Ethical Issues in Cross-Cultural Neuropsychology

Culturally-informed neuropsychological evaluations of patients with spina bifida: Application of the ECLECTIC framework to a complex pediatric medical condition

Objective: The pediatric patient populations in the United States are becoming increasingly diverse in culture. In addition to medical factors, a variety of sociocultural factors (including educational systems, language, immigration status, etc.) can impact a child's cognitive development, performance on traditional neuropsychological measures, provider interactions, differential diagnosis, and recommendations. A culturally-informed neuropsychological evaluation aims to understand the impact of sociocultural factors and integrate them into the assessment approach. Fujii's ECLECTIC framework (acronym for Education & Literacy, Culture/Acculturation, Language, Economic Issues, Communication Style, Testing Situation, Intelligence Conceptualization, and Context of Immigration) can be used to guide culturally-informed neuropsychological evaluations of children with complex medical conditions. Method: Using the ECLECTIC framework, this paper describes clinical considerations and offers practical solutions for providing culturally-informed pediatric neuropsychology evaluations. Four diverse patients with spina bifida are reviewed. Results: The case presentations highlight the application of the ECLECTIC framework within a medically complex pediatric patient population. Conclusions: Spina bifida is one example of a pediatric medical population in which both medical and sociocultural factors can impact cognitive development and the evaluation process. The ECLECTIC framework defines a variety of sociocultural factors that can influence cognitive development and multiple aspects of a pediatric neuropsychological evaluation. Pediatric neuropsychologists should use the ECLECTIC framework to provide culturally-informed evaluations for our increasingly diverse patient populations.

Psychometric reliability, validity, and generalizability of 3MSE scores among American Indian adults: the Strong Heart Study

OBJECTIVE

Modified Mini-Mental State Examination (3MSE) is often used to screen for dementia, but little is known about psychometric validity in American Indians.

METHODS

We recruited 818 American Indians aged 65-95 for 3MSE examinations in 2010-2013; 403 returned for a repeat examination in 2017-2019. Analyses included standard psychometrics inferences for interpretation, generalizability, and extrapolation: factor analysis; internal consistency-reliability; test-retest score stability; multiple indicator multiple cause structural equation models.

RESULTS

This cohort was mean age 73, majority female, mean 12 years education, and majority bilingual. The 4-factor and 2nd-order models fit best, with subfactors for orientation and visuo-construction (OVC), language and executive functioning (LEF), psychomotor and working memory (PMWM), verbal and episodic memory (VEM). Factor structure was supported for both research and clinical interpretation, and factor loadings were moderate to high. Scores were generally consistent over mean 7 years. Younger participants performed better in overall scores, but not in individual factors. Males performed better on OVC and LEF, females better on PMWM. Those with more education performed better on LEF and worse on OVC; the converse was true for bilinguals. All differences were significant, but small.

CONCLUSION

These findings support use of 3MSE for individual interpretation in clinic and research among American Indians, with moderate consistency, stability, reliability over time. Observed extrapolations across age, sex, education, and bilingual groups suggest some important contextual differences may exist.

Comparing Cognitive Tests and Smartphone-Based Assessment in 2 US Community-Based Cohorts

BACKGROUND

Smartphone-based cognitive assessments have emerged as promising tools, bridging gaps in accessibility and reducing bias in Alzheimer disease and related dementia research. However, their congruence with traditional neuropsychological tests and usefulness in diverse cohorts remain underexplored.

METHODS AND RESULTS

A total of 406 FHS (Framingham Heart Study) and 59 BHS (Bogalusa Heart Study) participants with traditional neuropsychological tests and digital assessments using the Defense Automated Neurocognitive Assessment (DANA) smartphone protocol were included. Regression models investigated associations between DANA task digital measures and a neuropsychological global cognitive Z score (Global Cognitive Score [GCS]), and neuropsychological domain-specific Z scores. FHS participants' mean age was 57 (SD, 9.75) years, and 44% (179) were men. BHS participants' mean age was 49 (4.4) years, and 28% (16) were men. Participants in both cohorts with the lowest neuropsychological performance (lowest quartile, GCS1) demonstrated lower DANA digital scores. In the FHS, GCS1 participants had slower average response times and decreased cognitive efficiency scores in all DANA tasks (P<0.05). In BHS, participants in GCS1 had slower average response times and decreased cognitive efficiency scores for DANA Code Substitution and Go/No-Go tasks, although this was not statistically significant. In both cohorts, GCS was significantly associated with DANA tasks, such that higher GCS correlated with faster average response times (P<0.05) and increased cognitive efficiency (all P<0.05) in the DANA Code Substitution task.

CONCLUSIONS

Our findings demonstrate that smartphone-based cognitive assessments exhibit concurrent validity with a composite measure of traditional neuropsychological tests. This supports the potential of using smartphone-based assessments in cognitive screening across diverse populations and the scalability of digital assessments to community-dwelling individuals.

Ethical issues in clinical neuropsychology: International diversity perspectives

OBJECTIVE

Much of the information about the ethical practice of clinical neuropsychology has focused on North America. Additionally, of the scholarly publications on the intersection of ethical issues and cultural diversity practices in neuropsychology, most have focused on North America. The extent to which practitioners in other parts of the world are aware of, and find useful, such information is largely unknown. Similarly, the extent to which North American neuropsychologists are familiar with ethical issues and challenges encountered around the world is unknown. The purpose of this article is to advance the discussion of ethical issues in clinical neuropsychology from an international diversity perspective.

METHOD

The article presents, via a panel interview format, the thoughts and experiences of a small sample of neuropsychologists who represent all continents except North America (and Antarctica).

RESULTS

Neuropsychologists across continents share an ethical commitment to providing services that are beneficial, and not harmful, to the recipients of the services. Professional competence is at the heart of such services.

CONCLUSIONS

Through continued and expanded dialogue about ethical issues with neuropsychology colleagues around the world, the potential exists for improvement in the provision of effective and compassionate care in our own towns.

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.

Evaluating memory testing to distinguish dementia severity among White, Black, and Spanish-speaking individuals in the Uniform Data Set (UDS)

INTRODUCTION

Little work has compared the effectiveness of using multiple types of memory tests alone or in combination to distinguish dementia severity in diverse research cohorts including Black individuals and Spanish speakers. Here we evaluate word list and paragraph recall tests to distinguish cognitively normal, mild cognitively impaired, and those with Alzheimer's disease in diverse cohorts.

