Measuring Cognitive Status in Older Age
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SAGE Working Paper No. 3. November 2012.
Measuring cognitive status in older age in lower income countries: Results from
a pilot of the Study on global AGEing and Adult Health (SAGE).
Brionne Alvord Carroll1, Paul Kowal2, Nirmala Naidoo2, Somnath Chatterji2 1 Department of Pharmacy Practice, University of Washington, Seattle, Washington, USA. 2 Department of Measurement and Health Information Systems, World Health Organization, Geneva, Switzerland. …. Corresponding author: Dr Paul Kowal co-PI SAGE World Health Organization Department of Health Statistics and Information Systems 20 Avenue Appia CH-1211 Geneva 27 Switzerland
Acknowledgements:
We would like to thank Kathleen Brodrick, Federico Campigotto, Monica Ferreira, Barry
Gurland, Sebastiana Kalula and Nadia Minicuci for their assistance in assessing and
measuring cognition across countries and cultures. SAGE is supported by the Division
of Behavioral and Social Research of the US National Institute on Aging through
Interagency Agreements (OGHA 04034785; YA1323-08-CN-0020; Y1-AG-1005-01)
with the World Health Organization.
Word Count (text only): 2233
Measuring Cognitive Status in Older Age
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Word Count (abstract): 232
Tables & Figures: 4 tables, 2 figures (if possible); otherwise 2 figures in the Appendix 1
Appendices: 4
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Abstract
Background. A reliable tool to measure cognition in older persons as part of
household health surveys is needed: in particular, a culture-fair instrument to distinguish
track decline in cognitive function. Additionally, the instrument should be sensitive to
different literacy levels. Currently available tools used to screen for cognitive decline
show substantial variation across different countries, suggesting limitations in accuracy
and reliability.
Methods. Implementing a battery of cognitive tests, verbal fluency, immediate and
delayed verbal recall and digit-span forward and backward, in a household health
survey pilot from the World Health Organization Study on AGEing and adult health
(SAGE) in Ghana, India, and Tanzania. The survey included self-reported health with
anchoring vignettes, plus self-reported and measured function.
Results. A total of 1446 respondents completed the study. Self-reported health differed
by age, sex and education. Verbal recall scores varied slightly by country and sex, with
women consistently scoring lower than men. Lower scores were also associated with
increasing age. The influence of sex was more pronounced in verbal fluency and less
impacted by age. Results varied on digit span by education. Higher education levels
positively impacted scores on all cognitive tests.
Conclusions. The SAGE survey proved to be a culture-sensitive screening tool in a
diverse set of countries. The instruments had face validity in all countries and were
sensitive to age, sex and education levels. This approach can be used for the
assessment of cognition in older age.
Measuring Cognitive Status in Older Age
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Measuring Cognitive Status in Older Age
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Introduction
Assessing cognition is a complex task even in a relatively homogenous population, but
measuring age-related cognitive decline across countries and in the context of an
ageing world presents significant challenges. With the expected ageing of populations
across the globe over the next 25 years, countries will be faced with larger older
populations, many experiencing cognitive changes. The established association
between increasing age and dementia rates could therefore lead to increased mental
health disease burdens. Dementia, one possible outcome from cognitive change, will
increasingly occur in low and middle income countries as a result of population aging1.
Mild cognitive impairment is often used to define those who might be at risk of
developing dementia and may be a target for early interventions; consequently,
measuring cognition to establish rates and trends would be useful2,3.
Older adults may experience changes in their abilities to name objects or with their
visual, verbal and short-term memory - some of which may be considered a normal
consequence of the ageing process.4,5,6 When these cognitive changes begin impacting
daily functioning or quality of life, the ability to accurately and reliably measure and
differentiate normal changes from disease processes becomes more important for
planning purposes.7,8,9
In recent years, research on cognition has improved the understanding of cognitive
impairment and progression to dementia.3,10 Estimates of cognitive impairment vary by
up to 25% within a given country, depending on the selected definition of
Measuring Cognitive Status in Older Age
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impairment.11,12 Adding a measure of function in the form of Instrumental Activities of
Daily Living (IADL), has been shown to improve the accuracy of cognitive assessments
even in populations with different education levels and socioeconomic status. 13 , 14
Lower cognition scores correlated with greater impairments in functioning, suggesting
IADL improves assessment of cognitive decline. 15 Similar to measuring cognitive
impairment rates, rates of various dementias differ between countries, even when using
consistent diagnostic definitions. 16 These discrepancies highlight the difficulty in
ascertaining true cognition levels with existing tools, and differentiating between
"normal" cognitive decline and decline preceding the onset of dementia.
