Such instruments could be divided in two main groups: batteries or tests for assessment of specific areas or cognitive aspects and procedures of clinical evaluation. On the bases of the second group we found the neurological clinical methods and observation of reactions and responds of patients which we may call as qualitative approach Sacks, ; Glozman, ; Luria, ; Xomskaya, , Nowadays, in modern neuropsychology it is possible to find the followers of both approaches and their combination as well.
However, the majority of popular and broadly used instruments are related the quantitative approach. It is necessary to mention that the data obtained by each kind of instrument of assessment is not of the same kind. This phenomenon is expressed in different diagnostics which could be given to the patients with brain damage. It is often rather difficult to compare the diagnostics established on the bases of the usage of quantitative and qualitative instruments.
The example of such situation can be. There is no direct correlation between types of aphasia in these two classifications. The instruments or tests for neuropsychological assessment of quantitative approach normally consider isolated processes or cognitive abilities. For example, in the case of verbal activity, since the beginnings of neuropsychology, only expressive and receptive language disturbances have been considered. Such disturbances or types of aphasia were related to two classic zones of the language Dejerine, : the Broca zone and the Wernicke zone respectively.
Other difficulties, such as problems with spatial orientation or memory were considered separately from verbal deficits. Some authors Goodglass, ; Bsalasubramanian, have tried to analyze specific errors in written language associated with particular kind of aphasia, the initial conception of isolated verbal deficits still remains in cognitive neuropsychology. When the patient presents any other difficulties, these are interpreted as associated alterations, i,e.
According to our opinion, the psychometric background of the majority of neuropsychological tests has an impact on the conception of adaptation of tests for other languages or dialects. During neuropsychological assessment, among the most frequently used tests for Spanish Speaking patients is Boston test for Aphasia. We claim, as neuropsychologists constantly attending patients and teaching at university level, that the usage of such tests in countries or regions with spanish speaking population do not guarantee the information necessary for accurate diagnostic. From the point of view of qualitative approach, with its background of neurological.
We consider that the neuropsychological assessment should not be limited to the descriptions of the symptoms or deficits of the patient. The objective of this analysis is to discover the causes and to establish the systemic effect of brain injury on psychological activity of the patient.
It is possible to achieve this goal only by proposing and creation of original procedures and items for tests for neuropsychological assessment according to specific features of each concrete language. It is also important to mention that the analysis and interpretation of the results of assessment should be done according to the knowledge not only of the theory of neuropsychology, but also on qualitative features of types of answers and types of characteristic errors of normal subjects within each population.
The objective of the present study is to show the necessity of creation of specific items for neuropsychological assessment for Spanish speaking patients instead of its adaptation or translation. To carry out the work of assessment and diagnosis of Spanish speaking patients our group has incorporated, in addition to the concepts of neuropsychology developed by Luria y Tsvetkova , the contributions of the diverse areas of the historical-cultural psychology established by Vigotsky Based on this approach, none of the functions language, reading, writing, etc.
Each verbal action requires the participation of a diverse number of brain zones which contribute with their specific work. For example, let us consider the functional work fulfilled by the superior temporary secondary zones of the left hemisphere which consists on analyzing and synthesizing the language sounds. This work allows the discrimination of opposite phonemes and consequently it is directly related to the comprehension of oral language. But in addition, this analytical-synthetic work is necessary for the accomplishment of other functions or actions: spontaneous language, denomination, repetition, reading aloud and dictation.
Therefore, an injury in these cerebral sectors will affect not only the understanding of the oral language, but all the functions that we have mentioned as well. This form of analysis allows us to point out that the difficulties observed in oral language comprehension, the spontaneous language, the denomination, the repetition, the reading aloud and. In the case of brain damage, verbal action can be altered by diverse causes. The goal of neuropsychological assessment is to identify the affected factor or factors responsible for the difficulties that the patient undergoes.
It is easy to see that direct translation of the examples presented above will immediately lose their specific features in another language. If we translate cold and gold into Spanish, we get frio and oro. These words do not serve for assessment of phonematic analysis and synthesis of Spanish speaking patients.
