Neuropsychological assessment in illiterates. II. Language and praxic abilities

The use of performance validity tests among inpatient forensic monolingual Spanish-speakers

Performance validity tests (PVTs) are an integral part of neuropsychological assessments. Yet no studies have examined how Spanish-speaking forensic inpatients perform on PVTs, making it difficult to interpret these tests in this population. The present study examined archival data collected from monolingual Spanish-speaking forensic inpatients (n = 55; Mage = 49.6 years, SD = 12.0; 84.9% male; 93.5% diagnosed with a Psychotic Spectrum Disorder) to determine how this population performs on several PVTs. Most participants' scores on the Dot Counting Test (DCT; 82.2%; n = 45), Repeatable Battery for Assessment of Neuropsychological Status-Effort Index (RBANS EI; 84.4%; n = 33), and Test of Memory Malingering (TOMM; 79.1%; n = 43) were indicative of valid performance. Few participants, however, had Rey-15 Item Test (FIT) scores in the valid range (24.5% to 48.0%; Recall n = 50 and Combined n = 49, respectively); although FIT Recall specificity was improved when cutoff scores were lowered. Total years of education, but not other educational factors, were significantly associated with performance on PVTs (r = .33-.40, p = .01-.03). Study results suggest the DCT, TOMM, and RBANS EI may be more appropriate PVTs for Spanish-speaking forensic inpatients compared to the FIT.

Illiteracy, Neuropsychological Assessment, and Cognitive Rehabilitation: A Narrative Review

OBJECT

Νeuropsychological assessment is particularly important for the accurate discrimination of cognitive abilities and weaknesses of patients in order to determine the appropriate therapeutic intervention. However, the reliability and validity of neuropsychological assessment appears to be influenced by a wide range of factors, including literacy and educational level.

AIM

This systematic review evaluates neuropsychological tests appropriate for the valid assessment of illiterate individuals and the effectiveness of cognitive rehabilitation programs for illiterate and/or low-educated individuals according to the results of English language studies that have been published in the PubMed/Medline electronic database until August 2022 (no initiation date).

RESULTS

49 studies were included for neuropsychological assessment and 4 studies for cognitive rehabilitation. In terms of investigating the validity and reliability of neuropsychological tests for the assessment of healthy illiterate individuals, most studies concluded that for the majority of neuropsychological tests there is a significant difference in performance between healthy illiterate and literate individuals. However, there was consensus among studies that the performance of illiterate subjects was equivalent to the performance of literate subjects on tasks depicting colored and real objects. Regarding cognitive rehabilitation programs, all four studies concluded that they are effective in improving the cognitive functions of illiterate and/or low-literate patients with mild cognitive impairment and/or mild dementia.

CONCLUSIONS

For the assessment of illiterate individuals, it is imperative that neuropsychological tests with high ecological validity (i.e., tests related to activities of daily living) be administered so as not to underestimate their cognitive functioning. At the same time, cognitive enhancement/stimulation programs seem to be effective in this population group; however, this area needs further investigation.

COGNITO (Computerized assessment of adult information processing): Normative scores for a rural Indian population from the SANSCOG study

INTRODUCTION

Neuropsychological assessments are inexpensive and efficient methods to understand the cognitive abilities of individuals in research studies and clinical settings. Normative scores for such measures are crucial in serving as a reference standard for identifying cognitively healthy and impaired individuals belonging to similar sociodemographic characteristics.

METHODS

Study subjects in rural India recruited into the Srinivaspura Aging, Neuro Senescence and Cognition (SANSCOG) study were administered the COGNITO battery of tests, which traverse cognitive domains of attention, memory, language, and visuospatial abilities. Percentile norms based on age and education stratification were derived for the above cohort.

RESULTS

Percentile norms are commensurate with literacy levels in this population. The percentile scores for the cognitive tests show a decline for the individuals aged 75 years and above indicating lower cognitive functioning in this age group.

DISCUSSION

This is the first-ever study reporting norms for diverse cognitive domains for illiterate, literate, low-literate individuals enrolled in a large-scale community-based cohort study in rural India.

Cognitive Screening Instruments for Older Adults with Low Educational and Literacy Levels: A Systematic Review

This study presents a systematic review on existing cognitive screening tools for mild cognitive impairment and dementia in populations with low education and literacy levels. Cochrane Library, PubMed and LILACS databases were examined for studies including adults aged 50 years old or older with low educational level. 61 articles were included. Despite its frequent use, studies on Mini-Mental State Examination (MMSE) revealed that educational level biased the score obtained, regardless of other factors. Separately, the Informant Questionnaire on Cognitive Decline in the Elderly, the Fototest, or the Eurotest, appear to minimize the effect of education and literacy. MMSE is unreliable for individuals with low literacy. Tasks involving reading, writing, arithmetics, drawing, praxis, visuospatial, and visuoconstructive skills have a greater educational bias than naming, orientation, or memory. An adequate determination of educational level and validation of instruments in populations with heterogeneous levels of literacy requires further research.

The Impact of Primary Progressive Aphasia on Picture Naming and General Language Ability

BACKGROUND

Primary progressive aphasia (PPA) is a clinical syndrome that is characterized by progressive deterioration of language while other cognitive domains remain relatively intact. The extent to which print exposure and cortical volume atrophy jointly influence picture naming and general language ability in individuals with PPA remains underexplored.

