Article

Journal of Geriatric Psychiatry

and Neurology
Cognitive Deficits in Healthy Elderly 1-7
ª The Author(s) 2016
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DOI: 10.1177/0891988716629858
on the Mini-Mental State Examination jgpn.sagepub.com

Kristen L. Votruba, PhD1, Carol Persad, PhD1,2, and Bruno Giordani, PhD1,2

Abstract
This study investigated whether healthy older adults with Mini-Mental State Examination (MMSE) scores above 23 exhibit cog-
nitive impairment on neuropsychological tests. Participants completed the MMSE and a neuropsychological battery including tests
of 10 domains. Results were compared to published normative data. On neuropsychological testing, participants performed well
on measures of naming and recall but showed mild to moderate impairment in working memory and processing speed and marked
impairment in inhibition, sustained attention, and executive functioning. Almost everyone (91%) scored at least 1 standard
deviation (SD) below the mean in at least 1 domain. The median number of domains in which individuals scored below 1 SD was
3.0 of 10.0, whereas over 21% scored below 1 SD in 5 domains or more. With the strictest of definitions for impairment, 20% of
this population scored below 2.0 SDs below the norm in at least 2 domains, a necessary condition for a diagnosis of dementia. The
finding that cognitive impairment, particularly in attention and executive functioning, is found in healthy older persons who
perform well on the MMSE has clinical and research implications in terms of emphasizing normal variability in performance and
early identification of possible impairment.

Keywords
Mini-Mental State Examination, neuropsychological testing, cognitive screening

Cognitive Deficits in Healthy Elderly
Population With ‘‘Normal’’ MMSE Scores
Dementia, and perhaps even more so mild cognitive impair-
ment (MCI), can be difficult to diagnose by general practi-
tioners, particularly when working with a well-educated
population with significant cognitive reserve capacities and
limited time to do a comprehensive assessment. Nevertheless,
detection of cognitive deterioration is important, as cognitive
impairment is a significant cause of morbidity and mortality in
the United States even after controlling for medical health.1,2
Further, pharmaceutical advancements have made early detec-
tion even more essential as efforts to slow the progression of
the disease early in the course have become available. The use
of sensitive and brief screening measures of cognitive function-
ing is therefore becoming more critical in geriatric settings.
The most commonly administered brief screen for cognitive
functioning is the Mini-Mental State Examination (MMSE),3
which was developed as a bedside test that could be used to
detect cognitive impairment. The MMSE is a 10-minute screen
that consists of 11 questions assessing a variety of domains
including orientation, attention, memory, language, and
visual-spatial abilities. It is proven to have good concurrent
validity with other neuropsychological assessment instruments
but is not highly specific.4 The standard cutoff score for normal
cognitive functioning is typically reported at 24 of 30,5,6 and
scores below 24 have been shown to detect dementia fairly
accurately.7,8 The MMSE and a more thorough cognitive eva-
luation using the Dementia Rating Scale did not differ with
respect to classification in nursing home settings that often
consist of more severely impaired elderly individuals,7 and the
MMSE discriminates well between Clinical Dementia Rating
(CDR) stages of 0.5, 1.0, 2.0, and 3.0.8 Further, studies have
found that in nondemented community samples older than
65 years, participants usually score 24 and above.3,9
However, the MMSE is not without its limitations. First, age
is associated with a decline in MMSE scores10,11 as is lower
education level.9-11 These factors can potentially lead to mis-
identification of dementia in these individuals. For example, in
participants aged 60 to 69 years with 0 to 4 years of education, a
score of 18 to 19 may be a more appropriate cut score for
1
Neuropsychology Section, Department of Psychiatry, University of Michigan
Medical Center, Ann Arbor, MI, USA
2
Michigan Alzheimer’s Disease Center (MADC), Ann Arbor, MI, USA
Corresponding Author:
Kristen L. Votruba, University of Michigan, 2101 Commonwealth Blvd Suite C,
Ann Arbor, MI 48105, USA.
