The Effects of Literacy and Education on the Quantitative and Qualitative Aspects of Semantic Verbal Fluency

Feasibility and Clinical Effectiveness of Computer-Based Cognitive Rehabilitation in Illiterate and Low-Educated Individuals with Mild Cognitive Impairment: Preliminary Data

OBJECTIVE

We investigated the feasibility of the RehaCom cognitive rehabilitation software in illiterate and low-educated individuals with mild cognitive impairment (MCI) and its clinical effectiveness in improving cognitive functions.

METHODS

Twenty illiterate or low-educated individuals with MCI were randomly assigned to an intervention (IG; n = 10) and control group (CG; n = 10). The IG participated in the cognitive enhancement program for 6 weeks, twice a week and a duration of 50-60 min for each session, while the CG did not receive any kind of intervention.

RESULTS

The two groups were demographically matched. The IG successfully completed all sessions of the cognitive enhancement program. A within-subject comparison between baseline and post-intervention assessment of cognitive functions indicated that the IG improved significantly on all administered neuropsychological tests, in contrast to the CG, whose performance remained stable between baseline and final assessment. A between-group comparison found statistically significant differences between the IG and CG groups on the Hindi Mental State Examination, Mini-Mental State Examination, and on delayed memory and recognition tasks, in favor of the IG.

CONCLUSIONS

The findings of the present study support the feasibility of applying computerized cognitive enhancement programs to illiterate and low-educated individuals. Moreover, these programs appear to contribute positively to improving the cognitive functions of this population group. In order to generalize and confirm similar findings in a broader population of illiterate and low-educated individuals, future studies should include larger samples, possibly with longer duration of treatment and control groups that will receive non-targeted interventions as placebo interventions.

Cognitive Training During Midlife: A Systematic Review and Meta-Analysis

Midlife has been suggested to be a crucial time to introduce interventions for improving cognitive functions. The effects of cognitive training (CT) in healthy middle-aged populations and more specifically during the menopausal transition have not been systematically investigated. To investigate the effects of CT on cognition in healthy middle-aged adults and specifically in females during the menopause transition, literature was searched inception to July 2023 and studies were included that examined the effects of CT on a defined cognitive outcome. The improvement on cognitive performance following CT was the main outcome measured as mean difference (from baseline to immediate post) estimates with corresponding 95% confidence intervals (CI) in meta-analysis and was discussed with the support of subgroup analysis based on outcome type (i.e., far or near-transfer) and cluster tabulations. Nineteen articles were included in the qualitative synthesis with a total of 7765 individuals, and eight articles were included in the meta-analyses. CT was categorized into six type clusters: Game-based CT, General CT, Speed of Processing Training, Working Memory Training, Strategy-based CT, and Cognitive Remediation. Cognitive outcome was divided into six clusters: working memory, verbal memory, language, executive function, attention/processing speed, and visual memory. Meta-analysis reported significant improvement in the domain of executive function (0.48, 95% CI 0.08-0.87), verbal memory (0.22, 95% CI 0.11-0.33), and working memory (0.16, 95% CI 0.05-0.26). CT confers benefits on various cognitive domains, suggesting a potential role of CT to promote optimal cognitive functioning in the midlife and specifically in women during the menopause transition.

Semantic and phonemic verbal fluency tests: Normative data for the Turkish population

Semantic and phonemic verbal fluency tests are widely used neuropsychological assessments of executive functions and language skills and are easy to administer. The aim of this study was to determine the impact of age, education, and gender on semantic and phonemic verbal fluency tests and to establish normative data for Turkish adults aged between 18 and 86 years. The results revealed significant main effects of age and education on all subscores of verbal fluency tests. Furthermore, an interaction effect between age and education was observed on semantic fluency and letter K fluency scores. While no significant differences were found among the 18-29, 30-39, and 40-49 age groups in any of the subscores, performance on the tests decreased with increasing age. Significant differences were observed among all education groups in all subscores. No main or interaction effects of gender were found on any subscore. These normative data could prove useful in clinical and research settings for the assessment of cognitive impairment.

Gaps in clinical research in frontotemporal dementia: A call for diversity and disparities-focused research

Frontotemporal dementia (FTD) is one of the leading causes of dementia before age 65 and often manifests as abnormal behavior (in behavioral variant FTD) or language impairment (in primary progressive aphasia). FTD's exact clinical presentation varies by culture, language, education, social norms, and other socioeconomic factors; current research and clinical practice, however, is mainly based on studies conducted in North America and Western Europe. Changes in diagnostic criteria and procedures as well as new or adapted cognitive tests are likely needed to take into consideration global diversity. This perspective paper by two professional interest areas of the Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment examines how increasing global diversity impacts the clinical presentation, screening, assessment, and diagnosis of FTD and its treatment and care. It subsequently provides recommendations to address immediate needs to advance global FTD research and clinical practice.

