Академический Документы
Профессиональный Документы
Культура Документы
Copyright © 2006 INS. Published by Cambridge University Press. Printed in the USA.
DOI: 10.10170S1355617706060073
Abstract
Neuropsychological test results are affected by multiple factors, but usually age and education are the only variables
by which norms are stratified. Some authors have questioned whether these variables alone are sufficient (e.g.,
Marcopulos et al., 1997; Manly et al., 2002), since such norms have lead to problems, such as poor specificity for
African Americans on dementia screening devices (Fillenbaum et al., 1990). Recent research has shown that reading
ability, a measure of educational quality, attenuated racial differences in test performance (Manly et al., 2002). We
specifically examined whether reading ability would account for a greater amount of variance than education in
executive function tests in a population traditionally subject to poor educational quality. Results determined that
reading ability accounted for a significantly greater amount of variance than years of education for Letter-Number
Sequencing, Similarities, COWA, Trail Making Test, and Coloured Progressive Matrices. Reading ability was found
to significantly mediate the relationship between each of these tests and education. Animal naming appears to be
least affected by educational quality or quantity. These findings hold implications for the interpretation of
neuropsychological test results, especially in those exposed to substandard educational quality, and for the way that
test norms are constructed. (JINS, 2006, 12, 64–71.)
Keywords: Literacy, Dementia, Norms, Educational quality, African Americans, Aged
It has been previously discussed by researchers that when participants were not excluded based on cognition. Impli-
years of education are held constant, cognitive outcome cations for this are in the Discussion section. Twenty dol-
can vary substantially. For example, with reference to mak- lars cash was given to each participant as compensation for
ing corrections to normative values from one geographic his or her time.
region to another, Gurland and colleagues (1992) noted, Of the 100 participants tested, 97 were administered the
“implausible is the implication in these adjustment formu- WRAT-3 Reading scale. Time constraint was the only rea-
lae that a certain number of years of education in one son that 3 of the participants were not administered the
school system is equivalent [in psychometric influence] to WRAT-3. Because this scale was pivotal to the purpose of
the same number of years in a different educational sys- this study, only the 97 that were administered the measure
tem” (p. 108). There are also reported differences in edu- were included in analyses.
cational quality, such as student0teacher ratios, per pupil
expenditures, access to facilities, and the like that have
been shown to correlate significantly with standardized Apparatus
achievement scores (for a review, see Manly et al., 2002) Wide Range Achievement Test-3 (WRAT-3):
and by definition, educational outcomes. When one con- Reading (Wilkinson, 1993)
siders the influence of these idiosyncratic educational fac-
tors along with variance due to heritability and parental This is a test of word familiarity and sight reading ability
encouragement of education, it appears even more unlikely involving the pronunciation of a series of 15 letters of the
that equivalent years of education will necessarily yield alphabet and 42 increasingly difficult words. A maximum
equivalent cognitive outcomes. score of 57 is possible. As reported in Spreen and Strauss
Because other research studies have found success using (1998), it has been useful in estimating premorbid intelli-
reading ability to explain excess variance in test scores gence, and moderately relates to WAIS-R IQ scores (Grif-
beyond age and years of education, this study aimed to fin et al., 2002).
examine the impact that reading ability has specifically on
executive function (EF) tests. As the participants in this Verbal Fluency (Benton & Hamsher, 1976)
study were specifically older adults, EF tests were chosen
This series of brief tests involves rapidly naming items that
due to their early decline resulting from frontal lobe atro-
fit a description provided by the administrator. This test
phy in normal aging (e.g., Double et al., 1996).
utilized both Controlled Oral Word Association (COWA-
In light of these findings, the following hypotheses will
Letters 0C0, 0F0, 0L0) and category fluency (Animal Nam-
be tested by this study: (1) Reading ability will account for
ing). A principal components analysis (Marcie et al., 1993)
significant variance in EF tests above and beyond that
found verbal fluency to load onto an “abstract mental oper-
accounted for by education. (2) Reading ability will statis-
ations” factor, along with other tasks such as mental calcu-
tically mediate the relationship between education and EF
lations and Digit Span. As reviewed by Lezak (1995), frontal
tests.
lobe lesions are consistently linked to lowered verbal flu-
ency output, although there is some evidence that the task is
mediated by the temporal lobes as well as the frontal.
