Skip to main content
NCBI home page
PLOS One logoLink to PLOS One
. 2024 Jun 26;19(6):e0305426. doi: 10.1371/journal.pone.0305426

The Hong Kong version of Montreal Cognitive Assessment for the Visually Impaired (HKMoCA-VI): Proposed cut-off and cognitive functioning survey of visually impaired elderly in residential homes

Calvin Chi Kong Yip 1, Winsy Wing Sze Wong 2,*, Calvin Pak Wing Cheng 3, Armstrong Tat San Chiu 4
Editor: Ryota Sakurai5
PMCID: PMC11207147  PMID: 38923967

Abstract

Background

Visual impairment has been strongly associated with the incidence of dementia. Appropriate cognitive screening for the elderly with visual impairment is crucial for early identification of dementia and its management. Due to challenges in processing visually presented stimuli among participants, the cut-off score of the Hong Kong version of the Montreal Cognitive Assessment for the Visually Impaired (HKMoCA-VI), also known as MoCA-BLIND or MoCA-22, was unknown. Besides, the cognitive status of elderly with visual impairment residing in care homes is rarely investigated. The current study aimed to 1) establish the cut-off score for HKMoCA-VI and 2) examine the general cognitive functioning of elderly with visual impairment living in residential homes in Hong Kong in terms of MoCA-VI percentile scores.

Method

HKMoCA-VI and the Cantonese version of the Mini-Mental State Examination (CMMSE) were administered to 123 visually impaired elderly residents in care homes in Hong Kong. Percentile scores of HKMoCA-VI by age and education level were determined, and the concurrent validity, sensitivity, and specificity of HKMoCA-VI were assessed.

Results

A cut-off score 12 was suggested for HKMoCA-VI, which yielded a sensitivity and specificity of 89.29% and 83.58%, respectively. Moreover, it strongly correlated with CMMSE, indicating satisfactory concurrent validity.

Conclusions

HKMoCA-VI is suggested to be a viable cognitive screening tool for elderly individuals with visual impairment in residential homes. Further modifications to enhance the sensitivity and specificity of the measure are proposed.

Background

Dementia, a degenerative neurological disorder affecting cognition, behavior, and ability to perform everyday activities, is a global public health concern [1]. Over 55 million people worldwide are affected by dementia, with 10 million new cases every year [2]. In Hong Kong, dementia affects approximately one-tenth of the elderly population [3]. The proportion of individuals aged 65 years or above in Hong Kong is projected to double from 16% in 2016 to 32% in 2046 [4], highlighting the urgency of preventive and management measures for dementia as the city transitions to a super-aged society.

Numerous risk factors for dementia, such as smoking, drinking, obesity, and depression, have been identified by the Lancet Commission Report [5]. Visual impairment has also been linked to increased cognitive decline in older adults [6–8]. In a cohort study examining 1,061 older women in the United States [9], participants with baseline visual impairment experienced a 2- to 5-fold increased risk of dementia over an average follow-up of 3.8 years, with risk escalating with severity of visual impairment. Similar findings were observed in studies conducted in Taiwan [10] and Hong Kong [11], further suggesting visual impairment as a potential risk factor for dementia. However, the underlying mechanism linking visual impairment to increased dementia risk remains unclear (e.g., see Discussion in Baltes and Lindenberger [12]). It has been hypothesized that visual impairment reduces participation in physical and cognitive activities [13], leading to neural degradation and cognitive decline in the long run. Moreover, a majority (57.1%) of the visually impaired suffer from multiple disabilities [14], potentially heightening their risk of dementia further.

Early diagnosis of dementia carries significant implications for persons with dementia, carers, and society as a whole. It not only aids in reducing associated risk factors but also helps delay disease progression [15]. Hence, valid and reliable cognitive screening tools have become vital. However, in the most widely used Montreal Cognitive Assessment (MoCA) [16], 8 out of 30 scores are attributed to items reliant on visual function, posing challenges in generalizing screening scores and percentiles to the population with visual impairment.

The MoCA 5-minute protocol [17], a validated tool for telephone administration, includes only the 1-minute verbal fluency task for assessing executive function, omitting assessment items related to attention and abstract concepts that rely on auditory function. Conversely, the Montreal Cognitive Assessment-Blind (MoCA-BLIND) or MoCA-22 [18, 19] is an adapted version of the original MoCA, specifically designed for the population with visual impairment, as it excludes items requiring visual abilities. In this study, we used the Cantonese-translated MoCA and eliminated items necessitating visual abilities in line with the MoCA-BLIND or MoCA-22. To distinguish this Cantonese version from the original Cantonese MoCA version, we refer to it as the Hong Kong version of the Montreal Cognitive Assessment for the Visually Impaired (HKMoCA-VI).