Clustering and Switching in Semantic Verbal Fluency: Their Development and Relationship with Word Productivity in Typically Developing Greek-Speaking Children and Adolescents

Performance in semantic verbal fluency (SVF) tasks, mainly measured by the number of words of a particular semantic category produced within a limited time, is a widely accepted measure of cognitive functioning used in the neuropsychological assessment of children and adults. Two strategic processes, Clustering and Switching (C&S) have been proposed to underlie fluency processes and affect performance in the task. However, few studies have reported on the development of those cognitive strategies and their relationship with word productivity in typically developing children. Even fewer studies have covered a broad developmental period from preschool to adolescence or measured the effect of contextual factors in this relationship. Based on a sample of 472 typically developing Greek-speaking children aged 4;0 to 16;11 years, we investigated the development of SVF performance and reported on the degree to which it is affected by C&S strategies, children's sex, and level of parental education. Results revealed a large effect of age on word productivity and on the use of C&S strategies. Two switching factors (number of clusters and number of switches) and two clustering factors (mean cluster size and a novel measure, maximum cluster size), appeared to be significantly associated with word productivity, with the largest effect being attributed to the two switching factors. C&S factors, together with children's age and parental education, predicted 91.7% of the variance in the SVF score. Children's sex was not found to have a significant effect on either word productivity or C&S strategies. Results are discussed for their theoretical implications on the strategic processes underlying word production in typically developing children.

Determination of cognitive status and influencing variables in patients with chronic neck pain: A cross-sectional study

OBJECTIVES

This study aimed to evaluate cognitive function in individuals with chronic neck pain (CNP) and investigate the effects of different variables on cognition.

METHODS

The sociodemographic characteristics of the individuals who participated in this study were recorded. Pain intensity of the individuals was evaluated using the Visual Analog Scale, pain-related disability was evaluated with the Neck Disability Index and cognitive function was evaluated using Montreal Cognitive Assessment (MoCA).

RESULTS

For this study, 95 patients with CNP were recruited. The mean age was 45.61 ± 11.14, and the median MoCA score was 24 (20-26), and 64.2% of the patients scored below the original cutoff (<26/30 points). The regression analysis showed that higher age and lower education levels were associated with lower MoCA scores. Education appeared to be the most influential variable. Younger participants (18-45) performed systematically better on naming, attention and language domains than their older counterparts (over 45).

CONCLUSIONS

The findings suggest that age and education play an important role in MoCA total and domain scores in these patients. While treating these patients, assessment of cognitive function can be useful for effective pain management.

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.

Identifying Appropriate Neuropsychological Tests for Uneducated/Illiterate Older Individuals

OBJECTIVES

We investigated the utility of traditional neuropsychological tests in older uneducated/illiterate individuals without dementia to determine the possibility that they are likely not appropriate for this group.

METHODS

We assessed the neuropsychological performance of 1122 older adults [≥65 years old; mean age: 74.03 (SD = 5.46); mean education: 4.76 (SD = 2.5) years; women: n = 714], in the context of the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD), a population-based study conducted in Greece.

RESULTS

We based our analyses on three groups: high-functioning/cognitively healthy (i.e., without dementia) uneducated/illiterate individuals (n = 80), high-functioning/cognitively healthy educated/literate individuals (n = 932), and low-functioning/cognitively impaired educated/literate individuals (presumably with dementia; n = 110). We used binary regression analyses with Bonferroni correction to investigate whether test performance differentiated uneducated/illiterate from educated/literate individuals. Models were adjusted for age and sex; raw test scores were the predictor variables. The uneducated/illiterate cohort was at a disadvantage relative to the healthy educated/literate group on all variables but verbal memory recognition and consolidation, congruent motor responses, and phonological fluency clustering (p > .002). Moreover, only word list learning immediate and delayed free recall and delayed cued recall differentiated the high-functioning/cognitively healthy uneducated/illiterate from the low-functioning/cognitively impaired educated/literate group, favoring the former (p's < .002).

CONCLUSIONS

Our findings suggest that only particular verbal memory test variables are fair in determining whether older uneducated/illiterate individuals have functional/cognitive impairment suggestive of a neurodegenerative process. On all other neuropsychological variables, this cohort was at a disadvantage. Therefore, we highlight the need for identifying appropriate methods of assessment for older uneducated/illiterate individuals.

Education level is a strong determinant of cognitive function as measured by MoCA in people with chronic low back pain

BACKGROUND

Over recent years there has been increasing clinical interest in the relationship between chronic pain and cognitive function. There are very few studies on individuals with low back pain (LBP) in the literature, which has remained under-researched.

