Functional assessment can help exclude dementia cases. Figure1 scatterplots show the score distribution relationships between MMSE and MoCA, coded by diagnostic group and with lines denoting various possible cutoff scores. Thats what makes it important to complete these tests so the patient can receive help if its needed. Table 1 Demographic and clinical characteristics by cognitive group, Table 2 Discriminant validity of the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) for diagnosis of any cognitive disorder, Table 3 Discriminant validity of the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) for diagnosis of dementia, Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease. 2006;114(4):27380. The optimal screening cutoff point for detection of any cognitive disorder for the MoCA had greater specificity (0.53), PPV (0.46), and percent correctly diagnosed (64%) than the optimal MMSE screening cutoff point (specificity = 0.38; PPV = 0.39; percent correctly diagnosed = 54%). 21-24 points: mild dementia . Current smoking was identified as a risk factor with a 37.3 and 28.8% higher odds of MCI by MMSE and MoCA, respectively, compared to no smoking. One problem with the MMSE is its ceiling effect or limited dynamic performance range for normal individuals, which increases the likelihood that persons in predementia stages score within the normal range (24 and above) [5, 6]. Further, for clinicians wishing to detect cognitive impairment earlier, knowing the MCI score range using an office-based test like the MoCA would be very helpful. https://doi.org/10.1016/0895-4356(88)90034-0. ADNI is funded by the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, and through generous contributions from the following: Alzheimers Association; Alzheimers Drug Discovery Foundation; BioClinica, Inc.; Biogen Idec Inc.; Bristol-Myers Squibb Company; Eisai Inc.; Elan Pharmaceuticals, Inc.; Eli Lilly and Company; F. Hoffmann-La Roche Ltd and its affiliated company Genentech, Inc.; GE Healthcare; Innogenetics, N.V.; IXICO Ltd.; Janssen Alzheimer Immunotherapy Research & Development, LLC. Investigation of the prevalence of cognitive impairment and its risk factors within the elderly population in Shanghai, China. MMSE 19 for illiterate individuals, 22 for participants with elementary school education, and26 for those with middle school education and above [29]. Compr Psychiatry. Our MCI criteria were 1) 1.5 SD below the normative data mean on tests in at least 1 cognitive domain, 2) self-report of cognitive decline, and 3) preserved IADLs. If the difference was significant among three subgroups and above, multiple comparison was conducted by Student-Newman-Keuls. Office-based, multi-domain cognitive tests are commonly administered in clinical situations to evaluate patients with cognitive impairment. In this multicenter observational study, MMSE and MoCA were administered in a random . PubMed Federal government websites often end in .gov or .mil. The correlation between the MMSE and MoCA total scores in Chinese population aged 55years. 2019;19(1):1442. https://doi.org/10.1186/s12889-019-7803-0. While patients may actually try to practice at home by going through some of the test questions or try to memorize the answers, this effort will only skew the test by providing false results and could hurt the patient in the long run. Alzheimers Dement Diagn Assess Dis Monit. A modification of the Peterson criteria27 that allows for impairments in a range of cognitive domains, called the Winblad criteria,28 was used to diagnose MCI. National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, 100050, China, Xiaofang Jia,Zhihong Wang,Feifei Huang,Chang Su,Wenwen Du,Hongru Jiang,Huijun Wang&Bing Zhang, School of Public Health, Hebei Medical University, Shijiazhuang, 050017, China, Yongkang Center for Disease Control and Prevention, Yongkang, 321300, China, Yuelu District Center for Disease Control and Prevention, Changsha, 410013, China, Changde Center for Disease Control and Prevention, Changde, 415000, China, Shaanxi Provincial Center for Disease Control and Prevention, Xian, 710054, China, You can also search for this author in 2009;23(3):14450. Vertesi A, Lever JA, Molloy DW, Sanderson B, Tuttle I, Pokoradi L, et al. For Alzheimer disease, the sensitivity and. [, Janvin CC, Larsen JP, Aarsland D, Hugdahl K. Subtypes of mild cognitive impairment in Parkinsons disease: progression to dementia. 