The initial study of HKMoCA-VI involved 34 visually impaired elderly with cognitive impairment and 17 neurologically healthy elderly with visual impairment [20]. Researchers identified a cut-off score of 7 to differentiate dementia from mild cognitive impairment (MCI) and normal controls, with a sensitivity and specificity of 100% and 65%, respectively. This cut-off score was notably lower than that of the original MoCA-BLIND (18 points) and slightly lower than the Malay version for the visually impaired elderly individuals (MoCA-BM-blind [21]), which had a cut-off score of 9. However, it should be noted that the education level of the elderly recruited in Fung [20] was generally low, with 91% of the participants being illiterate or having received six years of education or less. While the education level of MoCA-BM-blind participants was not reported, the mean years of education for healthy controls and dementia patients using MoCA were 13.3 years and 10 years, respectively. A larger sample size with a more diverse educational background may be necessary to develop HKMoCA-VI.

As the population ages, there is an increasing demand for quality long-term residential services for the elderly. Previous studies have shown that a majority of residents in nursing homes experience cognitive decline [22, 23]. A similar finding has been reported in Hong Kong, where about 57% of residents without visual impairment residing in nursing homes were found to have very mild to moderate dementia [24], as measured with Clinical Dementia Rating (CDR) and Mini-Mental State Examination (MMSE). Given that visual impairment may exacerbate cognitive decline, further investigation into the cognitive profile of visually impaired elderly residing in nursing homes is warranted.

The objectives of the present study were 1) to determine the cut-off score and percentile score of HKMoCA-VI and 2) to explore the concurrent validity of HKMoCA-VI with the Cantonese version of MMSE for elderly with visual impairment living in residential homes.

Method and materials

Study design

This cross-sectional study between 1 November 2019 and 31 January 2020 assessed the cognitive function of all elderly individuals residing in residential homes for the visually impaired who fulfilled the selection criteria. We then classified them into a dementia group and a non-dementia group according to their medical diagnoses.

Participants

The study employed convenience sampling and conducted data collection in residential homes operated by the Hong Kong Society for the Blind (HKSB). Elderly individuals who met the following selection criteria were invited to sign a written consent form and participate in the study. Inclusion criteria were: 1) Chinese individuals aged 60 years or above, 2) speaking Cantonese as their primary language, 3) medically diagnosed with visual impairment (low vision of 20/200 or worse), 4) residing in a residential home, and 5) capable of following instructions. Exclusion criteria were: 1) living outside of residential homes, 2) not speaking Cantonese as their primary language, 3) medically diagnosed with depression, delirium, anxiety, or other mental illnesses, 4) not capable of following instructions, and 5) individuals or their guardians who are unable to provide written consent for participation in the study.

Data collection procedures

The case therapists at residential homes assisted in screening the elderly to identify those meeting the selection criteria and guided them to sign the consent form. For individuals unable to comprehend the content of the consent form and thus incapable of making decisions, we sought consent from their guardians following a detailed explanation provided by the residential home staff. Subjects underwent assessment by a trained research assistant and trained HKSB staff using HKMoCA-VI and the CMMSE [25]. Assessments were conducted on the same day but during different sessions (morning and afternoon). Demographic data, such as education level and medical diagnosis of dementia, were also collected for each subject.

Statistical analysis

Statistical analysis utilized Statistical Package for the Social Sciences-Version 22 (SPSS, Inc., Chicago, IL, USA). The significance level was set at p < 0.05 (two-tailed).

Descriptive statistics were employed to analyze demographic characteristics. Percentile scores of HKMoCA-VI were calculated. A regression model investigated the relationship between HKMoCA-VI scores, age, and education level. A receiver operating characteristic (ROC) curve determined the cut-off score of HKMoCA-VI. The concurrent validity of HKMoCA-VI was assessed through a correlation coefficient with CMMSE.

Ethical approval

Ethical approval was obtained from the Research Ethics Committee of the School of Medical and Health Sciences, Tung Wah College (approval number: RSS400130092019).

