INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2009; 24: 1429–1437.

Published online 20 April 2009 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/gps.2282

The MMSE orientation for time domain is a strong predictor

of subsequent cognitive decline in the elderly
Elizabeth Guerrero-Berroa 1,2,3*, Xiaodong Luo 1,2, James Schmeidler 1, Michael A. Rapp 1,4,
Karen Dahlman 1, Hillel T. Grossman 1, Vahram Haroutunian 1,2 and Michal Schnaider Beeri 1
1
Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
2
James J. Peters VA Medical Center, Bronx, NY, USA
3
Neuropsychology Subprogram, Department of Psychology, Queens College and The Graduate Center of the City
University of New York, Flushing, NY, USA
4
Geriatric Psychiatry Center, Department of Psychiatry, Charité Campus Mitte, Humboldt University, Berlin, Germany

SUMMARY
Background The mini-mental state exam (MMSE) has been used to address questions such as determination of
appropriate cutoff scores for differentiation of individuals with intact cognitive function from patients with dementia
and rate of cognitive decline. However, little is known about the relationship of performance in specific cognitive domains to
subsequent overall decline.
Objective To examine the specific and/or combined contribution of four MMSE domains (orientation for time, orientation
for place, delayed recall, and attention) to prediction of overall cognitive decline on the MMSE.
Methods Linear mixed models were applied to 505 elderly nursing home residents (mean age ¼ 85, > 12 years
education ¼ 27%; 79% F, mean follow-up ¼ 3.20 years) to examine the relationship between baseline scores of these
domains and total MMSE scores over time.
Results Orientation for time was the only domain significantly associated with MMSE decline over time. Combination of
poor delayed recall with either attention or orientation for place was associated with significantly increased decline on the
MMSE.
Conclusions The MMSE orientation for time predicts overall decline on MMSE scores over time. A good functioning
domain added to good functioning delayed recall was associated with slower rate of decline. Copyright # 2009 John Wiley
& Sons, Ltd.

key words — MMSE; cognitive domains; cognitive decline; prediction; dementia; Alzheimer’s disease

INTRODUCTION increase as the elderly population is growing older

(Mendez and Cummings, 2003). Thus, research
Cognitive decline or dementia, has become one of studies have focused on the investigation of cognitive
the major concerns in the elderly population. tests that can be sensitive to change in cognitive
Alzheimer’s disease (AD) is one of the most functioning. Since its development, the mini-mental
debilitating and prevalent forms of dementia, account- state exam (MMSE; Folstein et al., 1975) has become
ing for approximately 70% of dementia cases. It is one of the most widely used cognitive screening
characterized by progressive cognitive and functional instruments for dementia. Its items cover various areas
decline. In the United States alone two to four million of cognitive domains (e.g., orientation, memory,
people suffer from AD, and the number is expected to language, and visual construction). The MMSE has
become a widely used cognitive screening tool in both
*Correspondence to: E. Guerrero-Berroa, James J. Peters VA
clinical and research settings due to factors including
Medical Center, 130 West Kingsbridge Rd. Room# 1F-01, Bronx, its brevity and straightforward administration. Indeed,
NY 10468, USA. E-mail: [email protected] the MMSE has inspired a myriad of scientific
Received 11 July 2008
Copyright # 2009 John Wiley & Sons, Ltd. Accepted 12 February 2009
1430 e. guerrero-berroa ET AL.