OBJECTIVE

To investigate the language performance of individuals with the nonfluent variant of primary progressive aphasia (nfvPPA) and to explore the impact of print exposure and cortical volume atrophy on their language ability.

METHOD

We compared 14 Greek individuals with nfvPPA and similar age, education, disease duration, and cognitive ability with age-, gender- and education-matched Greek controls on picture naming and on language tasks of the Boston Diagnostic Aphasia Examination-Short Form, including oral word reading, word and sentence repetition, complex ideational material, and reading comprehension. The effects of print exposure and left-hemisphere cortical volume on the individuals' language performance were estimated through stepwise regression models.

RESULTS

The language performance of the individuals with nfvPPA was affected by print exposure and cortical volume atrophy. Picture naming and word reading were affected by print exposure. The highest contributions of cortical volume atrophy were found for the repetition, complex ideational material, and reading comprehension tasks.

CONCLUSION

Print exposure and cortical volume atrophy may help explain variability in the language performance of nfvPPA individuals with similar age, education, disease duration, and cognitive ability.

Cross-cultural neuropsychological assessment in the European Union: a Delphi expert study

OBJECTIVE

The increasing ethnic diversity in the European Union (EU) calls for adaptations to neuropsychological assessment practices. The aims of this study were to examine the current state of cross-cultural neuropsychological assessment in EU-15 countries and to provide recommendations for researchers and policy makers.

METHOD

Twelve experts from nine EU-15 countries participated in a Delphi consensus study involving two sequential rounds of web-based questionnaires and an in-person consensus meeting. The experts individually rated Delphi topics on the basis of importance (scale 1-10). The degree of consensus was determined by assessing first and third quartiles (Q1 and Q3) and medians.

RESULTS

Consensus outcomes showed the following priorities: (a) the development of tests (median importance rating 10, Q1-Q3: 9-10), (b) the collection of normative data (median importance rating 9, Q1-Q3: 8-10), and (c) more training, awareness, and knowledge regarding cross-cultural assessment among neuropsychologists in the EU (median importance rating 9, Q1-Q3: 8-10). Whereas memory tests were often available, tests measuring social cognition (median 9, Q1-Q3: 8-10) and language (median 9, Q1-Q3: 7-10) are particularly lacking. Recommendations were made regarding essential skills and knowledge necessary for cross-cultural neuropsychological assessment.

CONCLUSIONS

This study in a small group of experts suggests that the development and availability of cross-cultural tests and normative data should be prioritized, as well as the development and implementation of training initiatives. Furthermore, EU guidelines could be established for working with interpreters during neuropsychological assessment. Before implementing these recommendations, follow-up studies are recommended that include more minority neuropsychologists and community stakeholders.

Diagnostic Accuracy of Usual Cognitive Screening Tests Versus Appropriate Tests for Lower Education to Identify Alzheimer Disease

INTRODUCTION

The accuracy of commonly used screening tests for Alzheimer's disease (AD) has not been directly compared to those that could be more appropriate for lower schooling.

OBJECTIVE

To compare the diagnostic accuracy of usual screening tests for AD with instruments that might be more appropriate for lower schooling among older adults with low or no literacy.

METHODS

The study included a clinical sample of 117 elderly outpatients from a Geriatric Clinic classified as literate controls (n = 39), illiterate controls (n = 30), literate AD (n = 30) and illiterate AD (n = 18). The tests were compared as follows: Black and White versus Colored Figure Memory Test; Clock Drawing Test versus Clock Reading Test; Verbal Fluency (VF) animal versus grocery category; CERAD Constructional Praxis versus Stick Design Test.

RESULTS

The means of literate and illiterate controls did not differ in the Black and White Figure Memory Test (immediate recall), Colored Figure Memory Test (delayed recall), Clock Reading Test and VF animals and grocery categories. The means of the clinical groups (controls versus AD), in the 2 schooling levels, differed significantly in most of the tests, except for the CERAD Constructive Praxis and the Stick Design Test. Diagnostic accuracy was not significantly different between the compared tests.

CONCLUSION

Commonly used screening tests for AD were as accurate as those expected to overcome the education bias in a sample of older adults with lower or no education.

Effects of Illiteracy on the European Cross-Cultural Neuropsychological Test Battery (CNTB)

OBJECTIVES

Test performances of illiterate and literate immigrants were compared to investigate the effects of illiteracy on the European Cross-cultural Neuropsychological Test Battery (CNTB), and associations between test performance and participant characteristics were examined.

METHOD

Participants were 20 illiterate and 21 literate middle-aged and older Turkish immigrants (50-85 years) matched by age and gender that completed the CNTB as well as a number of demographic and medical questionnaires.

RESULTS

No significant group differences or correlations between education, acculturation or health characteristics and test performances were found on 10 of 16 measures. Illiteracy status and participant characteristics affected measures of mental processing speed, executive function, and visuoconstruction.

CONCLUSIONS

The preliminary findings suggest that several of the measures in the CNTB may be valid for assessment of cognitive functioning in people who are illiterate when applied using available normative data. However, these findings need to be replicated in larger samples.

