Validation of a European Cross-Cultural Neuropsychological Test Battery (CNTB) for evaluation of dementia

European cross-cultural neuropsychological test battery (CNTB) for the assessment of cognitive impairment in multiple sclerosis: Cognitive phenotyping and classification supported by machine learning techniques

BACKGROUND

The European Cross-Cultural Neuropsychological Test Battery (CNTB) has been proposed as a comprehensive battery for cognitive assessment, reducing the potential impact of cultural variables. In this validation study, we aimed to evaluate the diagnostic capacity of CNTB for the assessment of participants with multiple sclerosis (pwMS) compared to the Neuronorma battery (NN) according to the International Classification of Cognitive Disorders in MS criteria, and to develop machine learning (ML) algorithms to improve the diagnostic capacity of CNTB and to select the most relevant tests.

METHODS

Sixty pwMS and 60 healthy controls (HC) with no differences in sex, age, or years of education were enrolled. All participants completed the CNTB and pwMS were also examined with NN, depression, and fatigue scales. Impaired domains and cognitive phenotypes were defined following ICCoDiMS based on CNTB scores and compared to NN, according to -1SD and -1.5SD cutoff scores. To select the most relevant tests, random forest (RF) was performed for different binary classifications.

RESULTS

PwMS showed a lower performance compared to HC with medium-large effect sizes, in episodic memory, executive function, attention, and processing speed, in accordance with their characteristic cognitive profile. There were no differences in impaired domains or cognitive phenotypes between CNTB and NN, highlighting the role of episodic memory, executive function, attention, and processing speed tests. The most relevant tests identified by RF were consistent with inter-group comparisons and allowed a better classification than SD cutoff scores.

CONCLUSION

CNTB is a valid test for cognitive diagnosis in pwMS, including key tests for the most frequently impaired cognitive domains in MS. The use of ML techniques may also be useful to improve diagnosis, especially in some tests with lower sensitivity.

Neuropsychological application of the International Test Commission Guidelines for Translation and Adapting of Tests

OBJECTIVE

The number of test translations and adaptations has risen exponentially over the last two decades, and these processes are now becoming a common practice. The International Test Commission (ITC) Guidelines for Translating and Adapting Tests (Second Edition, 2017) offer principles and practices to ensure the quality of translated and adapted tests. However, they are not specific to the cognitive processes examined with clinical neuropsychological measures. The aim of this publication is to provide a specialized set of recommendations for guiding neuropsychological test translation and adaptation procedures.

METHODS

The International Neuropsychological Society's Cultural Neuropsychology Special Interest Group established a working group tasked with extending the ITC guidelines to offer specialized recommendations for translating/adapting neuropsychological tests. The neuropsychological application of the ITC guidelines was formulated by authors representing over ten nations, drawing upon literature concerning neuropsychological test translation, adaptation, and development, as well as their own expertise and consulting colleagues experienced in this field.

RESULTS

A summary of neuropsychological-specific commentary regarding the ITC test translation and adaptation guidelines is presented. Additionally, examples of applying these recommendations across a broad range of criteria are provided to aid test developers in attaining valid and reliable outcomes.

CONCLUSIONS

Establishing specific neuropsychological test translation and adaptation guidelines is critical to ensure that such processes produce reliable and valid psychometric measures. Given the rapid global growth experienced in neuropsychology over the last two decades, the recommendations may assist researchers and practitioners in carrying out such endeavors.

Dementia among Minority Populations: A Scoping Review of Meaning, Language, and Translation

BACKGROUND

Dementia as a neurocognitive disorder is becoming increasingly common worldwide, and minority groups are more vulnerable than the general population. Many factors may contribute to their vulnerability such as misconceptions, language barriers, cultural factors, invalid assessment tools, lack of knowledge, or assigning spiritual beliefs to dementia symptoms. Therefore, this scoping literature review aimed to clarify how empirical studies reflect the meaning of dementia, language, and translation among minority ethnic groups.

