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T i t l e L i n k s for Cognition Abstracts 1 Procedures for the analysis of differential item functioning (DIF) for small sample sizes 2 Measurement issues in health disparities research 3 Differential Item Functioning in the Short Portable Mental Status Questionnaire 4 Spanish and English neuropsychological assessment scales (SENAS): Further development and psychometric characteristics 5 Test bias in a cognitive test: differential item functioning in the CASI 6 Education and sex differences in the mini-mental state examination: Effects of differential item functioning 7 Some statistical issues in the analyses of data from longitudinal studies of elderly chronic care populations 8 Influence of cognitive impairment, illness, gender, and African-American status on psychiatric ratings and staff recognition of depression 9 Performance of cognitive tests among different racial/ethnic and education groups: Findings of differential item functioning and possible item bias. Associated table . 10 Cognitive assessment among minority elderly: Possible test bias 11 Statistical methods for examination of differential item functioning (DIF) with applications to cross-cultural measurement of functional, physical and mental health 12 Some methodological guidelines for cross-cultural comparisons 13 Modern psychometric methods for detection of differential item functioning: Application to cognitive assessment measures 14 Applications of item response theory to the examination of the psychometric properties and differential item functioning of the comprehensive assessment and referral evaluation dementia diagnostic scale among samples of Latino, African American, and white Non-Latino elderly 15 Reading ability, education, and cognitive status assessment among older adults in Harlem, New York City 16 Use of latent class analyses for the estimation of prevalence of cognitive impairment, and signs of stroke and Parkinson’s disease among African-American elderly of Central Harlem: Results of the Harlemaging project 17 Differential item functioning in the mini mental state examination in English and Spanish speaking older adults 18 Relative rates of dementia by multiple case definitions, over two prevalence periods, in three sociocultural groups 19 Item bias in cognitive screening measures: Comparisons of elderly White, Afro-American, Hispanic and high and low education subgroups 20 Operating characteristics of brief screens for dementia in a multicultural population 21 Screening scales for dementia: Towards reconciliation of conflicting cross-cultural findings
Measurement Equivalence and Differential Item Functioning (DIF) in cognitive measures.
This set of references focuses on methodological issues in assessing cognition among older, ethnically diverse populations. Articles using modern psychometric theory to examine measurement properties, including metric equivalence and DIF across demographic subgroups are represented. The original publication abstract is included for most of the references.
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Lai JS, Teresi JA, Gershon R. Procedures for the analysis of differential item functioning (DIF) for small sample sizes. Evaluation & The Health Professions, Sept. 2005, Vol. 28, No. 3, pp. 283-294
An item with differential item functioning (DIF) displays different statistical properties, conditional on a matching variable. The presence of DIF in measures can invalidate the conclusions of medical outcome studies. Numerous approaches have been developed to examine DIF in many areas, including education and health-related quality of life. There is little consensus in the research community regarding selection of one best method, and most methods require large sample sizes. This article describes some approaches to examine DIF with small samples (e.g., less than 200). [PUBLICATION ABSTRACT] http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16123258&query_hl=21&itool=pubmed_docsum
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Ramirez M, Ford ME, Stewart
, Teresi JA. Measurement issues in health disparities research. Health Services Research, 2005, Vol. 40, No. 5, pp.1640-1657 AL
BACKGROUND: Racial and ethnic disparities in health and health care have been documented; the elimination of such disparities is currently part of a national agenda. In order to meet this national objective, it is necessary that measures identify accurately the true prevalence of the construct of interest across diverse groups. Measurement error might lead to biased results, e.g., estimates of prevalence, magnitude of risks, and differences in mean scores. Addressing measurement issues in the assessment of health status may contribute to a better understanding of health issues in cross-cultural research.
OBJECTIVE: To provide a brief overview of issues regarding measurement in diverse populations.
FINDINGS: Approaches used to assess the magnitude and nature of bias in measures when applied to diverse groups include qualitative analyses, classic psychometric studies, as well as more modern psychometric methods. These approaches should be applied sequentially, and/or iteratively during the development of measures.
