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45 Years of the mini-mental state examination (MMSE): A perspective from ibero-america

45 AÑOS DEL MINI-MENTAL STATE EXAMINATION (MMSE): UNA PERSPECTIVA HISTÓRICA DESDE IBEROAMÉRICA

ABSTRACT

The Mini-Mental State Examination (MMSE) was created by Marshal Folstein et al. in 1975 as an instrument for brief (5–10 min) assessment of mental status in hospitalized patients. It is considered the most widely used test for standardized cognitive assessment in the clinical setting, especially with the elderly population. It has countless translations in different languages, and according to the different international (PubMed) and regional (SciELO, Redalyc, and Dialnet) scientific databases, it has been widely used by the scientific community. This article describes the historical evolution of the MMSE, highlights its evaluative properties, and provides bibliometric data on its impact on scientific publications, with a special focus on Ibero-America.

Keywords:
Mental Status and Dementia Tests; History; Neuropsychology; Cognition; Latin America

RESUMO

El Mini-mental State Examination (MMSE) fue creado por Marshal Folstein et al. en 1975 como un instrumento para la evaluación breve (5-10 minutos) del estado mental de pacientes hospitalizados. Se lo considera la prueba más utilizada para la evaluación cognitiva estandarizada en el ámbito clínico, especialmente con la población adulta mayor. Tiene innumerables traducciones a diferentes idiomas y de acuerdo con las diferentes bases de datos científicas internacionales (PudMed) y regionales (Scielo, Redalyc y Dialnet) se puede constatar que ha sido ampliamente utilizada por la comunidad científica. En este trabajo se describe la evolución histórica del MMSE, se destacan sus propiedades evaluativas y se indican datos bibliométricos acerca de su impacto en las publicaciones científicas, con especial énfasis en IberoAmérica.

Palabras Clave:
Pruebas de Estado Mental y Demencia; Historia; Neuropsicología; Cognición; América Latina

INTRODUCTION

It has just been 45 years since the publication of the Mini-Mental State Examination (MMSE): a brief assessment of cognitive performance11 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):189-98. https://doi.org/10.1016/0022-3956(75)90026-6
https://doi.org/10.1016/0022-3956(75)900...
. The first construction of systematic, scientifically rigorous, psychological, and/or neuropsychological assessment instruments took place during the 20th century, even though there has always existed throughout human thought a need for the identification and description of psychological functions, such as character, temperament, personality, and intelligence22 Gould SJ. The mismeasure of man. New York: W.W. Norton & Co; 1981..

In this article, we give a brief history of the MMSE, detailing its advantages and disadvantages, and how it has impacted the neuroscientific community internationally, with a special emphasis on Ibero-America. Regional and international data are presented. The idea is to present a historical overview of the test, but not an in-depth review of all of its aspects, since there are several systematic reviews that could be consulted for this purpose — several of which are mentioned in this article.

Function of the MMSE

This test was designed for brief application due to the excessive length of the existing tests in the mid-1970s33 Mossello E, Boncinelli M. Mini-mental state examination: a 30-year story. Aging Clin Exp Res. 2006; 18(4):271-3. https://doi.org/10.1007/BF03324660
https://doi.org/10.1007/BF03324660...
. It focused on strictly cognitive issues, leaving out questions related to psychiatric disorders or behavior. Despite its minor modifications over time, the test still consists of two parts. The first part evaluates questions related to orientation, memory, and attention, and the second part assesses verbal and written ability (requiring pencil and paper).

It is a test that has become one of the most widely used internationally for the diagnosis and clinical prognosis of cognitive impairment, mainly in elderly patients. An adaptation of the test given by telephone has even been created44 Brandt J, Spencer M, Folstein M. The telephone interview for cognitive status. Neuropsychiatry, Neuropsychology and Behavioral Neurology. 1988;1(2):111-7.. Recently, its performance as a tele-neuropsychological test was evaluated and indicated that there are no substantial differences when applied traditionally or remotely55 Carotenuto A, Traini E, Fasanaro AM, Battineni G, Amenta F. Tele-neuropsychological assessment of Alzheimer’s disease. J Pers Med. 2021;11(8):688. https://doi.org/10.3390/jpm11080688
https://doi.org/10.3390/jpm11080688...
.

