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 0.872 and for the MMSE was 0.865. 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, 0.74. 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, 301-721, Korea Tel: +82-42-220-7801 Fax: +82-42-252-8654 E-mail: aelee@cnu.ac.kr 346
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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 30 100 ND; not done Table 2. Demographic data of the subjects Dementia (n=112) Contorl (n=99) p value Age (yr) 71.6 8.4 71.5 9.2 ns Sex (M:F) 1:1.9 1:1.9 ns Education (yr) 6.0 4.8 6.5 5.1 ns K-3MS 52.8 19.8 80.6 13.3 <0.01 MMSE 17.7 5.8 25.4 3.8 <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 0 22.6 1.8 25.7 2.3 21.2 4.1 22.0 3.8 (n=5) (n=3) (n=17) (n=25) 1~6 26.2 2.4 25.4 3.1 24.7 3.5 25.1 3.2 (n=5) (n=14) (n=14) (n=39) 7 29.5 0.7 27.6 1.6 26.5 2.3 28.1 2.0 (n=14) (n=11) (n=10) (n=35) Ignoring 27.4 3.1 26.3 2.7 23.8 4.0 25.4 3.8 education (n=24) (n=28) (n=47) (n=99) 349
Table 4. Age-and education-specific reference values of the K-3MS Education Age(years) (years) 55-64 65-74 75-90 Ignoring age 0 74.4 7.0 73.3 4.7 63.8 14.1 67.1 12.9 (n=5) (n=3) (n=17) (n=25) 1-6 82.8 4.9 81.4 9.8 78.6 9.8 80.2 9.3 (n=5) (n=14) (n=20) (n=39) 7 96.1 3.7 88.7 6.7 85.6 8.2 90.8 7.3 (n=14) (n=11) (n=10) (n=35) Ignoring 88.8 10.3 83.4 9.2 74.7 14.1 80.6 13.3 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
Table 5. Correlation between K-3MS and other cognitive function tests. Pearson coefficient p value MMSE 0.943 <0.01 K-WAIS(FIQ) 0.618 <0.01 VIQ 0.650 <0.01 PIQ 0.500 <0.05 K-DRS 0.817 <0.01 0.747 <0.01 0.392 ns 0.701 <0.01 0.722 <0.01 0.824 <0.01 CDR -0.601 <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 69 0.83 0.74 70 0.83 0.77 72 0.83 0.78 73 0.80 0.79 74 0.79 0.80 75 0.74 0.83 76 0.70 0.84 77 0.69 0.87 78 0.67 0.87 79 0.65 0.88 80 0.61 0.91 Table 7. Sensitivity and specificity of the MMSE according to the selected cut off score. Cut off score Sensitivity Specificity 19 0.94 0.57 20 0.93 0.59 21 0.88 0.65 22 0.85 0.68 23 0.78 0.74 24 0.72 0.80 25 0.66 0.87 26 0.58 0.92 27 0.50 0.96 28 0.37 0.97 351
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< 2> Age-and education-specific reference values of the MMSE Education Age (years) (years) 65~69 70~74 75~79 80~84 85 0~4 25.7 3.4 25.7 2.7 25.4 1.9 24.5 2.8 24.3 2.6 (n=78) (n=85) (n=93) (n=78) (n=65) 5~8 26.9 2.8 27.0 2.5 26.4 2.0 25.8 2.0 25.2 1.8 (n=495) (n=422) (n=556) (n=277) (n=239) 9~12 27.9 2.2 27.7 2.1 27.3 1.5 26.8 1.7 26.2 1.4 (n=942) (n=752) (n=921) (n=455) (n=332) 13 28.5 1.9 28.2 2.0 27.7 1.8 27.3 1.7 26.9 1.3 (n=581) (n=375) (n=535) (n=236) (n=208) Ignoring 27.7 2.5 27.5 2.3 27.1 1.8 26.5 2.0 25.9 1.8 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 80~84 85 0~4 82.0 8.7 82.6 7.5 81.0 5.4 79.6 8.1 77.0 8.8 (n=78) (n=85) (n=93) (n=78) (n=65) 5~8 87.1 7.7 87.1 8.1 85.7 5.8 84.0 6.0 82.6 5.1 (n=495) (n=422) (n=556) (n=277) (n=239) 9~12 91.7 6.5 90.7 6.3 89.8 4.7 87.5 5.1 85.6 4.3 (n=942) (n=752) (n=921) (n=455) (n=332) 13 93.9 5.7 92.9 6.4 91.3 5.2 89.8 5.3 88.0 4.2 (n=581) (n=375) (n=535) (n=236) (n=208) Ignoring 90.9 7.6 89.9 7.6 88.6 5.7 86.5 6.2 84.5 5.5 education (n=2098) (n=1638) (n=2112) (n=1051) (n=853) 356