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Existing assessment and diagnostic tools

Diagnosis, assessment and treatment.

Overview of existing assessment and diagnostic tools

Little research has been dedicated to the development of culturally sensitive (or culturally fair) tools despite the huge increase in the number of older people from minority ethnic groups likely to develop dementia in the next few decades (Khan 2015, Næss and Moen 2015, Nielsen et al. 2015, Sagbakken et al. 2018). This is starting to change, with several assessment/diagnostic tools having been developed or tested in the last five years on people from minority ethnic groups with and without dementia in memory clinics in Denmark (Nielsen et al. 2013), in Berlin, Brussels, Copenhagen, Malmö, Oslo and Thessaloniki (Nielsen et al. 2018a & 2018b) and in Amsterdam (Goudsmit et al. 2016), as well as on illiterate Turkish immigrants in Copenhagen (Nielsen and Jørgensen 2013). People from a range of minority ethnic groups have been involved in these studies, including but not limited to people from Turkish, Moroccan, Surinamese, Polish, Pakistani, Albanian, Indian, Serbian, Bosnia-Herzegovinian, Macedonian and Russian ethnic communities. The pros and cons of some of the key tools are described below.

The Mini-Mental State Examination (MMSE)

The Mini-Mental State Examination (MMSE) was developed by Folstein and colleagues in the 1970s and remains one of the most widely used cognitive screening tests in Europe (Nielsen et al. 2011a). It has become a kind of gold standard as an initial test for possible signs of dementia and has been translated into numerous languages. Despite its high level of accuracy in identifying people with dementia and the fact that it is quick and easy to administer, it has been criticised for having a cultural, social, ethnic and educational bias (Parker and Philp 2004). The test requires arithmetical ability as well as reading and writing skills. For this reason, it is not suitable for people with a low level of education. Chaaya et al. (2016), suggests that it is not suitable for Arabic-speaking populations from the Eastern Mediterranean Region where a high proportion of older people are illiterate (hence also to many people from those regions having moved to Europe). As pointed out by a GP in relation to the use of the MMSE:

“It stops there already ... I have to invent half of the test. Which day are we today? Does every Moroccan illiterate housewife have to know that it is the 23rd of February? Does she have dementia because she cannot count backwards from 100?” (Berdai Chaouni and De Donder 2018, p.7).

There is a risk when using the MMSE of misdiagnosing people from minority ethnic groups. Consequently, researchers and clinicians have tried to develop or adapt other instruments for use with these groups of people.

Clock Drawing Test (CDT)

The Clock Drawing Test (CDT) requires people to draw a clock and fill in the numbers and draw the hands of the clock in the right place, sometimes using a pre-drawn circle. It is a measure of visuospatial functioning. Drawing a clock is often included in other cognitive screening tests.  According to Schulman (2000), the CDT is quick and easy to administer and hence quite popular with busy physicians. However, educational level does have an impact on its accuracy.  If people are not used to writing/drawing, or don’t use a clock regularly, they would be at a clear disadvantage.  Some studies have reported low education being associated with lower specificity (i.e. the percentage of people without dementia correctly being identified as not having dementia) and an unacceptably low level of sensitivity (the percentage of people who are correctly identified as having dementia) (Schulman 2000). Whilst this is a drawback to the test, it can be useful in cases where language, but not education, is a serious barrier to cognitive testing (Silverstone et al. 1993 in Schulman 2000).  Also, it has been found to be useful in helping people to understand that they have cognitive problems (e.g. in cases where they lack awareness or may be in denial).

Rowland Universal Dementia Assessment Scale (RUDAS)

The Rowland Universal Dementia Assessment Scale (RUDAS) is a short cognitive screening instrument which was developed in Australia in a multi-cultural setting (Storey et al. 2004). RUDAS is considered as being at least as accurate as the MMSE (in distinguishing between people with and without dementia) (Rowland et al. 2006).  It was designed to minimise the effects of cultural learning and language diversity on the assessment of cognitive performance.  RUDAS contains six short tests and takes about ten minutes to administer. Minimal training is required to use it and it is available in more than 30 languages (Naqvi et al. 2015). The tests include an assessment of body orientation, praxis (alternating hand movements), drawing (copying a cube), judgement (linked to crossing a busy road), memory (recalling four items from a shopping list) and language (naming animals) (Nielsen et al. 2018a).

