|Year : 2021 | Volume
| Issue : 2 | Page : 118-125
Cognitive status of older adults with diabetes mellitus, hypertension, and dyslipidemia on Hindi Cognitive Screening Test and Saint Louis University Mental State
Rakesh Kumar Tripathi1, Shailendra Mohan Tripathi1, Nisha Mani Pandey1, Anamika Srivastava1, Kauser Usman2, Wahid Ali3, Sarvada C Tiwari1
1 Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Department of Biochemistry, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||12-Oct-2020|
|Date of Decision||15-Sep-2021|
|Date of Acceptance||15-Dec-2021|
|Date of Web Publication||31-Jan-2022|
Dr. Rakesh Kumar Tripathi
Department of Geriatric Mental Health, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Hindi cognitive screening test (HCST) and Saint Louis University Mental Status (SLUMS) Examination both claim that they are bias-free cognitive screening tests. HCST is highly sensitive and specific in screening Indian older adults. However, SLUMS is more comprehensive in terms of assessing visuospatial and memory functions. The present study presents and compare cognitive status of older adults with diabetes mellitus (DM), hypertension (HT), and dyslipidemia (DL) on HCST and SLUMS. Methods: The sample comprised of 150 older adults ≥60 years included in a consecutive series. Participants and their family members, giving written informed consent, residing permanently in central catchment areas Chowk, Lucknow, constituted the study sample. Semistructured sociodemographic details and medical history proforma, Socioeconomic Status (SES) Scale, General Health Questionaire – 12, SLUMS and HCST were administered. Blood pressure was measured by Medical Research Assistant. Biochemical investigations for DM and DL were carried out. Participants were categorized into two groups: (1) case groups (112): DM only + HT only + DL only and (2) control group (38): Without discernable abnormality of physical illness on the basis of invesigations. Data were analyzed using percentage, mean, standard devitation SD, Chi-square, and t-test. Results: There was a statistically significant difference on cognitive status between control and DM group on recall, reading, copying (P < 0.05 level), and on writing (P < 0.01) on HCST. A statistically significant difference was also found in writing (P < 0.01) between control and HT group. A statistically significant difference was found between control and DL on recall (P < 0.05) and writing (P < 0.01). According to SLUMS control and DM group differ significantly (0.01) for delayed recall and with HT and DL group on visuospatial function. Conclusion: Cognitive status of older adults with DM, HT, and DL was found to be significantly impaired on specific domains as compared to the control group.
Keywords: Cognitive impairment, diabetes mellitus, dyslipidemia, Hindi Cognitive Screening Test, hypertension, older adults, Saint Louis University Mental Status
|How to cite this article:|
Tripathi RK, Tripathi SM, Pandey NM, Srivastava A, Usman K, Ali W, Tiwari SC. Cognitive status of older adults with diabetes mellitus, hypertension, and dyslipidemia on Hindi Cognitive Screening Test and Saint Louis University Mental State. J Geriatr Ment Health 2021;8:118-25
|How to cite this URL:|
Tripathi RK, Tripathi SM, Pandey NM, Srivastava A, Usman K, Ali W, Tiwari SC. Cognitive status of older adults with diabetes mellitus, hypertension, and dyslipidemia on Hindi Cognitive Screening Test and Saint Louis University Mental State. J Geriatr Ment Health [serial online] 2021 [cited 2022 May 23];8:118-25. Available from: https://www.jgmh.org/text.asp?2021/8/2/118/336912
| Introduction|| |
Diabetes and hypertension (HT) is well-known disease associated with aging and cognitive impairment., A study reported 16.11% prevalence of diabetes in older adults aged 60 years and above in a community-based study. The rising incidence of diabetes and its complications are going to pose a grave health-care burden in our country., Timely effective interventions/measures and screening tests for complications at the time of diagnosis become imperative not only for early detection but also to prevent progression to end stage disease. Studies reported the prevalence of HT among elderlies is more than 40%.,, HT was found to be associated with a significant decline in cognitive functioning., The prevalence of diabetes mellitus (DM) among older adults reported to be 35.24% in India and 7.59% of urban elderlies to be suffering from DM with cognitive impairment. There is strong evidence also that DM increases the risk of cognitive impairment,,,,, and dementia.,,
Micro aneurisms as found in HT and DM can cause vessels to rupture leading to damage to various areas of brain cortex leading to cognitive impairment. Long-standing HT causes vascular leakage at the level of arterioles leading to local extra cellular edema, cerebral diastases, and cortical de-afferentiation until the lumen is obstructed, leading to the development of atherosclerosis in long run causing ischemic changes. These changes in the cerebrum may be responsible for poorer cognitive performances. Other studies also reported that HT is a risk factor for the compromise of cognitive function,,,,,, to the point of mental deterioration and dementia in advanced age.,,,,
Prevalence studies involving exclusively elderly participants regarding HT,,,,, DM,, and lipid profile,, are widely reported. Association of DM, HT with cognitive function is also reported, but there is dearth of study related with dyslipidemia (DL). However, a study reported that 86% patient with DL had cognitive dysfunction and others reported a possible correlation between the increased serum LDL cholesterol, serum total cholesterol and cognitive dysfunction among multiple sclerosis patients; relationship between plasma lipids and mild cognitive impairment in the elderly. However, both the studies were on hospitalized patients having other comorbidity. A review reported that relationship between plasma lipids and cognitive function inconclusive. Thus, to study the association of DM, HT, and DL with cognitive functions may open new dimensions of preventive and management strategies for the older adults.
