C J Long
rate; M=47.4 and S.D.=10.1 for age 16-29 ; M=43.4 and
S.D.=10.2 age 30-49; M=43.5 & S.D.=13.6 age 50-69]
[@ 2.0 sec. rate M=42,SD=12.5 for 16-29 yrs; M=41.9, SD=10.2 for 30-49 yrs; M=35.6,SD=14.6 for 50-69 yrs]
[@ 1.6 sec. rate M=36,SD=13 age 16-29; M=33.1,SD=12.2 age 30-49; M=30.8,SD=15.9 age 50-69]
[@ 1.2 sec. rate M=27.4,SD=9.9 age 16-29; M=24.6,SD=10.6 age 30-49; M=21.2,SD=14.4 age 50-69] (12)
2. PASAT has been used as a successful guide for
return to work after concussion, but it is unable to
predict when the return will likely be.
3. The test only becomes truly useful when it is used throughout the course of a recovery. The return of the patient to work, once 'normal' functioning is regained must also be gradual (3).
4. The clinical and psychometric evidence that validate the PASAT allow for its full use as a tests that is understood to focus on attentional mechanisms (1).
5. The test offers a homogeneous task for its full duration, making it optimal for such tests as PET study of uptake of tracers in the brain(1).
6. Only a small negative correlation exists between age and test results among concussed patients studied with PASAT.
7. There are significant practice effects between 1st and 2cd administrations, but little effect on subsequent tests (3).
8. One method of detecting malingering= both concussion and control patients will typically make fewer error/omissions during the 1st 1/3 of a trial. There is also very little variance in time scores for each trial at a session. If these patterns are not present, the test is suspect (3).
9. Borderline malingerers: if there is exactly 0.6 seconds difference between all time score at a test, the patient is given the benifit of the doubt, but should be informed that the scores are nearly unrealistic (3).
10. Recovery from concussion is defined by the PASAT as making a score within one standard deviation of the mean (6).
2) D'Esposito, M. et al. (1996). Working memory impairments in multiple sclerosis: evidence from a dual-task paradigm. Neuropsychology, 10:1, 51-56.
3) Gronwall, D.M.A. (1977). Paced auditory serial-addition task: a measure of recovery from concussion. Perceptual and Motor Skills, 44, 367-373.
4) Gronwall, D.M.A., & Wrightson, P. (1981). Memory and information processing capacity after closed head injury. Journal of Neurology, Neurosurgery, and Psychiatry, 44, 889-895.
5) Gronwall, D.M.A., & Wrightson, P. (1974). Delayed recovery of intellectual function after minor head injury. Lancet, 2, 605-609.
6) Gronwall, D.M.A., & Wrightson, P. (1975). The cumulative effect of concussion. Lancet, 2, 995-997.
7) Laidlaw, T.M. (1993). Hypnosis and attention deficits after closed head injury. International Journal of Clinical and Experimental Hypnosis, 41:2, 97-111.
8) Larrabee, G.J. et al. (1995). Construct validity of various verbal and visual memory tests. Journal of Clinical and Experimental Neuropsychology, 17:4, 536-547.
9) Ogden, J.A. (1996). Fractured Minds. New York: Oxford.
10) Othmer,E., & Othmer,S.C. (1994). The Clinical Interview Using DSM-IV. Washington: American Psychiatric Press. 11) Sbordone, R.J., & Long, C.J. (1996). Ecological Validity of Neuropsychological Testing. Delray Beach, Florida: GR Press/St.Lucie Press.
12) Spreen, O., & Strauss, E. (1991). A Compendium of Neuropsychological Tests. New York: Oxford.
A. Each astronomer had a personal equation that gave his amount of measurement "error" as compared to someone else's, this human element in scientific measurement prompted much study of reaction time during the 1800s.(Lachman et al)
B. The most important contribution was made by Donders
(1868-1969), a Dutch physiologist who in 1868 devised
methods for studying what he called the :"Speed of
Mental Processes" (Lachman et al).
C. Reaction-time nearly died with the advent of behaviorism,but engineering psychology and information theory revived it with being concerned about performance of well-learned skills and in promoting maximum performance from workers, pilots, and soldiers.(Lachman et al)
D. The study of choice reaction time under varying information-transmission conditions became a popular kind of research in the 1950s: the telecommunications problem became a psychological problem(Lachman et al).
E. Information theorists and engineering psychologists shared the contemporary information-processing interest in human performance, but their research had a definite functionalist flavor (Lachman et al).
F. Human-performance researchers eventually dropped functionalism and discovered structure, they were among the first psychologists to see the value of the computer analogy (Lachman et al).
G. It now has been propositioned that RT tasks be used to diagnose and to determine the severity of brain damage, RTs may provide additional measures of cognitive functions and increase the accuracy of decisions concerning the extent and presence of brain dysfunction (Western and Long, 1996).
A. Shum, McFarland, and Bain (1994) showed that the RT task produced measures that are related to commonly used psychological test of attention that have proven diagnostic and predictive validity, it can be argued that the RT task developed based on the information processing approach is not limited in its generality and clinical applicability.
B. RT measures are common in research for two primary reasons: 1) measures are components of real life tasks-sports and traffic 2) they measure the time taken for mental events, such as stimulus processing, decision making, and response programming (Taimela, 1991).
C. Hodgkins (1963) tested 930 men, women, and children to determine the differences between males and females of various ages in their speed of reaction and movement and determined by use of the split-half method the reliability of the test; a random sample of the 15 subjects from each group was used in the computation and the correlations obtained between odd and even scores ranged from .998 and .967.
D. Rueckert and Grafman (1996) performed a study on sustained attention in patients with right frontal lesions and they showed longer RTs and missed more targets than control subjects and they got worse over time.
E. Rueckert and Grafman also break down the effects of RT on specific areas of the brain- the anterior cingulate was overall slower and a significant difference on the RT story task, the basal ganglia showed significantly worse (longer RT and more missed targets), they also showed weak data that patients with corpus callosal lesions show greater deficits in sustaining attention that those without callosal lesions.
F. Right hemisphere damage slowed RTs to a greater extent that left hemisphere damage, although they did not differentiate between patients with anterior and posterior lesions (Rueckert and Grafman, 1996).
G. There were no main effects of lesion size for RT, proportion missed, or proportion false positive errors for any of the tasks in Rueckert and Grafman's experiment. (1996).
