Normative data on the Boston Diagnostic Aphasia Examination in a Spanish-speaking population

Is language translation enough in cross-cultural neuropsychological assessments of patients from Latin America?

OBJECTIVE

The purpose of this review was to highlight the need to consider factors other than language when adapting tests across cultural groups and to offer a list of tests that have been adapted for use among patients from or descended from Latin American Countries. Despite efforts in the field through publications and workshops, the authors were aware of continued errors in cross-cultural assessment of these patients, resulting in misdiagnosis and unintentional inequitable care. Thus, we sought to reinforce the existing literature.

METHOD

We reviewed the literature pertaining to cross-cultural adaptation of neuropsychological measures. Relevant papers were identified by our institution's Academic Enhanced Search Option (AcESO) Database, PubMed, and Google Scholar.

RESULTS

102 papers, articles, and other published literature were reviewed describing issues related to the adaptation of tests for groups originally from or descended from Latin American Countries residing in the United States.

CONCLUSIONS

It is imperative that tests be appropriately developed or adapted for the target population with appropriate normative data available, and ideally administered by a fluent speaker trained in assessment. Inappropriate use of tests not adapted for a particular patient's language and country of origin can result in misdiagnosis, potentially resulting in harm to the individual.

Intersectional sociodemographic and neurological relationships in the naming ability of persons with post-stroke aphasia

INTRODUCTION

Significant attention has been given to the role of brain function and disruption in determining performance on naming tasks among individuals with aphasia. However, scholarly pursuit of a neurological explanation has overlooked the fundamental cornerstone of individual health-the underlying social, economic, and environmental factors that shape how they live, work, and age, also known as the social determinants of health (SDOH). This study examines the correlation between naming performance and these underlying factors.

METHODS

Individual level data from the 2010 Moss Aphasia Psycholinguistic Project Database (MAPPD) was matched with the 2009-2011 Medical Expenditure Panel Survey (MEPS) using a propensity score algorithm based on functional, health, and demographic characteristics. Multilevel, generalized, nonlinear regression models were applied to the resulting data set to assess the correlation between the Boston Naming Test (BNT) percentile score and age, income, sex, race, household size, marital status, aphasia type, and region of residence. Poisson regression models with bootstrapped standard errors were used to estimate these relationships RESULTS: Discrete dependent variable estimation with non-normal prior specification included individual level (age, marital status, years of education), socioeconomic (family income), health (aphasia type), household (family size), and environmental (region of residence) characteristics. Regression results indicated that, relative to individuals with Wernicke's, individuals with Anomic (0.74, SE = 0.0008) and Conduction (0.42, SE = 0.0009) aphasia performed better on the BNT. While age at the time of testing was not significantly correlated, higher income level (0.15, SE = 0.0003) and larger family size (0.002, SE = 0.002) was associated with higher BNT score percentiles. Finally, Black persons with aphasia (PWA) (-0.0124, SE = 0.0007) had lower average score percentiles when other factors were held constant.

CONCLUSIONS

The findings reported here suggest higher income and larger family size are associated with better outcomes. As expected, aphasia type was significantly associated with naming outcomes. However, poorer performance by Black PWA and individuals with low income suggests that SDOH can play a critical role (positive and negative) in naming impairment in some populations with aphasia.

Multidimensional Clinical Assessment in Frontotemporal Dementia and Its Spectrum in Latin America and the Caribbean: A Narrative Review and a Glance at Future Challenges