OBJECTIVES

This study aimed to evaluate cognitive function in individuals with chronic back pain and investigate the effects of different variables on cognition.

DESIGN

Cross-sectional study.

METHODS

In this study, 115 individuals with chronic low back pain (CLBP) participated. The sociodemographic characteristics of the individuals who participated were recorded, including age, sex, weight, height, education and pain duration. Pain intensity of the individuals was evaluated using the Visual Analog Scale, functional status was evaluated with the Oswestry Disability Index, and cognitive function was evaluated using Montreal Cognitive Assessment (MoCA).

RESULTS

One hundred fifteen individuals with CLBP were recruited. The mean age was 48.4±11.8, and the mean MoCA score was 22.9±4.4. MoCA scores were associated with education, age, gender and pain intensity.

CONCLUSIONS

The findings obtained in the current study showed that individuals with CLBP had low MoCA scores and cognitive function was affected. In individuals with CLBP, cognitive function was affected depending on education level, age and intensity of pain. Assessment of the cognitive function in pain management can be useful for clinicians interested in LBP.

Intact fluency in autism? A comprehensive approach of verbal fluency task including word imageability and concreteness

Verbal fluency is a cognitive function reflecting executive functions and the ability to retrieve the appropriate information from memory quickly. Previous studies reported conflicting results—impaired and intact verbal fluency—in autism spectrum disorder (ASD). Most studies concentrate on overall word productivity, errors, perseverations, clustering, or switching. We used a comprehensive approach to evaluate the reported discrepancy in the literature and introduced a new angle using the concept of word abstraction and imageability. Moreover, we analyzed the performance in two‐time intervals (0–30 s and 31–60 s) to assess the temporal dynamics of verbal fluency and a possible activation or initiation deficit in autism. Sixteen adults with ASD and 16 neurotypical control participants, matched by gender, age, and education level, participated in our study. Contrary to our expectations, we did not find a significant difference between groups in word productivity, the number of errors, clustering, or temporal dynamics, neither in semantic nor in phonemic fluency tasks. Surprisingly, the two study groups' performance did not differ in terms of imageability or concreteness characteristics either. Our results raise the possibility that verbal fluency performance is intact in autism. We also suggest using a comprehensive approach when measuring fluency in autism.

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

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

Comparing the Cognitive Functioning Effects of Aerobic and Pilates Exercises for Inactive Young Adults: A Randomized Controlled Trial

Aerobic exercises (AE) have been found to have short-term positive effects on certain aspects of cognitive functioning. Pilates exercises (PE) may have similar benefits. In this randomized controlled study, we compared the effectiveness of PE and AE on participants' cognitive functions. We randomly assigned 52 physically inactive young adult volunteers into either a PE group (Mage = 20.85, SD = 2.11 years; 18 females and 8 males) or an AE group (Mage = 19.88, SD = 0.91 years; 18 females and 8 males). In both groups, participants engaged in a moderately intense exercise program three days a week for four weeks. We tested participants on cognitive measures of selective attention and inhibitory control (Stroop test), verbal fluency (verbal fluency tests (letter and category); VFTs), and speed of movement (Nelson's Speed of Movement Test; NSMT). There were no group differences on the Stroop and the VFTs (p>0.05). However, there was a significant pre- to post-exercise difference for participants in both groups with a medium-large effect size (ES) on Stroop sections 1, 3, 4, and 5, respectively (PE: p < 0.001, ES = 0.58, p = 0.001, ES = 0.54, p < 0.001, ES = 0.88, p = 0.001, ES = 0.60; AE: p < 0.001, ES = 0.70, p < 0.001, ES = 0.89, p < 0.001, ES = 0.86, p = 0.006, ES = 0.65). There was a large effect size pre- to post-exercise detected for VFT sections labeled letter (PE: p < 0.001, ES = 1.45; AE: p < 0.001, ES = 1.11), and category (PE: p < 0.001, ES = 1.11; AE: p < 0.001, ES = 0.83), and there was a large ES for NSMT in the PE group (p < 0.001, ES = 1.07). Both PE and AE may lead to short-term improvements in selective attention, verbal fluency, and executive control in inactive young adults, and PE may benefit speed of movement.

Inequality of educational opportunity at time of schooling predicts cognitive functioning in later adulthood

Objectives

Our understanding of how societal conditions and educational policies influence cognitive development across the life course is improving. We tested the extent to which inequality of educational opportunity (IEO), the country- and cohort-specific correlation of parents' and their offspring's length of schooling, offers systematically different opportunities to contribute to cognitive development, which in turn influences cognitive abilities up to older ages.

Methods

A total of 46,972 individuals of three cohorts born 1940-63 from 16 European countries and Israel provided up to six cognitive assessments and information on covariates in the SHARE survey 2004-2017. Individual-level data were linked to indicators of IEO at time of schooling, and economic, health, and human development, provided by World Bank, WHO, and the UN.