METHODS

Using Uniform Data Set (UDS) and site-specific supplemental data, logistic regression models and receiver operating characteristic-area under the curve were used to compare paragraph recall versus word list in differentiating among Clinical Dementia Rating (CDR) scale level.

RESULTS

Results reveal high discriminability for all groups and no difference between either test in distinguishing between CDR levels. Combining tests improved discriminability for the whole group but did not for Black individuals or Spanish speakers.

DISCUSSION

Our findings indicate that using multiple memory tests may not improve differentiation between cognitive impairment levels for diverse cohorts. The burden of added testing may be a barrier for maximizing inclusion of under-represented groups in research.

Impact of Family Function on the Quality of Life and Health Perception of Non-Institutionalized Dementia Patients

BACKGROUND

Dementia is one of the pathologies that has increased the most among the older population (mainly Alzheimer's disease), and it has a direct impact on the quality of life (QoL), cognitive performance, and health of these patients. Family functionality can play a role in this QoL if these patients are not institutionalized.

OBJECTIVE

To analyze the role of family function in the QoL and health perception of non-institutionalized dementia patients, as well as related variables such as anxiety, depression, optimism, or pessimism.

METHODS

Cross-sectional study with a sample of 54 patients diagnosed with some type of dementia, non-institutionalized, or in outpatient care, from different centers in the province of Valencia (Spain). The EQ-5D, MMSE, Apgar Family or general health, and Goldberg anxiety and depression questionnaires were utilized.

RESULTS

The correlation of the Apgar Family with the General Health Questionnaire-new onset problems variable (GHQ) and Chronicity and General Health Questionnaire-chronic problems (CGHQ) of the Goldberg Quality of Life questionnaire was statistically significant and negative (GHQ r = -0.310; p = 0.034. CGHQ r = -0.363; p = 0.012); as well as between Apgar Family and Anxiety-Depression (r = -0.341; p = 0.020). The correlation of the Apgar Family with the Life Orientation Test-Pessimism variable (LOT) was statistically significant and negative (r = -0.270; p = 0.061). Finally, severe dysfunction of Apgar Family has a negative correlation with self-perception of health (p = 0.036 B = -16.589) determined by the Visual Analogue Scale (VAS).

CONCLUSION

Family functionality directly influences anxiety, depression, optimism, and pessimism. This could explain why family function is related to the QoL of patients and their self-perception of health.

Regulatory issues and ethical considerations in cross-cultural neuropsychology with a special emphasis on Limited English Proficiency

Regulations addressing provision of healthcare services to individuals from diverse cultures and with limited English proficiency (LEP) are reviewed and balanced against ethical considerations with respect to a provider's competency in conducting such services. Federal regulations require providers at institutions receiving Federal financial assistance to provide services to individuals without allowing factors such as LEP to act as barriers to those services. However, regulations addressing these factors are not absolute, and must be applied reasonably, with respect to: the number of individuals who speak a particular language in an area, the criticalness of the services, and the costs to and resources of the provider's institution. Thresholds based on numbers of individuals speaking a language requiring provision of language assistance services are reviewed. It is also noted that a provider's competency in conducting a particular service to patients from diverse backgrounds may be factored as a resource, while accessing appropriate tools and knowledge to provide services to a particular group may be factored as a cost. A review of relevant issues pertaining to competence in conducting cross-cultural evaluations with an emphasis on LEP is presented, followed by case samples in which potential conflicts between regulations and provider ethical obligations are resolved.

Measurement of Prevalent Versus Incident Dementia Cases in Epidemiologic Studies

Because dementia is progressive, incident cases are on average milder than prevalent cases, affecting the performance of cognitive tests and questions on functional limitations (i.e., cognition/functional limitation items) used for dementia assessment. Longitudinal studies assess incident cases, while cross-sectional studies assess prevalent cases, but differences are not typically considered when researchers select items to include in studies. We used longitudinal data from the Religious Orders Study and Memory and Aging Project (ROSMAP) (n = 3,446) collected between 1994 and 2021 to characterize differences in associations between items (cognition: 35 items; functional limitations: 14 items) and incident or prevalent dementia using multinomial regression models with generalized estimating equations, controlling for ROSMAP cohort (Religious Orders Study or Memory and Aging Project), age, sex, race, and education. The association between a given item and incident dementia was significantly weaker than the association between the same item and prevalent dementia for 46 of 49 items. However, there was variability, with larger differences for some items, including naming a pencil (prevalence odds ratio = 0.02 (95% confidence interval: 0.02, 0.03); incidence odds ratio = 0.10 (95% confidence interval: 0.06, 0.17); P for difference < 0.001). Important differences exist in the performance of cognition/functional limitation items for measurement of incident versus prevalent dementia. Differences can inform the choice of items for cross-sectional studies of prevalent cases or longitudinal studies of incident cases, leading to reduced misclassification and increased statistical power.

Development and psychometric evaluation of the Test of Practical Judgment alternate form (Form B)

The Test of Practical Judgment (TOP-J) is increasingly used by neuropsychologists to measure everyday judgment ability in older adulthood. In the present study, we developed an alternate TOP-J Form B, which may be used to reduce practice effects for repeat assessment situations or in place of the original Form A. In developing the measure, special attention was given to limiting cultural bias and making items similar in content and difficulty to Form A. The TOP-J Form B was piloted in a clinical geriatric sample (N = 77) in the Midwestern U.S. Subsequently, older adults (N = 130) were recruited from several boroughs of New York City and surrounding areas (mean age = 77; mean years of education = 16; 69% female; 28% Black/African-American, 11% Hispanic). In this validation sample, both the 9-item and 15-item versions of the TOP-J Form B showed strong psychometric properties, including good unidimensional model fit in confirmatory factor analysis, preliminary convergent/divergent and criterion validity evidence, and strong inter-rater reliability, ICC (2, 1) = .93. The means and standard deviations for the TOP-J Form A and Form B were highly similar, particularly for the 9-item forms in which there was less than a one-point mean difference. Preliminary normative data for cognitively intact participants (n = 73) were established. We present means and standard deviations that will allow for the calculation of z scores as Form B scores were normally distributed. The newly developed TOP-J Form B should be useful in diverse clinical and research settings.

