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VALIDATION AND CULTURAL ADAPTATION OF THE ARABIC VERSIONS OF THE

MINI–MENTAL STATUS EXAMINATION – 2 AND MINI-COG TEST

Article  in  The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry · April 2020
DOI: 10.1016/j.jagp.2020.01.154

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Open Access Full Text Article ORIGINAL RESEARCH

Validation and cultural adaptation of the Arabic

versions of the Mini–Mental Status Examination –
2 and Mini-Cog test

Mohammad Albanna 1,* Introduction: The elderly population is increasing around the world, and the prevalence of
Arij Yehya 2,* dementia increases with age. Hence, it is expected that the number of people with dementia will
Abdalla Khairi 1 increase significantly in the coming years. The Mini–Mental Status Examination – 2 (MMSE-2)
Elnour Dafeeah 1 and Mini-Cog are widely used tests to screen for dementia. These scales have good reliability
Abdelsalam Elhadi 3 and validity and are easy to administer in clinical and research settings.
Aim: The purpose of this study was to validate the Arabic versions of MMSE-2 and Mini-Cog.
Lamia Rezgui 4
These scales were assessed against the Diagnostic and Statistical Manual of Mental Disorders,
Shahada Al Kahlout 4
Fourth Edition, Text Revision (DSM-IV-TR) criteria for dementia, as the gold standard.
Adil Yousif 5
Methods: The standard versions of the MMSE-2 and Mini-Cog were translated to Arabic follow-
Basim Uthman 6 ing the back-translation method. Then, a trained rater administered these tests to 134 Arab elderly
Hassen Al-Amin 2 aged 60 years. A physician, blind to the results of these two tests, assessed the participants for
Psychiatry Department, Hamad
1
vascular dementia or probable Alzheimer’s disease, based on the DSM-IV-TR criteria.
Medical Corporation, 2Psychiatry Results: The sample included 67.2% Qataris. The mean age was 74.86 years (standard
Department, Weill Cornell Medicine –
Qatar, 3Primary Health Care deviation 7.71), and 61.9% did not attend school. The mean of the adjusted scores of MMSE-2
Corporation, 4Geriatrics Department, based on age and education level was 19.60 (standard deviation 6.58). According to DSM-IV-TR,
Rumailah Hospital, Hamad Medical
17.2% of the participants had dementia. Sensitivity and specificity of the MMSE-2 and the Mini-Cog
Corporation, 5Department of
Mathematics, Statistics and Physics, together were 71.4% and 61.6%, respectively, which were better than those of each test alone.
College of Arts and Sciences, Qatar Conclusion: Together, the Arabic versions of MMSE-2 and Mini-Cog are good screening
University, 6Neurology Department,
Weill Cornell Medicine – Qatar, tools for cognitive impairment in Arabs.
Doha, Qatar Keywords: dementia, validation, MMSE-2, Mini-Cog, Arabic version
*These authors contributed equally
to this work
Introduction
Dementia is characterized by gradual deterioration in cognition resulting in significant
impairments in daily functioning.1 Dementia is diagnosed on clinical grounds, and
despite advances in medicine and technology, no particular laboratory tests or neu-
roimaging studies can be used to make a diagnosis of dementing illnesses. The onset
of dementia is mostly insidious, and the course of the illness is usually a progressive
decline in higher cortical functions and daily life activities; the course of progression
varies from subacute to chronic depending on the etiology. Dementia affects each person
differently and also has a significant impact on families and caregivers.2 Early diag-
Correspondence: Hassen Al-Amin nosis of cognitive impairment may increase the chance of a slower progression of the
Psychiatry Department, Weill Cornell
Medicine – Qatar, Education City, PO
disease.3 Early intervention can provide caregivers with early advice and support.4
Box 24144, Doha, Qatar Dementia screening tools should be brief, easy to use and valid in different
Tel 974 4492 8313
Fax 974 4492 8377
cultures and across elderly with various educational backgrounds.5 The Mini–Mental
Email [email protected] Status Examination (MMSE) and the Mini-Cog have been demonstrated in several

