Performance of Hispanics and Non-Hispanic Whites on the NIH Toolbox Cognition Battery: the roles of ethnicity and language backgrounds

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.

Normative data for executive function tests in an Ecuadorian Waranka minority population

Objective: To generate normative data (ND) for executive functions tests in the Waranka minority population of Ecuador. Method: Four-hundred participants aged 6-17 completed the Symbol-Digit Modalities Test (SDMT), Trail-Making Test (TMT), Modified-Wisconsin Card Sorting Test (M-WCST), and Test of Colors-Words (STROOP). Scores were normed using multiple linear regressions, including age, age2, natural logarithm of mean parent education (MPE), sex, bilingualism, and two-way interactions as predictors. Results: Age by MPE and Age2 by MPE interactions arose for SDMT, so that children with illiterate parents scored lower than those with literate parents. Girls scored higher in SDMT. All TMT and M-WCST scores were influenced by age2. Age by MPE interaction was found for TMT-A, so that children with higher MPE went faster; and age by bilingualism interaction for TMT-B, so that more bilingual children needed less time. Stroop-Word and Color were influenced by age2 by MPE interaction, so that children, while older, scored higher, especially those with higher MPE. Also, age2 by sex interaction arose, so that girls increased scores curvilinearly while boys linearly. Word-Color was influenced by age, while Stroop-interference by age2. Age by MPE interaction was found for MCST-Categories and Perseveration, so that perseverations decreased to then increased, especially in those with illiterate parents. M-WCST-Category scores increased to then decrease later on age in children with illiterate parents. Z-scores calculated through indigenous ND were significantly lower than generated through non-indigenous norms. Conclusions: ND for minority populations are critical since Waranka sample performed worse when using non-indigenous norms for z-score calculation.

Automated procedure for demographic adjustments on cognitive test scores

Performances of normal people on cognitive tests are known to vary by demographic characteristics, such as age, education, and sex. Thus, cognitive test scores should be corrected for demographic influences when they are used to detect below-expected results due to disease or injury involving the central nervous system (CNS). Normative corrections, if estimated from a large, diverse, and well-characterized cohort of controls, help to remove expected differences in cognitive performance associated with normal demographic characteristics and associated socio-economic disadvantages. In this paper, we (1) describe in detail the process of generating regression-based normative standards, and its advantages and limitations, (2) provide recommendations for applying these normative standards to data from individuals and populations at risk for CNS dysfunction, and (3) introduce an R package, test2norm, that contains functions for producing and applying normative formulas to generate demographically corrected scores for measuring deviations from expected, normal cognitive performances.

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.

Validity of the NIH toolbox cognitive battery in a healthy oldest-old 85+ sample

OBJECTIVE

To evaluate the construct validity of the NIH Toolbox Cognitive Battery (NIH TB-CB) in the healthy oldest-old (85+ years old).

METHOD

Our sample from the McKnight Brain Aging Registry consists of 179 individuals, 85 to 99 years of age, screened for memory, neurological, and psychiatric disorders. Using previous research methods on a sample of 85 + y/o adults, we conducted confirmatory factor analyses on models of NIH TB-CB and same domain standard neuropsychological measures. We hypothesized the five-factor model (Reading, Vocabulary, Memory, Working Memory, and Executive/Speed) would have the best fit, consistent with younger populations. We assessed confirmatory and discriminant validity. We also evaluated demographic and computer use predictors of NIH TB-CB composite scores.

RESULTS

Findings suggest the six-factor model (Vocabulary, Reading, Memory, Working Memory, Executive, and Speed) had a better fit than alternative models. NIH TB-CB tests had good convergent and discriminant validity, though tests in the executive functioning domain had high inter-correlations with other cognitive domains. Computer use was strongly associated with higher NIH TB-CB overall and fluid cognition composite scores.

CONCLUSION

The NIH TB-CB is a valid assessment for the oldest-old samples, with relatively weak validity in the domain of executive functioning. Computer use's impact on composite scores could be due to the executive demands of learning to use a tablet. Strong relationships of executive function with other cognitive domains could be due to cognitive dedifferentiation. Overall, the NIH TB-CB could be useful for testing cognition in the oldest-old and the impact of aging on cognition in older populations.

