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

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1 Archives of Clinical Neuropsychology 21 (2006) Abstract The relation of education and gender on the attention items of the Mini-Mental State Examination in Spanish speaking Hispanic elders Mónica Rosselli a,, Ruth Tappen b, Christine Williams c, Judy Salvatierra a a Department of Psychology, Charles E. Schmidt College of Science, Florida Atlantic University, 2912 College Avenue, Davie, FL 33314, United States b Louis and Anne Green Memory and Wellness Center and Christine E. Lynn College of Nursing, Florida Atlantic University, FL, United States c School of Nursing and Health Studies, University of Miami, Miami, FL, United States Accepted 3 August 2006 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, ] 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. Published by Elsevier Ltd on behalf of National Academy of Neuropsychology. Keywords: Mini-Mental Exam; Spanish; Education; Age; Gender; Culture; Cognition The Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) is a simple, brief, 11-item instrument designed to evaluate cognitive function in several domains including orientation, registration, attention, memory, language, and visual construction skills. It is often utilized as a screening instrument to detect dementia and cognitive changes in neurological, psychiatric, and geriatric populations (e.g., George, Landerman, Blazer, & Anthony, 1991; Lezak, Howieson, & Loring, 2004). Corresponding author. Tel.: address: mrossell@fau.edu (M. Rosselli) /$ see front matter. Published by Elsevier Ltd on behalf of National Academy of Neuropsychology. doi: /j.acn

2 678 M. Rosselli et al. / Archives of Clinical Neuropsychology 21 (2006) Scores on the MMSE range from 0 to 30 points with scores below points usually considered impaired (Kay et al., 1985; Mendez & Cummings, 2003). The MMSE is highly sensitive (87%) and specific (82%) in the identification of dementia (Anthony, LeResche, Niaz, vonkorff, & Folstein, 1982; Crum, Anthony, Bassett, & Folstein, 1993). Interrater reliability values of and test retest values of (Anthony, Niaz, LeResche, Bon Kirff, & Folstein, 1982; Dick et al., 1984; Folstein et al., 1975; Molloy, Alemayehu, & Roberts, 1991) suggest that this is an effective instrument, at least for the English speaking populations used in the above studies. However, these sensitivity and specificity indices differ in Spanish speaking individuals with low levels of education (Ostrosky-Solis, Lopez-Arangi & Ardila; Rosselli et al., 2000). A number of studies have demonstrated that education, age, and ethnicity have an effect on scores on the MMSE (Blesa et al., 2001; Fillenbaum, Heyman, Williams, Prosnitz, & Burchett, 1990; George et al., 1991; Launer, Dinkgreve, Jonker, Hooijer, & Lindeboom, 1993; Murden, McRae, Kaner, & Bucknam, 1991; Rosselli et al., 2000). A study of over 18,000 adults in 5 different cities in the U.S. found that both age and educational level influenced scores (Crum et al., 1993). In a longitudinal study that examined healthy community-dwelling elders aged 65 or older, researchers found that declines in scores were more evident for the older participants and for those that were less educated (Jacqmin-Gadda, Fabrigoule, Commenges, & Dartigues, 1997). In a healthy older Hispanic sample, educational level effects were found to be stronger than age effects on the MMSE scores (Ostrosky-Solis et al., 2000). In fact, the performance of participants with no schooling (score = 16.38; S.D. = 4.27) was similar to that of moderately demented patients, while the performance of participants with 1 4 years of education resembled the performance of mildly demented patients (score = 21.59; S.D. = 4.85). Even in a younger sample, educational levels were found to have an effect on MMSE scores (Escobar et al., 1986). The investigators found that items involving reading, writing, and calculation were the most sensitive to educational level. Ostrosky-Solis et al. (2000) also found that the specificity of the MMSE decreased to 50% in participants with an educational level of 0 4 years. This indicates that the MMSE may be of little diagnostic use among individuals with low levels of education. The effect of gender on the MMSE is less frequently mentioned than the education effect but has been addressed by some studies (Jones & Gallo, 2002; Rosselli et al., 2000; Tombaugh, McDowell, Kristjansson, & Hubley, 1996). Results have in some cases been contradictory probably because of differences in culture between studies. For example, Tombaugh et al. (1996) studied the total MMSE scores of a group of Canadian elderly participants with an average of 10 years of education and found that females scored higher than males on the total MMSE score. Rosselli et al. (2000) found no significant differences in the total MMSE scores between elderly Colombian males and females with more than 4 years of education. Rosselli et al. s study found, however, that gender was significant if low educated (i.e. 0 3 years of schooling) males and females were compared. In this case, males outperformed females. Other authors, like Jones and Gallo (2002), reported gender differences in the items of the MMSE with females