Validation Study of the Mini-Mental State Examination in Urdu Language for Pakistani Population

Plasma levels of phosphorylated tau and neurofilament light chain as potential biomarkers for Alzheimer's disease: A biochemical analysis in Pakistani population

The National Institute on Aging-Alzheimer's Association's research framework in 2018 proposed a molecular construct for the diagnosis of Alzheimer's disease (AD). Nonetheless, the clinical exclusionary strategy is still the mainstay of AD diagnosis in Pakistan. We looked at the plasma levels of amyloid beta-42 (Aβ-42), phosphorylated tau (P-tau), and neurofilament light (NFL) in patients with Alzheimer's clinical syndrome (ACS) and healthy controls (HC) from the Pakistani population to keep pace with the global efforts towards establishing accessible and affordable biochemical diagnostic markers for AD in Pakistan. Consultant neurologists screened patients who presented with cognitive impairment to three large tertiary care hospitals in Karachi, and after receiving informed consent, recruited participants with ACS and HC from the same facilities. We collected 5cc of blood in EDTA tubes along with demographic and lifestyle information of the subjects. Plasma aliquots were stored at -80°C after centrifugation. For analysis it was thawed at 4℃ and levels of the three proteins were measured through ELISA. Data from 28 ACS patients and 28 age matched healthy controls were evaluated. Among demographic factors, education and depression were related with health status (p = 0.03 and 0.003, respectively). NFL and P-tau mean values demonstrated a significant difference between the ACS and control groups (p = 0.003 and 0.006), however Aβ42 did not (p = 0.114). ROC analysis showed that plasma P-tau and NFL, with AUCs of 0.717 and 0.735, respectively, could substantially distinguish ACS from the HC group (p = 0.007 and 0.003, respectively). Both plasma P-tau (r = -0.389; p = 0.004) and NFL (r = -0.424; p = 0.001) levels were significantly and negatively correlated with individuals' MMSE scores. NFL and plasma P-tau show promise in differentiating AD patients from healthy individuals. However, similar larger studies are needed to validate our findings.

A new tool for assessing the cultural adaptation of cognitive tests: demonstrating the utility of the Manchester Translation Evaluation Checklist (MTEC) through the Mini-Mental State Examination Urdu

BACKGROUND

Low- and middle-income countries contribute to the majority of dementia and mild cognitive impairment cases worldwide, yet cognitive tests for diagnosis are designed for Western cultures. Language and cultural discrepancies mean that translated tests are not always reliable or valid. We propose a model for culturally adapting cognitive tests, one step of which is to assess the quality of any translation and cultural adaptation undertaken. We developed the Manchester Translation Evaluation Checklist (MTEC) to act as a tool for quality assessment and demonstrated its use by assessing a popular cognitive test that had been adapted.

AIMS

Assess quality of the translation and cultural adaptation of the Urdu Mini-Mental State Examination developed for a Pakistani population.

METHOD

Two raters completed the MTEC for the Mini-Mental State Examination (MMSE) Urdu and compared feedback. All authors were fluent in English and Urdu and familiar with Pakistani culture.

RESULTS

Raters had 78.5% agreement across the MTEC. The MMSE Urdu was appropriately translated and retained grammar and verb tense, but three questions had spelling errors. Across 20 MMSE questions, 5 required further cultural adaptation because the questions were not understandable in daily use, comfortable to answer, relevant to the language and culture, and relevant to original concepts.

CONCLUSIONS

The MTEC highlighted errors in the MMSE Urdu and demonstrated how this tool can be used to improve it. Future studies could employ the MTEC to improve existing translated measures of health assessment, particularly cognitive tests, and act as a quality check when developing new adaptations of tests and before psychometric validation.

Cognitive Impairment in Type 2 Diabetes Mellitus

Objective

To determine the incidence of cognitive impairment established on the mini-mental state assessment in type 2 diabetic patients presenting at Holy Family Hospital, Rawalpindi.

Materials and methods

This cross-sectional descriptive study was carried out from June 2019 to December 2019. Individuals with a diagnosis of type 2 diabetes mellitus were included, and detailed history, physical examination, and biochemical variables were noted. They were assessed through Mini-Mental State Examination (MMSE) (Urdu translation) to look for the primary outcome variable, i.e., cognitive impairment. All patients with type 2 diabetes mellitus diagnosed at least one year back, irrespective of gender, were included in this investigation. Patients with a previous history of head injury, epilepsy, stroke, those on an antidepressant or antipsychotic medications, those with deranged renal function tests, and those already diagnosed with dementia were excluded from the study.

