Integrating Diversity, Culture, and Equity into the Neuropsychological Evaluation

Cognition is influenced by a host of factors, including the patient's medical, psychiatric, and developmental history; sociocultural and demographic factors; modifiable behavioral factors; and structural and social determinants of health. Neuropsychological approaches include interpreting test data in the context of these factors to classify impairment and derive a cognitive diagnosis accurately. Failure to integrate an individual's sociodemographic, sociocultural, and developmental background can result in diagnostic errors, which have critical clinical implications for patient care.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Both mOTS-words and pOTS-words prefer emoji stimuli over text stimuli during a lexical judgment task

The visual word form area in the occipitotemporal sulcus (here OTS-words) is crucial for reading and shows a preference for text stimuli. We hypothesized that this text preference may be driven by lexical processing. Hence, we performed three fMRI experiments (n = 15), systematically varying participants' task and stimulus, and separately evaluated middle mOTS-words and posterior pOTS-words. Experiment 1 contrasted text with other visual stimuli to identify both OTS-words subregions. Experiment 2 utilized an fMRI adaptation paradigm, presenting compound words as texts or emojis. In experiment 3, participants performed a lexical or color judgment task on compound words in text or emoji format. In experiment 2, pOTS-words, but not mOTS-words, showed fMRI adaptation for compound words in both formats. In experiment 3, both subregions showed higher responses to compound words in emoji format. Moreover, mOTS-words showed higher responses during the lexical judgment task and a task-stimulus interaction. Multivariate analyses revealed that distributed responses in pOTS-words encode stimulus and distributed responses in mOTS-words encode stimulus and task. Together, our findings suggest that the function of the OTS-words subregions goes beyond the specific visual processing of text and that these regions are flexibly recruited whenever semantic meaning needs to be assigned to visual input.

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.

Interpreter-mediated neuropsychological assessment: Clinical considerations and recommendations from the European Consortium on Cross-Cultural Neuropsychology (ECCroN)

OBJECTIVE

With increasing international migration, societies have become increasingly diverse worldwide. Although neuropsychological assessment is influenced by several diversity characteristics, language barriers have repeatedly been identified as one of the main challenges to cross-cultural neuropsychological assessment in migrant populations. Importantly, neuropsychologists are often required to conduct interpreter-mediated neuropsychological assessments without any graduate training or continuing education on the topic. To address this gap, the objective of this paper is to provide guidelines for interpreter-mediated neuropsychological assessment.

METHOD

A European Consortium on Cross-Cultural Neuropsychology (ECCroN) task force conducted a conceptual literature review and provided recommendations for good practice and working principles to inform the preparation and administration of interpreter-mediated assessments.

RESULTS

ECCroN takes the position that it is the responsibility of neuropsychologists, as well as the institutions or organizations that employ them, to ensure effective communication between themselves and their patients. This may be accomplished by preparing for an interpreter-mediated assessment by engaging an appropriate interpreter, which in most circumstances will be a professional in-person interpreter speaking the same language(s) or dialect(s) as the patient, and considering practical, language, and cross-cultural issues. During the assessment, reasonable steps should be taken to proactively manage the proceedings and adopt a communication style that facilitates effective patient-directed communication, and when interpreting test data and determining formulations and diagnoses, the limitations of interpreter-mediated assessment should be carefully considered.

CONCLUSION

Adhering to the provided recommendations and working principles may help neuropsychologists provide competent interpreter-mediated neuropsychological assessments to linguistically diverse patients.

Both mOTS-words and pOTS-words prefer emoji stimuli over text stimuli during a reading task

The visual word form area in the occipitotemporal sulcus (OTS), here referred to as OTS-words, responds more strongly to text than other visual stimuli and is crucial for reading. We hypothesized, that this text preference may be driven by a preference for reading tasks, as in most prior fMRI studies only the text stimuli were readable. Hence, we performed three fMRI experiments (N=15) and systematically varied the participant's task and the stimulus, investigating mOTS-words and pOTS-words subregions. In experiment 1, we contrasted text stimuli with non-readable visual stimuli (faces, limbs, houses, objects). Experiment 2 utilized an fMRI adaptation paradigm, presenting compound words in text or emoji formats. In experiment 3, participants performed a reading or a color task on compound words in text or emoji format. Using experiment 1 data, we identified mOTS-words and pOTS-words by contrasting texts with non-readable stimuli. In experiment 2, pOTS-words, but not mOTS-words, showed fMRI adaptation for compound words in both text and emoji formats. In experiment 3, surprisingly, both subregions showed higher responses to compound words in emoji than text format. Moreover, mOTS-words showed higher responses during the reading than the color task and a task-stimulus interaction. Multivariate analyses revealed that distributed responses in pOTS-words encode the visual stimulus, while responses in mOTS-words encode both stimulus and task. Together, our findings suggest that the function of the OTS-words subregions goes beyond the specific visual processing of text and that these regions are flexibly recruited whenever semantic meaning needs to be assigned to visual input.

Illiterate Addenbrooke's Cognitive Examination-III in Three Indian Languages: An Adaptation and Validation Study

BACKGROUND

Literacy is an important factor that predicts cognitive performance. Existing cognitive screening tools are validated only in educated populations and are not appropriate for older adults with little or no education leading to poor performance on these tests and eventually leading to misdiagnosis. This challenge for clinicians necessitates a screening tool suitable for illiterate or low-literate older individuals.

OBJECTIVES

The objective was to adapt and validate Addenbrooke's Cognitive Examination-III (ACE-III) for screening general cognitive functions in illiterate and low-literate older populations in the Indian context in three languages.

METHOD

The Indian illiterate ACE-III was systematically adapted by modifying the original items of the Indian literate ACE-III to assess the cognitive functions of illiterates and low-literates with the consensus of an expert panel of professionals working in the area of dementia and related disorders. A total of 180 illiterate or low-literate participants (84 healthy-controls, 50 with dementia, and 46 with mild cognitive impairment [MCI]) were recruited from three different centers speaking Bengali, Hindi, and Kannada to validate the adapted version.

RESULTS

The optimal cut-off score for illiterate ACE-III to distinguish controls from dementia in all 3 languages was 75. The optimal cut-off scores in distinguishing between controls and MCI ranged from 79 to 82, with a sensitivity ranging from 93% to 99% and a specificity ranging from 72% to 99%.

CONCLUSION

The test is found to have good psychometric properties and is a reliable cognitive screening tool for identifying dementia and MCI in older adults with low educational backgrounds in the Indian context.

Diagnostic Accuracy of the Swedish Version of the Multicultural Cognitive Examination for Cognitive Assessment in Swedish Memory Clinics

BACKGROUND

Cognitive assessment for foreign-born individuals is suboptimal. The Multicultural Cognitive Examination (MCE) was developed for use in culturally, linguistically and educationally diverse populations. The MCE includes the Rowland Universal Dementia Assessment Scale (RUDAS) and performs assessment of memory, verbal fluency, and visuospatial function.

