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Friday Harbor 2005
Cultural and Demographic Influences on
Neuropsychological Test Scores
Jennifer J. Manly, Ph.D.
Columbia University Medical Center
Friday Harbor 2005
National Institutes on Aging
R01 AG16206
Alzheimer’s Association
New York City Council Speaker’s Fund Award for Biomedical Research
Friday Harbor 2005
G.H. Sergievsky CenterTaub Institute for Research on
Alzheimer’s Disease and the Aging Brain
Yaakov Stern, Ph.D.Nicole Schupf, Ph.D.
Richard Mayeux, M.D.Danurys SanchezCherita McDowellJudes Fleurimont
Iris PaltinRaquel Cabo
Akanksha Thakur
Mount Sinai School of Medicine
Desiree Byrd, Ph.D.
Methods in the Social Sciences Program Department of Sociology
Christopher Weiss
Columbia University
The problem of low specificity of neuropsychological measures
• Several studies show reduced specificity of cognitive measures among African Americans and Hispanics
• Reduced specificity may result in increased misdiagnosis of cognitive impairment
• Ethnic differences occur across cognitive domains
SAN DIEGO AANP
neuropsychological
test % impaired using
existing norms Category 31 Block Design 37 Trails A Time 26 Digit Symbol 21 Digit Vigilance Time 18 Story Loss 32 Figure Loss 2 Story Learn 39 Figure Learn 58 Information 35 Boston Naming 64 Sens-Perc Errors 25
IMPAIRMENT RATES for NORMAL AFRICAN AMERICANS (n = 137)
An Early Deconstruction of Race
• Army Alpha & Beta tests
From Klineberg, 1935
Cultural effects on test performance:WAIS-III Full Scale IQ
0%5%
10%15%20%25%30%35%40%45%50%
Perc
ent M
iscl
assi
fied
White
African-American
Hispanic
Age Corrected Age, Education & Gender Corrected
From Heaton & Taylor
Friday Harbor 2005
INWOOD
WASHINGTON HEIGHTS
HAMILTON HEIGHTS• N = 2,801 in 1999
• Age 65 and older• Spanish or English speaking• Education range 0 - 20
0
10
20
30
40
50
Per
cent of co
hort
Caucasian AfricanAmerican
Hispanic
PI: Richard Mayeux
Age-Specific Prevalence of Alzheimer’s Disease (1990-1992)
BlacksCaribbeanHispanic Whites
65-74
75-84
85+
0
5
10
15
20
25
30
35
40
CDR1.0
Friday Harbor 2005
The Important Questions• How can we improve the accuracy of
neuropsychological detection of MCI and AD among ethnic minorities?
– Are there any measures that can be used across groups with high sensitivity and specificity?
– Are separate norms or tests for ethnic minorities the best solution?
– What are the cultural, linguistic, racial, educational, and socioeconomic influences on cognitive test performance?
• Is AD more frequent among ethnic minorities?– What design and populations would best address this question?– If so, what are the underlying causes of this discrepancy?– Can these underlying causes be treated or changed?
Friday Harbor 2005
Are there any measures that can be used across groups with high
sensitivity and specificity?
• Use culturally neutral or “culture-free” tests
• Follows belief that there are universal constructs of cognition that can be assessed accurately across cultures
Failure of Universalism
“…that a test or test battery is “culture free” is a description born in the never-never land of psychometric wishful thinking that at once brands the claim as spurious.”
Nell, 2000
Universalism
• Neuropsychologists are trained that their measures assess “pure” cognitive abilities
• Universalist belief allows us to avoid issues of construct validity
• Source of naitivist beliefs (vs. environmentalist claims)
• BUT... tests are bound to the culture in which they are developed and normed
WHO Battery• Designed for cross-national studies
• Tests were selected and created to be “culture-free”
• Large cultural differences appeared on several measures, independent of years of education Reaction time Manual dexterity Psychomotor speed (Digit Symbol & Color Trails) Digit Span
• All WAIS-III performance subtests
– Picture Arrangement
• Benton Visual Retention Test
• Simple Reaction Time tests
• Cancellation tests
Nonverbal is not culture free
Racial/ethnic differences are found on:
Friday Harbor 2005
Are separate norms for ethnic minorities the best solution?