A. Stuss, Stethem, Hugenholtz, Picton, Pivik, and Richard, (1989) findings indicate that traumatic brain injury causes slower information processing, deficits in divided attention, an impairment of focused attention, and inconsistency of performance.
B. Long term recovery of visual reaction time after a closed head injury was investigated by Van Zomeren and Deelman (1978) and showed that choice reaction in particular seems to have some value for monitoring recovery and predicting final outcome and severity of injury.
C. It has also been shown that patients with left hemisphere disease show a more marked retardation in speed of response as the tasks grow more complex than do patients with right hemisphere disease (Dee & VanAllen, 1973).
D. Tartaglione, Bino, Manzino, Spadavecchia, & Favale, (1986) established that in right hemisphere lesions the volume had clear influence on the performance and the degree of RT slowing was proportional to the volume of the lesion, but in the left-hemisphere lesions, the lesion size did not effect velocity, often small lesions were related with more severe RT slowing than larger ones.
A. Craik, Govoni, Naveh-Benjamin, and Anderson (1996) did and extensive study on the effects of divided attention on encoding and retrieval processes in human memory and revealed that RT costs may be associated with the attempt to retrieve, regardless of the success of the retrieval attempt and the possibility that performance on a concurrent task is allowed because of response conflicts between concurrent task and recall.
B. The relationship between psychometric intelligence and speed of information-processing in a newly developed computerized RT task called the Concept-Verification-Test (CVT) was investigated in a sample of 104 undergraduates and found that both the Comprehension RT and the Verification RT correlated negatively with intelligence and found no evidence for the validity of the complexity hypothesis, which is that the more complex the task the slower the RT (Knorr and Neubauer, 1996).
C. It has been suggested that a relationship between IQ and reaction time (RT), arguing that individuals wiith quicker RTs are able to acquire information about the world more quickly and thus more information in general, which may lead to the development of higher IQ (Saklofske and Zeidner,1995).
D. In approximately 50 studies, schizophrenics have been found to be slower and more variable than normal controls, RT appears to have trait-like properties as it is stable over time, slowed in remitted patients, predictive of outcome, and mostly independent of the patient's clinical state (Schwartz, Carr, Munich, Glauber, Lesser, and Murray, 1989).
E. A slowing of RT is also found in affective disorders such as depression and it may be true for mania (Schwartz et al, 1989).
F. Conflicting results have been obtained in patients with focal brain damage, few studies have shown extension of time of CRT and SRT, but others have found no difference in the extent of response slowing between CRT and SRT , the interpretation of these results remains difficult because most of studies don't take into account for errors and prevent any conclusions being drawn on the efficacy of decision process (Godfrey and Rousseaux, 1996).
G. The majority of studies have restricted the assessment of decision processes to the evaluation of one performance level measurement, namely RT scores; a limitation to this method is that is does not take into account the fact that humans are able to trade speed for accruacy. (Godfrey and Rousseaux, 1996).
A. Collins and Long (1996) found statistically significant correlations demonstrating a positive relationship between RT and level of impairment demonstrated on neurological tests (Impairment Index of Halstead-Reitan Battery).
B. Collins and Long (1996) also showed that by adding the two short RT tests (simple and choice) to the neuropsychological test battery, more accurate predictions can be made about a patient's level of cognitive functioning.
C. Western and Long (1996) performed a number of experiments to compare the classification ability of RT to the abilities of other tests, a number of tests were compared and the results of two different experiments indicated that RT did show a significant level of agreement with the impairment score, but did not significantly exceed the rates gathered using other tests.
D. The third experiment of Western and Long (1996) showed that the impairment score in not superior to RT in classifying individuals with recent history of traumatic brain damage versus controls.
E. The results of Western and Long's (1996) study does not show full agreement between results of neuropsychological testing and RT testing or demonstrate that RT is superior to other tests in predicting neuropsychological impairment, but it does show that RT measures could be used to identify individuals requiring further testing.
F. There is still much need of further investigation of the use of RT in clinical settings.
Collins, L. F. & Long, C. J. (1996). Visual reaction time and its relationship to neuropsychological test performance. Archives of Clinical Neuropsychology, 11, 613-623.
Craik, F. I. M., Govoni, R., Naveh-Behjamin, M., & Anderson, N. D. (1996). The effects of divided attention on encoding and retrieval processes in human memory. Journal of Experimental Psychology: General, 125(2), 159-180.
Dee, H. L.& VanAllen M. W. (1973). Speed of decision-making processes in patients with unilateral cerebral disease. Archive of Neurology, 28, 163-166.
Godfrey, O. & Rousseaux, M. (1996). Binary choice in patients with prefrontal or posterior brain damage. A relative judgement theory analysis. Neuropsychologia,34(10), 1029-1038.
Hodgkins, J. (1963). Reaction time and speed of movement in males and females of various ages. The Research Quarterly, 34(3), 335-343.
Knorr, E. & Neubauer, A. C. (1996). Speed of information processing in an inductive reasoning task and its relationship to psychometric intelligence. Personality and Individual Differences, 20(6), 653-660.
Lachman, R., Lachman, J. L., & Butterfield, E. C. (1979). Cognitive psychology and information processing: An introduction. New Jersey: Lawrence Erlbaum Associates, Publishers.
Rueckert, L & Grafman, J. (1996). Sustained attention deficits in patients with right frontal lesions. Neuropsychologia, 34(10), 953-963.
Saklofske, D. H., & Zeidner, M.(eds) (1995). International Handbook of Personality and Intelligence. New York: Plenum Press.
Shum, D. K., McFarland, K., & Bain, J. D. (1994). Assessment of attention: Relationship between psychological testing and information processing approaches. Journal of Clinical and Experimental Neuropsychology, 16(4), 531-538.
Stuss, D. T., Stethem L. L., Hugenholtz, H., Picton, T., Pivik, J., & Richard M. T. (1989). Reaction time after head injury: Fatigue, divided and focused attention, and consistency of performance. Journal of Neurology, Neurosurgery, and Psychiatry, 52, 742-748.
Taimela, S. (1991). Factors affecting reaction -time testing and the interpretation of results. Perceptual and Motor Skills, 73, 1195-1202.