The Dutch version of the Oxford Cognitive Screen (OCS-NL): normative data and their association with age and socio-economic status

The Oxford Cognitive Screen (OCS) is a screening tool designed for stroke patients, assessing attention, executive functions, language, praxis, numeric cognition and memory. Here we present norms for the two parallel versions of the Dutch OCS (OCS-NL, acquired in 246 participants for version A and a subset of 179 participants for version B. We evaluated the association of age and socio-economic status (i.e. education, income, occupation) with OCS-NL performance There were no systematic performance differences between income groups, nor between manual and non-manual workers. There were small differences between education groups. The association of education and performance did not vary across subtests. The association of age and performance varied across subtests, with the strongest associations for the naming, praxis, verbal memory and executive task. Thus, OCS-NL norms do not need to be stratified on income and occupation and age-specific norms are recommended for some subtests.

Assessing Variability in Reading Performance with the New Greek Standardized Reading Speed Texts (IReST)

SIGNIFICANCE

This article evaluates the standardized Greek version of the International Reading Speed Texts (IReST) set, which enriches interlanguage comparisons and international clinical studies of reading performance. Moreover, it investigates how specific textual and subject-related characteristics modulate the variability of reading speed across texts and readers.

PURPOSE

The purpose of this study was to develop a standardized Greek version of the IReST set and investigate how specific textual and subject-related factors modulate the variability of reading speed across texts and readers.

METHODS

The English IReST texts were translated to Greek and matched for length, content, and linguistic difficulty. The Greek IReSTs were presented at a distance of 40 cm and size of 1 M to assess reading speeds of 25 normally sighted native speakers (age range, 18 to 35 years). The participants read the texts aloud while reading time was measured by stopwatch. Reading performance included measurement of reading speed in three units of analysis. Reading efficiency was assessed using a word-level oral reading task. Statistical analysis included evaluation of subject- and text-related variability, as well as correlations between reading speed and specific textual and subject-related factors.

RESULTS

The average reading speed between texts was 208 ± 24 words/min, 450 ± 24 syllables/min, and 1049 ± 105 characters/min. Differences between readers accounted for the 76.6%, whereas differences across texts accounted for the 23.4% of the total variability of reading speed. Word length (in syllables per word) and median word frequency showed a statistically significant contribution to the variability of reading speed (r = 0.95 and 0.70, respectively). Reading speed was also statistically correlated with word reading efficiency (r = 0.68).

CONCLUSIONS

The addition of the Greek version in the IReST language pack is expected to be a valuable tool for clinical practice and research, enriching interlanguage comparisons and international studies of reading performance.

Assessment of Visual Association Memory in Low-Educated, Non-Western Immigrants with the Modified Visual Association Test

BACKGROUND

Neuropsychological tests are influenced by culture, language, level of education, and literacy, but there are few cognitive tests of which the applicability in ethnic minority populations has been studied.

OBJECTIVES

The aim of this study was to assess the reliability and validity of the Visual Association Test (VAT), a test of visual association memory, in a non-Western, low-educated memory clinic population. Additionally, a modified version of the VAT using colored photographs instead of line drawings was studied (mVAT).

METHOD

Both the original VAT and the mVAT were administered to non-Western immigrants (n = 73) from 2 multicultural memory clinics in Rotterdam, The Netherlands, and a control sample of non-demented Turkish elderly (n = 14) with low education levels (32 and 29% illiterate, respectively).

RESULTS

Both the VAT and the mVAT were able to discriminate persons with and without dementia (area under the curve: VAT, 0.77-0.88; mVAT, 0.85-0.95). The mVAT had more homogeneous item difficulty levels than the VAT. Administration of parallel versions of the VAT and the mVAT within the same person revealed higher scores on the mVAT (Z = -3.35, p = 0.001).

CONCLUSIONS

The mVAT is a reliable and valid measure of memory in non-Western immigrants. Clinicians and researchers should be aware that the memory performance of immigrants may be systematically underestimated when using tests with black-and-white line drawings, such as the original VAT.

The IFS (INECO Frontal Screening) and level of education: Normative data

Level of education is known to confound neuropsychological test performance. The INECO Frontal Screening (IFS) is an easy-to-use and brief measure of several domains of executive function, which has previously shown reliably clinical usefulness and superior psychometric performance when compared to other frontal screening instruments. However, previous studies with the IFS have been limited to participants with high levels of education, preventing its generalizability to populations with less than 12 years of formal education. This is crucial, as less than half of the Latin American population and a large percentage of immigrants in developed countries attain high school education. The aim of this study was to generate IFS normative data in a sample stratified by age and education levels. One hundred and sixty one healthy adults were assessed with the IFS as well as measures of global cognitive screening, namely, the Addenbrooke Cognitive Examination Revised and the Mini-Mental State Examination. Multiple lineal regression analysis showed significant effects for education and nonsignificant effects for age. A correction grid for IFS raw scores was developed and cut-off scores were calculated. The correction grid and cut-off scores may be useful in the interpretation of IFS scores in participants with low education.