questions ranging from examining appropriate MMSE MMSE domains were examined: (1) orientation for
cutoff scores for differentiation of individuals with time (month, date, year, day of week, season); (2)
intact cognitive function from patients with dementia orientation for place (building, floor, city, county,
(Monsch et al., 1995), delineation of specific perfor- state); (3) delayed recall, which was assessed by asking
mance deficits on this instrument found at different participants to recall three words (book, telephone, and
stages of AD (Ashford et al., 1989; Galasko et al., penny) that they had previously been asked to repeat and
1990; Fillenbaum et al., 1994), examining prediction memorize; and (4) attention (spelling world backward).
and rate of cognitive decline in AD (see Small et al., Our definition of good performance was indicated by a
1997; Han et al., 2000) and relating ante-mortem score equal to or greater than the median score. For
cognitive performance to post-mortem AD markers example, the possible score for the domain orientation
(Koepsell et al., 2008). for time ranges from 0 to 5, and good performance on
Much is known about the MMSE in terms of its this variable was defined by a score equal to or greater
validity as a screening tool for dementia, cutoff scores, than 3. The domains orientation for place, delayed
sensitivity of items for differentiating subjects across recall, and attention had median scores of 4, 1, and 3,
levels of dementia severity, and rate of cognitive respectively.
decline. However, little is known about the relation- The other MMSE domains were excluded either
ship of decline in specific cognitive domains such as based on previous research suggesting they tend to be
orientation, memory, or attention to the natural course affected later in the course of dementia (e.g., language
of dementia. What is the additional contribution of items; Ashford et al., 1989; Small et al., 1997; Blair
the combination of specific domains to overall cog- et al., 2007), which was one of the exclusion criteria in
nitive decline? The main goal of this study was to this study, or due to the narrow range (0–1) of possible
predict the total MMSE score over time, from the scores (repetition, reading, writing, and praxis).
scores of specific baseline MMSE domains and their
combinations.
Data analysis
Descriptive analyses were performed to describe the
METHODS
study sample. Linear mixed models were used to
Participants examine, separately, the relationships of baseline
dichotomies from four MMSE domains, and the
Participants were 505 elderly nursing home residents
interactions of the six pairs of dichotomies, with the
from the Jewish Home and Hospital (JHH) in Bronx,
total MMSE scores over time. The use of the mixed
NY and Manhattan, NY. The JHH has been an
models enabled study of the MMSE scores across time
academic affiliate of the Mount Sinai School of
while accounting for the within-subject correlation,
Medicine (MSSM) for the last 25 years. Participants
thus providing an efficient way to use all the
were part of a prospective, longitudinal study of
information from each participant. Another advantage
cognition in old age, the Clinical and Biological
of using the mixed models is that it permits analysis of
Studies of Early Alzheimer’s Disease project, at the
the unbalanced data—i.e., different numbers of
Department of Psychiatry, MSSM. Inclusion criteria
follow-up occasions or different follow-up times.
in this study were age > 60, at least two MMSE
This fits the needs of the present analysis, since the
assessments, baseline MMSE scores of 10–25 (to
number of follow-up assessments varied from 1 to
avoid ceiling and floor effects), and complete
14 and the follow-up time ranged from 0.016 to
demographic information (age, sex, and education).
12.93 years due to participant death and other attrition
The study was approved by both the MSSM and JHH
factors. All of the linear mixed models fitted in the
institutional review boards.
present analysis included random intercept (i.e., fitted
baseline) and random slope (in follow-up time), to
take into account the fact that participants have
Administration of MMSE and definition of its
different baseline MMSE scores and extents of decline
subdomains
over the follow-up period. For analyses of each
We followed standard administration protocols for the domain separately, the model included the baseline
MMSE (Folstein et al., 1975) except for the domain (above or at median relative to below), time
administration of the attention domain, which was since baseline, the interaction of the baseline domain
assessed based on spelling world backward only— with time (i.e., the effect of the baseline domain on
serial seven calculations were not assessed. Four change over time), baseline age, female sex (relative to

Copyright # 2009 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2009; 24: 1429–1437.
DOI: 10.1002/gps
 COGNITIVE DECLINE IN THE ELDERLY 1431

male), and education (under 8 years or 9 through to or below 8 years, 235 (46.35%) had 9–12 years of
12 years, relative to over 12 years). For analyses of education, and 135 (26.63%) had 13–24 years.
pairs of domains, the two baseline domains and their Table 1 shows the number of participants scoring
interaction replaced a single domain in the model. below (poor) versus at or above the median (good) in
SAS GLIMMIX package was used to fit all linear all combinations of the four cognitive domains. As
mixed models. expected, the largest numbers of participants were in
the extreme cells in which participants were either
performing poorly on all domains (n ¼ 65) or
performing well on all domains (n ¼ 66). There were
RESULTS
fewer participants in cells in which the pattern of
The mean age of participants was 84.94 (SD ¼ 7.35, performance across the different domains was mixed
range ¼ 60–104). Of the 505 participants 399 (79.01%) (e.g., two good/ two poor). The minimum was 13
were women, reflecting the old age and the residence people who performed well on delayed recall and on
type (nursing home) of the study sample. The initial orientation for place, yet performed poorly on
mean MMSE score was 19.01 (SD ¼ 4.27, range by attention and orientation for time. Table 2 shows
definition ¼ 10–25), and the mean follow-up period was baseline demographic characteristics, length of fol-
3.20 years (SD ¼ 2.28, range ¼ 0.016–12.93). Of all low-up, and MMSE scores of participants with good
participants, 137 (27.02%) had an education level equal and poor performances in different MMSE domains.

