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1.  Diagnostic Validity of Age- And Education-Corrections for the Mini-Mental State Examination (MMSE) in African American Elders 
Objectives
To investigate whether demographic (age and education) adjustments for the Mini-Mental State Examination (MMSE) attenuate mean score discrepancies between African American and Caucasian adults, and to determine whether demographically-adjusted MMSE scores improve the diagnostic classification accuracy of dementia in African American adults when compared to unadjusted MMSE scores.
Design
Cross-sectional study.
Setting
Community-dwelling adults participating in the Mayo Clinic Alzheimer’s Disease Patient Registry (ADPR) and Alzheimer’s Disease Research Center (ADRC).
Participants
Three thousand two hundred fifty-four adults (2819 Caucasian, 435 African American) aged 60 and older.
Measurements
MMSE at study entry.
Results
African American adults obtained significantly lower unadjusted MMSE scores (23.0 ± 7.4) compared to Caucasian adults (25.3 ± 5.4). This discrepancy persisted despite adjustment of MMSE scores for age and years of education using established regression weights or newly-derived weights. However, controlling for dementia severity at baseline and adjusting MMSE scores for age and quality of education attenuated this discrepancy. Among African American adults, an age- and education-adjusted MMSE cut score of 23/24 provided optimal dementia classification accuracy, but this represented only a modest improvement over an unadjusted MMSE cut score of 22/23. The posterior probability of dementia in African American adults is presented for various unadjusted MMSE cut scores and prevalence rates of dementia.
Conclusion
Age, dementia severity at study entry, and quality of educational experience are important explanatory factors to understand the existing discrepancies in MMSE performance between Caucasian and African American adults. Our findings support the use of unadjusted MMSE scores when screening African American elders for dementia, with an unadjusted MMSE cut score of 22/23 yielding optimal classification accuracy.
doi:10.1111/j.1532-5415.2011.03766.x
PMCID: PMC3288600  PMID: 22150301
MMSE; African American; ethnicity; dementia; cognition
2.  Composite scores for executive function items: demographic heterogeneity and relationships with quantitative MRI 
Accurate neuropsychological assessment of older individuals from heterogeneous backgrounds is a major challenge. Education, ethnicity, language, and age are associated with scale level differences in test scores, but item level bias might contribute to these differences. We evaluated several strategies for dealing with item and scale level demographic influences on a measure of executive abilities defined by working memory and fluency tasks. We determined the impact of differential item functioning (DIF). We compared composite scoring strategies on the basis of their relationships with volumetric MRI measures of brain structure. Participants were 791 Hispanic, White, and African American older adults. DIF had a salient impact on test scores for 9% of the sample. MRI data were available on a subset of 153 participants. Validity in comparison with structural MRI was higher after scale level adjustment for education, ethnicity/language, and gender, but item level adjustment did not have a major impact on validity. Age adjustment at the scale level had a negative impact on relationships with MRI, most likely because age adjustment removes variance related to age-associated diseases.
doi:10.1017/S1355617708081162
PMCID: PMC2683684  PMID: 18764970
composite scores; item response theory; dementia; demographic-adjusted T scores; ordinal logistic regression; test bias
3.  The development of the Body Morph Assessment version 2.0 (BMA 2.0): Tests of reliability and validity 
Body image  2009;6(2):67-74.
This study tested the psychometric characteristics of the Body Morph Assessment version 2.0 (BMA 2.0). A sample of 563 adults composed of four groups classified by gender and ethnicity (Caucasian men and women and African-American men and women) were studied. Support for the internal consistency and test–retest reliability of the BMA 2.0 was found for both men and women. A study of convergent validity was conducted. The BMA 2.0 was found to have adequate reliability and validity. Norms were established for the BMA 2.0 estimates of current body size (CBS), ideal body size (IBS), and acceptable body size (ABS) for Caucasian and African-American men and women. In summary, the BMA 2.0 is a reliable and valid computerized measure of CBS, IBS, ABS, the CBS–IBS discrepancy (body dissatisfaction), and provides an estimate of over/underestimation of body size as compared to individuals of the same sex and body mass index.
doi:10.1016/j.bodyim.2009.01.006
PMCID: PMC2743122  PMID: 19244002
Body image; Eating disorders; Obesity; Morph; Body image assessment
4.  Bilateral Brain Regions Associated with Naming in Older Adults 
Brain and language  2010;113(3):113-123.