Why a clinical trial is as good as its outcome measure: A framework for the selection and use of cognitive outcome measures for clinical trials of Alzheimer's disease

A crucial aspect of any clinical trial is using the right outcome measure to assess treatment efficacy. Compared to the rapidly evolved understanding and measurement of pathophysiology in preclinical and early symptomatic stages of Alzheimer's disease (AD), relatively less progress has been made in the evolution of clinical outcome assessments (COAs) for those stages. The current paper aims to provide a benchmark for the design and evaluation of COAs for use in early AD trials. We discuss lessons learned on capturing cognitive changes in predementia stages of AD, including challenges when validating novel COAs for those early stages and necessary evidence for their implementation in clinical trials. Moving forward, we propose a multi-step framework to advance the use of more effective COAs to assess clinically meaningful changes in early AD, which will hopefully contribute to the much-needed consensus around more appropriate outcome measures to assess clinical efficacy of putative treatments. HIGHLIGHTS: We discuss lessons learned on capturing cognitive changes in predementia stages of AD. We propose a framework for the design and evaluation of performance based cognitive tests for use in early AD trials. We provide recommendations to facilitate the implementation of more effective cognitive outcome measures in AD trials.

Formal Neuropsychological Testing: Test Batteries, Interpretation, and Added Value in Practice

Neuropsychologists evaluate patients for cognitive decline and dementia, using validated psychometric tests, along with behavioral observation, record review, clinical interview, and information about psychological functioning, to evaluate brain-behavior relationships and aid in differential diagnosis and treatment planning. Also considered are premorbid functioning, education, sex, socioeconomic status, primary language, culture, and race-related health disparities when selecting tests, interpreting performance, and providing a diagnostic impression. Neuropsychologists provide diagnostic clarity, explain symptoms and likely disease course to patients and family members, and assist the family with future planning, behavioral management strategies, and ways to mitigate caregiver burden.

Measurement of prospective memory in Spanish speakers

Introduction

This study aimed to provide preliminary evidence on the psychometric properties of a measure of prospective memory in Spanish speakers, the Memory for Intentions Test (MIST) Spanish translation.

Methods

In addition, this study investigated whether acculturation influenced performance on the MIST. Finally, we measured other cognitive factors that might be impacting the relationship between culture and prospective memory performance. These factors were working memory, autobiographical memory, and episodic future thought.

Results

Overall, the psychometric properties of the Spanish MIST appear to be similar to the English language MIST, but our sample size was too small to allow for the creation of a normative database. The MIST recognition item was significantly related to years of education and years of speaking either Spanish or English.

Discussion

This suggests a need to investigate ways to improve the test to eliminate these effects. In addition, acculturation was related to the measure of episodic future thought.

Understanding racial differences in computerized neurocognitive test performance and symptom-reporting to deliver culturally competent patient-centered care for sport-related concussion

OBJECTIVE

This study examined neurocognitive performance and symptoms between concussed Black and White collegiate athletes at baseline, post-injury, and change from baseline to post-injury.

METHOD

The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) was used to measure neurocognitive performance and four concussion symptom clusters for 235 concussed collegiate athletes. Between-groups differences were documented at baseline and post-injury, along with change in scores for sex/race, and sport/race groups, using ANOVAs. Baseline scores, and days-to-post-test were covariates in post-injury comparisons. Symptom endorsement by race was evaluated using chi-square analyses.

RESULTS

At baseline, group comparisons by race and sex showed that Black male/female athletes scored lower on reaction time (RT; p = .008), White females scored higher on verbal memory (VerbMem; p = .001), Black females scored lower on visual motor processing speed (VMS; p = .001), and Black football athletes scored slower/poorer on RT (p = .001) and VMS (p = .006). Post-injury, Black males scored lower on visual memory (VisMem; p = .005) and VMS (p = .002), and Black football athletes scored slower on VMS (p = .005), whereas White non-football athletes scored higher on VerbMem (p = .002) and reported fewer symptoms. Significant time-by-sport/race interactions were found for VerbMem (p < .001), VisMem (p < .001) and reported symptoms. With respect to post-injury symptom scores/endorsement, Black athletes scored significantly higher for physical (p = .01) and sleep (p = .01) symptoms.

CONCLUSION

These findings drive the conversation of how subjective measures of symptoms, and objective clinical concussion measures, may relate to the concussion recovery process and providing a culturally competent clinical management approach for diverse patients.

Evaluating construct and criterion validity of NeuroScreen in assessing neurocognition among hospitalized Ugandan first-episode psychosis patients

Introduction

Neurocognitive impairment (NCI) is commonly exhibited among patients experiencing their first episode of psychosis. However, there are few resources in many low-income countries, such as Uganda, that allow for the administration of extensive neurocognitive test batteries for the detection of NCI. NeuroScreen is a brief tablet-based neurocognitive assessment battery that can be administered by all levels of healthcare staff. We examined the validity of NeuroScreen to assess neurocognition and detect NCI in first-episode psychosis (FEP) patients in Uganda.

Methods

We enrolled 112 participants FEP patients and matched controls at Butabika Mental Referral Hospital. Each participant completed NeuroScreen and a traditionally administered neurocognitive battery: the MATRIC Consensus Cognitive Battery (MCCB). We examined correlations between participant performance on NeuroScreen and the MCCB. A ROC curve determined sensitivity and specificity of NeuroScreen to detect NCI as determined by MCCB criterion.

Results

There was a large, statistically significant correlation between overall performance on NeuroScreen and the MCCB [r(112) = 0.64, p < .001]. Small to large correlations were found between tests in the MCCB and NeuroScreen batteries. The ROC curve of NeuroScreen performance to detect MCCB-defined NCI had an area under curve of 0.80 and optimal sensitivity and specificity of 83 % and 60 %, respectively.

Conclusion

There was a moderate positive correlation between overall performance on both batteries. NeuroScreen shows promise as a valid assessment battery to assess neurocognition and detect NCI in FEP patients in Uganda. Further studies of NeuroScreen in healthy individuals and in a range of mental disorders are recommended.

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

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

Re-evaluation of psychometric evidence and update of normative data for the Test of Practical Judgment

ObjectiveThe Test of Practical Judgment (TOP-J) has shown utility in inpatient and outpatient settings in older adults who present with mild cognitive impairment and various dementia subtypes. The TOP-J has two versions (i.e. 9 items and 15 items), and was initially validated within a small rural non-Hispanic White sample. In the current study, we re-evaluated the psychometric evidence and refined scoring criteria and administration guidelines in older adults with more diverse demographic characteristics than the original validation sample. Method: Participants (N = 348) were recruited from several boroughs of New York City and surrounding areas (mean/median age = 79; mean years education = 15, median = 15.5; 68% female; 30% Black/African-American, 8% Hispanic). Results: Reliability and validity were comparable to original findings. Based on confirmatory factor analysis, one item was replaced on the 9-item version, now called TOP-J Form A. Normative data for cognitively intact participants (n = 261) were updated and stratified by two education groups. Conclusions: The TOP-J is increasingly used in clinical and research settings in the U.S. and abroad, and the current study provides improved normative data and administration and scoring guidelines for use with demographically diverse older individuals.

