Normative data and construct validity of the Rey Auditory Verbal Learning Test in Brazilian elderly
ABSTRACT The Rey Auditory Verbal Learning Test (RAVLT) is an episodic memory test that is influenced by demographic variables, such as age, education, and gender. Classic word list learning has also been well documented to be an experimental cognitive paradigm that is very useful for the detection of Alzheimer’s disease. The present study analyzed the performance of healthy elderly subjects on the RAVLT, describing the effects of age, education, and gender. To verify its construct validity, the RAVLT was compared with delayed recall and recognition scores on the Brief Cognitive Screening Battery (DR-BCSB). The sample comprised 183 cognitively healthy elderly subjects from outpatient care units of two university reference centers in Rio de Janeiro and São Paulo, Brazil. All participants were subjected to physical and neurological evaluation and neuropsychological assessment. Pearson’s correlation and Student’s t-test were used to investigate the influence of demographic variables on RAVLT performance. To verify convergent-type construct validity, a correlation between RAVLT and DR-BCSB scores was calculated. These results revealed some normative data and convergent-type construct validity of the RAVLT for a Brazilian elderly population.
- SourceAvailable from: Jonas Jardim de Paula[Show abstract] [Hide abstract]
ABSTRACT: Objective: This transversal study aims to evaluate the discriminant validity of the Rey Auditory Verbal Learning Test (RAVLT) by comparing a sample of normal elderly with a patient at the initial stage of Alzheimer’s disease. Methods: Age and educational attainment matched patients at the initial stages of Alzheimer’s disease (n = 35) and normal elderly (n = 35) were submitted to the Rey Auditory Verbal Learning Test, Mini Mental State Examination and the Geriatric Depression Scale. The performance of the two groups was compared using the Mann-Whitney test at each stage of the RAVLT and by ROC analysis the discriminant validity of the test in both populations was evaluated. r esults: The group at the initial stages of Alzheimer’s disease had significantly worse performance in all steps of the RAVLT compared to the control group, and the steps showed good diagnostic power, with areas under the curve ranging between 0.806 and 0.989 (A1 = 0,806; A2 = 0,869; A3 = 0,958; A4 = 0,947; A5 = 0,989; A6 = 0,962; A7 = 0,985; TOTAL = 0,975; LOT = 0,895; REC = 0 ,915). Conclusion: The results suggest that the Rey Auditory Verbal Learning Test is effective for discriminating normal elderly seniors from the ones in early stages of Alzheimer’s disease.Jornal brasileiro de psiquiatria 01/2011; 60(4-004720-85):253-258.
- Dementia e Neuropsychologia 01/2011; 5:153 - 166.
- Revista de Psiquiatria Clínica 01/2012; 39(1-39):19-23. · 0.63 Impact Factor
Psychology & Neuroscience, 2010, 3, 1, 79 - 84
Normative data and construct validity of the Rey Auditory
Verbal Learning Test in a Brazilian elderly population
Helenice Charchat Fichman1,2,3, Luciana Brooking Teresa Dias1,2, Conceição Santos Fernandes2,
Roberto Lourenço2, Paulo Caramelli3,4 and Ricardo Nitrini3
1 Pontifícia Universidade Católica do Rio de Janeiro, Brazil
2 Universidade do Estado do Rio de Janeiro, Brazil
3 Universidade de São Paulo, Brazil
4 Universidade Federal de Minas Gerais, Brazil
The Rey Auditory Verbal Learning Test (RAVLT) is an episodic memory test that is influenced by demographic variables, such as
age, education, and gender. Classic word list learning has also been well documented to be an experimental cognitive paradigm that
is very useful for the detection of Alzheimer’s disease. The present study analyzed the performance of healthy elderly subjects on the
RAVLT, describing the effects of age, education, and gender. To verify its construct validity, the RAVLT was compared with delayed
recall and recognition scores on the Brief Cognitive Screening Battery (DR-BCSB). The sample comprised 183 cognitively healthy
elderly subjects from outpatient care units of two university reference centers in Rio de Janeiro and São Paulo, Brazil. All participants
were subjected to physical and neurological evaluation and neuropsychological assessment. Pearson’s correlation and Student’s t-test
were used to investigate the influence of demographic variables on RAVLT performance. To verify convergent-type construct validity,
a correlation between RAVLT and DR-BCSB scores was calculated. Significant correlations were found between age and ∑A1-A5 (r
= -.383, p < .01), A5-A1 (r = -.054, p < .01), A7 (r = -.361, p < .01), and REC A (r = -.288, p < .01). Educational level correlated with
∑A1-A5 (r = .405, p < .01), A5-A1 (r = .184, p < .01), A7 (r = .334, p < .01), and REC A (r = .329, p < .01). No correlation was found
between gender and RAVLT performance. A significant correlation was also found between RAVLT and DR-BCSB performance (r =
.5, p < .01). These results revealed some normative data and convergent-type construct validity of the RAVLT for a Brazilian elderly
population. Keywords: RAVLT, demographic variables, construct validity, normative data.
