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

A phase I trial of accelerated intermittent theta burst rTMS for amnestic MCI

BACKGROUND

Emerging evidence suggests that repetitive transcranial magnetic stimulation (rTMS) enhances cognition in mild cognitive impairment (MCI). Accelerated intermittent theta burst stimulation (iTBS) rTMS protocols are promising as they substantially reduce burden by shortening the treatment course, but the safety, feasibility, and acceptability of iTBS have not been established in MCI.

METHODS

24 older adults with amnestic MCI (aMCI) due to possible Alzheimer's disease enrolled in a phase I trial of open-label accelerated iTBS to the left dorsolateral prefrontal cortex (8 stimulation sessions of 600 pulses of iTBS/day for 3 days). Participants rated common side effects during and after each session and retrospectively (at post-treatment and 4-week follow-up). They completed brain MRI (for safety assessments and electric field modeling), neuropsychiatric evaluations, and neuropsychological testing before and after treatment; a subset of measures was administered at follow-up.

RESULTS

Retention was high (95%) and there were no adverse neuroradiological, neuropsychiatric, or neurocognitive effects of treatment. Participants reported high acceptability, minimal side effects, and low desire to quit despite some rating the treatment as tiring. Electric field modeling data suggest that all participants received safe and therapeutic cortical stimulation intensities. We observed a significant, large effect size (d=0.98) improvement in fluid cognition using the NIH Toolbox Cognition Battery from pre-treatment to post-treatment.

CONCLUSIONS

Our findings support the safety, feasibility, and acceptability of accelerated iTBS in aMCI. In addition, we provide evidence of target engagement in the form of improved cognition following treatment. These promising results directly inform future trials aimed at optimizing treatment parameters.

TRIAL REGISTRATION NUMBER

NCT04503096.

Robust reference group normative data for neuropsychological tests accounting for primary language use in Asian American older adults

OBJECTIVE

The present study aimed to develop neuropsychological norms for older Asian Americans with English as a primary or secondary language, using data from the National Alzheimer's Coordinating Center (NACC).

METHOD

A normative sample of Asian American participants was derived from the NACC database using robust criteria: participants were cognitively unimpaired at baseline (i.e., no MCI or dementia) and remained cognitively unimpaired at 1-year follow-up. Clinical and demographic characteristics were compared between Primary and Secondary English speakers using analyses of variance for continuous measures and chi-square tests for categorical variables. Linear regression models compared neuropsychological performance between the groups, adjusting for demographics (age, sex, and education). Regression models were developed for clinical application to compute demographically adjusted z-scores.

RESULTS

Secondary English speakers were younger than Primary English speakers (p < .001). There were significant differences between the groups on measures of mental status (Mini-Mental State Examination, p = .002), attention (Trail Making Test A, Digit Span Forward Total Score, p <.001), language (Boston Naming Test, Animal Fluency, Vegetable Fluency, p < .001), and executive function (Trail Making Test B, p = .02).

CONCLUSIONS

Separate normative data are needed for Primary vs. Secondary English speakers from Asian American backgrounds. We provide normative data on older Asian Americans to enable clinicians to account for English use in the interpretation of neuropsychological assessment scores.

Methodology for the generation of normative data for the U.S. adult Spanish-speaking population: A Bayesian approach

BACKGROUND

Hispanics are the largest growing ethnic minority group in the U.S. Despite significant progress in providing norms for this population, updated normative data are essential.

OBJECTIVE

To present the methodology for a study generating normative neuropsychological test data for Spanish-speaking adults living in the U.S. using Bayesian inference as a novel approach.

METHODS

The sample consisted of 253 healthy adults from eight U.S. regions, with individuals originating from a diverse array of Latin American countries. To participate, individuals must have met the following criteria: were between 18 and 80 years of age, had lived in the U.S. for at least 1 year, self-identified Spanish as their dominant language, had at least one year of formal education, were able to read and write in Spanish at the time of evaluation, scored≥23 on the Mini-Mental State Examination, <10 on the Patient Health Questionnaire- 9, and <10 on the Generalized Anxiety Disorder scale. Participants completed 12 neuropsychological tests. Reliability statistics and norms were calculated for all tests.

CONCLUSION

This is the first normative study for Spanish-speaking adults in the U.S. that uses Bayesian linear or generalized linear regression models for generating norms in neuropsychology, implementing sociocultural measures as possible covariates.

The Auditory Consonant Trigram (ACT) Test: A norm updating study for university students

The Auditory Consonant Trigram (ACT) Test is accepted as a pure measurement of verbal working memory, but its norm study and psychometric properties have not been sufficiently researched. This study aims to update the norm data of the ACT, validity and reliability studies of which have been previously conducted on an adult Turkish sample, on a broader young sample and in a way that would end some methodological limitations. For this purpose, the data is collected from 304 voluntary healthy young adults (aged 18-26, 152 females-152 males). According to the results, a difference is found among all delay intervals. While the test scores decrease in females as delay interval increases, there is no difference in males between the delay intervals of 9 and 18 sec. While there is no difference between the genders for very short delay intervals (0-3 sec), males show a more successful performance than females as the delay interval increases (9-18 sec). Males are also more successful than females in terms of total test scores of the ACT. In this respect, it is concluded that the ACT measurement of working memory with a total score reliability coefficient of 0.75 is reliable.

Mild Cognitive Impairment Subtype Performance in Comparison to Healthy Older Controls on the NIH Toolbox and Cogstate

BACKGROUND

Early detection is necessary for the treatment of dementia. Computerized testing has become more widely used in clinical trials; however, it is unclear how sensitive these measures are to early signs of neurodegeneration. We investigated the use of the NIH Toolbox-Cognition (NIHTB-CB) and Cogstate-Brief computerized neuropsychological batteries in the identification of mild cognitive impairment (MCI) versus healthy older adults [healthy control (HC)] and amnestic (aMCI) versus nonamnestic MCI (naMCI). Exploratory analyses include investigating potential racial differences.

