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Screening for depression and cognitive impairment in older people from ethnic minorities.

Keywords: cognitive impairment, depression, ethnic minority, screening

Introduction

In the next decade the UK will experience an increase in the number of older people from ethnic minority groups, particularly those who originated from the Caribbean and the South Asian sub-continent [1, 2]. Ethnicity may be seen as a personal expression of identity which may change with time, life experiences and place of habitation [3]. Ethnic minority elders can be described as heterogeneous groups of older people with defined cultural backgrounds [4].

Most psychiatric literature on old age is from North America and Western Europe [5]. The detection and management of dementia and depression among older people from ethnic minority groups has received relatively little attention, despite being associated with considerable disability. This is probably due to the complexity of cross-cultural issues [6, 7]. Currently available screening tests may not be applicable to these groups because of cultural and language constraints. Migrants may have different cultural perspectives and experiences after settling in the UK [8] and so screening instruments developed in the country of origin may not be relevant.

Cross-cultural development and use of screening instruments

To provide a scientific basis for the study of mental disorders across cultures, instruments should be designed which can be used in different cultures and provide reliable and valid data. Traditional approaches in cross-cultural research have been classified according to the standard anthropological terms `emic' and `etic' [9, 10]. The emic approach uses variables and observations that are culturally specific to a particular group, at a certain period in time, to develop an instrument. This does not allow for comparative research as it looks at variables in terms of language and culture and the instrument may not be relevant to other groups. The etic approach applies the same instrument in different cultures and by default does not provide insight into any cultural differences between groups and misses culturally specific symptoms. The ideal for comparative research would be a design that incorporated the descriptive qualities of the former approach with the validity across cultures of the second.

An anthropological approach to developing psychological instruments involves spending time in the culture of interest, generating a vocabulary for psychological distress and researching the cultural concepts associated with it [6]. This is often time-consuming and impractical. A modification involves the use of focus groups, formed to elaborate on key issues by using structured or semi-structured interviews, informal discussions, questions and vignettes. Such groups may include professionals (e.g. psychiatrists, sociologists and anthropologists) and lay members with experience of the culture and language. Good translation and back-translation are cardinal features [11-13].

Screening for mental illness

Certain ethnic minority groups have higher rates of physical illness, for example coronary artery disease [14], diabetes mellitus [15] and hypertension [16]. Physical disability has been related to a higher rate of depression [17]. The community prevalence of depression in South Asian elderly subjects may approach 20% [18] and is 13-19% in black people from Africa and the Caribbean [19]. The community prevalence (if dementia shows greater variability, with figures ranging from 2-8% for English-speaking black people from Africa and the Caribbean [19], higher levels for non-English speakers (black Africans and Chinese) and lower levels (4%) in elderly South Asians [18].

Screening instruments for cognitive impairment and depression are available in primary and secondary care [20], but may give false positives, especially for cognitive impairment [21, 22]. They are better used where the prevalence of mental illness is higher (for example in residential and nursing homes) [23] or if there is clinical suspicion of psychiatric illness.

Some general practitioners may not feel adequately trained to screen for and manage mental health problems [21]. This problem is accentuated when dealing with elderly people from different ethnic minorities, where culture and language may affect the presentation and consultation. The burden of untreated mental illness on the patient, caregivers and statutory services is high. Ethnic minority elders are under-represented in health, social, mainstream and voluntary services [24-26]. Depression in older people is common and treatable. Early identification of dementia allows for greater support, therapeutic intervention for concurrent illness and facilitating health and community services. Screening instruments can assist diagnosis.

Precedents have been set for using screening instruments devised in the West in other communities. Ideally they need to be validated in community populations, compared with a standard and have high sensitivity and specificity. Some instruments have now been translated, but few have been validated and little is known about their psychometric properties.

Screening for cognitive impairment

Cognitive impairment has been documented and studied in many countries. The criteria of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders for dementia require the effects of culture and education to be considered when reaching a diagnosis. Different cultures have unique patterns of experience, such as education, which influence performance during cognitive testing. Screening tests for cognitive function rely greatly on language recognition and ability.