Tartaglione, A, Bino, G., Manzino, M., Spadavecchia, L., & Favale, C. (1986). Simple reaction-time changes in patients with unilateral brain damage. Neuropsychologia, 24(5), 649-658.
VanZomeren, A. H. & Deelman B. G. (1978). Long-term recovery of visual reaction time after closed head injury. Journal of Neurology, Neurosurgery, and Psychiatry, 41, 452-457.
Welford, A. T. (ed) (1980). Reaction Times. New York: Academic Press.
Western, S. L. & Long, C.J. (1996). Relationship between reaction time and neuropsychological test performance. Archives of Clinical Neuropsychology, 11, 557-571.
|Full Scale IQ 79.||79.6||55-99||92.8||74-113|
Subtests, Cognitive Processes Evaluated, and Relationship of Performance to Type of Impairment
Comprehension Subtest- This test consists of 14 open-ended questions that assess common sense judgement and practical reasoning (11 items) and understanding of proverbs (3 items). Test time is usually ten minutes or less. It measures verbal intellectual ability since it relates to social knowledge and judgement. It is especially sensitive to dominant hemisphere dysfunction. Reliabilities range from .77 to .90 with a mean of .84.
Similarities Subtest- This test consists of 13 paired items and the patient must explain the similarities of each pair. Abstract responses are given more credit than concrete responses. This is a test of verbal concept formation. Low scores might indicate dysfunction in either the left hemisphere (impaired verbal functions) or frontal lobes (impaired concept formation). Reliabilities range from .78 to .87 with a mean of .84.
Vocabulary Subtest- This test consist of 35 words to be defined and scored according to quality. It can take from fifteen to twenty-five minutes. Vocabulary reflects social, economic, and cultural knowledge. This test can provide valuable information about premorbid level of functioning. Reliabilities range from .94 to .96 with a mean of .96.
Object Assembly Subtest- This test is a puzzle assembly task in which familiar objects are used. It measures speed and accuracy. Bonus points can be given for quick assembly and partial credit can be given for unfinished assembly. Test time is about ten minutes. This measures visual organization and constuction. It is most sensitive to posterior nondominant hemisphere dysfuntion. Lesions in other areas of the cortex can result in impairment of this test as well. Reliabilities range from .52 to .73 with a mean of .68.
Picture Arrangement Subtest- This test consists of sets of scrambled cartoon pictures. The patient must be able to arrange the pictures in a sensible order. Test time is approximately fifteen minutes. This test evaluates the ability of nonverbal social cues and logical and sequential thinking. Variations and performance errors may reflect certain brain dysfunctions. Reliabilities range from .66 to .82 with a mean of .74.
Picture Completion Subtest- This test consistsd of 20 pictures, each missing an important detail, and the patient is given twenty seconds to figure out the missing detail. Total test time is five minutes. This tests visual perception and recognition that requires practical and conceptual judgement. This is a very good test of premorbid ability. Impaired ability can be the result of left hemisphere damage. Reliabilities range from .71 to .83 with a mean of .81.
Digit Symbol Subtest- This test requires patients to copy symbols as part of a set code. Numbers and symbols must be paired. Tatol test time is less than five minutes. This is a psychomotor performance test that requires motor coordination and sustained attention. It is sensitive to brain dysfunction and emotional problems. Reliabilities range from .73 to .82 with a mean of .82.
(All information under the subheading "Subtests, Cognitive Processes, and Relationship of Performance to Type of Impairment" have been cited from references 1 and 2).
1. Dean, R.S. (Ed.). (1987).Introduction to Assessing Human Intelligence. Springfield, Il: Charles C. Thomas Publishers.
2. Hartlage, L.C., Asken,M/J., Hornsby, J.L. (1987). Essentials of Neuropsychological Assessment. New York, NY: Springer Publishing Company.
3. Ivnik, R.J., Smith, G.E., Malec, J.F., Tanglos, E.G., & Parisi, J.E. (1993). Comparison of Wechsler vs. Mayo Summary Scores In A Clinical Sample. Journal of Clinical Psychology, 49, 534-542.
4. Mattis, P.J., Hannay, J., Plenger, P.M., Pollock, L. (1994). Head Injury and the Satz-Mogel Type Short Form WAIS-R. Journal of Clinical Psychology,50, 605-613.
5. Moore, A.D., Stambrook, M., Gill, D.D., Hawryluk, G.A., Paters, L.C., Harrison, M.M. (1993). Factor Structure of the Wechsler Adult Intelligence Scale-Revised in a Traumatic Brain Injury Sample. Canadian Journal of Behavioural-Science, 25, 605-614.
Task 2- subjects must write as many words as possible beginning with the letter "C" in four minutes BUT the words must be four letters only. (2 rules)
A form of this test was first introduced by Thurstone in Primary Mental Abilities in 1938.
Controlled oral association tasks, as represented by measures of verbal fluency, are occasionally included as a component of psychodiagnostic batteries for assessing higher cortical functions. (Bolter, Long, & Wagner, 1983) Measures of verbal fluency and productivity have formed a part of many aphasia batteries and have also been used to assess intellectual loss in patients with cerebral disease, particularly for the purpose of defining the distinctive patterns of performance associated with lesions in different loci. (Borkowski, Benton, & Spreen, 1967)
1."It could be argued that over a 1 minute period, both difficult and easy letters make significant demands on cognitive linguistic abilities. Hence, it would be predicted that all letters will show equal discrimination between the diagnostic groups."
2."Letters with few associates may make greater demands on verbal fluency; in contrast, high frequency or easy letters may produce a large number of automized responses that make minimal demands on associative processes. If this is so, it would be predicted that the difficult letters will be more discriminative than the easier letters."
3."A final possibility is that the differentiation between brain damaged and control patients may be related to an interaction between letter difficulty and level of intelligence. Specifically, for groups of brain damaged and control patients of relatively low intelligence, easy letters may be more discriminative than difficult letters because even normal subjects of modest intelligence can make only a few associations to the difficult letters. In contrast, difficult letters may be more discriminative for groups of patients of relatively high intelligence because these letters make significant demands on associative fluency and the possibility of automatized responses is minimized."
In summary, they found that for patients with low verbal intelligence, letters with high and low frequency equally discriminated between brain damaged and control subjects. for subjects with high verbal intelligence, only letters of low frequency differentiated between brain damaged and normal controls. So, basically, the people with high verbal intelligence will do better on the first task even if brain damaged, and the second task is what is most reflective of brain damage with subjects of high intelligence.
