Ageism and Neuropsychological Tests

Abstract

The performance of older adults on neuropsychological (and cognitive) assessment tests can set the perspective on the capabilities of this population in general, hence contributing to ageism. These tests are administered with two implicit assumptions: (a) the tests are a valid gauge of performance in older adults and (b) cognitive abilities decline in older age. In the current chapter, we challenge these assumptions by discussing two potential sources of threat to test validity: the sensory and the social contexts. First, we review findings that age-related decline in performance may reflect, at least in part, a sensory (visual and auditory) rather than a purely cognitive decline. Next, we discuss the negative effect of age-based stereotype threat on older adults’ cognitive performance. Both contexts may be present in daily testing of older adults in the clinic or the lab. Thus, targeting the sensory and social context in neuropsychological assessment may assist in reducing age-bias (leading to ageism) in the scientific, medical and general community.

Full text

277© The Author(s) 2018
L. Ayalon, C. Tesch-Römer (eds.), Contemporary Perspectives on Ageism,
International Perspectives on Aging 19,
https://doi.org/10.1007/978-3-319-73820-8_17
Chapter 17
Ageism andNeuropsychological Tests
BoazM.Ben-David, GaliMalkin, andHadasErel
17.1 Introduction
Increase in life expectancy is one of the core characteristics of the modern life
(Schneider 1999). However, whereas medicine and technology enable relatively
good health (Eggleston and Fuchs 2012), the apparent cognitive decline is still con-
sidered one of the most central aspects of ageing (for an overview see, Craik and
Salthouse 1992; but for a steady age-related advantage in vocabulary, Ben-David
etal. 2015; also see Evans 2018; Chap. 16, in this volume). It is one of the most
feared aspects of growing old (Morley 2004). In this context, accurate measures of
cognitive decline have become increasingly important. These typically involve the
assessment of core cognitive skills, such as memory, language prociency, intelli-
gence and executive functions (for a review see, Monge and Madden 2016).
Older adults’ performance on cognitive assessment tests has important implica-
tions both on the individual level and on the societal level. For individuals, perfor-
mance is a marker for cognitive ability, inuencing self-image and life choices. For
society as a whole, performance sets the perspective (and expectations) on the capa-
bilities of older people in general, contributing to ageism. Cognitive assessment
tests are administered with two (dependent) implicit assumptions: (a) the tests are a
B. M. Ben-David (*)
Communication, Aging and Neuropsychology Laboratory (CANlab), Baruch Ivcher School
of Psychology, Interdisciplinary Center (IDC), Herzliya, Herzliya, Israel
Faculty of Medicine, Department of Speech-Language Pathology, University of Toronto,
Toronto, ON, Canada
Toronto Rehabilitation Institute– University Health Network, Toronto, ON, Canada
e-mail: boaz.ben.david@idc.ac.il
G. Malkin · H. Erel
Communication, Aging and Neuropsychology Laboratory (CANlab), Baruch Ivcher School
of Psychology, Interdisciplinary Center (IDC), Herzliya, Herzliya, Israel

278
valid gauge of performance in older adults and (b) cognitive abilities decline in
older age. Because test performance is taken to provide a good estimate of abilities
in older adults, reduced test performance is interpreted as reecting an age-related
cognitive decline. If one assumes an age-related cognitive decline, reduced perfor-
mance in cognitive tests can be seen as further support for test validity. In the cur-
rent chapter, we wish to challenge these assumptions, questioning the validity of
cognitive tests as an unbiased gauge of older adults’ abilities, and as a result, ques-
tioning the extent of age-related cognitive decline.
As a rst step, we review evidence suggesting that performance on cognitive
tests is affected by sensory decline. Currently, cognitive tests are not designed to
take this factor into account. Specically, sensory decline in ageing degrades the
information processed, impairing cognitive processing (Schneider and Pichora-
Fuller 2000). Indeed, age-related changes in cognitive performance (on several
tests) can be minimized (or even effaced) when sensory decline is controlled for, or
by changing the sensory context of the test (vision: Ben-David and Schneider 2009;
auditory: Ben-David etal. 2011a).
In the second part of this chapter, we discuss evidence of the impact of age-based
stereotype threat on test performance. Specically, the predicament arising from
negative ageing stereotypes on cognitive decline can be experienced as a self-
evaluation threat (Steele and Aronson 1995), leading to decreased performance,
thus fullling the ageist prophecy (Hess etal. 2003). Here, too, there is evidence to
suggest that elevating stereotype threat may minimize age-related changes in per-
formance (e.g., Mazerolle etal. 2017). Finally, notwithstanding age-related neuro-
logical changes (as frontal and hippocampal decline; West 1996), this chapter
suggests that the common assumption on the extent of age-related decline in cogni-
tive abilities may be exaggerated, and the respective role of the sensory and social
contexts on performance is considerably ignored.