Email: kvotruba@umich.edu

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2 Journal of Geriatric Psychiatry and Neurology
dementia, whereas in the same aged people with 13þ years of
education, a cut score of 26 to 27 is more appropriate.12 There
is also perhaps an overdiagnosis of dementia based on the
MMSE in African Americans, but the debate continues whether
an education correction can correct for this bias.13 The MMSE
is also criticized as insensitive to deficits in cognitive domains
such as psychomotor speed, problem solving, or attention,
areas of deficit that are commonly present in individuals with
subcortical dementias or dementia due to multiple sclerosis14
or HIV.15 Further, the MMSE is potentially not efficient in
detecting early signs of cognitive impairment, as evidenced
by its poor performance in separating CDR stages 0 from
0.58 and its poor discriminatory capacity in individuals with
MMSE scores ranging from 21 to 25.16 Further, the overall
score on the MMSE has been shown to be equivalent in healthy
participants and patients with MCI.17
The current study investigated the relationship between
MMSE scores in a nondemented population of older, healthy,
community-dwelling adults and the performance of these indi-
viduals when evaluated with more comprehensive neuropsy-
chological testing. We report the percentage of healthy elderly
participants with an MMSE score greater than 23 that exhibit
cognitive deficits and compare these results to what would be
expected based on normal variation in general cognitive pro-
files. The aim of this analysis was to identify whether the
MMSE is adequate to rule out cognitive impairment in a
healthy elderly sample. This study may have implications for
geriatric centers that frequently see many ‘‘healthy’’ older
adults. If the MMSE can accurately be utilized in this setting,
it could provide a quick and easy way to screen for neuropsy-
chological impairment and perhaps reduce health care costs by
eliminating unnecessary tests for patients who are cognitively
intact.
Methods
Participants
This retrospective study included 204 community-dwelling,
independent, healthy, older adults (39 men and 165 women).
The mean age was 79.44 years (standard deviation [SD] ¼ 7.5;
range ¼ 60-102), and the mean education level was 13.62 years
(SD ¼ 2.9; range ¼ 6-20). Average Full Scale IQ, as measured
by the Wechsler scales, was 108 (SD ¼ 8.6; range ¼ 86-127).
Individuals were recruited from the Human Subjects Core of
the University of Michigan Claude Pepper Older Adults Inde-
pendence Center (OAIC); the Michigan Alzheimer’s Disease
Center Clinical Core normal, healthy cohort; or 1 of 5 local
senior congregate apartment complexes. Participants were part
of a larger study examining mobility in older community-
dwelling individuals. Participants included in this study were
those who met the following criteria: (1) age equal to or greater
than 60 years; (2) no clinical evidence of dementia and an
MMSE score above 23 (mean MMSE score was 28.3 + 1.6);
(3) able to stand independently from a sitting position for at
least 5 minutes and able to walk independently, with or without
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Table 1. Sources of Normative Data.
Test Source of Normative Data
WAIS: Digit Span WAIS manual21
WMS: LII MOANS norms18
DRT: spatial Taylor et al16
BNT MOANS norms18
TMT A and B MOANS norms18
Stroop Stroop manual19
WCST Rhodes17
TOVA TOVA manual20
Abbreviations: BNT, Boston Naming Test; DRT, Delayed Recognition Test; LII,
Logical Memory II (delayed recall); MOANS, Mayo Older Americans
Normative Studies; TMT A and B, Trail Making Test, Parts A and B; TOVA,
Test of Variables of Attention; WAIS, Wechsler Adult Intelligence Scale–
Revised; WCST, Wisconsin Card Sort Test; WMS, Wechsler Memory Scale–
Revised.
an assistive device but without help from other; and (4) score
below 15 on the Geriatric Depression Scale (GDS). All parti-
cipants were given an examination by a geriatrician or nurse
clinician to rule out the presence of neurological disease, sig-
nificant visual impairment not corrected by glasses, recent limb
or spinal fracture, other musculoskeletal impairments, or per-
sistent symptoms of vertigo, lightheadedness, or unsteadiness.
