Feasibility and Determinants of Performance for a Tablet-Based Cognitive Assessment Tool in Rural and Urban Southeast Nigeria

Abstract

Background:

Cognitive assessment is a key component of clinical evaluations for patients with dementia and Alzheimer’s disease in primary health care (PHC) settings. The need for well-validated, culturally appropriate, and easy-to-use assessments is especially urgent in low- and middle-income countries (LMICs) that are experiencing rapid growth in their older adult populations.

Objective:

To examine the feasibility and demographic determinants of performance for a tablet-based cognitive assessment tool (TabCAT) battery, which includes subtests for four cognitive domains, among older PHC patients in southeastNigeria.

Methods:

A cross-sectional mixed-method descriptive study evaluating the useability and performance of TabCAT.

Results:

We enrolled 207 participants (mean age of 64.7±13.5 years; 52% with only primary, 41% secondary, and 7% tertiary education). Most (91%) who initiated the assessment were able to complete it, requiring 10–15 minutes to complete. More years of education was associated with better test scores across all tests (p < 0.001). Living in a rural location was also associated with better performance (p < 0.05). Male compared to female sex did not associate with performance on any of the tests (all ps > 0.05).

Conclusions:

Tablet-based cognitive assessment was feasible in rural and urban settings of Nigeria. Better performance on cognitive subtests linked to more education and residing in a rural area; however, sex did not predict performance. Digital cognitive assessment tools hold potential for widespread use in healthcare and educational contexts, particularly in regions with varying levels of urbanization and educational access.

Keywords

Alzheimer’s disease cognitive assessment dementia Nigeria primary healthcare

INTRODUCTION

The population of aging persons is increasing in LMICs contributing to a rise in global dementia prevalence and incidence. 1 The number of people with dementia will increase from 57.4 million globally in 2019 to 152.8 million in 2050. 2 Globally, up to 75% of people living with dementia (PLWD) are not diagnosed and this rate is projected to increase to 90% in some LMICs. 3 Early detection of dementia offers the opportunity for medical, social, and emotional benefits for PLWD and their caregivers 4 as well as financial benefits for both the affected individuals and the country. Improved quality of care allows PLWD to live well and their families to feel supported. 5

Nigeria accounts for about half of West Africa’s population with approximately 202 million people. 6 In 2022, the World Bank estimated that over 6 million Nigerians are aged 65 years and above, 7 with population aging contributing to a dramatic increase in global dementia prevalence and incidence. By 2050, the number of older Nigerians will triple to more than 33 million to become the world’s 11th largest older population. 6 Consequently, dementia will become the main cause of disability, dependency, and financial burden among older Nigerian adults. In a recent study from Nigeria, the proportion of older adults (age > 65 years) with mild cognitive impairment (MCI) was estimated at 59.4%, which was associated with low educational attainment. 8 The authors recommend that an assessment for MCI and other known risk factors be prioritized at geriatric clinics.

The PHC facilities’ role in the early detection of cognitive impairment (CI) and dementia is widely acknowledged as an important frontline entry point for this unmet medical need. 9 Yet, this is not a routine practice in most clinics, especially in LMICs where up to 50% of dementia diagnoses are missed.10 - 13 These clinics are an ideal point for early detection of CI since referrals can be facilitated when needed for follow-up care and primary management provided. Some hurdles for the detection of CI in PHC settings center around the workload with relatively short consultation intervals, the need for training to improve skills necessary to detect cognitive changes, as well as a lack of infrastructure, equipment, and resources needed to integrate cognitive assessment in the primary care setting.14 - 16

Cognitive screening in these settings is further hindered because available clinical tools are either not validated or often insufficient in recognizing the nuances surrounding multiple languages and the diversity of ethnicity, culture, numeracy, and literacy. 17 A recent qualitative study by dementia experts reported the need for cognitive assessment tools that are culturally valid, brief, comprehensive in their assessment of major cognitive domains, sensitive to early stages, and ideally digital with automated scoring. 18 Currently, there is no universal culturally appropriate cognitive assessment tool and no validated tool in Nigeria.