To understand the interplay between the implicit assumptions and the sensory
and social contexts, consider the following example. A 75-year-old goes to a univer-
sity lab to be tested for cognitive abilities, or to a clinic to be tested for cognitive
impairment, when decline (or even dementia) is suspected. The mere presentation
of the test may elicit the expectation to perform poorly, negatively affecting perfor-
mance. Auditory and visual information, such as test material and instructions, pres-
ent a greater sensory challenge due to age-related sensory decline, again negatively
affecting performance. Reduced performance serves to further validate common
stereotypes about the rate and extent of cognitive deterioration with ageing, as the
test is taken as valid and unbiased. Simply put, performance on tests, which may be
biased due to sensory and social aspects of ageing, conrms assumptions of reduced
cognitive abilities in ageing.
In sum, our analysis of the literature focuses on the two main threats to the valid-
ity of neuropsychological assessment in ageing: the sensory context and the social
context. These contexts not only describe the mechanisms underlying biases in
evaluating cognitive performance in older age, but also offer insights that can
improve the validity of such tests. Targeting the sensory and social context in
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279
neuropsychological assessment may assist in reducing age-bias (leading to ageism)
in the scientic, medical and general community.
17.2 Ageing andtheSensory Context ofNeuropsychological
Assessment
17.2.1 Age-Related Sensory Decline
Ageing is commonly accompanied by a sensory decline (Crews and Campbell
2004), indicated by an increase in the use of sensory aids, such as hearing devices
and glasses (Roberts and Allen 2016). To focus our discussion, we target auditory
and visual age-related decline in healthy ageing. Auditory decline in healthy ageing
is related to neural changes across different auditory areas in the brain, as well as
cochlear changes in the ear (Gordon-Salant etal. 2010). Auditory changes lead to an
increase in hearing thresholds, where one needs louder target sounds for correct
detection (Roberts and Allen 2016), and supra-threshold changes (Glasberg and
Moore 1992), such as distortion of the incoming stimuli (Grose and Mamo 2010).
Ageing is also marked by less efcient auditory scene analysis (Bregman 1990),
where both top-down and bottom-up processes impact difculties in segregating the
target speech from competing sound sources in the background (e.g., other people
talking; Tun and Wingeld 1999). Visual changes in healthy ageing typically include
retinal degeneration (Monge and Madden 2016), and presbyopia (Scialfa 2002).
These changes degrade basic visual processes, such as near-term vision (Spear
1993), visual acuity (clarity of vision, Owsley 2011), contrast sensitivity (the ability
to detect luminance differences to distinguish objects from background, Greene and
Madden 1987) and colour perception (e.g., Nguyen-Tri etal. 2003).
Intelligence Tests The age-related sensory decline discussed above is likely to
have an impact on cognitive processing, and therefore, on neuropsychological
assessment (Roberts and Allen 2016; Schneider and Pichora-Fuller 2000). Perhaps
the most striking evidence comes from a line of studies on age-related sensory
decline and scores on different intelligence batteries (e.g., Anstey et al. 2001;
Lindenberger and Baltes 1994). Findings show that visual and auditory acuity
scores (near and far visual acuity, pure tone auditory acuity) could account for
93.1% of the age-related variance in intelligence scores (with 156 participants aged
70–103). These ndings were later replicated and extended on a larger sample (687
participants), with a larger age range (25–103years, Baltes and Lindenberger 1997)
and to longitudinal data (Ghisletta and Lindenberger 2005). In sum, evidence sug-
gests that sensory decline is closely related to a decline in performance on neuro-
psychological assessment.
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280
17.2.2 Theories ontheInteraction ofSensory andCognitive
Ageing
How to explain this link between sensory and cognitive ageing? Four possible
hypotheses have been discussed (Schneider and Pichora-Fuller 2000, see also
Wayne and Johnsrude 2015): (1) Sensory deprivation hypothesis. Sensory decline,
over time, leads to a cognitive decline due to social isolation and reduced use of the
relevant cognitive functions (Lin et al. 2013); (2) Cognitive load hypothesis.
Cognitive decline leads to a decline in perceptual processes (the interpretation of the
sensory input). This is based on the idea that cognitive load can impair even simple
sensory tasks (Li etal. 2001; Lindenberger etal. 2000) (3) Common cause hypoth-
esis. Degeneration in the central nervous system causes a deterioration of both per-
ception and cognition (Baltes and Lindenberger 1997). Indeed, cardiovascular risk
factors have been associated with both hearing loss and cognitive decline (Roberts
and Allen 2016); nally, (4) Information degradation hypothesis. Unclear and dis-
torted perceptual information delivered to the cognitive system directly impairs
cognitive performance, due to an increase in the resources required for the percep-
tion process and errors embedded in the input (Schneider and Pichora-Fuller 2000).
These hypotheses are not necessarily mutually exclusive. Clearly, the interaction
of sensory and cognitive processing suggests that each factor can affect the other,
with similar biological changes inuencing both (Baltes and Lindenberger 1997).