CONCLUSIONS: Investigators performing comparative studies face the challenge of addressing measurement equivalence, crucial for obtaining accurate results in cross-cultural comparisons. [PUBLICATION ABSTRACT] http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16179000&query_hl=19&itool=pubmed_docsum
Stump TE, Monahan P, McHorney CA. Differential Item Functioning in the Short Portable Mental Status Questionnaire. Research on Aging. May, 2005, Vol. 27, Iss. 3, pp.355-384
This secondary data analysis investigated differential item functioning (DIF) in the Short Portable Mental Status Questionnaire (SPMSQ) across demographic subgroups. The study was conducted at an academic primary care group practice on 3,954 patients aged 60 years and older who completed the SPMSQ during routine office visits. After adjusting for overall cognitive ability, women were more likely than men to respond correctly to name-of-this-place and mother's-maiden-name items. African Americans were more likely than Whites to correctly give their correct telephone numbers. Those with 0 to 8 years of education were less likely to name the current president and correctly answer the serial-threes item than those with 12 or more years of education. Those aged 80 or older were less likely to correctly identify the day of the week than those aged 60 to 69. Future studies seeking to develop new cognitive screening measures should perform DIF analyses in the instrument development phase to eliminate DIF items a priority. [PUBLICATION ABSTRACT]
Mungas D, Reed BR,
Crane PK, Haan MN, Gonzalez H. Spanish and English neuropsychological assessment scales (SENAS): Further development and psychometric characteristics. Psychological Assessment, Dec. 2004, Vol.16, Iss. 4, pp. 347-359
The Spanish and English Neuropsychological Assessment Scales were devised to be a broad set of psychometrically matched measures with equivalent Spanish and English versions. Study 1 in this report used item response theory methods to refine scales. Results strongly supported psychometric matching across English and Spanish versions and, for most scales, within English and Spanish versions. Study 2 supported in both English and Spanish subsamples the 6-domain model of ability that guided scale construction. Study 3 examined differential item functioning (DIF) of one scale (Object Naming) in relation to education, ethnicity, gender, and age. Effects of DIF on scale-level ability scores were limited. Results demonstrate an empirically guided psychometric approach to test construction for multiethnic and multilingual test applications.[PUBLICATION ABSTRACT] http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15584794&query_hl=27&itool=pubmed_docsum
Crane PK, van Belle G, Larson EB. Test bias in a cognitive test: differential item functioning in the CASI. Statistics in Medicine, 2004, Vol. 23, pp. 241-256.
An ordinal logistic regression modeling technique was used to assess DIF in the Cognitive Assessment Screening Instrument (CASI). Ethnicity, gender, years of education and age were examined for potential DIF with respect to cognitive ability scores. DIF was found in a considerable number of items for at least one of the demographic variables examined. The authors discuss suggestions regarding what to do when items show DIF in cognitive measures. Advantages of techniques for detecting DIF used in this article were discussed in the context of techniques used by other scholars. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14716726&query_hl=30&itool=pubmed_docsum
Jones RN, Gallo JJ. Education and sex differences in the mini-mental state examination: Effects of differential item functioning. The Journals of Gerontology: Series B: Psychological sciences and social sciences. Nov. 2002, Vol. 57B, Iss. 6, pp. 548-558
Years of completed education is a powerful correlate of performance on mental status assessment. This analysis evaluates differences in cognitive performance attributable to level of education and sex. We analyzed Mini-Mental State Examination responses from a large community sample (Epidemiologic Catchment Area study, N = 8,556), using a structural equation analytic framework grounded in item response theory. Significant sex and education group differential item functioning (DIF) were detected. Those with low education were more likely to err on the first serial subtraction, spell world backwards, repeat phrase, write, name season, and copy design tasks. Women were more likely to err on all serial subtractions, men on spelling and other language tasks. The magnitude of detected DIF was small. Our analyses show that failing to account for DIF results in an approximately 1.6% overestimation of the magnitude of difference in assessed cognition between high- and low-education groups. In contrast, nearly all (95%) of apparent sex differences underlying cognitive impairment are due to DIF. Therefore, item bias does not appear to be a major source of observed differences in cognitive status by educational attainment. Adjustments of total scores that eliminate education group differences are not supported by these results. Our results have implications for future research concerning education and risk for dementia. [PUBLICATION ABSTRACT]
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Petkova, E, Teresi, J. Some statistical issues in the analyses of data from longitudinal studies of elderly chronic care populations. Psychosomatic Medicine. May/June 2002, 64(3):531-547.
