Diagnostic memory assessment in Italian-born Australians.
ABSTRACT In many English-speaking countries neuropsychological assessment of non-English speakers is often performed in English or through an interpreter. Relying on interpreters often involves unstandardized and ad hoc translations of tests which may limit valid assessment.
In a sample of 75 Italian-born elderly Australians from the general community (48 women and 27 men, aged 56-90 years) we administered standardized and normed psychological tests in both English (WMS-III, WAIS-III, BNT, Schonell Graded Word Reading Test) and Italian (Milan Overall Dementia Assessment, MODA). We examined the hypothesis that long-term retrieval ability assessed in English is primarily influenced by cognitive abilities assessed in Italian and by English language competence.
Regression analysis showed that the strongest predictor of long-term retrieval in English was long-term retrieval in Italian (R2 = 0.229, F(72) = 29.12, p<0.01). After inclusion of an estimate of general cognitive ability in Italian, English language competence failed to add significantly to variance explained in memory tested in English (p > 0.05).
Results of the present study support the view that long-term retrieval memory is not significantly affected by second language proficiency after control of cognitive ability assessed in Italian. As a consequence, if an Italian-born elder Australian with English as a second language scores poorly on a diagnostic memory test, this result may be due to cognitive impairment rather than language issues. If, instead, we attribute poor performance to language competence, an increased risk of false negative diagnosis may arise.
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ABSTRACT: The aim of this review is to update clinicians and researchers regarding neuropsychological tools that have been normed in Greece, thereby assisting them to improve diagnostic accuracy when undertaking neuropsychological assessment of Greek-speaking individuals. A growing number of neuropsychological tests of cognition have been normed in the healthy Greek adult population and the findings reported in the English-language literature. Neuropsychological Greek normative studies have revealed performance differences in Greek speakers. In general, research findings indicate that population-specific norms are required for accurate neuropsychological assessment of the Greek adult population. Validating neuropsychological tests of cognition in healthy Greek adults improves clinicians' and researchers' ability to accurately assess, diagnose and manage Greek individuals with cognitive disorders. Normative studies in Greek-speaking clinical populations and studies examining performance differences between native Greek speakers and the Greek diaspora are directions for future research.Current opinion in psychiatry 03/2010; 23(3):261-6. · 3.57 Impact Factor
- Australian Psychologist - AUST PSYCHOL. 01/2009; 44(4):216-223.
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ABSTRACT: Clinical neuropsychology has frequently considered visuospatial and non-verbal tests to be culturally and educationally fair or at least fairer than verbal tests. This paper reviews the cross-cultural differences in performance on visuoperceptual and visuoconstructional ability tasks and analyzes the impact of education and culture on non-verbal neuropsychological measurements. This paper compares: (1) non-verbal test performance among groups with different educational levels, and the same cultural background (inter-education intra-culture comparison); (2) the test performance among groups with the same educational level and different cultural backgrounds (intra-education inter-culture comparisons). Several studies have demonstrated a strong association between educational level and performance on common non-verbal neuropsychological tests. When neuropsychological test performance in different cultural groups is compared, significant differences are evident. Performance on non-verbal tests such as copying figures, drawing maps or listening to tones can be significantly influenced by the individual's culture. Arguments against the use of some current neuropsychological non-verbal instruments, procedures, and norms in the assessment of diverse educational and cultural groups are discussed and possible solutions to this problem are presented.Brain and Cognition 09/2003; 52(3):326-33. · 2.82 Impact Factor
International Psychogeriatrics (2011), 23:7, 1133–1143 C ?International Psychogeriatric Association 2011
Diagnostic memory assessment in Italian-born Australians
Sara Fratti,1Stephen C. Bowden1and Olimpia Pino2
1Department of Psychological Sciences, The University of Melbourne, Parkville, Victoria, Australia
2Department of Psychology, University of Parma, Parma, Italy
Background: In many English-speaking countries neuropsychological assessment of non-English speakers is
often performed in English or through an interpreter. Relying on interpreters often involves unstandardized
and ad hoc translations of tests which may limit valid assessment.
Methods: In a sample of 75 Italian-born elderly Australians from the general community (48 women and
27 men, aged 56–90 years) we administered standardized and normed psychological tests in both English
(WMS-III, WAIS-III, BNT, Schonell Graded Word Reading Test) and Italian (Milan Overall Dementia
Assessment, MODA). We examined the hypothesis that long-term retrieval ability assessed in English is
primarily influenced by cognitive abilities assessed in Italian and by English language competence.
