) are recommended (Crawford, Garthwaite, & Slick, 2009). PRs are defined as the percentage of people in a norm group that fall below or equal to the score of interest and the corresponding calculation is described in Crawford and colleagues (2009). In order to ease the calculation of PRs (2, 5, 9, 16, 25, 37, 50, 63, 75, 84, 95, and 99), a Microsoft Excel® (2013) spreadsheet containing automatic computation was used.

The data were divided into nine overlapping age tables with midpoints at 66, 69, 72, 75, 78, 81, 84, 87, and 90 years using the technique of overlapping cell procedure, which increases the accuracy and the clinical utility of the data (Malec et al., 1992; Pauker, 1988). The midpoint provides normative data for that age ±1 year, except in extreme cases (<68 and >88 years or more). Thus, the distribution of the age (years) in the sample allowed for calculating MMSE-37 normative data for nine midpoint age groups (i.e., <68, 68–70, 71–73, 74–76, 77–79, 80–82, 83–85, 86–88, >88), as Tables 2–10 show. Different ranges of 10 years were established following the rule midpoint ±5 years old (e.g., midpoint = 75 years; age range = 70–80 years). To interpret the total score of MMSE-37, the clinician or researcher will select the table with the closest midpoint to the subject's age. All tables are stratified by gender and educational level (illiterate, read and write, certificate of primary school, secondary, or higher). Each table depicts the mean, median, standard deviation, and PRs corresponding to Z-scores of −2.00, −1.66, −1.33, −1.0, −0.66, −0.33, 0.00, 0.33, 0.66, 1.0, 1.66, and 2.33, respectively.

Results

In comparison with non-demented subjects who were excluded because they did not complete the MMSE-37, the eligible sample was younger (mean = 73.4 ± 6.3 vs. 74.5 ± 7.2 years, t = 4.95, p< .001), more educated (53.6% with primary school or higher vs. 47.5 without a certificate of primary school, χ2 = 30.86, p < .001) and showed a slightly higher index of comorbidities (mean = 3.09 ± 1.8 vs. 2.22 ± 1.6, t = −13.27, p < .001). Table 1 shows the distribution of the sample in terms of age, gender, and level of education. In terms of gender, women were older (t = −2.72, p< .001), and less educated (χ2 = 89.21, p< .001), than men.

Table 1.

Mean and standard deviations of the 37-item version of the Mini-Mental State Examination (MMSE): stratification by age, gender, and level of education

 Participants
 
Mean SD 
Area of residence
 
Total, n (%) 
Lista, n (%) Arévalo, n (%) Margaritas, n (%) 
Age 
 65–69 412 (32.3) 417 (32.7) 448 (35.1) 1,277 (33.8) 30.8 4.8 
 70–74 285 (25.9) 460 (41.9) 354 (32.2) 1,099 (29.1) 29.8 4.9 
 75–79 223 (33.0) 237 (35.1) 215 (31.9) 675 (17.9) 28.5 5.4 
 80–84 151 (31.6) 166 (34.7) 161 (33.7) 478 (12.7) 27.5 5.5 
 85–89 81 (39.9) 73 (36.0) 49 (24.1) 203 (35.4) 25.9 5.9 
 ≥90 23 (51.1) 12 (26.79 10 (22.2) 45 (1.2) 25.3 6.8 
Gender 
 Men 482 (29.3) 653 (39.7) 511 (31.0) 1,646 (43.6) 30.8 5.0 
 Woman 693 (32.5) 712 (33.4) 726 (34.1) 2,131 (56.4) 28.2 5.3 
Education 
 Illiterate 11 (2.4) 160 (35.5) 280 (62.1) 451 (11.9) 23.4 5.1 
 Read and write 471 (29.9) 449 (28.5) 655 (41.6) 1,575 (41.7) 29.1 4.8 
 Primary School 304 (25.2) 739 (61.4) 161 (13.4) 1,204 (31.9) 30.4 4.7 
 Secondary or Higher 389 (71.1) 17 (3.1) 141 (25.8) 547 (14.5) 32.5 4.2 
 Participants
 
