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Introduction: Population ageing is a phenomenon which started to be noticed at the dusk of 20th century and dawn of 21^st century. The phenomenon of population ageing is a result of demographic transition. Ageing poses some important questions regarding mental and physical health of the elderly people. Lack of mental ability, which might be associated to cognitive impairment, may lead to dementia

Objective: The objective of this paper is to screen for cognitive impairment by using Hindi Mini Mental State Examination among the elderly belonging to rural community in Uttar Pradesh, a northern state of India.

Method: The sample comprised 594 elderly people aged 60 years and above, drawn by applying multistage random sampling technique from the different parts of Uttar Pradesh and northern and most populous state of India. Bi-variate analysis has been done and result is shown with the help of tables and chart.

Result: It is evident in present study that more female fell into MCI than male elderly. The major per centage of the elderly respondents who screened as MCI belonged to 80 years and above age-groups, which indicated that increase in age may lead to cognitive impairment. It is also evident that having no education is also a risk factor for cognitive impairment.

The objective of this paper is to screen for cognitive impairment by using Hindi Mini Mental State Examination among the elderly belonging to rural community in Uttar Pradesh, a northern state of India.

Pandey NM, Tripathi RK, Tripathi SM, Singh B, Tiwari SC conducted a study entitled “Cognitive impairment among Hindi Mental State Examination positive community‑dwelling rural older adults” in year 2020. Their study is based on the archived data of Bakshi Ka Talab of Lucknow rural elderly study which was an exploratory study total of 17 villages were identified and selected for the study and a total of 11260 population were covered. Hindi Mini mental State Examination (HMMSE) was used for screening cognitive impairment among large community dwelling elderly people of Lucknow. A total of 1320 (11.7%) individuals were at the age of 55 years and above, of these 1243 (94.2%) individuals gave consent to participate in the study and their households were labelled as “in families.” After getting the sociodemographic details, the HMMSE was applied on all the participants. Among the total participants, 81 (6.5%) were found to be HMSE positive. Moreover, these + ves were further assessed on CAMDEX‑R for making ICD‑10‑based diagnosis. Of these, only 66 were diagnosed as a case of cognitive impairment (MCI or dementia). Cognitive impairment, Alzheimer’s’ dementia, and other problems were present in 81.5% of the HMMSE‑positive patients. Age‑wise description of positive cases is given in Table 2. With the advancement in age, there was a significant decline in all areas of cognition; however, most deterioration is present in the recent memory. Majority of the patients diagnosed as a case of cognitive impairment were within the age range of 70–79 years. It indicates that advancing age makes one more prone for worsening of cognitive functions. Hence, a person approaching the age group of 70–79 years should regularly undergo assessments for cognitive functions. It can be observed that majority of the patients with cognitive impairment were aged 80 years and above. The results of the study demonstrate that HMMSE is an effective and relevant screening tool for the rural community using cutoff 23 and it is worthy of application in epidemiological studies. On further evaluation, 81% of HMMSE positives were found to be cognitively impaired. A triad of BCRS, FAST, and GDS was found to be useful in determining the severity of cognitive impairment. The article describes HMMSE is an effective tool to screen cognitive impairment of community‑dwelling rural older adults. However, further research may be done to determine score range for HMMSE positives, which can be applied in the rural community of older adults and enable the researchers, clinicians, and academicians in the assessment of cognitive impairment/decline status (age‑related memory impairment, MCI, mild cognitive disorder, and dementia) (Pandey, N.M. et al., 2020).

Rakesh Kumar Tripathi, Shailendra Mohan Tripathi, Nisha Mani Pandey, Anamika Srivastava, Kauser Usman, Wahid Ali, Sarvada C. Tiwari conducted ICMR funded case − control study entitled, “A study to evaluate effect of DM, HT, and lipid profile on cognitive function” in year 2021.  The sample comprised of 150 older adults aged 60 years and above, residing permanently in central catchment areas Chowk, Lucknow, constituted the study sample. Authors administered semi structured interview schedule containing sociodemographic details and medical history proforma, Socioeconomic Status (SES) Scale, General Health Questionnaire – 12, SLUMS and HCST. They measured the Blood pressure of the respondents by Medical Research Assistant. Biochemical investigations for DM and DL were also carried out. Authors categorized the participants into two groups: (1) case groups (112): DM only + HT only + DL only and (2) control group (38): Without discernible abnormality of physical illness on the basis of investigations. Data were analysed by calculating percentage, mean, standard deviation (SD), Chi‑square test, and t‑test. The authors found that there was a statistically significant difference on cognitive status between control and DM group on recall, reading, copying, and on writing on HCST. A statistically significant difference was also found in writing between control and HT group. A statistically significant difference was found between control and DL on recall and writing. According to SLUMS control and DM group differ significantly for delayed recall and with HT and DL group on visuospatial function. Therefore, it is concluded from this study that cognitive status of older adults with DM, HT, and DL was found to be significantly impaired on specific domains as compared to the control group (Tripathi, R.K. et al., 2021).