• Collection of separate group norms is the most popular approach in the literature, especially among geriatric neuropsychologists
Friday Harbor 2005
No significant ethnic differences in frequency of MCI
0
2
4
6
8
10
12
14
MCI with memoryimpairment
MCI with no memoryimpairment
White
Black
HispanicPer
cent
Manly et al, Arch Neurol (in press)
Friday Harbor 2005
Disadvantages of separate norms
• Used as a proxy for assumed educational, socioeconomic, or behavioral differences
• Diversity within ethnic groups:– educational– geographical– economic– exposure to Mainstream culture
• Separate norms leave ethnic differences unexplained and open for misinterpretation
Friday Harbor 2005
US CENSUS CLASSIFICATIONS
500 different tribesAfrican American
HaitiJamaicaWest Indian
EuropeMiddle EastNorth Africa
CambodiaChinaIndiaJapanKoreaMalaysiaPakistanPhilippine IslandsThailandVietnam
HawaiiGuamSamoa
CubanMexicanPuerto Rican
DominicanSouth or Central AmericanOther Spanish origin
Native Hawaiian or
Pacific Islander
White
American Indian or Alaska Native
Black or African American
Asian
Hispanic or Latino
Friday Harbor 2005
What are the cultural, linguistic, racial, educational, and
socioeconomic influences on cognitive test performance?
• Deconstruct race and ethnicity
DECONSTRUCT RACE/ETHNICITY
• Measure factors that vary within and between ethnic groups
• Determine relationship to test performance
• Adjust for significant factors before interpreting scores, regardless of race
CULTURAL EXPERIENCE
• Acculturation = level at which values, language, and cognitive styles are shared with ethnic community versus those of the dominant culture
OPERATIONALIZING CULTURE
ACCULTURATION
TRADITIONAL ETHNIC
UNACCULTURATED
MAINSTREAM
ACCULTURATED
Friday Harbor 2005
OPERATIONALIZING CULTURE
High EthnicLow Ethnic
Low Majority
High Majority
“marginal”
acculturated
unacculturated
bicultural
African American Acculturation Scale
Preference For African American Things1. Most of the music I listen to is by Black artists.6. Most of my friends are Black.
Traditional Childhood17. I went to a mostly Black elementary school.19. I grew up in a mostly Black neighborhood.
Religious Beliefs And Practices10. I am currently a member of a Black church.12. The church is the heart of the Black community.
Selected items from “The African American Acculturation Scale II: Cross-validation and short form,” by H. Landrine and E.A. Klonoff, 1995, Journal of Black Psychology, 21, p. 136.
Hispanic Acculturation Scale
1. Por lo general, que idioma(s) lee y habla usted?
6. Por lo general, en que idioma(s) son los programas de television que useted ve?
17. Sus amigos y amigas mas cercanos son:
Selected items from Marin, Gerardo; Sabogal, Fabio; Marin, Barbara V; Otero-Sabogal, Regina; et al. Development of a short acculturation scale for Hispanics. Hispanic Journal of Behavioral Sciences. 9 ,1987.