Frontotemporal dementia (FTD) is the third most common form of dementia across all age groups and is a leading cause of early-onset dementia. The Frontotemporal dementia (FTD) includes a spectrum of diseases that are classified according to their clinical presentation and patterns of neurodegeneration. There are two main types of FTD: behavioral FTD variant (bvFTD), characterized by a deterioration in social function, behavior, and personality; and primary progressive aphasias (PPA), characterized by a deficit in language skills. There are other types of FTD-related disorders that present motor impairment and/or parkinsonism, including FTD with motor neuron disease (FTD-MND), progressive supranuclear palsy (PSP), and corticobasal syndrome (CBS). The FTD and its associated disorders present great clinical heterogeneity. The diagnosis of FTD is based on the identification through clinical assessments of a specific clinical phenotype of impairments in different domains, complemented by an evaluation through instruments, i.e., tests and questionnaires, validated for the population under study, thus, achieving timely detection and treatment. While the prevalence of dementia in Latin America and the Caribbean (LAC) is increasing rapidly, there is still a lack of standardized instruments and consensus for FTD diagnosis. In this context, it is important to review the published tests and questionnaires adapted and/or validated in LAC for the assessment of cognition, behavior, functionality, and gait in FTD and its spectrum. Therefore, our paper has three main goals. First, to present a narrative review of the main tests and questionnaires published in LAC for the assessment of FTD and its spectrum in six dimensions: (i) Cognitive screening; (ii) Neuropsychological assessment divided by cognitive domain; (iii) Gait assessment; (iv) Behavioral and neuropsychiatric symptoms; (v) Functional assessment; and (vi) Global Rating Scale. Second, to propose a multidimensional clinical assessment of FTD in LAC identifying the main gaps. Lastly, it is proposed to create a LAC consortium that will discuss strategies to address the current challenges in the field.

The state of neuropsychological test norms for Spanish-speaking adults in the United States

Objective: The present review paper aimed to identify published neuropsychological test norms developed for Spanish-speakers living in the United States (U.S.). Methods: We conducted a systematic review of the literature via an electronic search on PubMed using keywords "Normative data," "Neuropsychological test," "norms", "Hispanic/Latinos," "Spanish Speakers," and "United States." We added other studies and published manuals as identified by citations in papers from the original search. Results Eighteen sources of normative data for Spanish-speakers in the U.S. were identified. Of the 18 citations identified, only four provide normative data on comprehensive batteries of tests for Spanish-Speakers. Two of these are based on persons living in the southwest of the U.S., who tend to be of Mexican origin. Overall, a number of the studies are focused on older persons and although the majority include participants with wide ranges of education, participants in the ends of the education distribution tend to be underrepresented. Conclusion: Here we provide a detailed description of the neuropsychological normative data currently available for Spanish-speakers living in the U.S. While there has been increased attention towards developing norms for neuropsychological batteries in Spanish-speaking countries (e.g., Latin America and Spain), there is still an urgent need to standardize neuropsychological tests among diverse groups of Spanish-speaking adults living in the U.S. The present review presents a list of norms for U.S.-dwelling Spanish-speakers, thus providing an important tool for clinicians and researchers.

Normative data for test of learning and memory in an ecuadorian adult population

OBJECTIVE

The objective of this study was to develop norms for two neuropsychological tests of learning and memory in an Ecuadorian adult population.

METHOD

322 healthy individuals, ages between 18 and 84, were enrolled in the Metropolitan District of Quito. Participants were administered a comprehensive neuropsychological evaluation that included tests of learning and memory (Rey-Osterrieth Complex Figure Test [ROCF] and Hopkins Verbal Learning Test-Revised [HVLT-R]). Backward stepwise multiple linear regression analyses were used to examine the influence of demographic variables age, education, and gender on test performance. Normative data were developed adjusting for demographic variables found to be significant in the final regression models.

RESULTS

The final multiple linear models revealed performance on tests of learning and memory worsened with age and improved as a function of education. A user-friendly Excel-based calculator is presented to calculate the z score and percentile automatically based on raw score and sociodemographic information.

CONCLUSION

This is the first study that presents normative data for tests of learning and memory for an adult population in Ecuador. It is expected that these norms will help to improve the clinical practice of neuropsychology in Ecuador by limiting erroneous raw score interpretation and incrementing diagnostic accuracy.