To determine structural brain correlates of naming abilities in older adults, we tested 24 individuals aged 56 to 79 on two confrontation-naming tests (the Boston Naming Test (BNT) and the Action Naming Test (ANT)), then collected from these individuals structural Magnetic Resonance Imaging (MRI) and Diffusion Tensor Imaging (DTI) data. Overall, several regions showed that greater gray and white matter volume/integrity measures were associated with better task performance. Left peri-Sylvian language regions and their right-hemisphere counterparts, plus left mid-frontal gyrus correlated with accuracy and/or negatively with response time (RT) on the naming tests. Fractional anisotropy maps derived from DTI showed robust positive correlations with ANT accuracy bilaterally in the temporal lobe and in right middle frontal lobe, as well as negative correlations with BNT RT, bilaterally, in the white matter within middle and inferior temporal lobes. We conclude that those older adults with relatively better naming skills can rely on right-hemisphere peri-Sylvian and mid-frontal regions and pathways, in conjunction with left-hemisphere peri-Sylvian and mid-frontal regions, to achieve their success.
doi:10.1016/j.bandl.2010.03.001
PMCID: PMC2975055  PMID: 20399492
5.  Measuring depression levels in HIV-infected patients as part of routine clinical care using the 9-item patient health questionnaire (PHQ-9) 
AIDS care  2010;22(7):874-885.
Little is known about the psychometric properties of depression instruments among persons infected with HIV. We analyzed data from a large sample of patients in usual care in two US cities (n=1467) using the 9-item Patient Health Questionnaire from the PRIME-MD (the PHQ-9). The PHQ-9 had curvilinear scaling properties and varying levels of measurement precision along the continuum of depression measured by the instrument. In our cohort, the scale showed a prominent floor effect and a distribution of scores across depression severity levels. Three items had differential item functioning (DIF) with respect to race (African-American vs. white); two had DIF with respect to sex, and one had DIF with respect to age. There was minimal individual-level DIF impact. Twenty percent of the difference in mean depression levels between African-Americans and whites was due to DIF. While standard scores for the PHQ-9 may be appropriate for use with individual HIV-infected patients in cross-sectional settings, these results suggest that investigations of depression across groups and within patients across time may require a more sophisticated analytic framework.
doi:10.1080/09540120903483034
PMCID: PMC3410748  PMID: 20635252
6.  Persistent Pain Biases Item Response on the Geriatric Depression Scale (GDS): Preliminary Evidence for Validity of the GDS-PAIN 
Pain medicine (Malden, Mass.)  2008;9(1):33-43.
Objective
Differential item functioning (DIF) assesses the consistency of items on a metric across clinical samples in relation to the attribute being measured. We hypothesized that in older adults with persistent pain, items of the Geriatric Depression Scale (GDS) would evidence DIF based on presence or intensity of pain.
Design
Unidimensionality was determined by factor and item analyses. DIF was tested using Rasch Modeling. We then evaluated the psychometric properties of a revised GDS (GDS-PAIN), comprised of items that did not evidence DIF.
Patient and Settings
A total of 677 community dwelling older adults (age 65–91) participating in observational or treatment studies of low back or knee pain who endorsed at least moderate pain for at least 3 months. A total of 201 pain-free controls were included in the analysis.
Results
Ten of the 30 items displayed significant DIF. These items were: 1) dropping activities and interests; 2) bothered by persistent thoughts; 3) often get fidgety and restless; 4) prefer to stay home; 5) do not feel full of energy; 6) do not enjoy getting up in the morning; 7) mind is not as clear as it was, 8) feel life is empty; 9) feel more problems with memory; and 10) do not find life very exciting. The modified GDS-PAIN scale did not adversely affect the psychometric properties of the scale.
Conclusions
The performance of the GDS is affected by pain. When unstable items are removed, the revised GDS (GDS-PAIN) appears to be psychometrically stable and maintains both internal consistency and similar correlation values with a measure of pain as the original scale.
doi:10.1111/j.1526-4637.2007.00406.x
PMCID: PMC2837555  PMID: 18254765
Depression; Geriatric; Chronic Pain; Measurement
7.  Geriatric Performance on an Abbreviated Version of the Boston Naming Test 
Applied neuropsychology  2007;14(3):215-223.
