Development of an activities of daily living scale to screen for dementia in an illiterate rural older population in India

Systemic inflammatory markers and their association with Alzheimer's disease: A cross-sectional analysis

Aim

To investigate the possible role of systemic inflammatory markers (interleukin; IL-6, C-reactive protein; CRP, and albumin levels) in the development of Alzheimer's dementia (AD) and also find their association with the severity of disease.

Material and Methods

It was a cross-sectional study. Patients with Alzheimer's dementia (AD) and vascular dementia (VaD) from outpatient settings in tertiary care hospitals and non-demented controls (NDC) were recruited from the community. Individuals aged 50 years and older (n = 110) were included. Serum levels of IL-6, CRP, and albumin levels in patients with AD, VaD, and NDC were measured. The clinical Dementia Rating Scale was used for staging the severity of dementia. Serum levels of IL-6, CRP, and serum albumin were compared in study subjects and also analyzed with the severity of dementia in dementia subgroups.

Results

Our main finding was that serum levels of IL-6 were significantly elevated in patients with AD and VaD (7.79 and 6.60) as compared to NDC (2.98) (P < 0.001). No significant difference in CRP or albumin levels was observed between the three groups. Serum IL-6 and CRP showed a positive correlation with the severity of AD, though the correlation was significant only for IL-6 (r = 0.777). The serum albumin levels showed a statistically significant negative correlation with the severity of AD (r > 0.3 but <0.5).

Conclusion

The study demonstrates a notable association between systemic inflammatory markers, particularly IL-6, and the severity of AD, indicating their potential role in its pathogenesis. These findings suggest that targeting these markers could offer new insights into therapeutic strategies for AD.

A Multidimensional, Person-Centered Framework for Functional Assessment in Dementia: Insights from the 'What', 'How', 'To Whom', and 'How Much' Questions

Dementia is a syndrome characterized by cognitive and neuropsychiatric symptoms associated with progressive functional decline (FD). FD is a core diagnostic criterion for dementia, setting the threshold between its prodromal stages and the full-blown disease. The operationalization of FD continues to generate a great deal of controversy. For instance, the threshold of FD for the diagnosis of dementia varies across diagnostic criteria, supporting the need for standardization of this construct. Moreover, there is a need to reconsider how we are measuring FD to set boundaries between normal aging, mild cognitive impairment, and dementia. In this paper, we propose a multidimensional framework that addresses outstanding issues in the assessment of FD: i) What activities of daily living (ADLs) are necessary to sustain an independent living in aging? ii) How to assess FD in individuals with suspected neurocognitive disorders? iii) To whom is the assessment directed? and iv) How much does FD differentiate healthy aging from mild and major neurocognitive disorders? Importantly, the To Whom Question introduces a person-centered approach that regards patients and caregivers as active agents in the assessment process of FD. Thus, once impaired ADLs have been identified, patients can indicate how significant such impairments are for them in daily life. We envisage that this new framework will guide future strategies to enhance functional assessment and treatment of patients with dementia and their caregivers.

Molecular genetics of neuropsychiatric illness: some musings

Research into the genetic underpinnings of neuropsychiatric illness has occurred at many levels. As more information accumulates, it appears that many approaches may each offer their unique perspective. The search for low penetrance and common variants, that may mediate risk, has necessitated the formation of many international consortia, to pool resources, and achieve the large sample sizes needed to discover these variants. There has been the parallel development of statistical methods to analyse large datasets and present summary statistics which allows data comparison across studies. Even so, the results of studies on well-characterised clinical datasets of modest sizes can be enlightening and provide important clues to understanding these complex disorders. We describe the use of common variants, at multiallelic loci like TOMM40 and APOE to study dementia, weighted genetic risk scores for alcohol-induced liver cirrhosis and whole exome sequencing to identify rare variants in genes like PLA2G6 in familial psychoses and schizophrenia in our Indian population.

Measurement differences in the assessment of functional limitations for cognitive impairment classification across geographic locations

INTRODUCTION

The measurement of dementia in cross-national contexts relies on the assessment of functional limitations. We aimed to evaluate the performance of survey items on functional limitations across culturally diverse geographic settings.

METHODS

We used data from the Harmonized Cognitive Assessment Protocol Surveys (HCAP) in five countries (total N = 11,250) to quantify associations between items on functional limitations and cognitive impairment.

RESULTS

Many items performed better in the United States and England compared to South Africa, India, and Mexico. Items on the Community Screening Instrument for Dementia (CSID) had the least variability across countries (SD = 0.73 vs. 0.92 [Blessed] and 0.98 [Jorm IQCODE]), but also the weakest associations with cognitive impairment (median odds ratio [OR] = 2.23 vs. 3.01 [Blessed] and 2.75 [Jorm IQCODE]).

DISCUSSION

Differences in cultural norms for reporting functional limitations likely influences performance of items on functional limitations and may affect the interpretation of results from substantive studies.

HIGHLIGHTS

There was substantial cross-country variation in item performance. Items from the Community Screening Instrument for Dementia (CSID) had less cross-country variability but lower performance. There was more variability in performance of instrumental activities of daily living (IADL) compared to activities of daily living (ADL) items. Variability in cultural expectations of older adults should be taken into account. Results highlight the need for novel approaches to assessing functional limitations.

Food insecurity and its association with health and well-being in middle-aged and older adults in India

AIM

Food insecurity is a global public health concern; however, there is limited knowledge about its health impacts in India. We examined the associations of food insecurity with socioeconomic conditions, chronic disease and various domains of health and well-being in a community sample of middle-aged and older adults (45+ years) in India.

METHODS

Cross-sectional nationally representative data were collected in wave 1 (2017-2018) of the Longitudinal Ageing Study in India. Food insecurity was measured by questions of access and availability of food. We used logistic regression analyses to examine associations of food insecurity with poor self-rated health, limitations in activities of daily living (ADLs), instrumental ADLs, low life satisfaction, depression, sleep problems and low body mass.

RESULTS

Food insecurity related to all seven indicators of poor health and well-being, even after controlling for material wealth and the presence of multimorbidity (which food insecurity also predicted). Associations with mental health were stronger for those for physical health. For instance, food insecurity related to a threefold increase in probable depression (OR=2.9, 95% CI=2.4 to 3.4) and low life satisfaction (OR=3.4, 95% CI=2.9 to 3.8).

CONCLUSIONS

Food insecurity is a powerful social determinant of poor health among older adults in India. Policy measures to improve population health and well-being should closely follow trends in food insecurity, particularly among those living in poverty and with multiple health conditions.

A normative study of the Color Trails Test in the adult Indian population

The Color Trails Test (CTT) is a neuropsychological measure assessing for frontal and executive functioning, while also minimizing the cultural and language barriers inherent in similar measures such as the Trail Making Test (TMT). This study establishes convergent validity for the CTT in the Indian population by comparing participant performance on the CTT and TMT. It also generates culturally appropriate normative data for CTT-Form A among the Indian adult population. Six-hundred and sixty-nine cognitively healthy, community-dwelling individuals between ages 18 and 69 participated in the study and were stratified based on age, gender, and educational attainment. Participant performance on the CTT and TMT were correlated to establish convergent validity. Strong correlation was found between TMT-A and CTT-1 (r = 0.61) and between TMT-B and CTT-2 (r = 0.66). An analysis of variance test was used to determine the mean and standard deviation for each stratified participant group. Further analysis found that age and educational attainment significantly impact participant performance on CTT-1 [F(4, 649) = 4.395, p = 0.002], whereas gender, age, and educational attainment significantly impact participant performance on CTT-2 [F(4,649) = 2.446, p = 0.045]. Normative data generated from this study has important clinical implications and contributes to the growing body of culturally appropriate normative data available for the Indian population.

