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

Heterogeneity in cognitive profiles of monolingual and bilingual Hispanic/Latino older adults in HABS-HD

OBJECTIVE

The present study characterized heterogeneity in the cognitive profiles of monolingual and bilingual Latino older adults enrolled in the HABS-HD.

METHODS

A total of 859 cognitively unimpaired older adults completed neuropsychological testing. Raw scores for cognitive tests were converted to z-scores adjusted for age, education, sex, and language of testing. A latent profile analysis (LPA) was conducted for monolingual and bilingual speaker groups. A series of 2-5 class solutions were examined, and the optimal model was selected based on fit indices, posterior probabilities, proportion of sample sizes, and pattern of scores. Identified classes were compared on sociodemographic, psychosocial, and health characteristics.

RESULTS

For the monolingual group (n = 365), a 3-class solution was optimal; this consisted of a Low Average Memory group with low average verbal memory performances on the SEVLT Total Learning and Delayed Recall trials, as well as an Average Cognition group and a High Average Cognition group. For the bilingual group (n = 494), a 3-class solution was observed to be optimal; this consisted of a Low Average Memory group, with low average verbal memory performances on the learning and delayed recall trials of Logical Memory; a Low Average Executive group, where performance on Trails A and B and Digit Substitution were the lowest; and a High Average Cognition group, where performance was generally in the high average range across most cognitive measures.

CONCLUSIONS

Cognitive class solutions differed across monolingual and bilingual groups and illustrate the need to better understand cognitive variability in linguistically diverse samples of Latino older adults.

Associations between multidomain modifiable dementia risk factors with AD biomarkers and cognition in middle-aged and older adults

This study aimed to determine associations between modifiable dementia risk factors (MDRF), across domains mood symptomatology, lifestyle behaviors, cardiovascular conditions, cognitive/social engagement, sleep disorders/symptomatology, with cognition, beta-amyloid (Aβ) and tau, and brain volume. Middle-aged/older adults (n=82) enrolled in a sub-study of the Healthy Brain Project completed self-report questionnaires and a neuropsychological battery. Cerebrospinal fluid levels of Aβ 1-42, total tau (t-tau), and phosphorylated tau (p-tau181) (Roche Elecsys), and MRI markers of hippocampal volume and total brain volume were obtained. Participants were classified as no/single domain risk (≤1 domains) or multidomain risk (≥2 domains). Compared to the no/single domain risk group, the multidomain risk group performed worse on the Preclinical Alzheimer's Cognitive Composite (d=0.63, p=.005), and Executive Function (d=0.50, p=.016), and had increased p-tau181 (d=0.47, p=.042) and t-tau (d=0.54, p=.021). In middle-aged/older adults, multidomain MDRFs were related to increases in tau and worse cognition, but not Aβ or brain volume. Findings suggest that increases in AD biomarkers are apparent in midlife, particularly for individuals with greater burden, or variety of MDRFs.

How Socio-economic Inequalities Cluster People with Diabetes in Malaysia: Geographic Evaluation of Area Disparities Using a Non-parameterized Unsupervised Learning Method

Accurate assessments of epidemiological associations between health outcomes and routinely observed proximal and distal determinants of health are fundamental for the execution of effective public health interventions and policies. Methods to couple big public health data with modern statistical techniques offer greater granularity for describing and understanding data quality, disease distributions, and potential predictive connections between population-level indicators with areal-based health outcomes. This study applied clustering techniques to explore patterns of diabetes burden correlated with local socio-economic inequalities in Malaysia, with a goal of better understanding the factors influencing the collation of these clusters. Through multi-modal secondary data sources, district-wise diabetes crude rates from 271,553 individuals with diabetes sampled from 914 primary care clinics throughout Malaysia were computed. Unsupervised machine learning methods using hierarchical clustering to a set of 144 administrative districts was applied. Differences in characteristics of the areas were evaluated using multivariate non-parametric test statistics. Five statistically significant clusters were identified, each reflecting different levels of diabetes burden at the local level, each with contrasting patterns observed under the influence of population-level characteristics. The hierarchical clustering analysis that grouped local diabetes areas with varying socio-economic, demographic, and geographic characteristics offer opportunities to local public health to implement targeted interventions in an attempt to control the local diabetes burden.

Determinants of diabetes self-care activities in patients with type 2 diabetes based on self-determination theory

AIMS

In type 2 diabetes control, self-management is an effective way to minimize the risk of developing complications and improve the quality of life. Self-determination theory (SDT) proposed a promising explanatory framework to predict self-regulated behavior which was particularly relevant for self-management. This study aimed to investigate whether SDT constructs can affect the self-management and controlling glycated hemoglobin A1c (HbA1c) levels in type 2 diabetic patients or not.

METHODS

This cross-sectional study was conducted from August to December 2022 at two diabetes clinics in Zahedan. The study included 300 patients with type 2 diabetes. Data collection was done using a researcher-administrated questionnaire that included demographic data, diabetes self-care activities, and self-determination constructs including autonomous support, autonomous motivation, and perceived competence.

RESULTS

The mean of the overall score of self-care activities was 34.62 ± 11.86 out of a maximum of 70. Patients in the fourth quarter (wealthiest) of the socioeconomic status had the highest mean self-care score (P = 0.003). There was a significant relationship between diet score with perceived competence (P = 0.009). Perceived competence (P<0.001) and controlled self-regulation (P<0.001) were the predictors of exercise score in diabetes patients. Independent self-regulation (P<0.001, r = 0.21) and overall self-regulation (P = 0.001, r = 0.19) were significantly related to blood-glucose testing score. There was a significant relationship between foot care score with perceived competence (P = 0.048, r = 0.11) and autonomous support (P = 0.013, r = 0.14). Multiple regression showed that exercise was the predictor of HbA1c (P = 0.014).

CONCLUSION

Exercise is crucial for achieving good individualized glycemic control and reducing the risk of diabetes complications. The findings provided valuable insights into the determinants of self-care activities in patients with type 2 diabetes and underscore the need for interventions that address socioeconomic disparities, enhance perceived competence, and provide autonomy support to improve diabetes self-care.

Increasing Realism and Variety of Virtual Patient Dialogues for Prenatal Counseling Education Through a Novel Application of ChatGPT: Exploratory Observational Study

BACKGROUND

Using virtual patients, facilitated by natural language processing, provides a valuable educational experience for learners. Generating a large, varied sample of realistic and appropriate responses for virtual patients is challenging. Artificial intelligence (AI) programs can be a viable source for these responses, but their utility for this purpose has not been explored.

OBJECTIVE

In this study, we explored the effectiveness of generative AI (ChatGPT) in developing realistic virtual standardized patient dialogues to teach prenatal counseling skills.

METHODS

ChatGPT was prompted to generate a list of common areas of concern and questions that families expecting preterm delivery at 24 weeks gestation might ask during prenatal counseling. ChatGPT was then prompted to generate 2 role-plays with dialogues between a parent expecting a potential preterm delivery at 24 weeks and their counseling physician using each of the example questions. The prompt was repeated for 2 unique role-plays: one parent was characterized as anxious and the other as having low trust in the medical system. Role-play scripts were exported verbatim and independently reviewed by 2 neonatologists with experience in prenatal counseling, using a scale of 1-5 on realism, appropriateness, and utility for virtual standardized patient responses.

RESULTS

ChatGPT generated 7 areas of concern, with 35 example questions used to generate role-plays. The 35 role-play transcripts generated 176 unique parent responses (median 5, IQR 4-6, per role-play) with 268 unique sentences. Expert review identified 117 (65%) of the 176 responses as indicating an emotion, either directly or indirectly. Approximately half (98/176, 56%) of the responses had 2 or more sentences, and half (88/176, 50%) included at least 1 question. More than half (104/176, 58%) of the responses from role-played parent characters described a feeling, such as being scared, worried, or concerned. The role-plays of parents with low trust in the medical system generated many unique sentences (n=50). Most of the sentences in the responses were found to be reasonably realistic (214/268, 80%), appropriate for variable prenatal counseling conversation paths (233/268, 87%), and usable without more than a minimal modification in a virtual patient program (169/268, 63%).

CONCLUSIONS

Generative AI programs, such as ChatGPT, may provide a viable source of training materials to expand virtual patient programs, with careful attention to the concerns and questions of patients and families. Given the potential for unrealistic or inappropriate statements and questions, an expert should review AI chat outputs before deploying them in an educational program.

