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Geriatr Gerontol Int 2015; 15: 594–600
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Development of the Thai version of Mini-Cog, a brief cognitive screening test Supaporn Trongsakul,1,2 Rod Lambert,2 Allan Clark,3 Nahathai Wongpakaran4 and Jane Cross2 1 School of Health Science, Mae Fah Luang University, Chiang Rai, Thailand; 2School of Allied Health Professions, Faculty of Medicine and Health Sciences, 3School of Medicine, Faculty of Medicine and Health Sciences, University of East Anglia, Norfolk, UK; and 4Geriatric Psychiatry Unit, Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
Aims: Cognitive impairment, such as dementia, has emerged as the leading public health problem among the elderly. Therefore, early detection of the disorder and providing appropriate healthcare and management is important, particularly, for the patients with comorbid diabetes who require long-term treatment strategies. In Thailand, because of a large number of elderly patients with diabetes, and time constraints in primary care settings, a short and effective cognitive screening test is required. The Mini-Cog is a short and valid cognitive screening test that was specifically designed for use in primary care settings. The present study translated the English language version into a Thai language version, and then measured the interrater reliability and concurrent validity. Methods: The processes of cross-language translation were carried out to develop a Thai language version of the Mini-Cog. A total of 21 Thai older adults with type 2 diabetes with a mean aged of 69 ± 7 years were recruited into a study investigating the interrater reliability and concurrent validity of the Mini-Cog Thai version in one primary care center in Thailand. Results: The Mini-Cog Thai version showed a good interrater reliability (K = 0.80, P < 0.001, 95% CI 0.50–1.00) and a positive concurrent validity (r = 0.47, P = 0.007, 95% CI 0.37,0.55) with the Mini-Mental State Examination Thai 2002. Conclusions: The findings show that the Thai version of the Mini-Cog is a reliable, performance-based tool in the screening for cognitive function in primary care settings in Thailand. It is recommended that it could be used as a new cognitive screening test for the aging population in the Thai community. Geriatr Gerontol Int 2015; 15: 594–600. Keywords: cognitive screening test, concurrent validity, cross-language translation, discriminant validity, interrater reliability.
Introduction The present study is one part of a prevalence study of undiagnosed cognitive impairment of Thai older adults with type 2 diabetes in a primary care center, and describes the development and testing of a short cognitive screening test that is suitable for use in primary care. Type 2 diabetes is a global health issue, it has been estimated that the number of people with diabetes worldwide was 285 million in 2010, and will increase to
Accepted for publication 19 April 2014. Correspondence: Miss Supaporn Trongsakul PhD, School of Health Science, Mae Fah Luang University, 333 Moo1, Tasud, Muang, Chiang Rai 57100 Thailand. Email: [email protected]
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doi: 10.1111/ggi.12318
439 million in 2030.1 Each year, more than 3.96 million people worldwide die from diabetes and its complications.2 In addition, the prevalence of type 2 diabetes increases with age.3 By 2030, there will be approximately 196 million people worldwide with diabetes aged between 60 and 79 years.3 Research has linked the disease to cognitive impairment in the elderly.4,5 Recent evidence from epidemiological studies suggests that type 2 diabetes is a risk factor for cognitive impairment, and for both vascular dementia and Alzheimer’s disease, which are the two most common forms of dementia.6–9 Elderly individuals (aged 60–80 years) with type 2 diabetes are associated with an approximately 1.5-fold increased risk of cognitive impairment compared with the non-diabetic group.10 Given the potential for cognitive problems to interfere with self-care management of diabetes, cognitive decline among elderly people with diabetes could lead to a further decline in health.11 © 2014 Japan Geriatrics Society
Thai version of Mini-Cog test
Type 2 diabetes is one of the main chronic diseases that causes health problems in Thai older adults,12 and the numbers of elderly people are expected to increase over the next few decades as a result of an aging population.13 Furthermore, the prevalence of dementia is 2–10% in Thai older adults, a prevalence that increases with age.14,15 Although diabetes is considered to be a risk factor for cognitive impairment,6,7,9 cognitive function of patients with type 2 diabetes is not usually evaluated in routine clinical care. For example, a community-based study showed that 95.6% (22/23 persons) of Thai older adults with dementia have never received a diagnosis of dementia.16 Many medical staff do not routinely carry out cognitive screening tests and might not be familiar with the parts of the cognitive assessment that are most useful for the early detection of cognitive impairment.17 In addition, dementia is not recognized as a high priority problem in developing countries, particularly in primary care settings, partly because of the difficulty in case detection and management.16 In Thailand, primary care is usually the first contact with medical services or a medical consultant for a large number of people in the community (semi-rural and rural areas) and, with no appointment system, a typical visit to a primary care center is short, approximately 3–5 min.18 Thus, there is the real need for a screening test that is quick, valid and reliable, and easy to use in order to help the healthcare staff identify high-risk cases of cognitive impairment or dementia. The Mini-Cog19 was originally developed in an ethnolinguistically diverse American sample, to screen for dementia in primary care settings. It is composed of a memory test (the recall of 3 unrelated words – total 3 scores) and a very simple free-hand version of the clock drawing test (CDT; total 2 scores) included as a distractor