Results: Regression analysis showed that the strongest predictor of long-term retrieval in English was long-term
retrieval in Italian (R2= 0.229, F(72) = 29.12, p<0.01). After inclusion of an estimate of general cognitive
ability in Italian, English language competence failed to add significantly to variance explained in memory
tested in English (p > 0.05).
Conclusions: Results of the present study support the view that long-term retrieval memory is not significantly
affected by second language proficiency after control of cognitive ability assessed in Italian. As a consequence,
if an Italian-born elder Australian with English as a second language scores poorly on a diagnostic memory
test, this result may be due to cognitive impairment rather than language issues. If, instead, we attribute poor
performance to language competence, an increased risk of false negative diagnosis may arise.
Key words: cross-cultural neuropsychology, dementia diagnosis, memory assessment, English as a second language
A primary role of clinical neuropsychological
assessment includes the evaluation of cognitive
functioning. Extensive analysis of diverse cognitive
ability batteries shows that the Carrol-Horn-
Cattel (CHC) model of cognition is the most
comprehensive theoretical approach to diagnostic
screening in clinical and non-clinical populations
(Flanagan and Harrison, 2005; McGrew, 2005;
2009). Use of the CHC model is becoming
commonplace in psychological test construction
and interpretation because it is the best-supported
theorywithin the clinical
tradition (McGrew, 2005; 2009; Lichtenberger and
Debate continues about the details of the
model and the trade-off between comprehensive
Psychological Sciences, The University of Melbourne, Parkville, Victoria,
3010, Australia. Phone: +62 03 8344 6354; Fax: +62 03 9347 6618. Email:
firstname.lastname@example.org. Received 30 Nov 2010; revision requested 4 Jan 2011;
revised version received 28 Jan 2011; accepted 30 Jan 2011. First published
online 22 March 2011.
shouldbe addressedto: SaraFratti, Departmentof
assessment and cost-effective screening assessment
(Bowden et al., 2008a; Gottfredson and Saklofske,
2009). Core abilities in the CHC model include
working memory, long-term retrieval, thinking or
problem-solving abilities, acquired knowledge and
processing speed (McGrew, 2009). These core
abilities closely correspond to the six-factor model
internationally, with the addition that long-term
retrieval is divided into material-specific memory
abilities (Flanagan and Harrison, 2005; Bowden
et al., 2008a, 2008b).
In the CHC model, long-term retrieval is the
ability to store information over extended periods
of time, and fluently recall the information later
(McGrew, 2009). Deficits of anterograde memory,
a clinical synonym for long-term retrieval, are
often found in people with a wide range of
neurological conditions (Lishman, 1998). Although
it is well established that long-term retrieval
performance (e.g. recall or recognition of recently
acquired information) deteriorates across the adult
S. Fratti et al.
semantic “memory” performance or crystallized
intelligence in the CHC model (e.g. recall or
recognition of overlearned general knowledge)
shows relatively little aging-related variation (see
Salthouse, 1991). The cognitive literature suggests
that tests assessing retrieval of semantic or general
knowledge show less age-related deterioration. In
standardized batteries, like the Wechsler Scales
evaluated with tests of general knowledge (e.g.
Vocabulary, Comprehension). In most brief mental
status tests, assessment of long-term retrieval
and crystallized intelligence is confounded and
effective normative comparisons are impractical if
the clinician follows the standard instructions and
interprets performance in terms of available norms
(see Holsinger et al., 2007).
An accurate assessment of long-term retrieval or
anterograde memory function is desirable for early
detection and targeted interventions in cognitive
decline. Most psychological tests, which articulate
these constructs, are developed and standardized
within the context of Western culture, especially in
North America and Western Europe (Nell, 2000).
In Australia, a neuropsychological assessment is
usually performed in English. Yet, Australia has
a strong history of migration, especially since
the Second World War. In 2006 approximately
24% of Australian residents were born overseas,
with one-third of people aged over 60 speaking a
language other than English at home (Australian
Bureau of Statistics, 2007). As a consequence, the
evaluation of cognitive abilities in people from non-
English speaking backgrounds is often performed
through an interpreter with ad hoc translation of
the cognitive assessment items.
interpreters presents additional problems (Artiola
i Fortuny and Mullaney, 1998; Artiola i Fortuny
et al., 1998; Artiola i Fortuny and Ricker, 2004;
Attix and Welsh-Bohmer, 2006). First, use of an
interpreter assumes that tests items are equivalent
This practice neglects cultural idiosyncrasies and
differences in item difficulties (e.g. word frequency
or relevance). Secondly, use of an interpreter with
ad hoc translation reduces access to ipsative or
normative control statistics, which are fundamental
to valid assessment (American Psychological As-
sociation, 1999; Australian Psychological Society,
2007). Thirdly, interpreters may detract from
accurate assessment due to lack of objectivity, for
example, when relying on a family member.
