0
May 12, 1993, Vol 269, No. 18 >
ARTICLE | May 12, 1993

Population-Based Norms for the Mini-Mental State Examination by Age and Educational Level FREE

Rosa M. Crum, MD, MHS; James C. Anthony, PhD; Susan S. Bassett, PhD; Marshal F. Folstein, MD
[+] Author Affiliations

Reprint requests to Department of Epidemiology, The Johns Hopkins University School of Hygiene and Public Health, 615 N Wolfe St, Baltimore, MD 21205 (Dr Crum).


JAMA. 1993;269(18):2386-2391. doi:10.1001/jama.1993.03500180078038
Text Size: A A A
Published online
Article
References

Objective.  —To report the distribution of Mini-Mental State Examination (MMSE) scores by age and educational level.

Design.  —National Institute of Mental Health Epidemiologic Catchment Area Program surveys conducted between 1980 and 1984.

Setting.  —Community populations in New Haven, Conn; Baltimore, Md; St Louis, Mo; Durham, NC; and Los Angeles, Calif.

Participants.  —A total of 18 056 adult participants selected by probability sampling within census tracts and households.

Main Outcome Measures.  —Summary scores for the MMSE are given in the form of mean, median, and percentile distributions specific for age and educational level.

Results.  —The MMSE scores were related to both age and educational level. There was an inverse relationship between MMSE scores and age, ranging from a median of 29 for those 18 to 24 years of age, to 25 for individuals 80 years of age and older. The median MMSE score was 29 for individuals with at least 9 years of schooling, 26 for those with 5 to 8 years of schooling, and 22 for those with 0 to 4 years of schooling.

Conclusions.  —Cognitive performance as measured by the MMSE varies within the population by age and education. The cause of this variation has yet to be determined. Mini-Mental State Examination scores should be used to identify current cognitive difficulties and not to make formal diagnoses. The results presented should prove to be useful to clinicians who wish to compare an individual patient's MMSE scores with a population reference group and to researchers making plans for new studies in which cognitive status is a variable of interest.(JAMA. 1993;269:2386-2391)