METHODS

Two hundred six older adults were diagnosed as aMCI (n = 58), naMCI (n = 15), or cognitively healthy (HC; n = 133).

RESULTS

The NIH Toolbox-CB subtests of Flanker, Picture Sequence Memory, and Picture Vocabulary significantly differentiated MCI from HC. Further, subtests from both computerized batteries differentiated patients with aMCI from those with naMCI. Although the main effect of race differences was noted on tests and in diagnostic groups was significant, there were no significant race-by-test interactions.

CONCLUSIONS

Computer-based subtests vary in their ability to help distinguish MCI subtypes, though these tests provide less expensive and easier-to-administer clinical screeners to help identify patients early who may qualify for more comprehensive evaluations. Further work is needed, however, to refine computerized tests to achieve better precision in distinguishing impairment subtypes.

Normative Data for the Judgment of Line Orientation Test (Long and Short Forms) in the Quebec-French Population Aged between 50 and 89 Years

The Judgment of Line Orientation (JLO) Test of Benton assesses visuospatial processing without requiring motor skills. The test is frequently used in geriatric or brain-injured populations. As with other cognitive tests, performance on the JLO test may vary according to age, level of education, sex, and cultural background of individuals. The present study aimed to establish normative data for a short (15 items) and a long (30 items) form of the JLO. The sample for the short and long forms comprised 198 and 260 individuals, respectively, aged 50-89 years. All participants were French-speaking people from the province of Quebec, Canada. Using regression-based norming, the effects of age, years of formal education, and sex on JLO performance were estimated. The normative adjustment of the JLO short and long forms considered the weight of each predictor on test performance. Results indicated that JLO performance was positively associated with years of formal education and male sex, whereas it was negatively associated with age. Accordingly, normative data were generated using Z-scores and adjusted scaled scores derived from the regression equations. To conclude, the present norms will ease the detection of visuospatial impairment in French-Quebec middle-aged and older adults.

Association of Obesity With Cognitive Decline in Black and White Americans

BACKGROUND AND OBJECTIVES

There are disparities in the prevalence of obesity by race, and the relationship between obesity and cognitive decline is unclear. The objective of this study was to determine whether obesity is independently associated with cognitive decline and whether the association between obesity and cognitive decline differs in Black and White adults. We hypothesized that obesity is associated with greater cognitive decline compared with normal weight and that the effect of obesity on cognitive decline is more pronounced in Black adults compared with their White counterparts.

METHODS

We pooled data from 28,867 participants free of stroke and dementia (mean, SD: age 61 [10.7] years at the first cognitive assessment, 55% female, 24% Black, and 29% obese) from 6 cohorts. The primary outcome was the annual change in global cognition. We performed linear mixed-effects models with and without time-varying cumulative mean systolic blood pressure (SBP) and fasting plasma glucose (FPG). Global cognition was set to a t-score metric (mean 50, SD 10) at a participant's first cognitive assessment; a 1-point difference represents a 0.1 SD difference in global cognition across the 6 cohorts. The median follow-up was 6.5 years (25th percentile, 75th percentile: 5.03, 20.15).

RESULTS

Obese participants had lower baseline global cognition than normal-weight participants (difference in intercepts, -0.36 [95% CI, -0.46 to -0.17]; p < 0.001). This difference in baseline global cognition was attenuated but was borderline significant after accounting for SBP and FPG (adjusted differences in intercepts, -0.19 [95% CI, -0.39 to 0.002]; p = 0.05). There was no difference in the rate of decline in global cognition between obese and normal-weight participants (difference in slope, 0.009 points/year [95% CI, -0.009 to 0.03]; p = 0.32). After accounting for SBP and FPG, obese participants had a slower decline in global cognition (adjusted difference in slope, 0.03 points/year slower [95% CI, 0.01 to 0.05]; p < 0.001). There was no evidence that race modified the association between body mass index and global cognitive decline (p = 0.34).

DISCUSSION

These results suggest that obesity is associated with lower initial cognitive scores and may potentially attenuate declines in cognition after accounting for BP and FPG.

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.

Cognitive impairment in racially/ethnically diverse older adults: Accounting for sources of diagnostic bias

INTRODUCTION

The Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study enrolled Asian, Black, Latino, and White adults ages 65+ without prior dementia diagnosis (N = 1709). We evaluated the prevalence of cognitive impairment (mild cognitive impairment or dementia) accounting for potential biases.

METHODS

A random subgroup (N = 541) received clinical evaluation and others were evaluated if they failed a cognitive screen. Diagnoses were made under two conditions: (1) demographics-blind, based on clinical exam and demographically adjusted neuropsychological test scores; and (2) all available information (clinical exam, demographics, and adjusted and unadjusted test scores).

RESULTS

Cognitive impairment prevalence was 28% for blinded-adjusted diagnosis and 25% using all available information. Black participants had higher impairment rates than White (both conditions) and Latino (blinded-adjusted diagnosis) participants. Incomplete assessments negatively biased prevalence estimates for White participants.

DISCUSSION

Racial/ethnic disparities in cognitive impairment were amplified by attrition bias in White participants but were unaffected by type of test norms and diagnosticians' knowledge of demographics.

