The association of smart mobile phone usage with cognitive function impairment in Saudi adult population

Background & Objectives: Excessive use of mobile phones has raised a great concern about adverse health effects on human health. The present study’s aim was to investigate the association of the usage of smartphones with cognitive function impairment in the Saudi adult population. Methods: The present cross-sectional study was conducted in the Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia during September 2019 to January 2020. A total of 251 Saudi adults who were using mobile phones were recruited, and knowledge, attitude and practices were assessed by interview using a predesigned proforma. The Montreal Cognitive Assessment (MOCA) tool was employed to assess the cognitive functions, comparison was made between daily mobile phone usage group and their correlated Montreal Cognitive Score (MOCA). Results: The mean age for 251 Saudi adult participants was 32.43 ± 12.8 years. More than 80% of the participants used their mobile phone for more than two hours daily. About 61% of the participants were not aware of the side effect of the radiation generated from mobile phone. The participants showed a decrease in MOCA score with increased daily mobile phone usage (MOCA=26.8 for <1 hour daily usage, 26.1 for 1-2 hours, and 24.6 for >2 hours with P< 0.05). In addition, participants showed decreased MOCA score by keeping their mobile phone near their pillow while sleeping; MOCA=24.35 for near pillow groups and >25.5 for the groups that placed their mobile phone away from the pillow. Conclusions: Excessive use of mobile phones can cause cognitive function impairment. Strict policies must be implemented to control the use of smartphones in order to minimize the effects on mobile phone radiation on cognition. The media has to be on the forefront in educating the public about the proper usage of mobile phones.


INTRODUCTION
The smartphones are containing multiple sophisticated features and became an inherent part of human life. It allows users to keep personal information, health and financial data, pictures and memories. Smartphones also became an integral part of modern telecommunications facilities, knowledge and multiple learning options to users, and becomes source of daily activities. The use of smart phone has increased in the last decade, and there is a great debate among people that whether smart phones have facilitated their daily tasks and have made every day life's needs more convenient. 1,2 The literature shows that mobile phones can negatively affect the human health. 3,4 The World Health Organization (WHO) revealed that exposure to Radiofrequency Electromagnetic Field Radiation (RF-EMFR) generated from mobile phones increases body core temperature and can cause cognition functions impairment. 5 The children who are exposed to RF-EMF radiation exhibit decreased motor skills as well as attention span and working memory, 6 poor attention and concentrations. 7,8 Moreover, literature also acknowledge the adverse effects of smartphone. [9][10][11][12][13] Although limited research has been conducted concerning the potential cognitive impacts of smartphone use in the Saudi society, the present study aim was to determine the association of use of smart mobile phone with cognitive function impairment in Saudi adult population.

METHODS
The present cross-sectional study was conducted in the Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia during September 2019 to January 2020. A total of 251 Saudi adult volunteers aged from 15-65 years using mobile phones were invited to participate in this study. Knowledge, attitude and practices were assessed by interview using a specially designed questionnaire in Arabic or English languages. Three questions were designed to determine the awareness of participants about mobile phone hazards. The Montreal Cognitive Assessment (MOCA) was used to assess cognition. From all the participants, a written consent was obtained who voluntarily agreed to join the research project, where they have the opportunity to read the research objectives and join or withdraw from the research at any time, without any profits or penalties. Subjects were recruited through convenience sampling technique. MOCA scores range between 0 and 30, score of 26 or over was considered normal, lower scores <26 indicate mild cognitive impairment (MCI). 14 Selection Criteria: Mobile phone users with history of known psychiatric disorders, central nervous system disorders, living near high voltage electricity towers, and subjects with chronic debilitating disorder such as diabetes mellitus, cardiac failure, malignancy were not included in the study. Participants who were below 15 or above 65 were excluded. Mobile phone users who smoke cigarette, shisha were also excluded. One investigator interviewed 251 volunteer male and female mobile phone users and a detailed clinical history was obtained, participant demographic and other characteristics were obtained (Table-I and II). Ethics Statement: This study was executed in harmony with the "Declaration of Helsinki," and the protocol was approved by the "Institutional Review Board, Ethics Committee," College of Medicine Research Centre, King Saud University (E-19-4232). Statistical Analysis: The data were entered into the computer, SPSS V. 22 and Microsoft Windows was used. Continuous variables were expressed as the mean ± standard deviation and descriptive data were expressed as percentages (%). Variables were compared between different groups by oneway ANOVA regarding all variables of knowledge, attitude and different practices of smart mobile phone users. Proportions were compared between different groups using Chi-square test. A p value <0.05 was considered significant.