"Fluency tests requiring word generation according to an initial letter give the greatest scope to subjects seeking a strategy for guiding the search for words and are most difficult for subjects who cannot develop strategies of their own. (Lezak, 1995)
"Accumulated evidence from several studies suggests that verbal fluency deficits are primarily associated with lesions in the dominant frontal lobe. (Benton, 1968; Milner, 1964; Perret, 1974; Ramier & Hecaen, 1970)
Verbal fluency is associated with frontal lobe damage, particularly the left frontal lobe anterior to Broca's area (Milner, 1975; Ramier and Hacaen, 1970). (Lezak, 1995)
1. "Newcombe (1969) found a significant difference between right and left brain damaged subjects on a verbal fluency task, with the left hemisphere damage associated with a poorer performance; however, deficits in verbal fluency were not s[specific for frontal lobe involvement. (Bolter et al, 1983")
2. "However, when fluency is tested during PET scanning, the metabolic pattern suggests that rather than predominantly frontal involvement in this task, both temporal and frontal regions participate bilaterally in a 'system...Of especial interest was the finding that normal subjects with the lowest fluency scores had the highest metabolic rates, suggesting that poorer performers have to invest more effort in the task." (Lezak, 1995)
-With his study, he confirmed that word fluency deficiency is related to left frontal lob damage when he found that "bilateral frontal lesions do not entail a greater impairment of performance than unilateral, left frontal lesions, despite the larger mass of cerebral tissue destroyed ." (Perret, 1973)
|Test||Right %||Left %||Bilateral %|
|Right Hemisphere Con||33.3|
-In summary, "Perret found that patients with left hemisphere lesions did significantly more poorly than did patients with right hemisphere lesions, and that both of these groups earned lower total fluency scores than did normal controls..." (Pendleton, et al., 1982)
1."Results of the comparisons between individual brain damaged groups and normal control group indicate that the word fluency score is sensitive to cerebral dysfunction, regardless of whether the lesion is diffuse or focal and regardless of lesion localization...This diagnostic accuracy suggests that the TWFT can be used as a relatively sensitive "screening' test for the presence of cerebral dysfunction"
2."Patients with focal lesions involving the frontal lobes were significantly more impaired than were patients with nonfrontal lesions"
3."Patients with left hemisphere lesions were significantly more impaired than were patients who had right hemisphere lesions"
2. The Utility of the Thurstone Word Fluency Test in Identifying Cortical Damage (Bolter, Long, and Wagner, 1983)
study designed to "determine if the verbal intelligence and letter association value directly effect the discriminating power of the Thurstone Word Fluency Test for identifying cortical lesion."(1983)
They noted Borkowski, Benton, and Spreen's (1967) finding that "performance on a verbal fluency task is related both to the association value of the letters and the patient's level of intelligence." (Bolter, Long, and Wagner, 1983) and that, for people with low verbal intelligence, both letters with high and low association value discriminated between brain damaged and normal controls while only the letters with low association value discriminated for people with high verbal intelligence.
"As suggested by Borkowski's et al. findings, the interaction between the verbal intelligence of the subjects being tested and the association value of the letters employed may also affect the localizing ability of a word fluency test." (Bolter et al., 1983)
Hypothesis- the S and C conditions would be different in their sensitivity to left lateralized cortical lesions and left frontal lesions when controlling for verbal intelligence.
|Group||VIQ mean||VIQ sd||Words mean||Words sd||S - mean||S - sd||C - mean||C - sd|
Performance on the word fluency test does depend on verbal intelligence and the association value of the letter (consistent with Borkowski's article)
More words were produced with the S letter (high association value than the C letter (having low association value because of the four letter condition)
2. "Although not statistically different from each other, patients with left hemisphere involvement tended to do more poorly than those with right hemisphere dysfunction."
3. "Similarly, patients with left frontal damage tended to do more poorly than patients with lesions elsewhere in the brain."
Borkowski, J.G., Benton, A.L., & Spreen, O. Word fluency and brain damage. Neuropsychologia, 1967, 6, 135-140.
Bolter, J. B, Long, C.J., & Wagner, M. The utility of the thurstone word fluency test in identifying cortical damage. Clinical Neuropsychology, 1983, 5:2, 78-82.
Lezak, M.D. Neuropsychological Assessment. New York: Oxford University Press, 1995.
Milner, B. Some effects of frontal lobectomy in man. In J.Warren and U. Akent, (Eds.), The Frontal Granular Cortex and Behavior. New York: McGraw-Hill, 1964.
Newcombe, F. Missile Wounds of the Brain. London: Oxford University Press, 1969.
Pendleton, M.G., Heaton, R.K., Lehman, R.A.W., & Hulihan, D. Diagnostic utility of the thurstone fluency test in neuropsychological evaluations. Journal of Clinical Neuropsychology, 1982, 4:4, 307-317.
Perrett, E. The left frontal lobe in man and the suppresion of habitual responses in verbal categorical behaviors. Neuropsychologia, 1974, 12, 323-330.
Ramier, A. & Hecaen, H. Role respectif des attenintes frontales et de la lateralization lesionele dons les deficits de la "fluence verbale." Revue Neuropsychologiques, 1970, 123, 17-22.
Thurstone, L. Primary Mental Abilities. Chicago: University of Chicago Press, 1938.
Zangwill, O.L. Psychological deficits associated with frontal lobe lesions. International Journal of Neurology, 1966, 5, 395.