This study based on an Indian Council of Medical Research (ICMR) funded research project provide an opportunity to present and explore the status of cognitive functions in patients with DM, HT, and DL.
| Methods|| |
The study is a part of 1st year report of an ICMR funded case − control study entitled, “A study to evaluate effect of DM, HT, and lipid profile on cognitive function.” The study protocol was approved by the Institutional Ethics Committee. Relevant detail and procedure related with this paper only is given here.
The older adults aged 60 years and above, residing permanently in the central (nearby) catchment areas (Chowk, Raja Bazar, and Nakhas) of the KG Medical University, Lucknow, formed the study universe. Participants aged 60 years and above with documentary proof given written informed consent fulfilling inclusion/exclusion criteria (given below) were included in the study during May 2016 to April 2017. The sample consisted of 333 consecutively included older adults residing permanently in the study location.
- Individuals aged 60 years and above with documentary proof, i.e., age certificate/ration card/voter card/any identity card/passport, etc
- Actual age at the time of marriage can be calculated by marriage year + age of elder son/daughter + gap when there is no documentary proof
- The diagnosis of DM, HT, and DL established on the basis of available records/medical prescriptions/investigations, etc., and baseline investigation reports on the basis of biochemical parameters and physical examinations as provided in [Table 1]
- Permanently residing in the study area
- Informed consent for participating in the study either by subject or first degree relative
- No evidence of any major physical illness other than one or more medical conditions out of diabetes mellitus, HT, and DL.
- Uncooperative individuals
- Having any other problem which impeded with conducting the interview or assessments
- Presence of any major physical illness or medication causing significant cognitive impairment other than DM, HT, and DL, for example, renal failure, hepatic problems, anemia, thyroid problems, electrolyte imbalance, head injury, seizure disorders use of corticosteroids, cholinesterase inhibitors, hypnotics, sedatives, etc
- Participants having any other neuropsychiatric illness which contributed to cognitive impairment such as mental retardation, depression, anxiety disorders, bipolar affective disorders, and schizophrenia other than cognitive impairment and dementia
- General Health Questionnaire-12 item (GHQ-12) positive subjects (score cutoff more than 2)
- Semistructured pro forma for sociodemographic, personal history details, information about diabetes, HT, and DL pertaining to age of onset, treatment history, reports and prescriptions, etc., was used to collect exhaustive information about the above-mentioned personal details of older adults individual.
- SES Scale, was administered to measure the SES of the included participants. The urban domicile subscale was used comprising of broad seven heads, namely house profile, material possession, education profile, occupational profile, economic profile, land/house profile, and social profile. The scores range on five categories which are, upper class, upper middle, middle class, lower middle, and lower class.
- GHQ:  GHQ with 12 items was included as a selection criteria using a cut-off score of more than 2 to rule out and having any psychiatric symptoms.