Table 1. Number of participants performing at or below the median and at or above the median in all cognitive domains

Copyright # 2009 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2009; 24: 1429–1437.
DOI: 10.1002/gps
1432 e. guerrero-berroa ET AL.

Table 2. Baseline demographic characteristics, length of follow-up, and MMSE raw scores of good and poor performers in MMSE
orientation-time, orientation-place, attention, and delayed recall domains

Orientation-time Orientation-place Attention Delayed recall

Variables Good Poor Good Poor Good Poor Good Poor

Age (years)
Mean 84.80 85.31 85.14 84.93 85.03 85.12 84.19 85.75
SD 7.43 6.94 7.44 6.95 6.47 7.96 7.75 6.63
Education (years)
Mean 11.22 10.79 11.45 10.56 10.90 11.12 11.79 9.99
SD 3.90 4.03 3.78 4.14 3.90 4.06 3.72 3.95

Sex (%)
Male 59.43 40.57 55.66 44.34 50.00 50.00 50.00 50.00
Female 51.63 48.37 50.13 49.87 55.38 44.62 44.86 55.14

Follow-up (years)
Mean 3.35 3.04 3.23 3.18 3.09 3.30 3.43 3.15
SD 2.39 2.15 2.31 2.26 2.29 2.28 2.37 2.16
MMSE
Mean 21.41 16.34 21.44 16.51 20.93 17.44 21.03 16.71
SD 3.04 3.80 2.99 3.90 3.52 4.16 3.33 3.91
n 269 236 259 246 232 273 262 221

Note: Data represent mean and standard deviations; good ¼ scores at or above the median; poor ¼ scores below the median; educ ¼
education; MMSE ¼ mini-mental state exam; n ¼ sample size.
For delayed recall: due to missing data, gender distribution does not add up to 100%.

There were no significant differences, in any of the Figure 1 compares fitted models for participants with
socio-demographic characteristics, between partici- poor and good orientation for time at baseline, in
pants with good and poor performance in any domain. which the covariates, age, gender, and education, were
Table 3 presents results of linear mixed models to evaluated at the mean levels obtained from the overall
determine whether specific MMSE domains at base- sample.
line can characterize the MMSE total scores over time, Table 4 presents results of linear mixed models to
after controlling for age (at baseline), sex, and determine whether pairs of MMSE domains at
education. In all analyses, except delayed recall when baseline can characterize the MMSE total scores over
paired with orientation for time ( p ¼ 0.04), each time, after controlling for age (at baseline), sex, and
domain was strongly positively associated with the education. In contrast to the specific domains, no
MMSE total score ( p < 0.0001). Orientation for time interaction of pairs of domains was significantly
was the only domain with a significant interaction with associated with the total score. In the analyses of
time (with less decline over time for participants with interactions of pairs of domains with time, there
good baseline orientation for time) in its analysis. were significant interactions for delayed recall with

Table 3. Linear mixed models of change in MMSE score over time based on poor performance on single cognitive domains

Domain Delayed recall Attention Orientation for time Orientation for place

Variable Estimatea p-value Estimate p-value Estimate p-value Estimate p-value

Baseline age
0.0858 0.0142
0.0971 0.0082
0.1044 0.0009
0.1249 0.0002
Female 0.0083 0.9892
0.4295 0.5035 0.2970 0.5912 0.2577 0.6578
Education  8yrs
2.4037 0.0003
1.1834 0.0988
2.4323 < 0.0001
1.5425 0.0146
9  education  12
0.6004 0.3086
0.2954 0.6359
0.4114 0.4396
0.6399 0.2538
Domain(above median) 3.5890 < 0.0001 3.3335 < 0.0001 5.2985 < 0.0001 5.0991 < 0.0001
Time
1.5682 < 0.0001
1.4579 < 0.0001
1.7799 < 0.0001
1.5517 < 0.0001
Domain*time 0.1776 0.1420
0.0951 0.4399 0.4635 0.0001 0.1054 0.3768
a
Estimates represent the extent of annual increase on the MMSE.

