SUMMARYThe Indo-US Cross-National Dementia Epidemiology Study seeks to compare two rural populations, in the US and India: the Monongahela Valley, a rural community of relatively low socioeconomic status in southwestern Pennsylvania (USA), and Ballabgarh, a rural community near New Delhi in North India. Of particular interest is the fact that the Ballabgarh elderly population is exclusively Hindi-speaking, has little or no education and is largely illiterate, rendering its cognitive screening a particular challenge. In this article we report methods and preliminary data on the development of a Hindi cognitive screening instrument suitable for the Ballabgarh elderly population. We use as an example our Hindi adaptation of the Mini-Mental State Examination (MMSE), a widely used global cognitive screening scale. Systematic, item-by-item, empirically based test development has shown that effective modifications can be made to existing tests that require reading and writing; and that culturally sensitive modifications can be made to render the test meaningful and relevant while still tapping the appropriate cognitive domains. Certain cognitive functions, particularly orientation to time, remain difficult to test adequately in this type of population. In Ballabgarh, as in the Monongahela Valley, educated individuals obtain higher test scores. Implications for dementia screening are discussed, including those relevant to the hypothesis that low education predisposes to dementia.KEY WORDS-dementia epidemiology; ageing; neuropsychology; cross-cultural research Cognitive impairment, characteristic of dementia, is measured objectively by standard neuropsychological (cognitive) tests. Screening for dementia is usually accomplished by means of a global cognitive

Interpretation of cognitive test performance among individuals from a given population requires an understanding of cognitive norms in that population. Little is known about normative test performance among elderly illiterate non-English-speaking individuals. An age-straMied random sample of men and women, aged 55 years and older, was drawn from a community-based population in the rural area of Ballabgarh in northern India. These Hindispeaking individuals had little or no education and were largely illiterate. A battery of neuropsychological tests, specially adapted from the CERAD neuropsychological battery, which was administered to this sample, is described. Subjects also underwent a protocol diagnostic examination for dementia. Norms for test performance of 374 nondemented subjects on these tests are reported across the sample and also by age, gender, and literacy. Cognitive impairment, the hallmark of dementia, is detected subjectively from historical information offered by patients and other informants, and from the clinician's observations of general mental status. Objective assessment requires 507 508 M. Ganguli et al.the clinician to measure the individual's performance on one or more cognitive (neuropsychological) tests on one or more occasions. Interpretation of these measurements as being within or outside the normal range requires prior knowledge of the normal range for the population to which the individual belongs. Normative values on standardized cognitive tests are becoming increasingly available for westernized, predominantly Anglophone populations in industrialized countries. Norms are much less readily available for the populations of non-English-speaking developing societies, particularly where those populations have little education. Indeed, standardized cognitive tests barely exist for such populations.The need for tests appropriate to the culture and educational level of the population to be tested has been discussed previously Escobaret al., 1986;Ganguli et al., 1995;Graves et al., 1994;Hall et al., 1993). If neuropsychological test scores are to be used to detect the presence of dementia, and to measure its severity, it is essential to distinguish the effects of dementia on test performance from the preexisting and independent effects of culture, language, and education (White, 1989). No test is completely "culturefree"; at best, it can be relatively "culture-fair" and it can avoid penalizing members of one culture for poor performance on tests designed for, and standardized on, members of another. Culturally relevant factors can include comprehensibility, acceptability, perceived relevance of test content, fluency in the language, and familiarity with testing situations, concepts, procedures, and materials.In preparation for an epidemiological study of dementia in a rural community in northern India, we developed a battery of cognitive tests to screen for and characterize dementing illness among the elderly in that community. In this article, we describe the test battery and report nor...

These data provide evidence that homebound older adults have a disproportionate share of morbidity and disability and suggest a sociodemographic and clinical profile to help identify those older people at risk of being or becoming homebound. They also point to the need for home-based health services for the older adults, particularly in medically underserved communities such as rural areas.

Objective: to develop a measure of activities of daily living appropriate for use in assessing the presence of dementia in illiterate rural elderly people in India. Design: identification of relevant items, pre-testing of items and refinement of administrative procedures and scoring in four successive groups of 30 subjects each, pilot testing in a group of 100 subjects comparable to those for whom the measure is intended, administration to a representative sample of 387 people aged 55 and older, and assessment of the reliability of the final measure. Setting and subjects: age-stratified random sample of older men and women in rural areas of Ballabgarh, Northern India Results: the original pool of 35 items covering mobility, instrumental and personal care activities was reduced to an 11-item unidimensional scale (to which an additional item on mobility was added) with internal consistency (Cronbach's a) = 0.82, perfect inter-and intra-rater reliability, test-retest reliability (intraclass correlation) = 0.82 (any disability) and 0.92 (unable to perform for 'mental' reasons). Women, older subjects, the totally illiterate and subjects with poorer cognitive function performed significantly more poorly (P Յ 0.02 for all). Product: a brief, reliable and valid activities of daily living measure, with norms, which is appropriate for use in assessing dementia in illiterate rural elderly people in India.

Sleep complaints were common among these older individuals. Because these data were collected prospectively, they also provide objective evidence that insomnia is relatively persistent or chronic among older adults. This finding has implications for the diagnosis and long-term management of sleep disorders in older people. Derivation from a random community-based sample rather than from samples of patients or volunteers makes these data more generalizable to the general older population. Finally, these data describe a rural older populations, a group which, in general, is medically underserved and understudied.