Most cognitive tests are developed abroad and are available only in English, creating an obstacle for health practitioners in India.

Representative image of a doctor consultation, where a patient can be seen sitting in front of a doctor wearing a
news Health Thursday, August 13, 2020 - 18:57

It is a known-fact that patients suffering from mental health illnesses in India have a hard time seeking treatment. For patients suffering from Mild Cognitive Impairment (MCI), it is not only the stigma that they have to deal with, but also the dearth of the right testing facilities, as these tests are rarely available in their vernacular languages.

“Since most of these tests are developed abroad, they are available only in English or other foreign languages. While the health practitioners translate or culturally adapt these tests for the ease of the patients, they lack uniformity,” said Srinivasan Jayaraman, a clinical neuropsychologist from SRM Medical College in Chennai. 

Keeping this in mind, as part of his PhD studies, he is working on culturally adapting the Brain Injury Rehabilitation Trust Memory and Information Processing Battery (BMIPB) test in Tamil. The test helps in the early detection of dementia and cognitive deficits in alcohol-related brain damage and he plans to provide it freely to the Tamil Nadu Government Medical College Hospitals.

Developed in the UK, the paper-based test assesses memory and information processing and is currently available in English and Thai. With a proposed sample size of 1500, the tests are now in the sample collection stage.

“We have culturally adapted the Clock-Drawing test to a Dosa test and in the Speed of Information Processing Test the numbers are replaced with the dice. These are things our population would be more familiar with. With this medical practitioners will be able to reach out to more people,” said Jayaraman.

While some tests like the Montreal Cognitive Assessment (MoCA) and Addenbrooke's Cognitive Examination -III (ACE-III) are available in Tamil, they come with their share of issues. 

“These tests are a preferred tool for early identification of MCI around the world. However, there are no published norms for the Indian population. Also the translated tests have used Sanskritised Tamil language, which even clinicians and literate people find it difficult to understand,” adds Jayaraman. 

Early detection of MCI is important to avoid the development of cognitive diseases like Dementia, where brain cells degenerate causing a loss of cognitive functioning. Though prevalent among the elderly, it is usually unrecognised and eventually leads to a decline in language, memory and problem-solving skills. 

“The conversion rate of MCI to dementia is 18-20%. So if we can detect it early the condition is reversible and we can help delay a whole lot of problems. Conducting tests in the local language will help us form a better bond with the patients. It will also help us cater to more patients,” says Dr Srivatsa VG, Geriatric Neuropsychiatrist, Apollo Hospitals, Chennai. 

Dr Ann Simi John, clinical psychologist at Minds Matter, Gurgaon, says, “Many people are not tested due to the non-availability of the right tests or sometimes we have to use several tests to reach the same conclusion. There is so much we can contribute to this field by having better tests in vernacular languages.”

Meanwhile, a Bengaluru-based company is in the process of translating a cognitive test from English to Hindi. The test, called Cognitive Assessment System (CAS), also helps in the early detection of Mild Cognitive Impairment (MCI). They also propose to translate it in Kannada soon and make it available to the state government.

It assesses five major ability areas — language, spatial skills, memory, calculations and reasoning. Developed in 1979 at Stanford University, it uses several terms that may not be familiar in our country. The Canadian company’s Indian subsidiary based out of the city, Cognitive Health and Rehabilitation Systems, has now tied-up with All India Institute of Medical Sciences (AIIMS), Delhi to conduct clinical studies, translation, cross cultural adaptation and development of the test for persons from northern India. 

“The test takes about 20 to 30 minutes and requires the participants to recognise images, do simple calculations and apply reasoning. The original test in English uses words like ‘Sparrow’. A more familiar term for the average Indian population would be ‘Kauva’ (crow). So we are culturally adapting the test to make it more sensitive and accurate to the population,” said Barry Prabhu, Managing Director, Cognistat India. 

Eighty percent of the translated test is completed and the research paper is likely to be published by the end of this year. Meanwhile, they have begun conducting pilot tests at Nightingales Medical Trust in the city. The company is also planning to tie-up with the Karnataka government soon to provide these tests in the public hospitals in the state and also plans to open up memory clinics in Bengaluru. 

“Under the National Health Mission, the Karnataka government is focussing on mental health. We were just about to speak to the state Health Department about our tests when the lockdown was announced. With the Mental Healthcare Act, 2017 we see a future for better facilities in the country and so we also plan to reach out to the Central government to procure our tests,” said Prabhu. 

A computer-assisted instrument, it is already available in 13 languages like Mandarin, French and Arabic and Cognistat plans to translate them in more Indian languages like Malayalam, Kannada and Bengali. 

Dr Jamuna Rajeswaran, professor of Clinical Neuropsychology, National Institute of Mental Health and Neuro-Sciences (NIMHANS) stresses on the need for tests in vernacular languages in India. “Taking western tests and administering them to the Indian population is a wrong practise. The cultures are different and so the kind of materials they have used will not be applicable here. So the need of the hour is to develop tests accordingly that will suit both our literate and illiterate population.”

At NIMHANS, they have standarised some of the internationally used tests for the Indian population in the age group of 16 to 65 years. The NIMHANS Neuropsychology Battery takes into consideration several factors like occupation, education, age, etc. and has translated them into most south Indian languages and in Hindi. “Here we have modified the western tests according to our Indian conditions. We have to keep the cultural context in mind and then develop the tests. Having tests in the vernacular language helps us get better results as the patients are able to identify things better,” says Dr Rajeswaran.