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

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.

Normative data for verbal fluency and naming tests in Spanish-speaking adults in the United States

BACKGROUND

Linguistic deficits are common across neurological and neurodegenerative disorders. Currently there are limited neuropsychological norms available for Spanish-speaking adults residing in the U.S.

OBJECTIVE

To generate norms for two verbal fluency tests and the Boston Naming Test (BNT) in a Spanish-speaking population in the U.S., with adjustments for demographic and cultural variables.

METHODS

The sample consisted of 245 adults from the U.S. Participants completed phonological and semantic verbal fluency tests and the BNT. A standardized two-step statistical procedure was used.

RESULTS

For the phoneme F, interactions between Spanish proficiency, age, and education arose. Better performance on phonemes A, S, and M was related to education. Spanish proficiency, acculturation, and time in the U.S. were associated with the phonemes S, A, P, M, and R. An age by education interaction was found for phonemes M and R. The FAS and PMR triads were related to age, sex, time in U.S., and Spanish proficiency. For the semantic verbal fluency tests, an interaction between education and Spanish proficiency arose. For the BNT, test scores were related to education, and significant interactions were also found based on education's interaction with Spanish proficiency and acculturation.

CONCLUSION

This study highlights the importance of accounting for sociodemographic and acculturative factors when developing normative data for verbal fluency tests and the BNT for dominant Spanish-speaking adults in the U.S. These sociodemographically-adjusted norms will help improve accuracy of diagnosis and interpretation of linguistic test performance in Spanish speakers living in the U.S.

Disparities in Metabolic Syndrome and Neurocognitive Function Among Older Hispanics/Latinos with Human Immunodeficiency Virus

Neurocognitive impairment and metabolic syndrome (MetS) are prevalent in persons with HIV (PWH). We examined disparities in HIV-associated neurocognitive function between Hispanic and non-Hispanic White older PWH, and the role of MetS in explaining these disparities. Participants included 116 community-dwelling PWH aged 50-75 years enrolled in a cohort study in southern California [58 Hispanic (53% Spanish speaking) and 58 age-comparable non-Hispanic White; overall group: age: M = 57.9, standard deviation (SD) = 5.7; education (years): M = 13, SD = 3.4; 83% male, 58% AIDS, 94% on antiretroviral therapy]. Global neurocognition was derived from T-scores adjusted for demographics (age, education, sex, ethnicity, language) on a battery of 10 cognitive tests. MetS was ascertained via standard criteria that considered central obesity, and fasting elevated triglycerides, low high-density lipoprotein cholesterol and elevated glucose, or medical treatment for these conditions. Covariates examined included sociodemographic, psychiatric, substance use and HIV disease characteristics. Compared with non-Hispanic Whites, Hispanics showed worse global neurocognitive function (Cohen's d = 0.56, p < 0.05) and had higher rates of MetS (38% vs. 56%, p < 0.05). A stepwise regression model including ethnicity and significant covariates showed Hispanic ethnicity was the sole significant predictor of worse global neurocognition (B = -3.82, SE = 1.27, p < 0.01). A model also including MetS showed that both Hispanic ethnicity (B = -3.39, SE = 1.31, p = 0.01) and MetS (B = -2.73, SE = 1.31, p = 0.04) were independently associated with worse neurocognition. In conclusion, findings indicate that increased MetS is associated with worse neurocognitive function in both Hispanic and non-Hispanic White older PWH, but does not explain neurocognitive disparities. MetS remains an important target for intervention efforts to ameliorate neurocognitive dysfunction among diverse older PWH.

Phonological fluency norms for Spanish middle-aged and older adults provided by the SCAND initiative (P, M, & R)

OBJECTIVE

Verbal fluency tests are quick and easy to administer neuropsychological measures and are regularly used in neuropsychological assessment. Additionally, phonological fluency is a widely used paradigm that is sensitive to cognitive impairment. This paper offers normative data of phonological verbal fluency (letters P, M, R) for Spanish middle- and older-aged adults, considering sociodemographic factors, and different measures such as the total number of words, errors (perseveration and intrusions), and 15 sec-segmented scores.

METHOD

A total of 1165 cognitively unimpaired participants aged between 50 and 89 years old, participated in the study. Data for P were obtained for all participants. Letters M and R were also administered to a subsample of participants (852) aged 60 to 89 years. In addition, errors and words produced every 15 seconds were collected in the subsample. To verify the effect of sociodemographic variables, linear regression was used. Adjustments were calculated for variables that explained at least 5% of the variance (R2 ≥ .05).

