|Year : 2014 | Volume
| Issue : 2 | Page : 90-93
Socioeconomic status has bearing on the Mini Mental State Examination score among Indian Urban elderly
Santosh Kumar1, Sarvada Chandra Tiwari2, Rakesh Kumar Tripthi2, Nisha Mani Pandey2
1 Department of Psychiatry, Nalanda Medical College, Patna, Bihar, India
2 Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||3-Mar-2015|
Dr. Rakesh Kumar Tripthi
Assistant Professor cum Clinical Psychologist, Department of Geriatric Mental Health, King George's Medical University, Lucknow, UP
Source of Support: Indian Council of Medical Research, Conflict of Interest: None
Background: Mini Mental State Examination (MMSE) has been used widely for screening of cognitive disorders. It has been validated and adapted in various languages. Corrections have been proposed to rule out the bias in the scoring of MMSE based on education and age. However association of MMSE scores with socioeconomic status (SES)has not been studied. Aim: This study was aimed at evaluating the association of SES and MMSE. Materials and Methods: SES and the MMSE scores of participants more than 55 years of age were determined by trained social workers and clinical psychologists. The SES was determined by SES scale. Education and age bias was corrected using specific cut-off criteria for education and age bias while applying MMSE. The data thus obtained was analyzed using Epi-Info software to find the differences in MMSE positive (cognitive impairment present for the educational status and age) and MMSE negative (cognitive impairment absent for the educational status and age) individuals across different SES. Results: The study included 2,283 participants of whom 652 (28.6%), 1326 (58.1%) and 305 (13.4%) belonged to lower socio economic status (LSES), middle socio economic status (MSES) and upper socio economic status (USES) respectively. The MMSE scores were also compared across the SES. Persons from MSES had higher cognitive impairment when compared with LSES and USES, respectively. Significant difference was found among the two genders on the MMSE scores (more females had cognitive impairment) in only the LSES and not in USES and MSES. Conclusion: The findings suggest putative relationship between cognitive functioning and SESsocioeconomic status amongst the elderly.
Keywords: Cognitive functioning, elderly, Mini Mental State Examination, socioeconomic status
|How to cite this article:|
Kumar S, Tiwari SC, Tripthi RK, Pandey NM. Socioeconomic status has bearing on the Mini Mental State Examination score among Indian Urban elderly. J Geriatr Ment Health 2014;1:90-3
|How to cite this URL:|
Kumar S, Tiwari SC, Tripthi RK, Pandey NM. Socioeconomic status has bearing on the Mini Mental State Examination score among Indian Urban elderly. J Geriatr Ment Health [serial online] 2014 [cited 2020 Sep 22];1:90-3. Available from: http://www.jgmh.org/text.asp?2014/1/2/90/152428
| Introduction|| |
Research excavating the deeper underpinnings of cognitive impairment is gaining significance worldwide with increasing proportion of aging population. With aging population cognitive impairment has added to significant healthcare and economic burden apart from its social impact. Mini Mental State Examination (MMSE) by Folstein et al.  has been widely acknowledged as preliminary screening tool for both clinical and research purposes for delineating cognitive impairment. It has the ease of application and covers most areas of cognition. The scale has good construct validity. Persons scoring ≤23 are suspected to have cognitive impairment. The scale unfortunately renders poor help in identification of mild cognitive impairment and severe dementia. 
It has been proven that age and education has bearing on MMSE scores.  But, the variations in MMSE scores across different socioeconomic strata have not been tested in Indian settings. A large scale epidemiological study  sponsored by Indian Council of Medical Research (ICMR) was undertaken at two urban wards of Lucknow, the capital of state of Uttar Pradesh for screening the urban elderly for neuro-cognitive impairment employing MMSE.
Aims and objectives
This study aimed at evaluating the association of socioeconomic status (SES) and MMSE scores in subjects aged more than 55 years of age.
| Materials and Methods|| |
The study was an ICMR funded cross sectional survey conducted under aegis of Department of Geriatric Mental Health, King George's Medical University; Lucknow termed "Lucknow Urban Elderly Study". It was conducted in consultation with the government authorities at Musahebganj and Jankipuram, two randomly selected urban wards of Lucknow. The survey was conducted during the period of 2007-2009. After visiting all the houses door to door for identifying the elderly above 55 years of age and obtaining informed consent, SES and the MMSE scores were determined by trained social workers and clinical psychologists, who had fair inter-rater reliability. The SES was determined by SES scale. 
