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Copyright0 1988Pergamon Press plc

J Clin Epidemiol Vol. 41, No. 10, pp. 971-978, 1988


Printed in GreatBritain.All rightsreserved

A CHINESE VERSION OF THE MINI-MENTAL STATE


EXAMINATION; IMPACT OF ILLITERACY IN A
SHANGHAI DEMENTIA SURVEY
ROBERT KATZMAN,~*

MINCYUAN

ZHANG, OUANG-YA-Qu,

WILLIAM T. LIU, ELENA Yu,*

ZHENGYU WANG,

SIN-CHI WONG, DAVID P. SALMONS

and IGOR GRANT


Shanghai Mental Health Centre, Shanghai, China, 2Pacific/Asian-American Mental Health
Research Center, University of Illinois, Chicago, IL 60607 and 3Alzheimer Disease Research
Center, University of California, San Diego, La Jolla, CA 92093, U.S.A.
(Received in revised form 24 May 1988)

Abstract-A
dementia screening survey was carried out in Shanghai using a culturally adapted
Chinese version of the Mini-Mental State Examination. A probability sample of 5055 communitydwelling elderly in Shanghai was surveyed, 1497 aged 55-64, 2187 aged 6574, and 1371 aged 75
and over. In the 73.3% of the subjects who had gone to school, using the age and education
adjustments suggested by Kittner et al. (1986), [Kittner ef al. J Chron Dis 39: 163-170; 19861
suitable cutoff scores could readily be selected to identify the subjects who should be examined
intensively for the presence of dementia. However, in the 26.7% who had not gone to school, there
was a significant increase in low scores on the mental status test as well as a different error pattern,
reflecting the lack of formal education. Methods for following cognitive changes in illiterate
individuals need further development.

MMSE

Mini-Mental State Exam

Dementia

INTRODUCTION

We report the findings of a dementia screening


survey of a probability
sample of 5055
community-dwelling persons 55 years and older
living in Shanghai. The lack of any formal
education and the subsequent illiteracy in more
than one-fourth of this sample has affected the
response pattern to certain items in the screening instrument and raised questions about the
use of a standard cutoff point as a criterion
for dementia across cultures. Kittner et al. [l]
recently discussed the issue of education adjustment in screening for dementia. As these
authors noted, dementia surveys are usually
carried out in two steps: the first step employs
screening test(s) to identify persons whose level
of congnitive function is sufficiently low; the
*Reprint requests should be addressed to: Robert
Katzman, M.D., Department of Neurosciences, M-024,
University of California. San Diego, La Jolla, CA
92093, U.S.A.

Illiteracy

Cross-cultural

Survey

second requires trained clinicians to conduct


intensive clinical evaluations on those who fail
the screening. If education significantly affects
the score on the initial screening test, it becomes
likely that highly educated individuals with
early dementia may be missed because of the
high rate of false negatives. Conversely, poorly
educated individuals without evidence of the
change in cognition required for the diagnosis of
dementia will be oversampled in the selection of
subjects for intensive clinical investigation,
thereby increasing the cost of the second-stage
evaluation process.
In the Shanghai Epidemiologic Survey of
Dementia, we went beyond the usual process of
instrument translation and adapted the MiniMental State Examination (MMSE; developed
by Folstein et al. [2]) to the Chinese cultural
context. Despite the cultural adaptation, certain
items in the MMSE remained highly sensitive to
education. The lack of schooling in 26.6% of
the sample resulted in the inability of many to
971

ROBERT
KATZMAN
et al.

912

read and do the test phrase, Close your


eyes,- a task usually carried out without
difficulty, even by quite impaired dementia patients in the United States. Preliminary analyses
also indicate that, due to the lack of formal
schooling, many respondents had had little or
no experience in using a pen or in drawing. As
a result, their performance on an item often
considered to be culture-free (namely, copy two
intersecting pentagons), was affected.
To determine the optimum criteria for selection of subjects for intensive clinical evaluation
of dementia, we compared the established criteria commonly used in the United States for
this type of study with those obtained by using
the nonparametric method suggested by Kittner
et al. [l] to adjust for the confounding of age
and education.
METHODS