A reliable tool to measure cognition in older persons as part of household health
surveys is needed: in particular, a culture-fair instrument to distinguish normal cognition
from pathological decline.17,18,19 Additionally, the instrument should be sensitive to
different literacy levels. Currently available tools used to screen for cognitive decline
show substantial variation across different countries, suggesting limitations in accuracy
and reliability.20,21,22, 23
The battery of tests in this study originated from the World Health Organization's World
Health Survey (WHS) programme, which has used self-reported and measured
cognition in over 70 countries.24 The three cognitive tests selected as part of the Study
on AGEing and adult health's (SAGE) pilot test - word list recall, verbal fluency and digit
span - accurately measure the cognitive domains most impacted by age, impairment
and the early stages of dementia. The selected tasks are also brief compared to other
Measuring Cognitive Status in Older Age
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neuropsychological tests, allowing for a culture-fair screening tool within a household
health survey that combines subjective and objective measures of cognition and
physical function. Lastly, it can be implemented by trained lay interviewers.8 We
present the initial results from a pilot study of the World Health Organization's SAGE
instrument.
Methods
The SAGE survey was piloted in Ghana, India and Tanzania from April to July 2005.
Face-to-face interviews were conducted in respondent's dwellings. Translation and
back-translation methods based on the WHS protocol were used (WHO, 2003). Data
collected included household and housing characteristics, income, expenditures and
transfers, self-reported health in 12 domains, and measured cognitive and physical
function.
India and Ghana used a convenience sample to obtain the desired sample size of
N=500 persons aged 50 years and older, with an emphasis on enlisting similar numbers
of men and women across the older age ranges. Respondents in Tanzania were
randomly selected from household listings within a demographic surveillance site in the
north-eastern region of the country. India included a small sample of respondents
younger than 50 years as a comparator group. Training sessions for survey
methodologies and instruments were provided in each country.
Measuring Cognitive Status in Older Age
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Self-reported cognition was assessed through two questions, one about concentration
and the other about learning. In addition, measures of functioning - were assessed
through the WHO Disability Assessment Scale, Version 2.0 (WHODAS) along with
additional questions about Activities of Daily Living (ADLs) and Instrumental Activities of
Daily Living (IADL).25
Performance tests:
Three domains were selected to objectively measure cognition: assessment of memory
and learning (using the word-list learning task); working memory (using digit span
forward and backward); and, verbal fluency (using the category fluency test).26,27,28 All
three performance tests were scored according to standard practices for each test.
Verbal recall, measured with a 10-word learning task, was estimated by summing the
four trials, three immediate recall and one delayed by 10 to 15 minutes.2612 Scoring for
digit span forward and backward involved tabulations based on first or second try
correct recitation of each number series - two points or one point per row, with eight
rows in total for each of the two tests. The final task, verbal fluency, was measured as
the sum of all admissible words regarding the category of animals. STATA version 9.2
was used for all analyses.
Results
A total of 1446 respondents completed the survey. Fifty-four percent of respondents
were women (see Table 1). The mean age was 59 years in India, 61 years in Ghana
and 65 years in Tanzania. The sample in Ghana was primarily urban, Tanzania
Measuring Cognitive Status in Older Age
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primarily rural and the India sample a mixture between rural and urban. It was possible
in Ghana to collect follow-up data on 119 respondents from the baseline World Health
Survey conducted in 2003. Levels of education varied by country, but women
consistently had lower levels of education than men across all countries.
[Table 1 about here]
The pattern of self-reported cognition, memory and learning, were significantly different
by sex and age (p
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[Table 2 about here: Mean VR, VF scores by country, sex, age and education level]
Verbal fluency results were comparable in Ghana, India, and Tanzania: the mean
number of animals named in one minute was 10.8, 11.5 and 9.5, respectively. The
influence of sex was more pronounced in verbal fluency than verbal recall, with larger
differences between mean scores of women and men than with verbal recall. Verbal
fluency was less influenced by age until respondents reached the 80 year and older
group. Mean verbal fluency scores increased with higher levels of education. Each
additional year of education completed resulted in almost one additional animal named
(0.928, p < 0.001). Respondents in India, for example, who completed college degrees
or further education named a third more animals than those with no formal education.