2019;12:12130. Does intellectual activity prevent cognitive impairment? J Am Geriatr Soc. Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, et al. [, Aarsland D, Bronnick K, Larsen JP, Tysnes OB, Alves G, for the ParkWest Study Group. B. and Dehlin, O. All statistical procedures were performed with SPSS 15.0 for Windows.32. Gladsjo JA, Shuman CC, Evans JD, Peavy GM, Miller SW, Heaton RK. Nazem S, Siderowf A, Duda JE, et al. Neurology 2005;65:12391245. Jia L, Quan M, Fu Y, Zhao T, Li Y, Wei C, et al. Lines in graphs indicate MMSE cutoff of 24 and MoCA cutoffs of 17 and 19. Data used in preparation of this article were obtained from the Alzheimers Disease Neuroimaging Initiative (ADNI) database (adni.loni.usc.edu). And the agreement disparity could attribute to the difference in the functions of the instruments themselves, in which MoCA was developed in particular for MCI screening [8] whereas MMSE was originally invented as a tool to detect and monitor the development of dementia [7, 39]. The MMSE and MoCA were collected from post-stroke patients (within 15 days to 1 month after stroke, including ischemic stroke and hemorrhagic stroke) in 14 hospitals of northern and southern China (including 10 top-graded hospitals and 4 community hospitals) between June 2011 and September 2013. Diagnostic procedures for Parkinsons disease dementia: recommendations for the Movement Disorder Society Task Force. According to the definition of MCI, we excluded subjects because of their inability to perform basic activities of daily living involving eating, dressing, bathing, toileting, grooming, transferring bed or chair, walking across a room, and urinary or fecal continence (n=71). doi: 10.1002/14651858.CD006430.pub3. Regardless of diagnosis, 37.1% of the study population had deficits in 2 domains, 22.7% had deficits in 1 domain, and 40.2% had no domain deficits. A Movement Disorder Society task force recommended diagnostic criteria for probable PDD16,26 that included cognitive deficits in at least 2 of the 4 core cognitive domains (attention, executive functions, visuospatial, and memory), as well as cognitive deficiency severe enough to impair daily life (e.g., inability to manage finances and cope in social situations). Razali R, Jean-Li L, Jaffar A, Ahmad M, Shah SA, Ibrahim N, et al. Trzepacz PT, Hochstetler H, Wang S, Walker B, Saykin AJ, Alzheimers disease neuroimaging I. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Before By using this website, you agree to our Mini-Mental State Examination (MMSE) abnormal result 29. All analyses were carried out in SAS version 9.2 unless specified otherwise. Moser DJ, Cohen RA, Clark MM, Aloia MS, Tate BA, Stefanik S, et al. Mov Disord 2008;23:9981005. If a patient comes in and is clearly functionally impaired, theres no need for that highly sensitive test., The MoCA discriminates very well between normal cognition and mild impairment or dementia, but its too difficult for moderate to severe conditions, says Barbara Messinger-Rapport, MD, PhD, director of the Center for Geriatric Medicine at the Cleveland Clinic. 2016 Jun;11(4):420-4. doi: 10.1177/1747493016632238. Google Scholar. PubMed Central Int Psychogeriatr. Additional file 1:(30K, docx) Development and validation of a geriatric depression screening scale: a preliminary report. The MMSE is the most widely used cognitive screening test by physicians and researchers for general cognitive evaluation [2]. Ther Adv Endocrinol Metab. Tombaugh TN, McIntyre NJ. Sensitivity, specificity and cut-off scores of the MoCA to detect mild cognitive impairment or Alzheimer's disease and distinguish it from . The MoCA [3] was developed more recently to address the shortcomings of the MMSE in detecting MCI. Compared with the MMSE three-step command test (15.5%), the MoCA trail-making (57.8%), abstraction (48.0%) and abstraction (measurement tool; 45.7%) detected more patients with executive dysfunction (P < 0.001), whereas the MoCA digit span forwards (4.3%) and backwards (11.6%) detected fewer patients (P < 0.001 and P = 0.005, respectively). According to Chinese MoCA norms [27], 13 for illiterate individuals, 19 for individuals with 16years of education, and24 for those with 7 or more years of education. You may switch to Article in classic view. The sample was 75.8% male and 94.7% white, and mean (SD) age = 65.1 (9.7) years, PD duration = 6.3 (5.3) years, and education = 16.4 (3.1) years. In both tests, the strictest cut-off points were used to avoid false positives (23 in the MoCA and 24 in the MMSE). Prevalence of dementia in rural China: impact of age, gender and education. Differential effects of body mass index on domain-specific cognitive outcomes after stroke. volume21, Articlenumber:485 (2021) The cultural and linguistic modifications of MoCA Beijing version we used from the original English version were also concretely described [27]. The idea of undergoing testing for possible cognitive impairment is often daunting to older patients, who may become nervous and worry that their anxiety will only make the results worse. MoCA normal result 27. However, because test distributions were similar at the recommended cutoffs and highly correlated in the dementia group (r=.86), these tests can be considered more comparable for use in dementia patients. J Neural Transm (Vienna). Siqueira GSA, Hagemann PMS, Coelho DS, Santos FHD, Bertolucci PHF. Mild cognitive impairment. Cons The Adaface Mocha Online test screens candidates for the typical skills recruiters look for in a QA tester: Understanding of QA practices and automation testing. The neuropsychological battery included measures in the following 4 cognitive domains: memory (Hopkins Verbal Learning Test [HVLT]20), executive abilities (Tower of London-Drexel [TOLDX],21 Stroop Color-Word Test,22 and Semantic Verbal Fluency23), attention (Backward Digit Span), and visuospatial (Cube Copying, which was extracted from the MoCA and rescored for this purpose using a more detailed methodology outlined below). As MCI becomes a more commonly targeted population for clinical trials, the ability to capture the full range of MCI cases is crucial. PLoS One. MoCA LINIC DATA. The overall MCI prevalence was 28.6% for MMSE and 36.2% for MoCA. The study cohort was reflective of the overall clinic populations in terms of sociodemographic characteristics, clinical status, and global cognition, as compared to a larger sample of 884 subjects from the 2 centers (data not shown). California Privacy Statement, The percentages of subjects screening positive for possible cognitive impairment were 57%/53% (MMSE/MoCA) for the PD patients and 50%/32% for the controls. Both tests detected amnestic MCI better than nonamnestic single-domain impairment. *Time: >6 months between index and reference tests. 1982;17(1):3749. Eshkoor SA, Hamid TA, Mun CY, Ng CK. For mild impairment, the MoCA is the better test, says Abhay Moghekar, MBBS, an assistant professor of neurology at The Johns Hopkins University School of Medicine in Baltimore. 2009 Nov 24; 73(21): 17381745. [14] and in similar diagnostic groups. Questionnaires were used to collect information on age, gender, educational level, current employment status, household income, residence area, current smoking, alcohol intake during last year, sleep duration covering daytime napping and full-night sleep, and disease histories of hypertension, diabetes, stroke and myocardial infarction by trained investigators. S Hoops, BA, S Nazem, BA, [], and D Weintraub, MD. Present study further focused on cognitive domains tested by both MMSE and MoCA, and found significant increased trends in proportions of subjects with cognitive dysfunction in terms of orientation, execution, calculation, naming, repetition, visuoconstruction and recall by MMSE across strata of the corresponding cognitive domain score by MoCA (all p<0.0001, Fig. https://doi.org/10.1016/j.archger.2017.11.003. First, we evaluated score distributions and their overlap for the MoCA as compared to the MMSE using ADNI data for 618 cases. Sains Malaysiana. We certainly dont want patients to be uncomfortable. Study protocols were approved by each sites IRB/REB (Additonal file 1). J Geriatr Psychiatry Neurol. 