IN ASSESSMENT, ALL SCORES ARE NOT CREATED EQUAL
To the Editor:
An article in the June 2001 issue, "Detection of Depression in the Cognitively Intact Older Adult Protocol" (Vol. 27, No. 6) written by Mary Lynn Scotton Piven and edited by Stacie Salsbury Lyons and Marita G. Tltler, was well done. Busy nursing staff and their patients will benefit from this protocol.
Unfortunately, the published Folstein's Mini-Mental State Examination was not complete (p. 1 1). It missed the "Three Stage Command." This command is worth 3 points. If any readers plan to use this test, the missing points will artificially cause the patient to score a maximum of 27 of what should be a possible score of 30. There is a danger that cognitively well patients may be labeled as demented. I also noticed that the order in which some of the questions are listed had been changed from Folstein's original. This is not as grave an error, but as with any standardized test, the order of questions is important.
Peter Wiebe, RN, GNC(C), BRE
Winkler, MB, Canada
Thank you for alerting the editorial staff and the authors of the omission of the "Three Stage Command" section of the Mini-Mental Status Examination (MMSE) (Folstein, Folstein, & McHugh, 2975) from the protocol published in the June 2001 issue. You are absolutely correct that this omission could cause health care practitioners to inaccurately identify older adults as needing further screening for cognitive impairment. This misidentification could be psychologically and emotionally devastating to the person who has been labeled as possibly having cognitive impairment.
In addition, the financial ramifications of conducting further geropsychiatric assessments of the individuals who -were inaccurately identified as having impaired cognition would be considerable in a society as large the the United States.
The MMSE is a widely used screening tool for the identification impaired cognitive function. The instrument has been translated into 20 languages and is used around the world by both clinicians and researchers. However, no clinical assessment instrument is suitable for all patient populations.
In a populations-based study of more than 18,000 adults age 18 and older, investigators reported that MMSE scores are related to age and education. In this study, the median MMSE scores for persons age 18 to 24 was 29, while the median scores for persons age 80 and older was 25.
Individuals who had completed at least 9 years of schooling had median MMSE scores of 29, those with 5 to 8 years of schooling scored 26, and persons with O to 4 years of schooling scored 22 (Crum, Anthony, Sasseti, & Folstein, 1993).
Further, researchers note that the average MMSE score of older adults diagnosed with dementia is slighter lower in African American and Hispanic American samples as compared with European American samples (Bohnsledt, Fox, & Kohatsu, 1994). Clearly, health care providers must know the demographic and social background of their patients to correctly interpret scores on the MMSE or any clinical assessment tool.
Stacie Salsbnry Lyons, MSN, RN
The University of Iowa Gerontological
Nursing Interventions Research Center
Iowa City, Iowa
Bohnstedt, M., Fox, P.J., & Kohatsu, N.D. (1994). Correlates of Mini-Mental Status Examination scores among elderly demented patients: The influence of race-ethnicity. Journal of CUnical Epidemiology, 47(12), I381-I387.
Crum, R.M., Anthony, J.C., Bassett, S.S., & Folstein, M.F. (1993). Population-based norms for the Mini-Mental State Examination by age and education level. Journal of the American Medical Association, 269(18), 2386-2391.
Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). "Mini-Mental State": A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189-198.