A normative study of the Color Trails Test in the adult Indian population

The Color Trails Test (CTT) is a neuropsychological measure assessing for frontal and executive functioning, while also minimizing the cultural and language barriers inherent in similar measures such as the Trail Making Test (TMT). This study establishes convergent validity for the CTT in the Indian population by comparing participant performance on the CTT and TMT. It also generates culturally appropriate normative data for CTT-Form A among the Indian adult population. Six-hundred and sixty-nine cognitively healthy, community-dwelling individuals between ages 18 and 69 participated in the study and were stratified based on age, gender, and educational attainment. Participant performance on the CTT and TMT were correlated to establish convergent validity. Strong correlation was found between TMT-A and CTT-1 (r = 0.61) and between TMT-B and CTT-2 (r = 0.66). An analysis of variance test was used to determine the mean and standard deviation for each stratified participant group. Further analysis found that age and educational attainment significantly impact participant performance on CTT-1 [F(4, 649) = 4.395, p = 0.002], whereas gender, age, and educational attainment significantly impact participant performance on CTT-2 [F(4,649) = 2.446, p = 0.045]. Normative data generated from this study has important clinical implications and contributes to the growing body of culturally appropriate normative data available for the Indian population.

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

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

Assessment of Neurocognitive Functions, Olfaction, Taste, Mental, and Psychosocial Health in COVID-19 in Adults: Recommendations for Harmonization of Research and Implications for Clinical Practice

OBJECTIVE

To propose a set of internationally harmonized procedures and methods for assessing neurocognitive functions, smell, taste, mental, and psychosocial health, and other factors in adults formally diagnosed with COVID-19 (confirmed as SARS-CoV-2 + WHO definition).

METHODS

We formed an international and cross-disciplinary NeuroCOVID Neuropsychology Taskforce in April 2020. Seven criteria were used to guide the selection of the recommendations' methods and procedures: (i) Relevance to all COVID-19 illness stages and longitudinal study design; (ii) Standard, cross-culturally valid or widely available instruments; (iii) Coverage of both direct and indirect causes of COVID-19-associated neurological and psychiatric symptoms; (iv) Control of factors specifically pertinent to COVID-19 that may affect neuropsychological performance; (v) Flexibility of administration (telehealth, computerized, remote/online, face to face); (vi) Harmonization for facilitating international research; (vii) Ease of translation to clinical practice.

RESULTS

The three proposed levels of harmonization include a screening strategy with telehealth option, a medium-size computerized assessment with an online/remote option, and a comprehensive evaluation with flexible administration. The context in which each harmonization level might be used is described. Issues of assessment timelines, guidance for home/remote assessment to support data fidelity and telehealth considerations, cross-cultural adequacy, norms, and impairment definitions are also described.

CONCLUSIONS

The proposed recommendations provide rationale and methodological guidance for neuropsychological research studies and clinical assessment in adults with COVID-19. We expect that the use of the recommendations will facilitate data harmonization and global research. Research implementing the recommendations will be crucial to determine their acceptability, usability, and validity.

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.

Representation of U.S. Black Americans in neuropsychology research: How well do our reporting practices show that Black lives matter?

OBJECTIVE

Black American individuals comprise about 13% of the population in the United States (U.S.). It is estimated by 2045, approximately 50% of U.S. residents will belong to an ethnic minority group underscoring the importance of the provision of culturally competent services. The present study provides a critical/systematic review of the literature to examine the representation of Black Americans in recent neuropsychological research in U.S. neuropsychology journals. We examined the representation of U.S. Black American individuals across journals, year of study, and by study sample.

METHOD

We evaluated 1,151 journal articles published in 4 neuropsychology journals published in 2011, 2014, 2017 and 2019. Articles were coded for reporting of age, sex/gender, years of education, ethnicity/race, and if race was a focus of the study. We also recorded sample size and type of sample.

RESULTS

Out of the 397 articles meeting inclusion criteria, 37.5% did not report ethnic or racial demographic information. Additionally, 96% of the articles were not racially/ethnically focused. Black participants comprised 10.7% of participants in articles that reported race/ethnicity. The proportion of Black participants increased by 3.7% between 2011 and 2019.

CONCLUSION

Our results demonstrate the underrepresentation of U.S. Black Americans in neuropsychological research over the targeted years. This highlights our shortcomings as a field in demonstrating the importance of including Black Americans in research.

The Ethics of Using Caregivers as Cognitive Testers

O'Caoimh et al. demonstrated that caregivers or family members could administer and score a brief cognitive screening instrument and detect cognitive impairment with comparable accuracy to similar measures administered in-person by trained staff. This novel approach challenges us to consider the boundaries of how caregivers or other family members are used in remote testing. We discuss the potential risks of administration bias, test integrity, and impacts on the patient and caregiver or family member, and we recommend further research before incorporating this practice into routine clinical or research use.

Case study of an Iranian-American neuropsychological assessment in the surgical setting: role of language and tests

There is a growing need to conduct a neuropsychological assessment with bilingual Middle Eastern populations, particularly those who speak the Persian language (Farsi). Although validated neuropsychological and language tests have emerged in Iran, there remains a shortage of appropriate psychometric tests in the U.S. that have been validated for use with the Iranian-American population. This often leads to an assortment of using U.S. tests in English, U.S. tests translated into Farsi, and Iranian tests in Farsi, which can complicate the clinical assessment. To better understand common testing issues when working with bilingual Iranian-American patients, we review the first report of a 62-year-old, bilingual (English-Farsi) Iranian-American male with 18-years of education who was tested using U.S.-developed and Iranian-developed tests in both English and Farsi language. Pre-surgical, 6 months post-surgical, and 1.5 years of post-surgical assessment data are discussed. We highlight the strengths and limitations of naming tests, test used in the native country versus U.S. language tests, the importance of baseline testing, general bilingual Persian-English assessment considerations, and case-based learning points.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Normative Data for Ten Neuropsychological Tests for the Guatemalan Pediatric Population Updated to Account for Vulnerability

The Guatemalan pediatric population is affected by a high incidence of poverty and violence. The previous literature showed that these experiences may ultimately impact cognitive performance. The aim of this article is to update the standardized scores for ten neuropsychological tests commonly used in Guatemala considering vulnerability. A total of 347 healthy children and adolescents from 6 to 17 years of age (M = 10.83, SD = 3) were assessed, controlling for intelligence, mental health and neuropsychological history. The standard scores were created using multiple linear regression and standard deviations from residual values. The predictors included were the following: age, age squared (age²), mean parental education (MPE), mean parental education squared (MPE²), gender, and vulnerability, as well as their interaction. The vulnerability status was significant in the scores for language, attention and executive functions. To the best of our knowledge, this is the first study that includes the condition of vulnerability in the calculation of neuropsychological standard scores. The utility of this update is to help in the early detection of special needs in this disadvantaged population, promoting more accurate interventions in order to alleviate the negative effects that living in vulnerable conditions has on children and adolescents.

