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T.I. Ionova

Multinational Center for Quality of Life Research;
Saint Petersburg State University Hospital

E.V. Frolova

Mechnikov North-Western State Medical University

K.V. Ovakimyan

Mechnikov North-Western State Medical University

E.A. Mkhitaryan

Pirogov Russian National Research Medical University;
Russian Clinical and Research Center of Gerontology Pirogov — Russian National Research Medical University

O.N. Tkacheva

Pirogov Russian National Research Medical University

N.M. Porfirieva

Multinational Center for Quality of Life Research

T.P. Nikitina

Multinational Center for Quality of Life Research;
Saint Petersburg State University Hospital

Linguistic and cultural adaptation of the Russian version of general practitioner assessment of cognition questionnaire ― GPCOG in elderly and senile patients at the primary care level

Authors:

T.I. Ionova, E.V. Frolova, K.V. Ovakimyan, E.A. Mkhitaryan, O.N. Tkacheva, N.M. Porfirieva, T.P. Nikitina

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To cite this article:

Ionova TI, Frolova EV, Ovakimyan KV, Mkhitaryan EA, Tkacheva ON, Porfirieva NM, Nikitina TP. Linguistic and cultural adaptation of the Russian version of general practitioner assessment of cognition questionnaire ― GPCOG in elderly and senile patients at the primary care level. Zhurnal Nevrologii i Psikhiatrii imeni S.S. Korsakova. 2022;122(12):117‑127. (In Russ., In Engl.)
https://doi.org/10.17116/jnevro2022122121117

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Introduction

A clear trend towards an increase in the life expectancy of the population of the Russian Federation over the past decade dictates the need to develop and implement comprehensive medical and social programs aimed at maintaining and improving the quality of life of elderly people. Among them, early diagnosis of cognitive impairments, especially Alzheimer’s disease (AD), play an important role in preventing the development of dementia/or mitigating the severity of cognitive impairments [1, 2]. The importance of timely measures in the early stages of AD is due to the high prevalence of the disease and its severe course in the later stages [3]. According to Dementia Forecasting Collaborators, there are about 50 million people worldwide with dementia, with about 60–70 % of patients suffering from Alzheimer’s disease [3]. In our country, there are currently no data from large epidemiological studies to assess the prevalence and incidence of this condition. However, the estimated number of patients with Alzheimer’s disease is about 1.4 million people [3]. The management of this disease is accompanied by significant difficulties and is a great burden for the patient’s family and society as a whole [3, 4]. In addition to the high prevalence and burden of the disease, it is worth noting that cognitive impairment is one of the main geriatric syndromes and represents a subjective and/or objective worsening of higher brain functions (attention, memory, gnosis, praxis, speech, thinking), compared to an initial higher level due to organic pathology of the brain, which affects the efficacy of educational, professional, daily life and social activities [2, 5, 6]. Cognitive impairment progresses in neurodegenerative diseases (such as Alzheimer’s disease), leading to a loss of individual independence and a high burden on the patient’s family and society as a whole [4]. In the healthcare system, there are many difficulties associated with the early diagnosis of cognitive disorders [7]. One of the difficulties is associated with the patient and his/her relatives visiting a neurologist or psychiatrist with symptoms of cognitive disorders only in the later stages, when the possibilities for providing assistance are significantly limited [8]. Another problem is the lack of awareness and focus of primary care physicians on cognitive disorders in elderly and senile patients [9–11]. Another difficulty is the limited number of screening programs, as well as validated tools for diagnosing cognitive disorders by primary care physicians, which can help to identify cognitive disorders in the early stages with a subsequent visit to a specialist in a timely manner [7]. It is desirable to develop effective and easy-to-use tools that allow general practitioners to assess cognitive disorders, that reduce the time for assessing cognitive status, and that have an accuracy close to specialized neuroscales requiring a lot of time and expert specialization. In general, the solution to these problems will contribute to the timely prevention and treatment of cognitive impairments that do not reach the degree of dementia, undoubtedly improving quality of life, and slowing down and in some cases preventing severe manifestations that lead to disability, dependence on others, and the need for constant medical and social assistance and protection [12–14]. Diagnostics of cognitive impairments is part of a comprehensive examination of elderly people and includes, among other things, a neuropsychological examination of patients with suspected cognitive impairments [2, 15]. There are a significant number of different methods of neuropsychological diagnosis of cognitive dysfunctions, but for the routine practice of primary care physicians, in particular, general practitioners, a limited number of screening methods able to provide quick assessment of the presence or absence of significant cognitive dysfunction can be recommended [2, 14, 16]. Recommended tools for cognitive function assessment in elderly patients are the Mini-Mental State Examination (MMSE) [17], the Modified Mini-Cog (Mini-Cog) [18], the Montreal Cognitive Assessment (MoCa) [19], and the 3-CT scale [20]. However, it should be noted that these tools have moderate sensitivity and specificity when used in elderly and senile patients, and their results depend on the education, neuropsychological profile, and nosological type of cognitive impairment [16, 20–22].