REFERENCES

1 +
Folstein MF, Folstein SE, McHugh PR.  `MiniMental State': a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res . 1975;;12:189-198.
2 +
Teng EL, Chui HC, Schneider LS, Metzger LE.  Alzheimer's dementia: performance on the MiniMental State Examination. J Consult Clin Psychol . 1987;;55:96-100.
3 +
Folstein M, Anthony JC, Parhad I, Duffy B, Gruenberg EM.  The meaning of cognitive impairment in the elderly. J Am Geriatr Soc . 1985;;33: 228-235.
4 +
Horton AM, Slone DG, Shapiro S.  Neuropsychometric correlates of the Mini-Mental State Examination: preliminary data. Percept Mot Skills . 1987;;65:64-66.
5 +
Knights EB, Folstein MF.  Unsuspected emotional and cognitive disturbance in medical patients. Ann Intern Med . 1977;;87:723-724.
6 +
Roca RP, Klein LE, Kirby SM, et al.  Recognition of dementia among medical patients. Arch Intern Med . 1984;;144:73-75.
7 +
Rovner BW, Kafonek S, Filipp L, Lucas MJ, Folstein MF.  Prevalence of mental illness in a community nursing home. Am J Psychiatry . 1986;;143: 1446-1449.
8 +
Steele C, Rovner B, Chase GA, Folstein M.  Psychiatric symptoms and nursing home placement of patients with Alzheimer's disease. Am J Psychiatry . 1990;;147:1049-1051.
9 +
Fried LP, Borhani NO, Enright P, et al.  The Cardiovascular Health Study: design and rationale. Ann Epidemiol . 1991;;1:263-276.
10 +
Li G, Shen YC, Chen CH, Zhao YW, Li SR, Lu M.  An epidemiological survey of age-related dementia in an urban area of Beijing. Acta Psychiatr Scand . 1989;;79:557-563.
11 +
George LK, Landerman R, Blazer DG, Anthony JC.  Cognitive impairment.  In: Robins LN, Regier DA, eds. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study . New York, NY: The Free Press; 1991;:291-327.
12 +
Gauthier S, Bouchard R, Lamontagne A, et al.  Tetrahydroaminoacridine-lecithin combination treatment in patients with intermediate-stage Alzheimer's disease: results of a Canadian doubleblind, crossover, multicenter study. N Engl J Med . 1990;;322:1272-1276.
13 +
Chatellier G, Lacomblez L.  Tacrine (tetrahydroaminoacridine; THA) and lecithin in senile dementia of the Alzheimer type: a multicentre trial. BMJ . 1990;;300:495-499.
14 +
Devanand DP, Sackeim HA, Brown RP, Mayeux R.  A pilot study of haloperidol treatment of psychosis and behavioral disturbance in Alzheimer's disease. Arch Neurol . 1989;;46:854-857.
15 +
Indaco A, Carrieri PB.  Amitriptyline in the treatment of headache in patients with Parkinson's disease: a double-blind placebo-controlled study. Neurology . 1988;;38:1720-1722.
16 +
Balestreri R, Fontana L, Astengo F.  A doubleblind placebo controlled evaluation of the safety and efficacy of vinpocetine in the treatment of patients with chronic vascular senile cerebral dysfunction. J Am Geriatr Soc . 1987;;35:425-430.
17 +
Bird HR, Canino G, Stipec MR, Shrout P.  Use of the Mini-Mental State Examination in a probability sample of a Hispanic population. J Nerv Ment Dis . 1987;;175:731-737.
18 +
Salmon DP, Riekkinen PJ, Katzman R, Zhang M, Jin H, Yu E.  Cross-cultural studies of dementia: a comparison of Mini-Mental State Examination performance in Finland and China. Arch Neurol . 1989;;46:769-772.
19 +
Uhlmann RF, Larson EB, Rees TS, Koepsell TD, Duckert LG.  Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. JAMA . 1989;;261:1916-1919.
20 +
Farber JF, Schmitt FA, Logue PE.  Predicting intellectual level from the Mini-Mental State Examination. J Am Geriatr Soc . 1988;;36:509-510.
21 +
Liu IY, Anthony JC.  Using the `Mini-Mental State' Examination to predict elderly subjects' completion of a follow-up interview. Am J Epidemiol . 1989;;130:416-422.
22 +
