Neuropsychological Testing in Culturally and Linguistically Diverse Indian Context
Avanthi Paplikar, Ph.D.
Dementia refers to a brain disorder that causes decline in a person’s cognition and affect their ability to carry on with day-to-day activities. Early diagnosis is key to optimal management of the disease and care for people with dementia. According to Dementia India Report 2010 by Alzheimer’s and Related Disorders Society of India (ARDSI), there are approximately 5.29 million people living with dementia in India and this number is expected to increase to 7.61 million by 2030. Despite the high number of people with dementia in the country, community awareness continues to be low. This serves as a barrier to diagnosis leading to poor quality of care for many people with undiagnosed dementia.
Another obstacle towards accurate and timely diagnosis is the unavailability of culturally and linguistically sensitive tests essential for diagnosis of dementia. To address this gap in diagnosis, the Indian Council of Medical Research (ICMR), commissioned a multidisciplinary team of experts from various fields including neurologists, psychologists, speech-language pathologists to develop a culturally, educationally and linguistically relevant neurocognitive toolbox (Iyer, Paplikar, Alladi et al., 2019). Indian Council of Medical Research – Neuro Cognitive Tool Box (ICMR-NCTB) is a product of the collective effort by six centres across India: All Indian Institute of Medical Sciences (AIIMS), New Delhi; Apollo Hospitals, Kolkata; Nizam’s Institute of Medical Sciences (NIMS), Hyderabad; National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore, Manipal Hospital Bangalore, Jawaharlal Nehru Medical College, Belgaum, and Sri Chitra Tirunal Institute of Medical Sciences and Technology (SCTIMST), Trivandrum from three different states in Southern India. The process of development of the test battery has been detailed in our study design paper (Iyer, Paplikar, Alladi et al., 2019).
The ICMR-NCTB is a unique tool consisting of various tests and questionnaires and is sensitive to factors that affect performance on cognitive tests including education, languae and culture. This toolbox is available in five Indian languages: Hindi, Bengali, Telugu, Kannada and Malayalam. It includes various cognitive tests to assess different domains such as attention and executive function, memory, language, and visuospatial functions and the questionnaires to assess depression, functional assessment, neuropsychiatric symptoms, informant questionnaire on cognitive decline and quality of life (Table 1).
Table 1: Tests and Questionnaires in the ICMR Neuro-Cognitive Tool Box
To facilitate early and accurate diagnosis of dementia, ICMR has made the toolbox freely accessible to professionals and researchers across the country and for Indian diaspora. Most of the existing batteries are largely designed for educated English-speaking population, the ICMR-NCTB, on the other hand, was developed to the culturally and linguistically diverse Indian context. The toolbox provides detailed neuropsychological profile of patients and is a standardized measure to diagnosis mild cognitive impairment (MCI) (Menon, Varghese, Paplikar et al., 2020) and dementia (Verma, Thripathi, Nehra, Paplikar et al. accepted).
Screening and diagnosis of language deficits in the Indian context, necessitated the adaptation and validation of Frenchay Aphasia Screening Test (FAST) in two Indian languages: Telugu and Kannada, for both literates and illiterates (Paplikar, Iyer, Varghese et al., 2020). FAST is a reliable, valid, and easy to use screening measure for detecting stroke-related language disabilities in the Indian context (Figure 1).
Figure 1: Frenchay Aphasia Screening Test (FAST) validated in the Indian contex
As part of the ICMR-NCTB study, 267 monolingual and 263 bilingual speakers (matched for age and education) were evaluated using the ICMR-NCTB to develop standards of testing cognition in the bilingual context (Paplikar, Alladi, Varghese et al., 2021). Using a systematic approach, a few guidelines are recommended to test cognition in bilingual speakers in the Indian context (Figure 2).
Figure 2: Guidelines for cognitive testing in bilingual speakers in the Indian context using ICMR-NCTB
To conclude, the ICMR-NCTB is a comprehensive toolbox which can be used for the diagnosis of dementia and MCI in culturally and linguistically diverse Indian context.
Acknowledgements
I would like to thank all the members of the ICMR-NCTB Consortium, ICMR Experts, and ICMR-NCTB Experts. This work was supported by Indian Council for Medical Research under Grant [SWG/Neuro/32/2017-NCD-1].
References
ARDSI. (2010). The Dementia India Report: prevalence, impact, costs and services for Dementia.
Iyer, G. K., Paplikar, A., Alladi, S., Dutt, A., Sharma, M., Mekala, S., ... & ICMR Neurocognitive Tool Box Consortium. (2020). Standardising dementia diagnosis across linguistic and educational diversity: study design of the indian council of medical research-neurocognitive tool box (ICMR-NCTB). Journal of the International Neuropsychological Society, 26(2), 172-186.
Menon, R. N., Varghese, F., Paplikar, A., Mekala, S., Alladi, S., Sharma, M., ... & Vishwanath, Y. (2020). Validation of Indian Council of Medical Research Neurocognitive Tool Box in Diagnosis of Mild Cognitive Impairment in India: Lessons from a Harmonization Process in a Linguistically Diverse Society. Dementia and Geriatric Cognitive Disorders, 49(4), 355-364.
Paplikar, A., Iyer, G. K., Varghese, F., Alladi, S., Pauranik, A., Mekala, S., ... & ICMR Neuro-Cognitive Tool Box Consortium. (2020). A screening tool to detect stroke aphasia: Adaptation of frenchay aphasia screening test (FAST) to the Indian context. Annals of Indian Academy of Neurology, 23(Suppl 2), S143.
Paplikar, A., Alladi, S., Varghese, F., Mekala, S., Arshad, F., Sharma, M., ... & ICMR-NCTB Consortium. (2021). Bilingualism and Its Implications for Neuropsychological Evaluation. Archives of Clinical Neuropsychology.
Verma, M., Tripathi, M., Nehra, A., Paplikar, A., Varghese, F., Alladi, S….. & ICMR Neuro-Cognitive Tool Box Consortium (Accepted). Validation of ICMR Neurocognitive Toolbox for dementia in the linguistically diverse context of India. Frontiers in Neurology, section Dementia and Neurodegenerative Diseases.