|Year : 2016 | Volume
| Issue : 1 | Page : 80-85
Research priorities for cognitive decline in India
Jahnavi S Kedare, Chetan D Vispute
Department of Psychiatry, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||6-May-2016|
Chetan D Vispute
Department of Psychiatry, Seth GS Medical College and King Edward Memorial Hospital, Acharya Donde Marg, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
The elderly population with cognitive decline is increasing at an alarming rate in developing countries such as India. There is a paucity of basic clinical research in the field of cognitive decline dealing with areas of prevalence, etiology, diagnosis, and management. In India, prioritization of research capabilities is obligatory to decrease the research gap, i.e., the difference between the information needed to plan services and that which is available. The information can be gathered and utilized to frame policies and early remedial measures to tackle the emerging disease burden on the community. This article highlights the research done on cognitive decline so far and the further need for priority research on various important areas such as epidemiology, assessment methods and diagnosis, psychobehavioral symptoms, mild cognitive impairment (MCI), and interventional studies to create an evidence base for our population.
Keywords: Cognitive decline, dementia, mild cognitive impairment
|How to cite this article:|
Kedare JS, Vispute CD. Research priorities for cognitive decline in India. J Geriatr Ment Health 2016;3:80-5
| Introduction|| |
Normal aging is associated with some amount of cognitive impairment. The speed of intellectual and physical activities decreases; however, cognitive decline associated with normal aging does not lead to impairment in activities of daily living. Those patients who experience these age-related changes as dysfunctional have age-associated cognitive impairment. Age-associated memory impairment (AAMI) is nonprogressive and associated with mild deficit in memory retrieval. Mild cognitive impairment (MCI) is defined as cognitive changes in the absence of dementia. Peterson described the term MCI and gave its diagnostic criteria, which include the following:
- Memory problems,
- Objective memory disorder,
- Absence of other cognitive disorders or repercussions on daily life,
- Normal general cognitive function, and
- Absence of dementia.  At present, three subtypes of MCI are recognized, i.e.,
- Amnestic MCI, which progress preferentially to Alzheimer's disease;
- Multiple domain slightly impaired MCI, which may progress to Alzheimer's disease and also to vascular dementia (VaD), or may even represent a cognitive aging process qualified as normal; and
- Single domain nonmemory MCI, which may progress to non-Alzheimer's type dementia. 
MCI has assumed importance because it can be a precursor of dementia and the conversion rate to dementia ranges from 10% to 15%. , The Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition (DSM-5) introduced the terms mild and major neurocognitive disorders (NCDs).  The revised criteria in DSM-5 allowed us to include individuals with less severe cognitive deficits than that required for Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition (DSM-IV) Text Revision (TR) diagnosis. The diagnosis of dementia requires detailed assessment and determination of the level of cognitive deterioration.
| Need for research on cognitive decline|| |
As a developing country, India has seen a rapid growth in the elderly population over the recent years and cognitive decline has become a major public health issue due to the huge cost of treatment and the impaired quality of life of patients and caregivers. Of all people with dementia, 71% will be living in developing countries by 2040 as per the Alzheimer's Disease International (ADI) Delphi consensus study. In the next four decades, the number of people suffering from dementia in India, i.e., 1.5 million, is going to increase by almost 300%.  According to the Global Burden of Disease report, disability from dementia was accorded a higher disability weight (0.67) than that for almost any other condition, with the exception of severe developmental disorders. This signifies a two-third loss for each year lived with dementia in measuring disability-adjusted life years (DALYs).  In India, the symptoms of cognitive impairment are attributed to normal aging and patients usually present late during the course of dementia with moderate to severe cognitive deterioration, thereby delaying the intervention. Behavioral and psychological symptoms of dementia (BPSDs) prompt the relatives to seek professional help, thereby delaying the intervention. Delay in diagnosis and lack of awareness about dementia is a major hindrance in providing care to dementia patients and caregivers. Caregiver burden is associated with all these factors including the clinical symptoms of dementia, psychobehavioral symptoms, and the time and cost of treatment. A high caregiver burden often leads to psychiatric disorders in them.
