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Lifting the fog over dementia diagnosis in India

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28 May 2020
Lifting the fog over dementia diagnosis in India

India is ageing. Approximately 104 million Indians are above sixty and vulnerable to cognitive disorders affecting memory, such as dementia. Despite this impending future, we haven't been able to assess the current prevalence of such illnesses in the country. It is partly due to the geographical and cultural vastness of India, and the barriers of language and ethics prohibit the use of tests used in western countries. Now, a new study is trying to close this gap by introducing a psychological test that is adapted to the cultural and linguistic diversity of India.

The study, published in the Archives of Clinical Neuropsychology, presents a translation of Addenbrooke's cognitive examination III (ACE III)—a screening test for dementia—to seven Indian languages. It involved an international team of researchers, including those from LMU Munich, Nizam’s Institute of Medical Sciences, Hyderabad, National Institute of Mental Health and Neurosciences, Bengaluru, Manipal Hospital, Bengaluru, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, All India Institute Of Medical Sciences, New Delhi, Nightingales Center for Aging and Alzheimer’s, Bengaluru, University of East Anglia, Sree Chitra Tirunal Institute for Medical Sciences, Trivandrum, University of Sydney and Texas. The study was partially funded by the Department of Science and Technology (DST), Indian Council for Medical Research (ICMR), and the Department of Biotechnology (DBT).

"Dementia is a progressive disorder of intellectual or cognitive decline, common among the elderly. It is typically diagnosed using clinical tests that measure cognitive functions," says Prof.Suvarna Alladi. She is a professor of neurology at NIMHANS in Bengaluru, and the senior researcher  of this study. Her study found that the translated version of ACE III was efficient in the diagnosis of dementia and other mild cognitive problems.

A dementia screening test needs to be sensitive enough to identify persons with dementia early and accurately. The Addenbrooke Cognitive Examination (ACE), a standard test used today, was first developed in 2000. It has since been improved, and we now use the third version of the test to diagnose dementia and mild cognitive impairment.

"Anybody with complaints of memory problems or slowdown of intellectual functions can take this dementia test by approaching a neurology or psychiatry clinic," explains Prof Alladi . 

The test involves a short questionnaire that can be conducted by clinical psychologists, physicians, or trained health care professionals.

"It is a simple paper and pencil test that takes 10-15 minutes to complete," explains Dr Shailaja Mekala, the lead author of the study. Individuals are asked to respond with the date, time, place of living, memorise some words, name a few everyday objects and draw some geometrical figures. "The total score of the test is 100 points. Persons with dementia are more likely to have a score below 82 points. In contrast, persons with mild cognitive impairment have a score below 86 points", she says.

The global version of the test has aspects that are unfamiliar in the Indian context, like addresses, or names of famous people. Hence, participants taking the test may have a problem in remembering them because of unfamiliarity rather than cognitive disorders. Therefore, the researchers translated this test into the seven most common Indian languages to tune it to the Indian audience. These languages include Hindi, Telugu, Kannada, Malayalam, Urdu, Tamil, and Indian English.

The study also included behavioural neurologists, neuropsychologists, speech-language-pathologists, and local language experts to translate the global test into Indian languages. They used addresses within India, names of famous Indians, including movie actors and politicians, and fragmented letters, words and sayings in regional languages with the appropriate complexity, length, and cultural accuracy.

The researchers used the translated questionnaire on 1,203 participants, of which 757 were healthy adults, and 446 had dementia or mild cognitive disorder. It found that patients with mild cognitive impairment had better test scores than patients with dementia—a finding consistent with the tests elsewhere. Interestingly, higher levels of education were associated with better test performance, whereas language difference did not affect the scores. This finding implied that any such psychological test could be translated into all Indian languages without losing the accuracy of the results.

"This adapted version of ACE-III, developed by Prof. Alladi and the team is vital in the Indian context. It can be used to diagnose dementia in people speaking different languages from both rural and urban populations," says Prof BN Gangadhar, who was not a part of the study. He is the Director and Vice-Chancellor at NIMHANS, Bengaluru. As India ages, the need for early diagnosis and treatment of dementia becomes critical. "Our study, which has developed a dementia screening test in many languages, facilitates early diagnosis, research and treatment," concludes Prof  Alladi. 

This article has been run past the researchers, whose work is covered, to ensure accuracy.