Incorporating Intersectionality in Neuropsychology: Moving the Discipline Forward

OBJECTIVE

Intersectionality is the interface between a person's identities in relation to social systems and institutional discrimination. The concept has generated much interest in psychology for understanding societal inequities and providing culturally informed services to minoritized patients but has yet to be incorporated in clinical neuropsychology. This omission is unfortunate as it is argued that appreciating the impact of institutional discrimination on minoritized groups can enhance our understanding of brain organization and functioning and bolster access to competent neuropsychological services to minoritized patients. The purpose of this article is to illustrate how intersectionality is germane to the discipline of clinical neuropsychology and to make recommendations for infusing it into the practice.

METHOD

Theories and findings in cultural neuroscience are summarized to provide a theoretical background for understanding how the environment can impact brain development and organization. The literature on disparities in education, economics, and health disparities between Whites and minoritized groups was reviewed for institutional biases that place minoritized groups at a disadvantage. These topics were selected due to their known impact on brain organization and cognition. This was followed by a similar review for access to competent neuropsychological assessments for minoritized patients.

RESULTS

There is a confluence of institutional discriminatory processes that contribute to disparities in education attainment, economic status, health disparities, and accessibility to culturally informed neuropsychological services. Perceived discrimination has significant health and cognitive ramifications.

CONCLUSIONS

Intersectionality is germane to appreciating brain functioning and providing competent services to minoritized patients. Recommendations were made to incorporate intersectionality in clinical neuropsychology.

Consideration of sex and gender in Alzheimer's disease and related disorders from a global perspective

Sex or gender differences in the risk of Alzheimer's disease and related dementias (ADRD) differ by world region, suggesting that there are potentially modifiable risk factors for intervention. However, few epidemiological or clinical ADRD studies examine sex differences; even fewer evaluate gender in the context of ADRD risk. The goals of this perspective are to: (1) provide definitions of gender, biologic sex, and sexual orientation. and the limitations of examining these as binary variables; (2) provide an overview of what is known with regard to sex and gender differences in the risk, prevention, and diagnosis of ADRD; and (3) discuss these sex and gender differences from a global, worldwide perspective. Identifying drivers of sex and gender differences in ADRD throughout the world is a first step in developing interventions unique to each geographical and sociocultural area to reduce these inequities and to ultimately reduce global ADRD risk. HIGHLIGHTS: The burden of dementia is unevenly distributed geographically and by sex and gender. Scientific advances in genetics and biomarkers challenge beliefs that sex is binary. Discrimination against women and sex and gender minority (SGM) populations contributes to cognitive decline. Sociocultural factors lead to gender inequities in Alzheimer's disease and related dementias (ADRD) worldwide.

Executive function measurement in urban schools: Exploring links between performance-based metrics and teacher ratings

When compared to research centered on the executive function development of white, middle-class children, relatively little is known about their non-white, low socioeconomic status peers. In an effort to harmonize how executive functions are measured within under-represented contexts, the present study addresses gaps in the evaluation of everyday executive functioning to better understand whether behavior rating scales completed by teachers (BASC2_EF - BASC executive function scale, 2nd edition; BASC3_EF - BASC executive function scale, 3rd edition) capture distinctions between performance-based measures. This study includes two large samples of older, ethnic minority children from high-poverty backgrounds (Sample 1. N = 243; M_age  = 9.28 years, SD_age  = 0.80; n_female  = 125; n_{AfricanAmerican}  = 216, n_{LatinAmerican}  = 15, n_{AsianAmerican}  = 6; Sample 2. N = 229; M_age  = 10.02 years, SD_age  = 1.01; n_female  = 120; n_{AfricanAmerican}  = 132, n_{LatinAmerican}  = 92, n_White  = 3, n_{PacificIslander}  = 1). Based on structural equation models testing the links between computerized performance-based measures and the teacher rating scales, the results indicate that BASC2_EF in its original form might be a good fit for some populations but there is not a strong factor structure for the current high-poverty samples. In addition, post-hoc analyses suggest that only including BASC2_EF items also in BASC3_EF or using BASC3_EF is best practice for high-poverty populations. BASC3_EF seems better able to capture different components of performance-driven tasks, whereas BASC2_EF captures overall executive functioning better than individual tasks. These findings encourage continued questioning surrounding metrics used to assess everyday executive functions in older children from diverse backgrounds. HIGHLIGHTS: This study explores whether teacher ratings of children's everyday executive functioning (using standardized behavior rating scales) capture distinctions between performance-based measures. Results indicate that BASC2_EF teacher rating scale (Karr & Garcia-Barrera, 2017) is not a good representation of everyday executive function behaviors by children from schools in high-poverty communities. The findings suggest that restricting BASC2_EF analyses to only items included in BASC3_EF (Reynolds & Kamphaus, 2015) or using BASC3_EF for high-poverty populations. BASC3_EF seems better able to capture the different components of performance-driven tasks, whereas BASC2_EF captures overall executive functioning better than individual tasks.