However, the information degradation hypothesis presents the framework for under-
standing the possible age biases in neuropsychological testing that may lead to age-
ism. If perception and cognition are taken to comprise one integrated system
(Wingeld and Tun 2007), where both processes share the same pool of resources
(Glisky 2007), then when perceptual processing requires more resources due to age-
related sensory decline, less resources are available for cognitive processing
(Heinrich etal. 2008). Furthermore, cognitive processing demands more resources
when it is based on degraded sensory information, tapping into the already reduced
pool. This model suggests that sensory degradation (i.e., the reduced quality of sen-
sory information) is an alternative explanation for age-related declines in perfor-
mance. Thus, it directly challenges the two implicit assumptions underlying
neuropsychological testing in ageing: test validity and the extent of age-related cog-
nitive decline. The validity of this model can be tested very easily with simple
experimental manipulations (see Monge and Madden 2016). This hypothesis also
affords a possible remediation for neuropsychological assessments in older age.
Mainly, ameliorating the sensory input (or removing them all together, Ben-David
and Icht 2017),can minimize age-related differences.
In the next sections, we discuss the assessment of three main cognitive abilities,
taken to represent age-related cognitive decline: inhibition, speech comprehension
and memory. We offer evidence to suggest that the neuropsychological assessment
can be drastically impacted by age-related sensory degradation in vision (inhibi-
tion), in hearing (comprehension) or both (memory).
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17.2.3 Inhibition: AnExample oftheEffect ofVisual
Degradation onNeuropsychological Tests
The need to inhibit irrelevant information is a central cognitive ability in daily activ-
ities. For example, when driving a car one must attend to the road, while ignoring
irrelevant visual distractors, such as billboards. Similarly, when reading this text,
one needs to ignore irrelevant dimensions, such as the size and shape of the page,
and focus on the content of the words. One of the prominent theories on cognitive
changes in ageing suggests that this specic process deteriorates in ageing (Hasher
and Zacks 1988). The age-related decrease in the efciency of inhibitory processes
is a part of a general theory on a decrease in executive functions– a decrease in
monitoring and control of behaviour (Baddeley 1996). This cognitive decline is
generally attributed to selective prefrontal deterioration in ageing (Dempster 1992).
However, recent studies suggest that visual sensory degradation can explain some of
the age-related variance in performance(see a discussion in Ben-David etal. 2014a).
The ‘gold standard’ for evaluating inhibition in ageing is the colour-word Stroop
test (Stroop 1935; see Melara and Algom 2003 for a relevant review). In this para-
digm, participants are asked to name aloud the font colours of printed words, ignor-
ing their content. For example, saying aloud “blue” when presented with the word
RED printed in blue. The latency advantage for naming the font colour of a colour-
neutral word (e.g., TABLE printed in blue) over an incongruent colour-word (RED
in blue) is termed Stroop interference. An age-related increase in Stroop interfer-
ence has been shown repeatedly in the literature (for reviews, see Ben-David and
Schneider 2009; McDowd and Shaw 2000). It is commonly interpreted as reecting
an age-related decrease in the efciency in inhibition (e.g., Troyer etal. 2006).
In the past decade, a line of studies by Ben-David and colleagues suggest that
variance in colour-vision (in people with clinically normal colour-vision) can medi-
ate performance on the Stroop test in various populations: healthy ageing (Anstey
et al. 2002; Ben-David and Schneider 2009), people with dementia (Ben-David
etal. 2014b) and people with traumatic brain injury (Ben-David etal. 2011b, 2016).
In a meta-analysis (Ben-David and Schneider 2009), an age-related increase in
colour-naming latencies (naming the font colour of a colour-neutral word) was
found to be signicantly larger than an age-related increase in reading latencies
(reading a word printed black on white). This increased difculty in colour-vision
processing was found to be a possible source for reduced performance on the Stroop
test, beyond any changes in inhibition. In a follow-up study, to simulate an age-
related colour deciency, the Stroop test was presented with desaturated colour-set
for a group of younger adults. By reducing the amount of colour information avail-
able, Ben-David and Schneider (2010) were able to “age” younger adults, generat-
ing the age-related increase in Stroop interference. Somewhat similar results were
obtained in other inhibition test. For example, Bertone etal. (2007) simulated age-
related visual acuity degradation by tting younger adults with occlusion lter
lenses to blur their vision (e.g., to 20/40), severely reducing performance on an
inhibition test.
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282
In sum, mimicking an age-related decrease in colour perception in younger
adults was sufcient to lead to Stroop interference that is similar to that found in
older adults. Because the colour-word Stroop test is widely used in clinical, neuro-
psychological and experimental screening tests as a measure of inhibitory control in
older participants, there is reason to question the validity of inhibition diagnosis and
the extent to which the inhibitory process in ageing decreases.
17.2.4 Comprehension: AnExample oftheEffect ofAuditory
Degradation onNeuropsychological Tests
Age-related auditory degradation impairs speech perception on various levels:
single- word identication, sentence comprehension, source localization and the
ability to segregate the source speaker from a noisy background (Ben-David etal.