Results

A total of 123 subjects (54 males and 69 females) participated in the study and completed cognitive assessments using HKMoCA-VI and CMMSE. Their ages ranged from 62 to 102 years, with a mean (standard deviation; S.D.) of 82.8 (9.7). Of these participants, 29.3% had a confirmed diagnosis of dementia. Their demographic characteristics are shown in Table 1.

Table 1. Demographic characteristics of subjects.

Count (n = 123) Percentage
Gender
Male 54 43.9%
Female 69 56.1%
Age group
60 to 69 years 21 17.1%
70 to 79 years 20 16.3%
80 to 89 years 55 44.7%
90 years or above 27 22.0%
Education level
No formal education 31 25.2%
Primary school or below 38 30.9%
Secondary 3 26 21.1%
Secondary 5 or above 28 22.8%
Residential home
Kowloon Home for the Aged Blind 24 19.5%
Jockey Club Tuen Mun Home for the Aged Blind 39 31.7%
Yuen Long Home for the Aged Blind (Jockey Club Yan Hong Building) 25 20.3%
Bradbury Care and Attention Home for the Aged Blind 35 28.5%
Medical diagnosis of dementia
No 87 70.7%
Yes 36 29.3%
Mean (n = 123) Standard Deviation (S.D.)
Age 82.7 9.7
HKMoCA-VI 12.3 5.7
CMMSE 16.8 7.2
Open in a new tab

HKMoCA-VI, the Hong Kong version of the Montreal Cognitive Assessment for the visually impaired; CMMSE, the Cantonese version of the Mini-Mental State Examination.

The elderly attained mean scores of 12.3 (S.D. = 5.7) and 16.8 (S.D. = 7.2) on HKMoCA-VI and CMMSE, respectively. The Pearson correlation coefficient between HKMoCA-VI and CMMSE was.829 (p < .001). A regression model adjusted for age and level of education revealed an R-squared value of 0.272, indicating that age and level of education explained 27.2% of the variance in HKMoCA-VI scores. The model HKMoCA-VI = 31.33 + 0.653 (education level)– 0.255 (age) was statistically significant with p < 0.001. The unstandardized coefficients (B) for education level and age were statistically significant at p = 0.017 and p < 0.001, respectively. Subsequently, we calculated the percentiles of HKMoCA-VI scores by age group, education level, and their combination, as shown in Tables 2–4, respectively.

Table 2. Percentile of HKMoCA-VI score by age group.

Age group Percentile
2 7 12.5 16 25 37.5 50 52.5 75 87.5 100
60–69
(n = 21)		 4 7 11 12 13 17 19 19 20 21 22
70–79
(n = 20)		 5 6 7 8 10 13 16 16 19 20 22
80–89
(n = 55)		 1 4 5 6 7 9 11 12 15 18 22
90 or above
(n = 27)		 1 2 3 4 5 7 9 9 12 17 20
All participants
(N = 123)		 2 4 5 6 7 10 12 13 17 20 22
Open in a new tab

Table 4. Percentile of HKMoCA-VI score by age group and education level.

Age Group Education level Percentile
2 7 12.5 16 25 37.5 50 52.5 75 87.5 100
60–69 No formal education 4 4 4 4 6 12 16 17 19 19
Primary school or below
Secondary 3 13 13 13 14 18 20 20 20 21 22
Secondary 5 or above 10 10 10 11 13 16 17 18 21 21 21
70–79 No formal education 7 7 7 7 9 15 18 18 20 20
Primary school or below 9 9 9 9 10 11 14 14 19 20
Secondary 3 5 5 5 6 11 13 16 16 21 22
Secondary 5 or above 6 6 6 6 8 14 15 15 16 16
80–89 No formal education 1 1 4 5 6 8 10 10 15 18 21
Primary school or below 3 3 4 4 5 7 8 8 15 15 22
Secondary 3 6 6 7 8 11 12 14 14 20 21 21
Secondary 5 or above 5 5 7 9 9 12 14 14 16 18 18
90 or above No formal education 2 2 3 3 5 6 6 6 8 11 11
Primary school or below 1 1 2 3 4 6 8 8 10 18 20
Secondary 3 12 12 12 12 12 12 13 13 16 17
Secondary 5 or above 9 9 9 9 9 12 15 15 19
Open in a new tab

Table 3. Percentile of HKMoCA-VI score by education level.