OBJECTIVE

To compare the psychometric properties of the Swedish version of the Multicultural Cognitive Examination (MCE-S) with the Swedish versions of the RUDAS (RUDAS-S), the Mini-Mental State Examination (MMSE-SR), and the Clock Drawing Test (CDT), and to explore the ability of the MCE-S test to differentiate patients with and without dementia in a multicultural population.

METHODS

117 outpatients at four memory clinics were tested using the MCE-S to complement the routine cognitive assessment.

RESULTS

Significant differences between patients with and without dementia were observed for all MCE-S components. There were significant differences between foreign-born and Swedish-born patients in the MMSE-SR, but not in the MCE-S or the RUDAS-S. The MCE-S, had good diagnostic performance for detecting dementia (AUC, 0.82), and was at least as good as the RUDAS-S alone (AUC, 0.79). The MCE-S also distinguished Alzheimer's disease (AD) from non-AD dementia. Contrary to expectations, the MCE-S was also at least as good as the MMSE-SR among the Swedish-born patients.

CONCLUSIONS

The MCE-S is adequate for detecting dementia in both foreign-born and Swedish-born populations. Based on the cultural diversity of general society, adapted cognitive tests that can be used for everyone are practical and beneficial for both patients and health-care professionals. Further studies are needed within primary care.

Norms for the Triana Test: A Story Recall Test Based on Emotional Material

Background

The "Triana Test" is a novel story recall test based on emotional material with demonstrated accuracy in diagnosing mild cognitive impairment patients.

Objective

This study aims to obtain normative data for the "Triana Test".

Methods

A normative study was conducted at a university hospital in Spain. Partners of patients were systematically recruited if eligible (age ≥50, no memory complaints, and a total TMA-93 score at or above the 10th percentile). The "Triana Test" was administered and scored. For developing the normative data, a regression-based method was followed.

Results

The final sample included 362 participants (median age = 66, range = 50-88; 64.9% females). A model including age and educational level better predicted the total scores. Combinations of these variables resulted in different 10th percentile scores.

Conclusions

Norms for using the "Triana Test" are now available. The provided cutoffs for the 10th percentile will aid in the diagnosis of prodromal Alzheimer's disease.

Neuropsychological Test Norms for the Assessment of HIV-Associated Neurocognitive Impairment Among South African Adults

Reliable and valid neurocognitive (NC) test batteries that assess multiple domains of cognitive functioning are vital tools in the early detection of HIV-associated NC impairment. The HIV Neurobehavioral Research Center's International Neurobehavioral Battery (HNRC Battery) is one such diagnostic tool and has shown cultural validity in several international neuroHIV studies. However, no published norms are currently available for the full HNRC Battery in South Africa. To accurately interpret NC test results, appropriate reference norms are required. In light of this challenge, data were collected from 500 healthy, HIV-uninfected participants to develop demographically corrected South African norms. When demographically corrected United States of America (U.S.) norms were applied to the performance scores of our neurologically intact, HIV-negative sample, an impairment rate of 62.2% was observed compared to a 15.0% impairment rate when the newly generated South African norms were applied. These results reiterate the findings of other low- and middle-income countries, highlighting the need for localized, country-specific norms when interpreting NC performance.

Clinical Utility of WAIS-IV Matrix Reasoning Among Adult Low Educated Recent Immigrants; A Note of Caution

OBJECTIVE

To examine the clinical utility of Wechsler Adult Intelligence Scale-IV (WAIS-IV) Matrix Reasoning in limited educated recently arrived immigrants in Denmark.

METHOD

Participants were 64 limited educated (0-9 years' education) independently living adult immigrants primarily from Middle Eastern and Sub-Saharan African countries who completed WAIS-IV Matrix Reasoning as well as demographic, and medical questionnaires.

RESULTS

Thirty-eight participants (59%) scored more than two standard deviations below the Scandinavian mean (scaled score < 4). Performances were significantly associated with years of education but not with occupational status, years of residence in Denmark, or Danish language skills. The most common error types were repetition errors (15.84%) and incomplete correlate errors (10.47%), with a strong trend for a higher proportion of repetition errors in participants with <5 years of education.

CONCLUSIONS

The findings indicate that WAIS-IV Matrix Reasoning underestimates cognitive functioning in limited educated recently arrived immigrants, thus calling its clinical utility into question.

Cognitive Performance in Asymptomatic Elderly People with Hepatitis C: The Role of Education

BACKGROUND

Neurotropism of the hepatitis C virus (HCV) can be the source of subtle neuropsychological symptoms in non-cirrhotic patients. Age is a risk factor for cognitive impairment (CI). Thus, asymptomatic elderly people who carry HCV might be at a greater risk of CI. Education can influence test performance.

OBJECTIVES

(1) To verify whether elderly people with HCV performed poorer than controls on cognitive tests. (2) To analyze how education affects performance. (3) To verify whether the extent of the effect of education on performance depends on the group (HCV vs. controls) and the type of cognitive test.

METHODS

Asymptomatic HCV carriers older than 60 years (n = 41) were matched with 41 corresponding controls. All participants performed the following tests: Mini-Cog, Mini Mental State Examination, clock drawing test (CDT), and verbal fluency.

RESULTS

(1) There were no significant differences in cognitive performance between the two groups. (2) Higher education was always associated with better performance. (3) There was a significant group difference in the slopes of the regression lines between years of education and CDT performance. No differences were found for the other three tests.

CONCLUSION

Considering the scores on the CDT, the rate of improvement in performance when schooling increases is higher in HCV carriers.

Neuroanatomical correlates of macrostructural receptive abilities in narrative discourse in unilateral left hemisphere stroke: A behavioural and voxel-based morphometry study

BACKGROUND

Little is known about story retelling and comprehension abilities in groups with lower levels of education and socio-economic status (SES). A growing body of evidence suggests the role of an extended network supporting narrative comprehension, but few studies have been conducted in clinical populations, even less in developing countries.

AIMS

To extend our knowledge of the impact of a stroke on macrostructural aspects of discourse processes, namely main and complementary information, in individuals with middle-low to low SES and low levels of education. Relationships were tested between the performance in story retell and comprehension and reading and writing habits (RWH). Also, the associations between retelling and comprehension measures and their structural grey matter (GM) correlates were explored.

METHODS & PROCEDURES

A total of 17 adults with unilateral left hemisphere (LH) chronic ischaemic stroke without the presence of significant aphasia and 10 matched (age, education and SES) healthy controls (HC) participated in the study. Retell and comprehension tasks were performed after listening or reading narrative stories. Voxel-based morphometry (VBM) analysis was conducted on a subgroup of nine individuals with LH stroke and the 10 matched controls using structural magnetic resonance imaging (MRI).

OUTCOMES & RESULTS

Retelling and comprehension abilities were not significantly different between LH and HC, nonetheless quantitively lower in LH. Exploratory correlations showed that retelling and comprehension abilities in both written and auditory modalities were correlated with naming abilities. At the neural level, written comprehension positively correlated with GM density of the LH, including areas in the temporal pole, superior and middle temporal gyrus as well as the orbitofrontal cortex, precentral and postcentral gyri. Auditory narrative comprehension was associated with GM density of the lingual gyrus in the right hemisphere.