Language ability and adult homelessness

BACKGROUND

People experiencing homelessness are at increased risk of neurological disorder due to multiple factors such as substance abuse, infection, and higher rates of serious mental illness and traumatic brain injury. This could affect cognitive and language skills. Indeed, past research has suggested that certain language-related skills tend to be lower in people experiencing homelessness. However, that research has compared homeless samples with age-matched normative samples and not with samples of people from similar socio-economic backgrounds. Therefore, it is unclear whether homelessness is even a relevant factor, or if adults who are homeless tend to have appropriate linguistic skills relative to their social and educational background.

AIMS

To compare the language skills of a group of adults with histories of homelessness with an education-matched control group. It was hypothesized that participants with histories of homelessness would have worse language performance than their matched controls.

METHODS & PROCEDURES

A quasi-experimental design was employed involving 17 adults with histories of homelessness, mainly rough sleeping, in the city of Quito in Ecuador, and a sample of 16 adults who had never been homeless. All were assessed with measures of head injury, substance dependence, affective disorder and language skills. A paired-sample analysis was performed on homeless and control participants matched for educational background, used as an index of socio-economic background.

OUTCOMES & RESULTS

The mean years of formal education was low in both the homeless sample (mean = 5.82 years) and the control sample (mean = 6.75 years). There were no differences between the groups for any demographic or clinical factors, nor for a measure of expected or 'premorbid' ability based on single-word reading, nor for current non-verbal cognitive functioning. In contrast, the homeless group scored significantly worse than the control group on measures of auditory comprehension and oral expression.

CONCLUSIONS & IMPLICATIONS

Adults with histories of homelessness may have worse language skills than would be expected based on their educational backgrounds and non-verbal cognitive abilities. It is possible that some of this lower language ability is pathological, in the form of either a developmental language disorder or an acquired impairment. As such, some adults who are homeless may benefit from therapy directed at clinical language disorders.

Age of language acquisition and cortical language organization in multilingual patients undergoing awake brain mapping

OBJECTIVE Most knowledge regarding the anatomical organization of multilingualism is based on aphasiology and functional imaging studies. However, the results have still to be validated by the gold standard approach, namely electrical stimulation mapping (ESM) during awake neurosurgical procedures. In this ESM study the authors describe language representation in a highly specific group of 13 multilingual individuals, focusing on how age of acquisition may influence the cortical organization of language. METHODS Thirteen patients who had a high degree of proficiency in multiple languages and were harboring lesions within the dominant, left hemisphere underwent ESM while being operated on under awake conditions. Demographic and language data were recorded in relation to age of language acquisition (for native languages and early- and late-acquired languages), neuropsychological pre- and postoperative language testing, the number and location of language sites, and overlapping distribution in terms of language acquisition time. Lesion growth patterns and histopathological characteristics, location, and size were also recorded. The distribution of language sites was analyzed with respect to age of acquisition and overlap. RESULTS The functional language-related sites were distributed in the frontal (55%), temporal (29%), and parietal lobes (16%). The total number of native language sites was 47. Early-acquired languages (including native languages) were represented in 97 sites (55 overlapped) and late-acquired languages in 70 sites (45 overlapped). The overlapping distribution was 20% for early-early, 71% for early-late, and 9% for late-late. The average lesion size (maximum diameter) was 3.3 cm. There were 5 fast-growing and 7 slow-growing lesions. CONCLUSIONS Cortical language distribution in multilingual patients is not homogeneous, and it is influenced by age of acquisition. Early-acquired languages have a greater cortical representation than languages acquired later. The prevalent native and early-acquired languages are largely represented within the perisylvian left hemisphere frontoparietotemporal areas, and the less prevalent late-acquired languages are mostly overlapped with them.

A tutorial on aphasia test development in any language: Key substantive and psychometric considerations

BACKGROUND

There are a limited number of aphasia language tests in the majority of the world's commonly spoken languages. Furthermore, few aphasia tests in languages other than English have been standardized and normed, and few have supportive psychometric data pertaining to reliability and validity. The lack of standardized assessment tools across many of the world's languages poses serious challenges to clinical practice and research in aphasia.