Education level Percentile
2 7 12.5 16 25 37.5 50 52.5 75 87.5 100
No formal education
(n = 31)		 1 3 4 4 6 7 9 9 15 19 21
Primary school or below
(n = 38)		 1 3 4 4 6 8 10 10 15 19 22
Secondary 3
(n = 26)		 5 6 10 11 12 13 14 15 20 21 22
Secondary 5 or above
(n = 28)		 5 6 9 9 11 14 15 15 18 20 21
Open in a new tab

To determine the HKMoCA-VI cut-off score, we categorized the subjects based on their medical diagnosis into those with and without dementia. Subjects diagnosed with dementia were significantly older than those without (see Table 5). Additionally, the two groups significantly differed in their CMMSE and HKMoCA-VI scores (see Table 5).

Table 5. Comparison of age and cognitive performance between groups.

Group with Dementia diagnosis (n = 36) Group without Dementia diagnosis (n = 87)
Mean (S.D.) Mean (S.D.)
Age 87.9 (6.61) 80.6 (10.10) p < 0.001
CMMSE 13.0 (6.59) 18.4 (6.82) p < 0.001
HKMoCA-VI 8.0 (4.40) 14.1 (5.27) p < 0.001
Open in a new tab

Referring to Table 2, adjusting to the age group, 75% of subjects without a diagnosis of dementia scored above the 25th percentile on HKMoCA-VI. Conversely, 60% of subjects diagnosed with dementia scored below the 25th percentile.

The HKMoCA-VI cut-off scores for dementia, based on the medical diagnosis and the CMMSE cut-off score, were determined using the ROC curves, with results presented in Table 6. A cut-off score of 12 showed the highest sensitivity, specificity, and Youden’s Index when using the CMMSE criterion for dementia. A cut-off score of 9 showed the highest sensitivity, specificity, and Youden’s Index when based on medical diagnosis. The areas under the ROC curves were 0.93 and 0.807 (p < 0.001), respectively (see Fig 1).

Table 6. HKMoCA-VI cut-off score determined by dementia diagnosis or CMMSE cut-off score.

Cut-off score By Medical Diagnosis By CMMSE cut-off score
Sensitivity Specificity Youden’s Index Sensitivity Specificity Youden’s Index
7 85.10 50.00 0.351 98.21 44.80 0.430
8 83.91 61.10 0.45 98.21 52.20 0.505
9 79.31 72.22 0.515* 96.43 62.69 0.591
10 73.56 75.00 0.486 92.86 68.66 0.615
11 67.82 80.56 0.484 91.07 77.61 0.687
12 63.22 83.33 0.466 89.29 83.58 0.729*
13 57.47 86.11 0.436 82.14 86.57 0.687
14 51.72 91.67 0.434 75.00 91.04 0.660
Open in a new tab

Fig 1. ROC curves of HKMoCA-VI determined by dementia diagnosis and CMMSE cut-off score.

Fig 1

Open in a new tab

Discussion

The present study aimed to establish the cut-off score of HKMoCA-VI and evaluate the cognitive functions of visually impaired elderly residing in nursing homes. Cognitive function assessment was conducted on 123 elderly individuals aged 60 years or above using cognitive screening tasks, namely the CMMSE and HKMoCA-VI. The former was used to determine the cut-off score and develop the concurrent validity of HKMoCA-VI. It was found that HKMoCA-VI effectively distinguished cognitive decline among visually impaired elderly, showing a strong correlation with the CMMSE (r = 0.829; p < 0.001), demonstrating good concurrent validity. Furthermore, comparing cut-off scores of HKMoCA-VI based on dementia diagnosis versus CMMSE cut-off scores revealed better sensitivity, specificity, and a balanced approach (as indicated by Youden’s index) for the latter. We, therefore, suggest that HKMoCA-VI is a clinically effective tool for cognitive screening in elderly with visual impairment, with an optimal cut-off score of 12, akin to the MoCA-22 for mild to moderate dementia [18]. In addition, considering the influence of age and education on cognitive performance, healthcare professionals can utilize percentile scores stratified by age/education to assess cognitive status in older adults with visual impairment, particularly those in residential homes, for management planning.