Received 6 November 2009; received in revised form 19 March 2010; accepted 19 March 2010. Available on line 26 June 2010
Helenice Charchat-Fichman, Departamento de Psicologia, Pontifícia
Universidade Católica do Rio de Janeiro, Brazil; Laboratório de
Pesquisa em Envelhecimento Humano - GeronLab, Departamento
de Medicina Interna, Faculdade de Ciências Médicas, Universidade
do Estado do Rio de Janeiro, Brazil; Grupo de Neurologia Cognitiva
e do Comportamento do Departamento de Neurologia da Faculdade
de Medicina da Universidade de São Paulo, Brazil. Luciana Brooking
Teresa Dias, Departamento de Psicologia, Pontifícia Universidade
Católica do Rio de Janeiro, Brazil; Laboratório de Pesquisa em
Envelhecimento Humano - GeronLab, Departamento de Medicina
Interna, Faculdade de Ciências Médicas, Universidade do Estado do Rio
de Janeiro, Brazil. Conceição Santos Fernandes, Laboratório de Pesquisa
em Envelhecimento Humano - GeronLab, Departamento de Medicina
Interna, Faculdade de Ciências Médicas, Universidade do Estado do
Rio de Janeiro, Brazil. Roberto Lourenço, Laboratório de Pesquisa em
Envelhecimento Humano - GeronLab, Departamento de Medicina
Interna, Faculdade de Ciências Médicas, Universidade do Estado do Rio
de Janeiro, Brazil. Paulo Caramelli, Grupo de Neurologia Cognitiva e
do Comportamento do Departamento de Neurologia da Faculdade de
Medicina da Universidade de São Paulo, Brazil; Grupo de Pesquisa
em Neurologia Cognitiva e do Comportamento, Departamento de
Clínica Médica da Faculdade de Medicina da Universidade Federal de
Minas Gerais, Brazil. Ricardo Nitrini, Grupo de Neurologia Cognitiva
e do Comportamento do Departamento de Neurologia da Faculdade
de Medicina da Universidade de São Paulo, Brazil. Correspondence
regarding this article should be directed to: Helenice Charchat Fichman.
Rua Visconde de Pirajá, 550 / 603, Ipanema, Rio de Janeiro, RJ, CEP
22410-901. E-mail: firstname.lastname@example.org
Memory assessment is essential to neuropsychological
evaluation in elderly populations with cognitive dysfunction.
Memory decline is a marker of mild cognitive impairment
(Mattos et al., 2003; Meyer, Xu, Thornby, Chowdhury, &
Quach, 2002; Petersen et al., 2001) and is an early predictor
of dementia, especially Alzheimer’s disease (AD) (Almeida,
1998). In addition to the importance of diagnostic issues,
demographic variables influence memory performance
(Van Der Elst, Van Boxtel, Van Breukelen, & Jolles, 2005).
Episodic memory is the long-term memory of facts and
Fichman et al
events in our life, delimited by time and space (Sternberg,
2000). The scientific literature contains several tests
that assess episodic memory, such as the delayed recall
test from the Consortium to Establish a Registry for
Alzheimer’s Disease (CERAD) neuropsychological
battery (DR-CERAD) (Bertolucci et al., 2001; Morris
et al., 1989), California Verbal Learning Test (CVLT)
(Elderkin-Thompson, Mintz, Haroon, Lavretsky, &
Kumar, 2006), Visual Reproduction Test (VRT), Free and
Cued Selective Reminding Test (FCSRT) (Buschke &
Fuld, 1974; Minett, da Silva, Ortiz, & Bertolucci, 2007),
Episodic Memory Test (Jorm et al., 1997), Wechsler
Memory Scale (WMS-R) (Janowski, Carper, & Kaye,
1996; Wechsler, 1987), and the delayed recall test from
the Brief Cognitive Screening Battery (DR-BCSB)
(Nitrini et al., 2004; Takada et al., 2006).
The present study focused on the Rey Auditory Verbal
Learning Test (RAVLT) (Spreen & Strauss, 1998), which
is a widely used task to assess episodic memory (Mattos
et al., 2003). The RAVLT was developed by André Rey
from the Edouard Claparäde list (Lezak, Howieson, &
Loring, 2004) and is an easily administered (Knight,
McMahon, Green, & Skeaff, 2006) episodic learning
memory test (Knight, McMahon, Skeaff, & Green, 2007;
Malloy-Diniz, Lasmar, Gazinelli, Fuentes, & Salgado,
2007; Minett et al., 2007; Spreen & Strauss, 1998).