The similar situation happens with the other examples mentioned above. The problem is that this is precise situation with all traditional neuropsychological tests which are used for Spanish speaking patients: the items of the tests are translated instead of being created specifically. In order to propose accurate items for neuropsychological assessment of Spanishspeaking patients it is necessary, first of all, to analyse, phonological, lexical and syntactical structure of Spanish language.
Let us revise the items for assessment of phonematic discrimination. Phonematic discrimination is related to perception of acoustic oppositions significant for comprehension of each language. Such discrimination is not separated from acquisition of words in oral speech and depends on efficient functioning of temporal zones of left hemisphere for Indo-European group of languages. Brain injury in these zones conduct to lost of phonematic discrimination and to sensory.
In order to verify the efficiency of phonematic discrimination it is necessary to find fine examples of words and syllables which include significant acoustic oppositions for each language. For instance, as for phonematic features of Spanish language we can found the following differentiations: 1 voiced unvoiced b p in words beso - peso ; 2 long short rr r in words perra - pera ; 3 soft sharp n in words pea - pena ; 4 stressed unstressed in words esta est. In order to accomplish proper assessment of phonematic discrimination typical for Spanish we have created specific items.
Tasks for assessment of phonematic discrimination: Repetition of pairs of words Repetition of syllables Identification of verbal sounds phonemes Tasks for kinesthetic Integration: Repetition of series of syllables and sounds. Our tests are constantly applied to Spanish speaking patients with brain injury in Mexico in different hospitals and in private neuropsychological service. As an illustration of disturbance of phonematic integration the case of a Spanish speaking patient with brain injury in temporal zones of left hemisphere is presented below.
Masculine patient of 40 years old, right handed, with eleven years of formal education had suffered TCE as a consequence of arterial venous malformation. In the Hospital the patient received a diagnostic of aphasia. The patient was sent for neuropsychological assessment 4 months after TCE in order to precise the form of aphasia. The results of neuropsychological assessment pointed out deficit in phonematic discrimination which conducted to severe difficulties in both verbal production and comprehension on level of sounds, words, sentences and texts.
The patient failed. The table 1 shows the errors of patients during neuropsychological assessment of phonematic and kinesthetic integration. The patient shows impossibility for recognition of verbal sounds. These difficulties are especially severe in items of phonematic integration. Verbal sounds which form phonematic oppositions are not accessible for the patient.
In the case of items for kinesthetic integration, the patient can fill, with the help of tactil perception; the sounds with are close to each other by point and mode of articulation afferent motor production. The patient tries to find the sound by articulation and not by acoustic audio-verbal perception which suffer as consequence of brain injury in temporal zones of left hemisphere. Table 1. Examples of tasks for phonematic and kinesthetic integration by the patient.
All examples correspond to Spanish language. Phonematic integration Task: Repetition of pairs of words Item. The example shows the necessity of usage of sensible tasks created according to phonematic structure of Spanish language. None of translated tests could serve to this purpose. The accurate neuropsychological diagnostic with the help of tests in Spanish language, detection of the form of aphasia, can help to create specific strategies for rehabilitation of Spanish speaking patients with brain injury. References Ardila A. Miami, Florida Internacional University.
Benson D. A clinical perspective. New Cork, Oxford University Press. For example, Siedlecki and colleagues used structural equation modeling to determine whether a set of neuropsychological tests exhibited measurement invariance across English and Spanish speakers, and found that English speakers obtained higher scores on all tests in the battery. Because of this scalar invariance, they cautioned against comparing means across English- and Spanish-speaking samples. However, given the metric invariance they observed, they also concluded that the same constructs are likely being measured across both language groups—a conclusion that could suggest that, despite measurement bias, the measures will be sensitive to impairment across groups.
Along these lines, Hispanic minorities in the United States are often Spanish—English bilinguals and this can also influence neuropsychological test performance.
Bilinguals may exhibit cognitive advantages compared with matched monolinguals on several measures of executive function. For example, young adult bilinguals exhibited smaller Stroop interference effects e. Bilingual advantages may also increase with age. For example, Bialystok et al.
This suggests that executive control may decline more slowly in aging bilinguals than in aging monolinguals.