The utility of the Cognitive Reserve Index questionnaire in chronic traumatic brain injury

Objective: This study examined the relationship between cognitive reserve measured with the Cognitive Reserve Index questionnaire (CRIq) and cognitive and functional outcomes in a chronic traumatic brain injury (TBI) cohort compared to a non-TBI cohort. The utility of the CRIq was compared to common proxies of cognitive reserve (premorbid IQ and years of education) in TBI and non-TBI cohorts. Method: Participants were 105 individuals with moderate-severe TBI (10-33 years post injury) and 91 participants without TBI. Cognitive outcome was examined across four cognitive factors; verbal memory, visual ability and memory, executive attention, and episodic memory. Functional outcome was measured using the Glasgow Outcome Scale Extended. The CRIq total score and three subscale scores (education, work, leisure) were examined. Results: In the TBI cohort, associations were identified between two CRIq subscales and cognitive factors (CRIq education and verbal memory; CRIq work and executive attention). There were no associations between CRIq leisure and cognitive outcomes, or between CRIq and functional outcome. Model selection statistics suggested premorbid IQ and years of education provided a better fit than the CRIq for the relationship between cognitive reserve with two cognitive factors and functional outcome, with neither model providing an improved fit for the remaining two cognitive factors. This finding was broadly consistent in the non-TBI cohort. Conclusion: Cognitive reserve contributes significantly to long-term clinical outcomes following moderate-severe TBI. The relationship between cognitive reserve and long-term cognitive and functional outcomes following TBI is best characterised with traditional proxies of cognitive reserve, mainly premorbid IQ, rather than the CRIq.

How Modifiable Are Modifiable Dementia Risk Factors? A Framework for Considering the Modifiability of Dementia Risk Factors

Many risk factors for dementia, identified from observational studies, are potentially modifiable. This raises the possibility that targeting key modifiable dementia risk factors may reduce the prevalence of dementia, which has led to the development of dementia risk reduction and prevention strategies, such as intervention trials or dementia prevention guidelines. However, what has rarely been considered in the studies that inform these strategies is the extent to which modifiable dementia risk factors can (1) be identified by individuals, and (2) be readily modified by individuals. Characteristics of modifiable dementia risk factors such as readiness of identification and targeting, as well as when they should be targeted, can influence the design, or success of strategies for reducing dementia risk. This review aims to develop a framework for classifying the degree of modifiability of dementia risk factors for research studies. The extent to which these modifiable dementia risk factors could be modified by an individual seeking to reduce their dementia risk is determined, as well as the resources that might be needed for both risk factor identification and modification, and whether modification may be optimal in early-life (aged <45 years), midlife (aged 45-65 years) or late-life (aged >65 years). Finally, barriers that could influence the ability of an individual to engage in risk factor modification and, ultimately, dementia risk reduction are discussed.

Multiple socioeconomic risks and cognitive impairment among older men and women in India

Introduction

Socioeconomic status (SES) is negatively associated with innumerable health outcomes, including cognitive functioning. Yet much remains undiscovered about SES patterns in later-life cognition in low-and middle-income countries (LMICs). The purpose of this study was to examine the association between separate and combined socioconomic risks and cognitive impairment among older adults in India. Further, given gender disparities in later life cognitive functioning and SES, the study examines the associations between socioeconomic risks and cognitive impairment separately, for older men and women.

Methods

Data come from the 2017-18, first wave of the Longitudinal Aging Study in India (LASI), with 31,464 older adults aged 60 years and above. Cognitive impairment was assessed using multiple broad measures of memory, orientation, arithmetic function, and visuo-spatial construction skills. We present descriptive statistics along with cross-tabulation of the outcome variable. Additionally, binary logistic regression analysis was used to test the association between outcome and explanatory variables. SES is measured using education, paid work status, and household wealth measured using monthly per-capita consumption expenditure (MPCE).

Results

A proportion of 7.14% of the older men and 20.03% of older women reported cognitive impairment. The odds of cognitive impairment were higher among uneducated older men and women, and older men and women in lowest wealth quintile. Surprisingly, older women without current or prior work history report lower odds of cognitive impairment compared to their peers in labor force. While odds of cognitive impairment are higher among non-working older men, this association is not statistically significant. In older men, the odds of cognitive impairment were 5.34, 7.14, and 13.05 times higher with one, two, and three risk factors, respectively, compared with those with no risk exposure. A similar trend was observed for women but with comparatively lower odds.

Conclusions

Our findings underscore the need to distinguish between varying elements of SES to construct "upstream" health policies and programs that redistribute resources. In particular, the findings support the use of multiple SES indicators in identifying older adults most susceptible to cognitive deficits, and planning gender-based interventions to improve cognitive health in late life.

Readability of spine-related patient education materials: a standard method for improvement

PURPOSE

Orthopaedic patient education materials (PEMs) have repeatedly been shown to be well above the recommended reading level by the National Institute of Health and American Medical Association. The purpose of this study is to create a standardized method to improve the readability of PEMs describing spine-related conditions and injuries. It is hypothesized that reducing the usage of complex words (≥ 3 syllables) and reducing sentence length to < 15 words per sentence improves readability of PEMs as measured by all seven readability formulas used.

METHODS

OrthoInfo.org was queried for spine-related PEMs. The objective readability of PEMs was evaluated using seven unique readability formulas before and after applying a standardized method to improve readability while preserving critical content. This method involved reducing the use of > 3 syllable words and ensuring sentence length is < 15 words. Paired samples t-tests were conducted to assess relationships with the cut-off for statistical significance set at p < 0.05.

RESULTS

A total of 20 spine-related PEM articles were used in this study. When comparing original PEMs to edited PEMs, significant differences were seen among all seven readability scores and all six numerical descriptive statistics used. Per the Flesch Kincaid Grade level readability formula, one original PEM (5%) versus 15 edited PEMs (75%) met recommendations of a sixth-grade reading level.

CONCLUSION

The current study shows that using this standardized method significantly improves the readability of spine-related PEMs and significantly increased the likelihood that PEMs will meet recommendations for being at or below the sixth-grade reading level.

Discrimination and Education Quality Moderate the Association of Sleep With Cognitive Function in Older Black Adults: Results From the Einstein Aging Study

OBJECTIVES

Heterogeneity among Black adults' experiences of discrimination and education quality independently influence cognitive function and sleep, and may also influence the extent to which sleep is related to cognitive function. We investigated the effect of discrimination on the relationship between objective sleep characteristics and cognitive function in older Black adults with varying education quality.

METHOD

Cross-sectional analyses include Black participants in the Einstein Aging Study (N = 104, mean age = 77.2 years, 21% males). Sleep measures were calculated from wrist actigraphy (15.4 ± 1.3 days). Mean ambulatory cognitive function (i.e., spatial working memory, processing speed/visual attention, and short-term memory binding) was assessed with validated smartphone-based cognitive tests (6 daily). A modified Williams Everyday Discrimination Scale measured discriminatory experiences. Linear regression, stratified by reading literacy (an indicator of education quality), was conducted to investigate whether discrimination moderated associations between sleep and ambulatory cognitive function for individuals with varying reading literacy levels. Models controlled for age, income, sleep-disordered breathing, and sex assigned at birth.

RESULTS

Higher reading literacy was associated with better cognitive performance. For participants with both lower reading literacy and more discriminatory experiences, longer mean sleep time was associated with slower processing speed, and lower sleep quality was associated with worse working memory. Later sleep midpoint and longer nighttime sleep were associated with worse spatial working memory for participants with low reading literacy, independent of their discriminatory experiences.

DISCUSSION

Sociocultural factors (i.e., discrimination and education quality) can further explain the association between sleep and cognitive functioning and cognitive impairment risk among older Black adults.

Differences in rates of impairment in adults who use methamphetamine using two sets of demographically corrected norms

Neuropsychologists can expect to meet with increasing rates of patients who use methamphetamine (MA), as MA use is on the rise, often comorbid with other substance use disorders, and frequently accompanied by changes in cognitive functioning. To detect impairment, neuropsychologists must apply the appropriate normative data according to important demographic factors such as age, sex, and education. This study involved 241 adults with and without MA dependence who were administered the Neuropsychological Assessment Battery. Given the high rates of polysubstance use among adults who use MA, we included adults with mono-dependence and poly-dependence on MA and at least one other substance. We compared the rates of adults with and without previous MA dependence classified as impaired on neurocognitive testing when using norms corrected for age, education, and sex versus norms corrected only for age. Norms corrected for age, education, and sex resulted in less frequent identification of impairment compared to norms corrected only for age, but both sets of norms appeared sufficient and similar enough to warrant their use with this population. It may be appropriate to explore the possible implications of discrepancies between education-corrected and non-education corrected sets of scores when assessing impairment in individuals who use MA.

