MoCA in five Indian languages: A brief screening tool to diagnose dementia and MCI in a linguistically diverse setting.

INTRODUCTION AND OBJECTIVES: Early dementia diagnosis in low and middle-income countries (LMIC) is challenging due to limited availability of brief, culturally appropriate, and psychometrically validated tests. Montreal Cognitive Assessment (MoCA) is one of the most widely used cognitive screening tests in primary and secondary care globally. In the current study, we adapted and validated MoCA in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam) and determined the optimal cut-off points that correspond to screening for clinical diagnosis of dementia and MCI. METHODS: A systematic process of adaptation and modifications of MoCA was fulfilled. A total of 446 participants: 214 controls, 102 dementia, and 130 MCI were recruited across six centers. RESULTS: Across five languages, the area under the curve for diagnosis of dementia varied from 0.89 to 0.98 and MCI varied from 0.73 to 0.96. The sensitivity, specificity and optimum cut-off scores were established separately for five Indian languages. CONCLUSIONS: The Indian adapted MoCA is standardized and validated in five Indian languages for early diagnosis of dementia and MCI in a linguistically and culturally diverse population.

Picture-naming test for a linguistically diverse population with cognitive impairment and dementia.

BACKGROUND: Picture-naming tests (PNTs) evaluate linguistic impairment in dementia due to semantic memory impairment, impaired lexical retrieval or perceptual deficits. They also assess the decline in naming impairment at various stages of dementia and mild cognitive impairment (MCI) that occurs due to progressive cognitive impairment. With the increasing numbers of people with dementia globally, it is necessary to have validated naming tests and norms that are culturally and linguistically appropriate. AIMS: In this cross-sectional study we harmonized a set of 30 images applicable to the Indian context across five languages and investigated the picture-naming performance in patients with MCI and dementia. METHODS & PROCEDURES: A multidisciplinary expert group formed by the Indian Council of Medical Research (ICMR) collaborated towards developing and adapting a picture naming test (PNT) known as the ICMR-PNT in five Indian languages: Hindi, Bengali, Telugu, Kannada and Malayalam. Based on cross-cultural adaptation guidelines and item-wise factor analysis and correlations established separately across five languages, the final version of the ICMR-PNT test was developed. A total of 368 controls, 123 dementia and 128 MCI patients were recruited for the study. Psychometric properties of the adapted version of the ICMR-PNT were examined, and sensitivity and specificity were examined. OUTCOMES & RESULTS: The ICMR-PNT scores in all languages combined were higher in controls compared with patients with dementia and MCI (F2, 615 = 139.85; p < 0.001). Furthermore, PNT scores for MCI was higher in comparison with patients with dementia in all languages combined (p < 0.001). The area under the curve across the five languages ranged from 0.81 to 1.00 for detecting dementia. There was a negative correlation between Clinical Dementia Rating (CDR) and ICMR-PNT scores and a positive correlation between Addenbrooke's Cognitive Examination-III (ACE-III) and ICMR-PNT scores in control and patient groups. CONCLUSIONS & IMPLICATIONS: The ICMR-PNT was developed by following cross-cultural adaptation guidelines and establishing correlations using item-wise factor analysis across five languages. This adapted PNT was found to be a reliable tool when assessing naming abilities effectively in mild to moderate dementia in a linguistically diverse context. WHAT THIS PAPER ADDS: What is already known on this subject Picture-naming evaluates language impairment linked to naming difficulties due to semantic memory, lexical retrieval or perceptual disturbances. As a result, picture naming tests (PNTs) play an important role in the diagnosis of dementia. In a heterogeneous population such as India, there is a need for a common PNT that can be used across the wide range of languages. What this study adds to existing knowledge PNTs such as the Boston Naming Test (BNT) were developed for the educated, mostly English-speaking, Western populations and are not appropriate for use in an Indian context. To overcome this challenge, a PNT was harmonized in five Indian languages (Hindi, Bengali, Telugu, Kannada and Malayalam) and we report the patterns of naming difficulty in patients with MCI and dementia. The ICMR-PNT demonstrated good diagnostic accuracy when distinguishing patients with mild to moderate dementia from cognitively normal individuals. What are the potential or actual clinical implications of this work? With the growing number of persons suffering from Alzheimer's disease and other forms of dementia around the world, its critical to have culturally and linguistically relevant naming tests and diagnosis. This validated ICMR-PNT can be used widely as a clinical tool to diagnose dementia and harmonize research efforts across diverse populations.