Neuropsychological Evaluation of the Spanish Speaker / Edition 1
For example, Bialystok found that bilingual 6-year-olds were faster in completing both Trailmaking Test Parts A and B than matched monolinguals. These bilingual advantages in executive control may have developed to allow bilinguals to manage competition between their two languages when conversing. Roberts, Garcia, Desrochers, and Hernandez administered the BNT to monolingual and French—English and Spanish—English bilingual adults, and found significantly lower scores for bilinguals compared with age- and education-matched monolinguals.
The BNT is commonly used in the neuropsychological assessment of dementia and has shown declines during the preclinical period of AD e. It is not clear, however, if this test would be diagnostically useful in bilinguals, given that cognitively healthy bilingual individuals perform less well on this test than matched monolinguals. Verbal fluency is another commonly used neuropsychological measure that is susceptible to a bilingual disadvantage.
Even more problematic for the detection of early AD is that this bilingual disadvantage resembles the effect of AD on fluency. Studies have shown that semantic fluency is more adversely affected by AD than phonemic fluency e. Similarly, the bilingual disadvantage is greater for semantic fluency than phonemic fluency in both young Gollan et al.
Given these results, it is not clear if bilingualism will attenuate the pattern of fluency deficits associated with AD in monolinguals, or if a further discrepancy between semantic and phonemic fluency should be expected for bilinguals when they begin to develop AD. It is interesting, however, that a study by Salvatierra, Rosselli, Acevedo, and Duara showed that cognitively healthy elderly bilinguals produced more responses in semantic than in phonemic fluency tasks but see Gollan et al.
These results suggest that a greater decline in semantic fluency than phonemic fluency remains evident in bilinguals with AD. It remains to be determined, however, whether or not verbal fluency particularly semantic fluency is as effective in detecting preclinical AD in bilinguals as it is in monolinguals e. A further complication for predicting future onset of AD in Hispanic elderly is that differences have been reported for age of onset and rate of progression of AD in Hispanics compared with non-Hispanics.
Several studies report an earlier age of onset of AD in Hispanic older adults compared with non-Hispanics, after adjusting for education Clark et al. In contrast, several studies have found no difference in the age of onset of AD in Hispanics and non-Hispanics Duara et al. Whether this is due to differences in age of diagnosis or biological factors is still unclear.
An open question, given these many differences between cultural groups, is whether the same tests are sensitive to preclinical AD across groups. Given these questions, we took an exploratory approach to investigating differences between Hispanic and non-Hispanic elderly adults on a battery of commonly used neuropsychological tests. Our overarching goal was to determine which tests might be useful as preclinical markers of AD regardless of cultural group.
Existing research on cognitive measures that are useful for predicting future decline in individuals with preclinical AD has focused almost exclusively on non-Hispanic Caucasians e. We began by comparing baseline neuropsychological test performance of non-Hispanic and Hispanic participants who remained cognitively healthy in subsequent years i. We then examined which tests were sensitive to eventual progression to AD in patients who were initially diagnosed as normal but subsequently declined.
Finally, we asked if some tests that were sensitive to eventual progression to AD in one cultural group were sensitive in the other cultural group, and considered the possible theoretical implications of such differences. Participant characteristics are summarized in Table 1. To identify Hispanics and non-Hispanics who began participation at the ADRC prior to developing a diagnosis of probable AD, we screened longitudinal data from Hispanic and non-Hispanic participants who entered the ADRC study as normal control participants to the present. Participants with a history of alcoholism, drug abuse, severe psychiatric disturbances, severe head injury, and learning disabilities are excluded from participation in the ADRC study.
Upon their first evaluation i. Of these participants, 11 initially normal Hispanics were eventually diagnosed with probable AD during annual ADRC reevaluations, an average of 5. Diagnosing neurologists were not aware of specific test scores but were provided with a general statement regarding the evaluation results e.
These 11 non-Hispanic decliners were randomly selected from a larger group of non-Hispanic decliners who were carefully matched to Hispanics on age, education, and years prior to diagnosis. The respective non-Hispanic and Hispanic decliners were then matched for age and education to 33 non-Hispanic and 27 Hispanic normal controls who remained cognitively healthy for the duration of their participation in the ADRC study, and for at least two consecutive years but many remained in the study as controls for additional years [an average of 9.