Mean SD 
Area of residence
 
Total, n (%) 
Lista, n (%) Arévalo, n (%) Margaritas, n (%) 
Age 
 65–69 412 (32.3) 417 (32.7) 448 (35.1) 1,277 (33.8) 30.8 4.8 
 70–74 285 (25.9) 460 (41.9) 354 (32.2) 1,099 (29.1) 29.8 4.9 
 75–79 223 (33.0) 237 (35.1) 215 (31.9) 675 (17.9) 28.5 5.4 
 80–84 151 (31.6) 166 (34.7) 161 (33.7) 478 (12.7) 27.5 5.5 
 85–89 81 (39.9) 73 (36.0) 49 (24.1) 203 (35.4) 25.9 5.9 
 ≥90 23 (51.1) 12 (26.79 10 (22.2) 45 (1.2) 25.3 6.8 
Gender 
 Men 482 (29.3) 653 (39.7) 511 (31.0) 1,646 (43.6) 30.8 5.0 
 Woman 693 (32.5) 712 (33.4) 726 (34.1) 2,131 (56.4) 28.2 5.3 
Education 
 Illiterate 11 (2.4) 160 (35.5) 280 (62.1) 451 (11.9) 23.4 5.1 
 Read and write 471 (29.9) 449 (28.5) 655 (41.6) 1,575 (41.7) 29.1 4.8 
 Primary School 304 (25.2) 739 (61.4) 161 (13.4) 1,204 (31.9) 30.4 4.7 
 Secondary or Higher 389 (71.1) 17 (3.1) 141 (25.8) 547 (14.5) 32.5 4.2 

Note: SD = standard deviation.

Effect of Age, Gender, and Education on MMSE-37 Scores

Pearson correlations showed that young people (r = −.282, p < .001) and those with a higher level of education (r = .417, p < .001) obtain better scores on the MMSE-37, while the female category was associated with lower scores on MMSE-37, t = 15.16, p < .001. Also, results of the hierarchical multiple regression analysis revealed a modest (R2 = 0.27) but independent significant association between all sociodemographic variables [Education (β = 0.385, t = −27.60, p < .001), age (β = −0.261, t = −18.86, p < .001), and gender (β = 0.179, t = 12.85, p < .001)] and MMSE-37 score [F(3, 3773) = 482.64, p < .001]. Education accounted for 16.6% of the variance on total MMSE-37 scores, while age accounted for only 8.0% and gender for 3.2%. Therefore, the interpretation of MMSE-37 scores requires taking into account the effects of age, gender, and education. Normative data stratified by these sociodemographic variables are described below.

MMSE-37 Norms

According to the PRs, normative data for the 37 items version of MMSE are shown in Tables 2–10. The age (range) and sample size used to create norms for each group are provided above each table.

Table 2.

Normative data for the 37-item version of the MMSE: ages <68 years (n = 746)

Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 29 149 83 68 60 182 114 61 
M (mdn) 25.8 (26) 31.5 (32) 33.1 (34) 34.9 (35) 25.0 (25) 30.0 (30) 31.3 (32) 32.4 (32) 
SD 5.12 3.99 3.04 3.95 5.19 4.06 4.01 3.39 
Percentile 
 2nd 16 20 24 30 11 21 22 25 
 5th 17 24 28 31 16 23 23 26 
 9th 18 26 29 32 17 24 25 27 
 16th 20 27 30 33 21 26 27 28 
 25th 22 29 31 33 22 27 29 29 
 37th 25 31 32 34 23 29 30 32 
 50th 26 32 34 35 25 30 32 32 
 63rd 27 33 35 36 27 32 33 35 
 75th 30 34 36 37 28 33 35 35 
 84th 31 35 36 37 30 34 35 36 
 95th 35 37 37 37 34 36 36 37 
 99th  37    37 37  
Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 29 149 83 68 60 182 114 61 
M (mdn) 25.8 (26) 31.5 (32) 33.1 (34) 34.9 (35) 25.0 (25) 30.0 (30) 31.3 (32) 32.4 (32) 
SD 5.12 3.99 3.04 3.95 5.19 4.06 4.01 3.39 
Percentile 
 2nd 16 20 24 30 11 21 22 25 
 5th 17 24 28 31 16 23 23 26 
 9th 18 26 29 32 17 24 25 27 
 16th 20 27 30 33 21 26 27 28 
 25th 22 29 31 33 22 27 29 29 
 37th 25 31 32 34 23 29 30 32 
 50th 26 32 34 35 25 30 32 32 
 63rd 27 33 35 36 27 32 33 35 
 75th 30 34 36 37 28 33 35 35 
 84th 31 35 36 37 30 34 35 36 
 95th 35 37 37 37 34 36 36 37 
 99th  37    37 37  

Note: M = mean; Mdn = median (in parenthesis); SD = standard deviation.

Table 3.

Normative data for the 37-item version of the MMSE estimated from the ages 65–75 years and used for the ages 68–70 years (n = 2,176)

Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 71 419 307 185 170 493 395 136 
M (mdn) 25.4 (25) 30.8 (32) 32.3 (35) 34.3 (35) 24.3 (25) 29.4 (29) 30.6 (31) 32.5 (33) 
SD 4.74 4.85 3.49 2.99 4.86 4.28 3.95 3.44 
Percentile 
 2nd 16 19 23 22 14 21 22 24 
 5th 17 23 26 290 16 22 23 26 
 9th 18 25 27 31 17 24 25 27 
 16th 21 27 29 32 20 26 27 29 
 25th 22 28 30 33 22 27 28 30 
 37th 24 30 32 34 23 28 30 32 
 50th 25 32 33 35 25 29 31 33 
 63rd 27 33 34 36 26 31 33 35 
 75th 29 34 35 36 28 33 34 36 
 84th 31 35 36 37 29 34 35 36 
 95th 33 37 37 37 32 36 36 37 
 99th 37 37 37 36 37 37 37 
Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 71 419 307 185 170 493 395 136 
M (mdn) 25.4 (25) 30.8 (32) 32.3 (35) 34.3 (35) 24.3 (25) 29.4 (29) 30.6 (31) 32.5 (33) 
SD 4.74 4.85 3.49 2.99 4.86 4.28 3.95 3.44 
Percentile 
 2nd 16 19 23 22 14 21 22 24 
 5th 17 23 26 290 16 22 23 26 
 9th 18 25 27 31 17 24 25 27 
 16th 21 27 29 32 20 26 27 29 
 25th 22 28 30 33 22 27 28 30 
 37th 24 30 32 34 23 28 30 32 
 50th 25 32 33 35 25 29 31 33 
 63rd 27 33 34 36 26 31 33 35 
 75th 29 34 35 36 28 33 34 36 
 84th 31 35 36 37 29 34 35 36 
 95th 33 37 37 37 32 36 36 37 
 99th 37 37 37 36 37 37 37 

Note: M = mean; Mdn = median (in parenthesis); SD = standard deviation.

Table 4.

Normative data for the 37-item version of the MMSE estimated from the ages 67–77 years and used for the ages 71–73 (n = 2,343)

Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 69 428 361 184 178 539 444 140 
M (mdn) 25.1 (25) 30.3 (31) 31.9 (33) 33.6 (35) 23.9 (24) 28.6 (29) 30.0 (30) 31.5 (32) 
SD 4.63 5.14 3.62 3.69 4.86 4.40 4.08 4.38 
Percentile 
 2nd 17 19 23 21 14 20 21 21 
 5th 18 22 25 26 16 21 23 24 
 9th 19 24 26 29 18 23 24 25 
 16th 20 26 28 31 19 25 26 26 
 25th 21 28 30 32 21 26 27 29 
 37th 23 30 31 34 22 27 29 31 
 50th 25 31 33 35 24 29 30 32 
 63rd 27 33 34 36 25 30 32 34 
 75th 28 34 35 36 27 32 33 35 
 84th 31 35 36 37 29 33 34 36 
 95th 33 36 37 37 32 36 36 37 
 99th 35 37 37 37 36 37 37 37 
Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 69 428 361 184 178 539 444 140 
M (mdn) 25.1 (25) 30.3 (31) 31.9 (33) 33.6 (35) 23.9 (24) 28.6 (29) 30.0 (30) 31.5 (32) 
SD 4.63 5.14 3.62 3.69 4.86 4.40 4.08 4.38 
Percentile 
 2nd 17 19 23 21 14 20 21 21 
 5th 18 22 25 26 16 21 23 24 
 9th 19 24 26 29 18 23 24 25 
 16th 20 26 28 31 19 25 26 26 
 25th 21 28 30 32 21 26 27 29 
 37th 23 30 31 34 22 27 29 31 
 50th 25 31 33 35 24 29 30 32 
 63rd 27 33 34 36 25 30 32 34 
 75th 28 34 35 36 27 32 33 35 
 84th 31 35 36 37 29 33 34 36 
 95th 33 36 37 37 32 36 36 37 
 99th 35 37 37 37 36 37 37 37 

Note: M = mean; Mdn = median (in parenthesis); SD = standard deviation.

Table 5.

Normative data for the 37-item version of the MMSE estimated from the ages 70–80 years and used for the ages 74–76 (n = 1,894)

Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 63 345 286 144 156 417 367 116 
M (mdn) 24.9 (22) 30.0 (31) 31.4 (32) 32.9 (34) 23.1 (23) 28.0 (28) 29.2 (30) 30.8 (31) 
SD 5.05 4.80 4.24 3.95 4.72 4.55 4.16 4.68 
Percentile 
 2nd 17 19 22 21 12 18 20 18 
 5th 18 22 24 26 15 21 22 23 
 9th 18 24 26 28 18 22 24 24 
 16th 20 25 27 30 19 24 25 25 
 25th 21 27 29 31 20 25 26 27 
 37th 22 29 31 32 21 27 28 30 
 50th 24 31 32 34 23 28 30 31 
 63rd 27 32 34 35 25 30 31 33 
 75th 28 34 34 36 26 31 33 35 
 84th 31 35 35 36 28 33 34 36 
 95th 34 36 37 37 31 35 35 37 
 99th 36 37 37 37 36 37 36 37 
Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 63 345 286 144 156 417 367 116 
M (mdn) 24.9 (22) 30.0 (31) 31.4 (32) 32.9 (34) 23.1 (23) 28.0 (28) 29.2 (30) 30.8 (31) 
SD 5.05 4.80 4.24 3.95 4.72 4.55 4.16 4.68 
Percentile 
 2nd 17 19 22 21 12 18 20 18 
 5th 18 22 24 26 15 21 22 23 
 9th 18 24 26 28 18 22 24 24 
 16th 20 25 27 30 19 24 25 25 
 25th 21 27 29 31 20 25 26 27 
 37th 22 29 31 32 21 27 28 30 
 50th 24 31 32 34 23 28 30 31 
 63rd 27 32 34 35 25 30 31 33 
 75th 28 34 34 36 26 31 33 35 
 84th 31 35 35 36 28 33 34 36 
 95th 34 36 37 37 31 35 35 37 
 99th 36 37 37 37 36 37 36 37 

Note: M = mean; Mdn = median (in parenthesis); SD = standard deviation.

Table 6.

