J Korean Neurol Assoc / Volume 21 / August, 2003 The Validity and Reliability of the Korean Modified Mini-Mental State (K-3MS) Examination Eun-Hee Soh

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1 J Korean Neurol Assoc / Volume 21 / August, 2003 The Validity and Reliability of the Korean Modified Mini-Mental State (K-3MS) Examination Eun-Hee Sohn, Ae-Young Lee, Hyun-Ju Park* Department of Neurology Chungnam National University College of Medicine, Section of Neuropsychology, Chungnam National University Hospital* B a c k g r o u n d: The Folstein Mini-Mental State Examination (MMSE) is a well-established and reliable cognitive screening instrument. However, recent investigations have reported limitations in the MMSE as a cognitive screening tool. The Modified Mini-Mental State Examination (3MS) taps a broader range of cognitive abilities by including evaluations of semantic fluency, delayed memory, remote personal information, and abstraction as well as those areas included in the MMSE. We report age- and education-specific reference values of the Korean Modified Mini-Mental State (K-3MS) Examination and the MMSE in the non-demented elderly population. We also evaluate the validity and reliability of the K-3MS for cognitive screening. M e t h o d s: The K-3MS and the MMSE were administered to 112 dementia patients and 99 controls, aged 50~90 years old. K-WAIS, K-DRS, CDR were done with K-3MS in dementia patients. Test-retest reliability coefficients were obtained from 50 patients. NINCDS-ADRDA criteria for probable AD and NINDS-AIREN criteria for VaD were used. Results: The K-3MS correlated with the MMSE (r=0.94, p<0.05). The area under the receiver operating characteristic (ROC) curve for the K-3MS was and for the MMSE was There was no statistically significant difference between both tests. The sensitivity and specificity of the K-3MS (cutoff score=72) for a dementia diagnosis were 0.83, 0.78 and those of the MMSE (cut-off score=23) were 0.78, The K-3MS was found to have high test-retest reliability (r=0.93). Conclusions: The K-3MS is a reliable, valid, and stable cognitive screening instrument. The K-3MS is comparable to the MMSE as a dementia screening test. J Korean Neurol Assoc 21(4):346~356, 2003 Key Words: 3MS, K-3MS, MMSE, Sensitivity, Specificity, Normal data Manuscript received January 13, 2003 Accepted in final form March 20, 2003 Address for correspondence Ae-Young Lee, M.D. Department of Neurology, Chungnam National University 640 Daesa-dong Jung-gu, Daejeon, , Korea Tel: Fax: aelee@cnu.ac.kr 346

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4 Table 1. Comparison of MMSE and 3MS Domain MMSE 3MS Total Items Score Total Items Score Orientation Time/Place 5 / 5 Time/Place 5 / 5 Registration Any three objects 3 Specified word 3 Attention & calculation Serial 7s or spell backward 5 Count 5 to 1 2 Spell backward 5 Recall Recall object above 3 Spontaneous, cued, 9 recognition Language Name/Repeat 2 / 1 Name/ Repeat 5 / 5 Follow command 3 Follow command 3 Read and obey 1 Read and obey 3 Write sponteneous sentence 1 Write specified sentence 5 Spatial Copy pentagon 1 Copy pentagon 10 Remote memory ND Date and place of birth 5 Fluency ND Name animals 10 Abstract thinking ND Verbal similarities 6 Delayed recall ND Spontaneous, cued, 9 recognition Total ND; not done Table 2. Demographic data of the subjects Dementia (n=112) Contorl (n=99) p value Age (yr) ns Sex (M:F) 1:1.9 1:1.9 ns Education (yr) ns K-3MS <0.01 MMSE <0.01 ns; not significant Table 3. Age-and education-specific reference values of the MMSE Education Age (years) (years) 55~64 65~74 75~90 Ignoring age (n=5) (n=3) (n=17) (n=25) 1~ (n=5) (n=14) (n=14) (n=39) (n=14) (n=11) (n=10) (n=35) Ignoring education (n=24) (n=28) (n=47) (n=99) 349

5 Table 4. Age-and education-specific reference values of the K-3MS Education Age(years) (years) Ignoring age (n=5) (n=3) (n=17) (n=25) (n=5) (n=14) (n=20) (n=39) (n=14) (n=11) (n=10) (n=35) Ignoring education (n=24) (n=28) (n=47) (n=99) Figure 2. Correlation between K-3MS and CDR Figure 1. Correlation between K-3MS and MMSE Figure 3. The receiver operating characteristic curve of the K- 3MS and MMSE. 350

6 Table 5. Correlation between K-3MS and other cognitive function tests. Pearson coefficient p value MMSE <0.01 K-WAIS(FIQ) <0.01 VIQ <0.01 PIQ <0.05 K-DRS < < ns < < <0.01 CDR <0.01 ns; not significant Table 6. Sensitivity and specificity of the K-3MS according to the selected cut off score. Cut off score Sensitivity Specificity Table 7. Sensitivity and specificity of the MMSE according to the selected cut off score. Cut off score Sensitivity Specificity