for the memory task. It consists of two orally presented tasks (a three-item word recall) combined with an executive CDT. Mini-Cog scores, therefore, range from 0 (minimum score-worst) to 5 (maximum score-best).19,20 A cut-off of 2 out of 5 provides the optimal combination of sensitivity (99%) and specificity (96%) for detecting cognitive impairment.19–22 The original version of the Mini-Cog can be administered in an average of 3.2 min, and showed high sensitivity (99%) and specificity (96%) in a community sample of 249 ethnolinguistically diverse older adults, half of whom had dementia and half of whom were cognitively intact.19 In a community-based study of participants with a low level of education and non-English speaking groups, a similar outcome to the Mini-Mental State Examination (MMSE) in identifying dementia was shown. In that study, Mini-Cog’s sensitivity of 76% and specificity of 89% were similar to the MMSE’s sensitivity of 79% and specificity of 88%.21 Although the MMSE Thai 2002 remains a preferred clinical screening test used in Thailand,23 it is limited in its ability to assess © 2014 Japan Geriatrics Society
executive function that has been shown to be altered in the early stage of cognitive impairment or mild cognitive impairment (MCI).24–27 Furthermore, although several studies, including the study in Thailand, found the limitations of the MMSE in the very old and in those with limited education,28–31 it remains the most familiar and widely used cognitive screening test worldwide. It is also used as the reference standard for other cognitive tests in research.32–34 Unlike the MMSE, the Mini-Cog is not affected by education and language.19 Furthermore, in a multiethnic sample, the Mini-Cog detects a higher proportion of subjects with a mild cognitive impairment in addition to subjects with moderate and severe cognitive impairment, much of which is not recognized by their physicians.20 Given that the duration of appointments in primary care settings in Thailand is between 3 and 5 min,18 the Mini-Cog might well be suitable for use in this primary care setting. The aim of the present study was to develop a Mini-Cog Thai version and to provide estimates of the interrater reliability. Additionally, the concurrent validity was also estimated by measuring the relationship between Mini-Cog and the known reference standard, MMSE Thai 2002, on the same population.
Methods Part 1: Translation of the Mini-Cog The Mini-Cog was translated into Thai according to the guideline for cross-language translation35 as follows.
Copyright permission The Mini-Cog is copyrighted by the developers, Borson,19 therefore permission was sought from them. In the original version of Mini-Cog, the three-item recall words are “apple”, “table” and “penny”. These words are not familiar in the Thai culture. Thus, a new set of the three-item words consisting of “house”, “cat” and “green” was proposed and agreed for translation. These three words were chosen for their simplicity and because they are recognized in the Thai culture (see Mini-Cog Thai version in Appendix S1).
Forward translations Translators 1 and 2,36 who both fluently speak Thai (target language) and English (original language), independently translated the Mini-Cog from English to Thai. Both translators have experience in neurocognitive screening questionnaire design and development. They were instructed to aim for conceptual rather than literal translation, and to keep the language easy to understand for the individuals without the knowledge of technical terminology. | 595
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Synthesis of the translations The results of the translation from the two translators were compared by the translation committee, which consisted of one expert (a Thai psycho-geriatrician) and the authors. In this step, the discrepancies of meaning in the translations were checked. If any discrepancies were found, the translators would discuss with the translation committee and come to an agreement.
Back translations Two different translators (3 and 4)36 were invited for back translation. The back-translators were bilingual and bicultural. They spoke Thai and English fluently, and did not have a background in medicine or cognitive screening tests. They were blinded to the original version of Mini-Cog, and translated the proposed Thai Mini-Cog into English.
Stage 4: Equivalence testing The back-translated versions were examined and compared by an original developer in order to see any differences in the back-translation. The results of backtranslation showed that there was no difference in the meaning of the words or concepts between the two English versions of Mini-Cog (original and backtranslated version).
and has adequate power to detect any trends.37 Participants were included if they aged over 60 years with type 2 diabetes and any type of diabetic treatment (e.g. diet control, medication or insulin injection). In order to communicate and understand the instructions provided by the researcher, all participants were competent Thai speakers. Participants were excluded from the study if they had a previous diagnosis of either vascular dementia or Alzheimer’s disease, as this was part of a larger study to estimate the prevalence of undiagnosed cognitive impairment in Thai elderly older adults type 2 diabetes. Those with a diagnosis of a depressive disorder, schizophrenia or epilepsy; were receiving medical treatment with psychoactive drugs (anticholinergics, anticonvulsants, antiparkinsonians or major tranquilizers); had any cerebrovascular accident history or complicated hypertension or renal failure; and/or communication difficulties that require an interpreter were also excluded. Ethical approval was gained from the Faculty of Medicine and Health Sciences Research Ethics Committee, University of East Anglia, UK and the Research Ethics Committee, Ministry of Public Health, Thailand. Details of the research were sent to potential participants with the appointment information. When attending their appointment, the participants gave written informed consent before they were interviewed and assessed by the Mini-Cog Thai version.
