1. Friday Harbor 2005 Cultural and Demographic Influences on Neuropsychological Test Scores Jennifer J. Manly, Ph.D. Columbia University Medical Center

2. Friday Harbor 2005 National Institutes on Aging R01 AG16206 Alzheimer’s Association New York City Council Speaker’s Fund Award for Biomedical Research

3. Friday Harbor 2005 G.H. Sergievsky Center Taub Institute for Research on Alzheimer’s Disease and the Aging Brain Yaakov Stern, Ph.D. Nicole Schupf, Ph.D. Richard Mayeux, M.D. Danurys Sanchez Cherita McDowell Judes Fleurimont Iris Paltin Raquel 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

4. 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

5. SAN DIEGO AANP IMPAIRMENT RATES for NORMAL AFRICAN AMERICANS (n = 137)

6. An Early Deconstruction of Race Army Alpha & Beta tests From Klineberg, 1935

7. Cultural effects on test performance: WAIS-III Full Scale IQ Age Corrected Age, Education & Gender Corrected From Heaton & Taylor

9. 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 PI: Richard Mayeux

10. Age-Specific Prevalence of Alzheimer’s Disease (1990-1992) CDR  1.0

11. 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?

12. 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

13. 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

14. 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

15. 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

16. 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:

17. 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

18. Friday Harbor 2005 No significant ethnic differences in frequency of MCI Percent Manly et al, Arch Neurol (in press)

19. 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

20. Friday Harbor 2005

21. US CENSUS CLASSIFICATIONS 500 different tribes African American Haiti Jamaica West Indian Europe Middle East North Africa Cambodia China India Japan Korea Malaysia Pakistan Philippine Islands Thailand Vietnam Hawaii Guam Samoa Cuban Mexican Puerto Rican Dominican South or Central American Other Spanish origin Native Hawaiian or Pacific Islander White American Indian or Alaska Native Black or African American Asian Hispanic or Latino

22. Friday Harbor 2005 What are the cultural, linguistic, racial, educational, and socioeconomic influences on cognitive test performance? Deconstruct race and ethnicity

23. 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

24. CULTURAL EXPERIENCE Acculturation = level at which values, language, and cognitive styles are shared with ethnic community versus those of the dominant culture

25. OPERATIONALIZING CULTURE ACCULTURATION TRADITIONAL ETHNIC UNACCULTURATED MAINSTREAM ACCULTURATED

26. Friday Harbor 2005 OPERATIONALIZING CULTURE High Ethnic Low Ethnic Low Majority High Majority “marginal” acculturated unacculturated bicultural

27. African American Acculturation Scale Preference For African American Things 1. Most of the music I listen to is by Black artists. 6. Most of my friends are Black. Traditional Childhood 17. I went to a mostly Black elementary school. 19. I grew up in a mostly Black neighborhood. Religious Beliefs And Practices 10. 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.

28. 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

29. Puente & Ardila 2000 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)

30. San Diego African American Neuropsychological Norms Project (AANP)  Exclusion criteria: current or past drug dependence serious mental illness HI with LOC > 5 minutes neurological disorder urine analysis performed day of testing

31. MEASURES Neuropsychological battery Acculturation –self report - African American Acculturation Scale –linguistic - Black English use

32. BLACK ENGLISH USE an objective measure of acculturation  Language sample recorded during Story Memory Test  Transcribed X 2  Good interrater reliability  Coded for certain Black English variants

33. RESULTS AMONG 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

34. 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

35. RESULTS AMONG HIV+ INDIVIDUALS  Self-reported acculturation accounted for existing ethnic group differences  abstraction, visuospatial ability, figure learning, verbal skill  NOT STORY LEARNING  gist vs. detail

36. ELDERLY PARTICIPANTS No stroke, Alzheimer’s or Parkinson’s disease, substance abuse (past or current), or major psychiatric illness Nondemented based on neurologist diagnosis