The survey

This epidemiological survey of Alzheimers


disease and dementia in the Shanghai elderly
was planned as a two-stage procedure: the first
stage was an initial screening interview of more
than 5000 persons, 55 years and older. The
sample was nearly equally divided into three age
groups: 55-64 yr, 65-74 yr, and 75 yr and older.
The second stage was an intensive clinical diagnostic study of those who show evidence of
congnitive dysfunction on the initial screening.
The survey was conducted in the Jing An District, one of 12 districts in the City of Shanghai.
It had a population of 497,657 at the end of
1985, with about 15,000 persons estimated to
be over age 75 and 6000 persons over age 80.
Jing An was selected as the research site
because of its stable population and preexisting
relationship with the Shanghai Psychiatric
Hospital.
A probability sample of the multifamily
neighborhood groups (called jumin xiaozu)
was drawn by a random sampling procedure
specifically developed for this study by Dr Paul
Levy* [Levy et al., in preparation]. Briefly, all
households within the neighborhood groups
that were drawn into the sample were targeted
for interviews as long as the age-eligibility criterion was fulfilled. The reason for not subsampling within the neighborhood group was to
avoid concern that certain individuals have been
singled out.
*Professor of Biometry and Epidemiology at the University
of Illinois, Chicago.

Based upon population estimates the sampling design allowed for an oversampling of
persons in the higher age group to ensure that
the final sample would contain about equal
numbers of subjects in the three age groups.
The instrument
The survey instrument consisted of 114 questions, in addition to the MMSE items. For
respondents who could not be interviewed reliably due to severe deafness, illness, or symptoms of dementia, a separate Proxy Interview,
of nearly equal length and covering almost the
same set of questions, was made with the
respondents closest caretaker. The portion of
the instrument considered in this paper is
the Chinese Mini-Mental
Status (CMMS)
test which was administered in face-to-face
interviews with the sampled elderly person.
The MMSE was translated into Chinese and
back-translated
by a bi-national team of
psychiatrists and social scientists vu et al., in
preparation].
The process emphasized both
translation accuracy and cultural propriety of
the wording of the questions. Most of the items
on the MMSE could be directly translated and
used in Shanghai, China. Items requiring major
adaptations included the repetition phrase, No
ifs, ands, or buts, the phrase, Please close
your eyes, and the writing test, Please write a
sentence. There is no suitable Chinese counterpart for the repetition phrase and the Chinese
phrase forty-four stone lions, an alliteration
in Chinese, was substituted. The phrase, Please
raise your hands, replaced the phrase, Please
close your eyes, which sometimes has a death
connotation in the Chinese culture. For the
writing test, the respondent was asked to Say
a sentence to guard against failure on this item
due to inability to write as a result of lack of
education. The items in the CMMS and the
MMSE are outlined in Table 1.
Pretests
The CMMS was pretested in the Chicago
Chinatown population with a sample size of 159
elderly of both sexes, 55 yr and older, in a
sample of 150 elderly drawn from the HongKou District of Shanghai, and in a clinical
sample of 100 geriatric patients. Forty-five of
these 100 patients have been diagnosed clinically
as being demented and 55 as not demented.
In the Hong-Kou pilot study, a cutoff score
of ~21 on the CMMS was found to have
a sensitivity of 79% and specificity of 74%

Impact
Table

1. Comparison

of Illiteracy

in a Shanghai

of Mini-Mental

Status:
Percentage

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

What is year, etc. (5 parts)


Where are we, etc. (5 parts)
Registration:
rose, ball, key
Serial sevens (5)
Recall: rose, ball, key
Name: pencil, watch
Repeat phrase
Three-step command
(fold paper)
Close your eyes (raise your hand)
Write or say a sentence
11. Copy intersecting pentagons

Dementia
subjects

Survey

973

with scores less than

of possible

correct

21

answersa

UCSD: MMSE
(N = 97)

Shanghai: CMMS
(N = 75)

