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.

Differences between episodic and semantic memory in predicting observation-based activities of daily living in mild cognitive impairment and Alzheimer's disease.

Individuals with mild cognitive impairment (MCI) can often progress into Alzheimer's Disease (AD). Research suggests that decline in episodic memory and semantic memory, as well as functional abilities, can be sensitive in predicting disease progression. This study aimed to (a) investigate episodic and semantic memory performance differences between AD and MCI, (b) determine if memory performance predicts observation-based activities of daily living (ADLs), and (c) explore whether semantic memory mediates the relationship between episodic memory and ADLs. Fifty-eight AD, 53 MCI, and 72 healthy control participants were administered the Rey-O, California Verbal Learning Test, Animal Fluency Test, Boston Naming Test, and Direct Assessment of Functional Status (DAFS). The results revealed, first, that AD participants performed significantly lower than the MCI participants across semantic memory and episodic memory tasks, with the exception of the Boston Naming Test. Second, hierarchical-stepwise regression analyses found that semantic memory significantly predicted DAFS orientation, communication, and financial skills in AD, but episodic memory predicted shopping skills. Furthermore, semantic memory significantly predicted DAFS transportation skills in AD and MCI. Third, within the overall sample, semantic memory mediated the relationship between episodic memory and ADLs. Taken together, the findings suggest decline in semantic memory (as measured by confrontational naming and category fluency) and episodic memory (as measured by list and complex visual design learning and recall) may lead to decline in different and specific aspects of functional abilities in AD and MCI.

HIV Antiretroviral Medication Neuropenetrance and Neurocognitive Outcomes in HIV+ Adults: A Review of the Literature Examining the Central Nervous System Penetration Effectiveness Score.

This literature review summarizes the existing research examining the CNS penetration effectiveness (CPE) score and neurocognitive outcomes (i.e., neuropsychological assessment and neurocognitive screening) in HIV+ individuals. Despite the effectiveness of Combined Antiretroviral Therapy (CART) in reducing mortality and morbidity in HIV and controlling viral replication, HIV often persists in the Central Nervous System (CNS), and rates of neurocognitive impairment remain higher than predicted in the post-CART era. The CPE score was developed to rank antiretroviral regimens on their ability to penetrate the CNS and potency in inhibiting the virus, and it has been examined in relation to neurocognitive functioning for over a decade. Based on the results of 23 studies, we conclude that CPE is not as strongly associated with neurocognitive outcomes as initially hypothesized, although higher CPE ARV regimens may be associated with modest, improved outcomes in global neurocognitive functioning, and to a lesser extent attention/working memory and learning/memory. Conclusions, however, are limited by the heterogeneity in study design and methods, and the lack of a more recent CPE metric update. It is recommended that future research in this area employ comprehensive, standardized neuropsychological test batteries and examine domain-level performance, and use the newer 2010 CPE metric, although an updated CPE ranking is urgently needed.

Patterns of deficits in daily functioning and cognitive performance of patients with Alzheimer disease.

Previous research has identified patterns of cognitive deficits in patients with Alzheimer disease (AD), but little is known about their pattern of daily functional impairment. A total of 49 patients with AD and 52 healthy elderly controls were administered neuropsychological tests as well as the Direct Assessment of Functional Status (DAFS) test, an observation-based test of activities of daily living (ADLs). In this project, we assessed 14 separate tasks assessed by the DAFS. To analyze the data, 4 cognitive domains were created using neuropsychological composite z scores (means and standard deviation obtained from control data) for patients with AD. Results revealed that patients with AD performed worse on the memory, language, and visual-spatial relative to the executive domain. Additionally, patients with AD performed poorer than the controls on nearly all 14 DAFS tasks, with their worse performance being on the shopping-related tasks which, in part, requires memory skills. Logistic regression revealed better specificity than sensitivity classifications based on the DAFS tasks, and stepwise regression analyses indicated that cognitive domains predicted specific aspects of functional abilities. These findings suggest that patients with AD display a distinct pattern of ADLs performance, that traditional neuropsychological tests are useful in predicting daily functioning, and the DAFS has some strengths and weaknesses in classifying AD and controls.