Procedure
Participants underwent a neuropsychological battery that
included measures of global mental status, intelligence, and
mood as well as reaction time, memory (verbal and visual),
confrontation naming, working memory, processing speed,
sustained attention, inhibition, mental flexibility, and concept
formation. After excluding participants with MMSE < 24 and
those who endorsed significant symptoms of depression (GDS
 15), descriptive statistics were computed for each of the 10
domains listed previously according to the percentage of parti-
cipants who scored below a designated point (SDs below the
mean compared to others of the same age). All normative data
used were adjusted based on age or age and gender. These
sources are listed in Table 1. When possible, normative data
were obtained from the test manual or from the Mayo Older
Americans Normative Studies (MOANS) norms, as the
MOANS norms are based on age and are shown to be reliable
and valid.18 Normative data for the delayed recognition test
(DRT) came from the study by Taylor et al.19 With regard to
the Wisconsin Card Sort Test (WCST), normative data were
taken from a meta-analytic review of published normative data
(Rhodes)20 in order to allow for the inclusion of the wide
breadth of ages included in our sample (the manual only pro-
vides normative data up to age 79 years). When comparing the
normative data of younger individuals, the normative data of the
WCST manual and the Rhodes20 were not significantly different.
The proportion of domains in which each individual scored
below 1, 1.5, or 2.0 SDs from expected norms was calculated
in order to compare these results to the variation in performance
that would be expected in a truly healthy sample.
Votruba et al 3

Measures
Working memory: Digit Span subtest (Wechsler Adult Intelligence
Scales–Revised). The Digit Span subtest is a measure of simple
auditory attention that measures immediate forward and back-
ward repetition of digit series.21

Inhibition: Stroop Color and Word Test. This task is a measure of

attentional abilities, particularly rapid shifting and inhibition of
attentional set.22 The task has 3 trials: the first requires parti-
cipants to rapidly read words (red, green, or blue) printed in
black ink; the second requires participants to name the colors of
the ink (red, green, or blue) presented in a box; and the third
requires the participant to name the color, not the word (red,
green, or blue), printed in a different color ink than the word
itself (color–word condition). Participants are given 45 seconds
for each trial, and the total score reflects the number of words
completed within the time limit. The total score on the color–
word condition was used in these analyses, as it is thought to be
the most ‘‘pure’’ measure of an individual’s ability to alternate
attentional focus and inhibit prepotent responses.

Sustained attention: Test of Variables of Attention. This is a com-

puterized continuous performance test measuring sustained
attention and impulsivity.23 It provides error rates for omis-
sions, which is a measure of sustained attention abilities and
error rates for commissions which measures impulsivity. The
rate of omission errors was used in the current analyses.
Verbal memory: Logical Memory subtests (Wechsler Memory Scale–
Revised). This is a memory test in which participants are asked
to recall short stories that are read to them immediately and
then recall these stories 30 minutes later (ie, delayed recall).24
On both tasks, total scores range from 0 to 50.
Visual memory: Digit Recognition Task (DRT). This test measures
memory recognition for spatial positions using a delayed
nonmatch-to-sample paradigm.19 The task involves identifying
a new stimulus in a variable array each time it appears with
scores ranging from 0 to 14.
Confrontation naming: Boston Naming Test. This test requires
participants to name 60 ink drawings of items ranging in famil-
iarity.25 When an individual is unable to name a drawing, the
examiner gives a stimulus cue. If the participant is still unable
to give a correct name, a phonetic cue is provided. The total
score is the number of items correctly named immediately or
with a semantic cue (range: 0-60).
Reaction time: Test of Variables of Attention. In addition to doc-
umenting omission and commission errors (described previ-
ously), the Test of Variables of Attention (TOVA) provides a
measure of mean response time to target stimuli providing a
good measure of reaction time.23
Processing speed: Trail Making Test, Part A. The Trail Making
Test, Part A (TMT-A) is a test of visuomotor tracking requiring
Figure 1. Percentage of participants below a given standard deviation
on a battery of neuropsychological tests (controlled for age). BNT
indicates Boston Naming Test; DRT, Delayed Recognition Test; LII,
Logical Memory II (delayed recall); TMT, Trail Making Test; TOVA,
Test of Variables of Attention; WAIS, Wechsler Adult Intelligence
Scale; WMS, Wechsler Memory Scale; WCST, Wisconsin Card Sort
Test.
the connection of consecutively numbered circles from 1 to
25 printed on a page.26 Higher scores reflect a longer time to
complete this task (worse performance).