Various approaches have been proposed to
remove the language component from cognitive
assessment when assessing people with English as
span, thereis convergingevidencethat
a second language and provide a culture-fair testing
approach (Rosselli and Ardila, 2003). However,
these approaches, for example using non-verbal
tests for cognitive assessment, may not eliminate
cultural bias and may not provide comprehensive
information (Rosselli and Ardila, 2003).
Walker and colleagues (2009; 2010) reviewed the
effects of cultural background and education on
the Wechsler Scales, finding the expected tendency
for poorer performance in individuals with English
as a second language, and in individuals from
more diverse cultural backgrounds, when compared
to people from English-speaking backgrounds.
Australian studies support these results (LoGiudice
some authors recommend the development of
language-specific normed tests in order to avoid
risks of diagnostic false-positives (Plitas et al., 2009;
Plitas and Pliakiotis, 2010). However, development
of language-specific normed tests is expensive and
The Italian-Australian community is the third
largest ethnic group in Australia, numbering about
200,000 persons who were born in Italy. The
greatest concentration (41.5%) lives in Victoria
(Australian Bureau of Statistics, 2007). As reported
in the 2006 Census,
(81.4%) of Italian-born Australian residents speak
Italian at home. Among these people, the ability
to speak English is described as “not well” or
“not applicable” by 21% and 18% of the sample,
respectively (Australian Bureau of Statistics, 2007).
The rate of immigration from Italy has dropped
significantly since the 1970s, and thus the Italian-
born population is aging with 63% being 60
years or older at the time of the 2006 Census.
These data are notable in view of the increasing
number of Australians expected to have dementia
in the future (Alzheimer’s Australia, 2003). Ethnic
minorities with English as a second language will
constitute a significant proportion of those in need
of dementia diagnosis and care. Since the Italian-
born population in Melbourne will include people
at risk of dementia in the foreseeable future, this
study sought to evaluate the validity of normed
psychological tests in both English and Italian.
Specifically, the aims of the present study were
(1) to explore normative comparisons of cognitive
performance in English and Italian in order to
evaluate discrepancies in diagnostic inferences, (2)
to examine the study variables for fit with respect
to the CHC model of cognitive ability, and (3) to
investigate whether memory and broader cognitive
assessment in Italian, or English competence,
predict memory performance in English. In line
with previous research, it was hypothesized that our
sample would perform better on tests of long-term
Diagnostic memory assessment in Italian-born Australians
Table 1. Demographic variables collected during the general interview (descriptives in Section A), and
frequencies and percentages of the study sample characteristics (Section B).
(N = 75)
MALES (N = 27)
FEMALES (N = 48)
Age 71.0 (6.7)56–90
Years in Italy 24.5 (7.0)13–45
Years in Australia46.6 (6.6) 31–74
Years of education (Italy)5.4 (2.8)0.25–13
Years of education (Australia)0.4 (1.2)0–8
Years of education (Total)5.7(3.33)0.25–19
(N = 75)
MALES (N = 27)
FEMALES (N = 48)
Language spoken at home
Relatives in Italy
Type of job
Factory worker 17 22.7
Tailor/machinist 24 32
retrieval when using their native language than
when using English, and that English competence
would predict memory performance when assessed
in English, in addition to cognitive status when
assessed in Italian.
Setting and participants
Seventy-five Italian-born healthy volunteers –
48womenand 27 men–participated in
the study. Demographic characteristics of the
sample are shown in Table 1. The study was
approved by the University of Melbourne HREC
and the recruitment was made possible with
the generous assistance of staff at CO.AS.IT
(Comitato Assistenza Italiani – Italian Association
for Italians and Australians of Italian descent. The
Senior Citizens Clubs in the Melbourne area. The
inclusion criteria for participation were: (1) being
born in Italy, and (2) being an Australian resident.