Eliminating racial disparities in dementia risk by equalizing education quality: A sensitivity analysis

BACKGROUND

Higher risk of dementia among racial/ethnic minorities compared to White populations in the U.S. has been attributed to life-course exposures to adverse conditions such as lower educational attainment, but most studies have not considered additional disparities in education quality. We sought to determine the extent to which disparities in dementia would be reduced had different racial groups received the same quality of education, with no change to present disparities in educational attainment.

METHODS

We conducted a literature review to assess whether and how measures of educational attainment and quality are utilized in the development of norms for standard cognitive screening measures. In a separate search of the literature, we identified estimates of relationships between race, education quality and dementia; and calculated the adjusted association between race and dementia had education quality been equalized between Black and White participants.

RESULTS

Most norms for cognitive measures included educational attainment, but few addressed quality. Our search identified relevant parameter estimates: 44.3% of Black participants and 10.5% of White participants had "limited literacy" (<9th grade reading level, a potential marker of poor education quality), which was associated with a 53% greater hazard of dementia compared with "adequate literacy" (≥ 9th grade reading level) after adjusting for educational attainment. Applying these parameters to a hazard ratio of 1.37 (95%CI: 1.12,1.67) for the risk of dementia comparing Black to White participants, we obtained an adjusted hazard ratio of 1.17 (0.96,1.43), a 54% reduction.

DISCUSSION

Present studies are limited in their consideration of education quality. Our work using available measures from the literature suggests that if education quality were equalized across groups by race, without changing disparities in attainment, racial disparities in dementia would be reduced by about half. Future work should seek to consistently incorporate education quality in order to better understand the sources of disparities.

Educational quality may be a closer correlate of cardiometabolic health than educational attainment

Educational quality may be a closer correlate of physical health than more commonly used measures of educational attainment (e.g., years in school). We examined whether a widely-used performance-based measure of educational quality is more closely associated with cardiometabolic health than educational attainment (highest level of education completed), and whether perceived control (smaller sample only), executive functioning (both samples), and health literacy (smaller sample only) link educational quality to cardiometabolic health. In two samples (N = 98 and N = 586) collected from different regions of the US, educational quality was associated with cardiometabolic health above and beyond educational attainment, other demographic factors (age, ethnoracial category, sex), and fluid intelligence. Counter to expectations, neither perceived control, executive function, nor health literacy significantly mediated the association between educational quality and cardiometabolic health. Findings add to the growing literature suggesting that current operationalizations of the construct of education likely underestimate the association between education and multiple forms of health. To the extent that educational programs may have been overlooked based on the apparent size of associations with outcomes, such actions may have been premature.

Sentence Comprehension in Primary Progressive Aphasia: A Study of the Application of the Brazilian Version of the Test for the Reception of Grammar (TROG2-Br)

Sentence-comprehension deficits have been described in patients with primary progressive aphasia (PPA). However, most instruments to address this domain in more detail and in a clinical context have not been adapted and translated into several languages, posing limitations to clinical practice and cross-language research.

Objectives

The study aimed to (1) test the applicability of the Brazilian version of the Test for Reception of Grammar (TROG2-Br) to detect morphosyntactic deficits in patients with PPA; (2) investigate the association between performance in the test and sociodemographic and clinical variables (age, years of formal education, and disease duration); (3) characterize the performance of individuals presenting with the three more common variants of PPA (non-fluent, semantic, and logopenic) and mixed PPA (PPA-Mx) and analyze whether TROG-2 may assist in the distinction of these clinical profiles.

Methods

A total of 74 cognitively healthy participants and 34 individuals diagnosed with PPA were assessed with TROG2-Br. Overall scores (correct items, passed blocks), types, and categories of errors were analyzed.

Results

In controls, block scores were significantly correlated with years of formal education (Spearman's r = 0.33, p = 004) but not with age. In PPA, age, education, and disease duration were not significantly associated with performance in the test. Controls presented a significantly higher performance on TROG2-Br compared to PPA individuals and their errors pattern pointed to mild general cognitive processing difficulties (attention, working memory). PPA error types pointed to processing and morphosyntactic deficits in nonfluent or agrammatic PPA, (PPA-NF/A), logopenic PPA (PPA-L), and PPA-Mx. The semantic PPA (PPA-S) subgroup was qualitatively more similar to controls (processing difficulties and lower percentage of morphosyntactic errors). TROG2-Br presented good internal consistency and concurrent validity.

Discussion

Our results corroborate findings with TROG-2 in other populations. The performance of typical older adults with heterogeneous levels of education is discussed along with recommendations for clinical use of the test and future directions of research.

Assessing socioeconomic inequalities in cognitive impairment among older adults: a study based on a cross-sectional survey in India

Background

The rapidly aging population is a major concern for countries, especially where cognitive health in older age is poor. The study examined the socioeconomic and health-related factors associated with cognitive impairment among older adults and the contribution of those factors to the concentration of low cognitive functioning among older adults from economically poor households.

Methods

Data this study were derived from the “Building Knowledge Base on Population Ageing in India” (BKPAI) survey, which was carried out in seven major states of India. The effective sample size for the analysis was 9176 older adults aged 60 years and above. Results from descriptive and bivariate analysis were reported in the initial stage. Multivariable logistic regression analysis was conducted to explore the associations. Additionally, the concentration index and concentration curve were used to measure socioeconomic inequality in cognitive impairment among older adults. Wagstaff decomposition was employed to explore the key contributors in the concentration index.

Results

Nearly 60% of older adults suffered from cognitive impairment in the study. The likelihood of cognitive impairment were higher among older adults with a low level of self-perceived income sufficiency [coefficient: 0.29; confidence interval (CI): 0.07- 0.52] compared to older adults with higher levels of perceived income status. Older adults with more than 10 years of schooling were less likely to be cognitively impaired [coefficient: -1.27; CI: − 1.50- -1.04] in comparison to those with no education. Cognitive impairment was concentrated among older adults from households with the lowest wealth quintile (concentration index (CCI): − 0.10: p < 0.05). Educational status explained 44.6% of socioeconomic inequality, followed by 31.8% by wealth status and 11.5% by psychological health. Apart from these factors, difficulty in instrumental activities of daily living (3.7%), caste (3.7%), and perceived income sufficiency to fulfil basic needs (3.0%) explained socioeconomic inequality in cognitive impairment among older adults.

Conclusions

Findings suggest that older adults with lower perceived income, lower levels of education, poor physical and mental health, and poor physical and social resources were more likely to be cognitively impaired. Education, wealth and psychological health are major contributors in socioeconomic inequality in late-life cognitive impairment, which may be target areas in future policy formulation to reduce the inequality in cognitive impairment in older Indian adults.

Cultural factors related to neuropsychological performance and brain atrophy among Hispanic older adults with amnestic Mild Cognitive Impairment (aMCI): A pilot study

OBJECTIVES

This study examined the association of cultural factors and literacy to neuropsychological performance and measures of regional brain atrophy among Hispanic elders diagnosed with amnestic Mild Cognitive Impairment (aMCI).

METHOD

Acculturation and literacy levels were measured among 45 subjects tested in Spanish; their primary language. Scores for measures of memory, executive functioning, and verbal fluency, as well as volumetric analysis of MRI scans of left hemisphere structures commonly affected by Alzheimer's disease (AD) were examined. Linear regression models were employed to examine the association of acculturation and literacy to neuropsychological performance and MRI measures.

RESULTS

After controlling for age, higher literacy levels were associated with better performance on phonemic verbal fluency (r = 0.300, p < .05), while higher levels of acculturation to the U.S. was associated with poorer performance on category verbal fluency (r = 0.300, p < .05). There was a significant inverse relationship after controlling for age between literacy and the left entorhinal cortex (r = -0.455, p < .05), left precuneus (r = -0.457, p < .05), and left posterior cingulate (r = -0.415, p < .05).