We aimed to compare the psychometric properties of HKMoCA-VI with other MoCA versions. Its sensitivity and specificity values are slightly lower than that of HKMoCA, which has a sensitivity and specificity of 92.3% and 91.8%, respectively. While MoCA-BLIND demonstrates high sensitivity (94%) and specificity (98%), MoCA-BM-blind shows comparable sensitivity (86.8%) and specificity (72.7%) to HKMoCA-VI. Regarding cut-off scores, HKMoCA-VI aligns closely with the Spanish version (cut-off score of 12) and is more akin to MoCA-BM-blind (cut-off of 9) than MoCA (cut-off of 18). The difference in the participants’ education levels in MoCA-BLIND (over 10 years) and HKMoCA-VI (8.4 years) may account for the difference in cut-off scores. Besides, MoCA-BLIND validation involved re-analyzing the existing data collected from the non-visually impaired population, while MoCA-BM-blind exclusively tested elderly with visual impairment for validation. Notably, in Fadzil et al. [21], participants without visual impairment attained a higher mean score than the visually impaired group (i.e., 18.76 versus 17.53), although the statistical significance of this difference was not reported. In sight of this, we propose that including visually impaired participants in test validation could better account for their performance and, hence, determine cut-off scores.

The availability of HKMoCA-VI is expected to enhance dementia identification awareness among nurses and other healthcare professionals, facilitating regular cognitive screening of elderly residents in residential homes.

Our study represents one of the pioneering investigations in Hong Kong exploring the general cognitive profile of visually impaired elderly residing in residential homes. Based on the percentile rank in Table 2, approximately half of the visually impaired elderly participants in the current study scored above the cut-off, offering insight into the overall cognitive functioning of elderly individuals living in residential homes for the visually impaired. The prevalence rate of dementia, as determined by HKMoCA-VI in the current study, appears to be slightly lower than that reported by Cheng et al. [24], although different cognitive measures were employed. For elderly individuals not exhibiting signs of cognitive decline, regular screening and interventions aimed at managing and preventing further deterioration of both visual impairment and cognitive functioning are essential. For visually impaired elderly experiencing cognitive decline, interventions such as cognitive stimulation and evidence-based therapy for dementia [26] should be adapted to accommodate their vision loss. Additionally, the use of technology, such as digitally enhanced visual and auditory stimuli delivered via virtual reality [27], could be considered.

Limitations and suggestions for future research

The current study has several limitations. The first concerns the definition of the sample recruited for determining the cut-off scores of HKMoCA-VI. In some previous studies, the clinical and control groups were clearly defined (e.g., [19, 21]) through comprehensive neuropsychological assessments. However, due to the lack of cognitive assessment tools for older adults with visual impairment in Hong Kong, our study resorted to the CMMSE to determine the cut-off score. This yielded better sensitivity and specificity, especially given the under-recognition of dementia in long-term care homes in Hong Kong [24]. Another limitation pertains to the unavailability of data or test measures for a more comprehensive evaluation of the psychometric properties of HKMoCA-VI. Test-retest reliability and internal consistency were not assessed. Including these measures would undoubtedly strengthen the test. Additionally, unlike the MoCA-BLIND and HKMoCA, our study did not consider evaluating cut-off scores for individuals with mild cognitive impairment (MCI). Future research on identifying cut-off scores for visually impaired elderly with MCI is strongly recommended. Moreover, approximately 25% of participants received no formal education, and the impact of education on their cognitive performance remained inconclusive. Similarly, age and education level, known to be associated with cognitive functions in the elderly [28, 29], were not thoroughly considered in determining the cut-off score. Employing age and education-corrected cut-off scores, as adopted in the 5-minute protocol of HKMoCA [17], may provide a more accurate screening tool for the population.

Fung [20] raised a significant concern regarding the recruitment of visually impaired participants from nursing homes. Previous studies [30, 31] highlighted the association between place of residence and cognitive decline. Moreover, the elderly in our study had severe visual impairment. These sample characteristics limit the generalizability of our findings to community-dwelling elderly with varying degrees of visual impairment in Hong Kong. In summary, we recommend validating HKMoCA-VI with a larger sample, encompassing community-dwelling and nursing home-residing elderly with different ages and education levels.

Conclusion

HKMoCA-VI proves to be a clinically viable tool for cognitive screening among Cantonese-speaking elderly individuals. The performance of visually impaired elderly residing in residential homes on HKMoCA-VI may offer insights into the elderly’s overall cognitive functioning, providing valuable information for the management and service planning for this population.

Acknowledgments

We extend our gratitude to the elderly residents and the staff members of the elderly homes at the Hong Kong Society for the Blind, and the research assistants for their participation and assistance in this study.

Data Availability

The data relevant to this paper are available from OSF at osf.io/62gwf.

Funding Statement

The author(s) received no specific funding for this work.