Throughout its history, a series of advantages and disadvantages have been discovered. Its international acceptance and application, easy administration, short duration, application to large samples, and free access are among some of its advantages. Among the disadvantages are the multiplicity of versions, lack of exploration of all cognitive domains, lack of copyright for several years, and lack of sensitivity to cultural variations and the school level of the participants66 Llamas-Velasco S, Llorente-Ayuso L, Contador I, Bermejo-Pareja F. Versiones en español del Minimental State Examination (MMSE). Cuestiones para su uso en la práctica clinica. Rev Neurol. 2015;61(8):363-71.1010 Kochhann R, Cerveira MO, Godinho C, Camozzato A, Chaves MLF. Evaluation of Mini-Mental State Examination scores according to different age and education strata, and sex, in a large Brazilian healthy sample. Dement Neuropsychol. 2009;3(2):88-93. https://doi.org/10.1590/S1980-57642009DN30200004
https://doi.org/10.1590/S1980-57642009DN...
.

The creators of the MMSE have recognized the importance of these criticisms and have attempted to improve the original version through increased precision and an indication of the need to comply with copyright; therefore, it is no longer available through public access and thus there is greater control over new translations and adaptations1111 Folstein M, Folstein S. Invited reply to “The death knoll for the MMSE: has it outlived its purpose?” J Geriatr Psychiatry Neurol. 2010;23(3):158-9. https://doi.org/10.1177/0891988710375213
https://doi.org/10.1177/0891988710375213...
.

The international dissemination of the MMSE

Folstein’s work has been reported to be among the 50 most cited articles in the Web of Science database during the 20th century, receiving 15,000 citations as of January 200433 Mossello E, Boncinelli M. Mini-mental state examination: a 30-year story. Aging Clin Exp Res. 2006; 18(4):271-3. https://doi.org/10.1007/BF03324660
https://doi.org/10.1007/BF03324660...
and 19,721 citations up to February 20071212 Nilsson FM. Mini Mental State Examination (MMSE) – probably one of the most cited papers in health science. Acta Psychiatr Scand. 2007; 116(2):156-7. https://doi.org/10.1111/j.1600-0447.2007.01037.x
https://doi.org/10.1111/j.1600-0447.2007...
. A more recent study found 29,057 citations up to December 31, 20121313 Carnero-Pardo C. Should the mini-mental state examination be retired? Neurologia. 2014; 29(8):473-81. https://doi.org/10.1016/j.nrl.2013.07.003
https://doi.org/10.1016/j.nrl.2013.07.00...
. It is also a test that has more than 70 translations into different languages66 Llamas-Velasco S, Llorente-Ayuso L, Contador I, Bermejo-Pareja F. Versiones en español del Minimental State Examination (MMSE). Cuestiones para su uso en la práctica clinica. Rev Neurol. 2015;61(8):363-71.. As of August 18, 2021, in the international database PubMed, 20,032 related documents were retrieved for the keyword “MMSE.” Notably, 262 documents were retrieved with this keyword in the regional SciELO database. Table 1 shows the 10 journals with the highest number of mentions of MMSE.

Table 1
Journals containing articles on the MMSE.

Two Brazilian journals have the highest concentration of these publications (109) according to the SciELO database, which has a predominance of Brazilian journals. However, a search of the Dialnet database, whose coverage is more Ibero-American, retrieved 298 articles, 109 theses, 3 book chapters, and 1 book related to the MMSE. Meanwhile, a search of the Redalyc database, with Latin American coverage, resulted in 376 articles: 221 in Spanish, 86 in English, and 69 in Portuguese. The disciplines referencing MMSE the most, according to Redalyc, are psychology with 146 papers, medicine with 138 papers, and health with 50 papers.