having more difficulties with the serial 7 s item of the MMSE while males had more problems with the backwards spelling. In addition to the age, education and gender effects over the MMSE scores, a number of studies have found that the MMSE is sensitive to cultural background (Anthony, LeResche et al., 1982; Anthony, Niaz et al., 1982; Escobar et al., 1986). Cultural bias may lead a clinician to mistakenly classify Hispanics as cognitively impaired (Bird, Canini, Stipee, & Shrout, 1987; Escobar et al., 1986). Adjustment to the score in an attempt to eliminate bias is a frequent practice in psychometrics. Blesa et al. (2001) found that in a Spanish population, adjustment of scores for age and educational level increased the specificity of the MMSE without decreasing its sensitivity. Mungas, Marshall, Weldon, Haan, and Reed (1996) showed that adjustment of scores resulted in greater stability of sensitivity and specificity across ethnic groups and educational levels. An alternative approach to compensating for the cultural bias is to modify (Ostrosky-Solis et al., 2000) or delete the item that generates the bias (Anthony, LeResche et al., 1982; Anthony, Niaz et al., 1982). The items on the MMSE vary in difficulty. Using Hispanic and non-hispanic, unimpaired older adults, Marshall, Mungas, Weldon, Reed, and Haan (1997) found that the attention items were among the most difficult items. This may be due to the fact that the skills necessary to perform these items correctly are susceptible to deterioration in normal aging. The attention items consist of either the serial 7 s item, in which the subject is required to perform serial subtraction, or the backwards spelling item, which requires that the subject spell the word WORLD ( MUNDO in Spanish) backward. Attention tasks may be especially helpful when assessing age-related declines in older adults (McDowd & Shaw, 2000); although some researchers have cautioned that the attention item of the MMSE may not yield a reliable measure of change over time (Hopp, Dixon, Grut, & Backman, 1997; Olin & Zelinski, 1991).

3 M. Rosselli et al. / Archives of Clinical Neuropsychology 21 (2006) The attention item represents an important percentage of the MMSE score (5 out of 30 points) so the unreliability of this item may significantly impact the total score. The possible unreliability of the MMSE attention tasks may be caused by the way these items are generally administered. Subjects are usually asked to perform the serial 7 s item. If the subject is unable or refuses to perform the task, the backwards spelling task is administered. Galasko et al. (1990) found that English speaking elderly subjects perform better on the backwards spelling item than the serial 7 s suggesting that the backwards spelling is an easier task. Clinicians, however tend to use the backwards spelling item as an alternative test for serial 7 s with no consideration of the possible differences in the level of difficulty between the two items. Clinically, serial 7 s and backwards spelling tasks do not tap exactly the same cognitive abilities. Serial subtraction items, similar to serial 7 s, are arithmetic tasks frequently included in calculation ability testing (Ardila & Rosselli, 2002). Backwards spelling is a working memory task, requiring the internal manipulation of certain information (the written word). It can be conjectured that, even though both tasks are attention-demanding, they assess different cognitive domains. Equivalence of both tasks in testing for general cognition can be challenged. The purpose of this study was to compare the total scores on the MMSE when using the serial 7 s attention item of the MMSE or the backwards spelling item in Spanish speaking Hispanic elders. Our primary purpose was to examine the influence of education and gender on the Spanish MMSE test performance of cognitively normal and cognitively impaired Hispanic elders. Our hypothesis was that people with low levels of education would score significantly lower in the MMSE if the serial 7 s item was used rather that the backwards spelling. This difference was expected in both the normal sample and in the mildly cognitively impaired sample. A second aim in this study was to analyze the possible interaction of education and gender on the total MMSE scores. Previous research by Ardila, Rosselli, and Rosas (1989), Rosselli et al. (2000), and Rosselli, Ardila, and Rosas (1990) showed that females from very low educational levels score significantly lower than males of the same educational level in diverse cognitive tests. These differences disappear when females and males of high education levels are compared. A third aim of the study was to analyze the correlates of the two attention items with the other items in the MMSE to evaluate whether or not the serial 7 s and the backwards spelling items evaluate the same underlying construct. If both items tap the same cognitive abilities they should correlate with the same items. 