Professional Documents
Culture Documents
00
Copyright0 1988Pergamon Press plc
MINCYUAN
ZHANG, OUANG-YA-Qu,
ZHENGYU WANG,
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
Dementia
INTRODUCTION
Illiteracy
Cross-cultural
Survey
ROBERT
KATZMAN
et al.
912
The survey
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.
Dementia
subjects
Survey
973
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.
ROBERTKATZMANet al.
914
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
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-
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
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
977
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
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
978
ROBERTKATZMANet
al.
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