CROSS-CULTURAL NEUROPSYCHOLOGY OF AGING AND DEMENTIA: AN UPDATE

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1 CROSS-CULTURAL NEUROPSYCHOLOGY OF AGING AND DEMENTIA: AN UPDATE Nicola Wolfe INTRODUCTION As the population of the United States ages and regional demographics change, neuropsychologists have been challenged to adapt to a range of clinical populations. Cross-cultural approaches to the neuropsychology of aging are in increasing demand for two major applications. First, the ethnic, racial, linguistic, and cultural diversity within the United States has called for tools of assessment and research that are appropriate for each of these groups with differing backgrounds. Second, research on aging and dementia has increasingly moved toward epidemiological studies that compare rate s and expression of illness across nations or between ethnic groups with different linguistic, racial, or socio-cultural identities. A RECENT HISTORICAL PERSPECTIVE The need for a cross-cultural approach to neuropsychology has been increasingly recognized over the past few years. In 1992, Matthews presidential address to the International Neuropsychological Society (INS) called for increasing the international role of the INS (Matthews, 1992). In 1993, the first INS symposium on Cross-cultural Neuropsychology was held at the annual Z' meeting in Galveston, Texas. Interest among professionals was growing, and several instruments were already developed specifically designed for cross-cultural use. By 1995, Ardila pointed to the need for a new field called cross-cultural neuropsychology. He described this as a critical new direction of research for the 21st century (Ardila, 1995). There has been a surge in interest in comparative rate s of dementing illnesses, for example, between the US. and Asia (White, Petrovitch, Ross, Masaki, Abbott, Wergowske, Chiu, Foley, Murdaugh, & Curb, 1996; Graves, Larsen, White, Teng, & Homma, 1996), and between the U.S. and East African populations (Friedland & Kalaria, 1998). Key in this process is the development of standardized diagnostic methods. Historically, neuropsychologists have generally relied on standard normative data obtained from a cross-section of the American population and extrapolated to

2 348 Neurobehavior of Language and Cognition the individual, knowing only limited information about a client s culture and language. With non-english speakers, neuropsychologists relied on simple translation of items, assuming that the test instruments administered in an individual s own language would still yield valid information in spite of the lack of norms based on that client s cultural or linguistic group. LIMITATIONS OF EXISTING INSTRUMENTS However, in neuropsychological assessment, as has occurred in educational assessment, many of the existing neuropsychological instruments used to evaluate neuropsychological functioning in the elderly have been demonstrated to have limitations in cross-cultural use. For example, the Mini Mental State Exam (MMSE), a standard instrument for screening for cognitive decline and dementia, has been reported to be biased by education level (Escobar, Burnam, Karno, Forsythe, Landsverk, & Golding, 1986; Anthony, Le Resche, Niaz, et al., 1982) and culture (Katzman, Zhang, Orang-Ya-Qu, Wang, Liu, Wong, Salmon, & Grant, 1988). Gurland, Wilder, Cross, Teresi, and Barrett (1992) applied a compendium of five widely used screening scales in cross-cultural application. The five scales examined were the CARE Diagnostic (Golden, Teresi, & Gurland, 1983), the Kahn- Goldfarb Mental Status Questionnaire (Kahn, Goldfarb, Pollack, & Peck, 1960), the Short Portable Mental Status Questionnaire (Pfeiffer, 1975), the Blessed Memory Information Concentration (Blessed, Tomlinson, & Roth, 1968), and the MMSE (Folstein, Folstein, & McHugh, 1975). In application with Black, Hispanic, and White groups, Gurland et al. found drastically conflicting results for absolute and culturally relative rates of cognitive impairment. They concluded that differences between the scales were mostly due to their varying sensitivities, but that sociocultural bias also played a role. Education bias also has been reported on many other neuropsychological instruments such as the Wisconsin Card Sort Test (WCST) (Rosselli & Ardila. 