METHOD
Wechsler Adult Intelligence Scale-III
Research Participants (WAIS-III): Similarities (Wechsler, 1997)
One hundred participants were recruited from the city of This task involves the presentation of 19 increasingly dis-
Detroit; all were between the ages of 59 and 95. Partici- parate pairs of words (e.g., dog and lion). Participants are
pants were recruited from various independent living cen- asked to state how the two words are alike. A maximum of
ters and community centers, through the distribution of flyers score of 33 is possible. The number of errors on this task
and by word of mouth. Participant education ranged from 5 has been implicated as an indication of dysexecutive syn-
to 20 years. Ninety-three percent were African American drome seen in dementing disorders (Giovannetti et al., 2001).
and 81.4% were female. This reflects a slightly greater pro- The Similarities subtest has been used in many studies as a
portion of females than in the Detroit older adult cohort, measure of executive function (see Giovannetti et al., 2001).
which is 70% female (Chaplewski, 2002), but is not incon-
sistent with other studies of older, African American adults WAIS-III: Letter-Number Sequencing
(e.g., Albert & Teresi, 1999; Manly et al., 2002).
(Wechsler, 1997)
No special inclusion or exclusion criteria were enforced,
with the exception that participants must be above age 59 Participants are read a series of numbers and letters, and are
and native English speakers. Willing participants who were instructed to mentally rearrange the digits so that the num-
sufficiently cognizant to understand and comply with instruc- bers are said in order, followed by the letters said in alpha-
tions were admitted to the study. Because this study was betical order. Participants begin by manipulating 2 digits,
interested in the influence reading ability had on all people, and work up to 8 digits or until they meet discontinue cri-
66 A. Schafer-Johnson, L.J. Flicker, and P.A. Lichtenberg
teria. Maximum score is 21. Factor analyses have consis- first clock drawing has been purported to be more depen-
tently shown this subtest to be among those thought to tap dent on executive ability than the second; as such, it has
working memory (Wechsler, 1997; Ryan & Paolo, 2001), a also been found to be more highly correlated to the same
facility commonly associated with prefrontal, executive func- executive ability interview, as would be expected (Royall
tion (Loring, 1999). et al., 1998).
Table 1. Demographics and health characteristics of the sample listwise deletions are reported in the data that follows. As a
result of using listwise deletions for each regression that
n Mean0Percentage SD was conducted, individuals having missing data for the cri-
Age 97 72.34 7.89 terion variable were eliminated from that particular analy-
Education 97 12.34 3.12 sis. Because there were different regressions conducted for
Gender each EF variable, the specific individuals that were elimi-
Female 79 81.4% nated varied per analysis.
Male 18 18.6% Using the hierarchical regression analyses with pairwise
Ethnicity deletions, R 2 Change values were significant at Block 1 for
African American 91 93.8%
all executive function variables, indicating that all tests were
European American 4 4.1%
suspect to the effects of age and0or education. R 2 Change
Other 2 2.1%
Medical history significant for was significant in Block 2 for WAIS-III Letter-Number
Stroke 21 21.6% Sequencing, COWA, Coloured Progressive Matrices, WAIS-
TIA 10 10.3 III Similarities, and Trail Making Test B, indicating that for
Hypertension 67 69.1% these 5 tests there was additional variance to be explained
Diabetes 27 27.8% by reading ability even after variance due to age and edu-
Head injury w0LOC 5 5.2% cation had been partialled out. See Table 3.
Heart Attack 14 14.4% The beta values in Table 4 reveal that after the addition of
Parkinson’s disease 2 2.1% reading ability in Block 2, correlations between test scores
Huntington’s disease 0 0% and years of education were reduced to nonsignificance.