Different review papers on the MMSE have highlighted its wide use in cognitive assessment worldwide33 Mossello E, Boncinelli M. Mini-mental state examination: a 30-year story. Aging Clin Exp Res. 2006; 18(4):271-3. https://doi.org/10.1007/BF03324660
https://doi.org/10.1007/BF03324660...
,99 Brucki SMD, Nitrini R. Mini-Mental State Examination among lower educational levels and illiterates: transcultural evaluation. Dement Neuropsychol. 2010;4(2):120-5. https://doi.org/10.1590/S1980-57642010DN40200008
https://doi.org/10.1590/S1980-57642010DN...
,1414 Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992;40(9):922-35. https://doi.org/10.1111/j.1532-5415.1992.tb01992.x
https://doi.org/10.1111/j.1532-5415.1992...
. As noted, there have been several translations and adaptations of the instrument to various national contexts, and in several cases, different versions can be found, some validated and others not validated, as is the case with the Spanish-language versions for Latin America and Spain. This situation has made it difficult to compare the results of this instrument55 Carotenuto A, Traini E, Fasanaro AM, Battineni G, Amenta F. Tele-neuropsychological assessment of Alzheimer’s disease. J Pers Med. 2021;11(8):688. https://doi.org/10.3390/jpm11080688
https://doi.org/10.3390/jpm11080688...
. Comparisons can also be difficult due to cultural differences, for example, between applications in Spanish-speaking Latin America and Spanish-speaking communities in the United States1515 Allegri RF, Ollari JA, Mangone CA, Arizaga RL, De Pascale A, Pellegrini M, et al. El “Mini Mental State Examination” en la Argentina: instrucciones para su administración. Rev Neurol Arg. 1999;24(1):31-5.,1616 Escobar JI, Burnam A, Karno M, Forsythe A, Landsverk J, Golding JM. Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts. J Nerv Ment Dis. 1986;174(10):607-14. https://doi.org/10.1097/00005053-198610000-00005
https://doi.org/10.1097/00005053-1986100...
.

The first MMSE was created in Spain in the 1970s; since then, multiple validation efforts have been made1717 Lobo A, Saz P, Marcos G, Día JL, de la Cámara C, Ventura T, et al. Revalidation and standardization of the cognition mini-exam (first Spanish version of the Mini-Mental Status Examination) in the general geriatric population. Med Clin (Barc). 1999;112(20):767-74. PMID: 10422057. However, despite Spanish being a common language to several countries, it is necessary to create regional versions, for example, in a country like Argentina, where there are normative references for different regions1515 Allegri RF, Ollari JA, Mangone CA, Arizaga RL, De Pascale A, Pellegrini M, et al. El “Mini Mental State Examination” en la Argentina: instrucciones para su administración. Rev Neurol Arg. 1999;24(1):31-5.,1818 Butman J, Arizaga RL, Harris P, Drake M, Baumann D, De Pascale A, et al. El “Mini-Mental State Examination” en Español. Normas para Buenos Aires. Rev Neurol Arg. 2001;26(1):11-5.2121 Martino PL, Cervigni MA, Infante L, Audisio EO, Politis DG. Mini Mental State Examination (MMSE): normative data for the Rosario metropolitan area, Argentina. Vertex. 2020;15(147):1-8. PMID: 33890924.