References

Decision Letter 0

Ryota Sakurai

9 Feb 2024

PONE-D-23-42809The Hong Kong version of Montreal Cognitive Assessment for the visually impaired (HKMoCA-VI): Its cutoff and a survey on the cognitive functioning of visually impaired elderly in residential homesPLOS ONE

Dear Dr. Wong,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Two reviewers made significant comments, and they are reasonable. Please improve the manuscript following the comments.

Please submit your revised manuscript by Mar 25 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ryota Sakurai, Ph.D.

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please describe in your methods section how capacity to provide consent was determined for the participants in this study. Please also state whether your ethics committee or IRB approved this consent procedure. If you did not assess capacity to consent please briefly outline why this was not necessary in this case.

3. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process.

4. We notice that your supplementary figures are uploaded with the file type 'Figure'. Please amend the file type to 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper represents a major effort to establish the cutoff score for the Hong Kong Version of the Montreal Cognitive Assessment for the visually impaired and to assess the cognitive performance of nursing home elderly residents with visual impairment in Hong Kong. I believe that the goal of the study is worthwhile and appropriate for the readership of the PLOS ONE. The study is providing important data that can be applied in clinical practice. However, major concerns should be addressed before resubmission.

1. The manuscript should be checked by professional editing service before resubmission.

2. The introduction section is long. While comprehensive, the introduction could be more impactful by focusing on the most essential background information.

3. The quality of the image in figure 1 is poor and should be improved.

4. The Cantonese version of the Mini Mental State Examination was described in the manuscript in different ways as CMMSE-VI, CMMSE, The modified CMMSE. The authors need to unify the term used to describe the tool throughout the manuscript.

5. Regarding the methodology section: there are many major concerns as

o While restricting the study to individuals with severe visual impairment simplifies the analysis by minimizing confounding factors, it also limits the generalizability of the findings. This point should be acknowledged in the limitations section.

o Another limitation of the study was including those with no information regarding their education level. 31 cases that comprises 25.2% of the sample recruited.

o Restricting the study to cases in nursing homes will prevent results generalizability to elderly within community, however; this limitation was highlighted in the limitations.

o The absence of data on depression and delirium, known to affect memory and attention, makes it difficult to draw definitive conclusions about the cognitive abilities of the cases. Were the cases with depression and /or delirium excluded from the study?

o The Cantonese version of the Mini Mental State Examination (as cited in reference 27) recommended a cut-off score of 19/20 that yielded a high sensitivity rate of 97.5 and an equally good specificity of 97.3. This appeared to be the best cut-off score for their sample of subjects. Moreover, those cut off scores were obtained without adjusting for visual impairment thus can’t be applied to your sample.

o Linear regression would adjust better for age and educations than using the percentiles, then it would be better to add tables 2,3,4 as supplementary data.

Reviewer #2: Dear Authors

I read your work entitled “The Hong Kong version of Montreal Cognitive Assessment for the visually impaired (HKMoCA-VI): Its cutoff and a survey on the cognitive functioning of visually impaired elderly in residential homes” and here I enclose my recommendations to you:

1. Please have the text checked for language issues, since several mistakes have been tracked. A native speaker of English or a professional Editing company would help towards this.

2. Abstract General comments: The Abstract need a reconstruction and Methods section and the results section.

3. The “Introduction” section: It would be beneficial for the authors to include more precise information in the introduction about the gaps of the existing knowledge and how this study attempts to fill them. An augmentation of the existing literature in the text would benefit more for the Introduction and it will strengthen the rational of this study. Additionally, I suggest the Authors to focus more on the HKMoCA-VI and why it is so important.

4. The “Methods” section: The Authors report criteria that are not based on the existing literature. I suggest them to elaborate this.

5. The “Methods” section: It is strange that the Author do not report which groups severed as clinical and the controls in this study.

6. The “Discussion” section: The Authors are developing this section according to their results and connect them in an adequate manner to the existing knowledge but as we can see most of the studies used a control group that in this study is not clearly reported. I suggest the Authors to address that as well. This will help the Authors to strengthen more their work.

Thank you.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Doha Rasheedy

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2024 Jun 26;19(6):e0305426. doi: 10.1371/journal.pone.0305426.r002

Author response to Decision Letter 0

8 Apr 2024

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: The format and file naming of the manuscript has been checked and revised.

2. Please describe in your methods section how capacity to provide consent was determined for the participants in this study. Please also state whether your ethics committee or IRB approved this consent procedure. If you did not assess capacity to consent please briefly outline why this was not necessary in this case.