Removing the noose item from the Boston naming test: A step toward antiracist neuropsychological assessment

Objective: The Boston Naming Test-Second Edition (BNT-2), the "gold-standard" assessment of confrontation naming used to diagnosis disorders such as dementia, includes aculturally insensitive item, the noose. Given calls to stop structural racism in psychology, this study examined changes in scores and performance classification if the noose item were omitted from the BNT-2. Methods: Participants were 291 Black, White, and Latinx adults who were administered the BNT-2 within a comprehensive neuropsychological evaluation. Ethnoracial differences in BNT-2 scores with and without the noose item and percentages of participants answering the noose item incorrectly were investigated. Results: Significant differences were found between ethnoracial groups in BNT-2 raw scores, T-scores, and percentage of participants incorrectly answering the noose item. Follow-up analyses revealed White participants obtained significantly higher raw scores and had significantly fewer participants answer the noose item incorrectly than Black and Latinx groups, who did not differ significantly. For T-scores, Black participants obtained significantly higher scores than White participants who obtained significantly higher scores than Latinx participants. Despite these differences, giving credit for the omitted noose item changed performance classification for only 10 participants (3.4%). Conclusions: Performance classification did not change significantly for the vast majority of a large ethnoculturally diverse sample when giving credit for the noose item as if it were not administered. Therefore, the non-noose BNT-2remains accurate while reducing cultural insensitivity towards Black populations, emphasizing a step in working towards anti-racism and fostering culturally-competent services within psychology.

Updated demographically adjusted norms for the Brief Visuospatial Memory Test-revised and Hopkins Verbal Learning Test-revised in Spanish-speakers from the U.S.-Mexico border region: The NP-NUMBRS project

OBJECTIVE

We generated demographically adjusted norms for the Brief Visuospatial Memory Test-revised (BVMT-R) and the Hopkins Verbal Learning Test-revised (HVLT-R) for Spanish-speakers from the U.S.-Mexico border region as part of a larger normative project. Methods: Healthy native Spanish-speakers (n = 203; Age: 19-60 years; Education: 0-20 years, 59% women) living in Arizona (n = 63) and California (n = 140) completed the BVMT-R and the HVLT-R as part of the larger Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project. Raw scores were converted to T-scores utilizing fractional polynomial equations, which considered linear and non-linear effects of demographic variables (age, education, sex). To demonstrate the benefit of employing our population-specific norms, we computed the proportion of our participants whose test performance fell below one standard deviation (T-score < 40) when applying published norms from non-Hispanic English-speakers, compared to the base rate derived from the new normative sample. Results: The resulting demographically adjusted T-scores showed the expected psychometric properties and corrected the misclassification in rates of impairment that were obtained when applying norms based on the English-speaking sample. Unexpectedly, participants in Arizona obtained slightly lower HVLT-R T-scores than those in California. This site effect was not explained by available sociodemographic or language factors. Supplementary formulas were computed adjusting for site in addition to demographics. Conclusions: These updated norms improve accuracy in identification of learning and memory impairment among Spanish-speaking adults living in the U.S.-Mexico border region. It will be important to generate additional data for elders, as the present norms are only applicable to adults age 60 and younger.

Expanded Demographic Norms for Version 3 of the Alzheimer Disease Centers' Neuropsychological Test Battery in the Uniform Data Set

BACKGROUND

Norms for the Uniform Data Set Version 3 Neuropsychological Battery are available for cognitively normal individuals based on age, education, and sex; however, these norms do not include race. We provide expanded norms for African Americans and whites.

METHODS

Data from 32 Alzheimer's Disease Centers (ADCs) and ADC affiliated cohorts with global Clinical Dementia Rating Scale (CDR) Dementia Staging Instrument scores of 0 were included. Descriptive statistics for each test were calculated by age, sex, race, and education. Multiple linear regressions were conducted to estimate the effect of each demographic variable; squared semipartial correlation coefficients measured the relative importance of variables.

RESULTS

There were 8313 participants (16% African American) with complete demographic information, ranging from 6600 to 7885 depending on the test. Lower scores were found for older and less educated groups, and African Americans versus whites. Education was the strongest predictor for most tests, followed in order by age, race, and sex. Quadratic terms were significant for age and education, indicating some nonlinearity, but did not substantially increase R.

CONCLUSIONS

Although race-based norms represent incomplete proxies for other sociocultural variables, the appropriate application of these norms is important given the potential to improve diagnostic accuracy and to reduce misclassification bias in cognitive disorders of aging such as Alzheimer disease.

Introduction to the Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) Project

OBJECTIVE

The present introduction to the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project aims to provide an overview of the conceptual framework and rationale that guided the development of this project.

METHODS

We describe important aspects of our conceptual framework, which was guided by some of the main purposes of neuropsychological testing, including the identification of underlying brain dysfunction, and the characterization of cognitive strengths and weakness relevant to everyday functioning. We also provide our rationale for focusing this norm development project on Spanish-speakers in the United States, and provide an outline of the articles included in this Special Issue focused on the NP-NUMBRS project.

CONCLUSIONS

The data presented in this Special Issue represent an important tool for clinicians and researchers working in the neuropsychological assessment of Spanish-speakers in the United States.

Group differences in normal neuropsychological test performance for older non-Hispanic White and Black/African American adults

OBJECTIVE

Although researchers have documented the influence of cultural factors on neuropsychological test performance, few studies have examined the distribution of test scores among neurologically healthy older adults from different ethnic groups. The objective of this study was to determine whether there are group differences in neuropsychological test score distributions with ethnicity-specific norms for non-Hispanic White and Black/African American older adults.

METHOD

Participants from the National Alzheimer's Coordinating Center were selected if they were not diagnosed with dementia within 5 years (Mage = 75.26, SDage = 6.98; Meducation = 15.70, SDeducation = 2.91). Groups were formed based on self-identified ethnicity of White (n = 5,311) or Black/African American (n = 1,098). All participants completed neuropsychological testing, including the Mini Mental State Exam, Logical Memory Immediate and Delayed, Digit Span Forward and Backward, Trail Making Test A & B, Animal Naming, Vegetable Naming, Digit Symbol, and Boston Naming Test.