1. Method 1.1. Participants Following Institutional Review Board (IRB) approval, participants were recruited from various community sites including independent living and assisted living. Potential participants were recruited at informational sessions held at the housing sites or were referred by housing managers. A family member was contacted to provide consent for those unable to consent. Assent was assessed for impaired individuals by their willingness to participate after a simple explanation. One hundred and two cognitively unimpaired Hispanic elders (30 males and 72 females) and 58 memory impaired adults (18 males and 40 females) were recruited from various community sites for older adults in the South Florida area. Exclusion criteria were: history of neurological or psychiatric disease and alcohol or drug abuse use. All unimpaired subjects had normal scores on the Fuld Object-Memory Evaluation (FOME) (Fuld, 1981). This test has shown to provide sufficient discrimination between normal and impaired Spanish speaking elders (Loewenstein, Duara, Arguelles, & Arguelles, 1995). All unimpaired subjects were functionally normal and were living independently. The impaired sample included elders who had impaired scores on the FOME. Thirty of the impaired participants lived independently and 28 lived in a long-term care facility where some supervision was available. None of the memory impaired sample had a history of cerebrovascular disease, substance abuse, or psychiatric problems. The ages of all participants ranged from 54 to 98 with a mean age of (S.D. = 8.81). Spanish was the primary language of all the participants. Few spoke any English at all. The participants were divided into three groups based on educational level: less than 7 years of education (unimpaired = 35; impaired = 22), between 7 and 11 years of education (unimpaired = 27; impaired = 12), and over 11 years of education (unimpaired = 40; impaired = 24). This classification was used to make the educational groups roughly equivalent to the structure of the educational system that exists in the U.S. Six years or less would correspond to elementary school, from 7 to 11 years would correspond to middle or high school, and 12 years or more would correspond to a high school diploma or higher. No participant was illiterate; the minimum educational level of participants

4 680 M. Rosselli et al. / Archives of Clinical Neuropsychology 21 (2006) Table 1 Characteristics of the sample Education groups (years) F p < >11 Unimpaired Age (7.25) (8.29) (7.74) Gender, M:F 9:26 9:18 12:28.44 a.80 FONE total scores (1.93) (2.81) (3.22) Impaired Age (11.13) (7.28) (9.40) Gender, M:F 7:15 4:8 7:17.07 a.96 FONE total scores (6.86) (5.43) (5.40) a Chi square. was 2 years of school. No age differences across the unimpaired and the impaired subgroups groups were found. The characteristics of the sample are presented in Table 1. One-way ANOVAs demonstrated no significant differences between males and females in the unimpaired group by age, F(1, 101) =.34, p =.55, level of education, F(1, 101) =.05, p =.82, or FOME scores, F(1, 101) =.276, p =.10. The males and females of the impaired group also did not differ in age, F(1, 57) = 1.89, p =.17, level of education, F(1, 57) =.21, p =.64, or FOME scores, F(1, 57) =.15, p = Instrument The Spanish translation of the MMSE developed by Loewenstein, Rubert, Arguelles, and Duara (1995) and previously tested in South Florida was used Procedure Participants were evaluated individually at their place of residence or community center. The MMSE was administered as part of a larger neuropsychological test battery. The serial 7 s item of the attention section was first administered to all participants as part of the MMSE. If the participant received a score of zero or refused to perform that particular item, the backwards spelling item was administered immediately. If the participant received at least one point for the serial 7 s item, then the backwards spelling item was administered at the end of the test. The administration of the serial 7 s item was consistent across subjects but there was a slight variation in the administration of the backwards spelling item. Two total scores were obtained from each participant. One score included only the points obtained on the serial 7 s item, while the other total score included only the points obtained on the backwards spelling item Statistical analysis The following analyses were performed for the impaired and unimpaired samples separately. The performance of the three education groups of participants on the MMSE was analyzed using a 3 2 repeated measures analysis of variance mixed design. The between subjects factor was level of education. The within subjects factor was the attention item ( serial 7 s versus backwards spelling ). A 3 2 analysis of variance between subjects design was performed using gender and education as between subject factors for each of the MMSE total scores. One-way ANOVA was used to compare mean differences between education groups. The effect sizes of the unvariate and multivariate Fs were analyzed using partial eta squares (η 2 ). Regression analyses were performed using education and gender as predictors and the MMSE item scores as dependent measures. In addition, Pearson s correlations between the attention items and all the other MMSE items were carried out to analyze the correlates of the two attention items with the other items in the MMSE. These two latter analyses were performed using the whole sample (impaired and unimpaired together).