The RAVLT presents some international (Lezak,
1995) and only one Brazilian normative date for the
elderly population (Malloy-Diniz et al., 2007). Studies
have emphasized its psychometric properties, suggesting
a correlation between the internal content of the RAVLT
and that of other memory tests (Spreen & Strauss,
1998). Some authors have reported the reliability of
the test (ranging from 0.60 to 0.77) from the test-retest
method after a period of time and use of parallel forms.
Van Den Burg & Kingma (1999), for example, noted
that the most reliable measure was the total number of
words, in addition to showing the contribution of the
effect of age on the results. The greater reliability of
the total number of recalled words was also reported
by Geffen, Butterworth and Geffen (1994) in a sample
of normal 20- to 67-year-old adults. Strauss, Shermann
and Spreen (2006) reported levels of temporal stability
for the RAVLT. In a recent study by Knight et al. (2007),
significant results concerning test-retest reliability in
healthy, elderly, 65-year-old subjects were found.
These results suggest some important findings
regarding the reliability of this test, despite a few
studies showing temporal instability and a lack of
construct validity for the RAVLT. Most studies have
used the RAVLT for diagnostic purposes (Schoenberg
et al., 2006). In qualitative studies, people with
frontotemporal dementia (FTD) have more intrusion
words in RAVLT recall than AD and Parkinson’s
disease (PD) patients. Moreover, more words are
recalled in PD compared with AD and FTD.
Moreover, the RAVLT has been previously shown
to help differentiate patients with dementia with Lewy
bodies from those with AD (Ferman et al., 2006)
and assess memory function in people with mild
cognitive impairment with vascular risk factors (Siuda,
Gorzkowska, Opala, & Ochudlo, 2007).
Similar to the majority of cognitive and memory
tasks, the RAVLT is influenced by demographic
variables, such as age (Malloy-Diniz et al., 2007;
Messinis, Tsakona, Malefaki, & Papathanasopouolos,
2007; Lezak et al., 2004; Schoenberg et al., 2006;
Spreen & Strauss, 1998; Van Der Elst et al., 2005)
and education (Foss, Vale, & Speciali, 2005; Lezak
et al., 2004; Malloy-Diniz et al., 2007; Messinis et
al., 2007; Schoenberg et al., 2006; Spreen & Strauss,
1998; Van Der Elst et al., 2005). Malloy-Diniz et al.
(2007) obtained data on education, age, and gender
in an elderly population sample. Education positively
correlated with performance on the RAVLT, whereas
age had a negative correlation. With regard to gender,
they found that women had better performance than
men. However, some studies are controversial about the
influence of gender (Knight, et al., 2006; Messinis et
al., 2007; Van Der Elst et al., 2005). In another study,
Malloy-Diniz, Cruz, Torres and Cosenza (2000) applied
the test in a sample ranging in age from 16 to 93 years
and showed differences in mean and standard deviations
for adolescents, adults, and the elderly, demonstrating
not only differences among the elderly but also between
different age groups.
As mentioned above, the RAVLT is a well
documented and accepted memory test. Furthermore,
word list learning has been a classic paradigm of memory
assessment since the Hermann Ebbinghaus experimental
studies about forgetfulness in 1885. However, only one
normative study of the RAVLT has been conducted
in a Brazilian elderly sample (Malloy-Diniz et al.,
2007), and no study has assessed the construct validity
of this test within this setting. To achieve this goal, a
comparison with other memory tests is required. For the
present study, we chose the memory test from the BCSB
because it has been previously validated in Brazil and is
not influenced by education (Nitrini et al., 2004).
The goal of the present study was to analyze
normative data of the RAVLT in a sample of Brazilian
healthy elderly subjects and investigate the effects of
age, education, and gender on test performance. The
study also verified the construct validity of the RAVLT
by comparing it with DR-BCSB performance.
The sample was composed of 183 normal elderly
(65 female, 118 male) from outpatient care units of
two university reference centers in Rio de Janeiro and
The Rey Auditory Verbal Learning Test81
São Paulo, Brazil (150 subjects from the Behavioral
and Cognitive Neurology Unit, University of São
Paulo; 33 subjects from the Geriatrics Unit “Mario A.
Sayeg,” Policlínica Piquet Carneiro, State University
of Rio de Janeiro). All subjects were normal elderly
without a dementia diagnosis and free of neurological
and psychiatric drugs. The primary sociodemographic
characteristics and global cognitive performance of the
participants are depicted in Table 1.