Cognitive flexibility: Trail Making Test-B. Part B of the TMT
requires the consecutive connection of alternating numbered
and lettered circles as quickly as possible.26 Time to complete
Part B is often used as a measure of executive functioning
abilities, particularly mental flexibility. As in Part A of the
TMT, higher scores reflect slower (worse) performance.
Concept formation: Wisconsin Card Sorting Test. In this task, a
participant is given 128 cards on which are printed 1 to 4 sym-
bols, in one of 4 colors.27 The individual’s task is to place his or
her cards under one of 4 stimulus cards according to a principle
that the participant must deduce based on examiner feedback.
The number of times that the participant correctly categorizes a
specific number of cards in a row (ie, categories generated) was
used in the analyses.
Results
Figure 1 presents the percentage of participants classified as
normal by the MMSE who scored below various standards
compared to the mean on the cognitive measures. Scoring
below 1 SD indicates that these individuals were in the bottom

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4 Journal of Geriatric Psychiatry and Neurology
16th percentile compared to others of their age. Results are
further classified by those who scored below 1.5 and 2.0 SDs
below the mean compared to others their age. Scoring 1.5 SDs
below the norm indicates that these individuals performed at
approximately the seventh percentile compared to their same-
aged peers, whereas those scoring 2 or more SDs below the
mean compared to others their age are comparable to the sec-
ond percentile. Individuals scoring in this range are typically
considered impaired in a clinical evaluation and have signifi-
cant functional difficulties arising from their objective cogni-
tive deficits. As can be seen in Figure 1, mild impairment (ie, at
least 1.0 SDs below the mean) was common on measures of
working memory (digit span: 72.4%), sustained attention
(TOVA omissions: 23.6%), processing speed (TMT-A:
24.9%), inhibition (Stroop Color–Word: 40.0%), and executive
functioning (TMT-B: 35.3%; WCST categories completed:
65.8%). Scoring in the moderate range of impairment (ie, at
least 1.5 SDs below the mean) in this healthy population was
not rare, particularly on measures of inhibition (Stroop:
26.3%), sustained attention (TOVA: 20.9%), cognitive flexi-
bility (TMT-B: 22.8%), and concept formation (WCST correct
categories: 44.6%). Severe impairment (at least 2.0 SDs below
the mean) was noted on measures of attention (TOVA omis-
sions: 18.1%) and executive functioning (TMT-B: 20.1%;
WCST categories completed: 13.0%).
Importantly, some variability in neuropsychological profiles
is to be expected and may reflect characteristic long-standing
weaknesses. In fact, in their publications of a large base nor-
mative data set, Heaton et al report that normal patients may
show impairment (‘‘conservatively’’ recorded in their sample
as 1 SD below the norm) on 10% to 12% of the measures in
their test battery.28,29 Using the same criteria for impairment as
Heaton et al, our study shows that 91% of the elderly popula-
tion with normal MMSE scores showed impairment in 10% of
the measures that we administered and over half of our sample
showed impairment in at least 30% of the measures that were
administered. Figure 2 presents the number of domains in
which participants scored below 1, 1.5, and 2.0 SDs below the
mean. As mentioned, almost everyone in our sample scored at
least 1 SD below the mean in at least 1 domain within this brief
neuropsychological battery, and 73% of the sample scored
below 1 SD on at least 2 of the domains assessed, a necessary
condition for a diagnosis of dementia. The average number of
domains in which individuals scored below 1 SD was 2.89
(SD ¼ 1.99; median ¼ 3.0), while over 10% of the individuals
scored below 1 SD in 5 domains or more. With stricter defini-
tions for impairment, the average number of domains in which
individuals scored below 1.5 SDs below the norm was 1.44 (SD
¼ 1.54; median ¼ 1.0), with 38.5% of the population scoring
below 1.5 SDs below the norm in 2 domains or more. With the
strictest of criteria (2.0 SDs below the norm indicating severe
impairment), 43% of this population scored below this level in
1 cognitive domain and 20% of the population scored below
this level in at least 2 domains.