5 M. Rosselli et al. / Archives of Clinical Neuropsychology 21 (2006) Table 2 Means and (S.D.) in MMSE serial 7 s and the MMSE backwards spelling by education groups Education groups (years) Education Gender Interaction < >11 F p F p F p Unimpaired MMSE <*, <* Serial 7 s (3.42) (2.39) (2.53) MMSE <*, Backwards spelling (3.68) (1.88) (2.65) Impaired MMSE <*, Serial 7 s (3.75) (2.93) (3.80) MMSE <*, Backwards spelling (3.95) (2.40) (3.19) Education and gender main effects and interactions are presented. <* The mean difference of adjacent groups is significant at the.05 level. + The mean difference between groups <7 and >11 years is significant at the.05 level. 2. Results The mean MMSE scores by educational groups using each type of MMSE (MMSE serial 7 s and MMSE backwards spelling ) for the impaired and unimpaired groups are presented in Table 2. The education effect was significant in all cases Education effects on the attention items of the MMSE in the unimpaired group The mean MMSE total score for all unimpaired participants using the serial 7 s item was (S.D. = 3.37) and the mean total score using the backwards spelling item was (S.D. = 3.13). The within subject factor (type of attention item) had a significant effect, F(1, 99) = 22.43, p =.001, η 2 =.19, and the education effect was also significant, F(2, 99) = 12.87, p =.0001, η 2 =.21. The interaction between the type of attention item and the educational group was not significant, F(2, 99) =.84, p =.43, η 2 =.02. Significant differences were observed in the MMSE when using the serial 7 s mean total scores of the participants with less than 7 years of education and the 7 11 years of education group, F(1, 60) = 3.70, p =.05, η 2 =.06 and between the less than 7 years of education and the group with more than 11 years of education, F(1, 73) = 20.94, p =.001, η 2 =.22. The backwards spelling score of the group with less than 7 years of education differed significantly from the 7 to 11 years of education group (F(1, 60) = 6.37, p =.01, η 2 =.10) and from the more than 11 years of education group (F(1, 73) = 15.94, p =.001, η 2 =.18). The mean scores of the participants with 7 11 years of education significantly differed from the mean scores of the participants with more than 11 years of education in the serial 7 s, F(1, 65) = 6.34, p =.01, η 2 =.09 but did not differ from this group s scores in the backwards spelling, F(1, 65) = 2.68, p =.10, η 2 =.04. The less educated group had a significantly better performance in the backwards spelling than in the serial 7 s task, F = 9.18, p =.005, η 2 =.21. This difference was also significant for the 7 11 years of education group (F = 20.23, p =.001, η 2 =.35), and for the most educated group (F = 7.11, p =.010, η 2 =.10) Education effects on the attention items of the MMSE in the impaired group The total mean MMSE scores of the impaired participants using the serial 7 s item was (S.D. = 4.3) and the backwards spelling item was (S.D. = 4.14). In this group, the within subject factor (type of attention item) had a significant effect, F(1, 55) = 13.82, p =.001, η 2 =.20, and the education group effect was also significant, F(2, 55) = 15.50, p =.001, η 2 =.36. The interaction between the type of attention item and the educational group was not significant (F(2, 55) =.03, p =.96, η 2 =.00). Univariate analysis showed that that the MMSE serial 7 s mean total scores of the group of participants with less than 7 years of education was significantly different from the group with 7 11 years of education (F(1, 31) = 6.30, p =.01, η 2 =.17) and from the group with more than 11 years of education