Results

In multilevel (mixed-effects) models with random individual and country-cohort effects and adjusted for a large set of confounders, higher IEO was associated with lower levels of cognitive functioning in men and women. Interaction analyses suggested lower cognitive levels particularly of women who were schooled in higher IEO contexts and had lower educational attainment. Associations with rate of change in cognitive functioning were present only in women, however there was little clinically relevant cognitive decline across the window of observation. Result patterns were mostly consistent after including additional contextual indicators, and in a subsample with childhood information.

Discussion

Findings suggest that IEO is able to substantially influence cognitive development with long-lasting impacts. Lower-educated women of the cohorts under investigation may have been particularly vulnerable to high-inequality educational contexts.

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.

What matters: Factors impacting the recovery process among outpatient mental health service users

OBJECTIVE

Understanding factors that promote and hinder the recovery process for people living with serious mental illness remains of critical importance. We examine factors, including limited literacy, associated with mental health recovery among public mental health service users.

METHOD

This study uses data from a mixed-methods, service-user informed project focused on the impact of limited literacy in the lives of people with serious mental illness. Data from structured interviews evaluate perceptions of recovery as assessed with the Recovery Assessment Scale (RAS). Regression models examine factors related to recovery controlling for sociodemographic factors, literacy, neurocognition, mental health status, perceived social support, and stigma.

RESULTS

Despite bivariate relationships between RAS and limited literacy, the full models suggest that other factors account for this relationship. These include mental health status, higher social support, higher self-reported community status, and higher stigma consciousness, as well as race for some models.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Our findings that social support and perceptions of community status are associated with higher scores on the RAS echo prior work demonstrating the importance of social connection and context in mental health recovery. Though literacy was not a predictor of recovery, further research should examine the relationship between literacy and recovery given the deep literature on literacy on health outcomes. In order to better support people in the recovery process it is important that more research is done to examine the complex relationship between stigma consciousness and recovery as well as understand the racial disparities that exist within the recovery subscales. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Semantic verbal fluency task: The effects of age, educational level, and sex in Lebanese-speaking adults

Verbal fluency tasks are considered clinically valuable measures of cognitive impairment for they are short, easy to score and administer, and of low costs. Sociodemographic, cultural, and linguistic variables have been shown to affect verbal fluency performance. Information concerning the effects of sociodemographic variables on semantic verbal fluency (SVF) performance in Lebanon and other Arabic-speaking countries is lacking. This study examined the effects of age, educational level, and sex on SVF performance in healthy Lebanese-speaking adults. Data were obtained from 70 adult Lebanese speakers ages 19-79. Participants were presented with fourteen categories, each at a time, and were asked to generate as many exemplars as they could in 60 seconds. Results from regression analyses showed that age (p < .001) and educational level (p = .002) variables had significant effects on overall SVF performance resulting in younger adults and adults with higher educational levels achieving higher SVF scores. Overall, sex did not emerge a predictor of SVF performance. Category-specific differences demonstrate variability. Consequently, the effects education and age present on SVF may be due to their critical roles in the semantic and non-semantic components of SVF, respectively.

Assessing within-task verbal fluency performance: the utility of individual time intervals in predicting incident mild cognitive impairment

The current study aimed to determine whether word generation performance on individual within-task 20-second time intervals predicted conversion to Mild Cognitive Impairment (MCI) status. Longitudinal data (Mean follow-up=2.95±1.64 years) was collected from cognitively-healthy community-dwelling older adults (N=344; %female=56.1). Performance on letter and semantic fluency tasks was divided into three consecutive within-task 20-second intervals. Incident MCI status (n=50) was determined via established diagnostic case conference. Fully adjusted Cox proportional-hazards regression models revealed that greater word production on semantic fluency across all time intervals significantly predicted a reduced risk of incident MCI [0-20 seconds (HR=0.906, p=0.002), 21-40 seconds (HR=0.904, p=0.02), and 41-60 seconds (HR=0.892, p=0.017)]. Conversely, on letter fluency, greater word production within the 41-60 second time interval only was significantly associated with reduced risk of incident MCI (HR=0.886, p=0.002). Overall, the clinical use of within-interval performance is supported given evidence of predictive sensitivity and ease of administration.