Predicting everyday functional abilities of dementia patients with the Mini-Mental State Examination.

The Mini-Mental State Examination is a widely used cognitive screening measure. The purpose of the present study was to assess how 5 specific clusters of Mini-Mental State Examination items (ie, subscores) correlate with and predict specific areas of daily functioning in dementia patients, 61 patients with varied forms of dementia were administered the Mini-Mental State Examination and an observation-based daily functional test (the Direct Assessment of Functional Status). The results revealed that the orientation and attention subscores of the Mini-Mental State Examination correlated most significantly with most functional domains. The Mini-Mental State Examination language items correlated with all but the shopping and time orientation tasks, while the Mini-Mental State Examination recall items correlated with the Direct Assessment of Functional Status time orientation and shopping tasks. Stepwise regression analyses found that among the Mini-Mental State Examination subscores, orientation was the single, best independent predictor of daily functioning.

Normative data for Farsi-speaking Iranians in the United States on measures of executive functioning.

As the Farsi-speaking Iranian population continues to grow in the United States, examination of their cognitive performance is an imperative first step to providing this group with culturally competent services. Thirty-six healthy primarily Farsi-speaking Iranian adults completed Farsi-translated and adapted versions of three frequently used measures of executive/subcortical functioning: Wisconsin Card Sorting Test (WCST), Trail Making Test (TMT), and Color Trails Test (CTT). Participants' performance on each measure was compared to published normative data resulting in 0-85% of cognitively and medically healthy individuals being classified as impaired depending on the executive/subcortical test score examined, with the highest impairment rates for specific WCST outcome scores. These findings raise questions for the use of published norms with Farsi-speaking Iranians residing in the US. The present study provided normative data from this group of Farsi-speaking Iranians on the Farsi-translated and adapted versions of the WCST, TMT, and CTT.

The Functional Ability of MCI and Alzheimer's Patients Predicts Caregiver Burden.

Sixty patients and their caregivers participated in this study. Patients completed activities of daily living tasks and several neuropsychological tests assessing memory, abstract reasoning, and language. Caregivers completed self-report measures assessing caregiver burden and psychological distress. Results revealed that the mAD caregivers endorsed greater physical burden and feelings of missing out on life compared to MCI caregivers. The mAD caregivers indicated greater depression and anxiety relative to MCI caregivers. Stepwise regression found that fewer patient neuropsychological scores predicted caregiver burden, as compared to patients' daily functioning. Overall, mAD displayed more severe types of burden and psychological distress relative to MCI caregivers and patients' daily functional abilities better predicated caregivers' burden and psychological distress than patients' neuropsychological functioning.

Predicting caregiver burden from daily functional abilities of patients with mild dementia.

OBJECTIVES: To assess the relationship between performance- and informant-based measures of activities of daily living (ADLs) in patients with early dementia and burden or psychological distress experienced by the patients' caregivers. DESIGN: Descriptive study. SETTING: Ambulatory center. PARTICIPANTS: Thirty-four patient-caregiver dyads in which the patient had mild dementia (Mini-Mental State Examination score >17). MEASUREMENTS: A performance-based ADL measure (the Direct Assessment of Functional Status (DAFS)) was administered to patients with mild dementia. Caregivers completed an informant-based measure of patient functional status (instrumental activities of daily living). Caregivers also completed the Caregiver Burden Inventory (CBI) and the Brief Symptom Inventory (BSI). RESULTS: Significant correlations were found between the informant-based ADL measure and caregiver burden (CBI) and psychological distress (BSI) (correlation coefficient (r)=-0.34 to -0.71, all P<.05). Alternatively, fewer and weaker relationships were observed between the DAFS (performance-based) ADL measure and caregiver burden or distress ratings (r=-0.32 to -0.43, all P<.05). Of the seven tasks assessed using the DAFS, impairments in orientation, communication, financial, and transportation skills in patients were associated with greater time and developmental burden and greater hostility in caregivers. Impairment in financial skills in patients was the strongest predictor of time-dependence burden and hostility in caregivers, whereas impairment in patient transportation skills was the best predictor of developmental burden. CONCLUSIONS: The ADL abilities of cognitively impaired patients can predict caregiver burden and psychological distress, with informant-based measures having the greatest association with patient impairment.