Morbidity status and changes in difficulty in activities of daily living among older adults in India: A panel data analysis

Introduction

The study explored the socioeconomic and demographic factors that determine the onset of difficulty, recovery from difficulty and difficulty remaining in functional activity in later years of life. Additionally, the study examined the effects of several combinations of chronic diseases on the changes in later-life functional difficulty.

Methods

We used data from two rounds of India Human Development Survey (IHDS) conducted during 2004–2005 and 2011–2012. A sample of 13,849 respondents aged 55 years and above with a seven year follow-up was considered for this study. The Katz Index of Independence in activities of daily living (ADL) was used to measure the functional disability as an outcome variable. Multinomial logistic regression has been conducted to fulfil the study objectives.

Results

The overall functional difficulty among older adults was 27.3% and onset of functional difficulty (23.5%) was higher than the recovery from difficulty (2.1%) and remaining with difficulty (1.7%). Onset of functional difficulty in second round was higher among women (27.3%) than men (19.3%). Bivariate and multivariate analyses showed that single and multi-morbidity had a positive significant association with all categories of functional difficulty. Female sex, increasing age and rural place of residence had positive association with onset of difficulty and difficulty remaining in second round. The combinations of morbidities were also found to have positive significant association with functional difficulty i.e., the relative risk (RR) of onset of difficulty in second round is higher among those who had diabetes with high blood pressure (RR-1.7; CI: 1.4–2.0), cataracts with high blood pressure (RR-2.0; CI: 1.5–2.6) and cataracts with asthma (RR-3.1; CI: 2.1–4.6) compared to those with no diabetes and cataract but with high blood pressure or asthma, respectively.

Conclusion

The findings suggest that the risk of onset of functional difficulty is higher among older individuals with single and multiple morbidities compared to their healthy counterparts. It is also found that functional difficulty increased with age and was more prevalent in older women and rural residents, suggesting the need for appropriate policy interventions with special focus on the vulnerable senior adults.

Anxiety and depression in the elderly due to COVID-19 pandemic: a pilot study

Background

The elderly are a vulnerable section of the population who are prone to physical, mental, social, and economic deprivation. The effect of COVID-19 had a worldwide impact on all age groups, with a particularly higher mortality and morbidity rate among the elderly population. The present study was undertaken to know about the psychological morbidity in the geriatric population during the period of the COVID-19 pandemic. The study was cross-sectional and was done through a telephonic survey. Eligible elderly subjects were contacted telephonically, and the Geriatric Anxiety Scale and the Geriatric Depression Scale were administered. To evaluate the functional ability of elderly subjects, the Everyday Abilities Scale for India (EASI) scale was administered. For the telephonic survey, verbal consent was sought.

Results

A total of 92 elderly subjects were included. Male outnumbered the females with a ratio of 1.8:1. Spouse and children were primary caregivers in 83.7% of the subjects. 90.2% were married, and 66.3% had earned a graduate/professional level of education. Chronic illness was present in 50% of subjects. The most common co-morbidities were hypertension (27.2%) and diabetes (21.7%). The proportion of elderly with anxiety and depression was 8.7% and 15.2% respectively.

Conclusion

The elderly showed lower levels of anxiety and depression. Higher resilience among the elderly and good family support may be the reasons for such an unexpected finding. However, more studies are required to validate the findings of the current study.

Everyday Abilities Scale for India in Screening for Poststroke Dementia Among Young Stroke Survivors

INTRODUCTION

Cognitive dysfunction after stroke is an important concern. We explored the utility of everyday abilities scale for India (EASI) for screening for dementia among young stroke survivors.

METHODS

We interviewed 150 young stroke survivors and caregivers. Vascular dementia was diagnosed according to American Heart Association-American Stroke Association (ASA-AHA) criteria. EASI was administered to all caregivers. Receiver operating characteristic curve analysis was used to determine the area under the curve and optimum cut-points for EASI for the identification of dementia.

RESULTS

Median EASI scores among subjects with dementia (n=35; 23.3%) was 2 (interquartile range: 0-4) and significantly different from those without (median: 0; interquartile range: 0-1; P<0.001). The area under the curve was 0.768 (95% confidence interval: 0.674-0.863), and at the optimum cut-point of 2 on EASI, a sensitivity of 60% and specificity of 91.3% was achieved for the identification of dementia.

CONCLUSION

EASI appears to be a promising tool to screen for dementia among young stroke survivors.

Validation of Malayalam Version of Everyday Abilities Scale for India

BACKGROUND

Cognitive impairment is usually associated with impairment in everyday activities. Scales to assess activities of daily living, like the Everyday Abilities Scale for India (EASI), have been employed as screening tools for dementia or major neurocognitive disorder. EASI had not been validated in Malayalam. This study's objective was to validate the Malayalam version of EASI (M-EASI) in those aged ≥60 years.

METHODS

In a study undertaken in a tertiary care center, those aged ≥60 years attending psychiatry, neurology, or geriatric clinic of general medicine departments were evaluated using M-EASI and the Malayalam version of Addenbrooke's Cognitive Examination (M-ACE). A total of 304 participants were recruited for this questionnaire validation. Information for M-EASI was obtained from a reliable informant.

RESULTS

The mean age of the sample was 70.04 years (standard deviation-7.33). The majority of them were males (58.6%) and educated up to primary school (42.4%), while the majority of the informants were sons/daughters/siblings (47.7%) and were females (73.7%). Taking M-ACE scores as the gold standard for diagnosing MNCD according to Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria, there were 162 cases of MNCD and 142 normal controls. Cronbach's α was 0.91. At an optimal cut-off of 4.5, adequate sensitivity (77.8%), and specificity (75.4%) were observed. The positive predictive value was 78.6%, and the negative predictive value, 74.5%.

CONCLUSION

M-EASI has adequate psychometric properties as a screening tool for MNCD.

Instrumental Activities of Daily Living Scales to Detect Cognitive Impairment and Dementia in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

The largest proportion of people with dementia worldwide live in low- and middle- income countries (LMICs), with dementia prevalence continuing to rise. Assessment and diagnosis of dementia involves identifying the impact of cognitive decline on function, usually measured by instrumental activities of daily living (IADLs).

OBJECTIVE

This review aimed to identify IADL measures which are specifically developed, validated, or adapted for use in LMICs to guide selection of such tools.

METHODS

A systematic search was conducted (fourteen databases) up to April 2020. Only studies reporting on development, validation, or adaptation of IADL measures for dementia or cognitive impairment among older adults (aged over 50) in LMICs were included. The QUADAS 2 was used to assess quality of diagnostic accuracy studies.

RESULTS

22 papers met inclusion criteria; identifying 19 discrete IADL tools across 11 LMICs. These were either translated from IADL measures used in high-income countries (n = 6), translated and adapted for cultural differences (n = 6), or newly developed for target LMIC populations (n = 7). Seven measures were investigated in multiple studies; overall quality of diagnostic accuracy was moderate to good.