Abbreviated neuropsychological protocols are increasingly utilized secondary to time-constraints within research and healthcare settings, yet normative data for these abbreviated instruments are lacking. We present geriatric performances and normative data for the Boston Naming Test 30-item even verion (BNT-30). Data were utilized from the BU-ADCC registry (n = 441, ages 55-98) and included 219 normal controls (NC), 155 participants with mild cognitive impairment (MCI), and 67 participants with Alzheimer’s disease (AD). The NC group (M = 28.7, SD = 1.8) significantly outperformed both MCI (M = 26.2, SD = 4.4) and AD (M = 22.1, SD = 4.8) groups, and the MCI group outperformed the AD group. Normative data generated for the NC participants revealed a significant between-group difference for sex (males M = 29.1, SD = 1.7; females M = 28.4, SD = 1.8) and race (White M = 28.8, SD = 1.7; African American M = 27.5, SD = 2.1). The racial disparity remained even after adjusting for education level (p = .002) and literacy (p < .001). ANOVAs for the NC group were non-significant for age but significant for education level (p = .001). Geriatric normative data therefore suggest that sex, race, and education are all associated with naming performance, and these variables should be taken into consideration when interpreting geriatric BNT-30 performance.
doi:10.1080/09084280701509166
PMCID: PMC2741691  PMID: 17848132
Alzheimer’s disease; Boston Naming Test; geriatrics; language; lexical retrieval; mild cognitive impairment; neuropsychological measures; normative data
8.  Influence of Reading Ability on Neuropsychological Performance in African American Elders 
Use of normative data stratified by education may result in misclassification of African American older adults because reading ability, an estimate of educational attainment, is lower than reported years of education for some African American elders. This study examined the contribution of reading ability versus education to neuropsychological test performance in 86 community-dwelling African American elders ages 56–91 with 8–18 years of education. Hierarchical multiple regression analyses revealed that reading ability, but not education, was significantly associated with performances on the Trail Making Test, Controlled Oral Word Association Test, Animal Naming, Digit Span, and the Stroop test. Reading ability was not significantly related to performances on measures of memory. Medium to large effect sizes (Cohen's d = 0.58–1.41) were found when comparing mean performances on neuropsychological measures in groups with low versus high reading scores. Results indicate that reading ability contributes beyond educational attainment to performances on some neuropsychological measures among African American elders. These findings have implications for reducing misclassification among minority populations through the use of appropriate normative data.
doi:10.1093/arclin/acr062
PMCID: PMC3198584  PMID: 21835850
Assessment; Elderly; Geriatrics; Aging; Norms; Normative studies
9.  Prevalence of osteoporosis and osteopenia among African Americans with early rheumatoid arthritis: the impact of ethnic-specific normative data. 
PURPOSE: To examine the prevalence of osteopenia and/or osteoporosis among African Americans with early rheumatoid arthritis (RA) and to assess the effect of using race/ethnicity-specific normative data. METHODS: Bone mineral density (BMD) of the hip and spine was assessed in African Americans with early RA. To examine the impact of using different normative data on disease classification, we calculated two sets of T scores, the first using sex-matched reference data from Caucasians and the second using data from African Americans. Osteoporosis was defined as a BMD at either site > or =2.5 SD below the young adult mean. Osteopenia was defined as a BMD > or =1 SD and <2.5 SD below this mean. RESULTS: Using Caucasian referent data, 33% (n=48) of patients had osteopenia or worse (n=48, 32.9%) and 5% (n=8) were osteoporotic. With the use of African-American normative data, 55% (n=94) were osteopenic or worse, and 16% (n=27) were osteoporotic. CONCLUSION: African Americans with RA are at risk of osteopenia and/or osteoporosis. Different diagnostic classifications may occur in this population based solely on the normative data used for assessing fracture risk. These results underscore the need for a standardized approach in defining osteopenia and osteoporosis in African Americans.
PMCID: PMC1364462  PMID: 16173331
10.  Prevalence of Osteoporosis and Osteopenia among African Americans with Early Rheumatoid Arthritis: The Impact of Ethnic-Specific Normative Data 
Purpose: To examine the prevalence of osteopenia and/or osteoporosis among African Americans with early rheumatoid arthritis (RA) and to assess the effect of using race/ethnicity-specific normative data.
Methods: Bone mineral density (BMD) of the hip and spine was assessed in African Americans with early RA. To examine the impact of using different normative data on disease classification, we calculated two sets of T scores, the first using sex-matched reference data from Caucasians and the second using data from African Americans. Osteoporosis was defined as a BMD at either site ≥2.5 SD below the young adult mean. Osteopenia was defined as a BMD ≥1 SD and <2.5 SD below this mean.