Normative data for the 37-item version of the MMSE estimated from the ages 73–83 years and used for the ages 77–79 (n = 1,478)

Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 47 259 217 110 133 337 278 97 
M (mdn) 23.8 (23) 29.3 (30) 30.8 (32) 32.4 (33) 22.1 (22) 27.4 (27) 28.6 (29) 29.8 (31) 
SD 5.83 5.00 4.59 3.93 4.28 4.58 4.53 4.81 
Percentile 
 2nd 18 21 21 12 18 19 17 
 5th 17 21 23 26 15 20 21 22 
 9th 18 23 25 27 17 22 23 23 
 16th 19 25 27 29 18 23 24 25 
 25th 20 26 28 30 19 24 26 26 
 37th 22 28 30 32 20 26 27 29 
 50th 23 30 32 33 22 27 29 31 
 63rd 25 32 33 35 23 29 31 32 
 75th 28 33 34 35 25 31 32 34 
 84th 30 34 35 36 26 32 33 35 
 95th 34 36 36 37 29 35 35 36 
 99th  37 37 37 36 37 36  
Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 47 259 217 110 133 337 278 97 
M (mdn) 23.8 (23) 29.3 (30) 30.8 (32) 32.4 (33) 22.1 (22) 27.4 (27) 28.6 (29) 29.8 (31) 
SD 5.83 5.00 4.59 3.93 4.28 4.58 4.53 4.81 
Percentile 
 2nd 18 21 21 12 18 19 17 
 5th 17 21 23 26 15 20 21 22 
 9th 18 23 25 27 17 22 23 23 
 16th 19 25 27 29 18 23 24 25 
 25th 20 26 28 30 19 24 26 26 
 37th 22 28 30 32 20 26 27 29 
 50th 23 30 32 33 22 27 29 31 
 63rd 25 32 33 35 23 29 31 32 
 75th 28 33 34 35 25 31 32 34 
 84th 30 34 35 36 26 32 33 35 
 95th 34 36 36 37 29 35 35 36 
 99th  37 37 37 36 37 36  

Note: M = mean; Mdn = median (in parenthesis); SD = standard deviation.

Table 7.

Normative data for the 37-item version of the MMSE estimated from the ages 76–86 years and used for the ages 80–82 (n = 1,103)

Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 34 204 149 83 107 259 199 68 
M (mdn) 23.9 (24) 28.6 (29) 29.7 (31) 32.4 (33) 21.4 (21) 27.0 (27) 27.9 (29) 29.8 (31) 
SD 6.24 5.02 5.48 3.91 4.38 4.46 5.19 23.38 
Percentile 
 2nd 18 17 19 12 18 16 20 
 5th 13 20 21 27 14 20 21 22 
 9th 18 22 23 27 17 21 22 22 
 16th 19 24 26 29 18 23 24 24 
 25th 20 25 27 30 19 24 25 26 
 37th 22 27 28 32 20 25 27 28 
 50th 23 29 31 33 21 27 29 31 
 63rd 25 31 32 34 23 28 30 32 
 75th 28 32 34 35 24 30 31 34 
 84th 30 34 34 36 26 32 33 35 
 95th 33 36 36 37 28 35 35 36 
 99th  37 37  34 36 36  
Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 34 204 149 83 107 259 199 68 
M (mdn) 23.9 (24) 28.6 (29) 29.7 (31) 32.4 (33) 21.4 (21) 27.0 (27) 27.9 (29) 29.8 (31) 
SD 6.24 5.02 5.48 3.91 4.38 4.46 5.19 23.38 
Percentile 
 2nd 18 17 19 12 18 16 20 
 5th 13 20 21 27 14 20 21 22 
 9th 18 22 23 27 17 21 22 22 
 16th 19 24 26 29 18 23 24 24 
 25th 20 25 27 30 19 24 25 26 
 37th 22 27 28 32 20 25 27 28 
 50th 23 29 31 33 21 27 29 31 
 63rd 25 31 32 34 23 28 30 32 
 75th 28 32 34 35 24 30 31 34 
 84th 30 34 34 36 26 32 33 35 
 95th 33 36 36 37 28 35 35 36 
 99th  37 37  34 36 36  

Note: M = mean; Mdn = median (in parenthesis); SD = standard deviation.