SUMMARY

The PRISMA extension for the scoping review protocol was used. Thirty-eight studies published in English were reviewed and analysed. The findings revealed that lack of knowledge about dementia and attributing the disease to the normal ageing process were frequent among minority groups. Furthermore, their cultural-specific perspectives and worldviews of wellness and well-being can impact the way dementia is perceived, consequent help-seeking behaviours, or caregiving. Facilitating educational programs to enhance the knowledge and experiences of ethnic communities might be beneficial. Moreover, language is shown to be an important aspect in dementia assessment and participants' educational level could significantly impact their functional capacity when responding to cognitive measures. Even though there are some useful screening tests, diagnosis barriers might be eased by assessment tool development, modifications, and accurate translations for ethnic communities.

KEY MESSAGES

A promising pathway to support ethnically diverse communities regarding dementia can be raising awareness, providing ethnic-specific services, developing cultural-specific tools to assess dementia or any cognitive impairment by considering perceptions, language, and culture among ethnic groups. Cultural and spiritual considerations could also encourage engagement during assessment.

Interpreter-mediated neuropsychological assessment: Clinical considerations and recommendations from the European Consortium on Cross-Cultural Neuropsychology (ECCroN)

OBJECTIVE

With increasing international migration, societies have become increasingly diverse worldwide. Although neuropsychological assessment is influenced by several diversity characteristics, language barriers have repeatedly been identified as one of the main challenges to cross-cultural neuropsychological assessment in migrant populations. Importantly, neuropsychologists are often required to conduct interpreter-mediated neuropsychological assessments without any graduate training or continuing education on the topic. To address this gap, the objective of this paper is to provide guidelines for interpreter-mediated neuropsychological assessment.

METHOD

A European Consortium on Cross-Cultural Neuropsychology (ECCroN) task force conducted a conceptual literature review and provided recommendations for good practice and working principles to inform the preparation and administration of interpreter-mediated assessments.

RESULTS

ECCroN takes the position that it is the responsibility of neuropsychologists, as well as the institutions or organizations that employ them, to ensure effective communication between themselves and their patients. This may be accomplished by preparing for an interpreter-mediated assessment by engaging an appropriate interpreter, which in most circumstances will be a professional in-person interpreter speaking the same language(s) or dialect(s) as the patient, and considering practical, language, and cross-cultural issues. During the assessment, reasonable steps should be taken to proactively manage the proceedings and adopt a communication style that facilitates effective patient-directed communication, and when interpreting test data and determining formulations and diagnoses, the limitations of interpreter-mediated assessment should be carefully considered.

CONCLUSION

Adhering to the provided recommendations and working principles may help neuropsychologists provide competent interpreter-mediated neuropsychological assessments to linguistically diverse patients.

Diagnostic Accuracy of the Swedish Version of the Multicultural Cognitive Examination for Cognitive Assessment in Swedish Memory Clinics

BACKGROUND

Cognitive assessment for foreign-born individuals is suboptimal. The Multicultural Cognitive Examination (MCE) was developed for use in culturally, linguistically and educationally diverse populations. The MCE includes the Rowland Universal Dementia Assessment Scale (RUDAS) and performs assessment of memory, verbal fluency, and visuospatial function.

OBJECTIVE

To compare the psychometric properties of the Swedish version of the Multicultural Cognitive Examination (MCE-S) with the Swedish versions of the RUDAS (RUDAS-S), the Mini-Mental State Examination (MMSE-SR), and the Clock Drawing Test (CDT), and to explore the ability of the MCE-S test to differentiate patients with and without dementia in a multicultural population.

METHODS

117 outpatients at four memory clinics were tested using the MCE-S to complement the routine cognitive assessment.

RESULTS

Significant differences between patients with and without dementia were observed for all MCE-S components. There were significant differences between foreign-born and Swedish-born patients in the MMSE-SR, but not in the MCE-S or the RUDAS-S. The MCE-S, had good diagnostic performance for detecting dementia (AUC, 0.82), and was at least as good as the RUDAS-S alone (AUC, 0.79). The MCE-S also distinguished Alzheimer's disease (AD) from non-AD dementia. Contrary to expectations, the MCE-S was also at least as good as the MMSE-SR among the Swedish-born patients.

