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

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.

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

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

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 >=65 years counts 2067 residents (2.5 %) on prevalence day (January 1st 2003), according to the Israel Central Statistics Bureau.

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.

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.

Methods Study procedures

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

Methods Study procedures Clinical 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.

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

Methods Cognitive evaluation

An Arabic translation of the MMSE (maximum score=30) Brookdale Cognitive Screening Test (BCST, maximum score=24) The BCST test developed in the Brookdale Institute of Gerontology, Jerusalem

Methods Cognitive evaluation BCST

Orientation in time and place Memory Praxis Naming Stimulus selection Abstraction Calculation Attention Left-right orientation LeftVisuo-spatial Visuoorientation
No items related to reading and writing

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

Methods Statistical analysis

Education was stratified: 1=0-4 years, 2=5-8 years, 3=>8 years =>8 Comparison of proportions by chi-square chiThe comparison of means of MMSE and BCST by gender and levels of education by Analysis of Covariance, using age as a covariate

Results
442 subjects approached 438 agreed (refusal rate 0.9 %) Four were excluded: severe systemic nonnonneurological disease

Cognitively normal
The study population consisted of 266 subjects (158 males) (158 Mean age (SD) was 72.4 (5.5) years 72. Range 65 -91 years Mean age: Males: 72.8 (5.6); females: 71.6 (5.4) 72. 71. years (p>0.1) (p>0

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 (r=0.852, p<0.0001) (r=0 852, p<0 0001) Males r=0.8223, Females r=0.854, r=0 8223, r=0 854, p<0 p<0.0001 both

Education levels
90 80 70 60 50

%
within

40 20 10 0 0-4 years 5-8 years > 8 years

p<0 p<0.001 Education years

males females

gender 30

MMSE by gender & education

30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15

M M S E

males females
p<0.05 p<0.0001

0-4 yrs

5-8 yrs

>8 yrs

Education years

BCST by gender & education

B C S T
24 23 22 21 20 19 18 17 16 15 14 13 12

p<0.05

males females

p<0.0001

0-4 yrs

5-8 yrs

>8 yrs

Education years

Occupation categories

60 50 % 40 within gender 30 20 10 0 no handy agricult. office

Occupation category

males females females males

p<0 p<0.05

Occupation and education within genders

For males MMSE and BCST scores were significantly higher for higher education (p<0.05). Occupation (p<0 05). category had no significant effect. For females MMSE and BCST scores were significantly higher for higher education (p<0.0001). Occupation (p<0 0001). category had no significant effect. The main effect was due to education and not occupation.

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

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

Conclusions
We found a divergent effect of gender in different education levels. Females with low-schooling (<=4 years) low(<=4 perform significantly worse than males. However, females with higher schooling (>=5 (>=5 years) perform significantly better than males.

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 ? life-

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.

Conclusions
Different cut-off scores should be used in cutdifferent 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.

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

Occupation categories by education levels

80 60

% within gender

40 20 0 no handy agricult. office females males

males females

Education 0-4 years

Education 5-8 years

50 40 males females females males no handy agricult. office

% within gender

30 20 10 0

Occupation categories education 0-4 years

80 60 males females females males no handy agricult. office

%
within gender

40 20 0

Occupation category
p<0.05

Occupation categories education 5-8 years

50 40 males females females males no handy agricult. office

%
within gender

30 20 10 0

Occupation category
p<0.05