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studies as valid and brief tests that provide satisfactory Geriatrics and Neurology departments of Hamad Medi-
screening of cognitive deficits and determine their severity cal Corporation (HMC), Doha, Qatar. In this study, the
at the time of evaluation. They can also serve as measuring subjects recruited were only Arabic native speakers aged
tools of progression or improvement of cognition in cogni- 60 years. The study excluded elderly who: 1) had depres-
tive illness.6,7 These tests were originally made in English sion or other psychiatric disorders other than dementia, 2)
and were translated and scientifically validated in other had a major medical or neurological disorder that mandated
languages.8,9 Although a recent version of MMSE attempted acute treatment or needed immediate care in the 4 weeks
to minimize the impact of the confounding factors, most before enrollment, 3) used psychotropics or anti-dementia
screening measures are often skewed by factors such as medications for more than 4 weeks before the recruitment
language, culture and level of education.10 To maximize the time to avoid the confounding effects of medications, 4)
sensitivity and specificity of MMSE, experts recommend reported a history of drug or alcohol use, and 5) having
combining MMSE with Clock-Drawing Test (CDT) or hearing or vision impairment or showed presence of slurred
Mini-Cog.11 These tests have not been scientifically validated or incomprehensible speech. The latter were excluded
in Arabic, and in general, the Arab countries are still lacking as instructions had to be explained to the subjects and
the proper tools to screen for dementia. their answers involve copying and comprehensive verbal
We did not find any informative epidemiological studies communication.
on the prevalence of dementia in the Middle East and North We do not have consensus on the number of elderly
African (MENA) countries. The experts working with the attending these different clinics, but between June 2013
World Health Organization (WHO) estimated that the preva- and March 2014, the investigators screened ^420 elderly
lence of dementia is ^6% among adults aged 60 years in subjects where 276 subjects fulfilled the inclusion and exclu-
the MENA countries.12,13 A study assessing the prevalence sion criteria and of which only 134 accepted enrollment
of mental illness in the Qatari population (n1,660) reported in the study. All of them completed the MMSE-2:SV and
that dementia accounted for only 1.1% of the total sample but were clinically assessed if they met the criteria for dementia
reached up to 52% in people aged 50 years (n297).14 according to DSM-IV-TR, but only 113 had a conclusive
Qatar is a rapidly growing country with several ethnicities Mini-Cog as the rest could not complete the CDT because
and nationalities. The last official census in 2010 conducted of illiteracy (could not read or write the numbers). The
by the Qatar Statistics Authority15 showed that the total sample size differed across validations of different scales.
population in Qatar is ^1.5 million where 40% of them are Figure 1 illustrates the number of subjects who finalized
Arabs. The senior citizens (aged 60 years) accounted for the different assessments along with the sample size for
only 2% of the total population with the majority of them each analysis.
being males. The aim of this study was to validate the new In regard to sample size, we believe that we satisfied
Arabic versions of the MMSE-2, standard version (SV), and the condition of having at least 10 measures for each item,16
the Mini-Cog test in the Arab elderly population residing in as the MMSE-2 has 11 items and the additional one from
Qatar. We also determined the sensitivity and specificity for Mini-Cog is the CDT. The sample was recruited using con-
different cutoffs of MMSE-2:SV and Mini-Cog in predict- venient sampling technique. The selected sample size was
ing the clinical diagnosis of dementia in the Arab elderly also adequate for the estimation of sensitivity and specificity
population in Qatar. The diagnosis is based on the criteria to within a maximum margin of error of 7% at a 95% confi-
for dementia in Diagnostic and Statistical Manual of Mental dence interval (CI). It was also consistent with the number of
Disorders, Fourth Edition, Text Revision (DSM-IV-TR). We patients used in the other studies that validated the translated
hypothesized that using both scales together (MMSE-2:SV scales in other languages such as Persian.17
and Mini-Cog) would result in more accurate diagnosis of The Institutional Review Board of HMC approved the
dementia compared to either one alone. study. It was granted an exemption from obtaining written
informed consent, as all the tests administered are usu-
Methods ally part of routine clinical screening for elderly patients.
Subjects However, the participants (or a family member) were given
Subjects were recruited from the elderly population who a written document, which explained the purpose of the
attended the primary health care centers (PHCCs) and study, the tests to be done and the estimated time needed
the outpatient services at the Psycho-geriatrics, Medical to finish them.