Effects of acculturation on tests of attention and information processing in an ethnically diverse group.

The objective of this study was to examine differences between fluent English-speaking ethnically diverse (ED) individuals (from Hispanic, Asian and Middle-Eastern descent) and monolingual English-speaking Anglo-Americans (MEAA) on commonly used tests of information processing and attention. A sample of 123 (84 ED and 39 MEAA) healthy individuals participated. The results revealed that the MEAA group outperformed the ED group on Trail Making Test Part B, Stroop B and C, and Auditory Consonant Trigrams (18s delay condition). Additionally, a host of acculturation variables such as score on a formal acculturation scale, amount of time educated outside of the U.S., and the amount of English spoken when growing up correlated with these various neuropsychological tests. The findings from this study highlight the importance of taking acculturation into account for fluent English-speaking ED individuals when administering and interpreting neuropsychological tests.

The association between neuropsychological scores and ethnicity, language, and acculturation variables in a large patient population.

The relationship between ethnicity and cognitive test performance was examined in a sample of 161 patients referred for evaluation at a public hospital-affiliated neuropsychology clinic; 83 patients were Caucasian (non-Hispanic), 31 were African-American, 30 were Hispanic, and 17 were Asian. Significant group differences were present on some measures of language (Boston Naming Test), attention (Digit Span ACSS), constructional ability (Rey-Osterrieth [RO] copy), nonverbal processing speed (Trails A), and executive skills (Wisconsin Card Sorting Test [WCST]). Comparison of those who spoke English as a first language (or who learned English concurrently with a second language) versus those who spoke English as a second language (ESL) revealed significantly higher performance in the non-ESL group for Digit Span, Boston Naming Test, and FAS, and a higher score in the ESL group for RO copy. Boston Naming Test scores were significantly related to years educated in the United States; Boston Naming Test and Digit Span scores were significantly correlated with age at which conversational English was first learned and number of years in the United States; and finally, FAS scores were also significantly related to number of years in the United States. These findings are consistent with data from published literature on ethnic differences and the effects of acculturation on cognitive test performance in nonpatients, and also indicate that these observations are not attenuated by the presence of psychiatric or neurologic illness. The results further caution that normative data derived on Caucasian samples may not be appropriate for use with other ethnic groups.

Daily Activity Abilities in MCI, Alzheimer's Disease, and Healthy Controls.

Mild cognitive impairment (MCI) is a risk state for dementia. The present study assessed daily functioning in MCI individuals (amnestic [aMCI] and nonamnestic [naMCI]) relative to those with Alzheimer's disease (AD) and healthy controls (NC). Twenty AD participants, 14 aMCI, 12 naMCI, and 30 healthy controls were administered the Direct Assessment of Functional Status (DAFS). The AD group performed poorer than all groups on all DAFS subscales. The aMCI group performed poorer than controls on the shopping subtests, while the naMCI group performed poorer than controls on only the free recall shopping. Finally, DAFS subscales discriminated the AD and aMCI groups well, but only recognition shopping discriminated between naMCI and aMCI individuals. These findings suggest that circumscribed ADL deficits distinguish subtypes of MCI and AD.

The Effects of Declining Functional Abilities in Dementia Patients and Increases Psychological Distress on Caregiver Burden Over a One-Year Period.

