The diagnostic accuracy of MMSE in patients with post-stroke cognitive impairment: a meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

WU Tingting ^1,2 , CHEN Xiaoli ¹ , WEI Xiaoqin ¹ , QIAN Xiaoling ² , ZHANG Ziyao ³ ,  HAN Lin ^1,4 ,  MA Yuxia ¹

1. Evidence-Based Nursing Center, School of Nursing, Lanzhou University the First School of Clinical Medicine, Lanzhou 730000, P. R. China;
2. Ward IV, Department of Neurology, Second Hospital of Lanzhou University, Lanzhou 730000, P. R. China;
3. Lanzhou University of Arts and Science, Lanzhou 730000, P. R. China;
4. Nursing Department, Gansu Provincial People’s Hospital, Lanzhou 730000, P. R. China;

Corresponding author：

HAN Lin, Email: hanlin@lzu.edu.cn; MA Yuxia, Email: yuxiama@lzu.edu.cn

Keywords：

Mini-mental state examination; Stroke; Cognitive impairment; Cut off; Diagnostic test; Meta-analysis

DOI：

10.7507/1672-2531.202302088

Video：

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Objective To systematically review the accuracy of the mini-mental state examination scale (MMSE) in the screening of poststroke cognitive impairment (PSCI), and the diagnostic value of different cut-off values of the scale, so as to provide references for the selection of the threshold of the MMSE scale. Methods Databases including PubMed, EMbase, Cochrane Library, Web of Science, CINAHL, CBM, VIP, CNKI, and WanFang data were searched for diagnostic tests about MMSE for PSCI from inception to November 2022. Two researchers independently screened the literatures, extracted data and assessed the risk of bias of the included studies. Then, meta-analysis was performed by Stata 16.0 software. Results A total of 23 studies involving 1 525 patients were included. The results of meta-analysis showed that after the analysis of bivariate mixed effect model, the optimal cutoff value of MMSE scale was 23/24 (the pooled sensitivity=0.75, 95%CI 0.52 to 0.89; the pooled Specificity=0.90, 95%CI 0.81 to 0.95; DOR=28, 95%CI 12 to 65; AUC=0.92, 95%CI 0.89 to 0.94). The results of hierarchical summary receiver-operating characteristic (HSROC) curve model showed that the pooled sensitivity=0.77, 95%CI 0.70 to 0.83; the pooled specificity=0.76, 95%CI 0.69 to 0.83, Beta=0.1, 95%CI −0.13 to 0.33, Z=0.82, P=0.41, Lambda=2.38, 95%CI 2.12 to 2.64, and the area under the SROC curve was 0.84. Fagan pre-test probability was 38%, positive likelihood ratio was 3.3, positive post-test probability was 67%, negative likelihood ratio was 0.3,negative post-test probability was 16%. Conclusion The current evidence shows that MMSE has a certain diagnostic value as a screening tool for PSCI, the overall diagnostic efficacy is moderate, and the diagnostic value is highest when the cut-off value is 23/24. Due to the limited quality and quantity of the included studies, more high quality studies are required to verify the above conclusion.

Citation： WU Tingting, CHEN Xiaoli, WEI Xiaoqin, QIAN Xiaoling, ZHANG Ziyao, HAN Lin, MA Yuxia. The diagnostic accuracy of MMSE in patients with post-stroke cognitive impairment: a meta-analysis. Chinese Journal of Evidence-Based Medicine, 2023, 23(8): 923-929. doi: 10.7507/1672-2531.202302088 Copy