Fillenbaum GG, Heyman A, Wilkinson WE, Haynes CS.  Comparison of two screening tests in Alzheimer's disease: the correlation and reliability of the Mini-Mental State Examination and the Modified Blessed Test. Arch Neurol . 1987;;44:924-927.
23 +
Zillmer EA, Fowler PC, Gutnick HN, Becker E.  Comparison of two cognitive bedside screening instruments in nursing home residents: a factor analytic study. J Gerontol . 1990;;45:P69-P74.
24 +
Colohan H, O'Callaghan E, Larkin C, Waddington JL.  An evaluation of cranial CT scanning in clinical psychiatry. Ir J Med Sci . 1989;;158:178-181.
25 +
Tsai L, Tsuang MT.  The Mini-Mental State Test and computerized tomography. Am J Psychiatry . 1979;;136:436-439.
26 +
Pearlson GD, Tune LE.  Cerebral ventricular size and cerebrospinal fluid acetylcholinesterase levels in senile dementia of the Alzheimer type. Psychiatry Res . 1986;;17:23-29.
27 +
DeKosky ST, Shih WJ, Schmitt FA, Coupal J, Kirkpatrick C.  Assessing utility of single photon emission computed tomography (SPECT) scan in Alzheimer disease: correlation with cognitive severity. Alzheimer Dis Assoc Disord . 1990;;4:14-23.
28 +
Finley WW, Faux SF, Hutcheson J, Amstutz L.  Long-latency event-related potentials in the evaluation of cognitive function in children. Neurology . 1985;;35:323-327.
29 +
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;;12:397-408.
30 +
Holzer CE, Tischler GL, Leaf PJ, Myers JK.  An epidemiologic assessment of cognitive impairment in a community population.  In: Greenley JR, ed. Research in Community and Mental Health . Greenwich, Conn: JAI Press; 1984;;4:3-32.
31 +
Bleecker ML, Bolla-Wilson K, Kawas C, Agnew J.  Age-specific norms for the Mini-Mental State Exam. Neurology . 1988;;38:1565-1568.
32 +
Feinstein AR. Clinical Epidemiology . Philadelphia, Pa: WB Saunders Co; 1985;.
33 +
Armitage P, Berry G. Statistical Methods in Medical Research . 2nd ed. Boston, Mass: Blackwell Scientific Publications Inc; 1987;.
34 +
Elveback LR, Guillier CL, Keating FR.  Health, normality, and the ghost of Gauss. JAMA . 1970;; 211:69-75.
35 +
Feinstein AR.  Clinical biostatistics, XXV: a survey of the statistical procedures in general medical journals. Clin Pharmacol Ther . 1974;;15:97-107.
36 +
Murphy EA. Biostatistics in Medicine . Baltimore, Md: Johns Hopkins University Press; 1982;.
37 +
Robins LN, Helzer JE, Croughan J, Ratcliff KS.  The National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry . 1981;; 38:381-389.
38 +
Eaton WW, Kessler LG, eds. Epidemiologic Field Methods in Psychiatry: The NIMH Epidemiologic Catchment Area Program . Orlando, Fla: Academic Press Inc; 1985;.
39 +
Anthony JC, Folstein M, Romanoski AJ, et al.  Comparison of the lay Diagnostic Interview Schedule and a standardized psychiatric diagnosis: experience in eastern Baltimore. Arch Gen Psychiatry . 1985;;42:667-675.
40 +
Eaton WW, Kramer M, Anthony JC, Dryman A, Shapiro S, Locke BZ.  The incidence of specific DIS/DSM-III mental disorders: data from the NIMH Epidemiologic Catchment Area Program. Acta Psychiatr Scand . 1989;;79:163-178.
41 +
Eaton WW, Kramer M, Anthony JC, Chee EML, Shapiro S.  Conceptual and methodological problems in estimation of the incidence of mental disorders from field survey data.  In: Cooper B, Helgason T, eds. Epidemiology and the Prevention of Mental Disorders . London, England: Routledge; 1989;:108-127.
42 +
SAS Institute Inc. SAS User's Guide: Statistics, Version 5 Edition . Cary, NC: SAS Institute Inc; 1985;.
43 +
Leaf PJ, Myers JK, McEvoy LT.  Procedures used in the Epidemiologic Catchment Area Study.  In: Robins LN, Reiger DA, eds. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study . New York, NY: The Free Press; 1991;: 11-32.