2012; Humes and Dubno 2009; Schneider etal. 2002). This is supported by a line
of studies showing that when the listening situation is adjusted to match older and
younger adults’ auditory abilities, speech processing can be equated (for a review,
see Schneider et al. 2010). For example, (Ben-David et al. 2011b) used an eye-
tracking paradigm to measure age-related effects on speech processing, as the spo-
ken word unfolds in time. The study found equivalent online speech processing for
older and younger adults, when speech was presented in quiet. When the noise level
was tailored to compensate for age-related auditory changes (by setting different
signal-to-noise ratios to equate single-word identication across age-groups), again,
online speech processing was mostly not affected by ageing (for possible cognitive
effects, see Hadar etal. 2016).
Age-related changes in speech perception, as presented above, can directly affect
performance on neuropsychological tests. Generally, basic test instructions are spo-
ken, presenting a possible source for misunderstanding. The additional effort for
deciphering spoken instructions may also decrease available resources and induce
stress (Schneider etal. 2010). Importantly, in many cognitive tests, test stimuli are
spoken rather than printed, presenting further sources for biases. For example,
Schneider etal. (2000) asked older and younger participants to listen to lectures
(8–13min) on a noisy background and to later answer questions concerning their
content. When both age groups heard the lecture at the same sound level (mimick-
ing conditions in the clinic), signicant age-related differences were found.
However, when auditory conditions were individually adjusted to compensate for
sensory degradation, these differences were eliminated. In other words, older adults
were able to perform as well as younger adults, even in a complex listening compre-
hension task, when sensory degradation was compensated for (for replication, see
Lu etal. 2016). These results may be further supported by a recent study indicating
that younger adults with hearing impairment show equal cognitive performance to
older adults with similar sensory decline (Verhaegen et al. 2014). Noting that
declines in comprehension are often interpreted as a direct indication of age-related
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283
cognitive decline and even pre-dementia (Schneider et al. 2005), these ndings
present implications for various neuropsychological assessment tools.
17.2.5 Memory: AnExample oftheEffect ofAuditory
andVisual Degradation onNeuropsychological Tests
As discussed in the second section of this chapter, memory deterioration is one of
the most prominent stereotypes in ageing. Research presents abundant evidence
suggesting an age-related decline in a variety of memory tasks (Craik and Jennings
1992; Zacks et al. 2000). Yet, like comprehension, memory was also shown to
depend on the perception of the auditory stimuli (Peelle and Wingeld 2005).
Consider studies of spoken word-pairs, where listeners are presented with a list of
spoken word-pairs, and later asked to recall a target word when given its pair. In an
early study (Murphy etal. 2000), memory performance of older adults listening in
quiet was nearly equivalent to that of younger adults listening in noise. Later,
Heinrich and Schneider (2011) adjusted signal-to-noise ratios to equate identica-
tion of a single spoken word across age-groups (i.e., louder background noise was
presented to younger adults). In this condition, memory performance of older adults
matched that of younger adults, when ample time was given.
Visual decline was also shown to impair performance on memory tests. For
example, Dickinson and Rabbitt (1991) occluded younger adults’ vision to mimic
older adults’ visual perception when asked to read aloud a passage for later recall.
Memory performance was severely diminished, even though no errors were per-
formed during reading. In other words, the additional toll on processing (generated
by visual degradation) can affect non-perceptual, higher-order cognitive processes,
even when visual processing is still intact. Finally, visual sensory degradation was
also correlated with other visual memory tasks (Stevens etal. 1998).
Dementia Screening Tests Age-related sensory degradation was not only found to
impact memory tests in healthy ageing, but also dementia assessment, with severe
implications for false positive mistakes (e.g., Feldman etal. 2008). We focus on
commonly used screening tests for dementia such as the Mini-Mental State
Examination (MMSE; Folstein etal. 1975) and the Montreal Cognitive Assessment
(MoCA: Nasreddine etal. 2005). These tests are considered accurate tools for iden-
tifying indicators for pre-dementia and mild cognitive impairment (MCI: Luis etal.
2009). Yet, there is a body of evidence in the literature to indicate that these tools
can be affected by sensory degradation as well. For example, Dupuis etal. (2015)
found that older adults with sensory loss (whose vision and\or hearing scores did
not meet the criteria for healthy ageing) were twice as likely to score below the cut-
off point for potential pre-dementia as older adults with clinically normal visual and
auditory thresholds. Indeed, in a different study, one third of older adults with hear-
ing loss, who were already diagnosed with dementia, were reclassied as having a
lesser degree of dementia when the MMSE was administered using sound
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284
amplication (Weinstein and Amsel 1986). Similarly, signicantly better MMSE
scores were documented when older adults with hearing loss were using tted hear-
ing aids (Acar et al. 2011). Dementia measures are also affected by age-related
sensory decline that is still within clinically normal boundaries. For example, tailor-
ing stimuli contrast level for older participants to resemble contrast perception of
younger adults was sufcient to erase all age-related differences in a digit cancella-
tion task (another indicator for pre-dementia) with healthy adults. When the same
manipulation was conducted with older adults diagnosed with dementia, it signi-
cantly minimized performance decline (Toner et al. 2012). In sum, age-related
visual and auditory decline can lead to overestimation and false-positive diagnosis
of dementia. Results call for a careful examination of test results in light of age-
related sensory decline.
