Tools for cross cultural assessment

Multiculturalism is an increasingly relevant challenge for neuropsychology, requiring a thoughtful approach to selecting cognitive tests that accommodate the cross-cultural dimension, as well as validating new ones. For neuropsychology to become more cross-cultural, it is essential to establish a network of collaboration among specialists in Europe and migrants’ countries of origin.

Healthcare professionals may find themselves unprepared to provide appropriate guidance and pathways- spanning from the provision of information on the condition to the diagnostic route and the steps to access treatment- for patients and caregivers of diverse backgrounds who are increasingly seeking services for an initial dementia diagnosis. Language barriers are likely the first obstacle clinicians face during the neuropsychological assessment of a patient with cognitive decline and a migration history. In addition, caregivers’ perception of early symptoms, such as memory loss, may regard these signs as part of normal ageing rather than as the onset of an illness. These factors often delay migrants’ access to healthcare and their first meeting with a clinician to address their symptoms.

A clinical approach to cognitive disorders in migrants requires the adoption of tools and procedures sensitive to cultural backgrounds. However, most cognitive assessment and screening tools routinely used were developed in Western contexts and may be influenced by the individual’s language, educational level, and cultural background. Using these tools with migrants can distort cognitive assessments and lead to inaccurate diagnoses, potentially resulting in the excessive use of costly (e.g., neuroimaging) or invasive (e.g., lumbar puncture) diagnostic procedures to achieve a more precise diagnosis.

Dementia risk should be evaluated individually, adopting a life-course perspective that considers the interplay of various protective and triggering factors. Conversely, reductionist or categorical frameworks may lead to unbalanced risk evaluations, contributing to biases and stigmatising attitudes toward migrants.

Migration should be understood as a “modifier of dementia risk," an additional layer of complexity that must be adequately addressed to deliver person-centred and culturally competent prevention, support, and care pathways.

Neuropsychological assessments include collecting patient’s and family’s medical histories, conducting interviews, administering neuropsychological tests, and using behavioural and functional scales completed by caregivers.
These assessments rely on cognitive screening tests to evaluate overall cognitive function and more targeted tests for specific cognitive abilities (e.g., attention, memory, language, executive functions and visuospatial skills). These sets of tests are tailored to the diagnostic question that brings the patient to the neuropsychologist.

The combinations of neuropsychological test batteries are selected at each centre by the individual neurologist or neuropsychologist administering them and can vary significantly in duration. In the context of the Immidem Study Group, the Centre for the Treatment and Study of Cognitive Disorders at Luigi Sacco Hospital is working on selecting the most suitable tools- those less influenced by cultural factors (e.g., ethnicity, language, education and literacy)- for diagnosing migrants with cognitive impairments who come to the CDCD. Fortunately, several cross-cultural cognitive tools have been developed and validated in multicultural cohorts.

Cognitive screening tests allow clinicians to assess multiple cognitive functions in a few minutes, helping determine whether further exams are required to assess the patient’s condition and individual cognitive functions. Examples of cognitive screening tests suitable for multicultural contexts include:

• Rowland Universal Dementia Assessment Scale (RUDAS).

• Montreal Cognitive Assessment (MoCA).

The Mini-Mental State Examination (MMSE), widely used in Italy for dementia screening, is heavily influenced by language and ethnicity, making it unsuitable for assessing migrants’ cognitive function.

Selecting Tools that Embrace the Cross-Cultural Dimension

anne Franzen and colleagues, in their study “Cross-cultural neuropsychological assessment in the European Union: a Delphi expert study”, aim to outline the current state of cross-cultural neuropsychological evaluation in EU-15 countries, with the goal of generating recommendations for researchers and policymakers.

The most pressing issues to be addressed to achieve a cross-cultural perspective in cognitive assessment include: the training and collaboration of neuropsychologists, the development of cross-cultural tests, and the collection of administrative data. The study also highlights the need for a network of collaboration and skill exchange, both within Europe and with neuropsychologists from the countries of origin of minority ethnic groups.

Developing and validating cross-cultural tests is a crucial task with identified priorities, including a focus on: assessing social cognition and validating language evaluation tests. Additionally, it is necessary to refine tests targeting executive functions, visuospatial skills, working memory and orientation.

The research suggests that tests accommodating a broader range of minority ethnic groups are preferable over those specific to a particular culture or language. While the involvement of formal interpreters is essential, neuropsychological assessments using interpreters are not immune to biases.

In the EU-15 countries there is a variety of cross-culturally validated tools and test batteries, particularly memory tests, widely used across several countries. The tests deemed most cross-cultural- having been studied on diverse ethnic minority groups with varying education levels in research studies from multiple European countries- form part of the European version of the Cross-Cultural Neuropsychological Test Battery (CNTB), including the Rowland Universal Dementia Assessment Scale (RUDAS), which serves as a screening subtest.

These tools measure various cognitive functions:

• General cognitive functioning (RUDAS);

• Memory (learning, free recall, recognition of images, image learning with semantic cues, and copying/recalling semi-complex pictures);

• Language (picture naming and verbal fluency);

• Executive functions (Color Trails Test, Five Digit Test, and Serial Threes Test);

• Visuospatial skills (Clock Reading Test, Clock Drawing Test, and copying simple or semi-complex images).

According to the authors, cross-cultural neuropsychological assessment requires regulatory data collection in addition to the development of cross-cultural tests. Stratifying data only by age and education may be inadequate for low-education patients from minority ethnic groups who often perform poorly on neuropsychological tests that require even minimal literacy. This limitation underscores the importance of investing in new test development. In order to address the increasing need to assess diverse patient groups, the international literature recommends designing tests with colourful drawing, without culturally specific stimuli or test elements relying on school-based skills.

Literature findings also reveal the significant role of interpreters- both formal and informal ones such as family members- in the cognitive evaluation process:

• Using relatives as interpreters is associated with risks such as the exclusion of the patient from conversations, inadequate translation of medical terminology, obscuring the patient’s explanatory models and challenges in assessing their level of insight.

• Using formal interpreters can also present complex challenges, particularly when employing tests that require high interpreter skill levels or when interpreters receive insufficient training.

Given the importance of informal interpreters, ongoing investments in training are essential to cultivate cultural awareness and knowledge tailored to the patient’s cultural background. Additionally, EU guidelines could be established for collaborating with interpreters and cultural mediators during neuropsychological assessments.