Mirza et al. BMC Medical Research Methodology (2017) 17:141
DOI 10.1186/s12874-017-0413-6
RESEARCH ARTICLE
Open Access
Reporting of the translation and cultural
adaptation procedures of the
Addenbrooke’s Cognitive Examination
version III (ACE-III) and its predecessors: a
systematic review
Nadine Mirza1, Maria Panagioti1, Muhammad Wali Waheed2 and Waquas Waheed1*
Abstract
Background: The ACE-III, a gold standard for screening cognitive impairment, is restricted by language and culture,
with no uniform set of guidelines for its adaptation. To develop guidelines a compilation of all the adaptation
procedures undertaken by adapters of the ACE-III and its predecessors is needed.
Methods: We searched EMBASE, Medline and PsychINFO and screened publications from a previous review. We
included publications on adapted versions of the ACE-III and its predecessors, extracting translation and cultural
adaptation procedures and assessing their quality.
Results: We deemed 32 papers suitable for analysis. 7 translation steps were identified and we determined which
items of the ACE-III are culturally dependent.
Conclusions: This review lists all adaptations of the ACE, ACE-R and ACE-III, rates the reporting of their adaptation
procedures and summarises adaptation procedures into steps that can be undertaken by adapters.
Keywords: Cognitive assessment, cognitive impairment, cognitive screening test, dementia, diagnosis, primary care,
systematic review, cultural adaptation, translation, language
Background
The Addenbrooke’s Cognitive Examination (ACE) [1]
was developed in 1990 to act as a screening tool for detecting cognitive impairment while also incorporating
the Mini Mental State Examination (MMSE) [2]. It was
designed to assess the five cognitive domains attention,
memory, verbal fluency, language and visuospatial abilities, as well as provide an overall indication of cognitive
function. It was later updated in 2006 to account for
cross cultural usage and improved sensitivity [3], resulting in the development of the Addenbrooke’s Cognitive
Examination Revised (ACE-R) [4]. However, the ACE-R
contained items that incorrectly indicated cognitive
* Correspondence: waquas.waheed@manchester.ac.uk
1
Centre for Primary Care, The University of Manchester, Suite 6, 5th Floor,
Williamson Building, Oxford Road, Manchester M13 9PL, UK
Full list of author information is available at the end of the article
impairment and these were corrected in 2012, with sections of the MMSE removed due to copyright issues [5],
resulting in the recent Addenbrooke’s Cognitive Examination Version III (ACE-III) [6].
The ACE-III is regarded as the gold standard for the
screening and diagnostic accuracy of cognitive impairment [5]. It consists of 19 items, takes 15–20 min to administer and 5 min to score, scores being out of 100,
and a higher score indicating healthier cognitive functioning [6, 7]. The ACE-III retains many of the items
originally found in the ACE-R and the ACE, and is considered a comprehensive screening tool for cognitive impairment [5], comparing favourably to other standard
neuropsychological tests [8]. It is not surprising therefore, that all three versions of the ACE [1, 4, 6] have
been translated into various languages and are used
widely across the globe. However, the ACE-III and its
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Mirza et al. BMC Medical Research Methodology (2017) 17:141
predecessors [1, 4, 6] have a key limitation. They have
been designed for fluent English speakers aware of the
cultural norms of the country where it was developed.
Specific items such as verbal fluency and language require participants to read, speak, write and understand
English [9–11].
Several translation and cultural adaptation procedures
to produce suitable versions of psychometric instruments [1, 4, 6] are evidenced in the literature but there
is an absence of a uniform set of guidelines to conduct
the translation and adaptation of these instruments. The
case of the ACE-III is not an exemption. At present,
there is no formal guidance on the steps that should be
undertaken in translating the ACE-III and its predecessors [1, 4, 6] into any given language and no official indication given as to which items of the ACE, ACE-R and
ACE-III are culturally independent and which are culturally dependent and therefore may require a certain
process to be appropriately adapted. The adaptation procedures for the ACE-III are fully dependent on replicating the procedures reported in previously published
ACE adaptations. Yet, to the extent of our knowledge,
there is no existing compilation of all the translation and
culturally adaption procedures.
An important step for producing evidenced-based
guidelines for the translation and cultural adaptation of
the ACE-III is to conduct a systematic compilation of all
the translation and culturally adaptation procedures
undertaken by existing published versions of the ACE,
ACE-R and ACE-III. This systematic review aims to
meet this challenge. In this endeavour, we paid particular
attention to recording the translation and cultural adaptation procedures reported by each publication because
our primary focus was to identify the translation and
cultural adaptation steps and processes and which items
are deemed culturally dependent in which publication.
To undertake this process as robustly as possible, we utilised two scales that assess the quality of reported
translation and cultural adaptation, the Manchester
Translation Reporting Questionnaire (MTRQ) and
Manchester Cultural Adaptation Reporting Questionnaire (MCAR). These scales were applied to each publication to determine which report a procedure that can
be successfully replicated by future cultural adapters of
the ACE-III. We were able to produce a successful systematic review that lists all the existing translations and
cultural adaptations of the ACE, ACE-R and ACE-III
[1, 4, 6], and were able to rate all the reporting of their
translation and cultural adaptation procedures on reliable scales that we have developed for public use. We
were also able to extract all translation and cultural
adaptation procedures from these publications, break
them down and summarise them to allow for an understanding of what steps are most commonly undertaken
Page 2 of 10
by adapters. Such steps can be undertaken by future
adapters when translating or culturally adapting the
ACE-III for their purposes.