Semantic memory impairment in dementia: A cross-cultural adaptation study.

BACKGROUND: Semantic memory deficits are frequently encountered in dementia and distinct patterns of semantic impairment characterize the subtypes of dementia. Life course and cultural experiences significantly influence semantic memory. Hence, there is a need to assess semantic memory using culturally appropriate tests, to aid accurate diagnosis of dementia and facilitate cross-cultural collaborative research. AIMS: In this prospective study, we adapted and validated the Cambridge Semantic Memory (CSM) test battery to the Indian cultural context and studied the patterns of semantic memory impairment across dementia subtypes. METHODS: The CSM battery was modified using standard methods and by incorporating culturally appropriate changes and new semantic categories relevant to India. The adapted Indian Semantic Memory (ISM) test battery was administered to a cohort of 121 subjects, consisting of controls and dementia: Alzheimer's disease (AD), progressive non-fluent aphasia (PNFA), semantic dementia (SD), and behavioral variant fronto-temporal dementia (BvFTD). Profile of semantic memory performance across groups was examined. RESULTS: The ISM battery was found to be a valid measure of semantic memory. The novel semantic categories of gods/religious icons, vegetables, and food items added value to the diagnostic process. Distinct semantic memory profiles in SD, PNFA, AD, and BvFTD were demonstrated. CONCLUSIONS: The cultural adaptation of a semantic memory battery for the Indian context provided sensitive evidence of semantic memory impairment in dementia and its subtypes. The clinical and research application of the ISM battery will enhance diagnostic evaluation that can aid in early and accurate identification of deficits and devising intervention strategies and enable research across cultures.

Validation of ICMR Neurocognitive Toolbox for Dementia in the Linguistically Diverse Context of India.

Objectives: The growing prevalence of dementia, especially in low- and middle-income countries (LMICs), has raised the need for a unified cognitive screening tool that can aid its early detection. The linguistically and educationally diverse population in India contributes to challenges in diagnosis. The present study aimed to assess the validity and diagnostic accuracy of the Indian Council of Medical Research-Neurocognitive Toolbox (ICMR-NCTB), a comprehensive neuropsychological test battery adapted in five languages, for the diagnosis of dementia. Methods: A multidisciplinary group of experts developed the ICMR-NCTB based on reviewing the existing tools and incorporation of culturally appropriate modifications. The finalized tests of the major cognitive domains of attention, executive functions, memory, language, and visuospatial skills were then adapted and translated into five Indian languages: Hindi, Bengali, Telugu, Kannada, and Malayalam. Three hundred fifty-four participants were recruited, including 222 controls and 132 dementia patients. The sensitivity and specificity of the adapted tests were established for the diagnosis of dementia. Results: A significant difference in the mean (median) performance scores between healthy controls and patients with dementia was observed on all tests of ICMR-NCTB. The area under the curve for majority of the tests included in the ICMR-NCTB ranged from 0.73 to 1.00, and the sensitivity and specificity of the ICMR-NCTB tests ranged from 70 to 100% and 70.7 to 100%, respectively, to identify dementia across all five languages. Conclusions: The ICMR-NCTB is a valid instrument to diagnose dementia across five Indian languages, with good diagnostic accuracy. The toolbox was effective in overcoming the challenge of linguistic diversity. The study has wide implications to address the problem of a high disease burden and low diagnostic rate of dementia in LMICs like India.

Bilingualism and Its Implications for Neuropsychological Evaluation.

OBJECTIVE: In the background of a large population of bilinguals globally, the study aimed to develop standards of neuropsychological testing in the context of bilingualism. Because bilingualism is known to affect cognitive processes, bilinguals and monolinguals were compared on their performance on cognitive tests, to investigate the possibility of the need for separate normative data for the two groups. METHOD: A comprehensive neuropsychological test battery, standardized across five Indian languages: the Indian Council of Medical Research-Neuro Cognitive Tool Box (ICMR-NCTB) was administered to 530 participants (267 monolingual and 263 bilinguals matched for age and education). A systematic method of testing cognition in bilinguals was developed; to identify the appropriate language for testing, ensure language proficiency of examiner, and to interpret the bilingual responses. Additionally, the performance of bilinguals on the ICMR-NCTB was compared with monolinguals. RESULTS: Cognitive testing in the bilingual context was performed in the most proficient language of the participants, by examiners well versed with the language. Results from the language-based tests suggested that the frequent occurrence of borrowed- and language-mixed words required consideration while scoring. The reported bilingual effect on cognitive processes did not reflect as differences in the performance between bilinguals and monolinguals. CONCLUSIONS: Observations from the study provide robust recommendations for neuropsychological testing in the context of bilingualism. Results indicate that separate normative data may not be required for bilinguals and monolinguals. The study will be relevant and provide a reference framework to address similar issues in the large population of bilinguals in other societies.