Multiple sclerosis 1 1.0%
Since the relationship between years of education and exec-
utive function tests was reduced to nonsignificance for sev-
eral of these variables when reading ability was entered
into the regression, it is thought that reading ability may
that a sizable proportion (21.6%) of the participants had mediate their relationship. Reading ability’s significance as
previously experienced strokes. Because of this, the analy- a mediator was tested via the Sobel (1988) method, as out-
ses were conducted with and without those with stroke his- lined by Holmbeck (2002). This method examines the rela-
tory. As no differences in data interpretation were found, tionship between the predictor and criterion variables and
participants with strokes remained in this study. determines whether any drop in effect size resulting from
CLOX 1, CLOX 2, and Trail Making Test A were signif- the addition of the mediator variable is statistically signifi-
icantly skewed. Both CLOX 1 and CLOX 2 had a single cant. It was not expected that reading ability would act as a
low outlying variable; the deletion of these variables elim- mediator between years of education and test score for any
inated significant negative skew. Significant positive skew- of the EF tests that were not significantly influenced by
ness remained for Trail Making Test A even after eliminating reading ability—by definition this would counter the mean-
its outlier; consequently, the square root of this variable ing of mediation. Indeed, none was significant. The rela-
was taken to transform the variable into one with a normal tionships between the remaining EF tests and education
distribution. Listwise and pairwise regressions were both were dropped to nonsignificance upon the entry of WRAT-3
examined in the following analyses, and no difference was Reading score; each of these decreases was shown to be
found between them; subsequently, the more conservative statistically significant at p , .05. Z-scores for the indirect
effects and the percent of the relationship mediated by read-
ing ability are illustrated in Table 5.
Lastly, an analysis was conducted to determine how well
Table 2. Sample test results
the reported educational attainment of our participants cor-
n Mean SD responded with their demonstrated reading ability. Educa-
tion and reading ability scores were correlated at r 5 .58
WRAT Reading 97 39.87 7.03
( p , .01). Of our participants, 73.19% (n 5 71) read at a
Letter-Number 94 6.64 2.82
COWA 95 26.73 11.22
grade level below their stated educational attainment, 19.59%
Animal Naming 93 13.41 4.34 (n 5 19) read at a grade level approximately equivalent to
CPM 95 23.00 6.21 their stated educational attainment, and 7.22% (n 5 7) read
CLOX 1 90 10.38 2.42 at a grade level above their educational attainment. See
CLOX 2 90 12.28 2.14 Figure 1 for a distribution of how these participants’ read-
Similarities 89 13.98 7.00 ing levels differ from their educational attainment. People
Trails A 89 79.94 44.09 who had between 9 and 12 years of education were consid-
Trails B 88 180.16 84.03 ered to be reading at grade level if they read at a “high
school” equivalency. Likewise, people with 13 years of edu-
Note. Letter-Number 5 WAIS–III Letter-Number Sequencing, COWA 5
Controlled Oral Word Association Test, CPM 5 Coloured Progressive cation or more were considered to read at grade level if they
Matrices, Similarities 5 WAIS–III Similarities. read at “post high school” equivalency. These truncations
68 A. Schafer-Johnson, L.J. Flicker, and P.A. Lichtenberg
Note. LN 5 WAIS-III Letter-Number Sequencing, COWA 5 Controlled Oral Word Association Test, ANI 5 Animal Naming, CPM 5 Coloured Progres-
sive Matrices, CLX1 5 Royall’s CLOX 1, CLX2 5 Royall’s CLOX 2, SIM 5 WAIS-III Similarities, TMTA 5 Trail Making Test A (transformed), TMTB 5
Trail Making Test B.
*Trend at p , .05 level (2-tailed).