44 +
Regier DA, Boyd JH, Burke JD, et al.  Onemonth prevalence of mental disorders in the United States based on five Epidemiologic Catchment Area sites. Arch Gen Psychiatry . 1988;;45:977-986.
45 +
Regier DA, Farmer ME, Rae DS, et al.  Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study. JAMA . 1990;;264:2511-2518.
46 +
Evans DA, Funkenstein HH, Albert MS, et al.  Prevalence of Alzheimer's disease in a community population of older persons. JAMA . 1989;;262:2551-2556.
47 +
Feinstein AR. Clinical Biostatistics . St Louis, Mo: CV Mosby Co; 1977;.
48 +
Magaziner J, Bassett SS, Hebel JR.  Predicting performance on the Mini-Mental State Examination. J Am Geriatr Soc . 1987;;35:996-1000.
49 +
Folstein MF, Bassett SS, Anthony JC, Romanoski AJ, Nestadt GR.  Dementia: case ascertainment in a community survey. J Gerontol . 1991;;46:M132-M138.
50 +
O'Connor DW, Pollitt PA, Treasure FP, Brook CPB, Reiss BB.  The influence of education, social class, and sex on Mini-Mental State scores. Psychol Med . 1989;;19:771-776.
51 +
Kittner SJ, White LR, Farmer ME, et al.  Methodological issues in screening for dementia: the problem of education adjustment. J Chronic Dis . 1986;; 39:163-170.
52 +
Jorm AF, Scott R, Henderson AS, Kay DWK.  Educational level differences on the Mini-Mental State: the role of test bias. Psychol Med . 1988;;18: 727-731.
53 +
Bassett SS, Folstein MF.  Cognitive impairment and functional disability in the absence of psychiatric diagnosis. Psychol Med . 1991;;21:77-84.
54 +
Berkman LF.  The association between educational attainment and mental status examinations: of etiologic significance for senile dementias or not? J Chronic Dis . 1986;;39:171-174.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Folstein MF, Folstein SE, McHugh PR.  `MiniMental State': a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res . 1975;;12:189-198.
2 +
Teng EL, Chui HC, Schneider LS, Metzger LE.  Alzheimer's dementia: performance on the MiniMental State Examination. J Consult Clin Psychol . 1987;;55:96-100.
3 +
Folstein M, Anthony JC, Parhad I, Duffy B, Gruenberg EM.  The meaning of cognitive impairment in the elderly. J Am Geriatr Soc . 1985;;33: 228-235.
4 +
Horton AM, Slone DG, Shapiro S.  Neuropsychometric correlates of the Mini-Mental State Examination: preliminary data. Percept Mot Skills . 1987;;65:64-66.
5 +
Knights EB, Folstein MF.  Unsuspected emotional and cognitive disturbance in medical patients. Ann Intern Med . 1977;;87:723-724.
6 +
Roca RP, Klein LE, Kirby SM, et al.  Recognition of dementia among medical patients. Arch Intern Med . 1984;;144:73-75.
7 +
Rovner BW, Kafonek S, Filipp L, Lucas MJ, Folstein MF.  Prevalence of mental illness in a community nursing home. Am J Psychiatry . 1986;;143: 1446-1449.
8 +
Steele C, Rovner B, Chase GA, Folstein M.  Psychiatric symptoms and nursing home placement of patients with Alzheimer's disease. Am J Psychiatry . 1990;;147:1049-1051.
9 +
Fried LP, Borhani NO, Enright P, et al.  The Cardiovascular Health Study: design and rationale. Ann Epidemiol . 1991;;1:263-276.
10 +
Li G, Shen YC, Chen CH, Zhao YW, Li SR, Lu M.  An epidemiological survey of age-related dementia in an urban area of Beijing. Acta Psychiatr Scand . 1989;;79:557-563.
11 +
George LK, Landerman R, Blazer DG, Anthony JC.  Cognitive impairment.  In: Robins LN, Regier DA, eds. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study . New York, NY: The Free Press; 1991;:291-327.
12 +