22
39
77
46
30
77
54
69
68
64
36

62
78
56
15
24
95
52
43
9
53
11

X2.h

28.07*
24.97d
8.80
19.50d
0.72
9.7lC
0.05
I 2.08d
59.96
1.95
14.70d

Percentage of possible correct answers for each item or group of items: calculated from: correct
scores X number of respondents/maximum
score X number of respondents.
Comparison
is
between UCSD Alzheimer Research Center and first portion of Shanghai Survey.
%mificant
differences between USCD and Shanghai scores were found using chi-square (1 df)
analysis, as indicated below.
p < 0.005.
p < 0.001.

in differentiating patients clinically diagnosed


method of Kittner et al. [1] in which education
as demented from those clinically diagnosed as standardization is achieved by ranking scores
nondemented.
according to education stratum and ageThe interviewers were recruited from the pool adjusted by application of a weighting method.
of psychiatrists and nurses working at the
Shanghai Institute of Mental Health and the
RESULTS
Shanghai Psychiatric Hospital. A lo-day training session which included videotapes of indiOf 5055 persons 55 yr and older who were
vidual interviews and practice live interviews
given the CMMS, information on education
was carried out with Chinese-speaking U.S. was available for 5030 subjects. Of these, some
members of the collaborative research team
1350 (or 26.7%) had not gone to school (NO
(W. T. L. and E. Y.) serving as a training faculty.
ED), 1853 (36.65%) had informal literacy trainThe intensive clinical evaluation was piloted
ing (Si-Shu) or elementary education (ELEM),
on 190 subjects as will be described in the and 1827 (36.15%) had middle school or higher
education (MIDDL.E+). Overall, 56.28% were
Results. This evaluation included additional
history designed to date changes in specific women (Table 2). Table 3 shows grouped
cognitive functions, the Pfeffer functional ques- CMMS scores by age and education group.
Figure 1 shows the mean CMMS scores by age,
tionnaire [3], a repeat CMMS, a Chinese version
education and sex. The lower CMMS scores in
of the Blessed et al. [4] InformationMemory-Concentration
test, and a Chinese the noneducated, especially in the noneducated
translation of the Hasegawa mental status females, are evident.
If one used the cutoff score ~21 on the
questionnaire [5]. Psychometric tests included
Chinese versions of the Fuld Object Memory
CMMS as obtained in the Hong-Kou pilot data,
Test [6]; block design (WISC-R); draw a clock; it is apparent that there are marked differences
Digit Span (WAIS-R); Digit Symbol (WAIS-R);
between the age groups in terms of the proporTrail Making Test (part A); category fluency [7]; tion of the subjects scoring 20 or less. Only
and an abbreviation of the Boston Naming Test 2.00% of those less than 64yr old had such
[8]. A clinical diagnosis of dementia or probable
scores, whereas 19.91% of those over 75 yr old
dementia was made on the basis of these did. These differences could be attributed to the
findings and verbal discussion with the inter- known increase in prevalence of dementia with
viewer by two of us (M.Z. and W.Q.).
increasing age. However, a similar result was
Standard descriptive statistics were used. Sen- obtained if education was used to group subsitivity and specificity were calculated according
jects: 19.33% of those without education but
to Fletcher et al. [9]. Age and education adjust- only 1.26% of those with middle school or
ment were carried out using the nonparametric
higher scored 20 or less on the CMMS. Further

ROBERTKATZMANet al.

914

Table 2. Distribution of subjects by age, sex, and education


Age (yr)
55-64
Education

65-74

75+

Total

Male

Female

Male

Female

Male

Female

Male

Female

NO ED
ELEM
MIDDLE
Dont know

26
189
419
0

210
360
292
1

91
397
504
1

488
431
263
6

113
234
232
4

422
236
117
13

230
820
1155
5

1120
1033
672
20

Total N

634

863

993

1194

583

788

2210

2845

evidence that education


directly impacted
the score was obtained from an analysis of
individual test items. Table 1 compares the
item-by-item performance by the first 75 Shanghai subjects with a CMMS score ~21 with
those made by 97 subjects in the UCSD Alzheimer Disease Research Center, using the same
MMSE cutoff score. Two-thirds of the 97 San
Diego subjects have Alzheimers Disease. Multiinfarct dementia was the second most common
diagnosis. It is evident from Table 1 that the
pattern of correct answers is very different in
Shanghai and San Diego. Shanghai subjects had
better scores on the time and place orientation
questions and naming, items that account for 12
points on this test. Shanghai subjects had
significantly poorer scores on reading a phrase
(Close your eyes/Raise you hand), on drawing
overlapping pentagons, and on serial sevens,
items that acount for 12 points on the test.
These patterns suggested that illiteracy had a
marked effect upon the Shanghai results. If the
inability to read the test phrase is taken as a
measure of illiteracy, then 91.7% of the NO ED
subjects were illiterate.
In considering various graphical presen-