CONCLUSIONS & IMPLICATIONS

The present results suggest that retelling and comprehension of auditory and written narratives are relatively well-preserved in individuals with a LH stroke without significant aphasia, but poorer than in HC. The findings replicate previous studies conducted in groups with higher levels of education and SES both at the behavioural and neural levels. Considering that naming seems to be associated with narrative retell and comprehension in individuals with lower SES and education, this research provides evidence on the importance of pursuing further studies including larger samples with and without aphasia as well as with various SES and education levels.

WHAT THIS PAPER ADDS

What is already known on this subject Story retell and comprehension of auditory and written discourse have been shown to be affected after stroke, but most studies have been conducted on individuals with middle to high SES and high educational levels. What this paper adds to existing knowledge The study reports on narrative retell and comprehension in both auditory and written modalities in groups of HC and individuals with LH brain damage, with low-to-middle SES and lower levels of education. What are the potential or actual clinical implications of this work? This study highlights the importance of taking into consideration the sociodemographic and RWH of patients when assessing discourse retell and comprehension in both auditory and written modalities. It also underlines the importance of including patients without significant aphasia following LH stroke to look at the effect of both stroke and aphasia on narrative comprehension and story retelling.

Neural correlates of verbal fluency revealed by longitudinal T1, T2 and FLAIR imaging in stroke

Diffusion-weighted imaging has been widely used in the research on post-stroke verbal fluency but acquiring diffusion data is not always clinically feasible. Achieving comparable reliability for detecting brain variables associated with verbal fluency impairments, based on more readily available anatomical, non-diffusion images (T1, T2 and FLAIR), enables clinical practitioners to have complementary neurophysiological information at hand to facilitate diagnosis and treatment of language impairment. Meanwhile, although the predominant focus in the stroke recovery literature has been on cortical contributions to verbal fluency, it remains unclear how subcortical regions and white matter disconnection are related to verbal fluency. Our study thus utilized anatomical scans of ischaemic stroke survivors (n = 121) to identify longitudinal relationships between subcortical volume, white matter tract disconnection, and verbal fluency performance at 3- and 12-months post-stroke. Subcortical grey matter volume was derived from FreeSurfer. We used an indirect probabilistic approach to quantify white matter disconnection in terms of disconnection severity, the proportion of lesioned voxel volume to the total volume of a tract, and disconnection probability, the probability of the overlap between the stroke lesion and a tract. These disconnection variables of each subject were identified based on the disconnectome map of the BCBToolkit. Using a linear mixed multiple regression method with 5-fold cross-validations, we correlated the semantic and phonemic fluency scores with longitudinal measurements of subcortical grey matter volume and 22 bilateral white matter tracts, while controlling for demographic variables (age, sex, handedness and education), total brain volume, lesion volume, and cortical thickness. The results showed that the right subcortical grey matter volume was positively correlated with phonemic fluency averaged over 3 months and 12 months. The finding generalized well on the test data. The disconnection probability of left superior longitudinal fasciculus II and left posterior arcuate fasciculus was negatively associated with semantic fluency only on the training data, but the result aligned with our previous study using diffusion scans in the same clinical population. In sum, our results presented evidence that routinely acquired anatomical scans can serve as a reliable source for deriving neural variables of post-stroke verbal fluency performance. The use of this method might provide an ecologically valid and more readily implementable analysis tool.

Cognitive assessment of literacy learning difficulties in adult non- or low-literate second language learners

The population of non- or low-literate adult immigrants studying a new language is large and growing in many countries. The aim of this study was to develop and validate a new instrument for the assessment of cognitive impairment that may hinder literacy learning in adult non- or low-literate L2 learners, the Cognitive Assessment of Literacy Learning Difficulties (CALL), in a language center setting. This was a case-control study in which the CALL was validated in adult non- or low-literate students, or students who were not literate in the Latin alphabet, in nine Danish language centers. Educator classification of students with very slow progression in learning basic Danish literacy was used as a benchmark for literacy learning difficulties. Classification was further based on the number of lessons participants had required to pass tests during Danish language program levels. An acceptable discriminative validity (AUC 0.76; specificity 0.94, sensitivity 0.64) for literacy learning difficulties (n = 32) versus schooling and sex matched control participants (n = 28) was found. In comparison, years of formal schooling had an AUC of 0.58. Age had a small effect on the ability of the CALL to predict literacy learning difficulties (OR = 1.097, p = 0.013), whereas sex and years of schooling did not. CALL was found to be a valid instrument for identification of cognitive impairment that may hinder literacy learning in adult non- or low-literate L2 learners in a Danish language center setting.

Validation of the cross-cultural dementia screening test in Alzheimer's disease and Parkinson's disease

Objective

The Cross-Cultural Dementia (CCD) is a new screening tool to evaluate cognitive impairment based on a cross-cultural perspective to reduce the bias of education, and language and cultural differences. We aimed to evaluate the diagnostic properties of the CCD in Spaniards for the assessment of patients with Alzheimer's disease in mild cognitive impairment (AD-MCI) and mild dementia stages (AD-D) and patients with mild cognitive impairment associated with Parkinson's disease (PD-MCI).

Methods

Sixty participants with AD (50% MCI) and thirty with PD-MCI were enrolled. Each clinical group was compared against a healthy control group (HC) with the same number of participants and no significant differences in age, education, and sex. A comprehensive neuropsychological test battery and CCD were completed. Intergroup comparisons, ROC curves, and cut-off scores were calculated for the study of diagnostic properties.

Results

Intergroup differences were found in accordance with the cognitive profile of each clinical condition. Memory measures (Objects test) were especially relevant for the classification between AD and HC. Memory and executive function scores (Sun-Moon and Dots tests) were useful in the case of PD-MCI and HC. Furthermore, CCD described differences in executive functions and speed scores comparing AD-MCI and PD-MCI. Correlations between standardized neuropsychological tests and CCD measures supported the convergent validity of the test.

Conclusion

CCD showed good discrimination properties and cut-off scores for dementia and extended its application to a sample of prodromal stages of AD and PD with mild cognitive impairment.

Neuropsychological assessment in the multicultural memory clinic: Development and feasibility of the TULIPA battery

Neuropsychological assessment of culturally diverse populations is hindered by barriers in language, culture, education, and a lack of suitable tests. Furthermore, individuals from diverse backgrounds are often unfamiliar with being cognitively tested. The aim of this study was to develop a new neuropsychological test battery and study its feasibility in multicultural memory clinics.

Composition of the TULIPA battery (Towards a Universal Language: Intervention and Psychodiagnostic Assessment) entailed a literature review and consultation with experts and individuals from diverse backgrounds. Feasibility was investigated by examining administration and completion rates and the frequency of factors complicating neuropsychological assessment in 345 patients from 37 countries visiting four multicultural memory clinics in the Netherlands.