A. A short (5-10 minute) screening test developed by Folstein, Folstein, and McHugh in 1975 to assess cognitive impairment or characterize functioning (2,3,6,7)
1. First validated with hospital patients and later adapted to be used in National Institute of Mental Health's Epidemiological Catchment Area Program (6)
2. One of the tests used most frequently to assess cognitive functioning in older people (1)
B. The MMSE consists of five areas
1. Orientation = includes questions about time, day, date and location (3)
2. Registration = a short-term memory task (3)
3. Attention and Calculation = subject counts backwards by seven from 100 (3)
4, Recall = subject is asked to recall three objects named in Registration section (3)
5. Language := subject names simple objects, repeats a sentence, and follows a command (3)
a. This section also includes a visuospatial task where the subject is asked to copy overlapping pentagons (3,7)
C. Scores on the MMSE range from 0 (severely impaired) to 30 (perfect score) (3)
1. Mean scores on MMSE
a, Mean score for normal elderly people is 27.6 (10)
b. Mean score for mood disorder and depressed patients is 25.1 (10)
c. Mean score for depressed patients who also have related disturbances in orientation and memory is 19.0 (10)
d. Mean score for demented patients is 9,7 (10)
2. Meaning of scores
a. Severely impaired = score less than 18 (6)
b. Mildly impaired = scores between 18 and 23 (6)
c. Unimpaired = scores of 24 and above (6)
1. MMSE has demonstrated good reliability
a. For same examiner, retest reliability in a 24-hour period is r = .89 (10)
b. For different examiners, reliability is r= .83 in same time period (1 0)
c. Within 28 days the correlation coefficient is .98 (10)
d. Another study found within 28 days that r = .99 for demented, depressed and schizophrenic patients (3)
2. MMSE has also been shown to discriminate demented patients from less severe cases
a. Sometimes used to discriminate between different types of dementia, such as that related to Alzheimer's as opposed to that related to Huntington's disease (2)
3. Nevertheless, some organizations, such as NIA Alzheimer's Disease Centers and Alzheimer's Disease Diagnostic and Treatment Centers of California, use MMSE in conjunction with other measures, like the Blessed Information, Orientation, and Concentration Test (IOCT) (1 2)
a. The combination of the two (even though they are similar) provides more accurate assessment (12)
b. Most assessments of cognitive functioning, on an individual basis, seem to exclude important information (I 2)
4. Another problem with reliability of MMSE (and most cognitive functioning measures) may be in scoring (12)
a. A summary score may not be as reliable as grouping items so that they address separate areas of deficit (12)
1. Shows concurrent validity
a. Seems to be strongly correlated with Wechsler Adult Intelligence Scale (1,3)
b. In a study of 26 psychiatric patients, MMSE showed correlation of r = .78 with Verbal IQ and r = .66 with Performance IQ of the WAIS (1,3)
2. One study evaluated the validity of MMSE for recognizing dementia and delirium in 97 patients on a general medical ward (3)
a. When a score of 23 and below was considered impaired and 24 and above was considered unimpaired, the MMSE correctly detected 87% of impaired patients and 82% of unimpaired patients (3)
b. Has also been validated against anatomical support of dementia due to Alzheimer's (10)
C. Relevant Research
1. Previous research has shown MMSE performance to be related strongly to age and level of education (7,8)
a. Age is negatively associated with score (7)
b. Education is positively associated with score (1,7)
c. Uneducated people, therefore, have increased risk of being falsely diagnosed as impaired cognitively (1)
d. Some researchers think an education level adaptation would make assessments more accurate (1)
2. Studies have shown a negative correlation between the MMSE and rural residency, lower level of occupation, being a minority, and being a female (8)
a. The cause of these relationships may also be related to less education (8)
3. Researchers are not sure if level of education is directly involved in cognitive changes or if there is another related variable that should be implicated (1)
a. One study found "health behaviors and general health status" to be possibly related (1)
b. Another study found genetic effects as a cause for the education-cognition correlation (l)
c. A genetic relationship has also been found in some animal studies (1)
4. A study by Kelman, et al. found individuals that were severely impaired on the MMSE were older, poorer, had less education, had worse health, and were more likely to be women than those who were unimpaired (6)
a. However, those who were mildly impaired only differed from unimpaired in age and income, not education or health (6)
b. This may be suggestive for different origins for mild and severe impairment (6)
c. This study also found overall prevalence of Impairment was not significantly different between (39,2%) and women (42.1%) (6)
A. MMSE identifies the signs of Impairment but does not provide a diagnosis (6)
1. Impairment may be the result of many things, including dementia, depression, brain injury, and retardation (6)
a. A negative correlation has also been noted between MMSE score and Parkinson's disease, diabetes and stroke in older individuals (7)
B. Tasks that address verbal and visuospatial skills, such as the MMSE's Language section, are effective in determining the stage of dementia (5)
C. Episodic memory tasks, such as the Recall section of the MMSE, are more useful in detecting the presence of dementia (5)
A. Patients who show deficits in Attention and Calculation area are sometimes schizophrenic or depressed; also seen in epilepsy, dementia, and head injury patients (9)
B, When patient cannot answer questions about orientation, suggests "severe organic pathology" (9)
1. Confabulation on the Orientation section may suggest severely impaired memory, such as the type related to chronic alcoholism (9)
A. MMSE is used for the assessment of dementia as a result of disease and multi-infarct dementia (4,12)
B. May be used without adaptation in the assessment of the severity of dementia in schizophrenic patients (4)
1. The clinical qualities of schizophrenia and thus psychiatric illnesses in general do not seem to reduce the reliability of the test (4)
C. In cases of head injury with cognitive deficits, MMSE can be used repeatedly over time to follow patient's recovery (3)
A. When dementia is being assessed, poor MMSE score may be easier to understand than poor scores on other tests, such as the WAIS-R (3)
1,WAIS-R is more ambiguous (3)
2. Implications for "day-today competency" of patient are apparent from bad MMSE score (3)
a. These straight-forward implications can be understood by non-psychologists, such as lawyers, judges, and social workers, who need information about patient's functioning (3)
B. The Iowa Screening Battery For Mental Decline designed to assess same problems as MMSE (1)
1. This test also positively correlates with educational level (1)
C. Mattis Dementia Rating Scale (MDRS) covers more aspects of cognitive functioning than MMSE, (11)
1. However, MMSE takes less time to administer, so may be preferred, especially in cases where attention span is a consideration (11)
The Mini-Mental State Exam
(5) What is the year, season, date, day, and month? 1 point for each correct answer (5) Where are we now?
(County, state, city, _____ hospital, and floor or address)
1 point for each correct answer (3) Name three objects: table, comb, tree.
Ask the _____ patient to repeat them after you have told them.
1 point for each correct answer on 1st trial (5) Spell the word 'world' backwards. 1 point for each letter correct (3) What are those three words I said to you? 1 point for each correct word (2) Show the patient a pencil and watch and
ask patient _____ to name them.