Data analyses Part 2: Interrater reliability of the Mini-Cog Thai version The first part of the original Mini-Cog is a task that requires the recall of three words (total score available 3 – 1 word/score). The participant gains the score by answering precisely the word(s) that they have been told by the researcher; that is, “home”, “cat” and “green”. In the second part (clock drawing) of the test, the score depends on the subjective judgement of the researcher using the scoring system. Therefore, this aspect of the scoring system needs to study interrater reliability. Therefore, after the back-translation was approved by the authors of the Mini-Cog,19 the Mini-Cog Thai version was evaluated to determine the interrater reliability of the second part (clock drawing test) of the Mini-Cog, and its concurrent validity and discriminant validity against the MMSE Thai 2002.
Participants In the present study, 21 participants were recruited from a primary care center (Nong-Han) in the San-sai district, Chiang Mai, Thailand. It has been suggested that a minimum number of 20–30 participants or greater is appropriate to estimate a parameter for a pretest study, 596 |
Interrater reliability was determined by two independent raters who alternately carried out the test (Mini-Cog Thai version). Each rater was blinded to the other rater’s results. Data were analyzed using SPSS version 16 (SPSS, Chicago, IL, USA). Interrater reliability was measured using the kappa (K) statistic.38 The Mini-Cog score results were assigned to two categories: (i) possible abnormal cognitive function result (scores 0–2); and (ii) normal cognitive function result (scores 3–5). Then the overall results from two raters were assigned; 0 (zero) denotes the participants with normal cognitive function, 1 (one) denotes the participants who were classified with possible abnormal cognitive function. In order to determine concurrent validity, the Pearson product-moment correlation coefficient (Pearson’s r)39 was applied to examine the correlation coefficient between the score results of the Thai version of the Mini-Cog and MMSE Thai 2002.
Results A total of 21 participants were recruited into the present study – 76% (16) were women. The mean age was 69 ± 7 years (range 61–82 years). A total of 76% of participants finished primary school (4 years in school), © 2014 Japan Geriatrics Society
Thai version of Mini-Cog test
Table 1 Mini-Cog scores for individual participants involved in the study from the researcher and expert Participant 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Mini-Cog score Researcher
Expert
0 0 1 0 0 0 1 1 1 0 0 0 1 0 0 1 0 0 0 1 0
0 1 1 0 0 0 1 1 1 0 0 0 1 0 0 1 1 0 0 1 0
Table 2 Two by two table of agreement
Researcher n (%) Total
0 1
Expert n (%) 0
Total n (%) 1
12 (57%) 0 (0%) 12 (57%)
2 (10%) 7 (33%) 9 (43%)
14 (67%) 7 (33%) 21 (100%)
A total of 21 participants were scored by the researcher and expert. 0 (zero) denotes the participants with normal cognitive function, 1 (one) denotes the participants who are classified with possible abnormal cognitive function.
52.4% (11) were married, 38.1% (8) were widowed and 9.5% (2) were single. The mean scores of Mini-Cog and MMSE Thai 2002 were 2.71 + 1.65 and 19.71 + 4.04, respectively. An average time to administer the Mini-Cog Thai version was 4.6 min. The raw scores for each participant from both raters are presented in Table 1. The interrater reliability of Mini-Cog scoring classified as “normal cognitive function” and “possible abnormal cognitive function” are presented in Table 2. The researcher and expert both agreed (57%) on “normal cognitive function” and both agreed (33%) on “possible abnormal cognitive function”. There were 10% where the expert disagreed with the researcher on “normal © 2014 Japan Geriatrics Society
cognitive function”, thus agreement on “normal cognitive function” and “possible abnormal cognitive function” was 90%. The K statistic for the interrater reliability of Mini-Cog shows a good agreement according to Altman40 with K = 0.80, P < 0.001, 95% CI 0.50–1.00. By using Pearson’s correlation coefficients (r) between the scores of Mini-Cog and MMSE Thai 2002, the scores of Mini-Cog showed a significantly positive and moderate correlation according to Pallant41 with Pearson’s correlation (r) of 0.47, P < 0.001, 95% CI 0.37– 0.55.