The test battery included existing tests such as the Cross-Cultural Dementia screening (CCD), Rowland Universal Dementia Assessment Scale (RUDAS), tests from the European Cross-Cultural Neuropsychological Test Battery, and newly developed tests. Completion rates for the test battery were generally high (82%-100%), except for CCD Dots subtest B (58%). Although tests of the "core" TULIPA battery were administered often (median: 6 of 7, IQR: 5-7), supplementary tests were administered less frequently (median: 1 of 9; IQR: 0-3). The number of administered tests correlated with disease severity (RUDAS, ρ=.33, adjusted p < .001), but not with other patient characteristics. Complicating factors were observed frequently, e.g. suboptimal effort (29%-50%), fatigue (29%), depression (37%-57%).

The TULIPA test battery is a promising new battery to assess culturally diverse populations in a feasible way, provided that complicating factors are taken into account.

Supplemental data for this article is available online at https://doi.org/10.1080/13854046.2022.2043447 .

Illiteracy, Neuropsychological Assessment, and Cognitive Rehabilitation: A Narrative Review

OBJECT

Νeuropsychological assessment is particularly important for the accurate discrimination of cognitive abilities and weaknesses of patients in order to determine the appropriate therapeutic intervention. However, the reliability and validity of neuropsychological assessment appears to be influenced by a wide range of factors, including literacy and educational level.

AIM

This systematic review evaluates neuropsychological tests appropriate for the valid assessment of illiterate individuals and the effectiveness of cognitive rehabilitation programs for illiterate and/or low-educated individuals according to the results of English language studies that have been published in the PubMed/Medline electronic database until August 2022 (no initiation date).

RESULTS

49 studies were included for neuropsychological assessment and 4 studies for cognitive rehabilitation. In terms of investigating the validity and reliability of neuropsychological tests for the assessment of healthy illiterate individuals, most studies concluded that for the majority of neuropsychological tests there is a significant difference in performance between healthy illiterate and literate individuals. However, there was consensus among studies that the performance of illiterate subjects was equivalent to the performance of literate subjects on tasks depicting colored and real objects. Regarding cognitive rehabilitation programs, all four studies concluded that they are effective in improving the cognitive functions of illiterate and/or low-literate patients with mild cognitive impairment and/or mild dementia.

CONCLUSIONS

For the assessment of illiterate individuals, it is imperative that neuropsychological tests with high ecological validity (i.e., tests related to activities of daily living) be administered so as not to underestimate their cognitive functioning. At the same time, cognitive enhancement/stimulation programs seem to be effective in this population group; however, this area needs further investigation.

Normative Data in Cross-Cultural Neuropsychological Instruments in Spaniards and Colombians Living in Spain

BACKGROUND

Cross-Cultural Dementia Screening (CCD), Rowland Universal Dementia Assessment Scale (RUDAS), and European Cross-cultural Neuropsychological Test Battery (CNTB) are three novel neuropsychological instruments developed from a cross-cultural perspective to reduce the impact of culture in cognitive assessment and improve the assessment in diverse populations.

OBJECTIVE

We aimed to collect and present normative data on these tests in a majority population sample (Spaniards living in Spain) and in a minority population sample (Colombians living in Spain).

METHODS

CCD, RUDAS, and CNTB were administered to a group of 300 cognitively healthy participants (150 Spaniards and 150 Colombians). Linear regression modeling strategy was used to provide adjusted norms for demographic factors and to explore the influence of these factors on test performance.

RESULTS

Most of the CCD and CNTB scores were predicted by age and years of education, with some tests only predicted by age or showing a ceiling effect. The comparison of normative data between the two samples confirmed the favorable cross-cultural properties of these instruments, with only some differences in processing speed and executive functioning scores.

CONCLUSIONS

Our study finds a comparable influence of demographic factors in both populations on the performance of CCD, RUDAS, and CNTB, confirming their adequate cross-cultural properties. We provide normative data for these tests in Spaniards and Colombians living in Spain.

Education bias in typical brief cognitive tests used for the detection of dementia in elderly population with low educational level: a critical review

Dementia is a significant decline in cognition that interfere with independent, daily functioning. Dementia is a syndrome caused by a myriad and include primary neurologic, neuropsychiatric, and medical conditions. It has been projected that the prevalence of dementia will triple in the elderly population by the year 2050. Despite the benefits of early diagnosis, there is an effective under-detection of around 62% of people with mild cognitive impairment (MCI) or dementia. One of the factors associated with this problem is that diagnostic techniques are affected by the educational level of those evaluated. This is an important aspect to consider in the use of brief cognitive tests for the detection of dementia. This review presents and critically analyzes the available evidence regarding the effect of educational level on the diagnostic utility of three of the most widely used tools in the clinical setting: the Mini-mental Test Examination (MMSE), the Montreal Cognitive Assessment (MoCA), and the Addenbrooke's Cognitive Examination (ACE). Previous evidence shows that the tasks that require reading, writing, calculation, phonological fluency, and visuoconstruction are affected by educational level. These results lead to discourage the use of these tests in older people with less than 6 years of schooling. The development of brief cognitive tests appropriate for people with a low educational level is recommended. We posit that adequate cognitive tests should not consider tasks or items that resemble characteristics of academic contexts and should be more analogous to daily activities situations.

Validity of Visuoconstructional Assessment Methods within Healthy Elderly Greek Australians: Quantitative and Error Analysis

Aims

Visuospatial skills are frequently assessed with drawing tests. Research has suggested that the use of drawing tasks in low educated groups may lack the ability to discriminate healthy individuals from clinical populations. The aims of this study were to investigate the validity of visuoconstructional tests in a sample of older Greek Australian immigrants and compare their performances to a matched sample of patients with Alzheimer’s disease (ad).

Method

We assessed visuoconstructional performances in a sample of 90 healthy older Greek Australians, with a primary school level of education, and compared performances to a demographically matched sample of 20 Greek Australians with a diagnosis of ad on four visuoconstructional drawing tests: Greek cross, four-pointed star, intersecting pentagons, and the Necker Cube.

Results

While healthy participants tended to outperform the ad group on most copy tasks, high fail rates within the healthy sample were observed for the intersecting pentagons and Necker cube (78% and 73% fail rates, respectively) when using established clinical cut-off scores. High rates of curved angle, omission, distorted relation between elements, spatial disorganization and three-dimensional design errors were found across the four-pointed star, intersecting pentagons, and the Necker cube in both healthy participants and those with ad. Exploratory receiver operating characteristic curve analysis revealed that, with perhaps the exception of the Greek cross, meaningful sensitivity and specificity could not be reached for the four-pointed star, intersecting pentagons, and Necker cube.

Conclusion

Cognitively healthy immigrants with low education appear to be at a disadvantage when completing visuoconstructional drawing tests, as their performance may be misinterpreted as indicating cognitive impairment. Future research is needed to identify alternative approaches to assess visuoconstructional ability in culturally and linguistically diverse older cohorts with limited education.