AIMS

The current review addresses this lack of assessment tools by providing conceptual and statistical guidance for the development of aphasia assessment tools and establishment of their psychometric properties.

MAIN CONTRIBUTION

A list of aphasia tests in the 20 most widely spoken languages is included. The pitfalls of translating an existing test into a new language versus creating a new test are outlined. Factors to consider in determining test content are discussed. Further, a description of test items corresponding to different language functions is provided, with special emphasis on implementing important controls in test design. Next, a broad review of principal psychometric properties relevant to aphasia tests is presented, with specific statistical guidance for establishing psychometric properties of standardized assessment tools.

CONCLUSIONS

This article may be used to help guide future work on developing, standardizing and validating aphasia language tests. The considerations discussed are also applicable to the development of standardized tests of other cognitive functions.

The combined impact of virtual reality neurorehabilitation and its interfaces on upper extremity functional recovery in patients with chronic stroke

BACKGROUND AND PURPOSE

Although there is strong evidence on the beneficial effects of virtual reality (VR)-based rehabilitation, it is not yet well understood how the different aspects of these systems affect recovery. Consequently, we do not exactly know what features of VR neurorehabilitation systems are decisive in conveying their beneficial effects.

METHODS

To specifically address this issue, we developed 3 different configurations of the same VR-based rehabilitation system, the Rehabilitation Gaming System, using 3 different interface technologies: vision-based tracking, haptics, and a passive exoskeleton. Forty-four patients with chronic stroke were randomly allocated to one of the configurations and used the system for 35 minutes a day for 5 days a week during 4 weeks.

RESULTS

Our results revealed significant within-subject improvements at most of the standard clinical evaluation scales for all groups. Specifically we observe that the beneficial effects of VR-based training are modulated by the use/nonuse of compensatory movement strategies and the specific sensorimotor contingencies presented to the user, that is, visual feedback versus combined visual haptic feedback.

CONCLUSIONS

Our findings suggest that the beneficial effects of VR-based neurorehabilitation systems such as the Rehabilitation Gaming System for the treatment of chronic stroke depend on the specific interface systems used. These results have strong implications for the design of future VR rehabilitation strategies that aim at maximizing functional outcomes and their retention. Clinical Trial Registration- This trial was not registered because it is a small clinical study that evaluates the feasibility of prototype devices.

Bilingual aphasia: a theoretical and clinical review

PURPOSE

To provide an overview of the potential bilingual client population in the United States, present current neurolinguistic and psycholinguistic views of bilingualism in adults with and without aphasia, review related bilingual aphasia recovery patterns and the factors that might influence these recovery patterns, and provide insight into diagnostic and therapy procedures for addressing the needs of bilingual clients with aphasia.

METHOD

A review of the literature was conducted to summarize and synthesize previously published research in the area of bilingual aphasia, highlight unique aspects of aphasia recovery, assessment, and treatment, and identify areas in need of future research.

CONCLUSIONS

Despite a growing understanding of bilingualism and the various recovery patterns identified with bilingual aphasia, there remains a dire need for empirically validated management techniques, particularly in terms of determining which language to target, identifying which aspects of various languages are most vulnerable to insult as well as most responsive to treatment, and establishing how to exploit language similarities to maximize treatment efficiency.

Influence of sociodemographic variables on neuropsychological test performance in Spanish-speaking older adults

There is limited information regarding the impact of sociodemographic variables on the neuropsychological test performance of the Spanish-speaking older adult residing in the United States (US). This study examines the influence of age, education, gender, age of arrival in the US, percentage of lifetime in the US, acculturation, and reported depressive symptoms on neuropsychological test performance in a group of cognitively normal Spanish-speaking elders, the majority of whom were Cuban born. Educational attainment had a broad effect on test scores, with the other variables having only limited effects. These results underscore the impact of educational attainment on neuropsychological test performance among the cognitively normal Spanish-speaking older adult.

