Hektoen International

A Journal of Medical Humanities

“I’m really bad with numbers”: Using the mini mental status examination among farm workers in rural California

Bernardo Ng
Imperial County, California, United States


César Chávez visitas colegio César Chávez en 1974. Movimiento. 1974.

In 1975, Dr. Marshal F. Folstein and his colleagues at Tufts University published the seminal paper “Mini-mental state. A practical method for grading the cognitive state of patients for the clinician.”1 Since then, this test has been widely used by clinicians both to screen for cognitive deficits when a Major Neurocognitive Disorder (MaND) is suspected, and to measure the progress of such deficits in an individual receiving treatment. It is also used as a screening tool in clinical trials probing new molecules for the treatment of Alzheimer’s disease (AD) and has been mentioned in thousands of scientific publications. Widely used in different countries, it has been translated and standardized in various languages.

This test examines cognitive functions such as orientation, memory, attention, concentration, calculation, gnosis, praxis, and language. One of the most interesting tasks in Dr. Folstein’s test consists of subtracting the number seven from a hundred. It starts with the following instruction: “Please take 7 from 100, and take 7 from the result you get, and keeping on taking 7 from the next result, until I tell you to stop.” One of the pearls learned in training is that the typical patient with a cognitive deficit will come up with evasive answers in an attempt to prevent the examiner from realizing that he cannot respond accurately, and when challenged with the calculation test is likely to answer “I’ve never been good with numbers…”

On the other hand, Dr. Folstein’s test has been criticized for its bias against the less educated, where people can be found to have deficits that do not correspond with their level of function, the low scores representing a false positive rather than a cognitive deficit. Such persons may have never been good with numbers, but are not developing a MaND. Other tests have been proposed, but this one continues to be the most frequently used, although it may not be used enough in the Latino community.

In 1968, the Latino activist Cesar Chavez completed a twenty-five-day hunger strike advocating better wages and safer working conditions for farmers in California and neighboring states. He had become a farmer himself at the age of fifteen, and founded the United Farm Workers (UFW) union, helping workers get contracts and prevent exposure to pesticides through aggressive yet peaceful demonstrations. Though born in Arizona, he relocated to California as a child with his parents, who became “migrant workers.” He left school in seventh grade to work in the fields and help his family. Unfortunately, the UFW has lost presence, going from 80,000 members in the 1970’s to fewer than 10,000 members in the last decade.2

Migrant farm workers in California, mostly Latinos of Mexican origin, cover the geographical stretch of the state’s “inland” from Calexico (a border town with Mexico) all the way to San Jose (near San Francisco), raising grapes, melons, watermelons, onions, and other produce. During the summer temperatures in the fields of Brawley and Coachella may rise to 115 degrees Fahrenheit, obligating workers to start their shifts around 3:00 am, whereas the winters in Fresno and Merced can go as low as 6 degrees Fahrenheit.

Also not properly documented in this population is a high rate of alcohol, marijuana, and illegal drug consumption. Since 1993 I have had first-hand experience treating patients in the fields of Imperial County who, regardless of their age, consume excessive amounts of alcohol and drugs to compensate for the dehydration caused by the high temperatures, to increase their energy, or to abate pain. Regardless of the reason, many of these workers end up with some health complication associated with substance use, such as liver cirrhosis.

In the last decade, the University of California Davis has published a series of papers with the findings of the MICASA (Mexican Immigration to California: Agricultural Safety and Acculturation) study. The results reflect barriers to health such as starting work at a very young age, low levels of education, and social marginalization.3,4 In general, they manage to work, rent a house, buy a car, shop for groceries and clothes, pay utilities, and celebrate birthdays, weddings and other religious or social events. But frequently they have dropped out of school (i.e. 6th grade), and/or immigrated as adults, and are illiterate with regard to estate planning, saving for retirement, life insurance, banking and credit management, and healthcare.

The low level of education is only one of several factors that gets intertwined with other more complex factors to explain the low scores in screening tests such as the mini mental state exam. Exposure to chemicals used in agriculture such as pesticides, extreme temperatures, and alcohol and drug consumption also seem to play a role in their developing cognitive and other health issues.