Tak P, Rohilla J, Jhanwar S. conducted a study entitled “Comparison of two screening instruments to detect dementia in Indian elderly subjects in a clinical setting” in year 2021 of the medical OPD of a tertiary care teaching hospital in North India which consists total of 776 subjects aged 65 years and above and receiving treatment from medicine OPD in a tertiary care hospital were screened for dementia using AD 8 and Hindi Mini Mental State Examination (HMMSE). The clinical diagnosis was established after detailed clinical assessment using ICD‑10 criterion. The authors found that the comparison of receiver operating characteristic (ROC) curves showed that HMSE were better than AD 8 in detecting dementia. Although, increasing the cut-off value of AD 8 from a recommended score of ≥2 to ≥3 improved sensitivity from 35% to 48.9%, high false‑positive rate limited its utility as a cognitive screening tool. Conclusion: Although AD8 is easy to use and quickly administered with either patient or informant, it does not seem to be a suitable cognitive screening test for Indian elderly with chronic medical disorders. HMMSE at a cut‑off score of ≤23 is able to find out dementia among geriatric patients in a busy medical setting (Tak P, Rohilla J, Jhanwar S., 2021).

Panghal C, Belsiyal CX, Rawat VS, Dhar M. conducted a study entitled “Impact of cognitive impairment on activities of daily living among older adults of North India” in year 2022. It was a cross‑sectional descriptive study was conducted among 135 older adults visiting a selected tertiary care centre in Uttarakhand (India) during December 2020, recruited using total enumerative sampling. Data were collected using standardized and validated tools that consisted of socio‑demographic information, Hindi Mental Status Examination (HMMSE), and Everyday Abilities Scale for India. Data were analysed using SPSS version 23, including descriptive (frequency, percentage, mean, and median) and inferential statistics (Chi‑square test, binary logistic regression). The results with pooled analysis have shown that 30% of the older adults had mild cognitive impairment, 9% had moderate cognitive impairment, and 61% had normal cognition. About 16% of the older adults’ ADL were affected. The statistically significant predictors for cognitive impairment were age group 80 years and above, Muslim religion, and belonging to middle‑class families. Therefore, it may be concluded that a considerably large proportion of the older adults in sample of study had cognitive impairment, which further impacted activities of daily living. The authors suggested that an urgent need to develop geriatric mental health services across all hospitals in the region (Panghal, C. et al., 2022).

Pandit P, Kumari R, Tripathi A and Mishra P.  carried out a study entitled “Cognitive Functioning Among Community-dwelling Older Adults in Rural Population of Lucknow and Its Association with Comorbidities”. This study was published in 2024. It was a descriptive cross-sectional study was conducted among 350 older adults aged 60 years and above residing in rural areas of Lucknow. The sample was selected using multistage cluster sampling. The Hindi Mental State Examination (HMMSE) scale was used to assess cognitive function. A pretested semi-structured questionnaire was used to collect information on sociodemographic characteristics and comorbidity status. The authors as a result found that among 350 participants, with mean ± SD age 70.66 ± 9.53 years, the prevalence of CI as per HMMSE (<23) was 24.9%. Overall, the mean HMMSE score was less in individuals with (25.2) than without (27.19) comorbidities. Those with comorbidities had significantly lower mean scores in all individual domains of HMMSE. Hence, it may be concluded that CI affects one-fourth of the older adult population. Risk increases with the presence of comorbidities. Hence, screening, and early treatment are recommended (Pandit, P. et al, 2024).