Educational level, socioeconomic status and aphasia research: a comment on Connor et al. (2001)--effect of socioeconomic status on aphasia severity and recovery

Is there a relation between socioeconomic factors and aphasia severity and recovery? describe correlations between the educational level and socioeconomic status of aphasic subjects with aphasia severity and subsequent recovery. As stated in the introduction by, studies of the influence of educational level and literacy (or illiteracy) on aphasia severity have yielded conflicting results, while no significant link between socioeconomic status and aphasia severity and recovery has been established. In this brief note, we will comment on their findings and conclusions, beginning first with a brief review of literacy and aphasia research, and complexities encountered in these fields of investigation. This serves as a general background to our specific comments on, which will be focusing on methodological issues and the importance of taking normative values in consideration when subjects with different socio-cultural or socio-economic backgrounds are assessed.

Performance of a Brazilian population sample in the Boston Diagnostic Aphasia Examination: a pilot study

Brazilian researchers and health professionals often face the challenge of having to use tests developed in foreign languages and standardized for populations of other countries, especially in the fields of Neuropsychology and Neurolinguistics. This fact promotes a feeling that some scoring systems may be inadequate for our sociocultural reality. In the present study, we describe the performance of a Brazilian population sample submitted to a translated and adapted version of the Boston Diagnostic Aphasia Examination (BDAE). Sixty normal volunteers (21 men and 39 women), all Portuguese native speakers, ranging in age from 15 to 78 years (average 43.7) and with an educational level of 2 to 16 years (average 9.9), were tested using a translated and adapted Portuguese version of the BDAE. Cut-off scores are suggested for our population and the performance of the Brazilian sample is compared to that of American and Colombian samples, with the results being closely similar in all tasks. We also performed a correlation analysis between age, gender and educational level and the influence of these variables on the performance of the subjects. We found no statistically significant differences between genders. Educational level correlated positively with performance, especially in the subtests involving reading and writing. There was a negative correlation between age and performance in two subtests (Visual Confrontation Naming and Sentences to Dictation), but a coexisting effect of educational level could not be ruled out.

A calculation and number processing battery for clinical application in illiterates and semi-literates

Ten simple tasks assessing counting, number processing, elementary calculation and quantity estimation were proposed to 122 normal Brazilian adults aged between 18 and 58 years with 0, 1, 2, 3 or 4 years of education. Tasks such as counting the number of elements in small sets were almost perfectly mastered by these illiterate or semi-literate normal subjects; however in other tasks (e.g. those assessing knowledge of the correspondence between numbers and banknotes) a sizeable proportion of the sample showed errors. The pattern of errors was analysed to identify difficulty factors. A strong gender effect with better performance in men than women was observed, which was even greater than the expected effect of educational level. Results in normals allowed to propose cut-off scores for neuropsychological assessment in brain-damaged patients with very low levels of education, which were tested in a small sample of illiterate or semi-literate patients with cerebrovascular accident. It is argued that the relatively neglected area of neuropsychological assessment in illiterates is of great practical and theoretical interest.

Bilingual performance on the boston naming test: preliminary norms in Spanish and English

A total of 100 young educated bilingual adults were administered the Boston Naming Test (BNT) (Kaplan, Goodglass, & Weintraub, 1983) in both Spanish and English. Three group performance scores were obtained: English only, Spanish only, and a composite score indicating the total number of items correctly named independent of language. The scores for the entire group were significantly greater in English than in Spanish. An additional set of analyses explored individual differences in picture naming performance across the two languages as measured by the BNT. For a subset of the larger group (n = 25) there were significant differences in composite over single language scoring, but no significant differences between Spanish and English. Item analyses of correct responses were conducted in both languages to explore the construct validity of the standardized administration of the BNT with this population. There was much greater variability in responses over the Spanish items for this bilingual group. The results of a correlation analysis of information obtained from the initial questionnaire with the BNT scores in each language is also reported. The practical implications of this preliminary bilingual BNT normative data are discussed.