Multiple independent sample t -tests were conducted to ensure that matching conditions were met see Table 1. We address this possible limitation later. Although non-Hispanics might potentially represent a heterogeneous group, all non-Hispanics included in our sample were Caucasian, with the exception of one decliner who was African American. A majority of Hispanic participants at the ADRC are bilingual with varying degrees of proficiency in each of their two languages. Of Hispanic decliners, five were born in the United States, four in Mexico, one in Argentina, and one was born in Poland but immigrated to Mexico at age 5.
All Hispanics at the ADRC are tested in their self-reported dominant language during annual neuropsychological evaluations. Qualitatively, there appeared to be a relationship between country of origin e. Detailed information see Table 1 on language background was available for eight of the 11 Hispanic decliners, and for a subset of the Hispanics who remained cognitively healthy 15 of 27 controls. For these individuals, those born in a Spanish-speaking country were exposed to English, on average, at age We excluded Hispanics who reported a third proficient language, and the level of bilingualism in the non-Hispanic cohort is negligible.
Hispanics have been shown to have greater risk of stroke compared with non-Hispanics e. Thus, it was important for the purposes of our study to consider this potential confound, given that strokes and vascular dementia affect test performance differently than AD e. To address this potential confound, we compared baseline Hachinski ischemia scores, a measure of stroke risk, across the Hispanic and non-Hispanic decliner groups.
Although we did not have Year 1 scores for three decliners two non-Hispanics and one Hispanic , these individuals obtained scores of 0 in subsequent years of testing Years 2, 4, and 9. We also assessed for diabetes, given its greater risk in Hispanics e. Only four individuals had a diabetes diagnosis two non-Hispanic decliners; two Hispanic normal controls , making diabetes an unlikely confound in our study.
Free Neuropsychological Evaluation Of The Spanish Speaker 1994
All but one of these six decliners endorsed none of the questions i. We obtained the earliest CDR available for the remaining 15 decliners, although all of these participants had been in the ADRC for at least 2 years average of 4. Despite this delay, average global CDR for both groups was only slightly above 0 0. Psychometrists for the Hispanic cohort were bilingual and bicultural, with most having Mexican American heritage, and some from Central American countries and Puerto Rico.
Here we report data from the first year of ADRC participation i.
Compatible con los siguientes dispositivos:
When necessary, translation of test materials was performed by bilingual psychologists and physicians in consultation with one of the ADRC psychometrists who is a certified translator. Back translation was performed for any tests with materials shown to the participant during testing. In previous studies, measures most sensitive to future decline included episodic memory assessed with verbal memory tests such as Word List Learning Chen et al.
We were, however, able to include a measure of nonverbal episodic memory. The measures included are as follows:. The MMSE is a brief, standardized point scale that assesses orientation to time and place, attention and concentration, recall, language, and visual construction. The DRS is a standardized point mental status test with subscales for Attention 37 points , Initiation and 1 39 points , Construction 6 points , Conceptualization 37 points , and Memory 25 points.
Participants are asked to define 35 words of increasing difficulty. The test is discontinued after five consecutive incorrect responses. Definitions are scored on a 0- to 2-point scale for a total possible score of 70 points.
- FROM THE ASHES OF MADNESS (Ashes Trilogy Book 1).
- Neuropsychological Evaluation of the Spanish Speaker.
- Spanish Speaking.
Participants are presented with a key that associates nine unfamiliar symbols with the numbers 1 through 9. They are then asked to use the key to draw the appropriate symbols below a random series of their associated numbers as quickly as possible for 90 s. The number of correctly completed symbols is the score of interest. Three figures of increasing complexity are presented to participants for 10 s each.
Immediately after each presentation, participants are asked to draw the figure from memory. After 30 min of unrelated testing, participants are again asked to draw the three figures from memory. Immediately after this delayed recall attempt, participants are asked to copy the figures to assess their perceptual and constructional abilities. Three scores are obtained: the sum of scores for all three figures 21 possible points in the immediate recall, delayed recall, and copy conditions.
In Part A TMT A , participants draw a line to connect the numbers 1 to 25 in consecutive order as quickly as possible within a s time limit. In Part B TMT B , participants draw a line to connect 25 numbers and letters in alternating, consecutive order as quickly as possible within a s time limit. Time to complete each task is scored. This abbreviated version of the BNT requires the participant to name 30 objects depicted in outline drawings.