Objective: This article discusses broad statistical issues common to much medical research: intent-to-treat analysis vs. completers analysis; clustered hierarchical and repeated-measures data; missing data and dropouts; and assessment of direct, indirect, and total effects. Traditional approaches and statistical techniques are reviewed and contrasted with modern methods for analysis of medical studies. Method: The concepts are introduced and discussed in general terms; they are illustrated with an example. The example comes from a study of the effect of residence in special care units (SCUs) for demented elderly on the daily function of nursing homes residents. More than 700 residents from 22 nursing facilities, residing in either an SCU or a non-SCU were assessed three times at approximate 6-month intervals. Results: Results from both the application of traditional statistical techniques and modern methods for the analysis of repeated-measures of hierarchical multicenter data are presented, interpreted, and compared. Advantages and shortcomings of these approaches are discussed. Conclusion: This article advocates the use of mixed models and proper causal reasoning and terminology in the analysis and publication of results from studies on aging and life course. [PUBLICATION ABSTRACT]
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Teresi JA, Abrams R, Holmes D, Ramirez M, Shapiro C, Eimicke JP. Influence of cognitive impairment, illness, gender, and African-American status on psychiatric ratings and staff recognition of depression. American Journal of Geriatric Psychiatry, 2002, Vol. 10, No. 5, pp. 506-514
Objective: The authors examined the multivariate relationships between depression recognition by staff members and characteristics of nursing home residents. Methods: Analyses used a simple random sample of 270 residents, drawn from six randomly selected nursing homes, who were evaluated by psychiatrists for depression and depressive symptomatology. Results: African Americans were generally seen by psychiatrists as having less depressive symptomatology than residents from other ethnic groups. The data suggest that nurse aides, perhaps because they see residents more often or because they are less influenced by demographic characteristics, may be the most valid source of information about residents’ depression. In contrast, after partialing out the degree of depression severity, nurses tended to overrecognize depression among African-American residents. Social workers underrecognized depression among residents with cognitive impairment and/or Parkinson disease and among women, and overrecognized depression among African Americans. Conclusion: The results underline the need for more training in depression recognition, particularly in distinguishing social from clinical phenomena and in distinguishing symptoms of dementia from those of depression. Equally important is further investigation of the potential biases associated with diagnosis and recognition of depression among African Americans. [PUBLICATION ABSTRACT]
Teresi JA, Holmes D, Ramirez M, Gurland BJ, Lantigua R. Performance of cognitive tests among different racial/ethnic and education groups: Findings of differential item functioning and possible item bias. Journal of Mental Health and Aging, 2001, Vol. 7, No.1, pp. 79-89.
The focus of this review is on studies of differential item functioning and of item bias among cognitive assessment measures, with respect to race/ethnicity and education. Several of the items found to perform differently across education or racial/ethnic groups require literacy or skills practiced in school, such as calculation tasks. Some of the poorly performing items relate to language: repeating phrases or following commands. Generally, the results presented here suggest that a) shorter tests, b) measures comprised of easier items, and c) those that rely more on overlearned memory tasks (recall) rather than on performance related to language and literacy, including reading, writing and repeating, perform better. However, recall items that may have variability due to differential cultural relevance may be problematic. More work is needed, using differential item functioning to examine the new versions of widely used scales as well as other screening and neuropsychological measures. [PUBLICATION ABSTRACT]
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Ramirez M, Teresi JA, Silver S, Holmes D, Gurland B, Lantigua R. Cognitive assessment among minority elderly: Possible test bias. Journal of Mental Health and Aging, 2001, Vol. 7, No. 1, pp. 91-118.