Clinical characteristics and presenting symptoms of dementia - a case-control study of older ethnic minority patients in a Dutch urban memory clinic

OBJECTIVES

Despite the suspected higher prevalence of dementia in first generation ethnic minority populations, little is known about their pathway to geriatric diagnostic facilities. This study describes presenting symptoms, demographic and clinical characteristics of a large cohort of patients from ethnic minority populations at their first visit to a geriatric day clinic and compares them with those of native majority (Dutch) patients.

METHOD

Retrospective case control study in an urban geriatric day clinic setting. Participants were 415 minority patients (cases) from 47 different countries and 428 native Dutch control patients. Measurements were demographic characteristics, cognitive screening results, informant questionnaires, neuropsychiatric and depressive symptoms and somatic comorbidity.

RESULTS

Ethnic minority patients presented with a different profile of psychiatric and somatic comorbidity. They were younger, had longer duration of symptoms and possibly presented somewhat later in the course of the dementia than the controls. Minority patients had more neuropsychiatric and depressive symptoms than native Dutch patients. They also had more often somatic comorbidities than controls, especially diabetes mellitus.

CONCLUSIONS

Clinicians in geriatric diagnostic facilities should be aware of the younger age at presentation and the high prevalence of some specific risk factors for dementia in ethnic minority patients.

Identifying Appropriate Neuropsychological Tests for Uneducated/Illiterate Older Individuals

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic Accuracy of the Swedish Version of the Rowland Universal Dementia Assessment Scale (RUDAS-S) for Multicultural Cognitive Screening in Swedish Memory Clinics

Background:

The number of people with a migration background and dementia is increasing in Europe. All patients with suspected dementia have the right to an appropriate cognitive assessment and correct diagnosis for optimal treatment and support. Rowland Universal Dementia Assessment Scale (RUDAS) cognitive screening instrument is less affected by language, culture, and educational background, and adapted for use in multicultural populations.

Objective:

To compare the diagnostic accuracy of RUDAS-S to the Swedish version of Mini-Mental State Examination (MMSE-SR) for detecting dementia in a multicultural group of outpatients in Swedish memory clinics.

Methods:

We tested 123 outpatients (36 nonnative Swedish), in 4 memory clinics in Southern Sweden with RUDAS-S to supplement the usual cognitive assessment.

Results:

RUDAS-S had moderate to good diagnostic performance for detecting dementia in a multicultural population in Sweden, with an area under the receiver operating characteristic curve (AUC) of 0.81. At a cutoff score <25 its sensitivity was 0.92, specificity 0.60, and accuracy 76%. The AUC for the MMSE-SR was 0.79. At a cutoff score <23 its sensitivity was 0.65, specificity 0.81, and accuracy 73%.

Conclusion:

RUDAS-S is at least as accurate as MMSE-SR for detecting dementia in memory clinics in Sweden and can be used for all patients undergoing a cognitive assessment, irrespective of their cultural, language, and educational background. However, there is a need for other cross-cultural cognitive tests to complement RUDAS-S to extend cognitive examination.

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.

Mild cognitive impairment in patients with systemic sclerosis and features analysis

Objective

Nervous system damage in patients with SSc has recently attracted attention. In this study, we aimed to explore mild cognitive impairment (MCI) in SSc patients and the characteristics of these patients.

Methods

A total of 103 SSc patients were consecutively enrolled from July 2018 to May 2019, and 97 matched healthy individuals were also included as controls. Brief cognitive tests, such as the Beijing version of the Montreal Cognitive Assessment (MoCA-BJ), were used to assess the cognitive function of all subjects. We compared the differences in MCI between SSc patients and healthy controls, as well as the differences in demographic and clinical features between SSc patients with and without MCI. Associations of quantitative demographic and clinical features with MoCA-BJ scores in the SSc patients were also evaluated.

Results

The score of MoCA-BJ was lower in the SSc group compared with those in the healthy group [24 (9–30) vs 26 (15–30), P &lt; 0.001]. MCI (MoCA-BJ score ≤ 25) was found in 61.2% (63/103) of the enrolled SSc patients but only in 27.8% (27/97) of the healthy individuals. Other tests evaluating some of the specific domains of cognitive functions showed that the SSc patients had impaired memory, attention and executive ability. Compared with SSc patients without MCI, SSc patients with MCI had lower education level, total serum protein and serum albumin but higher ANA positivity.

Conclusion

MCI is common in patients with SSc and should be drawn to the attention of rheumatologists. Lower education level, malnutrition and higher ANA positivity were closely related to the cognitive dysfunctions in SSc patients, providing directions for further interventions.

Macrostructural Aspects in Oral Narratives in Brazilian Portuguese by Left and Right Hemisphere Stroke Patients With Low Education and Low Socioeconomic Status

OBJECTIVE

Individuals with a stroke in either the left hemisphere (LH) or the right hemisphere (RH) often present macrostructural impairments in narrative abilities. Understanding the potential influence of low education and low socioeconomic status (SES) is critical to a more effective assessment of poststroke language. The first aim was to investigate macrostructural processing in low-education and low-SES individuals with stroke in the LH or RH or without brain damage. The second aim was to verify the relationships between macrolinguistic, neuropsychological, and sociodemographic variables.

METHOD

Forty-seven adults with LH (n = 15) or RH (n = 16) chronic ischemic stroke and 16 matched (age, education, and SES) healthy controls produced three oral picture-sequence narratives. The macrostructural aspects analyzed were cohesion, coherence, narrativity, macropropositions, and index of lexical informativeness and were compared among the three groups. Then, exploratory correlations were performed to assess associations between sociodemographic (such as SES), neuropsychological, and macrostructural variables.

RESULTS

Both the LH and the RH presented impairments in the local macrostructural aspect (cohesion), whereas the RH also presented impairments in more global aspects (global coherence and macropropositions). All five macrostructural variables correlated with each other, with higher correlations with narrativity. Naming was correlated with all macrostructural variables, as well as prestroke reading and writing habits (RWH), showing that higher naming accuracy and higher RWH are associated with better macrostructural skills.

CONCLUSIONS

The present results corroborate the role of the LH in more local processing and that of the RH in more global aspects of discourse. Moreover, this study highlights the importance of investigating discourse processing in healthy and clinical populations of understudied languages such as Brazilian Portuguese, with various levels of education, SES, and RWH.

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.

Cultural factors related to neuropsychological performance and brain atrophy among Hispanic older adults with amnestic Mild Cognitive Impairment (aMCI): A pilot study

OBJECTIVES

This study examined the association of cultural factors and literacy to neuropsychological performance and measures of regional brain atrophy among Hispanic elders diagnosed with amnestic Mild Cognitive Impairment (aMCI).

METHOD

Acculturation and literacy levels were measured among 45 subjects tested in Spanish; their primary language. Scores for measures of memory, executive functioning, and verbal fluency, as well as volumetric analysis of MRI scans of left hemisphere structures commonly affected by Alzheimer's disease (AD) were examined. Linear regression models were employed to examine the association of acculturation and literacy to neuropsychological performance and MRI measures.