This study is based on a sample of 594 elderly people belonging to the different parts of rural Uttar Pradesh, a northern state of India, under a survey entitled “Socio-Economic Status, Behavioural Problems and Health Hazards of the Elderly Across Diverse Settings in India”. A sample of 600 people was drawn by applying a multistage random sampling technique. For the selection of districts, a stratum provided by Planning Atlas Uttar Pradesh – 2006 was used. In this atlas five different stratums are given on the basis of Human Development index. From each stratum one district is selected randomly and two districts were selected from the lowest strata. After selecting the districts blocks and villages were selected randomly and finally household were selected randomly in each and every Bastis / Purvas of the selected village and 100 respondents were selected for the interview. Interview was conducted by researcher himself. Due to being unable to perform in HMMSE six cases were excluded from the analysis. Thus, this study deals with 594 elderly people only. The instrument of data collection was a personal interview method. A detailed information has been taken on the socio-economic status, behavioural problems and health hazards, etc. two types of structured interview schedule have been used in this survey- (1) household schedule, and (2) individual schedule. The individual schedule included data relating to health status of the elderly in relation to various socio-economic and cultural characteristics of elderly with particular references to appetite, digestion, memory, vision, sleeping, mental, etc as well as on the morbidity in respect of each elderly members of the household. Besides other information detailed information on the health-related problems of the elderly people was collected. Hindi Mini Mental State Examination, a Hindi version of Mini Mental State Examination (Folstein et al. 1975) modified by Mary Ganguly et al. 1995, was used for screening cognitive impairment in highly illiterate population of the elderly in rural Uttar Pradesh a northern state of India.

Independent Variables: In present study Sex, Age, Education, Type of Family, Religion, Type of House, Category (Constitutional classification of Caste in India), Self-Assessment of health of the respondents, other health Related Issues viz. Sleeping Disorder, Blood Pressure and Tuberculosis are independent variables.

Dependent variables: Hindi Mini mental State Examination was administered and score was recorded. According to the protocol of HMMSE the maximum score is 30 and obtained score was having 3 categories i.e. SCI, MCI and NCI. Since no case found with having SCI (0-17) therefore MCI (18-23) and NCI (24-30) were included and considered as dependent variable in this study.

In this study 600 respondents were interviewed, but due to unable to perform in HMMSE six cases were excluded from the analysis and this analysis is based on 594 respondents only. Out of 594 respondents 299 (50.3 per cent) were male while 295 (49.7 per cent) were female. Only 192 (32.3 per cent) were widow/widower while 402 (67.7 per cent) were presently married. In study area most of the population never attended school (76.8 per cent), while rest of the responded attend school and above. Age group is taken as 60 years and above and it is categorised as 60 – 69, 70 – 79, 80 – 89 and 90 years and above. Among all the respondents, 52.4 per cent respondents belong to the age group 60 to 69 age-group, 31.0 percent from 70 to 79 age-group, while 12.3 per cent were from 80 to 89 and 4.4 per cent respondents belongs to above 90 age group.

Dementia occurs as a result of a disease process. When a person is diagnosed by his/her physician, and is said to have a dementing illness - AD or a related disorder - it is because that person shows clear signs of impaired memory, thinking and behaviour. The first signs the family may see problems in remembering recent events and difficulty performing routine, familiar tasks. The person may also experience confusion, personality change, behaviour change, impaired judgment, difficulty finding words, finishing thoughts, or following directions. Alzheimer's disease is the most common cause of dementia. Also common is vascular dementia.

In HMMSE, 30 are the total score. After administrating HMMSE test successfully when a person scores between 24 to 30 he is declared of no cognitive impairment, when he scores between 18 to 23 than he has mild cognitive impairment (MCI), below 18 score is declared as severe cognitive impairment (Folstein, Folstein & McHugh, 1975).

Table 1. HMMSE Scores of the Respondents according to Sex and Age of the Respondents

Variables		Severity of Cognitive Impairment		Total
		MCI (18-23)	NCI (24-30)
Sex	Male	6 (2.0)	293 (98.0)	299 (100)
	Female	8 (2.7)	287 (97.3)	295 (100)
Age	60 -69	4 (1.3)	307 (98.7)	311 (100)
	70-79	5 (2.7)	179 (97.3)	184 (100)
	80 & above	5 (5.1)	95 (94.9)	99 (100)
Total		14 (2.4)	580 (97.6)	594 (100)

(The Percentage are shown in Parenthesis)

In this study no one was found with severe cognitive impairment. Among the total respondents, 2.4 per cent were reported with MCI, whereas 97.6 per cent had no cognitive impairment. It was found that 2 percent of total male and 2.7 per cent of total female was mild cognitive impaired. The percentage of MCI was more (5.1 per cent) in the respondents of 80+ age group (see table 1).

