Linguistic adaptation of the Clinical Dementia Rating scale for a Spanish-speaking population: a focus group approach.
Abstract: Background: Alzheimer's disease (AD) is the most common form of dementia worldwide. In Hispanic populations there are few validated tests for the accurate identification and diagnosis of AD. The Clinical Dementia Rating (CDR) scale is an internationally recognized questionnaire used to stage dementia. This study's objective was to develop a linguistic adaptation of the CDR for the Puerto Rican population.

Methods: The linguistic adaptation consisted of the evaluation of each CDR question (item) and the questionnaire's instructions, for similarities in meaning (semantic equivalence), relevance of content (content equivalence), and appropriateness of the questionnaire's format and measuring technique (technical equivalence). A focus group methodology was used to assess cultural relevance, clarity, and suitability of the measuring technique in the Argentinean version of the CDR for use in a Puerto Rican population.

Results: A total of 27 semantic equivalence changes were recommended in four categories: higher than 6th grade level of reading, meaning, common use, and word preference. Four content equivalence changes were identified, all focused on improving the applicability of the test questions to the general population's concept of street addresses and common dietary choices. There were no recommendations for changes in the assessment of technical equivalence.

Conclusions: We developed a linguistically adapted CDR instrument for the Puerto Rican population, preserving the semantic, content, and technical equivalences of the original version. Further studies are needed to validate the usefulness of the adapted CDR instrument with the staging of Alzheimer's disease in the Puerto Rican population.

Key words: Dementia rating scales, Hispanics, Validation

La enfermedad de Alzheimer es el tipo de demencia mas comun a nivel mundial. Hay pocas pruebas validadas para la identificacion y el diagnostico preciso de la enfermedad de Alzheimer en la poblacion hispana. La escala de valoracion cllnica para demencia (CDR, por sus siglas en ingles) es un cuestionario, reconocido a nivel internacional, que se usa para evaluar el estadlo o cuantificar la severidad de los slntomas de demencia. El objetivo de este estudio fue desarrollar una adaptacion lingulstica del CDR para la poblacion puertorriquena. Para la adaptacion lingulstica, se evaluo cada una de las preguntas del CDR y sus instrucciones en relacion a las similaridades en el significado (equivalencia semantica), relevancia del contenido (equivalencia del contenido) y lo apropiado del formato del cuestionario y la tecnica de medicion (equivalencia tecnica). Se uso un grupo focal para evaluar la relevancia cultural, la claridad y lo apropiado de la tecnica de medicion de la version argentina del CDR para uso en la poblacion puertorriquena. Se recomendaron un total de 27 cambios por equivalencia semantica en cuatro categorlas: nivel de lectura de 6to grado, significado, uso comun y preferencia de palabras. Se identificaron cuatro cambios por equivalencia de contenido, todos enfocados en mejorar la aplicabilidad de las preguntas de la prueba al concepto de la poblacion general en el formato de las direcciones y los alimentos para seleccionar. No hubo recomendaciones para cambios en la evaluacion de la equivalencia tecnica. En conclusion, desarrollamos una version del CDR adaptado lingulsticamente a la poblacion puertorriquena que conserva las equivalencias semanticas, de contenido y tecnicas de la version original. Se necesitan mas estudios para validar el CDR para cuantificar la severidad de la enfermedad de Alzheimer en la poblacion puertorriquena.
Subject: Latinoamericanos (Investigacion cientifica)
Latinoamericanos (Aspectos de salud)
Latinoamericanos (Analisis de casos)
Authors: Oquendo-Jimenez, Ilia
Mena, Rafaela
Antoun, Mikhail D.
Wojna, Valerie
Pub Date: 06/01/2010
Publication: Name: Puerto Rico Health Sciences Journal Publisher: Universidad de Puerto Rico, Recinto de Ciencias Medicas Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Universidad de Puerto Rico, Recinto de Ciencias Medicas ISSN: 0738-0658
Issue: Date: June, 2010 Source Volume: 29 Source Issue: 2
Geographic: Geographic Name: Estados Unidos
Accession Number: 226567981
Full Text: Prevalence estimates of mental illnesses in the United States (U.S.) show Alzheimer's disease (AD) to be the most common form of dementia (1, 2). A recent statistical report of data on AD estimated over 5 million cases in 2008 (3). Given this figure, 13% of the U.S. population older than 65 years suffers from the disease. This prevalence is expected to reach 7.7 million in 2030.