RESULTS

After controlling for age, higher literacy levels were associated with better performance on phonemic verbal fluency (r = 0.300, p < .05), while higher levels of acculturation to the U.S. was associated with poorer performance on category verbal fluency (r = 0.300, p < .05). There was a significant inverse relationship after controlling for age between literacy and the left entorhinal cortex (r = -0.455, p < .05), left precuneus (r = -0.457, p < .05), and left posterior cingulate (r = -0.415, p < .05).

CONCLUSIONS

Results of the current pilot study indicate that high acculturation to the U.S. among aMCI immigrants from Latin-American countries may hinder performance on verbal learning measures when they are administered in one's primary language. Moreover, in this cohort, a higher literacy level, which is indicative of greater cognitive reserve, was associated with better performance in language measures, but with greater atrophy in brain regions susceptible to neurodegenerative disease. These preliminary findings should be further examined among larger cohorts and using more diverse measures, which capture other cultural constructs.

The effect of illiteracy on performance in screening tools for dementia: A meta-analysis

INTRODUCTION

Research indicates that many tools designed for screening dementia are affected by literacy level. The objective of this study was to estimate the overall effects of this confounding factor. A meta-analysis was conducted to evaluate differences in performance in dementia screening tools between literate and illiterate individuals.

METHOD

Electronic databases were searched from 1975 to June 2021 to identify empirical studies examining performance in dementia screening tools in literate and illiterate individuals over 50 years old. Data for effect sizes, participant demographic information, and study information were extracted.

RESULTS

We identified 27 studies methodologically suitable for meta-analysis. Multi-level random-effects modeling demonstrated a significant overall effect, with literate participants scoring significantly higher than illiterate participants (g = -1.2, 95% CI = -1.47, -0.95, p < .001). Moderator analyses indicated significant effects of test type and the presence of cognitive impairment on the extent of the difference in performance between literate and illiterate participants. The difference in performance between groups was smaller in screening tests modified for illiterate individuals (p < .01), and in individuals with cognitive impairment (p < .001).

CONCLUSIONS

Our findings substantiate the unsuitability of many dementia screening tools for individuals who are illiterate. The results of this systematic review and meta-analysis emphasize the need for the development and validation of tools that are suitable for individuals of all abilities.

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

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

Validation of Picture Free and Cued Selective Reminding Test for Illiteracy in Lima, Peru

Dementia in Latin America is a crucial public health problem. Identifying brief cognitive screening (BCS) tools for the primary care setting is crucial, particularly for illiterate individuals. We evaluated tool performance characteristics and validated the free and total recall sections of the Free and Cued Selective Reminding Test-Picture version (FCSRT-Picture) to discriminate between 63 patients with early Alzheimer's disease dementia (ADD), 60 amnestic mild cognitive impairment (aMCI) and 64 cognitively healthy Peruvian individuals with illiteracy from an urban area. Clinical, functional, and cognitive assessments were performed. FCSRT-Picture performance was assessed using receiver operating characteristic curve analyses. The mean ± standard deviation scores were 7.7 ± 1.0 in ADD, 11.8 ± 1.6 in aMCI, and 29.5 ± 1.8 in controls. The FCSRT-Picture had better performance characteristics for distinguishing controls from aMCI compared with several other BCS tools, but similar characteristics between controls and early ADD. The FCSRT-Picture is a reliable BCS tool for illiteracy in Peru.

Culture, Ethnicity, and Level of Education in Alzheimer's Disease

Alzheimer's disease (AD) is the most frequent cause of dementia, where the abnormal accumulation of beta-amyloid (Aβ) and tau lead to neurodegeneration as well as loss of cognitive, behavioral, and functional abilities. The present review analyzes AD from a cross-cultural neuropsychological perspective, looking at differences in culture-associated variables, neuropsychological test performance and biomarkers across ethnic and racial groups. Studies have found significant effects of culture, preferred language, country of origin, race, and ethnicity on cognitive test performance, although the definition of those grouping terms varies across studies. Together, with the substantial underrepresentation of minority groups in research, the inconsistent classification might conduce to an inaccuratte diagnosis that often results from biases in testing procedures that favor the group to which test developers belong. These biases persist even after adjusting for variables related to disadvantageous societal conditions, such as low level of education, unfavorable socioeconomic status, health care access, or psychological stressors. All too frequently, educational level is confounded with culture. Minorities often have lower educational attainment and lower quality of education, causing differences in test results that are then attributed to culture. Higher levels of education are also associated with increased cognitive reserve, a protective factor against cognitive decline in the presence of neurodegeneration. Biomarker research suggests there might be significant differences in specific biomarker profiles for each ethnicity/race in need of accurate cultural definitions to adequately predict risk and disease progression across ethnic/racial groups. Overall, this review highlights the need for diversity in all domains of AD research that lack inclusion and the collection of relevant information from these groups.

A systematic review and meta-analysis of HIV associated neurocognitive disorders (HAND) among people with HIV in Ethiopia

Background

Ethiopia, being in the Sub Saharan region of Africa, is one of the countries with a substantial burden of HIV infection. Because of the high burden of HIV and poor health care settings, HAND is prevalent as demonstrated in various cross-sectional studies. However, no review has been conducted to report the consolidated magnitude of HAND among people with HIV in Ethiopia. Therefore, this systematic review and meta-analysis aimed to estimate the prevalence of HAND in Ethiopia.

Methods

Following the PRISMA guidelines, we systematically reviewed and meta-analyzed studies that investigated the prevalence of HAND in Ethiopia from PubMed, Google Scholar, Science Direct, HINARI, EMBASE, and Cochrane library databases. We also looked at the reference lists of the included studies to include other relevant studies. Subgroup analysis was performed based on publication year, study location, and sample size. Heterogeneity across studies was evaluated using the I2 test. Potential publication bias was assessed using Egger’s test and visual inspection of symmetry in the funnel plots.

Results

In the present meta-analysis, 627 articles were initially identified and evaluated. Of these, 8 studies that met the inclusion criteria were included in the final analysis. The pooled prevalence of HAND in people with HIV in Ethiopia was 39.15% (95% CI 29.36, 48.94). The highest prevalence observed in the Southern Nations, Nationalities, and Peoples’ Region (SNNPR) with 53.20% (95% CI 25.96, 80.44) followed by others 34.87% (Tigray, Addis Ababa, and Oromia) (95% CI 33.49, 36.24) and Amhara 34.07% (95% CI 25.39, 42.74).The funnel plot was asymmetrical. However, Egger’s regression tests provided no evidence of publication bias in the prevalence of HAND.

Conclusion

In this meta-analysis, the pooled prevalence of HAND, in Ethiopia, was high. Older age, substance use, advanced stages of the disease, and lack of education were the main determinants of HAND in Ethiopia. Health education, early screening of people with HIV, and training of health professionals working in hospitals on HAND are highly recommended.