Methods
Our methods followed a previously conducted systematic
review and a meta-analysis of the Addenbrooke’s Cognitive Examination (ACE) and its revised version (ACE-R)
[12, 13]. The guidelines on the reporting of systematic
reviews in the PRISMA statement were followed [14].
Search criteria
Due to the nature of the review the search was conducted using health care based electronic databases
EMBASE, Medline and PsychINFO. The search terms
were “addenbrooke's cognitive examination or ace-iii or
screen* or test or instrument or measure or tool or diagnos*”, “dementia or Alzheimer* or cognitive”, and “sensitivity and specificity or accuracy or cut-off or receiver
operator or ROC or Youden”. The search period was restricted from January 2013 to December 2015 as the first
paper on the Addenbrooke’s Cognitive Examination
Version III (ACE-III) was introduced in 2013 [6].
SCOPUS was also searched to locate publications that
have cited the original paper by Hsieh et al. [6]. The
search was run till 31st December 2016 to account for
any new publications that could potentially meet our
inclusion criteria but none were identified.
The searches were supplemented by screening all the
included and excluded studies of Larner and Mitchell’s
recent meta-analysis which examined the accuracy of
ACE and ACE-R [13].
Inclusion criteria
Publications that referred to translated and/or culturally
adapted versions of the ACE, the ACE-R and the ACEIII, from English into any other language, and were the
primary source of that version of the assessment, were
included.
Exclusion criteria
Publications that did not refer to a translated or culturally adapted version of the ACE, ACE-R or ACE-III were
excluded.
Study selection
The results of the searches in each database were
exported to Endnote and duplicates were removed.
Study selection was completed in two stages. First, the
titles and abstracts of the identified studies were
screened and subsequently the full-texts of relevant
studies were accessed and further screened against the
eligibility criteria. When the full texts were unavailable,
the authors of the publications were contacted to
Mirza et al. BMC Medical Research Methodology (2017) 17:141
provide additional information. A final attempt to obtain
the publications was by contacting the respective journals and putting in a request. The full text of publications was read through by two authors individually (NM
and MWW), who determined what language the ACE,
ACE-R or ACE-III had been adapted to and extracted
the section that described the translation and cultural
adaptation process. The translation and cultural adaptation steps were identified in each extraction and
separated.
Analysis
The reported translation procedure of each publication
was broken down into individual steps such that there
was no overlap between two steps. The steps of all the
publications were later merged and duplicates removed
to create a list of all potential steps that could take
place when translating the ACE, ACE-R and ACE-III.
Page 3 of 10
The reported cultural adaptation procedure of each
publication was reviewed to identify which questions
of the ACE, ACE-R and ACE-III were culturally
dependent and how each question was appropriately
adapted.
The quality of the reported translation and cultural
adaptation procedures were assessed through the MTRQ
and MCAR respectively. Both MTRQ and MCAR (See
Fig. 1) are seven point rating scales that were developed
at the Centre for Primary Care at the University of
Manchester to quantify the overall quality of reported
procedures undertaken in the translation or cultural
adaptation of any assessment, in particular, neuropsychological assessments. In the development of these
scales the quality of a described translation or cultural
adaptation procedure is considered dependent on the
extent to which it can be replicated successfully through
the information it provides.
Fig. 1 Manchester Translation Reporting Questionnaire (MTRQ) and Manchester Cultural Adaptation Reporting Questionnaire (MTRQ)
Mirza et al. BMC Medical Research Methodology (2017) 17:141
It is important to note that MTRQ and MCAR were designed to only account for reported translation and cultural adaptation procedures. Scores on the MTRQ and
MCAR cannot assess the quality of the actual translation
and cultural adaptation procedures that were potentially
undertaken by adapters, only the manner in which they
have reported it.
The reported translation and cultural adaptation procedures that were extracted by our two authors were also
assessed by these authors independently, using the MTRQ
and MCAR scales. At this stage an interrater reliability
analysis, using the Kappa statistic, was performed to determine consistency among raters for both scales [15]. Following this, scores between the two authors that did not
match were reviewed by a third author (WW) and a consensus was reached after discussion to determine the final
score to be assigned to that publication.
Fig. 2 Flow diagram of the search process (PRISMA; Moher et al. [14])
Page 4 of 10
Results
Search results
Our search identified 113 publications on the ACE, ACER and ACE-III (See Fig. 2 for the PRISMA flow diagram).
The abstracts of the publications were screened and 63
publications were excluded as they only focused on the
original English versions of the ACE, ACE-R and ACE-III
[1, 4, 6]. Full texts of the remaining 50 publications were
searched for, including contacting authors and journals, of
which two were not available to us. The remaining 48
publications were reviewed and 16 of these were excluded
as they were not the primary papers for their respective
non-English versions of the ACE, ACE-R and ACE-III.
