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.