Discussion This is the first translation of the English version of the Mini-Cog into the Thai language. The processes of cross-language translation showed and ensured consistency and quality of content between the English and Thai versions of the test. The Mini-Cog Thai version has been shown to be practical to administer, and acceptable in the Thai language and culture. The participants showed that they could clearly understand the wording and instructions of the test, and there was no need for revision. The time to interview and administer the test (5 min) was acceptable to both participants and clinicians in the primary care setting.18 In order to validate the Thai version of the Mini-Cog, concurrent validity was established by comparing the performance of Mini-Cog against the MMSE Thai 2002.42,43 Pearson’s correlation (r; 0.47, P < 0.001, 95% CI 0.37–0.55) between Mini-Cog and MMSE showed a positive correlation between the Mini-Cog and the MMSE Thai 2002 scores. This demonstrates acceptable validity of Mini-Cog Thai against the MMSE Thai 2002. The MMSE Thai 2002 is limited in its ability to assess executive function, and this has been found to be altered in the early stages of cognitive impairment or in MCI.24–27 The Mini-Cog, however, detects more subjects with a mild cognitive impairment as well as subjects with a moderate to severe cognitive impairment.20 Hence, a discriminant validation technique is used to assess whether the new test (Mini-Cog) is highly correlated with an established test (MMSE Thai 2002), as they are designed to measure theoretically different concepts.44 A result less than 0.85 suggest discriminant validity between the two tests. In contrast, a result greater than 0.85 shows the tests overlap greatly and thus are likely to be measuring the same thing.45 In the present study, the discriminant validity between MiniCog and MMSE Thai 2002 was less than 0.85 (Pearson’s r = 0.47, P < 0.001, 95% CI 0.37–0.55), and therefore shows that the Mini-Cog presents discriminant validity with MMSE Thai 2002. There is a good level of agreement (interrater reliability) of the Thai version of the Mini-Cog with K = 0.80 (P < 0.001, 95% CI 0.50–1.00).40 The CDT part in the | 597
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Thai version of the Mini-Cog applies the updated version of the CDT scoring system, which is divided into categorical ratings (normal and abnormal). The revised CDT (categorical rating) replaced the original version (ordinal rating), because the previous studies of the CDT in categorical rating shows an overall high concordance (89%) score between expert and naive raters, and is more simple to use compared with the original version (ordinal rating).22 The old version of the CDT scoring system originally arranged the results into ordinal ratings (0 = normal, 1 = mild, 2 = moderate, 3 = severe) with more than two raters.19 Therefore, the CDT part of the original (English) version of the MiniCog shows the result of reliability of the CDT part in an intraclass correlation coefficient (ICC; 0.90)19 instead of interrater reliability, which rates the score in categorical score with two raters.38,46 Nevertheless, from the literature, no study of the Mini-Cog, in the original English version, addressed the interrater reliability of the CDT using a categorical rating scale. Studies of the translated version of the Mini-Cog have been found in Korean and Italian.47,48 In the Korean version, the Mini-Cog was assessed for validity (sensitivity 90%, specificity 95.8%), but there is no information regarding the reliability.47 It showed a high level of sensitivity and specificity in the elderly both in the community and in nursing homes, although details of age and education levels were not reported.47The Mini-Cog Thai and Italian versions both use the CDT with the same scoring (categorical rating), the method to analyze reliability of the Mini-Cog test are, however, different. The present study only analyzed data regarding two raters scoring, the Mini-Cog Thai version, whereas in the Italian version,48 there were 40 raters across a large geographical area (11 regions). The researchers reported reliability only for the part of the CDT that yields an ICC of 0.89.48 However, in clinical practice, the reliability is the repeatability under similar conditions, either by the same rater or different rater. It is a measure of the consistency that two or more individuals will have the same findings with the same assessment.49 Furthermore, it is vital that any tool used in the assessment of a patient is repeatable between clinicians in the whole processes.50 Hence, the present study used kappa analysis to measure interrater reliability38 of the overall test. The strength of the present study was that it is the first study that aimed to establish the interrater reliability between two raters who administered the overall test. Although the current work was limited by a small sample size, a minimum sample size of two raters is acceptable when a moderate level or higher kappa coefficient is expected.51 The present study showed a high kappa value at 0.8.40 To confirm the interreliability of the Mini-Cog Thai version in an elderly population, further data should be tested in the general older 598 |
population, using a larger number of subjects, the psychometric properties of the Mini-Cog Thai version should be further explored. The present study showed the good interrater reliability of the Thai version of the Mini-Cog and its concurrent validity with MMSE Thai 2002. The Thai version of the Mini-Cog can therefore be considered to be both reliable and valid compared with similar screening tools, such as the MMSE Thai 2002, particularly for practical use in primary care centers. The present results shed light on the future use of the Thai version of the Mini-Cog, both in clinical practice and research, for the cognitive screening in Thai older adults with type 2 diabetes. This is particularly the case in the primary care setting, where there is limited time and a brief cognitive screening method is required. A test such as this can assist healthcare professionals to be aware of cognitive decline in diabetic patients, which could improve the quality of care, and the use of healthcare strategies for diabetic patients and their families.
Acknowledgment This study was partly supported by the Thai Ministry of Science and Technology and the Thai Royal Government Scholarship.
Disclosure No potential conflicts of interest were disclosed.
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Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Appendix S1 MINI-COG.