In an attempt to delineate what neuropsychological tests
may predict MMSE score, a multiple regression was
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Figure 2. Participants scoring below 1.0, 1.5, and 2.0 standard
deviations (SDs) in multiple domains. The 10 total domains assessed:
working memory, verbal memory, visual memory, naming, processing
speed, cognitive flexibility, inhibition, sustained attention, reaction
time, and concept formation. Average number of domains below 1.0
SD ¼ 2.89 (1.99); median: 3.0. Average number of domains below
1.5 SD ¼ 1.44 (1.54); median: 1.0. Average number of domains below
2.0 SD ¼ 0.77 (1.14); median: 0.0.
conducted. With MMSE as the dependent variable, the specific
neuropsychological domains were entered as independent vari-
ables. The total model was significant, F11,136 ¼ 3.30, P < .01,
R2 ¼ .21. The squared semipartial correlations, which indicate
the amount of unique variance attributable to the individual
predictors in the model, indicated that Logical Memory II was
the only uniquely significant predictor of MMSE score
(sr2 ¼ .03). In contrast, when using neuropsychological tests
as the dependent variable, the MMSE score predicted approx-
imately 8.6% of the variance in the Logical Memory II subtest
scores (F1,178 ¼ 17.87, P < .01, R2 ¼ .09), supporting the strong
relationship between MMSE and memory performance. Inter-
estingly, despite critiques of the MMSE as being insensitive to
deficits in executive functioning, the MMSE was best as pre-
dicting scores on the TMT-B (F1,182 ¼ 37.38, P < .01, R2 ¼ .17)
and the Stroop Color–Word test (F1,173 ¼ 27.90, P < .01, R2 ¼ .13).
Discussion
Several prior studies have suggested that in early dementia, a
cut score of 24 of 30 on the MMSE is likely too low.9,30 For
example, Benedict and Brandt31 found that over half of indi-
viduals with amnesia scored above 24 on the MMSE, and
Galasko and colleagues32 found that 24 of 74 individuals with
probable Alzheimer disease (AD) scored above the typical cut
score of 24. It has even been shown that in some cases of
probable AD, individuals have been able to score perfectly
on the MMSE.33 These studies highlight the concerns about
using the MMSE as the sole representation of cognition in
patients with known diagnoses or medical problems. Addition-
ally, reviews of what other factors (other than MMSE score)
should be incorporating into a diagnosis of AD or MCI have
varied. Relevant factors include patient history, objective test
Votruba et al
performance, and longitudinal assessment of functional abil-
ities. Unfortunately, such longitudinal assessment is not always
possible early in the disease course as many people experience
cognitive difficulties for several years before seeking assis-
tance. Little research has investigated the very common (and
often recommended) use of the MMSE in healthy older adults
in the community who are coming in for routine medical check-
ups before presenting with cognitive complaints. Such routine
assessment could promote earlier and comprehensive neurop-
sychological assessments in patients identified as at risk for
cognitive impairment and subsequently result in improved
knowledge regarding characterization of specific cognitive
phenotypes, biomarker associations, stability of diagnoses,
and prediction of progression, as proposed by Bondi and
colleagues.34
The findings of the current study clearly indicate that cog-
nitive impairment often exists, even in healthy elderly individ-
uals who perform well on the MMSE. Much of our sample of
individuals who received ‘‘passing’’ scores on the MMSE
showed substantial deficits in attention, processing speed, men-
tal flexibility, and concept formation upon more thorough neu-
ropsychological testing. These findings make clear that a score
of 24 or above on the MMSE does not assure the lack of
cognitive impairment and concurs with prior research claiming
that the MMSE may not be as accurate in identifying cognitive
impairment in domains such as attention and executive func-
tioning.14,15 Interestingly, however, when we analyzed the clin-
ical domains that predict poor performance on the MMSE, tests
of cognitive flexibility and response inhibition predicted the
most unique variance in the overall MMSE score, even more
than memory. These results suggest that although the MMSE
may lack specific items sensitive to executive functioning, the
overall score is often impacted substantially by deficits in these
skills.