Abroad, the GPCOG (General Practitioner’s Assessment of Cognition) questionnaire has become widespread in the screening of elderly patients for cognitive impairment by general practitioners [23–25]. The GPCOG questionnaire for general practitioners to assess cognitive impairment was developed by Prof. G. Brodaty et al. (University of New South Wales, Australia) and has proved itself to be a simple, sensitive and specific tool for screening assessment of cognitive impairment in the elderly [26, 27]. This questionnaire consists of two parts: the first part is for the patient (stage 1); the second part is for the Informant (patient’s relative/other close person (stage 2). Patient testing includes the following items: time orientation, clock drawing, discussion of recent events, and a “Name and address” recall test. The patient’s relative/other close person is interviewed regarding the following: the patient’s ability to recall recent events and ability to recall the essence of a conversation a few days later, the patient’s ability to choose the right words and avoid wrong words during conversation, the patient’s ability to independently manage financial affairs and money, the patient’s ability to manage medication, and the need for the assistance with personal or public transport. If the patient’s test score is 9, then the patient has no cognitive impairment. If the patient’s total test score is between 5 and 8, an interview with the patient’s relative/other close person is required. If the patient’s test score is ≤ 4, or if the patient’s relative/other close person is interviewed with a score of ≤ 3, this indicates that the patient has a cognitive impairment. In accordance with foreign data, the GPCOG questionnaire has acceptable sensitivity and specificity [23–27] and is used by general practitioners and other primary care specialists for screening assessment of cognitive impairment in elderly and senile patients [28].

Given the expediency of the use of the GPCOG questionnaire by domestic primary care specialists to assess cognitive impairment in elderly and senile patients, development of the Russian version of this tool seems relevant. The language version of the questionnaire can be used in research and clinical practice, provided that language and cultural adaptation — as well as their validation — have been performed in accordance with international guidlines [29, 30]. Linguistic and cultural adaptation of the tool is carried out based on existing recommendations [31, 32].

The objective of this work was the linguistic and cultural adaptation of the Russian version of the GPCOG questionnaire, including testing in the population of elderly and senile patients.

Materials and Methods

The GPCOG questionnaire was tested as part of its linguistic and cultural adaptation in the Russian Gerontological Research and Clinical Center of the Pirogov Russian National Research Medical University (Moscow) and the Department of Family Medicine of the North-Western State Medical University named after I. I. Mechnikov (St. Petersburg) from May to June 2022. The testing involved patients who are followed up in municipal geriatric/gerontological centers in Moscow and St. Petersburg, as well as their relatives/other close people. The criteria for participation in testing were the absence of dementia and psychiatric disorders in patients, as well as the absence of severe hearing and vision impairments that would make it difficult for the patient to complete the tasks of the questionnaire and the interview. Patients and their relatives participated in testing of the tools during a scheduled visit to a specialist. Testing included completion of the GPCOG questionnaire by a specialist based on the results of completed tasks and answered questions, as well as interview of patients and their relatives/other close persons using an interview form specially designed for this project.

The protocol of linguistic and cultural adaptation of the GPCOG questionnaire was approved at the meeting of the LEC (Extract from protocol No. 54 of the meeting of the LEC of the Russian Gerontological Research and Clinical Center dated May 24, 2022).

After permission to create its Russian version had been obtained from Prof. G. Brodaty, the author of the GPCOG questionnaire, linguistic and cultural adaptation of the tool was carried out including the following steps:

— Forward translation of the questionnaire in accordance with international standards from English into Russian, creation of two versions of the forward translation.