Table 8.

Normative data for the 37-item version of the MMSE estimated from the ages 79–89 years and used for the ages 83–85 (n = 798)

Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 25 150 92 62 88 199 134 48 
M (mdn) 22.8 (23) 28.3 (29) 29.3 (30) 32.3 (33) 20.7 (21) 26.6 (27) 27.1 (28) 28.75 (30) 
SD 6.47 4.65 5.34 3.25 4.06 4.59 5.47 5.40 
Percentile 
 2nd 16 14 24 10 16 12 
 5th 19 21 27 14 18 19 20 
 9th 14 21 23 27 15 20 21 22 
 16th 18 24 25 29 17 22 24 23 
 25th 19 26 27 30 18 24 25 25 
 37th 21 27 28 32 19 25 26 26 
 50th 23 28 30 33 21 27 28 30 
 63rd 25 30 32 34 23 28 29 31 
 75th 27 32 33 35 24 30 31 33 
 84th 30 33 34 36 25 31 32 35 
 95th 32 35 35 37 27 34 34 36 
 99th  36    37 36  
Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 25 150 92 62 88 199 134 48 
M (mdn) 22.8 (23) 28.3 (29) 29.3 (30) 32.3 (33) 20.7 (21) 26.6 (27) 27.1 (28) 28.75 (30) 
SD 6.47 4.65 5.34 3.25 4.06 4.59 5.47 5.40 
Percentile 
 2nd 16 14 24 10 16 12 
 5th 19 21 27 14 18 19 20 
 9th 14 21 23 27 15 20 21 22 
 16th 18 24 25 29 17 22 24 23 
 25th 19 26 27 30 18 24 25 25 
 37th 21 27 28 32 19 25 26 26 
 50th 23 28 30 33 21 27 28 30 
 63rd 25 30 32 34 23 28 29 31 
 75th 27 32 33 35 24 30 31 33 
 84th 30 33 34 36 25 31 32 35 
 95th 32 35 35 37 27 34 34 36 
 99th  36    37 36  

Note: M = mean; Mdn = median (in parenthesis); SD = standard deviation.

Table 9.

Normative data for the 37-item version of the MMSE estimated from the ages 82–92 years and used for the ages 86–88 (n = 485)

Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 11 92 53 37 60 124 79 29 
M (mdn) 22.5 (23) 27.9 (28) 28.0 (28) 31.5 (32) 20.2 (21) 25.9 (26) 26.3 (27) 28.14 (27) 
SD 4.86 4.43 5.85 3.63 4.68 4.47 6.34 5.90 
Percentile 
 2nd 13 16 24 16 12 
 5th 13 19 17 24 13 18 12 15 
 9th 13 20 22 25 14 20 19 20 
 16th 16 24 24 27 16 21 23 22 
 25th 19 26 26 29 17 23 24 24 
 37th 22 27 27 30 18 24 26 26 
 50th 23 28 28 32 20 26 27 27 
 63rd 24 30 31 34 22 27 28 31 
 75th 27 31 32 35 24 29 30 33.5 
 84th 27 33 33 35 25 30 32 35 
 95th  34 34 36 27 33 34 36 
 99th      37   
Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 11 92 53 37 60 124 79 29 
M (mdn) 22.5 (23) 27.9 (28) 28.0 (28) 31.5 (32) 20.2 (21) 25.9 (26) 26.3 (27) 28.14 (27) 
SD 4.86 4.43 5.85 3.63 4.68 4.47 6.34 5.90 
Percentile 
 2nd 13 16 24 16 12 
 5th 13 19 17 24 13 18 12 15 
 9th 13 20 22 25 14 20 19 20 
 16th 16 24 24 27 16 21 23 22 
 25th 19 26 26 29 17 23 24 24 
 37th 22 27 27 30 18 24 26 26 
 50th 23 28 28 32 20 26 27 27 
 63rd 24 30 31 34 22 27 28 31 
 75th 27 31 32 35 24 29 30 33.5 
 84th 27 33 33 35 25 30 32 35 
 95th  34 34 36 27 33 34 36 
 99th      37   

Note: M = mean; Mdn = median (in parenthesis); SD = standard deviation.