Adaptation and validation of the Alzheimer's Disease Assessment Scale - Cognitive (ADAS-Cog) in a low-literacy setting in sub-Saharan Africa

OBJECTIVE

This study aimed to assess the feasibility of a low-literacy adaptation of the Alzheimer's Disease Assessment Scale - Cognitive (ADAS-Cog) for use in rural sub-Saharan Africa (SSA) for interventional studies in dementia. No such adaptations currently exist.

METHODS

Tanzanian and Nigerian health professionals adapted the ADAS-Cog by consensus. Validation took place in a cross-sectional sample of 34 rural-dwelling older adults with mild/moderate dementia alongside 32 non-demented controls in Tanzania. Participants were oversampled for lower educational level. Inter-rater reliability was conducted by two trained raters in 22 older adults (13 with dementia) from the same population. Assessors were blind to diagnostic group.

RESULTS

Median ADAS-Cog scores were 28.75 (interquartile range (IQR), 22.96-35.54) in mild/moderate dementia and 12.75 (IQR 9.08-16.16) in controls. The area under the receiver operating characteristic curve (AUC) was 0.973 (95% confidence interval (CI) 0.936-1.00) for dementia. Internal consistency was high (Cronbach's α 0.884) and inter-rater reliability was excellent (intra-class correlation coefficient 0.905, 95% CI 0.804-0.964).

CONCLUSION

The low-literacy adaptation of the ADAS-Cog had good psychometric properties in this setting. Further evaluation in similar settings is required.

The Development of the Dementia Screening Battery-100: Instrument Presentation, Reliability, and Construct Validity

Background/Aim

The screening of dementia in non-Westerners has so far relied on translations and adaptations of reputed instruments. Other efforts focused on developing culturally appropriate tests or tests in touch with new developments in the field. This study presents the rationale behind the construction of a new dementia screening test: the Dementia Screening Battery-100 (DSB-100).

Methods

The DSB-100 was administered to 46 demented individuals and 159 healthy matched controls. All demented participants met the DSM-IV criteria for dementia. The healthy controls showed no cognitive impairment and were independent in activities of daily living. The DSB-100 was administered as part of a larger neuropsychological assessment to collect additional indices on the severity of patients' dementia, depression, and frontal dysfunctions. The same information was used for comparisons with DSB-100 scores.

Results

Multiple regression analysis suggested that age and education, but not the variable sex, are essential in predicting cognitive performance. Construct validation yielded 4 factors, namely attention-visuospatial factors, memory, language, and executive functions. The results showed that the DSB-100 has a high interrater reliability and an acceptable overall internal homogeneity.

Conclusion

These results validate the DSB-100 and suggest its appropriateness for dementia screening in Tunisian elderly and possibly elderly people from other cultures with modifications to some subscales.

Cognitive screening tools for identification of dementia in illiterate and low-educated older adults, a systematic review and meta-analysis

BACKGROUND

The majority of older adults with dementia live in low- and middle-income countries (LMICs). Illiteracy and low educational background are common in older LMIC populations, particularly in rural areas, and cognitive screening tools developed for this setting must reflect this. This study aimed to review published validation studies of cognitive screening tools for dementia in low-literacy settings in order to determine the most appropriate tools for use.

METHOD

A systematic search of major databases was conducted according to PRISMA guidelines. Validation studies of brief cognitive screening tests including illiterate participants or those with elementary education were eligible. Studies were quality assessed using the QUADAS-2 tool. Good or fair quality studies were included in a bivariate random-effects meta-analysis and a hierarchical summary receiver operating characteristic (HSROC) curve constructed.

RESULTS

Forty-five eligible studies were quality assessed. A significant proportion utilized a case-control design, resulting in spectrum bias. The area under the ROC (AUROC) curve was 0.937 for community/low prevalence studies, 0.881 for clinic based/higher prevalence studies, and 0.869 for illiterate populations. For the Mini-Mental State Examination (MMSE) (and adaptations), the AUROC curve was 0.853.

CONCLUSION

Numerous tools for assessment of cognitive impairment in low-literacy settings have been developed, and tools developed for use in high-income countries have also been validated in low-literacy settings. Most tools have been inadequately validated, with only MMSE, cognitive abilities screening instrument (CASI), Eurotest, and Fototest having more than one published good or fair quality study in an illiterate or low-literate setting. At present no screening test can be recommended.

Does learning to read shape verbal working memory?

Many experimental studies have investigated the relationship between the acquisition of reading and working memory in a unidirectional way, attempting to determine to what extent individual differences in working memory can predict reading achievement. In contrast, very little attention has been dedicated to the converse possibility that learning to read shapes the development of verbal memory processes. In this paper, we present available evidence that advocates a more prominent role for reading acquisition on verbal working memory and then discuss the potential mechanisms of such literacy effects. First, the early decoding activities might bolster the development of subvocal rehearsal, which, in turn, would enhance serial order performance in immediate memory tasks. In addition, learning to read and write in an alphabetical system allows the emergence of phonemic awareness and finely tuned phonological representations, as well as of orthographic representations. This could improve the quality, strength, and precision of lexical representations, and hence offer better support for the temporary encoding of memory items and/or for their retrieval.