Response: Capacity to provide consent was determined by their comprehension ability of the information provided when written consent was sought. For those who were not fit to provide consent themselves, their guardians were invited to give consent upon explanation given by the staff of the residential homes. The information was included on p. 9 (lines 146-150). Information on ethical approval is included (p. 10, lines 167-169).

3. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process.

Response: The data availability statement has been added (p. 20, lines 320-321).

4. We notice that your supplementary figures are uploaded with the file type 'Figure'. Please amend the file type to 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list.

Response: The file type of the ‘Figure’ has been amended with the legend listed in the manuscript.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper represents a major effort to establish the cutoff score for the Hong Kong Version of the Montreal Cognitive Assessment for the visually impaired and to assess the cognitive performance of nursing home elderly residents with visual impairment in Hong Kong. I believe that the goal of the study is worthwhile and appropriate for the readership of the PLOS ONE. The study is providing important data that can be applied in clinical practice. However, major concerns should be addressed before resubmission.

1. The manuscript should be checked by professional editing service before resubmission.

Response: The manuscript has been checked by professional editing service before resubmission.

2. The introduction section is long. While comprehensive, the introduction could be more impactful by focusing on the most essential background information.

Response: The introduction section has been revised to focus on the development of HKMoCA-VI and the rationales (p. 5, lines 79-93), with the implications of findings stressed in Discussion (p. 15, lines 225-226, 231-234).

3. The quality of the image in figure 1 is poor and should be improved.

Response: The quality of the image of Figure 1 has been improved and re-submitted.

4. The Cantonese version of the Mini Mental State Examination was described in the manuscript in different ways as CMMSE-VI, CMMSE, The modified CMMSE. The authors need to unify the term used to describe the tool throughout the manuscript.

Response: The term ‘CMMSE’ has been used consistently throughout the manuscript.

5. Regarding the methodology section: there are many major concerns as

o While restricting the study to individuals with severe visual impairment simplifies the analysis by minimizing confounding factors, it also limits the generalizability of the findings. This point should be acknowledged in the limitations section.

Response: This point has been acknowledged in the limitations section (p. 19, lines 304-306).

o Another limitation of the study was including those with no information regarding their education level. 31 cases that comprises 25.2% of the sample recruited.

Response: This point has been addressed in the limitation (p. 18, lines 293-295).

o Restricting the study to cases in nursing homes will prevent results generalizability to elderly within community, however; this limitation was highlighted in the limitations.

Response: Thanks for raising this point out, which has been included as one of the limitations.

o The absence of data on depression and delirium, known to affect memory and attention, makes it difficult to draw definitive conclusions about the cognitive abilities of the cases. Were the cases with depression and /or delirium excluded from the study?

Response: We excluded elderly with a diagnosis of depression, delirium or other mental illness (p. 9, lines 141-142).

o The Cantonese version of the Mini Mental State Examination (as cited in reference 27) recommended a cut-off score of 19/20 that yielded a high sensitivity rate of 97.5 and an equally good specificity of 97.3. This appeared to be the best cut-off score for their sample of subjects. Moreover, those cut off scores were obtained without adjusting for visual impairment thus can’t be applied to your sample.

Response: The method for determining the HKMoCA-VI has been explained (p. 10, lines 157-165, p. 11, lines 182-190, 196-213).

o Linear regression would adjust better for age and educations than using the percentiles, then it would be better to add tables 2,3,4 as supplementary data.

Response: Linear regression has been conducted to account for the effects of age and education on the scores (p. 11, lines 182-190). We would still keep tables 2-4 in the main text for the clinicians’ easier reference.

Reviewer #2: Dear Authors

I read your work entitled “The Hong Kong version of Montreal Cognitive Assessment for the visually impaired (HKMoCA-VI): Its cutoff and a survey on the cognitive functioning of visually impaired elderly in residential homes” and here I enclose my recommendations to you:

1. Please have the text checked for language issues, since several mistakes have been tracked. A native speaker of English or a professional Editing company would help towards this.

Response: The manuscript has been checked for language accuracy.

2. Abstract General comments: The Abstract need a reconstruction and Methods section and the results section.

Response: The abstract has been reconstructed (p. 2, lines 25-31, 37-39).

3. The “Introduction” section: It would be beneficial for the authors to include more precise information in the introduction about the gaps of the existing knowledge and how this study attempts to fill them. An augmentation of the existing literature in the text would benefit more for the Introduction and it will strengthen the rational of this study. Additionally, I suggest the Authors to focus more on the HKMoCA-VI and why it is so important.