Cognitive Screening Instruments for Older Adults with Low Educational and Literacy Levels: A Systematic Review

This study presents a systematic review on existing cognitive screening tools for mild cognitive impairment and dementia in populations with low education and literacy levels. Cochrane Library, PubMed and LILACS databases were examined for studies including adults aged 50 years old or older with low educational level. 61 articles were included. Despite its frequent use, studies on Mini-Mental State Examination (MMSE) revealed that educational level biased the score obtained, regardless of other factors. Separately, the Informant Questionnaire on Cognitive Decline in the Elderly, the Fototest, or the Eurotest, appear to minimize the effect of education and literacy. MMSE is unreliable for individuals with low literacy. Tasks involving reading, writing, arithmetics, drawing, praxis, visuospatial, and visuoconstructive skills have a greater educational bias than naming, orientation, or memory. An adequate determination of educational level and validation of instruments in populations with heterogeneous levels of literacy requires further research.

The challenges of achieving timely diagnosis and culturally appropriate care of people with dementia from minority ethnic groups in Europe

In a just society, everyone should have equal access to healthcare in terms of prevention, assessment, diagnosis, treatment and care. Europe is a multicultural society made up of people who identify with a wide range of ethnic groups. Many older people from minority ethnic groups also have a direct migration background. Several studies have shown that there is a lack of equity in relation to dementia diagnoses and care because equal opportunities do not necessarily translate into equal outcomes. An expert ethics working group led by Alzheimer Europe has produced an extensive report on this issue, a policy brief and a guide for health and social care workers. In this brief summary, the authors/members of the expert working group present some of the key challenges and recommendations for healthcare clinicians striving to provide timely diagnosis and good quality care and treatment to people with dementia from all ethnic groups.

Cultural Bias in Intelligence Assessment Using a Culture-Free Test in Moroccan Children

OBJECTIVE

Previous research has shown that cognitive tests can lead to misclassification when applying non-representative norms to measure cognitive performance. The objective of this study was to investigate whether this misclassification also occurs with a non-verbal so-called "culture-free" intelligence test administered to different age groups.

METHOD

The intelligence of a sample of healthy Moroccan children (N = 147) ages 7, 9, and 11 was assessed using the Coloured Raven's Progressive Matrices (CPM). Raw scores were used to study age differences, as well as misclassifications when applying the norms of three countries culturally different from Morocco (United Kingdom, Spain, and Oman).

RESULTS

Intelligence performance was not within the normal range when non-representative norms were applied to the Moroccan raw scores. Misclassifications accounted for a large percentage of the participants that supposedly displayed intelligence deficits, especially when applying the British norms. Up to 15.68% of the healthy children fell within the "intellectually impaired" range, and up to 62.5% fell "below average," with these percentages especially higher at older ages.

CONCLUSIONS

Our findings confirm that "culture-free" tests should be adapted to each culture and applied together with their culture's specific norms to prevent misclassification and allow for a better, unbiased neuropsychological assessment.

Brief version of the CAMCOG for illiterate older adults with Alzheimer's dementia

BACKGROUND

The Cambridge Cognition Examination (CAMCOG) is one of the most used cognitive assessment batteries for older adults.

OBJECTIVE

To evaluate a brief version of the CAMCOG for illiterate older adults (CAMCOG-BILL) with Alzheimer's dementia (AD) and healthy controls (CG).

METHODS

Cross-sectional case-control study with 246 illiterate older adults (AD [n=159] and CG [n=87], composed by healthy seniors without cognitive complaints) who never attended school or took reading or writing lessons. Diagnosis of AD was established based on the NIA-AA and DSM-5 criteria. All participants were assessed with the CAMCOG by a researcher blinded for diagnosis. To assess the consistency of the chosen CAMCOG-BILL sub-items, we performed a binary logistic regression analysis.

RESULTS

Both the CAMCOG and the CAMCOG-BILL had satisfactory psychometric properties. The area under the curve (AUC) was 0.932 (p<0.001) for the original version of CAMCOG and 0.936 for the CAMCOG-BILL. Using a cut-off score of ≥60 (CAMCOG) and ≥44 (CAMCOG-BILL), both instruments had the same sensitivity and specificity (89 and 96%, respectively).

CONCLUSION

The CAMCOG-BILL may be a preferred tool because of the reduced test burden for this vulnerable subgroup of illiterate patients with dementia.

Associations Between Loneliness, Reading Ability and Episodic Memory in Non-Hispanic Black and White Older Adults

OBJECTIVE

Reading ability reflects a variety of beneficial life course exposures and may better index these exposures above and beyond education in racially diverse samples. Growing evidence suggests a negative impact of perceived loneliness on late-life cognitive health when parsing out the effect of other aspects of social relations. Few studies have examined how loneliness interacts with the reading ability or whether it operates differently in Black older adults who have higher dementia risk than Whites.

METHODS

Participants in this cross-sectional study were drawn from the Washington Heights-Inwood Columbia Aging Project (n = 425 older adults, Mage = 74.23; 58% Black). Linear regressions estimated the main effects and interactions involving reading ability, loneliness, and race (non-Hispanic Black vs. non-Hispanic White) on episodic memory, controlling for age, sex/gender, and years of education. Subsequent models additionally controlled for income, employment status, depressive symptoms, disease burden, marital status, social network size, and number of social groups.

RESULTS

Higher reading ability was associated with better memory, but loneliness was not associated with memory. The positive association between reading ability and memory was weaker among individuals with greater loneliness, and this interaction did not differ by race.

CONCLUSIONS

Loneliness may suppress the protective effect of higher reading ability on cognitive health among both Black and White older adults. Future longitudinal work is needed to clarify causal relationships among loneliness, reading ability, and memory decline.

Engagement of Language and Domain General Networks during Word Monitoring in a Native and Unknown Language

Functional neuroimaging studies have highlighted the roles of three networks in processing language, all of which are typically left-lateralized: a ventral stream involved in semantics, a dorsal stream involved in phonology and speech production, and a more dorsal "multiple demand" network involved in many effortful tasks. As lateralization in all networks may be affected by life factors such as age, literacy, education, and brain pathology, we sought to develop a task paradigm with which to investigate the engagement of these networks, including manipulations to selectively emphasize semantic and phonological processing within a single task performable by almost anyone regardless of literacy status. In young healthy participants, we administered an auditory word monitoring task, in which participants had to note the occurrence of a target word within a continuous story presented in either their native language, Portuguese, or the unknown language, Japanese. Native language task performance activated ventral stream language networks, left lateralized but bilateral in the anterior temporal lobe. Unfamiliar language performance, being more difficult, activated left hemisphere dorsal stream structures and the multiple demand network bilaterally, but predominantly in the right hemisphere. These findings suggest that increased demands on phonological processing to accomplish word monitoring in the absence of semantic support may result in the bilateral recruitment of networks involved in speech perception under more challenging conditions.

