DESK REVIEWS | 07.01.04. Are there differences in diagnostic assessment according to geographical areas (rural/urban) and also according to other socio-economic factors?

DESK REVIEW | 07.01.04. Are there differences in diagnostic assessment according to geographical areas (rural/urban) and also according to other socio-economic factors?

We do not have data on this for the country, neither for smaller areas. According to our previous study conducted in one city (São José dos Campos, in São Paulo state), we found that rates of under diagnosis were lower in the rich areas of the city (Nakamura et al., 2015).


Nakamura, A., Opaleye, D., Tani, G., & Ferri, C. P. (2015). Dementia underdiagnosis in Brazil. The Lancet, 385(9966), 418–419.

There are differences in diagnostic assessment across the country due to diversity in demographics (rural/urban, region and state) and socioeconomic status. Diagnostic tools have been developed and/or adapted to account for this diversity. The Indian Council of Medical Research (ICMR), Department of Health Research (2021), released a Neurocognitive Tool Box. It is culturally validated and available in 5 Indian languages (Hindi, Bengali, Telugu, Kannada and Malayalam) (ICMR, 2021). The 10/66 Dementia Research Group has developed a cross-culturally validated dementia diagnostic algorithm (Prince et al., 2008). There are also other neuropsychological assessments that have been translated into various regional languages as well as culturally adapted to the Indian context. These include: Addenbrookes Cognitive Examination (ACE) (Version III and Version R), Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessments (MoCA) (Porrselvi and Shankar, 2017).

Table 7.1 shows the Cognitive screening measures with Indian adaptions:

Global Screening Measures Indian adaptation Literacy / socioeconomic background
Mini Mental State Examination Hindi mental state examination (HMSE) Hindi-speaking, illiterate, rural elderly population.
Addenbrooke’s Cognitive Examination-Revised and ACE III Tamil, Hindi, Indian English, Kannada, Telugu, Urdu, Malayalam and Marathi. Literate and illiterate versions.
Montreal Cognitive Assessment (MoCA) Bengali, Kannada, Malayalam, Marathi, Tamil, Telugu, Hindi, and Urdu. Computerized version in development.
Community Screening Instrument for Dementia   Developed for use in primary care settings by non-specialist health workers.
Kolkata Cognitive Screening Battery Bengali Test developed for Kolkata population.
Mattis Dementia Rating Scale Hindi Hindi-speaking Indian population.
Rowland Universal Dementia Assessment tool (RUDAS) Malayalam Kerala state population
Picture-based memory impairment screen Used for all languages Culture-fair (measure cognition without the influence of sociocultural factors), picture-based cognitive screen designed to be administered by non-specialists.

Source: (Porrselvi and Shankar, 2017)


Indian Council of Medical Research (ICMR). 2021. INDIAN COUNCIL OF MEDICAL RESEARCH -NEURO COGNITIVE TOOLBOX (ICMR-NCTB). Available from:

Porrselvi, A.P., Shankar, V., 2017. Status of Cognitive Testing of Adults in India. Ann. Indian Acad. Neurol. 20, 334–340.

Prince, M. J., De Rodriguez, J. L., Noriega, L., Lopez, A., Acosta, D., Albanese, E., … & Uwakwa, R. (2008). The 10/66 Dementia Research Group’s fully operationalised DSM-IV dementia computerized diagnostic algorithm, compared with the 10/66 dementia algorithm and a clinician diagnosis: a population validation study. BMC public health, 8(1), 1-12.

To date, we found no guidelines specifying any difference in diagnostic assessment according to geographical areas. However, the practice might differ according to availability of healthcare facilities.

There are no national or county guidelines in Kenya on dementia management, making clinicians to rely on the typical path described previously. In one of the counties (Makueni) in Kenya, clinicians were trained by the Africa Mental Health Foundation (NGO) using the mental health Global Action Programme (mhGAP) (World Health Organization, 2016) to identify and manage priority conditions such as dementia. However, due to limited mental health budget, it was not possible to roll-out the programme to all the counties in Kenya  (Mutiso, Gitonga, et al., 2018). This makes it difficult to identify any differences in assessment in the different regions.


Mutiso, V. N., Gitonga, I., Musau, A., Musyimi, C. W., Nandoya, E., Rebello, T. J., … Ndetei, D. M. (2018). A step-wise community engagement and capacity building model prior to implementation of mhGAP-IG in a low-and middle-income country: a case study of Makueni County, Kenya. International Journal of Mental Health Systems, 12(1), 1–13.

World Health Organization. (2016). mhGAP Intervention Guide version 2.0. Geneva, Switzerland.


No data is available. However, as specialist doctors are scarce and those available work in the main metropolitan areas, we would expect smaller cities and rural areas to have even less people with access to a diagnostic assessment.