RESULTS

Means and standard deviations by age, scaled scores, and percentiles for all tests across different measures are shown. No determination coefficients equal to or greater than .05 were found for sex or age. The need to establish adjustments for the educational level was only found in some of the measures.

CONCLUSIONS

The current norms provide clinically useful data to evaluate Spanish-speaking natives from Spain aged from 50 to 89 years. Specific patterns of cognitive impairment can be analyzed using these normative data and may be important in neuropsychological assessment.

A Systematic Review of Normative Data for Verbal Fluency Test in Different Languages

Verbal fluency tests are easy and quick to use in neuropsychological assessments, so they have been counted among the most classical tools in this context. To date, several normative data for verbal fluency tests have been provided in different languages and countries. A systematic review was carried out with studies that provide normative data for verbal fluency tests. Studies were collected from Scopus, PubMed and Web of Science. 183 studies were retrieved from the database search, of which 73 finally met the inclusion criteria. An analysis of the risk of bias regarding samples selection/characterization and procedure/results reports is conducted for each article. Finally, a full description of the normative data characteristics, considering country and language, verbal fluency task characteristics (type of task) and sample characteristics (number of subjects, gender, age, education) is included. The current systematic review provides an overview and analysis of internationally published normative data that might help clinicians in their search for valid and useful norms on verbal fluency tasks, as well as updated information about qualitative aspects of the different options currently available.

Bilingual neurocognitive resiliency, vulnerability, and Alzheimer's disease biomarker correlates in Latino older adults enrolled in the Health and Aging Brain Study - Health Disparities (HABS-HD)

INTRODUCTION

The effects of bilingualism on neuropsychological test performance in bilinguals with and without cognitive impairment are not well-understood and are relatively limited by small sample sizes of Latinos.

METHODS

Using analysis of covariance (ANCOVA), we explored patterns of cognitive performance and impairment across a large sample of community-dwelling bilingual and monolingual Latino older adults with (n = 180) and without (n = 643) mild cognitive impairment (MCI) enrolled in HABS-HD.

RESULTS

Bilinguals demonstrated cognitive resiliency in the form of significantly better performance on the Trail Making Test and Digit Symbol Substitution Test, observed across the cognitively unimpaired and MCI groups. In contrast, bilinguals demonstrated cognitive vulnerability in the form of significantly poorer performance and higher impairment rates on phonemic fluency in the MCI phase, only. Follow-up analyses revealed less balanced bilinguals demonstrated poorer performance and higher impairment rates on this measure, supported by lower levels of plasma Aβ 42/40.

DISCUSSION

Patterns of cognitive performance and impairment differ as a function of bilingualism. Bilingualism must be considered when evaluating cognitive and biomarker outcomes in Latino older adults.

Highlights

Latino bilinguals perform better on measures of processing speed and coding.Latino bilinguals with MCI demonstrate cognitive vulnerability in verbal fluency.Less balanced bilinguals demonstrate greatest vulnerability anchored by Aβ 42/40.

Normative Data for Single-Letter Controlled Oral Word Association Test in Older White Australians and Americans, African-Americans, and Hispanic/Latinos

Background

The Controlled Oral Word Association Test (COWAT) is a commonly used measure of verbal fluency. While a normal decline in verbal fluency occurs in late adulthood, significant impairments may indicate brain injury or diseases such as Alzheimer's disease. Normative data is essential to identify when test performance falls below expected levels based on age, gender, and education level.

Objective

This study aimed to establish normative performance data on single-letter COWAT for older community-dwelling adults.

Methods

Over 19,000 healthy men and women, without a diagnosis of dementia or a Modified Mini-Mental State Examination score below 77/100, were recruited for the ASPREE trial. Neuropsychological assessments, including the COWAT with letter F, were administered at study entry.

Results

Median participant age was 75 years (range 65-98), with 56.5% being women. The majority of participants had 9-11 years of education in Australia and over 12 years in the U.S. The COWAT performance varied across ethno-racial groups and normative data were thus presented separately for 16,335 white Australians, 1,084 white Americans, 896 African-Americans, and 316 Hispanic/Latinos. Women generally outperformed men in the COWAT, except for Hispanic/Latinos. Higher education levels consistently correlated with better COWAT performance across all groups, while the negative association with age was weaker.