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Dovepress Arabic MMSE-2 and Mini-Cog

Figure 1 A flow chart showing the number of subjects and what tests they completed.
Abbreviations: MMSE-2, Mini–Mental Status Examination – 2; SV, standard version; DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.

MMSE and MMSE-2 items were replaced and several tasks were modified to
The original MMSE18 is the most commonly used cognitive minimize difficulty and to facilitate its translation into foreign
screening test worldwide. The examination takes ^7–10 minutes languages. It has been tested in a normal population and in
to complete. The total score is 30, and it tests a broad range people with Alzheimer’s disease and subcortical dementia.
of cognitive functions, including orientation, recall, attention, The raw score range (ie, 0–30) remains the same, and the
calculation, language processing and constructional praxis.18 MMSE-2:SV and MMSE cutoffs are comparable.22
Previous studies have suggested that different cutoff scores
on MMSE are needed to screen for cognitive impairment Mini-Cog test
and control for the differences in age, education and cultural Mini-Cog requires only 3 minutes to administer and consists
variations.19 In a study by Folstein and Folstein,20 the fol- of a CDT and non-cued recall of three unrelated words.
lowing cutoffs were determined: 27–30 is normal, 21–26 is Mini-Cog attained 99% sensitivity and 93%–96% specific-
mild impairment, 11–20 is moderate impairment and 10 is ity in elderly from diverse ethnic and linguistic backgrounds
severe impairment. The most widely used cutoff to suggest where the prevalence of dementia was 50%.5,11 The advan-
dementia is a score of 24.21 This cutoff score 24 yielded tages of the Mini-Cog include brevity, ease of administration,
a sensitivity and specificity of 58% and 98%, respectively.21 acceptability to patients, simple scoring and high sensitiv-
The SV of the MMSE-2 (MMSE-2:SV) is one of the three ity for predicting dementia status and diagnostic value not
revised versions of MMSE. It retains the structure and scor- limited by the subject’s education, language or cultural bias.
ing of the original 30-point MMSE, but the problematic Mini-Cog is more sensitive to mild dementia than MMSE.5