Solo Latinos
Mas Latinos que Americanos
Casi mitad y mitad
Mas Americanos que Latinos
Solo Americanos
Solo
Español
Español mejor que Inglés
Ambos por igual
Inglés mejor que Español
Solo Inglés
Solo
Español
Español mejor que Inglés
Ambos por igual
Inglés mejor que Español
Solo Inglés
Puente & Ardila2000
• Acculturation may be most critical factor in assessment of Hispanics
• What we measure = whether patient understands and answers questions in a manner that examiner feels is “normal”
• This is determined by acculturation
• We do not directly determine if there is brain damage - we infer it through performance (acculturation)
San Diego African American Neuropsychological Norms
Project (AANP)
Exclusion criteria:current or past drug dependenceserious mental illnessHI with LOC > 5 minutesneurological disorderurine analysis performed day of testing
MEASURES
• Neuropsychological battery
• Acculturation– self report - African American Acculturation
Scale– linguistic - Black English use
BLACK ENGLISH USEan objective measure of
acculturation
Language sample recorded during Story Memory Test
Transcribed X 2 Good interrater reliability Coded for certain Black English variants
RESULTSAMONG NORMAL AFRICAN AMERICANS
Unacculturated African Americans obtained lower scores on measures of verbal skills, even after accounting for age, education, and gender
Linguistically unacculturated African Americans obtained lower scores on measures of nonverbal abstraction and verbal skills
San Diego HIV Neurobehavioral Research
Center (HNRC)
Exclusion criteria: non-HIV related neurological or medical
disorder past IV drug use substance dependence HI with LOC > 30 minutes serious mental illness
RESULTSAMONG HIV+ INDIVIDUALS
Self-reported acculturation accounted for existing ethnic group differences abstraction, visuospatial ability, figure learning,
verbal skill
NOT STORY LEARNING gist vs. detail
ELDERLY PARTICIPANTS
No stroke, Alzheimer’s or Parkinson’s disease, substance abuse (past or current), or major psychiatric illness
Nondemented based on neurologist diagnosis
MEASURES Neuropsychological battery
verbal & nonverbal learning and memory, orientation, abstraction, naming, fluency, comprehension, and visuospatial ability
Functional Capacity Blessed Functional Activities Scale Schwab & England ADL Scale
African American Acculturation Scale 33-item self report
Friday Harbor 2005
TEST Sex Age Years education
SRT total recall .001 .119 .166
SRT delayed recall .001 .070 .091
BVRT recognition memory .004 .059 .156
MMSE Orientation .004 .012 .020
WAIS-R Similarities Raw .005 .062 .319
DRS Identities & Oddities .005 .045 .077
Boston Naming .002 .025 .148
Letter fluency .002 .046 .216
Category fluency .000 .070 .184
BDAE repetition .004 .010 .057
BDAE Comprehension .003 .012 .096
Rosen Drawing .001 .036 .071
BVRT matching .001 .058 .139
Demographics and cognitive test performance (R2)
Elderly African Americansn = 503
Test R2 for acculturation
Memory
Total recall .03* Delayed recall .01 Benton recognition .03*
Orientation
Mini-Mental Status Exam .00 Abstract Reasoning
Similarities .06* Identities/oddities total .00
* p < .01
Test R2 for acculturation
Language
Naming total .05* CFL mean .03* Category fluency mean .03* Repetition .03* Comprehension .02* Visuospatial Ability
Rosen .04* Benton matching .04*
* p < .01
Elderly African Americansn = 503
Deconstructing Race• Cultural experience
– Acculturation level
• Educational experience– Quality of education
EDUCATIONElementary in South 77%
Of high school educated, HS in South 62%
Of college educated, college in South 80%
Rural elementary 46%
Rural high school 15%
Mostly Black (>90%) elementary 84%
Mostly Black high school 64%
Friday Harbor 2005
Friday Harbor 2005
Per-pupil expendituresc. 1935
State Black White Ratio Alabama 17.50 53.18 .33 Florida 17.71 39.80 .45 Maryland 80.63 102.84 .78 Mississippi 13.36 58.61 .23 N. Carolina 32.92 51.43 .64 S. Carolina 18.62 67.74 .28 Virginia 33.05 63.81 .52 New York 110.97 Pennsylvania 75.74
Friday Harbor 2005
Length of School Term
60
80
100
120
140
160
180
200
NC White
NC Black
SC White
SC Black
NY All
Friday Harbor 2005
Student Teacher Ratio
25
35
45
55
65
75NC White
NC Black
SC White
SC Black
NY All
Friday Harbor 2005
Person-specific teacher-student ratio
• Alabama, Georgia, North Carolina, and South Carolina
• Calculated using date of birth and number of years of school
• Average state-level student-teacher ratio for years the respondent was in school
• Ranges from a low of 27 to a high of 76
Friday Harbor 2005
Quality of education & reading level
• In 1960’s, economists began to relate school characteristics to achievement of students– Coleman report
• Achievement was measured with standardized tests of reading, math, and spelling– Reading level is relatively stable across adulthood &
early dementia
– We could use reading level to estimate quality of school among elders
English Reading Level
Wide Range Achievement Test - reading subtest
I V Z J Q see red milk was
between cliff stalk grunt
clarify residence urge rancid
conspiracy deny quarantine deteriorate
regime beatify internecine regicidal
puerile factitious lucubration
epithalamion inefficacious synecdoche
Friday Harbor 2005
WRAT-3 reading
Spanish Reading Level Woodcock Johnson Batería - Revised
O B S R U de la ….