Addressing these obstacles will require a cognitive assessment tool that is efficient and functional across diverse populations, capable of producing automated individual patient performance reports where highly trained neuropsychologists are few and have high-performance characteristics with built-in user-friendly features to guide PHC providers in attending to many patients. Unfortunately, there is currently no cognitive assessment tool used in most PHCs in Nigeria, even though many PHC workers are aware of the Montreal Cognitive Assessment (MoCA), and Mini-Mental State Examination (MMSE) as cognitive assessment tools, yet do not use them. 19

The tablet-based cognitive assessment tool offers a user-friendly interface, 20 making it accessible for individuals with varying levels of technological proficiency and literacy in both rural and urban Southeast Nigeria. 20 Its portability and ability to store and process large amounts of data efficiently make it an ideal choice for widespread use in diverse settings. Additionally, the interactive nature of tablet-based assessments can enhance participant engagement and accuracy, leading to more reliable and comprehensive cognitive evaluations.

The goal of the current study is to characterize a screening tool included in the Tablet-based Cognitive Assessment Tool (TabCAT) entitled the Brain Health Assessment (TabCAT-BHA) in Nigeria. The TabCAT-BHA was developed for the efficient detection of mild cognitive disorders in Primary Care Settings, taking only about 10 min to administer. Moreover, there are few words used in the TabCAT-BHA and for illiterate persons, they can be read aloud by the examiner, which is useful given Nigeria’s moderate adult literacy and numeracy rate of between 62%–77.6%.21,22, 21,22 The study aims to examine the feasibility and demographic determinants of performance for a TabCAT battery, which includes subtests for four cognitive domains, among older PHC patients in southeast Nigeria.

METHODS

Study design and cognitive test task description

We employed a mixed method cross-sectional observational study approach with a convenience sample of 207 patients aged 40 and above who voluntarily consented to participate during their routine clinic visits. The study ran from December 1, 2022, to November 30, 2023. The TabCAT-BHA includes four subtests: Favorites (assessing associative memory), Match (evaluating executive functioning and processing speed), Line Length (measuring visuospatial skills), and Animal Fluency (testing language and category fluency abilities). 20 Higher scores on Line Length represent worse performance, and so these scores were inverted so that higher test scores on all tests would represent better performance. The traditional TabCAT-BHA includes Line Orientation (judging which line is parallel to a target line) instead of Line Length (judging which line is longer among two lines). We administered both Line tasks and hypothesized that the concept of “parallel” would not be understood by many participants, resulting in invalid performances on Line Orientation.

All participants underwent the TabCAT-BHA in a dedicated examination room. During administration, participants were seated at a desk with a 10.2-inch iPad positioned horizontally, raised 1 inch above the desk surface, and an administrator seated beside them to direct the test prompts. Detailed task descriptions can be found on the Tablet-based cognitive assessment tool Memory and Aging Center University of California San Francisco website. 20 Clinical assessments of the participants, including vital signs and physical examinations were done to ensure that participants met the inclusion criteria before enrollment.

Study site and participants

Nnamdi Azikiwe University Teaching Hospital (NAUTH) is a tertiary healthcare facility located in Nnewi, Anambra State, Nigeria. It offers comprehensive medical services in all subspecialties including PHC. The study received institutional review board (IRB) approval from the Nnamdi Azikiwe University Teaching Hospital Ethics Board. 23 Informed consent was obtained from all participants or the caregiver.

Exclusion criteria

Participants were excluded for known history of diabetes, hypertension, stroke, psychiatric problems, or HIV infection. We also excluded any reported history of active or recent substance abuse, or neurologic or systemic diseases that are meaningfully contributing to cognitive, behavioral, or functional decline. Also, patients with a lifetime history of psychiatric or developmental disorders (e.g., schizophrenia, autism spectrum disorders). Any sensory or motor impairments that may compromise testing procedures were also excluded as well as residence in a skilled nursing facility.

Data analysis

Initially, we performed descriptive analyses summarizing the participants. The test results were quantitatively analyzed to examine their association with patient characteristics (age, sex, education) using multivariate linear regression. Pearson correlation and further multivariate regression analyses were conducted to observe test performances comparing patients’ characteristics by location (rural versus urban), covarying for sex, age, and the interaction between sex and location (rural/urban). Scatter plots and bivariate linear regression/correlation plots are included in the Supplementary Material.