The Role of Moderating Variables on BOLD fMRI Response During Semantic Verbal Fluency and Finger Tapping in Active and Educated Healthy Seniors

Semantic verbal fluency is among the most employed tasks in cognitive aging research and substantial work is devoted to understanding the underlying mechanisms behind age-related differences at the neural and behavioral levels. The present investigation aimed to evaluate the role of moderating variables, such as age, sex, MMSE, and proxies of cognitive reserve (CR) on the hemodynamic response evoked by semantic verbal fluency in healthy young and healthy older adults. So far, no study has been conducted to this end. To elucidate the exclusive effect of the mentioned variables on brain activation during semantic fluency, finger tapping was included as a control task. Results showed that disregarding adjustments for age, older adults displayed important parietal activations during semantic fluency as well as during finger-tapping. Specifically, the anterior intra-parietal sulcus (IPS) and left inferior parietal lobule (IPL) were areas activated in both tasks in the older group. Younger adults, only displayed parietal activations related to age and sex when these demographics were employed as predictors. Concerning proxies of CR in semantic fluency, the only vocabulary was an important moderator in both age groups. Higher vocabulary scores were associated with lesser activation in occipital areas. Education did not show significant correlations with brain activity during semantic fluency in any of the groups. However, both CR proxies were significantly correlated to brain activations of older adults during finger tapping. Specifically, vocabulary was associated with frontal regions, while education correlated with parietal lobe and cingulate gyrus. Finally, the effects of MMSE were mostly observed on brain activation of older adults in both tasks. These findings demonstrate that the effects of moderating variables on shaping brain activation are intricate and not exclusive of complex verbal tasks. Thus, before adjusting for “nuisance variables,” their importance needs to be established. This is especially true for samples including older adults for whom a motor task may be a demanding operation due to normal age-related processes of dedifferentiation.

Demographically-adjusted norms for selected tests of verbal fluency: Results from the Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) project

OBJECTIVE

Verbal fluency tests are sensitive to various disorders affecting the central nervous system and are commonly included in neuropsychological evaluations. We aimed to develop normative data for two verbal fluency tests in a sample of native Spanish-speakers living in the US-Mexico border region.

METHOD

Participants included 254 adults from the Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) Project (Age: range = 19-60; Education: range = 0-20, 59% female). Participants completed two verbal fluency tests (i.e., letter [PMR] and semantic/category fluency [Animal Naming]) as part of a larger neuropsychological test battery. We examined linear and nonlinear effects of demographic factors (age, education, and gender) on verbal fluency raw scores, and developed T-scores using fractional polynomial equations controlling for demographics. We also calculated the rates of "impairment" (T-scores < 40) that would be obtained by applying the newly developed norms and available norms for non-Hispanic English-speakers on comparable tests.

RESULTS

There were positive small effects of age and medium effects of education on verbal fluency raw scores. The normalized distribution of T-scores with the new norms showed expected psychometric properties. However, rates of impairment for both letter and semantic fluency were significantly higher when applying non-Hispanic White norms, and significantly lower when applying non-Hispanic Black norms.

CONCLUSIONS

We provide norms for Spanish-speakers living along the US-Mexico border region for two verbal fluency tests that are co-normed with a more extensive neuropsychological battery. These regional norms will improve interpretation of verbal fluency test performance in Spanish-speakers living in the US-Mexico borderland.

Accuracy of the semantic fluency test to separate healthy old people from patients with Alzheimer’s disease in a low education population

ABSTRACT Objective Evaluate the accuracy of two semantic categories of the verbal fluency test (supermarket and animal categories) to separate healthy elderly individuals and lower educated Alzheimer’s disease patients. Methods We evaluated 69 older adults with less than 5 years of schooling, consisting of 31 healthy elderly, and 38 patients diagnosed with Alzheimer’s disease. Semantic verbal fluency was evaluated using the animal and supermarket categories. Mann-Whitney U and Independent t Tests were used to compare the two groups, and the diagnostic accuracy of the tests was analyzed by sensitivity, specificity, likelihood ratio’s, and the Area Under the Curve (AUC). Results We found a significant difference between the healthy older and Alzheimer’s disease groups, in both, animal (p = 0.014) and supermarket verbal fluency (p < 0.001). The supermarket category showed better overall diagnostic accuracy (AUC = 0.840, 95% CI = 0.746-0.933; p < 0.001) compared to the animal category (AUC = 0.671, 95% CI = 0.543-0.800; p = 0.014). Conclusion The supermarket category of semantic verbal fluency provides better accuracy than the animal category for the identification of dementia in a Brazilian elderly population with low educational level.

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.