**Significant at p , .01 level (2-tailed).
are necessary, as the WRAT-3 manual does not individuate contributed to the literature through its second aim—its
into specific reading-level equivalency past eighth grade statistical demonstration that the relationship between test
but compiles scores into the aforementioned “high school” performance and years of education is significantly medi-
and “post high school” categories. Because of these trunca- ated by a measure of educational quality. For one test
tions in reading levels, considering absolute differences (COWA), as much as 98.81% of its relationship with years
between scores is cautioned against. of education was explained by reading ability.
While reading ability did account for significant variance
on 6 tests, it did not for 3 others. Specifically, Animal Nam-
DISCUSSION
ing, CLOX 1, and CLOX 2 were not related to reading
This study determined that reading ability—a purported mea- ability. It may be that the concepts behind Animal Naming
sure of educational quality—accounted for significant vari- and CLOX are simpler than that of other tests. If they are
ance in several executive function tests above and beyond conceptually more easy to understand than the other tests
the variance explained by years of education. When reading and do not require much capacity for abstraction, the qual-
ability was added in a hierarchical regression, the relation- ity of one’s education may not make a difference. Alterna-
ships between years of education and most EF variables tively, it seems possible that drawing a clock (CLOX) and
(namely WAIS-III Letter-Number Sequencing and Similar- listing species of animals (Animal Naming) are more famil-
ities, COWA, Coloured Progressive Matrices, and the Trail iar and less anxiety-provoking than other tasks.
Making Test) were no longer significant. This was consis- Although there are some past studies that used reading
tent with the prediction that reading ability would have a ability as a predictor of test performance, these are rela-
greater influence on test performance and would explain tively limited thus far. Albert and Teresi (1999) found read-
more variance than simple educational quantity. Manly and ing ability to be a significant, independent predictor of Mini-
colleagues have done a great deal of research in this area; Mental State Exam (MMSE) performance even when years
the present study, however, demonstrates this effect with a of education were included in the equation. As mentioned
larger variety of tests specific to executive abilities. It also earlier, Manly and colleagues (2002) found that many dif-
Fig. 1. Difference between reading grade level and educational attainment plotted as a function of educational attainment.
ferences between racial groups on neuropsychological tests cantly affects test performance, variance among people
were reduced to nonsignificance when reading score was with the same amount of education is likely to impact test
introduced as a covariate. This included memory tests, EF interpretation.
tests (specifically, WAIS-R Similarities and DRS Identities There are obvious clinical implications of these results,
and Oddities), a visuospatial matching task, and language as well. If individuals score poorly on such measures because
tasks. In a 2004 follow-up study, this group determined that the measures are heavily dependent on reading ability, their
reading ability was still the best predictor of test perfor- performance may erroneously be considered a pathological
mance even after a measure of acculturation was added to sign. Although attempts to control for such issues have been
their regression. Along with the Boston Naming Test, COWA made by stratifying some norms by educational level, this
and Similarities were the variables most affected by read- and other studies reviewed here demonstrate the deficien-
ing ability. cies of this approach because educational attainment often
The implications of this study are numerous. It demon- does not reflect underlying cognitive abilities. For exam-
strated that there is a great deal of variance in cognitive ple, a person reporting twelve years of education may only
ability even when educational attainment is held constant. have learned to read at a sixth grade level, and his or her
This is illustrated well by Figure 1. For this particular cohort, other cognitive abilities may also be consistent with that of
it was found that reading ability was much lower than someone having six years of education.
expected based on the participant’s reported educational This begs the question of whether there are tests that are
attainment, and it seems likely that other cognitive abilities appropriate to use with persons of poor reading ability and0or
(e.g., mathematical ability, reading comprehension) would persons who have received an overall substandard educa-
be below grade-equivalency. Other studies have also found tional experience. This study determined that category flu-
this to be the case: Using a sample of African American ency and a clock drawing test were not influenced by reading
participants, Albert and Teresi (1999) found approximately ability. Because clinicians are likely to continue using tests
50% read at a level lower than grade-equivalency, and Manly that have a significant relationship with educational quality,
and colleagues (2002) found this for 33% of its African it would behoove them to use reading level to estimate
American participants. The present study found that 73% premorbid intelligence. They would be able to make more
of its participants read at a level lower than expected based accurate interpretations by taking the reading level of the
on educational attainment. Thus, although many studies patient into consideration.