Copyright # 2009 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2009; 24: 1429–1437.
DOI: 10.1002/gps
 COGNITIVE DECLINE IN THE ELDERLY 1433

Figure 1. Fitted linear models for MMSE score over time according to baseline performance on orientation for time.

attention and delayed recall with orientation for place, research examining whether specific or combinations
and a trend level interaction for attention with of MMSE domains can predict cognitive decline has
orientation for time. In each interaction, participants been limited. Our analysis revealed that orientation for
who performed well on both domains declined less time was the only MMSE domain for which poor
than would have been expected from the separate baseline performance was significantly associated
effects of performing well on each domain separately. with faster rate of decline in the total MMSE score
Thus participants who scored well on both domains after controlling for age, sex, and education. Poor
had a decline that was less than or similar to the other orientation for time doubled the rate of decline in the
three combinations of good and poor baseline MMSE. Additionally, although delayed recall by itself
performance. Figure 2 compares fitted models for did not predict the rate of decline in the MMSE, when
participants with combinations of good and poor considered in combination with attention or orien-
attention and delayed recall, in which the covariates, tation for place, those performing well on both delayed
age, gender, and education, were evaluated at the recall and the other domain had slower or similar rate
overall sample mean values. of decline to those with poor or mixed baseline
For all analyses of both domains and pairs, total performance on the pair of domains.
MMSE declined over time ( p < 0.0001). With the These results are similar to those of Ashford et al.
exception of the analysis for delayed recall and (1989), who found that MMSE-orientation (e.g., date)
attention ( p ¼ 0.055), the MMSE total score decreased and delayed recall were among the earliest items to be
with increasing age. There was no association of total lost in AD. Orientation for time and place were the
MMSE with sex or education of 9 through 12 years. MMSE domains with the largest extent of change over
Education less than nine years was significantly time in patients with AD (Small et al., 1997). The
associated with lower total MMSE in all analyses that longitudinal nature, length of follow-up, and sample
did not include attention. size of this study extend those findings. Other studies
aimed at differentiating normal controls from early
dementia and in identifying the different stages of
DISCUSSION
dementia, have found that MMSE-orientation is
The MMSE is one of the most widely used cognitive impaired early in the disease process (e.g., Galasko
screening tools in dementia research; however, et al., 1990; Fillenbaum et al., 1994). Impairment in

Copyright # 2009 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2009; 24: 1429–1437.
DOI: 10.1002/gps
 1434

Table 4. Linear mixed models of change in MMSE score over time based on poor performance on pairs of cognitive domains
Domain combination Domain 1 Delayed recall Domain 1 Delayed recall Domain 1 Delayed recall Domain 1 Attention

Domain 2 Attention Domain 2 Orientation for time Domain 2 Orientation for place Domain 2 Orientation for time

Variable Estimatea p-value Estimate p-value Estimate p-value Estimate p-value

Baseline age
0.0666 0.0545
0.0872 0.0050
0.1045 0.0012
0.0875 0.0055
Female
0.2945 0.6251 0.2825 0.6022 0.2868 0.6103
0.0973 0.8600

Copyright # 2009 John Wiley & Sons, Ltd.

Education  8yrs
1.3083 0.0520
2.4971 < 0.0001
1.7151 0.0051
1.6592 0.0070
9  Education  12
0.4241 0.4690
0.4636 0.3743
0.6769 0.2119
0.3120 0.5591
Domain 1(above median) 3.4949 < 0.0001 1.6096 0.0358 3.0971 < 0.0001 2.6058 0.0003
Domain 2(above median) 3.1882 < 0.0001 4.3152 < 0.0001 4.9403 < 0.0001 4.8033 < 0.0001
Domain 1*domain 2 0.3815 0.7180 0.7939 0.4316
1.0105 0.3191 0.5168 0.5973
Time
1.3418 < 0.0001
1.8720 < 0.0001
1.4743 < 0.0001
1.5731 < 0.0001
Domain 1*time
0.2542 0.1852 0.3430 0.0911
0.1841 0.3350
0.3966 0.0338
Domain 2*time
0.3893 0.0148 0.6008 0.0001
0.1731 0.2724 0.2313 0.2128
Domain 1*domain 2*time 0.7002 0.0046
0.4012 0.1135 0.5717 0.0225 0.4247 0.0838

Domain combination Domain 1 Attention Domain 1 Orientation for time

e. guerrero-berroa

Domain 2 Orientation for place Domain 2 Orientation for place

Variable Estimate p-value Estimate p-value

ET AL.

