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Cognitive screening tools for identification of dementia in illiterate and low-educated older adults, a systematic review and meta-analysis

  • Stella-Maria Paddick (a1) (a2), William K. Gray (a1), Jackie McGuire (a1), Jenny Richardson (a1), Catherine Dotchin (a1) (a3) and Richard W. Walker (a1) (a4)...

Abstract

Background:

The majority of older adults with dementia live in low- and middle-income countries (LMICs). Illiteracy and low educational background are common in older LMIC populations, particularly in rural areas, and cognitive screening tools developed for this setting must reflect this. This study aimed to review published validation studies of cognitive screening tools for dementia in low-literacy settings in order to determine the most appropriate tools for use.

Method:

A systematic search of major databases was conducted according to PRISMA guidelines. Validation studies of brief cognitive screening tests including illiterate participants or those with elementary education were eligible. Studies were quality assessed using the QUADAS-2 tool. Good or fair quality studies were included in a bivariate random-effects meta-analysis and a hierarchical summary receiver operating characteristic (HSROC) curve constructed.

Results:

Forty-five eligible studies were quality assessed. A significant proportion utilized a case–control design, resulting in spectrum bias. The area under the ROC (AUROC) curve was 0.937 for community/low prevalence studies, 0.881 for clinic based/higher prevalence studies, and 0.869 for illiterate populations. For the Mini-Mental State Examination (MMSE) (and adaptations), the AUROC curve was 0.853.

Conclusion:

Numerous tools for assessment of cognitive impairment in low-literacy settings have been developed, and tools developed for use in high-income countries have also been validated in low-literacy settings. Most tools have been inadequately validated, with only MMSE, cognitive abilities screening instrument (CASI), Eurotest, and Fototest having more than one published good or fair quality study in an illiterate or low-literate setting. At present no screening test can be recommended.

Copyright

Corresponding author

Correspondence should be addressed to: Stella-Maria Paddick, Department of Medicine, North Tyneside General Hospital, Rake Lane, North Shields, Tyne and Wear, UK. Email: stella-maria.paddick@ncl.ac.uk.

