Contributing Towards a Cultural Neuropsychology Assessment Decision-Making Framework: Comparison of WAIS-IV Norms from Colombia, Chile, Mexico, Spain, United States, and Canada

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.

Assessing harmonized intelligence measures in a multinational study

Studies examining the neurocognitive and circuit-based etiology of psychiatric illness are moving toward inclusive, global designs. A potential confounding effect of these associations is general intelligence; however, an internationally validated, harmonized intelligence quotient (IQ) measure is not available. We describe the procedures used to measure IQ across a five-site, multinational study and demonstrate the harmonized measure's cross-site validity. Culturally appropriate intelligence measures were selected: four short-form Wechsler intelligence tests (Brazil, Netherlands, South Africa, United States) and the Binet Kamat (India). Analyses included IQ scores from 255 healthy participants (age 18-50; 42% male). Regression analyses tested between-site differences in IQ scores, as well as expected associations with sociodemographic factors (sex, socioeconomic status, education) to assess validity. Harmonization (e.g., a priori selection of tests) yielded the compatibility of IQ measures. Higher IQ was associated with higher socioeconomic status, suggesting good convergent validity. No association was found between sex and IQ at any site, suggesting good discriminant validity. Associations between higher IQ and higher years of education were found at all sites except the United States. Harmonized IQ scores provide a measure of IQ with evidence of good validity that can be used in neurocognitive and circuit-based studies to control for intelligence across global sites.

An examination of the validity of neuropsychological and physical testing batteries in Latin-American adults aged over 55 years

BACKGROUND

Valid and reliable measurements are necessary to understand and monitor age-related changes.

AIMS

To describe the factor structure and provide validity evidence of a neuropsychological and a physical testing batteries using factor analysis.

METHODS

We performed a secondary analysis of data from the Epidemiology and Development of Alzheimer's Disease (EDAD) project. Community-dwelling adults aged 55 to 85 years underwent comprehensive physical and neuropsychological assessments. An exploratory factor analysis was performed on both assessment batteries. The models were later confirmed with a random subsample using confirmatory factor analysis.

RESULTS

Data from 238 adults (163 females and 75 males) was included. The neuropsychological model revealed a four-factor structure formed by "Executive Functioning", "Verbal Memory", "Logical Memory", and "Labeling And Reading" (Extraction Sums of Squared Loadings [ESSL] = 56.41% explained variance; Standardized Root Mean Square Residual [SRMSR] = 0.06; Comparative Fit Index [CFI] = 0.98). The physical model was formed by a two-factor structure including "Health-related Fitness and "Functional Fitness" (ESSL = 50.54% explained variance; SRMSR = 0.07; CFI = 0.93).

DISCUSSION

To our knowledge, this is the first study to analyze the structure of comprehensive testing batteries for the Latin-American older adults. Our analysis contributes to the understanding of theoretical constructs that are evaluated in the EDAD project.

CONCLUSION

Our findings provide validity evidence for simplified and reduced testing batteries, which imply shorter testing times and fewer resources.

Integrating Technology in Neuropsychological Assessment

Abstract. Although neuropsychological assessments include some measures that are administered, scored, or interpreted using new technologies, most researchers in this area advocate that more technology should be integrated. The current situation in neuropsychological assessment may be conceptualized as triggering a crisis leading to a paradigm shift, as there is some resistance to adopting more technology. In this paper, the context of the present crisis in neuropsychological assessment, the main obstacles, and new developments will be discussed. An example of a new computerized assessment tool, the NIH Toolbox, is highlighted. Also addressed are potential issues: in the assessment with tablets illustrating it with the older adult population and how to ensure the compatibility of data collected through these devices within the framework of the European General Data Protection Regulation (GDPR). Recommendations for research, test development, and clinical practice are also provided.

Computerized Block Games for Automated Cognitive Assessment: Development and Evaluation Study (Preprint)

BACKGROUND

Cognitive assessment using tangible objects can measure fine motor and hand-eye coordination skills along with other cognitive domains. Administering such tests is often expensive, labor-intensive, and error prone owing to manual recording and potential subjectivity. Automating the administration and scoring processes can address these difficulties while reducing time and cost. e-Cube is a new vision-based, computerized cognitive assessment tool that integrates computational measures of play complexity and item generators to enable automated and adaptive testing. The e-Cube games use a set of cubes, and the system tracks the movements and locations of these cubes as manipulated by the player.