Although Axelrod35 has described normal variation in neu-
ropsychological performance across multiple domains, in
which most normal participants have 1 domain below 1 SD
from the mean, the findings reported in this study suggest that
in healthy elderly individuals, the frequency of scores substan-
tially below expectation given an adequate MMSE score was
much higher. In fact, in our sample, the typical participant
scored below 1 SD in 3 of the 10 domains that were assessed
and over 21% of the participants scored below 1 SD in 5
domains or more. More strikingly, with stricter criteria, almost
40% of the population scored below 1.5 SDs below the norm in
2 domains or more and 20% of the population scored below 2.0
SDs (which would be classified in the severely impaired range)
in at least 2 domains. Therefore, these data show that it is
critical for the primary care provider to understand that an
MMSE score above 23 does not guarantee intact cognition and
reinforces the holistic diagnostic process that incorporates
patient history and reported functioning abilities.
The findings of this article, suggesting that a substantial
proportion of individuals demonstrate values below norm-
based expectations, have relevance to the clinical/neuropsy-
chological evaluation of both patients with MCI and AD. For
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5
example, new, recently published clinical criteria for MCI rec-
ommend that an MCI diagnosis be considered if performances
on cognitive tests are approximately 1 to 1.5 SDs below expec-
tation,36 and consideration of AD is recommended if such
impairment is noted in 2 or more cognitive domains on testing
and there is evidence of impairment in functional activities.37
Our results suggest that this level of impairment often exists
even in healthy elderly individuals with normal MMSE scores.
Although our population was admittedly predominantly
women and perhaps slightly more educated than the elderly
general population, possibly limiting the generalizability, our
findings support the prior observation that almost half of
healthy individuals with only subjective cognitive complaints
(but no functional impairment) have objective cognitive
impairment upon formal neuropsychological testing.38 Partici-
pants in our study showed objective cognitive impairment even
without any subjective cognitive complaints. Relying solely on
an MMSE score may lead one to be particularly prone to mis-
identifying patients with MCI, which is important in terms of
treatment implications, predictions of future trajectory of
symptoms, and appropriate identification for research studies.
What appears critical to understand in the case of individual
patients seen clinically is whether objective cognitive impair-
ments represent a change in functioning from some previously
higher level and whether they interfere with everyday activi-
ties. Therefore, in a clinical setting, it may be particularly
important to have observer- or family-based evaluations of
functional status.
These findings have implications for both clinicians and
researchers. Clinically, although we cannot always be certain
of the functional manifestations of scoring below the norm on a
cognitive test and this study did not link cognitive performance
with functional abilities, we must be alert to the potentially
important deficits that may be present in attention and execu-
tive functioning in individuals with a normal MMSE score, as
the dangers associated with deficits in these areas can be sig-
nificant (poor decision making and inability to respond appro-
priately to novel situations). Executive functioning skills
appear to nonspecifically impact overall MMSE score, as mea-
sures of cognitive flexibility and response inhibition were the
most predictive of MMSE scores in this population.
Further, researchers must be mindful that creating a distinc-
tion in research studies based on a cutoff score of 24 on the
MMSE is a fairly arbitrary and perhaps inappropriate distinc-
tion, as it doesn’t guarantee a lack of cognitive impairment
when including groups of community-based, healthy individu-
als. Research findings could easily be improperly influenced by
inappropriate participant selection and categorization based on
these standards. Continued research investigating the demo-
graphic and personal characteristics that influence MMSE
scores and the associated cutoff scores that may indicate
dementia or MCI is warranted. Also, similar studies following
healthy elderly participants’ longitudinal cognitive status may
yield further information about the utility of various aspects of
the MMSE that may predict future preservation or decline in
cognitive abilities.
