|Year : 2021 | Volume
| Issue : 1 | Page : 39-44
Association of of noncommunicable diseases on cognitive functioning: A comparative study
Aseem Mehra, Seema Rani, Swapnajeet Sahoo, Ritu Nehra, Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||28-Feb-2021|
|Date of Decision||29-May-2021|
|Date of Acceptance||26-Jun-2021|
|Date of Web Publication||05-Aug-2021|
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh . 160 012
Source of Support: None, Conflict of Interest: None
Aim: To compare the level of cognitive functioning among those with and without noncommunicable diseases (NCDs). Methodology: Using a cross-sectional study design, 104 patients attending the NCD clinic of a community rural health center and 101 elderly participants attending the hospital as caregivers of patients coming to the same community clinic with different ailments, were assessed on Hindi Mental State Examination (HMSE), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7) scale. Results: Those with NCD performed poorly on all the domains of HMSE except orientation and registration. When the HMSE score of <25 was used to categorize the sample into those with and without cognitive impairment (CI), it was seen that the prevalence of CI was more among those with NCDs. The significant difference between the two groups persisted, even after controlling for age, gender, the income of the family, number of years of education, type of family, socioeconomic status, mean score of PHQ-9, and mean score of GAD-7. Conclusion: NCDs are negatively associated with cognitive functioning even after controlling for age, gender, the income of the family, number of years of education, type of family, socioeconomic status, mean score of PHQ-9, and mean score of GAD-7.
Keywords: Cognitive impairment, elderly, noncommunicable diseases
|How to cite this article:|
Mehra A, Rani S, Sahoo S, Nehra R, Grover S. Association of of noncommunicable diseases on cognitive functioning: A comparative study. J Geriatr Ment Health 2021;8:39-44
|How to cite this URL:|
Mehra A, Rani S, Sahoo S, Nehra R, Grover S. Association of of noncommunicable diseases on cognitive functioning: A comparative study. J Geriatr Ment Health [serial online] 2021 [cited 2021 Dec 9];8:39-44. Available from: https://www.jgmh.org/text.asp?2021/8/1/39/323116
| Introduction|| |
In the 21st century, noncommunicable diseases (NCDs) have emerged as the major health challenges worldwide. The World Health Organization estimated that every year nearly 55 million people would die due to NCDs. In 2015, almost 5.8 million people across India died due to NCDs, including cardiovascular diseases, diabetes mellitus (DM), cancers, respiratory diseases, and stroke. It is suggested that 1 in 4 Indians has a risk of dying due to NCDs before the attainment of the age of 70 years.
Emerging literature suggests a potential link between NCDs and cognitive impairment (CI).,, Older adults with NCDs are specifically at a greater risk of developing CI and acceleration of normal age-related cognitive decline to mild CI or dementia.,, It is evident that NCDs, such as DM and hypertension (HTN), are associated with cognitive decline.,,,
Currently, India is in a unique situation, encountering a rapid increase in the elderly population and a higher prevalence of NCDs. Available data suggest the prevalence of 4.6% for CI, and there is a significant association between CI with NCDs. [8,12]
The risk factors associated with CI in NCDs include female gender, poor medication compliance, poorly controlled blood pressure, and DM, older age, low level of education, duration of illness, use of a higher number of medications, active treatment, the type of scale used to assess cognitive functions, the presence of comorbid depression, and anxiety.,,,, The study conducted by Verma et al., 2020, from India, among the elderly population attending a rural NCD clinic reported a prevalence of CI to be 27.3% with a higher prevalence among patients suffering from HTN. The limitation of the study was that the study did not include a comparison group. However, this literature is limited, and studies across the globe that have compared the level of CI among those with and without NCDs have not controlled for the presence of comorbid depression and anxiety disorders. In this background, this study aims to compare the level of cognitive functioning among those with and without NCDs, after controlling for some of the confounding factors such as depression, age, gender, level of education, socioeconomic status, marital status, occupation, and type of family.
| Methodology|| |
It was a cross-sectional study conducted among the patients attending the NCD clinic of a community rural health center (RHC) run in collaboration with the Postgraduate Institute Medical Education and Research, Chandigarh, India. This NCD clinic was established exclusively for patients suffering from DM, HTN, hypothyroidism, and rheumatoid arthritis. The NCD clinic runs twice a week in a rural community health center, Naraingarh. On average, 40–50 patients attend the clinic each day and avail the services' facilities. The services are mainly provided by senior resident and junior residents from the Department of School of Public Health, under the faculty member's supervision. Other NCD clinic staff includes the nursing staff, public health nurse, and a health worker.