1993). Advances in the cross-cultural neuropsychology of aging can be grouped into three general areas: (1) Modification of existing tests translation and adaptation of existing instruments for different linguistic and socio-cultural groups; (2) De novo test construction construction of completely new tests specifically designed for cross-cultural purposes (including item selection, item analysis, pilot studies, normative studies, validity, and reliability studies); (3) Norm development developing norms for tests in a wide range of different populations (especially norms for age, education, and individual ethnic groups). MODIFICATION OF EXISTING TESTS In response to the need for cross-cultural neuropsychology, there has been a recent explosion of translations, modifications, and adaptations of existing instruments for a range of language and ethnic groups; these include Cree (Creespeaking natives on reserves in Manitoba), Czech, Chamorro (Guam), Chinese (Shanghaiese, Cantonese, Mandarin, and Kinmen, a Chinese islet), Croatian, Danish, Dutch, Finnish, French, German, Spanish, Hindi (India, Pakistan, and

3 N. Wolfe 349 Bangladesh), Icelandic, Italian, Japanese, Malay (Singapore), South African, Vietnamese, and Yoruba (Yoruba-speaking population of Ibadan, Nigeria). Increasingly, however, emphasis in cross-cultural neuropsychology has been shifting away from translation and adaptation (Brislin, Lanner, & Thorndike, 1973; Karno, Burman, Escobar, & Eaton, 1993) toward test development de novo, that is, new tests specifically designed for cross-cultural use (Wolfe, 1993). THREE NEWER CROSS-CULTURAL DEMENTIA SCREENING INSTRUMENTS In an attempt to assess elderly and demented persons with reduced cultural bias, there have been several excellent instruments developed over the past few years. Three of these instruments are briefly described below. Cognitive Abilities Screening Instrument (CASI) An excellent example of an instrument specifically designed for cross-cultural neuropsychology of the elderly is the Cognitive Abilities Screening Instrument (CASI) (Teng, 1996; Teng, Hasegawa, Homma, Imai, Larson, Graves, Sugimoto, Yamaguchi, Sasaki, Shui, & White, 1994). Evolving over years of research by Evelyn Teng and colleagues in the area of the epidemiology of dementia, the CASI offers tremendous advances in the field. The CASI has increasingly gained attention as a neuropsychological screening instrument for dementia that was designed for cross-cultural use. This instrument offers several advantages and has been applied especially in the international collaborative epidemiological research of dementia among Japan, the U.S., and China. White et al. (1996) used the CASI as the screening assessment instrument in a large scale epidemiological study of dementia called the Honolulu-Asia Aging Study. Briefly described, the CASI... provides quantitative assessment on attention, concentration, orientation, short-term memory, long-term memory, language abilities, visual construction, list-generating fluency, abstraction and judgement (Teng et al., 1994). Scores on the MMSE, the Modified Mini-Mental State Test (3MS), and the Hasegawa Dementia Screening Scale can also be estimated from subsets of the CASI items. Pilot testing conducted in Japan and in the US. has demonstrated its cross-cultural applicability and its usefulness in screening for dementia, in monitoring disease progression, and in providing profiles of cognitive impairment. Typical administration time is 15 to 20 minutes. The CASI has a Short Form (4- item) which has been reported to perform comparably to the MMSE, the 3MS, and to the Hasegawa Dementia Scale in sensitivity and specificity for detecting dementia in individuals aged 51 to 93 in the U.S. and Japan (Teng et al., 1994). The CASI requires literacy, however, and thus may be less appropriate for populations with little or no formal education.