RESULTS

Based on combined ethnicity norms, the scores of Black participants were overrepresented in the below-average and low-average clinical ranges, and the scores of White participants were overrepresented in the high-average and superior clinical ranges for all 11 neuropsychological measures. When group specific norms were used, the unbalanced pattern of score categorization was no longer present for any of the neuropsychological measures.

CONCLUSIONS

These findings emphasize the importance of developing and using ethnically and culturally appropriate neuropsychological test norms as well as the risk of interpreting some Black individual's scores as below average when they likely are not. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Psychometric Properties of the NIH Toolbox Cognition Battery in Healthy Older Adults: Reliability, Validity, and Agreement with Standard Neuropsychological Tests

OBJECTIVE

Few independent studies have examined the psychometric properties of the NIH Toolbox Cognition Battery (NIHTB-CB) in older adults, despite growing interest in its use for clinical purposes. In this paper we report the test-retest reliability and construct validity of the NIHTB-CB, as well as its agreement or concordance with traditional neuropsychological tests of the same construct to determine whether tests could be used interchangeably.

METHODS

Sixty-one cognitively healthy adults ages 60-80 completed "gold standard" (GS) neuropsychological tests, NIHTB-CB, and brain MRI. Test-retest reliability, convergent/discriminant validity, and agreement statistics were calculated using Pearson's correlations, concordance correlation coefficients (CCC), and root mean square deviations.

RESULTS

Test-retest reliability was acceptable (CCC = .73 Fluid; CCC = .85 Crystallized). The NIHTB-CB Fluid Composite correlated significantly with cerebral volumes (r's = |.35-.41|), and both composites correlated highly with their respective GS composites (r's = .58-.84), although this was more variable for individual tests. Absolute agreement was generally lower (CCC = .55 Fluid; CCC = .70 Crystallized) due to lower precision in fluid scores and systematic overestimation of crystallized composite scores on the NIHTB-CB.

CONCLUSIONS

These results support the reliability and validity of the NIHTB-CB in healthy older adults and suggest that the fluid composite tests are at least as sensitive as standard neuropsychological tests to medial temporal atrophy and ventricular expansion. However, the NIHTB-CB may generate different estimates of performance and should not be treated as interchangeable with established neuropsychological tests.

Benton judgment of line orientation test: Examination of four short forms

Objective: This multicenter retrospective study aimed at examining the clinical accuracy of four 15-item versions (Woodard's O and E; Quall's Q and S) of the original 30-item Benton judgment of line orientation test in a mixed clinical sample of 260 patients. It is a test frequently used as a measure of visuospatial processing. It has the advantage of requiring minimal motor skills, while a major weakness is the lengthy administration time.Method: An archival search was conducted within four in- and out-patient clinics. The frequency and magnitude of score differences were calculated to examine the equivalence of the short forms. We then checked the clinical accuracy of the short forms concerning classification of impaired, borderline, and non-impaired performance, according to NEURONORMA norms. After that, we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and kappa coefficients to assess the classification outcome of the short versions compared to the long version, when using a dichotomous classification (impaired versus intact performance).Results: When applying NEURONORMA norms, specificity (99.1%), PPV (93.1%), and kappa coefficient (0.87) were highest for version E. NPV (99.4%) and sensitivity (95.5%) were highest for version S, but the PPV of this version was relatively low (67.7%).Conclusions: We suggest use of version E when a short test is needed, as specificity, kappa coefficient, and PPV are highest for this version, while maintaining a high NPV (97.8%). However, future research should develop new normative data for these short 15-item versions.

Race modifies the relationship between cognition and Alzheimer's disease cerebrospinal fluid biomarkers

Background

African Americans have been reported to have a higher prevalence of Alzheimer’s disease (AD) than Caucasians, but etiology-specific AD biomarkers have not been systematically analyzed in older African Americans. Coexisting cerebrovascular disease may also contribute to this increased prevalence. We hypothesized that cerebrospinal fluid (CSF) biomarkers of amyloid, neurodegeneration, and endothelial dysfunction would differ between older African Americans and Caucasians with normal cognition and cognitive impairment associated with AD.

Methods

We prospectively recruited 135 older Americans to undergo detailed clinical, neuropsychological, genetic, magnetic resonance imaging (MRI), and CSF analysis from 2013 to 2015 at Emory University (Atlanta, GA, USA). We compared levels of CSF markers for β-amyloid (Aβ42, Aβ40), total and phosphorylated tau (t-tau and p-tau₁₈₁, respectively), endothelial dysfunction (soluble vascular cell adhesion molecule 1, soluble intercellular adhesion molecule 1), α-synuclein, and neurodegeneration (neurofilament light chain [NfL]), as well as MRI markers, for hippocampal atrophy and cerebrovascular disease (white matter hyperintensity [WMH] volume).

Results

Sixty-five older African Americans (average age, 69.1 years) and 70 older Caucasians (average age, 70.8 years) were included. After adjusting for demographic variables, AD risk alleles, and cognitive function, older African Americans had lower CSF levels of p-tau₁₈₁ (difference of 7.4 pg/ml; 95% CI, 3.7–11.2 pg/ml; p < 0.001), t-tau (difference of 23.6 pg/ml; 95% CI, 9.5–37.7; p = 0.001), and Aβ40 (difference of 1.35 ng/ml; 95% CI, 0.29–2.42 ng/ml; p = 0.013) despite similar levels of Aβ42, NfL, WMH volume, and hippocampal volume. Cognitively impaired African Americans also had lower CSF t-tau/Aβ42 (difference of 0.255 per 1-SD change in composite cognition; 95% CI, 0.100–0.409; p = 0.001) and p-tau₁₈₁/Aβ42 (difference of 0.076 per 1-SD change in composite cognition; 95% CI, 0.031–0.122; p = 0.001). These could not be explained by measured biomarkers of non-AD processes, but African Americans may be more susceptible than Caucasians to the cognitive effects of WMH.