CONCLUSION

Reliability, validity, and accuracy of IADL measures for supporting dementia diagnosis within LMICs was reported. Key components to consider when selecting an IADL tool for such settings were highlighted, including choosing culturally appropriate, time-efficient tools that account for gender- and literacy-bias, and can be conducted by any volunteer with appropriate training. There is a need for greater technical and external validation of IADL tools across different regions, countries, populations, and cultures.

The Research Protocol of SENIOR Project-Psychiatric Services and Support System for Serious Mental Illness in Old Age, Kerala, India

BACKGROUND

India has the second-largest population of elderly in the world. Serious mental illness (SMI) is a subset of the mental disorders that result in significant functional impairment and is usually long term. Persons with SMI face several challenges in their old age that are different from the issues faced by younger people with SMI. Understanding the problems faced by elderly individuals suffering from SMI is fundamental for planning programs to address them. The SENIOR (Support Systems Evaluation of Neuropsychiatric Illness in Old age) project is a study aimed at evaluating the problems faced in obtaining mental health care by elderly persons having SMI in the Kerala state of India.

AIM

To describe the scientific methodology of the SENIOR project.

METHODS

This study employs mixed-methods cross-sectional design among a minimum sample of 768 SMI patients identified through cluster sampling from three districts, and Focus Group Discussion among mental health program officials.

DISCUSSION

This paper presents a methodological model to assist researchers in future field epidemiological studies on mental illness. Assessing service needs and barriers to access for the most vulnerable among the mentally ill will help the policymakers make evidence-based decisions to improve their quality of life.

Resting state functional connectivity abnormalities and delayed recall performance in patients with amnestic mild cognitive impairment

Amnestic Mild Cognitive Impairment (aMCI) represents the transition between healthy aging and Alzheimer's dementia (AD) wherein gradual impairment of cognitive abilities, especially memory sets in. Impairment in episodic memory, especially delayed recall, is a hallmark of AD and therefore, patients with aMCI with more severe impairment in episodic memory are considered to be at greater risk of imminent conversion to AD. Brain structural and functional abnormalities were examined by comparing gray matter volumes, white matter micro-structural integrity and resting state functional connectivity (rsFC), between patients with aMCI (n = 46) having lower vs. higher episodic memory delayed recall (EM-DR) performance scores, correcting the influences of age, sex, number of years of formal education and total brain volumes using voxel-based morphometry, whole-brain tract based spatial statistics and dual regression analysis respectively. 'Low' performers (n = 27) when compared to 'high' performers (n = 19) showed significantly increased rsFC in the dorsal attention network (DAN) and central executive network (CEN) in the absence of demonstrable gray matter volumetric or white matter micro-structural integrity differences at family-wise error (FWE) corrected (p < 0.05) significance threshold. Follow-up data available for 38 (low performers = 22; high performers = 16) of the above 46 subjects (82.60% follow-up rate) over a median follow-up period of 24.5 months revealed that 7 subjects (18.42%) had converted to dementia. These converted subjects included 5 of the 22 low performers (22.72%) and 2 of the 16 high performers (12.5%) within the follow-up sample (n = 38). The results of the study indicate that imminent conversion of aMCI to dementia is higher in low performers in comparison to high performers, which may be characterized by increased rsFC in task positive networks, viz., DAN and CEN, as opposed to gray or white matter structural changes. This finding, therefore, might be considered as a prognostic indicator of progression from aMCI to dementia.

What matters to patients with stroke in India and why: a qualitative study

PURPOSE

To gain insight into the preferred outcomes of patients with stroke living in India and develop a conceptual framework of participation in daily activities based on patient perspectives informed by the International Classification of Functioning, Disability, and Health.

METHODS

This study took a phenomenological approach. A purposive sample of 30 patients with stroke and diverse socio-demographic and disease related characteristics participated in semi-structured interviews. Interviews consisted of open-ended questions about their post stroke rehabilitation goals. Data were analyzed using content analysis.

RESULTS

Patients expressed preference for outcomes such as the use of eastern toilets, squatting and sitting on the floor, eating with the right hand, taking a "bucket bath," walking for long distances (1-2 km) and the use of public transportation. Patients attributed their outcome preferences to contextual factors such as the physical environment (natural and built environment), family structure and living conditions, cultural values, norms and practices. Based on the outcomes identified by the patients, we developed the conceptual framework of participation in daily activities relevant to Indian context consisting of Mobility, Self-care, Domestic Life, and Social participation domains informed by the International Classification of Functioning, Disability, and Health.

CONCLUSIONS

Outcome preferences of patients with stroke are not universal. The conceptual framework including its domains and contents developed in this study can be a useful guide to clinicians and researchers in choosing what to measure within Indian as well as other similar sociocultural contexts.Implications for rehabilitationPost-stroke functional outcome measurement is meaningful only when it is conceptualized within the context in which the personal, social, and cultural values of patients are well-recognized.There are notable differences in the type of activities constituting daily activities and how they were performed in India compared to a western cultural context.Patients' daily functioning is characterized by the differences in personal preferences, cultural norms and practices, family and living arrangements, lifestyle, and characteristics of natural and built environment and the available public infrastructure.Differentiating activities patients cannot do from the "no need to do" or "don't want to do" should be viewed as a critical aspect of patient reported outcome measurement.

Geriatric Assessment in Multicultural Immigrant Populations

While the traditional comprehensive geriatric assessment provides valuable information essential to caring for older adults, it often falls short in multicultural immigrant populations. The number of foreign-born older adults is growing, and in some regions of the United States of America (U.S.), they encompass a significant portion of the older adult population. To ensure we are caring for this culturally diverse population adequately, we need to develop a more culturally competent comprehensive geriatric assessment. In this review, we explore ways in which to do this, address areas unique to multicultural immigrant populations, and identify limitations of the current assessment tools when applied to these populations. In order to be more culturally sensitive, we should incorporate the concepts of ethnogeriatrics into a comprehensive geriatric assessment, by addressing topics like healthcare disparities, language barriers, health literacy, acculturation level, and culturally defined beliefs. Additionally, we must be sensitive to the limitations of our current assessment tools and consider how we can expand our assessment toolkit to address these limitations. We discuss the limitations in cognitive screening tests, delirium assessments, functional and mental health assessments, advance care planning, and elder abuse.

Indian older adults and the digit span A preliminary report

The digit span test is widely used to assess attention and working memory. It is a portable, relatively culture-free and frequently used test. However, the cultural validity of this test, particularly in the Indian older population, is not well established.

Current approaches to dementia screening and case finding in low- and middle-income countries: Research update and recommendations

Approximately 47 million people have dementia worldwide, with this figure, it is expected to almost triple by 2050. Most people with dementia (approximately two-thirds) live in low- and middle-income countries (LMICs). This presents a significant challenge for such countries that often have limited financial resources and less well-developed health and social care systems. In the absence of a cure, reducing the future costs of dementia care and burden of disease may be best achieved by a greater emphasis on (1) more timely diagnosis with earlier intervention to maintain functional independence and (2) undertaking "screening" in groups at high risk of developing dementia, case finding, and using brief cognitive assessment instruments. In clinical settings, a wide range of instruments for dementia screening and diagnosis are currently available; however, few cognitive assessment tools have been developed specifically for clinical use within LMIC settings. Screening for dementia and cognitive impairment in LMICs largely relies on tools adapted from high-income countries (HICs); these often lack validation in these settings leading to education, literacy, and cultural biases. Research is urgently needed to develop cognitive assessment tools and dementia diagnostic approaches that are appropriate and feasible for clinical use in LMIC settings.