4 350 Neurobehavior of Language and Cognition The Cross-Cultural Cognitive Examination (CCCE) Filling a niche for use in non-literate populations, the Cross-Cultural Cognitive Examination (CCCE) (Glosser, Wolfe, Albert, et al., 1993) is an instrument similar to the CASI, designed for cross-cultural neuropsychological screening for dementia. The CCCE was also designed for epidemiological application, but specifically evolved out of demand for screening in non-literate populations. Originally constructed for an NIH neuroepidemiologic study of Guam-Parkinsonism- Dementia-Complex, the CCCE offers several unique advantages (Glosser, Wolfe, Albert, Lavine, Steele, Calne, & Schoenberg, 1993). The CCCE was designed to assess a range of basic cognitive functions over eight domains: attention, language, visuo-spatial, verbal memory? visual memory, recent memory, abstraction, and psychomotor speed. Incorporated in the CCCE, is the two-stage method of case identification used in population surveys. Thus, the test includes a five-minute brief screening procedure, designed to be highly sensitive, followed by a more extended 20 minute mental status examination, designed to be more specific for identifying dementia, intended for individuals who fail the screening portion. In several validation studies in mainland U.S. populations, Chamorro villagers in Guam, and in Japan, language, education, and social factors did not significantly compromise the high sensitivity and specificity of the CCCE for identifying cases of dementia (Wolfe, Imai, Otani, Nagatani, Hasegawa, Sugimoto, Tanaka, Kuroda, Glosser, & Albert, 1992; Tanaka, Miyazaki, Sugimoto, Yamaguchi, & Wolfe, 1992; Glosser et al., 1993). Criterion validity of the CCCE, with respect to other accepted dementia screening measures, was also demonstrated (Glosser et al., 1993). These findings support the usefulness of the CCCE in cross-cultural neuroepidemiological research. Community Screening Instrument for Dementia (CSI D) The purpose of the Community Screening Instrument for Dementia (CSI D) (Hall, Qgunniyi, Hendrie, Osuntokun, Hui, Musiek, Rodenberg: Unverzagt, Guerje, & Baiyewu, 1996) is, like the CCCE, to screen for dementia particularly in epidemiological studies. The CSI D has a unique two-part design; one part includes cognitive and risk factors, the other an interview with a relative about daily functioning and general health of the subject. The inclusion of information on daily functioning has been recommended, for example, by Jorm and Jacomb (1989) as a way to avoid educational bias in cognitive testing. The CSI D was developed and validated in a study comparing Cree Indians in Manitoba and Manitobans of European extraction (Hall, Hendrie, Rodgers, et al., 1993). It has been further applied to study incidence and prevalence of dementia in a cross-cultural study of elderly community-dwelling African Americans in Indianapolis and Yoruba in Ibadan, Nigeria. In each application, the instrument was adapted for the particular language and cultural setting. Although both the Cree language and Yoruba have written forms, they are predominantly spoken languages, and the subjects tested were largely unable to read or write. In an interview of approximately 20 minutes, the cognitive items are designed to measure memory, abstract thinking, judgment, other disturbances of higher cortical function, personality changes, and functioning at work and in social

5 N. Wolfe 351 relationships. Hall s careful development included item selection, adaptation, two independent translations, consensus translations, back-translation, two pilot tests and subsequent revisions, and determination of cut-off scores for screening (Hall et al., 1996). In their study of the CSI D (Hall et al., 1996) the screening stage was followed by a detailed diagnosis. Individuals identified as possibly demented based on performance on the CSI D then completed a range of other evaluations (CERAD- NB, CAMCOG, CT scans, relative interview, neurological assessment, and laboratory tests). Results suggest that the sensitivity and specificity of the instrument in both sites combined was 87.0% (sensitivity) and 83.1% (specificity), respectively (Hall et al., 1996). The three instruments above are among the best brief screening instruments for detecting possible dementia, but this list is not comprehensive. Tests of specific domains include the Taussig Cross-Cultural Memory Test (Taussig & Ponton, 1993). and instruments relying particularly on informant sources have also been developed for cross-cultural neuropsychological screening. One recent example of these is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) (Fuh, Teng, Lin, Larson, Wang, Lui, Chou, Kuo, & Lui, 1995). Valle (1994) has presented a so-called culture-fair behavioral assessment and intervention model for