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
[email protected]
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
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.

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.
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.
GENERAL CONCLUSION FOR MMSE 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
> 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.
THANK YOU