CONCLUSIONS

The MCE-S is adequate for detecting dementia in both foreign-born and Swedish-born populations. Based on the cultural diversity of general society, adapted cognitive tests that can be used for everyone are practical and beneficial for both patients and health-care professionals. Further studies are needed within primary care.

Cross-Cultural Adaptation and Spanish Validation of the Computerized Information Processing Assessment Battery (COGNITO)

INTRODUCTION

Mild cognitive impairment (CI) has an exponential increase in its prevalence and causes functional deficits and dependence. Its early detection allows for timely treatment and greater therapeutic efficacy. However, mild cognitive impairment (MCI) is currently underdiagnosed. Although recent decades have seen a rise in computerized instruments for the detection and early diagnosis of MCI, showing numerous advantages over the classic paper-and-pencil methods, such as standardized stimulus presentation. However, their limitations include the use of self-administered application without professional supervision. Few of these instruments have Spanish-adapted versions.

OBJECTIVE

To translate, adapt, and validate the computerized Information Processing Assessment Battery (COGNITO) battery in the Spanish population and to develop a portable administration system that facilitates its application in different settings. COGNITO was then administered to 232 Spanish participants (18-89 years) without cognitive impairment, after which preliminary normative data were obtained.

RESULTS

Strong positive correlations were found between the main cognitive domains assessed by COGNITO and the variables of age, educational level, and MEC score. The gender variable only correlated with visuospatial skills, with men outperforming women. The test-retest correlations conducted after 4 weeks with 89 participants revealed adequate reliability coefficients ranging between.63 and.66 (visuospatial skills = 0.35). Internal consistency coefficients were satisfactory in Attention-Executive Functions and Memory domains.

CONCLUSIONS

The Spanish adaptation of COGNITO shows adequate psychometric characteristics of validity and reliability. The preliminary normative data provided may contribute to the early detection of cognitive impairments associated with both normal aging and various types of neurological pathology. This tool has great utility and versatility for neuropsychological practice.

Validation of the cross-cultural dementia screening test in Alzheimer's disease and Parkinson's disease

Objective

The Cross-Cultural Dementia (CCD) is a new screening tool to evaluate cognitive impairment based on a cross-cultural perspective to reduce the bias of education, and language and cultural differences. We aimed to evaluate the diagnostic properties of the CCD in Spaniards for the assessment of patients with Alzheimer's disease in mild cognitive impairment (AD-MCI) and mild dementia stages (AD-D) and patients with mild cognitive impairment associated with Parkinson's disease (PD-MCI).

Methods

Sixty participants with AD (50% MCI) and thirty with PD-MCI were enrolled. Each clinical group was compared against a healthy control group (HC) with the same number of participants and no significant differences in age, education, and sex. A comprehensive neuropsychological test battery and CCD were completed. Intergroup comparisons, ROC curves, and cut-off scores were calculated for the study of diagnostic properties.

Results

Intergroup differences were found in accordance with the cognitive profile of each clinical condition. Memory measures (Objects test) were especially relevant for the classification between AD and HC. Memory and executive function scores (Sun-Moon and Dots tests) were useful in the case of PD-MCI and HC. Furthermore, CCD described differences in executive functions and speed scores comparing AD-MCI and PD-MCI. Correlations between standardized neuropsychological tests and CCD measures supported the convergent validity of the test.

Conclusion

CCD showed good discrimination properties and cut-off scores for dementia and extended its application to a sample of prodromal stages of AD and PD with mild cognitive impairment.

Validation of the European Cross-Cultural Neuropsychological Test Battery (CNTB) for the assessment of mild cognitive impairment due to Alzheimer's disease and Parkinson's disease

Background

The Cross-Cultural Neuropsychological Test Battery (CNTB) is a novel test battery specifically designed to reduce the impact of multiculturality in cognitive assessment.