non-cognitive behaviors. For more in-depth clinical neuropsychological assessment there is the Spanish and English Neuropsychology Assessment Scale (SENAS) (Mungas, 1996). Still under development, the SENAS has been designed with 12 tests, 6 verbal and 6 non-verbal assessments of a range of cognitive domains. Ideally suited for assessment of elderly and demented subjects, it could have broader applications as well (Mungas, personal communication). This instrument should represent a substantial advance over available methods, as it is specifically designed de novo with cross-cultural application in mind, using rigorous psychometric methods including item-analysis. SOME METHODS FOR CONSTRUCTING NEW CROSS-CULTURAL INSTRUMENTS (DE NOVO) Some of the psychometric methods recommended by Mungas to reduce cultural bias are outlined in an excellent chapter in Ethnicity and the dementias (Mungas, 1996). Cultural sensitivity of the test developer may not be sufficient. Mungas suggests that one cannot always anticipate bias. Instead, he recommends specifically testing for bias. He emphasizes the importance of combining knowledge and experience with rigorous empirical methods (Mungas, 1996). RECOMMENDATIONS Define Culturally Equivalent Ideally, a neuropsychological instrument or item used in cross-cultural application would be culture-fair or culturally equivalent. Cultural equivalence might be defined as equivalence of scores across national, cultural boundaries or ethnically non-discriminatory use within a society. Early attempts based on non-

6 352 Neurobehavior of Language and Cognition verbal and performance tests (Anastasi, 1988; Cattell, 1940) did not prove to be as culture-fair as hoped (Anastasi, 1988; Vernon, 1969). Unfortunately, non-verbal testing does not necessarily reduce cultural bias, and many non-verbal abilities, such as the ability to draw in three dimensions, are highly education-dependent (Cattell, 1979). Thus, it is probably more realistic to aim for culturally-reduced tasks rather than culturally-loaded tasks. Documenting Population Demographics In cross-cultural applications of neuropsychology it can be particularly helpful to start with a thorough delineation of population demographics; these include the more routinely obtained age, sex, and education information. In addition, to fully describe the sociocultural context, many other variables are relevant; these include race, socioeconomic status, occupation, religion, size of community (urban versus rural), and language preference. Demographic infomiation is especially important when attempting to match samples and compare two cultural groups (Wolfe et al., 1992). Ardila has emphasized the importance of clearly distinguishing education and cultural variables. Differences resulting from education are sometimes attributed to cultural and even ethnic differences (Ardila, 1995). Ardila (1995) noted that less educated individuals sometimes perform on neuropsychological tests like some brain-injured subjects. This is called the Ardila effect. Thus, education should be coded and analyzed rigorously, including years of education and country of origin, to evaluate its contribution to a cohort effect (Taussig & Ponton, 1996). Ethnicity can be difficult to define. Self-report is often relied upon. However, in ethnic minorities, variables such as the degree of acculturation and assimilation are difficult to quantify (Sue, 1996). In many cross-cultural applications, for example with immigrant populations, it helps to assess an individual s degree of acculturation and bilingualism. This can be accomplished with the aid of acculturation scales and by allowing for multiple responses in regional dialects. Multi-site studies help as well (Taussig & Ponton, 1996). Measures of acculturation generally include items such as age at immigration, educational history, social class, health care preferences, and beliefs. Translation and Back Translation Several useful translation methods outlined by Brislin (1980) include: back translation a bilingual translator performs independent translation into the original language to ensure original meaning is preserved; bilingual technique two groups of bilinguals compare items in each language, and items which yield discrepant responses can be identified; committee approach translation by a committee of bilinguals; and pretest procedures field testing to ensure items are well understood (Brislin, 1980). Careful translation still does not necessarily solve all problems. Standard screening instruments such as the MMSE (Folstein et al., 1975) have been translated, but still require attention to individual items. For example, Katzman (1988) noted that the item that asks individuals to read close your eyes had a death connotation in Shanghai and was changed to the less offensive raise your arms.

