Neuropsychological Assessment and Intervention with African Americans. In: Fletcher-janzen E, Strickland TL, Reynolds CR, editors. Handbook of Cross-Cultural Neuropsychology. Boston: Springer US; 2000. pp. 31-42. [DOI: 10.1007/978-1-4615-4219-3_3]

Evaluating memory testing to distinguish dementia severity among White, Black, and Spanish-speaking individuals in the Uniform Data Set (UDS)

INTRODUCTION

Little work has compared the effectiveness of using multiple types of memory tests alone or in combination to distinguish dementia severity in diverse research cohorts including Black individuals and Spanish speakers. Here we evaluate word list and paragraph recall tests to distinguish cognitively normal, mild cognitively impaired, and those with Alzheimer's disease in diverse cohorts.

METHODS

Using Uniform Data Set (UDS) and site-specific supplemental data, logistic regression models and receiver operating characteristic-area under the curve were used to compare paragraph recall versus word list in differentiating among Clinical Dementia Rating (CDR) scale level.

RESULTS

Results reveal high discriminability for all groups and no difference between either test in distinguishing between CDR levels. Combining tests improved discriminability for the whole group but did not for Black individuals or Spanish speakers.

DISCUSSION

Our findings indicate that using multiple memory tests may not improve differentiation between cognitive impairment levels for diverse cohorts. The burden of added testing may be a barrier for maximizing inclusion of under-represented groups in research.

Diagnosing Mild Cognitive Impairment Among Racially Diverse Older Adults: Comparison of Consensus, Actuarial, and Statistical Methods

BACKGROUND

Actuarial and statistical methods have been proposed as alternatives to conventional methods of diagnosing mild cognitive impairment (MCI), with the aim of enhancing diagnostic and prognostic validity, but have not been compared in racially diverse samples.

OBJECTIVE

We compared the agreement of consensus, actuarial, and statistical MCI diagnostic methods, and their relationship to race and prognostic indicators among diverse older adults.

METHODS

Participants (N = 354; M age = 71; 68% White, 29% Black) were diagnosed with MCI or normal cognition (NC) according to clinical consensus, actuarial neuropsychological criteria (Jak/Bondi), and latent class analysis (LCA). We examined associations with race/ethnicity, longitudinal cognitive and functional change, and incident dementia.

RESULTS

MCI rates by consensus, actuarial criteria, and LCA were 44%, 53%, and 41%, respectively. LCA identified three MCI subtypes (memory; memory/language; memory/executive) and two NC classes (low normal; high normal). Diagnostic agreement was substantial, but agreement of the actuarial method with consensus and LCA was weaker than the agreement between consensus and LCA. Among cases classified as MCI by actuarial criteria only, Black participants were over-represented, and outcomes were generally similar to those of NC participants. Consensus diagnoses best predicted longitudinal outcomes overall, whereas actuarial diagnoses best predicted longitudinal functional change among Black participants.

CONCLUSION

Consensus diagnoses optimize specificity in predicting dementia, but among Black older adults, actuarial diagnoses may be more sensitive to early signs of decline. Results highlight the need for cross-cultural validity in MCI diagnosis and should be explored in community- and population-based samples.

Deliberate Context-Driven Conceptualization in Psychological Assessment

Clinical formulation and case conceptualization in clinical psychological assessment typically organize a client's presenting problems within a psychological framework and narrative that explains the cluster of symptoms, etiological and maintenance factors, and explaining both how and why a client is struggling or suffering. However, many of the most commonly used models of case conceptualization, as well as the preponderance of tests and measures used in psychological assessment, minimize or ignore the impacts of contextual factors, including dominant culture's expectations for normative behavior and the client's history of trauma and adverse and negative events. This paper presents a rationale and model for encouraging psychologists conducting clinical psychological assessment to be deliberate in first considering contextual factors in case conceptualization before relying entirely on primarily intrapsychic models. While contextual conceptualizations will not always replace (or join) intrapsychic models of case formulation, being deliberate and explicit about at least considering them is an important way to mitigate some of psychologists' biases and has the potential to situate a narrative of client difficulties in a way that takes at least some of the burden off the client.

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.

Factors Associated with Māori Performance on the WAIS-IV

Neuropsychological tests are routinely used to assess Māori, the indigenous people of New Zealand, yet very few investigations of the psychometric properties of these tests with this population have been conducted. This paper focuses on factors that may impact performance of Māori adults on neuropsychological testing. The Wechsler Adult Intelligence Scale-IV (WAIS-IV) was administered to a sample of 284 Māori stratified for age (between 16 years and 90 years) and gender in order to establish a Māori normative data set. The sample who primarily spoke English as their first language were recruited from a range of urban, regional and rural areas in New Zealand to obtain representation of the main Māori Iwi (tribes). Analysis of test results suggests acculturation, education, income, and, "a culturally positive experience" may have accounted for some of the variance in test performance.