References

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Almeida, O. P. (1998). Mini exame do estado mental e o diagnóstico de demência no Brasil. Arq Neuropsiquiatria, 56, 605612.
Aprahamian, I., Martinelli, J. E., Cecato, J. and Yassuda, M. S. (2011). Screening for Alzheimer's disease among illiterate elderly: accuracy analysis for multiple instruments. Journal of Alzheimer's Disease, 26, 221229.
Ardila, A. et al. (2010). Illiteracy: the neuropsychology of cognition without reading. Archives of Clinical Neuropsychology, 25, 689712.
Babacan-Yildiz, G. et al. (2013). COST: cognitive state test, a brief screening battery for Alzheimer disease in illiterate and literate patients. International Psychogeriatrics, 25, 403412.
Baiyewu, O. et al. (2005). The stick design test: a new measure of visuoconstructional ability. Journal of the International Neuropsychological Society, 11, 598605.
Baos Sánchez, L., Ruiz Muñoz, M. A., Bernal López, M. D., Ballester Rodríguez, B. and Ángora Mazuecos, F. (2007). Estudio de la validez del Test de las Fotos en el cribado de Deterioro Cognitivo en Atención Primaria. Revista Clínica de Medicina de Familia, 2, 5762.
Basic, D. et al. (2009). The validity of the rowland universal dementia assessment scale (RUDAS) in a multicultural cohort of community-dwelling older persons with early dementia. Alzheimer Disease & Associated Disorders, 23, 124129.
Bottino, C. M. C. et al. (2009). Combined instruments for the screening of dementia in older people with low education. Arquivos de Neuro-Psiquiatria, 67, 185190.
Brodaty, H., Low, L. F., Gibson, L. and Burns, K. (2006). What is the best dementia screening instrument for general practitioners to use? American Journal of Geriatric Psychiatry, 14, 391400.
Bustamante, S. E. Z. et al. (2003). Instrumentos combinados na avaliação de demência em idosos: resultados preliminares. Arquivos de Neuro-Psiquiatria, 61, 601606.
Caamano-Isorna, F., Corral, M., Montes-Martinez, A. and Takkouche, B. (2006). Education and dementia: a meta-analytic study. Neuroepidemiology, 26, 226232.
Caramelli, P., Carthery-Goulart, M. T., Porto, C. S., Charchat-Fichman, H. and Nitrini, R. (2007). Category fluency as a screening test for Alzheimer disease in illiterate and literate patients. Alzheimer Disease & Associated Disorders, 21, 6567. 10.1097/WAD.1090b1013e31802f31244f.
Carnero-Pardo, C., Lendinez-Gonzalez, A. and Navarro-Gonzalez, E. (1999). The coin test. Revue Neurologique, 29, 801804.
Carnero-Pardo, C. and Montoro-Ríos, M. (2004a). Evaluación preliminar de un nuevo test de cribado de demencia (Eurotest). Revue Neurologique, 38, 201209.
Carnero-Pardo, C. and Montoro-Ríos, M. (2004b). Test de las fotos. Revue Neurologique, 39, 801806.
Carnero-Pardo, C., Orduna, I. C., Martínez, B. E., Viedma, S. C., García, P. T. and Rodríguez, J. O. (2013). Efectividad del mini-mental en la detección del deterioro cognitivo en atención primaria. Atención Primaria, 45, 426433.
Carnero-Pardo, C., Sáez-Zea, C., De la Vega Cotarelo, R. and Gurpegui, M. (2012). Estudio FOTOTRANS: estudio multicéntrico sobre la validez del Fototest en condiciones de práctica clínica. Neurologia, 27, 6875.
Carnero-Pardo, C. et al. (2006). Diagnostic accuracy of the Eurotest for dementia: a naturalistic, multicenter phase II study. BMC Neurology, 6, 1.
Carnero Pardo, C. et al. (2007). Diagnostic accuracy of the phototest for cognitive impairment and dementia]. Neurologia, 22, 860869.
Carnero-Pardo, C. et al. (2011a). Diagnostic accuracy, effectiveness and cost for cognitive impairment and dementia screening of three short cognitive tests applicable to illiterates. PLoS One, 6, e27069.
Carnero-Pardo, C. et al. (2011b). Effectiveness and costs of phototest in dementia and cognitive impairment screening. BMC Neurology, 11, 92.
Castro-Caldas, A., Petersson, K. M., Reis, A., Stone-Elander, S. and Ingvar, M. (1998). The illiterate brain. Learning to read and write during childhood influences the functional organization of the adult brain. Brain, 121, 10531063.
Choi, S. H. et al. (2011). Validation of the literacy independent cognitive assessment. International Psychogeriatrics, 23, 593601.
Chung, J. C. (2009). Clinical validity of Fuld Object Memory Evaluation to screen for dementia in a Chinese society. International Journal of Geriatric Psychiatry, 24, 156162.
Crum, R. M., Anthony, J. C., Bassett, S. S. and Folstein, M. F. (1993). POpulation-based norms for the mini-mental state examination by age and educational level. JAMA, 269, 23862391.
de Paula, J. J., Costa, M. V., Bocardi, M. B., Cortezzi, M., De Moraes, E. N. and Malloy-Diniz, L. F. (2013). The stick design test on the assessment of older adults with low formal education: evidences of construct, criterion-related and ecological validity. International Psychogeriatrics, 25, 20572065.
De Yebenes, M. J., Otero, A., Zunzunegui, M. V., Rodriguez-Laso, A., Sanchez-Sanchez, F. and Del Ser, T. (2003). Validation of a short cognitive tool for the screening of dementia in elderly people with low educational level. International Journal of Geriatric Psychiatry, 18, 925936.