Results: Using Caucasian referent data, 33% (n=48) of patients had osteopenia or worse (n=48, 32.9%) and 5% (n=8) were osteoporotic. With the use of African-American normative data, 55% (n=94) were osteopenic or worse, and 16% (n=27) were osteoporotic.
Conclusion: African Americans with RA are at risk of osteopenia and/or osteoporosis. Different diagnostic classifications may occur in this population based solely on the normative data used for assessing fracture risk. These results underscore the need for a standardized approach in defining osteopenia and osteoporosis in African Americans.
PMCID: PMC1364462  PMID: 16173331
osteoporosis; osteopenia; African Americans; DXA; rheumatoid arthritis
11.  Age and education effects on relationships of cognitive test scores with brain structure in demographically diverse older persons 
Psychology and aging  2009;24(1):116-128.
This study examined how age and education influence the relationship between neuropsychological test scores and brain structure in demographically diverse older adults spanning the range from normal cognition to dementia. A sample of 351 African Americans, 410 Hispanics, and 458 Caucasians received neuropsychological testing; volumetric MRI measures of total brain, white matter hyperintensity, and hippocampus were available for 79 African Americans, 102 Hispanics, and 134 Caucasians. Latent variable modeling was used to examine effects of age, education, and brain volumes on test scores and determine how much variance brain volumes explained in unadjusted and age and education adjusted scores. Age adjustment resulted in weaker relationships of test scores with MRI variables and adjustment for ethnicity yielded stronger relationships. Education adjustment increased relationships with MRI in the combined sample and in Hispanics, made no difference in Caucasians, but decreased some associations in African Americans. Results suggest that demographic adjustment is beneficial when demographic variables are strongly related to test scores independent of measures of brain structure, but adjustment has negative consequences when effects of demographic characteristics are mediated by brain structure.
doi:10.1037/a0013421
PMCID: PMC2861868  PMID: 19290743
Neuropsychological tests; ethnicity; brain structure; age; education; structural MRI
12.  Duloxetine in the treatment of major depressive disorder: comparisons of safety and efficacy. 
BACKGROUND: Pooled data from double-blind, placebo-controlled studies were utilized to compare the safety and efficacy of duloxetine in the treatment of major depressive disorder (MDD) in African-American and Caucasian patients. METHODS: Efficacy and safety data were pooled from seven double-blind, placebo-controlled clinical trials of duloxetine. Patients (aged > or =18 years) meeting DSM-IV criteria for MDD received duloxetine (40-120 mg/day; African Americans, N=69; Caucasians, N=748) or placebo (African Americans, N=59; Caucasians, N=594) for up to nine weeks. Efficacy measures included the 17-item Hamilton Rating Scale for Depression (HAMD17) total score, the Clinical Global Impression of Severity (CGI-S) and Patient Global Impression of Improvement (PGI-I) scales, and Visual Analog Scales (VAS) for pain. Safety was assessed using discontinuation rates, spontaneously reported treatment-emergent adverse events, vital signs and laboratory analyses, RESULTS: Based upon mean changes in HAMD17, CGI-S and PGI-I scales, the magnitude of duloxetine's treatment effects did not differ significantly between African-American and Caucasian patients. Discontinuation rates due to adverse events among duloxetine-treated patients were 13.0% for African Americans and 17.0% for Caucasians. No adverse event led to discontinuation in more than one African-American patient. The most common treatment-emergent adverse events in both ethnic groups included nausea, headache, constipation, dizziness and insomnia. The rate of occurrence of these events did not differ significantly between African-American and Caucasian patients. Mean changes from baseline for pulse, blood pressure, weight and laboratory analytes were small and showed no significant differences between African-American and Caucasian patients. CONCLUSION: In this analysis of data from seven clinical trials, no convincing evidence was found to suggest that the overall safety and tolerability profile or the efficacy profile for duloxetine in this cohort of African-American patients differed from that observed in a comparator group of Caucasian patients. The results from these analyses provide supportive evidence for the efficacy and safety of duloxetine in the treatment of MDD in African-American patients.