Associations Between Country where Education is Obtained and Cognitive Functioning Among South American and Caribbean Older Adults Living in the U.S

The increasing prevalence of AD among Hispanics calls for a need for examining factors that affect cognitive functioning and risk of AD among Hispanic older adults. The current study examined cognitive functioning among older Hispanic adults living in the U.S. from two Hispanic regions, South America and the Caribbean, in relation to the country where education was obtained. Participants (n = 139) were stratified into groups based on Hispanic education region and diagnostic categories: cognitively normal and amnestic MCI (aMCI). Results of Pearson correlations showed that among Hispanic Americans in general, there were significant positive correlations between the country of education to performance on measures of episodic, verbal, and word list tests. When examined separately by region and diagnosis, only cognitively normal (CN) South Americans showed significant relationships between country of education and cognitive functioning in these areas. Results of general linear models controlling for education identified differences in neuropsychological performance between groups with the CN groups demonstrating better performance than the aMCI groups within each region. Overall, it was evident that relationships between years of education obtained outside of the U.S. and cognitive functioning were not similar among individuals from these two disparate Spanish speaking regions. This is the first study to examine the country where education was obtained among individuals from countries located in different regions with different cultures that may influence their education and cognitive development throughout life. Findings contribute to the cross-cultural neuropsychological literature in understanding factors that are unique to Hispanic older adults at risk for developing AD.

Influence of Educational Background, Childhood Socioeconomic Environment, and Language Use on Cognition among Spanish-Speaking Latinos Living Near the US-Mexico Border

OBJECTIVES

We investigated the impact of culturally relevant social, educational, and language factors on cognitive test performance among Spanish speakers living near the US-Mexico border.

METHODS

Participants included 254 healthy native Spanish speakers from the Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) project (Age: M = 37.3, SD = 10.4; Education: M = 10.7, SD = 4.3; 59% Female). A comprehensive neuropsychological battery was administered in Spanish. Individual test scaled scores and T-scores (based on region-specific norms adjusted for age, education, and sex) were averaged to create Global Mean Scaled and T-scores. Measures of culturally relevant factors included a self-reported indicator of educational quality/access (proportion of education in Spanish-speaking country, quality of school/classroom setting, stopped attending school to work), childhood socioeconomic environment (parental education, proportion of time living in Spanish-speaking country, childhood socioeconomic and health status, access to basic resources, work as a child), and Spanish/English language use and fluency.

RESULTS

Several culturally relevant variables were significantly associated with unadjusted Global Scaled Scores in univariable analyses. When using demographically adjusted T-scores, fewer culturally relevant characteristics were significant. In multivariable analyses, being bilingual (p = .04) and working as a child for one's own benefit compared to not working as a child (p = .006) were significantly associated with higher Global Mean T-score, accounting for 9% of variance.

CONCLUSIONS

Demographically adjusted normative data provide a useful tool for the identification of brain dysfunction, as these account for much of the variance of sociocultural factors on cognitive test performance. Yet, certain culturally relevant variables still contributed to cognitive test performance above and beyond basic demographics, warranting further investigation.

Wisconsin Card Sorting Task-64 performance among HIV+ Black/African American and Latinx adults compared to normative samples and by sociocultural and health variables

Many people living with HIV experience cognitive impairment, and HIV disproportionately affects racial/ethnic minority groups. Independent of HIV, racial/ethnic minority individuals perform worse than White individuals on cognitive tasks, even after accounting for education. Our goals were to (1) compare WCST-64 scores between HIV+ Black/African American (Black/AA) (n = 45) and Latinx (n = 41) urban-dwelling adults; (2) compare our total sample to the WCST-64 manual's normative (N) and clinical normative (CN) groups; and (3) explore relationships between WCST-64 performance and sociocultural/health variables. In our sample, employment (12%), mean annual income (<$10,000), and mean education (<12 years) were low, while mean medication adherence rates were high for both Black/AA (90%) and Latinx (87%). WCST-64 scores were similar between groups (p > .05). Percentages of "below average" and "mildly impaired" scores in our sample were higher than the N group, and similar to the CN group. Lifetime heroin use, dementia, and longer HIV illness duration were significantly associated with worse WCST-64 performance (ps < .05). The observed low scores in our asymptomatic sample are likely due to the intersectionality of sociocultural and medical burden, highlighting complexities in interpreting neuropsychological data in real-world HIV+ clinics. Executive deficits are linked to poorer outcomes, and routine cognitive screening may be clinically indicated.