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It is also useful for assessing visuoconstructive abilities, the sociodemographic data (such as age, gender, educational
including praxis and executive higher functions. level, etc.) and the clinical history from the patient and/or
his family. Medical records were also checked to retrieve
Translation and cultural adaptation the missing data. After that, the trained raters administered
After obtaining the proper permission from the copyright MMSE-2 and Mini-Cog tests. Then, a physician, who was
holders of the MMSE-2, ie, Psychological Assessment blind to the scores on MMSE-2 and Mini-Cog, interviewed all
Resources (PAR), a committee of one professional translator, the participants and assessed whether they clinically met the
three bilingual psychiatrists and a neurologist independently criteria for dementia (either Alzheimer’s or vascular dementia
translated the MMSE-2 and Mini-Cog. The committee or both) based on DSM-IV-TR. The physicians involved (one
deliberated over few sessions to decide anonymously on neurologist, three geriatricians, two psycho-geriatricians and
one preliminary Arabic version for each test. A pilot study one primary care physician) met before the start of recruit-
was then carried out to test the language and clarity of the ment, reviewed the DSM-IV criteria and agreed on the defini-
scales in a sample of Arab elderly (n20). The concerns tions and the clinical assessment of the criteria.
of the subjects were about the different terms used in the
section on orientation to place such as state vs country, city Statistical analysis
vs town, etc., but these can be changed to fit with the country The sample was described in terms of age, gender, country
of the participants as indicated in the English version. Other born and educational level for 134 cases (refer to Figure 1
concerns were about the choice of words to remember, the for details on sample sizes for the different analyses). The
serial sevens and the meaning of the sentence to repeat sample was split into two groups based on whether the indi-
but not about the Arabic translation per se. However, with viduals met the criteria of either type of dementia (vascular
encouragement, subjects were able to perform these sections. or Alzheimer as per DSM-IV-TR) or not. The raw scores
Finally, they hesitated to write a sentence but then were able on MMSE-2 were corrected based on age and educational
to do it with more prompting. In regards to the Mini-Cog, level of the participants; we also used the T-scores that are
subjects needed more explanations on how to do the clock provided by PAR in the MMSE-2 Manual. Scores’ range
drawing and some added that they “do not know how to draw and mean were calculated. Adjusted scores were compared
a clock”. The physicians and nurses who administered the across males and females (using paired t-test) and different
scales commented on the Arabic translations for the levels of educational levels (using analysis of variance [ANOVA])
consciousness where few mentioned that these terms are not with Bonferroni corrections for multiple comparisons. Effect
commonly used by lay people, and it was explained that this sizes were also reported. Pearson’s correlation was carried
is usually assessed by trained individuals and not by patients. out to test if age and MMSE-2 adjusted scores were cor-
The comments and issues were then raised to the committee, related. The prevalence of dementia in the sample was
and further changes were made accordingly. The final version calculated, and differences between females and males were
that was approved by the committee was then back translated tested using chi-square test.
to English by a new independent professional translator and Using receiver-operating characteristic (ROC) curves,
was compared to the original version by the committee of separate analyses were carried out to determine the sensitiv-
psychiatrists. This back translation was sent back to PAR ity and specificity of each of the MMSE-2:SV and Mini-Cog
that reviewed and suggested making two changes before compared to the gold standard (clinical diagnosis based on
their approval of the final back translation. The two changes DSM-IV-TR). After that, ROC curves were drawn to assess the
were related to two words (aloud and comprehension) where sensitivity and specificity for using both scales together com-
their Arabic translations gave different meanings in the back pared to those who have dementia diagnosis on both MMSE-
translation but the Arabic words were changed to fit linguisti- 2:SV and Mini-Cog. Statistical analyses were carried out using
cally with the original English translation. IBM-Statistical Package 23.0 (IBM Corporation, Armonk,
NY, USA). Statistical significance was set at 0.05 level.
Procedure
The psycho-geriatricians involved in the study trained two Results
raters on the administration of MMSE-2 and were supervised The sample (n134) had more males than females, 61.9%
on several cases before allowing them to finalize them alone. and 38.1%, respectively. The age group ranged between 60
After obtaining the assent of the participant, a rater collected and 96 years. The mean age was 74.86 (SD o7.71). In this

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Dovepress Arabic MMSE-2 and Mini-Cog