medicoquigúrico
Friday Harbor 2005
Woodcock Johnson Batería - Revised
Spanish Reading Level Word Accentuation Test
ACULLA
ABOGACIA
ANOMALO
CELIBE
ALELI
RABI
APATRIDA
HUSAR
ALEGORIA
MANCHU
DIAMETRO
MOARE
CONCAVO
AMBAR
PUGIL
POLIGAMO
ACME
SILICE
GRISU
ALBEDRIO
CANON
PIFANO
TACTIL
VOLATIL
DESCORTES
DISCOLO
BULGARO
BALADI
ACOLITO
CUPULA
Friday Harbor 2005
Word Accentuation
Test
Friday Harbor 2005
Quality of school and current reading level
• Controlling for race, age, and unobserved state level factors (HLM)
• Higher student-teacher ratios associated with lower scores on the WRAT-3
( = -0.54, p <.001).
Self-reported WRAT-3 years of education
estimate 0-3 4-6 7-8 9-12 13+ 0-3 3 8 5 11 4-6 5 6 11 1 7-8 2 2 2 16 3 9-12 2 9 30 40 13+ 1 3 40 40
READING LEVEL AND YEARS OF EDUCATION
ETHNICITY, GRADE, AND READING LEVEL
African-American
non-Hispanic
White
N 125 74reading level = actual grade 29% 47%reading level > actual grade 24% 35%reading level < actual grade 47% 18%
Friday Harbor 2005
Reading ability accounts for ethnic group differences
Test
African American N = 192
White
N = 192
ANOVA
ANCOVA with
WRAT-3
Mean Mean F F Memory
SRT Total recall 39.8 43.5 12.9** 1.7 SRT Delayed recall 5.8 6.7 8.9* 0.7 Benton figure recognition 7.4 8.1 20.4** 2.5 Orientation
10 Items from MMSE 9.7 9.8 3.5 Abstract Reasoning
WAIS-R Similarities 12.0 16.0 34.8** 3.7 Identities/oddities total 14.6 15.1 10.8* 1.8
** p < .01; *** p < .001Manly et al, 2002, J Int Neuropsychol Soc 8: 341-348
Friday Harbor 2005
Reading ability accounts for ethnic group differences
Test African American N = 192
White
N = 192
ANOVA
ANCOVA with
WRAT-3
Mean Mean F F Language
15-item Boston Naming 14.0 14.1 0.5 Letter fluency 9.9 12.2 31.8** 10.0* Category fluency 14.6 16.8 31.4** 0.8 BDAE Repetition 7.8 7.8 0.0 BDAE Comprehension 5.5 5.8 13.4** 3.2 Visuospatial skill
Rosen Drawing 2.6 3.0 30.0** 10.9* Benton Figure Matching 8.9 9.4 13.1** 3.4
* p < .05; ** p < .01Manly et al, 2002, J Int Neuropsychol Soc 8: 341-348
Friday Harbor 2005
TEST Age Years education Reading level
SRT total recall .119 .166 .189
SRT delayed recall .070 .091 .105
BVRT recognition memory .059 .156 .211
MMSE Orientation .012 .020 .033
WAIS-R Similarities Raw .062 .319 .386
DRS Identities & Oddities .045 .077 .088
Boston Naming .025 .148 .316
Letter fluency .046 .216 .401
Category fluency .070 .184 .184
BDAE repetition .010 .057 .095
BDAE Comprehension .012 .096 .137
Rosen Drawing .036 .071 .116
BVRT matching .058 .139 .156
Demographics and cognitive test performance (R2)
Friday Harbor 2005
Quality of school and current cognitive ability
• Controlling for race and sex
• Student-teacher ratio was a significant predictors of performance on measures of memory ( = -1.08, p = .001), executive function ( = -.54, p < .001), and language ( = -.10, p = .005).