Eighteen studies examining the performance of cognitive screening measures across samples representing ethnically diverse populations in terms of sensitivity and specificity with respect to a clinical diagnosis are summarized. Studies were identified through a search of four databases (MEDLINE, CINAHL, HealthGate, PsycINFO) and presented in terms of: a) method of data collection and clinical criteria, b) sampling methods, response rate and sample characteristics, c) methods of analysis, and d) recommendations of the investigators. Methodological caveats relevant to the interpretation of sensitivity and specificity across studies are discussed; scales showing promise for culture-fair assessment are highlighted. [PUBLICATION ABSTRACT]
Teresi JA. Statistical methods for examination of differential item functioning (DIF) with applications to cross-cultural measurement of functional, physical and mental health. Journal of Mental Health and Aging, 2001, Vol. 7, No. 1, pp. 31-4
Different statistical methodologies for the detection of differential item functioning (DIF)
are reviewed. The focus is on methods that have been applied to cross-cultural comparisons of mental health and health scales among elderly cohorts. Methods based on item response theory as well as other parametric and non-parametric approaches are discussed. Differences among methods can be characterized as to whether they: (a) are model based; (b) assume unidimensionality; (c) are based on latent or observed variables; (d) treat the disability dimension as continuous; (e) assume equal discrimination parameters; (f) can detect both uniform and non-uniform (DIF); (g) can examine polytomous responses; (h) can include covariates in the model.[PUBLICATION ABSTRACT]
Teresi JA, Holmes D. Some methodological guidelines for cross-cultural comparisons. Journal of Mental Health and Aging, 2001, Vol. 7, No. 1, pp. 13-19.
The purpose of this article is to review and revisit some methodological issues of relevance to cross-cultural research. Companion articles by Liang and Teresi in this volume discuss statistical invariance issues and the role of Confirmatory Factor Analyses and Item Response Theory in such research. Several guidelines related to interpretation of reliability and validity coefficients that are well addressed in the measurement and biostatistics literature, but that are frequently ignored in common practice are also discussed. Some of these guidelines are based on conclusions presented in the psychometric literature over 70 years ago, but have since been forgotten (or were never learned). [PUBLICATION ABSTRACT]
Teresi JA, Kleinman M, Ocepek-Welikson K. Modern psychometric methods for detection of differential item functioning: Application to cognitive assessment measures. Statistics In Medicine, 2000, Vol. 19, pp.1651-1683
Cognitive screening tests and items have been found to perform differently across groups that differ in terms of education, ethnicity and race. Despite the profound implications that such bias holds for studies in the epidemiology of dementia, little research has been conducted in this area. Using the methods of modern psychometric theory (in addition to those of classical test theory), we examined the performance of the Attention subscale of the Mattis Dementia Rating Scale. Several item response theory models, including the two-and three-parameter dichotomous response logistic model, as well as polytomous response model were compared. (Log-likelihood ratio tests showed that the three-parameter model was not an improvement over the two-parameter model.) Data were collected as part of the ten-study National Institute on Aging Collaborative investigation of special dementia care in institutional settings. The subscale KR-20 estimate for this sample was 0.92. IRT model-based reliability estimates, provided at several points along the latent attribute, ranged from 0.65 to 0.97; the measure was least precise at the less disabled tail of the distribution. Most items performed in similar fashion across education groups; the item characteristic curves were almost identical, indicating little or no differential item functioning (DIF). However, four items were problematic. One item (digit span backwards) demonstrated a large error term in the confirmatory factor analysis; item-fit chi-square statistics developed using BIMAIN confirm this result for the IRT models. Further, the discrimination parameter for that item was low for all education subgroups. Generally, persons with the highest education had a greater probability of passing the item for most levels of 2. Model-based tests of DIF using MULTILOG identified three other items with significant, albeit small, DIF. One item, for example, showed non-uniform DIF in that at the impaired tail of the latent distribution, persons with higher education had a higher probability of correctly responding to the item than did lower education groups, but at less impaired levels, they had a lower probability of a correct response than did lower education groups. Another method of detection identified this item as having DIF (unsigned area statistic = 3.05, p<0.01, and 2.96, p<0.01). On average, across the entire score range, the lower education group’s probability of answering the item correctly was 0.11 higher than the higher education group’s probability. A cross-validation with larger subgroups confirmed the overall result of little DIF for this measure. The methods used for detecting differential item functioning (which may, in turn, be indicative of bias) were applied to a neuropsychological subtest. These methods have been used previously to examine bias in screening measures across education and ethnic and racial subgroups. In addition to the important epidemiological applications of ensuring that screening measures and neuropsychological tests used in diagnoses are free of bias so that more culture-fair classifications will result, these methods are also useful for the examination of site differences in large multi-site clinical trials. It is recommended that these methods receive wider attention in the medical statistical literature. [PUBLICATION ABSTRACT]
