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Ethnic and Educational Differences in Cognitive Test Performance on Mini-Mental State Examination in Asians

From the Gerontological Research Programme (T-PN, MN, P-CC, E-HK), Faculty of Medicine and the Department of Psychological Medicine (T-PN, MN, E-HK), National University of Singapore; and the Institute of Mental Health (P-CC), Ministry of Health, Singapore.

Objective: The objective of this study is to examine ethnic differences in Mini-Mental State Examination (MMSE) test performance in discriminating between demented and nondemented elderly Asians.

Methods: A nationally representative population sample (N = 1,092) of community-living elderly, comprising Chinese, Malays, and Indians in Singapore, was interviewed using MMSE, Geriatric Mental State, and demographic and health questionnaires.

Results: There were significant ethnic differences in mean MMSE scores among Chinese (26.2), Indians (25.0), and Malays (23.6), but only in noneducated subjects. No ethnic differences in MMSE were observed in higher educated subjects. The sample proportion of subjects with dementia was 4.2% in Chinese, 9.4% in Malays, and 8.8% in Indians. Overall, MMSE discriminated well between subjects with and without dementia (cutoff: 23/24, area under the curve: 95%, sensitivity: 97.5%, specificity: 75.6%). MMSE test performance was much better in higher educated subjects (higher specificity: 85.2%). Lower specificities were shown in less educated subjects (57.3%), and in Malays (62.8%), and especially in less educated Malays (35.3%) and Indians (50.0%). Significant differences in MMSE scores in less educated subjects persisted after adjusting for differences in sociodemographic, health, and behavioral variables

Conclusion: Ethnic nonequivalence in MMSE test performance should be taken into account in dementia screening in Asians in less educated subjects. Known correlates of cognitive functioning did not sufficiently explain these differences.

Key Words: Cognitive function • dementia • ethnicity • education • risk factors • screening

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