The drawings are graded in difficulty, with the easiest drawings presented first. If the participant encounters difficulty in naming an object, a stimulus i. Correct responses produced spontaneously and after semantic cues are summed to provide the score of interest for a maximum score of Participants must sort 48 cards into three distinct categories twice for each category based on various perceptual features of the cards.
The sorting rule in effect changes throughout the test and must be determined by the participant through examiner-provided feedback regarding accuracy of the sort. The number of categories achieved out of six possible categories, and the number of perseverative and nonperseverative errors produced, are scored. The means and standard deviations of neuropsychological test scores of the four groups at Year 1 are shown in Table 2. Because previous studies have shown that bilingualism and differences in culture can affect performance on neuropsychological tests in cognitively healthy individuals, we first compared non-Hispanic and Hispanic normal controls to examine these effects.
These initial comparisons are necessary because baseline group differences could impact the sensitivity of cognitive tests to distinguish between controls and those who go on to develop probable AD. We then examined which cognitive tests in Year 1 distinguished decliners from controls in the Hispanic and non-Hispanic groups. After this initial comparison, we then present the remaining results in the following order: a tests that did not distinguish between decliners and controls in either group, b tests that distinguished between decliners and controls in both groups, c tests that distinguished between decliners and controls in Hispanics but not non-Hispanics, and d tests that distinguished between decliners and controls in non-Hispanics but not Hispanics.
Sample sizes for each analysis differed based on the availability of specific tests for each subject. Our predictions for tests of executive function were less clear. Although the Trail-Making Test sometimes reveals bilingual advantages e. In one study, a version of the test that was meant to be culture neutral i. Given these discrepant findings, either culture- or bilingual-related advantages or disadvantages seemed possible for our participants.
Confirming our predictions, Hispanics obtained lower scores relative to non-Hispanic normal controls on all language tests. As previously reported for bilinguals versus monolinguals e. A similar general pattern of results emerged for semantic fluency. Looking at animals likely the most commonly administered semantic category , the Hispanic disadvantage was significant see also Gollan et al. Consistent with the results of Verney et al.
These results are consistent with a study by Lyness and colleagues that showed lower scores in cognitively normal Hispanics compared with non-Hispanics on these same DRS subtests.
Even though a large component of the DRS Initiation and Perseveration subtest involves supermarket fluency, there was no difference between Hispanic and non-Hispanic controls on this subtest, perhaps because scoring procedures impose a hard ceiling on the number of items credited. This is consistent with the results of La Rue et al.
Taken together, our results revealed consistently lower scores for Hispanic normal controls relative to age-, education-, and gendermatched non-Hispanic controls on tests of language, executive function, and global cognitive ability. This discrepancy in performance is evident, even though the controls in the present study were longitudinally followed for a number of years to ensure that individuals with preclinical or prodromal AD or other neurodegenerative conditions were not included in the Hispanic or non-Hispanic group.
Whether the discrepancy in performance between groups is related to culture such as test bias , bilingualism, or other demographic differences e. Having found several significant baseline group differences in performance, we next considered the possible impact of these differences on the utility of cognitive tests for distinguishing between Hispanics with preclinical or prodromal AD i.
Based on previous literature, we predicted that tests of global functioning e. The utility of phonemic fluency and visual memory for detecting preclinical AD is mixed see Twamley et al. Although previous studies have shown that certain tests of episodic memory, semantic memory, and attention are sensitive to preclinical AD in non-Hispanics for review, see Twamley et al. Tests on which Hispanic controls obtained lower scores may have underestimated performance in this group, or could be culturally biased, and for this reason may be less sensitive to small changes in cognitive status.
This finding is consistent with a number of previous studies. Twamley et al. Given the paucity of research in this area, we made limited predictions. Although none of the differences between Hispanic normal controls and Hispanic decliners approached significance across all three semantic fluency categories i. This result stands out in contrast to the otherwise consistently lower scores that cognitively healthy Hispanics had in semantic fluency e.