assume approximate equivalence in educational outcomes Finally, there are implications for norm development.
between people having equivalent educational quantity, sev- There are substantial problems with current norm develop-
eral studies including the present have demonstrated that ment as demonstrated by both the vast disparity between
this is often not the case. Considering that educational actual ability and expectations based on educational attain-
quality (operationalized here by reading ability) signifi- ment, and the interethnic differences resulting from the use
70 A. Schafer-Johnson, L.J. Flicker, and P.A. Lichtenberg
of current norms. As reading ability explains a greater amount reading measure correlates with g and g correlates well
of the variance in test scores compared to educational attain- with most standardized tests (e.g., Diaz-Asper et al., 2004),
ment (and largely mediates the relationship between years it is entirely possible that a measure of reading ability pre-
of education and test scores), designing norms stratified in dicts well to all cognitive tests because of the issue of inter-
part by reading ability would lead to more accurate test correlation. Even if it is no more than a proxy for g, reading
interpretation. This would be easy to accomplish, as sight ability is still quick and easy to ascertain, and unlike most
reading tests such as WRAT-3 Reading are quick and pain- other cognitive measures is considered a “hold” test in that
less to administer, making it simple for both researchers to it does not endure clinically significant declines early in
include them in norm development and clinicians to include most neurocognitive disorders, including mild to moderate
them for interpretation. dementia (Johnstone & Wilhelm, 1996; Schmand et al.,
Understanding educational quality seems to be an espe- 1998).
cially important issue for African Americans and poten- Reading level is not the panacea for poor norms. Through
tially for other ethnic minority groups, as well. In their its use we can make more accurate interpretations of test
2002 study, Manly and colleagues found that only 7% of data. Although covarying by reading ability attenuated sig-
their European American participants read below stated grade nificant differences between whites and African Americans
level compared to 33% of African Americans. Ours, too, on neuropsychological tests, racial disparities still existed
was an older cohort, many of whom anecdotally related (Manly et al., 2002). Further research ought to be directed
having been raised in the southern U.S. before moving to at uncovering which covariates further narrow this racial
Detroit. As such, many older African Americans were edu- gap.
cated in the “separate but equal” conditions prior to the
Brown vs. the Board of Education ruling. The quality of ACKNOWLEDGMENTS
their educational experience was certainly poorer than that
of their white peers, as can be seen by the high student-to- We are grateful to our participants in the Detroit community and
teacher ratios, low per student expenditures, less access to others who helped connect us with participants, including staff
facilities, fewer hours in the school week, and poorer teacher members at Joseph Walker Williams Community Center, Hannan
quality compared to predominantly white schools (U.S. House, Arnold Home, and Brush Park Manor. The professional
and technical support of Coletta Nelson-Thomas, Annmarie Cano,
Department of Health, Education, and Welfare, 1966). This
Scott Moffat, Paul Cernin, and Thomas Jankowski is also appre-
substandard educational experience may also be the reason ciated. Financial support for this research was provided by inter-
that such a large percentage of African Americans are read- nal funds of the Wayne State University Institute of Gerontology.
ing below grade equivalency in several samples. This phe-
nomenon is certainly not limited to African Americans and
other minority groups, however. Note that 7% of the white REFERENCES
sample in Manly and colleagues’ (2002) study also read at Albert, S.M. & Teresi, J.A. (1999). Reading ability, education, and
expected grade equivalency. The base rate of any education- cognitive status assessment among older adults in Harlem, New
ability discrepancy will vary based on quality of the educa- York City. American Journal of Public Health, 89, 95–97.
tional experiences of any population. Benton, A.L. & Hamsher, K. (1976). Multilingual Aphasia Exam-
There are limitations to this study. Participant selection ination. Iowa City: University of Iowa.