Validation of At-Home Application of a Digital Cognitive Screener for Older Adults

Standardized neuropsychological assessments of older adults are important for both clinical diagnosis and biobehavioral research. Over decades, in-person testing has been the basis for population normative values that rank cognitive performance by demographic status. Most recently, digital tools have enabled remote data collection for cognitive measures, which offers the significant promise to extend the basis for normative values to be more inclusive of a larger cross section of the older population. We developed a Remote Characterization Module (RCM), using a speech-to-text interface, as a novel digital tool to administer an at-home, 25-min cognitive screener that mimics eight standardized neuropsychological measures. Forty cognitively healthy participants were recruited from a longitudinal aging research cohort, and they performed the same measures of memory, attention, verbal fluency and set-shifting in both in-clinic paper-and-pencil (PAP) and at-home RCM versions. The results showed small differences, if any, for how participants performed on in-person and remote versions in five of eight tasks. Critically, robust correlations between their PAP and RCM scores across participants support the finding that remote, digital testing can provide a reliable assessment tool for rapid and remote screening of healthy older adults’ cognitive performance in several key domains. The implications for digital cognitive screeners are discussed.

Algorithms for Operationalizing Mild Cognitive Impairment Using the Spanish-Language NIH Toolbox Cognition Battery

OBJECTIVE

Neuropsychologists would benefit from flexible methods for operationalizing psychometric cognitive impairment in Spanish-speaking examinees that vary in association with intelligence, education, and sociocultural characteristics. The current study combined low and high score base rates (BRs) for the Spanish-language NIH Toolbox Cognition Battery (NIHTB-CB) to identify score combinations that are uncommon within different stratifications of the normative sample and may indicate cognitive impairment.

METHOD

The Spanish-language NIHTB-CB normative sample included 250 healthy Latinx adults with complete data on two crystallized and five fluid cognitive tests (M = 38.8 ± 13.7 years old, 72.0% women). Test performances were converted into age-adjusted and demographically adjusted normed scores, adjusting for age, gender, and education. The frequencies at which participants obtained one or more low scores or few to no high scores on fluid cognitive tests were combined into algorithms that occurred at BRs approximately 1 SD (~16%) or 1.5 SDs (~7%) below the mean.

RESULTS

Algorithms are provided for age-adjusted and demographically adjusted scores, with BRs stratified by crystallized ability, education, and sociocultural characteristics. Using demographically adjusted norms, the BR of obtaining any one of the following, 5 scores <50th, 4+ scores ≤25th, 3+ scores ≤16th, or 2+ scores ≤9th percentile, approximates 1 SD below the mean in participants born (BR = 16.2%) or educated abroad (BR = 18.6%), who are monolingual Spanish speakers (BR = 16.4%) or who reside in low-income households (BR = 13.6%).

CONCLUSIONS

These algorithms offer a flexible approach to operationalizing psychometric cognitive impairment, through which different definitions can be applied to different examinees based on varying crystallized ability, education, and sociocultural characteristics.

A cultural approach to dementia - insights from US Latino and other minoritized groups

Alzheimer disease and related dementias present considerable challenges to health-care and medical systems worldwide. In the USA, older Black and Latino individuals are more likely than older white individuals to have Alzheimer disease and related dementias. In this Perspective, we leverage our experience and expertise with older US Latino groups to review and discuss the need to integrate cultural factors into dementia research and care. We examine the importance of considering the effects of cultural factors on clinical presentation and diagnosis, dementia risk, clinical research and recruitment, and caregiving practices, with a focus on minoritized groups in the USA. We highlight critical gaps in the literature to stimulate future research aimed at improving the prevention and early detection of Alzheimer disease and related dementias and developing novel treatments and interventions across ethnoracially diverse populations. In addition, we briefly discuss some of our own initiatives to promote research and clinical care among Latino populations living in the USA.

