Intersecting pentagons as surrogate for identifying the use of mini mental state examination in assessment of dementia in a largely illiterate populationSK Raina1, A Maria2, V Chander1, S Raina3
1 Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Tanda, Himachal Pradesh, India
2 Freelance Researcher, Kangra (HP), Himachal Pradesh, India
3 Department of Medicine, Dr. Rajendra Prasad Government Medical College, Tanda, Himachal Pradesh, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.166513
Source of Support: None, Conflict of Interest: None
Background and Rationale: The mini-mental state evaluation (MMSE) is often used to identify patients with dementia. One component of the MMSE is the intersecting pentagon copying (IPC) test, which may be difficult to be used in an illiterate population. Materials and Methods: A post hoc analysis on an elderly population (60 years and above) from Himachal Pradesh was carried out. The data of only 1,513 elderly individuals out of a total of 2,000 participants with a score of more than 26 (nondemented) out of a possible score of 30 on cognitive battery available were used. The scores on the IPC were evaluated and their association with some demographic variables was also assessed. Results: Illiterate participants, female participants, those with greater age, and the rural/tribal population groups faced the most difficulty in drawing the intersecting pentagons and even greater difficulty in drawing them correctly. Discussion: The IPC presents challenges for people who are illiterate and the scoring method needs to be addressed and changed particularly when the test is used in largely illiterate populations.
Keywords: Intersecting pentagons, mini-mental state examination (MMSE), surrogate, use
Dementia is defined as an acquired deterioration in the cognitive abilities that impairs the successful performance of the activities of daily living (ADL). In patients with dementia, memory is the most common cognitive ability lost alongside other mental faculties such as language, visuospatial ability, calculation, judgment, and problem-solving. The mini-mental state examination (MMSE) and its modified versions capture cognition based on the response of the individual to a set of questions capturing various domains of cognition. One of the items in the MMSE is the intersecting pentagon copying (IPC) test. This involves the participant copying an intersecting double pentagon and is given a maximum score of 1 point based on the correctness of copying. The IPC addresses visuospatial constructional skills and executive function. The idea of asking individuals to draw IPC for assessment of dementia has been the subject of research for many investigators previously. In Alzheimer's disease (AD), drawing and constructional abilities get impaired as the disease progresses. Förstl et al. showed a correlation between widespread brain changes and several neuropsychological deficits in severe AD, one of which is drawing disability as seen by the use of the IPC. In another study, compared to the controls the spontaneous drawings of patients with AD using the IPC exhibited fewer angles, impaired perspectives and spatial relations, and overall impairment.  Studies point to an impairment in visuospatial functions in dementia and more so later in the disease.  MMSE and its modified versions have also been used to capture the level of dementia by Indian researchers. The use of the IPC, which is a key component of the MMSE and is task-based, can be difficult when the participant is illiterate. The present study is a post hoc analysis of the IPC in an illiterate population of an earlier study that evaluated the Hindi and Bharmouri versions of the MMSE in northern India. 
The study protocol was approved by the institutional review board. Written informed consent was obtained from the participants or their legally accepted representatives.
Study population and study design
Participant data were obtained from an earlier cross-sectional study conducted on an elderly population (defined as 60 years and above) from selected geographical areas (migrant, urban, rural, and tribal) of the state of Himachal Pradesh in Northwest India.  No formal sample size calculation was made for the present study. A total of 500 elderly individuals were included from the original study using nonprobability sampling to give a total sample size of 2,000. This sample size represented all geographic areas. The present study has two parts: A screening phase and a clinical phase.
Case definition of literacy
This was based on the definition listed in the census of the country (the ability to read and write with understanding). 
Screening phase and a brief description of the original study
Demographic details such as age, sex, and educational status were recorded. In the original study, the MMSE was administered to the participant by the interviewer. A Hindi version of the MMSE, the Hindi mental state examination (HMSE) was used for the urban, rural, and migrant populations. For the tribal population a modified version of MMSE (in Bharmouri, the regional language), hereafter referred to as Bharmouri version of mental state examination (BMSE), was used. The details on the development of BMSE have been provided elsewhere.  The original HMSE version had a modified IPC with a diamond within a square.  For the post hoc analysis, we retained the original intersecting pentagons for both HMSE and BMSE.
Clinical phase and inclusion criteria
The MMSE gives a total score of 30 points. A score below 24 on MMSE is considered as a suspect case of dementia and patients with such a score were excluded from the study but evaluated clinically to confirm the presence of dementia. An individual was confirmed as a case of dementia only after clinical evaluation. The clinical evaluation also meant a revisiting of the cognitive screen scores by the clinical team; wherever a difference in scores was noted between the field investigator and the clinical team, the score by the clinical team was taken as final. For the purpose of the present study, the data of only 1,513/2,000 participants with a score of more than 26 (thus classified as not having dementia) were used.