S. Fratti et al.
The neuropsychological assessments were conduc-
ted on an individual basis at a time convenient
to the participant during their respective Citizens
Club hours. Each Club provided a quiet, private
room for the interview and testing, which lasted
approximately one hour for each participant.
The interview and assessment consisted of three
sections: (a) a general interview for collecting
demographic data; (b) the administration of two
long-term retrieval tests, one in English and
one in Italian; (c) additional neuropsychological
language competence assessment. English and
Italian memory assessments were presented in
was performed using the participant’s preferred
language. All participants chose to be interviewed
in Italian. The results are shown in Table 1.
ENGLISH MEMORY ASSESSMENT
Word List, Wechsler Memory Scale – Third Edition
(WMS-III). Long-term retrieval in English was
evaluated using the WMS-III Word List subtest
(Wechsler, 1997b). In this test the participant is
asked to recall a list of 12 common concrete nouns
repeated over several trials in immediate succession.
Word list learning is considered as one of the more
sensitive clinical memory tests with a better signal
to noise ratio in the form provided with the WMS-
III (Wechsler, 1997b). The total score from the
learning trials was used as the measure of long-
term retrieval in English for normative comparison,
and the sum of immediate and delayed recall (sum
of Word Lists I and II) was used in the regression
ITALIAN MEMORY ASSESSMENT
Milan Overall Dementia Assessment (MODA). The
MODA is an Italian cognitive screening for
dementia (Brazzelli et al., 1994) developed as
an Italian alternative to the Mini-Mental State
Examination (MMSE; Folstein et al., 1975).
Compared to the MMSE, the MODA is a more
detailed test of cognitive performance, aimed
at evaluating the neuropsychological features of
Alzheimer’s disease (AD) (Cossa et al., 1999;
Spinnler, 1999). The MODA is used either in
parallel or as an alternative to the MMSE (Cossa
et al., 1997; Cazzaniga et al., 2003; Bianchi and
Dai Pr` a, 2008; Parnetti et al., 2008; Ambron
et al., 2009). The MODA consists of three sections:
a caregiver support scale, a test of orientation
and a neuropsychological section. All the tests
included in the neuropsychological section of
the MODA are drawn from an Italian series of
neuropsychological tests used in clinical practice
(Spinnler and Tognoni, 1987). The total score for
the whole test ranges from 0 to 100 (age-adjusted
scores cut-offs: > 89.0 = “not impaired”, 85.5 to
89.0 = “borderline” and < 85.5 = “impaired”).
Like most screening test summary scores, the
abilities. The MODA normative data provided in
the test manual (Brazzelli et al., 1994) are based
on an age- and education- stratified sample of 217
people from the general community aged between
20 and 97 years (M = 60.8, SD = 18.5), with a
mean education of 9.1 years (SD = 4.9, range =
1–17). The test manual reports a retest reliability
of 0.83 based on the MODA total score. Effects
of age, gender and education on the MODA total
score were investigated and only age and education
were found to be significant. Adjusted scores are
provided in the test manual.
For the purpose of the current research,
we administered the MODA neuropsychological
manual, assesses the following domains: attention
intelligence (logical reasoning), verbal memory
(prose memory), language (token test, categorical
fluency), visuo-spatial cognition (finger agnosia,
constructional apraxia/figure copy), and visual
perception (figure completion; Brazzelli et al.,
1994). The MODA Prose Memory subtest was
chosen as our study measure of long-term retrieval
and consists of a story paragraph that has to be
recalled immediately after presentation. Although
the MODA Prose Memory score range is 0–8
according to the manual, we also used a revised
method of scoring (range 0–22), adopting a “per
unit” scoring system (i.e. similar to WMS-III
Logical Memory subtest: Wechsler, 1997b; see
Appendix). The test manual does not provide
separate norms for each subtest but for the overall
neuropsychological test section only. Therefore, the
MODA neuropsychological total score was used
for normative comparisons, and the more discrete,
Prose Memory revised scoring (out of 22) was used
for latent-structure and regression analysis.
ENGLISH COMPETENCE ASSESSMENT
According to Carroll’s (1993) seminal work on
the structure of cognitive abilities, language can
be regarded as a unitary ability, with an increasing
differentiation of skills and competencies seen in
the individuals’ native or second language. Some of
Diagnostic memory assessment in Italian-born Australians
these language traits are included under the CHC’s
broad ability of Acquired Knowledge (Gc). For
example, Lexical Knowledge (VL) is the extent
of a person’s vocabulary (i.e. semantic meanings
of words), while Language Development (LD)
is the general development and application of
words, sentences, and paragraphs (not requiring
reading) used to communicate a thought or feeling
(see Institute for Applied Psychometrics, 2003, for
comprehensive definitions). An individual’s Foreign
Language Proficiency (KL) is also classified under
Gc and according to Carroll’s analysis (1993) it is
language. Carroll’s operational definitions and the
CHC model provide a theoretical justification for
choosing the following tests as a measure of English
Boston Naming Test – Second Edition (BNT).