2012;13(7):6269. A comparison between the MoCA and the MMSE visuoexecutive sub-tests in detecting abnormalities in TIA/stroke patients. These investigators and others who have evaluated lower MoCA cutoff values of 23 [12, 18, 19] and 20 [20] report increased detection of impaired MCI cases from HCs but risk leaving more subtly impaired MCI cases within the normal range. [, Winblad B, Palmer K, Kivipelto M, et al. 2018;33(7):9729. Read free for 30 days The ceiling for MMSE is that a highly educated person may score well on the MMSE but not be able to recognize their grandchildren, she says. Unable to load your collection due to an error, Unable to load your delegates due to an error. "If you wish to continue using the MoCA Test without being officially trained and certified, you will be at increased risk for. As research increasingly focuses on milder stages of AD [11], options other than the MMSE are needed for clinicians for earlier diagnosis and management. Mild cognitive impairment (MCI), referring to cognitive decline from a previous level of functioning both subjectively and by objective evidence, represents the preclinical, transitional stage between healthy cognitive aging and dementia, and affects 1015% of the population over the age of 65 [2]. Mean (SD) MoCA and MMSE scores were 25.0 (3.8) and 28.1 (2.0). The Montreal Cognitive Assessment (MoCA) was developed to enable earlier detection of mild cognitive impairment (MCI) relative to familiar multi-domain tests like the Mini-Mental State Exam (MMSE). The analysis was performed using the equate library in the R statistical program. MMSE had good correlation with MoCA (Spearman correlation coefficient = 0.8374, p < 0.0001) and moderate agreement for detecting MCI with Kappa value of 0.5973 ( p < 0.0001). MMSE normal result = 30. Because of the non-normal distribution, non-parametric Wilcoxon rank-sum test or Kruskal-Wallis analysis was performed to test differences in distribution of MMSE or MoCA total score by sociodemographic and health-related factors. Google Scholar. 2022 Feb 1;11(3):798. doi: 10.3390/jcm11030798. The Canadian Institutes of Health Research is providing funds to support ADNI clinical sites in Canada. J Psychiatr Res. Mov Disord 2008;23:18671874. found a higher correlation of the MoCA than MMSE with neuropsychological tests for memory, executive functioning, visuospatial, and the Mattis Dementia Rating Scale [17]. better homes and gardens no touch sensor trash can manual fun places to have a birthday party for 11year olds girl SW participated in the design of the study and performed the statistical analyses. Clinical Gerontology: A Guide to Assessment and Intervention. Changes in criteria and differences in populations studied and methodology have produced a wide range of prevalence estimates for MCI. https://doi.org/10.1002/gps.5016. Jia, X., Wang, Z., Huang, F. et al. SC, DW, JH, WJ, WF, SW, XH, and WY collected and managed the data. Ceiling effect for MCI was less frequent using MoCA versus MMSE according to the distribution of total score. Use of a functional tool such as the FAQ can help discern dementia patients with MoCA scores overlapping in the MCI range and more sensitive neuropsychological testing can be done for HCs with overlapping scores. J Intern Med 2004;256:240246. Subjective reports of cognitive decline and impairment in IADLs were obtained from subjects by the study PI (D.W.) during an unstructured interview (in person or by telephone, asking participants if they had noted any meaningful change over the course of PD in their ability to plan, remember, pay attention, or complete tasks), and when available the input of informed others was solicited. Mov Disord 2007;23:297299. Giri M, Chen T, Yu W, L Y. The MoCA and MMSE optimal diagnostic cutoff points were 20/21 and 25/26. A Systematic Review. Controlling for age, sex, and educational level, there were no significant between-group differences in MoCA or MMSE scores (data not shown). Functional Activities Questionnaire (FAQ) was evaluated as a strategy to separate dementia from MCI. Average score of cognitive test using MMSE and MoCA in total population was 25.54.9 and 22.66.1, respectively (Table 2), and the MoCA RSD% (26.9%) was significantly greater than that in MMSE (19.0%) (p<0.0001). The greater RSD% in MoCA (26.9%) relative to that in MMSE (19.0%) further suggested MoCA distributed samples across a broader score range with less ceiling effect and had better detection of cognitive heterogeneity of the sample [33]. Both consistently demonstrated adequate level of concurrent validity between MoCA Beijing version and the Chinese version of MMSE for community dwellers. Correspondence to https://doi.org/10.1159/000338905. The discriminant validity of the MoCA and MMSE as screening and diagnostic instruments was ascertained. Table2 presents demographic, test, and rating scale scores for each diagnostic group. Is the Montreal Cognitive Assessment superior to the Mini-Mental State Examination to detect poststroke cognitive impairment? Based on the distribution