After final application of the exclusion criteria, 32 papers
were deemed suitable for the analysis; 12 for ACE, 17 for
ACE-R and 3 for ACE-III (See Table 1 for details on the
papers that were analysed).
Authors
Year
ACE
Language
MTRQ
MCAR
Translation
Back
Translation
Alexopoulos et al. [16]
2006
ACE
German
4a
2a
X
X
Bier et al. [30]
2004
ACE
French
4a
2a
X
X
Custodio et al. [22]
2012
ACE
Peruvian Spanish
0
2a
Garcia-Caballero et al. [31]
2006
ACE
Spanish
2a
4a
X
Heo et al. [10]
2012
ACE
Korean
2a
4a
X
Hummelová-Fanfrdlová et al. [32]
2009
ACE
Czech
4a
2a
X
Mathuranath et al. [33]
2004
ACE
Malayalam
2a
4a
X
Newman. [28]
2006
ACE
Hebrew
2a
1
X
Pouretemad et al. [34]
2009
ACE
Persian
4a
4a
X
Sarasola et al. [25]
2004
ACE
Spanish
1
2a
Stokholm et al. [29]
2009
ACE
Danish
4a
2a
Users in coproduction
Expert
Recommendations
Revisions based on
step by step feedback
Involvement of
original authors
Pilot
Study
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Yoshida et al. [35]
2011
ACE
Japanese
4a
4a
X
X
Al-Salman. [9]
2013
ACE-R
Saudi Arabian
4a
4a
X
X
X
Alexopoulos et al. [36]
2010
ACE-R
German
4a
4a
X
Bartoš et al. [37]
2011
ACE-R
Czech
2a
4a
X
Bastide et al. [21]
2012
ACE-R
French
2b
2b
X
Carvalho et al. [38]
2007
ACE-R
Brazilian
4a
2a
X
X
X
X
X
X
Mirza et al. BMC Medical Research Methodology (2017) 17:141
Table 1 All publications identified by our analysis with the reported translation steps undertaken
X
X
X
Dos Santos Kawata et al. [23]
2012
ACE-R
Japanese
1
4a
Fang et al. [39]
2014
ACE-R
Chinese
2a
4a
X
Ferreira et al. [27]
2012
ACE-R
Portuguese
2a
0
X
Gondova et al. [18]
2012
ACE-R
Slovak
4a
4a
X
X
X
Konstantinopoulou et al. [40]
2011
ACE-R
Greek
4a
4a
X
X
X
Kwak et al. [24]
2010
ACE-R
Korean
1
1
Margevičiūtė et al. [41]
2013
ACE-R
Lithuanian
4a
2a
X
X
Munoz-Neira et al. [42]
2012
ACE-R
Chilean Spanish
2a
2a
X
X
X
X
X
X
X
X
Pigliautile et al. [19]
2011
ACE-R
Italian
4a
4a
X
X
Torralva et al. [43]
2011
ACE-R
Spanish
4a
2a
X
X
2013
ACE-R
Cantonese
2a
4a
X
2012
ACE-R
Japanese
2a
4a
X
X
Machado et al. [26]
2015
ACE-III
Portuguese
4a
0
X
X
Matias-Guiu et al. [11]
2015
ACE-III
Spanish
4a
4a
X
Qassem et al. [17]
2014
ACE-III
Egyptian Arabic
4a
2a
X
X
X
X
X
X
X
X
X
X
X
X
X
Page 5 of 10
Wong et al. [44]
Yoshida et al. [20]
X
Mirza et al. BMC Medical Research Methodology (2017) 17:141
Quality of translation and cultural adaptation reporting
The quality of the reported translation and cultural
adaptation procedures were rated on the MTRQ and
MCAR scales respectively (See Table 1 for the MTRQ
and MCAR scores of the papers that were accessible to
us in full text). The interrater reliability for the raters
regarding the MTRQ was found to be Kappa = 0.242
(p > 0.001), 95% CI (0.426, 0.058). The interrater reliability for the raters regarding the MCAR was found to be
Kappa = 0.581 (p < 0.001), 95% CI (0.797, 0.365) [15].
Reported translation and cultural adaptation
This review identified seven individual steps that can be
undertaken when translating the ACE, ACE-R and
ACE-III:
i. Translation: Direct translation, without any form of
cultural adaptation, from English into the target
language, often with the assistance of a native or
fluent speaker of the language or an official translator.
Eg. “Independently of one another, two members of
our group translated the ACE into German” [16].
ii. Back Translation: Creating a retroversion of the
initial translation, from the target language back to
English, often with the assistance of a native or
fluent speaker of the language or an official
translator. Eg. “First, the questionnaire was translated
into Arabic, and then back translated into English.