In Puerto Rico, Alzheimer's disease ranked fifth among causes of mortality in 2004 (4). Although a completed prevalence study of AD is lacking in Puerto Rico, there is an ongoing prevalence study that will eventually supply this information (5). Extrapolating the U.S. prevalence data to Puerto Rico's elderly population (aged over 65) in 2008, we estimate there are 70,000 cases of AD on the island. In view of the increasing Puerto Rican population aged over 65 years and the likely increased prevalence of AD, there is an urgent need for valid and reliable methods for the early diagnosis and staging of dementia in this population.

The Clinical Dementia Rating (CDR) scale, developed at the Washington University School of Medicine in St. Louis, Missouri, was first published by Hughes and coworkers in 1982 (6). Originally developed to measure the staging of dementia in Alzheimer's disease patients, it has been extended to other dementias and is used worldwide in memory assessment clinics, research studies, and clinical trials of potential therapeutic agents.

The CDR consists of independent semi-structured interviews that usually take place in a clinical setting performed face to face with the patient. Prior to the patient's interview a reliable informant (usually the spouse or a close family member) is interviewed to confirm the patient's cognitive abilities. It is considered a global clinical scale as it also measures social, behavioral, and functional changes in the patient's accustomed activities. It has several advantages: it is independent from other psychometric testing; it does not require a baseline evaluation; and the individual serves as his/her own control. It has been found to correlate with histological markers of dementia severity (7) and has a predictive value in AD longitudinal studies (8). CDR administration requires special training, as its high validity and reliability rely on the skills and judgment of the interviewer to obtain pertinent information (9).

The CDR Scale

The CDR evaluates cognitive performance in six domains: three cognitive (memory, orientation, and judgment and problem solving) and three functional (community affairs, home and hobbies, and personal care). A worksheet includes the questions required for each domain evaluation individually rated on a 5-point scale, according to the level of impairment. A score of 0 suggests no impairment; a score of 0.5 indicates very mild impairment; a score of 1 indicates mild impairment; a score of 2 indicates moderate impairment; and a scale of 3 indicates severe impairment. Personal care is rated on a 4-point scale as there is no distinction, as above, between the no (0) and the very low (0.5) levels of impairment (10). The sum of the individual category ratings for each domain (sum of boxes) provides a quantitative expansion of the CDR that ranges from 0 (0 x 6 when there is no impairment in any domain) to 18 (3 x 6 when there is maximum impairment in all domains) (7).

A global score is then derived using the individual ratings in the six domains applying predefined rules. A global CDR score is also rated on a 5-point scale. A score of 0 suggests absence of dementia; 0.5, questionable or very mild dementia; 1, mild dementia; 2, moderate dementia; and 3, severe dementia (10). The 0.5 score is divided into two subcategories, very mild or incipient dementia and uncertain dementia (11). These subcategories include patients who have some cognitive impairment but not severe enough to interfere with their daily functions, and those who suffer another condition, such as depression, that may be the cause of their impairment. Some clinical studies have included two additional staging levels: 4 for patients with profound dementia and 5 for those with terminal dementia (12).

The CDR, revised by Morris in 1993, is currently used for the clinical and neuropsychological assessment of AD and other dementias of the elderly (10). This version has been translated into Bulgarian, Chinese, Dutch, Finnish, French, German, Italian, Japanese, Korean, Portuguese, and Spanish (13-14). Although there are several Spanish translations of the CDR, none has been linguistically adapted or validated for the Puerto Rican population. Cross-cultural research literature shows that cultural and linguistic differences may affect the interpretation of quantitative neuropsychological instruments, thus limiting the reliable and valid interpretation of the scale when applied to a particular population. Even when translated versions are in a population's native language, there can b e cultural differences in the verbal expression of concepts, in meaning, and in relevance that may affect confidence in the validity of results obtained using the translation (15).

Cultural adaptation of a tool involves the production of an equivalent instrument for a target population, one that measures the same phenomenon in both, the original and the target cultures. The first phase of the process includes a translation of words and sentences from the original language to another and then further linguistic adaptation to the cultural context of the target population to ensure that the new version is conceptually and culturally pertinent. The second phase of the cultural adaptation includes a validation phase during which the instrument is proved to be psychometrically equivalent to the original version (16-17).