Statistical limitations• The following must be eliminated for
accurate “adjustment” for SES– Residual confounding due to categorization– Measurement error– Aggregation– Incommensurability
• In a large study, race effects will ALWAYS persist after adjustment, even if there is in fact no true difference between groups
Deconstructing Race• Cultural experience
– Acculturation level
• Educational experience– Quality of education – Literacy level
ILLITERACY AMONG ETHNIC MINORITY ELDERS
• Ethnic minority and immigrant elders had fewer opportunities to receive formal education
• Illiteracy rate is 1.4% among age 65+, five times higher than age 25-44
• 21-23% of those with low literacy levels are 65+• In 1981, illiteracy among 65+ was 61% in
Dominican Republic
Limitations of prior studies
• Many compared schooled populations to unschooled populations
• The IQ problem: inability to eliminate possibility that differences (in behavioral data or imaging data) exist due to differences in overall “intellectual” ability between groups
An example• Ardila, 1994
• Compared illiterates to literates and brain-damaged literates
• Illiterates performed like brain damaged persons on several tests– Rey-O figure frequently drawn right to left– Digit span = 3 1– Naming parts rather than whole line drawings– Low scores on repetition measures
Friday Harbor 2005
EFFECTS OF LITERACY
• Literacy skills affect cognitive development
• Test bias
• Literacy increases cognitive reserve
PARTICIPANTS
• WHICAP - Washington Heights - Inwood Columbia Aging Project– 6.5% of WHICAP cohort is illiterate
• all report receiving no formal education
• all age 65 and above (range from 66-97)
• fluent in English or Spanish
LITERACYTest (max. score) LITERATE ILLITERATE F
LEARNING AND MEMORY SRT total recall (72) 31.19 28.30 2.01 SRT delayed recall (12) 4.07 3.70 .51 SRT recognition memory (12) 9.33 9.25 .02 BVRT recognition memory (10) 4.92 3.57 8.04** ORIENTATION MMSE orientation (10) 9.27 8.51 6.17* ABSTRACT REASONING WAIS-R Similarities (19) 6.96 5.34 8.69** DRS Identities & Oddities (16) 12.38 12.79 .45 LANGUAGE Boston Naming (15) 12.75 11.09 9.09** Category fluency 11.30 12.19 1.31 BDAE repetition (8) 7.52 7.11 2.60 BDAE Comprehension (6) 4.48 3.48 9.37** VISUOSPATIAL ABILITY Rosen Drawing (5) 1.58 .89 8.26** BVRT matching (10) 6.58 4.96 9.52**
* p<.05; ** p<.01
Education & AD
• Low education has been established as a significant risk factor for AD and other dementias
• Prevalence (Brazil, China, Finland, France, Italy, Israel, Netherlands, Sweden, USA)
• Incidence (Evans et al. 1993, Letenneur et al. 1994, Stern et al., 1994; White
et al., 1994)
Education and cognitive decline among
nondemented elders• More rapid cognitive and functional decline
among individuals with lower educational attainment Albert et al., 1995, Butler et al., 1996; Chodosh et al., 2002; Christensen et al., 1997; Farmer et al., 1995)
• Same education-related factors that delay the onset of dementia also allow individuals to cope more effectively with normal age-related changes
Cognitive reserve: The link between low education and
higher risk of dementia/cognitive decline?
• Native ability – Years of education is a proxy for brain or cognitive
characteristics that are already present at birth. – The same cognitive strengths or robust brain structures
that allow for academic or occupational success are also are less susceptible to sudden or gradual insult.
• Lifetime experience– Educational or workplace experience affects the brain
through either functional or structural pathways. – Education could be a proxy for the presence of
protective environmental factors
Education as a proxy for innate ability among
ethnic minorities• Educational opportunities were limited due to
institutionalized racism and poverty among minority or immigrant elders.
• Indices of reserve (whether assessed either in childhood or as an adult) may also underestimate the strength of the relationship between native ability and protection from cognitive decline among ethnic minorities
Education as a proxy for exposure to “educational
process”
• Great deal of discordance between years of education and quality of education among ethnic minorities
The Literacy AdvantageWe propose that:• Literacy or reading level, as an estimate of the
quality of education, will serve as a more meaningful proxy for reserve among ethnic minorities – a more sensitive proxy for reserve than years of
education because it more accurately reflects the quality of the educational experience provided to ethnic minority elders.