Characterisation of neurodevelopmental and psychological outcomes in CHD: a research agenda and recommendations from the cardiac neurodevelopmental outcome collaborative

The Neurodevelopmental and Psychological Outcomes Working Group of the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute with the goals of identifying knowledge gaps regarding the neurodevelopmental and psychological outcomes of individuals with CHD and investigations needed to advance science, policy, clinical care, and patient/family outcomes. Accurate characterisation of neurodevelopmental and psychological outcomes in children with CHD will drive improvements in patient and family outcomes through targeted intervention. Decades of research have produced a generalised perspective about neurodevelopmental and psychological outcomes in this heterogeneous population. Future investigations need to shift towards improving methods, measurement, and analyses of outcomes to better inform early identification, prevention, and intervention. Improved definition of underlying developmental, neuropsychological, and social-emotional constructs is needed, with an emphasis on symptom networks and dimensions. Identification of clinically meaningful outcomes that are most important to key stakeholders, including patients, families, schools and providers, is essential, specifically how and which neurodevelopmental differences across the developmental trajectory impact stakeholders. A better understanding of the discontinuity and patterns of neurodevelopment across the lifespan is critical as well, with some areas being more impactful at some ages than others. Finally, the field needs to account for the impact of race/ethnicity, socio-economic status, cultural and linguistic diversity on our measurement, interpretation of data, and approach to intervention and how to improve generalisability to the larger worldwide population of patients and families living with CHD.

Technology meets tradition: a hybrid model for implementing digital tools in neuropsychology

The COVID-19 pandemic has significantly impacted the provision of mental health care services and the ability to provide neuropsychological evaluations. The inability to conduct traditional evaluations has left neuropsychologists with the unprecedented task of determining how to modify existing paradigms while balancing the need to provide services and adhere to safety parameters. The COVID-19 literature suggests clinicians are modifying their evaluations based on the following models: (1) continuing to administer in-person evaluations; (2) discontinuing all evaluations due to issues related to standardization, test security, and patient-specific characteristics; (3) conducting virtual evaluations; and/or (4) adopting a hybrid model incorporating both traditional and technology-based modalities. Given the challenges with models 1-3, along with the modifications in telehealth guidelines and insurance reimbursement rates, neuropsychologists are more poised than ever to solidify the implementation of a hybrid model that lasts beyond COVID-19. We introduce the term Hybrid Neuropsychology, a model for the future of neuropsychological evaluations that includes three Action Items: (1) building a technology-based practice; (2) integrating data science; and (3) engaging with innovators in other fields. Hybrid Neuropsychology will enable clinicians to effectively modernize their practice, improve health care equity, and ensure neuropsychology secures its place in a technology-based world.

Baseline Results: The Association Between Cardiovascular Risk and Preclinical Alzheimer's Disease Pathology (ASCEND) Study

BACKGROUND

The rate of AD for African Americans (AAs) is 64% higher than for non-Hispanic White Americans (Whites). It is hypothesized that poor peripheral vascular function, in combination with genetics, stress, and inflammation may directly contribute to the accumulation of AD pathologic biomarkers. These risk factors may disproportionately affect AAs.

OBJECTIVE

Our objective was to determine if in a healthy middle-aged cohort at risk for AD (1) AD biomarkers in CSF differ by race, (2) peripheral vascular dysfunction and cognition are related to a higher burden of CSF AD biomarkers, and (3) these relationships differ by race.

METHODS

We enrolled 82 cognitively normal, middle-aged (45 and older) adults including AAs and Whites at high risk for AD due to parental history. Study procedures included lumbar puncture, vascular ultrasound, and cognitive testing.

RESULTS

While participants were in overall good health, AAs exhibited poorer indices of preclinical vascular health, including higher central SBP, central MAP, and EndoPAT AI, a marker of arterial stiffness. AAs also had significantly less cerebrospinal fluid tau burden than Whites. After polynomial regression analysis, adjusted for age, gender, education, and ApoE4 status, race significantly modified the relationship between total tau, phospho-tau, and Trails B, a marker of executive function. Small differences in tau correlated with poorer cognition in AAs.

CONCLUSION

In a healthy middle-aged cohort at risk for AD, AAs had worse peripheral vascular health and worse cognition than Whites. Despite lower tau burden overall, race modified the relationship between tau and cognition, such that small differences in tau between AAs was related to worse cognition when compared to Whites.

An Adaptable, Open-Access Test Battery to Study the Fractionation of Executive-Functions in Diverse Populations

The umbrella-term 'executive functions' (EF) includes various domain-general, goal-directed cognitive abilities responsible for behavioral self-regulation. The influential unity and diversity model of EF posits the existence of three correlated yet separable executive domains: inhibition, shifting and updating. These domains may be influenced by factors such as socioeconomic status (SES) and culture, possibly due to the way EF tasks are devised and to biased choice of stimuli, focusing on first-world testees. Here, we propose a FREE (Free Research Executive Function Evaluation) test battery that includes two open-access tasks for each of the three abovementioned executive domains to allow latent variables to be obtained. The tasks were selected from those that have been shown to be representative of each domain, that are not copyrighted and do not require special hardware/software to be administered. These tasks were adapted for use in populations with varying SES/schooling levels by simplifying tasks/instructions and using easily recognized stimuli such as pictures. Items are answered verbally and tasks are self-paced to minimize interference from individual differences in psychomotor and perceptual speed, to better isolate executive from other cognitive abilities. We tested these tasks on 146 early adolescents (aged 9-15 years) of both sexes and varying SES, because this is the age group in which the executive domains of interest become distinguishable and in order to confirm that SES effects were minimized. Performance was determined by Rate Correct Scores (correct answers divided by total time taken to complete blocks/trial), which consider speed-accuracy trade-offs. Scores were sensitive to the expected improvement in performance with age and rarely/inconsistently affected by sex and SES, as expected, with no floor or ceiling effects, or skewed distribution, thus suggesting their adequacy for diverse populations in these respects. Using structural equation modeling, evidence based on internal structure was obtained by replicating the three correlated-factor solution proposed by the authors of the model. We conclude that the FREE test battery, which is open access and described in detail, holds promise as a tool for research that can be adapted for a wide range of populations, as well as altered and/or complemented in coming studies.