Objective

We aimed to validate the CNTB in Spaniards in patients with Alzheimer's disease (AD), including patients at mild cognitive impairment (MCI) and mild dementia stages, and Parkinson's disease with MCI (PD-MCI).

Methods

Thirty patients with AD-MCI, 30 with AD-dementia (AD-D), and 30 with PD-MCI were recruited. Each clinical group was compared against a healthy control group (HC) with no differences in sex, age, or years of education. Intergroup comparisons, ROC analysis, and cut-off scores were calculated.

Results

AD-MCI scored lower than HC in those subtests associated with episodic memory and verbal fluency. AD-D also showed lower scores in executive functions and visuospatial tests. Effect sizes for all the subtests were large. PD-MCI showed lower performance than HC in memory and executive functions, particularly on error scores, with large effect sizes. Comparing AD-MCI and PD-MCI, AD-MCI had lower memory scores, while PD-MCI showed the worst performance in executive functions. CNTB showed appropriate convergent validity with standardized neuropsychological tests measuring the same cognitive domains. We obtained similar cut-off scores to previous studies performed in other populations.

Conclusions

The CNTB showed appropriate diagnostic properties in AD and PD, including those stages with mild cognitive impairment. This supports the utility of the CNTB for the early detection of cognitive impairment in AD and PD.

Normative Data in Cross-Cultural Neuropsychological Instruments in Spaniards and Colombians Living in Spain

BACKGROUND

Cross-Cultural Dementia Screening (CCD), Rowland Universal Dementia Assessment Scale (RUDAS), and European Cross-cultural Neuropsychological Test Battery (CNTB) are three novel neuropsychological instruments developed from a cross-cultural perspective to reduce the impact of culture in cognitive assessment and improve the assessment in diverse populations.

OBJECTIVE

We aimed to collect and present normative data on these tests in a majority population sample (Spaniards living in Spain) and in a minority population sample (Colombians living in Spain).

METHODS

CCD, RUDAS, and CNTB were administered to a group of 300 cognitively healthy participants (150 Spaniards and 150 Colombians). Linear regression modeling strategy was used to provide adjusted norms for demographic factors and to explore the influence of these factors on test performance.

RESULTS

Most of the CCD and CNTB scores were predicted by age and years of education, with some tests only predicted by age or showing a ceiling effect. The comparison of normative data between the two samples confirmed the favorable cross-cultural properties of these instruments, with only some differences in processing speed and executive functioning scores.

CONCLUSIONS

Our study finds a comparable influence of demographic factors in both populations on the performance of CCD, RUDAS, and CNTB, confirming their adequate cross-cultural properties. We provide normative data for these tests in Spaniards and Colombians living in Spain.

Validity of Visuoconstructional Assessment Methods within Healthy Elderly Greek Australians: Quantitative and Error Analysis

Aims

Visuospatial skills are frequently assessed with drawing tests. Research has suggested that the use of drawing tasks in low educated groups may lack the ability to discriminate healthy individuals from clinical populations. The aims of this study were to investigate the validity of visuoconstructional tests in a sample of older Greek Australian immigrants and compare their performances to a matched sample of patients with Alzheimer’s disease (ad).

Method

We assessed visuoconstructional performances in a sample of 90 healthy older Greek Australians, with a primary school level of education, and compared performances to a demographically matched sample of 20 Greek Australians with a diagnosis of ad on four visuoconstructional drawing tests: Greek cross, four-pointed star, intersecting pentagons, and the Necker Cube.

Results

While healthy participants tended to outperform the ad group on most copy tasks, high fail rates within the healthy sample were observed for the intersecting pentagons and Necker cube (78% and 73% fail rates, respectively) when using established clinical cut-off scores. High rates of curved angle, omission, distorted relation between elements, spatial disorganization and three-dimensional design errors were found across the four-pointed star, intersecting pentagons, and the Necker cube in both healthy participants and those with ad. Exploratory receiver operating characteristic curve analysis revealed that, with perhaps the exception of the Greek cross, meaningful sensitivity and specificity could not be reached for the four-pointed star, intersecting pentagons, and Necker cube.