— Harmonization and expert evaluation of translations, preview of GPCOG in Russian.

— Back translation, harmonization of translations and creation of a test version of GPCOG in Russian.

— Interview with patients and their relatives/other close persons, survey among of specialists to test the GPCOG questionnaire.

— Amendments to the questionnaire based on the results of interviews and questioning — decentering.

— A final review of all translations and decentering results, creation of the final version of GPCOG in Russian.

As part of the interviews with patients and their relatives/other close persons, the time required to complete the GPCOG questionnaire was determined. Based on the results of the interview, the face validity of the tool was determined. To do this, we analyzed the proportion of patients who noted the clarity of tasks and the absence of inconvenience (discomfort) during their completion, as well as the proportion of the patient’s relatives/other close persons who noted the absence of inconvenience (discomfort) and ease in answering questions. It was assumed that if more than 15 % of respondents label the same task as difficult to understand or causing inconvenience, it will require further development and, possibly, restatement.

The content validity of the GPCOG questionnaire was assessed based on the questioning of specialists. To do this, we determined the proportion of respondents who noted the clarity, informational value, suitability and ease of use of this tool for assessing cognitive impairment in elderly and senile patients. The general impression of specialists about the suggested method for assessing cognitive impairment in patients was also evaluated. The final examination of the tool was based on the international guidelines [31].

Results

Translation of the GPCOG questionnaire into Russian

Forward translation of the GPCOG questionnaire was carried out by two independent translators with knowledge in the field and experience in translating medical literature. As a result, two versions of the GPCOG questionnaire in Russian were created. Based on the results of their review, a preliminary version of the GPCOG was compiled. For two tasks, choice of the optimal wording in the preliminary version of the questionnaire in Russian required additional coordination with translators in order to ensure their better linguistic and cultural compliance (Appendix 1). Particularly, the wording of the task “Name and address” was changed and instead of the English name and address proposed in the translation, wording of the task was chosen that would prompt the physician to choose the name and address themselves. Also, the word “informant” was replaced in the preliminary version with another wording; more clear for the Russian-speaking audience but close in meaning — “patient’s relative/other close person”. After back translation, the expert committee harmonized the translations, discussing the significant discrepancies identified between the original version and the back translation. The following adjustments were made at this stage. It was decided to replace the expression “auditory memory test” with “test for subsequent recall”, and the term “examination” with “testing”, as these would be more precise in meaning. In addition, for a more correct sound in all questions about the patient addressed to a relative, the design of the questions was changed using the noun “patient” instead of the pronouns “he/she”. The full name of the questionnaire is also included in the test version for the convenience of its further application in practice: In the original version, the name of the GPCOG questionnaire is provided in the abbreviated form. Thus, the first test version of GPCOG was created.

Interview with patients and their relatives, questioning of specialists

Before testing, each patient and his relative/other close person provided written informed consent to participate in the interview. The interview procedure included 8 elderly and senile patients with a mean age of 71.6 years (range 61–77 years) and a male/female ratio of 3:5. The patients had no obvious signs of dementia. Patients had the following diseases: 6 patients with hypertension, coronary heart disease; 2 patients with a history of acute cerebrovascular accident; 1 patient with diabetes mellitus; 1 patient with myoma, cholelithiasis and urolithiasis; 2 patients with Alzheimer’s disease. 8 relatives/other close persons also took part in the interviews: their average age was 53.4 years, and the male/female ratio was 3:5. All respondents were relatives of patients: 5 of them were their children, 3 were their spouses.

The average time to complete the GPCOG questionnaire is 8 minutes.

The results of interviewing patients and their relatives are provided in Fig. 1-3. As can be seen from Figure 1, the vast majority of patients (more than 85 %) understand all the tasks on the questionnaire. As for the convenience (lack of discomfort) during completion, all tasks except for one caused no inconvenience in most cases (more than 85 %) (Fig. 2). Completion of the “Name and address” task caused inconvenience for two patients. Also, the majority (88 %) of patients expressed a generally positive impression of the proposed method for assessing memory, attention and other cognitive impairments. According to the results of the interview with relatives, all respondents noted the clearness of the questions from the questionnaire and the ease of choosing an answer to them. In total, 88 % of the respondents reported that the questions on the questionnaire caused no discomfort and generally expressed a positive impression of this method of assessing memory, attention and other cognitive impairments in their relatives (Fig. 3).