1.	汪凯, 董强, 郁金泰, 等. 卒中后认知障碍管理专家共识2021. 中国卒中杂志, 2021, 16(4): 376-389.
2.	Jokinen H, Melkas S, Ylikoski R, et al. Post-stroke cognitive impairment is common even after successful clinical recovery. Eur J Neurol, 2015, 22(9): 1288-1294.
3.	Munthe-Kaas R, Aam S, Ihle-Hansen H, et al. Impact of different methods defining post-stroke neurocognitive disorder: the Nor-COAST study. Alzheimers Dement (N Y), 2020, 6(1): e12000.
4.	曲艳吉, 卓琳, 詹思延. 中国脑卒中后认知障碍流行病学特征的系统评价. 中华老年心脑血管病杂志, 2013, 15(12): 1294-1301.
5.	Maya D, Boyko S, Margarita A, et al. Post-stroke cognitive impairment – phenomenologu and prognostic factors. J of IMAB, 2012, 18(3): 290-297.
6.	Hommel M, Miguel ST, Naegele B, et al. Cognitive determinants of social functioning after a first ever mild to moderate stroke at vocational age. J Neurol Neurosurg Psychiatry, 2009, 80(8): 876-880.
7.	Mijajlović MD, Pavlović A, Brainin M, et al. Post-stroke dementia - a comprehensive review. BMC Med, 2017, 15(1): 11.
8.	Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2016, 47(6): e98-e169.
9.	中国卒中学会, 卒中后认知障碍管理专家委员会. 卒中后认知障碍管理专家共识. 中国卒中杂志, 2017, 12(6): 519-531.
10.	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(3): 189-198.
11.	Shen YJ, Wang WA, Huang FD, et al. The use of MMSE and MoCA in patients with acute ischemic stroke in clinical. Int J Neurosci, 2016, 126(5): 442-447.
12.	Cumming TB, Churilov L, Linden T, et al. Montreal cognitive assessment and mini-mental state examination are both valid cognitive tools in stroke. Acta Neurol Scand, 2013, 128(2): 122-129.
13.	Whiting PF, Rutjes AW, Westwood ME, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med, 2011, 155(8): 529-536.
14.	张天嵩, 熊茜. HSROC模型在诊断试验Meta分析中的应用及Stata实现. 循证医学, 2012, 12(4): 241-243, 247.
15.	Reitsma JB, Glas AS, Rutjes AW, et al. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol, 2005, 58(10): 982-990.
16.	Deeks JJ, Macaskill P, Irwig L. The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol, 2005, 58(9): 882-893.
17.	王延平, 徐桂兰, 杨少青, 等. 蒙特利尔认知评估量表识别首次卒中后轻度血管性认知障碍的作用. 中华神经医学杂志, 2010, 9(5): 503-507.
18.	粟珺, 陈婷, 陈李芳, 等. MoCA-B和MMSE对首发急性脑卒中患者认知功能障碍筛查作用的比较. 中国神经精神疾病杂志, 2019, (2): 72-75.
19.	雷军. MoCA与MMSE在缺血性脑卒中患者认知功能改变中的应用价值. 中国实用神经疾病杂志, 2016, 19(8): 26-29.
20.	金花, 刘国利, 姜彩霞, 等. 不同量表对首发脑小血管闭塞性卒中患者早期认知功能评价的比较. 中国老年学杂志, 2020, 40(10): 2029-2032.
21.	王慕秋, 任明山. 蒙特利尔认知评估量表在缺血性脑卒中人群中的应用价值探讨. 中国临床神经科学, 2012, 20(2): 199-204.
22.	袁正洲, 马勋泰, 王雪梅, 等. 长沙版蒙特利尔认知评估量表在腔隙性脑梗死后认知功能障碍筛查中的应用. 第三军医大学学报, 2012, 34(19): 2025-2027.
23.	袁正洲, 李作孝, 李经伦, 等. 长沙版蒙特利尔认知评估量表在血管性认知功能障碍中应用的初步研究. 重庆医学, 2014, 43(2): 132-135.
24.	Dong Y, Slavin MJ, Chan BP, et al. Improving screening for vascular cognitive impairment at three to six months after mild ischemic stroke and transient ischemic attack. Int Psychogeriatr, 2014, 26(5): 787-793.
25.	Dong Y, Venketasubramanian N, Chan BP, et al. Brief screening tests during acute admission in patients with mild stroke are predictive of vascular cognitive impairment 3-6 months after stroke. J Neurol Neurosurg Psychiatry, 2012, 83(6): 580-585.
26.	Pendlebury ST, Mariz J, Bull L, et al. MoCA, ACE-R, and MMSE versus the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards Neuropsychological Battery after TIA and stroke. Stroke, 2012, 43(2): 464-469.