Conclusion

Cognitively healthy immigrants with low education appear to be at a disadvantage when completing visuoconstructional drawing tests, as their performance may be misinterpreted as indicating cognitive impairment. Future research is needed to identify alternative approaches to assess visuoconstructional ability in culturally and linguistically diverse older cohorts with limited education.

Diagnostic Accuracy of the Swedish Version of the Rowland Universal Dementia Assessment Scale (RUDAS-S) for Multicultural Cognitive Screening in Swedish Memory Clinics

Background:

The number of people with a migration background and dementia is increasing in Europe. All patients with suspected dementia have the right to an appropriate cognitive assessment and correct diagnosis for optimal treatment and support. Rowland Universal Dementia Assessment Scale (RUDAS) cognitive screening instrument is less affected by language, culture, and educational background, and adapted for use in multicultural populations.

Objective:

To compare the diagnostic accuracy of RUDAS-S to the Swedish version of Mini-Mental State Examination (MMSE-SR) for detecting dementia in a multicultural group of outpatients in Swedish memory clinics.

Methods:

We tested 123 outpatients (36 nonnative Swedish), in 4 memory clinics in Southern Sweden with RUDAS-S to supplement the usual cognitive assessment.

Results:

RUDAS-S had moderate to good diagnostic performance for detecting dementia in a multicultural population in Sweden, with an area under the receiver operating characteristic curve (AUC) of 0.81. At a cutoff score <25 its sensitivity was 0.92, specificity 0.60, and accuracy 76%. The AUC for the MMSE-SR was 0.79. At a cutoff score <23 its sensitivity was 0.65, specificity 0.81, and accuracy 73%.

Conclusion:

RUDAS-S is at least as accurate as MMSE-SR for detecting dementia in memory clinics in Sweden and can be used for all patients undergoing a cognitive assessment, irrespective of their cultural, language, and educational background. However, there is a need for other cross-cultural cognitive tests to complement RUDAS-S to extend cognitive examination.

Language Ability Accounts for Ethnic Difference in Mathematics Achievement

The mathematics achievement of minority students has always been a focal point of educators in China. This study investigated the differences in mathematics achievement between Han and minority pupils to determine if there is any cognitive mechanism that can account for the discrepancy. We recruited 236 Han students and 272 minority students (including Uygur and Kazak) from the same primary schools. They were tested on mathematics achievement, language abilities, and general cognitive abilities. The results showed that Han pupils had better mathematics achievement scores and better Chinese language ability than minority students. After controlling for age, gender, and general cognitive abilities, there were still significant differences in mathematics achievement between Han and minority students. However, these differences disappeared after controlling for language ability. These results suggest that the relatively poor levels of mathematics achievement observed in minority students is related to poor Chinese language skills.

A nationwide survey of Italian centers for cognitive disorders and dementia on the provision of care for international migrants

Background

More than 500,000 dementia cases can be estimated among migrants living in Europe. There is the need to collect “real world” data on the preparedness of healthcare services to support the inclusion of migrants in the public health response to dementia. The present study aimed (i) to estimate the number of migrants referred to Italian memory clinics (Centers for Cognitive Disorders and Dementia [CCDDs]) and (ii) to identify possible barriers and resources for the provision of diversity‐sensitive care.

Methods

A survey of all Italian CCDDs was conducted between December 2020 and April 2021. An online questionnaire was developed to obtain information on the number of migrants referred to Italian CCDDs in 2019, the challenges encountered in the diagnostic approach, and possible facilitators in the provision of care.

Results

Overall, 343 of the 570 contacted CCDDs completed the survey questionnaire (response rate: 60.2%). Nearly 4527 migrants were referred to these services in 2019. Migrants accounted for a median 1.1% (IQR: 0.9%–2.8%) of overall CCDD referrals. More than one‐third of respondents reported that the number of migrants referred to their facilities had increased in the last 5 years. The overall quality of the migrants' cognitive assessment was deemed to be very poor or insufficient in most cases. A minority of CCDDs had translated information material on dementia and reported the possibility to contact cultural mediators and interpreters.

