Neuropsychological assessment in the multicultural memory clinic: Development and feasibility of the TULIPA battery

Figures & data

Table 1. Neuropsychological and achievement tests in the TULIPA test battery.

Core battery	Cognitive domain	Description	Approximate administration time
RUDAS	General cognitive functioning	Screening test measuring global cognition by assessing memory, body orientation, praxis, drawing, judgment, and language	20 min
CCD Objects test (subtest A & B)	Memory	Immediate and delayed recognition of photographs presented in a grid alongside distractors	30 min (full CCD)
CCD Sun Moon subtest A	Mental speed & attention	Sequentially name suns and moons printed on paper; score based on time corrected for errors
CCD Sun Moon subtest B	Executive functioning	Sequentially name antonym for printed suns and moons (i.e. sun = moon); score based on time corrected for errors
CCD Dots subtest A	Mental speed & attention	Connect rectangles containing an increasing number of dots in increasing order with a pencil
CCD Dots subtest B	Executive functioning	Similar to A, but patients need to switch between black and white items
Animal and foods fluency	Language & executive functioning	Patients name as many animals and edible things in 1 minute	2 min
Modified Visual Association Test	Memory	Patients are required to remember visually presented stimuli that are not usually associated with the stimulus they are paired with	5–10 min
Supplementary tests
Literacy screener total	Reading/writing	Screening tool that examines academic achievement through the assessment of phonological awareness, receptive language abilities, and language production	5–10 min
Five Digit Test Reading	Mental speed & attention	Requires patients to name a series of 50 printed digits (digits between 1–5)	10 min (full FDT)
Five Digit Test Counting	Mental speed & attention	Requires patients to count a series of 50 printed asterisks (number of asterisks per square between 1–5)
Five Digit Test Choosing	Executive functioning	Requires patients to count an incongruent number of digits, e.g. three fives
Five Digit Test Shifting	Executive functioning	Similar to Choosing, but switch to reading instead of counting if item is highlighted
Stroop Cards 1, 3, 4 (Turkish)	Mental speed & attention	Read colors printed in black (1); name colored dots (3); name color of neutral, non-color words printed in color (4)	10 min (full Stroop)
Stroop Cards 2, 5 (Turkish)	Executive functioning	Read words printed in an incongruent color (2); name the color of incongruent color-words (5)
Recall of Pictures Test—naming	Language	Naming of 10 items presented as colored line drawings	1 min
Recall of Pictures Test—memory	Memory	Incidental, immediate, and delayed recall, as well as recognition, of 10 colored line drawings	15 min (incl. delay)
Corsi Block Tapping Test	Working memory	Reproduce block-tapping sequences of increasing length; includes a forward and backward condition	5–10 min
Coin in the Hand Test	Performance validity	10-item performance validity test in which patient has to remember in which hand a coin is placed while performing a mock distraction task	5 min
Stick Design Test	Visuospatial & construction	Copying of a matchstick configuration with four matches	5 min
Clock Reading Test	Visuospatial & construction	Read the time on 12 clock faces without numbers	5 min
Naming Assessment in Multicultural Europe	Language	Naming of 60 colored photographs	5–20 min

Table 2. Demographic characteristics of the full sample^a.

	Rotterdam 1 (n = 177)	Rotterdam 2 (n = 22)	Enschede (n = 48)	The Hague (n = 98)
Age	66.6 (12.6)	70.3 (9.7)	69.7 (9.3)	74.0 (7.6)
Education n(%):	42 (24%)	0 (0%)	16 (33%)	29 (30%)
Zero years of education
>0 but < completed primary education	30 (17%)	6 (27%)	7 (15%)	22 (22%)
Primary education	33 (19%)	5 (23%)	13 (27%)	26 (27%)
Higher than primary education	70 (41%)	11 (50%)	12 (25%)	21 (21%)
Sex (n(%) male)	83 (47%)	12 (55%)	20 (42%)	38 (39%)
Years in the Netherlands	37.6 (14.0)	28.6 (16.3)	34.2 (15.3)	39.7 (12.8)
RUDAS^b	21.8 (5.1; n = 148)	21.2 (5.8; n = 17)	20.2 (6.2; n = 41)	19.2 (6.1; n = 75)
Number of core tests administered^c	6.0 (5.0–7.0)	7.0 (6.0–7.0)	7.0 (5.0–7.0)	6.0 (3.0–7.0)
Supplementary tests administered^c	2.0 (1.0–4.0)	2.0 (1.8–3.0)	1.0 (1.0–2.0)	0.0 (0.0–1.0)
Interpreters
Formal interpreter present (%)	148 (84%)	22 (100%)	0 (0%)	6 (6%)
Informal interpreter present (%)	7 (4%)	0 (0%)	42 (88%)	52 (55%)
No interpreter present (%)	22 (12%)	0 (0%)	6 (12%)	40 (41%)
Diagnosis n(%)
Subjective cognitive impairment	36 (20%)	5 (23%)	7 (15%)	12 (12%)
Mild cognitive impairment	21 (12%)	6 (28%)	3 (6%)	14 (14%)
Dementia	44 (25%)	7 (32%)	12 (25%)	49 (50%)
Psychiatric disorder	40 (23%)	3 (14%)	16 (33%)	9 (9%)
Cognitive disorder due to other known medical condition	11 (6%)	0 (0%)	3 (6%)	2 (2%)
Could not be determined	23 (14%)	0 (0%)	7 (15%)	12 (12%)