27.	Godefroy O, Fickl A, Roussel M, et al. Is the Montreal cognitive assessment superior to the mini-mental state examination to detect poststroke cognitive impairment? A study with neuropsychological evaluation. Stroke, 2011, 42(6): 1712-1716.
28.	Wong GK, Lam SW, Wong A, et al. Comparison of montreal cognitive assessment and mini-mental state examination in evaluating cognitive domain deficit following aneurysmal subarachnoid haemorrhage. PLoS One, 2013, 8(4): e59946.
29.	Zhu Y, Zhao S, Fan Z, et al. Evaluation of the mini-mental state examination and the montreal cognitive assessment for predicting post-stroke cognitive impairment during the acute phase in Chinese minor stroke patients. Front Aging Neurosci, 2020, 12: 236.
30.	Xu Y, Yi L, Lin Y, et al. Screening for cognitive impairment after stroke: validation of the Chinese version of the quick mild cognitive impairment screen. Front Neurol, 2021, 12: 608188.
31.	Fure B, Bruun Wyller T, Engedal K, et al. Cognitive impairments in acute lacunar stroke. Acta Neurol Scand, 2006, 114(1): 17-22.
32.	Grace J, Nadler JD, White DA, et al. Folstein vs. modified mini-mental state examination in geriatric stroke. Stability, validity, and screening utility. Arch Neurol, 1995, 52(5): 477-484.
33.	Bour A, Rasquin S, Boreas A, et al. How predictive is the MMSE for cognitive performance after stroke?. J Neurol, 2010, 257(4): 630-637.
34.	Morris K, Hacker V, Lincoln NB. The validity of the Addenbrooke's Cognitive Examination-Revised (ACE-R) in acute stroke. Disabil Rehabil, 2012, 34(3): 189-195.
35.	Nys GM, van Zandvoort MJ, de Kort PL, et al. Restrictions of the mini-mental state examination in acute stroke. Arch Clin Neuropsychol, 2005, 20(5): 623-629.
36.	Custodio N, Montesinos R, Alva-Diaz C, et al. Diagnostic accuracy of brief cognitive screening tools to diagnose vascular cognitive impairment in Peru. Int J Geriatr Psychiatry, 2022, 37(1): 278.
37.	Xu Q, Cao WW, Mi JH, et al. Brief screening for mild cognitive impairment in subcortical ischemic vascular disease: a comparison study of the montreal cognitive assessment with the mini-mental state examination. Eur Neurol, 2014, 71(3-4): 106-114.
38.	Pendlebury ST, Cuthbertson FC, Welch SJ, et al. Underestimation of cognitive impairment by mini-mental state examination versus the montreal cognitive assessment in patients with transient ischemic attack and stroke: a population-based study. Stroke, 2010, 41(6): 1290-1293.
39.	Lees R, Selvarajah J, Fenton C, et al. Test accuracy of cognitive screening tests for diagnosis of dementia and multidomain cognitive impairment in stroke. Stroke, 2014, 45(10): 3008-3018.
40.	Shi D, Chen X, Li Z. Diagnostic test accuracy of the montreal cognitive assessment in the detection of post-stroke cognitive impairment under different stages and cutoffs: a systematic review and meta-analysis. Neurol Sci, 2018, 39(4): 705-716.
41.	中国卒中学会卒中后认知障碍研究圆桌会议专家组. 中国卒中后认知障碍防治研究专家共识. 中国卒中杂志, 2020, 15(2): 158-166.
42.	Ciesielska N, Sokołowski R, Mazur E, et al. Is the montreal cognitive assessment (MoCA) test better suited than the mini-mental state examination (MMSE) in mild cognitive impairment (MCI) detection among people aged over 60? Meta-analysis. Psychiatr Pol, 2016, 50(5): 1039-1052.

