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Gender differences in the norms of the Minimental State Examination in Arabic

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 &

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Gender differences in the norms of the Minimental State Examination in Arabic

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  1. Gender differences in the norms of the MinimentalState 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

  2. 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.

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

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

  5. 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.

  6. 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.

  7. 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.

  8. Methods – Study procedures • Participants systematically evaluated for: • Cardiovascular risk factors • Questionnaires concerning activities of daily living • Life style • Cognitive function

  9. Methods – Study proceduresClinical 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.

  10. 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

  11. 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

  12. Orientation in time and place Memory Praxis Naming Stimulus selection Abstraction Calculation Attention Left-right orientation Visuo-spatial orientation No items related to reading and writing Methods – Cognitive evaluation BCST

  13. 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.

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

  15. Results • 442 subjects approached • 438 agreed (refusal rate 0.9 %) • Four were excluded: severe systemic non-neurological disease

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

  17. 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) • Males r=0.8223, Females r=0.854, p<0.0001 both

  18. Education levels % within gender p<0.001 Education years

  19. MMSE by gender & education MMSE p<0.05 p<0.0001 Education years

  20. BCST by gender & education BCST p<0.05 p<0.0001 Education years

  21. Occupation categories % within gender p<0.05 Occupation category

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

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

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

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

  26. 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 ?

  27. 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.

  28. Conclusions • Different cut-off scores should be used in different 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.

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

  30. Occupation categories by education levels % within gender Education 0-4 years Education 5-8 years % within gender

  31. Occupation categorieseducation 0-4 years % within gender Occupation category p<0.05

  32. Occupation categorieseducation 5-8 years % within gender Occupation category p<0.05

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