Conclusions

A relevant number of migrants are being referred to Italian CCDDs that are still not adequately prepared to deliver diversity‐sensitive care and support.

Cognitive Assessment in Culturally, Linguistically, and Educationally Diverse Older Populations in Europe

Due to increasing cultural, linguistic, and educational diversity in older populations across Europe, accurate assessment of cognitive functioning in people from diverse backgrounds becomes increasingly important. This paper aims to provide a state-of-the-art review of cognitive assessment in culturally, linguistically, and educationally diverse older populations in Europe, focusing on challenges and recent advances in cross-cultural assessment. Significant work has been carried out on the identification of challenges in cognitive assessment in culturally, linguistically, and educationally diverse older populations and on development and validation of cross-cultural cognitive tests. Most research has addressed the influences of language barriers, education and literacy, and culture and acculturation and in particular, the European Cross-Cultural Neuropsychological Test Battery (CNTB) and the Rowland Universal Dementia Assessment Scale (RUDAS) are well-validated across European countries. However, cross-cultural cognitive assessment is largely still a developing field in Europe, and there is a continuing need for developments within the field.

Mild Cognitive Impairment in the Migrant Population Living in Europe: An Epidemiological Estimation of the Phenomenon

Background:

The construct of mild cognitive impairment (MCI) is triggering growing clinical and research interest. The detection of MCI may be affected by diverse ethno-cultural determinants possibly influencing the personal and social perception of the individual cognitive functioning as well as the reliability of objective cognitive assessment. These challenges may acquire special relevance in subjects with a migration background and composing ethnic minority groups.

Objective:

The present study is aimed at providing an estimate of the number of MCI cases occurring in the migrant population living in the extended European Union (EU) in 2018.

Methods:

The number of MCI cases in older migrants living in Europe and in each of the 32 considered countries was estimated by multiplying the number of migrants, provided by Eurostat, with the age-specific prevalence rates, derived by the harmonized data produced by the COSMIC collaboration and based on different operational definitions of MCI.

Results:

Nearly 686,000 cases of MCI were estimated in the extended EU by applying age-specific prevalence rates based on the International Working Group criteria. Higher figures were obtained when the Clinical Dementia Rating- and the Mini Mental State Examination-based criteria were applied. The proportion of MCI cases in migrant subjects ranged from 1.1% (Romania) to 54.1% (Liechtenstein) (median: 8.4%; IQR: 4.7%–14.2%).

Conclusions:

MCI represents and will increasingly constitute a relevant issue in the migrant population living in Europe. The present data reinforce the need of developing approaches and models of care that may be diversity-sensitive and inclusive for a culturally variegated population.

Cross-cultural dementia screening using the Rowland Universal Dementia Assessment Scale: a systematic review and meta-analysis

OBJECTIVES

To quantitatively synthesize data on the accuracy of the Rowland Universal Dementia Assessment Scale (RUDAS) in different sociocultural settings and compare its performance to other brief screening instruments for the detection of dementia.

DESIGN

Systematic review and meta-analysis. Literature searches were performed in PubMed, EMBASE, and CINAHL from January 1, 2004 until September 1, 2019.

SETTING

Community, outpatient clinic, and hospital settings in high-, and low- and middle-income countries.

PARTICIPANTS

Twenty-six studies reporting diagnostic accuracy of the RUDAS were included with almost 4000 participants, including approximately 1700 patients with dementia.

MEASUREMENTS

Procedures for translation and cultural adaption of the RUDAS, and influence of demographic variables on diagnostic accuracy, were compared across studies. Bivariate random-effects models were used to pool sensitivity and specificity results, and diagnostic odds-ratios and the area under the hierarchical summary receiver operator characteristic curve were used to present the overall performance.