The degree to which changes in caregiver burden over a one year period can be predicted by functioning of dementia patients and caregiver psychological stress was examined. The Direct Assessment of Functional Status (DAFS) was administered to 44 patients and the Caregiver Burden Inventory and the Brief Symptom Inventory were administered to their next-of-kin caregivers. All patients and caregivers were assessed at baseline and again in approximately one year with the same measures. Hierarchical regression revealed that baseline patient functioning predicted overall changes in caregiver burden, but that increases in psychological symptoms of caregivers such as depression, anxiety and hostility were the best predictors for specific types of increased caregiver burden, such as social, developmental, or physical burden. These results suggest that interventions should target reduction of particular psychological symptoms in order to reduce caregiver burden over time.

Aspects of Attention Predict Real-World Task Performance in Alzheimer's Disease.

More research is needed to examine the relationship between specific neuropsychological functions and observation-based daily activity tests in patients with Alzheimer's disease (AD). Fifty-six patients with AD were administered tests of attention and processing speed and an observation-based activities-of-daily-living (ADL) task. Complex short-term attention capacity best predicted real-world task performance, accounting for several domains of ADL functioning. These results suggest that complex attention requiring working-memory systems, but not simple attention or processing speed, account for moderate portions of variability in daily task performance. These results may aid in understanding the attentional processes required for performing daily activities and can be useful to health care professionals in treatment planning.

Survey results regarding use of the Boston Naming Test: Houston, we have a problem.

Members of the National Academy of Neuropsychology were surveyed in 2005 to assess then current practices regarding Boston Naming Test (BNT) administration, interpretation, and reporting procedures. Nearly half of 445 respondents followed discontinuation rules that differed from instructions published with the test, and nearly 10% did not administer items in reverse order to achieve the required 8 consecutive item basal. Of further concern, between 40% and 55% of respondents indicated that they did not interpret BNT scores in light of linguistic and ethnic background, and over 25% reported that they did not consider educational level. Despite the fact that non-normal distribution of BNT test scores renders use of percentiles misleading, nearly 60% of respondents endorsed using percentiles when reporting BNT data. The implications of these results are discussed, and recommendations are provided.

Semantic networks for odors and colors in Alzheimer's disease.

OBJECTIVE: Impairment in odor-naming ability and in verbal and visual semantic networks raised the hypothesis of a breakdown in the semantic network for odors in Alzheimer's disease (AD). The current study addressed this hypothesis. METHOD: Twenty-four individuals, half patients with probable AD and half control participants, performed triadic-similarity judgments for odors and colors, separately, which, utilizing the multidimensional scaling (MDS) technique of individual difference scaling analysis (INDSCAL), generated two-dimensional configurations of similarity. The abilities to match odors and colors with written name labels were assessed to investigate disease-related differences in ability to identify and conceptualize the stimuli. In addition, responses on attribute-sorting tasks, requiring the odor and color perceptions to be categorized as one polarity of a certain dimension, were obtained to allow for objective interpretation of the MDS spatial maps. RESULTS: Whereas comparison subjects generated spatial maps based predominantly on relatively abstract characteristics, patients with AD classified odors on perceptual characteristics. The maps for patients with AD also showed disorganized groupings and loose associations between odors. Their normal configurations for colors imply that the patients were able to comprehend the task per se. The data for label matching and for attribute sorting provide further evidence for a disturbance in semantic odor memory in AD. The patients performed poorer than controls on both these odor tasks, implying that the ability to identify and/or conceptualize odors is impaired in AD. CONCLUSION: The results provide clear evidence for deterioration of the structure of semantic knowledge for odors in AD.

Diversity Summit 2008: challenges in the recruitment and retention of ethnic minorities in neuropsychology.

The 2008 Diversity Summit recognized the many advantages of increasing the number of neuropsychologists from ethnically diverse backgrounds. The Summit addressed the aspiration of creating a more ethnically diverse body of neuropsychologists by increasing the recruitment of ethnic minority students to neuropsychology training programs. Challenges to successful recruitment and retention of ethnic minority students were discussion points at the Summit. This paper summarizes and expands these points and also suggests solutions to these challenges with the aim of stimulating innovative approaches to increasing the representation of ethnic minorities in neuropsychology.

The effects of culture on WASI test performance in ethnically diverse individuals.