The Mini-Mental State Examination (MMSE) [27] was originally developed in institutionalized subjects but has been widely used for population screening to estimate the prevalence of severe cognitive impairment. The MMSE has been assessed in primary care and shown to increase recognition of cognitive impairment, be acceptable to patients and have consistency between interviewers [22]. It is a popular instrument in cross-cultural research and has already been modified and translated into languages including Chinese and Finnish [28], Korean [29] and Hindi [30]. There has been criticism that the MMSE has cultural and educational bias [31-37]: the association between years of education and test performance is shown in community and hospital samples. This is pertinent when considering the use of MMSE in populations who have fewer years of education, whereby lower attainment would result in lower scores and possible mis-classification as cognitive impairment. The use of age- and education-specific equations has been suggested to improve interpretation of scores [38, 39]. Studies have also shown independent relationships with ethnic background [40] and associations with lower socio-economic status [41]. Current studies are validating the use of the MMSE with South Asian and African Caribbean groups in the UK [42]. The Abbreviated Mental Test Score [43] has also been translated [44], with similar reservations about its performance across cultures.

Some instruments are devised for specific communities using a combination of items from different scales and new items, rather than using a single scale or developing a new one. This approach has generated a cognitive instrument for Cree Indians and English-speaking Canadians [45]. This instrument has high sensitivity and specificity and the approach is now being tested in other cultural groups.

Screening for depression

There are similarities in the pattern of depression across cultures [9]. The vocabulary employed to describe symptoms of depression can be complex and interpretation of analogies or local idiom can be very difficult. For example, in some South Asian languages the words used to describe pain may be used to signify a physical pain and an expression of emotional pain or distress (heartache). The translated meaning may not be conveyed, or may be lost.

There are many screening instruments for depression including the Geriatric Depression Scale (GDS) [47], Hospital Anxiety and Depression Scale [48] and the BASDEC [49].

The GDS and BASDEC have been specifically developed for an older population. The GDS was originally devised as a 30-question scale. Shorter versions are more suitable for general practice, with the 15-item scale demonstrating a sensitivity of 91% and specificity of 72% in a community sample [50]. It has been studied in physically ill and cognitively impaired subjects. Examples of adapting the GDS include its use in India with a rural illiterate population [51] and with Chinese immigrants in the USA [52].

The BASDEC (an adaptation of the Brief Assessment Schedule) is presented as a deck of 19 cards. The cards are presented to the patient one at a time and can be read by them or to them. Sensitivities and specificities of 71%, and 88% [49] and 91% and 85% [53] have been demonstrated with hospital inpatients but no data are available on community populations. Although the BASDEC cards have been translated into South Asian languages, they have not yet been validated in these groups but are being used in current research [42].

Studies with the older people from Somali and Bengali communities in London have used pre-existing scales, including one for assessing anxiety and depression. This was translated by health care professionals, it demonstrated good internal consistency and allowed for comparison of results across communities [54].

Various scales have been translated and modified in the UK, but not specifically for older people. The Hospital Anxiety and Depression Scale has been translated into Urdu [55].

There are few examples of screening instruments developed specifically for particular elderly groups. This may reflects the degree of initial work required or perhaps a lack of research interest. In London an instrument for detecting emotional distress in older African-Caribbeans has been developed [56]. After semistructured interviews with older African-Caribbeans, a lay classification of mental illness and 13-point screen were produced [57]. This allowed community participation, discussion of cultural concepts and formulation of an instrument which reflected these considerations.

Conclusion

The use of existing screening instruments has the advantages that they are readily available, accessible and familiar. This saves time and money. It is also reassuring to have a previously validated instrument as a basis for modification. With so many minority groups in the UK, a well-constructed and

practical protocol for modifying present instruments may be sufficient. The disadvantages are those of cultural inappropriateness and the necessity for a rigorous translation and modification process, without compromising validity.