Baseline age
0.1097 0.0010
0.1101 0.0003

Female
0.1209 0.8348 0.3854 0.4672
Education  8yrs
0.6000 0.3546
1.9999 0.0005
9  Education  12
0.4423 0.4327
0.5106 0.3165
Domain 1 2.7374 0.0002 4.3719 < 0.0001
Domain 2 4.8446 < 0.0001 3.9984 < 0.0001
Domain 1*domain 2 0.1517 0.8822
1.0233 0.3179
Time
1.5988 < 0.0001
1.7532 < 0.0001
Domain 1*time 0.0851 0.6299 0.4988 0.0045
Domain 2*time 0.3217 0.0858
0.0681 0.7335
Domain 1*domain 2*time
0.3557 0.1450
0.0008 0.9976
a
Estimates represent the extent of annual increase on the MMSE.

DOI: 10.1002/gps
Int J Geriatr Psychiatry 2009; 24: 1429–1437.
 COGNITIVE DECLINE IN THE ELDERLY 1435

Figure 2. Fitted linear models for MMSE score over time according to baseline performance on attention and delayed recall.

orientation as measured by the MMSE constitutes a strongly the progression of AD dementia as memory.
clear specific deficit, and is not due to diffused Several longitudinal studies of individuals with MCI
cognitive dysfunction. as well as persons with intact cognition found that
Such a deficit is likely to be associated with specific memory and non-memory domains can accurately
neural substrates. Animal studies have shown the predict decline to dementia (Mickes et al., 2007;
involvement of the hippocampus in the processing of Silveri et al., 2007). The present results suggest that
spatial and temporal information (Eichenbaum et al., assessment of the orientation domain is important in
1999). A clinicopathological study of AD patients investigations aimed at identifying individuals at high
found that poor performance on tasks of orientation risk of cognitive decline, and in which memory
was associated with neurofibrillary tangle densities in impairment has been the main focus. The current
the CA1 field of the hippocampus, superior parietal, findings may also have implications for clinical trials,
and posterior cingulate cortex of the right hemisphere which could benefit from enriching their sample of at-
(Giannakopoulos et al., 2000). Similarly, a more risk elderly showing deficits in orientation tasks.
recent study found that impairment in an actual navi- Delayed recall, by itself, at baseline did not predict
gation task among patients with AD and mild cogni- faster rate of decline in the MMSE. This finding is
tive impairment (MCI) was associated with right inconsistent with the myriad of neuropsychological
posterior hippocampus and parietal volumes (Delpolyi studies reporting an association between poor per-
et al., 2007). Although inconsistent with the findings formance on tests of delayed recall and cognitive
of Giannakopoulos et al. (2000) who found that both decline (Kluger et al., 1999; Lange et al., 2002;
spatial and temporal orientations were associated with Mortimer et al., 2004). It is noteworthy that, unlike
neuropathology in the CA1 field of the hippocampus, neuropsychological tests, the brevity of the MMSE-
superior parietal, and posterior cingulate cortex, the memory domain (recall of three objects) may affect its
fact that in the current study orientation for place, by sensitivity in predicting cognitive decline (this same
itself, was not associated with faster decline suggests rationale can explain the lack of sensitivity of the
that specific neural pathways may underlie different MMSE-attention domain, which was assessed by
aspects of the more general orientation domain. spelling world backward—not serial seven calcu-
Overall, the unique contribution of orientation as a lations, which is a more challenging task). Thus,
separate predictor of cognitive decline indicates that differences in study design and sample characteristics
cognitive domains other than memory may predict as (i.e., length of follow-up, number of assessments, and

Copyright # 2009 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2009; 24: 1429–1437.
DOI: 10.1002/gps
1436 e. guerrero-berroa ET AL.

severity of dementia) could explain this discrepancy.