Assessing Cognitive Decline in High-Functioning Spanish-Speaking Patients: High Score Base Rates on the Spanish-Language NIH Toolbox Cognition Battery

OBJECTIVE

Prior research has focused on the normal frequency of obtaining low scores on a neuropsychological test battery, but few studies have examined the normal frequency of obtaining high scores. This study involved the preparation of high score multivariate base rates for the Spanish-language National Institutes of Health (NIH) Toolbox Cognition Battery (NIHTB-CB).

METHOD

Participants included 250 healthy Latinx adults (age range: 19-80) from the Spanish-language NIHTB-CB normative sample who completed the full battery (two crystallized and four fluid cognition tests). Multivariate base rates, stratified by education, crystallized ability, and sociocultural characteristics, quantified the frequency at which participants obtained one or more "high" fluid test scores (i.e., ≥50th, ≥63rd, ≥75th, ≥84th, ≥91st, ≥95th, and ≥ 98th percentile).

RESULTS

It was common for participants to obtain one or more high scores (i.e., 50.8% obtained one or more scores ≥84th percentile) and uncommon for participants to obtain "no" high scores, especially when using non-conventional thresholds for defining a high score (i.e., 10.8% obtained no scores ≥50th percentile). High scores were more commonly obtained by participants with greater education and higher crystallized ability, who were bilingual, born and educated within the United States, and from higher income households.

CONCLUSIONS

This study demonstrated that participants administered multiple neuropsychological tests commonly obtain high scores, and that the frequency of high scores varies by education, crystallized ability, and sociocultural characteristics. The absence of high scores may be indicative of cognitive impairment among examinees who are higher functioning, have greater education, and have specific sociocultural characteristics (e.g., bilingualism, higher socioeconomic status).

Associations of Family Distress, Family Income, and Acculturation on Pediatric Cognitive Performance Using the NIH Toolbox: Implications for Clinical and Research Settings

OBJECTIVE

There is a growing recognition that the use of conventional norms (e.g., age, sex, years of education, race) as proxies to capture a broad range of sociocultural variability on cognitive performance is suboptimal, limiting sample representativeness. The present study evaluated the incremental utility of family income, family conflict, and acculturation beyond the established associations of age, gender,maternal years of education, and race on cognitive performance.

METHOD

Hierarchical linear regressions evaluated the incremental utility of sociocultural factors on National Institutes of Health Toolbox in a nationally representative sample of pre-adolescent children (n = 11,878; Mage = 10.0 years; Adolescent Brain Cognitive Development Study). A regression-based norming procedure was implemented for significant models. Paired sample t-tests were used to compare original and newly created demographically corrected T-scores.

RESULTS

Nearly all regression models predicted performance on the NIH-TB subtests and composite scores (p < .005). Greater family income and lower family conflict predicted better performance, although the effect sizes were small by traditional standards. Acculturation scores did not explain additional variance in cognitive performance. Lastly, there were no significant differences between the original and newly created demographically corrected T-scores (Mdiff < 0.50).

CONCLUSIONS

The present study highlights that, although family income, family conflict, and acculturation have been shown to routinely influence cognitive performance in preadolescent children, the NIH-TB appears to be highly robust to individual differences in sociocultural factors in children between ages 9 and 10. Contextual and temporal implications of the present results are discussed.

A Multivariate Interpretation of the Spanish-Language NIH Toolbox Cognition Battery: The Normal Frequency of Low Scores

OBJECTIVE

The current study involved the preparation of multivariate base rates for the Spanish-language NIH Toolbox Cognition Battery (NIHTB-CB) based on the U.S. normative sample, quantifying the normal frequency of low scores among healthy adults.

METHOD

Participants included 250 healthy Latinx adults (M = 38.8 ± 13.7 years old, range: 19-80; 72.0% women; education: M = 11.5 ± 3.9 years) who completed the full Spanish-language NIHTB-CB, including two tests of crystallized cognition and five tests of fluid cognition. Multivariate base rates quantified the frequency at which participants obtained 1 or more fluid scores ≤25th, ≤16th, ≤9th, ≤5th, and ≤2nd percentile, per age-adjusted or demographically adjusted (age, gender, education) normed scores.

RESULTS

A substantial minority of participants had 1 or more low scores (e.g., 40.4% had 1 or more age-adjusted score ≤16th percentile). The frequencies of low scores increased with fewer years of education and lower crystallized cognitive ability. Higher frequencies of low scores were observed among participants who were born and educated abroad, versus within the USA; monolingual Spanish speakers, versus bilingual Spanish/English speakers; and from households below the national median income, versus households above the national median.