In our study, the linguistic adaptation and psychometric validation of the CDR scale was aimed at providing a valid and reliable tool for the expansion of research efforts and early diagnosis of AD-related conditions in Puerto Rican Hispanics, allowing the comparison of results with other populations for whom the instrument has already been culturally adapted.

Materials and Methods

Preparatory Phase

The Institutional Review Board for Human Subjects (IRB) of the Medical Sciences Campus, University of Puerto Rico approved the pilot project in January 2007. The first author (IOJ) was trained and certified as a CDR rater by the Alzheimer's Disease Research Center (ADRC) at Washington University in St. Louis, Missouri. The ADRC gave permission to adapt the CDR instrument for use in a Puerto Rican population.

A translator was recruited to evaluate several Spanish-language versions of the CDR and to recommend the one closest to Puerto Rican Spanish. The recommendation was based on similarities in vocabulary between the chosen version and the Spanish used in Puerto Rico. The Argentinean version translated by Mapi Research Institute (Mapi) was recommended with replacement of some words by their Puerto Rican Spanish equivalents.

Linguistic Adaptation

Mapi, an internationally recognized institution in France, has ample expertise in the translation of patient-reported and clinical assessment instruments for cross-cultural use. The translation process used by Mapi includes the clarification of concepts investigated in the original instrument to ensure they are reflected appropriately in the target language, forward and back-translations to the target and source language, and a pilot testing (18).

Cross-cultural research methodology identifies five major dimensions to be considered in the equivalence process: 1) content equivalence (relevance of the content of items to each culture); 2) semantic equivalence (similar meaning of items in each culture); 3) technical equivalence (comparable method of measuring techniques in each culture); 4) criterion equivalence (capacity to measure the same phenomena among cultures); and 5) conceptual equivalence (capacity to measure the same basic construct among cultures) (19-20). The Mapi approach to translation for the Argentinean version preserved content, conceptual, and technical equivalence of the original CDR English version (18).

During the initial phase of the linguistic adaptation of the CDR to be used in Puerto Rico, a professional translator evaluated the semantic equivalence of Argentinean Spanish and Puerto Rican Spanish. During the translator's first revision of the CDR Argentinean version, some words were substituted for the corresponding words or phrases used in Puerto Rico. For example, because the word birome is not used in Puerto Rico, it was replaced by boligrafo, the word commonly used for a ballpoint pen. The word geridtrico was replaced by hogar de ancianos, the common name in Puerto Rico for nursing homes, and premdrbida, a medical term requiring a higher than 6th grade level of reading, was replaced by the phrase antes de enfermar, which means before becoming sick.


Focus Group

The focus group consisted of 7 persons (6 women and 1 man), ages 20 to 75 years, who were life-long residents of Puerto Rico. They considered themselves to be completely bilingual and represented diverse occupations (clinical psychologist, nurse, geriatric pharmacist, accountant, secretary, laboratory technician, and a student). The translator monitored the process and the PI served as moderator. After the individual evaluation, an additional 1 1/2 hour group discussion followed. The focus group recommendations for changes coincided with many of the words the translator had identified as problematic in the Argentinean version. A discussion followed each recommendation with ample and enthusiastic participation. Proposed changes and recommendations were approved by consensus.


After the translator's initial revision, the modified Argentinean version was evaluated in a pilot testing using a focus group method to assess cultural relevance, clarity, and suitability of the measuring technique; group members were asked to suggest modifications and to explain why the changes were needed. A self-administered written questionnaire to evaluate each CDR item was developed in a worksheet form (Table 1). The evaluation worksheet questionnaire required each focus group evaluator to identify words, terms, or phrases not pertinent to the Puerto Rican culture and to give reasons for their choices. An evaluation of the clarity of each item was also required; if an item was considered unclear, then evaluators were asked to recommend how to improve it. The translator was an observer during the focus group discussion, having interaction with the group only when a clarification was requested or any member of the focus group asked for expert advice. The translator kept a record of the focus group evaluators' comments and opinions, and served as quality check for the appropriateness of words recommended by group members to be used in place of terms in the Argentinean version.

The information gathered from the focus group was reviewed by investigators and the translator, who together classified the proposed changes on the basis of type of change and reason for change. After this analysis, an experimental version of the CDR for Puerto Rico was developed.