The third performance test included reciting a digit-span forward and backward. In each
country, fewer respondents completed this task in comparison to the other performance
tests. Tanzanian respondents consistently scored lower in the forward and backward
tests compared to the other countries (see Table 3). Respondents in Ghana scored 1.2
points higher than those in India for digits forward, while mean scores in India were 2.4
points higher than in Ghana for digits backward. The influence of sex and age were
inconsistent across countries for digit span. As with the previous two tests, higher
educational levels resulted in higher mean scores.
[Table 3 about here]
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Since cognitive function is an intrinsic component of ADLs,158 we included WHODAS to
measure function associated with cognition, plus additional ADL/IADL type questions.
The WHODAS contains many of the most commonly asked ADL and IADL questions -
plus the WHODAS approach also assesses severity of disability. Tanzanians reported
less disability than either Ghana or India. Forty percent of the respondents in
Tanzania reported no problems with ADLs (see Table 4), and correspondingly had the
lowest disability assessment score of 18.5. Comparatively, between 26 and 28% of
respondents in Ghana and India stated no difficulties with ADLs.
Across all three countries, substantially more women reported problems with
ADL/IADLs. In Ghana, 51% of women reported difficulties in at least two activities of
daily living compared to 35% of men. Additionally, women had higher mean WHODAS
scores, with even a third higher score in India than for men. Older age groups reported
higher WHODAS scores. Seventy-one percent of respondents in India, ages 18-49 had
no difficulty with ADLs compared to 25% at the ages 50-59, and almost 12% in
respondents aged 80 years and older. Those with less education, particularly no formal
education, reported substantially more disability than the respondents who had at
minimum completed high school or the equivalent. In Tanzania, mean WHODAS
scores declined from 22.9 in respondents with no formal education, to 5.6 in
respondents who have completed college or university.
[Table 4 about here]
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As an objective measure of mobility, the mean time to complete a 4 meter walk at usual
pace was longest in Ghana at 6.2 seconds, followed by Tanzania at 5.8 seconds and
4.5 seconds in India. Mean times were longer for women in each country, and
increased with increasing age. The differences in mobility as measured by the timed
walk and WHODAS scores across countries reflect the multidimensionality of the
WHODAS tool and both followed recognizable age and sex trends.
Discussion
Currently, an estimated 24 million persons worldwide live with dementia, a number
expected to reach 81 million by 2040. 29 Accurately measuring cognition and
determining global prevalence of dementia will continue to be a problem due to the
inconsistency of available data across countries. Previous attempts to reconcile
differences in cross-cultural observations of dementia found that less than half of
dementia cases across countries were consistently diagnosed correctly.30 Even among
developed regions with sound epidemiological studies, a large proportion of variability
exists in reported dementia rates. 31 , 32 Yet it is in developing countries where the
majority of persons with dementia reside, but where little is known about prevalence.
An estimated 60% of those with dementia currently live in developing countries and this
is projected to climb to nearly three-fourths of the population with dementia by 2040.2915
Attempting to measure cognition within a household health survey requires additional
considerations in regards to interview time, complexity and selection of cognition
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domains. Mild cognitive impairment and early stages of dementia particularly impact
memory, attention, learning, and language. 33 , 34 Episodic, semantic, and working
memory decline early in disease progression.35,36 Testing these elements of memory
may therefore be ideal for screening patients for dementia prior to diagnosis.
Another challenge is the reliability and comparability of answers to questions that use
ordered categorical response scales like those used for self-reported cognition.37 One
method to address this comparability problem is the anchoring vignettes approach.38
The vignettes use a concrete level of cognition and respondents are asked to rate the
vignettes using the same questions and response categories that they use to describe
their own cognition. Vignettes fix the level of cognitive ability so that variation in
categorical responses is attributable to variation in response category cutpoints.
Objective cognition tests are employed as one step to establish the validity this
methodology. Vignette adjusted results for this SAGE pilot will be presented elsewhere.