7 N. Wolfe 353 Adaptation of individual test items must also preserve difficulty level. For example, for Digit Span tests repetition may be easier in languages where each digit is spoken in a single syllable, reducing the time and complexity of the task. Similarly, the task of naming the months of the year may be easier in Japan versus in the U.S. because names of the months are simply in numerical order (month one, month two, etc.). Selection and Adaptation of Individual Item election Jensen (1980) recommended several general methods in test construction that can help to reduce cultural loading. These include choosing the following: performance tests, oral instructions, pictorial responses, power tests (instead of speed tests), non-verbal content, abstract reasoning (instead of specific factual knowledge), non-scholastic tasks, and solving novel problems (instead of recall of past-learned information) (Jensen, 1980). Several general principles for selecting items are suggested below: Items should (1) be understandable and meaningful to all subjects (i.e., items should have maximum ecological validity): (2) be interpretable by other neuropsychologists, and previously normed tests should be used when possible, (3) be able to be scored in an objective fashion, (4) be readily translatable, (5) not be obviously biased in one culture, (6) not require special training that some subjects do not have (e.g., literacy or mathematical ability), (7) be practical for administration, and (8) be as nonthreatening as possible. In addition, Mungas (1996) suggests making more items than needed in order to have room to eliminate biased items during test development, and including a range of difficulties such that demented subjects are able to pass some items and healthy individuals may fail some items. A key methodological consideration in new test construction is that two versions of an instrument must be matched for overall difficulty level. Chapman and Chapman (1973; 1988) note that scales must be matched according to their psychometric characteristics to reach valid conclusions about the presence of differential deficits in an ability. DEFINING ITEM BIAS An item can be defined as biased if individuals with the same amount of an underlying trait, from different sub-populations, have different probabilities of responding to an item correctly (Hulin, Drasgow, & Parsons, 1983). The use of item analysis is described well by Mungas (1996) in his development of SENAS. The item response approach is well suited to cross-cultural application because it uses non-linear regression of the probability of passing each item. An item is nonbiased if the item curves are equal in two groups that is, if two individuals of equal ability from different groups have the same expected outcome. The difficulty with using item response theory in the development of cross-cultural tests is the reliance on large normative sample sizes. While this has been somewhat easier to obtain with multiple choice tests used in educational assessment, the longer, more complex administration of the neuropsychological batteries makes large samples more difficult to obtain.

8 354 Neurobehavior of Language and Cognition SPECIFIC ADAPTATIONS TO CONTROL FOR EDUCATION DIFFERENCES Education clearly affects performance on neuropsychological tests and differs tremendously among sociocultural, racial, and ethnic groups. Two major methods for management of education effects have been proposed: A neuropsychological instrument could be statistically adjusted for education (Kittner, White, Farmer, Wolz, Kaplan, Moes, Brody, & Feinlieb, 1986) using a stratified regression or nonparametric method, or it could be designed to be less sensitive to education effects (Berkman, 1986). These two approaches, however, are not mutually exclusive. The best methods may be those that design instruments to be less sensitive to education effects and also adjust for education level. However, investigators differ in opinion on whether to develop items that are not education- biased. Some explain that because underlying abilities (cognitive processes) are education-biased, it is not appropriate to eliminate educational effects from instruments. In order to reduce the