The process was then repeated until a consensus
was reached about the optimal translation” [17].
iii. Users in Coproduction: Potential or future users of
the assessment, such as those from a target
population, including native and fluent speakers of
the language, providing feedback or information in
any way that influences the development of the
translated assessment. Eg. “There were […]
cognitively healthy participants of age range 60–70
who were tested with Slovak ACE-R […]. Afterwards
the participants were asked for a feedback especially
on the questions where more possibilities were considered to be used in the final version” [18].
iv. Expert Recommendations: Experts on translation, the
target languages, or subject matters related to the
assessment providing feedback or information in any
way that influences the development of the translated
assessment. Eg. “A review committee composed by
two psychologists and two geriatricians chose the final
version of the Italian ACE-R” [19].
v. Revisions based on step-by-step feedback: Constant
and continuous revisions of the translated assessment developed whenever a change or suggestion is
proposed and approved. Eg. “At different points of
this process, members of the original team and
Spanish speakers, suggested modifications [19]”.
Page 6 of 10
vi. Involvement of the original authors: Authors of the
original assessment providing feedback or
information in any way that influences the
development of the translated assessment. Eg. “We
translated and modified ACE-R with advice from the
authors of the original version” [20].
vii. Pilot Study: Administering translated versions of the
assessment to assess its feasibility and acceptability
amongst potential users. Eg. “The ACE plus 1 of the
3 new ACE-R versions were administered to patients
who were examined by one of the authors (J.-C.B.)
at the ERASME Hospital Memory Clinic” [21].
Out of the 32 papers only one, Custodio et al. [22] did
not mention a translation process occurring at all,
resulting in a score of 0 on the MTRQ. 3 of the papers
(Dos Santos et al. [23], Kwak et al. [24], and Sarasola et
al. [25]) mentioned that a translation process took place
but not in enough detail to determine any individual
steps or elaborate on the process. This is reflected in
their receiving a score of 1 on the MTRQ.
Table 1 also shows the translation steps reported by
the remaining 28 papers, indicating the frequency with
which individual translation steps were reportedly
undertaken. Only one paper, Gondova et al. [18], reported undertaking all the potential steps for translating
that this review has identified. The remaining 27 papers
reportedly undertook translation steps in various combinations; Translation was undertaken by all the papers,
16 papers undertook back translation, 5 papers reported
users in coproduction, 7 papers approached experts for
recommendations, 9 papers made revisions based on
step-by-step feedback, 4 papers involved original authors
and 14 papers conducted pilot studies.
Out of the 32 Machado et al. [26] and Ferreira et al.
[27] did not mention a cultural adaptation process at all,
resulting in a score of 0 on the MCAR. 2 papers, Kwak
et al. [24] and Newman [28], mentioned that a cultural
adaptation process took place but did not describe it,
therefore receiving a score of 1 on the MCAR.
Table 2 shows which items of the ACE, ACE-R and
ACE-III were reportedly culturally adapted by which of
the remaining 28 papers, indicating the frequency with
which individual items were culturally adapted across
publications. Items 3: Attention and Concentration,
5b: Fluency - Animals, 15a: Visuospatial Abilities - Infinity Diagram, 15b: Visuospatial Abilities - Wire Cube
and 16: Visuospatial Abilities were not culturally
adapted across any of the papers as they only required
direct translation. The remaining items were culturally
adapted by various numbers of publications; Items 8:
Language – Comprehension and 9: Language –
Writing were culturally adapted in 1 paper, items 1:
Attention - Orientation, 2: Attention - Registration, 4:
Mirza et al. BMC Medical Research Methodology (2017) 17:141
Page 7 of 10
Table 2 The frequency of cultural adaptation per item of the ACE-III
Papers
6
7
10
11
I8
19
Alexopoulos et al. [16]
1
2
3
4
X
X
X
X
X
X
N/A
Bier et al. [30]
X
X
X
X
X
X
N/A
Custodio et al. [22]
X
X
X
X
X
N/A
Garcia-Caballero et al. [31]
X
X
X
X
X
X
N/A
X
X
X
X
X
X
N/A
Heo et al. [10]
5a
X
5b
8
9
12
13
14
15a
15b
15c
16
17
X
Hummelová-Fanfrdlová et al. [32]
N/A
X
X
X
X
X
X
X
X
X
X
X
X
Sarasola et al. [25]
X
X
X
X
Stokholm et al. [29]
X
Mathuranath et al. [33]
X
Pouretemad et al. [34]
Yoshida et al. [35]
X
Alexopoulos et al. [36]
X
Al-Salman [9]
Bartoš et al. [37]
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Gondova et al. [18]
X
X
X
Konstantinopoulou et al. [40]
X
X
X
Margevičiūtė et al. [41]
X
Munoz-Neira et al. [42]
X
X
X
X
X
Pigliautile et al. [19]
X
X
Torralva et al. [43]
X
N/A
X
X
X
X
X
X
X
N/A
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
N/A
X
X
X
X
X
X
X
Yoshida et al. [20]
Qassem et al. [17]
X
X
Wong et al. [44]
Matias-Guiu et al. [11]
N/A
N/A
X
X
X
X
X
X
Carvalho et al. [38]
Dos Santos Kawata et al. [23]
X
X
X
X
X
Bastide et al. [21]
Fang et al. [39]
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
The frequency of cultural adaptation:
1: Attention - Orientation. 2: Attention - Registration. 3: Attention and Concentration. 4: Memory - Recall. 5a: Fluency - Letters
5b: Fluency - Animals. 6: Memory - Anterograde. 7: Memory - Retrograde. 8: Language – Comprehension. 9: Language - Writing
10: Language - Repetition. 11: Language - Repetition. 12: Language - Naming. 13: Language - Comprehension 14: Language - Reading
15a: Visuospatial Abilities - Infinity Diagram. 15b: Visuospatial Abilities - Wire Cube. 15c: Visuospatial Abilities - Clock. 16: Visuospatial Abilities.