Response: The Introduction section has been revised to focus on HKMoCA-VI (p. 5, lines 79-93; p. 7, lines 115-118).

4. The “Methods” section: The Authors report criteria that are not based on the existing literature. I suggest them to elaborate this.

Response: Inclusion and exclusion criteria have been elaborated (p. 8, lines 127-144).

5. The “Methods” section: It is strange that the Author do not report which groups severed as clinical and the controls in this study.

Response: We attempted to classify the participants into dementia group and non-dementia group according to their medical diagnosis (p. 8, lines120-125). Nevertheless, due to the under-recognition of dementia in Hong Kong while CMMSE has been used to determine cut-off of HKMoCA-VI. This point has been discussed in the Discussion section (p. 17-18, lines 278-285).

6. The “Discussion” section: The Authors are developing this section according to their results and connect them in an adequate manner to the existing knowledge but as we can see most of the studies used a control group that in this study is not clearly reported. I suggest the Authors to address that as well. This will help the Authors to strengthen more their work.

Response: This point has been addressed in the Discussion section (p. 17-18, lines 278-285).

Decision Letter 1

Ryota Sakurai

7 May 2024

PONE-D-23-42809R1The Hong Kong version of Montreal Cognitive Assessment for the visually impaired (HKMoCA-VI): Its cut-off and a survey on the cognitive functioning of visually impaired elderly in residential homesPLOS ONE

Dear Dr. Wong,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 21 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ryota Sakurai, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Thank you for your effort in improving your manuscript. Reviewer #1 made a minor comment. Since they are reasonable comments, please respond to them.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper represents a major effort to establish the cutoff score for the Hong Kong Version of the Montreal Cognitive Assessment for the visually impaired and to assess the cognitive performance of nursing home elderly residents with visual impairment in Hong Kong. I believe that the goal of the study is worthwhile and appropriate for the readership of the PLOS ONE. However, minor changes are required.

• The introduction includes some redundant information. Consider streamlining it to focus on the core research question and the rationale for the study.

• The manuscript would benefit from some English editing to ensure clarity and flow. Consider using a professional editing service or collaborating with a colleague with strong English language skills.

• Currently, the inclusion and exclusion criteria are presented in separate bullet points. For improved readability, consider combining them into a single, well-structured paragraph. This will allow you to explain the rationale behind each criterion more effectively.

Reviewer #2: Dear authors,

Thank you for addressing all my comments. Please have a final check again for English.

Thank you.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Doha Rasheedy

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2024 Jun 26;19(6):e0305426. doi: 10.1371/journal.pone.0305426.r004

Author response to Decision Letter 1

22 May 2024

1. We note your current Data Availability statement is: All datasets will be available from open-access repository (e.g., OSF, Harvard Dataverse) upon manuscript acceptance.;

Tick here if the URLs/accession numbers/DOIs will be available only after acceptance of the manuscript for publication so that we can ensure their inclusion before publication."

In the online submission form, you indicated that your data will be submitted to a repository upon acceptance. We strongly recommend all authors deposit their data before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire minimal dataset will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption.

Response: The data availability statement 'The raw data in the validation process is available at https://osf.io/62gwf/files/osfstorage/6614a02ac053943299b4dd01' , which is included in the mauscript, has been updated in the online submission form. The corresponding box 'Tick here if the URLs/accession numbers/DOIs will be available only after acceptance of the manuscript for publication so that we can ensure their inclusion before publication." has been checked. The dataset has been uploaded and will be made public after manuscript acceptance.

Thanks you very much.

Regards,

Winsy Wong

Decision Letter 2

Ryota Sakurai

30 May 2024

The Hong Kong version of Montreal Cognitive Assessment for the Visually Impaired (HKMoCA-VI): Proposed cut-off and cognitive functioning survey of visually impaired elderly in residential homes

PONE-D-23-42809R2

Dear Dr. Wong,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ryota Sakurai, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The manuscript improved with comments from the reviewers. Thanks for providing important information to PLOS ONE.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

Acceptance letter

Ryota Sakurai

18 Jun 2024

PONE-D-23-42809R2

PLOS ONE

Dear Dr. Wong,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ryota Sakurai

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Data Availability Statement

    The data relevant to this paper are available from OSF at osf.io/62gwf.

    Articles from PLOS ONE are provided here courtesy of PLOS

    RESOURCES