- Hindi Cognitive Screening Test (HCST):, HCST is an education and culture bias cognitive screening test in which items suited to both literate and illiterate participants and could be interchanged depending upon the literacy level. It assesses orientation to time (culture fair scoring) and place, registration (culture fair items), attention and concentration (calculation depending upon literacy), recall, naming, repetition, follow commands (verbal and cued depending upon literacy), writing or telling a sentence (depending upon literacy), and copying (depending upon literacy). HCST has a high level of sensitivity (0.93), specificity (0.96), and high positive (0.96), and negative (0.94) predictive value against Brief Cognitive Rating Scale (BCRS). A statistically significant (P < 0.01) negative correlation (r = −0.87) with BCRS total scores and different axes of BCRS was found for concentration (r = −0.79), recent memory (r = −0.83), past memory (r = −0.79), orientation (r = −0.73), and functioning/self care (r = −0.77). HCST total score was found to be negatively correlated with education (r = −0.15) also. A cutoff score <24 on HCST is used for cognitive impairment in the study.
- Saint Louis University Mental Status (SLUMS) Examination was included to assess the cognitive status and categorize the sample in categories with and without cognitive impairment. The scoring criteria for individuals with high school education is: Scores 1–20 signifies dementia, 21–26 scores represent mild neurocognitive disorder (MNCD), and score of 27–30 represents no cognitive impairment/normal, whereas for individuals who are educated below the high school, the scoring criteria is: Scores 1–19 signifies dementia, 20–24 scores represent MNCD, and score of 25–30 represents no cognitive impairment/normal. Although Hindi version of SLUMS was available adaptation of SLUMS was done in Hindi using standard procedure for its feasiablity to the Hindi-speaking Indian population.
- Biochemical investigations: Approximately 5 ml blood was drawn from the included subjects for biochemical investigations. The biochemical investigations were carried out under supervision of co-investigator in the project, as per standard procedures adopted in the Department of Pathology and Bacteriology, King George's Medical University, Uttar Pradesh, Lucknow, India. The status of normalcy and abnormalcy was decided on the basis of parameters, as provided in [Table 1].
After training of the research staff, preparation of semistructured proformas were undertaken, Hindi translation and back translation of the English version tools were done using the standardized procedure. Semistructured pro forma for sociodemographics and personal details, SES Scale, HCST, and SLUMS Examination were administered by psychologist. Semistructured medical history pro forma and GHQ-12 were administered by Research Assistant (Medical). All participants were screened for HTN applying provided criteria given in [Table 1] in the community by Research Assistant (Medical) and the patients who have been screened positive on the criteria for the first time were referred to a geriatric physician at KGMU to establish the diagnosis. On the basis of available treatment records and measurement of blood pressure, the diagnosis of HT was done by Research Assistant (Medical). Biochemical investigations for DM and DL were carried out on all the subjects.
On the basis of the assessment, investigations, medical history, and available treatment records, participants were assigned in following eight groups of the study: Group A: participants without discernable abnormality of physical illness and GHQ negative (control). Group B: participants with DM only, Group C: participants with HT only, Group D: participants with DL only, Group E: participants with DM and HT, Group F: participants with DM and DL, Group G: participants with HT and DL, and Group H: participants with DM, HT, and DL. For this paper, only control Group A (38 subjects) and case Groups B (32 subjects), Group C (32 subjects), and Group D (48 subjects) are being reported to rule out any impact of other comorbiditits on cognitive function.
The statistical analysis was done using the Statistical Package for the Social Science (SPSS), version 24.0 developed by IBM Corporation, Armonk, New York (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp., 2016) and graphpad calculator. Data were analyzed using statistics for frequencies, percentage, mean, standard devitation (SD), and Chi-square and t-test.
| Results|| |
Total houses were screened 1627 where 683 older adults aged 60 years and above residing. Of them, 350 older adults were excluded and 333 were included using exclusion/inclusion criteria of them ony 150 subjects were taken for this study. Out of them, 38 were in control and 112 participants were in case group. Sociodemographic profile wise there was insignificant difference between case and control group except on employment status. The Chi-square value (7.93) for the employment status was found to be significant (P < 0.01) between case and control group. Significantly, higher percentages of control group were non working; however, more older adults of case group were working. The mean age of the control group was found to be 67.78 ± 6.72 years and case group 67.64 ± 6.87 years. Representation of older adults with advanced age (70 years and above) was more in the control group than case group in the study and it was reported in an earlier study that cognitive dysfunction increases with advanced age among normaly aging urban older adults. Majority were males in control group, whereas case groups had more representation of females. Majority were dependant, Hindu, married individuals living in joint family setup and belonging to lower middle and middle SES. Females outnumbered males in case groups with 53.22% and 46.78% respectively, whereas the males outnumbered the females in the control group with 55.26% and 44.74%, respectively. Both the study groups show a very high representation of Hindu religion compared to the other religions with 95.25% in case groups and 97.37% in control group. The case groups comprised of 87.12% literate participants as compared to the control group with 81.58% of literate individuals. Lower SES constitutes 17.29% of case groups and 18.42% of control group. Lower middle SES constitutes 44.07% of case groups and 42.11% of control group. The middle SES comprises of 33.56% of participants in case groups and 39.47% of participants in the control group. No one found to belong upper middle SES in control group.
