Gender differences in the norms of the Minimental State Examination in Arabic

1
Gender differences in the norms of the Minimental
State Examination in Arabic

• Amin Abuful, Rivka Inzelberg, Magda Masarwa, Aziz
  Mazarib, Edna Schechtman Rosa Strugatsky
  Robert P. Friedland
• Hillel Yaffe Medical Center, Technion Rappaport
  Faculty of Medicine, Ben Gurion University,
  Israel
• Case Western University School of Medicine,
  Cleveland, Ohio, USA

2
Background

• The prevalence of Alzheimer's disease is
  increasing.
• There is a need for accurate and easily
  administered screening instruments.
• The Minimental State Examination (MMSE) is widely
  used.
• It has been validated in North America, Europe
  and Asia , but not in Arabic populations.

3
Aim

• To present gender differences in the normative
  data of an Arabic translation of the MMSE.

4
Methods

• The present work is part of our epidemiological
  study of brain aging related disorders carried
  out in Wadi Ara villages in northern Israel.

5
Methods Study population

• Wadi Ara houses a population of 81,400 Arab
  inhabitants (51 men) in Northern Israel.
• Most of the population is younger than 45 years.
• Only 9,831 residents (12 ) are older than 45
  years.
• The population gt65 years counts 2067 residents
  (2.5 ) on prevalence day (January 1st 2003),
  according to the Israel Central Statistics
  Bureau.

6
Methods Study population

• We systematically approached consecutive houses
  in the villages.
• We examined all residents who agreed to
  participate in the study.
• Elderly subjects in Wadi Ara live with their
  family. None were in an institution.

7
Study team

• All participants were examined in their homes by
  a fluently Arabic speaking native team
• The team comprised an academic nurse, a social
  worker and neurologists.

8
Methods Study procedures

• Participants systematically evaluated for
• Cardiovascular risk factors
• Questionnaires concerning activities of daily
  living
• Life style
• Cognitive function

9
Methods Study proceduresClinical assessment

• First visit All subjects were approached by
  nurse
• Interview medical and family history,
  medications
• History of changes in behavior, cognitive
  abilities, ADL, occupational and recreational
  activities
• Second visit Neurologist performed complete
  neurological examination.
• Consensus conference Four neurologists reviewed
  all subjects files.

10
Definition of cognitively normal

• No complaints about memory impairment
• Or any other cognitive domain
• No evidence of such disturbance according to
  surrogates
• No evidence of impairment in ADL stemming from
  cognitive disturbances

11
Methods Cognitive evaluation

• An Arabic translation of the MMSE (maximum
  score30)
• Brookdale Cognitive Screening Test (BCST, maximum
  score24)
• The BCST test developed in the Brookdale
  Institute of Gerontology, Jerusalem

12
Methods Cognitive evaluation BCST

• Orientation in time and place
• Memory
• Praxis
• Naming
• Stimulus selection

• Abstraction
• Calculation
• Attention
• Left-right orientation
• Visuo-spatial orientation
• No items related to reading and writing

13
Methods Occupation

• Questionnaires about occupation (present and
  past)
• Categorized for statistical analysis
• 1never worked outside the house, or housewife
• 2handy work (trader in shop, cook, carpenter,
  builder, etc),
• 3agriculture
• 4office.

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Methods Statistical analysis

• Education was stratified
• 10-4 years, 25-8 years, 3gt8 years
• Comparison of proportions by chi-square
• The comparison of means of MMSE and BCST by
  gender and levels of education by Analysis of
  Covariance, using age as a covariate

15
Results

• 442 subjects approached
• 438 agreed (refusal rate 0.9 )
• Four were excluded severe systemic
  non-neurological disease

16
Cognitively normal

• The study population consisted of 266 subjects
  (158 males)
• Mean age (SD) was 72.4 (5.5) years
• Range 65 -91 years
• Mean age
  Males 72.8 (5.6) females
  71.6 (5.4) years (pgt0.1)

17
Results

• Mean MMSE entire population 25 (4)
• Mean BCST entire population 19 (4) points
• Highly significant correlation between MMSE and
  Brookdale scores in the entire group (r0.852,
  plt0.0001)
• Males r0.8223, Females r0.854, plt0.0001 both

18
Education levels
within gender
plt0.001
Education years
19
MMSE by gender education
MMSE
plt0.05
plt0.0001
Education years
20
BCST by gender education
BCST
plt0.05
plt0.0001
Education years
21
Occupation categories
within gender
plt0.05
Occupation category
22
Occupation and education within genders

• For males MMSE and BCST scores were significantly
  higher for higher education (plt0.05). Occupation
  category had no significant effect.
• For females MMSE and BCST scores were
  significantly higher for higher education
  (plt0.0001). Occupation category had no
  significant effect.
• The main effect was due to education and not
  occupation.

23
Conclusions

• We described normative data for an Arabic
  translation of the MMSE by gender.

24
Conclusions

• Mean values of the MMSE scores were comparable to
  population-based norms described in English in
  the USA at all correspondent education levels
  (Crum et al. JAMA, 1993).

25
Conclusions

• We found a divergent effect of gender in
  different education levels.
• Females with low-schooling (lt4 years) perform
  significantly worse than males.
• However, females with higher schooling (gt5
  years) perform significantly better than males.

26
Discussion

• We verified whether working in the community
  might contribute to the performance.
• We found that scores are influenced by education
  and not by occupation within genders, when these
  two factors are analyzed.
• Influence of social exposure and life-style ?

27
Brookdale Cognitive Screening

• We found a highly significant correlation between
  MMSE and BCST scores in both genders.
• Despite the fact that BCST does not include
  reading or writing items, it is still influenced
  by education as much as the MMSE.

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Conclusions

• Different cut-off scores should be used in
  different education strata.
• Scores of females at low education levels should
  be considered cautiously to prevent false
  positive interpretation.
• Information on education is mandatory.
• Still, MMSE may serve for measuring change over
  time.

29
Thank you

• Rob P. Friedland, Case Western Reserve
  University- Lab of Neurogenetics , USA
• Lindsay Farrer, Boston University- Genetics
  Program, USA
• Edna Schechtman, Ben Gurion University- Dept.
  Industrial Engineering, Beer Sheva, Israel
• Hillel Yaffe Medical Center, Hadera, Israel
• Rivka Inzelberg
• Aziz Mazarib
• Magda Masarwa
• Saif Abo-Mouch
• Rosa Strugatsky
• Gital Gamliel

30
Occupation categories by education levels
within gender
Education 0-4 years
Education 5-8 years
within gender
31
Occupation categorieseducation 0-4 years
within gender
Occupation category
plt0.05
32
Occupation categorieseducation 5-8 years
within gender
Occupation category
plt0.05