CONCLUSION

Low scores were common and related to crystallized ability, education, and sociocultural variables. Although using demographically adjusted scores reduced group differences related to sociocultural variables, group differences were not eliminated, indicating that age, gender, and education score adjustments do not fully explain the associations between sociocultural variables and test performances. These stratified base rates may be useful when working with Spanish-speaking patients with diverse sociocultural characteristics.

Latent Factor Structure and Measurement Invariance of the NIH Toolbox Cognition Battery in an Alzheimer's Disease Research Sample

OBJECTIVE

This study investigated the latent factor structure of the NIH Toolbox Cognition Battery (NIHTB-CB) and its measurement invariance across clinical diagnosis and key demographic variables including sex, race/ethnicity, age, and education for a typical Alzheimer's disease (AD) research sample.

METHOD

The NIHTB-CB iPad English version, consisting of 7 tests, was administered to 411 participants aged 45-94 with clinical diagnosis of cognitively unimpaired, dementia, mild cognitive impairment (MCI), or impaired not MCI. The factor structure of the whole sample was first examined with exploratory factor analysis (EFA) and further refined using confirmatory factor analysis (CFA). Two groups were classified for each variable (diagnosis or demographic factors). The confirmed factor model was next tested for each group with CFA. If the factor structure was the same between the groups, measurement invariance was then tested using a hierarchical series of nested two-group CFA models.

RESULTS

A two-factor model capturing fluid cognition (executive function, processing speed, and memory) versus crystalized cognition (language) fit well for the whole sample and each group except for those with age < 65. This model generally had measurement invariance across sex, race/ethnicity, and education, and partial invariance across diagnosis. For individuals with age < 65, the language factor remained intact while the fluid cognition was separated into two factors: (1) executive function/processing speed and (2) memory.

CONCLUSIONS

The findings mostly supported the utility of the battery in AD research, yet revealed challenges in measuring memory for AD participants and longitudinal change in fluid cognition.

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.

Demographically-adjusted norms for the Grooved Pegboard and Finger Tapping tests in Spanish-speaking adults: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project

OBJECTIVE

We developed demographically-corrected norms for Spanish-speakers from the U.S.-Mexico border regions of California and Arizona on two tests of motor skills - the Grooved Pegboard Test (Pegboard) and Finger Tapping Test (Tapping) - as part of a larger normative effort.

METHOD

Participants were native Spanish-speakers from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project (Pegboard: N = 254; Tapping: N = 183; age: 19-60 years; education: 0-20 years; 59% women). We examined the association of demographics (age, education and gender) with raw scores. Raw test scores were then converted to demographically-corrected T-scores via fractional polynomial equations. We also examined rates of impairment (T-score < 40) based on the current norms and on previously published norms for English-speaking non-Hispanic Whites and Blacks.

RESULTS

Having more years of education was associated with better raw test score performance on both tests (p < .001), and increased age was associated with worse performance on Pegboard (p < .001). Men outperformed women on Tapping, and older age was associated with lower raw scores in men only on the Tapping non-dominant hand trial (p = .02). The normed T-scores were confirmed to be normally distributed and free from demographic influences, and resulted in expected rates of impairment. Applying existing norms for English-speaking non-Hispanic Whites and Blacks to the raw scores of Spanish-speakers generally yielded lower than expected impairment rates (2-13%), with one exception: non-dominant Pegboard, for which non-Hispanic White norms overestimated impairment (23%).

CONCLUSIONS

Present findings underscore the importance of appropriate, population-specific normative data, even for tests of motor ability.

Neurocognitive impairment in Spanish-speaking Latinos living with HIV in the US: Application of the neuropsychological norms for the US-Mexico border region in Spanish (NP-NUMBRS)