Sex Differences in Verbal Fluency Among Young Adults

Verbal fluency tasks have been used as tools to measure various cognitive processes, such as executive functions, memory, and language. Sex differences in verbal fluency performance have been mostly investigated in population studies. Little of this research has focused on young adults. The goal of this study was to assess the impact of sex and task category on word production and verbal strategies (i.e., cluster size and switches) in young adults. The phonemic (letter “k”, letter “f”) and semantic (animals, fruits, sharp objects) fluency measures were used. Men and women were compared in terms of the number of produced words and the use of verbal strategies (number of switches and mean cluster size controlled for produced words). Results revealed subtle sex differences in verbal fluency in young adults. Men performed slightly better in semantic fluency, producing more words, while there were no sex differences in verbal strategies. There were also no sex differences in word production and verbal strategies in the phonemic fluency tasks. Furthermore, there were differences in the number of produced words, mean cluster sizes, and switches between semantic tasks as well as between phonemic tasks. These results can be interpreted in the context of potential differences in mental lexicon and social roles. Moreover, our results suggest that assessment of verbal strategies and overall word production may be important in the context of sex differences in verbal fluency among young adults as well as in neuropsychological diagnosis

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

A cross-linguistic comparison of category verbal fluency test (ANIMALS): a systematic review

Background

Cross-linguistic information about performance in neuropsychological verbal tests is extremely scarce. It has been suggested that verbal fluency test using animal fluency test is one of the few tests fulfilling the fundamental criteria desirable in a robust neuropsychological test.

Objective

To compare and establish cross-linguistic information about performance in the animal fluency test.

Results

In an extensive search, it was found that norms for the semantic fluency test using the category ANIMALS are available in 15 different languages. These languages represent a relatively broad spectrum of world languages, including not only Indo-European languages, but also Semitic, Sino-Tibetan, Austroasiatic, Dravidian, and even Amerindian languages. Normative data in these 15 languages are analyzed and the results are compared.

Conclusions

It is concluded that (a) pure linguistic factors, such as type of language and word-length, seemingly do not significantly affect the performance in this test; (b) two major demographic variables—age and education—account for a significant percentage of the variance in this test; the effect of sex seems to be neglectable; (c) in bilinguals, when the native language has few speakers and/or is a marginalized language, a very low score can be observed in the native language, even lower than in the second language; (d) there is a frequently overlooked major factor accounting for differences in cognitive test performance: the effort made in performing the test. It depends on the significance given to the test performance. Effort is quite variable across cultures and is higher in psychometric-oriented societies.

How to Assess Executive Functions in a Low-Educated and Multicultural Population Using a Switching Verbal Fluency Test (the TFA-93) in Neurodegenerative Diseases?

Few neuropsychological tests are available to assess executive dysfunction in low-educated and multicultural populations. To address this issue, the TFA-93, a switching verbal fluency test to assess cognitive flexibility, was administered to 70 healthy controls, 57 patients with a clinical diagnosis of Alzheimer's disease, and 21 with a clinical diagnosis of a neurodegenerative disease associated with frontal disorders. Most of the participants were low-educated and nonnative French speakers. The TFA-93 comprises 2 categorical fluency tasks (animals and fruits) and a fluency task in which participants have to switch between animals and fruits. Correct responses and errors were collected, and a flexibility index expressed the switching cost. Results showed that correct responses were lower, and the switching cost was greater in both patient groups. In low-educated and multicultural populations, the TFA-93 seems to be a good alternative to assess flexibility compared to the standard neuropsychological tools based on academic abilities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Addenbrooke's cognitive examination III in the diagnosis of dementia: a critical review

Addenbrooke's cognitive examination III is a screening test that is composed of tests of attention, orientation, memory, language, visual perceptual and visuospatial skills. It is useful in the detection of cognitive impairment, especially in the detection of Alzheimer's disease and fronto-temporal dementia. The aim of this study is to do a critical review of the Addenbrooke's cognitive examination III. The different language versions available and research about the different variables that have relationship with the performance of the subject in the ACE-III are listed. The ACE-III is a detection technique that can differentiate patients with and without cognitive impairment, is sensitive to the early stages of dementia, and is available in different languages. However, further research is needed to obtain optimal cutoffs for the different versions and to evaluate the impact of different age, gender, IQ, and education variables on the performance of the test.

Cognitive Assessment Tools for Screening Older Adults With Low Levels of Education: A Critical Review

Introduction: Cognitive assessment of older adults who are either illiterate or with low levels of education is particularly challenging because several battery tasks require a certain educational background. Early detection of mild cognitive impairment (MCI) in the elderly using validated screening tools is of great importance since this population group could benefit from new drugs that are being investigated for the treatment of dementias. Cutoff scores for psychometric properties of cognitive tests are not well established among adults with low levels of education. The present study aimed to critically review the literature on cognitive assessment tools for screening cognitive syndromes including MCI and Alzheimer's disease (AD) in older adults with low levels of education. Methods: We conducted a systematic search of MEDLINE, LILACS, Cochrane, and SCOPUS electronic databases of cross-sectional and prospective studies with adults over 55 years of age. Results: We found a significant number of assessment tools available (n = 44), but only a few of them showed diagnostic accuracy for the diagnosis of MCI and AD in older adults with low levels of education: the Mini-Mental State Exam; the Montreal Cognitive Assessment; the Persian Test of Elderly for Assessment of Cognition and Executive Function; the Six-Item Screener; and the Memory Alteration Test. Few studies evaluated individuals with low levels of education, with a wide range of cutoff scores and cognitive test batteries. Conclusion: We found that a small number of studies evaluated adults with 4 years of formal education or less. Our findings further support the importance of developing specific tools for the assessment of older adults with low levels of education.