CONCLUSIONS

Results of the current pilot study indicate that high acculturation to the U.S. among aMCI immigrants from Latin-American countries may hinder performance on verbal learning measures when they are administered in one's primary language. Moreover, in this cohort, a higher literacy level, which is indicative of greater cognitive reserve, was associated with better performance in language measures, but with greater atrophy in brain regions susceptible to neurodegenerative disease. These preliminary findings should be further examined among larger cohorts and using more diverse measures, which capture other cultural constructs.

Laptop-Administered NIH Toolbox and Cogstate Brief Battery in Community-Dwelling Black Adults: Unexpected Pattern of Cognitive Performance between MCI and Healthy Controls

OBJECTIVE

Black adults are approximately twice as likely to develop Alzheimer's disease (AD) than non-Hispanic Whites and access diagnostic services later in their illness. This dictates the need to develop assessments that are cost-effective, easily administered, and sensitive to preclinical stages of AD, such as mild cognitive impairment (MCI). Two computerized cognitive batteries, NIH Toolbox-Cognition and Cogstate Brief Battery, have been developed. However, utility of these measures for clinical characterization remains only partially determined. We sought to determine the convergent validity of these computerized measures in relation to consensus diagnosis in a sample of MCI and healthy controls (HC).

METHOD

Participants were community-dwelling Black adults who completed the neuropsychological battery and other Uniform Data Set (UDS) forms from the AD centers program for consensus diagnosis (HC = 61; MCI = 43) and the NIH Toolbox-Cognition and Cogstate batteries. Discriminant function analysis was used to determine which cognitive tests best differentiated the groups.

RESULTS

NIH Toolbox crystallized measures, Oral Reading and Picture Vocabulary, were the most sensitive in identifying MCI apart from HC. Secondarily, deficits in memory and executive subtests were also predictive. UDS neuropsychological test analyses showed the expected pattern of memory and executive functioning tests differentiating MCI from HC.

CONCLUSIONS

Contrary to expectation, NIH Toolbox crystallized abilities appeared preferentially sensitive to diagnostic group differences. This study highlights the importance of further research into the validity and clinical utility of computerized neuropsychological tests within ethnic minority populations.

The relationship between cognitive engagement and better memory in midlife

INTRODUCTION

Engagement in cognitively stimulating work and activities may slow cognitive decline and dementia. We examined the individual and combined associations of four cognitive engagement indices (educational attainment, occupational complexity, social engagement, and cognitively stimulating leisure activities) with objective and subjective cognition.

METHODS

Middle-aged adults (n = 1864) enrolled in the Healthy Brain Project completed the Cogstate Brief Battery, the Cognitive Function Instrument, and self-report questionnaires of cognitive engagement.

RESULTS

Educational attainment and leisure activity engagement were individually associated with memory performance. Participants were classified based on whether they rated highly in zero to four cognitive engagement indices. Compared to participants with no indices, participants with two or more indices performed moderately better on memory.

DISCUSSION

Results suggest that greater variety of cognitive engagement across different areas of life is related to better memory in midlife. Possible explanation for this relationship may be increased opportunity for enhancing cognitive reserve, but further investigations are required.

The Frequency of Low Scores on ImPACT in Adolescent Student-Athletes: Stratification by Race and Socioeconomic Status Using Multivariate Base Rates

This study examined the associations between the frequency of low scores on the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) by race and socioeconomic status (SES), using the proxy of Title I school status, among adolescent student-athletes and calculated multivariate base rates. There were 753 participants assigned to groups based on race (White: n = 430, 59.8%; Black: n = 289, 40.2%) and SES. Black student-athletes obtained more low neurocognitive test scores, which was associated with lower SES. The current study offers a resource to clinicians involved in concussion management who may wish to consider race and SES when interpreting ImPACT test performances.

Are there differences in performance validity test scores between African American and White American neuropsychology clinic patients?

OBJECTIVE

The purpose of the present study was to compare performance on a wide range of PVTs in a neuropsychology clinic sample of African Americans and White Americans to determine if there are differences in mean scores or cut-off failure rates between the two groups, and to identify factors that may account for false positive PVT results in African American patients.

METHOD

African American and White American non-compensation-seeking neuropsychology clinic patients were compared on a wide range of standalone and embedded PVTs: Dot Counting Test, b Test, Warrington Recognition Memory Test, Rey 15-item plus recognition, Rey Word Recognition Test, Digit Span (ACSS, RDS, 3-digit time, 4-digit time), WAIS-III Picture Completion (Most discrepant index), WAIS-III Digit Symbol/Coding (recognition equation), Rey Auditory Verbal Learning Test, Rey Complex figure, WMS-III Logical Memory, Comalli Stroop Test, Trails A, and Wisconsin Card Sorting Test.

RESULTS

When groups were equated for age and education, African Americans obtained mean performances significantly worse than White Americans on only four of 25 PVT scores across the 14 different measures (Stroop Word Reading and Color Naming, Trails A, Digit Span 3-digit time); however, FSIQ was also significantly higher in White American patients. When subjects with borderline IQ (FSIQ = 70 to 79) were excluded (resulting in 74 White Americans and 25 African Americans), groups no longer differed in IQ and only continued to differ on a single PVT cutoff (Trails A). Further, specificity rates in African Americans were comparable to those of White Americans with the exception of the b Test, the Dot Counting Test, and Stroop B.

CONCLUSIONS

PVT performance generally does not differ as a function of Black versus White race once the impact of intellectual level is controlled, and most PVT cutoffs appear appropriate for use in African Americans of low average IQ or higher.

Culture, Ethnicity, and Level of Education in Alzheimer's Disease

Alzheimer's disease (AD) is the most frequent cause of dementia, where the abnormal accumulation of beta-amyloid (Aβ) and tau lead to neurodegeneration as well as loss of cognitive, behavioral, and functional abilities. The present review analyzes AD from a cross-cultural neuropsychological perspective, looking at differences in culture-associated variables, neuropsychological test performance and biomarkers across ethnic and racial groups. Studies have found significant effects of culture, preferred language, country of origin, race, and ethnicity on cognitive test performance, although the definition of those grouping terms varies across studies. Together, with the substantial underrepresentation of minority groups in research, the inconsistent classification might conduce to an inaccuratte diagnosis that often results from biases in testing procedures that favor the group to which test developers belong. These biases persist even after adjusting for variables related to disadvantageous societal conditions, such as low level of education, unfavorable socioeconomic status, health care access, or psychological stressors. All too frequently, educational level is confounded with culture. Minorities often have lower educational attainment and lower quality of education, causing differences in test results that are then attributed to culture. Higher levels of education are also associated with increased cognitive reserve, a protective factor against cognitive decline in the presence of neurodegeneration. Biomarker research suggests there might be significant differences in specific biomarker profiles for each ethnicity/race in need of accurate cultural definitions to adequately predict risk and disease progression across ethnic/racial groups. Overall, this review highlights the need for diversity in all domains of AD research that lack inclusion and the collection of relevant information from these groups.

Cingulo-opercular and Cingulo-parietal Brain Networks Functional Connectivity in Pre-adolescents: Multiplicative Effects of Race, Ethnicity, and Parental Education

Introduction

A growing body of research has shown a diminished association between socioeconomic status (SES) indicators and a wide range of neuroimaging indicators for racial and ethnic minorities compared to majority groups. However, less is known about these effects for resting-state functional connectivity between various brain networks.

Purpose

This study investigated racial and ethnic variation in the correlation between parental education and resting-state functional connectivity between the cingulo-opercular (CO) and cingulo-parietal (CP) networks in children.

Methods

This cross-sectional study used data from the Adolescent Brain Cognitive Development (ABCD) study; we analyzed the resting-state functional Magnetic Resonance Imaging (rsfMRI) data of 8,464 American pre-adolescents between the ages of 9 and 10. The main outcome measured was resting-state functional connectivity between the CO and CP networks calculated using rsfMRI. The independent variable was parental education, which was treated as a nominal variable. Age, sex, and family marital status were the study covariates. Race and ethnicity were the moderators. Mixed-effects regression models were used for data analysis, with and without interaction terms between parental education and race and ethnicity.

Results

Higher parental education was associated with higher resting-state functional connectivity between the CO and CP networks. Race and ethnicity both showed statistically significant interactions with parental education on children's resting-state functional connectivity between CO and CP networks, suggesting that the correlation between parental education and the resting-state functional connectivity was significantly weaker for Black and Hispanic pre-adolescents compared to White and non-Hispanic pre-adolescents.