The calculated total societal cost of dementia for India was estimated to be `147 billion (US$ 3.415 billion). While informal care is more than half the total cost (56%, `88.9 billion), nearly one-third (29%) of the total cost is direct medical cost (`46.8 billion). The total cost per person with dementia is `43,285 (US$ 925). Interestingly, the informal care cost per person in urban areas (US$ 257) was two and half times more than those in rural areas (US$ 97). 
All these facts underline the need for research on various aspects of cognitive decline. Apart from MCI and dementia, other mental disorders such as schizophrenia, depression, and substance use disorders also cause cognitive impairment. This leads to a loss of productivity, decreased quality of life, and difficulties in rehabilitation and social integration of the individual causing a further increase in caregiver burden.
| Research in cognitive decline|| |
There is a dearth of research on cognitive decline in India. On systematic electronic search, only 207 articles related to cognitive decline were found on Pubmed in the last 10 years. In an article on Indian research on aging and dementia, it was found that from 1958 to 2009 only nine research studies and two case reports were published in the Indian Journal of Psychiatry along with five other studies on cognitive disturbances due to other causes.  India ranks 16 th among the top 20 nations contributing to dementia research during 2002-11 with the global publication share of 1.24%.  The top 15 Indian and foreign journals publishing Indian research on dementia contributed 241 papers during 2002-11.  Publication done under the subject of psychiatry and psychology accounted for only 4.24% share of the total publications among eight medical subspecialties.
Priority research on cognitive decline should looks into various issues such as epidemiology, assessment methods and diagnosis, psychobehavioral symptoms, caregiver issues, and interventional studies to create an evidence base for our population. In the view of few available studies, it is also becoming increasingly important to study the various aspects of MCI including diagnosis, conversion to dementia, and interventions.
| Development of screening and assessment tools|| |
The Clinical Dementia Rating (CDR) is a global clinical scale with established diagnostic and severity-ranking utility that have been widely administered in epidemiological studies,  with good interrater reliability  and predictive validity.  The scoring of certain CDR domains, in particular the categories of judgment and problem-solving, community, and home and hobbies, may also be subject to the influence of cultural factors and local social settings.  Studies for validating the scales so that they become suitable for use in our culture are required. Also, research should be focused on the development of specific scales and test for assessing the severity of cognitive decline and functional impairment in activities of daily living (ADLs). A few studies found that the eight-item Instrumental Activities of Daily Living (IADL) scale has physical and cognitive domains and is cross-culturally applicable. , A brief version of the full Community Screening Instrument for Dementia (CSI-D) appears to have favorable screening properties.  Attempts have been made till now to construct culture-sensitive instruments to test for cognitive impairment, especially in the community setting. In our country while constructing screening tools and assessment tools, various factors such as level of education, rural urban divide, and gender differences have to be taken into account. Validation of mini-mental state examination (MMSE) and Hindi mental state examination (HMSE) are examples of the development of cognitive screening instruments for the Indian population.  The Bharmouri version of MMSE was developed for screening of cognitive impairment in the elderly tribal population of Himachal Pradesh, India.  Screening instruments with patient and informant version based on the activities of daily living were developed at Vellore, Tamil Nadu, India. These instruments have good psychometric properties and interrater reliability when used in the hospital and in the community setting.  Apart from the screening test, there is a need to culturally validate various neurocognitive test batteries. Other criteria to develop the screening test for early detection are that the test should be nonexpensive, simple, and can be executed by primary health care workers at the grassroot level of health care system hierarchy.
| Research directed toward the awareness of cognitive decline|| |
According to the few qualitative research studies done in India, ,,, the symptoms of cognitive decline have been considered as the normal phenomenon of aging. The symptoms of dementia have been attributed various names in the local languages but no awareness was present among the population for medical help-seeking. In Kerala, India, it was reported that most caregivers tended to misinterpret symptoms of the disease and designate these as deliberate misbehavior by the person with dementia.  Efforts should be directed toward the development of awareness modules in regional languages. Multicentric qualitative research studies regarding understanding of the symptoms of cognitive decline would guide us in the development of awareness modules for grassroot level implementation. A randomized controlled trial was conducted in two talukas of Goa, India. It evaluated the benefits of a low-cost home-based intervention following a flexible stepped care model. It proved to be effective in reducing the care giver burden due to the BPSDs by improving the knowledge of the family caregivers, providing emotional support to them, and improving care giving skills. 
