Psychometric Characteristics of the Mini-Mental State Examination among Older Chinese Immigrants

Psychometric Characteristics of the Mini-Mental State Examination among Older Chinese Immigrants

Fengyan Tang1*, Ph.D.; Laura E. Gibbons2, Ph.D.; Beth E. Snitz3, Ph.D.; XinQi Dong4, MD

1School of Social Work, University of Pittsburgh, Pittsburgh, PA, USA; 2General Internal Medicine, University of Washington, Seattle, WA, USA; 3School of Medicine, University of Pittsburgh, PA, USA; 4Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, USA

Backgrounds: The recent growth of older adult immigrants and the increased burden of Alzheimer’s disease and related dementias (ADRD) call for validation of the assessment tools and timely detection of cognitive impairment. In particular, older Chinese Americans are among the fastest growing populations in the U.S., who are at high risk for delayed diagnosis and deficient management of ADRD due to limited knowledge of dementias and barriers to healthcare access. The value of the MMSE as a screening tool in detecting ADRD is well documented in western countries. Yet, little is known about the psychometric characteristics of a Chinese version of the MMSE (CMMSE) in older Chinese immigrants, whose cognitive test performances may relate to cultural and linguistic differences.

Purpose: The study aims to assess factor structure and psychometric properties of CMMSE among older Chinese immigrants in the United States.

Methods: Participants were recruited from the greater Chicago area in the Population-based Study of Chinese Elderly (PINE). The sample included 3,126 respondents aged 60 or over, who selected Chinese dialects in completing face-to-face interviews. A bifactor analysis was conducted to test unidimensionality of the CMMSE. Rasch modeling was used to assess scale properties. Age, sex, and education were tested for differential item functioning (DIF).

Results: A bifactor analysis identified a unidimensional general factor with 30 items, reflecting a single underlying construct of cognitive capacity. We also found five concurrent subdomains with 19 items. The general factor explained 71 percent of the variance in the CMMSE. The Rasch model provided evidence of construct validity with acceptable item fit statistics. The DIF analysis showed that item biases were generally negligible.

Conclusion: The CMMSE appeared to be a valid, reliable screening instrument for cognitive impairment in the US Chinese older adults. Findings provided support for the use of the CMMSE in detecting cognitive impairment among older Chinese immigrants. Although the five-factor solution has been replicated, item compositions of subdomains remain controversial. Future efforts are needed to improve neuropsychological assessment accuracy by developing a culturally and linguistically appropriate assessment tool in minority older populations.

Keywords: Mini-Mental State Examination, bifactor model, psychometrics, unidimensionality, item response theory

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How to cite this article:
Fengyan Tang, Laura E. Gibbons, Beth E. Snitz, XinQi Dong. Psychometric Characteristics of the Mini-Mental State Examination among Older Chinese Immigrants. International Journal of Aging Research, 2021, 4:89. DOI: 10.28933/ijoar-2021-08-3105