High altitude with monotonous environment has significant impact on mood and cognitive performance of acclimatized lowlanders: Possible role of altered serum BDNF and plasma homocysteine level

BACKGROUND

Monotony resulting due to the wilderness, sparse population and isolation from society could adversely affect human physiology and cause mood alterations. Thus, observations need to be conducted in order to elucidate the possible role of circulating biomarkers in inducing altered mood and cognitive performance following prolonged exposure to high altitude (HA) with persistent monotonous environment.

OBJECTIVE

The present study aimed towards investigating the impact of monotonous environment in remote HA on mood and cognitive performance of human volunteers and its correlation with serum brain derived neurotrophic factor (BDNF) and plasma homocysteine level.

METHODS

The present study was conducted on male lowlander participants who had normal social life prior to induction in HA environment. Baseline data was acquired at altitude ≤240 m mean sea level (MSL). Thereafter, the participants were inducted to an altitude of 4500-4800 m MSL. After acclimatization to HA, the participants were assigned as acclimatized low landers (ALL). Longitudinal follow up was conducted after 8 months of high altitude induction on acclimatized low landers (8ALL). Further, to study the effect of monotony, the participants were randomly assigned into different group sizes during their further stay of 4 months in HA viz. ≤5 (12ALL ≤ 5) and ≥10 (12ALL ≥ 10). Mood and cognitive performance of the participants were assessed by standard self-administered questionnaires. Serum BDNF and plasma homocysteine were estimated and their correlation with mood and cognition were determined.

RESULTS

The findings showed significantly low serum BDNF in 12ALL ≤ 5 group when compared to baseline, 8ALL and 12AL ≥ 10 groups. Alleviated serum BDNF was associated with increased prevalence of mood alterations in HA with persistent monotonous environment. Participants of 12ALL ≥ 10 group showed significantly higher cognitive performance as compared to 12ALL ≤ 5 group which was associated with reduced plasma homocysteine level.

LIMITATIONS

Total registered volunteers during baseline study were not available during the entire period of this study. The second limitation was exclusion of participants with medical history of severe head injuries, chronic diseases in family and extreme baseline serum profile. Third limitation of the study was to exclude the participants detected with MCI after 8 months of HA induction for negating the role of hypobaric hypoxia on mood and cognition.

CONCLUSION

The study advocated that ALLs of 12ALL ≤ 5 group have increased prevalence of depressive trait and cognitive impairment which was correlated with reduced serum BDNF and augmented plasma homocysteine level as compared to participants of 12ALL ≥ 10 group having better social interaction with improved cognition and mood. The basic findings of the present study revealed that prolonged HA stay after physiological acclimatization should be regulated by proper social interaction involving normal group size to avoid detrimental effect of monotony and its significant impact on circulatory biomarkers.

Mutation burden profile in familial Alzheimer's disease cases from India

This study attempts to identify coding risk variants in genes previously implicated in Alzheimer's disease (AD) pathways, through whole-exome sequencing of subjects (N = 17) with AD, with a positive family history of dementia (familial AD). We attempted to evaluate the mutation burden in genes encoding amyloid precursor protein metabolism and previously linked to risk of dementias. Novel variants were identified in genes involved in amyloid precursor protein metabolism such as PSEN1 (chr 14:73653575, W161C, tgg > tgT), PLAT (chr 8:42039530,G272R), and SORL1 (chr11:121414373,G601D). The mutation burden assessment of dementia-related genes for all 17 cases revealed 45 variants, which were either shared across subjects, or were present in just the 1 patient. The study shows that the clinical characteristics, and genetic correlates, obtained in this sample are broadly comparable to the other studies that have investigated familial forms of AD. Our study identifies rare deleterious genetic variations, in the coding region of genes involved in amyloid signaling, and other dementia-associated pathways.

Clinical and neuropsychological profile of persons with mild cognitive impairment, a hospital based study from a lower and middle income country

Mild Cognitive impairment (MCI) is an important pre-dementia stage to be identified towards prevention. We screened a large number of older adults seeking help at hospital and community towards a diagnosis of MCI and this study describe their clinical and neuropsychological profile. Older adults aged 60 years & above seeking help at NIMHANS outpatient & community services were screened for early cognitive deficits. Persons were diagnosed to have MCI according to Petersen's criteria, after detailed clinical and neuropsychological assessments. Age, gender and education matched healthy controls were recruited for comparison. A total of 7469 older adults were screened during the study period (July 2012-December 2014). Less than 1% (n=56) were diagnosed with MCI. Majority were males, from urban background with an average of 13 years of education. They presented mainly with memory disturbances, more than 75% (n=43) were found to have amnestic type of MCI (aMCI). Of the aMCI subjects, majority (80%) had deficits in more than one cognitive domain. They performed significantly worse (p<0.001) on tests of episodic memory, logical memory, attention and executive functions. Neuropsychiatric symptoms were prevalent in 55% of MCI group and influenced their cognitive scores. The findings suggest that persons with MCI perform worse not only on memory tasks but also on some of the attention and executive functions tasks. As observed in earlier studies, amnestic multiple-domain MCI was the most common type of MCI in this study population. Indigenous assessment tools were of significant value in distinguishing MCI from normal ageing.

Effect of CLU and PICALM polymorphisms on AD risk: A study from south India

OBJECTIVES

To study the association of apolipoprotein E (APOE), Clusterin (CLU) and phosphatidylinositol binding clathrin assembly protein (PICALM) polymorphisms in Alzheimer's disease (AD) subjects compared to cognitively normal control subjects in an Indian population.

METHODS

The study subjects included persons with AD (N=243) and age group matched healthy controls (N=164). All the AD subjects were evaluated using a standard protocol. DNA was isolated from whole blood. APOE (rs7412, rs429358), CLU (rs11136000) and PICALM (rs3851179) were genotyped. General linear model was used to test the association between the individual risk genotypes and AD.

RESULTS

The presence of APOE ε4 was associated with AD after adjusting for age and gender (p<0.0001). There was no association observed with AD at both rs11136000 CLU (p=0.25) and rs3851179 PICALM (p=0.54).

CONCLUSION

Our results confirmed a significant association of APOE ε4 carrier status with AD. No association was observed for CLU and PICALM with AD. This might be due to a different genetic background. There are no previous reports of these polymorphisms in an Indian cohort. Future Indian AD studies should investigate additional SNPs in a larger sample size in these genes.