New instruments have the advantage that they are developed for a specific community, are culturally sensitive for that group and provide pertinent information. However, this may lead to less comparable results between groups and limited applications. Moreover, developing new instruments can take a long time.

Descriptions of emotional concepts associated with depression tend to be unique to particular cultures, and cognitive screening depends on greatly on language ability. If rating scales are not newly developed and rely on pre-existing scales then the use of focus groups, assessment, pre-testing and piloting are essential. The ratings may also have to be reviewed in the context of a subject's education, culture and gender. Also, with the evolution of communities instruments may need refinement and updating with time.

No nationally validated screening instruments are yet available for South Asian and African-Caribbean elderly people. Research in the UK is now being directed towards screening instruments in these groups [56, 58, 59]. The comparison of newly developed culture-specific tests with modified existing tests in different ethnic groups may reveal whether current screening instruments can be adapted to provide sufficient and acceptable information or whether they should be superseded by specifically designed instruments.

References

[1.] Ballard R, Kalra VS. The ethnic dimensions of the 1991 Census. Manchester: University of Manchester Census Dissemination Unit, 1994.

[2.] Office of Population Censuses and Surveys. 1991 Census: Ethnic Groups and Country of Births, volume 1/2. London: HMSO, 1993.

[3.] Senior PA, Bhopal R. Ethnicity as a variable in epidemiological research. Br Med J 1994; 309: 327-30.

[4.] Manthorpe J, Hettiaratchy E Ethnic minority elders in the UK. Int Rev Psychiatry 1993: 5: 171-8.

[5.] Chandra V, Ganguli M, Ratcliff G et al. Studies of the epidemiology of dementia: comparisons between developed and developing countries. Aging Clin Exp Res 1994; 6: 307-21.

[6.] Leff J. The `New cross-cultural psychiatry'. A case of the baby and the bathwater. Br J Psychiatry 1990; 156: 305-7.

[7.] Westermeyer J. Psychiatric diagnosis across cultural boundaries. Am J Psychiatry 1985; 142: 798-805.

[8.] Murphy HBM. Migration, culture and mental health. Psychol Med 1977; 7: 677-84.

[9.] Marsella AJ. Thoughts on cross-cultural studies on the epidemiology of depression. Culture Med Psychiatry 1978; 2: 343-57.

[10.] Patel V, Mann A. Etic and emic criteria for non-psychotic mental disorder: the study of the CISR and care provider assessment in Harare. Soc Psychiatry Psychiatr Epidemiol 1997; 32: 84-9.

[11.] Breslin R. Back translation for cross-cultural research, J Cross-Cultural Psychol 1970; 1: 185-216.

[12.] McDermott MA, Palchanes K. A literature review of the critical elements in translation theory. IMAGE: J Nursing Schol 1994; 26: 2: 113-7.

[13.] Bradley C. Translation of questionnaires for use in different languages and cultures. In: Handbook of Psychology and Diabetes. Basel: Harwood Academic, 1994.

[14.] McKeigue P. Coronary heart disease in Indians, Pakistanis, Bangladeshis: aetiology and possibilities for prevention. Br Heart J 1992. 67: 341-2.

[15.] Cruickshank J. Diabetes: contrasts between peoples of black, Indian and white European origin. In: Cruickshank C, Beevers D eds. Ethnic Factors in Health and Disease. Sevenoaks, UK Wright, 1989.

[16.] Chaturvedi N, McKeigue PM, Marmot MG. Resting and ambulatory blood pressure differences in Afro-Caribbeans and Europeans. Hypertension 1993; 22: 90-6.

[17.] Baldwin R. Outcome of depression in old age. Int J Geriatr Psychiatr 1991; 6: 395-400

[18.] Bhatnagar K, Frank J. Psychiatric disorders in elderly from the Indian sub-continent living in Bradford. Int J Geriatr Psychiatry 1997; 12: 907-12.