of each cognitive domain subscore in total samples assessed by different items of MMSE and MoCA (Table4), the performance of execution, repetition and registration among 75% subjects using MMSE met maximum scores, whereas executive and recall dysfunctions were found in about 75% participants by MoCA test. Ciesielska N, Sokolowski R, Mazur E, Podhorecka M, Polak-Szabela A, Kedziora-Kornatowska K. Is the Montreal cognitive assessment (MoCA) test better suited than the Mini-mental state examination (MMSE) in mild cognitive impairment (MCI) detection among people aged over 60? Odessa, FL: Psychological Assessment Resources; 1988. Second, while the MoCA includes a minor correction for lower educational levels, the MMSE does not, which affects the diagnostic accuracy of the latter in highly educated individuals.40 Third, the majority of patients had mild to moderate PD (i.e., Hoehn & Yahr stages 13). windows 10 new boot drive . https://doi.org/10.1111/j.1600-0404.2006.00641.x. Cognitive tests for the detection of mild cognitive impairment (MCI), the prodromal stage of dementia: Meta-analysis of diagnostic accuracy studies. Assessing many of the same areas as the MMSE, the MoCA is a little more in depth and includes tasks such as a clock-drawing test and a trail test (connecting the dots). 2012;47(6):2708. The scores are generally grouped as follows: 25-30 points: normal cognition. Increasing age (MMSE: OR=2.073 for 75years; MoCA: OR=1.869 for75years), female (OR=1.280 for MMSE; OR=1.163 for MoCA), living in county town (OR=1.386 and 1.862 for MMSE and MoCA, respectively) or village (OR=2.579 and 2.721 for MMSE and MoCA, respectively), smoking (OR=1.373 and 1.288 for MMSE and MoCA, respectively), hypertension (MMSE: OR=1.278; MoCA: OR=1.208) and depression (MMSE: OR=1.465; MoCA: OR=1.350) were independently associated with greater likelihood of MCI compared to corresponding reference group in both scales (all p<0.05). This site needs JavaScript to work properly. 2016;123(4):4318. Items and domains for the MMSE and MoCA are provided in Table1. 2019;24(1):7887. First, the MMSE was conducted, and a score 23 was interpreted as dementia [39,40]. 1. Montreal Cognitive Assessment (MoCA) abnormal result 26 (screening cutoff point). People who smoked currently and drank alcohol last year accounted for 15.6 and 17.1%, respectively. Getting an answer wrong or a low score does not mean a patient is stupid. Zhang Z, Hong X, Li H, Zhao J, Huang J, Jing W, et al. Attention deficit was a score 4 on the Backward Digit Span, as recommended for the elderly.24 Finally, visuospatial deficit was a score of 02 on a 5-point scale scoring method for Cube Copying.25 Due to impaired color discrimination, approximately 10% of subjects were unable to perform the Stroop. Bing Zhang. Sci Rep. 2019;9(1):851. https://doi.org/10.1038/s41598-018-37286-z. Scatter plot of Fig. Present study targeted at subjects recruited in the cohort of AD. 2017;17(12):232935. ADNI data are disseminated by the Laboratory for Neuro Imaging at the University of Southern California. The Mini-Mental State Examination: A comprehensive review. We found a broader score distribution for MCI subjects on the MoCA than the MMSE, with a reduced ceiling effect. We found that the MoCA has good overall discriminant validity as a global cognition assessment instrument for the detection of MCI or dementia in PD. Pendlebury ST, Markwick A, de Jager CA, Zamboni G, Wilcock GK, Rothwell PM. All findings indicated serious condition of cognitive impairment along with progressive increase in the growth rate of aging population in China and huge challenges on the prevention and treatment of MCI to the society and government. Methods: [24], education influenced MoCAs test performance in unpredictable manner, those with more education performed poorer relative to those with less education, which was likely to attribute to tests of MoCA domains of naming, attention, language, abstraction, and orientation. [, Kalbe E, Calabrese P, Kohn N, et al. Fu C, Jin X, Chen B, Xue F, Niu H, Guo R, et al. Specificity for . MCI was identified using education-specific cutoff points of total scores of MMSE and MoCA, respectively. It is also necessary to distinguish whether there is disparity in potential factors for cognition when applying different cognitive screening tools to the same population. 