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Cognitive testing of illiterate elderly in Brazil
Symposia: S2-01: Multicultural Issues In Neuropsychological Assessment
MONDAY, JULY 16, 2012 SYMPOSIA: S2-01 MULTICULTURAL ISSUES IN NEUROPSYCHOLOGICAL ASSESSMENT S2-01-01
NEUROPSYCHOLOGICAL ASSESSMENT OF DEMENTIA ON GUAM
David Salmon, UCSD, La Jolla, California, United States. Background: Parkinson-Dementia Complex (PDC) is a neurodegenerative disorder that occurs almost exclusively in the indigenous Chamorro population on the Marianas island of Guam. Parkinsonism typically occurs concomitantly with the onset of dementia and is essentially identical to that of idiopathic Parkinson’s disease (PD). PDC is a tauopathy characterized by neurofibrillary tangles and neuron loss in a number of brainstem nuclei, limbic structures, and association cortices. There is little deposition of amyloid and alpha-synuclein pathology is rare. A pure dementia syndrome without significant motor abnormality is also quite prevalent in Guam’s elderly Chamorro population. Little is known about the underlying neuropathology of this late-life Guam dementia (GD), but it has been variably associated with Alzheimer’s disease (AD) or PDC pathology in a handful of cases. The dementia syndromes of PDC and GD have not been carefully characterized, but clinical reports suggest that they usually begin with forgetfulness, disorientation, and difficulty with problem solving and calculations. Methods: A battery of culturally-adapted neuropsychological tests was administered to Chamorro patients with clinically-diagnosed PDC (n ¼ 37) or GD (n ¼ 55), and to healthy Chamorro elderly control (EC) subjects (n ¼ 45). The tests were chosen to be sensitive to cognitive changes associated with PD or AD, and included measures of memory, attention, language, executive function, visuospatial ability, and psychomotor speed. Results: Patients with PDC and GD were impaired relative to EC subjects on all neuropsychological tests and exhibited similar profiles of deficits that included frank amnesia (i.e., poor learning, abnormally rapid forgetting, impaired free recall and recognition memory), mild aphasia (i.e., anomia, verbal fluency impairment), executive dysfunction, and constructional apraxia. This qualitative pattern of deficits resembles that of the cortico-limbic dementia syndrome of AD. However, some features of fronto-striatal dysfunction were also evident (i.e., set shifting deficits, equally poor semantic and letter fluency), even in those without Parkinsonism. Conclusions: The striking similarities in the cognitive profiles associated with PDC and GD suggest that the two conditions may reflect different points along a spectrum of a single disease in the Chamorro population. The dementia syndrome appears largely corticolimbic in nature and may reflect the tauopathy common to both disorders. S2-01-02
BARRIERS TO THE COGNITIVE ASSESSMENT OF DEMENTIA IN INDIA
Jacob Kuriakose, Sukumaran Shaji, Alzheimer’s and Related Disorders Society of India, Comprehensive Dementia Care, Ernakulam, Kunamkulam, Kerala, India. Background: Assessment of cognitive functions is an integral part of evaluation of elderly persons. Cognitive assessment is commonly used for the screening for cognitive impairment, differential diagnosis of causes, rating severity of the disorder and monitoring the disease progression. There is a well documented tendency for cognitive tests to underestimate the abilities of older people in developing countries like India. This gives rise to a substantially higher risk of mistaken diagnosis of dementia. Methods: Epidemiological studies conducted in India since 1990 were reviewed with the focus on cognitive assessment methods used in these studies. Cognitive assessment tools developed in western context were translated and adapted for the purpose of cognitive screening in general. Difficulties encountered while assessing the cognitive functions were analyzed. Results: Specificity was low with many cognitive screening tools.2. Cognitive screening test like Mini Mental State Examination can overestimate cognitive impairment.3. Language barriers and low education can lead to difficulties in assessment.4. Low education can result in inappropriate response due to educational misinterpretation as opposed to cognitive dysfunction.5. Dementia is consid-
P227
ered as a part of normal aging.6. Lack of familiarity with western calendar can make mistakes in assessing orientation. 7. Cultural beliefs about dementia are a barrier to its acceptance and diagnosis. 8. Factors like sensory impairments, depression, other psychiatric and neurological disorders and physical disabilities can make cognitive assessment difficult. Conclusion: Clinicians and health care workers face several barriers in assessment of cognitive functions of the elderly persons in India Accuracy of assessment of cognitive functions can be improved by adapting the tools to suit the socio-cultural setting, adjustment of cut points, translation and replacement of culture specific items and development of culture free tests. S2-01-03
COGNITIVE TESTING OF ILLITERATE ELDERLY IN BRAZIL