6 682 M. Rosselli et al. / Archives of Clinical Neuropsychology 21 (2006) Fig. 1. MMSE scores by education and gender in the (A) unimpaired group and the (B) impaired group. (F(1, 47) = 22.36, p =.001, η 2 =.32). The MMSE backwards spelling scores of the group with less than 7 years of education was significantly different from the 7 to 11 years of education group (F(1, 31) = 8.54, p =.006, η 2 =.22) and from the more than 11 years of education group (F(1, 47) = 27.06, p =.001, η 2 =.37). The less educated impaired group had a significantly better performance in the backwards spelling than in the serial 7 s task (F(1, 21) = 4.94, p =.03, η 2 =.19); this difference was also significant for the 7 11 years of education group (F(1, 11) = 8.80, p =.01, η 2 =.44) and for the most educated group (F = 5.03, p =.03, η 2 =.18) Gender and education The effect of gender was only significant in MMSE serial 7 s with females scoring significantly lower than males (see Fig. 1). None of the interactions between education and gender were significant although, the gender differences were more pronounced in the low educated groups. A regression analysis shown in Table 3 demonstrated that, although education is a very important predictor of the variability of the MMSE scores, after controlling for it gender is a significant predictor of the MMSE test scores as well. Gender has a more significant effect on the MMSE total scores when the serial 7 s is used and less effect when the backwards spelling is used. This effect was observed in both the impaired and the unimpaired samples Correlations To analyze the association between the two attention items and the other MMSE items, correlation analyses were performed (Table 4). A significant correlation between both attention items was found (.37). Both the serial 7 s and

7 Table 3 Predictive value of education and gender on the MMSE scores M. Rosselli et al. / Archives of Clinical Neuropsychology 21 (2006) Variable Unimpaired Impaired Serial 7 s Backwards spelling Serial 7 s Backwards spelling Step 1 Education.44 **.40 ** 54 ** 57 ** R 2.19 **.16 ** 29 ** 36 ** Step 2 Education.44 **.39 ** 56 ** 58 ** Gender.22 **.18 ** 29 ** 16 ** R 2 change.05 **.04 *.08 **.02 * p <.05. ** p <.01. Table 4 Correlations between each of the attention items and the other MMSE items MMSE item Serial 7 s Backwards spelling Temporal orientation.34 **.27 ** Spatial orientation.22 **.33 ** Repetition of words Serial 7 s ** Recall of words.18 *.08 Sentence repetition Three-step command Reading a sentence Writing a sentence ** Figure copying.22 *.10 Naming is not included because the maximum score was obtained by all participants. * p <.05. ** p <.01. the backwards spelling items significantly correlated with the two orientation items. However, only the backwards spelling item correlated with the writing item and only the serial 7 s item correlated with the recall of the three words and with the copying of the pentagons. 3. Discussion We found that differences in scores of about 1.5 points emerged when total MMSE scores were calculated with the serial 7 s versus the backwards spelling items. All of the groups, regardless of educational level, obtained significantly higher total scores when the backwards spelling item was used rather than the serial 7 s. This confirms previous findings that suggest that the backwards spelling item is an easier task than serial 7 s (Folstein, 1998; Galasko et al., 1990). Galasko et al. (1990) found that 20% of an elderly control sample and 71% of the mild Alzheimer s disease sample scored higher on spelling WORLD backwards than when calculating serial 7 s. Correlation between serial 7 s and backwards spelling items was moderate (.37) but significant. The correlation matrix of serial 7 s and backwards spelling items with other MMSE items supports the suggestion that they are tapping different but overlapping abilities. Both items significantly correlated with orientation items to a similar degree. The results of this study indicate that educational level plays a significant role in the total score on the MMSE. This effect is significant in individuals with less than 11 years of education if the serial 7 s item is used and in individuals with less than 7 years of education if the backwards spelling item is used. As previously observed by Ostrosky-Solis et al. (2000), the effect of education on the MMSE scores is significant in individuals with less than 4 years of schooling. Individuals with lower levels of education might be classified as impaired if their total score is not adjusted for educational level (Mungas et al., 1996).