tations of the data, we have found it most useful


to plot the number of subjects obtaining individual CMMS scores separately for each of the
three education groups and three age groups
(Fig. 2). These data show a complex relationship
of age and education. On inspection (Fig. 2), it
is apparent that in the MIDDLE + group, over
half of the subjects under 75 yr of age had a
perfect score of 30 or a score of 29 on the
CMMS. The curve is a steeply declining exponential. In the group 75 yr and older, the
largest number had scores of 30, but the slope
of the decline of the curve is much less than in
the younger age groups. Respondents with
scores less than 25 appear to be appropriate
subjects for clinical evaluation of possible dementia. Indeed this fits exactly the experience in
the U.S. where a cutoff of ~25 on the MMSE
is often used as the limit of normal for elderly
high school graduates. In contrast, in the NO
ED group, the distribution of scores is very
different from that of the MIDDLE+
group.
There were only a few respondents who scored
30 and the peak of the frequency curve is at
24 for the 55- to 64-yr age group, at 22 for the
65- to 74-yr group, and at 21 for the oldest

a1
0

-0-M

NOED

ELEM

MIDDLE+

NOED

ELEM

MIDDLE+

NOED

ELEM

MIDDLE+

Fig. 1. Mean CMMS scores as function of age groups (A, 55-64 yr; B, 65-74 yr; C, 75+ yr), education
(NO ED, no education; ELEM, informal literacy training or elementary education; and MIDDLE+,
middle school or higher education), and sex (0, male; 0, female).

Impact

of Illiteracy

in a Shanghai

Dementia

Survey

975

19

NOED
5o-

Fig. 2. The frequency distribution of CMMS scores is shown


stratified according
to education
(NO ED, no education;
ELEM, informal literacy training or elementary education;
and MIDDLE+,
middle school or higher education) and
age (0, 55-64 yr; A, 65-74 yr; and ??
, 75 yr and older).

o-000

group, 75 yr or older. Among those with elementary education, the curves were intermediate between the MIDDLE+ and NO ED
groups. Cutoff points based upon change in
slope of the frequency distribution is the same
in both the ELEM and MIDDLE+ group at a
score of <21.
An alternate method of viewing the data is
shown in Fig. 3, in which the data are plotted
according to age-adjusted education groups
using the nonparametric
weighting method
demonstrated by Kittner et al. [l]. This adjustment had little effect on the distribution curves
of the ELEM or MIDDLE+ respondents, but
the age adjustment did displace the curve for the
NO ED group. Again, there are apparent cutoff
values at < 25 for the MIDDLE + and at < 21
for the ELEM and NO ED groups.
However, the use of these cutoff values as the
basis of selection of subjects for intensive evaluation would result in very different proportions
of the three educational groups. The cutoff of
~21 includes 19.3% of the NO ED cohort but

ROBERTKATZMAN et al.

NOED

ELEM

MlDDLEI

Fig. 3. Cumulative CMMS scores are plotted according to


age-adjusted education groups using the nonparametric
weighting method demonstrated by Kittner et al. [I]. 0, NO
ED: 0, ELEM: and ??
, MIDDLE+.

only 6.0% of the ELEM cohort. The cutoff of


~25 includes 6.4% of the MIDDLE+ cohort.
To be able to determine whether these or
other cutoff values provided the sensitivity and
specificity needed to select individuals for more
intensive clinical evaluations, we carried out a
clinical and neuropsychological examination of
a sample of 190 individuals to obtain diagnoses
with which to compare the CMMS scores, The
190 individuals included 92 persons with
CMMS scores of 20 or lower, and 98 persons
with CMMS scores of 21 or higher. The sample
was further stratified to include suitable numbers with different CMMS scores, ages, and
education. We first used the CMMS score of 21
or higher as normal. We found that among
those with lower scores, 35 of 92 persons were
considered to be nondemented clinically, 20
probably demented, and 37 definitely demented.
Among the 98 with scores of 21 or better, 81
were clinically nondemented, 14 probably demented, and 3 definitely demented. Better separation was obtained if separate scores for the
three education groups were used (Table 4). For