37. 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

38. Friday Harbor 2005 TESTSexAgeYears 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 (R 2 )

39. Elderly African Americans n = 503 * p <.01

40. Elderly African Americans n = 503

41. Deconstructing Race Cultural experience –Acculturation level Educational experience –Quality of education

42. EDUCATION Elementary in South77% Of high school educated, HS in South62% Of college educated, college in South80% Rural elementary46% Rural high school15% Mostly Black (>90%) elementary84% Mostly Black high school64%

43. Friday Harbor 2005

45. Per-pupil expenditures c. 1935

46. Friday Harbor 2005 Length of School Term

47. Friday Harbor 2005 Student Teacher Ratio

48. 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

49. 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

50. English Reading Level Wide Range Achievement Test - reading subtest I V Z J Q seeredmilkwas betweencliffstalkgrunt clarifyresidenceurgerancid conspiracydenyquarantinedeteriorate regimebeatifyinternecineregicidal puerilefactitiouslucubration epithalamioninefficacioussynecdoche

51. Friday Harbor 2005 WRAT-3 reading

52. Spanish Reading Level Woodcock Johnson Batería - Revised O B S R U dela…. medicoquigúrico

53. Friday Harbor 2005 Woodcock Johnson Batería - Revised

54. 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

55. Friday Harbor 2005 Word Accentuation Test

56. 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).

57. READING LEVEL AND YEARS OF EDUCATION

58. ETHNICITY, GRADE, AND READING LEVEL

59. Friday Harbor 2005 Reading ability accounts for ethnic group differences ** p <.01; *** p <.001 Manly et al, 2002, J Int Neuropsychol Soc 8: 341-348

60. Friday Harbor 2005 Reading ability accounts for ethnic group differences * p <.05; ** p <.01 Manly et al, 2002, J Int Neuropsychol Soc 8: 341-348

61. Friday Harbor 2005 TESTAgeYears educationReading 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 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 (R 2 )

62. 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).

63. 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

64. Deconstructing Race Cultural experience –Acculturation level Educational experience –Quality of education –Literacy level

65. 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

66. 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

67. 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

68. Friday Harbor 2005 EFFECTS OF LITERACY Literacy skills affect cognitive development Test bias Literacy increases cognitive reserve

69. 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

70. LITERACY * p<.05; ** p<.01

71. 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)

72. 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

73. 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

74. 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

75. Education as a proxy for exposure to “educational process” Great deal of discordance between years of education and quality of education among ethnic minorities

76. The Literacy Advantage We 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

77. 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

78. 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

79. DEPENDENT MEASURES  Selective Reminding Test  Total words recalled over 6 learning trials  Number of words recalled after a 15-minute delay

80. 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)

81. Low literacy groupHigh literacy group Number of subjects6769 MSDrangeMSDrange Age79.85.867-9480.35.268-94 Years of education a 10.63.40 - 1613.03.21 - 18 WRAT-3 Reading score b 40.37.80 - 4751.22.248-56 Sex, % female76.1%63.8% Ethnicity, % minority c 76.1%39.1%

82. Friday Harbor 2005 Literacy and SRT Total Recall Manly et al, 2003, J Clin Exp Neuropsychol, 25: 680-690

83. Friday Harbor 2005 Literacy and SRT Delayed Recall Manly et al, 2003, J Clin Exp Neuropsychol, 25: 680-690

84. Friday Harbor 2005 Literacy and Incident AD 1.3 (0.4 - 4.2) 2.0 (0.6 – 6.1) 4.7 (1.8 – 12.2) p=.001 N – 1,192

85. Age-Specific Prevalence of Alzheimer’s Disease (1990-1992) CDR  1.0

86. Friday Harbor 2005 Race, education, literacy, & incident AD Relative Risk ** p <.01; *** p <.001 *** **

87. Deconstructing Race Cultural experience –Acculturation level Educational experience –Quality of education –Literacy Racial socialization –Stereotype threat

88. 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 “Ability Diagnostic” “Mental Challenge”

89. 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

90. 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

91. Friday Harbor 2005 Future of Research on 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

92. Friday Harbor 2005 Future of Research on 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?

93. 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?