Gauthier S, Bouchard R, Lamontagne A, et al.  Tetrahydroaminoacridine-lecithin combination treatment in patients with intermediate-stage Alzheimer's disease: results of a Canadian doubleblind, crossover, multicenter study. N Engl J Med . 1990;;322:1272-1276.
13 +
Chatellier G, Lacomblez L.  Tacrine (tetrahydroaminoacridine; THA) and lecithin in senile dementia of the Alzheimer type: a multicentre trial. BMJ . 1990;;300:495-499.
14 +
Devanand DP, Sackeim HA, Brown RP, Mayeux R.  A pilot study of haloperidol treatment of psychosis and behavioral disturbance in Alzheimer's disease. Arch Neurol . 1989;;46:854-857.
15 +
Indaco A, Carrieri PB.  Amitriptyline in the treatment of headache in patients with Parkinson's disease: a double-blind placebo-controlled study. Neurology . 1988;;38:1720-1722.
16 +
Balestreri R, Fontana L, Astengo F.  A doubleblind placebo controlled evaluation of the safety and efficacy of vinpocetine in the treatment of patients with chronic vascular senile cerebral dysfunction. J Am Geriatr Soc . 1987;;35:425-430.
17 +
Bird HR, Canino G, Stipec MR, Shrout P.  Use of the Mini-Mental State Examination in a probability sample of a Hispanic population. J Nerv Ment Dis . 1987;;175:731-737.
18 +
Salmon DP, Riekkinen PJ, Katzman R, Zhang M, Jin H, Yu E.  Cross-cultural studies of dementia: a comparison of Mini-Mental State Examination performance in Finland and China. Arch Neurol . 1989;;46:769-772.
19 +
Uhlmann RF, Larson EB, Rees TS, Koepsell TD, Duckert LG.  Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. JAMA . 1989;;261:1916-1919.
20 +
Farber JF, Schmitt FA, Logue PE.  Predicting intellectual level from the Mini-Mental State Examination. J Am Geriatr Soc . 1988;;36:509-510.
21 +
Liu IY, Anthony JC.  Using the `Mini-Mental State' Examination to predict elderly subjects' completion of a follow-up interview. Am J Epidemiol . 1989;;130:416-422.
22 +
Fillenbaum GG, Heyman A, Wilkinson WE, Haynes CS.  Comparison of two screening tests in Alzheimer's disease: the correlation and reliability of the Mini-Mental State Examination and the Modified Blessed Test. Arch Neurol . 1987;;44:924-927.
23 +
Zillmer EA, Fowler PC, Gutnick HN, Becker E.  Comparison of two cognitive bedside screening instruments in nursing home residents: a factor analytic study. J Gerontol . 1990;;45:P69-P74.
24 +
Colohan H, O'Callaghan E, Larkin C, Waddington JL.  An evaluation of cranial CT scanning in clinical psychiatry. Ir J Med Sci . 1989;;158:178-181.
25 +
Tsai L, Tsuang MT.  The Mini-Mental State Test and computerized tomography. Am J Psychiatry . 1979;;136:436-439.
26 +
Pearlson GD, Tune LE.  Cerebral ventricular size and cerebrospinal fluid acetylcholinesterase levels in senile dementia of the Alzheimer type. Psychiatry Res . 1986;;17:23-29.
27 +
DeKosky ST, Shih WJ, Schmitt FA, Coupal J, Kirkpatrick C.  Assessing utility of single photon emission computed tomography (SPECT) scan in Alzheimer disease: correlation with cognitive severity. Alzheimer Dis Assoc Disord . 1990;;4:14-23.
28 +
Finley WW, Faux SF, Hutcheson J, Amstutz L.  Long-latency event-related potentials in the evaluation of cognitive function in children. Neurology . 1985;;35:323-327.
29 +
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;;12:397-408.
30 +
Holzer CE, Tischler GL, Leaf PJ, Myers JK.  An epidemiologic assessment of cognitive impairment in a community population.  In: Greenley JR, ed. Research in Community and Mental Health . Greenwich, Conn: JAI Press; 1984;;4:3-32.
31 +
Bleecker ML, Bolla-Wilson K, Kawas C, Agnew J.  Age-specific norms for the Mini-Mental State Exam. Neurology . 1988;;38:1565-1568.
32 +
Feinstein AR. Clinical Epidemiology . Philadelphia, Pa: WB Saunders Co; 1985;.