17: Visuospatial Abilities. 18: Memory - Recall. 19: Memory - Recognition
Memory – Recall and 15c: Visuospatial Abilities Clock in 2 papers, item 17: Visuospatial Abilities in 6
papers, items 5a: Fluency - Letters, 12: Language –
Naming and 13: Language - Comprehension in 10 papers, item 11: Language Repetition in 13 papers, item
14: Language – Reading in 20 papers, item 10:
Language - Repetition in 21 papers, item 7: Memory –
Retrograde in 23 papers, item 18: Memory - Recall in
26 papers and item 6: Memory - Anterograde was
culturally adapted in all 28 papers. Item 19: Memory Recognition does not exist in the ACE but was culturally adapted in 16 papers out of the 17 ACE-R and
ACE-III papers.
Out of the 32 papers that mentioned translation and
cultural adaptation procedures in some level of detail, 16
papers elaborated further on their processes in terms of
individuals involved. Table 3 further elaborates on who
these individuals were and which papers reported on
their involvement; 9 papers mentioned bilingual experts
and researchers, 6 papers mentioned psychiatrists and
psychologist, 3 papers mentioned accredited translators,
3 papers mentions experts in linguistics, 2 papers mentioned physicians and neurologists, 1 paper mentioned
geriatricians, 1 paper mentioned speech therapists, 1
paper mentioned care givers and 1 paper mentioned test
administrators.
Mirza et al. BMC Medical Research Methodology (2017) 17:141
Page 8 of 10
Table 3 Individuals reportedly involved in translation and cultural adaptation
Papers
Psychiatrist/ Physicians/ Geriatricians Bilingual experts/ Accredited Experts in Speech
Care Test
Psychologists Neurologists
researchers
translators linguistics therapists Givers Administrators
x
Alexopoulos et al. [16]
x
Bier et al. [30]
Heo et al. [12]
x
x
Hummelova-Fanfrdlova et
al. [32]
Pouretemad et al. [34]
x
x
Yoshida et al. [35]
Al-Salman [9]
x
x
x
Alexopoulos et al. [36]
x
Gondova et al. [18]
x
x
x
x
x
x
x
x
Konstantinopoulou
et al. [40]
Margevičiūtė et al. [41]
x
x
x
Wong et al. [44]
x
Yoshida et al. [20]
Machado et al. [26]
x
x
Bartoš et al. [37]
Pigliautile et al. [19]
x
x
x
Discussion and conclusions
Conclusively, our review summarises the reported
translation and cultural adaptation procedures of the
stated 32 publications, which can guide those who may
want to translate and adapt the ACE-III in future.
However, we were also able to successfully identify
which of these publications reported procedures in sufficient detail for potential adapters to be able to replicate the process (See Table 1) through utilisation of the
MTRQ and the MCAR. Inter rater reliability of the
MTRQ was found to be fair and for the MCAR was
found to be moderate [15], however, comparisons of
the scores with a third author as a mediator and better
understanding of the scales deemed the scores we
assigned in this review as suitable ratings for the ACE,
ACE-R and ACE-III publications. We can also determine from our scoring of the ACE, ACE-R and ACEIII publications, that the MTRQ and MCAR scores are
not dependent on one another; a publication may score
high on the MTRQ due to a high quality of reporting
of the translation procedure and low on the MCAR
due to a low quality of reporting of the cultural adaptation procedure and vice versa.
However, it is important to acknowledge that the
MTRQ and the MCAR cannot assess the quality of
translation or cultural adaptation of an assessment. As it
focuses only on the reporting of the translation and
adaptation procedure, not of the actual assessment itself,
it can only determine if the quality of reporting is of a
high standard. A publication may report the translation
and cultural adaptation procedure in sufficient detail for
it to be replicated, yet this may still result in the production of an inappropriate or poorly adapted assessment.
Or, as is the case with our review, we accounted for
translation steps and cultural adaptation processes that
were reported across the 32 full text publications we had
access to, not necessarily whether cultural adaptation or
translation took place. Adapters of each non-English version of the ACE, ACE-R and ACE-III may have translated the assessment and culturally adapted questions
and not mentioned it in their publications, resulting in a
score of 1 or 0.
Despite this, having access to scales that can assess the
quality of reporting of the translation and cultural adaptation procedures within publications provides future
adapters with a crucial starting point to determine which
publications’ procedures they should consider replicating, particularly when, as in the case of the ACE-III and
its predecessors, there are no formal guidelines or
instructions.