– a more accurate reflection of native ability because it does not assume that all individuals get the same amount of learning from a certain grade level
PARTICIPANTS
Population-based study of aging and dementia in the Northern Manhattan neighborhoods of Harlem and Washington Heights
Age 65 and older English is first and primary language
PARTICIPANTS
• Cognitively intact at all time points based on physician’s diagnosis
• No stroke, Parkinson’s disease, substance abuse (past or current), or major psychiatric illness
• Four completed evaluations required
DEPENDENT MEASURES Selective Reminding Test
Total words recalled over 6 learning trials Number of words recalled after a 15-minute delay
PREDICTORS Age (67 – 79 vs. >80 years) Years of education (split at median of 12 years) WRAT-3 Reading Level (split at median of 47) Race/Ethnicity (white vs. ethnic minority)
Low literacy group High literacy group
Number of subjects 67 69
M SD range M SD range
Age 79.8 5.8 67-94 80.3 5.2 68-94
Years of educationa 10.6 3.4 0 - 16 13.0 3.2 1 - 18
WRAT-3 Reading scoreb 40.3 7.8 0 - 47 51.2 2.2 48-56
Sex, % female 76.1% 63.8%
Ethnicity, % minorityc 76.1% 39.1%
Friday Harbor 2005
Literacy and SRT Total Recall
353739414345474951
0 1 2 3
Time
To
tal R
ecal
l Sco
re
High literacy
Low literacy
Manly et al, 2003, J Clin Exp Neuropsychol, 25: 680-690
Friday Harbor 2005
Literacy and SRT Delayed Recall
5
5.5
6
6.5
7
7.5
8
8.5
0 1 2 3
Time
Del
ayed
Rec
all
Sco
re
High literacy
Low literacy
Manly et al, 2003, J Clin Exp Neuropsychol, 25: 680-690
Friday Harbor 2005
Literacy and Incident AD
0
1
2
3
4
5
Hi educHi lit
Lo educHi lit
Hi educLo lit
Lo educLo lit
1.3 (0.4 - 4.2)
2.0 (0.6 – 6.1)
4.7 (1.8 – 12.2)
p= .001
N – 1,192
Age-Specific Prevalence of Alzheimer’s Disease (1990-1992)
BlacksCaribbeanHispanic Whites
65-74
75-84
85+
0
5
10
15
20
25
30
35
40
CDR1.0
Friday Harbor 2005
Race, education, literacy, & incident AD
1.0
1.5
2.0
2.5
3.0
Model 1 Model 2 Model 3
Race
Education
Reading level
Rel
ativ
e R
isk
** p < .01; *** p < .001
***
***
***
***
**
Deconstructing Race• Cultural experience
– Acculturation level
• Educational experience– Quality of education– Literacy
• Racial socialization– Stereotype threat
STEREOTYPE THREAT
• Steele et al. (1995)• Concern that
performance will confirm a negative stereotype
• May affect some test-takers more than others within the same ethnic group
0%
2%
4%
6%
8%
10%
12%
Black White
“AbilityDiagnostic”
“Mental Challenge”
Cultural experience
Quality of education
Racial socialization
• Salience of task in everyday life
• Familiarity with items and procedures
• Emphasis on particular skills during development
• Comfort during testing session
• Attitude toward testing/motivation
Friday Harbor 2005
CONCLUSIONS• Cognitive tests have reduced specificity
among ethnic minorities• No cognitive measure is “culture free”• Cultural and educational experiences are
significantly related to test performance• Years of education represent
incommensurate values across ethnic groups
• Literacy is a superior predictor of cognitive decline to years of education
Friday Harbor 2005
Future of Researchon Cognitive Aging and Dementia
• Race-specific norms only partial solution• “Race/ethnicity” should be deconstructed into more
meaningful and predictive variables• Explore role of cultural and linguistic experience on
cognitive function with aging
Friday Harbor 2005
Future of Researchon Cognitive Aging and Dementia
• Quality of education must be considered in cognitive studies of diverse elders
• Quality of education is important in cross-sectional and longitudinal studies of cognition among age cohorts
• Determine the best indicator of quality of education and literacy across life span
• Is benefit of literacy skills limited to school age experiences?
Friday Harbor 2005
Jen’s Friday Harbor initial wish list
• How does IRT address construct validity?
• Can reading level/quality of education/test-wiseness/IQ be distinguished in a non-birth cohort?
• How to equate reading level measures in Spanish and English for comparison?