Psychometric Properties of a Neuropsychological Assessment Scale for Diagnosing Alzheimer's Disease in the Illiterate and Low-Educated Subjects in Iran
,
Abstract
Objective: Because of changes in the population structure over time, dementia is one of the main concerns of the health systems worldwide. Screening for dementia in primary care settings, especially among high-risk populations, is essential. The aim of this study was to design, develop, and evaluate the reliability and validity of a diagnostic scale for Alzheimer's disease tailored to low-educated and illiterate populations.
Method: This study, conducted at Roozbeh Psychiatric Hospital and Yaadmaan Institute for Brain Cognition and Memory Studies, utilizes a mixed-methods approach for collecting, analyzing, and interpreting the data. Once the questionnaire was confirmed to be clear, appropriate, and consistently presented, it was administered to a purposive sample of 250 patients selected based on the study's specific inclusion criteria. These patients underwent a comprehensive neuropsychological assessment, which included the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), The Katz Activities of Daily Living Scale (Katz ADL) and The Functional Assessment Staging Tool (FAST). The scale construction process was conducted in four phases.
Results: Confirmatory factor analysis showed that all questions significantly loaded on their respective factors, effectively measuring their intended constructs. The root mean square error of approximation (RMSEA) was less than 0.08, indicating a good model fit and supporting the scale's validity. The Adjusted Goodness of Fit Index (AGFI) and Goodness of Fit Index (GFI) were near 0.9, while the Comparative Fit Index (CFI), Normed Fit Index (NFI), Non-Normed Fit Index (NNFI), and Incremental Fit Index (IFI) exceeded 0.9. Correlational analysis with the FAST, Activities of Daily Living (ADL), and BEHAVE-AD scales confirmed significant relationships, validating the scale's convergent and divergent validity. The overall reliability, measured by Cronbach’s alpha coefficient, was 0.96, indicating excellent internal consistency, with subdomain reliability coefficients ranging from 0.7 to 0.88.
Conclusion: The diagnostic scale for Alzheimer's disease demonstrates adequate fit and construct validity for assessing cognitive impairments in low-educated and illiterate patients across the 12 domains of orientation, judgment, abstract thinking, similarity, verbal fluency, repetition, working memory, visual-spatial skills, calculation, executive function, prosopagnosia, and naming. This culturally and linguistically adaptable assessment addresses gaps in diagnostic tools for low-literacy populations, enabling accurate evaluations of dementia and facilitating early diagnosis and treatment. The findings enhance existing knowledge by providing a reliable tool for early Alzheimer's diagnosis among low-literacy groups. However, further research is needed to validate the scale across diverse ethnic backgrounds and geographical locations to ensure its relevance and sensitivity to various contexts.
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9. 2023 Alzheimer's disease facts and figures. Alzheimers Dement. 2023;19(4):1598-695.
10. Mitra S. Special Issue 'Advances in Neurodegenerative Diseases Research and Therapy 2.0'. Int J Mol Sci. 2024;25(9):4709.
11. Wang XJ, Xu W, Li JQ, Cao XP, Tan L, Yu JT. Early-Life Risk Factors for Dementia and Cognitive Impairment in Later Life: A Systematic Review and Meta-Analysis. J Alzheimers Dis. 2019;67(1):221-9.
12. Zhang Z, Zhao Y, Bian Y. A Role of Socioeconomic Status in Cognitive Impairment Among Older Adults in Macau: A Decomposition Approach. Front Aging Neurosci. 2022;14:804307.
13. Terracciano A, Sutin AR. Personality and Alzheimer's disease: An integrative review. Personal Disord. 2019;10(1):4-12.
14. Suh SW, Han JW, Park JY, Hong JW, Kim K, Kim T, et al. Impacts of Illiteracy on the Risk of Dementia: A Global Health Perspective. J Alzheimers Dis. 2016;53(2):731-41.
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16. Hay L. Health literacy. Perspect Public Health. 2010;130(3):105.
17. Alzola P, Carnero C, Bermejo-Pareja F, Sánchez-Benavides G, Peña-Casanova J, Puertas-Martín V, et al. Neuropsychological Assessment for Early Detection and Diagnosis of Dementia: Current Knowledge and New Insights. J Clin Med. 2024;13(12):3442.
18. Reiss AB, de Levante Raphael D, Chin NA, Sinha V. The physician's Alzheimer's disease management guide: Early detection and diagnosis of cognitive impairment, Alzheimer's disease and related dementia. AIMS Public Health. 2022;9(4):661-89.
19. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98.
20. Nielsen TR. Cognitive Assessment in Culturally, Linguistically, and Educationally Diverse Older Populations in Europe. Am J Alzheimers Dis Other Demen. 2022;37:15333175221117006.
21. Spencer RJ, Wendell CR, Giggey PP, Katzel LI, Lefkowitz DM, Siegel EL, et al. Psychometric limitations of the mini-mental state examination among nondemented older adults: an evaluation of neurocognitive and magnetic resonance imaging correlates. Exp Aging Res. 2013;39(4):382-97.
22. Jia X, Wang Z, Huang F, Su C, Du W, Jiang H, et al. A comparison of the Mini-Mental State Examination (MMSE) with the Montreal Cognitive Assessment (MoCA) for mild cognitive impairment screening in Chinese middle-aged and older population: a cross-sectional study. BMC Psychiatry. 2021;21(1):485.
23. Pellicer-Espinosa I, Díaz-Orueta U. Cognitive Screening Instruments for Older Adults with Low Educational and Literacy Levels: A Systematic Review. J Appl Gerontol. 2022;41(4):1222-31.
24. Maestri G, Nicotra A, Pomati S, Canevelli M, Pantoni L, Cova I. Cultural influence on clock drawing test: A systematic review. J Int Neuropsychol Soc. 2023;29(7):704-14.
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| Issue | Vol 20 No 2 (2025) | |
| Section | Original Article(s) | |
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How to Cite
1.
Ahmadi A, Noroozian M, Kachooei M, Hooshyari Z, Golsokhan A. Psychometric Properties of a Neuropsychological Assessment Scale for Diagnosing Alzheimer’s Disease in the Illiterate and Low-Educated Subjects in Iran. Iran J Psychiatry. 2025;20(2):157-174.
