ALZHEIMER EUROPE 2015 Parallel Session Minority groups Cognitive assessment in cross-cultural situations Specific case of elderly from minority groups in France Rachid OULAHAL University of Toulouse II oulahal@yahoo.fr 04/09/2015
CONTEXT We will present first results from a research currently ongoing as part of a PhD in Psychology in the University of Toulouse 2 Jean Jaurès. Our research considers the cognitive assessment of elderly in cross-cultural environments. This research is made under the cross-cultural psychology field. The starting point of our search is in France but we intend to spread our reflection to other environments where cognitive assessment of elderly patients has to be crossculturally aware.
PUTTING RESEARCH INTO PRACTICE In France, several studies stated a "surprise" related to individuals from minority groups, who came to France as young adults during the 60s and 70s, and who were not really expected to grow old in France. This reality is now a society issue and has to be addressed by the public health policies. The National Assembly considered the question and performed a survey regarding the elderly immigrants. The report of this survey was presented in July 2013 > «It is time to break with the illusion of a return to the home country, maintained at the expense of any coherent action towards them. On the contrary, we have to recognize the reality of their ageing in France». > The report recommends actions to improve quality of life and support for elderly from minority groups who, so far, remain distant from health care centers. > The report also emphasizes the need to provide appropriate support to Alzheimer patients, indicating that «Alzheimer patients among elderly immigrants, who managed to learn the French language, may eventually forget it and return to their maternal language».
WHICH TOOL FOR A COGNITIVE ASSESSMENT? Our question : How to consider the specificity of non French-speaking elderly with respect to cognitive assessment? We will address the necessity to adapt cognitive evaluation tools and psychologists practices to the cross-cultural situation where patients, carers and professionals are involved. We considered 2 tests : MMSE as it is recommended by the High Authority of Health ( HAS) for cognitive assessment of elderly. TMA-93 (Test of Associative Memory of the 93) validated in October 2013 by the GRECO (French reflection group on cognitive evaluations) to address characteristics of the cognitive assessment for individuals who are illiterate and/or with low educational level and/or of non French-speaking origins. These two tests can be performed within 15 minutes and instructions are simple. Normative data are available for both tests and dementia is suspected from a score lower than 24/30.
MMSE This test is made of 30 questions The MMSE enables evaluation on the following six categories: time and space orientation (day, month, year, place, floor), transcription of information (manipulate a sheet of paper according to instructions from the examiner), attention and calculation (backward counting), mnesic ability, naming of objects and constructive praxie (reproduction of a geometrical shape). Each of the questions is marked and the examiner then obtains a global mark on 30. A score upper or equal to 28 is considered as normal. A score of 23 or less is said abnormal. For a score between 24 and 27, criteria such as age, socio-educational level must be taken into account for the interpretation.
TMA-93 Phase 1 : NAMING 10 couples of images are presented to the participant The participant is asked to name all the images and to remember the associations
TMA-93 Phase 2 : RECALLING Each couple of image is presented with a missing image The participant is asked to name the missing image (score /10) This step is repeated 3 times => score /30
TMA-93
It is thus important, when we consider assessments with individuals from minority groups, to take into account these biases. These biases are obstacles to the adaptation of cognitive assessment tools from a cultural environment to another. BIASES TO BE CONSIDERED Several types on the biases can exist with respect to the tests and their application with subject from different cultural backgrounds. The conceptual bias when the concept evaluated by the test does not exist in a given cultural group. So, even the best translation will not make identical the original test and the one adapted for another cultural background. The method bias includes biases related to the sampling and to the test management. > Difficult to define inclusion criteria to get normative data (Nationality? Language? Religion?). > Misunderstandings, intervention of a translator (professional, family member) are all elements that can impact the test progress. The item bias describes situations where an item will measure a variable different from the one that it is supposed to measure. These biases can appear in test material as it may not be familiar in the cultural context of the patient. As an example, tests may rely on images that are unknown in the patient s environment.
Our methodology Hypothesis : Evaluation for elderly involved in cross-cultural environments requires adaptation that goes beyond the translation of an existing test. The translation of the MMSE (recommended by the HAS for elderly cognitive evaluation) is not adapted for elderly from minority groups who don t speak French or only little. Biases in connection with cultural differences will appear during the evaluations. The TMA-93 test, which considers low French language skills and illiteracy, is more adapted than the MMSE test for cognitive evaluation of elderly from minority groups who don t speak French or only little. Our research is performed in a community health center located in the town of Toulouse, in the south-west of France ( www.casedesante.org ). Patients are met during their appointments at the health center. We met these patients in a separate office in a quiet environment.
Our methodology At the beginning of the session, we asked the participant to indicate languages he used to speak during his childhood as well as those he would speak today. The MMSE and TMA-93 tests were then administered. For the MMSE test, we used a translated version of the MMSE test in dialectal Arabic. Patient 1 is 71 and is from Syria. Patient 1 came to France a few years ago due to the political events in Syria. Patient 2 is 84 and is of Algerian origin. Patient 2 came to France 6 years ago to stay with daughter and family. Patient 3 is 82 years old and is also from Algerian origin. Patient 3 came to France in the 70s and worked in various factories. Patient 3 is married with children. Patient 4 is 79 years and is also of Algerian origin. Patient 4 came to France in the 70s but has been living there alone. His wife and children stayed in Algeria. The 4 of them never had any cognitive assessment and were not diagnosed with any cognitive impairment. However, the health center doctors had concerns about them (missed appointments, forgotten context of injury )
RESULTS ANALYSIS 1/4 Patient 1 obtains a score of 23/30 in the TMA-93 and 22/30 in the dialectal Arabic MMSE. In both cases, the score is situated below the normative level. For the TMA-93, we notice a score improvement in the second and third round of the test where Patient 1 obtains a score of 9/10. It is interesting to notice that the image forgotten in these last two rounds of the test is the book. During an informal exchange after the test administration, Patient 1 justified the error by telling: I have never been to school. For the MMSE test, it appears that some questions are not relevant with respect to Patient 1 s situation. Patient 1 does not know the name of the department and the region where we were. Patient 1 does not either know the year at that time but knew precisely the day of the week, the month as well as the season.