Overall, our review has provided an existing summation of all publications that introduce a translated and
culturally adapted version of the ACE, ACE-R and ACEIII. A complete list such as this is a point of referral for
designing future translation and cultural adaptations of
the ACE-III and to locate any currently existing versions.
However, we were not only able to identify all the existing publications, but also the translation and cultural
adaptation procedures reported within these publications in their entirety.
Mirza et al. BMC Medical Research Methodology (2017) 17:141
A full list of independent translation steps were identified and defined which can be undertaken by future
adapters and the frequency of the occurrence of each of
these steps across the publications that reported translation steps, both in sufficient and insufficient detail, has
been tabulated (See Table 1). We can see that direct
translation was the most common step, undertaken by
all the publications, followed by back translation, pilot
studies, revisions based on step by step feedback, expert
recommendations, users in coproduction and lastly, the
involvement of original authors, which was reportedly
only undertaken by four publications. The frequency of
the translations steps across publications will allow future adapters to make judgement calls regarding which
steps they may endeavour to undertake as this review
highlights the translation steps that previous adapters
sought to follow.
We were also able to identify which items were considered culturally dependent by which publications and
which items were most likely to be culturally adapted.
Table 2 successfully shows the frequency of reported cultural adaptation taking place across any non-English version of the ACE, ACE-R or ACE-III and for any given
item of the ACE, ACE-R or ACE-III. For example, item
6: Memory – Anterograde has been culturally adapted in
all 28 of the publications whereas item 15c: Visuospatial
Abilities – Clock has only been reportedly culturally
adapted in two publications. In the same way, Qassem et
al. [17] and Yoshida et al. [20] were reportedly the most
culturally adapted publications while Stokholm et al.
[29] was the least. This will indicate to future adapters
which items were prioritised for cultural adaptation by
previous adapters.
The knowledge of which individuals were involved in
the translation and cultural adaptation of each version
were also extracted and described in Table 3. This provides information regarding who these individuals were
most likely to be. This is particularly important as accurate replication of the reported translation and cultural
adaptation procedures can only occur with existing
knowledge of who was involved in adapting the assessment. Bilingual experts were most commonly involved,
having been mentioned in 9 publications, followed by
psychologists and psychiatrists, accredited translators,
linguistic experts and physicians and neurologists. Geriatricians, speech therapists, care givers and test administrators were only involved in one publication each.
Overall, we were able to produce a successful systematic
review that lists all the existing translations and cultural
adaptations of the ACE, ACE-R and ACE-III [1, 4, 6], and
were able to rate all the reporting of their translation and
cultural adaptation procedures on reliable scales that we
have developed for public use. We were also able to extract all translation and cultural adaptation procedures
Page 9 of 10
from these publications, break them down and summarise
them to allow for an understanding of what steps are most
commonly undertaken by adapters. Such steps can be
undertaken by future adapters when translating or culturally adapting the ACE-III for their purposes.
Acknowledgements
Alex J Mitchell, Andrew J Larner.
Funding
There were no sponsorship or funding arrangements relating to this research.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Authors’ contributions
NM was involved in the designing and running of the search, collated and
selected the studies, extracted the data, conducted the qualitative analysis and
wrote this review. MP was involved in the designing and running of the search
and assisted in the write up of the review. MWW extracted data and conducted
the qualitative analysis. WW was involved in the designing and running of the
search, approved the studies selected and the data extraction and oversaw the
analysis. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Not Applicable.
Consent for publication
Not Applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
Centre for Primary Care, The University of Manchester, Suite 6, 5th Floor,
Williamson Building, Oxford Road, Manchester M13 9PL, UK. 2The University
of Leicester, Leicester, UK.
1
Received: 10 May 2017 Accepted: 31 August 2017
References
1. Mathuranath PS, Nestor PJ, Berrios GE, Rakowicz W, Hodges JR. A brief
cognitive test battery to differentiate Alzheimer’s disease and
frontotemporal dementia. Neurology. 2000;55:1613–20.
2. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: A practical method
for grading the cognitive state of patients for the clinician. J Psychiatr Res.
1975;12:189–98.
3. Nooone P. Questionnaire review: Adenbrooke’s cognitive examination III.
Occup Med (Oxf). 2015;65:418–20.
4. Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges JR. The Addenbrooke’s
cognitive examination revised (ACE-R): a brief cognitive test battery for
dementia screening. Int J Geriatr Psychiatry. 2006;21:1078–85.
5. Cheung G, Clugston A, Croucher M, Malone D, Mau E, Sims A, Gee S.
Performance of three cognitive screening tools in a sample of older New
Zealanders. Int Psychogeriatr. 2015;27:981–9.
6. Hsieh S, Schubert S, Hoon C, Mioshi E, Hodges J. Validation of the
Addenbrooke’s cognitive examination III in frontotemporal dementia and
Alzheimer’s disease. Dement Geriatr Cogn Disord. 2013;36:242–50.
7. NeuRA 2012, www.neura.edu.au/frontier/research).
8. Velayudhan L, Ryu S, Raczek M, Philpot M, Lindesay J, Critchfield M,
Livingston G. Review of brief cognitive tests for patients with suspected
dementia. Int Psychogeriatr. 2014;26:1247–62.