33 +
Armitage P, Berry G. Statistical Methods in Medical Research . 2nd ed. Boston, Mass: Blackwell Scientific Publications Inc; 1987;.
34 +
Elveback LR, Guillier CL, Keating FR.  Health, normality, and the ghost of Gauss. JAMA . 1970;; 211:69-75.
35 +
Feinstein AR.  Clinical biostatistics, XXV: a survey of the statistical procedures in general medical journals. Clin Pharmacol Ther . 1974;;15:97-107.
36 +
Murphy EA. Biostatistics in Medicine . Baltimore, Md: Johns Hopkins University Press; 1982;.
37 +
Robins LN, Helzer JE, Croughan J, Ratcliff KS.  The National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry . 1981;; 38:381-389.
38 +
Eaton WW, Kessler LG, eds. Epidemiologic Field Methods in Psychiatry: The NIMH Epidemiologic Catchment Area Program . Orlando, Fla: Academic Press Inc; 1985;.
39 +
Anthony JC, Folstein M, Romanoski AJ, et al.  Comparison of the lay Diagnostic Interview Schedule and a standardized psychiatric diagnosis: experience in eastern Baltimore. Arch Gen Psychiatry . 1985;;42:667-675.
40 +
Eaton WW, Kramer M, Anthony JC, Dryman A, Shapiro S, Locke BZ.  The incidence of specific DIS/DSM-III mental disorders: data from the NIMH Epidemiologic Catchment Area Program. Acta Psychiatr Scand . 1989;;79:163-178.
41 +
Eaton WW, Kramer M, Anthony JC, Chee EML, Shapiro S.  Conceptual and methodological problems in estimation of the incidence of mental disorders from field survey data.  In: Cooper B, Helgason T, eds. Epidemiology and the Prevention of Mental Disorders . London, England: Routledge; 1989;:108-127.
42 +
SAS Institute Inc. SAS User's Guide: Statistics, Version 5 Edition . Cary, NC: SAS Institute Inc; 1985;.
43 +
Leaf PJ, Myers JK, McEvoy LT.  Procedures used in the Epidemiologic Catchment Area Study.  In: Robins LN, Reiger DA, eds. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study . New York, NY: The Free Press; 1991;: 11-32.
44 +
Regier DA, Boyd JH, Burke JD, et al.  Onemonth prevalence of mental disorders in the United States based on five Epidemiologic Catchment Area sites. Arch Gen Psychiatry . 1988;;45:977-986.
45 +
Regier DA, Farmer ME, Rae DS, et al.  Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study. JAMA . 1990;;264:2511-2518.
46 +
Evans DA, Funkenstein HH, Albert MS, et al.  Prevalence of Alzheimer's disease in a community population of older persons. JAMA . 1989;;262:2551-2556.
47 +
Feinstein AR. Clinical Biostatistics . St Louis, Mo: CV Mosby Co; 1977;.
48 +
Magaziner J, Bassett SS, Hebel JR.  Predicting performance on the Mini-Mental State Examination. J Am Geriatr Soc . 1987;;35:996-1000.
49 +
Folstein MF, Bassett SS, Anthony JC, Romanoski AJ, Nestadt GR.  Dementia: case ascertainment in a community survey. J Gerontol . 1991;;46:M132-M138.
50 +
O'Connor DW, Pollitt PA, Treasure FP, Brook CPB, Reiss BB.  The influence of education, social class, and sex on Mini-Mental State scores. Psychol Med . 1989;;19:771-776.
51 +
Kittner SJ, White LR, Farmer ME, et al.  Methodological issues in screening for dementia: the problem of education adjustment. J Chronic Dis . 1986;; 39:163-170.
52 +
Jorm AF, Scott R, Henderson AS, Kay DWK.  Educational level differences on the Mini-Mental State: the role of test bias. Psychol Med . 1988;;18: 727-731.
53 +
Bassett SS, Folstein MF.  Cognitive impairment and functional disability in the absence of psychiatric diagnosis. Psychol Med . 1991;;21:77-84.
54 +
Berkman LF.  The association between educational attainment and mental status examinations: of etiologic significance for senile dementias or not? J Chronic Dis . 1986;;39:171-174.

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