The BNT (Kaplan et al., 2001) is a well-
known confrontation-naming test. Naming ability
is essential for successful communication and
several cognitive skills, such as semantic, lexical
and phonological processing (Gollan et al., 2007).
Worrall and colleagues (1995) developed the BNT
normative data for the Australian elder population,
suggesting that the Australian adaptation reduced
cultural bias. The Australian norms did not include
ethnic minorities. However, the BNT has been
widely used in bilingual samples (Moreno and
shows that bilinguals have more difficulty retrieving
words than monolinguals and name fewer pictures
correctly on standardized naming tests such as the
BNT (Roberts et al., 2002).
Schonell Graded Word Reading Test. The Schonell
Reading Test (Schonell and Schonell, 1960) is
composed of 100 words (both regular and irregular)
in order of increasing difficulty, with a score range
from 0 to 100. The Schonell Reading Test is used
commonly as a screening test for reading ability and
was used here as a second English competence test.
Vocabulary subtest, Wechsler Adult Intelligence
Scale – Third Edition (WAIS-III). The Vocabulary
subtest (Wechsler, 1997a) is a measure of word
knowledge where the examinee is requested to give
verbal definitions for different words of increasing
All the above tests were administered according
to the standard instructions.
Analyses were carried out using Statistical Package
for the Social Sciences (SPSS, Version 18) and
included: (a) a descriptive analysis of demographic
data, (b) two-tailed t-tests and measures of
effect size to compare mean performance on the
English and Italian long-term retrieval measures,
and (c) stepwise multiple regression analyses
which were generated to test the influence of
English language proficiency on long-term retrieval
performance. A maximum likelihood confirmatory
factor analysis (CFA) was conducted on the
MODA neuropsychological subtests together with
the memory and English competence variables to
explore the latent-ability structure in line with the
CHC model. This CFA was analyzed using Mplus
5.1 (Muth´ en and Muth´ en, 2008).
A total of 75 participants took part in the study.
These comprised 27 males and 48 females with a
mean age of 70.9 years (SD 6.7 years; range 56–
90 years). Details regarding age, place of birth,
citizenship, level of education, past occupation,
nationality of the spouse or partner, preferred
language at home, number of years lived in Italy
and Australia are shown in Table 1.
English competence and long-term retrieval
The raw score means and standard deviations
(SD) for the cognitive variables used in the study
are shown in Table 2. Because the English and
Italian tests have a different number of items
and different means, comparison of raw score
means is uninformative. Instead, z-scores were
calculated based on the published, age-corrected
norms from the English language memory test and
the overall battery score in Italian. The mean z-
intervals (CI) for the WMS-III Word List and
the MODA Neuropsychological Total Score were
respectively Z = −1.55 (SD = 0.96; 95% CI:
−1.77, −1.32) and Z = −1.40 (SD = 1.28;
95% CI: −1.70, −1.11). A matched-samples t-
test comparing the z-scores on the WMS-III Word
List to the MODA Neuropsychological Total Score
produced a statistically non-significant result and
small effect (t(73) = 1.006, p = 0.318, Cohen’s d =
0.11). As a consequence, we retained the hypothesis
of no difference between the available normative
scores on the long-term retrieval test assessed in
English and the overall neuropsychological battery
score in Italian.