OBJECTIVE

The primary objectives of the study were to validate the play complexity measures that form the basis of developing the adaptive assessment system and evaluate the preliminary utility and usability of the e-Cube system as an automated cognitive assessment tool.

METHODS

This study used 6 e-Cube games, namely, Assembly, Shape-Matching, Sequence-Memory, Spatial-Memory, Path-Tracking, and Maze, each targeting different cognitive domains. In total, 2 versions of the games, the fixed version with predetermined sets of items and the adaptive version using the autonomous item generators, were prepared for comparative evaluation. Enrolled participants (N=80; aged 18-60 years) were divided into 2 groups: 48% (38/80) of the participants in the fixed group and 52% (42/80) in the adaptive group. Each was administered the 6 e-Cube games; 3 subtests of the Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV; Block Design, Digit Span, and Matrix Reasoning); and the System Usability Scale (SUS). Statistical analyses at the 95% significance level were applied.

RESULTS

The play complexity values were correlated with the performance indicators (ie, correctness and completion time). The adaptive e-Cube games were correlated with the WAIS-IV subtests (r=0.49, 95% CI 0.21-0.70; P<.001 for Assembly and Block Design; r=0.34, 95% CI 0.03-0.59; P=.03 for Shape-Matching and Matrix Reasoning; r=0.51, 95% CI 0.24-0.72; P<.001 for Spatial-Memory and Digit Span; r=0.45, 95% CI 0.16-0.67; P=.003 for Path-Tracking and Block Design; and r=0.45, 95% CI 0.16-0.67; P=.003 for Path-Tracking and Matrix Reasoning). The fixed version showed weaker correlations with the WAIS-IV subtests. The e-Cube system showed a low false detection rate (6/5990, 0.1%) and was determined to be usable, with an average SUS score of 86.01 (SD 8.75).

CONCLUSIONS

The correlations between the play complexity values and performance indicators supported the validity of the play complexity measures. Correlations between the adaptive e-Cube games and the WAIS-IV subtests demonstrated the potential utility of the e-Cube games for cognitive assessment, but a further validation study is needed to confirm this. The low false detection rate and high SUS scores indicated that e-Cube is technically reliable and usable.

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.

Neurocognitive Profiles Associated With Limited English Proficiency in Cognitively Intact Adults

OBJECTIVE

The objective of the present study was to examine the neurocognitive profiles associated with limited English proficiency (LEP).

METHOD

A brief neuropsychological battery including measures with high (HVM) and low verbal mediation (LVM) was administered to 80 university students: 40 native speakers of English (NSEs) and 40 with LEP.

RESULTS

Consistent with previous research, individuals with LEP performed more poorly on HVM measures and equivalent to NSEs on LVM measures-with some notable exceptions.

CONCLUSIONS

Low scores on HVM tests should not be interpreted as evidence of acquired cognitive impairment in individuals with LEP, because these measures may systematically underestimate cognitive ability in this population. These findings have important clinical and educational implications.

Preseason Baseline Neurocognitive Performances and Symptom Reporting on Immediate Post-Concussion Assessment and Cognitive Testing: A Comparison of Adolescent Student-Athletes Tested in Spanish and English

CONTEXT

Student-athletes are commonly administered the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery at preseason baseline and postconcussion. The ImPACT is available in many languages, but few researchers have examined differences in cognitive performances and symptom ratings based on the language of administration.

OBJECTIVE

To examine differences in ImPACT neurocognitive composites and symptom reporting at preseason baseline testing between student-athletes who completed ImPACT in Spanish versus English.

DESIGN

Cross-sectional study.

SETTING

Preseason baseline testing for a high school concussion-management program in Maine.

PATIENTS OR OTHER PARTICIPANTS

Adolescent student-athletes who completed testing in Spanish (n = 169) and English (n = 169) were matched on age, gender, and health and academic history. Language groups were compared on each outcome for the full sample and for gender-stratified subsamples.

MAIN OUTCOME MEASURE(S)

Neurocognitive composite scores and individual and total symptom severity ratings from the ImPACT battery.