The ethics committee of the institute approved the study. The study included two groups of participants, i.e., those with at least one NCD and those with no history of any of the NCD. Those with NCD were recruited from the NCD clinic, whereas the participants of the healthy control group were recruited from the caregivers, i.e. older adults (aged ≥60 years), who were accompanying their patients in the general outpatients' clinic department in the same community clinic.
To be included in the study, the study participants were required to be aged ≥60 years, of either gender, and cooperative for physical and mental status examination, and providing written informed consent. Patients who refused to give consent, those who were severely ill, those who were diagnosed with a mental illness in the past, had a history of substance dependence except for tobacco dependence, were on psychotropics, or had severe visual and auditory impairment to interfere in the formal assessment were excluded.
A qualified psychiatrist recruited the participants and administered instruments for assessment of cognitive functions, depression, and anxiety. The participants who screened positive for psychiatric illness (depression, anxiety, or CI) were managed by the psychiatry team visiting the RHC, which runs the Psychiatric outreach outpatient clinic runs once a week.
The participants were assessed on the following instruments:
Hindi mental status examination
Cognitive functions were assessed by using Hindi Mental State Examination (HMSE). This scale is designed mainly for the illiterate Hindi-speaking population. This a modified version of the mini-mental state examination with less emphasis on calculation ability. The sensitivity and specificity of the scale are 94% and 98%, respectively. [20,21] In the current study, those with HMSE scores ≤25 were considered “cognitively impaired.”
Patient Health Questionnaire-9
The Hindi version of this tool was used to assess depression. It is a self-report questionnaire, which comprises nine items, each evaluating the Diagnostic and Statistical Manual of Mental Disorders criteria of depression, rated as “0” (not at all) to “3” (nearly every day). Score ≥10 has a sensitivity of 88% and a specificity of 88% for the diagnosis of major depression made by a mental health professional. In the present study, the cutoff of 10 was used for making the diagnosis of depression.
Generalized Anxiety Disorder-7 scale
It is a 7-item scale with good reliability as well as a criterion, constructs, procedural, and factorial validity. Mild, moderate, and severe levels of anxiety are interpreted on the cutoff points of 5, 10, and 15. There is a good agreement between self-report and interviewer-administered versions of the scale. However, the diagnostic threshold has been reported to be a cutoff score of 10 or more. In the present study, a cutoff score of 10 or more, which has been used in the previous studies, [23,24] was used to consider the diagnosis of an anxiety disorder.
Sociodemographic profiles such as age, gender, type of family, socioeconomic status, occupation, marital status, number of years of education, and locality were also recorded.
The statistical analysis was carried out using the SPSS software version 14.0 for Windows (SPSS for Windows, Version 14.0. Chicago, IL, USA, SPSS Inc.). Descriptive analysis was carried out using mean and standard deviation with a range for the continuous variables. Descriptive analysis was computed as frequency and percentage for the ordinal and nominal variables. The comparative analysis was done by using the unpaired t-test. ANCOVA analysis was done to control the effects of covariates include age, sex, the income of the family, number of years of education, type of family, socioeconomic status, mean score of PHQ-9 and GAD-7.
| Results|| |
The NCD group included 104 participants, whereas the control group included 101 participants. As is evident from [Table 1], compared to those without any NCD, those with NCD were significantly more educated, were more often on paid occupation, were more often from nuclear families, and had a significantly higher income.
When the cognitive profile as assessed on HMSE was compared between those with and without NCDs, it was seen that compared to those without NCD, those with NCD performed poorly on all the domains of HMSE except orientation and registration. When HMSE <25 was used to categorize the sample into those with and without CI, it was seen that the prevalence of CI was more among those with NCDs. When compared with those without NCD, the prevalence of depression and anxiety was also higher among those with NCDs [Table 2]. When age, gender, the income of the family, number of year of education, type of family, socioeconomic status, mean score of PHQ-9, and mean score of GAD-7 were used as covariates, participants with NCD scored significantly low on all the domains of the HMSE when compared to the non-NCD group [Table 2].