The tests are generally considered as being relatively unaffected by gender, cultural background and language use (Naqvi et al. 2015). However, some studies have found that people with limited or no education do not perform well on the cube drawing and alternating hand movement tests (Nielsen et al. 2013 and 2018a, Chaaya et al. 2016).  In a recent study involving people with normal cognition, people with MCI and people with dementia from the non-Western migrant population in the Netherlands, an alternative visuospatial test was used for the RUDAS, which consisted of using matchsticks instead of a pencil to draw/copy the cube (as developed by Matute and colleagues in 2000). The researcher found that literacy did not significantly affect performance of the alternative task amongst the people with normal cognition and suggests that this test might be less challenging for people who are illiterate (Soumaya 2018).

On the basis of a five-country European assessment of RUDAS, Nielsen et al (2018a) suggest using an education-adjustment of scores when testing people with low levels of education. In addition, a study comparing the diagnostic accuracy of the RUDAS compared to the MMSE by Goudsmit et al. (2018), amongst a wide range of people from minority ethnic groups who had been referred to a geriatric outpatient clinic, recommended the RUDAS for use in a highly illiterate, culturally diverse geriatric outpatient population.

Cross-Cultural Dementia (CCD) screening tool

The Cross-Cultural Dementia (CCD) screening tool was developed in a general hospital in the Netherlands. It consists of three sub-tests designed to measure memory, mental speed and executive functioning. Goudsmit et al. (2016) recently tested this screening tool on people from six different ethnic groups, including Dutch. The series of tests measures memory (using coloured pictures of everyday household items), mental speed and inhibition (using line drawings of the sun and the moon) and mental speed and divided attention (using images resembling domino pieces). The various tasks involve recognising images that have been presented, naming as quickly as possible images of the sun and moon in the person’s own language, saying the word for sun when a moon is presented and vice versa (to measure the Stroop effect)[1] and linking up domino pieces according to the number of dots or by colour.

The CCD does not require knowledge of facts or the ability to read and write. It can be administered without the need for an interpreter or for the tester to speak the language of the person being tested as the test instruction are given to the person by a computer. Currently, instructions can be given in six languages: Dutch; Turkish; Moroccan-Arabic and Tarifit (two languages that are commonly spoken by Moroccans in the Netherlands); Sranantongo and Sarnámi-Hindustani. The influence of ethnicity, age and education on performance has been found to be small (Goudsmit et al. 2016). There were some differences in performance between the ethnic groups but when matched for age and education, the apparent ethnic differences were no longer significant. A difference in performance between ethnic groups on the Sun-Moon test was, according to the researchers, perhaps due to the words for sun and moon being longer in some languages (e.g. the word for sun is two syllables long in Turkish and only one syllable in Surinamese) (Goudsmit et al. 2016). Only a small number of people with dementia were included in the study and many found one of the tests (the dots test) too difficult, as did a few illiterate people in the control group. The researchers nevertheless conclude that the CDD is a promising and culture-fair test for the screening of cognitive impairment in older immigrants.

European Cross-Cultural Neuropsychological Test Battery (CNTB)

The European Cross-Cultural Neuropsychological Test Battery (CNTB) consists of a series of tests covering a range of functions (Nielsen et al. 2018b), namely:

  • RUDAS for the assessment of global cognitive function,
  • The Recall of Pictures Test (RPT), Enhanced Cue Recall (ECR) and recalling a semi-complex figure for the assessment of memory
  • Picture Naming Task, and animal and supermarket fluency (naming, within a minute, as many animals as possible or naming, within a minute, as many things as possible that can be bought in a supermarket) for the assessment of language
  • The Colour Trails Test (CTT), The Five Digit Test (FDT) and the Serial Threes Test (STT) (counting down from 20 by threes) for the assessment of executive functioning
  • Copying of Simple Figures, The Clock Drawing Test (CDT) (completing the drawing of a clock from a pre-drawn circle), the Clock Reading Test (CRT) (reading the time on a series of drawn clocks on which the clock hands show the time but there are no numbers) and copying a semi-complex figure for the assessment of visuospatial functioning