[19.] McCraken CFM, Boneham M, Copeland JRM et al. Prevalence of dementia and depression among elderly people in Black and ethnic minorities. Br J Psychiatry 1997; 171: 269-73.

[20.] Royal College of Physicians and British Geriatric Society. Standardized Assessment Scales for Elderly People. London: Royal College of Physicians, 1992.

[21.] Wind AW, Schellevis F. van Staveren G, Scholten RJ, Jonker C, van Eijk JT. Limitations of the MMSE in diagnosing dementia in general practice. Int J Geriatr Psychiatry 1997; 12: 101-8.

[22.] Iliffe S, Booroff A, Gallivan S, Goldenberg E, Morgan P, Haines A. Screening for cognitive impairment in the elderly using the mini-mental state examination. Br J Gen Prac 1990; 40: 277-9.

[23.] Ames D. Epidemiological studies of depression among the elderly in residential and nursing homes. Int J Geriatr Psychiatry 1991; 6: 347-54.

[24.] Devore W. Responses to ageing in Great Britain: the Black experience. J Sociol Social Welfare 1995; 22: 173-84.

[25.] Karseras PA. Minorities and access to health care, part 1: confronting myths. Care Elderly 1991; 429-70.

[26.] Blakemore K. Health and illness among the elderly of minority ethnic groups living in Birmingham: some new findings. Health Trends 1982; 14: 69-72.

[27.] Folstein M, Folstein S, McHugh PR. Mini-mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiat Res 1975: 12: 189-98.

[28.] Salmon DP, Reikkinen PJ, Katzman R et al. Cross-cultural studies of dementia: A comparison of MMSE performance in Finland and China. Arch Neurol 1989; 46: 769-72.

[29.] Park JH, Kwon YC. Modification of the MMSE for the use in the elderly in a non-western society. Int J Geriatr Psychiatry 1990; 5: 381-7.

[30.] Ganguli M, Ratcliff G, Chandra V et al. A Hindi version of the MMSE: the development of a cognitive screening instrument tilt a largely illiterate rural elderly population in India. Int J Geriatr Psychiatry 1995; 10: 367-77.

[31.] Yu SH, Lui WT Levy P, Zhang M, Katzman R, Lung C, Wong S. Cognitive impairment among elderly adults in Shanghai, China. J Gerontol 1989: 3: S97-106.

[32.] Mungas D, Marshall SC, Weldon M, Haan M, Reed BR. Age and education correction of mini-mental state examination for English and Spanish speaking elderly. Neurology 1996; 46: 700-6.

[33.] Escobar JI, Furnam A, Karno M, Forsythe A, Landswerk J, Golding JM. Use of the MMSE in a community of mixed ethnicity. J Nerv Ment Dis 1986; 176: 607-14.

[34.] Fillenbaum G, Heyman A, Williams K, Prosnitz B, Burchett B. Sensitivity and specificity of standardised screens of cognitive impairment and dementia among elderly black and white community residents. J Clin Epidemiol 1990; 43: 651-60.

[35.] Shaji S, Promodu K, Abraham T, Roy J, Verghese A. An epidemiological study of dementia in a rural community in Kerala, India. Br J Psychiatry 1996; 168: 745-9.

[36.] Phanthumchinda K, Jitapunkul S, Sitthi-Amorn C, Bunnag SC, Ebrahim S. Prevalence of dementia in an urban slum population in Thailand: validity of screening methods. Int J Geriatr Psychiatr 1991; 6: 639-46.

[37.] Tombaugh TN, McIntyre NJ. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc 1992: 40: 922-53.

[38.] Magaziner J, Bassett SS, Hebel JR. Predicting performance on the MMSE. J Am Geriatr Soc 1987; 35; 996-1000.

[39.] Mungas D, Marshall SC, Weldon M, Haan M, Reed BR. Age and education correction (if MMSE for English- and Spanish-speaking elderly. Neurology 1996; 46: 700-6.