The verbal recall word-list test involves short- and long-term memory, plus learning a
new task.2612 This verbal recall test, along with a verbal fluency test, rank among the
best discriminating tests for cognitive impairment and the most sensitive for patients
with Alzheimer's disease.3521, 3622, 39 Verbal fluency tests both language and semantic
memory. Cognitive impairment impacts category fluency over letter fluency.40 Among
categories, animal fluency performs as a better marker for dementia than listing words
beginning with a certain letter.41 Category fluency maintains as high as 100% sensitivity
for dementia.42 Digit span, the third in our battery of tests, assesses short-term and
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working memory as well as attention and concentration with a high degree of
reliability.2713, 3622 Cognitively impaired patients scored lower than normal respondents,
particularly on the reverse span.43
The results of this study across the three countries indicated strong face validity for the
self-reported questions and performance tests. Women, persons of older age, and
those with less education scored lower on both the self-reported and administered
cognitive tests. These results support the battery of tests presented in this study as a
culture-fair measure of cognition as well as a comprehensive tool in its assessment of
both self-report and performance-based measures of function. One recognized
limitation was initiating the digit span performance task with too complex a series,
evidenced in the results by the small number of respondents able to complete even the
first row correctly. This task has been altered in the recent survey to a series of three
digits for digit forward and two digits for digit backwards to facilitate greater accuracy.
This pilot data covered relatively smaller populations from three different countries.
These pilot results has informed the implementation of the full survey and further
develop a culture-fair cognitive screening tool for use in household health surveys.
Data from an anticipated six countries will help to improve the assessment of cognition
worldwide.
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TABLES AND FIGURE
Table 1. Sociodemographic characteristics by sex and country.
Ghana India Tanzania
Male Female Total Male Female Total Male Female Total
Age
18-49 na* na na 14.8 6 10.4 na na na
50-59 50.9 44.1 47.2 32.2 37.3 34.8 40.9 37.5 39.0
60-69 24.8 30.4 27.9 34.7 30.5 32.6 28.8 35.1 32.4
70-79 16.4 17.1 16.8 16.1 20.6 18.3 20 15.4 17.4
80+ 6.5 6.5 6.5 2.1 5.2 3.6 10.2 11.9 11.2
Missing 1.4 1.9 1.7 0 0.4 0.2 0 0 0
Residence
Urban 90.7 89.4 89.9 53.8 54.9 54.4 1.4 0.7 1.0
Rural 9.3 10.6 10.1 46.2 45.1 45.6 98.6 99.3 99.0
Marital Status
Never 2.3 0.4 1.3 5.5 0.4 3 0.5 0 0.2
Currently 79.0 36.5 55.6 87.7 58.8 73.4 80.5 28.8 51.0
Separated/Divorced 7.9 25.1 17.4 0 1.3 0.6 8.8 22.5 16.6
Widowed 10.3 37.6 25.4 6.8 39.1 22.8 10.2 47.0 31.2
Co-habiting 0 0.4 0.2 0 0 0 0 1.8 1.0
Missing 0.5 0 0.2 0 0.4 0.2 0 0 0
Education No formal education 17.3 49.4 35 31.8 71.2 51.4 33.5 80.7 60.4
Less than Primary 9.3 12.5 11.1 14.4 4.7 9.6 37.2 14.4 24.2
Primary 32.2 24.3 27.9 19.1 11.6 15.4 23.3 4.6 12.6
Secondary 20.6 8.0 13.6 11.9 4.3 8.1 4.7 0 2.0
High School 12.1 4.6 8.0 8.1 2.1 5.1 0 0.4 0.2
College/University 6.1 1.1 3.4 8.9 4.7 6.8 1.4 0 0.6
Post Graduate 1.9 0 0.8 5.9 0.9 3.4 0 0 0
Missing 0.5 0 0.2 0 0.4 0.2 0 0 0
Income quintile
1 (lowest) 13.6 24.0 19.3 20.3 17.2 18.8 8.8 28.1 19.8
2 19.6 18.3 18.9 17.8 19.7 18.8 19.1 20.4 19.8
3 21.5 17.5 19.3 14.4 23.2 18.8 19.1 20.7 20.0
4 20.1 18.6 19.3 20.3 20.2 20.3 23.7 17.2 20.0
5 (highest) 22.9 16.0 19.1 25.4 19.3 22.4 28.4 13.0 19.6
Missing 2.3 5.7 4.2 1.7 0.4 1.1 0.9 0.7 0.8
Total 100 100 100 100 100 100 100 100 100
Number 214 263 477 236 233 469 215 285 500
*na = not applicable
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Table 2. Mean verbal recall (VR), verbal fluency (VF) scores by country, sex, age and education level.*
Ghana India Tanzania
VR VF VR VF VR VF
Sex
Male 21.2 11.7 19.1 12.6 19.2 11.2
Female 20.2 10.2 17.5 10.3 19.1 8.2
Total 20.6 10.8 18.3 11.4 19.2 9.5
Age group
18-49 23.7 14
50-59 21.8 11.4 19.4 11.7 20.2 9.9
60-69 20.9 10.8 17.6 11.3 19.1 9.5
70-79 19.1 10.4 15.6 10.1 19 9.4
80+ 15 8.7 13.7 9.5 16 8.1
Total 20.7 10.9 18.4 11.4 19.2 9.5
Education
No formal 19.7 9.9 16.0 9.9 18.8 8.6
Less than primary 19.1 10.8 19.2 11.8 20.1 10.6
Primary completed 20.6 10.8 20.2 12.8 18.5 11.1
Secondary completed 21.7 12.2 20.7 12.3 22.2 12.9
High school 22.7 11.7 20 12.8 25 1
College/university completed 24.3 12.6 24.1 15.6 14 11
Post-graduate degree completed 29.3 13.5 22.8 15.3 Total 20.7 10.8 18.4 11.4 19.2 9.5
*See Appendix 2 for the word-list (VR) and category fluency (VF) performance tests.