RESULTS

Athletes tested in Spanish displayed lower levels of neurocognitive performance on 2 of 5 composite scores (visual motor speed: P < .001, d = 0.51; reaction time: P = .004, d = 0.33) and reported greater symptom severity (P < .001, r = 0.21). When the analyses were stratified by gender, similar visual motor speed differences were observed between language groups among boys (P = .001, d = 0.49) and girls (P = .001, d = 0.49), whereas reaction time showed a larger group difference for boys (P = .012, d = 0.42) than for girls (P = .128, d = 0.21). Language-group differences in symptom reporting were similar for boys (P = .003, r = 0.22) and girls (P = .008, r = 0.21), with more frequent endorsement of physical and affective symptoms by athletes tested in Spanish.

CONCLUSIONS

Language-group differences in total symptom severity were small (r = 0.21) and in neurocognitive performances were small to medium (d = 0.05-0.51). Versus previous authors who compared athletes tested in Spanish and English with ImPACT, we observed smaller effects, which may be attributable to close matching on variables related to neurocognitive performances and symptom reporting.

Regression-Based Norms for the Hopkins Verbal Learning Test-Revised and the Rey-Osterrieth Complex Figure in a Portuguese Adult Population

OBJECTIVE

The principal goal of this study was to produce adjusted normative data for European Portuguese native speakers from Portugal on 2 neuropsychological tests widely used to assess learning and memory: the Hopkins Verbal Learning Test-Revised (HVLT-R) and the Rey-Osterrieth Complex Figure Test (ROCF).

METHOD

The study included 300 individuals aged 18-92 years (M = 50.4, SD = 21.2), who had educational backgrounds ranging from 3 to 25 years (M = 10.4, SD = 5.2).

RESULTS

Age, education, and sex were significantly associated with HVLT-R and ROCF performance. These demographic variables accounted for 61% of the variance in HVLT-R total recall, 54% in HVLT-R delayed recall, 18% in HVLT-R recognition, 55% in ROCF copy, and 39% in ROCF immediate recall.

CONCLUSIONS

The normative data are presented as regression-based algorithms to adjust direct and derived test scores for age, education, and sex. This study provides a calculator of normative data derived from the results of the regression models.

On the importance of using local tests and local norms in the assessment of memory

The current study compared the assessment of memory with a translated story recall test and its original published norms and an equivalent local test with local norms. Analyses used data from 232 individuals with memory complaints who underwent neuropsychological evaluation at an outpatient memory clinic. One group of participants completed a translated test (N = 126) and another group completed a local test (N = 106). Additionally, participants completed tasks of word list recall, picture naming, and verbal fluency, all having local norms. The results showed that raw scores on the delayed story recall test, and on all other cognitive tasks, did not differ across groups, and the cross-task correlations were significant and similar in size in both groups. Yet, there was an interaction between group and standardized tests scores, whereby the standardized scores on the translated story recall test were equivalent to population mean, whereas all other scores fell below the mean. Conversion of raw scores to the original norms indicated that the performance of individuals with memory complaints was intact, while conversion of scores on a local test to local norms revealed the expected memory impairment. The findings highlight the importance of using local tests and local norms in the assessment of memory.

Demographically-adjusted norms for the processing speed subtests of the WAIS-III in a Spanish-speaking adult population: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) project

OBJECTIVE

The Wechsler Adult Intelligence Scale (WAIS) processing speed subtests are among the most ubiquitous indices of processing speed in the field. The aim of this study was to develop and examine demographically-adjusted normative data for Spanish language versions of the WAIS-III Digit Symbol Coding (DSC) and Symbol Search (SS) subtests for US-dwelling Spanish-speakers living in the US/Mexico border region.

METHODS

The sample included 203 healthy participants who were part of the larger Neuropsychological Norms for the US-Mexico Border Region in Spanish (NP-NUMBRS) project (DSC: n = 201; SS: n = 200).