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Geriatr Gerontol Int 2015; 15: 594–600
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Development of the Thai version of Mini-Cog, a brief cognitive screening test Supaporn Trongsakul,1,2 Rod Lambert,2 Allan Clark,3 Nahathai Wongpakaran4 and Jane Cross2 1 School of Health Science, Mae Fah Luang University, Chiang Rai, Thailand; 2School of Allied Health Professions, Faculty of Medicine and Health Sciences, 3School of Medicine, Faculty of Medicine and Health Sciences, University of East Anglia, Norfolk, UK; and 4Geriatric Psychiatry Unit, Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
Aims: Cognitive impairment, such as dementia, has emerged as the leading public health problem among the elderly. Therefore, early detection of the disorder and providing appropriate healthcare and management is important, particularly, for the patients with comorbid diabetes who require long-term treatment strategies. In Thailand, because of a large number of elderly patients with diabetes, and time constraints in primary care settings, a short and effective cognitive screening test is required. The Mini-Cog is a short and valid cognitive screening test that was specifically designed for use in primary care settings. The present study translated the English language version into a Thai language version, and then measured the interrater reliability and concurrent validity. Methods: The processes of cross-language translation were carried out to develop a Thai language version of the Mini-Cog. A total of 21 Thai older adults with type 2 diabetes with a mean aged of 69 ± 7 years were recruited into a study investigating the interrater reliability and concurrent validity of the Mini-Cog Thai version in one primary care center in Thailand. Results: The Mini-Cog Thai version showed a good interrater reliability (K = 0.80, P < 0.001, 95% CI 0.50–1.00) and a positive concurrent validity (r = 0.47, P = 0.007, 95% CI 0.37,0.55) with the Mini-Mental State Examination Thai 2002. Conclusions: The findings show that the Thai version of the Mini-Cog is a reliable, performance-based tool in the screening for cognitive function in primary care settings in Thailand. It is recommended that it could be used as a new cognitive screening test for the aging population in the Thai community. Geriatr Gerontol Int 2015; 15: 594–600. Keywords: cognitive screening test, concurrent validity, cross-language translation, discriminant validity, interrater reliability.
Introduction The present study is one part of a prevalence study of undiagnosed cognitive impairment of Thai older adults with type 2 diabetes in a primary care center, and describes the development and testing of a short cognitive screening test that is suitable for use in primary care. Type 2 diabetes is a global health issue, it has been estimated that the number of people with diabetes worldwide was 285 million in 2010, and will increase to
Accepted for publication 19 April 2014. Correspondence: Miss Supaporn Trongsakul PhD, School of Health Science, Mae Fah Luang University, 333 Moo1, Tasud, Muang, Chiang Rai 57100 Thailand. Email: [email protected]
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doi: 10.1111/ggi.12318
439 million in 2030.1 Each year, more than 3.96 million people worldwide die from diabetes and its complications.2 In addition, the prevalence of type 2 diabetes increases with age.3 By 2030, there will be approximately 196 million people worldwide with diabetes aged between 60 and 79 years.3 Research has linked the disease to cognitive impairment in the elderly.4,5 Recent evidence from epidemiological studies suggests that type 2 diabetes is a risk factor for cognitive impairment, and for both vascular dementia and Alzheimer’s disease, which are the two most common forms of dementia.6–9 Elderly individuals (aged 60–80 years) with type 2 diabetes are associated with an approximately 1.5-fold increased risk of cognitive impairment compared with the non-diabetic group.10 Given the potential for cognitive problems to interfere with self-care management of diabetes, cognitive decline among elderly people with diabetes could lead to a further decline in health.11 © 2014 Japan Geriatrics Society
Thai version of Mini-Cog test
Type 2 diabetes is one of the main chronic diseases that causes health problems in Thai older adults,12 and the numbers of elderly people are expected to increase over the next few decades as a result of an aging population.13 Furthermore, the prevalence of dementia is 2–10% in Thai older adults, a prevalence that increases with age.14,15 Although diabetes is considered to be a risk factor for cognitive impairment,6,7,9 cognitive function of patients with type 2 diabetes is not usually evaluated in routine clinical care. For example, a community-based study showed that 95.6% (22/23 persons) of Thai older adults with dementia have never received a diagnosis of dementia.16 Many medical staff do not routinely carry out cognitive screening tests and might not be familiar with the parts of the cognitive assessment that are most useful for the early detection of cognitive impairment.17 In addition, dementia is not recognized as a high priority problem in developing countries, particularly in primary care settings, partly because of the difficulty in case detection and management.16 In Thailand, primary care is usually the first contact with medical services or a medical consultant for a large number of people in the community (semi-rural and rural areas) and, with no appointment system, a typical visit to a primary care center is short, approximately 3–5 min.18 Thus, there is the real need for a screening test that is quick, valid and reliable, and easy to use in order to help the healthcare staff identify high-risk cases of cognitive impairment or dementia. The Mini-Cog19 was originally developed in an ethnolinguistically diverse American sample, to screen for dementia in primary care settings. It is composed of a memory test (the recall of 3 unrelated words – total 3 scores) and a very simple free-hand version of the clock drawing test (CDT; total 2 scores) included as a distractor