Conclusions

Despite comparable levels of CSF Aβ42 and Aβ42/Aβ40, cognitive impairment in African Americans is associated with smaller changes in CSF tau markers but greater impact from similar WMH burden than Caucasians. Race-associated differences in CSF tau markers and ratios may lead to underdiagnosis of AD in African Americans.

Trial registration

ClinicalTrials.gov, NCT02089555. Retrospectively registered on 14 March 2014.

Neuropsychological Assessment: Past and Future

Neuropsychological assessment tools are the staple of our field. The development of standardized metrics sensitive to brain-behavior relationships has shaped the neuropsychological questions we can ask, our understanding of discrete brain functions, and has informed the detection and treatment of neurological disorders. We identify key turning points and innovations in neuropsychological assessment over the past 40-50 years that highlight how the tools used in common practice today came to be. Also selected for emphasis are several exciting lines of research and novel approaches that are underway to further probe and characterize brain functions to enhance diagnostic and treatment outcomes. We provide a brief historical review of different clinical neuropsychological assessment approaches (Lurian, Flexible and Fixed Batteries, Boston Process Approach) and critical developments that have influenced their interpretation (normative standards, cultural considerations, longitudinal change, common metric batteries, and translational assessment constructs). Lastly, we discuss growing trends in assessment including technological advances, efforts to integrate neuropsychology across disciplines (e.g., primary care), and changes in neuropsychological assessment infrastructure. Neuropsychological assessment has undergone massive growth in the past several decades. Nonetheless, there remain many unanswered questions and future challenges to better support measurement tools and translate assessment findings into meaningful recommendations and treatments. As technology and our understanding of brain function advance, efforts to support infrastructure for both traditional and novel assessment approaches and integration of complementary brain assessment tools from other disciplines will be integral to inform brain health treatments and promote the growth of our field. (JINS, 2017, 23, 778-790).

Problems in Classifying Mild Cognitive Impairment (MCI): One or Multiple Syndromes?

As the conceptual, methodological, and technological advances applied to dementias have evolved the construct of mild cognitive impairment (MCI), one problem encountered has been its classification into subtypes. Here, we aim to revise the concept of MCI and its subtypes, addressing the problems of classification not only from the psychometric point of view or by using alternative methods, such as latent class analysis, but also considering the absence of normative data. In addition to the well-known influence of certain factors on cognitive function, such as educational level and cultural traits, recent studies highlight the relevance of other factors that may significantly affect the genesis and evolution of MCI: subjective memory complaints, loneliness, social isolation, etc. The present work will contemplate the most relevant attempts to clarify the issue of MCI categorization and classification, combining our own data with that from recent studies which suggest the role of relevant psychosocial factors in MCI.

Culture as a variable in neuroscience and clinical neuropsychology: A comprehensive review

Culture is a dynamic system of bidirectional influences among individuals and their environment, including psychological and biological processes, which facilitate adaptation and social interaction. One of the main challenges in clinical neuropsychology involves cognitive, behavioral and functional assessment of people with different sociocultural backgrounds. In this review essay, examining culture from a historical perspective to ethical issues in cross-cultural research, including the latest significant and publications, the authors sought to explore the main features related to cultural variables in neuropsychological practice and to debate the challenges found regarding the operational methods currently in use. Literature findings suggest a more comprehensive approach in cognitive and behavioral neuroscience, including an interface between elementary disciplines and applied neuropsychology. Thus, as a basis for discussion on this issue, the authors analyzed key-topics related to the study of new trends in sociocultural neuroscience and the application of their concepts from a clinical perspective.

[Standardization of the Test Your Memory and evaluation of their concordance with the outcome of the psychometric examination]

OBJECTIVE

To explore the relationship between scores on the Test Your Memory (TYM) battery and findings from a more exhaustive neurocognitive assessment.

METHODS

The TYM and fourteen psychometric tests were administered to 84 subjects aged 50 or older who attended an outpatient neurology clinic due to cognitive symptoms. Each patient's cognitive state was determined independently from his/her score on the TYM (CDR 0, n=25; CDR 0.5, n=45; CDR 1, n=14). We analysed concurrent validity of TYM scores and results from the psychometric tests, as well as the degree of concordance between the two types of measurement, by contrasting normalised data from each instrument.

RESULTS

Although the intraclass correlation coefficient was 0.67 (confidence interval 95%, 0.53-0.77), analysis of the Bland-Altman plot and the curve on the survival-agreement plot (Luiz et al. method) demonstrates that the individual distances between the two methods exhibit excessive dispersion from a clinical viewpoint. TYM-based predictions of the mean z-score on psychometric tests differed substantially from real results in 30% of the subjects. Concordance of 95% can only be achieved by accepting absolute inter-instrument differences of up to 0.87 as identical values. Furthermore, the TYM underestimates cognitive performance for low values and overestimates it for high values.

CONCLUSIONS

The TYM is a cognitive screening test which should not be used to predict results on psychometric tests or to detect cognitive changes in clinical trials.

RBANS Norms based on the Relationship of Age, Gender, Education, and WRAT-3 Reading to Performance within an Older African American Sample

OBJECTIVE

Due to factors including differences in educational opportunity, African Americans and Caucasians frequently differ on cognitive tests creating diagnostic error risks. Such differences have been found on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and preliminary norms based on a small sample of African Americans have been generated. In a larger sample of community-dwelling older African Americans, we explored sources of variance including age, gender, common medical conditions, years of education, and reading level to generate norms stratified on the most relevant bases.