Development of executive functions in Lebanese children

The current study focused on adapting EF tests for children to the Arabic language and examine the developmental trajectories of a sample of school-aged Lebanese children in four domains of EF (inhibition, flexibility, working memory, and planning). It also focused on examining the effects of gender and parental education level on EF performance. The study population included 100 Lebanese children aged from 6 to 12-years old who were grouped and comparable for age, gender, and parental level of education. Results revealed a main effect of age and level of education of parents while the effect of gender was non-significant.

Editorial S.I: Early Identification in Autism Spectrum Disorders: The Present and Future, and Advances in Early Identification

Early identification of autism spectrum disorder (ASD) is considered by most scholars and clinicians to be a feasible and useful step for improving the wellbeing of individuals on the autism spectrum and their families. Arguments supporting early detection efforts include the benefit of earlier access to services providing autism-specific evidence-based interventions (Vivanti et al., Journal of Autism and Developmental Disorders, 46(7), 2441-2449, 2016; Zwaigenbaum et al., Pediatrics, 136(Suppl), S10-S40, 2015), and its potential to mitigate or even prevent the challenges associated with ASD symptoms, reduce care costs, and improve the quality of life and productivity of individuals with ASD (Constantino et al., Pediatrics, 146(3), e20193629, 2020; Jacobson et al., Behavioral Interventions, 13(4), 201-226, 1998; Jacobson and Mulick, Journal of Autism and Developmental Disorders, 30(6), 585-593, 2000). Nevertheless, controversies and challenges in this field exist.

The state of neuropsychological test norms for Spanish-speaking adults in the United States

Objective: The present review paper aimed to identify published neuropsychological test norms developed for Spanish-speakers living in the United States (U.S.). Methods: We conducted a systematic review of the literature via an electronic search on PubMed using keywords "Normative data," "Neuropsychological test," "norms", "Hispanic/Latinos," "Spanish Speakers," and "United States." We added other studies and published manuals as identified by citations in papers from the original search. Results Eighteen sources of normative data for Spanish-speakers in the U.S. were identified. Of the 18 citations identified, only four provide normative data on comprehensive batteries of tests for Spanish-Speakers. Two of these are based on persons living in the southwest of the U.S., who tend to be of Mexican origin. Overall, a number of the studies are focused on older persons and although the majority include participants with wide ranges of education, participants in the ends of the education distribution tend to be underrepresented. Conclusion: Here we provide a detailed description of the neuropsychological normative data currently available for Spanish-speakers living in the U.S. While there has been increased attention towards developing norms for neuropsychological batteries in Spanish-speaking countries (e.g., Latin America and Spain), there is still an urgent need to standardize neuropsychological tests among diverse groups of Spanish-speaking adults living in the U.S. The present review presents a list of norms for U.S.-dwelling Spanish-speakers, thus providing an important tool for clinicians and researchers.

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

OBJECTIVE

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

UDSNB 3.0 Neuropsychological Test Norms in Older Adults from a Diverse Community: Results from the Einstein Aging Study (EAS)

BACKGROUND

The Uniform Data Set, Version 3 Neuropsychological Battery (UDSNB3.0), from the database of the University of Washington's National Alzheimer's Coordinating Center (NACC), is widely used to characterize cognitive performance in clinical and research settings; however, norms for underrepresented community-based samples are scarce.

OBJECTIVE

We compared UDSNB 3.0 test scores between the Einstein Aging Study (EAS), composed of racially/ethnically diverse, community-dwelling older adults aged≥70 and the NACC, and report normative data from the EAS.

METHODS

Analyses included 225 cognitively normal EAS participants and comparable data from 5,031 NACC database participants. Linear regression models compared performance between the samples, adjusting for demographics (sex, age, education, race/ethnicity), depressive symptoms, and whether English was the first language. Linear regression models to examine demographic factors including age, sex, education and race/ethnicity as predictors for the neuropsychological tests were applied in EAS and NACC separately and were used to create a demographically adjusted z-score calculator.

RESULTS

Cognitive performance across all domains was worse in the EAS than in the NACC, adjusting for age, sex, education, race/ethnicity, and depression, and the differences remained in visuo-construction, visuospatial memory, confrontation naming, visual attention/processing speed, and executive functioning after further adjusting for whether English was the first language. In both samples, non-Hispanic Whites outperformed non-Hispanic Blacks and more education was associated with better cognitive performance.

CONCLUSION

Differences observed in demographic, clinical, and cognitive characteristics between the community-based EAS sample and the nationwide NACC sample suggest that separate normative data that more accurately reflect non-clinic, community-based populations should be established.

Acceptability and Usability of Computerized Cognitive Assessment Among Australian Indigenous Residents of the Torres Strait Islands

OBJECTIVES

This cross-sectional study aimed to investigate the acceptability and usability of the Cogstate Brief Battery (CBB) in a community-based sample of Australian Indigenous people from the Torres Strait region, based on a user experience framework of human-computer interaction.

METHODS

Two-hundred community participants completed the four subtests of the CBB on an iPad platform, during a free adult health check on two islands in the region, between October and December 2016. Acceptability was defined as completing the learning trial of a task and usability as continuing a task through to completion, determined by examiner acumen and internal Cogstate completion and integrity criteria. These were combined into a single dichotomous completion measure for logistic regression analyses. Performance-measured as reaction times and accuracy of responses-was analyzed using linear regression analyses.

RESULTS

CBB completion ranged from 82.0% to 91.5% across the four tasks and the odds of completing decreased with age. After adjusting for age, iPad/tablet familiarity increased the odds of completion for all tasks while level of education and employment increased the odds for some tasks only. These variables accounted for 18.0%-23.8% of the variance in reaction times on speeded tasks. Age and education had the most effect, although semipartial correlations were modest.