is one of these, as we accepted participants using relatively Chaplewski, E. (2002). Facing the future: City of Detroit needs
few exclusion criteria. Therefore, there were participants assessment of older adults. Detroit, MI: Department of Senior
Citizens.
with histories of stroke, transient ischemic attack, head injury,
Diaz-Asper, C.M., Schretlen, D.J., & Pearlson, G.D. (2004). How
and probably MCI or early dementia. Based on previous well does IQ predict neuropsychological test performance in
findings, reading ability scores should hold for all of these normal adults? Journal of the International Neuropsychologi-
groups (Johnstone & Wilhelm, 1996), although the EF scores cal Society, 10, 82–90.
of some may have been negatively affected by pathology. Double, K.L., Halliday, G.M., Kril, J.J., Harasty, J.A., Cullen, K.,
As these findings may not be universal across the lifespan, Brooks, W.S., Creasey, H., & Broe, G.A. (1996). Topography
another limitation of this study was that it included only of brain atrophy during normal aging and Alzheimer’s Disease.
older adults. Neurobiology of Aging, 17, 513–521.
A final caveat about these research findings: While sev- Fillenbaum, G., Heyman, A., William, K., Prosnitz, B., & Bur-
eral researchers have connected reading ability to educa- chett, B. (1990). Sensitivity and specificity of standardized
tional quality (e.g., Greenwald et al., 1996; Wilkinson, 1993; screens of cognitive impairment and dementia among elderly
black and white community residents. Journal of Clinical Epi-
Manly et al., 2002), reading ability may be correlated to all
demiology, 43, 651– 660.
of these measures not because of its properties as a measure Froehlich, T.E., Bogardus, S.T., & Inouye, S.K. (2001). Dementia
of educational quality but because of the relationship it has and race: Are there differences between African Americans
with g. Reading ability is highly correlated with IQ scores. and Caucasians? Journal of the American Geriatrics Society,
Griffin et al. (2002) found a correlation between WAIS-R 49, 477– 484.
FSIQ and WRAT-3 reading of r 5 .63 ( p , .001), while Giovannetti, T., Lamar, M., Cloud, B.S., Swenson, R., Fein, D.,
Wilkinson (1993) reported a correlation of .53. Since our Kaplan, E., & Libon, D.J. (2001). Different underlying mech-
Reading ability and executive function tasks 71
anisms for deficits in concept formation in dementia. Archives gressive Matrices: Its usefulness for identifying gifted0talented
of Clinical Neuropsychology, 16, 547–560. students. Roeper Review, 15, 183–186.
Greenwald, R., Hedges, L.V., & Laine, R.D. (1996). The effect of Raven, J. (1965). The Coloured Progressive Matrices Test. Lon-
school resources on student achievement. Review of Educa- don: Lewis Publishers.
tional Research, 66, 361–396. Reitan, R. & Wolfson, D. (1985). The Halstead-Reitan Neurolog-
Griffin, S.L., Mindt, M.R., Rankin, E.J., Ritchie, A.J., & Scott, ical Test Battery: Theory and clinical interpretation. Tucson,
J.G. (2002). Estimating premorbid intelligence: Comparison of AZ: Neuropsychology Press.
traditional and contemporary methods across the intelligence Reynolds, C.R., Chastain, R.L., Kaufman, A.S., & McLean, J.E.
continuum. Archives of Clinical Neuropsychology, 17, 497–507. (1987). Demographic characteristics and IQ among adults:Analy-
Gurland, B.J., Wilder, D.E., Cross, P., Teresi, J., & Barrett, V.W. sis of the WAIS-R standardization sample as a function of the
(1992). Screening scales for dementia: Toward reconciliation stratification variables. Journal of School Psychology, 25,
of conflicting cross-cultural findings. International Journal of 323–342.