Mirza et al. BMC Medical Research Methodology (2017) 17:141
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Al-Salman ASA. The Saudi Arabian adaptation of the Addenbrooke’s
cognitive examination revised (ACE-R). Glasgow: University Glasgow. 2013.
p. 40–65.
Heo JH, Lee KM, Park TH, Ahn JY, Kim MK. Validation of the Korean
Addenbrooke’s cognitive examination for diagnosing Alzheimer’s dementia
and mild cognitive impairment in the Korean elderly. Appl Neuropsychol.
2012;19:127–31.
Matias-Guiu JA, Fernández de Bobadill R, Escudero G, Pérez-Pérez J, Cortés
A, Morenas-Rodríguez E, Valles-Salgado M, Moreno-Ramos T, Kulisevsky J,
Matías-Guiu J. Validation of the Spanish version of Addenbrooke’s cognitive
examination III for diagnosing dementia. Neurologia. 30(9):545–51.
Crawford S, Whitnall L, Robertson J, Evans JJ. A systematic review of the
accuracy and clinical utility of the Addenbrooke’s cognitive examination
and the Addenbrooke’s cognitive examination revised in the diagnosis of
dementia. Int J Geriatr Psychiatry. 2012;27:659–69.
Larner AJ, Mitchell AJ. A meta-analysis of the accuracy of the Addenbrooke’s
cognitive examination (ACE) and the Addenbrooke’s cognitive examination
revised (ACE-R) in the detection of dementia. Int Psychogeriatr. 2014;26:555–63.
Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred
reporting items for Systematic Reviews and Meta-Analyses: The PRISMA
Statement. PLoS Med. 6(7):e1000097. https://doi.org/10.1371/journal.pmed.
1000097.
Landis JR, Koch GG. The measurement of observer agreement for
categorical data. Biometrics. 1977;33:159–74.
Alexopoulos P, Greim B, Nadler K, Martens U, Krecklow B, Domes G,
Herpertz S, Kurz A. Validation of the Addenbrooke’s cognitive examination
for detecting early Alzheimer’s disease and mild vascular dementia in a
German population. Dement Geriatr Cogn Disord. 2006;22:385–91.
Qassem T, Khater MS, Emara T, Tawfik HM, Rasheedy D, Mohammedin AS,
Tolba MF, Aziz KA: Translation and cross cultural adaptation of the
Addenbrooke’s cognitive examination III into Egyptian Arabic. Royal College
of Psychiatrists International Congress. 2014.
Gondova: Translation and Cultural Adaptation of the Addenbrooke’s
Cognitive Examination – Revised (ACE-R) for the Slovak Population. The
University of Edinburgh. 2012; 14–16.
Pigliautile M, Ricci M, Mioshi E, Ercolani S, Mangialache F, Monastero R,
Croce MF, Federici S, Mecocci P. Validation study of the Italian
Addenbrooke’s Cognitive Examination Revised in a young-old and old-old
population. Dement Geriatr Cogn Disord. 2011;32:301–7.
Yoshida H, Terada S, Honda H, Kishimoto Y, Takeda N, Oshima E, Hirayama
K, Yokota O, Uchitomi Y. Validation of the revised Addenbrooke’s cognitive
examination (ACE-R) for detecting mild cognitive impairment and dementia
in a Japanese population. Int Psychogeriatr. 2012;24:28–37.
Bastide L, De Breucker S, Van den Berge M, Fery P, Pepersack T, Bier JC. The
Addenbrooke’s Cognitive Examination Revised is as effective as the original
to detect dementia in a French-speaking population. Dement Geriatr Cogn
Disord. 2012;34:337–43.
Custodio N, Lira D, Montesinos R, Gleichgerrcht E, Manes F. Utilidad del
Addenbrooke’s cognitive examination versión en español en pacientes
peruanos con enfermedad de Alzheimer y demencia frontotemporal. Rev
Arg de Psiquiat. 2012;23:165–72.
Dos Santos Kawata KH, Hashimoto R, Nishio Y, Hayashi A, Ogawa N, Kanno
S, Hiraoka K, Yokoi K, Iizuka O, Mori E. A validation study of the Japanese
version of the Addenbrooke’s cognitive examination revised. Dement
Geriatr Cogn Disord. 2012;2:29–37.
Kwak YT, Yang Y, Kim GW. Korean Addenbrooke’s cognitive examination
revised (K-ACER) for differential diagnosis of Alzheimer’s disease and
subcortical ischemic vascular dementia. Geriatr Gerontol Int. 2010;10:295–301.
Sarasola D, Calcagno MDL, Sabe L, Caballero A, Manes F. Utilidad del
Addenbrooke’s cognitive examination en Español para el diagnóstico de
demencia y para la diferenciación entre la enfermedad de Alzheimer y la
demencia frontotemporal. Rev Argent Neuropsicol. 2004;4:1–11.
Machado A, Baeta E, Pimentel P, Peixoto B. Psychometric and normative
indicators of the Portuguese version of the Addenbrooke’s cognitive
examination III: Preliminary study on a sample of healthy subjects. Acta
Neuropsychol. 2015;13:127–36.