1 point for each correct answer (1) Please say what I say: "No if's, and's, or but's." 1 point if no error (3) A 3-stage command: "Please listen. Take this paper in your right hand;
fold it in half and put it on the floor."
1 point for each correct act (1) Show the patient a card with the sentence:
Close your eyes. Ask the patient to read it and do what it says.
1 point if patient closes eyes (1) Please write a sentence here (give patient a pencil and paper.).
Any sentence will do.
1 point if complete, meaningful sentence is written (1) Show the patient a card with a figure. Ask him to copy it. 1 point if drawing resembles figure
1. Carmelli, D. et al. (1995) Genetic Mediation in the Relationship of Education to Cognitive Function in Older People. Psycholoqy-and Aging (1), 48-53.
2. Fillenbaum, G.G., Molls, R.C., Welsh, K.A,, & Wilkinson, W.E. (1994)
Discrimination Between Stages of Alzheimer's Disease With Subsets of Mini-Mental State ExarNnaton Items. Archives of Neurology, 51, 916-920,
3. Gregory, R.J. (1987) Adult Intellectual Assessment. Boston: Allyn and Bacon, Inc.
4. Harvey, P.D. et al. (1 992) Assessment of Dementia in Elderly Schizophrenics With Structured Rating Scales, Schizophrenia Research, 7, 85-90.
5. Herlitz, A. et al. (I 995) Episodic Memory and Visuospatial Ability in Detecting and Staging Dementia in a Community-Based Sample of Very Old Adults. Journal of Gerontology, 50A, (2), M 107- M 113.
6. Kelman, H,R. et al. (I 994) Cognitive Impairment and Mortality in Older Community Residents. American Journal of Public Health, 84 (8), 1255-1259.
7. Launer, L.J. et al. (1993) Are Age and Education Independent Correlates of the Mini-Mental State Exam Performance of Community-Dwelling Elderly? Journal of Gerontology-, 48 (6), P271-P277.
8. Liu, H. et al. (I 994) Performance on a Dementia Screening Test in Relation to Demographic Variables, Archives of Neurology, 51, 910-915.
9. Morrison, J. (1 993) The First Interview. New York: The Guilford Press.
10. Othmer, E. & Othmer, S. (1 994) The Clinical Interview Using DSM-IV, Volume 1: Fundamentals, Washington, D.C.: American Psychiatric Press.
11. Spreen, 0, & Strauss, E. (1991) A Compendium of Neuropsychological Tests. New York: Oxford University Press.
12. Weiler, P.G. et al. (I 994) Comparison of Mental Status Tests: Implications for Alzheimer's Patients and Their Caregivers- Journal of Gerontology, 49, (1), 544-551.
Exams for Testing Aphasia with Specific Regard to the Reitan-Indiana Aphasia Screening Test
A. In 1861 Broca described a rather detailed testing procedure that employed clinicians in examining aphasics. He began by asking a patient conversational questions, commented on the patient's speech output and comprehension, and went on to describe his gestures, tested his tongue movements, his writing, and arithmetic.
B. Hughlings Jackson added sign making, writing, comprehension, repetition, reading, and tongue movements, as well as a description of spontaneous speech, as regular features of the aphasia examination. In 1906 Pierre Marie emphasized the importance of deficits in comprehension and worked with Moutier, an aphasic patient, who described a complete set of systematic tests for aphasics in a large monograph entitled "L'aphasie de Broca."
C. The first systematic aphasia examination in English was detailed in two large volumes by Henry Head in 1926. He examined head-injured soldiers by tailoring tests to their deficits and covering the possible modalities affected. Few anecdotal controls were used, the administration was not standardized, and he emphasized flexibility. However, many of his ideas in testing have been adopted.
1. Naming and recognition of common objects used the same six objects in assessing word recognition, nonverbal matching, naming, reading, and writing, much like the PICA. He studied sentence formation by using picture description, writing, copying, and reading of sentences, as well as comprehension tests which are considered a precursor to the Token Test. He also studied sequential tasks which identified left and right orientation and praxis.
2. Head complemented these tests with understanding a paragraph from a newspaper, arithmetic tests, setting a clock, drawing objects from a model and memory, sketching a ground plan of a familiar room, finding the way along some familiar route, completing puzzles, and playing games such as dominoes and cards.
D. A standardized test battery was constructed by Weisenberg and McBride in 1935 from various existing intelligence tests, but was reconstructed several times to reduce the amount of time of the test and to make it more sensitive for mild and severe disorders. Definitions of severity were not given and standardization was incomplete, however, they did obtain nonnative data.
E. The battery from 1935 and later editions of it was considered a precursor of many of the current tests of word recognition and sentence comprehension, as well as for apraxia. (Incagnoli, Goldstein, Golden, 1986)
F. In the 1960's aphasia testing became well established because of a need for diagnostic; assessment and planning for therapy, and to compare patients for research. Eisenson's Examination for Aphasia (I 954), The Language DAodah6es Test for Aphasia (LMTA- 1 96 1), and The Minnesota Test for Differential Diagnosis of Aphasia were some of the batteries that became prominent during this time. Since then, others have been developed, adopted, and standardized.
G. Aphasia testing can be difficult to standardize because of differences between goals of clinicians and researchers. Specifically for the Reitan-Indiana Aphasia Screening Test, standardization can be difficult in relation to the examiner/interpreter of the test. The person must be able to identify a defective performance and judge whether or not it is the type of deficit that is characteristic of persons with cerebral damage. Adequate experience and education of the examiner is paramount in detecting abnormal brain functions. These questions all contribute to the reliability and validity of the test, and in order to make results more clear and reliable, Reitan published a 1984 volume that provided detailed illustrations of brain related deficits on the Aphasia Test. (Reitan, 1985) In 1970, Russell, Neuringer, and Goldstein published a quantitative scoring system that included a 5-point scaling of the figure drawings, a modification of the one or zero (presence or absence of impaired response) system. Relatively higher interrater reliabilities have been reported using this method. (Williams, Shane-1986)
H. One portion of the Aphasia Screening Test requires the copying of the general shape of a skeleton key. A study published in 1985 studied 138 normal and 1,235 neuropsychological/neurological patients and key orientation (reversed, vertical, diagonal, indeterminant) to determine clinical significance of this portion of the test. Even though each of the patient groups produced nonstandard orientations more frequently than the normal control group (79% more frequently), the difference did not approach statistical significance.