Conclusions

This study provides comprehensive normative data for the COWAT stratified by ethno-racial groups in Australia and the U.S., considering age, gender, and education level. These norms can serve as reference standards for screening cognitive impairments in older adults in both clinical and research settings.

Clinical Neuropsychological Profile and Quality of Life in Women Who Have Suffered Gender-Based Violence

Background

This research characterizes the clinical and neuropsychological profiles and the quality of life in a group of Ecuadorian women who suffered physical violence, psychological violence, or sexual violence, exploring their relationships with sociodemographic factors.

Methods

A battery of tests were used to explore the clinical and neuropsychological functions and quality of life in 120 participants who were selected from a population affected by violence.

Results

Sixty percent of the participants showed clinical anxiety, 26.7% clinical depression, 40% post-traumatic stress disorder symptoms, 15% moderate personality disorder, and 51.7% a low quality-of-life index. Their Z-scores in the neuropsychological domains evaluated were verbal memory (Rey Auditory Verbal Learning Test = -1.35), working memory (Digits = -1.67), attention (D2 = -1.24), processing speed (Coding = -1.33; Trail Making Test A = 1.81), and executive function (Trail Making Test B = -1.15; Stroop = -0.20; verbal-semantic fluency test = 0.05; verbal fluency test = -1.23).

Conclusions

The majority of women who suffered gender-based violence presented clinical levels of anxiety, depression, and post-traumatic symptoms. The cognitive functions with lower scores (Z < -1.5) were working memory and processing speed, mediated by education factor.

Concurrent validity and reliability of at-home teleneuropsychological evaluations among people with and without HIV

OBJECTIVE

To determine the reliability of teleneuropsychological (TNP) compared to in-person assessments (IPA) in people with HIV (PWH) and without HIV (HIV-).

METHODS

Participants included 80 PWH (Mage = 58.7, SDage = 11.0) and 23 HIV- (Mage = 61.9, SDage = 16.7). Participants completed two comprehensive neuropsychological IPA before one TNP during the COVID-19 pandemic (March-December 2020). The neuropsychological tests included: Hopkins Verbal Learning Test-Revised (HVLT-R Total and Delayed Recall), Controlled Oral Word Association Test (COWAT; FAS-English or PMR-Spanish), Animal Fluency, Action (Verb) Fluency, Wechsler Adult Intelligence Scale 3rd Edition (WAIS-III) Symbol Search and Letter Number Sequencing, Stroop Color and Word Test, Paced Auditory Serial Addition Test (Channel 1), and Boston Naming Test. Total raw scores and sub-scores were used in analyses. In the total sample and by HIV status, test-retest reliability and performance-level differences were evaluated between the two consecutive IPA (i.e., IPA1 and IPA2), and mean in-person scores (IPA-M), and TNP.

RESULTS

There were statistically significant test-retest correlations between IPA1 and IPA2 (r or ρ = .603-.883, ps < .001), and between IPA-M and TNP (r or ρ = .622-.958, ps < .001). In the total sample, significantly lower test-retest scores were found between IPA-M and TNP on the COWAT (PMR), Stroop Color and Word Test, WAIS-III Letter Number Sequencing, and HVLT-R Total Recall (ps < .05). Results were similar in PWH only.

CONCLUSIONS

This study demonstrates reliability of TNP in PWH and HIV-. TNP assessments are a promising way to improve access to traditional neuropsychological services and maintain ongoing clinical research studies during the COVID-19 pandemic.

Regression-Based Normative Data for Independent and Cognitively Active Spanish Older Adults: Verbal Fluency Tests and Boston Naming Test

An increased cognitive reserve is associated with changes in the pattern of cognitive decline during aging. Thus, normative data adapted to the characteristics of the target population are needed to reduce the possibility of false diagnoses. The aim of this work was to develop normative data for the Phonemic Verbal Fluency test, the Semantic Verbal Fluency test and the Boston Naming Test (BNT).

METHOD

Regression-based normative data were calculated from a sample of 118 non-depressed, cognitively active, independent community-dwelling adults aged 55 or older (64.4% women) from SABIEX (University for Seniors at the Universidad Miguel Hernández de Elche). Raw scores were regressed on age, sex, and education.

RESULTS

The effects of age and education varied across neuropsychological measures. No effect of sex was found in any of the tests assessed. Statistically significant differences were found in the proportion of low scores using SABIEX or population-based normative datasets. The level of agreement identifying individuals labeled as showing one or more low scores was only fair-to-good.