17.2.6 Clinical Implications: Compensating forSensory
Degradation
Simple actions may overcome the sensory bias in neuropsychological testing. We
recommend adjusting test stimuli and instructions to compensate for age-related
sensory changes. These include sound amplication, reducing background noise
and increasing target sound level (enhancing signal-to-noise ratio), enhancing stim-
uli visual contrast, using larger font size, increasing the amount of light in the room,
careful choice of colours and so on. We also recommend assessing the visual and
auditory abilities of older participants in all cases of neuropsychological assess-
ments. It is imperative to ensure the use of corrective aids (visual or auditory) when
these are needed, as hearing and visual loss can severely reduce performance. These
sensory scores can also serve to statistically adjust neuropsychological assessment
scores to better reect abilities (e.g., the Stroop task, Ben-David and Schneider
2010). In sum, to avoid a false diagnosis of a clinical cognitive decline one must not
ignore or underestimate sensory decline.
17.2.7 Sensory Context: Summary
In the rst section of this chapter, we discussed evidence showing that physical
aspects of the test material (and instructions) present a direct threat to the validity of
neuropsychological testing in ageing. Namely, age-related decline in performance
on assessment tools may reect, at least in part, a sensory rather than a cognitive
decline. When reduced performance is evident, it is likely to be attributed to lower
cognitive ability of the older test taker, rather than transient sensory contextual fac-
tors. This ageist bias might serve to further validate negative ageing stereotypes,
resulting ultimately in the negative portrayal of older adults across both scientic
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285
literature and every day cultural representations. In the following section, we dis-
cuss how such age-based stereotypes may have a negative impact on performance,
suggesting that the social aspects of the test may also put into question the validity
of neuropsychological testing in ageing.
17.3 The Social Context ofNeuropsychological Assessment
inAgeing
Stereotype threat, one of the most widely investigated topics in social psychology
(Pennington etal. 2016) occurs when underachievement among stigmatized group
members is rooted in the situation more than in the individual (Leyens etal. 2000).
The existence of a negative stereotype about a person’s group means that in situa-
tions where the stereotype is applicable, the person will be at risk of conrming it
as self-characteristic (Aronson 2002). In the seminal work of Steele and Aronson
(1995), African American participants were tested on a verbal reasoning task. When
the task was presented as a diagnostic indicator of intellectual ability, the perfor-
mance of African-Americans (a population that generally suffers from a stereotype
on intellectual abilities) was signicantly worse compared to that of their Caucasian
peers. When the task was presented as non-diagnostic, these differences in perfor-
mance were eliminated. Therefore, making the racial stereotype about intellectual
ability relevant to test performance impaired African Americans’ performance rela-
tive to Caucasian participants.
Stereotype threat effects have been studied across different stereotyped social
groups including women (e.g., Spencer etal. 1999), individuals from low socioeco-
nomic status (e.g. Spencer and Castano 2007), gay men (Bosson etal. 2004), and
older adults, as we will review in the next sections.
17.3.1 Age-Based Stereotype Threat
Older adults face pervasive negative stereotypes portraying them as forgetful,
incompetent, and cognitively inferior to younger adults (Hummert etal. 1994; Kite
and Wagner 2002). These stereotypes were found to have a negative impact on older
adults’ performance across diverse domains, and on their general well-being. A
recent meta-analysis of 32 studies, covering more than a decade of research (Lamont
etal. 2015), suggests that age-related reduced performance on memory tests and
other cognitive measures may be vulnerable to age-based stereotype threat (with a
moderate effect size, d=0.36−an effect size measures the strength of a phenom-
enon, Sawilowsky 2009). In the current section of the chapter, we focus on how
older adults’ negative beliefs about their memory and other cognitive abilities can
impact their performance on assessment tools.
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286
Age-based stereotype threat is typically induced in the lab by manipulating the
relevance of the stereotype to task performance. Most studies usually invoke age-
based stereotype threat by presenting participants with ctitious information con-
rming that cognitive abilities decline with age, by emphasizing the task’s evaluative
nature, or by implying an age-based comparison. One of the pioneering investiga-
tions of age-based stereotype threat is a study by Hess etal. (2003). In this study,
stereotype threat was manipulated by informing younger and older adults about
research ndings depicting either the negative impact of ageing on memory (threat
condition), or describing that memory is maintained across the lifespan (no-threat
condition). Participants were then given a free recall memory test. Consistent with
the stereotype threat framework, no age-related differences were noted in the no-
threat condition. However, in the threat condition, recall was higher for younger
than for older adults. In sum, traditional ndings on a signicant age-related
decrease in performance on memory tasks might be affected by the activation of
pervasive negative ageing stereotypes.
Real-world testing situations, such as testing in the clinic or a research lab, may
induce a stereotype threat by nature, without requiring any special manipulations
(Spencer etal. 2016). Simply taking a test in a negatively stereotyped domain, in the
context of performance evaluation in ageing, is enough to trigger stereotype threat.