Table 10.

Normative data for the 37-item version of the MMSE estimated from the ages 85–97 years and used for the ages over 88 years (n = 248)

Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 46 23 16 33 70 39 15 
M (mdn) 23.6 (25) 27.7 (28) 27.4 (30) 31.3 (32) 20.0 (19) 25.5 (26) 24.9 (27) 27.6 (27) 
SD 5.98 4.54 7.66 3.94 4.62 4.75 7.06 5.71 
Percentile 
2nd 13 16 24 10 14 12 
5th 13 19 24 12 17 12 12 
9th 13 19 18 24 13 19 14 17 
16th 14 24 22 26 15 20 17 24 
25th 20 25 24 28 17 22 23 25 
37th 22 26 26 30 18 24 25 26 
50th 25 28 30 32 19 26 27 27 
63rd 27 30 32 34 21 28 27 30 
75th 28 31 33 35 24 29 29 31 
84th 29 33 33 35 25 30 30 34 
95th  34 35  27 33 34  
99th         
Education Men
 
Women
 
Illiterate Read and write Primary Secondary or higher Illiterate Read and write Primary Secondary or higher 
n 46 23 16 33 70 39 15 
M (mdn) 23.6 (25) 27.7 (28) 27.4 (30) 31.3 (32) 20.0 (19) 25.5 (26) 24.9 (27) 27.6 (27) 
SD 5.98 4.54 7.66 3.94 4.62 4.75 7.06 5.71 
Percentile 
2nd 13 16 24 10 14 12 
5th 13 19 24 12 17 12 12 
9th 13 19 18 24 13 19 14 17 
16th 14 24 22 26 15 20 17 24 
25th 20 25 24 28 17 22 23 25 
37th 22 26 26 30 18 24 25 26 
50th 25 28 30 32 19 26 27 27 
63rd 27 30 32 34 21 28 27 30 
75th 28 31 33 35 24 29 29 31 
84th 29 33 33 35 25 30 30 34 
95th  34 35  27 33 34  
99th         

Note: M = mean; Mdn = median (in parenthesis); SD = standard deviation.

Discussion

The aim of the present study is to provide normative values for the 37-item version of the MMSE in a large population-based cohort of older Spanish adults without dementia, aged 65 years and over. Previous studies have reported normative data for the MMSE and other cognitive tests in Spain (Lobo et al., 1999; Lobo, Saz, & Marcos, 2002; Pena-Casanova et al., 2009); however, the normative values of the MMSE-37 are currently unknown. Accordingly, the definition of reference values based on PRs would facilitate the characterization of cognitive functioning in the elderly by both clinicians and researchers (Busch, Chelune, & Suchy, 2006). Moreover, some authors suggest that cut-off points based on normative data have a greater descriptive and diagnostic accuracy than fixed cut-off points (Busch & Chapin, 2008; Cullen et al., 2005; O'Connell & Tuokko, 2010), especially in people with low levels of education (Heaton, Ryan, & Grant, 2009; Marcopulos, Gripshover, Broshek, McLain, & McLain, 1999).

There are some conditions which determine the degree of validity of normative data: (a) the study sample should be randomly selected (Crocker & Algina, 1986); (b) the sample size should be large enough to ensure that robust estimations are achieved (Bravo & Hébert, 1997). In the present study, data were collected from a large population-based cohort of older adults aged 65 years and over who lived in three different socioeconomic areas of central Spain. In addition, all eligible subjects from Margaritas and Arévalo underwent the initial screening, whereas a proportionate stratified random sampling method was used to select subjects for screening in Lista. The mentioned aspects support the validity of the data.