CONCLUSIONS

Normative data obtained from the general population might not be sensitive to identify low scores in cognitively active older adults, increasing the risk of misdiagnoses. A friendly calculator is available for neuropsychological assessment.

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.

Cognitive Health and Differential Cortical Functioning in Dissociative Trance: An Explorative Study About Mediumship

Aim

To evaluate the cognitive functioning of subjects practicing trance mediumship in Brazil.

Method

The study was based on the measurement of cognitive functions of 19 spirits mediums through neuropsychological tests such as the Brief Cognitive Screening Battery (BCSB), the Verbal Fluency Test (FAS), the digit span test, the cube test, the five digit test (FDT) and an evaluation of mental health through scales such as the Beck Depression Inventory (BDI), the Self-Report Questionnaire (SRQ), and the Trauma History Questionnaire (THQ). The sample included the participation of spirit mediums divided into two groups. The more experienced group (MEG) with 11 subjects had more than 10 years of mediumistic practice, while the other less experienced group (LEG) with 8 subjects had 1–5 years of experience. The inclusion criteria were psychophonic mediums (who have the ability to communication when deceased beings communicate directly via speaking) with regular trance practices for at least one year. The data collected were analyzed using the SPSS statistical package.

Results

Regarding performance on the BCSB and digit span test, all subjects reached scores at the median or higher in comparison to standardized scores of Brazilians. Scores of 90% on the cube test and 42% on the FAS were reached in comparison to median or higher values, versus the median of standardized scores among Brazilians. On the FDT, we found statistical significance (p = 0.038) in the choice stage, with higher performance of subjects whose initial age of trance recognition occurred before 21 years old. On the BDI scale, no participant met the criteria for major depression. The SRQ showed an incidence of common mental disorders in 21% of the sample, which was more prevalent in the LEG (p = 0.008).

Conclusion

The cognitive functioning of subjects who practice trance mediumship in Brazil is associated with cognitive health. Executive dysfunction may be a tendency in LEG. However, an incidence of common mental disorders in the LEG was observed. Executive processing was higher in the subgroup with early practices of recognizing the phenomenon.

A narrative review of the biopsychosocial and health characteristics of Asian Indians in the United States: Clinical and research implications for neuropsychological functioning

Objective: The prevailing scientific literature aggregates Asians living in America into one omnibus category and thus can problematically result in a subpar and at times inaccurate understanding of health, social and cultural factors necessary for competent and informed medical care. Method: A literature search was conducted by cultural experts familiar with Asian Indian culture with a focus on immigrants from this community living in the US. Database using search engines was sought in the following domains: immigration patterns, prevalence for key medical and neurological conditions commonly associated with cognitive dysfunction, psychiatric/psychological needs in the community, some preliminary neuropsychological testing considerations while working with this community, and treatment considerations that could affect adherence and efficacy of outcomes. Articles were selected from 2000 to the most recent date, with emphasis on compiling information from review papers and meta-analysis from the past decade. Conclusions: Asian Indians living in the US are distinct from the larger Asian American community. Immigration trends underscore that Asian Indians have a bimodal distribution of wealth. Regarding medical conditions, a key and highly concerning finding is the higher prevalence of cardiovascular risk factors, especially in young males. The lack of non-existent cognitive data in this community is glaring and should serve as an impetus for conducting high-priority research in this community. Preliminary neuropsychological testing considerations are discussed from a practical perspective with emphasis on multilingualism and region of origin. Finally, treatment considerations include understanding attitudes and beliefs regarding traditional medicine.

Regression-based, demographically adjusted norms for Victoria Stroop Test, Digit Span, and Verbal Fluency for Sri Lankan adults

OBJECTIVE

Lack of test norms is a major limitation in neuropsychological assessment in many non-English-speaking countries. Our objective was to generate sex-, age-, and education-adjusted, regression-based norms for three pen-and-paper-based executive function/working memory tests, viz. Victoria Stroop Test (VST), Digit Span, and Verbal Fluency, for Sinhala-Speaking Sri Lankan adults.

METHOD

Six-hundred and six healthy, community-living, Sinhala-speaking adults (273 men) aged 19-83 years completed VST, Digit Span (forward and backward), and Phonemic (Sinhala phonemes "N," "P," and "S") and Category (animals and vegetables) Fluency tests. We conducted multiple linear regression analyses with sex, age, and years of education fitted as predictors to model the test outcome variables.