Fig. 1. Distribution of patients according to the degree of clarity of the tasks wording in the Russian version of the GPCOG.

Here and in Fig. 2: on the abscissa axis — the number of patients (n) and percentage (%) relative to the sample; on the ordinate axis — a brief statement of the task.

Fig. 2. Distribution of patients according to the degree of convenience of the tasks wording in the Russian version of the GPCOG.

Fig. 3. Distribution of the patient’s relatives according to the degree of clarity, convenience of the questions wording and ease of choosing answers to the questions of the GPCOG.

On the abscissa axis — the number of respondents (n) and percentage (%) relative to the sample; on the ordinate axis — indicators of the external validity of the questionnaire.

Eight (8) physicians from the Department of Family Medicine of the North-Western State Medical University named after I. I. Mechnikov (St. Petersburg) and the Russian Gerontological Research and Clinical Center of the Pirogov Russian National Research Medical University (Moscow) took part in the surveying of specialists. All specialists are women with mean age of 35 years (range between 24 and 52 years) and mean professional experience of 10 years (range between 3 and 23 years). By specialty, the physicians were distributed as follows — 4 neurologists, 2 therapists, 1 general practitioner, 1 family doctor.

According to the surveying result, all specialists noted that the Russian version of the GPCOG questionnaire is suitable and informative for assessing cognitive impairment in elderly and senile patients. Of these, 75 % of specialists noted a general positive impression of the questionnaire, the clarity of the tasks and the convenience of its use to assess cognitive impairment, while 63 % of specialists expressed their willingness to use the tool in daily clinical practice.

However, two specialists (a general practitioner and a primary care physician) noted that the “Name and address” and “Clock Drawing” tasks may be difficult and need to be improved. It was suggested that a specific name and address be included in the Name and Address task to ensure a universal level of difficulty in its completion. The “Clock Drawing” task, meanwhile, required a more detailed wording for its completion.

Decentering

The results of the GPCOG testing were discussed by an expert committee consisting of the project coordinator, a psychologist and a linguist under the supervision of the project manager.

Analysis of patient interview data showed that, according to the majority of patients, there were no items that required amendments on the GPCOG questionnaire. The wording of two tasks required revision — “Name and Address” and “Clock Drawing”. According to interviews with relatives of patients, there were no wordings in the questionnaire that required changes.

Data analysis of the questioning of specialists also showed that the wording of the two tasks needs to be revised. Regarding the first task “Name and Address”, it was suggested that it would be appropriate to provide specific information to homogenize the task. Additionally, the options for providing the first name, patronymic and last name were revised based on the information in the original version of the questionnaire and according to the scoring principle. It was decided to leave only the first name and last name (without patronymic) in the wording of the task. From the specific options proposed by specialists for the “Name and Address” task, the name and address were chosen, which, according to experts, will cause no difficulties for patients to remember (Appendix 1). According to the questioning of specialists, it was also determined that the wording of the “Clock Drawing” task is incomplete and makes it difficult for the patient to complete it. The members of the expert committee decided to supplement the “Clock Drawing” task with the wording that is generally accepted and used by specialists for this task in other tests (Appendix 1). Thus, the final version of the GPCOG questionnaire in Russian was developed and approved, being equivalent to the original version and corresponding to the cultural and linguistic characteristics of the population (Appendix 2).

Discussion

On the basis that currently there is an obvious objective need for doctors of various specialties, and primarily for primary care specialists, to use screening methods to determine cognitive impairments in elderly and senile people, and the number of sensitive and specific tests for these purposes is limited, we developed the Russian version of the GPCOG questionnaire. For this purpose, the GPCOG questionnaire was linguistically and culturally adapted.

The quality of linguistic and cultural adaptation is known to further determine the psychometric properties of the tool [30, 31]. The GPCOG questionnaire was adapted in accordance with modern international recommendations [29]. A fundamentally important component of linguistic and cultural adaptation is the testing stage of the language version of the questionnaire, aimed at bringing the concept of the tool as close as possible to the cultural and linguistic traditions and characteristics of the patient population in the target country [32]. To do this, the test version of GPCOG was tested in the national population of elderly and senile patients and their relatives/other close persons in the process of individual interviews, and a survey of specialists was also conducted.