7 18. Murden RA, McRae TD, Kaner S, Buckman ME. Mini- Mental State exam score vary with education in blacks and whites. J Am Geriatr Soc 1991;39: 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 Aging 1990;19: Teng EL, Chui HC. The Modified Mini-Mental State (3MS) Examination. J Clin Psychiatry 1987;48: Teng EL, Chui HC. Comparison between the Mini-Mental State Exam (MMSE) and its modified version - the 3MS test. In: Psychogeriatrics: Biomedical and Social Advances. Princeton, NJ: Excerpta Medica, 1990; Bravo G, Hebert R. Age-and education -specific reference values for the Mini-Mental and Modified Mini-Mental State Examinations derived from a non-demented elderly population. Int J Geriatr Psychiatry 1997;12: Loewenstein DA, Barker WW, Harwood DG, Luis C, Acevedo A, Rodriguz I, et al. Utility of a modified Mini- Mental State Examination with extended delayed recall in screening for mild cognitive impairment and dementia among community dwelling elders. Int J Geriatr Psychiatry REFERENCES 11. Folstein MF, Folstein SE, McHugh PR. M i n i - M n e t a l S t a t e : a practical method for grading cognitive state of patients for the clinicians. J Psychiatr Res 1975 ; 12 : Anthony JC, LeResche 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: Kaszniak AW: The neuropsychology of dementia. In: Gran I, Adams KM, eds. Neuropsychological assessment of neuropsychiatric disorders. New York, Oxford University Press, 1986; Schwamm LH, Van Dyke C, Kiernan RJ, Merrin EL, Mueller J. The Neurobehavioral Cognitive Status Examination: comparison with the Cognitive Capacity Screening Examination in a neurosurgical population. Ann Intern Med 1987;107: Pfeffer RI, Kurosaki TT, Harrach CH, Chance JM, Bates D, Deltes R, et al. A survey diagnostic tool for senile dementia. Am J Epidemiol 1981;114: Dick JP, Guiloff RJ, Stewart A, Blackstock J, Bielawska C, Paul EA, et al. Mini-Mental State Examination in neurological patients. J Neurol Neurosurg Psychiatry 1984 ; 47: Tsai L, Tsuang MT. The Mini-Mental State Test and computerized tomography. Am J Psychiatry 1979 ; 136 : ;15: Bravo G, Herbert R. Reliability of the Modified Mini- Mental State Examination in the context of a two-phase community prevalence study. N e u r o e p i d e m i o l o g y 1997 ; 16: McDowell I, Kristjansson B, Hill GB, Herbert R. Community screening for dementia: The Mini-Mental State Exam (MMSE) and Modified Mini-Mental State Exam (3MS) compared. J Clin Epidemiol 1997 ; 50 : Grace J, Nadler JD, White DA, Guilmette TJ, Giuliano AJ, Monsch AU, et al. Folstein vs Modified Mini-Mental State Examination in geriatric stroke: stability, validity, and screening utility. Arch Neurol 1995;52: Lamarre CJ, Patten SB. Evaluation of the Modified Mini- Mental State Examination in a general psychiatric population. Can J Psychiatry 1991;36: Besson PS, Labbe EE. Use of the Modified Mini-Mental State Examination with children. J Child Neurol 1997 ; 12: McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer s disease: report of NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer s Disease. N e u r o l o g y 1984 ; 34 : Roman GC, Tatemichi TK, Erkinjuntti T, Cummings JL, Masdeu JC, Garcia JH, et al. Vascualr dementia: diagnostic criteria for research studies. Report on the NINDS- AIREN International Workshop. Neurology 1993;43: Hanley JA, McNeil BJ. A method of comparing the areas 352

8 under receiver operating characteristic curve derived from the same cases. Radiology 1983;148: Lee AY, Ltness S, Mack W, Zarow C, Teng E, Chui H. Poor delayed recall in the modified Mini-Mental State Exam(3MS) increases the probability of Alzheimer s disease in mild dementia. Neurology 2000;54(Suppl 3):A Lee AY, Sohn EH, Park HJ. Differentiation of Alzheimer s disease from vascular dementia using the modified minimental state examination. J Korean Neurol Assoc ; 20: Hanley JA, McNeil BJ. The meaning and use of the area under a receivor operating characteristic (ROC) curve. Radiology 1982;143: Kang YW, Na DL, Hahn SH. A validity study on the korean mini-mental state examination (K-MMSE) in dementia patients. J Korean Neurol Assoc 1997;15:

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11 < 2> Age-and education-specific reference values of the MMSE Education Age (years) (years) 65~69 70~74 75~79 80~ ~ (n=78) (n=85) (n=93) (n=78) (n=65) 5~ (n=495) (n=422) (n=556) (n=277) (n=239) 9~ (n=942) (n=752) (n=921) (n=455) (n=332) (n=581) (n=375) (n=535) (n=236) (n=208) Ignoring education (n=2098) (n=1638) (n=2112) (n=1051) (n=853) Age-and education-specific reference values of the 3MS Education Age (years) (years) 65~69 70~74 75~79 80~ ~ (n=78) (n=85) (n=93) (n=78) (n=65) 5~ (n=495) (n=422) (n=556) (n=277) (n=239) 9~ (n=942) (n=752) (n=921) (n=455) (n=332) (n=581) (n=375) (n=535) (n=236) (n=208) Ignoring education (n=2098) (n=1638) (n=2112) (n=1051) (n=853) 356

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