Geriatric Psychiatry, 7, 105–113. Royall, D.R., Cabello, M., & Polk, M.J. (1998). Executive dys-
Holmbeck, G.N. (2002). Post-hoc probing of significant modera- control: An important factor affecting the level of care received
tional and mediational effects in studies of pediatric popula- by older retirees. Journal of the American Geriatrics Society,
tions. Journal of Pediatric Psychology, 27, 87–96. 46, 1519–1524.
Loring, D.W. (Ed.). (1999). INS dictionary of neuropsychology. Royall, D.R., Mulroy, A.R., Chiodo, L.K., & Polk, M.J. (1999).
New York: Oxford University Press. Clock drawing is sensitive to executive control: A comparison
Johnstone, B. & Wilhelm, K.L. (1996). The longitudinal stability of six methods. Journal of Gerontology: Psychological Sci-
of the WRAT-R Reading subtest: Is it an appropriate estimate ences, 54B, 328–333.
of premorbid intelligence? Journal of the International Neuro- Ryan, J.J. & Paolo, A.M. (2001). Exploratory factor analysis of the
psychological Society, 2, 282–285. WAIS-II in a mixed patient sample. Archives of Clinical Neuro-
Lezak, M.D. (1995). Neuropsychological assessment (3rd ed.). psychology, 16, 151–156.
New York: Oxford University Press. Schmand, B., Geerlings, M.I., Jonker, C., & Lindeboom, J. (1998).
Manly, J.J., Jacobs, D.M., Touradji, P., Small, S.A., & Stern, Y. Reading ability as an estimator of premorbid intelligence: Does
(2002). Reading level attenuates difference in neuropsycholog- it remain stable in emergent dementia? Journal of Clinical and
ical test performance between African American and White Experimental Neuropsychology, 20, 42–51.
elders. Journal of the International Neuropsychological Soci- Sobel, M.E. (1988). Direct and indirect effect in linear structural
ety, 8, 341–348. equation models. In J.S. Long (Ed.), Common problems 0
Manly, J.J., Byrd, D.A., & Touradji, P. (2004). Acculturation, read- proper solutions: Avoiding error in quantitative research
ing level, and neuropsychological test performance among Afri- (pp. 46– 64). Beverly Hills, CA: Sage.
can American elders. Applied Neuropsychology, 11, 37– 46. Spreen, O. & Strauss, E. (1998). A compendium of neuropsycho-
Marcie, P., Roudier, M., Goldblum, M., & Boller, F. (1993). Prin- logical tests: Administration, norms, and commentary. New
cipal component analysis of language performances in Alzhei- York: Oxford University Press.
mer’s disease. Journal of Communication Disorders, 26, 53– 63. U.S. Department of Health, Education, and Welfare. (1966). Equal-
Marcopulos, B.A., McLain, C.A., & Giuliano, A.J. (1997). Cog- ity of educational opportunity. Washington, DC: U.S. Govern-
nitive impairment or inadequate norms? A study of healthy, ment Printing Office.
rural, older adults with limited education. The Clinical Neuro- Wechsler, D. (1997). Wechsler Adult Intelligence Scale–Third
psychologist, 11, 111–131. Edition. San Antonio, TX: Harcourt Brace.
Mast, B.T., Fitzgerald, J., Steinberg, J., MacNeill, S.E., & Licht- Welsh, K.A., Fillenbaum, G., Wilkinson, W., Heyman, A., Mohs,
enberg, P.A. (2001). Effective screening for Alzheimer’s R.C., Stern, Y., Harrell, L., Edland, S.D., & Beekly, D. (1995).
disease among older African Americans. The Clinical Neuro- Neuropsychological test performance in African-American
psychologist, 15, 196–202. and white patients with Alzheimer’s disease. Neurology, 45,
Miles, T.P. (2001). Dementia, race, and education: A cautionary 2207–2211.
note for clinicians and researchers. Journal of the American Wilkinson, G.S. (1993). WRAT-3 administration manual. Wilm-
Geriatrics Society, 49, 490. ington, Delaware: Wide Range.
Mills, C.J., Ablard, K.E., & Brody, L.E. (1993). The Raven’s Pro-