| Research on risk factors and prevention of cognitive decline|| |
In developing countries such as India, there is abundant literature on cardiovascular disease (CVD) risk factors such as diabetes, hypertension and hyperlipidemia, dietary deficiencies, particularly of micronutrients such as folate and vitamin B12, anemia, and raised homocysteine levels, contributing to vascular cognitive impairment and VaD. The Indian study found that reversible causes, neuroinfection, and vitamin B12 deficiency account for 18% of dementia. 
Hypertension is perhaps the most widely studied factor. Hypertension, along with diabetes mellitus and smoking, were found to be the risk factors for MCI in a study conducted by Das et al. in the East Indian population.  Family history of dementia for Alzheimer's dementia (AD), smoking,g and hypertension for VaD were documented as a risk factor in a study from South India.  A recent study from northwest India assessed the association between raised blood pressure and dementia although it could not differentiate the difference caused by diastolic and systolic blood pressure hypertension.  There is a need of a multicentric longitudinal study to assess the association between cardiovascular risk factors and dementia.
Insulin resistance (IR) is a condition that is believed to underlie many vascular-based disorders including diabetes and obesity. A meta-analysis revealed a detrimental effect of diabetes mellitus type 2 on cognitive subdomains, namely, episodic memory and cognitive flexibility, logical memory, phonemic fluency, and processing speed to be affected, subsequently rendering the person vulnerable to dementia. 
| Post stroke dementia|| |
Increasing stroke prevalence and incidence has pointed that stroke dementia will be on the rise in India. Recently, a prospective community study from Kolkata, West Bengal, India  documented the prevalence rate of poststroke dementia to be 13.88%. In a study from South India, 52.4% patients with stroke had subcortical vascular damage, 26.2% had cortical-subcortical damage, whereas 14.3% and 7.1% had strategic infarcts and cortical dementia, respectively. 
Smoking is a significant risk factor for the cerebrovascular system independently as well as in combination with other CVD risk factors. Earlier case-control studies indicated that smoking had a protective role in the development of AD. However, recent systematic reviews of longitudinal studies have shown that smoking increases the risk of Alzheimer's disease and may increase the risk of other dementias in older adults in combination with other cardiovascular risk factors. Dementia has been positively associated with history of tobacco smoking in developing countries. 
It was observed that smoking has been associated with cognitive decline due to structural brain changes such as accelerated cerebral atrophy, reduced cortical gray matter density, increased white matter lesions, and cerebral hypoperfusion in several brain regions.
| Subclinical thyroid dysfunction|| |
Subclinical thyroid dysfunction (hypo- or hyperthyroidism) is one of the potentially reversible causes of dementia. The prevalence of subclinical hypothyroidism [elevated thyroid stimulating hormone (TSH) in the presence of normal thyroxine (T4) and triiodothyronine (T3)] rises with increasing age (>25% in persons over 60 years of age).  There is a substantial body of evidence to support the association between subclinical thyroid dysfunction and cognitive impairment but there is no clear mechanistic explanation for these associations. Larger and more detailed prospective longitudinal or randomized controlled trials are required to address these important questions. 
| Vitamin B12 and Folate Deficiency|| |
The prevalence of vitamin B12 deficiency increases with age (up to 20% in those over 75 years).  Vitamin B12 deficiency is found to be more prevalent and severe in the geriatric age group with neuropsychiatric manifestations irrespective of the dietary status.  According to a study from South India,  vitamin B12 deficiency is found to increase the cognitive decline and aggravate the behavioral symptoms especially in the neurodegenerative dementias, particularly among elderly males. Mean folate was found to be in the normal range in the majority, whereas serum homocysteine levels were elevated in contrast to the previous studies from western countries, indicating the higher risk of endothelial injury among the Indian population.  Anemia, strongly linked to undernutrition, has been identified as a risk factor for dementia in India, and needs to be explored. It is necessary to build research capacity in India in order to generate an evidence base relevant to our population and a better understanding of the risk factors and identification of factors, which would reduce the risk for dementia. Further studies are required to ascertain the dietary patterns, clinical presentations as well as the treatment outcomes after vitamin B12 administration.