CONCLUSIONS

When administered in a health-screening context, the acceptability and usability of the CBB were greatest in young- to middle-aged participants with some education and iPad/tablet experience. Older and more vulnerable participants may have benefited from additional time and practice on the CBB prior to administration.

Taking the Test: A Qualitative Analysis of Cultural and Contextual Factors Impacting Neuropsychological Assessment of Xhosa-Speaking South Africans

Objective

There is an urgent need to make neuropsychological (NP) testing more acceptable, accessible, and culturally salient, particularly for culturally, educationally, and linguistically diverse individuals from countries who may have little-to-no experience with NP testing. In settings with limited resources such as South Africa, unique cultural and contextual factors (e.g., structural inequality, poverty) may impact the experience of NP evaluation. Research in this area is limited and requires further exploration. This qualitative study explores the role of cultural and contextual factors that may impact the experience of NP evaluation in a sample of Xhosa-speaking South African adults. Participant interviews explored the context from which individuals arrived at the NP assessment (e.g., quality of education, understanding of cognitive disorders), and their experience of completing NP tests.

Method

This qualitative study used data from semistructured interviews to conduct a thematic analysis exploring contextual factors and the experience of completing NP tests for the first time among Xhosa-speaking South African adults (N = 22). Results: Although no participants had prior experience with NP testing, most found testing procedures acceptable. Most participants, however, reported a limited understanding of the purpose of NP testing and cognitive problems. Additionally, some participants reported perceptions and attitudes that could affect test performance, such as misinterpreting standard testing procedures (e.g., no feedback from the examiner, being stopped mid-task) as indicative of poor performance.

Conclusions

This study provided much needed exploration into unique cultural factors that may impact the experience of NP assessment in South Africa, which could bias test performance and interpretation, and may aid the field of cross-cultural NP in better serving culturally and linguistically diverse populations. In these countries, neuropsychologists may need to actively evaluate participants’ understanding of NP testing to help foster optimal assessment conditions. They may also need to educate participants on possible causes of cognitive disorders.

Teleneuropsychology for Monolingual and Bilingual Spanish-Speaking Adults in the Time of COVID-19: Rationale, Professional Considerations, and Resources

OBJECTIVE

Neuropsychological assessments with monolingual Spanish and bilingual Spanish/English-speaking adults present unique challenges. Barriers include, but are not limited to, the paucity of test norms, uncertainty about the equivalence of translated neuropsychological tests, and limited proficiency in the provision of culturally competent services. Similar issues generalize to telephone- and video-based administration of neuropsychological tests or teleneuropsychology (TeleNP) with Hispanics/Latinos (as), and few studies have examined its feasibility and validity in this group. The sudden onset of the COVID-19 pandemic prompted neuropsychologists to identify alternative ways to provide equitable care. Clinicians providing TeleNP to this population during (and after) the pandemic must consider safety, professional factors, and systemic barriers to accessing and benefitting from virtual modalities.

METHOD

This clinical process manuscript describes how cross-cultural neuropsychologists across five U.S. academic institutions serving Hispanics/Latinos (as) developed TeleNP models of care during the pandemic.

RESULTS

Workflows, test batteries, and resources for TeleNP assessment with monolingual and bilingual Spanish-speaking patients are included. Factors guiding model development and informing decisions to incorporate virtual administration of neuropsychological tests into their practice are also discussed.

CONCLUSIONS

Provision of TeleNP is a promising modality. Additional research in this area is warranted with focus on cultural and contextual factors that support or limit the use of TeleNP with this community.

Adaptation of the Spanish version of the Frontal Assessment Battery for detection of executive dysfunction

BACKGROUND

The Frontal Assessment Battery (FAB) evaluates executive dysfunctions; however, there is no culturally adapted version of this instrument for the Spanish population. The aim of this study was the translation and cross-cultural adaptation of the original version of the FAB into Spanish and to pilot test this version.

METHODS

The cross-cultural adaptation was conducted following standard procedures. The final Spanish version of the FAB (FAB-E) was pilot tested with 19 healthy Spanish individuals. Total and subtest FAB-E scores were analysed to verify that the test could be understood and that the items assessed what they were intended to assess.

RESULTS

The FAB-E revealed that items/instructions were culturally appropriate and written clearly. Pilot testing showed that most of the participants had scores ranging between 2 and 3 points in all the items. The mean of the total FAB-E was 15.8 (SD=1.3) and the values ranged from 13 to 18. Age and educational level seemed to indicate differences in FAB-E scores.

CONCLUSION

Our findings support that the FAB-E can be used to screen for executive dysfunctions in a Spanish-speaking population.

Association of Blood Pressure and Cognition after Stroke

BACKGROUND AND AIM

It is unclear whether blood pressure (BP) is associated with cognition after stroke. We examined associations between systolic and diastolic BP (SBP, DBP), pulse pressure (PP), mean arterial pressure (MAP), and cognition, each measured 90 days after stroke.

METHODS

Cross-sectional analysis of prospectively obtained data of 432 dementia-free subjects greater than or equal to 45 (median age, 66; 45% female) with stroke (92% ischemic; median NIH stroke score, 3 [IQR, 2-6]) from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project in 2011-2013.

PRIMARY OUTCOME

Modified Mini-Mental Status Examination (3MSE; range, 0-100).

SECONDARY OUTCOMES

Animal Fluency Test (AFT; range, 0-10) and Trail Making Tests A and B (number of correct items [range, 0-25]/completion time [Trails A: 0-180 seconds; Trails B: 0-300 second]). Linear or tobit regression adjusted associations for age, education, and race/ethnicity as well as variables significantly associated with BP and cognition.

RESULTS

Higher SBP, lower DBP, higher PP, and lower MAP each were associated with worse cognitive performance for all 4 tests (all P < .001). After adjusting for patient factors, no BP measures were associated with any of the 4 tests (all P > .05). Lower cognitive performance was associated with older age, less education, Mexican American ethnicity, diabetes, higher stroke severity, more depressive symptoms, and lower BMI. Among survivors with hypertension, anti-hypertensive medication use 90 days after stroke was significantly associated with higher AFT scores (P = .02) but not other tests (P > .15).

CONCLUSIONS

Stroke survivors' BP levels were not associated with cognitive performance at 90 days independent of sociodemographic and clinical factors.

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

OBJECTIVE

Test and normative data selection in cross-cultural neuropsychology remain a complex issue. Despite growing awareness, more studies and instruments are needed to adequately address the impact of cultural factors, such as quantity and quality of education. In this study, we examine the interpretive effects of applying six relevant WAIS-IV norms to a Colombian sample.