The SES scale assesses seven domains including "house, material possession, education, occupation, monthly income, land, social participation and understanding". Three classes of scores are categorized namely, 0-25.5, 25.6-47.5 and 47.6-70 dividing people into lower socioeconomic status (LSES), middle socioeconomic status (MSES) and upper socioeconomic status (USES) SES, respectively. While applying the MMSE, the education and age bias was corrected using specific cut off criteria for education and age bias.  The data thus obtained were analyzed using Epi Info software to find the differences in MMSE positive (cognitive impairment present for the educational status and age) and MMSE negative (cognitive impairment absent for the educational status and age) individuals across different SES. The study was approved by the ethics committee of the institute.
| Results|| |
The survey identified 1274 and 1188 subjects aged more than 55 years from Musahebganj and Jankipuram wards respectively, totaling to 2,462 elderly individuals. Of them 1,216 and 1,067 from the two wards respectively totaling to 2,283 (92.7%) agreed to participate in the study. When both wards clubbed together, 652 (28.6%), 1326 (58.1%) and 305 (13.4%) subjects were categorized into LSES, MSES and USES respectively. Significant differences in the MMSE status (after Crum's correction) were found across age groups in MSES and LSES [Table 1].
The analysis of the data across age strata as depicted in [Table 1] revealed that significant differences in the MMSE scores (after Crum's correction) was found across the age strata in LSES (χ2 = 11.19, df = 1, P < 0.05) and MSES (χ2 = 26.65, df = 3, P < 0.01) respectively. There were no significant differences in the MMSE status in USES for age.
The MMSE scores were also compared across the SES. The findings are depicted in [Figure 1].
|Figure 1: Gender socioeconomic status and mini mental state examination scores|
Click here to view
Of the total sample, 22 (7.21%), 122 (9.2%) and 37 (5.67%) individuals were MMSE positive (cognitive impairment present for the educational status and age) in the Upper, middle and the LSES respectively, totaling to 181.
When analyzed for MMSE positivity across different SES, the difference was statistically significant. The Chi-square value was 7.691 with degree of freedom 2.
Persons from MSES had higher cognitive impairment when compared to LSES and USES respectively. Significant difference was found across the gender and MMSE status (more females had cognitive impairment) in only the LSES and not in USES and MSES.
| Discussion|| |
Mini Mental State Examination  continues to be the most widely used screening tool for cognitive impairment worldwide. Despite the criticism, revisions and the corrections proposed, it continues to be a routine in psycho-geriatric assessments. It has been standardized in different languages to rule out language and culture bias.  The most significant of these was correction for age and the education by Crum et al.  The age and education bias among the individuals were ruled out by the Crum's criteria in the current study. The higher sample size of the MSES in the sample was probably because of the higher selection by the SES scale. The sample of the population studied in the selected locality may have influenced the constitution of the sample. Probably higher mortality amongst elderly from lower SES may be the reason of the lesser number of individuals selected from the lower SES. These factors may have influenced the nature of the sample in which the number of persons from MSES was highest.
Studies correlating the SES and the cognitive status , have reported that the LSES is associated with lower cognitive functioning. It has been further found that LSES is associated with higher basal levels of the stress hormones cortisol and catecholamines in a graded fashion.  This is contrary to our findings which show that there is highest incidence of cognitive impairment among people from MSES, followed by LSES and USES, respectively.
The difference in the cognitive functioning across two genders was not obvious except in the LSES where the females had higher prevalence of cognitive impairment.
Middle SES is characterized by highest perceived stress.  The persons from the middle SES bear maximum brunt of the economic and societal changes for maintaining their quality of life. They are most prone to slip back to their original low socio economic group.  The stress may have been a factor contributing to the poorer MMSE scoring pattern among persons from MSES. Dietary pattern rich in fats and oils may be implicated in higher incidence of metabolic syndrome  and consequently vascular states leading to higher incidences of cognitive decline among persons from USES. The diet poor in essential nutrients and antioxidants may be implicated in relatively poorer MMSE scores amongst persons from LSES.