Spontaneous language production and aging: sex and educational effects

Sex and educational level effects on spontaneous language production at different ages were analyzed in a 180-normal subject sample taken from the general population. Subjects were divided into groups according to three variables: (1) age (16-30, 31-50, and 51-65 years), (2) educational level (3-7, 8-12 and more than 12 years of formal educational), and (3) sex (males and females) with 10 subjects in each cell. The oral description of the Plate #1 ("The Cookie Theft") from the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1972) was selected. Number of nouns, verbs, adjectives and grammatical connectors were scored for each subject's picture description. It was concluded that: (1) the ratio among different phrase elements was very uniform across age, educational level and sex groups; (2) the total number of words used to describe the "The Cookie Theft" picture significantly increased with the subject's educational level; (3) the amount of spontaneous language in general decreased with age; however, a significant interaction-effect between age and sex was observed. A steady and pronounced spontaneous language decrease across age-groups was observed in males. However, only mild differences across age-groups were observed in female subjects. It was hypothetized that language changes during aging are strongly sex-dependent: while in men spontaneous language rapidly decreases with aging, in women spontaneous language production remains quite well-preserved.

Directions of research in cross-cultural neuropsychology

Comparable cognitive disturbances associated with brain pathology have similar manifestations across members of the human species. However, cognitive abilities measured by neuropsychological tests represent, at least in their contents, culturally learned abilities. Performance is under the influence of a vast array of moderating variables, including: culture, ecological demands, primary language, and educational level. Test scores are associated therefore, not only with the subject's learning opportunities, but also with those variables which a culture dictates are worthy of cognitive amplification. Different cultural environmental contexts will result in the development of different patterns of abilities. The evaluation of an alien cultural group using our current neuropsychological instruments, procedures and norms, results in conceptual errors in assessment. Cross-cultural neuropsychology is in need of addressing several key focal points of neglected research: (1) the normalization of current basic neuropsychological instruments, in different cultural contexts, (2) the development of new neuropsychological instruments, appropriate for different cultural contexts, (3) the analysis of educational factors and subcultural variations in relation to test performance, (4) the analysis of cognitive disturbances in cases of brain pathology in different cultural and educational contexts, (5) the search for commonality in neuropsychological performance among existing human groups, and (6) the analysis of the origins of cognitive activity.

Averbia as a selective naming disorder: a single case report

After a moderate head injury a 33-year-old woman presented a selective defect in finding verbs and name actions. Objects, colors, body parts, and qualities were named in a normal way. No other associated aphasic defects were observed. It was proposed that the selection and use of verbs in their correct forms implies two different aspects, which eventually can become dissociated: (1) the ability to retrieve the lexical item (the action name); and (2) the ability to use the correct affixation, that is, to select the morphological form according to the current context. Only the second would be associated with agrammatism. Defects in the first aspect (selection of the lexical item) would represent a particular form of anomia, a category-specific anomia, or anomia for verbs (averbia). Our patient illustrated this particular type of category-specific naming disorder.

Luria's approach to neuropsychological assessment

A. R. Luria's approach to neuropsychological assessment was examined. Three basic points of departure from Luria are presented: his interpretation of cognitive activity as functional systems, his emphasis on the individualized approach, and the importance of the analysis of the errors. A distinction was introduced between Luria's neuropsychological testing, and Luria's neuropsychological approach; the former refers to the specific set of neuropsychological tests Luria used and developed and the latter, to the specific clinical use of these tests. It is emphasized that Luria's basic contribution to assessment in neuropsychology, refers to the clinical approach he proposed and developed. Problems related to the normalization and validity of neuropsychological tests are analyzed. It is concluded that different approaches in neuropsychological assessment are related to the specific goals for which neuropsychological assessment is performed.