METHOD

A sample of 305 highly educated Colombian corporate executives completed the WAIS-IV. Data were scored using norms from Colombia, Chile, Mexico, Spain, United States, and Canada and scores were compared using ANOVA. Additionally, a comparative sociodemographic framework was established to contextualize our sample to the standardization samples and populations of the six countries.

RESULTS

Colombian and Chilean norms yielded systematically similar FSIQ/Index scores (mean range = 117-121), while incrementally lower scores were found with norms from Mexico (-3-9 points), Spain (-3-11 points), USA (-8-13 points), and Canada (-11-18 points). Verbal scores differed, with highest scores obtained with Mexican and Spanish norms. Working memory and processing speed scores had the lowest score agreement across norms.

CONCLUSIONS

Although the Chilean norms are more frequently used in Colombia, the recently developed Colombian norms appear optimal for our sample; the scores do not have meaningful differences with those obtained with Chilean norms and offer local population representation fidelity. Mexican, Spanish, US, and Canadian norms underestimated WAIS-IV scores and distorted the sample's score distribution. Finally, verbal scores highlight potential education representation within Spanish and Mexican norms, while working memory and processing speed scores suggest cultural nuances likely captured within different norms.

Construct validity of the Visual Cognitive Assessment Test (VCAT)-a cross-cultural language-neutral cognitive screening tool

BACKGROUND

The Visual Cognitive Assessment Test (VCAT) is a language-neutral cognitive screening tool designed for use in culturally diverse populations without the need for translations or adaptations. While it has been established to be language-neutral, the VCAT's construct validity has not been investigated.

METHODS

471 participants were recruited, comprising 233 healthy comparisons, 117 mild cognitive impairment (MCI), and 121 mild Alzheimer's disease (AD) patients. VCAT and domain-specific neuropsychological tests were administered in the same sitting. Construct validity was assessed by analyzing domain-specific associations between the VCAT and well-established cognitive assessments. Reliability (internal consistency) was measured by Cronbach's alpha. Diagnostic ability (area under the curve) and recommended cutoffs were determined by receiver operating characteristic (ROC) analysis.

RESULTS

The VCAT and its subdomains demonstrated good construct validity in terms of both convergent and divergent validity and good internal consistency (α = .74). ROC analysis found that the VCAT was on par with the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) at distinguishing between healthy comparisons, MCI, and mild AD. Consistent with previous studies, VCAT scores were not affected by language of administration or ethnicity in our cohort. Findings suggest the following cutoffs: Dementia 0-19, MCI 20-24, Normal 25-30.

CONCLUSION

This study established the construct validity of the VCAT, which is vital to ensure its subdomains effectively measure the cognitive processes they were designed to. The VCAT is capable of detecting early cognitive impairments and allows for meaningful cross-cultural comparisons, especially useful for international collaborations and clinical trials, and for clinical use in diverse multiethnic populations.

The validity of the test of memory malingering (TOMM) with deaf individuals

OBJECTIVE

Administration of performance validity tests (PVT) during neuropsychological assessments is standard practice, with the Test of Memory Malingering (TOMM) being a commonly used measure. The TOMM has been well validated in hearing populations with various medical and psychiatric backgrounds. A major gap in the literature is the use of the TOMM amongst culturally Deaf individuals who use American Sign Language (ASL) as their first and preferred language. The purpose of this study was to explore the use of the TOMM with this population to determine if there may be differences related to the use of semantic knowledge and recall using signs rather than spoken phonemes.

METHOD

This study recruited 30 culturally Deaf, community-dwelling adults, who self-reported that they were not involved in litigation ordisability claims. In addition to the TOMM, participants were screened for cognitive ability using non-verbal components of the Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II) and the Mini Mental State Examination: ASL Version (MMSE:ASL).

RESULTS

Nonverbal intelligence for this sample was within the average range of ability. No participants scored lower than the standard cut-off score for Trial 2 or the Retention Trial on the TOMM (≤44 raw score to indicate invalid responding). Trial 1 performances ranged from 44 to 50, Trial 2 performances ranged from 49 to 50, and Retention performances ranged from 49 to 50.

CONCLUSION

These results support the use of the same standard cut-off scores established for hearing individuals in culturally Deaf individuals who use ASL.

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.

Factors Associated with Māori Performance on the WAIS-IV

Neuropsychological tests are routinely used to assess Māori, the indigenous people of New Zealand, yet very few investigations of the psychometric properties of these tests with this population have been conducted. This paper focuses on factors that may impact performance of Māori adults on neuropsychological testing. The Wechsler Adult Intelligence Scale-IV (WAIS-IV) was administered to a sample of 284 Māori stratified for age (between 16 years and 90 years) and gender in order to establish a Māori normative data set. The sample who primarily spoke English as their first language were recruited from a range of urban, regional and rural areas in New Zealand to obtain representation of the main Māori Iwi (tribes). Analysis of test results suggests acculturation, education, income, and, "a culturally positive experience" may have accounted for some of the variance in test performance.

Results of scoping review do not support mild traumatic brain injury being associated with a high incidence of chronic cognitive impairment: Commentary on McInnes et al. 2017

A recently published review of 45 studies concluded that approximately half of individuals who sustain a single mild traumatic brain injury (MTBI) experience long-term cognitive impairment (McInnes et al. Mild Traumatic Brain Injury (mTBI) and chronic cognitive impairment: A scoping review. PLoS ONE 2017;12:e0174847). Stratified by age, they reported that 50% of children and 58% of adults showed some form of cognitive impairment. We contend that the McInnes et al. review used a definition of “cognitive impairment” that was idiosyncratic, not applicable to individual patients or subjects, inconsistent with how cognitive impairment is defined in clinical practice and research, and resulted in a large number of false positive cases of cognitive impairment. For example, if a study reported a statistically significant difference on a single cognitive test, the authors concluded that every subject with a MTBI in that study was cognitively impaired–an approach that cannot be justified statistically or psychometrically. The authors concluded that impairment was present in various cognitive domains, such as attention, memory, and executive functioning, but they did not analyze or report the results from any of these specific cognitive domains. Moreover, their analyses and conclusions regarding many published studies contradicted the interpretations provided by the original authors of those studies. We re-reviewed all 45 studies and extracted the main conclusions from each. We conclude that a single MTBI is not associated with a high incidence of chronic cognitive impairment.