There were insignificant differences in total mean scores on HCST and SLUMS between control and different case groups. Therefore, domain wise comparison was also done on HCST an SLUMS between the case and control groups to see the differenc if any and given in [Table 2] and [Table 3].
|Table 2: Comparison of cognitive functions between case diabetes mellitus, hypertension, dyslipidemia, and control group on Hindi Cognitive Screening Test|
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|Table 3: Comparison of cognitive functions between case diabetes mellitus, hypertension, dyslipidemia, and control group on Saint Louis University Mental Status examination|
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[Table 2] shows different domain wise comparison of cognitive functions between case and control group on HCST. The findings suggest that there is a significant difference (P < 0.01) in mean scores for the cognitive function of “recall” between control and DM group and between control and DL group (P < 0.05). For the cognitive functions related to “writing,” the P value is significant at P < 0.01 level for the comparisons of control group with all the disease groups, namely DM, HT, and DL. Moreover, control and DM group differ significantly at 0.05 level for the items of “copying” cognitive functions.
[Table 3] reveals that control and HT group differ significantly for the cognitive function of “delayed recall with interference” at P < 0.01 level. For the “visual spatial” cognitive function, the P value of all the case groups differ significantly with control group at P < 0.01 level. There were insignificant differences between case and control group and between case groups on total mean scores of SLUMS and mean scores on different domains also.
| Discussion|| |
The objective was to study the cognitive status of older adults with DM only, HT only, and DL only and control group on HCST, and SLUMS. The comparison was done between the case and the control groups on different cognitive domains of HCST and SLUMS.
Sociodemographic detail wise insignificant differences were found between case and control groups except on employment. Employment wise, significantly (P < 0.01) more older adults of control group were nonworking compared to case group. Most of them were businessman. It may be due to they handed over their business to their offspring and now they are not actively involved in this as also reported earlier. Majority older adults were between 60 and 69 years of range of both the groups. The lowest representation of 80–89 years and 90–99 years old participants was seen in both case and control groups. These representations are with the consonance of population distribution of India. Females outnumbered males in case groups whereas the males outnumbered the females in the control group. Females are more prone to develop diseases compared to males. Both the study groups have a similar percentage of married older adults, majority were living in joint families. The case groups comprised of 87.12% literate participants as compared to the control group with 81.58% of literate individuals. The reason, “Illiterates were lesser in both the groups because mostly there were businessman families residing in the study area, and they have privileged to have educational facilities” is also reported earlier. Majorty older adults were belonged to lower middle SES followed by Middle SES in both the groups. No one found to belong upper middle SES in control group. As SES is a comprehensive scale to assess not only financial condition but educational, occupational, social participation, and understanding also., If scores found less in any of the area during assessment, SES status becomes lower on this scale. One more reason is the less sample recruited in the control group compared to case into consecutive series.
As shown in [Table 2], control and DM groups differ significantly for the cognitive functions of recall (P < 0.01), writing (P < 0.01), and copying (P < 0.05) on HCST. Mean scores and SD showed that the DM group has performed significantly better on recall, writing and copying cognitive functions compared to control group. The result is similar with a recent study and contrast with others., Studies with the contrast results did not claim that they had included DM only witout any comorbid condions like HT and DL. Hence, results of these studies may not present actual cognitive status of older adults with DM only. Here one more point emerges with the study result that “recall,” “writing” and “copying” skills become better with increased glucose level only (DM only).
The control and HT groups suggests a significant difference in the area of writing (P < 0.01) only signifying that HT group has a greater mean score as compared to the control group for this cognitive functions. The results is again contrast with other studies. Higher value of systolic blood pressure is found to be associated with cognitive deficit.,, The specific cognitive functions affected by high blood pressure have not yet been thoroughly studied; however, it is consistently related to deficits in attention,,, episodic memory,,,,, some visuospatial functions, language,, and abstract reasoning and other executive functioning.,,,
The control and DL groups differ significantly for the functions of recall (P < 0.05) and writing (P < 0.01) suggesting that the older adults with DL aged 60 years and above have performed better for the items pertaining to these cognitive functions. Findings are contrast with the findings of other studies.,
[Table 2] also reveals that the total mean scores of case and control groups are within normal limits. It is also on lower side among control group followed by DL, HTN and DM. Recently one study reported that total mean score on HMSE is lower in HTN than DM group but the study did not include DL and control group for comaprision.
