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Psychologists are researching better ways to detect and measure cognitive impairment in the elderly, and one of the challenges that poses is devising tests that are culturally valid across racial and ethnic groups.

"We need to understand what some of the issues are in ethnic minorities, in order to refine the effectiveness of treatments, or understand whether the treatments are effective in all groups," says Columbia University associate psychology professor Jennifer Manly, PhD, who is studying cognitive tests for elderly African-Americans.

Some studies, she notes, suggestthat African Americans are at a higher risk than non-Hispanic whites for developing Alzheimer's disease and cognitive impairments as they age.

One possible reason for that higher risk, Manly says, could be that people with lower levels of education have a higher risk of developing cognitive impairments as they age, according to research such as a study published in 1996 in the Archives of Neurology (Vol. 53, No.2, pages 134-140). Literacy also seems to play a role, in that someone who is literate may be better able to compensate for the cognitive effects of aging than someone with no or poor literacy skills.

But Manly believes that one of the deeper issues at work than years of schooling is the quality of a person's educational experience when they were young.

Schooling quality counts

Manly became interested in the question of educational quality after interviewing senior citizens in New York City while researching the cultural experiences of older African Americans. During the visits, many of the participants talked about attending one-room, segregated schools in the rural South and then moving northward with their families during the "Great Migration" of African Americans from 1910 to 1950. In those decades, although motivation for learning was high among African Americans, segregated black schools for African-American children had a shorter school year then schools for white students, instructional materials were meager and there were inadequate facilities for training African-American teachers. Public per-capita spending per student in schools for African-American children was much less, she says.

For example, a 1938 federal study listed per-pupil expenditures for a child in an African-American school in Florida as almost $18, while per-pupil expenditures for white schools in Florida was listed as almost $40.

Looking for the effects of quality of education on seniors, Manly led a group of researchers trying to determine if discrepancies in educational quality could explain differences in cognitive test scores between African-American and European-American seniors who were matched on years of education.

In a study published in 2002 in the Journal of the International Neuropsychological Society (Vol. 8, No. 3, pages 341-348), Manly and her co-authors found that African-American seniors scored lower then European-American seniors on several of the neuropsychological tests, despite being matched for years of school.

But when seniors from both groups were matched on a specific reading measurement tied to quality of education, the racial difference in cognitive scores was greatly reduced, the researchers found.

Neuropsychological tests for cognitive impairment might need to factor in these differences in educational quality to prevent cognitive impairment from being overdiagnosed among the African-American elderly, Manly said.

Remembering in a new way

Given the importance that quality of education may play in cognitive functioning later in life, psychologist Peter Lichtenberg, PhD, has concentrated his research on developing more accurate tests for people who often didn't get a chance to receive a good education when they were young.

In fact, he's working with Detroit-area seniors with similar backgrounds to the New York seniors. Manly focused on African American elders who grew up in segregated school systems. Lichtenberg's work, though, centers on involving primary-care providers. That focus stems from his work with seniors at a rehabilitation hospital in the Detroit area from 1991 to 1998.

Lichtenberg was encountering seniors, mostly African-American patients, who had suffered injuries such as leg fractures as a result of falls, often in their homes. He was concerned that physicians treating the seniors didn't seem to be catching evidence of cognitive decline and dementia, even though the seniors' injuries from falls and walking problems were often connected to their cognitive health.

When he came to the Institute of Gerontology at Wayne State University in 1998, he seized the chance to study how primary-care providers could detect cognitive impairment among older African-American patients using better assessment tools. One of tests he and his fellow researchers turned to was the Fuld Object Memory Evaluation (FOME) test. In that test, participants are asked to reach into a black bag, and, alternating their left and right hands, pick out an object and identify it by touch, not by sight, until all 10 items are named and drawn out. The objects are things most people can quickly identify from everyday life, such as a key, a ball or a cup. Next, participants are given a distraction task, such as naming all the men's first names they can think of in 60 seconds.

Then the tester asks the participant to name everything in the bag, working from memory. The tester gives the participant some "selective reminding" to help remember what they missed on the first round. That's followed by four more rounds of distraction tasks, and four more times the participant is asked to remember every item in the bag.

The more objects a participant consistently remembers, the better the state of their cognitive functioning, Lichtenberg says.

Lichtenberg says the FOME is preferable to the Mini Mental State Examination (MMSE) because the importance of a person's educational background is minimized. The MMSE tests for cognitive impairment with questions related to orientation;memory; attention and calculation; language; writing; and drawing. According to a study co-authored by Lichtenberg and published in 2001 in The Clinical Neuropsychologist (Vol. 15, No. 2, pages 196-202), the FOME is more sensitive to the presence of dementia in African Americans than is the MMSE, when both tests are used to screen elderly hospital patients for Alzheimer's disease.

In a study published in October in the Journal of the National Medical Association (Vol. 98, No. 10, pages 1,590-1,597) Lichtenberg co-authored the first study to determine the safety of Aricept, a cholinesterase inhibitor, in African-American elders. The study utilized the FOME and demonstrated its utility in primary-care settings, he says.