Consider again a memory test. The typical procedure for testing the memory abili-
ties of older adults (Hughes etal. 2013) involves multiple stereotype threat cues.
These include the testing location: a college campus where older adult participants
are surrounded by younger adults, or a hospital clinic highlighting sickness and dis-
ability. Test instructions may also trigger stereotype threat as participants are
informed that their memory will be tested, with the commonly implicit assumption
that their performance will be compared to that of younger adults. In fact, recruiting
participants based on their age, or merely asking them to indicate their age in a
demographic questionnaire can serve as a cue (Kang and Chasteen 2009). All of
these cues may potentially lead to performance decrement, ultimately resulting in
an over-estimation of age-related memory decline.
17.3.2 Clinical Implications ofAge-Based Stereotype Threat
Perhaps the most striking indication of the consequences of age-based stereotype
threat on assessment arises from two seminal studies on dementia assessment.
Mazerolle etal. (2017) used the most common brief neuropsychological assessment
batteries in ageing, MMSE and MoCA (as discussed in the previous part of this
chapter). Experimenters simply informed all participants that they would perform a
memory task and that both younger and older adults are taking part in the study
(threat condition). In the reduced-threat condition, participants were also informed
that typically there are no age-related differences in this task. Results show that 40%
of the sample of community-dwelling older adults met the screening criteria for pre-
dementia in the threat condition. However, only 10% of the participants in the
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287
reduced-threat condition met these criteria. This nding is further supported in a
study by Haslam et al. (2012) investigating a commonly used measure for early
dementia detection (ACE-R). When participants were self-categorized as old, and
were also led to expect that age-related cognitive decline is all-encompassing (rather
than limited to a specic domain), 70% met the diagnostic criterion for dementia.
By contrast, only 14% on average met this criterion in all other (lower-threat) condi-
tions. In sum, stereotype threat may lead not only to overestimation of cognitive
decline but also to the false-positive diagnosis of pre-dementia, suggesting potential
severe implications in real life.
It is important to note that age-based stereotype threat does not begin and end in
the testing situation alone. There is evidence that older adults perform worse on a
memory test following negative, rather than positive, age-related subliminal primes.
That is, when words associated with negative aspects of aging (e.g., DEMENTIA)
were presented at a speed allowing perception but not awareness (i.e. subliminal
presentation), performance on a subsequent memory test was worse than when a
positive word (e.g., SAGE) was subliminally presented (e.g., Hess and Hinson
2006; Levy 1996; Levy and Leifheit-Limson 2009). These implicit stereotypes may
generate expectations that act as self-fullling prophecies (Levy and Leifheit-
Limson 2009), which may be at the root of the motivation of the older adult to
search for a neuropsychological evaluation in the rst place (Régner etal. 2016).
For example, when an older adult is placed in situations predominantly occupied by
younger adults (i.e., stereotype threat), typical memory lapses may be interpreted as
abnormal age-related decline. There is evidence that both younger and older adults
attribute older adults’ memory failures to internal, stable factors (Erber etal. 1990).
Older adults may refer to a case of forgetfulness as their “senior moment” (Barber
2017). Interpreting every-day memory failures as a sign for a need for intervention
(Erber et al. 1990) may lead the older person to search for clinical assessment.
Because the clinical assessment is also negatively affected by stereotype threat, this
person may perform below his/her abilities, with profound clinical, social and eco-
nomic consequences. Moreover, even if the person does in fact suffer a probable
cognitive impairment, the debilitating effects of stereotype threat may be especially
prominent for him/her (Scholl and Sabat 2008). These effects may inuence the
choice of suitable treatment options, and the adherence to treatment, resulting in an
entirely different course of disease.
Eliminating age based stereotype cues calls for a multi-faceted approach, as
demonstrated by Sindi et al. (2013). The authors compared younger and older
adults’ salivary cortisol levels, as a measure for stress, and performance on a mem-
ory neuropsychological test. The focus of the study was a manipulation of the envi-
ronments to be stressful (unfavourable condition) or not stressful (favourable
condition) for each age group. The unfavourable condition for older adults included:
(1) A testing location known to young adults but not to older adults (university cam-
pus); (2) Testing performed in the afternoon, a non-optimal time for testing older
adults, but optimal for younger adults; (3) A younger adult research assistant; (4) A
memory task with which older adults, as opposed to younger adults, were not famil-
iar (word list recall); (5) Instructions emphasizing the memory component of the
17 Ageism andNeuropsychological Tests

288
task, matching the negative stereotype for older, but not for younger adults. In con-
trast, the favourable condition for older adults included: (1) A testing location that
was known to older adults, but not to young adults (an older adult community cen-
tre); (2) Testing performed in the morning, an optimal time for testing older adults,
but not for younger adults; (3) An older adult research assistant; (4) A memory task
that was developed based on learning capacities of older adults (a face-association
memory task, as older adults perform better when asked to recall relevant informa-
tion, rather than unrelated words); (5) Instructions excluding an explicit indication
that the task is testing memory. As expected, higher cortisol levels and lower mem-
ory performance were found for older adults in the unfavourable as compared to the
favourable conditions. However, younger adults were not affected by the testing
conditions. Although it is impossible to identify the relative contributions of each of
these situational factors, this study demonstrates that many facets in the testing
environment may be experienced differently by older and younger adults.