Del Ser, T., Sanchez-Sanchez, F., Garcia de Yebenes, M. J., Otero, A. and Munoz, D. G. (2006). Validation of the seven-minute screen neurocognitive battery for the diagnosis of dementia in a spanish population-based sample. Dementia and Geriatric Cognitive Disorders, 22, 454464.
Doebler, P. and Holling, H. (2012). Meta-analysis of diagnostic accuracy with mada. cran.mtu.edu; last accessed 8 February, 2017.
Dua, T. et al. (2011). Evidence-based guidelines for mental, neurological, and substance use disorders in low-and middle-income countries: summary of WHO recommendations. PLoS Medicine, 8, e1001122.
Guerchet, M. et al. (2009). Cognitive impairment and dementia in elderly people living in rural Benin, West Africa. Dementia and Geriatric Cognitive Disorders, 27, 3441.
Jin, H. et al. (1989). Cross-cultural studies of dementia: use of a Chinese version of the blessed-Roth information-memory-concentration test in a Shanghai dementia survey. Psychology and aging, 4, 471.
Jitapunkul, S., Lailert, C., Worakul, P., Srikiatkhachorn, A. and Ebrahim, S. (1996). Chula mental test: a screening test for elderly people in less developed countries. International Journal of Geriatric Psychiatry, 11, 715720.
Keskinoglu, P., Ucku, R., Yener, G., Yaka, E., Kurt, P. and Tunca, Z. (2009). Reliability and validity of revised Turkish version of mini mental state examination (rMMSE-T) in community-dwelling educated and uneducated elderly. International Journal of Geriatric Psychiatry, 24, 12421250.
Kochhann, R., Varela, J. S., de Macedo Lisboa, C. S. and Chaves, M. L. F. (2010). The Mini Mental State Examination. Population, 11, 15.
Kraemer, H. C., Moritz, D. J. and Yesavage, J. (1998). Adjusting mini-mental state examination scores for age and educational level to screen for dementia: correcting bias or reducing validity? International Psychogeriatrics, 10, 4351.
Lam, L. C. W. et al. (1998). Clock-face drawing, reading and setting tests in the screening of dementia in Chinese elderly adults. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 53, P353–P357.
Leeflang, M. M. G., Rutjes, A. W. S., Reitsma, J. B., Hooft, L. and Bossuyt, P. M. M. (2013). Variation of a test's sensitivity and specificity with disease prevalence. Canadian Medical Association Journal, 185, E537–E544.
Lin, K. N., Wang, P. N., Liu, C. Y., Chen, W. T., Lee, Y. C. and Liu, H. C. (2002). Cutoff scores of the cognitive abilities screening instrument, Chinese version in screening of dementia. Dementia and Geriatric Cognitive Disorders, 14, 176182.
Liu, H.-C. et al. (1994). Assessing cognitive abilities and dementia in a predominantly illiterate population of older individuals in Kinmen. Psychological Medicine, 24, 763770.
LoGiudice, D. et al. (2006). Kimberley indigenous cognitive assessment tool (KICA): development of a cognitive assessment tool for older indigenous Australians. International Psychogeriatrics, 18, 269280.
Lourenço, R. A., Ribeiro-Filho, S. T., Moreira, I. d. F. H., Paradela, E. M. P. and Miranda, A. S. d. (2008). The clock drawing test: performance among elderly with low educational level. Revista Brasileira de Psiquiatria, 30, 309315.
Lourenço, R. A. and Veras, R. P. (2006). Mini-exame do estado mental: características psicométricas em idosos ambulatoriais. Revista de Saúde Pública, 40, 712719.
Lu, J. et al. (2011). Montreal cognitive assessment in detecting cognitive impairment in Chinese elderly individuals: a population-based study. Journal of Geriatric Psychiatry and Neurology, 24, 184190.
Martínez de la Iglesia, J., DueñasHerrerob, R., Carmen Onís Vilchesa, M., Aguado Tabernéa, C., Albert Colomerc, C. and Luque Luquec, R. (2001). Adaptación y validación al castellano del cuestionario de Pfeiffer (SPMSQ) para detectar la existencia de deterioro cognitivo en personas mayores e 65 años. Medicina Clínica, 117, 129134.
Meng, X. and D'Arcy, C. (2012). Education and dementia in the context of the cognitive reserve hypothesis: a systematic review with meta-analyses and qualitative analyses. PLoS one, 7, e38268.
Mitchell, A. J. and Malladi, S. (2010). Screening and case finding tools for the detection of dementia. Part I: evidence-based meta-analysis of multidomain tests. American Journal of Geriatric Psychiatry, 18, 759782.
Moher, D., Liberati, A., Tetzlaff, J. and Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339, b2535.
Napon, C., Traore, S., Niakara, A., Ouango, G., Ouango, A. and Kabore, J. (2009). Les démences en Afrique subsaharienne: aspects cliniques et étiologiques en milieu hospitalier à Ouagadougou (Burkina Faso). African Journal of Neurological Sciences, 28, 3743.
Ostrosky-Solis, F., Ardila, A., Rosselli, M., Lopez-Arango, G. and Uriel-Mendoza, V. (1998). Neuropsychological test performance in illiterate subjects. Archives of Clinical Neuropsychology, 13, 645660.
Paddick, S.-M. et al. (2014). The association between educational level and dementia in rural Tanzania. Dementia & Neuropsychologia, 8, 117125.