for the memory task. It consists of two orally presented tasks (a three-item word recall) combined with an executive CDT. Mini-Cog scores, therefore, range from 0 (minimum score-worst) to 5 (maximum score-best).19,20 A cut-off of 2 out of 5 provides the optimal combination of sensitivity (99%) and specificity (96%) for detecting cognitive impairment.19–22 The original version of the Mini-Cog can be administered in an average of 3.2 min, and showed high sensitivity (99%) and specificity (96%) in a community sample of 249 ethnolinguistically diverse older adults, half of whom had dementia and half of whom were cognitively intact.19 In a community-based study of participants with a low level of education and non-English speaking groups, a similar outcome to the Mini-Mental State Examination (MMSE) in identifying dementia was shown. In that study, Mini-Cog’s sensitivity of 76% and specificity of 89% were similar to the MMSE’s sensitivity of 79% and specificity of 88%.21 Although the MMSE Thai 2002 remains a preferred clinical screening test used in Thailand,23 it is limited in its ability to assess © 2014 Japan Geriatrics Society
executive function that has been shown to be altered in the early stage of cognitive impairment or mild cognitive impairment (MCI).24–27 Furthermore, although several studies, including the study in Thailand, found the limitations of the MMSE in the very old and in those with limited education,28–31 it remains the most familiar and widely used cognitive screening test worldwide. It is also used as the reference standard for other cognitive tests in research.32–34 Unlike the MMSE, the Mini-Cog is not affected by education and language.19 Furthermore, in a multiethnic sample, the Mini-Cog detects a higher proportion of subjects with a mild cognitive impairment in addition to subjects with moderate and severe cognitive impairment, much of which is not recognized by their physicians.20 Given that the duration of appointments in primary care settings in Thailand is between 3 and 5 min,18 the Mini-Cog might well be suitable for use in this primary care setting. The aim of the present study was to develop a Mini-Cog Thai version and to provide estimates of the interrater reliability. Additionally, the concurrent validity was also estimated by measuring the relationship between Mini-Cog and the known reference standard, MMSE Thai 2002, on the same population.
Methods Part 1: Translation of the Mini-Cog The Mini-Cog was translated into Thai according to the guideline for cross-language translation35 as follows.
Copyright permission The Mini-Cog is copyrighted by the developers, Borson,19 therefore permission was sought from them. In the original version of Mini-Cog, the three-item recall words are “apple”, “table” and “penny”. These words are not familiar in the Thai culture. Thus, a new set of the three-item words consisting of “house”, “cat” and “green” was proposed and agreed for translation. These three words were chosen for their simplicity and because they are recognized in the Thai culture (see Mini-Cog Thai version in Appendix S1).
Forward translations Translators 1 and 2,36 who both fluently speak Thai (target language) and English (original language), independently translated the Mini-Cog from English to Thai. Both translators have experience in neurocognitive screening questionnaire design and development. They were instructed to aim for conceptual rather than literal translation, and to keep the language easy to understand for the individuals without the knowledge of technical terminology. | 595
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Synthesis of the translations The results of the translation from the two translators were compared by the translation committee, which consisted of one expert (a Thai psycho-geriatrician) and the authors. In this step, the discrepancies of meaning in the translations were checked. If any discrepancies were found, the translators would discuss with the translation committee and come to an agreement.
Back translations Two different translators (3 and 4)36 were invited for back translation. The back-translators were bilingual and bicultural. They spoke Thai and English fluently, and did not have a background in medicine or cognitive screening tests. They were blinded to the original version of Mini-Cog, and translated the proposed Thai Mini-Cog into English.
Stage 4: Equivalence testing The back-translated versions were examined and compared by an original developer in order to see any differences in the back-translation. The results of backtranslation showed that there was no difference in the meaning of the words or concepts between the two English versions of Mini-Cog (original and backtranslated version).
and has adequate power to detect any trends.37 Participants were included if they aged over 60 years with type 2 diabetes and any type of diabetic treatment (e.g. diet control, medication or insulin injection). In order to communicate and understand the instructions provided by the researcher, all participants were competent Thai speakers. Participants were excluded from the study if they had a previous diagnosis of either vascular dementia or Alzheimer’s disease, as this was part of a larger study to estimate the prevalence of undiagnosed cognitive impairment in Thai elderly older adults type 2 diabetes. Those with a diagnosis of a depressive disorder, schizophrenia or epilepsy; were receiving medical treatment with psychoactive drugs (anticholinergics, anticonvulsants, antiparkinsonians or major tranquilizers); had any cerebrovascular accident history or complicated hypertension or renal failure; and/or communication difficulties that require an interpreter were also excluded. Ethical approval was gained from the Faculty of Medicine and Health Sciences Research Ethics Committee, University of East Anglia, UK and the Research Ethics Committee, Ministry of Public Health, Thailand. Details of the research were sent to potential participants with the appointment information. When attending their appointment, the participants gave written informed consent before they were interviewed and assessed by the Mini-Cog Thai version.