Conclusions

In line with the Minorities' Diminished Returns theory, the association between parental education and pre-adolescents resting-state functional connectivity between CO and CP networks may be weaker in Black and Hispanic children than in White and non-Hispanic children. The weaker link between parental education and brain functional connectivity for Blacks and Hispanics than for Whites and non-Hispanics may reflect racism, racialization, and social stratification that collectively minimize the returns of SES indicators, such as parental education for non-Whites, who become others in the US.

Changes in prevalence of cognitive impairment and associated risk factors 2000-2015 in São Paulo, Brazil

INTRODUCTION

Decreases in prevalence of cognitive impairment and dementia over the last two decades have been observed in different countries for cohorts entering older age. This study aimed to assess the cognitive impairment prevalence and explore associated factors among subjects aged >60 living in São Paulo, Brazil.

METHOD

Data came from a population-based Health, Welfare and Aging survey conducted in 2000, 2006, 2010, and 2015. Cognitive impairment was detected using the abbreviated Mini-Mental State Exam corrected by formal education years. In total, there were 5922 respondents in the statistical analyses.

RESULTS

Logistic regression models adjusted for age group, income, race, cardiovascular risk factors, and depression were used to estimate cognitive impairment prevalence. Between 2015 and 2000, respondents were more likely to report formal education, hypertension, diabetes, and overweight/obesity. Moreover, the weighted analyses showed that cognitive impairment prevalence was higher in 2015, even adjusting for sociodemographic and socioeconomic characteristics, cardiovascular risk factors, and depression.

CONCLUSION

In contrast to decreases in cognitive impairment prevalence in other countries and despite increases in educational years, our findings suggest no secular improvements in cognitive health for the 2015 wave of older adults residing in São Paulo.

Socioeconomic Mobility and Psychological and Cognitive Functioning in a Diverse Sample of Adults With and Without HIV

OBJECTIVE

This cross-sectional study examined the effects of socioeconomic status (SES) mobility from childhood to adulthood on psychological and cognitive well-being in African American and non-Hispanic White HIV-positive (HIV+) and HIV-seronegative (HIV-) adults who are part of an ongoing study investigating psychosocial and neurobehavioral effects of HIV.

METHODS

Participants (N = 174, 24.1% female, 59.2% African American, 67.8% HIV+) were categorized into four groups (upward mobility, downward mobility, stable-not-poor, chronic-poverty) based on self-reported childhood and current community SES (which were correlated with objective measures of SES and proxies of childhood SES). SES groups were compared on self-report measures of psychological well-being, subjective executive functioning ratings, and performance across six cognitive domains. Primary analyses were stratified by HIV status.

RESULTS

For the HIV+ group, SES mobility was associated with psychological well-being (chronic burden of stress: F(7,101) = 3.17, mean squared error [MSE] = 49.42, p = .030, η2 = 0.14; depressive symptoms: F(7,101) = 4.46, MSE = 70.49, p = .006,η2 = 0.14), subjective ratings of executive dysfunction (F(7,101) = 6.11, MSE = 114.29, p = .001,η2 = 0.18), and objective performance in executive functioning (F(9,99) = 3.22, MSE = 249.52, p = .030, η2 = 0.15) and learning (F(9,99) = 3.01, MSE = 220.52, p = .034, η2 = 0.13). In the control group, SES mobility was associated with chronic stress burden (F(5,49) = 4.677, p = .025, η2 = 0.15); however, no other relationships between SES mobility and outcomes of interest were observed (all p values > .20). In general, downward mobility and chronic poverty were associated with worse ratings across psychological well-being measures and cognitive performance.

CONCLUSIONS

Findings within the HIV+ group are consistent with previous studies that report downward mobility to be associated with poor psychological outcomes. People living with HIV may be particularly vulnerable to the adverse effects of socioeconomic instability.

Race, Socioeconomic Status, and Cerebellum Cortex Fractional Anisotropy in Pre-Adolescents

Introduction

Cerebellum cortex fractional anisotropy is a proxy of the integrity of the cerebellum cortex. However, less is known about how it is shaped by race and socioeconomic status (SES) indicators such as parental education and household income.

Purpose

In a national sample of American pre-adolescents, this study had two aims: to test the effects of two SES indicators, namely parental education and household income, on cerebellum cortex fractional anisotropy, and to explore racial differences in these effects.

Methods

Using data from the Adolescent Brain Cognitive Development (ABCD) study, we analyzed the diffusion Magnetic Resonance Imaging (dMRI) data of 9565, 9-10-year-old pre-adolescents. The main outcomes were cerebellum cortex fractional anisotropy separately calculated for right and left hemispheres using dMRI. The independent variables were parental education and household income; both treated as categorical variables. Age, sex, ethnicity, and family marital status were the covariates. Race was the moderator. To analyze the data, we used mixed-effects regression models without and with interaction terms. We controlled for propensity score and MRI device.

Results

High parental education and household income were associated with lower right and left cerebellum cortex fractional anisotropy. In the pooled sample, we found significant interactions between race and parental education and household income, suggesting that the effects of parental education and household income on the right and left cerebellum cortex fractional anisotropy are all significantly larger for White than for Black pre-adolescents.

Conclusions

The effects of SES indicators, namely parental education and household income, on pre-adolescents' cerebellum cortex microstructure and integrity are weaker in Black than in White families. This finding is in line with the Marginalization-related Diminished Returns (MDRs), defined as weaker effects of SES indicators for Blacks and other racial and minority groups than for Whites.

Middle-aged and older Black adults' experiences completing a traditional paper-and-pencil cognitive battery and two contemporary computerized cognitive batteries

Traditional neuropsychological batteries may account for disparities in education and may produce testing anxiety, particularly for older Black adults. Computerized batteries may be more amenable to use. The current study used mixed-methods content analysis to explore the perceptions of middle-aged and older Black adults (N = 92) about the CogState Brief Battery (CSBB) and Joggle® computerized battery and a traditional paper-and-pencil neuropsychological battery. The data was analyzed using Atlas.ti. Themes were developed and qualitative responses were converted to quantitative counts to make comparisons to thematic differences based on demographics. Results: The majority of participants liked all three batteries. There were no differences based on demographics. Two prevalent themes across all three measures for what participants liked were 1) mental stimulation and memory, and 2) challenging. A disliked theme specific to the computerized batteries was personal competence. In summary, an array of accessible cognitive batteries is necessary to address individual preferences.

Relationship of Early-Life Residence and Educational Experience to Level and Change in Cognitive Functioning: Results of the Minority Aging Research Study

OBJECTIVE

Investigate associations of early-life residence and school segregation with cognitive change in the Minority Aging Research Study.

METHODS

Four hundred ninety-eight blacks (age ~ 73.5; 75% = women) without dementia at baseline self-reported State of birth, residence at age 12, and school segregation status. Census Bureau definitions of South and Northeast/Midwest were used to categorize early-life residence. We evaluated global cognition and five cognitive domains at baseline and annually for ~7.5 years. Linear mixed effects models examined the associations of region of birth and residence at age 12 with baseline level and longitudinal change in cognition. Additional models examined school segregation experience.

RESULTS

~65% of Southern-born participants still lived in the South at age 12. Southern birth was associated with lower baseline global cognition and all cognitive domains (p-values ≤ .02) compared to Northern birth, but not cognitive change. A similar profile was seen for Southern residence at age 12. Segregation experience significantly modified associations of residence at age 12 on levels of cognition. Participants residing in the South attending a legally desegregated school demonstrated lower baseline levels of cognition (global, semantic, and working memory) than their Northeast/Midwest counterparts attending a legally desegregated or segregated school as well as their Southern counterparts attending a legally segregated school. This profile for participants attending a desegregated school in the South held for processing speed and visuospatial ability in comparisons to Northeast/Midwest counterparts, particularly those attending a legally desegregated school.

CONCLUSION

Baseline cognition was poorer in individuals born and residing in the South, particularly those attending desegregated schools at age 12.

Normative data for middle-aged Brazilians in the Mattis Dementia Rating Scale

Despite the advances in the diagnosis of dementia, neuropsychological assessment remains an important tool. The Mattis Dementia Rating Scale (DRS) was designed to evaluate people with suspected dementia and allows for the analysis of different cognitive domains. Considering the numerous cases of early-onset dementia, specific reference standards aimed at the middle-aged population are necessary.