The illiterate brain and the neuropsychological assessment: From the past knowledge to the future new instruments

The lifetime learning of illiterate and low-educated individuals shapes their cognitive skills, which are challenging to grade by the current available neuropsychological tools. Eight hundred million of the global population are illiterate. It is very challenging to interpret the cognitive performance of this population by the available formal neuropsychological tests, mainly developed for higher educated people. From extensive literature investigation, we reviewed the cognitive process and performance of illiterate and low-educated population on various cognitive domains including language, executive function, memory, visual-related function, and motor skills. We also suggested the concept in the development of the appropriate tools for the cognitive assessment among this population. Finally, we provide the available cognitive screening tools validated in the illiterate and low-educated subjects within the last three decades.

A Review about Functional Illiteracy: Definition, Cognitive, Linguistic, and Numerical Aspects

Formally, availability of education for children has increased around the world over the last decades. However, despite having a successful formal education career, adults can become functional illiterates. Functional illiteracy means that a person cannot use reading, writing, and calculation skills for his/her own and the community's development. Functional illiteracy has considerable negative effects not only on personal development, but also in economic and social terms. Although functional illiteracy has been highly publicized in mass media in the recent years, there is limited scientific knowledge about the people termed functional illiterates; definition, assessment, and differential diagnoses with respect to related numerical and linguistic impairments are rarely studied and controversial. The first goal of our review is to give a comprehensive overview of the research on functional illiteracy by describing gaps in knowledge within the field and to outline and address the basic questions concerning who can be considered as functional illiterates: (1) Do they possess basic skills? (2) In which abilities do they have the largest deficits? (3) Are numerical and linguistic deficits related? (4) What is the fundamental reason for their difficulties? (5) Are there main differences between functional illiterates, illiterates, and dyslexics? We will see that despite partial evidence, there is still much research needed to answer these questions. Secondly, we emphasize the timeliness for a new and more precise definition that results in uniform sampling, better diagnosis, conclusion, and intervention. We propose the following working definition as the result of the review: functional illiteracy is the incapability to understand complex texts despite adequate schooling, age, language skills, elementary reading skills, and IQ. These inabilities must also not be fully explained by sensory, domain-general cognitive, neurological or mental disorders. In sum, we suggest that functional illiteracy must be more thoroughly understood and assessed from a theoretical, empirical, and diagnostic perspective.

TNI-93: A New Memory Test for Dementia Detection in Illiterate and Low-Educated Patients

OBJECTIVE

To validate the TNI-93 test in illiterate and low-educated subjects by setting cutoff scores to discriminate non-demented and demented subjects in a clinical setting (CESILL) and verifying the adequacy of these cutoff scores in a population-based study (AMI cohort).

METHOD

We used two study samples. First, a clinical setting (CESILL) comprising normal elderly participants and demented patients, mostly multicultural, low educated, or illiterate, was used to compute the cutoff scores of TNI-93 for the detection of dementia. Second, the AMI cohort, a population-based cohort of retired farmers living in a rural setting, was used as a replication study, to assess the detection properties of the cutoff scores in a different population composed mostly of low-educated older people.

RESULTS

When combining the two scores, that is, free recall <6 or total recall <9, TNI-93 can detect dementia with a high sensitivity (87%) and specificity (96%), in the CESILL setting. These cutoff scores were roughly similar in the AMI cohort with high sensitivity (80% sensitivity) and specificity (81% specificity). In both study samples, the level of education had no effect on performance.

CONCLUSIONS

The TNI-93 appears to be a good test to detect dementia. The absence of a significant effect of education level on the performances makes the TNI-93 a tool of choice in the screening of dementia in illiterate/low-educated subjects.

Neurobiological Substrates of Illiteracy

Comparable subjects except for the knowledge of orthography and school attendance in the proper age provided the case material for a series of studies that are reviewed. The results suggest that the acquisition of orthographic skills provides a basis for changes in the pattern of activation of the brain.

Low compliance to pharmacological treatment is linked to cognitive impairment in euthymic phase of bipolar disorder

BACKGROUND

Cognitive impairment and low compliance to pharmacological treatment are frequent complications in bipolar disorder. Moreover, low compliance in patients with bipolar disorder is one of the main reasons for relapse. This in turn, is associated with an increase in neurocognitive symptoms. The current study aimed to determine whether attention, memory, and executive function are related to the level of compliance to pharmacological treatment in individuals with bipolar disorder in euthymic phase.

METHOD

We examined 34 patients with bipolar disorder (12 with low compliance to the treatment and 22 with high compliance to the treatment) according to the DSM-IV criteria, in the range of 18-55 years. All patients were assessed through a neuropsychological battery in one single session. Analysis of covariance (ANCOVA) was used to compare neuropsychological test scores between low and high compliance patients. Clinical and sociodemographic characteristics were included as covariates in the study.

RESULTS

Patients with low level of compliance performed significantly worse than high treatment compliance on verbal memory immediate free recall (F (1)=12.14, p=.002), verbal memory immediate cued recall (F (1)=10.45, p=.003), verbal memory delayed free recall (F (1)=5.52, p=.027), and verbal memory delayed cued recall (F (1)=6.11, p=.021). Covariates such as number of manic episodes, history of psychosis and years of education were found significant for executive functions and processing speed.