The report concluded that nonstandard orientations in drawings are infrequent, somewhat unreliable in appearance, and without definite relationship to other variables. They occur slightly more commonly in patients than in normal controls, but the difference is not reliable. (Dodril, 198'))
1. A comparison of clinical and automated interpretation of the Halstead-Reitan Battery was done in 1981 and found that the clinicians' independent ratings of the battery were more reliable and more accurate. The test for the aphasia exam used the zero to five ratings system since it does not use a conven6onal scoring procedure. This report contributes to the assumption that the reliability and validity of the test are in the hands of the examiner and his/her interpretations. (Heaton, 1981)
J. A study done in 1990 compared teaming disabled individuals, head injured individuals and nondisabled young adults using the Aphasia Screening Test for naming, pronunciation, and sentence interpretation. All people were given the WAIS and the HRNTB. Results concluded that the teaming disabled and head injured did not differ in responses and made significantly more errors on the aphasia exam than did the nondisabled individuals. It also reported that one-third of the learning disabled and head injured peopled exhibited language deficits, and severity ratings for the aphasia exam did not improve group discrimination. (O'Donnell, et.al., 1990)
K. A study done in Toronto, Ontario compared patients with lateralized stroke or tumor in the frequency of errors on specific test items of the Aphasia Screening Test. Right and left hemisphere damaged patients showed a statistically significant difference on only one of the 33 items-- drawing the skeleton key by the right hemisphere group. Another significant statistic involved the categorization according to task type, such as spelling, reading, calculation, etc. The right hemisphere patients made significantly more errors in drawing the figures of the AST. (Snow, 1987)
A. Description. The Reitan-Indiana Aphasia Screening Test is a modification of the Halstead-Reitan Aphasia Screening Test of 1949 that included 51 items which covered the major areas of language disability. The Reitan-Indiana dropped some of the nondiscriminant questions and consists of 32 items. The test is devised to identify failures of performance and specific deficits, therefore not employing any definite scoring system. Observations of indications of brain-related deficiencies and abnormalities give results. The test asks the patient to perform a series of tasks such as naming common objects, spelling simple words, identifying individual numbers and letters, reading/writing/enunciating/understanding spoken language, identifying body parts, calculating simple arithmetic problems, differentiating between right and left, and copying simple shapes. (Reitan, 1985)
B. The administrator follows instructions on the back of each card that corresponds to the s6nmulus seen by the subject. The most likely type of deficit associated with a negative performance is noted on the back of the card for the administrator's observational use. The administrator should encourage the patient to attempt every task and encourage him/her to perform correctly on the first attempt each time. The administrator should listen and observe closely and write down each response as it occurs.
C. As stated earlier, there is no scoring table for the aphasia exam, but rather is observed for deficits in brain function. (Reitan, 1985)
A. According to Wheeler & Reitan (1962, 1963), the Reitan-Indiana Aphasia Screening Test research results have shown that performances on the test are strongly correlated to the status of each cerebral hemisphere and actually appear to contain almost as much diagnostic information as the test in the entire Halstead-Reitan Battery. The statement is based on discriminant function analyses of the Aphasia and Sensory-perceptual Examination which permitted classification of normal subjects and persons with right, left, and generalized cerebral lesions into their appropriate groups with essentially the same degree of accuracy as achieved using the rest of the HRB. (Wheeler, Burke, & Reitan, 1963) Additional information regarding brain sensitivity is addressed in the next section.
A. For complete understanding of an Aphasia Exam, it is necessary to be familiar with terminology associated with disorders.
1. Dysarthria--disorder of articulation in which basic language (grammar and word choice) is intact. Patients with this problem produce distorted speech sounds that are unintelligible and may not resemble normal words.
2. Dysprosody--interruption of speech melody, focusing on inflection and rhythm. Speech may be sound monotonal or have characteristics of a foreign accent.
3. Apraxia--the inability to carry out skilled movements of the face and speech apparatus in the presence of normal comprehension, muscle strength, and coordination.
4. Aphasia--patient produces errors of grammar and word choice.
5. Alexia--loss of reading ability in a literate person with functional vision.
6. Agraphia--an acquired disturbance in writing, referring specifically to errors of language and not to problems with formation of letters. (Strub, Black 1990)
B. Cerebral Dominance. 90% of the population is thought to be right handed, and of this percentage, 99% are strongly left hemisphere dominant for language. Therefore, damage to the left hemisphere will cause aphasia whereas damage to the opposite hemisphere will spare language functions in these people. Of left handed people, 40% are right hemisphere dominant for speech while 60% are left hemisphere dominant. Also the degree of dominance is not as strong as right handers, with 80% of all left handers having some mixed dominance for language. (Benson, Geschwind, 1968)
C. Areas of the Brain.
1. Wernicke's Area (posterior language area) is the cortical area primarily concerned with the comprehension of spoken language. Patients with damage to this are often referred to as 'receptive aphasics.'
2. Language production occurs in the anterior language area, within Broca's area. Patients with damage to this are often referred to as 'expressive aphasics'.
**One problem with the terminology of 'expressive' and 'receptive' is that all aphasics have some degree of abnormal language expression. The classifications described in the following text follow anatomic patterns of the brain and are useful in localizing lesions. However, this system will be more difficult in the classification of left handed patient.
a. Global Aphasia.
Performance: It is the most common, most severe, and characterized by speech that is nonexistent of reduced to a few words or sounds, such as ba, ba, ba. Comprehension will be absent, with the patient only identifying a few selected words such as his/her name. Reading and writing will also be nonexistent.
Location: Lesion in language areas I and 2, which are completely or almost completely damaged. A very common lesion is an occlusion of the internal carotid artery or the middle cerebral artery at its origin.
b. Broca's Aphasia.
Performance: Nonfluent, dysarthric, effortful speech of mostly nouns and verbs characterizes this disorder. Repetition and reading aloud are as severely impaired as spontaneous speech, but auditory and reading comprehension are intact. Naming will show paraphasias at times.
Location: This syndrome results in a lesion in Broca's area, covering more than area 44. (Lesions only in area 44 produce transient dysarthria or dysprosody.) Auditory and visual comprehension are intact because parietal and temporal lobes have not been damaged.
c. Wernicke's Aphasia.