METHOD

Three hundred and fifty-five African Americans aged 55+ and living independently completed the RBANS and health, education, and psychosocial interviews.

RESULTS

Hypertension and type 2 diabetes were unrelated to overall RBANS performance once age and education were accounted for. Age, education, and WRAT-3 Reading score (a proxy for scholastic attainment) were independent predictors of RBANS performance. Females performed better on List Learning, Story Memory, Fluency, Coding, List Recall, and List Recognition; males were superior on Line Orientation and Picture Naming.

CONCLUSIONS

In addition to generating norms stratified by age, we provide descriptive statistics grouped by age and education, and by age and WRAT-3 Reading grade level, to provide clinicians with the opportunity to tailor their interpretation of scores based upon perceived best fit for their patient. Regression formulas are provided to address gender differences. To complement the standard index norms, we provide norms for alternative indexes representing additional an factor structure of cognitive domains.

Normative data for 8 neuropsychological tests in older blacks and whites from the atherosclerosis risk in communities (ARIC) study

Accurate assessment of cognitive impairment requires comparison of cognitive performance in individuals to performance in a comparable healthy normative population. Few prior studies have included a large number of black participants and few have excluded participants from the normative sample with subclinical/latent neurological disease or dementia. This study provides age, race, and education-specific normative data for 8 cognitive tests derived from 320 black and 392 white participants aged 61 to 82 years (mean 71 y) in the Atherosclerosis Risk in Communities (ARIC) study without clinical or subclinical/latent neurological disease. Normative data are provided for the Delayed Word Recall Test, Logical Memory Parts I and II, the Word Fluency Test, Animal Naming, the Trail Making Test Parts A and B and the Digit Symbol Substitution Test. Age, race, and education-specific mean and -1.5 SD scores are given in tabular form and graphically, as well as regression-based equations to derive adjusted score cut-points. These robust normative data should enhance comparison across studies of cognitive aging, where these measures are widely used, and improve interpretation of performance on these tests for the diagnosis of cognitive impairment not only within the ARIC cohort, but also among older blacks and whites with similar demographics.

Normative data for a Spanish version of the Rey auditory-verbal learning test in older people

The Rey Auditory-Verbal Learning Test is an easy to administer test that assesses many memory domains and is, therefore, widely used in the area of clinical neuropsychology. The purpose of this study was to provide normative data for an elderly population living in Spain. The sample of this study was comprised of 156 volunteers over 60 years of age, which were grouped into six different age groups. These groups comprised of 10 participants between the ages of 61 and 65 in the first group, 23 participants (66-70) in the second, 28 participants (71-75) in the third, 35 participants (76-80) in the fourth, 32 participants (81-85)in the fifth and 28 participants (86-95) in the sixth group. Demographic data were collected and means, deviations, and ranges of all the measures were evaluated. Normative data were calculated from the percentiles, and then converted into age-corrected scaled scores with a mean of 10 and a standard deviation of 3.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

DISCUSSION

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

Nonamnestic mild cognitive impairment progresses to dementia with Lewy bodies

OBJECTIVE

To determine the rate of progression of mild cognitive impairment (MCI) to dementia with Lewy bodies (DLB).

METHODS

We followed 337 patients with MCI in the Mayo Alzheimer's Disease Research Center (range 2-12 years). Competing risks survival models were used to examine the rates of progression to clinically probable DLB and Alzheimer disease (AD). A subset of patients underwent neuropathologic examination.

RESULTS

In this clinical cohort, 116 remained as MCI, while 49 progressed to probable DLB, 162 progressed to clinically probable AD, and 10 progressed to other dementias. Among nonamnestic MCI, progression rate to probable DLB was 20 events per 100 person-years and to probable AD was 1.6 per 100 person-years. Among amnestic MCI, progression rate to probable AD was 17 events per 100 person-years, and to DLB was 1.5 events per 100 person-years. In 88% of those who developed probable DLB, the baseline MCI diagnosis included attention and/or visuospatial deficits. Those who developed probable DLB were more likely to have baseline daytime sleepiness and subtle parkinsonism. In 99% of the clinically probable AD group, the baseline MCI diagnosis included memory impairment. Neuropathologic confirmation was obtained in 24 of 30 of those with clinically probable AD, and in 14 of 18 of those with clinically probable DLB.

CONCLUSION

In a clinical sample, patients with nonamnestic MCI were more likely to develop DLB, and those with amnestic MCI were more likely to develop probable AD.

Which neuropsychological tests predict progression to Alzheimer's disease in Hispanics?

OBJECTIVE

To investigate which neuropsychological tests predict eventual progression to Alzheimer's disease (AD) in both Hispanic and non-Hispanic individuals. Although our approach was exploratory, we predicted that tests that underestimate cognitive ability in healthy aging Hispanics might not be sensitive to future cognitive decline in this cultural group.

METHOD

We compared first-year data of 22 older adults (11 Hispanic) who were diagnosed as cognitively normal but eventually developed AD (decliners), to 60 age- and education-matched controls (27 Hispanic) who remained cognitively normal. To identify tests that may be culturally biased in our sample, we compared Hispanic with non-Hispanic controls on all tests and asked which tests were sensitive to future decline in each cultural group.

RESULTS

Compared to age-, education-, and gender-matched non-Hispanic controls, Hispanic controls obtained lower scores on tests of language, executive function, and some measures of global cognition. Consistent with our predictions, some tests identified non-Hispanic, but not Hispanic, decliners (vocabulary, semantic fluency). Contrary to our predictions, a number of tests on which Hispanics obtained lower scores than non-Hispanics nevertheless predicted eventual progression to AD in both cultural groups (e.g., Boston Naming Test [BNT], Trails A and B).