Based on the interview of patients and their relatives, an acceptable measure of face validity of the Russian version of the GPCOG questionnaire was established: the majority of patients and their relatives reported the clarity of each of the questionnaire tasks and the absence of discomfort in the wording, and also expressed a general positive impression of the proposed method for assessing memory, attention and other cognitive impairments in patients. The content validity of the Russian version of the GPCOG questionnaire is confirmed by the specialist surveying data. Indicators of face and content validity are similar to the data obtained with development of other language versions of the tool [23–25].

Test results of the GPCOG questionnaire in a focus group of patients and in specialist surveying made it possible to amend two tasks of the questionnaire at the decentering stage, thus improving the conceptual and operational equivalence of the tool to its original, taking into account the cultural and linguistic characteristics of the national population. Based on the results of an expert assessment, the final version of the GPCOG questionnaire in Russian was developed and approved, being equivalent to the original version and corresponding to the cultural and linguistic characteristics of the population.

To use the Russian version of GPCOG in national clinical practice and scientific research, testing of the tool is required with the participation of various primary health care professionals, along with additional surveying among patients and their relatives regarding the suitability, information content, convenience and acceptability of using GPCOG to assess cognitive impairment in geriatric practice compared to other tests, as well as the assessment of psychometric properties — reliability, sensitivity and specificity of the Russian version of GPCOG — as part of its validation.

Conclusion

In accordance with modern international recommendations, as a result of linguistic and cultural adaptation, a Russian version of the GPCOG questionnaire has been developed.

As part of the development of the Russian version of the GPCOG questionnaire, it was tested in a group of elderly and senile patients and their relatives, with a survey among specialists.

Based on interview of patients and their relatives, an acceptable measure of face validity of the Russian version of the tool was established; specialist survey results confirmed its content validity.

To use the Russian version of GPCOG in domestic clinical practice and scientific research, it is necessary to evaluate its psychometric properties and test the tool in clinical practice in a target patient population.

The study was independently conducted by the Multinational Center for Quality of Life Research with financial support of the questionnaire translation into Russian by Roche-Moscow JSC.

Acknowledgement

The authors of the article thank Prof. G. Brodati for his research support while the development of the Russian version of the GPCOG questionnaire. The authors also would like to express their appreciation to M.D., PhD. A. Kulchikov from Roche’s Scientific Health Chapter for his informational and methodological support in the preparation of this project.

Appendix 1

Characteristics of the tasks of the GPCOG questionnaire-test, which were modified at the stage of creating the preliminary and final Russian-language versions

English version

Preliminary Russian version

Final Russian version

Name and address for subsequent recall test

I am going to give you a name and address. After I have said it, I want you to repeat it. Remember this name and address because I am going to ask you to tell it to me again in a few minutes: John Brown, 42 West Street, Kensington. (Allow a maximum of 4 attempts.)

Тест «Имя и адрес» на воспроизведение

Назовите, пожалуйста, имя и адрес, которые я попросил/а Вас запомнить

Имя и отчество ...

Фамилия ...

Город ...

Название улицы ...

Номер дома ...

(Допускается максимум 4 попытки)

Тест «Имя и адрес» на воспроизведение

Назовите, пожалуйста, имя и адрес, которые я попросил/а Вас запомнить

Имя — Сергей

Фамилия — Мартынов

Город — Санкт-Петербург

Название улицы — ул. Ленина

Номер дома — 42

(Допускается максимум 4 попытки)

Clock drawing (use blank page)

Please mark in all the numbers to indicate the hours of a clock. (correct spacing required)

Тест «Рисование часов»

(выполняется на отдельном листе)

Пожалуйста, расставьте на циферблате все цифры в правильном порядке (соблюдая правильный интервал между цифрами)

Тест «Рисование часов» (выполняется на отдельном листе)

Пожалуйста, нарисуйте круглые часы с цифрами на циферблате

Informant interview

Интервью с родственником пациента/другим близким лицом

Интервью с родственником пациента/другим близким лицом

Appendix 2

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