Mini-mental state examination as a predictor of mortality among older people referred to secondary mental healthcare

Abstract

Background: Lower levels of cognitive function have been found to be associated with higher mortality in older people, particularly in dementia, but the association in people with other mental disorders is still inconclusive.

Methods and findings: Data were analysed from a large mental health case register serving a geographic catchment of 1.23 million residents, and associations were investigated between cognitive function measured by the Mini-Mental State Examination (MMSE) and survival in patients aged 65 years old and over. Cox regressions were carried out, adjusting for age, gender, psychiatric diagnosis, ethnicity, marital status, and area-level socioeconomic index. A total of 6,704 subjects were involved, including 3,368 of them having a dementia diagnosis and 3,336 of them with depression or other diagnoses. Descriptive outcomes by Kaplan-Meier curves showed significant differences between those with normal and impaired cognitive function (MMSE score<25), regardless of a dementia diagnosis. As a whole, the group with lower cognitive function had an adjusted hazard ratio (HR) of 1.42 (95% CI: 1.28, 1.58) regardless of diagnosis. An HR of 1.23 (95% CI: 1.18, 1.28) per quintile increment of MMSE was also estimated after confounding control. A linear trend of MMSE in quintiles was observed for the subgroups of dementia and other non-dementia diagnoses (both p-values<0.001). However, a threshold effect of MMSE score under 20 was found for the specific diagnosis subgroups of depression.

Conclusion: Current study identified an association between cognitive impairment and increased mortality in older people using secondary mental health services regardless of a dementia diagnosis. Causal pathways between this exposure and outcome (for example, suboptimal healthcare) need further investigation.

Figure 1. Diagram of sample selection and diagnosis subgroups.

Figure 2. Kaplan–Meier curves comparing groups with and without cognitive impairment (MMSE<25) among subjects with dementia (left, n = 3,336), depression (middle, n = 1,129), and other diagnoses (right, n = 2,207).

Footnote: Shaded areas present 95% confidence intervals; all the p-values for log-rank tests <0.01.

Figure 3. Adjusted associations Mini-Mental State Examination score and mortality in subjects with dementia (left, n = 3,368), depression (middle, n = 1,129), and other diagnoses (right, n = 2,207).

Footnote: All were adjusted for age at assessment, gender, ethnicity group, marital status, and index of deprivation score. Hazard ratio per unit increment for quintiles = 1.26 (95% CI 1.18–1.34; p-value<0.01), 1.21 (95% CI 1.10–1.34; p-value<0.01), and 1.18 (95% CI 1.10–1.27; p-value<0.01).