Evaluation of a novel Serious Game based assessment tool for patients with Alzheimer's disease

Despite growing interest in developing ecological assessment of difficulties in patients with Alzheimer's disease new methods assessing the cognitive difficulties related to functional activities are missing. To complete current evaluation, the use of Serious Games can be a promising approach as it offers the possibility to recreate a virtual environment with daily living activities and a precise and complete cognitive evaluation. The aim of the present study was to evaluate the usability and the screening potential of a new ecological tool for assessment of cognitive functions in patients with Alzheimer's disease. Eighteen patients with Alzheimer's disease and twenty healthy controls participated to the study. They were asked to complete six daily living virtual tasks assessing several cognitive functions: three navigation tasks, one shopping task, one cooking task and one table preparation task following a one-day scenario. Usability of the game was evaluated through a questionnaire and through the analysis of the computer interactions for the two groups. Furthermore, the performances in terms of time to achieve the task and percentage of completion on the several tasks were recorded. Results indicate that both groups subjectively found the game user friendly and they were objectively able to play the game without computer interactions difficulties. Comparison of the performances between the two groups indicated a significant difference in terms of percentage of achievement of the several tasks and in terms of time they needed to achieve the several tasks. This study suggests that this new Serious Game based assessment tool is a user-friendly and ecological method to evaluate the cognitive abilities related to the difficulties patients can encounter in daily living activities and can be used as a screening tool as it allowed to distinguish Alzheimer's patient's performance from healthy controls.

Psychiatric morbidity in the community: A population based-study from Kerala

BACKGROUND

Estimates of psychiatric morbidity in the community will help service development. Participation of trained nonspecialist health-care providers will facilitate scaling up of services in resource-limited settings.

AIMS

This study aimed to estimate the prevalence of priority mental health problems in populations served by the District Mental Health Program (DMHP).

SETTINGS AND DESIGN

This is a population-based cross-sectional survey.

MATERIALS AND METHODS

We did stratified cluster sampling of households in five districts of Kerala. Trained Accredited Social Health Activists (ASHAs) identified people who had symptoms suggestive of schizophrenia or bipolar disorder. Clinicians evaluated the information collected by the ASHAs and designated individuals as probable cases of psychosis or noncases. Screening instruments such as General Health Questionnaire-12, CAGE questionnaire, and Everyday Abilities Scale for India were used for identifying common mental disorders (CMDs), clinically significant alcohol-related problems, and functional impairment.

RESULTS

We found 12.43% of the adult population affected by mental health conditions. We found CMD as most common with a prevalence of 9%. The prevalence of psychosis was 0.71%, clinically significant alcohol-related problems was 1.46%, and dementia and other cognitive impairments was 1.26%. We found informant-based case finding to be useful in the identification of psychosis.

CONCLUSIONS

Mental health problems are common. Nonspecialist health-care providers can be trained to identify psychiatric morbidity in the community. Their participation will help in narrowing the treatment gap. Embedding operational research to DMHP will make scaling up more efficient.

Caregiver burden in Alzheimer-type dementia and psychosis: A comparative study from India

BACKGROUND

Caregiver burden in dementia is an important area of research. Providing care for a relative can be a potent source of chronic stress and can have deleterious consequences for both the physical and emotional health of caregivers. This study aims to evaluate the burden of care in caregivers of patients with Alzheimer-type dementia and compare it with elderly psychosis; and to also study the factors that influence burden of care in Alzheimer's dementia.

METHODS

Thirty-two caregiver-patient dyads of Alzheimer-type dementia were compared with thirty-two caregiver-patient dyads of psychosis. Cognitive assessment, abilities to perform activities of daily living and severity of dementia was assessed in the patients. Zarit Burden Interview was used to study the caregiver burden in both groups.

RESULTS

The mean burden score in dementia caregivers was high at 47.7, whereas the mean burden score for elderly psychosis caregivers was lesser at 33.6, and this difference in mean burden scores was found to be statistically significant. Spouses had the highest mean burden scores of 53.48. Caregiver burden in dementia was positively correlated with cognitive impairment and inability to carry out ADLs. Presence of psychological distress in caregivers was also an indicator for greater caregiver burden in dementia.

CONCLUSION

The study revealed that dementia carries a greater caregiver burden when compared with elderly patients with psychosis. Innovative interventions are needed to remove burden from caregiving, making it a meaningful practice integral to the Indian society.

Social Network and Mental Health Among Older Adults in Rural Uttar Pradesh, India: A Cross-Sectional Study

The rapid growth of the older population in India draws attention to the factors that contribute to their changing health realities. However, there has hardly been any study in India that has looked at the effects of specific social networks with children, relatives, friends and confidant on depression among older adults. The objective of the study is to investigate the association between social network and depression among the rural elderly. The study population comprised over 630 older adults (aged 60 and above) from the rural areas of Varanasi, Uttar Pradesh. We adopted Berkman's theoretical model of the impact of social relations on depression among the elderly in the Indian context. Results of the Confirmatory Factor Analysis (CFA) demonstrated that the four specific social network types: children, relatives, friends and confidant were tenable. The results showed that a better social network with 'friends/neighbours' was protective against depression among the rural elderly. This clearly points to the need for more social network centres for older adults, so that they can interact with friends within the community or between communities and participate in group activities.

A Multimodal Structural and Functional Neuroimaging Study of Amnestic Mild Cognitive Impairment

Examination of brain structural and functional abnormalities in amnestic mild cognitive impairment (aMCI) has the potential to enhance our understanding of the initial pathophysiological changes in dementia. We examined gray matter volumes and white matter microstructural integrity, as well as resting state functional connectivity (rsFC) in patients with aMCI (N = 48) in comparison to elderly cognitively healthy comparison subjects (N = 48). Brain volumetric comparisons were carried out using voxel-based morphometric analysis of T1-weighted images using the FMRIB Software Library. White matter microstructural integrity was examined using whole-brain tract-based spatial statistics analysis of fractional anisotropy maps generated from diffusion tensor imaging data. Finally, rsFC differences between the samples were examined by Multivariate Exploratory Linear Optimised Decomposition into Independent Components of the resting state functional magnetic resonance imaging time series, followed by between-group comparisons of selected networks using dual regression analysis. Patients with aMCI showed significant gray matter volumetric reductions in bilateral parahippocampal gyri as well as multiple other brain regions including frontal, temporal, and parietal cortices. Additionally, reduced rsFC in the anterior subdivision of the default mode network (DMN) and increased rsFC in the executive network were noted in the absence of demonstrable impairment of white matter microstructural integrity. We conclude that the demonstrable neuroimaging findings in aMCI include significant gray matter volumetric reductions in the fronto-temporo-parietal structures as well as resting state functional connectivity disturbances in DMN and executive network. These findings differentiate aMCI from healthy aging and could constitute the earliest demonstrable neuroimaging findings of incipient dementia.

Status of Cognitive Testing of Adults in India

The assessment of cognitive function is a challenging yet an integral component of psychological, psychiatric, and neurological evaluation. Cognitive assessment tools either can be administered quickly for screening for neurocognitive disorders or can be comprehensive and detailed to identify cognitive deficits for the purpose of localization, diagnosis, and rehabilitation. This article is a comprehensive review of published research that discusses the current challenges for cognitive testing in India, available tools used for the assessment of cognitive function in India, and future directions for cognitive testing in India.

Feasibility of using everyday abilities scale of India as alternative to mental state examination as a screen in two-phase survey estimating the prevalence of dementia in largely illiterate Indian population

INTRODUCTION

A situation analysis report on elderly in India shows that the literacy rate for persons aged above 60 is 36%. Using HMSE and its modification in the first phase of a two phase study to estimate the prevalence of dementia in such a population must be read with caution as these tests are literacy dependent. We conducted a post hoc analysis to explore the feasibility of using EASI as an alternative to HMSE and its modifications as the first phase screen in two phase surveys to estimate the prevalence of dementia.