CONCLUSION

We found that low compliance to pharmacological treatment is consistently linked to immediate and delayed verbal memory. In addition, executive function and processing speed were associated with clinical and demographic characteristics. Limitations of this study include the small sample size, a cross-sectional design that cannot address causality, and inability to account for pharmacologic effects.

Italian normative data for the Battery for Visuospatial Abilities (TERADIC)

Battery for Visuospatial Abilities (BVA, known in Italy as TeRaDiC) has been developed to analyse putative basic skills involved in drawing and to plan and monitor outcomes after rehabilitation of visuoconstructional disorders. It encompasses eight tasks assessing both simple "perceptual" abilities, such as line length and line orientation judgments and complex "representational" abilities, such as mental rotation. The aim of present study was to provide normative values for BVA collected in a wide sample of healthy Italian subjects. Three hundred seventeen healthy Italian subjects (173 women and 144 men) of different age classes (age range, 40-95 years) and education level (from primary to university), with a normal score on Mini Mental State Examination, completed BVA/TeRaDiC. Multiple linear regression analysis revealed that age and education significantly influenced performance on most tests of the BVA/TeRaDiC; only line length judgment was not affected by educational level. Gender significantly affected line orientation judgment and mental rotation, with an advantage for males in both tests. From the derived linear equations, a correction grid for adjusting BVA/TeRaDiC raw scores was built. Using a non-parametric technique, inferential cut-off scores were determined and equivalent scores computed. The present study provided Italian normative data for the BVA/TeRaDiC useful for both clinical and research purposes.

Analysis of figure recognition on the modified MT Beta-86 test for adaptation: description and discussion of methodological aspects

PURPOSE

The purpose of this study was to analyze the recognition of figures from the modified MT Beta-86 test for subsequent refinement and adaptation of this language assessment instrument.

METHODS

This study was organized into two parts. The first part of the study involved 61 subjects with educational level higher than nine years. Naming of 266 visual stimuli was elicited and concordance among participants on figure naming was also determined. Concordance of responses was assessed using Cochrane's test at a 5% level of significance. Some visual stimuli were subsequently re-designed and images were replaced. The second part of this study involved the re-testing of the new images among 110 individuals ranging in age from 18 to 75 years of both genders, stratified into four educational bands (A: 1-4 years; B: 5-8 years; C: 9-11 years; and D: more than 12 years). Stimuli with concordance level of 70% or higher were considered adequate.

RESULTS

In part A of the study, from the index of agreement of naming, the figures considered suitable for inclusion in the adapted version were selected. In part B, all the figures had a response concordance level over 70%.

CONCLUSION

Figures in the Modified MT Beta-86 test suitable for retention in the new version of the instrument were identified. Analysis of low sample recognition was used to identify boards for replacement, and those for retention, in the new version of the test.

Effect of literacy level on cognitive and language tests in Korean illiterate older adults

AIM

Illiterate individuals represent a significant proportion of the world's population. Acquisition of reading and writing skills influences the functional status of the brain, and consequently alters the performance on cognitive and language tests. Thus, it is important to identify the degree of the impact of levels of both illiteracy and education as potential confounders on test performance in people with neurological communication disorders.

METHODS

A total of 203 community-dwelling older adults aged 65 years and older were recruited for the present study. Participants were classified into four groups based on the literacy level; pure illiterate (n=29), semi-illiterate (n=67), literate (n=75) and high-level literate (n=32). The participants completed the Mini-Mental State Examination, Boston Naming Test, Controlled Oral Word Association Test (animal), verb naming, and sentence comprehension tests.

RESULTS

The pure illiterate group showed the lowest performance on all five tests. Regression analysis showed that literacy level was the variable that best predicted the performance on cognitive and language tests.

CONCLUSIONS

These findings suggest that literacy in performance on cognitive and language tests is an important factor in neuropsychological evaluations for older adults.

Impact of phonological processing skills on written language acquisition in illiterate adults

Illiteracy remains a world-wide problem not only for children but also for adults. Phonological processing has been defined as a crucial factor for the acquisition of written language, which usually occurs in childhood. However, it is unclear to what extent phonological processing is necessary in order for adults to acquire written language skills. We tested 47 illiterate adults before and after a one-year alphabetization course in several cognitive domains relevant to phonological processing and compared their results to 41 matched controls who did not take part in the alphabetization course. Phonological awareness in the narrower sense (e.g., phoneme association) was a stronger predictor of alphabetization outcome than demographic variables such as years of education. In addition, despite improvement of illiterate individuals in phonological awareness, short-term memory, and visual attention from before to after the alphabetization course, they did not reach the phonological processing level of literate controls. Our results confirm that the alphabetization of adults requires and enhances phonological processes similar to those of children. Nevertheless, specific aspects, such as improvements in short-term memory or visual attention, need to be considered in order to improve and optimize alphabetization programs for adults.

Normative data for the letter-cancellation task in school children

Aims:

To establish the norms for the letter-cancellation task—a psychomotor performance task.

Materials and Methods:

Eight hundred nineteen school students were selected in the present study in an age range between nine and 16 years (M = 12.14; SD = 1.78 years). Subjects were assessed once for the cancellation task.

