The relation of education and gender on the attention items of the Mini-Mental State Examination in Spanish speaking Hispanic elders

The Mini-Mental State Examination (MMSE) [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, 189-198] has frequently been challenged for its bias against individuals with lower levels of education and the use of scoring adjustments for lower educational levels has become standard practice [Ostrosky-Solis, F., Lopez-Arango, G., & Ardila, A. (2000). Sensitivity and specificity of the Mini Mental State Examination in a Spanish-speaking population. Applied Neuropsychology, 7, 25-31]. An additional source of concern is that original instructions specify that the "serial 7's" item may be replaced by an apparently less difficult "backwards spelling" task. This study compared the performance on these items and the effects for total scores on 102 unimpaired and 58 memory impaired elder Hispanic individuals (age 54-98), divided into 3 groups based on educational level (<7, 7-11, and >11 years of education). The effects of education and gender on the total MMSE scores were analyzed using the "serial 7's" and the "backwards spelling" items. For all the studied groups, MMSE scores were higher by an average of 1.5 points when using the "backwards spelling" task. Correlation between "serial 7's" and "backwards spelling" was a modest .37. Education had a significant effect on the MMSE scores in both the impaired and the unimpaired groups. After controlling for education, gender also explains a significant proportion of the variance of the results. The "backwards spelling" and "serial 7's" items do not appear to be either equivalent in difficulty or to test the same abilities in the unimpaired and the impaired Hispanics elders tested in this study.