PMCID: PMC2576123  PMID: 16573311
13.  Robust and Expanded Norms for the Dementia Rating Scale 
The Dementia Rating Scale (DRS) is a widely used measure of global cognition, with age- and education-corrected norms derived from a cross-sectional sample of adults participating in Mayo's Older Americans Normative Studies (MOANS). In recent years, however, studies have indicated that cross-sectional normative samples of older adults represent an admixture of individuals who are indeed cognitively normal (i.e., disease-free) and individuals with incipient neurodegenerative disease. Theoretically, the “contamination” of cross-sectional normative samples with cases of preclinical dementia can lead to underestimation of the test mean and overestimation of the variance, thus reducing the clinical utility of the norms. Robust norming, in which dementia cases are removed from the normative cohort through longitudinal follow-up, is an alternative approach to norm development. The current study presents a reappraisal of the original MOANS DRS norms, provides robust and expanded norms based on a sample of 894 adults age 55 and over, and critically evaluates the benefits of robust norming.
doi:10.1093/arclin/acq030
PMCID: PMC2904669  PMID: 20427376
Dementia Rating Scale; DRS; Alzheimer's disease; Robust; Norms
14.  Multiple, correlated covariates associated with differential item functioning (DIF): Accounting for language DIF when education levels differ across languages 
Ageing research  2011;2(1):19-25.
Differential item functioning (DIF) occurs when a test item has different statistical properties in subgroups, controlling for the underlying ability measured by the test. DIF assessment is necessary when evaluating measurement bias in tests used across different language groups. However, other factors such as educational attainment can differ across language groups, and DIF due to these other factors may also exist. How to conduct DIF analyses in the presence of multiple, correlated factors remains largely unexplored. This study assessed DIF related to Spanish versus English language in a 44-item object naming test. Data come from a community-based sample of 1,755 Spanish- and English-speaking older adults. We compared simultaneous accounting, a new strategy for handling differences in educational attainment across language groups, with existing methods. Compared to other methods, simultaneously accounting for language- and education-related DIF yielded salient differences in some object naming scores, particularly for Spanish speakers with at least 9 years of education. Accounting for factors that vary across language groups can be important when assessing language DIF. The use of simultaneous accounting will be relevant to other cross-cultural studies in cognition and in other fields, including health-related quality of life.
doi:10.4081/ar.2011.e4
PMCID: PMC3418868  PMID: 22900138
cognitive testing; item response theory; logistic regression; test bias; translation
15.  Grey Matter Correlates of Three Language Tests in Non-demented Older Adults 
PLoS ONE  2013;8(11):e80215.
Language has been extensively investigated by functional neuroimaging studies. However, only a limited number of structural neuroimaging studies have examined the relationship between language performance and brain structure in healthy adults, and the number is even less in older adults. The present study sought to investigate correlations between grey matter volumes and three standardized language tests in late life. The participants were 344 non-demented, community-dwelling adults aged 70-90 years, who were drawn from the population-based Sydney Memory and Ageing Study. The three language tests included the Controlled Oral Word Association Task (COWAT), Category Fluency (CF), and Boston Naming Test (BNT). Correlation analyses between voxel-wise GM volumes and language tests showed distinctive GM correlation patterns for each language test. The GM correlates were located in the right frontal and left temporal lobes for COWAT, in the left frontal and temporal lobes for CF, and in bilateral temporal lobes for BNT. Our findings largely corresponded to the neural substrates of language tasks revealed in fMRI studies, and we also observed a less hemispheric asymmetry in the GM correlates of the language tests. Furthermore, we divided the participants into two age groups (70-79 and 80-90 years old), and then examined the correlations between structural laterality indices and language performance for each group. A trend toward significant difference in the correlations was found between the two age groups, with stronger correlations in the group of 70-79 years old than those in the group of 80-90 years old. This difference might suggest a further decline of language lateralization in different stages of late life.
doi:10.1371/journal.pone.0080215
PMCID: PMC3818244  PMID: 24224044
16.  Racial Differences in Parental Reports of Attention-Deficit/Hyperactivity Disorder Behaviors 
Objective
Accurate assessment of racial disparities in attention-deficit/hyperactivity disorder (ADHD) depends on measurement that is equally valid for all groups. This study examines differences among African American and white children in ADHD measurement with a widely used parental report instrument, the Diagnostic Interview Schedule for Children (DISC).
Methods
Data come from 1070 children in the Fast Track Project, a longitudinal study of predominantly low-income children at risk of emotional and/or behavioral problems. Item Response Theory (IRT) methodology is used to determine whether ADHD screening items provide comparable information for African American and white children or whether differential item function (DIF) exists. IRT scores and race/ethnicity are entered in logistic regression models predicting use of ADHD medication.