1. 汪凯, 董强, 郁金泰, 等. 卒中后认知障碍管理专家共识2021. 中国卒中杂志, 2021, 16(4): 376-389.
2. Jokinen H, Melkas S, Ylikoski R, et al. Post-stroke cognitive impairment is common even after successful clinical recovery. Eur J Neurol, 2015, 22(9): 1288-1294.
3. Munthe-Kaas R, Aam S, Ihle-Hansen H, et al. Impact of different methods defining post-stroke neurocognitive disorder: the Nor-COAST study. Alzheimers Dement (N Y), 2020, 6(1): e12000.
4. 曲艳吉, 卓琳, 詹思延. 中国脑卒中后认知障碍流行病学特征的系统评价. 中华老年心脑血管病杂志, 2013, 15(12): 1294-1301.
5. Maya D, Boyko S, Margarita A, et al. Post-stroke cognitive impairment – phenomenologu and prognostic factors. J of IMAB, 2012, 18(3): 290-297.
6. Hommel M, Miguel ST, Naegele B, et al. Cognitive determinants of social functioning after a first ever mild to moderate stroke at vocational age. J Neurol Neurosurg Psychiatry, 2009, 80(8): 876-880.
7. Mijajlović MD, Pavlović A, Brainin M, et al. Post-stroke dementia - a comprehensive review. BMC Med, 2017, 15(1): 11.
8. Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2016, 47(6): e98-e169.
9. 中国卒中学会, 卒中后认知障碍管理专家委员会. 卒中后认知障碍管理专家共识. 中国卒中杂志, 2017, 12(6): 519-531.
10. 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(3): 189-198.
11. Shen YJ, Wang WA, Huang FD, et al. The use of MMSE and MoCA in patients with acute ischemic stroke in clinical. Int J Neurosci, 2016, 126(5): 442-447.
12. Cumming TB, Churilov L, Linden T, et al. Montreal cognitive assessment and mini-mental state examination are both valid cognitive tools in stroke. Acta Neurol Scand, 2013, 128(2): 122-129.
13. Whiting PF, Rutjes AW, Westwood ME, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med, 2011, 155(8): 529-536.
14. 张天嵩, 熊茜. HSROC模型在诊断试验Meta分析中的应用及Stata实现. 循证医学, 2012, 12(4): 241-243, 247.
15. Reitsma JB, Glas AS, Rutjes AW, et al. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol, 2005, 58(10): 982-990.
16. Deeks JJ, Macaskill P, Irwig L. The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol, 2005, 58(9): 882-893.
17. 王延平, 徐桂兰, 杨少青, 等. 蒙特利尔认知评估量表识别首次卒中后轻度血管性认知障碍的作用. 中华神经医学杂志, 2010, 9(5): 503-507.
18. 粟珺, 陈婷, 陈李芳, 等. MoCA-B和MMSE对首发急性脑卒中患者认知功能障碍筛查作用的比较. 中国神经精神疾病杂志, 2019, (2): 72-75.
19. 雷军. MoCA与MMSE在缺血性脑卒中患者认知功能改变中的应用价值. 中国实用神经疾病杂志, 2016, 19(8): 26-29.
20. 金花, 刘国利, 姜彩霞, 等. 不同量表对首发脑小血管闭塞性卒中患者早期认知功能评价的比较. 中国老年学杂志, 2020, 40(10): 2029-2032.
21. 王慕秋, 任明山. 蒙特利尔认知评估量表在缺血性脑卒中人群中的应用价值探讨. 中国临床神经科学, 2012, 20(2): 199-204.
22. 袁正洲, 马勋泰, 王雪梅, 等. 长沙版蒙特利尔认知评估量表在腔隙性脑梗死后认知功能障碍筛查中的应用. 第三军医大学学报, 2012, 34(19): 2025-2027.
23. 袁正洲, 李作孝, 李经伦, 等. 长沙版蒙特利尔认知评估量表在血管性认知功能障碍中应用的初步研究. 重庆医学, 2014, 43(2): 132-135.
24. Dong Y, Slavin MJ, Chan BP, et al. Improving screening for vascular cognitive impairment at three to six months after mild ischemic stroke and transient ischemic attack. Int Psychogeriatr, 2014, 26(5): 787-793.
25. Dong Y, Venketasubramanian N, Chan BP, et al. Brief screening tests during acute admission in patients with mild stroke are predictive of vascular cognitive impairment 3-6 months after stroke. J Neurol Neurosurg Psychiatry, 2012, 83(6): 580-585.
26. Pendlebury ST, Mariz J, Bull L, et al. MoCA, ACE-R, and MMSE versus the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards Neuropsychological Battery after TIA and stroke. Stroke, 2012, 43(2): 464-469.