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Table 3. Number (N) of respondents completing the digit span tests and mean scores for forward (DF) and backward (DB) by country, sex, age and education level.* Ghana India Tanzania
DF DB DF DB DF DB
N Mean N Mean N Mean N Mean N Mean N Mean
Sex
Male 182 3.9 63 2.3 39 2.4 11 3.6 68 1.5 17 1.4
Female 174 3.0 56 2.7 16 2.3 3 9.7 43 1.7 14 2.4
Total 356 3.5 119 2.5 55 2.3 14 4.9 111 1.6 31 1.8
Age group
18-49 0 0 0 0 16 2.3 7 3.3 0 0 0 0
50-59 186 3.8 67 2.5 19 2.5 1 13 58 1.6 16 1.4
60-69 99 3.4 34 2.7 16 2.1 2 2 36 1.6 10 2.7
70-79 48 3.0 12 2.2 4 3.0 4 7.3 15 1.5 5 1.4
80+ 18 2.3 1 1.0 0 0 0 0 2 1.5 0 0
Total 351 3.5 114 2.5 55 2.3 14 4.9 111 1.6 31 1.8
Education
No formal 84 2.1 23 2.7 6 1.7 2 8.5 36 1.3 7 2.7
Less than 38 2.8 14 2.4 4 1.5 1 8 36 1.6 11 1.4
Primary 113 3.6 30 2.3 7 2.1 0 0 29 1.7 9 1.9
Secondary 64 4.6 30 2.7 7 2.9 2 7 8 1.8 2 1
High school 37 4.5 13 1.8 4 2.5 1 2 1 7 1 3
College/university
completed
16 4.3 6 3.2 19 2.4 3 1.7 1 1 1 1
Post-graduate
degree
4 5.3 3 2.7 8 2.8 5 4.6 0 0 0 0
Total 356 3.5 119 2.5 55 2.3 14 4.9 111 1.6 31 1.8
*See Appendix 2 for the digit span forward and backward performance tests.
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Table 4. ADL deficiencies (%) and mean WHODAS score by country, sex, age and education level.* Ghana India Tanzania
ADL Mean
DAS
ADL MeanDA
S
ADL MeanDA
S Non
e One
2+ Non
e One
2+ Non
e One
2+
Sex
Male 38.3
26.6
35 17.8 37.7 22.
5 39.
8 17 51.2
23.3
25.6
12.5
Female 16
33.1
51 27.4 18.5 20.
2 61.
4 29.3 32.6
24.6
42.8
23.1
Total 26
30.2
43.8
23.1 28.1 21.
3 50.
5 23.1 40.6 24
35.4
18.5
Age group
18-49 0 0 0 0 71.4
12.2
16.3
8.7 0 0 0 0
50-59 35.1 32
32.9
15.9 25.2 27 47.
9 20.2 57.4 20
22.6
11.7
60-69 24.1
28.6
47.4
24.7 27.5 22.
2 50.
3 23 38.3 29
32.7
18
70-79 10
31.3
58.8
33 12.8 17.
4 69.
8 33.1 19.5
29.9
50.6
26.7
80+ 0
25.8
74.2
45.3 11.8 5.9 82.
4 45.1 21.4
14.3
64.3
31
Total 26
30.2
43.8
23.3 28.1 21.
3 50.
5 23.2 40.6 24
35.4
18.5
Education
No formal 14.4
40.1
45.5
26.9 19.5 17.