Objective Latinos in the US are at increased risk for HIV-associated neurocognitive impairment (NCI). Most studies of US Latinos living with HIV have included primarily English-speakers only. We investigated the rate, pattern, and correlates of HIV-associated NCI in native Spanish-speaking Latinos living in the US near the Mexican border. Methods Participants included 407 native Spanish-speaking Latinos (Age: M = 37.65, SD = 10.0; Education: M = 10.75, SD = 4.1; 53% male): 153 persons living with HIV (PLWH; 56% AIDS) and 254 healthy controls. All participants completed comprehensive neuropsychological assessments in Spanish. Raw neuropsychological test scores from seven domains were converted to demographically-adjusted T-scores using norms developed with healthy controls. Global and domain NCI were defined per established criteria. Among PLWH we applied norms developed for non-Hispanic (NH) Whites and Blacks, and investigated correlates of global NCI, including HIV disease characteristics and psychiatric comorbidities. Results Utilizing population specific norms, rates of global NCI were significantly higher among PLWH (39%) than healthy controls (17%), comparable to previously published rates. In contrast, rates of global NCI in the same group of PLWH were significantly different when NH White norms (63%, p < 0.0001) and NH Black norms were used (18%, p < 0.0001). Among PLWH without a history of lifetime substance use disorder, more years of antiretroviral exposure were significantly associated with decreased rates of global NCI. Conclusions Present findings lend support to the validity of newly developed norms for native Spanish-speakers living near the US-Mexico border, and underscore the importance of utilizing appropriate norms to accurately identify HIV-associated NCI.

Acculturation in Context: The Relationship Between Acculturation and Socioenvironmental Factors With Level of and Change in Cognition in Older Latinos

OBJECTIVES

Latinos are 1.5 times as likely to develop Alzheimer's dementia as non-Latino Whites. This health disparity may arise from multiple influences with culturally relevant factors receiving increasing attention. Models of acculturation stress the importance of considering acculturation-related factors within the context of socioenvironmental factors to better capture the Latino experience in the United States.

METHODS

We measured 10 acculturation and contextually-related variables in 199 Latinos (age 69.7 years) without dementia participating in Rush Alzheimer's Disease Center studies. We tested the relationship between these variables via Principal Component Analysis (PCA), then investigated how resulting components associated with level of and longitudinal change in global and domain-specific cognition using separate linear mixed-effects models adjusted for relevant confounders and their interactions with time.

RESULTS

The PCA revealed a 3-factor unrotated solution (variance explained ~70%). Factor 1, representing acculturation-related aspects of nativity, language- and social-based acculturation, was positively associated with level, but not change, in global cognition, semantic memory, and perceptual speed. Factor 2, representing contextually-related socioenvironmental experiences of discrimination, social isolation, and social networks, was negatively associated with level of global cognition, episodic and working memory, and faster longitudinal decline in visuospatial ability. Factor 3 (familism only) did not associate with level or change in any cognitive outcome.

DISCUSSION

Acculturation- and contextually-related factors differentiated from each other and differentially contributed to cognition and cognitive decline in older Latinos. Providers should query acculturation and lived experiences when evaluating cognition in older Latinos.

The NIH Toolbox: Overview of Development for Use with Hispanic Populations

OBJECTIVE

Hispanics/Latinos are the largest and fastest-growing minority population in the United States. To facilitate appropriate outcome assessment of this expanding population, the NIH Toolbox for Assessment of Neurological and Behavioral Function® (NIH Toolbox®) was developed with particular attention paid to the cultural and linguistic needs of English- and Spanish-speaking Hispanics/Latinos.

METHODS

A Cultural Working Group ensured that all included measures were appropriate for use with Hispanics/Latinos in both English and Spanish. In addition, a Spanish Language Working Group assessed all English-language NIH Toolbox measures for translatability.

RESULTS

Measures were translated following the Functional Assessment of Chronic Illness Therapy (FACIT) translation methodology for instances where language interpretation could impact scores, or a modified version thereof for more simplified translations. The Spanish versions of the NIH Toolbox Cognition Battery language measures (i.e., Picture Vocabulary Test, Oral Reading Recognition Test) were developed independently of their English counterparts.

CONCLUSIONS

The Spanish-language version of the NIH Toolbox provides a much-needed set of tools that can be selected as appropriate to complement existing protocols being conducted with the growing Hispanic/Latino population in the United States.

