Design, participants and procedure
The study was cross-sectional conducted from the 1st of Dhul Hijjah of the year 1438 Hijri Calendar (the 23rd of August 2017) until the 8th of Dhul Hijjah of the year 1438 Hijri Calendar (the 30th of August 2017). Pilgrims who are 60 years old or older, attending Hajj season 1438 Hijri Calendar (August 2017), speak the Arabic language and able to write Arabic numbers were included in the study. Pilgrims were excluded if they did not complete the study questionnaire or refused to participate.
A multi-stage random sampling method was used, stratified by gender. The Hajj organizing “Twafa” establishments of countries where the majority of their pilgrims speak Arabic were approached. These countries were, in alphabetical order, Algeria, Bahrain, Egypt, Eritrea, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Saudi Arabia, Sudan, Syria, Tunisia and Yemen.
A list of offices affiliated with each establishment was sought. Offices were chosen randomly, but in case of difficulties, offices that were ailing to help were approached for convenience. A list of buildings and hotels managed by each office were sought with numbers of registered pilgrims in each. A random sample of buildings was selected, and within each, a pre-specified number of pilgrims were targeted within each building, the pilgrims with even numbers in the pilgrims’ list were approached. Those who met the study criteria were included until the prespecified number of pilgrims were completed, satisfying a male to female ratio of 1:1.
Material and instruments
The study protocol was approved by the Ethics Committee of Security Forces Hospital Program (No. 0124-210817). Before data collection, all participants and their relatives were informed about the study purpose and its procedure. Pilgrims were interviewed for demographics; whether travelling alone or with someone else; whether they think they need help to perform Hajj, by whom, and what the type of help they need; medical history; history of visiting a clinic for memory problem; history of a diagnosis with a disease related to a memory problem; and whether needed medication for memory problems. Then, pilgrims underwent the Mini-Cog [20] and were asked to complete the Arabic version of the ADL instrument either by themselves or by the help of their caregivers/relatives [21].
The Mini-Cog is a 3-min cognitive screening tool that can detect cognitive impairment in older adults. This brief instrument was initially designed for community setting and was found to be free of cultural and educational biases [20, 22]. A recent systematic review indicated that the Mini-Cog could be used as an alternative tool to the Mini-Mental State Examination (MMSE) with better sensitivity and specificity although further studies were suggested to provide better evidence on the diagnostic accuracy [23, 24]. It consists of two components, a recall task of three unrelated words and a clock-drawing test (CDT). Scores range from 0 to 5. Each recalled word scores 1 point. For CDT scores, 2 points are scored for a normal CDT. Since there are different ways to administer the CDT, the most commonly used method was used [25]. Pilgrims were asked to draw the circle, write the clock numbers, and draw the clock hands indicating the time of 10:11. A normal CDT was considered if all time numbers were correctly written and the hand positions pointed to the specified time (10:11). Otherwise, 0 for poorly or partially performed CDT was recorded. A recent systematic review reported a high accuracy of the CDT in the diagnosis of dementia [26]. For Arab elderly, scores of the CDT was found to show significant correlations with scores of the MMSE supporting the validity of the CDT for Arab elderly [27].
The ADL instrument is a questionnaire that screens elderly respondents for physical functioning and assesses the degree of dependence in their daily activities [28]. There are mainly two types of ADL, the basic and the instrumental [29]. The instrumental ADL (IADL) impairment is often apparent in mild to moderate cognitive impairment, while the basic ADL impairment may not be evident unless the cognitive impairment is severe. Since we did not find a validated Arabic IADL instrument, the validated ADL instrument by Ramzi Nasser and Jacqueline Doumit [21] was used. The instrument assesses six functional domains, which are dressing, bathing, going to the toilet, transferring, continence, and feeding. Each domain has a score of 0 (complete dependence), 0.5 (partial independence), or 1 (complete independence). The total scores of all six domains were summed, divided by 6, and then multiplied by 100. A score of 67 or above indicates “no or mild dependence”, 34 to 66 indicates “moderate dependence” and 0 to 33 indicates “severe dependence”. A score of 100 was also categorized as “full independence”.
Statistical analysis
SPSS, version 21.0 was used for all statistical analysis. Numeric data were presented as mean ± SD and range according to the type of distribution of each variable. For categorical variables, percentages were used. Comparison between groups made among pilgrim by Student’s t test, the Mann-Whitney test or the Kruskal-Wallis test according to data distribution and the number of compared groups. Chi-squared test was used for comparing categorical values. A Spearman’s rank-order correlation was run to examine the correlation between the scores of the MINI-Cog and the ADL.
To determine predictors for positive MINI-Cog, univariate logistic regression was used. Afterwards, significant predictors found in univariate analysis were analysed in multivariate logistic regression to determine their interaction effect on the response variable (positive MINI-Cog). Statistical significance was set at P < 0.05.