Results:

Both age and sex influenced performance on the SLCT; therefore, correction scores were obtained on the basis of these factors.

Conclusions:

The availability of Indian normative data for the SLCT will allow wider application of this test in clinical practice.

Relationship of ethnicity, age, education, and reading level to speed and executive function among HIV+ and HIV- women: the Women's Interagency HIV Study (WIHS) Neurocognitive Substudy

Use of neuropsychological tests to identify HIV-associated neurocognitive dysfunction must involve normative standards that are well suited to the population of interest. Norms should be based on a population of HIV-uninfected individuals as closely matched to the HIV-infected group as possible and must include examination of the potential effects of demographic factors on test performance. This is the first study to determine the normal range of scores on measures of psychomotor speed and executive function among a large group of ethnically and educationally diverse HIV-uninfected, high-risk women, as well as their HIV-infected counterparts. Participants (n = 1,653) were administered the Trail Making Test Parts A and B (Trails A and Trails B), the Symbol Digit Modalities Test (SDMT), and the Wide Range Achievement Test-3 (WRAT-3). Among HIV-uninfected women, race/ethnicity accounted for almost 5% of the variance in cognitive test performance. The proportions ofvariance in cognitive test performance accounted for by age (13.8%), years of school (4.1%), and WRAT-3 score (11.5%) were each significant, but did not completely account for the effect of race (3%). HIV-infected women obtained lower scores than HIV-uninfected women on time to complete Trails A and B, SDMT total correct, and SDMT incidental recall score, but after adjustment for age, years of education, racial/ethnic classification, and reading level, only the difference on SDMT total correct remained significant. Results highlight the need to adjust for demographic variables when diagnosing cognitive impairment in HIV-infected women. Advantages of demographically adjusted regression equations developed using data from HIV-uninfected women are discussed.

Effect of literacy and education on the visuoconstructional ability of non-demented elderly individuals

Learning to read and to write influences not only verbal skills but also global cognitive performance. Our study aimed to compare the visuoconstructional abilities of elderly illiterates with those of elderly literates. A total of 125 healthy subjects over 65 years old were recruited. Korean version of Mini-Mental State Examination (K-MMSE) and the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) constructional praxis examination were used. We divided subjects into three groups (educated literate n = 53, uneducated literate n = 36 and uneducated illiterate n = 36). Interlocking pentagons drawing, a part of the K-MMSE, was scored using the 6-point hierarchical scale. The uneducated-illiterate group obtained significantly lower scores than did the other two groups. Scores on the ADAS-cog constructional praxis test were highest in the educated-literate group and those in the uneducated-illiterate group obtained the lowest scores. We demonstrated that illiteracy influences not only language performance but also visuoconstructional functioning.

A influência do gênero e da escolaridade no diagnóstico de demência

Um problema no diagnóstico das demências é a ausência de informação prévia sobre o nível cognitivo dos pacientes, anterior às manifestações atuais. A análise das discrepâncias nos testes cognitivos torna-se assim uma referência para o diagnóstico. A relação entre gênero, nível de escolaridade, experiência profissional e resultados da avaliação neuropsicológica foi analisada a partir de prontuários clínicos de pacientes idosos. A amostra masculina de nível superior apresentou médias significativamente menores nas subescalas de execução em relação às verbais. Apesar do nível de escolaridade e da atividade intelectual ocultarem a perda de performance nos quadros demenciais, a análise das discrepâncias evidencia as quedas de rendimento. Na amostra feminina, com menor nível de escolaridade, embora os resultados mostrassem deficiência cognitiva, não ocorreram diferenças significativas entre os subtestes verbais e de execução. A análise da covariância indicou que o nível de escolaridade, e não o gênero, foi o fator responsável pela diferença.

Illiteracy and dementia

There is a current concept that illiteracy and lower educational levels are risk factors for cognitive decline and dementia. Our aims were to review the association between illiteracy and dementia; and to describe some results on neuropsychological findings in illiteracy. A literature search of the PubMed database was performed. The search terms were “dementia”, “illiteracy”, “neuropsychological evaluation”, “educational levels”, and “education”. Only papers published in Portuguese, English, and Spanish were reviewed. Illiteracy is an incontestable risk factor for dementia. It influences performance on almost cognitive tests. Many other factors could be connected to the high prevalence of dementia among illiterates: low cognitive reserve, poor control of cerebrovascular disease risk factors, difficulties in cognitive evaluation, and poor adaptation of neuropsychological tests for this specific population. Functional tests must be coupled with cognitive tests to ameliorate diagnostic accuracy.

Effects of recurrence on the cognitive performance of patients with bipolar I disorder: implications for relapse prevention and treatment adherence

OBJECTIVE

To determine if the repeated occurrence of manic episodes in bipolar I disorder (BD-I) patients is associated with reduced cognitive performance, which could in turn imply a worsening in the disorder's evolution.

METHOD

Cognitive performance in euthymic patients was assessed using attention, memory, and executive function tests on 24 BD-I patients who had experienced only 1 manic episode, on 27 BD-I patients with 2 manic episodes, on 47 BD-I patients with 3 or more manic episodes, and on 66 healthy control subjects.