sample, there were more people born in Qatar than in the Table 2 Mean (SD) scores on Arabic versions of MMSE-2:SV and
other Arab countries (including Egypt, Iraq, Jordan, Lebanon, Mini-Cog by dementia diagnosis (using DSM-IV-TR criteria) in the
study sample
Libya, Morocco, Oman, Palestine, Saudi Arabia, Sudan,
Scales Dementia No dementia
Syria and Yemen), 63.1% and 36.9%, respectively. More than
(n23) (n111)
half (61.9%) of the sample did not attend school. Table 1 lists
Mean (SD) Mean (SD)
the frequencies and percentages of the sociodemographic
MMSE-2:SV (n134)
variables based on whether patients were diagnosed with Raw scores* 15.26 (4.06) 19.52 (7.12)
dementia (as per DSM-IV-TR criteria) or not. In this sample, T-scores* 21.41 (13.47) 32.57 (18.68)
there were 23 (12.3%) subjects with dementia vs 111 with- Adjusted scores* (for age 16.39 (4.21) 20.42 (6.82)
and level of education)
out. In regard to dementia diagnosis as per DSM-IV-TR,
Mini-Cog (n113)
21 patients had vascular dementia and two cases had possible
Score* 1.55 (0.89) 2.07 (0.47)
Alzheimer’s dementia. There were no significant differences Note: *Scores are lower in the dementia group, P0.05.
based on gender, age and educational level, but the Qataris Abbreviations: MMSE-2, Mini–Mental Status Examination – 2; SD, standard deviation;
SV, standard version; DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders,
were significantly more in both groups compared to other Fourth Edition, Text Revision.
Arabs (P0.05).
Table 2 lists the various scores obtained in the two
groups (dementia vs no dementia). The MMSE-2 and Mini- completed the CDT, and in 32 elderly (52.5%), the drawing
Cog scores in the dementia group were significantly lower was incorrect.
compared to those without clinical dementia (P0.05; The results also showed that there was no significant
Table 2). Based on the Mini-Cog scores, 78 elderly (58.2%) difference between males and females on the Mini-Cog
were potentially having dementia out of the total sample score (P0.180). However, there were differences in
that had conclusive Mini-Cog (n113). Only 61 subjects MMSE-2:SV adjusted scores, P0.004. Males scored higher
on MMSE-2:SV adjusted scores compared to females,
with mean values 21.11 (SD 6.48) and 17.16 (SD 6.03),
Table 1 Sociodemographic data by dementia diagnosis according
respectively. There was a significant negative correlation
to DSM-IV-TR
between the participants’ age and their adjusted scores on
Variable Dementia (n23) No dementia (n111)
MMSE-2:SV, r 0.46 and P0.01. This correlation has
Frequency (%) Frequency (%)
medium to large effect size.
Gender
Male 12 (52.2) 71 (64.0) MMSE-2 mean-adjusted score was higher in groups of
Female 11 (47.8) 40 (36.0) elderly with higher levels of education compared to those
Age (years) with no education. The mean-adjusted scores on MMSE-2
60–64 2 (8.7) 13 (11.7) for educational levels no schooling, intermediate schooling,
65–69 0 (0) 18 (16.2)
secondary schooling and college and above were 16.66
70–74 7 (30.4) 26 (23.4)
75–79 5 (21.7) 23 (20.7) (SD 5.24), 23.00 (SD 4.69), 25.60 (SD 5.15) and 26.53
80–84 6 (26.1) 16 (14.4) (SD 4.88), respectively. ANOVA showed a significant dif-
85–89 3 (13.0) 7 (6.3) ference in MMSE-2:SV scores across elderly with different
90 0 (0) 4 (3.6)
levels of education, F(3,119) 25.83, P0.001 and partial
Unknown 0 (0) 4 (3.6)
eta-squared d20.39 for the differences between groups.
Country born
Qatar* 20 (87.0) 70 (63.1) Bonferroni post hoc tests showed only significant differences
Other 3 (13.0) 40 (36.0) on MMSE-2:SV adjusted scores between no schooling and
Unknown 0 (0) 1 (0.9) each of the other three groups, P0.001.
Educational level
Similarly, there were significant differences on the Mini-
No schooling 18 (81.8) 65 (58.6)
Intermediate 2 (9.1) 11 (9.9)
Cog scores between elderly with different levels of education,
Secondary 0 (0) 10 (9.0) F(3,98) 10.91, P0.01 and partial eta-squared d20.25.
College and above 2 (9.1) 15 (13.5) However, post hoc analysis showed significant differences
Unknown 1 (4.3) 10 (9.0) between no schooling and attended high school (mean
Note: *P0.05, more Qatari in both groups compared to other Arabs.
Abbreviation: DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders,
difference 0.95, standard error [SE] 0.27, P0.003, CI
Fourth Edition, Text Revision. [0.24, 1.67]) and between those with no schooling and those