To further explore this apparent reversal of the disadvantage with pending onset of AD, we conducted a series of 2 normal controls vs. These analyses confirmed the presence of a significant crossover interaction effect: In those who remained cognitively normal, Hispanics produced fewer correct semantic fluency responses than non-Hispanics, whereas in those who later developed AD, Hispanics produced more correct responses than non-Hispanics see Figure 1.
These results suggest that semantic fluency scores remain stable in Hispanics for a longer period of time prior to clinical presentation of AD. The goal of this study was to determine which neuropsychological tests are sensitive to preclinical AD and future cognitive decline in elderly Hispanic adults. Our prediction was that tests sensitive to future decline in monolingual non-Hispanics might not be sensitive to future decline in Hispanics because of cultural and linguistic differences that could affect test performance. Possible effects of these factors in our participants were initially assessed by comparing cognitively healthy Hispanics with non-Hispanics, and these comparisons revealed a number of significant differences in test performance between cultural groups.
Despite these differences, the results only partially confirmed our predictions, with some notable exceptions that have clinical implications in terms of the diagnostic utility of neuropsychological tests for identifying cognitive changes cross-culturally. In addition, the results may shed light on the nature of cognitive changes in preclinical AD. Looking first at participants who remained cognitively healthy for years after initial testing i. Hispanic controls also obtained lower scores than non-Hispanic controls on a number of nonverbal or at least less verbally dependent measures, including the WAIS-R Digit Symbol Substitution test and several subscales of the DRS Attention, Conceptualization, and Memory.
These lower scores in Hispanic participants on these tests is consistent with previous reports and could be related to bilingualism, cultural bias, unidentified differences in socioeconomic status SES between the Hispanics and non-Hispanics, differences in the quality of education between the groups, or some combination of these or other factors. A number of measures were not sensitive to future cognitive decline in Hispanics or non-Hispanics.
Overcoming barriers in cognitive assessment of Alzheimer's disease
The lack of sensitivity to preclinical AD for these measures at least in the non-Hispanic group is generally consistent with previous reports see review in Twamley et al. It was somewhat surprising that our only measure of delayed recall, the Visual Reproduction Test, lacked sensitivity to preclinical AD. Previous studies showed that tests of delayed recall predict future cognitive decline, but these studies have typically used sensitive tests of verbal episodic memory Twamley et al.
Additional power may be needed to detect relatively subtle changes in visual memory if they occur in preclinical AD. A primary goal of the present study was to identify whether cognitive tests that are sensitive to preclinical AD in non-Hispanics would also be sensitive in Hispanics.
Contrary to our prediction, a number of tests seemed to predict future cognitive decline in both cultural groups. A few measures emerged as uniquely sensitive for detecting preclinical AD in Hispanic but not in non-Hispanic participants e. It is not clear why these measures should be uniquely sensitive in one cultural group more than the other, but if replicated in future work, this might provide useful information for early diagnosis of AD in Hispanics.
In addition, a number of other measures revealed sensitivity to future decline in Hispanics, even though Hispanics were disadvantaged, with medium to large effect sizes, on these measures. For example, the BNT, a picture naming task known to exhibit robust bilingual disadvantages e. It is not clear why certain cognitive tests are sensitive to future decline in both groups despite robust cultural group effects on performance, but it could suggest that, despite cultural bias, similar constructs are measured cross-culturally by these tests see Siedlecki et al.
Although it may be tempting to use these measures to predict cognitive decline in Hispanic older adults, we caution against this approach, as it may lead to inappropriate conclusions in other respects. However, this is only a temporary solution to a larger issue in neuropsychology. The reported findings speak to the importance of considering how demographic differences e.
More in line with our prediction, two verbal tests were sensitive to future decline in non-Hispanics but not in Hispanics. Specifically, non-Hispanic decliners had lower vocabulary and semantic fluency scores relative to matched controls, whereas Hispanic decliners and their matched controls performed similarly. Based on a closer examination of the mean scores for these two tests, we speculate that they may be insensitive to future decline in Hispanics for different reasons.