Deconstructing racial differences: the effects of quality of education and cerebrovascular risk factors

OBJECTIVES

To evaluate the effects of vascular conditions and education quality on cognition over time in White and African American (AA) older adults.

METHOD

We investigated cross-sectional and longitudinal racial differences in executive functioning (EF) and memory composites among Whites (n = 461) and AAs (n = 118) enrolled in a cohort study. We examined whether cerebrovascular risk factors and Shipley Vocabulary scores (a proxy for education quality) accounted for racial differences.

RESULTS

On average, AAs had lower quality of education and more cerebrovascular risk factors including hypertension, diabetes, and obesity. AAs had lower mean EF and memory at baseline, but there were no group differences in rates of decline. Cross-sectional racial differences in EF and memory persisted after controlling for vascular disease, but disappeared when controlling for Shipley Vocabulary.

DISCUSSION

Quality of education appears to be more important than cerebrovascular risk factors in explaining cross-sectional differences in memory and EF performance between White and AA older adults. Further investigation is needed regarding the relative contribution of education quality and cerebrovascular risk factors to cognitive decline among ethnically/racially diverse older adults.

Ethical Issues in Cross-Cultural Neuropsychology

Clinical neuropsychologists who assess patients from diverse cultural and linguistic backgrounds face unique ethical challenges. In this article, we address 4 critical questions relevant to ethics of cross-cultural neuropsychology: (a) Should culture or race be considered in neuropsychological testing? (b) Should race- and ethnicity-specific normative data be used in the clinical neuropsychological evaluation? (c) Who is competent to design and translate tests for ethnic minority groups and non-English speakers and who is competent to administer and interpret them? and (d) Are neuropsychology training programs adequately preparing clinicians to be competent in the assessment of cross-cultural groups? The overall aims of the article are to highlight the complexity of these clinical and ethical issues, to provide comprehensive and balanced information to help guide clinician choices, and to stimulate future research in this area.

Mayo's Older African Americans Normative Studies: norms for Boston Naming Test, Controlled Oral Word Association, Category Fluency, Animal Naming, Token Test, WRAT-3 Reading, Trail Making Test, Stroop Test, and Judgment of Line Orientation

Normative data for older African Americans are presented for several clinical neuropsychological measures, including Boston Naming Test, Controlled Oral Word Association, Category Fluency, Token Test, WRAT-3 Reading, Trail Making Test, Stroop Color and Word Test, and Judgment of Line Orientation. Age-adjusted norms were derived from a sample of 309 cognitively normal, community-dwelling individuals, aged 56 through 94, participating in Mayo's Older African Americans Normative Studies (MOAANS). Years of education were modelled on age-scaled scores to derive regression Equations that may be applied for further demographic correction. These data should enhance interpretation of individual test performances and facilitate analysis of neuropsychological profile patterns in older African American patients who present for dementia evaluations.

Mayo's Older African Americans Normative Studies: normative data for commonly used clinical neuropsychological measures

This report describes the methodology and sample characteristics of Mayo's Older African Americans Normative Studies (MOAANS). These studies reflect a multidisciplinary, collaborative effort by investigators at Mayo Clinic to provide age-appropriate normative data for African American elders on commonly used neuropsychological tests. A sample of 309 community-dwelling individuals over age 55 contributed to the MOAANS sample. Norms were calculated for midpoint age groups, based on percentile scores derived from cumulative frequencies of raw test scores. Demographic, medical, and sociocultural data were also collected, and are summarized to assist clinicians in making determinations regarding the appropriateness of these norms for individual patients. In most cases, the use of MOAANS norms should improve diagnostic accuracy in dementia evaluations of African American elders.

Discrepancies between self-reported years of education and estimated reading level: potential implications for neuropsychologists

Current standard neuropsychology practice is to examine normative sample performance for systematic influences of demographic variables and then to correct for these influences. The most commonly examined demographic variables are age, gender, and years of education, and current normative databases frequently take these into consideration. However, there is a literature to suggest that self-reported years of educational attainment may not be an accurate reflection of some patients' level of performance and may actually overpredict grade estimates based on reading level. Many of these studies have focused on older samples of individuals who were free of neurological or psychiatric symptoms. In this study, a younger sample (average age = 44.5) of African American (N = 62) and Caucasian (N = 133) patients referred to an outpatient psychiatry unit was examined. Results suggest that the prior findings of a significant discrepancy between self-reported years of education and Wide Range Achievement Test-3rd Edition Reading Recognition performance hold for a younger sample with a broad range of clinical diagnoses. How these findings might influence clinical practice are discussed.