RESULTS

Younger age was associated with better performance in all tests except in Phonemic Fluency. Longer education was associated with better performance in all outcomes except VST errors and interference. Women had a significant but small advantage over men in VST Neutral and Color Word tests, and Phonemic Fluency. We report regression equations to predict norms for the test performance measures based on sex, age, and years of education; and the test variances accounted by these factors.

CONCLUSIONS

We propose demographically adjusted norms for VST, Digit Span, and Verbal Fluency for Sinhala-speaking Sri Lankans aged 19-83 years, and supplement the regression formulae with a calculator that produces predicted and standard scores. These norms would help in interpreting the results of clinical samples in the future, taking into account the variability introduced by sex, age, and education.

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.

Characterization of HIV-Associated Neurocognitive Impairment in Middle-Aged and Older Persons With HIV in Lima, Peru

Background: With widespread use of antiretroviral medications, people living with HIV (PWH) are living longer worldwide, increasing their risk of developing neurocognitive impairment (NCI). The proportion of Peruvians over age 60 is expected to increase to 25% of the population by 2050, including PWH. Therefore, the problem of aging and NCI, especially in the setting of HIV infection, is uniquely pressing. We sought to study the rates of and risk factors associated with NCI among middle-aged and older PWH in Lima, Peru. Materials and Methods: Sociodemographic, medical (infectious and non-infectious), and psychiatric comorbidity and laboratory data were collected. We administered a brief neuropsychological battery evaluating seven cognitive domains affected in HIV-associated NCI and a depression screening. Cognitive test raw scores were converted to T-scores that were demographically adjusted. Descriptive statistics were performed together with regression (unadjusted and adjusted) analyses to determine potential risk factors for NCI among PWH. Results: This was a cross-sectional study in which 144 PWH aged ≥40 years attending a large HIV clinic in Lima, Peru, were recruited from September 2019 to March 2020. Mean age was 51.6 ± 7.7 years, and mean years of education were 14.0 ± 3.1 with 15% females. Median [interquartile range (IQR)] current CD4 and nadir CD4 were 554 (371, 723) and 179 (83, 291), respectively, and 10% currently had AIDS. The prevalence of NCI was 28.5%, and many demonstrated difficulty with attention and working memory (70%). One-quarter of PWH had mild depression or worse on Patient Health Questionnaire 9 (PHQ-9 ≥ 5). In bivariate analyses, neither a depression history nor a higher PHQ-9 score correlated with NCI. No other non-communicable medical or psychiatric comorbidity nor HIV characteristic was predictive of NCI. Having a positive lifetime history of hepatitis B infection, pulmonary tuberculosis, or syphilis increased risk of NCI (PR 1.72; 95% CI 1.04-2.86) in unadjusted analyses, but not in adjusted analyses. Conclusions: NCI among older Peruvians with HIV was found to be highly prevalent with levels consistent with prior reports of HIV-associated NCI worldwide. Common latent HIV-associated co-infections, including latent syphilis, hepatitis B infection, or pulmonary tuberculosis, may increase the risk of NCI among middle-aged and older PWH in Peru.

Demographically adjusted normative data for the Wisconsin Card Sorting Test-64 item: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project

OBJECTIVE

The Wisconsin Card Sorting Test (WCST) is among the most commonly used tests of executive functioning. We aimed to generate normative data on the 64-item version of this test (WCST-64) for Spanish-speakers living in the U.S.-Mexico Border region.

METHODS

Participants included 189 native Spanish-speakers (Age: 19-60; Education: 0-20; 59.3% female) from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project who completed the WCST-64. Univariable and interactive associations between demographic variables and raw scores were examined via Spearman correlations, Wilcoxon Rank-sum tests and linear regressions. T-scores for various WCST-64 measures (Total Errors, Perseverative Responses, Perseverative Errors, Conceptual Level Responses and Number of Categories) were obtained using fractional polynomial equations with weights for age, education, and gender. Percentile scores were reported for Failures to Maintain Set. Rates of impairment (T-score < 40) were calculated by applying the newly developed norms and published norms for non-Hispanic English-speaking Whites and Blacks.

