Formal education, health literacy and Mini-Mental State Examination

The Mini-Mental State Examination (MMSE) is a widely used screening test for cognitive impairment, but is heavily biased by education. Educational level has frequently been ranked using years of schooling, which may not be a good indirect measure of educational level because there is great heterogeneity in standards of schooling among populations and across regions of the same country. S-TOFHLA is a measure of health literacy with some results indicating that it is a good measure for literacy level. Objective To evaluate the correlations between years of schooling and scores on the S-TOFHLA and the MMSE. Methods Healthy subjects without cognitive impairment were submitted to the S-TOFHLA and the MMSE. Correlations and regression analysis were performed to determine possible associations among variables. Results Both years of schooling and S-TOFHLA scores were strongly correlated with MMSE scores, but the strongest association was reached by the S-TOFHLA (r=0.702, p<0.01), where the S-TOFHLA was the best predictor of MMSE scores (R2=0.494, p<0.001). Conclusions A stronger association between S-TOFHLA scores and MMSE performance was found than between years of education and MMSE scores. This finding justifies further studies incorporating years of schooling together with S-TOFHLA score, to evaluate cognitive performance.