1. 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, 189–198.
2. Schultz-Larsen, K., Kreiner, S., & Lomholt, R. K. (2007). Mini-Mental Status Examination: Mixed Rasch model item analysis derived two different cognitive dimensions of the MMSE. Journal of Clinical Epidemiology, 60, 268–279.
3. Shim, Y.S., Yang, D.W., Kim, H-J, Park, Y.H., and Kim, S. (2017). Characteristic differences in the mini-mental state examination used in Asian countries. BMC Neurology, 17:141, 1-9. DOI 10.1186/s12883-017-0925-z
4. Teresi, J.A. (2007). Mini-Mental State Examination (MMSE): Scaling the MMSE using item response theory (IRT). Journal of Clinical Epidemiology, 60, 256-259. https://doi:10.1016/j.jclinepi.2006.06.009
5. Rubright, J.D., Nandakumar, R., & Karlawish, J. (2016). Identifying an appropriate measurement modeling approach for the Mini-Mental State Examination. Psychological Assessment, 28, 125-133.
6. Ideno, Y., Takayama, M., Hayashi, K., Takagi, H., and Sugai,Y. (2012). Evaluation of a Japanese version of the mini-mental state examination in elderly persons. Geriatrics and Gerontology International, 12, 310-316. https://doi:10.1111/j.1447-0594.2011.00772.x
7. Melo, D. M., Barbosa, A.J.G., Castro, N.R. et al. (2020). Mini-mental state examination in Brazil: An item response theory analysis. Psychological Evaluation, 30, e3014, 1-10.
8. Brugnolo, A., Nobili, F., Barbieri, M. P., et al. (2009). The factorial structure of the Mini Mental State Examination (MMSE) in Alzheimer’s disease. Archives of Gerontology and Geriatrics, 49, 180–185.
9. Castro Costa, E., Dewey, M. E., Uchôa, E., Firmo, J. O., Lima‐Costa, M. F., & Stewart, R. (2014). Construct validity of the mini mental state examination across time in a sample with low‐education levels: 10‐year followup of the Bambui Cohort Study of Ageing. International Journal of Geriatric Psychiatry, 29, 1294-1303. https://doi:10.1002/gps.4113
10. Jones, R. N., & Gallo, J. J. (2000). Dimensions of the Mini-Mental State Examination among community dwelling older adults. Psychological Medicine, 30, 605–618.
11. Shyu, Y.L. & Yip, P. (2001). Factor structure and explanatory variables of the Min-Mental State Examination (MMSE) for elderly persons in Taiwan. J Formos Med Assoc, 100, 676-683. PMID: 11760373
12. Mungas, D., Reed, B. R., Marshall, S. C., & González, H. M. (2000). Development of psychometrically matched English and Spanish language neuropsychological tests for older persons. Neuropsychology, 14, 209–223.
13. U.S. Census Bureau (2016). Asian American Data Links. Retried January 11, 2018 from
14. Woo, B.K. (2017). Dementia health promotion for Chinese Americans. Cureus, 9, e1411. https://doi:10.7759/cureus.1411
15. Wrobel, N.H., and Farrag, M.F. (2007). Preliminary validation of an Arabic version of the MMSE in the elderly. Clinical Gerontologist, 75-93.
16. Reise, S. P. (2012). The rediscovery of bifactor measurement models. Multivariate Behavioral Research, 47, 667–696.
17. Chen, F.F., West, S.G., and Sousa, K.H. (2006). A Comparison of Bifactor and Second-Order Models of Quality of Life. Multivariate Behavioral Research, 41(2), 189-225. DOI: 10.1207/s15327906mbr4102_5
18. Reise, S. P., Morizot, J. and Hays, R. D. (2007). The role of the bifactor model in resolving dimensionality issues in health outcomes measures. Qual Life Res, 16,19–31. DOI 10.1007/s11136-007-9183-7
19. Rijmen, F. (2010). Formal relations and an empirical comparison among the bi-factor, the testlet, and a second-order multidimensional IRT model. Journal of Educational Measurement, 47, 361–372.
20. Crane, P.K., Narasimhalu, K., Gibbons, L., Pedraza, O., Mehta, K.M., Tang, X. et al. (2008). Composite scores for executive function items: Demographic heterogeneity and relationships with quantitative MRI. J Int Neuropsychol Soc., 14(5), 746–759. doi:10.1017/S1355617708081162.
21. Meade, A.M. and Lautenschlager, G.J. (2004). Same question, different answers: CFA and two IRT approaches to measurement invariance. Symposium presented at the 19th Annual Conference of the Society for Industrial and Organizational Psychology, Chicago, IL.
22. Jones, R. N., and Gallo, J. J. (2002). Education and sex differences in the Mini-Mental State Examination: Effects of differential item functioning. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 57B(6), P548–P558.
23. Jones, R. N. (2006). Identification of Measurement Differences Between English and Spanish Language Versions of the Mini-Mental State Examination: Detecting Differential Item Functioning Using MIMIC Modeling. Medical Care, 44 (11), S124-S133.
24. Chang, E-S. & Dong, X. (2014). A battery of tests for assessing cognitive function in U.S. Chinese older adults – findings from the PINE study. J Gerontol A Biol Sci Med Sci., 69A (S2), S23–S30. doi:10.1093/gerona/glu195
25. Chiu, H.F., Lee, H.C., Chung, W.S., and Kwong, P.K. (1994). Reliability and validity of the Cantonese version of mini-mental state examination-a preliminary study. Hong Kong Journal of Psychiatry, 4 (SP2), 25-28.
26. Dong, X., Wong, E., & Simon, M.A. (2014). Study design and implementation of the PINE study. Journal of Aging and Health, 26, 1085-1099.
27. Hu, L.-t., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6(1), 1–55.
28. Browne, M.W. & Cudeck R. (1993). Alternative Ways of Assessing Model Fit. In: Bollen K, Long J, editors. Testing Structural Equation Models. Sage; Newbury Park, CA: 1993. pp. 136–162.
29. Linacre, J. M. (2002). What do infit and outfit, mean-squared and standardized mean? Rasch Measurement. Transactions,16, 878.
30. Edelen. M.O. and Reeeve, B.B. (2007). Appling item response theory (IRT) modeling to questionnaire development, evaluation, and refinement. Qual Life Res, 16, 5–18. DOI 10.1007/s11136-007-9198-0
31. Bond, T. G. and Fox, C. M. (2007). Applying the Rasch Model, 2nd ed. Mahwah, NJ: Lawrence Erlbaum.
32. Molde, H., Hynninen, K.M., Torsheim, T. et al. (2017). A bifactor and item response analysis of the geriatric anxiety inventory. International Psychogeriatrics, 29, 1647-1656.
33. Swaminathan, H. and Rogers, H.J. (1990). Detecting differential item functioning using logistic regression procedures. Journal of Educational Measurement, 27 (4), 361-370.
34. Carnero-Pardo, C. (2014). Should the Mini-Mental State Examination be retired? Neurologia, 29 (8), 473-481. https://doi:10.1016/j.nrl.2013.07.003
35. McGrory, S., Doherty, J. M., Austin, E. J., Starr, J. M., & Shenkin, S. D. (2014). Item response theory analysis of cognitive tests in people with dementia: A systematic review. BMC Psychiatry, 14, 47. https://doi:10.1186/1471-244X-14-47
36. Steis, M.R. & Schrauf, R. W. (2009). A review of translation and adaptations of the Mono-Mental State Examination in languages other than English and Spanish. Research in Gerontological Nursing, 2 (3), 214-224. doi: 10.3928/19404921-20090421-06.

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