RESULTS

Older age was associated with worse performance and education was linked to better performance on most WCST-64 raw scores, with stronger education effects among females than males. The norms developed here resulted in expected rates of impairment (14-16% across measures). Applying published norms for non-Hispanic Blacks resulted in generally comparable impairment rates. In contrast, applying previously published norms for non-Hispanic Whites overestimated impairment (38-52% across measures).

CONCLUSIONS

These data will enhance interpretation performance on the WCST-64 for Spanish-speakers living in the U.S.-Mexico Border region. Future work will need to examine the generalizability of these norms to other Hispanic/Latino groups.

The Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project: Overview and considerations for life span research and evidence-based practice

OBJECTIVE

This paper summarizes the findings of the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project and offers a roadmap for future research.

METHODS

The NP-NUMBRS project represents the largest and most comprehensive co-normed neuropsychological battery to date for native Spanish-speaking healthy adults from the U.S. (California/Arizona)-Mexico borderland region (N = 254; ages 19-60 years). These norms provide demographic adjustments for tests across numerous domains (i.e., verbal fluency, processing speed, attention/working memory, executive function, episodic memory [learning and delayed recall], visuospatial, and fine motor skills).

CONCLUSIONS

This project: 1) shows that the NP-NUMBRS norms consistently outperformed previously published norms for English-speaking non-Hispanic (White and African-American) adults in identifying impairment; 2) explores the role of Spanish-English bilingualism in test performance; and 3) provides support for the diagnostic validity of these norms in detecting HIV-associated neurocognitive impairment. Study limitations include the limited assessment of sociocultural variables and generalizability (e.g., other Latina/o populations, age limit [19 - 60 years]). Future research is needed to: 1) investigate these norms with U.S.-dwelling Spanish-speakers of non-Mexican heritage and other clinical subpopulations; 2) expand coverage of cognitive domains (e.g. language, visuospatial); 3) develop large normative datasets for children and older Latina/o populations; 4) examine how sociocultural factors impact performance (e.g., bilingualism, acculturation); 5) investigate these norms' diagnostic and ecological validity; and 6) develop norms for neurocognitive change across time. It is hoped that the NP-NUMBRS norms will aid researchers and clinicians working with U.S.-dwelling Spanish-speakers from the U.S.-Mexico borderland to conduct research and evidence-based neuropsychological evaluations in a more culturally responsive and ethical manner.

Demographically adjusted norms for the Trail Making Test in native Spanish speakers: Results from the neuropsychological norms for the US-Mexico border region in Spanish (NP-NUMBRS) project

OBJECTIVE

Despite the wide use of the Trail Making Test (TMT), there is a lack of normative data for Spanish speakers living in the USA. Here we describe the development of regional norms for the TMT for native Spanish speakers residing in the Southwest Mexico-Border Region of the USA.

METHOD

Participants were 252 healthy native Spanish speakers, 58% women, from ages 19 to 60, and ranging in education from 0 to 20 years, recruited in San Diego, CA and Tucson, AZ. All completed the TMT in Spanish along with a comprehensive neuropsychological test battery as part of their participation in the Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) project. Univariable and interactive effects of demographics on test performance were examined. T-scores were calculated using fractional polynomial equations to account for linear and any non-linear effects of age, education, and sex.

RESULTS

Older age and lower education were associated with worse scores on both TMT A and B. No sex differences were found. The newly derived T-scores showed no association with demographic variables and displayed the expected 16% rates of impairment using a -1 SD cut point based on a normal distribution. By comparison, published norms for English-speaking non-Hispanic Whites applied to the current data yielded significantly higher impairment for both TMT A and B with more comparable rates using non-Hispanic African Americans norms.

CONCLUSIONS

Population-specific, demographically adjusted regional norms improve the utility and diagnostic accuracy of the TMT for use with native Spanish speakers in the US-Mexico Border region.

Native Spanish-speaker's test performance and the effects of Spanish-English bilingualism: results from the neuropsychological norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project