When similar comparisons were made between those with HTN only and those without NCD group, after controlling for covariates (age, gender, the income of the family, number of year of education, type of family, the socioeconomic status, mean score of PHQ-9, mean score of GAD-7), those with HTN performed poorly on all the domains of HMSE [Table 3].
|Table 3: Comparison of cognitive profile those with hypertension and noncommunicable diseases|
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When similar comparisons were made for those with DM and those without any NCD after controlling for the covariates (age, gender, income of the family, number of year of education, type of family, the socioeconomic status, mean score of PHQ-9, and mean score of GAD-7), those with DM performed poorly on all the domains of HMSE except registration. However, there was no significant difference in the prevalence of CI between the two groups [Table 4].
|Table 4: Comparison of cognitive profile those with diabetes mellitus and noncommunicable diseases group|
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When those with the presence of comorbid DM and HTN, were compared with those without NCD after controlling for the covariates (age, gender, income of the family, number of year of education, type of family, socioeconomic status, mean score of PHQ-9, and mean score of GAD-7), participants with the presence of comorbid HTN and DM, performed poorly on the domains of HMSE except for registration and delayed recalled. There was no significant difference between those with NCD and without NCD in terms of the prevalence of CI [Table 5].
|Table 5: Comparison of cognitive profiles of those with comorbid hypertension and diabetes mellitus with the noncommunicable diseases group|
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| Discussion|| |
The present study aimed to compare the cognitive functioning of older people with or without NCDs in a rural community. In the present study, 38.5% of older people with NCDs had CI, which was significantly higher than those without NCDs. The studies from across the world done in patients with DM, HTN, and those with both DM and HTN suggest the prevalence of CI varying from 1.7% to 40%. [10, 17, 25-33]
In contrast to many of the previous studies, which did not control for many of the confounders, in the present study, we controlled for confounding variables such as age, sex, type of family, number of years of education, socioeconomic status, and psychiatric morbidity. Even after controlling for the confounders, the difference between those with and without NCD persisted. This suggests that NCDs have a negative impact on cognitive functions, and hence, there is a need to monitor the cognitive functions and institute preventive and treatment strategies for cognitive remediation to avoid further worsening of cognition.
Among the NCDs, when those with HTN were compared without NCDs, the prevalence of CI was significantly more in the HTN group. From these findings, it can be said that HTN is a risk factor for the development of CI and dementia, and it is in line with the existing fact. Available literature suggests that mid-life HTN, long-standing or untreated HTN might be associated with CI. The literature available from India also suggests that HTN is one of the significant factors associated with CI (9.18). Hence, an optimal preventive and treatment approach must be developed to delay the onset of CI.
In terms of the prevalence of CI, participants with DM and those with comorbid HTN and DM after adjusting for covariates, there was no significant difference in the prevalence of CI between those with these diseases and those without NCDs. These findings are in contrast to the existing literature, which suggests that the presence of DM and those with comorbid DM and HTN have a higher prevalence of CI and dementia. [8, 17, 35-43] The lack of significant difference in the prevalence of CI in the present study could be due to the small sample. However, when we look at the findings of cognitive functioning, the findings of the present study suggest that these diseases are associated with a higher level of CI and hence, support the findings of the existing studies.
Limitation of the study
It was a cross-sectional study with, small sample size and limited to a rural community. The association of duration of NCDs and level of CI was not assessed. The confounding variables which can impact the findings such as the severity of the NCDs, duration of the treatment, fluctuation of symptoms, white-matter changes, the effect of drugs, duration of illness were not taken into account.
| Conclusion|| |
To conclude, this study shows that NCDs are associated with impairment in cognitive functioning in almost all the cognitive domains and a higher prevalence of CI. Hence, there is a need to make the patients with these diseases aware of the same and institute preventive and treatment strategies. Patient and their caregivers should be educated about the possible contributing factors such as maladaptive behaviors, sedentary lifestyle, and unhygienic food, which contribute to the impairment of cognitive functioning. The screening for CI should be done at the level of primary health-care centers or the Community Health Center. The assessment of cognitive functioning can be done by a health worker, nursing staff, or any health care professional with a minimal training program. This small step will be a cost-effective strategy, as it will help in reducing the burden of care and disease. This will help in the improvement of the quality of life of older adults in a rural community.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]