CONCLUSIONS

Cross-cultural variation in test sensitivity to decline may reflect greater resistance of medium difficulty items to decline and bilingual advantages that initially protect Hispanics against some aspects of cognitive decline commonly observed in non-Hispanics with preclinical AD. These findings highlight a need for further consideration of cross-cultural differences in neuropsychological test performance and development of culturally unbiased measures.

Neuropsychology of Alzheimer's disease

The expression of neurodegenerative diseases can be categorized into three main symptomatic domains: neurological, cognitive and, neuropsychiatric. This review focuses on the cognitive profile and neuropsychological assessment of Alzheimer's disease (AD). The topography and progression of brain neuropathology determines the cognitive expression of the disease. Thus, in accordance with the initial involvement of the medial temporal lobe, cognitive changes in AD start with specific difficulties in encoding and storage of new information. This particular memory deficit can be optimally detected with memory tests that enhance mnemonic retrieval by means of encoding specificity technique such as the Free and Cued Selective Reminding Test (FCSRT). Along the course of the disease, the neuropathology spreads to association cortices, and other neuropsychological deficits can be detected. A comprehensive neuropsychological examination encompassing several cognitive domains can provide a pattern of altered and preserved functions that is helpful to early detection, differential diagnosis and even prognosis of progression in predementia stages. The use of adapted and standardized instruments is necessary to properly estimate cognitive and functional performance in AD.

Characterizing healthy samples for studies of human cognitive aging

Characterizing the cognitive declines associated with aging, and differentiating them from the effects of disease in older adults, are important goals for human neuroscience researchers. This is also an issue of public health urgency in countries with rapidly aging populations. Progress toward understanding cognitive aging is complicated by numerous factors. Researchers interested in cognitive changes in healthy older adults need to consider these complexities when they design and interpret studies. This paper addresses important factors in study design, patient demographics, co-morbid and incipient medical conditions, and assessment instruments that will allow researchers to optimize the characterization of healthy participants and produce meaningful and generalizable research outcomes from studies of cognitive aging. Application of knowledge from well-designed studies should be useful in clinical settings to facilitate the earliest possible recognition of disease and guide appropriate interventions to best meet the needs of the affected individual and public health priorities.

Reliable change on the Boston naming test

Serial assessments are commonplace in neuropsychological practice and used to document cognitive trajectory for many clinical conditions. However, true change scores may be distorted by measurement error, repeated exposure to the assessment instrument, or person variables. The present study provides reliable change indices (RCI) for the Boston Naming Test, derived from a sample of 844 cognitively normal adults aged 56 years and older. All participants were retested between 9 and 24 months after their baseline exam. Results showed that a 4-point decline during a 9-15 month retest period or a 6-point decline during a 16-24 month retest period represents reliable change. These cutoff values were further characterized as a function of a person's age and family history of dementia. These findings may help clinicians and researchers to characterize with greater precision the temporal changes in confrontation naming ability.

Using monolingual neuropsychological test norms with bilingual Hispanic americans: application of an individual comparison standard

Conventional neuropsychological norms developed for monolinguals likely overestimate normal performance in bilinguals on language but not visual-perceptual format tests. This was studied by comparing neuropsychological false-positive rates using the 50th percentile of conventional norms and individual comparison standards (Picture Vocabulary or Matrix Reasoning scores) as estimates of preexisting neuropsychological skill level against the number expected from the normal distribution for a consecutive sample of 56 neurologically intact, bilingual, Hispanic Americans. Participants were tested in separate sessions in Spanish and English in the counterbalanced order on La Bateria Neuropsicologica and the original English language tests on which this battery was based. For language format measures, repeated-measures multivariate analysis of variance showed that individual estimates of preexisting skill level in English generated the mean number of false positives most approximate to that expected from the normal distribution, whereas the 50th percentile of conventional English language norms did the same for visual-perceptual format measures. When using conventional Spanish or English monolingual norms for language format neuropsychological measures with bilingual Hispanic Americans, individual estimates of preexisting skill level are recommended over the 50th percentile.

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

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

Influence of reading ability on neuropsychological performance in African American elders

Use of normative data stratified by education may result in misclassification of African American older adults because reading ability, an estimate of educational attainment, is lower than reported years of education for some African American elders. This study examined the contribution of reading ability versus education to neuropsychological test performance in 86 community-dwelling African American elders ages 56-91 with 8-18 years of education. Hierarchical multiple regression analyses revealed that reading ability, but not education, was significantly associated with performances on the Trail Making Test, Controlled Oral Word Association Test, Animal Naming, Digit Span, and the Stroop test. Reading ability was not significantly related to performances on measures of memory. Medium to large effect sizes (Cohen's d = 0.58-1.41) were found when comparing mean performances on neuropsychological measures in groups with low versus high reading scores. Results indicate that reading ability contributes beyond educational attainment to performances on some neuropsychological measures among African American elders. These findings have implications for reducing misclassification among minority populations through the use of appropriate normative data.

Mini-Mental State Exam performance of older African Americans: effect of age, gender, education, hypertension, diabetes, and the inclusion of serial 7s subtraction versus "world" backward on score

The Mini-Mental State Exam (MMSE) is a clinically ubiquitous yet incompletely standardized instrument. Though the test offers considerable examiner leeway, little data exist on the normative consequences of common administration variations. We sought to: (a) determine the effects of education, age, gender, health status, and a common administration variation (serial 7s subtraction vs. "world" spelled backward) on MMSE score within a minority sample, (b) provide normative data stratified on the most empirically relevant bases, and (c) briefly address item failure rates. African American citizens (N = 298) aged 55-87 living independently in the community were recruited by advertisement, community recruitment, and word of mouth. Total score with "world" spelled backward exceeded total score with serial 7s subtraction across all levels of education, replicating findings in Caucasian samples. Education is the primary source of variance on MMSE score, followed by age. In this cohort, women out-performed men when "world" spelled backward was included, but there was no gender effect when serial 7s subtraction was included in MMSE total score. To ensure an appropriate interpretation of MMSE scores, reports, whether clinical or in publications of research findings, should be explicit regarding the administration method. Stratified normative data are provided.