Results
Seven of 39 DISC items performed differently among African Americans and whites. In most cases, parents of white children were more likely to endorse these items than were parents of African American children at comparable underlying levels of children’s hyperactivity. When items exhibiting differential functioning were deleted, race disparities predicting underlying need as indicated by ADHD medication use decreased and were no longer statistically significant.
Conclusions
Perceptions of ADHD-related symptoms among parents of African American children appear to differ in important ways from those of parents of white children, and screening instruments relying on parent report may yield different results for African American and white children with similar underlying treatment needs. Gathering information from additional sources including teachers and school counselors can provide a more complete picture of the behavioral functioning and therapeutic needs of children in all race/ethnic groups.
doi:10.1097/DBP.0b013e31811ff8b8
PMCID: PMC3396128  PMID: 18049317
attention-deficit/hyperactivity disorder; screening tests; disparities; African Americans; children’s mental health
17.  Text processing variables predict the readability of everyday documents read by older adults 
Reading research quarterly  1993;28(3):235.
A model is presented to predict the readability of documents encountered by older adults. The documents studied are contained in the Educational Testing Service’s Test of Basic Skills (1977 edition) and require readers to answer questions about charts (e.g., bus schedules), labels (e.g., plant spray labels and prescriptions), and forms (e.g., tax forms). The components of the model came from theoretical and empirical work on discourse processing and include such factors as discourse structure, emphasis, and position of an answer in a linguistic analysis of the everyday document.
A sample of 482 adults from 52 to 93 years of age took the everyday problems test as well as a psychometric ability battery. The correlation was .54 (p < .01) between the readability scores for test items predicted by the model and the percentage of older adults correctly answering those items. In addition, the more difficult test items as identified by the model were correlated more highly with fluid intelligence abilities (figural relations and induction), crystallized intelligence abilities (vocabulary, experiential evaluation), and with memory span.
PMCID: PMC2823075  PMID: 20169005
18.  DIFFERENCES IN EXERCISE PERFORMANCE AND LEISURE-TIME PHYSICAL ACTIVITY IN OLDER CAUCASIANS AND AFRICAN-AMERICANS 
Purposes
(a) To compare exercise performance and leisure-time physical activity (LTPA) between older Caucasians and African-Americans, (b) to assess the relationship between exercise performance and LTPA, and (c) to determine whether group differences in exercise performance persist after adjusting for differences in LTPA.
Methods
A total of 207 Caucasians and 160 African-Americans who were 65 years of age and older participated in this study. Subjects were characterized on exercise performance by a 6-minute walk test, and by a short physical performance battery (SPPB) score consisting of a repeated chair rise test, a standing balance test, and a 4-meter walk test. Additionally, LTPA was assessed using the Minnesota LTPA questionnaire.
Results
African-Americans had a 16% lower SPPB value (P < 0.001), a 14% shorter 6-minute walk distance (P < 0.001), and a 34% lower LTPA value (P < 0.011) than the Caucasians. LTPA was significantly related (P < 0.01) to both SPPB and 6-minute walk distance in both groups. Differences in SPPB and 6-minute walk distance between older Caucasians and African-Americans were no longer present (P > 0.05) after controlling for LTPA.
Conclusions
Older African-Americans had impaired exercise performance and lower LTPA compared to older Caucasians. Racial differences in exercise performance were no longer present after adjusting for differences in LTPA.
PMCID: PMC3193346  PMID: 22003300
19.  Family Matters: Dyadic Agreement in End-of-Life Medical Decision Making 
The Gerontologist  2009;50(2):226-237.
Purpose: We examined race/ethnicity and cultural context within hypothetical end-of-life medical decision scenarios and its influence on patient–proxy agreement. Design and Methods: Family dyads consisting of an older adult and 1 family member, typically an adult child, responded to questions regarding the older adult’s preferences for cardiopulmonary resuscitation, artificial feeding and fluids, and palliative care in hypothetical illness scenarios. The responses of 34 Caucasian dyads and 30 African American dyads were compared to determine the extent to which family members could accurately predict the treatment preferences of their older relative. Results: We found higher treatment preference agreement among African American dyads compared with Caucasian dyads when considering overall raw difference scores (i.e., overtreatment errors can compensate for undertreatment errors). Prior advance care planning moderated the effect such that lower levels of advance care planning predicted undertreatment errors among African American proxies and overtreatment errors among Caucasian proxies. In contrast, no racial/ethnic differences in treatment preference agreement were found within absolute difference scores (i.e., total error, regardless of the direction of error). Implications: This project is one of the first to examine the mediators and moderators of dyadic racial/cultural differences in treatment preference agreement for end-of-life care in hypothetical illness scenarios. Future studies should use mixed method approaches to explore underlying factors for racial differences in patient–proxy agreement as a basis for developing culturally sensitive interventions to reduce racial disparities in end-of-life care options.