The findings are not in concordance with previous findings by Basta et al.  who opined that socio economic deprivation rather than SES predicted poorer cognitive impairment amongst elderly in United Kingdom. But the inferences drawn from the study remain to be tested in larger population base in India. The findings may have implications in future planning and channelization of resources after further observation and analysis.
| Limitations|| |
There was no follow up data collected from these patients. Furthermore going by standards of epidemiological studies the sample size was small. The results can only be generalized after the findings are tested across various cultures and parts of the country with larger sample base.
| Conclusions|| |
Apart from the age and the educational status the SES is another variable which can affect the MMSE scores and the cognitive status among the urban Indian elderlies. The study raises concerns that "Do we need to have correction scores for socioeconomic states also?" Having such understanding for precise evaluation of the cognitive functioning can be crucial to appropriate channelization of the health care resources.
| Acknowledgments|| |
Funds for conducting the survey titled "Lucknow urban elderly study", was received from ICMR (Indian Council of Medical Research). The names of Research staff "Dr. Aditya Kumar, Mrs. Urvashi Rautela, Mr. Rajesh Kumar, Mrs. Reema Sinha, Mrs. Ritu Shukla, Mrs. Sandhya Rani, and Dr. Samridhi Tandon" for their dedicated support in data collection, data compilation and report writing of the Lucknow urban elderly project.
| References|| |
Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.
Lancu I, Olmer A. The minimental state examination - An up-to-date review. Harefuah 2006;145:687-90, 701.
Tiwari SC, Tripathi RK, Kumar A. Applicability of the Mini Mental State Examination (MMSE) and the Hindi Mental State Examination (HMSE) to the urban elderly in India: a pilot study. International Psychogeratrics, 21,1:123-8, 2009; doi:10.1017/S1041610208007916.
Tiwari SC, Kar AM, Singh R, Kohli V K, Agarwal GG. An epidemiological study of prevalence of neuro-psychiatric disorders with special reference to cognitive disorders amongst urban elderly. Report submitted to Indian Council of Medical Research, New Delhi, India 2009.
Tiwari SC, Kumar A, Kumar A. Development & standardization of a scale to measure socio-economic status in urban & rural communities in India. Indian J Med Res 2005;122:309-14.
Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;269:2386-91.
Ganguli M, Ratdiff G, Chandra V, Sharma S, Sharma J, Pandey R. A Hindi version of the MMSE: The development of a cognitive screening instrument for a largely illiterate rural elderly population in India. Int J Geriatr Psychiatry 1995;10:367-77.
Lee S, Kawachi I, Berkman LF, Grodstein F. Education, other socioeconomic indicators, and cognitive function. Am J Epidemiol 2003;157:712-20.
Scazufca M, Almeida OP, Vallada HP, Tasse WA, Menezes PR. Limitations of the Mini-Mental State Examination for screening dementia in a community with low socioeconomic status: Results from the Sao Paulo Ageing & Health Study. Eur Arch Psychiatry Clin Neurosci 2009;259:8-15.
Cohen S, Doyle WJ, Baum A. Socioeconomic status is associated with stress hormones. Psychosom Med 2006;68:414-20.
McBrier DB, Wilson G. Going down? Race and downward occupational mobility for white-collar workers in the 1990s. Work Occup 2004;31:283-322.
Hardaway CR, McLoyd VC. Escaping poverty and securing middle class status: How race and socioeconomic status shape mobility prospects for African Americans during the transition to adulthood. J Youth Adolesc 2009;38:242-56.
Zivkovic AM, German JB, Sanyal AJ. Comparative review of diets for the metabolic syndrome: Implications for nonalcoholic fatty liver disease. Am J Clin Nutr 2007;86:285-300.
Basta NE, Matthews FE, Chatfield MD, Brayne C, MRC-CFAS. Community-level socio-economic status and cognitive and functional impairment in the older population. Eur J Public Health 2008;18:48-54.