Further linguistic adaptation

The experimental version of the CDR for Puerto Rico was used for further linguistic and cultural input. It was distributed to 23 individuals in waiting rooms for outpatient evaluations in different geographical areas of Puerto Rico located at the University of Puerto Rico, Medical Sciences Campus Intramural Practice at San Juan, the Hospital Interamericano de Medicina Avanzada (HIMA) San Pablo del Este at Fajardo, Dr. Pila Hospital at Ponce, and Ramon E. Betances Hospital at Mayaguez (Figure 1).


Gender, age, and education of these participants are shown in Table 2. Seventy percent were female and 30% males. Their mean ages were 60.4 and 69.3 years, and the median levels of education were 7th and 8th grade, respectively.

The 23 participants were asked to read the questionnaire and suggest changes that would improve a reader's understanding of the text. There were no time limitations for this activity. Only recommendations made by at least 8 of the 23 individuals were incorporated into the final version of the CDR for Puerto Rico.


The focus group recommended 25 semantic changes from a total of 83 items. (Table 3). The semantic changes were divided into four categories depending on the reason for the change: higher than 6th grade level of reading, meaning, common use, and word preference. Four changes in content were also recommended. There were no recommendations for changes in the measuring scales used in the questionnaire. The presentation format and the 5-point scoring system were considered simple and easy to perform.

The educational level of understanding for the translation was established at the 6th grade level. Words requiring a higher than 6th grade level of reading were identified and substitutes were recommended. Words that would not be understood, either because they are not commonly used or because they denote a different concept in the Puerto Rican culture, were classified as changes in meaning. Synonyms, commonly used in Puerto Rico by the lay public, were classified as common use changes. Word preference mostly concerned with the use of the active voice, which the focus group considered to be clearer and easier to understand than passive voice.

Further linguistic adaptation followed the additional evaluation of the 23 individuals located in different areas of Puerto Rico who gave feedback on the focus group-modified version. Specifically, two additional semantic changes and five items for clarification were recommended (Table 4). For example, most of the participants did not understand the word esfinteres, and control del intestinoy de la orina was recommended in its place. Clarification of content, as with the term solidos simples, included the addition of examples such as cremas, viandas majadas, sopas. Another example of clarification of meaning is the use of ahora with un tiempo atrds, wording that makes it explicit that past activity and present activity are to be compared.


It is recognized in cross-cultural research literature that cultural and linguistic differences may affect the interpretation of quantitative neuropsychological instruments (19). Translation of an instrument is not enough to obtain language equivalence when the translated instrument is applied to a population from a different culture. A rigorous, systematic approach to the translation and validation process is needed to assure the equivalency necessary for clinical or research application (19).

Cross-cultural research methodology identifies five major equivalences to be considered in the adaptation process: content, semantic, technical, criterion, and conceptual. The Argentinean Spanish CDR version went through a detailed linguistic validation process in Mapi Research Institute comparable to the one proposed in the literature. In light of this rigorous and systematic procedure, it was decided to use the Argentinean translation for a linguistic adaptation to the Spanish used in Puerto Rico. Even though the semantic and content equivalences were maintained during the Mapi translation of the English language CDR into Argentinean Spanish, rewording of a number of items and changes in content were required to maintain the same meaning and relevance of content of the original English language version in the linguistic adaptation for the Puerto Rican population.

The CDR instrument was subjected to content, semantic, and technical assessment, and changes were recommended, accordingly, for its linguistic adaptation. The data obtained during this process supported the linguistic equivalence as the first step for the cultural adaptation of the instrument to the Puerto Rican population. The criterion and conceptual equivalences will be accomplished in the second phase of this study to complete the cultural adaptation to establish the psychometric properties of the instrument.

The focus group methodology was an effective way to obtain input about cultural relevance, clarity, and suitability of the format and measuring technique of the Argentinean version of the CDR for use in a Puerto Rican population. The worksheet developed to obtain feedback from focus group evaluators facilitated the needed systematic approach to data collection and interpretation, and it provided the structure for the focus group discussion. The diverse composition of the focus group with its broad range of ages and occupations provided wide-ranging input regarding the relevance of each item to the Puerto Rican culture. The evaluators' high proficiency in Spanish and English helped ensure that the words used were unambiguous, simple, and comprehensible to the Puerto Rican population without changing the original meaning.