Ferreira IS, Simoes MR, Maroco J. The Addenbrooke’s cognitive examination
revised as a potential screening test for elderly drivers. Accid Anal Prev.
2012;49:278–86.
Newman JP. Brief assessment of cognitive mental status in Hebrew:
Addenbrooke’s cognitive examination. Isr Med Assoc J. 2005;7:451–7.
Page 10 of 10
29. Stokholm J, Vogel A, Johannsen P, Waldemar G. Validation of the Danish
Addenbrooke’s cognitive examination as a screening test in a memory
clinic. Dement Geriatr Cogn Disord. 2009;27:361–5.
30. Bier JC, Ventura M, Donckels V, Van Eyll E, Claes T, Slama H, Fery P, Vokaer
M, Pandolfo M. Is the Addenbrooke’s Cognitive Examination effective to
detect frontotemporal dementia? J. Neurol. 2004;251:428–31.
31. Garcia-Caballero A, Garcia-Lado I, Gonzalez-Hermida J, Recimil MJ, Area R,
Manes F, Lamas S, Berrios GE. Validation of the Spanish version of the
Addenbrooke’s Cognitive Examination in a rural community in Spain. Int J
Geriatr Psychiatry. 2006;21:239–345.
32. Hummelová-Fanfrdlová Z, Rektorová I, Sheardová K, Bartos A, Línek V. Ceska
adaptace, Addenbrookskeho kognitivniho testu. Cesk Psychol. 2009;53(4):376–88.
33. Mathuranath PS, Hodges JR, Mathew R, Cherian PJ, George A, Bak TH.
Adaptation of the ACE for a Malayalam speaking population in southern
India. Int J Geriatr Psychiatry. 2004;19:1188–94.
34. Pouretemad HR, Khatibi A, Ganjavi A, Shams J, Zarei M. Validation of
Addenbrooke’s cognitive examination (ACE) in a Persian-speaking
population. Dement Geriatr Cogn Disord. 2009;28:343–7.
35. Yoshida H, Terada S, Honda H, Ata T, Takeda N, Kishimoto Y, Etsuko O, Ishihara T,
Kuroda S. Validation of Addenbrooke’s cognitive examination for detecting early
dementia in a Japanese population. Psychiatry Res. 2011;185:211–4.
36. Alexopoulos P, Ebert A, Richter-Schmidinger T, Scholl E, Natale B, Aguilar CA,
Gourzis P, Weih M, Perneczky R, Diehl-Schmid J, Kneib T, Forstl H, Kurz A,
Danek A, Kornhuber J. Validation of the German revised Addenbrooke’s
cognitive examination for detecting mild cognitive impairment, mild
dementia in Alzheimer’s disease and frontotemporal lobar degeneration.
Dement Geriatr Cogn Disord. 2010;29:448–56.
37. Bartoš A, Raisová M, Kopeček M. Novelizace české verze Addenbrookského
kognitivního testu (ACE-CZ). Cesk Neurol Neurochir. 2011;74:681–4.
38. Carvalho VA, Barbosa MT, Caramelli P. Brazilian adaptation of the
Addenbrooke’s Cognitive Examination Revised. Neuropsychologia. 2007;2:
212–6.
39. Fang R, Wang G, Huang Y, Zhuang JP, Tang HD, Wang Y, Deng YL, Xu W,
Chen SD, Ren RJ. Validation of the Chinese version of Addenbrooke’s
cognitive examination-revised for screening mild Alzheimer’s disease and
mild cognitive impairment. Dement Geriatr Cogn Disord. 2014;37:223–31.
40. Konstantinopoulou E, Kosmidis MH, Ioannidis P, Kiosseoglou G, Karacostas
D, Taskos N. Adaptation of Addenbrooke’s Cognitive Examination-Revised
for the Greek population. Eur J Neurol. 2011;18:442–7.
41. Margevičiūtė R, Bagdonas A, Butkus K, Kuzmickiene J, Vaitkevicius A, Kaubrys
GF, Bak TH. Adenbruko kognityvinio tyrimo metodikos – taisytos adaptacija
lietuviškai kalbantiems gyventojams (ACE-RLT). Neurologijos seminarai. 2013;
1(55):29–51.
42. Munoz-Neira C, Henríquez CF, Ihnen JJ, Sánchez CM, Flores MP, Slachevsky
CA. Psychometric properties and diagnostic usefulness of the
Addenbrooke's Cognitive Examination-Revised in a Chilean elderly sample.
Rev Med Chil. 2012;140(8):1006–13.
43. Torralva T, Roca M, Gleichgerrcht E, Bonifacio A, Raimondi C, Manes F.
Validation of the Spanish version of the Addenbrooke’s Cognitive
Examination-Revised (ACE-R). Neurologia. 2011;26:351–6.
44. Wong L, Chan C, Leung J, Yung CY, Wu KK, Cheung SYY, Lam CLM. A
validation study of the Chinese-Cantonese Addenbrooke’s Cognitive
Examination Revised (C-ACER). Neuropsychiatr Dis Treat. 2013;9:731–7.
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