RESULTS

Sociodemographic profile of the participants

A total of 207 participants were enrolled including 186 who were able to record their age (Table 1, scatter plots available in the Supplementary Material). The mean age of the participants with known age was 64.7±13.5 years. Regarding location, 51% were from urban areas. Most (70%) were females. More participants were right-handed (97%), while the rest were either ambidextrous or left-handed. Regarding educational attainment, 52% had a primary level of education; 41% secondary level, and a small proportion (7%) tertiary education.

Table 1

Descriptive analysis of sociodemographic variables of the respondents

Variables	Frequency (n = 207)	Percentage
Age category (n = 186)
40–50 y	37	19.9
51–63 y	49	26.3
64–76 y	58	31.2
77 y and above	42	22.6
Region
Rural	102	49.3
Urban	105	50.7
Sex (n = 205)
Female	143	69.8
Male	62	30.2
Handedness
Ambidextrous	2	1.0
Left	5	2.4
Right	200	96.6
Years of education
0–9	102	51.8
10–19	82	41.6
20–29	13	6.6

Visuospatial test validity

For Line Orientation (visuospatial skills), the average score for the test revealed that 126 (61.5%) study participants failed the catch trials, which are 10 interspersed very easy trials designed to evaluate whether the participant understood and followed instructions. Line orientation was therefore excluded from analysis as shown in the Supplementary Material. In contrast, only 4 (1.9%) of study participants failed the catch trials on Line Length, suggesting that participants understood the task, and this test was maintained.

Correlates to performance on TabCAT-BHA subtests

Educational attainment and rural versus urban location significantly impacted scores across all non-visuospatial tests on the TabCAT-BHA (Table 2). For educational attainment, effect sizes were small with higher levels of education linked to higher scores on all tests except Line Length where the effect was inverse. Rural location was associated with better performance across all tests with modest effect sizes noted. We identified no associations between sex and performance on any of the measures (all ps > 0.10). Greater age associated with worse performance on Match and Favorites tests (ps < 0.001) but not for Animal Fluency or Line Length (ps > 0.10).

Table 2

Regression coefficient examining influences on individual tests

Variables	Coefficient (95% CI, p)
Years of education
Favorites	0.26 (0.16–0.37, p < 0.001)^*
Match	1.03 (0.80–1.26, p < 0.001)^*
Animal fluency	0.26 (0.15–0.36, p < 0.001)^*
LL threshold^†	–0.15 (–0.25–(0.04, p = 0.005)^*
Sex (male)
Favorites	–0.50 (–2.33–1.33, p = 0.592)
Match	3.09 (–0.85–7.02, p = 0.123)
Animal fluency	0.08 (–1.69–1.84, p = 0.928)
LL threshold	–0.30 (–2.03–1.44, p = 0.736)
Location (rural)
Favorites	1.47 (0.55–2.88, p = 0.042)^*
Match	2.96 (–0.122–6.05, p = 0.060)
Animal fluency	1.76 (0.37–3.15, p = 0.013)^*
LL threshold	1.64 (0.27–3.01, p = 0.019)^*
Male rural interaction
Favorites	–1.79 (–4.42–0.84, p = 0.181)
Match	–0.59 (–6.26–5.08, p = 0.838)
Animal fluency	0.44 (–2.51–2.59, p = 0.973)
LL threshold^†	–1.70 (–4.21–0.81, p = 0.184)
Age
Favorites	–0.16 (–0.21–(–0.11, p < 0.001)^*
Match	–0.38 (–0.48–(–0.27, p < 0.001)^*
Animal fluency	–0.28 (–0.08–0.20, p = 0.257)
LL threshold	0.01 (–0.03–0.06, p = 0.589)

^†Greater scores represent poorer performance. ^*Represents significant findings.

To ensure that the location effect was not due to differences in gender roles by location, we examined sex-location interaction effects identifying none (all p > 0.15, Supplementary Tables). Adjusted R-squares for each test in full models were 0.37, 0.54, 0.17, and 0.09 for Favorites, Match, Animal Fluency and Line Length, respectively.