RESULTS ANALYSIS 2/4 Patient 2 obtains a score of 7/30 in the test TMA-93 and 18/30 in the MMSE test. In both cases, the score is situated below the normative level. We notice a very low score for the Test TMA-93 which would evoke an important disorder in the associative memory and could drive us to a dementia suspicion. However, we note that several errors may have a link with possible associations that Patient 2 could have made with the images proposed in this test. The score of the MMSE test also shows a low performance in the words recall task.
RESULTS ANALYSIS 3/4 Patient 3 obtains a score of 21/30 in the TMA-93 and 25/30 in the MMSE. For the TMA-93, it is necessary to consider that the first couple of images (Tree - Bird) were not recognized by the patient and this influenced the recall phase Besides, the first naming phase of this test indicated another error of naming on page 7 (Glasses - Book) where Patient 3 saw a mezzanine bed with a ladder instead of a book. Therefore, we shall question the relevance of the score for this test, especially as the global score of the MMSE in dialectal Arabic version shows good performances in the various categories evaluated by the test.
RESULTS ANALYSIS 4/4 Patient 4 obtains a score of 5/30 in the TMA-93 and 27/30 in the MMSE. The very low score for the TMA-93 would evoke an important disorder in the associative memory and could direct to a dementia suspicion. However, Patient 4 obtains a very good result in the dialectal Arabic version of MMSE. The results from the TMA-93 test show a certain mode of apprehension of the test by Patient 4. The patient mainly considered the test as a reflection task rather than a memory one. We understand that Patient 4 did not try to remember the images associations but rather proposed associations that seemed relevant to him. For the first round of the test, we notice that most of the patient s answers are not part of the test material (shepherd, man, human being). For the second and the third round of the test, there are many errors but the names proposed are part of the test material. It seems that the patient integrated in the second and third round that the answer he had to give had to be part of the images he saw in the first naming task of the test.
Several biases which can be linked to cultural differences. Several conceptual biases are identified > For Patient 1, knowing the current year does not seem to be a necessity. > For Patient 2, knowing the current season is not based on the day and month but on agricultural and farming observations. > The 4 patients did not mention the region and department. Moreover, item biases were also present, particularly for the sentence to be repeated. > «No ifs, ands or buts» became : «Laa illaa walaa wa». For two participants, this sentence was vocally similar to the Muslim profession of faith ("Shahada") which they automatically repeated instead of the sentence. Method biases GENERAL CONCLUSION FOR MMSE TEST > 3 of the 4 patients where not able to draw the figure > 2 of them refused to throw a piece of paper on the floor (invoking knowledge respect) Therefore, even translated in patient s language, MMSE does not seem relevant for the evaluation of the elderly immigrants. We also noted that several languages were used during the assessments. Several MMSE translated versions exist but in all cases, only one language can be used during the test administration. So, MMSE test is not adapted for multilingual situations.
GENERAL CONCLUSION FOR TMA-93 TEST For the TMA-93 test, our research did not identify conceptual biases that would involve that the test tries to evaluate concepts that do not exist in the studied cultural groups. We however noted several method biases which we believe can be linked to associations, considered wrong, but which may make sense with respect to the patients cultural background. The choice of the images used in the material of this test can be questioned. Item biases were also identified, in particular on page 7 where the book was not recognized by any of our patients. Such observation could be linked to the participants being illiterate but this should be further investigated. So, it seems to us that the TMA-93 test is more adapted than the MMSE for cognitive assessment of elderly from minority groups. We believe however that an update of the test material would be necessary to avoid association considered as wrong while they may make sense for the participant. On the practical aspect, the TMA-93 test administration seemed easier to us compared to MMSE.
Conclusion 1/2 For elderly from minority groups in France, access to memory evaluation centers is still an issue. To overcome this situation, our research showed that new tools such as the TMA-93 are an interesting first step but some item and method biases still need to be handled. For elderly from minority groups, a cognitive evaluation can be compared to a cross-cultural meeting between an individual and a professional who can both belong to culturally different groups and this can influence the evaluation and its result. A translator can also be part of this meeting, eventually adding a third cultural background. Adapting a test for a specific population often consists in its translation. But beyond the translation, the evaluation conditions themselves are also culturally influenced. Our research also showed that professionals need to consider their own subjectivity when analyzing the evaluation results.
Conclusion 2/2 Our research showed that several languages were used by the patients during the evaluations. Beyond the cognitive assessment, recent researches in the linguistic domain open the way to new possibilities as they highlighted that patients with Alzheimer Disease experience quantitative and qualitative limitation of their linguistic skills before the memory ones. Therefore, assessing language skills would enable a new type of evaluation for dementia diagnosis. We think that this orientation will be interesting for elderly individuals involved in cross-cultural environments and who may speak several languages. Therefore, we plan to pursue our research by defining a diagnosis protocol for elderly from minority groups which would involve analyzing patients discourses.
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