RESULTS

The pooled sensitivity and specificity for the detection of dementia were .82 (95% CI, .78-.86) and .83 (95% CI, .78-.87), respectively, with an area under the curve of .89. Subgroup analyses revealed that the RUDAS had comparable diagnostic performances across high-, and low- and middle-income settings (z = .63, P = .53) and in samples with a lower and higher proportion of participants with no formal education (z = -.15, P = .88). In 11 studies making direct comparison, the diagnostic performance of the RUDAS was comparable to that of the Mini-Mental State Examination (z = -.82, P = .41), with areas under the curve of .88 and .84, respectively.

CONCLUSIONS

The RUDAS has good diagnostic performance for detecting dementia in different sociocultural settings. Compared to other brief screening instruments, advantages of the RUDAS include its limited bias in people with limited or no formal education and a minimal need for cultural or language adaptation.

Neuropsychological Test Performance Among Native and Non-Native Swedes: Second Language Effects

Objective

We aimed to study second language effects on neuropsychological (NP) test performance.

Method

We administered an NP test battery in Swedish to 322 healthy community dwelling participants, recruited through the Gothenburg Pilot phase of the Swedish CArdioPulmonary BioImage Study (SCAPIS Pilot). All participants were conversationally fluent Swedish speakers (237 native, 85 non-native, mean age 61.1 years). We compared the NP scores of native and non-native participants. We also investigated the influence of (a) age of arrival to Sweden, (b) majority language family of the birth country, and (c) proficiency in Swedish as assessed with a 30 item Boston naming test (BNT).

Results

Native speakers obtained better results on all NP tasks with a verbal component, whereas no significant differences were seen on completely nonverbal tasks (Rey complex figure). For non-native speakers, lower age at arrival to Sweden, arrival from a country where Swedish was also spoken, or arrival from a country with a majority language closer to Swedish, were all linked to better NP scores. Dichotomizing by BNT showed that normally-to-highly proficient non-native speakers obtained better scores.

Conclusions

Second language effects may contribute to misclassification of non-native speakers. Assumptions of fluency based on short conversations may be misleading. A proficiency assessment with BNT may improve NP score interpretation among non-native speakers.

A Systematic Review of Neuropsychological Tests for the Assessment of Dementia in Non-Western, Low-Educated or Illiterate Populations

OBJECTIVE

Neuropsychological tests are important instruments to determine a cognitive profile, giving insight into the etiology of dementia; however, these tests cannot readily be used in culturally diverse, low-educated populations, due to their dependence upon (Western) culture, education, and literacy. In this review we aim to give an overview of studies investigating domain-specific cognitive tests used to assess dementia in non-Western, low-educated populations. The second aim was to examine the quality of these studies and of the adaptations for culturally, linguistically, and educationally diverse populations.

METHOD

A systematic review was performed using six databases, without restrictions on the year or language of publication.

RESULTS

Forty-four studies were included, stemming mainly from Brazil, Hong Kong, Korea, and considering Hispanics/Latinos residing in the USA. Most studies focused on Alzheimer's disease (n = 17) or unspecified dementia (n = 16). Memory (n = 18) was studied most often, using 14 different tests. The traditional Western tests in the domains of attention (n = 8) and construction (n = 15), were unsuitable for low-educated patients. There was little variety in instruments measuring executive functioning (two tests, n = 13), and language (n = 12, of which 10 were naming tests). Many studies did not report a thorough adaptation procedure (n = 39) or blinding procedures (n = 29).

CONCLUSIONS

Various formats of memory tests seem suitable for low-educated, non-Western populations. Promising tasks in other cognitive domains are the Stick Design Test, Five Digit Test, and verbal fluency test. Further research is needed regarding cross-cultural instruments measuring executive functioning and language in low-educated people.

Brazilian version of the European Cross-Cultural Neuropsychological Test Battery (CNTB-BR): diagnostic accuracy across schooling levels

Objective:

To translate, establish the diagnostic accuracy, and standardize the Brazilian Portuguese version of the European Cross-Cultural Neuropsychological Test Battery (CNTB) considering schooling level.