Teresi JA, Kleinman M, Ocepek-Welikson K, Ramirez M, Gurland B, Lantigua R, Holmes D. Applications of item response theory to the examination of the psychometric properties and differential item functioning of the comprehensive assessment and referral evaluation dementia diagnostic scale among samples of Latino, African American, and white Non-Latino elderly. Research on Aging, 2000, Vol. 22, No. 6, pp.738-773
Item response theory was used to examine the psychometric properties of a cognitive screening measure used in several epidemiological surveys among Latino, African American, and White non-Latino elderly. Estimates of precision (reliability) examined across several values of2 (the estimate of degree of cognitive impairment) were good (.70s to .90s) in the range representing most respondents. Overall reliability, although adequate, was lower among the White non-Latino and high-education sub-groups relative to other racial/ethnic and education subgroups. Differential item functioning (DIF) was examined using several area- and model-based tests. Tests of the magnitude of DIF showed the measure to be relatively free of DIF for the racial/ethnic subgroup and education subgroups examined. However, one item related to remembering the telephone number was more difficult for Latinos than for other racial/ethnic subgroups. Several other items evidenced mild DIF, and one (difficulty remembering words or names) was a poorly discriminating item. The subjective memory items, intended to provide additional information at the earlier, “borderzone” stages of cognitive impairment, did provide more information at the mild to moderate levels of impairment, although maximum information was not provided at these borderzone ranges. [PUBLICATION ABSTRACT]
Albert SM, Teresi JA. Reading ability, education, and cognitive status assessment among older adults in Harlem,
. American Journal of Public Health, 1999, Vol. 89, No. 1, pp. 95-97 New York City
Objectives. This study examined reported level of education and current reading ability as predictors of cognitive status among older African Americans in central
City. Methods. A probability sample of 164 noninstitutionalized older African Americans was assessed. Mini-Mental State Examination (MMSE) scores were regressed on education and reading ability measures. Results. Harlem, New York ability and educational attainment were significant, independent predictors of MMSE performance. Within any level of education, subjects whose grade-equivalent reading ability exceeded reported level of education scored significantly higher on the MMSE. Conclusions. Reading ability may be useful in interpreting the results of cognitive screening among low-educated and minority groups. [PUBLICATION ABSTRACT] Reading
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Teresi JA, Albert SM, Holmes D, Mayeux R. Use of latent class analyses for the estimation of prevalence of cognitive impairment, and signs of stroke and Parkinson’s disease among African-American elderly of Central Harlem: Results of the
Harlemaging project. Neuroepidemiology, 1999, Vol.18, pp. 309-321
A probability sample (response rate of 79.4%) of 164 African-American elderly residing in central
Harlemwas assessed using several standard cognitive screening measures and scales measuring stroke and Parkinson’s symptoms, respectively. Both traditional cutting scores and the methods of latent class analysis were used to estimate point prevalence. The latent class prevalence ratio estimates range from 10 to 14%. The confidence intervals for cognitive impairment ranged from 5 to 18% with an average estimate of 12%. The latent class estimate for stroke effects was 11% and for two measures of neurological signs associated with Parkinson’s disease 7 and 12%. About 2-3% of the sample were communication disordered, and 5% had significant ambulation disorder. These results indicate that a relatively large proportion of elderly community residents of central Harlemevidenced or reported health problems, any or all of which may constitute a public health challenge. [PUBLICATION ABSTRACT]
Marshall SC, Mungas D, Weldon M, Reed B, Haan M. Differential item functioning in the mini mental state examination in English and Spanish speaking older adults. Psychology and Aging, 1997, Vol. 12, No. 4, pp. 718-725