In terms of normative comparisons for cognitive
performance assessed in Italian, based on the
MODA Neuropsychological Total Score, 27% of
the sample obtained a score less than or equal to
−2 SD. When memory performance was assessed in
English, on the WMS-III Immediate list score, 44%
S. Fratti et al.
Table 2. Raw score means and standard deviations
for the cognitive variables in the study sample (N =
WMS-III Word List
(Max. 48 points)
MODA Prose Memory
(Max. 8 points)
MODA Prose Memory (revised scoring)
(Max. 22 points)
MODA Reversal Learning
(Max. 5 points)
MODA Digit Cancellation Test
(Max. 10 points)
MODA Verbal Intelligence
(Max. 6 points)
MODA Categorical Fluency
(Max. 5 points)
MODA Token Test
(Max. 5 points)
MODA Finger Agnosia
(Max. 5 points)
MODA Constructional Apraxia
(Max. 3 points)
MODA Figure Completion
(Max 3 points)
(Max. 50 points)
(Max. 66 points)
Boston Naming Test
(Max. 60 points)
(Max. 100 points)
of the sample was at −2 SD or below. Normative
comparisons with the MODA memory scores are
precluded because there are no separate norms
for the MODA subtests. All the participants in
the study performed less than or equal to the
10th percentile on the BNT, while 37% of the
sample scored at −2 SD or below on the WAIS-III
Vocabulary test. Based on the Schonell scores, the
participants’ English reading ability was equivalent
to a reading age of 9.16 years (SD 2.7).
To test the hypothesis that the CHC model
provided the best description of the neuropsy-
chological measures, including the English and
Italian language memory tests, and the English
proficiency tests, a CFA was conducted contrasting
three models. In this and subsequent analyses, the
revised MODA prose recall score (out of 22) was
used as the Italian-language memory test score.
The first factor model examined was a one-factor
model representing all tests. The second was a
two-factor model contrasting (1) verbal ability and
verbal memory (Gc and Glr in the CHC model;
McGrew, 2009), versus (2) visuo-spatial thinking
abilities (Gv and Gf combined, i.e. similar to
the conceptual definition of what is often termed
The third model contrasted (1) verbal (Gc),
(2) visuo-spatial (Gv and Gf combined) and (3)
long-term retrieval abilities (Glr). In the three-
factor model, verbal ability was represented by
the WAIS-III Vocabulary, Schonell Reading Test,
Boston Naming Test and the MODA tests of
Verbal Intelligence, Categorical Fluency and Token
Test. The visuo-spatial thinking abilities factor
was represented by the MODA tests of Finger
Agnosia, Apraxia (figure copy), Reversal Learning
(i.e. a visuo-motor sequence similar to the go/ no-
go paradigm), and Cancellation. The long-term
retrieval factor was represented by the WMS-
III list learning total scores at immediate and
scoring) and a joint loading with the Cancellation
test. Variable groupings were decided based upon
the CHC Broad (stratum II) and Narrow (stratum
I) operational definitions (see Institute for Applied
Psychometrics, 2003 for a review).
Briefly, the results showed that both the one and
whereas the three factor model provided a fit to the
data (χ2[df = 73] = 65.7, p = 0.72; TLI = 1,
CFI = 1, RMSEA < 0.001; full details of the CFA
are available on request from the authors). In line
with the CHC model, this analysis supported the
theoretical distinction between long-term retrieval
versus verbal and visuo-spatial abilities, where the
first two abilities were assessed by tests in Italian
To test the influence of long-term retrieval ability
in Italian, and of English competence on the long-
term retrieval test in English, regression analyses
were used. Initially, two separate regression analyses
were conducted and the dependent variable in
both cases was the long-term retrieval measure in
English (sum of immediate and delayed WMS-III
Word list raw scores used to improve the signal
to noise ratio). In the first model the influence of
demographic variables was examined, including age
in years, gender (dummy coded), language spoken
at home (Italian/dialect, English, or both: dummy
coded), number of years of education completed in
Italy, number of years of education completed in
Australia, total number of years of education, and
number of years lived in Australia. Only age was a
significant predictor of the long-term retrieval score
in English (adjusted R2= 0.194, F(1,73) = 18.79,
p < 0.001).
In the second regression analysis, the independ-
ent variables were age, the scores on the MODA
Diagnostic memory assessment in Italian-born Australians
Table 3. Final model regression coefficients. The dependent variable was the Word List (WMS III)
Immediate and Delayed Composite.
MODA Prose Memory (revised
MODA Neuropsychological Total
(minus Prose Memory)
STD. ERROR OF b
Prose Memory, the MODA neuropsychological
composite (excluding the Prose Memory score),
and a composite English proficiency score derived
from the sum of the BNT, Schonell Reading
Test, and WAIS-III Vocabulary. In this analysis
the hypothesis tested was that memory and
general cognitive status tested in Italian, together
with English language competence would predict
scores on the MODA Prose Memory, and MODA
neuropsychological composite were entered into
the regression, all three variables were significant
predictors of memory in English, and the inclusion
of the English competence score did not provide
significant improvement to the regression equation
(p > 0.05). Nonlinear (quadratic) terms for all of
the significant linear predictors were also examined
for inclusion, and none was significant. Nor were
interactions between the linear terms significant.