Ricardo Nitrini, University of S~ao Paulo, S~ao Paulo, Brazil. Background: The assessment of illiterates for the diagnosis of mild cognitive impairment or dementia is more complex than that of literate individuals. It is estimated that there are approximately 800 million illiterate adults worldwide (14 million in Brazil), with a large proportion of elderly among them. This issue is still important for developing countries and even for developed countries when evaluating individuals who do not understand the written system of the country. Methods: A search in Medline and LILACS was performed using the following keywords: illiteracy, dementia, cognitive impairment and cognitive evaluation in English and in Portuguese languages to identify the most widely used tests for the diagnosis of dementia in illiterate individuals in Brazil. Results: The most widely used test in Brazil for the diagnosis of cognitive impairment in the illiterate is the Mini-Mental State Examination with adjusted cut-off score (18 is the most accepted one). Semantic verbal fluency tests (animals/1 minute) with a cut-off score of 9 is also frequently used. The memory test for objects (FOME) and memory test of simple drawings (BCSB) have been used in research and in clinical practice. The clock drawing test is not recommended for the diagnosis of dementia in low educated or illiterate individuals. The combined use of cognitive tests with informant questionnaires showed the highest accuracy. Among the questionnaires the Functional Activities Questionnaire and IQCODE are the mostly used. The Neuropsi and CERAD batteries may be used with adjusted cut-off scores. Conclusions: The association of cognitive testing and informant questionnaire is the best option for the diagnosis of cognitive impairment in illiterate individuals in Brazil. S2-01-04
NEUROPSYCHOLOGICAL DETECTION OF DEMENTIA IN HISPANIC POPULATIONS
Dan Mungas, University of California, Davis, Sacramento, California, United States. Background: Cognitive impairment is the defining feature of dementia associated with Alzheimer’s disease and related diseases of aging. As demographic diversity increases there is a rapidly developing need for clinical assessment methods to evaluate brain function and consequences of brain injury in individuals from diverse cultural and linguistic backgrounds, and this is especially true for the rapidly growing population of older Hispanics. Neuropsychological assessment of Hispanics presents challenges that apply to other minority groups, but in addition, presents unique challenges related to language, culture, and life experiences. As a quantitative discipline, neuropsychology has much to offer in terms of standardized and empirically validated assessment procedures that can be used with diverse patients groups. This presentation will address important issues involved in constructing neuropsychological tests that can be used effectively in detecting cognitive impairment and dementia in older Hispanics. Methods: Modern psychometric methods based on item response theory were applied to a large linguistically and ethnically diverse sample to create a neuropsychological test battery, the Spanish and English Neuropsychological Assessment Scales (SENAS) with matched English and Spanish language versions. Sensitive and linear measurement across a broad ability range from fully normal to demented was emphasized. Sensitivity to cognitive impairment and cognitive decline and influences related to demographic characteristics have been tested in cross-sectional and longitudinal studies. Results: Empirical results evaluating measurement bias, sensitivity to clinical disease, and relations
MONDAY, JULY 16, 2012 SYMPOSIA: S2-01 MULTICULTURAL ISSUES IN NEUROPSYCHOLOGICAL ASSESSMENT S2-01-01
NEUROPSYCHOLOGICAL ASSESSMENT OF DEMENTIA ON GUAM
David Salmon, UCSD, La Jolla, California, United States. Background: Parkinson-Dementia Complex (PDC) is a neurodegenerative disorder that occurs almost exclusively in the indigenous Chamorro population on the Marianas island of Guam. Parkinsonism typically occurs concomitantly with the onset of dementia and is essentially identical to that of idiopathic Parkinson’s disease (PD). PDC is a tauopathy characterized by neurofibrillary tangles and neuron loss in a number of brainstem nuclei, limbic structures, and association cortices. There is little deposition of amyloid and alpha-synuclein pathology is rare. A pure dementia syndrome without significant motor abnormality is also quite prevalent in Guam’s elderly Chamorro population. Little is known about the underlying neuropathology of this late-life Guam dementia (GD), but it has been variably associated with Alzheimer’s disease (AD) or PDC pathology in a handful of cases. The dementia syndromes of PDC and GD have not been carefully characterized, but clinical reports suggest that they usually begin with forgetfulness, disorientation, and difficulty with problem solving and calculations. Methods: A battery of culturally-adapted neuropsychological tests was administered to Chamorro patients with clinically-diagnosed PDC (n ¼ 37) or GD (n ¼ 55), and to healthy Chamorro elderly control (EC) subjects (n ¼ 45). The tests were chosen to be sensitive to cognitive changes associated with PD or AD, and included measures of memory, attention, language, executive function, visuospatial ability, and psychomotor speed. Results: Patients with PDC and GD were impaired relative to EC subjects on all neuropsychological tests and exhibited similar profiles of deficits that included frank amnesia (i.e., poor learning, abnormally rapid forgetting, impaired free recall and recognition memory), mild aphasia (i.e., anomia, verbal fluency impairment), executive dysfunction, and constructional apraxia. This qualitative pattern of deficits resembles that of the cortico-limbic dementia syndrome of AD. However, some features of fronto-striatal dysfunction were also evident (i.e., set shifting deficits, equally poor semantic and letter fluency), even in those without Parkinsonism. Conclusions: The striking similarities in the cognitive profiles associated with PDC and GD suggest that the two conditions may reflect different points along a spectrum of a single disease in the Chamorro population. The dementia syndrome appears largely corticolimbic in nature and may reflect the tauopathy common to both disorders. S2-01-02
BARRIERS TO THE COGNITIVE ASSESSMENT OF DEMENTIA IN INDIA