Spanish multicenter normative studies (Neuronorma project): norms for the abbreviated Barcelona Test

The abbreviated Barcelona Test (a-BT) is an instrument widely used in Spain and Latin American countries for general neuropsychological assessment. The purpose of the present study was to provide new norms for the a-BT as part of the Neuronorma project. The sample consisted of 346 healthy controls. Overlapping cell procedure and midpoint techniques were applied to develop the normative data. Age, education, and sex influences were studied. Results indicated that although age and education affected the score on this test, sex did not. Raw scores were transformed to age-adjusted scaled scores (SS(A)) based on percentile ranks. These SS(A) were also converted into age-education scaled scores using a linear regression model. Norms were presented on age-education scaled scores. Also, the a-BT cognitive profile was presented and should prove to be clinically useful for interpretation. These co-normed data will allow clinicians to compare scores from a-BT with all the tests included in the Neuronorma project.

Robust and expanded norms for the Dementia Rating Scale

The Dementia Rating Scale (DRS) is a widely used measure of global cognition, with age- and education-corrected norms derived from a cross-sectional sample of adults participating in Mayo's Older Americans Normative Studies (MOANS). In recent years, however, studies have indicated that cross-sectional normative samples of older adults represent an admixture of individuals who are indeed cognitively normal (i.e., disease-free) and individuals with incipient neurodegenerative disease. Theoretically, the "contamination" of cross-sectional normative samples with cases of preclinical dementia can lead to underestimation of the test mean and overestimation of the variance, thus reducing the clinical utility of the norms. Robust norming, in which dementia cases are removed from the normative cohort through longitudinal follow-up, is an alternative approach to norm development. The current study presents a reappraisal of the original MOANS DRS norms, provides robust and expanded norms based on a sample of 894 adults age 55 and over, and critically evaluates the benefits of robust norming.

Computerized cognitive assessment of mild cognitive impairment in urban African Americans

Few objective cognitive assessment tools have been validated for mild cognitive impairment (MCI) in African Americans despite higher prevalence of disease. This preliminary study evaluated discriminant validity of a computerized cognitive assessment battery for MCI in an urban African American cohort. Twenty-seven participants with MCI and 22 cognitively healthy individuals completed a multidomain battery (Mindstreams, NeuroTrax Corp, New Jersey). Mild cognitive impairment participants performed more poorly than cognitively healthy participants in all domains, with significant differences in memory (P = .003; d = 0.96), executive function (P = .046; d = 0.64), and overall battery performance (P = .041; d = 0.63). Adjustment for intelligence quotient (IQ) yielded significant differences in memory (P < .001; d = 1.34), executive function (P = .007; d = 0.86), attention (P = .014; d = .80), and overall performance (P = .001; d = 1.09). Such a validated battery may help to address an important clinical need in this population.

Differential item functioning of the Boston Naming Test in cognitively normal African American and Caucasian older adults

Scores on the Boston Naming Test (BNT) are frequently lower for African American when compared with Caucasian adults. Although demographically based norms can mitigate the impact of this discrepancy on the likelihood of erroneous diagnostic impressions, a growing consensus suggests that group norms do not sufficiently address or advance our understanding of the underlying psychometric and sociocultural factors that lead to between-group score discrepancies. Using item response theory and methods to detect differential item functioning (DIF), the current investigation moves beyond comparisons of the summed total score to examine whether the conditional probability of responding correctly to individual BNT items differs between African American and Caucasian adults. Participants included 670 adults age 52 and older who took part in Mayo's Older Americans and Older African Americans Normative Studies. Under a two-parameter logistic item response theory framework and after correction for the false discovery rate, 12 items where shown to demonstrate DIF. Of these 12 items, 6 ("dominoes," "escalator," "muzzle," "latch," "tripod," and "palette") were also identified in additional analyses using hierarchical logistic regression models and represent the strongest evidence for race/ethnicity-based DIF. These findings afford a finer characterization of the psychometric properties of the BNT and expand our understanding of between-group performance.

Race-norming of neuropsychological tests

Recent studies in the United States indicate that some neurologically intact minority groupings perform well below White Americans on neuropsychological tests. This has sparked the production of race-norms, especially for African Americans, that seek to reduce false positive rates (i.e., neurologically intact individuals misdiagnosed with cognitive impairment) in neuropsychological assessments. There are problems with this enterprise including: possible justification for inferior/superior treatment of different racial groupings; unknown effects on false negative rates (i.e., cognitive deficit misdiagnosed as normal); the overlooking of factors possibly responsible for group racial differences (e.g., acculturation); non-scientific and non-operational definitions of race/ethnic groupings; and an impossibly large number of potential race/ethnic groupings for which to generate race-norms. An alternative approach is to use a single set of combined race/ethnic norms and estimate preexisting neuropsychological skill levels by using individual comparison standards. This alternative has been poorly researched, a situation that needs correcting.

Review of normative data for common screening measures used to evaluate cognitive functioning in elderly individuals

When conducting neuropsychological evaluations of the elderly, it is important to compare patients' test scores to appropriate normative data to maximize diagnostic and descriptive accuracy. Many sets of normative data are now available for screening measures that assess cognitive functioning in the elderly. This article systematically reviewed available norms for 6 widely used screening measures of cognitive functioning in elderly patients. Details regarding the sample characteristics and data collection methods are provided for each set of norms, thereby providing a useful reference for clinicians.