Objective: We aimed to investigate whether or not demographically-corrected test scores derived from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) would be less accurate if applied to Spanish-speakers with various degrees of English fluency. Spanish-English Method: One hundred and seventy primarily Spanish-speaking adults from the NP-NUMBRS project completed a comprehensive neuropsychological test battery. T-scores adjusted for age, education, and sex (but not degree of bilingualism), were derived for each test utilizing population-specific normative data. English fluency was assessed via the Controlled Oral Word Association Test in English (F-A-S), and Spanish fluency with "P-M-R," and degree of relative English fluency was calculated as the ratio of English language words over total words produced in both languages. Effects of degree of bilingualism on the NUMBRS battery test scores (raw scores and T-scores) were examined via Pearson's product moment correlation coefficients, and language groups (Spanish dominant vs. relative bilingual) were compared on demographically adjusted T-scores via independent samples t-tests. Results: Higher Spanish-English bilingualism was associated with higher education and SES, and was significantly associated with higher raw scores on all tests, but only associated with higher T-scores on a limited number of tests (i.e., WAIS-III Digit Symbol, Symbol Search, Letter-Number Sequencing and Trails B). Conclusion: Degree of Spanish-English bilingualism generally did not account for significant variance in the normed tests beyond the standard demographic adjustments on most tests. Overall, the normative adjustments provided by the NP-NUMBRS project appear applicable to native Spanish speakers from the U.S.-Mexico border region with various degrees of Spanish-English bilingualism.

Demographically-adjusted norms for the paced auditory serial addition test and letter number sequencing test in Spanish-speaking adults: Results from the neuropsychological norms for the U.S.-Mexico border region in Spanish (NP-NUMBRS) Project

OBJECTIVE

The Paced Auditory Serial Addition Test (PASAT) and Wechsler Adult Intelligence Scale Letter Number Sequencing subtest (LNS) are two commonly used measures of working memory. Demographic variables (age, education, ethnicity, etc.) can impact performance on these measures, underscoring the need for demographically adjusted norms. We aimed to develop normative data for the PASAT and LNS for Spanish-speaking adults living in the U.S.-Mexico border region 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. Two hundred and forty-nine participants completed the PASAT and 202 participants completed LNS. Ages ranged from 19 to 60 and education from 0 to 20 years.

RESULTS

Older age was associated with lower scores on LNS (p < .01) but not PASAT. Lower education was associated with lower scores on both tests (ps < .001). Women obtained lower raw scores than men on PASAT (ps < .003), and there were no significant main effects of gender on LNS raw scores. Raw-to-scaled score conversions were calculated, and fractional polynomial equations were developed to calculate demographically-adjusted T-scores accounting for age, education, and gender. Published norms for English-speaking non-Hispanic Whites substantially overestimated rates of impairment (defined as T-score < 40) on both the PASAT and LNS.

CONCLUSIONS

The use of the population-specific normative data may improve detection of working memory dysfunction in U.S. Spanish-speaking adults and contribute to improved diagnostic accuracy and treatment planning in this population. Whether the norms generalize to U.S. Spanish-speakers from other countries remains to be determined.

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.

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.

Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project: Methodology and sample characteristics

OBJECTIVE

The present paper describes the methodology and sample characteristics of the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project, which aimed to generate demographically-adjusted norms for a battery of neuropsychological tests in this population.

METHODS

The sample consisted of 254 healthy Spanish-speakers, ages 19-60 years, recruited from the U.S.-Mexico border regions of Arizona (n = 102) and California (n = 152). Participants completed a comprehensive neuropsychological test battery assessing multiple domains (verbal fluency, speed of information processing, attention/working memory, executive function, learning and memory, visual-spatial skills and fine motor skills). Fluency in both Spanish and English was assessed with performance-based measures. Other culturally-relevant data on educational, social, and language background were obtained via self-report. Demographic influences on test performances were modeled using fractional polynomial equations that allow consideration of linear and non-linear effects.

RESULTS

There were no significant demographic differences between participants tested in Arizona and California. Age and gender were similar across education ranges. Two thirds of the sample were Spanish dominant and the remainder were considered bilingual. Individual articles in this Special Issue detail the generation of demographically adjusted T-scores for the various tests in the battery as well as an exploration of bilingualism effects.

DISCUSSION

Norms developed through the NP-NUMBRS project stand to improve the diagnostic accuracy of neuropsychological assessment in Spanish-speaking young-to-middle-aged adults living in the U.S.-Mexico border region. Application of the present norms to other groups should be done with caution.

Cognitive Processes Underlying Verbal Fluency in Multiple Sclerosis

Background: Verbal fluency (VF) has been associated with several cognitive functions, but the cognitive processes underlying verbal fluency deficits in Multiple Sclerosis (MS) are controversial. Further knowledge about VF could be useful in clinical practice, because these tasks are brief, applicable, and reliable in MS patients. In this study, we aimed to evaluate the cognitive processes related to VF and to develop machine-learning algorithms to predict those patients with cognitive deficits using only VF-derived scores.