doi:10.1093/geront/gnp166
PMCID: PMC2838411  PMID: 20038541
End-of-life decision making; Race/ethnicity; Culture
20.  Recruitment of African Americans and Asian Americans with Late Life Depression and Mild Cognitive Impairment 
Objective
The purpose of this study was to compare the relative effectiveness of several different strategies for recruiting elderly Asians, African Americans, and Caucasians to participate in mental health research.
Participants
A total of 35 African American, 24 Asian American, and 215 Caucasian participants were phone-screened for potential enrollment into a University of California, San Francisco Department of Psychiatry treatment outcome study for older adults (60+ years of age) with major depression and mild cognitive impairment.
Design
The methods by which participants were recruited were recorded, coded into composite categories, and statistically analyzed to determine whether certain recruitment strategies were disproportionately effective for recruiting participants from the three racial groups.
Results
Fisher's exact test analyses revealed that Asians and African Americans were significantly less likely than Caucasians to be recruited through mental health-based methods, and African Americans were significantly more likely than Caucasians and Asians to be recruited via referrals rather than solicitations. Logistic regression, which controlled for potential confounds, largely supported these findings.
Conclusions
Findings suggest that the recruitment of elderly African or Asian Americans into mental health treatment outcome research can be facilitated by a flexible consumer-oriented strategy that integrates multiple recruitment methods. Establishing study credibility through non-mental health media and professional referral sources may be especially effective in engaging the participation of elderly Asian Americans; and cultivating ongoing relationships with key gatekeepers, who can observe benefits to the community, may be particularly effective in recruiting elderly African Americans.
doi:10.1097/JGP.0b013e3181cc0314
PMCID: PMC2898912  PMID: 20220590
recruitment; Asian; African American; minority; late life depression; cognitive impairment; executive dysfunction
21.  Assessment of a Short Diabetes Knowledge Instrument for Older and Minority Adults 
The Diabetes educator  2013;40(1):68-76.
Purpose
The purpose of the study was to assess the performance of a short diabetes knowledge instrument (SDKI) in a large multi-ethnic sample of older adults with diabetes and to identify possible modifications to improve its ability to document diabetes knowledge.
Research Design and Methods
A sample of 593 African American, American Indian, and white female and male adults 60 years and older, with diabetes diagnosed at least two years prior, was recruited from eight North Carolina counties. All completed an interview that included a 16-item questionnaire to assess diabetes knowledge. A subsample of 46 completed the questionnaire a second time at a subsequent interview. Item-response analysis was used to refine the instrument to well-performing items. The instrument consisting of the remaining items was subjected to analyses to assess validity and test-retest reliability.
Results
Three items were removed after item-response analysis. Scores for the resulting instrument were lower among minority and older participants, as well as those with lower educational attainment and income. Scores for test-retest were highly correlated.
Conclusions
The SDKI (13 item questionnaire) appears to be a valid and reliable instrument to evaluate knowledge about diabetes. Assessment in a multi-ethnic sample of older adults suggests that this instrument can be used to measure diabetes knowledge in diverse populations. Further evaluation is needed to determine whether or not this instrument can detect changes in knowledge resulting from diabetes education or other interventions.
doi:10.1177/0145721713508824
PMCID: PMC3946961  PMID: 24163359
22.  Effects of Health Status on Word Finding in Aging 
OBJECTIVES
To evaluate effects of health status on word-finding difficulty in aging, adjusting for the known contributors of education, sex, and ethnicity.
DESIGN
Cross-sectional.
SETTING
Community.
PARTICIPANTS
Two hundred eighty-four adults aged 55 to 85 (48.6% female) participating in an ongoing longitudinal study of language in aging.
MEASUREMENTS
Medical, neurological, and laboratory evaluations to determine health status and presence or absence of hypertension and diabetes mellitus. Lexical retrieval evaluated with the Boston Naming Test (BNT) and Action Naming Test.
