Development of Digital Neuropsychological Battery: A Use Case in Indian SLE Patients

Abstract

Despite India’s history of 40 years of neuropsychology, cognitive and psychological testing is still in its infancy. The diverse needs of linguistically, culturally, educationally, and socio-economically varied populations have resulted in a significant underrepresentation within this domain. The existing assessments’ gaps in applicability and reliability further compound the challenges faced in neuropsychological testing, especially in low and middle-income countries like India, characterized by diverse populations. To address the aforementioned challenges, we developed a prototype of a digital, language-independent neuropsychological test battery for a comprehensive assessment of cognitive health, psychological wellbeing, and quality of life. Our study specifically targets testing this battery among individuals affected by a complex autoimmune disease known as Systemic Lupus Erythematosus (SLE). SLE is a chronic disease that affects multiple organs in our body, including the central nervous system. This disease is frequently associated with a high prevalence of cognitive and psychological disorders, leading to a poor quality of life. Despite the increasing prevalence of SLE cases among the Asian population (range between 4.3-45.3/1 lakh), the neuropsychological data remain underrepresented. Factors such as poor consultant-to-patient ratio and inadequate tools to accommodate literacy, linguistic and cultural diversity hinder effective assessment. This study investigated the psychological and cognitive health of Indian SLE patients using a customized test battery tailored to meet the needs of India’s linguistically and culturally diverse population. A total of 102 SLE patients who met the 2012 SLE classification criteria volunteered to participate. The selection of SLE patient profiles was conducted by consultants who also provided the necessary medical records, including the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), to assess disease severity. Additionally, 105 healthy controls volunteered to participate, comprising two sub-groups: caregivers and college-going young adults. All the participants provided written informed consent, and the study was approved by Institutional Ethics committees. The battery comprised five cognitive tasks: Montreal Cognitive Assessment (MoCA) and indigenously oriented modified versions of the Attention Network Test (ANT), Sustained Attention to Response Task (SART), Picture Naming Task, and N-back working memory task. Additionally, it included five psychological tests: Patient Health Questionnaire (PHQ-9) for depression, Generalized Anxiety Disorder (GAD-7) for general anxiety, State-Trait Anxiety Inventory (STAI-T) for trait anxiety, Perceived Stress Scale (PSS-4) for stress, and World Health Organization Quality of Life (WHOQOL-BREF) for quality of life assessment. Results regarding psychological health indicated elevated levels of anxiety and stress among SLE patients, coupled with a reduced quality of life across physical, psychological, social, and environmental domains compared to healthy controls. In terms of cognitive functioning, SLE patients exhibited impairments across multiple domains, including working memory, processing speed, executive functioning, sustained attention, and language proficiency, compared to healthy controls. Cluster analysis was used to identify factors that distinguished individuals within the SLE patient population to understand the heterogeneity associated with this complex disease. Our analysis revealed intricate correlations between mental health challenges in SLE patients and various factors such as social interactions, environmental influences, physical condition, age, education, and occupation. Furthermore, our analysis unveiled significant associations between disease severity (SLEDAI-2K), neuropsychiatric manifestations (NPSLE and non-NPSLE), education levels, and cognitive functioning in SLE patients. This comprehensive approach contributes to a deeper understanding of the complex interplay between psychological wellbeing, cognitive health, disease severity, demographic factors, and socio-environmental influences. It underscores the multifaceted nature of mental and cognitive health within the context of autoimmune disorders like SLE, paving the way for more targeted interventions and improved patient care strategies. In summary, our study represents one of the pioneering efforts in comprehensively assessing the cognitive and psychological health of Indian SLE patients. Our work not only addresses the underrepresentation of Indian SLE patients in neuropsychological studies but also facilitates the advancements in neuropsychological testing in India, transcending language and cultural barriers. The development of a prototype for a digital, language-independent battery marks a significant step forward in neuropsychological testing within India, particularly where awareness and resources for such assessments are often lacking. Further, it is essential to focus on standardizing and validating this battery in young Indian adults to facilitate its widespread utilization.