17.3.3 Understanding Stereotype Threat Effects
Generally, stereotype threat may arise from any situational cue indicating that an
individual is at risk of conrming the stereotype, reminding the individual of cultur-
ally held stereotypes (Spencer et al. 2016). The literature has identied multiple
reasons for the effects of stereotype threat on performance among younger adults.
One of the rst mechanisms offered to understand stereotype threat effects is
Negative Affect (Steele and Aronson 1995). In particular, increased levels of anxiety
have been offered to mediate the effects of stereotype threat on performance.
However, results regarding this hypothesis have been mixed (see a review by
Pennington etal. 2016), with several studies failing to establish this relationship
(e.g., Spencer etal. 1999). Therefore, while anxiety may play a role in explaining
stereotype threat effects (especially when assessed via indirect measures, Bosson
etal. 2004), it is likely not the only or the key explanation.
Taking a cognitive resources perspective, the Process Model (Schmader etal.
2008) suggests that stereotype threat disrupts performance via three distinct, yet
interrelated, mechanisms: (a) triggering physiological stress response; (b) trigger-
ing a tendency to actively monitor performance, aimed to detect self-relevant infor-
mation and signs of failure; (c) triggering efforts to suppress negative thoughts and
emotions. Each of these mechanisms consumes cognitive resources that are required
for successful performance on a given task. Generally speaking, there is ample
direct and indirect evidence consistent with cognitive resource depletion in stereo-
type threat (Pennington etal. 2016).
Focusing specically on older adults, the mechanisms underlying age-based ste-
reotype threat are not fully understood, and may not be generalized from studies
conducted among younger adults. With regard to affective factors, similar to younger
adults, little evidence has been found for anxiety mediating the effects of age-based
stereotype threat on performance (Chasteen etal. 2005; Hess etal. 2003; but see
B. M. Ben-David et al.

289
Swift et al. 2013). Inconsistent support has also been noted for the cognitive-
resources hypothesis in older adults (Brelet etal. 2016; Mazerolle et al. 2012 vs.
Hess etal. 2009; Popham and Hess 2015).
Why is it so difcult to fully understand stereotype threat effects among older
adults? The answer may lie in the treatment of stereotype threat as a unitary con-
cept, tailored by younger adults’ experiences and perspectives. For example, accord-
ing to Barber (2017), the reason cognitive depletion does not necessarily explain
stereotype-threat effects in older adults may relate to their favourable emotion regu-
lation abilities. Namely, regulating the negative affective states (such as anxiety and
stress) induced by stereotype threat is resource demanding for younger adults.
However, for older adults, regulating aversive emotions is less resource demanding
(Scheibe and Blanchard-Fields 2009), suggesting a smaller role for this
mechanism.
If stereotype threat effects are not fully explained by cognitive-resources deple-
tion or by negative affect, what can explain them? Current literature appears to sup-
port the regulatory t hypothesis in explaining stereotype threat effects in older age.
According to this view, stereotype threat may elicit a prevention focus (Seibt and
Förster 2004), in which participants aim not to be their worst, as opposed to striving
to be their best. As suggested by the regulatory focus theory (Higgins 1997, 1999),
this prevention focus will result in more cautious, error-free and loss aversion strate-
gies. Consistent with the idea of a prevention focus, older adults under stereotype
threat have been found to be more risk-averse in their decision making compared to
non-threatened older adults (Coudin and Alexopoulos 2010), and respond more
slowly (Popham and Hess 2015). In addition, stereotype threat was found to reduce
older adults’ (veridical) recall and recognition, but improve memory accuracy
(Barber and Mather 2013b; Wong and Gallo 2016).
The fact that stereotype threat may elicit a prevention focus does not necessarily
mean that it will result in decreased performance. There is evidence that stereotype
threat could even improve older adults’ performance when the task is framed as
relating to losses rather than gains. For example, Barber and Mather (2013a) tested
older adults on a working memory task, after inducing an age-based stereotype
threat. When the tests were focused on gains (i.e., money earned for correct
responses), stereotype threat was found to impair performance. However, when the
tests were focused on losses (i.e., money lost for incorrect responses) threat
improved performance. These ndings were replicated using other memory tasks
(MMSE, Word List Memory; Barber etal. 2015). This line of ndings can support
the regulatory t (Higgins 2000) framework. According to this view, when task
demands match the person’s regularity focus, performance will increase, while a
mismatch will decrease it. In sum, the reported negative effects of stereotype threat
on older adults’ performance may stem from a mismatch between the task structure
and the threat-induced prevention focus (Grimm etal. 2009).