A Brief Report on WAIS-R Normative Data Collection in Mayo's Older African Americans Normative Studies

Historically, neuropsychological measures such as the Wechsler Adult Intelligence Scale-Revised (WAIS-R) have yielded unacceptably high rates of misdiagnosis of impairment among cognitively normal African Americans, primarily due to poor test specificity and inadequate representation of ethnic minorities in the normative sample. In this report, we briefly review these issues and describe efforts by investigators in Mayo's Older African Americans Normative Studies (MOAANS) to develop more appropriate norms for African American elders on the WAIS-R. During MOAANS data collection, the third edition of the WAIS (WAIS-III) was introduced with updated representation of ethnic minorities in the normative database. More recently, specific demographic corrections for African Americans have been derived for WAIS-III subtest scores and indices. As such, WAIS-R normative estimates are not presented here. Interested readers who wish to obtain a full set of MOAANS WAIS-R norms, however, are invited to contact the authors for these data.

African American acculturation and neuropsychological test performance following traumatic brain injury

The present study examined the influence of African American acculturation on the performance of neuropsychological tests following traumatic brain injury (TBI). Seventy one participants already enrolled in a larger-scale study assessing the impact of TBI (i.e., the South Eastern Michigan Traumatic Brain Injury Model Systems project) completed a self-report measure of African American acculturation (African American Acculturation Scale-Short Form; Landrine & Klonoff, 1995) in addition to a standardized battery of neuropsychological tests. Hierarchical regression analyses were conducted to evaluate the relationship between level of acculturation and test performance after controlling for injury-related (initial Glasgow Coma Scale score, time since injury) and demographic variables (age, sex, years of education, and socioeconomic status). Lower levels of acculturation were associated with significantly poorer performances on the Galveston Orientation & Amnesia Test, MAE Tokens test, WAIS-R Block Design, Rey Auditory Verbal Learning Test, and Symbol Digit Modalities Test. Decreased levels of acculturation were also significantly related to lower scores on a composite indicator of overall neuropsychological test performance. In addition, the examiner's ethnicity (Black or White) was related with scores on a few of the tests (i.e., Block Design, Trail Making Test), but was not significantly associated with the overall neuropsychological test performance. Overall, these findings suggest that differences in cultural experience may be an important factor in the neuropsychological assessment of African Americans following TBI, and provide additional support for the hypothesis that cultural factors may partially account for the differences among ethnic/cultural groups on neuropsychological tests.

Acculturation, reading level, and neuropsychological test performance among African American elders

The independent effects of cultural and educational experience on neuropsychological test performance were examined among 503 nondemented African Americans ages 65 and older. Measures of cultural experience (acculturation) and quality of education (reading level) were administered. Reading level was the most influential predictor of cognitive test performance, even after accounting for age, sex, years of education, and acculturation level. Age had small but significant unique effects on most measures, especially word list learning. Years of education had independent effects on measures of verbal abstraction, fluency, and figure matching. More acculturated African Americans obtained higher scores on most measures; however, after accounting for age, years of education, sex, and reading level, the effect of acculturation was diminished. The results suggest that quality of education and cultural experience influence how older African Americans approach neuropsychological tasks; therefore, adjustment for these variables may improve specificity of neuropsychological measures.

Attention deficits in children with sickle cell disease

Previous research has suggested that children with sickle cell disease may exhibit cognitive deficits even in the absence of direct cerebrovascular involvement (stroke). This study was designed to assess specific attentional deficits in children with sickle cell disease. 12 children with sickle cell disease (Hb SS) with a prior history of stroke, 14 children with sickle cell disease (Hb SS) without evidence of stroke, and 13 similar aged siblings (Hb AA or Hb AS) were compared on measures of attention, intellectual functioning, achievement, and adaptive functioning. Significant differences were found between children with sickle cell disease (with or without stroke) and healthy controls on a timed test of visual scanning, the Coding subtest of the Wechsler Intelligence Scale for Children-Revised, and subtests of Reading, Arithmetic, and Spelling from the Wide Range Achievement Test-Revised. The differences between children with sickle cell disease and their healthy siblings appear to be the result of strokes rather than sickle cell disease itself as children with sickle cell disease without strokes did not significantly differ from controls. Implications for the effects of sickle cell disease and stroke on academic performance are discussed.