27. Godefroy O, Fickl A, Roussel M, et al. Is the Montreal cognitive assessment superior to the mini-mental state examination to detect poststroke cognitive impairment? A study with neuropsychological evaluation. Stroke, 2011, 42(6): 1712-1716.
28. Wong GK, Lam SW, Wong A, et al. Comparison of montreal cognitive assessment and mini-mental state examination in evaluating cognitive domain deficit following aneurysmal subarachnoid haemorrhage. PLoS One, 2013, 8(4): e59946.
29. Zhu Y, Zhao S, Fan Z, et al. Evaluation of the mini-mental state examination and the montreal cognitive assessment for predicting post-stroke cognitive impairment during the acute phase in Chinese minor stroke patients. Front Aging Neurosci, 2020, 12: 236.
30. Xu Y, Yi L, Lin Y, et al. Screening for cognitive impairment after stroke: validation of the Chinese version of the quick mild cognitive impairment screen. Front Neurol, 2021, 12: 608188.
31. Fure B, Bruun Wyller T, Engedal K, et al. Cognitive impairments in acute lacunar stroke. Acta Neurol Scand, 2006, 114(1): 17-22.
32. Grace J, Nadler JD, White DA, et al. Folstein vs. modified mini-mental state examination in geriatric stroke. Stability, validity, and screening utility. Arch Neurol, 1995, 52(5): 477-484.
33. Bour A, Rasquin S, Boreas A, et al. How predictive is the MMSE for cognitive performance after stroke?. J Neurol, 2010, 257(4): 630-637.
34. Morris K, Hacker V, Lincoln NB. The validity of the Addenbrooke's Cognitive Examination-Revised (ACE-R) in acute stroke. Disabil Rehabil, 2012, 34(3): 189-195.
35. Nys GM, van Zandvoort MJ, de Kort PL, et al. Restrictions of the mini-mental state examination in acute stroke. Arch Clin Neuropsychol, 2005, 20(5): 623-629.
36. Custodio N, Montesinos R, Alva-Diaz C, et al. Diagnostic accuracy of brief cognitive screening tools to diagnose vascular cognitive impairment in Peru. Int J Geriatr Psychiatry, 2022, 37(1): 278.
37. Xu Q, Cao WW, Mi JH, et al. Brief screening for mild cognitive impairment in subcortical ischemic vascular disease: a comparison study of the montreal cognitive assessment with the mini-mental state examination. Eur Neurol, 2014, 71(3-4): 106-114.
38. Pendlebury ST, Cuthbertson FC, Welch SJ, et al. Underestimation of cognitive impairment by mini-mental state examination versus the montreal cognitive assessment in patients with transient ischemic attack and stroke: a population-based study. Stroke, 2010, 41(6): 1290-1293.
39. Lees R, Selvarajah J, Fenton C, et al. Test accuracy of cognitive screening tests for diagnosis of dementia and multidomain cognitive impairment in stroke. Stroke, 2014, 45(10): 3008-3018.
40. Shi D, Chen X, Li Z. Diagnostic test accuracy of the montreal cognitive assessment in the detection of post-stroke cognitive impairment under different stages and cutoffs: a systematic review and meta-analysis. Neurol Sci, 2018, 39(4): 705-716.
41. 中国卒中学会卒中后认知障碍研究圆桌会议专家组. 中国卒中后认知障碍防治研究专家共识. 中国卒中杂志, 2020, 15(2): 158-166.
42. Ciesielska N, Sokołowski R, Mazur E, et al. Is the montreal cognitive assessment (MoCA) test better suited than the mini-mental state examination (MMSE) in mild cognitive impairment (MCI) detection among people aged over 60? Meta-analysis. Psychiatr Pol, 2016, 50(5): 1039-1052.

Chinese Journal of Evidence-Based Medicine

The diagnostic accuracy of MMSE in patients with post-stroke cognitive impairment: a meta-analysis

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