A Screening Tool to Detect Stroke Aphasia: Adaptation of Frenchay Aphasia Screening Test (FAST) to the Indian Context.

BACKGROUND: Aphasia is a common consequence of stroke. To optimize recovery, it becomes critical as there are early identification and treatment of language deficits. The rising burden of stroke aphasia and lack of screening tools in the Indian context necessitates the need for a screening tool. OBJECTIVE: We aimed to adapt and validate the Frenchay Aphasia Screening Test (FAST) to the Indian context in two widely spoken Indian languages, Telugu and Kannada, for the literate and illiterate population. METHODS: A systematic process of adaptation and culturally appropriate modifications of the original FAST were done in 116 healthy controls and 115 patients. The validity of the adapted test was established. RESULTS: The optimum cut-off values for detecting aphasia in our sample ranged from 25 to 25.5 (literate) and 13.5 to 15.5 (illiterate) with high sensitivity and specificity. There was also a significant correlation between aphasia scores for adapted FAST and the Western Aphasia Battery (WAB), establishing good convergent validity. DISCUSSION: Results of the adaptation and validation of two Indian versions of FAST, suggest that it is an easy-to-use screening measure for detecting stroke-related language disabilities. The psychometric properties of the Indian version of FAST met the standardised requirements for adaptation and validation. CONCLUSIONS: The Indian version of FAST was found to be a reliable and valid bedside screening tool for aphasia in stroke patients. We aim that this study will facilitate the use of the test across other Indian languages and a large clinical population in the future.

Establishing support groups to support parents of preterm babies with retinopathy of prematurity: A pilot study.

India has the highest number of preterm births in the world, which along with low birth weight, are significant risk factors for retinopathy of prematurity (ROP). One of the challenges in combating visual loss from ROP is the lack of information and awareness among parents of preterm babies. The objective of establishing ROP parent support groups was to support parents of children with ROP by counseling, information and resource sharing, and general guidance. As part of a major initiative to combat ROP across four states in India, a strategy to develop parent support groups was developed and a pilot project was implemented in three cities. In collaboration with identified eye institutes, five ROP parent support group sessions were conducted in these cities. The concept is still in its initial stages of implementation and data are not yet available on the impact of the support groups. However, the overall turnout for the meetings was low as only 30% of parents invited attended meetings. Initial learning and experiences suggest that parent support groups could have a significant role to play in providing many benefits especially in improving awareness, knowledge, and compliance, alleviating anxiety, and empowering parents.

Validation of Indian Council of Medical Research Neurocognitive Tool Box in Diagnosis of Mild Cognitive Impairment in India: Lessons from a Harmonization Process in a Linguistically Diverse Society.

BACKGROUND/AIMS: In a linguistically diverse country such as India, challenges remain with regard to diagnosis of early cognitive decline among the elderly, with no prior attempts made to simultaneously validate a comprehensive battery of tests across domains in multiple languages. This study aimed to determine the utility of the Indian Council of Medical Research-Neurocognitive Tool Box (ICMR-NCTB) in the diagnosis of mild cognitive impairment (MCI) and its vascular subtype (VaMCI) in 5 Indian languages. METHODS: Literate subjects from 5 centers across the country were recruited using a uniform process, and all subjects were classified based on clinical evaluations and a gold standard test protocol into normal cognition, MCI, and VaMCI. Following adaptation and harmonization of the ICMR-NCTB across 5 different Indian languages into a composite Z score, its test performance against standards, including sensitivity and specificity of the instrument as well as of its subcomponents in diagnosis of MCI, was evaluated in age and education unmatched and matched groups. RESULTS: Variability in sensitivity-specificity estimates was noted between languages when a total of 991 controls and 205 patients with MCI (157 MCI and 48 VaMCI) were compared due to a significant impact of age, education, and language. Data from a total of 506 controls, 144 patients with MCI, and 46 patients with VaMCI who were age- and education-matched were compared. Post hoc analysis after correction for multiple comparisons revealed better performance in controls relative to all-cause MCI. An optimum composite Z-score of -0.541 achieved a sensitivity of 81.1% and a specificity of 88.8% for diagnosis of all-cause MCI, with a high specificity for diagnosis of VaMCI. Using combinations of multiple-domain 2 test subcomponents retained a sensitivity and specificity of >80% for diagnosis of MCI. CONCLUSIONS: The ICMR-NCTB is a "first of its kind" approach at harmonizing neuropsychological tests across 5 Indian languages for the diagnosis of MCI due to vascular and other etiologies. Utilizing multiple-domain subcomponents also retains the validity of this instrument, making it a valuable tool in MCI research in multilingual settings.