RUDAS = Rowland Universal Dementia Assessment Scale.

Values are displayed as mean (standard deviation) unless otherwise specified.

a A number of cases are missing for education and years in the Netherlands because patients were asked but were unable to report it.

b The maximum score for the RUDAS is 30, with a cut-off score of <22 in culturally, educationally, and linguistically diverse populations in the Netherlands.

c Median (first quartile-third quartile).

Table 3. Number of times TULIPA tests were administered and subsequently not completed.

	Administered (of n = 345)	Not completed (%)
Core battery RUDAS	290 (84%)	6 (2%)
CCD Objects test A	298 (86%)	7 (2%)
CCD Objects test B	284 (82%)	10 (4%)
CCD Sun Moon test A	290 (84%)	8 (3%)
CCD Sun Moon test B	281 (81%)	34 (12%)
CCD Dots test A	275 (80%)	49 (18%)
CCD Dots test B	230 (67%)	97 (42%)
Animal fluency	295 (86%)	2 (1%)
Food fluency; supermarket fluency^a	186; 35 (54%; 10%)	0 (0%)
Modified Visual Association Test (short or long)	227 (66%)	3 (1%)
Supplementary tests
Literacy screener total	71 (21%)	1 (1%)
Five Digit Test Reading and Counting	51; 51 (15%)	0 (0%)
Five Digit Test Choosing and Shifting	50; 39 (14%; 11%)	1; 4 (2%–10%)
Turkish Stroop Cards 1; 3; 4 (Attention/speed)	17; 17; 17 (5%)	0; 0; 1 (0%–6%)
Turkish Stroop Cards 2; 5 (Executive)	17; 16 (5%)	0; 0 (0%)
Recall of Pictures Test—naming subtest	90 (26%)	0 (0%)
Recall of Pictures Test—memory subtests	86 (25%)	0 (0%)
Corsi Block Tapping Test	66 (19%)	0 (0%)
Coin in the Hand Test	112 (32%)	3 (3%)
Stick Design Test	72 (21%)	2 (1%)
Clock Reading Test	85 (25%)	7 (8%)
Naming Assessment in Multicultural Europe	95 (28%)	3 (3%)

RUDAS = Rowland Universal Dementia Assessment Scale, CCD = Cross Cultural Dementia Screening.

a Supermarket fluency, which is traditionally recommended in the Netherlands for the assessment of low educated individuals, was administered in The Hague instead of food fluency in some cases.

Table 4. Presence of complicating factors in the assessments.

Complicating factor	Measure	Times observed (%)
Suboptimal effort/motivation	Suboptimal effort observed	92/314 (29%)
	Suboptimal effort on Coin-in-the-Hand	54/109 (50%)
	2–4 errors	31/109 (28%)
	≥5 errors (chance level and below)	23/109 (21%)
	Patient refuses to continue with testing	28/317 (9%)
Depression	Depressive symptoms observed during testing	98/262 (37%)
	Depression on GDS-15 (score ≥ 6)	138/243 (57%)
Anxiety	Anxiety observed/reported during testing	44/260 (17%)
Fatigue	Fatigue observed/reported during testing	103/317 (32%)
Pain	Pain observed/reported during testing	38/317 (12%)
	Other physical symptoms that hinder testing	19/317 (6%)
Motor impairment	Motor impairments that hinder testing	21/317 (7%)
Sensory impairment	Sensory impairments that hinder testing	41/317 (11%)