The objective of this study was to examine differences between fluent English-speaking ethnically diverse (ED) individuals (from Hispanic, Asian, and Middle-Eastern descent) and monolingual English-speaking Anglo-Americans (MEAA) on the Wechsler Abbreviated Scale of Intelligence (WASI). A sample of 86 (50 ED and 36 MEAA) healthy individuals participated. The results revealed that the MEAA group outperformed the ED group on the verbal (i.e., Vocabulary and Similarities), but not the nonverbal (i.e., Block Design and Matrix Reasoning) subtests. Various cultural factors such as the level of acculturation and the degree to which the English language was used correlated with verbal skills. Number of years the education was obtained outide of the US was an important predictor of verbal and some nonverbal performance in the ED group. The findings from this study underscore the importance of taking cultural factors, particularly level of acculturation, into account when interpreting test scores of ED individuals.

Relationship between executive functioning and activities of daily living in patients with relatively mild dementia.

There is very little research regarding the relationship between tests of executive functioning and actual functional ability in patients with dementia. Thirty-three patients diagnosed with dementia and 35 age- and education-matched healthy controls were administered tests of executing functioning and an observation- and informant-based activities of daily living (ADL). As expected, the results revealed that the controls outperformed the dementia patients on the executive and ADL tests. Additionally, executive functioning correlated significantly with aspects of functional ability in patients with dementia. This relationship was strongest for tests of verbal fluency and a complex test of cognitive flexibility and reasoning ability (i.e., Wisconsin Card Sorting Test). These findings suggest that some executive function tests are more sensitive than others for predicting specific functional abilities and that they may be most useful to healthcare professionals for treatment planning.

Effects of cigarette smoking history on cognitive functioning in healthy older adults.

OBJECTIVE: The authors assessed the unique effect of smoking history on cognitive functioning after adjusting for demographic factors such as age, education, and gender, and presence of vascular illness. METHODS: A sample of 127 healthy older adults (29 men, 98 women) between the ages of 47 and 83 (mean: 66.9) were administered a comprehensive neuropsychological battery. Information regarding risk for vascular illness was assessed with a detailed self-report history and/or medical examination. Smoking history was gathered with a self-report questionnaire, and a composite score reflecting amount and duration of cigarette use was computed. From this composite score, three smoking groups were created: None-Light, Moderate, and Heavy smokers. RESULTS: Analyses of covariance, using age, education, gender, and vascular status as the covariates, revealed that the heavy smokers performed significantly poorer than the other groups on two scores from a test assessing executive function/problem-solving (Wisconsin Card-Sorting Test), but not on any of the other cognitive tests. CONCLUSIONS: Consistent with previous findings, smoking history did not appear to have deleterious effects on most cognitive domains. Heavy smoking history, however, did appear to affect performance on a measure of executive functioning.

Apathy and cognitive performance in older adults with depression.

OBJECTIVES: Recent studies have linked apathy to frontal lobe dysfunction in persons with dementia, but few studies have explored this relationship in older, depressed persons without dementia. We examined the association between apathy and cognitive function in a group of older persons with major depression using standardized neuropsychological tests. We hypothesized that presence of apathy in depression is associated with poorer frontal executive performance. METHODS: We analyzed data from 89 older adults with major depression. We defined apathy using four items from the Hamilton Psychiatric Rating Scale for Depression which reflect the clinical state of apathy, including 'diminished work/interest,' 'psychomotor retardation,' 'anergy' and 'lack of insight.' RESULTS: Apathy most strongly correlated with two verbal executive measures (Stroop C and FAS), a nonverbal executive measure (Wisconsin Card Sorting Test-Other Responses), and a measure of information processing speed (Stroop B). Apathy was not associated with age, sex, education, medical illness burden, Mini-Mental State Examination score and Full Scale IQ score. Stepwise regression analyses of significant cognitive tests showed that apathy alone or apathy plus depression severity, age, or education accounted for a significant amount of the variance. CONCLUSIONS: The results of this study provide support for an apathy syndrome associated with poorer executive function in older adults with major depression.