Cognitive Impairment in Rural Elderly Population in Ecuador

INTRODUCTION

One of the clinical conditions that precede dementia is the cognitive impairment (CI).[1] In fact, it is considered that one-third of patients with CI develop dementia.[2] Thus, an early detection of CI could produce several benefits including early dementia diagnosis, access to treatments, and delay or even reversion of CI. Nowadays, the application of a simple and short test helps optimize the detection of CI in primary care. The Mini-Cog test meets the criteria above; however, some studies have shown influence of level of education in its performance.[3] The present study was designed to show the usefulness of the test in primary care in rural areas.

MATERIALS AND METHODS

RESULTS

From this sample, 214 patients were suitable for analysis. Two patients were excluded because of a diagnosis of Alzheimer's disease and visual deficit. No patient took longer than 5 min to complete the test. Ages ranged from 50 to 98 years and there was predominance of female gender: 142 (66%) versus 72 (33%). The percentage of illiteracy was 26.4% (CI: 25.32–27.48), and 63% (CI: 62.1–63.94) of patients had complete primary educational level. Other participant's data are showed in Table 1. Patients with a positive screening were older than those with a negative test (mean age 70 ± 10.6 years vs. 63 ± 10.5 years) and also had a lesser educational level. The overall prevalence of cognitive impairment in these rural areas was 50.9% (95% CI: 48.5–53.3) and 47.2% (95% CI: 45.2–49.2) in patients with risk factors. Analysis showed that illiterates without risk factors had higher prevalence of positive screening compared with those patients with at least elementary educational level: 35 (16.4%) versus 25 (11.7%). Figure 1 shows the distribution of screening results by educational level in the studied population. Furthermore, we found several established risk factors associated with cognitive impairment onset, including social factors (education), physiological factors (age), and comorbidities, mentioned in Table 1. However, there was no significance in some factors’ analysis perhaps due to the low number of cases in comparison to healthy patients. Negative-associated factors included aging (odds = 1.88, P = 0.022), illiterate (odds = 12.9, P ≤ 0.0001), NIDDM (odds = 0.66, P = 0.344), hypertension (odds = 0.82, P = 0.530), and two or more risk factors (odds = 0.9, P = 0.836). A positive-associated factor identified was higher education or at least lower educational level (odds = 14.1, P ≤ 0.0001). Table 2 and Figure 2 summarize the findings in the analysis of associated factors.

Table 1 Baseline data of study population (n=216)

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Figure 1

Distribution of screening results by educational level

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Table 2 Variable output

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Figure 2

Distribution of screening results by associated risk factors

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CONCLUSION

In Ecuador, statistics on cognitive impairment and risk factors had been reported in urban areas;[567] however, this study is the first epidemiological research of CI in rural populations in this country using the Mini-Cog as a screening tool. From the present study, it was demonstrated that the Mini-Cog test is an easy-to-use tool in primary care centers; furthermore, it has a high acceptability by the patients. The results showed that the 50.9% of individuals enrolled in this study had a positive screen for CI. The prevalence was higher with age >65 years and low levels of education. Significant risk factors as hypertension, diabetes mellitus, and illiteracy – being the most prevalent – were found. On the other hand, protective factors identified had at least low educational level. This correlates with the data reported in other studies.[8910] The prevalence of CI increases exponentially with age and in those with comorbid conditions; but in accordance with previous studies, cognitive impairment is also higher in people with low levels of education or illiterate, and in addition, higher levels of education independently reduced the risk.[11] We can conclude that Mini-Cog is a simple screening tool that is well accepted and quickly to apply during the routine visit, with a sensitivity and specificity that reaches up to 99% and 93%, respectively,[121314] especially when the health practicers are trained to apply the test correctly. In terms of associated risk factors, advanced age, low educational level, and comorbidities such as hypertension and diabetes mellitus were the main factors associated with CI, which suggests that adopting public health measures for the prevention and control of those modifiable risk factors can reduce the prevalence of this condition and even its progression to dementia. We recommend to carry out studies with greater population of rural areas. Likewise, this information can be used as an object of the future research that support its widespread use in primary care centers, allowing prevention, early diagnosis and treatment, and even reversion of cognitive impairment.