T. Rune Nielsen
T. Rune Nielsen, PhD
Danish Dementia Research Centre, Rigshospitalet, University of Copenhagen
NNF, Oslo
September 2016
Development and validation of the European Cross-Cultural Neuropsychological Test Battery
(CNTB)
T. Rune Nielsen
Background
Among European dementia experts, 64% find it more challenging to make cognitive assessments in patients with immigrant background
Nielsen et al., International Psychogeriatrics, 2011
1. Language proficiency (88%)
2. Presentation of symptoms (84%)
3. Educational level(84%)
4. Lacking clinical tools (68%)
5. Lacking cultural knowledge (44-56%)
T. Rune Nielsen
Variable n RUDAS MMSE
Total score 76 26.8 ± 2.4 23.7 ±4.3
Education
0-4 years 35 25.9 ± 2.2 20.7 ± 3.9
≥5 years 41 27.5 ± 2.2 p=0.002 26.3 ± 2.4 p<0.001
What is the problem with our clinical tools?
• The available clinical tools are usually developed and validated in Western educated populations and are biased by cultural, lingusitic and educational factors (ie. the MMSE).
Mini Mental State Examination (MMSE) and Rowland Universal Dementia Assessment Scale (RUDAS) in healthy Turkish immigrants
Nielsen et al., Scandinavian Journal of Psychology, 2012
T. Rune Nielsen
What is the problem with our clinical tools?
Daugherty et al., Applied Neuropsyhology: Adult, 2016
Percentage of diagnostic mistakes of Minor- and Major Neurocognitive Disorder (DSM-IV) when using original standardized US norms on available neuropsychological tests
Groups matched by: • age • gender • educational level • monthly income
All fluent in Spanish at an academic level
T. Rune Nielsen
European research alliance on development of a cross-cultural neuropsychological test battery
Copenhagen
Beirut
Rio de Janeiro og São Paulo
Oslo Malmö Berlin
Brussels
Thessaloniki
Manila / Colombo?
T. Rune Nielsen
The first European study on cross-cultural cognitive assessment
The CNTB study
T. Rune Nielsen
Healthy control sample (preliminary data)
Data on Pakistani immigrants generously made available by Peter Bekkhus-Wetterberg, MD
Majority Minority
Belgian,
Danish,
Norwegian,
Swedish
Polish Former
Yugoslavian Pakistani Turkish Moroccan
Total
sample p
N 139 42 20 47 76 15 339
Age
(years) 68.4 (11.1) 67.7 (8.7) 63.3 (6.0) 58.7 (6.8) 61.6 (7.3) 57.7 (8.1) 64.7 (9.9) <.001
Education
(years) 12.0 (3.3) 14.4 (2.5) 11.0 (3.1) 9.9 (4.8) 3.9 (3.9) 2.9 (2.6) 9.7 (5.2) <.001
T. Rune Nielsen
Culture reduced instruments in the CNTB
Requirements for included tests: • Sensitive to cognitive dysfunction in dementia.
• Short and easy to administer.
• Can be applied with an interpreter.
• Does not include elements that need written translation.
• Can be performed by individuals with limited or no schooling.
T. Rune Nielsen
The CNTB consists of 12 tests that can be administered in approximately 60 minutes
Global cognitive function
• Rowland Universal Dementia
Assessment Scale (RUDAS)
Executive functions
• Color Trails Test (CTT)
• Five Digit Test (FDT)
• Serial threes
Memory
• Recall of Pictures Test (RPT)
• Enhanced Cued Recall (ECR)
• Recall of simplified Rey figure
Visuospatial functions
• Copying of simple figures
• Copying of simplified Rey figure
• Clock Drawing Test (CDT)
• Clock Reading Test (CRT)
Language
• Picture naming (RPT)
• Animal fluency
• Supermarket fluency
Tests in the CNTB
T. Rune Nielsen
Global cognitive function - Rowland Universal Dementia Assessment Scale (RUDAS)
Storey et al., International Psychogeriatrics, 2004
P<.001
What explains the variation?
Age Education Country of origin
3% 15% <1%
T. Rune Nielsen
Learning and memory - Enhanced Cued Recall (ECR)
Based on Solomon et al., Archives of Neurology, 1998
T. Rune Nielsen
Learning and memory - Recall of Pictures Test (RPT)
Nielsen et al., International psychogeriatrics, 2012
T. Rune Nielsen
P=.28
p=.63 P<.001
P<.001
P<.001
Learning and memory - Preliminary data
What explains the variation?