Older Black Adults' Satisfaction and Anxiety Levels After Completing Alternative Versus Traditional Cognitive Batteries

OBJECTIVE

The objective of this study was to examine satisfaction, test anxiety, and performance using computer-based cognitive batteries versus a paper-and-pencil neuropsychological battery among older Blacks.

METHOD

Self-identified Black adults (n = 87, age range: 55-86; mean education = 14) completed two computer-based tests (CogState and Joggle) and a paper-and-pencil neuropsychological battery. After each battery, participants reported their testing anxiety and satisfaction using the batteries. Descriptive, correlational, and regression analyses compared satisfaction, anxiety, and performance across the batteries.

RESULTS

Majority of the participants reported more satisfaction with the computer-based (Joggle: 66%; CogState: 77%) than the neuropsychological (52%) battery. Participants also reported less testing anxiety after completing the computer-based batteries than the neuropsychological battery, F(2, 172) = 22.96, p < .001. Older adults' familiarity and comfort level with the computer were not associated with their performance on the computer-based tests (p > .05). Although testing anxiety was not associated with performance across the batteries, age and education quality were uniquely associated with performance on the CogState and neuropsychological batteries.

CONCLUSIONS

Computer-based cognitive batteries appear to be less intimidating than the commonly used paper-and-pencil neuropsychological tests for Black adults. Thus, these cognitive batteries may be useful tools for monitoring older Blacks' cognitive status.

Frequency and Predictors of HIV-Related Cognitive Impairment in East Africa: The Africa Cohort Study (AFRICOS)

BACKGROUND

Medication adherence is a critical issue in achieving viral suppression targets, particularly in resource-limited countries. As HIV-related cognitive impairment (CI) impacts adherence, we examined frequency and predictors of CI in the African Cohort Study.

SETTING

Cross-sectional examination of enrollment data from President's Emergency Plan for AIDS Relief supported clinic sites.

METHODS

In a 30-minute cognitive assessment, CI was defined as -1SD on 2 tests or -2SD on one, as compared with 429 controls. We performed univariable and multivariable logistic and linear models examining clinical and demographic factors associated with CI and global neuropsychological performance (NP-6).

RESULTS

Two thousand four hundred seventy-two HIV+ participants from Kenya (n = 1503), Tanzania (n = 469), and Uganda (n = 500). The mean (SD) age was 39.7 (10.7) years, and 1452 (59%) were women. The majority reported completing or partially completing primary school (n = 1584, 64%). Mean (SD) current and nadir CD4 count were 463 (249) and 204 (221) cells/mm, respectively; 1689 (68%) were on combination antiretroviral therapy. Nine hundred thirty-nine (38%) HIV+ versus 113 (26%) HIV- individuals showed CI: (P < 0.001). We found significant effects of literacy [odds ratio (OR): 0.3; 95% CI: 0.2 to 0.4; P < 0.001] and World Health Organization stage 4 (OR: 1.5; 95% CI: 1.0 to 2.q; P = 0.046) on CI. Tanzanians (OR: 3.2; 95% CI: 2.4 to 4.3; P < 0.001) and Kenyans (OR: 2.0; 95% CI: 1.6 to 2.6; P < 0.001) had higher risk of CI compared with Ugandans. Results were relatively unchanged in predictive models of NP-6, with the only difference being an additional significant effect of current CD4 cell count (coeff: 0.0; 95% CI: 0.0 to 0.0; P = 0.005).

CONCLUSIONS

Literacy, country, World Health Organization stage, and current CD4 cell count were associated with increased risk of cognitive dysfunction. Our findings help optimize care practices in Africa, illustrating the importance of strategies for early and effective viral-immunological control.

Discrepancy-Based Evidence for Loss of Thinking Abilities (DELTA): Development and Validation of a Novel Approach to Identifying Cognitive Changes

OBJECTIVE

To develop and validate the Discrepancy-based Evidence for Loss of Thinking Abilities (DELTA) score. The DELTA score characterizes the strength of evidence for cognitive decline on a continuous spectrum using well-established psychometric principles for improving detection of cognitive changes.

METHODS

DELTA score development used neuropsychological test scores from the Alzheimer's Disease Neuroimaging Initiative (ADNI) cohort (two tests each from Memory, Executive Function, and Language domains). We derived regression-based normative reference scores using age, gender, years of education, and word-reading ability from robust cognitively normal ADNI participants. Discrepancies between predicted and observed scores were used for calculating the DELTA score (range 0-15). We validated DELTA scores primarily against longitudinal Clinical Dementia Rating-Sum of Boxes (CDR-SOB) and Functional Activities Questionnaire (FAQ) scores (baseline assessment through Year 3) using linear mixed models and secondarily against cross-sectional Alzheimer's biomarkers.

RESULTS

There were 1359 ADNI participants with calculable baseline DELTA scores (age 73.7 ± 7.1 years, 55.4% female, 100% white/Caucasian). Higher baseline DELTA scores (stronger evidence of cognitive decline) predicted higher baseline CDR-SOB (ΔR2 = .318) and faster rates of CDR-SOB increase over time (ΔR2 = .209). Longitudinal changes in DELTA scores tracked closely and in the same direction as CDR-SOB scores (fixed and random effects of mean + mean-centered DELTA, ΔR2 > .7). Results were similar for FAQ scores. High DELTA scores predicted higher PET-Aβ SUVr (ρ = 324), higher CSF-pTau/CSF-Aβ ratio (ρ = .460), and demonstrated PPV > .9 for positive Alzheimer's disease biomarker classification.

CONCLUSIONS

Data support initial development and validation of the DELTA score through its associations with longitudinal functional changes and Alzheimer's biomarkers. We provide several considerations for future research and include an automated scoring program for clinical use.

Cultural Neuropsychology Considerations in the Diagnosis of HIV-Associated Neurocognitive Disorders

Human Immunodeficiency Virus Type-I (HIV) is a health disparities issue that affects culturally and linguistically diverse (CALD) and underrepresented minority populations to a greater degree than non-Hispanic white populations. Neurologically speaking, CALD populations experience worse HIV-related health outcomes, which are exacerbated by inadequate neurocognitive measures, poor normative samples, and the complex interplay of sociocultural factors that may affect test interpretation. Although cross-cultural neuropsychologists are working diligently to correct this gap in the literature, currently, studies examining neurocognitive outcomes among CALD populations are sparse. The most well-studied CALD groups are of African American/Black and Latinx adults in the US, and the chapter therefore focuses on these studies. There is more limited work among other populations in the US, such as Asians, Native Hawaiians, Pacific Islanders, and American Indians/Alaskan Natives, and even fewer studies for many CALD populations outside of the US. For example, HIV neuropsychology data is rare or nonexistent in the First Peoples of Australia and Indigenous People of Canada. It is often not adequately reported in Europe for the migrant populations within those countries or other world regions that have historically large multicultural populations (e.g., South America, Caribbean countries, Asia, and Africa). Therefore, this chapter reviews HIV-related health disparities faced by CALD populations with focus on North American research where it has been specifically studied, with particular attention given to disparities in HIV-Associated Neurocognitive Disorders (HAND). International data was also included for research with focus on First Peoples of Australia and Indigenous People of Canada. The chapter also examines other sociocultural and health factors, including global and regional (e.g., rural versus urban) considerations, migration, and gender. Further, guidelines for incorporating sociocultural consideration into assessment and interpretation of neurocognitive data and HAND diagnosis when working with HIV-positive CALD populations that would be relevant internationally are provided.

Semantic memory, but not education or intelligence, moderates cognitive aging: a cross-sectional study

Objective:

Aging studies regularly assume that years of education are a protective factor for baseline cognition. In developing countries with specific sociocultural issues, this relationship may not work as expected, and an unmet need remains for alternative resilience factors. This study aimed to analyze different moderators for the relationship between aging and general cognition that could reflect better protective factors.

Methods:

One hundred and fourteen Brazilian older adults, deemed healthy by global cognition, absence of psychiatric symptoms, or neurological history, participated in this cross-sectional study. Moderators for the relationship between age and global cognition included education, intelligence, and occupational factors. Semantic memory was added as a protective factor reflecting culturally acquired conceptual knowledge.