Results

Three hundred thirty-two patients meeting the inclusion criteria were included in the study. The mean ± standard deviation age of the study population was 65.32 ± 11.33 years, with maximum age being 80 years and the minimum being 50 years. Two hundred patients (60.24%) were below 65 years of age, and 132 patients (39.76%) were 65 years of age or above. Two hundred sixteen (65.06%) were males, and 116 (34.96%) were females. The mean duration of diabetes mellitus (DM) was 10.17 ± 4.81. The mean MMSE score was 22.69 ± 5.26. Out of 332 patients, 81 (24.4%) patients had cognitive impairment. Patients who were 65 or older had a significantly higher proportion of cognitive impairment, compared to those below 65 years of age (p-value = 0.0214). There was no significant difference in the proportion of cognitively impaired patients between males and females (p-value = 0.2497). Similarly, there was no significant difference between those who were diagnosed with type 2 diabetes for 10 years or more and those who were diagnosed less than 10 years ago (p-value = 0.3791).

Conclusion

Cognitive impairment is common in individuals having type 2 diabetes mellitus. It is also associated with the increasing age of diabetic patients. However, cognitive impairment in type 2 diabetes mellitus is not associated with gender. In addition, there is no significant difference in cognitive impairment between the patients who were diagnosed with diabetes more than 10 years ago and those who had it diagnosed less than 10 years ago.

Translation and validation of the stroke impact scale 3.0 into urdu for Pakistan

BACKGROUND

The Stroke Impact Scale version 3.0 (SIS 3.0) is a self-reported outcome measure designed to assess quality of life (QoL) following a stroke. Although the psychometric properties of the SIS 3.0 are identified as superior to the generic QoL scales, it has not been translated and tested in Pakistan.

OBJECTIVE

To validate the Urdu version of the SIS 3.0 (USIS 3.0) for Pakistan.

METHODS

A prospective cohort of 116 patients with mild to moderate stroke reported their recovery using the USIS 3.0. The patients were concurrently assessed on the established tools to assess the validity and were re-evaluated to determine the test-retest reliability, precision, minimal detectable change (MDC), and minimal clinically important difference (MCID).

RESULTS

The reliability and internal consistency of USIS were satisfactory except for the emotion domain. The correlations of USIS with the established tools were strong. The discriminant validity was also significant across the levels of the modified Rankin scale (MRS). Only hand function and communication domains exhibited significant floor and ceiling effects, respectively. Regarding weighted K, values ranged from 0.53 to 0.88.

CONCLUSIONS

The USIS 3.0 has satisfactory psychometric properties and can be used in clinical and research settings for stroke survivors.

Translation and Validation of 10/66 Dementia Diagnostic Battery in Urdu in Karachi, Pakistan

PURPOSE

The 10/66 dementia research group (DRG) diagnostic tool was devised to diagnose dementia in people with low education in low and middle-income countries. This study aimed to validate the 10/66 DRG tool in Urdu in Pakistan.

METHODOLOGY

People older than or equal to 60 years were included: (1) With normal cognition: no/low education, high education, and depression; (2) People with mild and moderate dementia. The diagnostic and statistical manual IV-TR clinician diagnosis was used as the gold standard for dementia. The Clinician Dementia Rating scale was used to rate dementia severity. The geriatric mental status AGECAT stage I output was used to diagnose depression. The 10/66 battery was comprised of CSI-D (cognitive screening instrument for dementia), CERAD (consortium to establish a registry of Alzheimer disease), and animal naming test.

RESULT

The sensitivity and specificity of CSI-D COG score for diagnosing dementia was 86.7% and 72.1%, for CSI-D DF score was 71.1% and 96.1%, for CERAD-10 word list delayed recall was 85.9% and 62.2% at a cut point of ≥5 words, and 70.3% and 97.7% for 10/66 diagnostic algorithm.

CONCLUSIONS

The 10/66 DRG tool is a valid instrument for diagnosing dementia in the Urdu-speaking population, including with low education and depression, in Pakistan.

Experiences of People With Dementia in Pakistan: Help-Seeking, Understanding, Stigma, and Religion

BACKGROUND AND OBJECTIVES

The prevalence of dementia will increase in low- and middle-income countries like Pakistan. Specialist dementia services are rare in Pakistan. Public awareness of dementia is low, and norms about family care can lead to stigma. Religion plays a role in caregiving, but the interaction between dementia and Islam is less clear.