Data analyses Part 2: Interrater reliability of the Mini-Cog Thai version The first part of the original Mini-Cog is a task that requires the recall of three words (total score available 3 – 1 word/score). The participant gains the score by answering precisely the word(s) that they have been told by the researcher; that is, “home”, “cat” and “green”. In the second part (clock drawing) of the test, the score depends on the subjective judgement of the researcher using the scoring system. Therefore, this aspect of the scoring system needs to study interrater reliability. Therefore, after the back-translation was approved by the authors of the Mini-Cog,19 the Mini-Cog Thai version was evaluated to determine the interrater reliability of the second part (clock drawing test) of the Mini-Cog, and its concurrent validity and discriminant validity against the MMSE Thai 2002.
Participants In the present study, 21 participants were recruited from a primary care center (Nong-Han) in the San-sai district, Chiang Mai, Thailand. It has been suggested that a minimum number of 20–30 participants or greater is appropriate to estimate a parameter for a pretest study, 596 |
Interrater reliability was determined by two independent raters who alternately carried out the test (Mini-Cog Thai version). Each rater was blinded to the other rater’s results. Data were analyzed using SPSS version 16 (SPSS, Chicago, IL, USA). Interrater reliability was measured using the kappa (K) statistic.38 The Mini-Cog score results were assigned to two categories: (i) possible abnormal cognitive function result (scores 0–2); and (ii) normal cognitive function result (scores 3–5). Then the overall results from two raters were assigned; 0 (zero) denotes the participants with normal cognitive function, 1 (one) denotes the participants who were classified with possible abnormal cognitive function. In order to determine concurrent validity, the Pearson product-moment correlation coefficient (Pearson’s r)39 was applied to examine the correlation coefficient between the score results of the Thai version of the Mini-Cog and MMSE Thai 2002.
Results A total of 21 participants were recruited into the present study – 76% (16) were women. The mean age was 69 ± 7 years (range 61–82 years). A total of 76% of participants finished primary school (4 years in school), © 2014 Japan Geriatrics Society
Thai version of Mini-Cog test
Table 1 Mini-Cog scores for individual participants involved in the study from the researcher and expert Participant 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Mini-Cog score Researcher
Expert
0 0 1 0 0 0 1 1 1 0 0 0 1 0 0 1 0 0 0 1 0
0 1 1 0 0 0 1 1 1 0 0 0 1 0 0 1 1 0 0 1 0
Table 2 Two by two table of agreement
Researcher n (%) Total
0 1
Expert n (%) 0
Total n (%) 1
12 (57%) 0 (0%) 12 (57%)
2 (10%) 7 (33%) 9 (43%)
14 (67%) 7 (33%) 21 (100%)
A total of 21 participants were scored by the researcher and expert. 0 (zero) denotes the participants with normal cognitive function, 1 (one) denotes the participants who are classified with possible abnormal cognitive function.
52.4% (11) were married, 38.1% (8) were widowed and 9.5% (2) were single. The mean scores of Mini-Cog and MMSE Thai 2002 were 2.71 + 1.65 and 19.71 + 4.04, respectively. An average time to administer the Mini-Cog Thai version was 4.6 min. The raw scores for each participant from both raters are presented in Table 1. The interrater reliability of Mini-Cog scoring classified as “normal cognitive function” and “possible abnormal cognitive function” are presented in Table 2. The researcher and expert both agreed (57%) on “normal cognitive function” and both agreed (33%) on “possible abnormal cognitive function”. There were 10% where the expert disagreed with the researcher on “normal © 2014 Japan Geriatrics Society
cognitive function”, thus agreement on “normal cognitive function” and “possible abnormal cognitive function” was 90%. The K statistic for the interrater reliability of Mini-Cog shows a good agreement according to Altman40 with K = 0.80, P < 0.001, 95% CI 0.50–1.00. By using Pearson’s correlation coefficients (r) between the scores of Mini-Cog and MMSE Thai 2002, the scores of Mini-Cog showed a significantly positive and moderate correlation according to Pallant41 with Pearson’s correlation (r) of 0.47, P < 0.001, 95% CI 0.37– 0.55.