RESULTS
More than 61% of the participants used the mobile phone for more than 10 years Table-I. More than 80% of the participants used the mobile phone for more than two hours daily. Table-II. In addition, more than 61% of participants used handheld mode for calling rather than placing the mobile phone away from body in order to minimize the radiation effect (Table-III). About 54% of the participants placed their mobile phone near their heads while sleeping. About 61% of the participants were not aware of the side effect of the radiation of the mobile phone.  The participants who exceeded two hours of daily usage, in them MOCA score decreased below normal (Fig.1). It also showed a significant difference between groups in the MOCA score except between those who used the mobile less than one hour and two hours.

Mobile Phones and MCI
The association of placement of the mobile phone while sleeping on cognition scores was also assessed (Fig.2). It was noticed that MOCA score was higher while users placed the mobile phone away while sleeping. Even though the effect of the placement of the mobile phone during sleep did not bring the scores to the normal level, but there was a significant effect on the scores. Fig.2 also shows significant difference between the effect of the placement of the mobile phone near the pillow and placing it inside the bedroom or outside on the MOCA score, but there was no significant difference between placing the mobile phone near the pillow and inside the bedroom versus outside the bedroom. However, there was no effect of the placement of the mobile phone while not calling on the scores (Table-IV).

Exposure to Radiofrequency Electromagnetic
Field Radiation (RF-EMFR) has various effects on human health including fatigue, headache, tension, sleep disturbance, 15 hearing and vision complaints 16 and risk of type 2 diabetes mellitus. 17 Extensive fixing of mobile phone base station towers (MPBSTs) in densely populated commercial, residential areas, and school buildings has started community concerns about adverse effects on human health, 6 mainly on brain functions. 18 To the best of our knowledge, this is the first study that investigate the relation between the knowledge, attitude and practices of mobile phone usage with cognitive impairment in Saudi adult population. In this study, it was identified that the cognitive functions were deteriorated with the increase daily usage of mobile phone. The present study results are in line with the results of other studies published in different countries. In the present study, the deterioration of cognitive function due to mobile usage was consistent with the conclusion of earlier published literature. 19 Arns et al. 20 reported that decrease in brain activity was associated with the use of mobile phone 22. In addition, Kalafatak et al. 8 found that mobile phone usage has a significant negative impact on working memory performance. The effect was noticed even after the 5-minutes use of mobile phone.
It has also been reported that continuous using or checking of the smart phone screen was associated with cognitive function impairment. The present study has explored how performance was affected among individuals who use their phones to take    a break from job tasks. The data showed that individuals who took break on their phones have shown cognition decline which was evident on their weak performance. 21 Moreover, sleep disorders have been associated with excessive use of smart phones. 22 Consequently, less sleep duration can lead to impairments in cognitions functions. In addition to the daily usage, deterioration of cognition was associated with placement of mobile phone while sleeping and subsequently cognitive deterioration. The present study results are in consistent with other studies which concluded that mobile phones can affect cognition functions as a result of sleep disturbance. 23,24 The general population need to be educated and counselled on the proper usage and practices of mobile phones. They need to be compelled to ensure mobile phone usage only for essential tasks and should be organized so it will not affect the performance of the students and the employees. Paul et al. 25 suggested that it is highly needed to teach people to be educated and structured, to know when to have the cell phone on, and to avoid becoming the slave of technology instead of its mastery. In addition, media has to come to frontline to educate the public about the side effects of the improper usage of such device.

Strengths of the study:
This is the first study to investigate the effect of mobile phone usage on cognition functions in Saudi adult population. The study exclusion criteria were highly standardized.
Limitations of the study: It includes its crosssectional design and small number of sample size. It was very difficult to find participants who use mobile phone less than one hour daily which reflected that it has become a known habit in the society. The reason to find more participants who used mobile phone for less than two hours was the attempt to increase the sample size. The difficulties to find non-smoking participants, without any debilitating disorders or central nervous systems disorders, and not living near high voltage electricity towers to eliminates the effects of these factors on the results should be countered. Further studies with larger sample size are essential to confirm the current evidence of the role of mobile related disturbance to cognition.

CONCLUSIONS
Excessive use of mobile phone is associated with cognitive function impairment assessed by Montreal cognitive Assessment (MOCA) score. The health authorities should employ strict policies regarding mobile phones in order to minimize their hazardous effects on human health including cognitive functions impairment. The media has to be on the forefront in educating the public about the proper usage of mobile phone.