| Conversion of mild cognitive impairment to dementia studies|| |
MCI is the preclinical stage characterized by isolated memory deficits gradually progressing to dementia in many patients. The prevalence of MCI varies a lot from 14.89% to as high as 59% in different studies. An Indian study from Kolkata, West Bengal  showed prevalence of MCI as 14.89%, out of which the amnesic type and the multiple domain types were 6.04% and 8.85%, respectively. The prevalence of MCI was also noted to be about 14.89% in a study from Kochi, Kerala, India.  Satishchandra et al.  reported a high incidence of 47.1% in a clinical setting. Mridula, Alladi et al.  too reported a high incidence rate of up to 59% of MCI in the elderly population of a clinic sample. This discrepancy in the prevalence may be because of methodological issues and also because a majority of the studies are conducted in clinic-based patient populations. It underlines the need for community studies to detect MCI in the population. Peterson reported the conversion rates from MCI to AD to be 10-15% in his sample at a specialty clinic and estimated the conversion rate to be 8-10% in the general population.  During a 13-month follow-up, Mridula, Alladi et al. also observed a conversion rate of 11% from MCI to dementia.  It may not suffice to just screen for the presence of MCI. It is also essential to diagnose the subtypes of MCI so that the risk of developing dementia in each subtype can be evaluated further. Srinivasan. S. found that nearly one-third of all subjects had MCI affecting the memory domain (singly or in combination) more commonly than nonamnestic MCI in a study conducted in a private sector memory clinic.  Alladi et al.  acknowledged MCI as emerging problem in urban India and suggested feasibility to operationalize the revised National Institute on Aging and the Alzheimer's Association (NIA-AA) criteria in identifying subjects with MCI. The above research available so far directs us to conduct longitudinal studies with a greater sample size to understand the emerging problem of MCI and devise intervention for early diagnosis and treatment of MCI.
| Behavioral and Psychological Symptoms of Dementia|| |
Many Indian studies ,,,, have found a high prevalence of BPSDs with paranoid ideation, agitation, and night disturbances being the common BPSD. In a study from Mumbai, Maharashtra, India BPSDs were described in 73.3% of the patients having MCI when compared to normal patients and the neuropsychiatric problems gave rise to significant distress in the caregivers.  BPSDs increase in both frequency and severity with increase in the level of cognitive decline.
In a study from South India, it was observed that neuropsychiatric symptoms of aberrant motor behavior, disinhibition, and appetitive/eating behavior differentiated frontotemporal dementia (FTD) from AD and VaD.  The frequency of utilization behavior was higher in subjects with FTD as noted in a study from Kolkata, West Bengal, India.  Newer research needs to focus on the classification of subtypes dementia and characteristics of the clinical features of BPSD in them. Ideally, longitudinal studies of patients with late onset of depression and psychosis will help in a better understanding of these and will also give a clue as to how many of these patients progress to develop dementia or MCI.
| Conclusion|| |
Cognitive decline has various facets ranging from age-associated memory impairment (AAMI), mild cognitive decline, and dementia. Research on cognitive decline has to focus on the early detection, correct diagnosis, and early interventions as a priority in developing nations such as India. Subjective memory complaints and forgetfulness by an elderly individual should be given due importance. It has to be kept in mind that primarily elderly individuals are looked after by family members. The changing social matrix is making it difficult for family members to look after their elderly. Ignorance regarding cognitive decline and associated problems is increasing the problems in effective management of dementia. Dementia care is still a specialized care and primary health care system is at a loss when it comes to managing dementia. Prioritizing research toward all these issues will definitely help in improving the care of patients and their quality of life. Due to cultural and regional diversities in our country, the differences between regions should form the basis for regional specificity in setting priorities in the field of research in cognitive decline. Region-specific intervention strategies, which can be applied at the level of primary health care needs to be explored. Emphasis should be laid on translating fundamental research to address local problems with local solutions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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