6 Journal of Geriatric Psychiatry and Neurology
Acknowledgments
The authors thank the Human Subjects cores of the University of
Michigan Claude Pepper Older Adults Independence Center (OAIC),
the Michigan Alzheimer’s Disease Center, and the senior apartment
complexes that assisted with participation.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This
research was supported in part by grant AG10542-0121 from the
National Institute on Aging.
References
1. Anstey KJ, Luszcz MA, Giles LC, Andrews GR. Demographic,
health, cognitive, and sensory variables as predictors of mortality
in very old adults. Psychol Aging. 2001;16(1):3-11.
2. Bosworth HB, Schaie KW, Willis SL. Cognitive and sociodemo-
graphic risk factors for mortality in the Seattle Longitudinal
Study. J Gerontol B Psychol Sci Soc Sci. 1999;54(5):273-282.
3. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a prac-
tical method for grading the cognitive state of patients for the
clinician. J Psychiatr Res. 1975;12(3):189-198.
4. Giordani B, Boivin MJ, Hall AL, et al. The utility and general-
izability of Mini-Mental State Examination scores in Alzheimer’s
disease. Neurology. 1990;40(12):1894-1896.
5. Gauthier S, Panisset M, Nalbantoglu J, Poirier J. Alzheimer’s
disease: current knowledge, management and research. CMAJ.
1997;157(8):1047-1052.
6. Doody RS, Steven JC, Beck C, et al. Practice parameter: manage-
ment of dementia (an evidence-based review). Report of the qual-
ity standards subcommittee of the American Academy of
Neurology. Neurology. 2001;56(9):1154-1166.
7. Nadler JD, Relkin NR, Cohen MS, Hodder RA, Reingold J, Plum
F. Mental status testing in the elderly nursing home population.
J Geriatr Psychiatry Neurol. 1995;8(3):177-183.
8. Pernecczky R, Wagenpfeil S, Komossa K, Grimmer T, Diehl J,
Kurz A. Mapping scores onto stages: mini-mental state examina-
tion and clinical dementia rating. Am J Geriatr Psychiatry. 2006;
14(2):139-144.
9. 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(2):
397-408.
10. Black S, Espino D, Mahurin R, et al. The influence of noncogni-
tive factors on the Mini-Mental State Examination in older
Mexican-Americans: findings from the Hispanic EPESE. J Clin
Epidemiol. 1999;52(11):1095-1102.
11. O’Connor DW, Pollitt PA, Treasure FP, et al. The influence of
education, social class and sex on Mini-Mental State scores. Psy-
chol Med. 1989;19(3):771-776.
Downloaded from jgp.sagepub.com at TEXAS A & M INTL UNIV on February 11, 2016
12. Crum RM, Anthony JC, Bassett SS, et al. Population-based norms
for the Mini-Mental State Examination by age and education
level. JAMA. 1993;269(18):2386-2391.
13. Lampley-Dallas VT. Neuropsychological screening tests in Afri-
can Americans. J Natl Med Assoc. 2001;93(9):323-328.
14. Franklin GM, Heaton RK, Nelson CM, et al. Correlation of neu-
ropsychological and MRI findings in chronic/progressive multi-
ple sclerosis. Neurology. 1988;38(12):1826-1829.
15. Dilley JW, Boccellari A, Davis A. The use of the Mini-Mental
State Exam as a cognitive screen in patients with AIDS. Abstracts
of the Fifth International Conference on AIDS; Montreal, Canada;
1989.
16. Kim SYH, Caine ED. Utility and limits of the Mini Mental State
Examination in evaluating consent capacity in Alzheimer’s dis-
ease. Psychiatr Serv. 2002;53(10):1322-1324.
17. Diniz BSO, Yassuda MS, Nunes PV, Radanovic M, Forlenza OV.
Mini-mental state examination performance in mild cognitive
impairment subtypes. Int Psychogeriatr. 2007;19(4):647-656.
18. Sternberg B, Bieliauskas L. Introduction to the special edition:
IQ-based MOANS norms for multiple neuropsychological instru-
ments. Clin Neuropsychol. 2005;19(3-4):277-279.
19. Taylor AE, Saint-Cyr JA, Lang AE. Frontal lobe dysfunction in
Parkinson’s disease: the cortical focus of neostriatal flow. Brain.