17 Ageism andNeuropsychological Tests

290
17.3.4 Social Context: Summary
Findings presented in this section suggest the pervasive negative impact of age-
based stereotype threat on performance in neuropsychological assessment. Evidence
in the literature also suggests that this effect can have severe consequences, as pre-
dementia may be falsely detected in healthy older adults in the presence of stereo-
type threat cues. These cues are not only the outcome of laboratory manipulations,
but may be present in the daily testing of older adults in the clinic or a university lab.
It is important to recognize these cues in order to shape testing environments that
evince the accurate capacities of older adults.
Although the mechanisms underlying threat effects in older adults are yet to be
fully understood, the possibility that in some cases, activating negative age-based
stereotypes does not necessarily result in performance decrement, is another prom-
ising direction. Changing the reward structure of the task to be loss-based (for
example by emphasizing accuracy and minimization of mistakes), may also have
important clinical implications.
Speaking more broadly, while several critiques have questioned whether stereo-
type threat actually generalizes from the laboratory into real-world testing situations
(e.g., Sackett etal. 2004), when focusing on older adults, we believe that stereotype
threat is responsible for an over-estimation of age-based cognitive decline among
both scholars and practitioners. In some cases, this may lead to crossing a clinical
boundary from normal to abnormal impairment (Haslam etal. 2012). Indeed, :“it is
hard to imagine a social psychological effect that could have greater clinical rele-
vance” (p.782).
17.4 General Discussion
The goal of this chapter was to test the two implicit assumptions underlying neuro-
psychological testing in ageing: test validity and the generalized view of the extent
of age-related decline in cognitive abilities. We presented evidence from the current
literature on the negative effects of age-related sensory decline and age-based ste-
reotype threat on test performance. Our ndings challenge these two assumptions,
suggesting that age-related changes may not be as severe as previously suggested.
Namely, age-related sensory decline and stereotype threat were shown to inuence
the context of the neuropsychological assessment and lead to an inaccurate measure
of cognitive performance. In extreme cases, their inuence may cause false diagno-
sis of pre-dementia, i.e., crossing a clinical boundary from normal to abnormal
impairment. These contextual factors are not only the outcome of laboratory manip-
ulation, but may be present in daily testing of older adults in the clinic or a univer-
sity lab. It is important to account for these factors in order to shape testing
environments appropriate for older adults.
B. M. Ben-David et al.

291
The pair of implicit assumptions appears to be embedded in test administration
and scoring in many of the available tools. Generally, test materials are not format-
ted to meet age-related sensory degradation, and administration protocols specify
neither the sensory context (such as illumination and noise levels) nor the social
context (how to minimize stereotype threat) of the test. In most tests, normative
scores are adjusted separately for each age group to compensate for the expected
age-related decline (e.g., Stroop, WAIS). Simply put, the same score on a neuropsy-
chological assessment may reect normative performance for 70 year olds, but
awed performance for 20year olds, echoing the pair of assumptions. Thus, test
results, coupled with these assumptions, may provide support for ageism, affecting
both the scientic and medical community and the public at large.
The evidence presented in this chapter has implications outside of the clinic/lab.
Consider the ofce environment. The lighting and the noise level may be challeng-
ing for older employees. Thus, employees may have more difculties in processing
the written information, and in taking an active part in conversations. The resources
allocated for deciphering the sensory input are not available for further cognitive
processing. As a result, it is more difcult for older employees to utilize the full
potential of their cognitive abilities. In turn, both colleagues and managers may
perceive reduced performance as reecting internal factors (an attribution
error) − i.e., an age-related cognitive decline − judging older employees more
harshly. This will lead to an atmosphere engendering stereotype threat. Taken
together, daily activities in the ofce may be perceived by older employees as a test
for cognitive abilities, where they are expected to underperform, and where sensory
conditions place them at a disadvantage. By considering the sensory and social
contexts, employers can improve the quality of work of older employees, extending
their participation in the labour market and improving their quality of life.
Finally, upon reading this chapter, one may be reminded of the seminal book by
Guthrie, “Even the Rat Was White: A Historical View of Psychology” (Guthrie
1976). Guthrie exposed how racist views shaped by studies in the early twentieth
century affected the implementation and analysis of intelligence assessment tools at
that time. Those studies suggested that the tone of skin was directly related to a
decline in cognitive performance, and were guided by implicit assumptions on (1)
test validity and (2) a racially-based decline in cognitive performance. Guthrie dem-
onstrates the devastating implications of such tests by citing the following conclu-
sions of a study by Philips, 1914: “If the Binet tests are at all a gauge of mentality,
it must follow that there is a difference in mentality between the coloured and the
white children. And this raises the question, should the two groups be instructed
under the same curriculum?” (as quoted in Guthrie 1976:55). We hope that we can
avoid repeating history, making the same mistakes in the twenty-rst century. If
researchers and clinicians acknowledge the current sensory and social biases of
cognitive testing in older adults, it will set us on a promising path towards the design
of more accurate assessment tools.
17 Ageism andNeuropsychological Tests

292
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