Table 4. Cumulative frequency distribution of CMMS scores by education and


clinical diagnosis (N = 190)
ELEM

NO ED
CMMS

Score
0

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
21
28
29
30

NONDEM
0
0
0

0
0
0
0
1
1

1
2
2
2
3
4
4
7
9
13
17
20
29
42
47
55
58
63
66
67
67
67

Note: NONDEM,

DEM

NONDEM

0
I
1

0
0
0

2
2
3
5
7
9
13
16
23
26
30
34
37
42
45
48
48
52
56
58
58
61
61
61
61
61
61

0
0
0
0
0
0
0
1
2
2
2
3
6
9
10
10
10
11
12
14
22
26
29
32
34
38
39

nondemented:

DEM,

MIDDLE+
DEM

1
1
1
1

1
1
1

I
I
1
2
2
2
2
4
5
5
6
7
9
9
IO
10
10
10
11
11
12
12
12
12
demented.

NONDEM
0

0
0
0
0

DEM
0
0
0
1

0
0
0
0
0
0
0
0

1
1
1
1

I
I
1
2

2
2
2
2
2
2
2
2
2
2
3
4
5
6
7

:
2
2
3
3
3
3
4
4
4
4
4
4
4
4
4

Impact of Illiteracy in a Shanghai Dementia Survey

977

Table 5. Specificity and sensitivity (%) for various CMMS scores


of each education group
NO ED
CMMS Scores SPEC
16
17
18
19
20
21
22
23
24
25
26

89.6
86.6
80.6
74.6
70.1
56.7
37.3
29.9
17.9
13.4
6.0

ELEM

MIDDLE+

SEN

SPEC

SEN

SPEC

SEN

60.7
68.9
73.8
78.7
78.7
85.2
91.8
95.1
95.1
100.0
100.0

84.6
76.9
74.4
74.4
74.4
71.8
69.2
64.1
43.6
33.3
25.6

41.7
50.0
58.3
75.0
75.0
83.3
83.3
83.3
83.3
83.3
91.7

71.4
71.4
71.4
71.4
71.4
71.4
71.4
71.4
71.4
71.4
57.1

50.0
50.0
75.0
75.0
75.0
75.0
100.0
100.0
100.0
100.0
100.0

Note: SEN, sensitivity; SPEC, specificity.

those with MIDDLE+


education, a cutoff of
~24 provided 100% sensitivity (probable plus
definite dementia)
and 71.4% specificity
(Table 5). For the ELEM group, a score of < 21
resulted in a sensitivity of 75% (probable plus
definite dementia) and a specificity of 74.4%.
For the NO ED group, a cutoff of < 18 provided a sensitivity of 68.9% and a specificity of
86.6%.
In the absence of a truly satisfactory way of
usng the CMMS scores to select subjects from
among the NO ED group for our intensive
clinical evaluation, we have adopted the following strategy (developed by M.Z. and RX.): an
evaluation
will be carried
out of the
MIDDLE+
respondents with CMMS scores
less than 25, ELEM respondents with CMMS
scores less than 21, and NO ED respondents
with CMMS scores less than 18 and an additional probability sample of 200 subjects from
among the ELEM group with scores between 21
and 24, and the NO ED group with scores
between 18 and 24. As a result, we should be
able to determine the accuracy of the agespecific prevalence of dementia in both the
MIDDLE+ and ELEM age groups and obtain
a close approximation in the NO ED group.
DISCUSSION