Paddick, S. M. et al. (2015). Utility of the mini-mental state examination (MMSE) for identification of dementia in a low-literacy setting in rural Tanzania. Age and Ageing, 44, ii25–ii25.
Pandav, R., Fillenbaum, G., Ratcliff, G., Dodge, H. and Ganguli, M. (2002). Sensitivity and specificity of cognitive and functional screening instruments for dementia: the Indo-US dementia epidemiology study. Journal of the American Geriatrics Society, 50, 554561.
Prince, M., Acosta, D., Chiu, H., Scazufca, M. and Varghese, M. (2003). Dementia diagnosis in developing countries: a cross-cultural validation study. The Lancet, 361, 909917.
Prince, M., Bryce, R. and Ferri, C. (2013a). World Alzheimer Report 201: The Benefits of Early Diagnosis and Intervention. Alzheimer's Disease International.
Prince, M., Guerchet, M. and Prina, M. (2013b). Policy Brief for Heads of Governments. N/A Ed. London: Alzheimer's Disease International.
Prince, M. et al. (2011). A brief dementia screener suitable for use by non-specialists in resource poor settings-the cross-cultural derivation and validation of the brief community screening instrument for dementia. International Journal of Geriatric Psychiatry, 26, 899907.
Ramlall, S., Chipps, J., Pillay, B. J. and Bhigjee, A. I. (2013). Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile. African Journal of Psychiatry, 16, 119135.
Reitsma, J. B., Glas, A. S., Rutjes, A. W., Scholten, R. J., Bossuyt, P. M. and Zwinderman, A. H. (2005). Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. Journal of Clinical Epidemiology, 58, 982990.
Ribeiro Filho, S. T. and Lourenço, R. A. (2009). The performance of the mini-cog in a sample of low educational level elderly. Dementia & Neuropsychologia, 3, 8187.
Rosselli, M., Ardila, A. and Rosas, P. (1990). Neuropsychological assessment in illiterates: II. Language and praxic abilities. Brain and Cognition, 12, 281296.
Saez-Zea, C., Carnero-Pardo, C. and Gurpegui, M. (2008). Names of persons: a verbal fluency test without socioeducational influences. Neurologia, 23, 356360.
Saxena, S., Thornicroft, G., Knapp, M. and Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. The Lancet, 370, 878889.
Scazufca, M., Almeida, O., Vallada, H., Tasse, W. and Menezes, P. (2009). Limitations of the Mini-Mental State Examination for screening dementia in a community with low socioeconomic status. European Archives of Psychiatry and Clinical Neuroscience, 259, 815.
Shulman, K. I. et al. (2006). IPA survey of brief cognitive screening instruments. International Psychogeriatrics, 18, 281294.
Smith, K. et al. (2009). Assessing cognitive impairment in Indigenous Australians: re-evaluation of the Kimberley indigenous cognitive assessment in Western Australia and the northern territory. Australian Psychologist, 44, 5461.
Sosa, A. L. et al. (2009). Population normative data for the 10/66 dementia research group cognitive test battery from Latin America, India and China: a cross-sectional survey. BMC Neurology, 9, 1.
Stanley, R. et al. (2009). The Vellore screening instruments and strategies for the diagnosis of dementia in the community. International Psychogeriatrics, 21, 539547.
Takada, L. T. et al. (2006). Comparison between two tests of delayed recall for the diagnosis of dementia. Arquivos de Neuro-Psiquiatria, 64, 3540.
Touré, K. et al. (2008). The test of Senegal: a valid and reliable screening tool to assess for dementia in a Senegalese elderly population. African Journal of Neurological Sciences, 27, 4.
Tsai, N. and Gao, Z. X. (1989). Validity of Hasegawa's Dementia Scale for screening dementia among aged Chinese. International Psychogeriatrics, 1, 145152.
Tsoi, K. F., Chan, J. C., Hirai, H. W., Wong, S. S. and Kwok, T. Y. (2015). Cognitive tests to detect dementia: a systematic review and meta-analysis. JAMA Internal Medicine, 175, 14501458.
Tsolaki, M., Iakovidou, V., Navrozidou, H., Aminta, M., Pantazi, T. and Kazis, A. (2000). Hindi Mental State Examination (HMSE) as a screening test for illiterate demented patients. International Journal of Geriatric Psychiatry, 15, 662664.
UNESCO (2015). Education Data 2015. Quebec, Canada: UNESCO.
Uwakwe, R. (2000). Psychiatric morbidity in elderly patients admitted to non-psychiatric wards in a general/teaching hospital in Nigeria. International Journal of Geriatric Psychiatry, 15, 346354.
Verghese, J. et al. (2012). Picture-based memory impairment screen for dementia. Journal of the American Geriatrics Society, 60, 21162120.
Whiting, P. F. et al. (2011). QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Annals of Internal Medicine, 155, 529536.
Xu, G., Meyer, J. S., Huang, Y., Du, F., Chowdhury, M. and Quach, M. (2003). Adapting Mini-Mental State Examination for dementia screening among illiterate or minimally educated elderly Chinese. International Journal of Geriatric Psychiatry, 18, 609616.
Yusuf, A. J., Baiyewu, O., Sheikh, T. L. and Shehu, A. U. (2011). Prevalence of dementia and dementia subtypes among community-dwelling elderly people in northern Nigeria. International Psychogeriatrics, 23, 379386.

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