In the Portuguese-language setting, and particularly in Brazil, the wide use and the existence of different versions of the MMSE have also been documented2222 Almeida OP. Mini exame dos estado mental e o diagnóstico de demência no Brasil. Arq Neuropsiquiatr. 1998;56(3B):605-12. https://doi.org/10.1590/S0004-282X1998000400014
https://doi.org/10.1590/S0004-282X199800...
2525 Santiago-Bravo G, Sudo FK, Assunção N, Drummond C, Mattos P. Dementia screening in Brazil: a systematic review of normative data for the mini-mental state examination. Clinics (Sao Paulo). 2019;74:e971. https://doi.org/10.6061/clinics/2019/e971
https://doi.org/10.6061/clinics/2019/e97...
, with 11 versions created for the study of elderly people, according to a review of September 20132626 Melo DM, Barbosa AJG. O uso do Mini-Exame do Estado Mental em pesquisas com idosos no Brasil: uma revisão sistemática. Ciên Saúde Colet. 2015;20(12):3865-76. https://doi.org/10.1590/1413-812320152012.06032015
https://doi.org/10.1590/1413-81232015201...
. However, according to this review, the most widely used version in Brazil was published by Bertolucci et al.2727 Bertolucci PHF, Brucki SMD, Campacci SR, Juliano Y. O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr. 1994;52(1):1-7. https://doi.org/10.1590/S0004-282X1994000100001
https://doi.org/10.1590/S0004-282X199400...
, in the Arquivos de Neuro-Psiquiatria, in 1994. Subsequently, recommendations were made for adaptation of the measure to hospitals, private practice, and community studies2323 Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr. 2003;61(3B):777-81. https://doi.org/10.1590/S0004-282X2003000500014
https://doi.org/10.1590/S0004-282X200300...
. In Portugal, the first known translation and adaptation of the MMSE were also in 19942828 Guerreiro M, Silva AP, Botelho M, Leitão O, Castro-Caldas A, Garcia C. Adaptação à população portuguesa da tradução do Mini Mental State Examination (MMSE). Revista Portuguesa de Neurologia. 1994;1:9-10., and since then, several adaptations have been created for various populations2929 Freitas S, Simões MR, Alves L, Santana I. The relevance of sociodemographic and health variables on MMSE normative data. Appl Neuropsychol Adult. 2015;22(4):311-9. https://doi.org/10.1080/23279095.2014.926455
https://doi.org/10.1080/23279095.2014.92...
,3030 Santana I, Duro D, Lemos R, Costa V, Pereira M, Simões MR, Freitas S. Mini-Mental State Examination: avaliação dos novos dados normativos no rastreio e diagnóstico do défice cognitivo. Acta Med Port. 2016;29(4):240-8. https://doi.org/10.20344/amp.6889
https://doi.org/10.20344/amp.6889...
.

This multiplicity of versions that have been generated over time at the international level has been criticized by the authors who originated the test, and they themselves have tried to rectify this problem by providing a guidance manual and a list of authorized versions and translations3131 Folstein MF, Folstein SE, McHugh PR. Reply. Acta Psychiatrica Scandinavica. 2007;116(2):157. https://doi.org/10.1111/j.1600-0447.2007.01038.x
https://doi.org/10.1111/j.1600-0447.2007...
. The proliferation of versions reflects not only the internationalization of the MMSE but also the need for a more precise instrument in the cognitive domain which is more in line with sociocultural variations.

The different versions that were established over time (e.g., 3MS, 3MS-R, SMMSE, MMSE-12, MMSE-20, and MMSE-37)3232 Tombaugh TN. Test-retest reliable coefficients and 5-year change scores for the MMSE and 3MS. Arch Clin Neuropsychol. 2005;20(4):485-503. https://doi.org/10.1016/j.acn.2004.11.004
https://doi.org/10.1016/j.acn.2004.11.00...
3535 Van Patten R, Britton K, Tremont G. Comparing the Mini-Mental State Examination and the modified Mini-Mental State Examination in the detection of mild cognitive impairment in older adults. Int Psychogeriatr. 2019;31(5):693-701. https://doi.org/10.1017/S1041610218001023
https://doi.org/10.1017/S104161021800102...
, many of them motivated by improving the assessment of cognitive abilities and covering aspects not covered in the initial version, did not achieve the popularity of the original test. This suggests at least two issues:

  • The new versions probably did not achieve qualitatively different contributions and

  • There is a strong weight of tradition inherited from the original version.