However, the lack of longitudinal change in delayed KEYPOINTS
recall has been noted (Brooks et al., 1993; Small et al.,  Poor performance on the MMSE-orientation for
1997). Given the broad clinical utility and use of the time domain is associated with faster rate of
MMSE, the insensitivity of the MMSE’s delayed decline on total MMSE scores over time.
recall component to the prediction of cognitive decline  Good performance on the MMSE-delayed recall
or dementia progression is noteworthy. domain, in addition to good performance on
To the extent that cognitive reserve (Scarmeas et al., another domain, is associated with slower rate of
2003) is affecting the synergistic effect between decline on total MMSE scores over time.
delayed recall and other cognitive domains—e.g.,
orientation and attention (indeed, we found that
elderly with higher levels of education were less likely
to decline), these findings may indicate that delayed 15 visits. Moreover, we analyzed longitudinal data
recall, in addition to impairment of other cognitive from elderly with a wide, yet more or less normally
domains, passes the threshold of cognitive reserve and distributed, range of educational attainment and a
the individual is no longer protected against cognitive wide range of cognitive functioning without the
decline. Moreover, the fact that these interactions confounds of floor and ceiling effects.
included delayed recall (memory) and orientation may There were weaknesses in this study. It is important
imply that these two domains are acutely sensitive to to note that cognitive measures are sensitive to the
disease progression and/or extensive brain pathology. effects of culture and education (see Ponton and
Indeed, studies have shown that deficits in multiple Ardila, 1999). Performance on the MMSE is affected
domains (e.g., memory and attention) are evident in by age, educational attainment, and cultural factors
the preclinical stage of dementia (Kluger et al., 1997; (Crum et al., 1993; Monsch et al., 1995; Black et al.,
Nordlund et al., 2005). Thus it is possible that when 1999). We were able to control for age and education,
performance on MMSE memory in addition to another and still the results remained strongly significant.
domain is impaired, there may be enough evidence to However, the sample was relatively homogeneous
recommend a comprehensive dementia evaluation. ethnically (70.50% Caucasians). Future studies
A specific contribution of attention functioning in addressing these findings to other elderly populations
the prediction of cognitive decline was absent. of different ethnic/cultural backgrounds are warranted
Nonetheless, its interactions with delayed recall and (i.e., minority elderly). Another important issue is the
orientation for time show that there were contributions possibility that baseline performance in orientation for
of attention that depended on the level of performance time may differentially predict cognitive decline
of the other domain. It is important to note that the across the different types of dementia. Thus, patterns
evaluation of attention functioning is a complex of decline using the MMSE domains across the
one given the various subdivisions that comprise the different types of dementia should also be examined.
attentional processing system, which appear to be Our study is unique in that it represents one of the few
distinctively affected at different levels of dementia attempts to directly characterize rate of cognitive
severity (see Foldi et al., 2002; Silveri et al., 2007). decline over a period as long as 13 years using four
Although attention can and does affect information MMSE domains as predictors. Future research can
encoding, the present findings suggest that memory also be aimed at examining whether MMSE domains,
and attention domains are not fully dependent on each which are relatively simple, can predict cognitive
other. For example, 146/505 (28.9%) participants had decline using more sophisticated neuropsychological
good scores on attention and poor scores on delayed tests and/or clinical rating scales.
recall. Moreover, based on these results, it appears that
people who score well on a given combination of
CONFLICT OF INTEREST
domains tend to be slower decliners than those whose
performance is either generally poor or more varied None declared.
across domains (e.g., poor orientation for place and
good delayed recall).
ACKNOWLEDGEMENTS
This study has several strengths. The follow-up
period was on average 3 years, with a maximum This study was supported by NIA grants K01 AG023515–
follow-up time of 13 years. Similarly, the number of 01A2 (Dr. Beeri), AG02219 (Dr. Haroutunian), and
assessments was high, comprising a maximum of AG05138 (Dr. Sano); the Dextra Baldwin McGonagle

Copyright # 2009 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2009; 24: 1429–1437.
DOI: 10.1002/gps
 COGNITIVE DECLINE IN THE ELDERLY 1437

Foundation; and the Joseph E. and Norma G. Saul Han L, Cole M, Bellavance F, McCusker J. 2000. Tracking cognitive
Foundation. decline in Alzheimer’s disease using the mini-mental state exam-
ination: a meta-analysis. Int Psychoger 12(2): 231–247.
Kluger A, Ferris SH, Golomb J, Mittelman MS. 1999. Neuropsy-
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Copyright # 2009 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2009; 24: 1429–1437.
DOI: 10.1002/gps