RESULTS

In BD-I patients, number of manic episodes was positively associated with poorer performance on neurocognitive tests, an association that was not accounted for by depression, disease chronicity, onset, or medication. Significant differences in attention and executive function were found between patients and controls and in those patients who had had just 1 manic episode compared to those who had 3 or more.

CONCLUSION

The number of manic episodes predicted poor cognitive performance, suggesting that the recurrence of mania may have a long-term neuropsychological impact. Prospective follow-up studies need to be completed to explore this effect further as better treatment adherence may have a protective effect on neurocognitive function.

Preliminary Arabic normative data of neuropsychological tests: the verbal and design fluency

OBJECTIVES

The objective of the present study was to provide preliminary norms for three fluency tests in Arabic language: the verbal fluency (phonemic and semantic) and design fluency tests.

METHODS

Three Arabic letters have been chosen for the phonemic fluency task, in accordance with the letter selection procedure described in the development of the standard test. Animal fluency was chosen for the semantic fluency, and the Five-Point test for the design fluency test.

PARTICIPANTS

An Arabic speaking sample of 215 healthy participants (125 male, 90 female), with age ranging from 18-59 years and with different educational levels, were selected for this study.

RESULTS

Age and education significantly influenced performance in the verbal phonemic and semantic tasks, but not in the design fluency test. No gender effect was found in any of the three tasks. The education effects were linear, while age effects appeared to be curvilinear.

CONCLUSION

This pattern is congruent with that reported in the western literature. The implications of these results in relation to the development of Arabic norms were discussed. It was concluded that these tests could be used in an Arabic-speaking population with due considerations to the effects of age and education.

The common objects memory test (COMT): a simple test with cross-cultural applicability

The Common Objects Memory Test (COMT) was developed to assess age-related memory impairments in individuals with a range of educational, language and cultural backgrounds. The COMT is a list-learning protocol that uses photographs of common objects to bypass difficulties posed by written words for individuals who are illiterate or have limited education. Preliminary data are presented for 336 healthy adults and 90 patients with dementia. Their age ranged from 54 to 99 years, education ranged from 0 to 22 years, and they were from five culturally and linguistically distinct populations: Caucasian and African-American English speakers, and native Chinese, Spanish, and Vietnamese speakers. Performance on the COMT was influenced by age, but little influenced by education, and un-influenced by gender or ethnic background. Among 11 neuropsychological tests, the recall scores from the COMT best distinguished healthy individuals from patients with dementia, underscoring its clinical utility for ethnically diverse populations.

Cambridge Cognitive Examination: performance of healthy elderly Brazilians with low education levels

This study aimed to estimate the quartile distribution on the cognitive assessment of normal elderly with low education as measured by the Cambridge Cognitive Examination (CAMCOG). A sample of 292 elderly (> 65 years of age), screened for dementia and depression, were assessed using the CAMCOG. The CAMCOG scores of normal subjects (n = 206) were stratified according to age (65-69, 70-74, 75-79, > 80) and schooling (illiterate, 1-4, and > 5 years of formal education). Mean age was 72.8 (± 3.5) and mean schooling was 3.5 years (± 3). The mean score on the CAMCOG was 71 (± 12.7). The scores at the first quartile for illiterate/1-4 years of schooling were 58/62 (65-69 years), 52/63 (70-74 years), 48/67 (75-79 years) and 46/64 (> 80 years), respectively. There was a significant difference in the CAMCOG quartiles according to education and age. This study provides normative data on the CAMCOG of elderly people with low educational levels which may be clinically useful.

Performance of a Brazilian population in the EC 301 calculation and number processing battery: a pilot study

BACKGROUND

From a neuropsychological point of view calculation is a very complex function. A simple arithmetic operation demands many neurocognitive mechanisms that involve verbal, spatial and graphical processing, memory and attention.

OBJECTIVE

To verify the calculation and number processing of healthy subjects and the effect of gender, age and schooling on their performance.

METHOD

Forty-four normal subjects without complaints or neurological changes were evaluated.

RESULTS

The educational level was significantly linked to performance in the majority of tests of the EC 301 battery, whereas no differences were noted regarding age and gender.

CONCLUSION

Evaluation of the data of the healthy population shown in this study indicated that educational level can affect calculation and number processing, It is possible to note that battery EC 301 demonstrated sensitivity for appraisal of these abilities and therefore can be employed for clinical assessment in calculation and number disorders.

Effects of race and socioeconomic status on the relative influence of education and literacy on cognitive functioning

Previous research has shown that reading ability is a stronger predictor of cognitive functioning than years of education, particularly for African Americans. The current study was designed to determine whether the relative influence of literacy and education on cognitive abilities varies as a function of race or socioeconomic status (SES). We examined the unique influence of education and reading scores on a range of cognitive tests in low- and higher-SES African Americans and Whites. Literacy significantly predicted scores on all but one cognitive measure in both African American groups and low-SES Whites, while education was not significantly associated with any cognitive measure. In contrast, both education and reading scores predicted performance on many cognitive measures in higher-SES Whites. These findings provide further evidence that reading ability better predicts cognitive functioning than years of education and suggest that disadvantages associated with racial minority status and low SES affect the relative influence of literacy and years of education on cognition.