A Systematic Review of Neuropsychological Tests for the Assessment of Dementia in Non-Western, Low-Educated or Illiterate Populations

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Abstract

Objective:

Neuropsychological tests are important instruments to determine a cognitive profile, giving insight into the etiology of dementia; however, these tests cannot readily be used in culturally diverse, low-educated populations, due to their dependence upon (Western) culture, education, and literacy. In this review we aim to give an overview of studies investigating domain-specific cognitive tests used to assess dementia in non-Western, low-educated populations. The second aim was to examine the quality of these studies and of the adaptations for culturally, linguistically, and educationally diverse populations.

Method:

A systematic review was performed using six databases, without restrictions on the year or language of publication.

Results:

Forty-four studies were included, stemming mainly from Brazil, Hong Kong, Korea, and considering Hispanics/Latinos residing in the USA. Most studies focused on Alzheimer’s disease ( n = 17) or unspecified dementia ( n = 16). Memory ( n = 18) was studied most often, using 14 different tests. The traditional Western tests in the domains of attention ( n = 8) and construction ( n = 15), were unsuitable for low-educated patients. There was little variety in instruments measuring executive functioning (two tests, n = 13), and language ( n = 12, of which 10 were naming tests). Many studies did not report a thorough adaptation procedure ( n = 39) or blinding procedures ( n = 29).

Conclusions:

Various formats of memory tests seem suitable for low-educated, non-Western populations. Promising tasks in other cognitive domains are the Stick Design Test, Five Digit Test, and verbal fluency test. Further research is needed regarding cross-cultural instruments measuring executive functioning and language in low-educated people.

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Most cited references 76

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Reading level attenuates differences in neuropsychological test performance between African American and White elders.

Marc Jacobs, Dylan S Small, Pegah Touradji … (2002)

The current study sought to determine if discrepancies in quality of education could explain differences in cognitive test scores between African American and White elders matched on years of education. A comprehensive neuropsychological battery was administered to a sample of African American and non-Hispanic White participants in an epidemiological study of normal aging and dementia in the Northern Manhattan community. All participants were diagnosed as nondemented by a neurologist, and had no history of Parkinson's disease, stroke, mental illness, or head injury. The Reading Recognition subtest from the Wide Range Achievement Test-Version 3 was used as an estimate of quality of education. A MANOVA revealed that African American elders obtained significantly lower scores than Whites on measures of word list learning and memory, figure memory, abstract reasoning, fluency, and visuospatial skill even though the groups were matched on years of education. However, after adjusting the scores for WRAT-3 reading score, the overall effect of race was greatly reduced and racial differences on all tests (except category fluency and a drawing measure) became nonsignificant. These findings suggest that years of education is an inadequate measure of the educational experience among multicultural elders, and that adjusting for quality of education may improve the specificity of certain neuropsychological measures.

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Illiteracy: the neuropsychology of cognition without reading.

Paulo Bertolucci, Esmeralda Matute, Antonio Braga … (2010)

Illiterates represent a significant proportion of the world's population. Written language not only plays a role in mediating cognition, but also extends our knowledge of the world. Two major reasons for illiteracy can be distinguished, social (e.g., absence of schools), and personal (e.g., learning difficulties). Without written language, our knowledge of the external world is partially limited by immediate sensory information and concrete environmental conditions. Literacy is significantly associated with virtually all neuropsychological measures, even though the correlation between education and neuropsychological test scores depends on the specific test. The impact of literacy is reflected in different spheres of cognitive functioning. Learning to read reinforces and modifies certain fundamental abilities, such as verbal and visual memory, phonological awareness, and visuospatial and visuomotor skills. Functional imaging studies are now demonstrating that literacy and education influence the pathways used by the brain for problem-solving. The existence of partially specific neuronal networks as a probable consequence of the literacy level supports the hypothesis that education impacts not only the individual's day-to-day strategies, but also the brain networks. A review of the issues related to dementia in illiterates is presented, emphasizing that the association between the education level and age-related cognitive changes and education remains controversial. The analysis of the impact of illiteracy on neuropsychological test performance represents a crucial approach to understanding human cognition and its brain organization under normal and abnormal conditions.

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Neuropsychological test performance in illiterate subjects.

F Ostrosky-Solis, A Ardila, M Rosselli … (1998)

The purpose of this study was to further analyze the effects of education across different age ranges on neuropsychological test performance. Two different analyses were performed. The first analysis was conducted in order to pinpoint the impact of school attendance on neuropsychological testing. A group of 64 illiterate normal subjects was selected in the Mexican Republic. Their performance was compared with two barely schooled control groups (1-2 and 3-4 years of schooling). The subjects' ages ranged from 16 to 85 years. In the second analysis, the illiterate subjects were further matched by age and sex with individuals with 1 to 4, 5 to 9, and 10 to 19 years of formal education. The Spanish version of the NEUROPSI neuropsychological test battery (Ostrosky, Ardila, & Rosselli, 1997) was used. Results indicated a significant educational effect on most of the tests. Largest educational effect was noted in constructional abilities (copying of a figure), language (comprehension), phonological verbal fluency, and conceptual functions (similarities, calculation abilities, and sequences). Aging effect was noted in visuoperceptual (visual detection) and memory scores. In the first subject sample, it was evident that, despite using such limited educational range (from 0-4 years of formal education), and such a wide age range (from 16-85 years), schooling represented a stronger variable than age. It is proposed that education effect on neuropsychological test performance represents a negatively accelerated curve, tending to a plateau.