RESULTS

Older age and higher education were both related to lower scores on the DSC and SS subtests (all ps < .0001). There were no significant effects for gender (all ps > .05). Raw-to-scaled score conversions were calculated for both subtests, and fractional polynomial equations were derived to compute demographically-adjusted T-scores accounting for age, education, and gender for each subtest and the Processing Speed Index. Published norms for English-speaking non-Hispanic white adults slightly overestimated impairment rates (T-scores <40) on both the DSC and SS subtests, while the norms for English-speaking non-Hispanic Black/African Americans and the new NP-NUMBRS norms Spanish-speakers both yielded impairment rates that fell within expected limits for healthy controls (i.e. 13%-14%).

CONCLUSIONS

This study suggests that population-specific normative data can improve the diagnostic validity of these measures for U.S.-dwelling Spanish-speakers living in the US/Mexico border region. Future research is needed to investigate the utility of these norms for other U.S.-dwelling Spanish-speaking subpopulations (e.g. Caribbean, Central American, South American).

Normative data of neuropsychological tests of attention and executive functions in Ecuadorian adult population

OBJECTIVE

The purpose of this study was to generate normative data for five tests of attention and executive functions (M-WCST, Stroop test, TMT, BTA, and SDMT), in a group of 322 Ecuadorian adults from Quito between the ages of 18 and 85.

METHOD

Multiple regression analyzes taking into account age, education, and gender were used to generate the normative data.

RESULTS

Age and education were significantly related to test performance such that scores decreased with age and improved as a function of education. An online calculator is provided to generate normative test scores.

CONCLUSIONS

This is the first study that presents normative data for tests of executive functions and attention in an Ecuadorian adult population. This data will improve the clinical practice of neuropsychology and help to develop the field in the country.

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.

Validation of the Latin American Spanish version of the face-name associative memory exam in a Colombian Sample

OBJECTIVE

The Face-Name Associative Memory Exam (FNAME) has been used to detect subtle cognitive changes in clinically normal older adults at increased risk for Alzheimer's disease. FNAME assesses learning and delayed recall for face-name pairs. The aim of this study is to introduce a Latin American Spanish version of the FNAME (LAS-FNAME), examine its psychometric properties, and provide preliminary normative data in a sample of clinically normal, Spanish-speaking individuals from Antioquia, Colombia.

METHOD

59 clinically-normal individuals (71% females) were recruited by the Grupo de Neurociencias in Antioquia (Colombia). Age ranged from 27 to 82 years (M = 50.31, SD = 15.32) and years of education ranged from 2 to 17 years (M = 9.02, SD = 4.11). All participants completed the LAS-FNAME and a brief neuropsychological evaluation. We examined associations between age, education, and sex and performance on the LAS-FNAME. Internal consistency, convergent and discriminant validity were also assessed. Test-restest reliability was computed for a subset of participants (n = 32).

RESULTS

LAS-FNAME exhibited moderate convergent validity with other memory measures (Free and Cued Selective Reminding Scale, r _s=.465, p<.01; Wechsler Memory Scale III - Logical Memory Delayed Recall, r _s=.479, p<.01). The subscales of the LAS-FNAME exhibited adequate internal consistency (α=.825). Test-retest reliability analyses demonstrated consistency of scores over time. Normative data was stratified by age (<50, 50-65, >65) and low and high educational attainment (≤8 and >8 years of education, respectively).

CONCLUSIONS

The LAS-FNAME is a valid and reliable measure to assess memory in clinically normal, Spanish-speaking individuals from Colombia for clinical and research purposes.

Age, education and gender effects on Wisconsin card sorting test: standardization, reliability and validity in healthy Argentinian adults

The Wisconsin Card Sorting Test (WCST) is a widely used neuropsychological assessment of executive functioning. The aim of this study was to provide norm values and analyze the psychometric properties of WCST in healthy Argentinian adults aged from 18 to 89 years old (N = 235). Descriptive statistics are reported as means, standard deviations and percentiles, with the effects of age, education and gender being investigated by ANOVA, and with the effect sizes being calculated. The psychometrics were studied using the WCST structure, reliability, convergent validity, and discriminant validity, and WCST norms adjusted for age and educational level are proposed. This instrument is a reliable and valid tool for the assessment of executive functions. However, as the age- and educational-related effects were demonstrated, these characteristics need to be considered before interpreting WCST scores. Regarding gender, no differences were found. Our results expand the geographical and sociocultural applicability of WCST.