Item and Scale Differential Functioning of the Mini-Mental State Exam Assessed Using the Differential Item and Test Functioning (DFIT) Framework

Objectives: To illustrate the application of the Differential Item and Test Functioning (DFIT) method using English and Spanish versions of the Mini-Mental State Examination (MMSE). Subjects: Study participants were 65 years of age or older and lived in North Manhattan, New York. Of the 1578 study participants who were administered the MMSE 665 completed it in Spanish. Measures: The MMSE contains 20 items that measure the degree of cognitive impairment in the areas of orientation, attention and calculation, registration, recall and language, as well as the ability to follow verbal and written commands. Research Design: After assessing the dimensionality of the MMSE scale, item response theory person and item parameters were estimated separately for the English and Spanish sample using Samejima's 2-parameter graded response model. Then the DFIT framework was used to assess differential item functioning (DIF) and differential test functioning (DTF). Results: Nine items were found to show DIF; these were items that ask the respondent to name the correct season, day of the month, city, state, and 2 nearby streets, recall 3 objects, repeat the phrase no ifs, no ands, no buts, follow the command, "close your eyes," and the command, the paper in your right hand, fold the paper in half with both hands, and put the paper down in your lap." At the scale level, however, the MMSE did not show differential functioning. Conclusions: Respondents to the English and Spanish versions of the MMSE are comparable on the basis of scale scores. However, assessments based on individual MMSE items may be misleading.