Origins Matter: Culture Impacts Cognitive Testing in Parkinson's Disease

Cognitive decline is common in Parkinson’s disease (PD), and precise cognitive assessment is important for diagnosis, prognosis, and treatment. To date, there are no studies in PD investigating cultural bias on neuropsychological tests. Clinical practice in multicultural societies such as, Toronto Canada where nearly half of the population is comprised of first generation immigrants, presents important challenges as most neuropsychological tools were developed in Anglosphere cultures (e.g., USA, UK) and normed in more homogeneous groups. We examine total scores and rates of deficits on tests of visuoperceptual/visuospatial, attention, memory, and executive functions in Canadians with PD born in Anglosphere countries (n = 248) vs. in Canadians with PD born in other regions (International group; n = 167). The International group shows lower scores and greater rates of deficits on all visuoperceptual and some executive function tasks, but not on attention or memory measures. These biases are not explained by demographic and clinical variables as groups were comparable. Age at immigration, years in Canada, and English proficiency also do not account for the observed biases. In contrast, group differences are strongly mediated by the Historical Index of Human Development of the participants’ country of birth, which reflects economic, health, and educational potential of a country at the time of birth. In sum, our findings demonstrate lasting biases on neuropsychological tests despite significant exposure to, and participation in, Canadian culture. These biases are most striking on visuoperceptual measures and non-verbal executive tasks which many clinicians still considered to be “culture-fair” despite the growing evidence from the field of cross-cultural neuropsychology to the contrary. Our findings also illustrate that socio-development context captures important aspects of culture that relate to cognition, and have important implications for clinical practice.

The structure of cognition in 9 and 10 year-old children and associations with problem behaviors: Findings from the ABCD study's baseline neurocognitive battery

The Adolescent Brain Cognitive Development (ABCD) study is poised to be the largest single-cohort long-term longitudinal study of neurodevelopment and child health in the United States. Baseline data on N= 4521 children aged 9-10 were released for public access on November 2, 2018. In this paper we performed principal component analyses of the neurocognitive assessments administered to the baseline sample. The neurocognitive battery included seven measures from the NIH Toolbox as well as five other tasks. We implemented a Bayesian Probabilistic Principal Components Analysis (BPPCA) model that incorporated nesting of subjects within families and within data collection sites. We extracted varimax-rotated component scores from a three-component model and associated these scores with parent-rated Child Behavior Checklist (CBCL) internalizing, externalizing, and stress reactivity. We found evidence for three broad components that encompass general cognitive ability, executive function, and learning/memory. These were significantly associated with CBCL scores in a differential manner but with small effect sizes. These findings set the stage for longitudinal analysis of neurocognitive and psychopathological data from the ABCD cohort as they age into the period of maximal adolescent risk-taking.

Generalizability of demographically corrected Zambian neuropsychological norms to South African women

Objective: Demographically corrected norms typically account for the effects of age, education, and in some cases, sex and other factors (e.g. race/ethnicity). However, generalizability of normative standards to different countries and ethnic groups is not universal. This study sought to determine whether demographically specific Zambian neuropsychological norms would generalize to a group of South African women.Method: 212 English-Xhosa bilingual, South African (SA) women were administered a comprehensive neuropsychological (NP) test battery in either English or Xhosa. We examined rates of "impairment" using Global Deficit Scores (GDS) based upon published, demographically corrected norms from a nearby African country (Zambia). Using multiple regression, we examined the extent to which Zambian norms "corrected" for the effects of age and education in this SA sample.Results: Compared to the normative standards from Zambia, the South African women performed somewhat worse than expected on a few test measures and better than expected on others, but their GDS and associated "impairment" rates were close to what was seen in Zambia. Demographically corrected Zambian norms adequately adjusted for the effects of age and years of education in this sample of SA women, with the exception that Zambian norms appeared to "under correct" for the positive effects of years of education on tests of information processing speed.Conclusions: Demographically corrected norms developed for Zambia may adequately adjust for the effects of age in SA women. Further research is needed to determine whether additional corrections for education are needed in SA, especially for tests of information processing speed.

Adolescent neurocognitive development and impacts of substance use: Overview of the adolescent brain cognitive development (ABCD) baseline neurocognition battery

Adolescence is characterized by numerous social, hormonal and physical changes, as well as a marked increase in risk-taking behaviors. Dual systems models attribute adolescent risk-taking to tensions between developing capacities for cognitive control and motivational strivings, which may peak at this time. A comprehensive understanding of neurocognitive development during the adolescent period is necessary to permit the distinction between premorbid vulnerabilities and consequences of behaviors such as substance use. Thus, the prospective assessment of cognitive development is fundamental to the aims of the newly launched Adolescent Brain and Cognitive Development (ABCD) Consortium. This paper details the rationale for ABC'lected measures of neurocognition, presents preliminary descriptive data on an initial sample of 2299 participants, and provides a context for how this large-scale project can inform our understanding of adolescent neurodevelopment.

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).