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.

Verbal fluency tests: Normative data for the Latin American Spanish speaking adult population

OBJECTIVE

To generate normative data for the Verbal Fluency Tests across 11 countries in Latin America, with country-specific adjustments for gender, age, and education, where appropriate.

METHOD

The sample consisted of 3,977 healthy adults who were recruited from Argentina, Bolivia, Chile, Cuba, El Salvador, Guatemala, Honduras, Mexico, Paraguay, Peru, and, Puerto Rico. Each subject was administered the Verbal Fluency Test as part of a larger neuropsychological battery. A standardized five-step statistical procedure was used to generate the norms.

RESULTS

The final multiple linear regression models for the letter F explained 8-30% of the variance, 7-32% for letter A, 8-32% for the letter S, and 16-43% for the animal category in Verbal Fluency Test scores. Although t-tests showed significant differences between men and women on the Verbal Fluency Test, they did not have an effect size larger than 0.3. As a result, gender-adjusted norms were not generated.

CONCLUSIONS

This is the first normative multicenter study conducted in Latin America aiming to create norms for the Verbal Fluency Test; this study will have important outcomes for the future of neuropsychology in the region.

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.

Comparison of performance on three neuropsychological tests in healthy Turkish immigrants and Danish elderly

BACKGROUND

Appropriate neuropsychological tests for cross-cultural assessment of dementia in elderly ethnic and linguistic minorities are generally lacking in Europe. The aim of this study was to investigate the cross-cultural applicability of the Recall of Pictures Test (RPT), Clock Reading Test (CRT), and supermarket fluency (SF) in samples of Turkish immigrants and Danish elderly.

METHODS

Samples of Turkish immigrants and Danish elderly were recruited from the Greater Copenhagen area. All participants were screened for factors known to affect cognitive test performance. Those who were included in the study underwent an approximately two-hour assessment, where the RPT, CRT, and SF were applied as a part of a comprehensive battery of neuropsychological tests.

RESULTS

A total of 109 elderly participants were included in the study: 73 Turkish and 36 Danish. Significant differences were found between the Turkish and Danish samples in CRT and SF performances, but not in any of the RPT measures. Age and acculturation level were the only demographic variables with significant impact on test performances. Performance data for the three tests are presented as percentiles.

CONCLUSIONS

Although small differences were observed between the Turkish and Danish samples on the CRT and SF, we consider the three tests to be important neuropsychological tests for assessment of dementia in elderly patients from ethnic minority migrant populations.

Neural processing of overt word generation in healthy individuals: the effect of age and word knowledge

Verbal fluency is a classical and widely used neuropsychological instrument to assess cognitive abilities. Results of previous studies indicate an influence on verbal fluency performance of both, age and word knowledge. So far, no imaging study has investigated the neural mechanisms underlying an age and word knowledge related decline on the quantitative verbal output in a highly demanding overt and continuous semantic fluency task. Fifty healthy volunteers (age 22-56 years, verbal IQ 95-143) overtly and continuously articulated words in response to ten visually presented semantic categories while BOLD signal was measured with fMRI. Verbal responses were recorded with an MRI compatible microphone and transcribed after the scanning session. The number of produced words as well as age, word knowledge and level of education was implemented in the design matrix enabling a separate analysis of these factors on both, neural responses and behavioral differences. There was a significant correlation of level of education and number of generated words, but no significant correlations of generated words and age or word knowledge were observed. On the neural level, a widespread network was found for the word production task as contrasted with the resting condition, encompassing the bilateral superior temporal gyri, the cerebellum and the SMA. An age related positive correlation was found in the bilateral inferior and middle frontal gyri, the anterior cingulate gyrus, the left precentral gyrus and the right insula. A lower word knowledge resulted in enhanced BOLD responses in the right superior temporal gyrus and the left superior frontal gyrus. Results are interpreted in terms of compensation mechanisms countervailing potential age and word knowledge related effects.

Differentiating illiteracy from Alzheimer's disease by using neuropsychological assessments

BACKGROUND

In Asia, where illiteracy rates are high, determining the degree to which neuropsychological measures can be used to identify cognitive impairment in illiterate elders is important. The aim of this study was to evaluate the effectiveness of using formal neuropsychological assessments to distinguish healthy illiterate elders from dementia patients.