The MMSE has also served as a model and an inspiration for the development of other tests more specific to the assessment of cognitive abilities. Some have been presented as complementary and others are considered as alternatives, for example the following: Montreal Cognitive Assessment (MoCA), Addenbrooke;s Cognitive Examination (ACE), and Mini-Cog. In general, the MMSE is often used comparatively to assess the metric properties and diagnostic value of these new tests. In fact, several comparative studies have analyzed the advantages and disadvantages of each of the different cognitive tests and suggested the best test according to the cognitive function under assessment3636 Ciesielska N, Sokołowski R, Mazur E, Podhorecka M, Polak-Szabela A, Kędziora-Kornatowska K. 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):1039-52. https://doi.org/10.12740/PP/45368
https://doi.org/10.12740/PP/45368...
3838 Milne A, Culverwell A, Guss R, Tuppen J, Whelton R. Screening for dementia in primary care: a review of the use, efficacy and quality of measures. Int Psychogeriatr. 2008;20(5):911-26. https://doi.org/10.1017/S1041610208007394
https://doi.org/10.1017/S104161020800739...
. Overall, however, beyond the discrepancy in results, the MMSE remains a widely recommended and utilized instrument, although the MoCA test has become a substantial competitor to the MMSE, given its increasing use in research undertaken in Latin America3939 Burke SL, Grudzien A, Burgess A, Rodriguez MJ, Rivera Y, Loewenstein D. The utility of cognitive screeners in the detection of dementia spectrum disorders in spanish-speaking populations. J Geriatr Psychiatry Neurol. 2021;34(2):102-18. https://doi.org/10.1177/0891988720915513
https://doi.org/10.1177/0891988720915513...
,4040 Custodio N, Duque L, Montesinos R, Alva-Diaz C, Mellado M, Slachevsky A. Systematic review of the diagnostic validity of brief cognitive screenings for early dementia detection in spanish-speaking adults in Latin America. Front Aging Neurosci. 2020;12:270. https://doi.org/10.3389/fnagi.2020.00270
https://doi.org/10.3389/fnagi.2020.00270...
.

The MMSE has become a normative test at the international level, accepted by the neuroscientific community, and recommended by the main clinical practice guidelines on the assessment of cognitive impairment, particularly in older adults. Although it is widely used to test for Alzheimer’s or other types of dementia, it should be noted that it was not designed for that purpose. Although somewhat obvious, it should also be noted that the MMSE should never be viewed as a single assessment test, but rather as a tool in the overall clinical evaluation.

Despite certain limitations that have been noted regarding the multiplicity of versions and the comparability of results for different samples, the MMSE’s efficacy as a brief test remains valid for clinical practice. In addition, its application has been extended to population studies, since it can be rapidly administered and can be administered by non-specialized personnel.

One of the most notable aspects of the historical evolution of the MMSE lies not only in its frequent and widespread use as a cognitive assessment tool worldwide (including extensively in Latin American countries) but also in the fact that it has inspired the creation of new cognitive tests, many of which have been developed as complementary or alternative tests to the MMSE.

  • This study was conducted by the Centro de Investigación en Neurociencias de Rosario, Facultad de Psicología, Universidad Nacional de Rosario, Santa Fe, Argentina.
  • Funding: none.