cultural bias that is due to more than just educational differences, Mungas (1996) described psychometric methods (for example, the use of ANCOVA), which examine the relationship between scales or items, and variables such as age, education, and language. VALIDITY AND RELIABILITY The principles of test construction? including establishing validity and reliability, are particularly important in cross-cultural neuropsychology. New instruments require structured clinical validation protocols (LaRue & Markee, 1995). Studies of criterion validity, comparing the new instrument to some existing gold standard, are especially important to ensure interpretability of the new instrument in each culture. An example of the design of such a study can be found in Wolfe, Imai, Otani, Nagatani, Hasegawa, Sugimoto, Tanaka, Kuroda, Glosser, and Albert (1 992). Excellent examples of test-retest and inter-rater reliability studies are also available (Hall et al., 1996). TEST ADMINISTRATION/TRAINING GOALS How does one adapt to culture that is not static? Training individuals for cross-cultural neuropsychology includes increasing awareness and knowledge of test items relevance to different cultures, keeping abreast of research related to culturally diverse groups, and achieving some cultural competency greater than only written and spoken language (Hinkle, 1994). Researchers can familiarize themselves with those dimensions of culture most relevant to neuropsychological assessment such as language (dialects and idiom), religions, family structures, recent history, attitudes toward disclosure, nonverbal conventions (e.g., eye contact and interpersonal distance), and attitudes toward health and disability. Some suggestions for the administration of cross-cultural instruments (Ardila, 1995) are that testers should speak the same language or dialect as the examinee. They should be familiar with principles of neuropsychological assessment such as maintaining a non-judgmental attitude, offering encouragement, confidentiality, and

9 N. Wolfe 355 explaining the goals of the evaluation. Furthermore, test instructions should not be in a formal language that people do not use themselves and that could be misunderstood (Ardila, 1995). Testers should be well trained in the instruments to be administered. An example of a sample tester training program is outlined below: (1) Select testers (bilingual, educated, and motivated); (2) Review goals of neuropsychological testing; (3) Provide detailed training with a written manual, video, and verbatim instructions; (4) Encourage testers to practice and provide detailed feedback; (5) Evaluate tester competency (e.g., quiz) to qualify the tester; and (6) Adapt the instrument and testing methods based on pilot results. Implementation of some of the recommendations outlined above could help to reduce cultural bias, making neuropsychological assessment more cross-cultural. FUTURE DIRECTIONS IN CROSS-CULTURAL NEUROPSYCHOLOGY In some regions of the United States, ethnic minorities will soon be the majority of those over 65 years old. Thus, the demand for cross-cultural neuropsychology of aging is urgent. In response to immediate needs, investigators have been working to establish norms and to construct new cross-cultural neuropsychological instruments. The progress described in this chapter presents the first advances in this rapidly emerging field. REFERENCES Ardila, A. (I 995). Directions of research in cross-cultural neuropsychology. Journal of Clinical and Experimental Neuropsychology, 17, Anastasi, A. (1988). Psychological resting. New York: Macmillan. Anthony, J. S., Le Resche, L., Niaz, U., Vo-Korff, M. R., & Folstein, M. F. (1982). Limits of the Mini- Mental State as a screening test for dementia and delirium among hospital patients. Psychological Medicine, 12, Berkman, L. F. (1986). The association between educational attainment and mental status examinations, of etiologic significance for senile dementia or not? Journal of Chronic Disease, 39, Blessed, G., Tomlinson, B. E., & Roth, M. (1968). The association between qualitative measures of dementia and senile change with cerebral matter of elderly subjects. British Journal of Psychiatry, 114, Brislin, R. W. (1980). Translation