Results:

As expected, age alone is a predictor of global cognitive scores; surprisingly, however, education, intelligence, and occupation were not moderators of the association. Semantic memory was a significant moderator (p = 0.007), indicating that knowledge acquired during life may be a protective factor.

Conclusion:

In developing countries, the use of resilience factors based only on years of education may be misleading. Sociocultural issues influence the educational system and achievement and, consequently, affect the use of this simple measure. Resilience-factor studies should consider using crystallized abilities when studying populations with sociocultural particularities.

Dimensional Change Card Sorting of American Children: Marginalization-Related Diminished Returns of Age

BACKGROUND

While age is associated with an increase in cognitive flexibility and executive functioning as a result of normal development during childhood, less is known about the effect of racial variation in children's age-related cognitive development. The Marginalization-related Diminished Returns (MDRs) phenomenon suggests that, under racism, social stratification, segregation, and discrimination, individual-level economic and non-economic resources and assets show weaker effects on children's development for marginalized, racialized, and minoritized families.

AIM

We conducted this study to compare racial groups of children for age-related changes in their card sorting abilities.

METHODS

This cross-sectional study included 10,414 9-10-year-old American children. Data came from the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was age, a continuous variable measured in months. The dependent variable was dimensional change card sort (DCCS) score, which reflected cognitive flexibility, and was measured by the NIH Dimensional Change Card Sort. Ethnicity, sex, parental education, and marital status were the covariates.

RESULTS

Older age was associated with higher DCCS score, reflecting a higher card-sorting ability and cognitive flexibility. However, age showed a weaker association with DCCS for Black than for White children. This was documented by a significantly negative interaction between race and age on children's DCCS scores.

CONCLUSION

Age shows a weaker correlation with the cognitive flexibility of Black than of White children. A similar pattern can be seen when comparing low-income with high-income children. Conceptualizing race as a social factor that alters normal childhood development is a finding that is in line with MDRs. Marginalization due to social stratification and racism interfere with the normal age-related cognitive development of American children.

A Framework of Minority Stress: From Physiological Manifestations to Cognitive Outcomes

Cognitive impairment and dementia continue to threaten the aging population. Although no one is immune, certain groups, namely black older persons, are more likely to have a diagnosis of certain dementias. Because researchers have not found a purely biological reason for this disparity, they have turned to a biopsychosocial model. Specifically, black persons in the United States are more likely to live with social conditions that affect their stress levels which in turn affect physiological regulation leading to conditions that result in higher levels of cognitive impairment or dementia. Here we discuss some of these social conditions such as discrimination, education, and socioeconomic status, and how physiological dysregulation, namely allostatic load that can lead to cognitive impairment and dementia in black persons especially.

Illiteracy, dementia risk, and cognitive trajectories among older adults with low education

OBJECTIVE

To investigate whether illiteracy was associated with greater risk of prevalent and incident dementia and more rapid cognitive decline among older adults with low education.

METHODS

Analyses included 983 adults (≥65 years old, ≤4 years of schooling) who participated in a longitudinal community aging study. Literacy was self-reported ("Did you ever learn to read or write?"). Neuropsychological measures of memory, language, and visuospatial abilities were administered at baseline and at follow-ups (median [range] 3.49 years [0-23]). At each visit, functional, cognitive, and medical data were reviewed and a dementia diagnosis was made using standard criteria. Logistic regression and Cox proportional hazards models evaluated the association of literacy with prevalent and incident dementia, respectively, while latent growth curve models evaluated the effect of literacy on cognitive trajectories, adjusting for relevant demographic and medical covariates.

RESULTS

Illiterate participants were almost 3 times as likely to have dementia at baseline compared to literate participants. Among those who did not have dementia at baseline, illiterate participants were twice as likely to develop dementia. While illiterate participants showed worse memory, language, and visuospatial functioning at baseline than literate participants, literacy was not associated with rate of cognitive decline.

CONCLUSION

We found that illiteracy was independently associated with higher risk of prevalent and incident dementia, but not with a more rapid rate of cognitive decline. The independent effect of illiteracy on dementia risk may be through a lower range of cognitive function, which is closer to diagnostic thresholds for dementia than the range of literate participants.

Word-reading ability as a "hold test" in cognitively normal young adults with history of concussion and repetitive head impact exposure: A CARE Consortium Study

Objective: Neuropsychological evaluations include hold tests like word-reading ability as estimates of premorbid intellect thought to be resilient to the effects of neurologic insult. We tested the alternative hypothesis that exposure to concussion or repetitive subclinical head impacts throughout early life may stunt acquisition of word-reading skills.Method: Data were obtained from student-athletes within the CARE Consortium that completed the Wechsler Test of Adult Reading (WTAR). Measures of head trauma burden included self-reported concussion history and cumulative years of exposure to collision sports. We evaluated the effects of head trauma, sociodemographic (race, SES), and academic (SAT/ACT scores, learning disorder) variables on WTAR standard score using linear regression. Analyses were repeated in a football-only subsample estimating age of first exposure to football as a predictor.Results: We analyzed data from 6,598 participants (72.2% white, 39.6% female, mean ± SD age = 18.8 ± 1.2 years). Head trauma variables collectively explained 0.1% of the variance in WTAR standard scores, with years of collision sport exposure weakly predicting lower WTAR standard scores (β = .026-.035, very small effect). In contrast, sociodemographic and academic variables collectively explained 20.9-22.5% of WTAR standard score variance, with strongest effects noted for SAT/ACT scores (β = .313-.337, medium effect), LD diagnosis (β = -.115 to -.131, small effect), and SES (β = .101-.108, small effect). Age of first exposure to football did not affect WTAR scores in a football-only sample.Conclusion: Wechsler Test of Adult Reading performance appears unrelated to history of self-reported concussion(s) and/or repetitive subclinical head trauma exposure in current collegiate athletes. Sociodemographic and academic variables should be incorporated in test score interpretations for diverse populations like athletes.

Academic aptitude mediates the relationship between socioeconomic status and race in predicting ImPACT scores in college athletes

Objective: To evaluate the influences of sociodemographic factors, estimated head impact exposure, and academic aptitude on ImPACT scores in college athletes.Methods: Data were reported on 18,886 participants (58% male) from the NCAA/DoD CARE Consortium. Race, SES, concussion history, estimated repetitive head impact exposure (eRHIE), and academic aptitude (SAT or ACT score) were our predictors of interest. Cognition was measured using ImPACT composite scores. We evaluated the mediating effects of academic aptitude on sociodemographic predictors and eRHIE on ImPACT scores. We then evaluated a football-only subsample and added age of first exposure to football (AFE) to the model. Males, females, and football players were analyzed separately using structural equation modeling.Results: Academic aptitude was associated with Black/African American race, SES, and each of the ImPACT composite scores. There were significant indirect effects of Black/African American race and SES on all ImPACT composite scores. Academic aptitude fully mediated SES effects and either fully or partially mediated race effects. Contrary to expectation, greater concussion history and eRHIE predicted better ImPACT scores.Conclusions: Academic aptitude, a stable indicator of premorbid cognitive function, consistently and most strongly predicted baseline ImPACT scores in collegiate student-athletes. Concussion and eRHIE history demonstrated a small positive, but non-significant, relationship with cognitive scores at the time of college athletic participation. This study suggests that attempts to characterize cognitive ability across the lifespan must consider premorbid functioning and sociodemographic variables.

Education as the Great Equalizer? Racial and Ethnic Differences in the Effect of Education on Cognitive Impairment in Later Life

Though evidence suggests that the prevalence of cognitive impairment has declined, there still exists a disproportionate burden of ill cognitive health for people of color. In this paper, we test two alternative mechanisms to explain the interactive effect of education and race/ethnicity on cognitive impairment risk: the minority poverty and diminishing returns hypotheses. Drawing on data from the 2012 wave of the Health and Retirement Study (HRS) (n = 8093), we estimate logistic regression models to determine differential effects of education on cognitive impairment. We find that non-Hispanic black and Mexican American older adults have higher odds of being cognitively impaired compared to whites, though the ethnic difference (whites vs. Mexican Americans) is mediated by education. Further, we find that while high levels of education are protective against cognitive impairment at older ages, it is more protective for non-Hispanic blacks than for whites and more protective for whites than Mexican Americans. Lastly, we find that racial/ethnic disparities are widest at lower levels of education, consistent with the minority poverty hypothesis. We conclude that the results herein highlight the importance of attending to how factors that are protective for cognitive functioning (e.g., education) may operate differently across racial and ethnic groups.