The state of California has the strongest economy in the United States; and agriculture, tourism, and the technologies of information continue to be the top sources of income.5 Among these three, agriculture has the workers with the lowest educational and socioeconomic levels. This has been associated with low health literacy and self-efficacy, putting them at risk for untimely metabolic disorders (i.e. HgbA1c), cancer (i.e. mammograms, pap smears), cognitive disorders, and other preventable diseases such as high blood pressure.7 As an under-represented group in the US social structure, Latinos have a much lower income than Non-Hispanic Whites. Currently, 25% of the Latino population lives in poverty. As of 2015, the median income of Non-Hispanic Whites was $62,950, while that of Latinos was $45,148. Despite a steady increase in median income in the Latino community, more than any other ethnic group, there has not been a significant change in the level of income inequality.8

Low educational attainment is associated with poor individual health outcomes, higher mortality rates, and neurocognitive disorders. The level of educational attainment and risk of developing AD or related disorders is still controversial since other factors could explain such an association. Nonetheless, low education level is associated with increased risk-factor exposures in adult life and differential brain reserve. In contrast, high educational attainment has been associated with cognitive resiliency in the elderly; suggesting that it could serve as a neuroprotective factor or at least increase the tolerance to environmental insults.8

There are approximately four million Latinos over the age of sixty-five living in the US, and that number is expected to double by 2030. The Latino community is estimated to be 1.5 times more prone to develop AD than Non-Hispanic Whites. In 2012, the number of Latinos diagnosed with AD was determined to be 379,000, and this number is estimated to increase nine-fold by 2060, reaching 3.5 million. These numbers are of epidemic magnitude and represent a serious social and economic burden. However, particular cultural perspectives and a lack of accurate information about normal aging, AD diagnosis, and medical and psychosocial interventions may lead to a significant number of undiagnosed cases.8

It is unfortunate, that after more than forty years of having an easy screening test available that takes about ten minutes to administer, and after fifty years of a labor movement trying to improve the working conditions of farm workers in rural California, the health inequity among ethnic groups in the US persists as an unsurmountable barrier.



  1. Folstein, Marshal F, et al. 1975. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 12(3) (November): 189-98.
  2. Gonzalez, Saul. “United Farm workers 50th anniversary” Religion and Ethics Newsweekly, Public Broadcasting System. June 22, 2012. https://www.pbs.org/wnet/religionandethics/2012/06/22/june-22-2012-united-farm-workers-50th-anniversary/11407/ Retrieved Apr 7,2019
  3. Hennessy-Burt, Tamara E, et al. 2015. “Factors associated with agricultural work performed by adolescents from an immigrant farm worker population (MICASA study).” J Agric Saf Health. 19(3) (July):163-73.
  4. Stoecklin-Marois, Maria T, et al. 2015. “Occupational exposures and migration factors associated with respiratory health in California Latino farm workers: the MICASA study.” J Occup Environ Med. 57(2) (February):152-8.
  5. Associated Press. “California is now the world’s fifth-largest economy, surpassing United Kingdom.” Los Angeles Times. May 4, 2018. https://www.latimes.com/business/la-fi-california-economy-gdp-20180504-story.html Retrieved Apr 7, 2019
  6. Litwin, Kevin. “Top Industries in California.” Livability, April 8, 2018. https://livability.com/ca/business/top-industries-in-california Retrieved Apr 7, 2019
  7. Guntzviller, Lisa M, et al. 2017 “Self-Efficacy, Health Literacy, and Nutrition and Exercise Behaviors in a Low-Income, Hispanic Population. J Immigr Minor Health. 19(2) (April):489-493.
  8. Vega, Irving E, et al. 2017. “Alzheimer’s Disease in the Latino Community: Intersection of Genetics and Social Determinants of Health.” J Alzheimers Dis. 58(4):979-992.



BERNARDO NG: Born in Mexicali, Mexico, Dr. Ng is a medical graduate from the University of Nuevo Leon in Mexico completed his residency at Texas Tech University and University of California, San Diego. He is certified by the American Board of Psychiatry and Neurology, the American Board of Psychosomatic Medicine, and the Consejo Mexicano de Psiquiatría. His activities include directing the Sun Valley Behavioral and Research Centers in Imperial California and Centro Geriátrico Nuevo Atardecer in Mexicali, Mexico.


Spring 2019  |  Sections  |  Psychiatry & Psychology

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