Age Education Country of origin
ECR 1% <1% 6%
RPT immediate recall 5% - 8%
RPT delayed recall 7% <1% 3%
RPT recognition <1% 1% 1%
Rey recall 9% 15% 3%
T. Rune Nielsen
Executive functions - Color Trails Test (CTT)
CTT 1 CTT2
Only participants with >4 years of education
d’Elia et al., Color Trails Test: Professional Manual, 1996
T. Rune Nielsen
Executive functions - Five Digit Test (FDT)
Sedó, FDT Manual, 2007
T. Rune Nielsen
P<.001
P<.001
P<.001 P<.001
P<.001 P<.001
* Scale multiplied with 10 to with other scales
Executive functions - Preliminary data
What explains the variation?
Age Education Country of origin
CTT 1 5% 22% 7%
CTT 2 4% 31% 10%
FDT 1 4% 31% 3%
FDT 2 4% 31% 5%
FDT 3 9% 22% 3%
20-3 <1% 13% 13%
T. Rune Nielsen
Language - RPT picture naming
T. Rune Nielsen
Language - Animal and supermarket fluency
Strauss et al., A Compendium of Neuropsychological Tests, 2006
T. Rune Nielsen
P<.001
P<.001
P<.001
Language - Preliminary data
What explains the variation?
Age Education Country of origin
RPT picture naming <1% 12% 5%
Animal fluency 2% 22% 7%
Supermarket fluency 11% 17% 5%
T. Rune Nielsen
Visuospatial functions - Copying tests
. . .
Simplyfied Rey figure (22 points) Simple copying tests
T. Rune Nielsen
Visuospatial functions - Clock Drawing Test (CDT)
Shulman et al., International Journal of Geriatric Psychiatry, 2000
T. Rune Nielsen
Visuospatial functions - Clock Reading Test (CRT)
Schmidtke and Olbrich, International Psychogeriatrics, 2007
T. Rune Nielsen
P<.001
P<.001
P<.001
P<.001
P<.001
Visuospatial functions - Preliminary data
What explains the variation?
Age Education Country of origin
Cross <1% 27% 6%
Star 2% 40% <1%
CDT 8% 12% 1%
CRT 5% 10% 6%
Rey 2% 40% <1%
T. Rune Nielsen
Structure Matrix
Component
1 2 3 4
FDT 2 -,871
FDT 1 -,863
CTT 1 -,847
CTT 2 -,808
FDT 3 -,761
CDT ,730
Copyng ,695 ,606
RPT naming ,587 ,406
Subtraction 20-3 ,569
RPT recall ,828
RPT immediate recall ,814
RPT recognition ,484
ECR ,367
Rey copy ,896
Rey recall ,440 ,764
CRT ,533 ,594
Supermarket fluency ,421 ,423 -,716
Animal fluency ,530 -,650
Extraction Method: Principal Component Analysis.
Rotation Method: Oblimin with Kaiser Normalization.
Internal structure of the CNTB
Only factors with loading <.4 are shown
Executive
Visuospatial
Memory
Language
T. Rune Nielsen
But is the CNTB sensitive to cognitive dysfunction?
Area Under the Curve
Test Result Variable(s) Area RPT recall ,993 RPT learning ,988 ECR ,928 Rey recall ,928 RUDAS ,920 Fluence, supermarket ,918 Fluence, animals ,894 FDT3 (time) ,869 Color2 (time) ,834 Color1 (time) ,814 FDT2 (time) ,809 CDT (Shulman,2000) ,803 CRT ,792 FDT1 (time) ,767 RPT recognition ,753 RPT naming ,672 Subtraction 20-3 ,667 Rey copy ,643 Copying ,580
Controls, n = 339 Patients with dementia, n = 61
T. Rune Nielsen
The CNTB - summary
The preliminary data from the CNTB control sample suggests that the included measures are suitable for the targeted cultural groups (on average, country of origin explains 5%
of the variation).
Although the measures seem to be relatively independant of cultural differences, education should be taken into consideration in the interpretation of test results (on average,
age explains 4% of the variation, while education explains 16%).
The majority of the test on the CNTB have satisfactory sensitivity to cognitive dysfunction in a multicultural sample. The final validation of the CNTB is expected during 2016.
T. Rune Nielsen
Acknowledgements
Funding
The study is supported by the EU-funded program Interreg IV A.
The Danish Dementia Research Center is supported by the Danish Health Insurance
Foundation and the Danish Ministry of Health.
Collaborators
Norway: Peter Bekkhus-Wetterberg, MD; Oslo University Hospital Ullevål, Oslo. Sweden: Lennart Minthon, MD, professor; Skåne University Hospital Malmö, Malmö. Germany: Ulrike Beinhoof, PhD; Charité - Universitätsmedizin Berlin, Berlin. Belgium: Kurt Segers, MD; Brugmann University Hospital, Brussels. Greece: Magda Tsolaki, MD, professor; Aristotle University of Thessaloniki, Thessaloniki.