8 684 M. Rosselli et al. / Archives of Clinical Neuropsychology 21 (2006) In our study, individuals with less education made significantly more errors than did the highly educated on the serial 7 s item when compared to the number of errors made on the backwards spelling item. Jones and Gallo (2002) found similar results in a sample of English speakers. They found that serial 7 s, backwards spelling, repeating phrases, writing, naming the season, and copying the intersecting pentagons were affected by level of education. In fact, although the two attention items are used clinically as equivalent in the administration of the MMSE and in our study they positively correlate with each other, we found that the correlations with the other items of the MMSE differ. The backwards spelling item correlated positively with writing and the serial 7 s item correlated with the recall of words and with the copying of the intersecting pentagons. These findings suggest that the backwards spelling item has a significant language component whereas the serial 7 s has a short-term memory and visuoconstructive/visuospatial component. It is interesting to note that spelling, although easier than subtracting in this Spanish speaking sample of Hispanics elders, is not a skill frequently used in Spanish. Because of its transparent orthography, oral spelling is rarely done in Spanish. Languages with an opaque orthography such as English require the use of oral spelling. Spanish speakers are less practiced in spelling than are English speakers (Ardila, 1998). It would be expected that if the performance of Spanish speakers in the two attention items of the MMSE is compared with the performance of English speakers in the same item, greater differences between the serial 7 s and the backwards spelling will emerge in English speakers. Future research comparing this cultural effect is recommended. Gender differences were observed on the total MMSE scores when using the serial 7 s item. Females scored significant lower than males. Although the interaction between gender and education was not significant in the unimpaired group, the gender differences in the MMSE scores were more pronounced in the lowest educated group as compared to the group with the highest level of education. In the Rosselli et al. (2000) study females with less than 3 years of education scored significantly lower than males with the same education level. No gender differences were observed in the groups with higher level of schooling. The reverse pattern was observed in our impaired group in which the better performance of males was more pronounced in the more educated group. Previous research has reported gender differences in the MMSE scores with women erring more on the serial 7 s item and men on the backwards spelling item (Jones & Gallo, 2002). In our study, females and males had on average higher scores in the MMSE backwards spelling than in the MMSE serial 7 s. One limitation of this study is that females were overrepresented in the sample, constituting 70% of total sample. The results of this study need to be replicated in a sample with equal representation of males and females. Another potential limitation of this study is the relatively small sample sizes in some groups, in particular the impaired groups. Further research is needed with a larger sample of impaired elders. A final shortcoming of this study is that our results may be specific for Spanish speaking Hispanics and may not generalize to other ethnic groups or to English speaking Hispanic elders. Education differences between these two groups of Hispanics have been reported by the U.S. Census. The educational attainment of the Hispanic American adult population has been reported to be lower than the education of African Americans and European Americans (U.S. Census Bureau News, 2004). For example, 57% of the Hispanics older than 25 in the U.S. have a high school diploma or more compared to 88% of the African Americans and 89% of the European Americans. Moreover, it was found that among this Hispanic population the percentage of the foreign born with a high school diploma was significantly lower than that of the U.S. born Hispanic populations. It could be expected that more Spanish speaking Hispanics elders would be included in the foreign born group. Hispanic Americans are the fastest growing minority group in the U.S. (U.S. Census Bureau, 2003). The number of Hispanic elders with Alzheimer s disease is projected to increase six times by 2050 (Alzheimer s Association Report, 2004). Hispanics are more likely than European Americans to be identified as demented (Espino, Lichtenstein, Palmer, & Hazuda, 2001) when the MMSE is used. The need for culture fair tests for assessing dementia will be critical in the years to come. This study has identified significant differences in difficulty level of the serial 7 s versus the backwards selling attention items suggesting that they are not equivalent in this Hispanic sample. The attention items have an important impact on the total MMSE score (i.e. 5 points) and therefore the use of one or the other item can influence diagnostic accuracy estimates. Future studies should evaluate the sensitivity of the MMSE based on the scores with the alternate attention items. Future studies are also needed to examine the potential bias of other items on the MMSE. An example of another potentially biased item in the MMSE is the orientation item in which the subject is asked to identify the season. For Hispanic elders who have lived in tropical and sub-tropical environments for much of their lives, there may be less awareness of the dates associated with four seasons of the year (Ostrosky-Solis et al., 2000). More recently, Simpao,

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