The focus group identified words not commonly used in Puerto Rico, words meaning something different in Puerto Rico than in Argentina, words requiring a higher than 6th grade reading level, verbs that could be changed to active voice to facilitate the reader's understanding, and some content changes for phrases not pertinent to the culture. Substitutions were made so that the text was better suited to Puerto Ricans. These changes generated a more culturally suitable questionnaire, which could be understood by the majority of people, while the original concepts were preserved. Although the educational level of the 23 participants from the community was diverse, the 6th grade level of reading established for the translation worked for all members of the sampled population.

The further linguistic adaptation in the community also offered the opportunity to assess the cultural relevance of the CDR focus group version in different towns and to factor in possible idiomatic regional differences. Native Spanish-speaking people from different areas of Puerto Rico mainly suggested rewording items to use common words or adding words or phrases to clarify a concept. This further linguistic adaptation made the questionnaire more comprehensible to Puerto Ricans.

A limitation of the study is that the linguistic adapted CDR version applies only to native Spanish speaking Puerto Ricans. As mentioned before, the focus group and the individuals who gave feedback on the focus group CDR modified version were only native Spanish speaking Puerto Ricans. The study did not consider input from other Hispanics or Latino sub groups. Nevertheless, the linguistic adapted version obtained in this study provides a tool for future cross-cultural efforts.


In conclusion, we applied cross-cultural research principles for the linguistic adaptation of the CDR scale to the Puerto Rican population. Key elements were a previous translation by Mapi, focus group evaluation, and input from persons living in different parts of the Island. Through this process, we obtained a linguistically adapted instrument for the Puerto Rican population while preserving the semantic, content, and technical equivalences of the original version. This is an important first step to establish the psychometric validity of the instrument upon completion of its cultural adaptation.


The authors thank Dyhalma Irizarry, Ph D, Medical Sciences Campus, University of Puerto Rico for the revision of the manuscript, and Cruz M. Nazario, Ph D, Graduate School of Public Health, and Jose R. Rodrlguez, Ph D, Rlo Piedras Campus, for their professional advice on the focus group methodology. The first author also thanks John C. Morris, MD, at the Washington University Alzheimer's Disease Research Center, St. Louis, Missouri, for her Clinical Dementia Rating training experience. This research is in partial fulfillment for the requisites of the Postdoctoral Master in Science in Clinical Research degree of Ilia Oquendo-Jimenez, Ph D, at the Medical Sciences Campus, University of Puerto Rico and partially supported by Grant Number R25 RR17589, RCMI Clinical Research Infrastructure Initiative (RCRII) Award, P20 RR011126, from the National Center for Research Resources (NCRR), National Institutes of Health, and S11 NS46278. The authors have no conflict of interest to disclose.


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Address correspondence to: Ilia Oquendo-Jimenez, PhD, School of Pharmacy-Medical Sciences Campus, University of Puerto Rico, P.O. Box 365067, San Juan, PR 00936-5067. Tel: (787) 758-2525 Ext. 5437 * Fax (787) 767-2796 * Email:

Ilia Oquendo-Jimenez, Ph D *; Rafaela Mena, MA *; Mikhail D. Antoun, Ph D *; Valerie Wojna, MD [[dagger]]

* School of Pharmacy, Medical Sciences Campus, University of Puerto Rico;

[[dagger]] Neurology Division, Department of Internal Medicine, School of Medicine, Medical Sciences Campus, University of Puerto Rico
Table 2. Demographic Characteristics of Community Participants

Gender        Female         Male
N = 23        n = 16 (70%)   n = 7 (30%)

Age, yrs.
  Mean (SD)   60.4 (13.1)    69.3 (15.6)
  Range       42-78          48-87
  Mean (SD)   7.3 (3.7)      8.8 (3.8)
  Median      7th grade      8th grade

Table 3. Translator and Focus Group Modifications to the CDR
Argentinean Spanish Version, March 2007

Categories              Argentinean Version     Modifications

Higher than 6th grade   esporadico *            ocasional
level of reading
                        cotidianas *            diarias

                        premorbida *            antes de enfermar

                        sinfonla *              concierto

Meaning                 birome *                bollgrafo

                        verduras *              vegetales

                        posicion social *       situacion actual

Common use              raramente *             rara vez

                        casamiento familiar *   boda familiar

                        fecha de casamiento *   fecha de su boda

                        canerlas *              tuberlas

                        geriatrico *            hogar de ancianos

                        estanterla *            librero

                        barrio                  vecindario

                        electrodomesticos *     enseres electricos

Word preference         se encuentra            esta
                        se le debe dar          tiene que ser
                        de comer *              alimentado

