Via Research Recognition Day Program VCOM-Carolinas 2025

Clinical Educational Research

MMSE Validity in Subjects of Lower Literacy Dr. Paul K Switzer III, MD DHA, JuliSu DiMucci-Ward, PhD, MPH, RDN, CDCES, LD, William Harmening III OMS-III i

, 1. Edward Via College of Osteopathic Medicine- Carolinas, Spartanburg, SC

Introduction

Results

Discussion

The Mini-Mental State Exam (MMSE) is a brief, neuropsychological screening tool demonstrated to be 87% sensitive and 82% specific in detecting cognitive impairment in general medical inpatients. However, the MMSE is not without limitations. Several factors, such as low education levels, blindness, deafness, and other disabilities, have been shown to significantly affect MMSE scores, limiting its predictive ability. Individuals with an education level below the eighth grade are commonly excluded due to literacy barriers, highlighting the tool’s dependence on reading and writing proficiency. This study investigates the influence of literacy levels on MMSE effectiveness, explores its validation across diverse populations, and evaluates shifts in literacy trends in the 21st century. • Participants: 188 patients admitted to general medical Floor at University of Alabama at Birmingham teaching hospital • Written Informed consent was obtained from each patient • Testing time lasted between 5 to 10 minutes, with 15 minutes being the average total time spent with the patient • Score below 23 is associated with a high likelihood of cognitive impairment, dementia, or delirium • Max score 30 out of 30 Methods

• One third of participants were excluded due to insufficient reading comprehension • Success rate for meaningful participation underscored the importance of aligning assessment tools with literacy levels of target populations • MMSE has been studied in 15 different languages, but gaps remain in addressing lower literacy populations • National Institute of Literacy reported in 2024 21% of adults in US are illiterate, of the 79% that are literate, 54% have a literacy rate at or below a 6 th grade level • While the cut off for the MMSE cognitive impairment remains at ≤ 23, additional strategies to accommodate literacy needs are essential for an accurate assessment • Future research includes, administering the test orally to eliminate barriers to literacy, and changing the literacy requirement of the MMSE to a 6 th grade reading level Conclusions Literacy barriers represent a significant challenge in MMSE administration, emphasizing the need for alternative approaches or modifications to the tool. Expanding the validation of the MMSE for diverse populations and developing low-literacy adaptations will enhance its utility in primary care clinical practice.

Figure 1. MMSE handout .

References

[1]Folstein MF, Folstein SE: "MINI-MENTAL STATE" A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 1975; 12:189-198. [2] Steis, Melinda R, and Robert W Schrauf . “A review of translations and adaptations of the Mini -Mental State Examination in languages other than English and Spanish.” Research in gerontological nursing vol. 2,3 (2009): 214 -24. doi:10.3928/19404921 20090421-06 [3] National Literacy Institute. “Literacy Statistics 2024 - 2025 (Where We Are Now).” National Literacy, 7 Mar. 2024, www.thenationalliteracyinstitute.com/post/literacy-statistics-2024-2025-where-we-are-now. [4] Anthony JC, LeResche L, Niaz U, Von Korff MR, Folstein MF: Limits of the 'Mini-Mental State' as a screening test for dementia and delirium among hospital patients. Psychological Medicine 1982; 12:397-408. A special thanks to a few investigators : Dr. Edward Kern MD, Dr. David Folks MD, Dr. Alwyn Sugarman MD, Dr. Fe’ A. Cardona MD MPH Acknowledgements

Figure 2. Percentage distribution of patients able or unable to take MMSE by sex and age . Of 188 patients who consented to participate, 30 (15.9%) were excluded due to inability to complete the MMSE caused by death or worsening medical conditions. The remaining 158 patients were assessed for literacy, with 55 individuals (34.8%) excluded for failing to meet an eighth-grade literacy threshold. The final study group consisted of 103 participants, with a completion rate of 65.1% (103/158). Cognitive impairment was defined as a score of 23 or lower on the MMSE [1].

2025 Research Recognition Day

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