1986;109(pt 5):845-883.
20. Rhodes MG.Age-related differences in performance on the Wis-
consin Card Sorting Test: a meta-analytic review. Psychol Aging.
2004;19(3):482-494.
21. Wechsler D. Wechsler Adult Intelligence Scale–Revised. San
Antonio, TX: The Psychological Corporation; 1981.
22. Golden CJ. Stroop Color and Word Test. Wood Dale, IL: Stoelt-
ing Company; 1978.
23. Greenberg LM. T.O.V.A. Manual. Los Alamitos, CA: Universal
Attention Disorders, Inc; 1993.
24. Wechsler D. Wechsler Memory Scale. 3rd ed. New York, NY:
Psychological Corporation; 1997.
25. Kaplan E, Goodglass H, Weintraub S. The Boston Naming Test.
Philadelphia, PA: Lea & Febiger; 1978.
26. Reitan RM, Wolfson D. The Halstead-Reitan Neuropsychological
Test Battery. Tucson, AZ: Neuropsychology Press; 1985.
27. Heaton RK. The Wisconsin Card Sorting Test Manual. Odessa,
FL: Psychological Assessment Resources; 1981.
28. Heaton RK, Grant I, Matthews CM. Comprehensive Norms for an
Expanded Halstead-Reitan Battery: Demographic Corrections,
Research Findings, and Research Applications. Odessa, FL: Psy-
chological Assessment Resources, Inc; 1991.
29. Heaton RK, Miller SW, Taylor MJ, Grant I. Revised Comprehen-
sive Norms for an Expanded Halstead-Reitan Battery: Demogra-
phically Adjusted Neuropsychological Norms for African
American and Caucasian Adults. Odessa, FL: Psychological
Assessment Resources, Inc; 2004.
30. Jackson JE, Ramsdell JW. Use of the Mini-Mental State Exam-
ination (MMSE) to screen for dementia in elderly outpatients.
J Am Geriatr Soc. 1988;36(7):662.
31. Benedict RHB, Brandt J. Limitation of the Mini-Mental State
Examination for the detection of amnesia. J Geriatr Psychiatry
Neurol. 1992;5(4):233-237.
Votruba et al
32. Galasko D, Klauber MR, Hofstetter R, Salmon DP, Lasker B,
Thal LJ. The Mini-Mental State Examination in the early
diagnosis of Alzheimer’s disease. Arch Neurol. 1990;47(1):
49-52.
33. Shiroky JS, Schipper HM, Bergman H, Chertkow H. Can you
have dementia with an MMSE score of 30? Am J Alzheimers Dis
Other Demen. 2007;22(5):406-415.
34. Bondi MW, Edmonds EC, Jak AJ, et al. Neuropsychological cri-
teria for mild cognitive impairment improves diagnostic precision,
biomarker associations, and progression rates. J Alzheimers Dis.
2014;42(1):275-289.
35. Axelrod B. Practical Issues in Clinical Neuropsychological
Assessment. Presented at: 2nd Annual American Academy of
Clinical Neuropsychology; Minneapolis, MN; February 2004.
Downloaded from jgp.sagepub.com at TEXAS A & M INTL UNIV on February 11, 2016
7
36. Albert MS, DeKosky ST, Dickson D, et al. The diagnosis of mild
cognitive impairment due to Alzheimer’s disease: recommenda-
tions from the National Institute on Aging—Alzheimer’s Associ-
ation workgroups on diagnostic guidelines for Alzheimer’s
disease. Alzheimers Dement. 2011;7(3):270-279.
37. McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of
dementia due to Alzheimer’s disease: recommendations from the
National Institute on Aging—Alzheimer’s Association work-
groups on diagnostic guidelines for Alzheimer’s disease. Alzhei-
mers Dement. 2011;7(3):263-269.
38. Gallassi R, Bisulli A, Oppi F, Poda R, Di Felice C. Subjective
cognitive complaints, neuropsychological performance, affective
and behavioral symptoms in non-demented patients. Int J Geriatr
Psychiatry. 2007;23(1):95-101.