It is impressive how well the CMMS, a relatively direct translation of the MMSE with
important modification of only a few items, has
worked as a survey tool in the majority of
respondents in the Shanghai survey despite
significant language and cultural differences.
Very simple education adjustments have permitted us to identify cutoff points that will be used
in the 74% of the cohort who had any formal

education to select individuals with cognitive


impairment for subsequent intensive clinical
evaluation. The determination of the prevalence
of dementia and the most common dementing
disorders in the educated 74% of the population
should be straightforward.
The situation is very different, however, in
regard to the 26% of the population that did not
have the opportunity to go to school when
young. Ninety percent of this group of elderly
uneducated individuals has remained illiterate
despite a serious attempt by the government to
educate them during the 1950s. The lower
CMMS scores among the uneducated women
than among the men may reflect their greater
isolation. An additional factor that may play an
important role in lowering CMMS scores
among the noneducated is mental retardation. It
is possible that retarded individuals were not
accepted into schools in China in the first
decades of this century. Hence some of the
noneducated may not simply be illiterate-they
may also be retarded.
Dementia is perhaps the best example of an
age-related disorder of the brain. The slope of
incidence or prevalence curves as a function of
age is very steep; in some studies prevalence
increases from a few percent in the early sixties
to 15-20% at age 80-85; annual incidence increases from 1 per 1000 at ages 60-65 to 3 per
100 at ages 80-85. These figures reflect the fact
that the two most common disorders that produce dementia, Alzheimers disease and cerebral
vascular disease (multi-infarct dementia), are
both age-dependent disorders. And our data
clearly show marked age effect in regard
to performance on the CMMS. But there is
little clear evidence as to whether education
itself affects the occurrence of dementia. When

978

ROBERTKATZMANet

uneducated individuals score low on a mental


status test, the intial assumption is that the
test was not properly designed for these
respondents.
Our experience indicates that the effect of age
and education upon the interpretation of a
survey instrument can be effctively dealt with in
those who have received any formal education,
either by stratification of the results as in Fig. 1
or by applying the method of Kittner et al. [l]
as in Fig. 2. Neither method has proven particularly useful in those without any formal education. Ideally one would need to develop new
survey instruments specifically designed for this
group. But to do so we would have to understand how dementia is expressed in the illiterate
or retarded. Present mental status examinations
[lo] are based upon the work, carried out over
decades, of a few devoted psychiatrists who
sought a method of distinguishing between organic and functional disorders; their success
is further demonstrated in this study by the
applicability of the mental status examination to
the Shanghai elderly. But the patients of these
early investigators were predominantly
educated individuals. We do not know in a detailed
way how dementia presents or how k should be
tested in the illiterate.

al.

REFERENCES
I.

2.

3.

4.

5.

6.
7.

8.
9.

10.

Kittner SJ, White LR, Farmer ME et al. Methodological issues in screening for dementia: The problem of education adjustment. J Chron Dis 1986; 39:
163-170.
Folstein MF, Folstein SE, McHugh PR. Mini-mental
state: A practical method for grading the cognitive
state of patients for the clinician. J Psycbiatr Res 1975;
12: 189-198.
Pfeffer RI, Kurosaki TT, Harrah Jr CH et al. Measurement of functional activities in older adults in the
community. J Gerontol 1982; 37: 323-329.
Blessed G, Tomlinson BE, Roth M. The association
between quantitative measures of dementia and of
senile change in the cerebral gray matter of elderly
subjects. Br J Psychiat 1968; 114: 797-811.
Hasegawa K, Inoue K, Moriya K. An investigation of
dementia rating scale for the elderly. Seishia-igaku
1974: 16: 965-969. fin Jananese).
Fuld PA The Fuld Object Memory Evaluation. Chicago: Stoelting Instrument Co.; 1981.
Butters N, Granholm E, Salmon DP, Grant I, Wolfe
J. Episodic and semantic memory: A comparison of
amnesic and demented patients. J Clin Exp Neuropsycho1 1987; 9: 479497.
Kaplan E, Goodglass H, Weintraub S. The Boston
Naming Test. Philadelphia: Lea & Febiger; 1983.
Fletcher RH, Fletcher SW, Wagner EH. Clinical
Epidemiology: The Essentials, 2nd edn. Baltimore:
Williams & Wilkins; 1988.
Katzman R, Kawas C. The evolution of the diagnosis
of dementia: past, present, and future. In: Poeck K.,
Freund HJ, Eds. Neurology: Clinical Aspects of the
Dementias, Berlin: Springer-Verlag; 1986: 4349.

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