Table 2. HMMSE Scores of the Respondents according to Their Education, Type of Family, religion and Categories (Caste)

Variables		Severity of Cognitive Impairment		Total
		MCI (18-23)	NCI (24-30)
Education	Didn’t attend School	14 (3.1)	442 (96.9)	456 (100.0)
	Attended School Up to 8th	0 (0.0)	108 (100.0)	108 (100.0)
	Attended School 9th & above	0 (0.0)	30 (100.0)	30 (100.0)
Type of family	Alone	0 (0.0)	74 (100.0)	74 (100.0)
	Nuclear	1 (2.5)	39 (97.5)	40 (100.0)
	Joint	13 (2.7)	467 (97.3)	480 (100.0)
Religion	Hindu	10 (2.2)	451 (97.8)	461 (100.0)
	Muslim	4 (3.2)	120 (96.8)	124 (100.0)
	Christian & Others	0 (0.0)	9 (100.0)	9 (100.0)
Type of House	Kachcha	2 (1.5)	135 (98.5)	137 (100.0)
	Half-pakka	9 (3.6)	238 (96.4)	247 (100.0)
	Pakka	3 (1.4)	207 (98.6)	210 (100.0)
Category	OBC	4 (2.3)	172 (97.7)	176 (100.0)
	SC/ST	5 (2.0)	245 (98.0)	250 (100.0)
	Others	5 (3.0)	163 (97.0)	168 (100.0)
Total		14 (2.4)	580 (97.6)	594 (100)

(The Percentage are shown in Parenthesis)

It was found that prevalence of MCI was more among the illiterate respondents and it was 3.1 per cent among all the illiterate respondents. Surprisingly 2.7 per cent MCI respondents came from joint family, very close to the 2.5 per cent who came from nuclear family. Among 594 respondents 77.4 per cent were Hindu, 20.9 per cent were Muslim and rest belonged to Christian and other religion. Among the respondents belonging to Hindu religion, only 2.2 per cent screened as MCI whereas 3.2 per cent of the Muslim respondents screened as MCI. Out of total respondents, 3.6 per cent of MCI were living in half-pakka house-hold followed by kachcha HH (1.5 per cent), and again followed by pakka HH. Prevalence of Dementia was more among other category’s respondents, it was 3 per cent followed by O. B. C.’s respondents by 2.3 per cent, and prevalence of dementia was 2 per cent among S. C. Population. (1.4 per cent) (see table 2).

Chart 1. HMMSE Scores of the Respondents according to their Current Health Status

Chart 1 clearly shows that out of total respondents screened as MCI in the test, 57 per cent reported their health as bad while 36 per cent reported their health as moderate. Only 7 per cent of the respondent scored between 18-23 rated their health as good. If we look into the other side of picture, we find that, among the respondents who screened as NCI 35 per cent reported their health as bad, 46 per cent as moderate whereas 19 per cent rated their health as good.

Table 3. HMMSE Scores of the Respondents according to having other health related issues

Other health Related Issues	Severity of Cognitive Impairment		Total
	MCI (18-23)	NCI (24-30)
Sleeping Disorder	12 (2.9)	407 (97.1)	419 (100.0)
Blood Pressure	3 (3.3)	87 (96.7)	90 (100.0)
Tuberculosis	1 (11.1)	8 (88.9)	9 (100.0)

(The Percentage are shown in Parenthesis)

Table 3 depicts that 2.9 per cent of the respondents having sleeping disorder scored between 18-23 and having MCI whereas 3.3 per cent of the respondents suffering from blood pressure scored between 18-23 and had MCI. It also illustrates that 11.1 per cent of the respondents suffering from Tuberculosis scored between 18-23 and had MCI.

Using a community-based data taken from different parts of a most populous northern state in India, an attempt was made to search out some possible determinants of test score in HMMSE among diversified rural elderly population of Uttar Pradesh. The strength of the study is that it is based on a large and diversified population sample of elderly people. It is evident in present study that more female fell into MCI than male elderly. The major per centage of the elderly respondents who screened as MCI belonged to 80 years and above age-groups, which indicated that increase in age may lead to cognitive impairment. It is also evident that having no education is also a risk factor for cognitive impairment.

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