Criteria for grading of intersecting pentagons in HMSE and BMSE
The IPC can be graded based on two sets of criteria, namely, original and relaxed, both of which are significantly different. Evaluation of responses was done using both the above criteria. As per the original criteria, in order to get a full score of 1, all 10 angles had to be present and the two pentagons had to be intersected.
To get a score of 1, there had to be two figures that seem to intersect. At least one of the figures had to have five angles. When more than one copy was available, the best copy was graded. Tremor, rotation, relative size, and symmetry in the drawing were ignored. Descriptive statistics were used to present both the demographic data and the impact of age, education, and gender.
Of the 1,513 participants who were included, 454 (30.01%) belonged to the urban setting and 456 (30.41%) to the rural setting. A total of 772 (51.02%) participants belonged to the age group of 60-65 years, 316 (20.89%) participants belonged to the age group of 66-70 years, 203 (13.42%) participants belonged to the age group of 71-75 years, 108 (7.14%) participants belonged to the age group of 76-80 years, and 114 (7.53%) were above 80 years old. There were 778 (51.42%) males and 735 (48.58%) females. A total of 777 (51.3%) participants were literate and the rest were illiterate. The number of people who attempted to copy the intersecting pentagons was maximum for the migrants (383/384; 99.74%) followed by the tribals (93/291; 42.66%) [Table 1]. Out of those who attempted, the least number of correct responses was from the tribal area (45/93; 48%) followed by the rural area (63/92; 68.92%) using relaxed criteria.
Effect of age
With the progress in age, the number of people who tried to attempt the test decreased; it was 54.53% (421/772) for the age group of 60-65 years, 45.25% (143/316) for the age group of 66-70 years, 42.36% (86/203) for the age group of 71-75 years, and 33.33% (38/114) only for those aged above 80 years [Table 2]. The number of correct responses (on the basis of relaxed criteria) fell as the age progressed, being 80.52% (339/421) for the age group of 60-65 years, 79.02% (113/143) for the age group of 66-70 years, 70.93% (61/86) for the age group of 71-75 years, 67.31% (35/52) for the age group of 76-80 years, and 44.74% (17/38) for those above 80 years of age.
Less than 50% of both the male and female participants could attempt the test. A total of 376/778 (48.33%) males versus 364/735 females (49.52%) attempted the test [Table 3]. Out of those who attempted (on the basis of original criteria), 39/376 (10.37%) got it right versus 22/364 females who got it right. On the basis of relaxed criteria, out of those who attempted 296/376 males (78.72%) versus 273/364 (75%) females got it right.
Effect of literacy
While 42.08% (327 out of 777) of all those who were literate attempted the test, 56.11% (413 out of 736) of those who were illiterate attempted the test [Table 4]. Out of those who attempted (on the basis of original criteria), 13.46% (44 out of 327) of the literates got it right. Among those who were illiterate, 4.12% (17 out of 413) could attempt it correctly. On the basis of relaxed criteria, 82.57% (270 out of 327) of those who were literate could attempt it correctly. Among illiterates, 71.67% (296 out of 413) could attempt it correctly. However, the number of correct responses (on the basis of relaxed criteria) increased with the level of educational status that was 71.67% (296 out of 413) for illiterates, 79.85% (107 out of 134) for people who were educated up to middle school, 83.33% (90 out of 108) for those who completed high school education, 85.71% (48 out of 56) for those who completed their graduation, 84.62% (11 out of 13) for those who completed their postgraduate studies, and 87.5% (14 out of 16) for professionals.
The IPC item of the MMSE is an acceptable and simple test of visuospatial function used as part of MMSE for assessment of dementia. The English version of the MMSE and its modifications have been used in the past across populations with the intersecting pentagon capturing one of the domains of cognition. There are, however, different findings among studies that have used the IPC for this purpose. A study from Sydney, New South Wales, Australia reported that one-third of the people dwelling in the community without dementia performed poorly on the test.  This can be explained by Katzman's hypothesis that  if one does not learn to copy as a child, he/she will not be able to complete the task when required at a later point in life. Also, the ability to draw is relatively independent of language and memory impairments.  This brings to the fore the findings of the present study, as reflected in the inability of an illiterate participant without dementia to successfully copy the intersecting pentagons. Our study based on data analyzed post facto using descriptive statistics shows that as educational status improves, the drawing ability improves as well. The IPC, thus, has limited utility in assessing dementia among illiterate participants and a rethinking on the score of 1 needs to be done for IPC, which in turn will impact the overall MMSE score.
Financial support and sponsorship
The data used in this study were obtained from a research funded by the Indian Council of Medical Research and conducted by the same author (SKR) as Principal Investigator.
Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4]