Development and public release of the Penn Reading Assessment Computerized Adaptive Test (PRA-CAT) for premorbid IQ

An important component of neuropsychological testing is assessment of premorbid intelligence to estimate a patient's ability independent of neurological impairment. A common test of premorbid IQ-namely, the Reading section of the Wide Range Achievement Test (WRAT)-has been shown to have high measurement error in the high ability range, is unnecessarily long (55 items), and is proprietary. We describe the development of an alternative, nonproprietary, computerized adaptive test for premorbid IQ, the Penn Reading Assessment (PRA-CAT). PRA-CAT items were calibrated using a 1-parameter item response theory model in a large community sample (N = 9,498), Ages 8 to 21, and the resulting parameters were used to simulate computerized adaptive testing sessions. Simulations demonstrated that the PRA-CAT achieves low measurement error (0.25; equivalent to Cronbach's alpha = .94) and acceptable measurement error (0.40; Cronbach's alpha = .84) after only 18 and 6 items, respectively (on average). Correlation of WRAT and PRA-CAT scores with numerous clinical, cognitive, demographic, and neuroimaging criteria suggests that validity of PRA-CAT score interpretation is comparable (and sometimes superior) with the WRAT. The fully functioning PRA-CAT for public use (including item parameter estimates reported here) has been built using the open-source program Concerto, and can be installed by anyone on a local computer or on the "cloud." Given the length and proprietary nature of the WRAT, the PRA-CAT shows promise as a potential alternative (and with minimal or no cost). Further validation in the context of neurological injury is needed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Multiple Influences on Cognitive Function Among Urban-Dwelling African Americans

This study examined multiple influences on cognitive function among African Americans, including education, literacy, poverty status, substance use, depressive symptoms, and cardiovascular disease (CVD) risk factors. Baseline data were analyzed from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. Participants were 987 African Americans (mean age 48.5 years, SD = 9.17) who completed cognitive measures assessing verbal learning and memory, nonverbal memory, working memory, verbal fluency, perceptuo-motor speed, attention, and cognitive flexibility. Using preplanned hierarchical regression, cognitive performance was regressed on the following: (1) age, sex, education, poverty status; (2) literacy; (3) cigarette smoking, illicit substance use; (4) depressive symptoms; and (5) number of CVD risk factors. Results indicated that literacy eliminated the influence of education and poverty status in select instances, but added predictive utility in others. In fully adjusted models, results showed that literacy was the most important influence on cognitive performance across all cognitive domains (p < .001); however, education and poverty status were related to attention and cognitive flexibility. Depressive symptoms and substance use were significant predictors of multiple cognitive outcomes, and CVD risk factors were not associated with cognitive performance. Overall, findings underscore the need to develop cognitive supports for individuals with low literacy, educational attainment, and income, and the importance of treating depressive symptoms and thoroughly examining the role of substance use in this population.

A Test Battery for Inner Speech Functions

Objective

Inner speech, or the ability to talk to yourself in your head, is one of the most ubiquitous phenomena of everyday experience. Recent years have seen growing interest in the role and function of inner speech in various typical and cognitively impaired populations. Although people vary in their ability to produce inner speech, there is currently no test battery which can be used to evaluate people's inner speech ability. Here we developed a test battery which can be used to evaluate individual differences in the ability to access the auditory word form internally.

Methods

We developed and standardized five tests: rhyme judgment of pictures and written words, homophone judgment of written words and non-words, and judgment of lexical stress of written words. The tasks were administered to adult healthy native British English speakers (age range 20-72, n = 28-97, varies between tests).

Results

In all tests, some items were excluded based on low success rates among participants, or documented regional variability in accent. Level of education, but not age, correlated with task performance for some of the tasks, and there were no gender difference in performance.

Conclusion

A process of standardization resulted in a battery of tests which can be used to assess natural variability of inner speech abilities among English speaking adults.

Cohort Differences in Cognitive Impairment and Cognitive Decline Among Mexican-Americans Aged 75 Years or Older

Research suggests that the prevalence and incidence of cognitive impairment among older adults is decreasing. This analysis used data from 9 waves (1993-2016) of the Hispanic Established Populations for the Epidemiologic Study of the Elderly to assess cognitive status and cognitive decline for 2 cohorts of Mexican-Americans aged ≥75 years in 1993-1994 versus 2004-2005. Logistic regression, joint longitudinal survival models, and illness-death models for interval-censored data were used to examine cohort differences in the odds of prevalent cognitive impairment, trajectories of cognitive decline, and the risk of 10-year incident cognitive impairment, respectively. Results indicated that compared with the 1993-1994 cohort, the 2004-2005 cohort had higher odds for prevalent cognitive impairment (odds ratio = 2.51, 95% confidence interval (CI): 1.92, 3.29), particularly among participants with <4 years of education (odds ratio = 2.99, 95% CI: 2.14, 4.18). Conversely, the 2004-2005 cohort exhibited significantly slower rates of cognitive decline (βˆ = 0.50, 95% CI: 0.39, 0.62) and had a significantly lower risk of incident cognitive impairment (hazard ratio = 0.75, 95% CI: 0.62, 0.91) compared with the 1993-1994 cohort. This analysis provides mixed results for cohort trends in the cognitive health of older Mexican-Americans. Continued research is needed to identify risk factors that contribute to these population-level trends.

The association between educational parameters and a cognitive screening measure in older blacks

ABSTRACTBackground:To expand on prior literature by examining how various education parameters (performance-based reading literacy, years of education, and self-rated quality of education) relate to a cognitive screening measure's total and subscale scores of specific cognitive abilities.

METHODS

Black adults (age range: 55-86) were administered self-rated items years of education and quality of education, and a measure of performance-based reading literacy. The Mini-Mental State Examination (MMSE) was used to screen for overall cognitive functioning as well as performance on specific cognitive abilities.

RESULTS

Sixty-nine percent of the sample had reading grade levels that were less than their reported years of education. Lower years of education and worse reading literacy are associated with poorer MMSE performance, particularly on the attention and calculation subscales.

CONCLUSIONS

Years of education, a commonly used measure for education, may not be reflective of Black adults' educational experiences/qualities. Thus, it is important to account for the unique educational experiences of adults that could influence their MMSE performance. Incorporating quality and quantity of education will provide a more comprehensive understanding of the individual's performance on cognitive measures, specifically as it relates to sociocultural differences.

Socioeconomic Status and Race Outperform Concussion History and Sport Participation in Predicting Collegiate Athlete Baseline Neurocognitive Scores

OBJECTIVES

The purpose of this study was to assess the contribution of socioeconomic status (SES) and other multivariate predictors to baseline neurocognitive functioning in collegiate athletes.

METHODS

Data were obtained from the Concussion Assessment, Research and Education (CARE) Consortium. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) baseline assessments for 403 University of Florida student-athletes (202 males; age range: 18-23) from the 2014-2015 and 2015-2016 seasons were analyzed. ImPACT composite scores were consolidated into one memory and one speed composite score. Hierarchical linear regressions were used for analyses.

RESULTS

In the overall sample, history of learning disability (β=-0.164; p=.001) and attention deficit-hyperactivity disorder (β=-0.102; p=.038) significantly predicted worse memory and speed performance, respectively. Older age predicted better speed performance (β=.176; p<.001). Black/African American race predicted worse memory (β=-0.113; p=.026) and speed performance (β=-.242; p<.001). In football players, higher maternal SES predicted better memory performance (β=0.308; p=.007); older age predicted better speed performance (β=0.346; p=.001); while Black/African American race predicted worse speed performance (β=-0.397; p<.001).

CONCLUSIONS

Baseline memory and speed scores are significantly influenced by history of neurodevelopmental disorder, age, and race. In football players, specifically, maternal SES independently predicted baseline memory scores, but concussion history and years exposed to sport were not predictive. SES, race, and medical history beyond exposure to brain injury or subclinical brain trauma are important factors when interpreting variability in cognitive scores among collegiate athletes. Additionally, sport-specific differences in the proportional representation of various demographic variables (e.g., SES and race) may also be an important consideration within the broader biopsychosocial attributional model. (JINS, 2018, 24, 1-10).