METHODS

We compared the cognitive performance of healthy elders who were illiterate (illiterate NC, n = 25) with those who were literate (literate NC, n = 25), literate patients with mild Alzheimer's disease (literate AD, n = 25), and illiterate patients with mild AD (illiterate AD, n = 25). Neuropsychological measures included the Mini-Mental State Examination (MMSE), the verbal fluency test, the Boston naming test, the Rosen drawing test, and the verbal learning test.

RESULTS

In the between-group analyses, the scores on all tests, except verbal fluency and recognition memory, were lower for illiterate NC compared to the literate NC. The scores on the MMSE, Boston naming test, Rosen drawing test, and immediate free recall could not distinguish the illiterate NC from literate AD. However, the scores on all tests, except the Rosen drawing test, could distinguish illiterate NC from illiterate AD. ROC analyses showed the same pattern of results. In addition, age-, sex-, and education-matched cut-off scores of all tests, except immediate recall and delayed recall trials of the verbal learning test, showed good specificities in participants who were illiterate compared to those in participants who were literate.

CONCLUSION

These findings suggest that the impact of literacy on neuropsychological test performance is an important aspect of cognitive evaluations for elders who are illiterate.

Language-mediated visual orienting behavior in low and high literates

The influence of formal literacy on spoken language-mediated visual orienting was investigated by using a simple look and listen task which resembles every day behavior. In Experiment 1, high and low literates listened to spoken sentences containing a target word (e.g., "magar," crocodile) while at the same time looking at a visual display of four objects (a phonological competitor of the target word, e.g., "matar," peas; a semantic competitor, e.g., "kachuwa," turtle, and two unrelated distractors). In Experiment 2 the semantic competitor was replaced with another unrelated distractor. Both groups of participants shifted their eye gaze to the semantic competitors (Experiment 1). In both experiments high literates shifted their eye gaze toward phonological competitors as soon as phonological information became available and moved their eyes away as soon as the acoustic information mismatched. Low literates in contrast only used phonological information when semantic matches between spoken word and visual referent were not present (Experiment 2) but in contrast to high literates these phonologically mediated shifts in eye gaze were not closely time-locked to the speech input. These data provide further evidence that in high literates language-mediated shifts in overt attention are co-determined by the type of information in the visual environment, the timing of cascaded processing in the word- and object-recognition systems, and the temporal unfolding of the spoken language. Our findings indicate that low literates exhibit a similar cognitive behavior but instead of participating in a tug-of-war among multiple types of cognitive representations, word-object mapping is achieved primarily at the semantic level. If forced, for instance by a situation in which semantic matches are not present (Experiment 2), low literates may on occasion have to rely on phonological information but do so in a much less proficient manner than their highly literate counterparts.

[Diagnosis of dementia in non-western elderly migrants in memory clinics: obstacles and solutions]

In the next decade the number of non-western elderly immigrants will double in the Netherlands. Because of specific risk factors (hypertension, diabetes), the number of elderly immigrants with dementia will probably increase. Memory clinics are not well prepared for these patients, because health professionals lack knowledge about important obstacles in intercultural dementia diagnostics. They should consider language barriers, cultural differences, low level of education and illiteracy, as well as ignorance about dementia, shame and special care expectations of patients and their families. We give recommendations to improve communication, (neuropsychological) testing and counseling in clinical practice.

Normative data for a battery of free recall, cued recall and recognition tests in the elderly Italian population

The present study aimed to provide normative data on a large sample of the elderly Italian population (N = 464; range of age = 49-94; range of education = 3-25) on both the word and the picture versions of a battery of free recall, cued recall, and recognition tests of memory. Results from multiple regression analyses showed that both age and education were significant predictors of performance. Therefore, norms were calculated taking into account these demographic variables. The availability of normative data based on a large sample will allow a more reliable use of the battery for clinical assessment in Italian-speaking dementia population.

Assessing neuropsychological performance in a migrant farm working Colonia in Baja California, Mexico: a feasibility study

Neuropsychological impairments (NPI) can lead to difficulties in daily functioning and ultimately contribute to poor health outcomes. However, evidence for the feasibility of NPI assessment in resource-limited settings using tests developed in high literacy/high education cultures is sparse. The main objectives were to: (1) determine the feasibility and appropriateness of conducting neuropsychological assessments among a migrant farm worker population in Baja California, Mexico and (2) preliminary describe neuropsychological test performance in this unique population. A neuropsychological test battery was administered to 21 presumably healthy adults (8 men, 13 women) during a two-day international health services and research collaboration. All but one neuropsychological test (i.e. figure learning) was feasible and appropriate to administer to the study population. Contrary to expectations, participants performed better on verbal rather than nonverbal neuropsychological tests. Results support inclusion of neuropsychological tests into future studies among migrant farm worker populations in Baja California, Mexico.