Neuropsychological rehabilitation, neuroimaging and neuroplasticity: A clinical commentary

Initial brain imaging studies on recovery of motor functioning after stroke suggested their potential prognostic value in neurorehabilitation. However, the value of brain imaging in documenting brain changes associated with cognitive and behavioral treatment effects seem less likely. Also, neuroimaging studies at that time seem to have little, if any, value for treatment planning. Advances in neuroimaging technology are beginning to challenge these initial impressions. In this clinical commentary, we propose that advances in the field of neuroimaging have relevance for the future development of neuropsychological rehabilitation. Neuropsychological rehabilitation is entering a new era that involves collaboration with neuroimaging and associated studies on neuroplasticity. We recognize that this may seem “aspirational” rather than practical in most rehabilitation settings. However, we provide examples of how this can be achieved as illustrated by collaborative efforts of clinicians and scientists in the SARAH Network of Rehabilitation Hospitals in Brazil. We also review selective papers on neuroplasticity, spontaneous recovery and diaschisis that have relevance for research which will expand and further develop the field of neuropsychological rehabilitation.

The Neuropsychological Profile of Severe and Enduring Anorexia Nervosa: A Systematic Review

Characteristics of Severe and Enduring Anorexia Nervosa (SE-AN) are being investigated to differentiate the patients experiencing SE-AN from those at earlier stages of the AN disease. The current systematic review was the first step in exploring neuropsychological functioning as a potentially identifying characteristic for long-term presentations. With a subgroup of AN patients reflecting a unique neuropsychological profile that is proportionate to the quantity of patients that go on to develop SE-AN, it was the aim of this review to assess neuropsychological functioning in the later stage of the disease. In accordance with PRISMA guidelines, a literature search was conducted using four electronic databases (PsycINFO, MEDLINE, Web of Science, and Scopus) for neuropsychological research on AN participants with a seven or more year illness duration. Datasets that met inclusion criteria were screened for SE-AN participants (N = 166) and neuropsychological data extracted together with potentially confounding variables and information required to conduct a quality assessment. In research investigating decision-making, participants with a SE-AN presentation demonstrated significantly lower functioning compared to healthy controls. There was conflicting evidence for differences in intellectual functioning and set-shifting abilities with no variability indicated in central coherence, memory, attention, reasoning, or processing speed. If findings from this preliminary analysis are confirmed through empirical research, implications include earlier identification of SE-AN patients and more effective treatment development.

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.

Cross-cultural neuropsychological assessment in the European Union: a Delphi expert study

OBJECTIVE

The increasing ethnic diversity in the European Union (EU) calls for adaptations to neuropsychological assessment practices. The aims of this study were to examine the current state of cross-cultural neuropsychological assessment in EU-15 countries and to provide recommendations for researchers and policy makers.

METHOD

Twelve experts from nine EU-15 countries participated in a Delphi consensus study involving two sequential rounds of web-based questionnaires and an in-person consensus meeting. The experts individually rated Delphi topics on the basis of importance (scale 1-10). The degree of consensus was determined by assessing first and third quartiles (Q1 and Q3) and medians.

RESULTS

Consensus outcomes showed the following priorities: (a) the development of tests (median importance rating 10, Q1-Q3: 9-10), (b) the collection of normative data (median importance rating 9, Q1-Q3: 8-10), and (c) more training, awareness, and knowledge regarding cross-cultural assessment among neuropsychologists in the EU (median importance rating 9, Q1-Q3: 8-10). Whereas memory tests were often available, tests measuring social cognition (median 9, Q1-Q3: 8-10) and language (median 9, Q1-Q3: 7-10) are particularly lacking. Recommendations were made regarding essential skills and knowledge necessary for cross-cultural neuropsychological assessment.

CONCLUSIONS

This study in a small group of experts suggests that the development and availability of cross-cultural tests and normative data should be prioritized, as well as the development and implementation of training initiatives. Furthermore, EU guidelines could be established for working with interpreters during neuropsychological assessment. Before implementing these recommendations, follow-up studies are recommended that include more minority neuropsychologists and community stakeholders.

Diagnostic Accuracy of Usual Cognitive Screening Tests Versus Appropriate Tests for Lower Education to Identify Alzheimer Disease

INTRODUCTION

The accuracy of commonly used screening tests for Alzheimer's disease (AD) has not been directly compared to those that could be more appropriate for lower schooling.

OBJECTIVE

To compare the diagnostic accuracy of usual screening tests for AD with instruments that might be more appropriate for lower schooling among older adults with low or no literacy.

METHODS

The study included a clinical sample of 117 elderly outpatients from a Geriatric Clinic classified as literate controls (n = 39), illiterate controls (n = 30), literate AD (n = 30) and illiterate AD (n = 18). The tests were compared as follows: Black and White versus Colored Figure Memory Test; Clock Drawing Test versus Clock Reading Test; Verbal Fluency (VF) animal versus grocery category; CERAD Constructional Praxis versus Stick Design Test.

RESULTS

The means of literate and illiterate controls did not differ in the Black and White Figure Memory Test (immediate recall), Colored Figure Memory Test (delayed recall), Clock Reading Test and VF animals and grocery categories. The means of the clinical groups (controls versus AD), in the 2 schooling levels, differed significantly in most of the tests, except for the CERAD Constructive Praxis and the Stick Design Test. Diagnostic accuracy was not significantly different between the compared tests.

CONCLUSION

Commonly used screening tests for AD were as accurate as those expected to overcome the education bias in a sample of older adults with lower or no education.

Effects of Acculturation on the Cross-Cultural Neuropsychological Test Battery (CNTB) in a Culturally and Linguistically Diverse Population in Denmark

OBJECTIVE

Assessment of individuals from diverse ethnic backgrounds is a major challenge in current clinical neuropsychology as most neuropsychological tests are biased by linguistic, educational, and cultural differences. The aim of this study was to examine the effects of acculturation on the newly developed European Cross-Cultural Neuropsychological Test Battery.

METHOD

The study was a cross-sectional study carried out in Copenhagen, Denmark. Neuropsychological test performances of a Danish sample were compared to a culturally and linguistically diverse sample, and the effects of a number of acculturation variables were assessed using group comparisons, correlation analyses, and regression analyses.

RESULTS

A total of 152 participants were included in the study: 26 were native-born monolingual Danes and 126 had culturally and linguistically diverse backgrounds: 66 were immigrants from Turkey, 41 from Poland, and 19 from former Yugoslavia. In direct comparison, the only significant difference between the Danish and culturally and linguistically diverse samples was found on Animal Fluency. However, within the culturally and linguistically diverse sample, higher and lower acculturated groups significantly differed on several measures. The main associations between neuropsychological test performance and acculturation variables were found on measures loading on processing speed and executive function.

CONCLUSIONS

Overall, only limited effects of acculturation were found on the European Cross-Cultural Neuropsychological Test Battery. However, administering cross-cultural measures in the preferred language may not be sufficient to resolve challenges in cross-cultural assessment of processing speed and executive function as concept of speed and speeded performance is highly culture dependent.