Jacob Kuriakose, Sukumaran Shaji, Alzheimer’s and Related Disorders Society of India, Comprehensive Dementia Care, Ernakulam, Kunamkulam, Kerala, India. Background: Assessment of cognitive functions is an integral part of evaluation of elderly persons. Cognitive assessment is commonly used for the screening for cognitive impairment, differential diagnosis of causes, rating severity of the disorder and monitoring the disease progression. There is a well documented tendency for cognitive tests to underestimate the abilities of older people in developing countries like India. This gives rise to a substantially higher risk of mistaken diagnosis of dementia. Methods: Epidemiological studies conducted in India since 1990 were reviewed with the focus on cognitive assessment methods used in these studies. Cognitive assessment tools developed in western context were translated and adapted for the purpose of cognitive screening in general. Difficulties encountered while assessing the cognitive functions were analyzed. Results: Specificity was low with many cognitive screening tools.2. Cognitive screening test like Mini Mental State Examination can overestimate cognitive impairment.3. Language barriers and low education can lead to difficulties in assessment.4. Low education can result in inappropriate response due to educational misinterpretation as opposed to cognitive dysfunction.5. Dementia is consid-
P227
ered as a part of normal aging.6. Lack of familiarity with western calendar can make mistakes in assessing orientation. 7. Cultural beliefs about dementia are a barrier to its acceptance and diagnosis. 8. Factors like sensory impairments, depression, other psychiatric and neurological disorders and physical disabilities can make cognitive assessment difficult. Conclusion: Clinicians and health care workers face several barriers in assessment of cognitive functions of the elderly persons in India Accuracy of assessment of cognitive functions can be improved by adapting the tools to suit the socio-cultural setting, adjustment of cut points, translation and replacement of culture specific items and development of culture free tests. S2-01-03
COGNITIVE TESTING OF ILLITERATE ELDERLY IN BRAZIL
Ricardo Nitrini, University of S~ao Paulo, S~ao Paulo, Brazil. Background: The assessment of illiterates for the diagnosis of mild cognitive impairment or dementia is more complex than that of literate individuals. It is estimated that there are approximately 800 million illiterate adults worldwide (14 million in Brazil), with a large proportion of elderly among them. This issue is still important for developing countries and even for developed countries when evaluating individuals who do not understand the written system of the country. Methods: A search in Medline and LILACS was performed using the following keywords: illiteracy, dementia, cognitive impairment and cognitive evaluation in English and in Portuguese languages to identify the most widely used tests for the diagnosis of dementia in illiterate individuals in Brazil. Results: The most widely used test in Brazil for the diagnosis of cognitive impairment in the illiterate is the Mini-Mental State Examination with adjusted cut-off score (18 is the most accepted one). Semantic verbal fluency tests (animals/1 minute) with a cut-off score of 9 is also frequently used. The memory test for objects (FOME) and memory test of simple drawings (BCSB) have been used in research and in clinical practice. The clock drawing test is not recommended for the diagnosis of dementia in low educated or illiterate individuals. The combined use of cognitive tests with informant questionnaires showed the highest accuracy. Among the questionnaires the Functional Activities Questionnaire and IQCODE are the mostly used. The Neuropsi and CERAD batteries may be used with adjusted cut-off scores. Conclusions: The association of cognitive testing and informant questionnaire is the best option for the diagnosis of cognitive impairment in illiterate individuals in Brazil. S2-01-04
NEUROPSYCHOLOGICAL DETECTION OF DEMENTIA IN HISPANIC POPULATIONS
Dan Mungas, University of California, Davis, Sacramento, California, United States. Background: Cognitive impairment is the defining feature of dementia associated with Alzheimer’s disease and related diseases of aging. As demographic diversity increases there is a rapidly developing need for clinical assessment methods to evaluate brain function and consequences of brain injury in individuals from diverse cultural and linguistic backgrounds, and this is especially true for the rapidly growing population of older Hispanics. Neuropsychological assessment of Hispanics presents challenges that apply to other minority groups, but in addition, presents unique challenges related to language, culture, and life experiences. As a quantitative discipline, neuropsychology has much to offer in terms of standardized and empirically validated assessment procedures that can be used with diverse patients groups. This presentation will address important issues involved in constructing neuropsychological tests that can be used effectively in detecting cognitive impairment and dementia in older Hispanics. Methods: Modern psychometric methods based on item response theory were applied to a large linguistically and ethnically diverse sample to create a neuropsychological test battery, the Spanish and English Neuropsychological Assessment Scales (SENAS) with matched English and Spanish language versions. Sensitive and linear measurement across a broad ability range from fully normal to demented was emphasized. Sensitivity to cognitive impairment and cognitive decline and influences related to demographic characteristics have been tested in cross-sectional and longitudinal studies. Results: Empirical results evaluating measurement bias, sensitivity to clinical disease, and relations