A final regression model was formulated to
include age, the MODA Prose Memory and the
MODA neuropsychological composite. Overall this
model explained 45.2% of variance in the WMS-
III word lists (see Table 3 for a model summary).
The single best predictor for the WMS-III Word
Lists in this final model was the MODA Prose
Memory score explaining 22.9% of the variance.
Age explained 20.5% of variance and general
cognitive status assessed in Italian added a modest
4% of variance.
English for people from non-English speaking
backgrounds suggest that there is increased risk
of diagnostic errors due to linguistic and cultural
differences, when the assessment is conducted
without appropriate language-specific test norms
(Artiola i Fortuny and Ricker, 2004; Pedraza and
studies ofcognitive assessment in
recent studies on ethnic minorities supported this
view, emphasizing the importance of subgroup
differences and suggesting cautious interpretation
in relation to diagnosis of cognitive impairment
(Carstairs et al., 2006; Plitas et al., 2009).
In contrast, the results of the present study
suggest that memory performance of Italian-born
older Australians may be assessed in English
without disadvantage due to English competence.
When the influence of memory and general
cognitive status assessed in Italian was controlled,
English language competence did not contribute
to the prediction of memory assessed in English.
The statistically significant predictors of long-
term retrieval assessed in English included age
and aspects of cognitive function assessed in
Italian. When cognitive performance was assessed
using their first or second language, participants
available norms. This result was a little surprising
in view of the fact that all participants were
resident in the community. However, as noted
below, many of the participants displayed little
dementias, and the overall pattern of results may
further highlight the relatively high incidence of
unmet health and health-education needs in this
type of immigrant community. All participants
who expressed concerns about aging and health
were encouraged to access appropriate professional
services; however, the specific number who sought
this information was not recorded.
So far as we are aware this is the only
study conducted in Australia using measures of
cognitive assessment normed in both English and
the participants’ native language, respectively. Plitas
and colleagues (2009) for example, compared
only Greek language cognitive screening outcomes
between groups of Greek-Australians and Greek
nationals, while Cairstairs and colleagues (2006)
analyzed the impact of language background on
the cognitive performance of three subgroups of
S. Fratti et al.
subjects with different English proficiency levels,
relying solely on English-based cognitive tests.
The MODA norms are based on a sample of
Italians living in Italy and application to an
elderly immigrant community living in Australia
is also qualified by historical-cultural factors
(e.g. educational opportunities and exposure to
more contemporary Italian culture). However, the
opportunity to use a normed Italian scale has clear
advantages when compared to the common prag-
matic strategy, to “simply translate existing English-
language instruments and apply English-language
norms to the translated instruments, seemingly
unaware of the methodological nightmare that this
constitutes” (Artiola i Fortuny and Ricker, 2004,
Three main conclusions can be derived from
our study. First, the absolute level of memory
performance in English and overall dementia
screening score in Italian, in terms of z-scores was
similar, suggesting no significant discrepancy of
assessment outcome when our sample of Italian-
born Australians was assessed using either English
or Italian. The observed effect, in terms of Cohen’s
d (Cohen, 1988) is small (d = 0.11) and not
likely to be of any clinical significance. Secondly,
despite the administration of memory tests in two
different languages, namely English and Italian,
the memory test scores in our study sample fell
along one cognitive ability dimension, the well-
established latent variable of long-term retrieval,
while the measures of English proficiency (i.e.
BNT, WAIS-III Vocabulary and Schonell) fell
along an acquired knowledge dimension. On a
minor note, the factor assignment of Fluency
tasks is slightly ambiguous in the CHC model,
since this type of task has overlearned (Gc), fluid
(Gf) and speed components. However, inspection
of modification indices revealed no evidence to
indicate re-assignment of indicator scores to factors.
More importantly, the factor analysis was based
on a small sample, but the resulting three-factor
model conformed to the dimensions of the CHC
model reported from many different populations
with similar tests batteries (Tulsky and Price, 2003;
McGrew, 2009; Tuokko et al., 2009). Therefore,
it appears unlikely that an incorrect model was
accepted due to lack of statistical power. Thirdly,
and contrary to what was originally hypothesized,
the strongest predictors of memory in English
was memory and broader cognitive status assessed
in Italian, rather than English competence. As
expected, age was also a significant predictor of
long-term retrieval performance.