RESULTS
Unadjusted regression models showed that presence of diabetes mellitus was not related to naming. Presence of hypertension was associated with significantly lower accuracy on both tasks (P<.02). Adjustment for demographics attenuated the effect of hypertension (P<.08). For the BNT, a variable combining presence, treatment, and control of hypertension was marginally significant (P<.10), with subjects with uncontrolled hypertension being least accurate (91.4%). Previously observed findings regarding the effects of age, education, sex, and ethnicity were confirmed.
CONCLUSION
In this sample of older adults, hypertension contributed to the word-finding difficulty of normal aging, but diabetes mellitus did not.
doi:10.1111/j.1532-5415.2009.02559.x
PMCID: PMC2946242  PMID: 20121990
language; aging; hypertension; diabetes mellitus
23.  Degree of Bilingualism Predicts Age of Diagnosis of Alzheimer’s Disease in Low-Education but not in Highly-Educated Hispanics 
Neuropsychologia  2011;49(14):3826-3830.
The current study investigated the relationship between bilingual language proficiency and onset of probable Alzheimer’s disease (AD) in 44 Spanish-English bilinguals at the UCSD Alzheimer’s Disease Research Center. Degree of bilingualism along a continuum was measured using Boston Naming Test (BNT) scores in each language. Higher degrees of bilingualism were associated with increasingly later age-of-diagnosis (and age of onset of symptoms), but this effect was driven by participants with low education level (a significant interaction between years of education and bilingualism) most of whom (73%) were also Spanish-dominant. Additionally, only objective measures (i.e., BNT scores), not self-reported degree of bilingualism, predicted age-of-diagnosis even though objective and self-reported measures were significantly correlated. These findings establish a specific connection between knowledge of two languages and delay of AD onset, and demonstrate that bilingual effects can be obscured by interactions between education and bilingualism, and by failure to obtain objective measures of bilingualism. More generally, these data support analogies between the effects of bilingualism and “cognitive reserve” and suggest an upper limit on the extent to which reserve can function to delay dementia.
doi:10.1016/j.neuropsychologia.2011.09.041
PMCID: PMC3223277  PMID: 22001315
24.  Difficulty and Discrimination Parameters of Boston Naming Test Items in a Consecutive Clinical Series 
The Boston Naming Test is one of the most widely used neuropsychological instruments; yet, there has been limited use of modern psychometric methods to investigate its properties at the item level. The current study used Item response theory to examine each item's difficulty and discrimination properties, as well as the test's measurement precision across the range of naming ability. Participants included 300 consecutive referrals to the outpatient neuropsychology service at Mayo Clinic in Florida. Results showed that successive items do not necessarily reflect a monotonic increase in psychometric difficulty, some items are inadequate to distinguish individuals at various levels of naming ability, multiple items provide redundant psychometric information, and measurement precision is greatest for persons within a low-average range of ability. These findings may be used to develop short forms, improve reliability in future test versions by replacing psychometrically poor items, and analyze profiles of intra-individual variability.
doi:10.1093/arclin/acr042
PMCID: PMC3142950  PMID: 21593059
Boston Naming Test; Item response theory; Item difficulty; Item discriminability
25.  Age-related Differential Item Functioning for the Patient-Reported Outcomes Information System (PROMIS®) Physical Functioning Items 
Purpose
To evaluate the equivalence of the PROMIS® wave 1 physical functioning item bank, by age (50 years or older versus 18-49).
Materials and methods
A total of 114 physical functioning items with 5 response choices were administered to English- (n=1504) and Spanish-language (n=640) adults. Item frequencies, means and standard deviations, item-scale correlations, and internal consistency reliability were estimated. Differential Item Functioning (DIF) by age was evaluated.
Results
Thirty of the 114 items were fagged for DIF based on an R-squared of 0.02 or above criterion. The expected total score was higher for those respondents who were 18-49 than those who were 50 or older.
Conclusions
Those who were 50 years or older versus 18-49 years old with the same level of physical functioning responded differently to 30 of the 114 items in the PROMIS® physical functioning item bank. This study yields essential information about the equivalence of the physical functioning items in older versus younger individuals.
doi:10.4172/2167-1079.1000131
PMCID: PMC3774524  PMID: 24052925
Survey Research; Physical function; Item Response Theory (IRT); Differential Item Functioning (DIF)

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