New tablet-based screening tool for assessment of cognitive decline in Nigeria

Ogbuagu et al. ¹ report on the novel use of a computer tablet-based cognitive assessment tool (TabCAT) in Nigeria. TabCAT was developed at the University of California San Francisco (https://tabcathealth.com/), and the version used in this study in Nigeria is called the Brain Health Assessment (TabCAT-BHA). Such assessments, administered on a computer or even hand-held device (e.g., iPad, cell phone), have the potential to profoundly impact diagnosis of cognitive deficits in wide-ranging populations, ² reducing health disparities in low- and middle-income countries. ³ These new approaches help to fill the need for a culturally appropriate tool for diagnosis of dementia and address barriers to diagnosis, potentially facilitating early treatment and education/support of patients and families. These types of diagnostic tools can positively impact societal well-being and the financial burden of health care on the government.

In any community, an effective tool for dementia screening must be feasible for a variety of patients, providers, and settings. It must be culturally appropriate, validated, brief, easily understandable to illiterate populations, and simple to use, as well as applicable to various stages of cognitive decline. Automated scoring and ease of interpretation are additional key features, such that providers of various specialties can be efficiently trained on its use. In the past, cognitive assessments have used paper-and-pencil, often requiring significant instruction and/or guidance by the test administrator, and they were typically administered to patients experiencing symptoms. The Montreal Cognitive Assessment (MoCA) ⁴ and the Mini-Mental State Exam (MMSE) ⁵ are considered lengthy for what they provide and not valid in all cultures. Online tests, such as MemTrax, have been shown to be as effective as these tests for cognitive screening,^6,7 while providing important metrics of cognitive function in multiple populations. ⁸ The California Cognitive Assessment Battery (CCAB), using calibrated tablet computers, is able to provide remote neuropsychological assessment. ⁹ In addition, the Cleveland Clinic recently reported on the C3B, their tablet-based tool developed to screen patients for cognitive impairment in primary health care settings in the United States. ¹⁰ Demeyere et al. ¹¹ reported on the Oxford Cognitive Screen-Plus (OCS-Plus), a tablet-based tool to detect subtle cognitive impairments in British and German patients. Such tests and their diverse applicability were recently reviewed in a special edition of Frontiers in Human Neuroscience. ²

Computer-based or online tests like TabCAT-BHA have the potential to improve screening of cognitive decline in a variety of diverse countries such as Nigeria. TabCAT-BHA is fast (10 min long) and portable. Literacy is not a prerequisite. The subtests are culturally appropriate and correspond to cognitive domains that are expected to decline with dementia: Favorites (associative memory), Match (executive functioning and processing speed), Line Length (visuospatial skills), and Animal Fluency (language and category fluency). Ogbuagu et al.'s study has a valid design and provides representative data, although validation of such tools on additional populations, as well as norming, are needed. Importantly, this tool was able to distinguish expected performance differences based on living community, education, and age, demonstrating its sensitivity and utility. Interestingly, superior cognitive performance was observed in those living in rural compared to urban communities, an effect that could not be explained by demographic differences in age or education. The authors considered a broad range of explanations for this finding but didn’t list the adverse effects of urban air pollution, which is increasingly recognized as an important factor in cognitive health.^12,13

This study represents an important step in using computer-based and online testing in primary health care settings throughout the world. Once validated and normed, the potential applications and impact of this type of testing are significant: it can be implemented in primary health care settings to evaluate cognitive performance, to track cognitive decline in aging populations, and could definitely be used in other countries and settings. Indeed, the TabCAT has been translated into several languages (https://www.nia.nih.gov/research/alzheimers-dementia-outreach-recruitment-engagement-resources/tablet-based-cognitive), as have several other such tests.

Early identification of cognitive decline and dementia can improve health disparities and quality of life on a broad scale. Ideally, such assessment could be incorporated in an annual visit to a primary health care provider or even home visits during a community well-being campaign. Financial analysis would be required. For scientists, there is potential for use in empirical research as well as epidemiological data collection.