RESEARCH DESIGN AND METHODS

Qualitative interviews were carried out with 20 people with dementia in Karachi and Lahore. Interviews were conducted in Urdu, translated to English, and respondents' views on help-seeking experiences, understanding of diagnosis, stigma, and religion were analyzed thematically.

RESULTS

Although some people with dementia understood what dementia is, others did not. This finding shows a more positive perspective on diagnosis in Pakistan than previously thought. Help-seeking was facilitated by social and financial capital, and clinical practice. Stigma was more common within the family than in the community. Dementia symptoms had a serious impact on religious obligations such as daily prayers. Participants were unaware that dementia exempts them from certain religious obligations.

DISCUSSION AND IMPLICATIONS

Understanding of dementia was incomplete despite all participants having a formal diagnosis. Pathways to help-seeking need to be more widely accessible. Clarification is needed about exemption from religious obligations due to cognitive impairment, and policy makers would benefit from engaging with community and religious leaders on this topic. The study is novel in identifying the interaction between dementia symptoms and Islamic obligatory daily prayers, and how this causes distress among people living with dementia and family caregivers.

Development of a core outcome set for disease modification trials in mild to moderate dementia: a systematic review, patient and public consultation and consensus recommendations

BACKGROUND

There is currently no disease-modifying treatment available to halt or delay the progression of the disease pathology in dementia. An agreed core set of the best-available and most appropriate outcomes for disease modification would facilitate the design of trials and ensure consistency across disease modification trials, as well as making results comparable and meta-analysable in future trials.

OBJECTIVES

To agree a set of core outcomes for disease modification trials for mild to moderate dementia with the UK dementia research community and patient and public involvement (PPI).

DATA SOURCES

We included disease modification trials with quantitative outcomes of efficacy from (1) references from related systematic reviews in workstream 1; (2) searches of the Cochrane Dementia and Cognitive Improvement Group study register, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Latin American and Caribbean Health Sciences Literature and PsycINFO on 11 December 2015, and clinical trial registries [International Standard Randomised Controlled Trial Number (ISRCTN) and clinicaltrials.gov] on 22 and 29 January 2016; and (3) hand-searches of reference lists of relevant systematic reviews from database searches.

REVIEW METHODS

The project consisted of four workstreams. (1) We obtained related core outcome sets and work from co-applicants. (2) We systematically reviewed published and ongoing disease modification trials to identify the outcomes used in different domains. We extracted outcomes used in each trial, recording how many used each outcome and with how many participants. We divided outcomes into the domains measured and searched for validation data. (3) We consulted with PPI participants about recommended outcomes. (4) We presented all the synthesised information at a conference attended by the wider body of National Institute for Health Research (NIHR) dementia researchers to reach consensus on a core set of outcomes.

RESULTS

We included 149 papers from the 22,918 papers screened, referring to 125 individual trials. Eighty-one outcomes were used across trials, including 72 scales [31 cognitive, 12 activities of daily living (ADLs), 10 global, 16 neuropsychiatric and three quality of life] and nine biological techniques. We consulted with 18 people for PPI. The conference decided that only cognition and biological markers are core measures of disease modification. Cognition should be measured by the Mini Mental State Examination (MMSE) or the Alzheimer's Disease Assessment Scale - Cognitive subscale (ADAS-Cog), and brain changes through structural magnetic resonance imaging (MRI) in a subset of participants. All other domains are important but not core. We recommend using the Neuropsychiatric Inventory for neuropsychiatric symptoms: the Disability Assessment for Dementia for ADLs, the Dementia Quality of Life Measure for quality of life and the Clinical Dementia Rating scale to measure dementia globally.

LIMITATIONS

Most of the trials included participants with Alzheimer's disease, so recommendations may not apply to other types of dementia. We did not conduct economic analyses. The PPI consultation was limited to members of the Alzheimer's Society Research Network.

CONCLUSIONS

Cognitive outcomes and biological markers form the core outcome set for future disease modification trials, measured by the MMSE or ADAS-Cog, and structural MRI in a subset of participants.

FUTURE WORK

We envisage that the core set may be superseded in the future, particularly for other types of dementia. There is a need to develop an algorithm to compare scores on the MMSE and ADAS-Cog.

STUDY REGISTRATION

The project was registered with Core Outcome Measures in Effectiveness Trials [ www.comet-initiative.org/studies/details/819?result=true (accessed 7 April 2016)]. The systematic review protocol is registered as PROSPERO CRD42015027346.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.