DISCUSSION

Our study demonstrates the feasibility of tablet-based cognitive assessments in both rural and urban settings. Educational attainment and rural residence correlated with superior cognitive performance, except for worse performance with higher education on Line Length, while sex did not predict outcomes. These findings emphasize the tool’s inclusivity, suggesting its potential for broad application in diverse healthcare and educational settings, especially in regions with varying urbanization and education. Primary healthcare clinics are usually the first contact in the health system for patients with cognitive issues.24,25, 24,25 Many studies support the idea that primary healthcare health workers and clinicians play a critical role in detecting and managing cognitive impairment.26,27, 26,27 Our present study provides the groundwork for the future examination of this brief digital tool in primary healthcare for the early detection of cognitive impairments in the elderly.

The mean age of our study participants was 64 years, which corresponds to the average age of dementia onset in Africa. 28 The geographic distribution including urban and rural areas is representative of primary healthcare in our region. Most of our participants were females which concurs with the study by Oghagbon et al. with more female participants, 29 and Anieto et al. among participants from Nigeria. 8 This suggests that health-seeking behavior was higher in female elderly patients when compared to men. Adewuwa et al. in Nigeria, and other studies reported a higher female-to-male ratio participation in cognitive assessments.30,31, 30,31

We found better cognitive performance among participants living in rural areas. Rural areas often provide greater access to natural environments. Exposure to nature has been associated with cognitive benefits, including improved attention and stress reduction. 32 The “restorative” effect of nature may positively impact cognitive performance. Rural environments may provide individuals with more opportunities for mental relaxation and reduced cognitive load associated with constant digital stimulation. Cognitive reserve is known to increase with continuing education, and a strong tendency to improve cognitive function and reduce dementia in an individual. 33 Differences in years of education, age, or gender did not explain the rural effect; the participants who live in rural communities performed better than their urban counterparts by a higher coefficient for all four domains.

In a study by Miller et al., similar to ours, they found a small to moderate memory advantage for rural dwellers when compared to urban dwellers, thereby leaving open the possibility that late-life rural living may be advantageous for some and promote resilience. 34 The rural residents’ better performance observed in this study was possibly due to the activities of a local Alzheimer’s Disease Association in Nigeria (ADAN) in promoting aging brain health activities and the old tradition of UBUNTU (communal living). ADAN has engaged in promotional aging brain health activities such as encouraging social connectedness, staying physically active, and monthly media public health education on healthy living for over two decades. Many of the participants may have benefited from these programs. This finding may relate to the common practice of regular rural meetings like the age groups, kindred meeting (nzuko-umunna), women meeting (nzuko umunwanyi), which encourages and provides some form of social safety net and reduces loneliness. Another study reported that associative memory is not globally and indiscriminately affected by Alzheimer’s disease in community-dwelling adults. 35 This did not correlate with our study which documented a significantly higher performance for rural residents.

Better performance in visuospatial skills functions noted in this study could be because of reduced reliance on transportation in rural areas encouraging physical activity which is known to contribute to improved mental health. 36 Repeated trekking for daily chores may contribute to better processing that involves visuospatial awareness and cognitive function. Rural dwellers engage more in communal spatial puzzle games like draft, African native indoor games (ncho/nchokoloto), and other hobbies that allow them to manipulate objects which train their visual skills while also entertaining them. They also engage in visual thinking with the ability to remember land community borders, and historical artifacts which greatly involves visual and analytical skills to recognize those olden objects, know their relationship to their surroundings, and organize it forposterity.

In addition to the rural effects on performance, we also found expected associations with education and age. Our finding that greater age was associated with declines in processing speed and executive functions aligns with prior work focused on processing speed, memory, working memory, set-shifting, fluency, and semantic memory. 37 The observed lack of sex-based differences in performance adds an inclusive dimension to the tool’s applicability. Although sex differences may exist and might have been identified with a larger sample, it is unlikely that sex will have a substantial influence based on our work.