and content analysis of oral and written materials. In H. C. Triandis & J. W. Berry (Eds.), Handbook of cross-cultural psychology. Methodology (Vol. 2, pp ). Boston: Allyn and Bacon, Inc. Brislin, R. W.. Lanner, W. J., & Thorndike, R. M. (1973). Cross-cultural research methods. New York: John Wiley. Cattell, R. B. (1940). A culture free intelligence test. Part 1. Journal of Educational Psychology, 31, Cattell, R. B. (1979). Are culture fair intelligence tests possible and necessary? Journal of Research and Development in Education, 12, 3-13 Chapman, L. S. & Chapman, J D. (1973). Disordered thought in schizophrenia. New York: Appleton- Century-Crofts. Chapman, L. C. & Chapman, J. C. (1988). Artifactual and genuine relationships of lateral difference scores to overall accuracy in studies of laterality. Psychological Bulletin, 104, Escobar, J. I., Burnam, A., Kamo, M., Forsythe, A., Landsverk, J., & Golding, J. M. (1986). Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts. Journal of Nervous and Mental Disease, 174 (10)

10 356 Neurobehavior of Language and Cognition Foldi, N. S. (1988). Research in human neuropsychology: Issues of aging. In B. Kent & R. N Butler (Eds.), Human aging research: Concepts and techniques (pp ). New York: Raven Press. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). The Mini-Mental State. A practical method of grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, Friedland, R. P. & Kalaria R. N. T (1998). The East African Dementia Project. Establishment of the Nyeri dementia study and training workshops in the clinical neurosciences. IBRO News, 1, 1. Fuh, J. L., Teng, E. L., Lin, K. N., Larson, E. B., Wang, S. J., Lui, C. Y., Chou, P., Kuo, B. I., & Lui, H. C. (1995). The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) as a screening tool for dementia for a predominantly illiterate Chinese population. Neurology, 45, Glosser, G., Wolfe, N., Albert, M. L., Lavine, L., Steele, J. C., Calne, D. B., & Schoenberg, B. S. (1993). Cross-cultural cognitive examination: Validation of a dementia screening instrument for neuroepidemiological research. Journal of the American Geriatric Society, 41, Golden, R. R., Teresi, J. A., & Gurland, B. J. (1983). Detection of dementia and depression cases with the Comprehensive Assessment and Referral Evaluation interview schedule. International Journal of Aging and Human Development, 16, Gurland, B. J., Wilder, D. E., Cross, T.. Teresi, J., & Barrett V. W. (1992). Screening scales for dementia: Toward reconciliation of conflicting cross-cultural findings. International Journal of Geriatric Psychiatry, 7, Graves, A. B., Larsen, E. B.. White, L. R., Teng, E. L., & Homma, A. (1994). Opportunities and challenges in international collaborative epidemiologic research of dementia and subtypes. Studies between Japan and the United States. International Psychogeriatrics, 6 (2), Hall, K. S., Hendrie, H. C., & Rodgers, D. D. (1993). The development of a dementia screening interview in two distinct languages. International Journal of Methods in Psychiatric Research, 3, Hall, K. S., Ogunniyi, A. O., Hendrie, H. C., Osuntokun, B. O., Hui, S. L., Musick B. S., Rodenberg C. A., Unverzagt, F. W., Gueje, O., & Baiyewu, 0. (1996). A cross-cultural community based study of dementias: Methods and performance of the survey instrument in Indianapolis, USA and Ibadan, Nigeria. International Journal of Methods in Psychiatric Research, 6, Hinkle, J. S. (1994). Practitioners of cross-cultural assessment: A practical guide to information and training. Special Issue: Multicultural assessment. Measurement and Evaluation in Counseling and Development, 27, Helin, C. L., Drasgow, F., & Parsons, C. K. (1983) Item response theory: Application to psychological measurement. Homewood, IL: Dow Jones-Irwin. Jensen, A. R. (1980). Bias in mental testing. New York: Free Press. Jorm, A. F. & Jacomb, P. A. (1989). The informant questionnaire on cognitive decline in the elderly (IQCODE): Socio-demographic correlates, reliability, validity and some norms. Psychological Medicine, 19, Kahn, R. L., Goldfarb, A. I., Pollack, M., & Peck, A. (1960). Brief objective measure for the determination of mental status in the aged American Journal of Psychiatry, 