Performance: The patient will exhibit fluent, effortless, well articulated speech, but the output will contain many paraphasias and be lacking substantive words. Often the patient with this form of aphasia will experience a great desire to overpower the listener with his/her speech. Spontaneous speech will range from comprehensive sentences with occasional errors to completely incomprehensible jargon spoken as if complete, meaningful sentences had been spoken. The prominent feature of Wernicke's Aphasia is a severe disturbance of auditory comprehension. The patient will answer questions inappropriately and be unaware that their answers are nonsense. Repetition is impaired, Naming is paraphasic, and reading and writing are impaired.
Location: The lesion causing this form of aphasia is in Wernicke's area. The more severe the auditory comprehension the more likely it is that the lesion involves the posterior portion of the superior temporal gyrus. If single word comprehension is good, and comprehension of complex material is impaired, the lesion is more likely to involve the parietal lobe rather than the superior-temporal.
d. Conduction Aphasia.
Performance: It is characterized by fluent, yet halting speech with word finding pauses and literal paraphasias. Comprehension is good, naming is mildly disturbed, but repetition is severely defective. Reading is good, but Nvm6ng shows errors in spelling, word choice, and syntax.
Location: The lesion is usually involves the arcuate fasciculus, which is a long fiber tract between the anterior and posterior areas.
e. Anomic Aphasia
Performance: It is characterized by word finding difficulty and an inability to name objects on confrontation.
Location: Localization of this type of lesion is difficult because lesions in many parts of the dominant hemisphere can cause Anomic aphasia. The most severe anomics are thought to have lesions in the temporal lobe involving the second and third temporal gyri, or in the parieto-temporal area.
f. Transcortical Aphasia.
Performance: It is characterized by intact repetition of spoken language, but disruption of other language functions. Patients will have difficulty producing language, yet comprehend what is being asked, while others will produce fluent speech, yet have poor comprehension.
Location: Lesions are thought to be within the borderzones between major cerebral vessels--anterior and middle cerebral arteries.
g. Pure Word Deafness
Performance: Patients will have a complete lack of comprehension of verbal language with no aphasic speech, agraphia, or alexia.
Location: The lesion is thought to be in the posterior language area but has not been specified.
h. Articulation Disturbances
Performance: The patient will not speak at all but will completely communicate normally when reading or writing.
Location: Lesions are in the inputs to the muscles of articulation. (Strub, Black-1990)
3. The potential is good for lateralizing lesions, categorizing them as expressive, receptive, or both, and for contributing to an overall neuropsychological evaluation, according to answers on the Reitan-Indiana AST. (Weisenburg, 1964)
A. From clinical experience with aphasics, standards derived from intelligence testing and construction of other psychological tests, the following are statements of what an aphasia test measures:
1. Explore all potentially disturbed language modalities.
2. Discriminate between clinically relevant aphasia types.
3. A range of difficulty in order to examine a representative range of severity of deficits (construct validity).
4. Discriminate between normals, aphasics and non-aphasic brain-damaged individuals (criterion validity).
5. Rate speech output or expressive function.
6. Measure comprehension, naming, repetition, reading, and writing.
7. Measure simple arithmetic ability.
8. Measure simple copying, drawing capability.
10. Distinguish lateralization, receptive, expressive, or receptive/expressive language (Incagnoli, Goldstein, Golden, 1986).
A. The Language Modalities Test for Aphasia uses a film strip to present visual stimuli, as well as auditory stimuli presented by the examiner. Responses are oral and graphic for both kinds of stimuli. A matching response is also used. There is a screening section of 11 items. If necessary, this is followed by another 46 items. The stimuli include objects, words, numbers, and sentences f increasing length. The scale is scored by syntactic errors, semantic errors, jargon or unintelligible response, or no response.
B. Boston Diagnostic Aphasia Examination is a comprehensive test designed for the diagnosis of presence and type of aphasic syndromes leading to differences concerning cerebral localization, measurements of levels of performance over a wide range for both initial evaluation and detection of change over time, and comprehensive assessment of the assets and liabilities of the patients in all areas as a guide to therapy. Expository speech, auditory comprehension, oral expression, reading comprehension, writing tasks, supplementary language teas, and supplementary nonlanguage tests are components of the exam. (Logue, Schear, 1984)
A. Strengths of the RIAVSI' are that specific deficits of known cerebral significance can be discerned and lateralized.
B. A weakness is that experience and knowledge on behalf of the examiner is absolutely paramount in detection.
1. Benson, Geschwind, (1968) Cerebral dominance and its disturbances, Clinical Pediatrics, 15, 759.
2. Dodrill, C. (1985) Incidence and doubtful significance of nonstandard orientations in reproduction of the key from the Aphasia Screening Test, Perceptual and Motor Skills, 60 (2), 411-415.
3. Heaton, R. (1981) A comparison of clinical and automated interpretation of the Halstead-Reitan Battery, Journal of Clinical Neuropsychology, 3, 121-141.
4. Incagnoli, Goldstein, Golden, (1986), Clinical Application of Neuropsychological Test Battery, Plenum Press.
5. Logue, Schear, (I 984), Clinical Neuropsychology, A Multidisciplinary Approach, Charles C. Thomas-Publisher.
6. O'Donnell, Romero, Leicht, (1990), A comparison of language deficits in learning-disabled, head injured, and nondisabled young adults: Results from an abbreviated Aphasia Screening Test, Journal of Clinical Psychology, 46, 310-315.
7. Reitan, Wolfson, (1990), The Halstead-Reitan Neuropsychological Test Battery, Theory and Clinical Interpretation, Neuropsychology Press.
8. Snow, (1987), Aphasia Screening Test performance in patients with lateralized brain damage, Journal of Clinical Psychology, 43, 266-27 1.
9. Strub, Black, (1990), The Mental Status Examination in Neurology, F.A. Davis Company.
10. Wheeler, Burke, and Reitan (1963), An application of discriminant functions to the problem of predicting brain damage using behavioral variables, Perceptual and Motor Skills, 16, 417-440.
11. Williams, Shane, (1986), The Reitan-Indiana Aphasia Screening Test: Scoring and Factor Analysis, Journal of Clinical Psychology, 42, 156-160.
12. Weisenburg, (1964), Aphasia: A Clinical and Psychological Study, Hafner Publishing Company.