The adaptability of the digital cognitive assessment tool makes it an asset in addressing cognitive health disparities and promoting inclusivity in both rural and urban environments. These encouraging outcomes pave the way for the integration of such technology into broader healthcare and educational contexts, especially in regions characterized by varying levels of urbanization and educational access. Our research substantiates the useability of tablet-based cognitive assessment in this diverse population and contributes to the ongoing discourse on leveraging digital tools for cognitive assessments, providing a foundation for future initiatives aimed at improving cognitive health outcomes on a broader scale. In some LMICs like Nigeria, dementia is seen as a normal form of aging with associated stigma, hindering timely diagnosis and medical intervention for affected individuals. Low awareness exacerbates the burden of cognitive disorders among older adults making this intervention timely.

It would be appropriate and recommended to utilize a culturally validated tablet-based cognitive assessment tool, 38 to ensure that the content is relevant and comprehensible to the local population, thereby improving the accuracy and reliability of the results. This approach minimizes cultural biases and enhances participant engagement, leading to more authentic and meaningful assessments. Additionally, incorporating culturally specific elements can help build trust and acceptance among the community, 38 fostering greater participation in cognitive health evaluations.

The possible effect of familiarity with electronic gadgets in our study participants may be a source of limitation, although the better performance among rural participants argues somewhat against this possibility. There may be a need for cross-validation using another cohort for comparison and possible future studies on test-retest reliability and prospective stability in Sub-Saharan Africa (SSA).

Conclusion

This project demonstrated the usability and associated demographic influences on the performance of a digital cognitive screening test in a primary healthcare clinic in Southeast Nigeria. We found expected associations with test performance for age and education and observed a cognitive advantage for people living in rural communities. Our work is aligned with Alzheimer’s Disease International’s mission to prioritize individuals living with dementia, caregivers, and families in driving innovation within dementia diagnostics, treatment, and care. By laying the foundation for proper validation studies this work has initiated a process toward potential multidisciplinary intervention studies, exploration of biomarkers, and advocating for inclusion in global aging brain health policy.

AUTHOR CONTRIBUTIONS

Chukwuanugo N. Ogbuagu (Conceptualization; Formal analysis; Project administration; Writing – original draft; Writing – review & editing); Ekenechukwu Ogbuagu (Validation; Writing – original draft); Obiageli Emelumadu (Methodology; Supervision); Uzoma Okereke (Formal analysis; Project administration); Irene Okeke (Formal analysis; Project administration); Godswill Chigbo (Data curation; Visualization); Shireen Javendal (Validation); Bruce Miller (Conceptualization; Methodology); Victor Valcour (Conceptualization; Writing – review & editing); Isabel Elaine Allen (Data curation; Validation; Writing – review & editing); Collette Goode (Validation); Katherine L. Possin (Conceptualization; Writing – review & editing); Richard Uwakwe (Supervision).

Footnotes

ACKNOWLEDGMENTS

We acknowledge all Primary healthcare providers and the elderly patients who participated in this study from the Center for Community Health and Primary Healthcare Neni and Ukpo, Anambra State Nigeria and the Alzheimer’s Disease Association of Nigeria (ADAN), for championing the course of awareness creation and enlightening the Nigerian community. We acknowledge the contribution of all co-authors and the Global Brain Health Institute University of California San Francisco.

FUNDING

The research study was supported by a grant from the Global Brain Health Institute (GBHI), Alzheimer’s Association, and Alzheimer’s Society UK Pilot Awards for Global Brain Health Leaders (GBHL-23-971131).

The source of funding for this research played no role in the study design and implementation; data collection and cleaning, management, analysis, and interpretation; draft preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. A number of co-authors are faculty at GBHI and contributed in mentoring for this project.

CONFLICT OF INTEREST

The authors have no conflict of interest to report.

DATA AVAILABILITY

The datasets generated and/or analyzed during the current study are available from the corresponding author upon request. All data supporting the findings of this study are maintained under appropriate security protocols to ensure the confidentiality and integrity of the data. Access to these data will be granted following the completion of a data-sharing agreement and, if applicable, the approval of the relevant ethical review board. Data sharing is intended solely for research and academic collaboration. For further inquiries or requests for data, please contact the corresponding author.

The supplementary material is available in the electronic version of this article: .

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