[40.] Escobar J, Burnam A, Karno M, Forsythe A, Landsverk J, Golding J. Use of the mini-mental state examination in a community population of mixed ethnicity. J Nerv Ment Dis 1986: 174: 607-14.

[41.] Brayne C, Calloway P. The association of education and socioeconomic status with the MMSE and the clinical diagnosis of dementia in elderly people. Age Ageing 1990; 19: 91-6.

[42.] Rait G, Burns A, Chew C. Age, ethnicity and mental illness: a triple whammy. Br Med J 1996; 313: 1347.

[43.] Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972; 1: 233-8.

[44.] Rocca W, Bonaiuto S, Lippi A et al. Validation of the Hodkinson Abbreviated Mental Test as a screening instrument for dementia in an Italian population Neuroepidemiology 1992; 11: 288-95.

[45.] Hall KS, Hendrie HC, Brittain HM et al. The development of a dementia screening interview in two distinct languages. Int J Methods Psychiatric Res 1993; 3: 1-28.

[46.] Beliappa J. Illness or Distress? Alternative Models of Mental Health. Confederation of Indian Organisations, 1991.

[47.] Yesavage JA, Brink TL, Rose T, Lum O, Huang V, Adey M, Leirer VO. Development and validation of a geriatric depression screening scale: A preliminary report. J Psychiat Res 1983: 17: 37-49.

[48.] Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: 361-70.

[49.] Adshead F, Cody D, Pitt B. BASDEC: a novel screening instrument for depression in elderly medical inpatients. Br Med J 1992; 305: 397.

[50.] D'Ath P, Katona P, Mullan E, Evans S, Katona C. Screening, detection and management of depression in elderly primary care attenders. Family Practice 1994; 11: 260-66.

[51.] Kohli A, Banerjee ST, Verma SK. Adaptation of a Geriatric Depression Scale in simple Hindi. Indian J Clin Psychol 1991; 18: 63-4.

[52.] Mui A. Geriatric depression scale as a community screening instrument for elderly Chinese immigrants. Int Psychogeriatr 1996; 8: 445-58.

[53.] Loke B, Nicklason F, Burvill P. Screening for depression: clinical validation of geriatricians' diagnosis, the Brief Assessment Schedule Depression Cards and the 5-item version of the symptom check list among non-demented geriatric inpatients. Int J Geriatr Psychiatry 1996; 11: 461-5.

[54.] Silveira E, Ebrahim S. Mental health and health status of elderly Bengalis and Somalis in London. Age Ageing 1995; 24: 474-80.

[55.] Mumford DB, Tareen IAK, Bajwa MAZ, Bhatti MR, Karim R. The translation and evaluation of an Urdu version of the Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1991; 83: 81-5.

[56.] Abas M. Depression and Anxiety Among Older Caribbean People in the UK: screening, unmet need and the provision of appropriate services.

[57.] Abas M. Initial development of a new culture-specific screen for emotional distress in older Caribbean people. Int J Geriatr Psychiatry 1996; 11:1097-1103.

[58.] Richards M, Brayne C. Cross-cultural research into cognitive impairment and dementia; some practical experiences. Int J Geriatr Psychiatry 1996; 11: 383-7.

[59.] Rait G, Morley M, Lambat I, Burns A. Modification of brief assessments for use with elderly people from the South Asian sub-continent. Aging Mental Health 1997; 1: 356-63.

Received 9 October 1997

GRETA RAIT, ALISTAIR BURNS

University Department of Old Age Psychiatry, University of Manchester, Withington Hospital, Manchester M20 8LR, UK

Address correspondence to: G. Rait, Department of Primary Care and Population Sciences, Archway Wing, Wittington Hospital, London N9 5NF, UK. Fax: (+44) 171 281 8004
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Author:RAIT, GRETA; BURNS, ALISTAIR
Publication:Age and Ageing
Geographic Code:4EUUK
Date:May 1, 1998
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