The purpose of this study was to determine if the Mini-Mental State Examination (MMS; M.F. Folstein, S.E. Folstein & P.R. McHugh, 1975) demonstrates item bias with respect to measuring cognitive functioning of older Hispanics and non-Hispanics. Assessment of differential item functioning (DIF) of individual MMS items across three language/ethnicity groups (English test administration/non-Hispanic ethnicity, English test administration/Hispanic ethnicity, and Spanish test administration/Hispanic ethnicity) was performed by using a logistic regression procedure. Fifteen of the 26 MMS items were significantly related to total score and were shown to provide unbiased measurement across the 3 groups. Normative data are presented for older Hispanics (n=365) and non-Hispanics (n=388) on the raw MMS, a 15-item version in which items with significant DIF were eliminated, and a total score statistically adjusted for effects of education and age.[PUBLICATION ABSTRACT]
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Gurland B, Wilder D, Cross P, Lantigua R, Teresi JA, Barrett V, Stern Y, Mayeux R. Relative rates of dementia by multiple case definitions, over two prevalence periods, in three sociocultural groups. The American Journal of Geriatric Psychiatry, 1995, Vol. 3, No.1, pp.6-20
The North Manhattan Aging Project registry, using both Reporting and Survey Components, identifies dementia cases among Latino, African-American, and non-Latino white sociocultural groups (9,349 persons 65 years of age or older) in contiguous census tracts. During a 2-year prevalence period of the reporting component, 1,592 persons were reported to the Registry and screened with five widely used brief cognitive measures; 844 were evaluated in a “clinical core”, and 452 met research criteria for dementia, covering all subtypes, according DSM-III-R criteria. Thirteen different case definitions for dementia were applied to the sociocultural groups at three levels of educational achievement, examining for associations with rates of dementia cases and controlling for age. The following findings were robust across case definitions: sociocultural membership was not associated, but lower education was associated, with increased rates of recorded dementia; however, the patterns of the association with education varied across sociocultural groups. [PUBLICATION ABSTRACT]
Teresi JA, Golden RR, Cross P, Gurland B, Kleinman M, Wilder D. Item bias in cognitive screening measures: Comparisons of elderly White, Afro-American, Hispanic and high and low education subgroups. Journal of Clinical Epidemiology, 1995, Vol. 48, No. 4, pp. 473-483
A study of item bias in standard cognitive screening measures was conducted in a sample of Afro-American, Hispanic and non-Hispanic white elderly respondents who were part of a dementia case registry study. The methods of item-response theory were applied to identify biased items. Both cross-cultural and high and low education groups were examined to determine which items were biased. Out of 50 cognitive items examined from six widely used cognitive screening measures, 16 were identified as biased for either high and low education groups or ethnic/racial group membership. [PUBLICATION ABSTRACT]
Wilder D, Cross P, Chen J, Gurland B, Lantigua R, Teresi JA, Bolivar M, Encarnacion P. Operating characteristics of brief screens for dementia in a multicultural population. The American Journal of Geriatric Psychiatry, 1995, Vol. 3, No. 2, pp. 96-107
Operating characteristics of seven screens for dementia were compared across various groups for 795 persons who had received a criterion diagnostic evaluation. Area under the curve (AUC), based on receiver operating characteristics, was compared between and within scales as an indication of their efficiency. Differences in AUC were only 5% across all the scales for the entire sample, but increased to 11% across sociocultural groups and scales and to 20% across education groups and scales. Two scales (the Mini-Mental State Exam and the Short Portable Mental Status Questionnaire) misclassified most nondementias for the entire sample, and all scales misclassified most nondementias among persons with less than 5 years of education. Findings could support a recommendation that certain shorter scales be used because they perform as well as longer ones, are more consistent across cultural and educational groups, and can be more easily modified to improve performance in culturally diverse populations. [PUBLICATION ABSTRACT]
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Gurland B, Wilder DE, Cross P, Teresi JA, Barrett V. Screening scales for dementia: Towards reconciliation of conflicting cross-cultural findings. International Journal of Geriatric Psychiatry, 1992, Vol. 7, pp. 105-113
A compendium instrument of five widely used dementia screening scales was applied to +550 subjects 65 years and older. Black, Hispanic and white groups were approximately equal in size. Recruitment was designed to produce an uneven and unknown mix of dementia cases and normals among these groups. A complex challenge to assessment and classification was thus contrived, approximating key aspects of the problem posed to cross-cultural epidemiology. The published scoring systems of these dementia screens gave drastically conflicting results for absolute and culturally relative rates of cognitive impairment. The conflicts between scales appeared to be largely due to the varying sensitivities of the scales and, to a lesser extent, sociocultural bias. The conflicts were partially resolved through adjustments of the scale cut points. [PUBLICATION ABSTRACT]
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