MATERIALS AND METHODS

A post hoc analysis was conducted on data obtained from a study conducted on elderly population (60 years and above) from selected geographical areas (Migrant, Urban, Rural and Tribal) of Himachal Pradesh state in North-west India. The co-relation coefficient was used to establish the strength of association between EASI and HMSE and its modification and therefore the feasibility of using it as an alternative.

RESULTS

As the scores on EASI rise, the scores on HMSE fall both pointing to identification of the same clinical diagnosis i.e., dementia. Further the Pearson Correlation coefficient at -2.52 was found to be statistically significant.

CONCLUSION

EASI may be used as alternative to mental state examination.

Alzheimer's disease with cerebrovascular disease: current status in the Asia-Pacific region

BACKGROUND

There is growing awareness of the coexistence of Alzheimer's disease and cerebrovascular disease (AD+CVD), however, due to lack of well-defined criteria and treatment guidelines AD+CVD may be underdiagnosed in Asia.

METHODS

Sixteen dementia specialists from nine Asia Pacific countries completed a survey in September 2014 and met in November 2014 to review the epidemiology, diagnosis and treatment of AD+CVD in Asia. A consensus was reached by discussion, with evidence provided by published studies when available.

RESULTS

AD accounts for up to 60% and AD+CVD accounts for 10-20% of all dementia cases in Asia. The reasons for underdiagnosis of AD+CVD include lack of awareness as a result of a lack of diagnostic criteria, misdiagnosis as vascular dementia or AD, lack of diagnostic facilities, resource constraints and cost of investigations. There is variability in the tools used to diagnose AD+CVD in clinical practice. Diagnosis of AD+CVD should be performed in a stepwise manner of clinical evaluation followed by neuroimaging. Dementia patients should be assessed for cognition, behavioural and psychological symptoms, functional staging and instrumental activities of daily living. Neuroimaging should be performed using computed tomography or magnetic resonance imaging. The treatment goals are to stabilize or slow progression as well as to reduce behavioural and psychological symptoms, improve quality of life and reduce disease burden. First-line therapy is usually an acetylcholinesterase inhibitor such as donepezil.

CONCLUSION

AD+CVD is likely to be under-recognised in Asia. Further research is needed to establish the true prevalence of this treatable and potentially preventable disease.

Cognitive Change Questionnaire as a method for cognitive impairment screening

The Cognitive Change Questionnaire (CCQ) was created as an effective measure of cognitive change that is easy to use and suitable for application in Brazil.

The Health of India's Elderly Population: A Comparative Assessment Using Subjective and Objective Health Outcomes

This study examined relationships between and predictors of objective and subjective health measures among 766 individuals aged ≥ 45 years in India using the 2010 pilot wave of the Longitudinal Aging Study in India (LASI). Correlations between and gender differences in objective [grip strength, lung function] and subjective [self-rated health (SRH), dependence in activities of daily living (dADL)] health measures were examined. Multivariate logistic regression analyses, accounting for sample design, were conducted to identify predictors of poor health. Fewer individuals were classified as at risk according to subjective (SRH, 9 %; dADL, 12 %) than objective (lung function, 57 %; grip strength, 77 % women, 87 % men) indicators. Poor SRH was only weakly correlated with dADL (r = 0.103, p ≤ 0.05) and grip strength (r = −0.138, p ≤ 0.001). From this study we conclude that older Indians tend to report more positive perception of health than the objective measures of health indicates, and that subjective and objective health indicators capture different aspects of health and only weakly correlated.

Neuropsychological markers of mild cognitive impairment: A clinic based study from urban India

Background:

Mild cognitive impairment (MCI) is a transitional stage between normal aging and dementia. Persons with MCI are at higher risk to develop dementia. Identifying MCI from normal aging has become a priority area of research. Neuropsychological assessment could help to identify these high risk individuals.

Objective:

To examine clinical utility and diagnostic accuracy of neuropsychological measures in identifying MCI.

Materials and Methods:

This is a cross-sectional study of 42 participants (22 patients with MCI and 20 normal controls [NC]) between the age of 60 and 80 years. All participants were screened for dementia and later a detailed neuropsychological assessment was carried out.

Results:

Persons with MCI performed significantly poorer than NC on word list (immediate and delayed recall), story recall test, stick construction delayed recall, fluency and Go/No-Go test. Measures of episodic memory especially word list delayed recall had the highest discriminating power compared with measures of semantic memory and executive functioning.

Conclusion:

Word list learning with delayed recall component is a possible candidate for detecting MCI from normal aging.

Case management approaches to home support for people with dementia

BACKGROUND

Over 35 million people are estimated to be living with dementia in the world and the societal costs are very high. Case management is a widely used and strongly promoted complex intervention for organising and co-ordinating care at the level of the individual, with the aim of providing long-term care for people with dementia in the community as an alternative to early admission to a care home or hospital.

OBJECTIVES

To evaluate the effectiveness of case management approaches to home support for people with dementia, from the perspective of the different people involved (patients, carers, and staff) compared with other forms of treatment, including 'treatment as usual', standard community treatment and other non-case management interventions.

SEARCH METHODS

We searched the following databases up to 31 December 2013: ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group,The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, Web of Science (including Science Citation Index Expanded (SCI-EXPANDED) and Social Science Citation Index), Campbell Collaboration/SORO database and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group. We updated this search in March 2014 but results have not yet been incorporated.

SELECTION CRITERIA

We include randomised controlled trials (RCTs) of case management interventions for people with dementia living in the community and their carers. We screened interventions to ensure that they focused on planning and co-ordination of care.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as required by The Cochrane Collaboration. Two review authors independently extracted data and made 'Risk of bias' assessments using Cochrane criteria. For continuous outcomes, we used the mean difference (MD) or standardised mean difference (SMD) between groups along with its confidence interval (95% CI). We applied a fixed- or random-effects model as appropriate. For binary or dichotomous data, we generated the corresponding odds ratio (OR) with 95% CI. We assessed heterogeneity by the I² statistic.