Consistent with previous studies, we found that age and education significantly influenced MMSE-37 scores (Quiroga, Albala, & Klaasen, 2004). The same findings have been reported with the original test (Bravo & Hébert, 1997; Hawkins, Cromer, Piotrowski, & Pearlson, 2011). It is known that MMSE scores decline with age, especially after 75 years of age (Tombaugh & McIntyre, 1992). In our study, MMSE-37 scores showed higher association with education than with age. Education had the greatest influence on MMSE performance and explained 16.6% of the MMSE-37 score variance, but fairly lower than other studies where 30.4% is reached (Kim et al., 2012).

Finally, we found a gender effect on MMSE scores, with men performing better than women. This result is consistent with the results reported in previous research (Ishizaki et al., 1998; Lechevallier-Michel, Fabrigoule, Lafont, Letenneur, & Dartiges, 2004; Mokri, Ávila-Funes, Meillon, Gutiérrez Robledo, & Amieva, 2013); however, gender differences in test scores have not been corroborated in other studies (Blesa et al., 2001; Bravo & Hébert, 1997; Hawkins et al., 2011). Some authors state that gender differences in cognition might be associated with women's lower educational level (Katzman et al., 1994), and this association appears to be age dependent (Schmand, Lindeboom, Hooijer, & Jonker, 1995). However, the effect of gender was still significant after controlling for age and education. This fact could be explained by other variables associated with cognitive performance, such as premorbid cognitive abilities. Hence, literacy measured by reading ability is a more reliable predictor of cognitive performance than years of education in older Spanish adults (Contador et al., 2015a). Furthermore, it should be considered that age and gender could have differential effects on the Mini-Mental items (Schultz-Larsen, Kreiner, & Lomholt, 2007).

There are some limitations of the present study. To start with, the general educational level of the sample was low because most of the older Spanish individuals did not receive formal education and illiterates are frequent. Some participants could not recall their years of education accurately, so they were classified following the established educational attainment (according to the Spanish General Law for Education, 1970). Secondly, the influence of cultural and linguistic diversity on MMSE-37 scores was not analyzed, which limits the possibility to generalize these results to other populations with a different background. Third, a stratum in the older group (illiterate men) had fewer than 10 subjects; therefore, the estimation in this stratum should be considered less robust due to the small size of the group.

Finally, it should be noted that the MMSE-37 was one of the criteria used as screening for detection of dementia, but all subjects who had a positive screening were evaluated by experienced neurologists who determined the diagnosis of dementia through DSM-IV (gold standard) using a standardized protocol. The diagnosis was based on extensive information from medical records, clinical interview, brief mental examination, information of relatives, and the presence of functional impairment (Bermejo-Pareja et al., 2008b, 2009).

The MMSE-37, a modified and adapted version of the original MMSE, is a cognitive assessment tool for older people with a low level of education (Baldereschi et al., 1995). The detection of dementia in individuals with low education is still a challenge nowadays (Noroozian, Shakiba & Iran-Nejad, 2014) and standardized cognitive measures are required. This study describes the normative data of the MMSE-37 stratified by age, gender, and education in a large population-based sample of older Spanish adults. The proper use of these normative values will ensure greater accuracy in the detection of dementia in different settings.

Funding

The NEDICES study was supported through grants from the World Health Organization Age-Associated Dementia Project (WHO-AAD), the EPICARDIAN study (PB1225-C04), the official Spanish Research Agencies (FIS 93/0773; 96/1993; 00-0011-01; CAM 94/0032) and the Spanish Office of Science and Technology (PB 1225-C04). More details about the study are listed on www.ciberned.es/estudio-nedices.

Conflict of Interest

None declared.

Acknowledgments

The authors thank all collaborators and institutions for their involvement in the NEDICES study.

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