Discussion This is the first translation of the English version of the Mini-Cog into the Thai language. The processes of cross-language translation showed and ensured consistency and quality of content between the English and Thai versions of the test. The Mini-Cog Thai version has been shown to be practical to administer, and acceptable in the Thai language and culture. The participants showed that they could clearly understand the wording and instructions of the test, and there was no need for revision. The time to interview and administer the test (5 min) was acceptable to both participants and clinicians in the primary care setting.18 In order to validate the Thai version of the Mini-Cog, concurrent validity was established by comparing the performance of Mini-Cog against the MMSE Thai 2002.42,43 Pearson’s correlation (r; 0.47, P < 0.001, 95% CI 0.37–0.55) between Mini-Cog and MMSE showed a positive correlation between the Mini-Cog and the MMSE Thai 2002 scores. This demonstrates acceptable validity of Mini-Cog Thai against the MMSE Thai 2002. The MMSE Thai 2002 is limited in its ability to assess executive function, and this has been found to be altered in the early stages of cognitive impairment or in MCI.24–27 The Mini-Cog, however, detects more subjects with a mild cognitive impairment as well as subjects with a moderate to severe cognitive impairment.20 Hence, a discriminant validation technique is used to assess whether the new test (Mini-Cog) is highly correlated with an established test (MMSE Thai 2002), as they are designed to measure theoretically different concepts.44 A result less than 0.85 suggest discriminant validity between the two tests. In contrast, a result greater than 0.85 shows the tests overlap greatly and thus are likely to be measuring the same thing.45 In the present study, the discriminant validity between MiniCog and MMSE Thai 2002 was less than 0.85 (Pearson’s r = 0.47, P < 0.001, 95% CI 0.37–0.55), and therefore shows that the Mini-Cog presents discriminant validity with MMSE Thai 2002. There is a good level of agreement (interrater reliability) of the Thai version of the Mini-Cog with K = 0.80 (P < 0.001, 95% CI 0.50–1.00).40 The CDT part in the | 597
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Thai version of the Mini-Cog applies the updated version of the CDT scoring system, which is divided into categorical ratings (normal and abnormal). The revised CDT (categorical rating) replaced the original version (ordinal rating), because the previous studies of the CDT in categorical rating shows an overall high concordance (89%) score between expert and naive raters, and is more simple to use compared with the original version (ordinal rating).22 The old version of the CDT scoring system originally arranged the results into ordinal ratings (0 = normal, 1 = mild, 2 = moderate, 3 = severe) with more than two raters.19 Therefore, the CDT part of the original (English) version of the MiniCog shows the result of reliability of the CDT part in an intraclass correlation coefficient (ICC; 0.90)19 instead of interrater reliability, which rates the score in categorical score with two raters.38,46 Nevertheless, from the literature, no study of the Mini-Cog, in the original English version, addressed the interrater reliability of the CDT using a categorical rating scale. Studies of the translated version of the Mini-Cog have been found in Korean and Italian.47,48 In the Korean version, the Mini-Cog was assessed for validity (sensitivity 90%, specificity 95.8%), but there is no information regarding the reliability.47 It showed a high level of sensitivity and specificity in the elderly both in the community and in nursing homes, although details of age and education levels were not reported.47The Mini-Cog Thai and Italian versions both use the CDT with the same scoring (categorical rating), the method to analyze reliability of the Mini-Cog test are, however, different. The present study only analyzed data regarding two raters scoring, the Mini-Cog Thai version, whereas in the Italian version,48 there were 40 raters across a large geographical area (11 regions). The researchers reported reliability only for the part of the CDT that yields an ICC of 0.89.48 However, in clinical practice, the reliability is the repeatability under similar conditions, either by the same rater or different rater. It is a measure of the consistency that two or more individuals will have the same findings with the same assessment.49 Furthermore, it is vital that any tool used in the assessment of a patient is repeatable between clinicians in the whole processes.50 Hence, the present study used kappa analysis to measure interrater reliability38 of the overall test. The strength of the present study was that it is the first study that aimed to establish the interrater reliability between two raters who administered the overall test. Although the current work was limited by a small sample size, a minimum sample size of two raters is acceptable when a moderate level or higher kappa coefficient is expected.51 The present study showed a high kappa value at 0.8.40 To confirm the interreliability of the Mini-Cog Thai version in an elderly population, further data should be tested in the general older 598 |
population, using a larger number of subjects, the psychometric properties of the Mini-Cog Thai version should be further explored. The present study showed the good interrater reliability of the Thai version of the Mini-Cog and its concurrent validity with MMSE Thai 2002. The Thai version of the Mini-Cog can therefore be considered to be both reliable and valid compared with similar screening tools, such as the MMSE Thai 2002, particularly for practical use in primary care centers. The present results shed light on the future use of the Thai version of the Mini-Cog, both in clinical practice and research, for the cognitive screening in Thai older adults with type 2 diabetes. This is particularly the case in the primary care setting, where there is limited time and a brief cognitive screening method is required. A test such as this can assist healthcare professionals to be aware of cognitive decline in diabetic patients, which could improve the quality of care, and the use of healthcare strategies for diabetic patients and their families.
Acknowledgment This study was partly supported by the Thai Ministry of Science and Technology and the Thai Royal Government Scholarship.
Disclosure No potential conflicts of interest were disclosed.
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Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Appendix S1 MINI-COG.
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