Standardising Dementia Diagnosis Across Linguistic and Educational Diversity: Study Design of the Indian Council of Medical Research-Neurocognitive Tool Box (ICMR-NCTB).

OBJECTIVES: While the burden of dementia is increasing in low- and middle-income countries, there is a low rate of diagnosis and paucity of research in these regions. A major challenge to study dementia is the limited availability of standardised diagnostic tools for use in populations with linguistic and educational diversity. The objectives of the study were to develop a standardised and comprehensive neurocognitive test battery to diagnose dementia and mild cognitive impairment (MCI) due to varied etiologies, across different languages and educational levels in India, to facilitate research efforts in diverse settings. METHODS: A multidisciplinary expert group formed by Indian Council of Medical Research (ICMR) collaborated towards adapting and validating a neurocognitive test battery, that is, the ICMR Neurocognitive Tool Box (ICMR-NCTB) in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam), for illiterates and literates, to standardise diagnosis of dementia and MCI in India. RESULTS: Following a review of existing international and national efforts at standardising dementia diagnosis, the ICMR-NCTB was developed and adapted to the Indian setting of sociolinguistic diversity. The battery consisted of tests of cognition, behaviour, and functional activities. A uniform protocol for diagnosis of normal cognition, MCI, and dementia due to neurodegenerative diseases and stroke was followed in six centres. A systematic plan for validating the ICMR-NCTB and establishing cut-off values in a diverse multicentric cohort was developed. CONCLUSIONS: A key outcome was the development of a comprehensive diagnostic tool for diagnosis of dementia and MCI due to varied etiologies, in the diverse socio-demographic setting of India.

Dementia in developing countries: does education play the same role in India as in the West? / Demência nos países em desenvolvimento: a edução desempenha o mesmo papel na Índia como no ocidente

Evidence suggests that education protects from dementia by enhancing cognitive reserve. However, this may be influenced by several socio-demographic factors. Rising numbers of dementia in India, high levels of illiteracy and heterogeneity in socio-demographic factors provide an opportunity to explore this relationship. OBJECTIVE: To study the association between education and age at dementia onset, in relation to socio-demographic factors. METHODS: Association between age at dementia onset and literacy was studied in relationship to potential confounding factors such as gender, bilingualism, place of dwelling, occupation, vascular risk factors, stroke, family history of dementia and dementia subtypes. RESULTS: Case records of 648 dementia patients diagnosed in a specialist clinic in a University hospital in Hyderabad, India were examined. All patients were prospectively enrolled as part of an ongoing longitudinal project that aims to evaluate dementia subjects with detailed clinical, etiological, imaging, and follow-up studies. Of the 648 patients, 98 (15.1%) were illiterate. More than half of illiterate skilled workers were engaged in crafts and skilled agriculture unlike literates who were in trade or clerical jobs. Mean age at onset in illiterates was 60.1 years and in literates 64.5 years (p=0.0002). Factors independently associated with age at dementia onset were bilingualism, rural dwelling and stroke, but not education. CONCLUSION: Our study demonstrates that in India, rural dwelling, bilingualism, stroke and occupation modify the relationship between education and dementia.

