Author's response on “Neuropsychiatric profiles in patients with Alzheimer's disease and vascular dementia”

Sir,

We sincerely thank the reader(s) for his/her/their interest in our article entitled “Neuropsychiatric profiles in patients with Alzheimer's disease and vascular dementia” published in Ann Indian Acad Neurol (2015;18:120-21).[1] As written in the article, we have used the mini-mental status examination (MMSE) for initial screening of our patients. The usual protocol we follow at our clinic is to apply the MMSE at the beginning and get the score. It gives us an estimate about the domains involved in a given patient. The qualitative assessment of MMSE (i.e., how a patient is performing while applying MMSE) tells more about the impairment the patient is having than the crude score itself. Similar to CDR (Clinical Dementia Rating) score, MMSE also used to determine the stage of dementia. Therefore, in our study, MMSE was not meant to select or reject patients but it was part of the whole assessment. We applied this initial test before embarking upon the full assessment.

The second concern of the reader(s) was why we did not use the Bengali version of MMSE in our subjects. We did not use a vernacular version because the available Hindi and Bengali versions of MMSE have limitations. The Hindi adaptation of the MMSE was developed by Ganguli et al. while developing a screening tool for rural illiterate Indian elderly subjects.[2] Thus, it was modified to enable an illiterate subject to complete the test without difficulty. The Bengali version of MMSE was an adaptation of the Hindi version.[3] While these are useful for illiterate subjects, both the batteries are too easy for an urban educated subject. The ‘ceiling effect’ is observed while generating the cut-off scores for educated subjects.[2,3] This means the 10^th percentile score of normative data for educated subject touches the highest possible score. Thus, early impairment is missed if these instruments are used for educated subjects. Hence, both Hindi and Bengali versions of MMSE are not useful for testing an educated subject. Conversely, MMSE is an accepted and widely used global cognitive screening scale used across the world. It is comprehensive, easy to apply, and useful for comparison. We therefore used MMSE for testing educated subjects in our clinic.