117, Kamo, M., Burman, M. A., Escobar, J. I., & Eaton, W. W. (1993). Development of the Spanish-language version of the National Institute of Mental Health diagnostic interview. Archives of General Psychiatry, Katzman R., Zhang, M., Orang-Ya-Qu, Wang, S., Liu, W. R, Wong, S., Salmon, D. P., & Grant, 1. (1988). A Chinese version of the Mini-Mental State Examination: lmpact of illiteracy in a Shanghai dementia survey. Journal of Clinical Epidemiology, 41, Kittner, S. J., White. L. R., Farmer, M. E., Wolz, M, Kaplan, E.. Moes, E., Brody, J. A., & Feinlieb, M. (1 986). Methodologic issties in screening for dementia: The problem of education adjustment. Journal of Chronic Disease, 39, LaRue, A. (1 987). Methodological concerns: Longitudinal studies of dementia. Alzheimer s Disease and Associated Disorders, 1, (3), Lowenstein, D. A., Arguelles, T., Arguelles, S., & Linn-Fuentes, P (1994). Potential cultural bias in the neuropsychological assessment of the older adult. Journal of Clinical and Experimental Neuropsychology, 16 (4), Matthews, C. G. (1992). Truth in labeling: Are we really an international society? Journal of Clinical and Experimental Neuropsychology, 14,

11 N. Wolfe 357 Mungas, D. (1996). The process or development of valid and reliable neuropsychological assessment measures for English- and Spanish-speaking elderly persons. In G. Yeo & D. Gallagher- Thompson (Eds.), Ethnicity and the dementias (pp ). Washington, DC: Taylor and Francis. Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatric Society, 22 (10), Rosselli, M. & Ardila, A. (1993). Effects of age, gender and socioeconomic level on the Wisconsin Card Sorting Test. The Clinical Neuropsychologist, 7, Sue, S. (1996). Measurement, testing and ethnic bias: Can solutions be found? In G. R. Sodowsky & J. C. lmpara (Eds.), Multicultural assessment in counseling and clinical psychology (pp. 7-36). Lincoln, NE: Buros Institute of Mental Measurements. Tanaka, Y., Miyaraki, M., Sugimoto, K., Yamaguchi, T., & Wolfe, N. (1992). Preliminary validation study of the Mental Status Examination (MSE) [in Japanese with English abstract]. Neurological Medicine, 36 (1), Taussig, I. M., Dick, M., Teng, E., & Kempler, D. (1993). The Taussig Cross-cultural Memory Test. University of Southern California, Andrus Gerontology Center, Los Angeles, CA. Taussig? I. M. & Ponton, M. (1996). Issues in neuropsychological assessment for Hispanic older adults: Cultural and linguistic factors. In G. Yeo & D. Gallagher-Thompson (Eds.), Ethnicity and the dementias (pp ). Washington, DC: Taylor and Francis. Teng, E. L., Hasegawa, K., Homma, A., Imai, Y., Larson, E., Graves, A., Sugimoto, K.. Yamaguchi, T., Sasaki, H., Shui, E., & White, L. R. (1994). The Cognitive Abilities Screening Instrument (CASI): A practical test for cross-cultural epidemiological studies of dementia. International Psychogeriatrics, 6, Teng, E. L. (1996). Cross-Cultural Testing and the Cognitive Abilities Screening Instrument. In G. Yeo & D. Gallagher-Thompson (Eds.), Etlinicity and the dementias (pp ). Washington, DC: Taylor and Francis. Valle, R. (1994). Culture fair behavioral symptom differential assessment and intervention in dementing illness. Alzheimer 's Disease and Associated Disorders, 8 (3), Vernon, P. E. (1969). Intelligence and cultural environment. London: Methuen. White, L., Petrovitch, H., Ross, G. W., Masaki, K. H., Abbott, R. D., Wergowske, G., Chiu, D., Foley, D. J., Murdaugh, D., & Curb, J. D. (1996). Prevalence of dementia in older Japanese-American men in Hawaii: The Honolulu-Asia Aging Study. Journal of the American Medical Association, 276 (12), Wolfe, N., Imai, Y., Otani, C., Nagatani, H., Hasegawa, K., Sugimoto, K., Tanaka, Y., Kuroda, Y., Glosser, G., 61 Albert, M. L. (1992). Criterion validity of the Cross-Cultural Cognitive Examination (CCCE) in Japan. Journal of Gerontology, 47 (4), Wolfe, N. (1993, February). Psychometric issues in cross-cultural neuropsychology. Cross-cultural Issues in Neuropsychological Assessment. Symposium held during the Twenty First Annual Meeting of the International Neuropsychological Society, Galveston, Texas, USA. Yeo, G. & Gallagher-Thompson, D. (Eds.). (1996). Ethnicity and the dementias. Washington, DC: Taylor and Francis.