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Table 3 Sensitivity and specificity of the Arabic versions of MMSE-2:SV and Mini-Cog compared to clinical diagnosis of dementia using
DSM-IV-TR criteria
Variables n AUC SE Cutoff CI Accuracy
Lower bound Upper bound Sensitivity (%) Specificity (%)
MMSE-2:SV adjusted scores 134 0.68* 0.05 18/19 0.580 0.781 60.9 59.5
MMSE-2:SV T-scores 134 0.66* 0.06 21/22 0.550 0.778 59.1 68.7
Mini-Cog score 113 0.65 0.07 1.5 0.517 0.777 92.9 34.3
MMSE-2:SV and Mini-Cog 113 0.65* 0.08 20/21 0.516 0.814 71.4 61.6
Note: *P0.05.
Abbreviations: MMSE-2, Mini–Mental Status Examination – 2; SV, standard version; DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision; AUC, area under the curve; SE, standard error; CI, confidence interval.

who attended college and above (mean difference 1.01, cutoff was 18/19 for these scores. According to this cutoff,
SE 0.20, P0.001, CI [0.46, 1.56]). 59 elderly had dementia (44% of the sample of 134 subjects).
The results of the ROC curves for the different scales Figure 2 illustrates the ROC curves for the individual and
are listed in Table 3. For the MMSE-2:SV adjusted scores, combined scores. The T-scores showed better specificity than
the sensitivity and specificity were 60.9% and 59.5% with the adjusted scores but with a lesser sensitivity. Mini-Cog
an area of 0.68, P0.05. The results showed that the best did not have a significant area under the curve. However, its

Figure 2 ROC curves for the unique and combined scores of the Arabic version of MMSE-2:SV and Mini-Cog compared to diagnosis of dementia according to DSM-IV-TR criteria.
Notes: The combined scores of MMSE-2:SV (adjusted) and Mini-Cog produced the optimal sensitivity (71.4%) and specificity (61.6%) where the AUC was 0.65 (P0.05) with
SE of 0.08 and CI of 0.516-0.814. The cutoff for the combined scores were 20/21.
Abbreviations: ROC, receiver-operating characteristic; MMSE-2, Mini–Mental Status Examination – 2; SV, standard version; DSM-IV-TR, Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision; AUC, area under the curve; CI, confidence interval; SE, standard error.

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Dovepress Arabic MMSE-2 and Mini-Cog