Evidências sugerem que a educação protége de demência pelo fortalecimento da reserva cognitiva. Todavia, pode ser influenciado por vários fatores socioeconômicos. O aumento no número de demência na Índia, altos índices de analfabetismo e heterogeneidade de fatores sociodemográficos fornecem uma oportunidade para explorar estas relações. OBJETIVO: Estudar a associação entre educação e idade no início da demência em relação aos fatores sociodemográficos. MÉTODOS: A associação entre idade de início da demência e alfabetismo foi estudado em relação aos potenciais fatores confundidores, como gênero, bilinguismo, local de moradia, ocupação, fatores de risco vasculares, acidente vascular cerebral (AVC), história familiar de demência e subtipos de demência. RESULTADOS: Arquivos de 648 pacientes com demência, diagnosticados numa clínica especializada no Hospital Universitário em Hyderabad, foram avaliados. Todos os pacientes foram prospectivamente incluídos num projeto de acompanhamento longitudinal cujo objetivo é avaliar indivíduos com demência através de estudo de detalhado de acompanhamento clínico, etiológico e de imagem. Dos 648 pacientes, 98 (15%) eram analfabetos. Mais da metade dos analfabetos estavam envolvidos em trabalhos manuais ao contrário dos alfabetizados, envolvidos em comércio ou escritórios. A idade média de início em analfabetos foi de 60,1 anos e entre alfabetizados 64,5 anos de idade (p=0,0002). Os fatores independentemente associados à idade de início da demência foram bilinguismo, AVC, moradia rural, mas não educação. CONCLUSÃO: Nosso estudo demonstra que na Índia, moradia rural, bilinguismo, AVC e ocupação modificam a relação entre educação e demência.

Dementia in developing countries: Does education play the same role in India as in the West?

Evidence suggests that education protects from dementia by enhancing cognitive reserve. However, this may be influenced by several socio-demographic factors. Rising numbers of dementia in India, high levels of illiteracy and heterogeneity in socio-demographic factors provide an opportunity to explore this relationship. OBJECTIVE: To study the association between education and age at dementia onset, in relation to socio-demographic factors. METHODS: Association between age at dementia onset and literacy was studied in relationship to potential confounding factors such as gender, bilingualism, place of dwelling, occupation, vascular risk factors, stroke, family history of dementia and dementia subtypes. RESULTS: Case records of 648 dementia patients diagnosed in a specialist clinic in a University hospital in Hyderabad, India were examined. All patients were prospectively enrolled as part of an ongoing longitudinal project that aims to evaluate dementia subjects with detailed clinical, etiological, imaging, and follow-up studies. Of the 648 patients, 98 (15.1%) were illiterate. More than half of illiterate skilled workers were engaged in crafts and skilled agriculture unlike literates who were in trade or clerical jobs. Mean age at onset in illiterates was 60.1 years and in literates 64.5 years (p=0.0002). Factors independently associated with age at dementia onset were bilingualism, rural dwelling and stroke, but not education. CONCLUSION: Our study demonstrates that in India, rural dwelling, bilingualism, stroke and occupation modify the relationship between education and dementia.

Evidências sugerem que a educação protége de demência pelo fortalecimento da reserva cognitiva. Todavia, pode ser influenciado por vários fatores socioeconômicos. O aumento no número de demência na Índia, altos índices de analfabetismo e heterogeneidade de fatores sociodemográficos fornecem uma oportunidade para explorar estas relações. OBJETIVO: Estudar a associação entre educação e idade no início da demência em relação aos fatores sociodemográficos. MÉTODOS: A associação entre idade de início da demência e alfabetismo foi estudado em relação aos potenciais fatores confundidores, como gênero, bilinguismo, local de moradia, ocupação, fatores de risco vasculares, acidente vascular cerebral (AVC), história familiar de demência e subtipos de demência. RESULTADOS: Arquivos de 648 pacientes com demência, diagnosticados numa clínica especializada no Hospital Universitário em Hyderabad, foram avaliados. Todos os pacientes foram prospectivamente incluídos num projeto de acompanhamento longitudinal cujo objetivo é avaliar indivíduos com demência através de estudo de detalhado de acompanhamento clínico, etiológico e de imagem. Dos 648 pacientes, 98 (15%) eram analfabetos. Mais da metade dos analfabetos estavam envolvidos em trabalhos manuais ao contrário dos alfabetizados, envolvidos em comércio ou escritórios. A idade média de início em analfabetos foi de 60,1 anos e entre alfabetizados 64,5 anos de idade (p=0,0002). Os fatores independentemente associados à idade de início da demência foram bilinguismo, AVC, moradia rural, mas não educação. CONCLUSÃO: Nosso estudo demonstra que na Índia, moradia rural, bilinguismo, AVC e ocupação modificam a relação entre educação e demência.