MAIN RESULTS

We include 13 RCTs involving 9615 participants with dementia in the review. Case management interventions in studies varied. We found low to moderate overall risk of bias; 69% of studies were at high risk for performance bias.The case management group were significantly less likely to be institutionalised (admissions to residential or nursing homes) at six months (OR 0.82, 95% CI 0.69 to 0.98, n = 5741, 6 RCTs, I² = 0%, P = 0.02) and at 18 months (OR 0.25, 95% CI 0.10 to 0.61, n = 363, 4 RCTs, I² = 0%, P = 0.003). However, the effects at 10 - 12 months (OR 0.95, 95% CI 0.83 to 1.08, n = 5990, 9 RCTs, I² = 48%, P = 0.39) and 24 months (OR 1.03, 95% CI 0.52 to 2.03, n = 201, 2 RCTs, I² = 0%, P = 0.94) were uncertain. There was evidence from one trial of a reduction in the number of days per month in a residential home or hospital unit in the case management group at six months (MD -5.80, 95% CI -7.93 to -3.67, n = 88, 1 RCT, P < 0.0001) and at 12 months (MD -7.70, 95% CI -9.38 to -6.02, n = 88, 1 RCT, P < 0.0001). One trial reported the length of time until participants were institutionalised at 12 months and the effects were uncertain (hazard ratio (HR): 0.66, 95% CI 0.38 to 1.14, P = 0.14). There was no difference in the number of people admitted to hospital at six (4 RCTs, 439 participants), 12 (5 RCTs, 585 participants) and 18 months (5 RCTs, 613 participants). For mortality at 4 - 6, 12, 18 - 24 and 36 months, and for participants' or carers' quality of life at 4, 6, 12 and 18 months, there were no significant effects. There was some evidence of benefits in carer burden at six months (SMD -0.07, 95% CI -0.12 to -0.01, n = 4601, 4 RCTs, I² = 26%, P = 0.03) but the effects at 12 or 18 months were uncertain. Additionally, some evidence indicated case management was more effective at reducing behaviour disturbance at 18 months (SMD -0.35, 95% CI -0.63 to -0.07, n = 206, 2 RCTs I² = 0%, P = 0.01) but effects were uncertain at four (2 RCTs), six (4 RCTs) or 12 months (5 RCTs).The case management group showed a small significant improvement in carer depression at 18 months (SMD -0.08, 95% CI -0.16 to -0.01, n = 2888, 3 RCTs, I² = 0%, P = 0.03). Conversely, the case management group showed greater improvement in carer well-being in a single study at six months (MD -2.20 CI CI -4.14 to -0.26, n = 65, 1 RCT, P = 0.03) but the effects were uncertain at 12 or 18 months. There was some evidence that case management reduced the total cost of services at 12 months (SMD -0.07, 95% CI -0.12 to -0.02, n = 5276, 2 RCTs, P = 0.01) and incurred lower dollar expenditure for the total three years (MD= -705.00, 95% CI -1170.31 to -239.69, n = 5170, 1 RCT, P = 0.003). Data on a number of outcomes consistently indicated that the intervention group received significantly more community services.

AUTHORS' CONCLUSIONS

There is some evidence that case management is beneficial at improving some outcomes at certain time points, both in the person with dementia and in their carer. However, there was considerable heterogeneity between the interventions, outcomes measured and time points across the 13 included RCTs. There was some evidence from good-quality studies to suggest that admissions to care homes and overall healthcare costs are reduced in the medium term; however, the results at longer points of follow-up were uncertain. There was not enough evidence to clearly assess whether case management could delay institutionalisation in care homes. There were uncertain results in patient depression, functional abilities and cognition. Further work should be undertaken to investigate what components of case management are associated with improvement in outcomes. Increased consistency in measures of outcome would support future meta-analysis.

Development and community-based validation of the IDEA study Instrumental Activities of Daily Living (IDEA-IADL) questionnaire

Background

The dementia diagnosis gap in sub-Saharan Africa (SSA) is large, partly due to difficulties in assessing function, an essential step in diagnosis.

Objectives

As part of the Identification and Intervention for Dementia in Elderly Africans (IDEA) study, to develop, pilot, and validate an Instrumental Activities of Daily Living (IADL) questionnaire for use in a rural Tanzanian population to assist in the identification of people with dementia alongside cognitive screening.

Design

The questionnaire was developed at a workshop for rural primary healthcare workers, based on culturally appropriate roles and usual activities of elderly people in this community. It was piloted in 52 individuals under follow-up from a dementia prevalence study. Validation subsequently took place during a community dementia-screening programme. Construct validation against gold standard clinical dementia diagnosis using DSM-IV criteria was carried out on a stratified sample of the cohort and validity assessed using area under the receiver operating characteristic (AUROC) curve analysis.

Results

An 11-item questionnaire (IDEA-IADL) was developed after pilot testing. During formal validation on 130 community-dwelling elderly people who presented for screening, the AUROC curve was 0.896 for DSM-IV dementia when used in isolation and 0.937 when used in conjunction with the IDEA cognitive screen, previously validated in Tanzania. The internal consistency was 0.959. Performance on the IDEA-IADL was not biased with regard to age, gender or education level.

Conclusions

The IDEA-IADL questionnaire appears to be a useful aid to dementia screening in this setting. Further validation in other healthcare settings in SSA is required.

The impact of illiteracy on the assessment of cognition and dementia: a critical issue in the developing countries

BACKGROUND

Dementia and Alzheimer's disease (AD) is considered a major public health challenge in this decade and in the future. Early detection of AD through appropriate screening tools would be valuable approach in facing the burden of disease specifically in developing societies with insufficient resources. Selecting a screening tool which is non-expensive, non-invasive and implementable by trained primary healthcare providers is the first and probably the most important step in detecting high risk individuals. The goal of this review is to address the key issues in assessment tools in developing countries with a high level of illiteracy.

METHOD

We set about a review on literature on the subject of cognitive function assessment among minorities, people with low or no education, and people who live in underdeveloped societies. We also reviewed the studies on validation of such tests in a new society.

RESULTS

The most popular assessment tools are more or less biased by the level of education; not all of them are useful for any type of dementia as they assess only some domains of cognitive function.

CONCLUSION

Even though people with lower level of education have a higher rate of developing dementia, cognitive function cannot be accurately assessed because of limitations of current available tools. It is strongly suggested that special attention be paid to assess them by functional scales and activity daily living scales. For a more efficient assessment, cognitive tests can also benefit from illustrative questions, proverbs, metaphors, traditions, religious rituals and historical events.

Age, education and gender effects on neuropsychological functions in healthy Indian older adults

It is essential to use culturally appropriate, sensitive and specific tests that reflect true cognitive performance. However, several factors including age, education and gender can influence neuropsychological test performance.

Objective

To examine the effects of age, education and gender on neuropsychological function in older adults using measures of global cognitive screening, attention, working memory, executive functions, memory, construction, language and parietal focal signs.

Methods

This is a cross sectional normative study of 180 community-dwelling normal older adults. All participants were screened with the Hindi Mental Status Examination (HMSE), Everyday Activities Scale for India (EASI), Edinburgh handedness inventory (EDI) and MINI Screen, and followed by a detailed neuropsychological assessment.

Results

Stepwise regression analysis revealed that education was associated with better performance on all the neuropsychological tests. Females performed significantly better on measures of memory. Further, most of the illiterate subjects, including low educated participants, refused to cooperate on measures of executive functioning.

Conclusion

Education was found to be the strongest determinant of neuropsychological test performance followed by age and gender. Our study demonstrates that Indian healthy normal older adults with low education perform poorly on measures of planning and working memory. Traditional measures of planning and working memory should be avoided or used cautiously in the presence of low education. There is an urgent need to develop tasks for measuring executive functions, especially in low educated Indian older adults.

Development and preliminary validation of a new scale to assess functional ability of older population in India

Identifying the decline in functional ability and preventing disability is the critical element of the quality of life of an old age. However, the lack of contextual scale to assess the decline in functional capacity is a major issue. Objective of this study is to design the functional ability assessment scale for elderly people in India and test its psychometric properties. Random sample of 659 individuals above 60 years of age from western part of India was recruited. This paper outlines the construction, reliability and validity of a newly developed 14 item scale named as Pune-Functional Ability Assessment Tool (Pune-FAAT). The factors were extracted using the principal component analysis. Two-factor-structure of scale was accepted after applying the K1 rule, scree plot and parallel analysis method. The two factor structure yielded variance of 64.4%. The psychometric properties of the scale were examined using confirmatory factor analysis. The scale has an excellent reliability (Cronbach's α 0.928) and very good test-retest reliability (r=0.884). Each subscale demonstrated good internal consistency (Subscale I - Cronbach's α 0.938 and Subscale II - Cronbach's α 0.762). Excellent convergent validity with Standford's health assessment questionnaire (r=0.959). Discriminant validity was very good as FAAT index showed significant difference in young adults (mean±SD 1.11±0.24) and older adults (mean±SD 1.69±0.70). This new measure is a potentially valuable research tool for investigating older adult's functional ability to perform basic and complex daily activities.