For Hispanics on this test, the effects of education level and degree of language exposure due to bilingualism may override any effects of an underlying disease process. Indeed, vocabulary test scores may be more resistant to decline than other tests e. The sensitivity of picture naming across both cultural groups suggests that picture naming may be more strongly affected by AD than vocabulary knowledge e. A different pattern of results was observed for the semantic fluency test. Hispanic decliners had significantly higher semantic fluency scores than non- Hispanic decliners—a pattern not seen on any other test we examined.
As shown in Figure 1 , this interaction between cultural group Hispanic, non-Hispanic and cognitive status decliner, control was consistent across two animals and vegetables of the three semantic categories tested. Although speculative, this pattern could suggest that Hispanics with preclinical AD may be protected from the vulnerability in semantic fluency that characterizes preclinical AD in non-Hispanics.
It is not clear why this was not observed for the fruits category, a category that also exhibited the numerically smallest difference of all three categories tested between decliners and controls in the non-Hispanic group. Note that patterns of performance on individual fluency categories and sensitivity to disease effects can vary within category type; for example, semantic categories usually but not in all cases generate more correct responses than most letter categories Acevedo et al.
It is possible that our findings reflect inherent differences between the individual categories, but given the small number of decliners tested, it also seems possible that the results would change with increased power. A possible explanation for the protective effect for Hispanics with preclinical AD may be related to effects of bilingualism on semantic fluency, and lifelong competition between languages. Cognitively healthy Spanish—English bilinguals exhibit a semantic fluency disadvantage relative to matched monolinguals Gollan et al.
As exemplars from both languages become active, bilinguals are effectively placed in a dual-task scenario in which they have to simultaneously generate semantic category members, verify that exemplars belong to the target language, and inhibit production of nontarget language category members. Similar competition effects present during normal language production may lead bilinguals to develop processing mechanisms that subsequently make them better able to produce exemplars from semantic memory despite changes to the integrity of semantic memory representations e.
This explanation is tentative but suggests avenues for future research that may ultimately lead to a better understanding of semantic fluency deficits in bilingualism and in AD. A number of limitations in the current study call for some caution in interpretation of the findings and suggest a need for further investigation. The longitudinal design of the ADRC study requires that test versions not be changed over time; as a result, several of the measures used in the current study have since been updated, and the results would need to be verified with updated versions e.
Another limitation is that we did not have a detailed measure of verbal episodic memory, a cognitive domain that previous work has shown to be particularly sensitive to preclinical AD e. It will be important in future work to determine if there are cultural or bilingual effects that limit the effectiveness of verbal episodic memory tests in predicting future cognitive decline in elderly Hispanics.
A third limitation is that there were more women than men decliners particularly in the Hispanic group; see Table 1 ; but note that key results, e.
Perhaps the most notable limitation is that we had a very small number of decliners 11 in each cultural group. This was because of our strict requirement that decliners be diagnosed as normal controls e. Nevertheless, our results confirm the presence of bilingual disadvantages, suggest sensitivity in some, but not all, measures for detecting future decline across cultural groups, and highlight the potential advantages of considering cross-cultural differences in neuropsychological test performance when evaluating cognition in the elderly.
In sum, the results we reported reveal significant differences between cultural groups in sensitivity of tests to future cognitive decline, and contrary to our predictions, some sensitivity of a number of existing test measures to progression to AD in Spanish-and English-speaking Hispanics.
These data may help to improve early diagnosis of AD in Hispanics, but in future work it will be important to create tests that can optimally detect cognitive impairment across multiple cultural groups e. In addition, the results we reported suggest some between-group variability in the pattern of deficits that emerge at the earliest stages of the disease e.
If replicated in future studies with a larger numbers of participants , these could reflect some cognitive advantages associated with cultural differences perhaps related to the need to manage two languages in a single cognitive system. In this respect, the current study illustrates how cross-cultural comparisons can shed light on the cognitive mechanisms underlying neuropsychological test performance and the effects of AD on these tests. One was diagnosed with mild neurocognitive disorder in Year 1 of testing, but was then reclassified as a normal control for 6 subsequent years, before receiving a diagnosis of probable AD.
Analyzing the data with and without this participant did not change the findings.
The second was diagnosed as a normal control in Year 1 of testing and with possible AD at Year 2 only 2 years of testing were available. McKhann et al. Analyzing the data without this participant slightly changed one finding see Footnote 4.
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