The CNTB takes about an hour to administer and can be done with or without an interpreter. It was tested on different ethnic groups in five European countries. The tests were carefully designed to minimise the need for translation and reading skills. Significant differences in performance were observed between the different ethnic groups on all measures except the RPT. Some groups performed better on some tasks than others. The Serial Threes Test, for example, was particularly difficult for the Turkish people (who had lower levels of education) but they performed better on the RPT. The RPT and ECR were unaffected by education. The RUDAS, however, was the only test that was not affected by ethnic group. The researchers suggest, based on their analysis of the findings, that the significant differences in performance between different ethnic groups were most likely due to educational differences rather than ethnicity or different levels of acculturation. They also concluded that further work was needed to develop a more effective assessment of language function within the CNTB (Nielsen et al. 2018b).

To conclude, individual test results obtained using such various tools should not be considered as stand-alone measures of cognitive function or to determine whether or not a person has dementia. There is, as yet, no tool or set of tools that is perfectly suited and completely adapted to the needs of people from minority ethnic groups, but great progress has been made. Ideally, a battery of tests should be used and the findings should be considered along with other elements of a complete diagnostic evaluation conducted by the relevant and qualified healthcare professionals.


[1] The Stroop effect is what happens when someone is asked to say the colour that a word is written in but not the word itself (e.g. if the word ‘blue’ is printed in red ink, the person should say ‘red’). This test was described in an article by JR Stroop (1935).

Key points

  • A range of tools are used to assess and diagnose dementia. Most of these are not suitable for use amongst people from minority ethnic groups. There is, as yet, no tool or set of tools that is perfectly suited and completely adapted to the needs of people from minority ethnic groups.
  • In recent years, researchers have looked at the pros and cons of some of the most commonly used tools with the aim of determining which are culturally fair, appropriate or neutral and hence suitable for use within minority ethnic communities.  This research has involved people from several minority ethnic groups in Europe.
  • The Mini-Mental State Examination (including translated versions) is one of the most widely-used cognitive screening tools in Europe. However, it has been criticised for having a cultural, social, ethnic and educational bias.
  • The Clock Drawing Test is quick and easy to use but scores tend to be affected by educational level.
  • The Rowland Universal Dementia Scale (RUDAS) is considered to be at least as accurate at the MMSE in identifying people who do or do not have dementia. The various sub-tests are generally unaffected by gender, cultural background and language. Educational level may influence scores on some sub-tests, but scores can be adjusted for education. An adapted version of one of the sub-tests may also be helpful in reducing educational bias.  The RUDAS can be used with people from all ethnic groups and is particularly suited to the assessment of people from minority ethnic groups.
  • The Cross-Cultural Dementia screening tool (CCD) does not require knowledge of any facts or the ability to read and write. Ethnicity, age and education have a very small influence on performance. The tool has not yet been tested on many people with dementia and many of those were involved in a study to evaluate the tool found one of the sub-tests too difficult, as did people who were illiterate.
  • The European Cross-Cultural Neuropsychological Test Battery (CNTB) includes a series of tests including the RUDAS and the Clock Drawing Test. The tests can be done with or without an interpreter and with minimum reading skills. With the exception of the RUDAS, there were considerable differences in performance between different ethnic groups. The researchers suggest that this was most probably linked to different levels of education between the groups. Further research will be carried out to determine whether this might have been the case and to improve the battery of tests.


  • Further research (together with necessary funding) is needed to develop culturally appropriate and assessment and diagnostic tools for dementia.
  • Pending the results of further, ongoing research, the RUDAS should be considered for the assessment and diagnosis of dementia in people from minority ethnic groups, perhaps in combination with other tests currently being developed.
  • Individual test results from various tools should not be considered as stand-alone measures of cognitive function or to determine whether or not a person has dementia.
  • The results of various tests need to be combined with a complete diagnostic evaluation conducted by qualified healthcare professionals.



Last Updated: Thursday 02 May 2019


  • Acknowledgements

    This report received funding under an operating grant from the European Union’s Health Programme (2014-2020) and from the Robert Bosch Stiftung. The content of the report represents the views of the author only and is his/her sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains
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