REFERENCES

  • 1
    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):189-98. https://doi.org/10.1016/0022-3956(75)90026-6
    » https://doi.org/10.1016/0022-3956(75)90026-6
  • 2
    Gould SJ. The mismeasure of man. New York: W.W. Norton & Co; 1981.
  • 3
    Mossello E, Boncinelli M. Mini-mental state examination: a 30-year story. Aging Clin Exp Res. 2006; 18(4):271-3. https://doi.org/10.1007/BF03324660
    » https://doi.org/10.1007/BF03324660
  • 4
    Brandt J, Spencer M, Folstein M. The telephone interview for cognitive status. Neuropsychiatry, Neuropsychology and Behavioral Neurology. 1988;1(2):111-7.
  • 5
    Carotenuto A, Traini E, Fasanaro AM, Battineni G, Amenta F. Tele-neuropsychological assessment of Alzheimer’s disease. J Pers Med. 2021;11(8):688. https://doi.org/10.3390/jpm11080688
    » https://doi.org/10.3390/jpm11080688
  • 6
    Llamas-Velasco S, Llorente-Ayuso L, Contador I, Bermejo-Pareja F. Versiones en español del Minimental State Examination (MMSE). Cuestiones para su uso en la práctica clinica. Rev Neurol. 2015;61(8):363-71.
  • 7
    Nieuwenhuis-Mark RE. The death knoll for the MMSE: has it outlived its purpose? J Geriatr Psychiatry Neurol. 2010;23(3): 151-7. https://doi.org/10.1177/0891988710363714
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    » https://doi.org/10.1590/S1980-57642010DN40200008
  • 10
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    » https://doi.org/10.1590/S1980-57642009DN30200004
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    » https://doi.org/10.1177/0891988710375213
  • 12
    Nilsson FM. Mini Mental State Examination (MMSE) – probably one of the most cited papers in health science. Acta Psychiatr Scand. 2007; 116(2):156-7. https://doi.org/10.1111/j.1600-0447.2007.01037.x
    » https://doi.org/10.1111/j.1600-0447.2007.01037.x
  • 13
    Carnero-Pardo C. Should the mini-mental state examination be retired? Neurologia. 2014; 29(8):473-81. https://doi.org/10.1016/j.nrl.2013.07.003
    » https://doi.org/10.1016/j.nrl.2013.07.003
  • 14
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    » https://doi.org/10.1111/j.1532-5415.1992.tb01992.x
  • 15
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  • 16
    Escobar JI, Burnam A, Karno M, Forsythe A, Landsverk J, Golding JM. Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts. J Nerv Ment Dis. 1986;174(10):607-14. https://doi.org/10.1097/00005053-198610000-00005
    » https://doi.org/10.1097/00005053-198610000-00005
  • 17
    Lobo A, Saz P, Marcos G, Día JL, de la Cámara C, Ventura T, et al. Revalidation and standardization of the cognition mini-exam (first Spanish version of the Mini-Mental Status Examination) in the general geriatric population. Med Clin (Barc). 1999;112(20):767-74. PMID: 10422057
  • 18
    Butman J, Arizaga RL, Harris P, Drake M, Baumann D, De Pascale A, et al. El “Mini-Mental State Examination” en Español. Normas para Buenos Aires. Rev Neurol Arg. 2001;26(1):11-5.
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  • 22
    Almeida OP. Mini exame dos estado mental e o diagnóstico de demência no Brasil. Arq Neuropsiquiatr. 1998;56(3B):605-12. https://doi.org/10.1590/S0004-282X1998000400014
    » https://doi.org/10.1590/S0004-282X1998000400014
  • 23
    Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr. 2003;61(3B):777-81. https://doi.org/10.1590/S0004-282X2003000500014
    » https://doi.org/10.1590/S0004-282X2003000500014
  • 24
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    » https://doi.org/10.1590/s0004-282x2008000400016
  • 25
    Santiago-Bravo G, Sudo FK, Assunção N, Drummond C, Mattos P. Dementia screening in Brazil: a systematic review of normative data for the mini-mental state examination. Clinics (Sao Paulo). 2019;74:e971. https://doi.org/10.6061/clinics/2019/e971
    » https://doi.org/10.6061/clinics/2019/e971
  • 26
    Melo DM, Barbosa AJG. O uso do Mini-Exame do Estado Mental em pesquisas com idosos no Brasil: uma revisão sistemática. Ciên Saúde Colet. 2015;20(12):3865-76. https://doi.org/10.1590/1413-812320152012.06032015
    » https://doi.org/10.1590/1413-812320152012.06032015
  • 27
    Bertolucci PHF, Brucki SMD, Campacci SR, Juliano Y. O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr. 1994;52(1):1-7. https://doi.org/10.1590/S0004-282X1994000100001
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Publication Dates

  • Publication in this collection
    29 July 2022
  • Date of issue
    Dec 2022

History

  • Received
    07 Oct 2021
  • Reviewed
    31 Mar 2022
  • Accepted
    03 May 2022
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