Methods: Two hundred participants with MS were enrolled and examined using a comprehensive neuropsychological battery, including semantic and phonemic fluencies. Automatic linear modeling was used to identify the neuropsychological test predictors of VF scores. Furthermore, machine-learning algorithms (support vector machines, random forest) were developed to predict those patients with cognitive deficits using only VF-derived scores.

Results: Neuropsychological tests associated with attention-executive functioning, memory, and language were the main predictors of the different fluency scores. However, the importance of memory was greater in semantic fluency and clustering scores, and executive functioning in phonemic fluency and switching. Machine learning algorithms predicted general cognitive impairment and executive dysfunction, with F1-scores over 67–71%.

Conclusions: VF was influenced by many other cognitive processes, mainly including attention-executive functioning, episodic memory, and language. Semantic fluency and clustering were more explained by memory function, while phonemic fluency and switching were more related to executive functioning. Our study supports that the multiple cognitive components underlying VF tasks in MS could serve for screening purposes and the detection of executive dysfunction.

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.

Demographically-adjusted norms for the WAIS-R Block Design and Arithmetic subtests: Results from the Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) project

OBJECTIVE

Wechsler Adult Intelligence Scale (WAIS) Block Design and Arithmetic subtests are frequently used as measures of visuospatial construction and verbal working memory, respectively. As part of a larger test adaptation and norming effort for this population, we generated and investigated demographically-adjusted interpretive norms for WAIS-R Block Design and Arithmetic in Spanish-speaking adults living in the US-Mexico border region.

METHOD

Participants included 183 community-dwelling adults ages 20-55 (education range: 0-20 years; 58% women) from the NeuroPsychological-Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) Project. They completed the WAIS-R Block Design and Arithmetic subtests in Spanish. Demographically-adjusted T-scores were calculated for these subtests using fractional polynomial equations adjusting for linear and non-linear effects of age, education (continuous), and sex. We compared our rates of impairment (i.e. T < 40) against rates calculated using published English-speaking WAIS-R standardization sample norms adjusted for age, education, and sex.

RESULTS

Education was positively associated with performance on Block Design and Arithmetic subtests, and men outperformed women on both subtests. The present Spanish-speaker norms for these subtests yielded expected rates of "impairment" (i.e. 15-16% impaired, a 1 SD cutoff), while existing norms for English-speakers underestimated impairment (i.e. 5-6% impaired) when applied to our Spanish-speaking sample.

CONCLUSIONS

Regional normative data will improve interpretation of test performance on Block Design and Arithmetic subtests for Spanish-speakers living in the US-Mexico border region and may aid in bolstering the overall analysis of neuropsychological profile patterns in this population. Cross-validation with Spanish-speakers in other regions and/or with other national origins is needed.

Demographically adjusted normative data for the Halstead category test in a Spanish-speaking adult population: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS)

OBJECTIVE

The present study aimed to develop norms applicable to Spanish-speakers living in the United States (U.S.)- Mexico border region for the Halstead Category Test (HCT), a test of executive function.

METHODS

Healthy native Spanish-speakers (N = 252; Age: range 19-60 years, M = 37.28, SD = 10.24; Education: range 0-20 years; M = 10.65, SD = 4.33; 58.33% women) living in the U.S.-Mexico border region of California and Arizona completed the HCT as part of a comprehensive neuropsychological test battery. The univariable and interactive effects of demographic variables on HCT raw scores were examined. Total scores were normed using fractional polynomial equations, controlling for age, education, and gender. T-scores were also computed for HCT scores of the current Spanish-speaking normative sample using published, demographically-adjusted norms for English-speaking non-Hispanic Whites and Blacks. Impairment rates (T-Scores < 40) were calculated using published and current norms.

RESULTS

Age was significantly associated with increased number of errors, and education and male gender were associated with decreased number of HCT errors (total raw scores). Applying norms developed for English-speaking non-Hispanic Whites and Blacks resulted in overestimation of impairment rates in the current sample (impairment: 48% with White norms and 27% with Black norms). This pattern was evident across levels of education except in participants with 13+ years of education, where rates of impairment using non-Hispanic Black norms were comparable to those based on newly developed norms.

CONCLUSION

The present study presents norms for the HCT in a sample of U.S. Spanish-speakers, providing an important tool for identifying executive dysfunction in this population.