8 62.
7 30.1 32.8
23.8
43.4
22.9
Less than primary
18.9 28.
3 52.
8 28.5 31.1 20
48.9
18.3 47.9 28.
1 24 12.9
Primary completed
33.1 26.
3 40.
6 22.2 27.8
30.6
41.7
18.1 54 20.
6 25.
4 11.1
Secondary completed
26.2 23.
1 50.
8 19.5 34.2
31.6
34.2
18 80 10 10 6.1
High school completed
39.5 23.
7 36.
8 16.4 50 25 25 12.4 100 0 0 8.3
College/university completed 56.3
18.8 25 11.6 46.9
15.6
37.5 10.8 100 0 0 5.6
Post-graduate degree completed 100 0 0 1.4 62.5
18.8
18.8 9 0 0 0 0
Total 26
30.2
43.8
23.2 28.1 21.
3 50.
5 23.2 40.6 24
35.4
18.5
Response scale: 1=none; 2=mild; 3=moderate; 4=severe; 5=extreme/cannot do.
*See Appendices 3 and 4 for the WHODAS and ADL-scale specific questions.
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APPENDIX 1. Self-reported Health
Figure 1. Self reported memory by age and sex ("Overall in the last 30 days, how much difficulty did you have with concentrating or remembering things?").
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
M,18-49 M,50-59 M,60-69 M,70-79 M,80+ F, 18-49 F,50-59 F,60-69 F,70-79 F,80+
None Mild Moderate Severe Extreme
Figure 2. Self reported learning by age and sex ("Overall in the last 30 days, how much difficulty did you have in learning a new task (for example, learning how to get to a new place, learning a new game, learning a new recipe)?").
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
M,18-49 M,50-59 M,60-69 M,70-79 M,80+ F, 18-49 F,50-59 F,60-69 F,70-79 F,80+
None Mild Moderate Severe Extreme
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APPENDIX 2. Cognitive tests used in SAGE
WORD-LIST RECALL (maximum 40 points) List of words used Arm, Bed, Plane, Dog, Clock, Bike, Ear , Hammer, Chair, Cat Immediate Recall plus learning saturation Number of words recalled correctly Trial 1, 2, 3 Number of words that respondent failed to recall Trial 1, 2, 3 Number of words substituted Trial 1, 2, 3 Delayed Recall Number of words recalled correctly Number of words that respondent failed to recall Number of words substituted
DIGIT SPAN (maximum 16 points for forward and 16 points for backward)
Points Sequence of numbers 0, 1,2 4-7-2-8-1
3-4 8-4-7-2-5-1
5-6 3-9-0-7-1-8-2 7-8 2-6-8-9-0-4-1-5
9-10 8-5-7-3-2-0-1-5-9
11-12 9-6-7-3-9-5-1-6-3-8
13-14 5-1-6-8-9-3-2-0-8-3-1
15-16 3-7-2-9-1-0-5-2-6-4-3-8
CATEGORY FLUENCY
Number of animals named correctly in one minute. Number of errors.
APPENDIX 3. WHO Disability Assessment Scale (WHODAS-12 item)
In the last 30 days, how much difficulty did you have …*
1 … in standing for long periods (such as 30 minutes)?
2 … in taking care of your household responsibilities?
3 … in learning a new task, for example, learning how to get to a new place?
4 … in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
5 … concentrating on doing something for 10 minutes?
6 … in walking a long distance such as a kilometer (or equivalent)?
7 … in washing your whole body?
8 … in getting dressed (including, for example, putting on your shoes and socks)?
9 … with people you do not know?
10 … in maintaining a friendship?
11 … in your day to day work?
12 In the last 30 days, how much have you been emotionally affected by your health condition(s)?
*Response scale: 1=none; 2=mild; 3=moderate; 4=severe; 5=extreme/cannot do.
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APPENDIX 4. Activities of Daily Living Scale
In the last 30 days, how much difficulty did you have …*
1 …in standing up from sitting down (such as, getting up from a chair after sitting for long periods)?
2 … in washing your whole body?
3 …in getting dressed (including, for example, putting on your shoes and socks)?
4 … with moving around inside your home (such as walking across a room)?
5 … with eating (including cutting up your food)?
6 … with getting up from lying down (for example, getting in and out of bed)?
7 … with getting to and using the toilet?
*Response scale: 1=none; 2=mild; 3=moderate; 4=severe; 5=extreme/cannot do.
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