Relationship of clinical and cognitive variables with brain morphometric abnormalities in Alzheimer's disease: a voxel based morphometric study using 3-tesla MRI

Alzheimer's disease (AD) is associated with widespread structural and functional brain alterations. The current study examined the gray matter (GM) voxel based morphometric (VBM) correlates of cognitive and clinical severity scores in patients with AD. The study included 34 patients with AD according to NINCDS/ADRDA AD criteria and 28 matched elderly controls. All subjects were clinically evaluated using Hindi Mental Status Examination (HMSE), Everyday Abilities Scale for India (EASI) and the Clinical Dementia Rating (CDR) scale. The structural Magnetic Resonance Imaging (MRI) data were acquired using a 3 Tesla MRI scanner and VBM analysis was performed using VBM5.1 toolbox. The patients with AD had significantly lower GM volume, white matter volume and total brain volume as compared to controls. The HMSE scores were positively correlated (p=0.009) and EASI (p=0.04) & CDR (p=0.0004) were negatively correlated with the total GM volumes in patients with AD. The VBM analysis revealed diffuse GM atrophy in patients with AD. Frontal& temporal GM volumes were positively correlated with the HMSE scores. Thus the results of the study replicate the previous observations of generalized GM atrophy, in an Indian sample with AD. The cognitive decline, clinical dementia severity and impairment in activities of daily living were correlated whole brain GM and WM volumes as well as with specific brain regional atrophy in AD. However further studies with larger samples & with more detailed cognitive evaluation are required for confirmation & validation of the relationship between regional morphometric abnormalities and cognitive deficits in AD.

Applicability of the MoCA-S test in populations with little education in Colombia

OBJECTIVES

The objectives of this study were to report on the use of the Spanish version of the Montreal Cognitive Assessment (MoCA-S) as cognitive screening tool in a population aged 65 to 74 years in the Andes Mountains of Colombia, assessing the influence of education, and to examine its test-retest reliability.

METHODS

We performed a cross-sectional study of 150 subjects aged 65 to 74 years recruited from older community social centers in Manizales, Colombia. The Leganes Cognitive Test (LCT), a cognitive screening test for populations with low education, was used to exclude those who were likely to have dementia. The associations between the MoCA total score and cognitive domains and education were examined in the total sample and in those likely free of dementia. MoCA-S test-retest reliability was estimated by the intraclass correlation coefficient (ICC) between two measurements taken 7 days apart.

RESULTS

Participants had low levels of formal education (mean years of schooling, 4.8). According to the LCT, the proportion of people screening positive for dementia was 16% (n = 24). The mean MoCA-S scores were 16.1/30 among illiterate subjects, 18.2/30 among those with incomplete primary school, and 20.3/30 among those with complete primary school (p < 0.001). Errors were frequent in the cube and clock drawing, attention-serial subtraction, verbal fluency, and abstraction. Test-retest reliability was high, ICC = 0.86, 95% CI (0.76-0.93).

CONCLUSION

The MoCA-S has high reliability in low-educated older Colombians, but scores were strongly dependent on years of education. Social and cultural factors must be considered when interpreting MoCA-S given the high error rates on items that depend on the ability to read and write and on culture.

Clinical validity of NIMHANS neuropsychological battery for elderly: A preliminary report

BACKGROUND

Neuropsychological assessment plays a crucial role in the assessment of cognitive decline in older age. In India, there is a dearth of culturally appropriate standardized measure to assess cognitive functions in early dementia. The aim of the study was to examine clinical validity of NIMHANS Neuropsychological Battery for Elderly (NNB-E) in identifying early dementia.

OBJECTIVES

To examine validity (discriminant and concurrent) of NIMHANS Neuropsychological Battery for Elderly (NNB-E).

RESULTS

Participants with AD showed significantly poorer performance on every test including memory and non-memory domains. However, tests of episodic and semantic memory were particularly sensitive in discriminating between normal and AD groups. Further scores on various subtests in the NNB-E were positively associated with scores on HMSE and negatively associated with Clinical Dementia Rating and Everyday Abilities Scale for India (EASI) scores.

CONCLUSIONS

NNB-E was able to differentiate normal controls from AD patients, and it can therefore be an ecologically valid tool for Indian older adults.

Dementia and diabetes mellitus: association with apolipoprotein e4 polymorphism from a hospital in southern India

Objective. To evaluate the association of Apolipoprotein E4 (ApoE4) in Alzheimer's dementia (AD) with comorbid diabetes mellitus (DM). Methods. The study included subjects with Alzheimer's dementia (AD) (n = 209), individuals with non-Alzheimer's dementia (nAD) (n = 122), individuals with parental history of AD (f/hAD) (n = 70), and control individuals who had normal cognitive functions and no parental history of dementia (NC) (n = 193). Dementia was diagnosed using International Classification of Diseases-10 revision (ICD-10) criteria. DM was assessed on the basis of self-report and/or use of antidiabetic medications. ApoE genotyping was done using sequence-specific primer polymerase chain reaction. Results. ApoE4 allele frequencies were highest among AD with comorbid DM (0.35) followed by AD without DM (0.25), nAD with DM (0.13), nAD without comorbid DM (0.12), and NC (0.08). Frequency of ApoE4 in persons with f/hAD was 0.13. The association of AD with co-morbid DM in ApoE4 carriers was more in comparison to NC with DM (OR = 5.68, P = 0.04). Conclusion. There is a significant association between AD with co-morbid DM and ApoE4 genotype.

Patient-reported physical activity questionnaires: a systematic review of content and format

Background

Many patients with chronic illness are limited in their physical activities. This systematic review evaluates the content and format of patient-reported outcome (PRO) questionnaires that measure physical activity in elderly and chronically ill populations.

Methods

Questionnaires were identified by a systematic literature search of electronic databases (Medline, Embase, PsychINFO & CINAHL), hand searches (reference sections and PROQOLID database) and expert input. A qualitative analysis was conducted to assess the content and format of the questionnaires and a Venn diagram was produced to illustrate this. Each stage of the review process was conducted by at least two independent reviewers.

Results

104 questionnaires fulfilled our criteria. From these, 182 physical activity domains and 1965 items were extracted. Initial qualitative analysis of the domains found 11 categories. Further synthesis of the domains found 4 broad categories: 'physical activity related to general activities and mobility', 'physical activity related to activities of daily living', 'physical activity related to work, social or leisure time activities', and '(disease-specific) symptoms related to physical activity'. The Venn diagram showed that no questionnaires covered all 4 categories and that the '(disease-specific) symptoms related to physical activity' category was often not combined with the other categories.

Conclusions

A large number of questionnaires with a broad range of physical activity content were identified. Although the content could be broadly organised, there was no consensus on the content and format of physical activity PRO questionnaires in elderly and chronically ill populations. Nevertheless, this systematic review will help investigators to select a physical activity PRO questionnaire that best serves their research question and context.