Improving Cognitive Testing for Older Black Adults
As adults grow older, especially over age 50, their risk of dementia, Alzheimer’s disease and other degenerative brain conditions increases. However, the decline is gradual over the years with subtle changes in cognitive function not apparent in everyday life. This raises the importance of regular testing as part of standard primary care to provide a baseline of performance that can be used for later comparison.
However, studies have noted that Black adults may have a different experience with cognitive test taking. One study found that Black adults who report a higher level of perceived discrimination and stereotyping do not perform as well on neuropsychological batteries as their white peers. Another study notes that, “since older Blacks report testing anxiety and/or dissatisfying experiences completing the commonly utilized paper-and-pencil neuropsychological batteries, they may be less inclined to monitor their cognitive functioning with performance-based tasks. Thus, some individuals may overlook the early signs of cognitive impairment and delay seeking treatment until symptoms are severely influencing their everyday functioning.”
Study Design and Results
A group of American researchers who focus on aging issues sought to gather the opinions of Black, middle-age and older adults on both a traditional, paper-and-pencil neuropsychological test battery and two computerized cognitive batteries, including the Cogstate Brief Battery (CBB). Specifically, they had three study goals; to compare the overall satisfaction, anxiety and performance by this cohort on the traditional test with the two computerized test batteries. They hypothesized that the computerized batteries would deliver higher satisfaction and lower anxiety than the traditional test battery and that lower performance on that battery would be related to anxiety and sociodemographic characteristics (i.e. education, income, perceived discrimination, stigma consciousness, computer use and familiarity).
They recruited 112 Black adults (age 55+) from the Tampa Bay area for two visits, first to screen for any dementia or depression symptoms. This left 95 eligible participants who came back for a three-hour visit to complete a standard neuropsychological paper-and-pencil test battery that took between 80 and 100 minutes, and then two computerized tests, the CBB and the Joggle Research Battery. In stark contrast to the traditional test, the two computerized tests took only fifteen minutes each. After completing the tests, each participant took a survey asking questions about their satisfaction and anxiety in taking each of the three tests.
In the original 2018 report, published in the Journal of Gerontology, the biggest takeaway was that both computerized batteries scored higher in satisfaction than the paper-and-pencil battery, with CBB rating highly on user satisfaction, ease of use and the ability to self-administer. In addition, the traditional battery caused a significantly higher level of anxiety during the test taking than the CBB and Joggle.
Regarding performance across the three domains, the study team reported partial support for their expectations. “Although these results did not fully support our hypothesis that testing anxiety, sociodemographic, and health conditions would be mainly and more strongly associated with the neuropsychological battery, we did observe that accounting for these factors explains much more of the variance in Neuropsychological (58%) battery performance than in computer-based battery (Joggle: 27%; CogState: 19%) performance.”
In addition to the rating questions on the survey, the participants were also given the opportunity to answer three open-ended questions about the two computerized batteries and the traditional battery.
- “What were some things you liked about the CBB/Joggle program/neuropsychological test?”
- “What were some things you did not like (disliked) about the CBB/Joggle/neuropsychological tests?”
- “What suggestions do you have to improve the CBB/Joggle/neuropsychological tests?”
Their answers were grouped into themes using a mixed methods content analysis approach as detailed in a subsequent 2020 paper, in the journal Aging, Neuropsychology and Cognition. Regarding what participants liked about the tests, several themes emerged, including that they liked the mental stimulation, the challenge, a specific task element, the fun, new learning experience, and a feeling of personal competence that they could complete the tests.
For what they did not like, the group responded with three issues; a concern about their ability to do well (the anxiety brought up earlier), a personal issue with the design of the tests, and finally the amount of time, some feeling there was not enough time to finish a task while others mentioned the total time was too long. But the most common response to this question of dislikes was “nothing”, indicating their overall positive experience.
Finally, when asked about possible improvements, the most common response was “nothing” with a few respondents mentioning the time required or the design.
Overall, across both papers, this group of Black adults reported a preference for the computerized test batteries, including the Cogstate Brief Battery.
“This study observed that while older Black adults had positive views about all three test batteries, they tended to report more positive feedback for the more interactive computerized test batteries than the traditional neuropsychological battery,” wrote the authors. “This is important given the need to identify measures that appeal to older Blacks and will increase their use of cognitive tests to detect cognitive decline and impairment…Our study supports that using computer-based batteries may be an effective approach to increasing older Blacks willingness to monitor their cognitive status.”