The [Table 3] reveals that control and DM groups differ significantly for the cognitive function of delayed recall with interference (P < 0.01) depicting a better performance by older adults with DM. For the visual spatial cognitive function, the P value of all the disease groups differs significantly with the disease free group (P < 0.01) suggesting that mean scores for the disease groups are higher compared to the control group.
Though, the significant differences were found on certain cognitive functions between case and control groups but the study findings are contrast with the findings of other studies. There were significant difference in mean scores for specific cognitive function but overall cognitive status was similar on HCST as all the groups found to have not cognitive impairment (i.e. total HCST mean score >24). It was also observed on total mean score of SLUMS (>21) that overall cognitive status for the case (DM, HT, DL) and control groups fall in MNCD as reprted by Krishnamoorthy et al. for DM and HT. Another study also reported that increased blood pressure variability is associated with poorer cognitive function in older people. The difference in cognitive status between HCST and SLUMS may be due to item difference between both the tools. SLUMS has five objects for registration and recall however in HCST only three objcts. Items for visuospatial function is the part of the SLUMS. There were less items for orientation in SLUMS compared to HCST. The score load of the items in SlUMS were more compared to HCST on Visuospatial function and recall and if a subjects have found to be impared on these cognitive functions the total score gone down and subject fall in th category of MNCD.
Impairment in visuspatial function, recall/delayed recall, copying, and in the area of writing was found between case and control group. Visuo-spatial dysfunctions suggest impairment in parietal lobe function. Delayed recall dysfunction suggests impairment in temporal lobe. Problems in writing ability suggest temporoparietal dysfunction and these findings has to be explored further through neuroimaging studies to look at defferential impact of these vascular factors on various regions of the brain.
| Conclusion|| |
There were no significant difference in the cognitive status of case and control groups on the basis of total mean scores on the HCST and SLUMS. But there was significant difference on cognitive status between Control and DM group on recall, reading, copying and on writing on HCST. Significant difference was also found in writing between control and HT group. Significant difference was found between control and DL on recall and writing. According to SLUMS control and DM group differ significantly for delayed recall and with HT and DL group on visuospatial function.
Key Messages from the study
- DM group found to have cognitive impairment in the area of recall, reading, writing, copying and visuospatial function compared to control group.
- HTN group found to have cognitive impairment in the area of writing, delayed recall with interference and visuospatial function compared to control group.
- DL group found to have cognitive imparement in the area of recall/delayed recall, writing and visuospatial function compared to control group.
Diagnostic criteria to diagnose dementia are not used in this study. SLUMS-based criteria are considered and discussed for this study. Type of DM (type 1 and 2) and different level of lipid profiles for dyslipedemia were not considered in this study and that limits to explain the specific impact of specific conditions on cognitive functions of older adults. Systolic versus diastolic blood pressure.
Although GHQ-12 was administered to rule out presence of any psychiatric symptoms, no standard instruments or structured clinical interview were applied to rule out the presence of psychiatric illness. Similarly, no standered tool was administered to rule out intellectual disability. No anthropometric data were obtained. Activities of daily living of the cognitively impaired participants were not assessed. The duration of having DM was not considered; hence, results may be biased. Although sociodemographic detail-wise, there were insignificant differences, a proper representation of illiterate and upper SES participants in both groups is lacking. The results of the study cannot be generalized due to small sample size and considering limitations, but providing clues and opens the opportunity to study those variables which affect cognitive status of older adults using sound methodology.
The authors are grateful to Department of Health Research, Indian Council of Medical Research, New Delhi for funding support, and study sample for participation and research staff Dr Amlendra Kumar, Mrs. Saima Ayyub, Mrs. Yashi Verma, Mrs. Tanu Shree Shukla, Shri Atul Kumar Pandey and Shri Sarvesh Datt Tiwari for their co-operation.
Financial support and sponsorship
This study was funded by Indian Council of Medical Research (ICMR) through Department of Health Research (DHR), New Delhi, India.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]