2005;53(4):6959. Without doing a variety of tests, some issues can be missed.. We would like to acknowledge writing assistance from Sara Kollack-Walker, Ph.D. and Kory Schuh, Ph.D., Associate Consultants Scientific Communications, Eli Lilly and Company. Its only meant to help.. The detection of dementia and cognitive impairment in a community population of elderly people with Parkinsons disease by use of the CAMCOG neuropsychological test. Significant positive correlation between total scores of MoCA and MMSE was also found in the assessment of cognitive deficit associated with chronic diseases [37, 38]. The sum of included item points was the subscore of cognitive domain. J Am Med Dir Assoc. AD dementia subjects had MMSE scores between 2026 (inclusive), Clinical Dementia Rating Scale (CDR) scores of either 0.5 or 1.0, and all met National Institute of Neurological and Communicative Disorders and Stroke/Alzheimers Disease and Related Disorders Association criteria for probable AD. 1988;41(10):9718. Correlation between Moca and mmse for the assessment of cognition in schizophrenia. Freitas et al. Based on subjects in ADNI, we recommend a MoCA score range for MCI using a lower threshold of 17 to 19, depending on the levels of sensitivity and specificity preferred, and an upper limit of 30. Part of 2014;43(5):4628. Dr. Weintraub has served on a scientific advisory board for Boehringer Ingelheim; serves on the editorial board of Movement Disorders; has received honoraria from Boehringer Ingelheim, ACADIA Pharmaceuticals Inc., Novartis, Osmotica Pharmaceutical Corp., BrainCells Inc., Merck Serono, Sanofi-Aventis, and Pfizer Inc.; and receives research support from Boehringer Ingelheim and the NIH [K23 MH067894 (Principal Investigator)]. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. A cutoff of 24 points for the MMSE and cutoffs of 17, 19, and 23 for the MoCA were denoted in scatterplots to show the lower ends of the potential MCI score ranges. Therefore, some caution is advised when interpreting the low end where very few of our cases were severely demented, and our conversion was most different from Roalf et al. Fahn S, Elton RL, the UPDRS Development Committee. Items that were not similar between the two tests were excluded from these domains. In subsequent visits, diagnoses could change and were not restricted by these entry score ranges on the MMSE. The optimal cutoff MMSE scores for MCI and dementia were 27 and 24, respectively. A cutoff of 17 on the MoCA may help capture early and late MCI cases; depending on the level of sensitivity desired, 18 or 19 could be used. Defrancesco M, Marksteiner J, Deisenhammer EA, Hinterhuber H, Weiss EM. https://doi.org/10.1016/j.comppsych.2013.04.010. Springer Nature. The MoCA is a widely used cognitive screening tool, composed of 19 items that evaluate eight cognitive domains, including executive skills, naming, memory . Lam et al. Mov Disord 2009;24:11031110. Clinical diagnostic criteria for dementia associated with Parkinsons disease. BMC Psychiatry 21, 485 (2021). Objective cognition was assessed by Chinese versions of MMSE and MoCA, and total score and subscores of cognitive domains were calculated for each. The optimal cutoff score on the MoCA was 23.5, with a high AUC of 0.89. https://doi.org/10.1017/S1041610218001527. Scatterplots and Pearson correlations were applied for better understanding of the relationships amid the within-case MoCA and MMSE scores for MCI compared to HCs and AD dementia cases. The more difficult content in the MoCA may enhance its sensitivity to detect earlier symptoms when the upper MCI score is 30. Aim: Psychometric properties for the detection of any cognitive disorder are listed in table 2. Athey RJ, Porter RW, Walker RW. J Clin Med. Amieva H, Mokri H, Le Goff M, Meillon C, Jacqmin-Gadda H, Foubert-Samier A, et al. The online version of this article (doi:10.1186/s12877-015-0103-3) contains supplementary material, which is available to authorized users. 3. In: Fahn S, Marsden CD, Calne D, Goldstein M, eds. Moreover, increasing age, female, living in county town/village, smoking, hypertension and depression significantly increased the risk of MCI in both tests. Prevalence and correlates of cognitive impairment and depression among elderly people in the worlds fastest growing city, Chongqing, Peoples republic of China. Paula T. Trzepacz, Email: moc.kooltuo@zcapezrttp. Ashford JW, Borson S, O'Hara R, et al.
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