The overall conclusion to this study is that, in
the absence of the native language assessment for
older Italian-born Australians, we may be able to
place some confidence in the English assessment
of clinical memory performance, memory of the
type most commonly affected in degenerative
dementias. This conclusion is contrary to common
clinical cautions regarding the risk of false-positive
diagnosis in non-English speakers. This caution
needs to be balanced against the risks of false-
negative diagnosis, a risk that may arise if poor
cognitive performance in a non-English speaker is
attributed to language factors alone. Instead, the
current results suggest that if an older native Italian
speaker scores poorly on a memory assessment
performed in English it may be due to cognitive
impairment rather than English language issues and
should lead to further investigation.
It is also interesting to note that participants
in our sample had very limited opportunities to
acquire an adequate level of English. They also
had limited opportunities to develop other cognitive
skills enhanced through formal education, for
example, analytic thinking and reasoning abilities,
and familiarity with academic assessment and
testing situations. Typically, migration from Italy
to Australia after the Second World War was more
common from rural areas, particularly within the
southern regions, where rates of unemployment
and illiteracy where higher. Such was the extent of
emigration that some participants commented that
their rural village no longer existed.
Also, the types of occupations endorsed by
our sample seemed to have limited their potential
ability to develop occupational or English-speaking
community involvement in Australia. Women, for
example, were mainly involved in jobs requiring no
specific language expertise. Some of them spent
their lives as housewives with limited chances
to integrate within the Australian community
due to language barriers. As a consequence,
during their initial interview, the majority of
the study participants communicated using a
mix of Italian and dialect, presenting also some
evident lack of educational and culture-related
learning opportunities more readily available in
contemporary Italy to younger native Italian
speakers. Many of our participants reported that,
although the Australian government offered free
English courses at the time of their arrival, they
preferred not to participate because of fear of
“losing their traditions”. Interestingly, this scenario
is very similar to the one presented by Plitas and
colleagues (2009) in their community sample of
Greek-Australians and may be a common pattern
in immigrant communities (Artiola i Fortuny and
In contrast, the opportunity to undergo a
memory assessment in Italian with no need for
conversation but with
Diagnostic memory assessment in Italian-born Australians
an interpreter was welcomed by many of the
participants in this study, and may have enhanced
establishment of rapport during the interview
session. However, some of the research participants
displayed mild anxiety regarding the purpose of the
and characteristics of dementia, suggesting a need
for more effective education regarding dementia in
this community sector.
In conclusion, it is important to note that
the reported results apply only to the memory
abilities studied. In addition, although our study
was underpowered for the CFA analysis, results
are precisely in line with the predicted model of
cognition for the type of test battery employed.
Future studies should examine the impact of
second-language competence in terms of other
cognitive domains relevant to dementia character-
ization in larger samples and in samples from other
cultural backgrounds. Prominent amongst these
abilities are language acquisition and use, and so-
called executive function reflecting, respectively,
aspects of crystallized and fluid cognitive abilities
and working memory, as defined in the CHC
Conflict of interest
Description of authors’ roles
Sara Fratti designed the study, collected and
analyzed the data, and wrote the paper. Stephen C.
Bowden assisted with design of the study, analyzed
the data and assisted in writing the paper. Olimpia
Pino assisted in writing the paper.
We gratefully acknowledge the excellent support
and collaboration of staff at CO.AS.IT (Mel-
bourne), as well as the Italian Seniors Citizen Clubs
members in Melbourne who so kindly agreed to
take part in the study. Without their effort this
study would have not been possible. We would also
like to thank the Department of Psychology at the
University of Parma (Italy) for their support.
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Diagnostic memory assessment in Italian-born Australians
MODA Prose Memory revised score
According to the manual (Brazzelli et al., 1994),
the Prose Memory score has a hierarchical thematic
scoring, ranging from zero to a maximum of eight
points. In order to reach a minimum score, subjects
must recall a specific minimum number of items. If
the examinee recalls only items of the short story
that are not included within the thematic scoring,
then the examinee will score zero.
In this study a revised scoring was used in
which the thematic procedure is replaced by a
“per item” scoring system, similar to the one
presented in the WMS-III Logical Memory subtest
(Wechsler, 1997b). This means that all the details
of the short story are included in the scoring
system. The examinee is credited one point
for each item recalled, to a maximum of 22
distribution of scores (details of the scoring system
are available on request from the authors).