Content                 Reconquista             Union

                        Buenos Aires            Mayaguez

                        rabano                  zanahoria

                        coliflor                lechuga

Argentinean Version     Reason(s) for change

esporadico *            Synonyms. "Esporadico" requires higher than
                        6th grade level of reading.

cotidianas *            Synonyms. "Cotidianas" requires higher than
                        6th grade level of reading.

premorbida *            Synonyms. "Premorbida" requires higher than
                        6th grade level of reading; more a technical
                        word used in medicine; would not be
                        understood by lay public.

sinfonla *              "Concierto" is a more general term used when
                        speaking about going to an event at which
                        music is played; "sinfonla" refers more
                        specifically to a music category.

birome *                "Birome" is the Argentinean word referring to
                        a ballpoint pen. It is not used in other
                        Spanish-speaking countries.

verduras *              In the statement used, the examples
                        zanahoria-lechuga are not classified
                        as verduras in Puerto Rico. The term
                        verduras is the name given to certain
                        vegetables with edible roots. It is not
                        used to name green leafy vegetables such
                        as lettuce, broccoli, and others.

posicion social *       "Posicion social" refers to level or position
                        in society that goes along with income,
                        education earned, and other characteristics
                        that confer standing. "Situacion actual"
                        refers to the situation of a person at a
                        certain moment or present time.

raramente *             Synonyms. "Rara vez" is more common in Puerto
                        Rico; it is similar to saying in English,
                        rarely or on rare occasions.

casamiento familiar *   Synonyms. "Boda" is the word commonly used in
                        Puerto Rico.

fecha de casamiento *   Same as above.

canerlas *              Synonyms. "Tuberlas" is the word used in
                        Puerto Rico.

geriatrico *            Both words are used for nursing homes.
                        "Hogar de ancianos" is the word commonly
                        used in Puerto Rico.

estanterla *            Synonyms. "Librero" is the word commonly used
                        in Puerto Rico.

barrio                  Synonyms. "Vecindario" is more common in
                        Puerto Rico.

electrodomesticos *     Synonyms. "Enseres electricos" is the term
                        commonly used in Puerto Rico.

se encuentra            Synonyms. "Esta" is active voice.
se le debe dar          "Tiene que ser alimentado" is the active
de comer *              voice; gives a clearer idea that the person
                        always needs to be fed by another one.

Reconquista             The address in the memory test should be
                        pertinent to Puerto Rico. Reconquista is not
                        a common name for a street in Puerto Rico.
                        Union is a common name for a street in Puerto

Buenos Aires            The address in the memory test should be
                        pertinent to Puerto Rico. Mayaguez is a
                        town on the west coast of the island.

rabano                  "Rabano" is not a vegetable consumed by the
                        general population in Puerto Rico.

coliflor                "Coliflor" is not a vegetable consumed by
                        the general population in Puerto Rico.

Table 4. Recommendations from community participants from
different areas of Puerto Rico, July-October 2007

Categories              Focus group version

Higher than 6th grade   Control de esfinteres
level of reading
Word preference         empresariales

Clarification           Evalue la capacidad
                        de el/ella para. ...

                        Puede el/ella Comprender
                        situaciones o explicaciones?

                        Solidos simples



Categories              Recommendations

Higher than 6th grade   Control del intestino
level of reading        y la vejiga
Word preference         de negocio

Clarification           Evalue la capacidad de
                        el/ella para. ... ahora
                        con un tiempo atras.
                        Puede el/ella comprender
                        situaciones o explicaciones
                        sobre algun asunto que se
                        le presente?
                        Incluir ejemplos: cremas,
                        viandas majadas, sopas
                        En el hogar

                        Add "intereses"

Categories              Reason (s) for change

Higher than 6th grade   "Esfinteres" requires higher than 6th grade
level of reading        level of reading. It is not understood by
Word preference         lay public.

                        Synonyms. "De negocio" is a term more
                        commonly used by lay public.

Clarification           Clarifies the question which requires a

                        Clarifies the question.

                        Helps the reader understand what sorts
                        of foods are considered simple solids.

                        Synonyms. "En el hogar" is used more
                        commonly by lay public.

                        Clarifies the required information; not
                        everybody has a hobby, but may have
                        activities that evoke enthusiasm.
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