Methods:

We first completed an English-Brazilian Portuguese translation and back-translation of the CNTB. A total of 135 subjects aged over 60 years – 65 cognitively healthy (mean 72.83, SD = 7.71; mean education 9.42, SD = 7.69; illiterate = 25.8%) and 70 with Alzheimer’s disease (AD) (mean 78.87, SD = 7.09; mean education 7.62, SD = 5.13; illiterate = 10%) – completed an interview and were screened for depression. The receiver operating characteristic (ROC) analysis was used to verify the accuracy of each CNTB test to separate AD from healthy controls in participants with low levels of education (≤ 4 years of schooling) and high levels of education (≥ 8 years of schooling). The optimal cutoff score was determined for each test.

Results:

The Recall of Pictures Test (RPT)-delayed recall and the Enhanced Cued Recall (ECR) had the highest power to separate AD from controls. The tests with the least impact from schooling were the Rowland Universal Dementia Assessment Scale (RUDAS), supermarket fluency, RPT naming, delayed recall and recognition, and ECR.

Conclusions:

The Brazilian Portuguese version of the CNTB was well comprehended by the participants. The cognitive tests that best discriminated patients with AD from controls in lower and higher schooling participants were RPT delayed recall and ECR, both of which evaluate memory.

Dementia detection with a combination of informant-based and performance-based measures in low-educated and illiterate elderly migrants

OBJECTIVE

Detecting dementia in people who are illiterate or have a low level of education is complicated because many cognitive screening tests are not suitable for these persons. Caregiver or informant-based judgment of cognitive status may aid diagnosis. Our goal was to investigate the diagnostic accuracy of the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) in a population of elderly non-Western migrants with a high illiteracy rate. Second, we wanted to investigate the diagnostic accuracy of IQCODE and Rowland Universal Dementia Screening (RUDAS) combined.

METHOD

109 geriatric outpatients and 20 community controls were included. Geriatricians provided a research diagnosis of intact cognition (n = 27), mild cognitive impairment (MCI; n = 33) or dementia (n = 49). Diagnostic accuracy was calculated for the clinical sample (n = 109). ROC curves for prediction of group status for IQCODE, RUDAS and the combination of both were created.

RESULTS

Predictive validity was high for both IQCODE and RUDAS and was highest for the combination (Area Under the Curve .91). Sensitivity, specificity, Youden index, predictive value, and likelihood ratio for IQCODE and RUDAS are reported.

CONCLUSIONS

In this study in non-Western elderly migrants, half of whom were illiterate, the IQCODE proved to be a valid instrument for dementia detection, and adding the RUDAS increased accuracy. Combining performance-based and informant-based data is recommended to enhance diagnostic precision.

Validation of a brief Multicultural Cognitive Examination (MCE) for evaluation of dementia

BACKGROUND

The aims of this study were to present the psychometric properties of a newly designed cognitive screening instrument, the Multicultural Cognitive Examination (MCE), and to compare it with the Rowland Universal Dementia Assessment Scale (RUDAS) in a multicultural population.

METHODS

The study was a Western European cross-sectional multicenter study. The MCE consists of four components evaluating separate cognitive functions and was constructed by adding measures of memory, verbal fluency, and visuospatial function to the RUDAS to create a scale with 0 to 100 points.

RESULTS

A total of 66 patients with dementia and 123 cognitively intact participants were included across six memory clinics; 96 had minority ethnic background, and 93 had majority ethnic background. Moderate to large differences were present between patients with dementia and control participants on all MCE components. The MCE significantly improved diagnostic accuracy compared with using the RUDAS alone, with area under the curves of .918, .984, and .991 for the RUDAS, MCE composite, and demographically corrected composite scores, respectively. Diagnostic accuracy of the MCE did not significantly differ between minority and majority ethnic groups. Across MCE subcomponents, patients with Alzheimer's disease (AD) dementia performed significantly poorer on the memory component compared with those with non-AD dementia.

CONCLUSIONS

The MCE is a brief cross-cultural cognitive screening instrument that expands evaluation of the cognitive functions covered by the RUDAS, does not require any specialized training, and may be useful for classification of mild dementia or dementia subtypes.