sensitivity was excellent (92.9%), but the specificity was very and 70 years. Caramelli et al28 showed that a score of 18 on
low (34.3%). Combining these two scales together, Mini-Cog MMSE is the best cutoff for illiterate elderly, which supports
and MMSE-2:SV adjusted scores added to the sensitivity the validity of our results in the Arab population where the
and specificity of MMSE-2:SV adjusted scores, 74.4% and illiteracy is high in the elderly population.
61.6%, respectively. Based on MMSE-2:SV and Mini-Cog The Arabic version of the Mini-Cog showed good sen-
scores, 48 elderly had dementia, making up to 42.5% of the sitivity and low specificity. This brief assessment did not
sample studied (n113). accurately predict a diagnosis of dementia. In the MMSE-2,
the raw scores could be adjusted based on age and educa-
Discussion tion. However, in the Mini-Cog, the results remained incon-
The aim of this study was to translate and validate the Arabic clusive and these individuals were dropped from the main
versions of the MMSE-2:SV and Mini-Cog test. Compared analysis, which might underpower the results of the Arabic
to the clinical diagnosis according to DSM-IV-TR criteria, the Mini-Cog. However, when used with the Arabic version of
combined Arabic versions of MMSE-2:SV and Mini-Cog MMSE-2:SV, the sensitivity and specificity were good and
were valid screening tools for dementia. Our results showed the significant measures were considered valid ones to test
that screening for dementia in the Arab population, the Arabic for dementia in elderly Arabs. Other studies also supported
MMSE-2:SV with the Arabic Mini-Cog, improved the bal- the use of Mini-Cog with MMSE in patients with cognitive
ance between sensitivity and specificity than using either deficits for more accurate screening outcomes.11
measure alone. This is the first study to translate, culturally
adapt and scientifically validate the Arabic versions of these Limitations
widely used tools to screen for cognitive impairment in the This study has several strengths that were mentioned earlier,
elderly. The official language used in all Arab countries is but it also has few limitations that are worth discussing. First,
formal Arabic. Hence, we translated the above tools to formal a good number of elderly could not complete several items on
Arabic so that they could be used across the different Arab MMSE-2 and Mini-Cog due to their inability to read, write
countries. Other strengths of this study are the standard proce- and draw. This could affect the power of our results. Thus,
dures for translation and validation, adjustment of MMSE-2 future studies with larger samples are needed to control for
scores by age and education and proper training of the raters this issue. Second, although the study included Arabs from
who were blinded to the diagnosis that was performed by different countries, the majority of Arabs in this sample
qualified clinicians and according to the standard criteria of were born in Qatar, and thus larger studies with better rep-
DSM-IV-TR. Recently and after the start of this study, two resentation of the different Arab countries can also control
other studies were published on the validation of the Arabic for the effects of subcultures in the different Arab countries.
version of the 10/66 Dementia Research Group (DRG) diag- Third, there could be a gender effect in this study as we had
nostic assessment for dementia23 and the Arabic Rowland more males in the enrolled sample, which might limit the
Universal Dementia Assessment Scale (A-RUDAS)24 in the generalizability of our results across gender. Fourth, MMSE
elderly population of Lebanon. These studies reported that is not sensitive to detect mild dementia, and scores may be
these scales are better suited for assessment of dementia in the influenced by age, education level, cultural background,
Arab population where the illiteracy is very high. However, social class, literacy and language.19,29–31 We tried to control
we do believe that the brevity and ease of administration of for many of these factors, but the gold standard used to test
the MMSE-2 and Mini-Cog and familiarity of health care the validity of Arabic MMSE-2:SV and Mini-Cog does not
providers with both tests are important factors in the facilita- provide a clear assessment of the severity of dementia. Thus,
tion of screening for cognitive impairment in epidemiological we could not use the scores of Arabic MMSE-2 to assess the
studies and in routine clinics and wards. various degrees of cognitive impairment.
The Arabic version of the MMSE-2:SV demonstrated
good specificity but low sensitivity. The cutoff in this Conclusion
sample was 18/19, which is similar to that found in other The Arabic versions of the MMSE-2 and Mini-Cog are valid
cultures.25,26 Nevertheless, this cutoff is less than what is usu- tools when used together for screening dementia. This study
ally found across different studies.21,27 Age and education are provides the foundation for future work on elderly with
known confounders of the results of MMSE,19 which were cognitive deficits in the Arab world. Future work might need to
different in this sample compared to other studies, as the focus on creating versions that adapt to the various educational
majority of the subjects enrolled in this study were illiterate levels in various Arabic subcultures. The adaptation of these

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scales to Arabic-speaking communities will also make it pos- 10. Woodford HJ, George J. Cognitive assessment in the elderly: a review
of clinical methods. QJM. 2007;100(8):469–484.
sible to explore with more detail the epidemiology of dementia 11. Scanlan J, Borson S. The Mini-Cog: receiver operating characteristics
and facilitate comparisons with international studies in regard with expert and naive raters. Int J Geriatr Psychiatry. 2001;16(2):
to risk factors, prognosis and treatment. 216–222.
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The authors report no conflicts of interest in this work. elderly with mild and moderate dementia. Aging Ment Health. 2016;
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