The RAVLT is divided into two lists (A and B),
each with 15 unrelated nouns. List A is first presented,
followed by free recall. This procedure is repeated five
times (A1, A2, A3, A4, A5). List B (interference) is
then presented, followed by free recall (B). Afterward,
the subject is asked to recall List A (A6). The next step
is a 30 minute delayed recall task (A7). The last part
of the test is the recognition task, in which 50 words
are presented (15 List A, REC A; 15 List B, REC B;
plus 20 others). In the latter task, each word list must
be followed by the subject indicating whether the
word was in List A or List B or in either of the lists
(Malloy-Diniz et al., 2007). The following scores were
calculated: total number of correct words across trials
(∑A1-A5), learning (A5 minus A1 score), proactive
interference (B1/A1), retroactive interference (A6/
A5), and forgetting speed (A7/A6) (Lezak et al., 2004;
Spreen & Strauss, 1998).
In the BCSB, 10 line drawings of common objects
are presented to the subject, who is asked to name them.
The first step is incidental free recall. In the second step,
the paper is shown again for 30 seconds two more times,
and the subject is asked to memorize and then recall
(immediate memory and learning tests). Finally, 5 minutes
later, the individual is asked to recall as many figures as
possible, followed by the recognition task, in which the
10 pictures previously seen are presented together with 10
other figures not previously seen (Takada et al., 2006).
All participants were subjected to physical
and neurological evaluation and to comprehensive
neuropsychogical assessment. Evaluation was conducted
in a quiet room, one subject at a time.
The participants demonstrated preservation of
global cognitive functioning in the Mini-Mental State
Examination (MMSE) (Brucki, Nitrini, Caramelli,
Bertolucci, & Okamoto, 2003; Folstein, Folstein, &
McHugh, 1975) and independence in daily living
activities determined by the Pffefer Functional Activities
Questionnaire (Pfeffer, Kurosaki, Harrah, Chance, &
Filos, 1982) or Lawton Scale (Lawton & Brody, 1969)
and did not meet the criteria for dementia according to the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) (American Psychiatric Association, 1994).
The study was approved by the Ethics Committee
from both university centers, and all participants
provided written informed consent.
RAVLT scores were composed of total (∑A1-A5),
learning (A5-A1), 30 minute delayed recall (A7), and
recognition List A (REC A). A descriptive analysis
was performed for age, education, gender, MMSE,
and RAVLT scores for all individuals. Pearson’s
N Mean Age (SD)
≤ 75 years 12063.10** (2.06) 10.94 (4.60)71/4926.94 (1.65)
> 75 years 63 70.36 (2.68) 10.03 (5.10)47/1626.46 (2.51)
< 8 years 8874.48** (7.37)4.65** (2.08) 63/2524.69** (3.05)
≥ 8 years89 69.65 (5.86) 13.55 (2.56)51/3827.34 (1.42)
Female11872.99 (7.36)8.07 (4.76) 11825.66 (2.93)
Male65 71.21 (6.84)10.21 (5.76)65 26.22 (3.03)
MMSE, Mini-Mental State Examination; **p < .01, Student’s t-test.
Table 1. Main characteristics of sample
Fichman et al
correlation coefficients were calculated between
age, education, and RAVLT scores. Student’s t-test
was used to analyze the effects of age, education,
and gender on RAVLT performance. Correlation
analysis between the delayed recall and recognition
tasks from the RAVLT and BCSB were performed to
verify convergent-type construct validity. Data were
analyzed using SPSS version 16.0 software. The
significance level was set at p < .01.
Effects of age, education, and gender
According to the Pearson analysis, significant
negative correlations were found between age and the
following scores: ∑A1-A5 (r = -.383, p < .01), A5-A1
(r = -.054, p < .01), A7 (r = -.361, p < .01), and REC
A (r = -.288, p < .01). Significant positive correlations
emerged between education and the following scores:
∑A1-A5 (r = .405, p < .01), A5-A1 (r = .184, p < .01),
A7 (r = .334, p < .01), and REC A (r = .329, p < .01).
No significant difference was found between gender and
the following scores: ∑A1-A5 (t = 1.9, p > .05), A5-A1
(t = .2, p > .05), A7 (t = 1.5, p > .05), and REC A (t = .7,
p > .05). The results of the descriptive analysis, means,
standard deviations, and t-test are shown in Table 2.
Positive correlations were found between A7-
RAVLT and DR-BCSB (r = .528, p < .01) and between
REC A-RAVLT and REC-BCSB (r = .197, p < .01).
In the RAVLT, processes such as codification,
storage, and recall (Atkinson, 1995) are assessed by a
learning curve (A1-A5) and recognition and delayed
recall (A7-RAVLT) aspects. In the present study,
RAVLT performance in healthy elderly subjects was
associated with age and education variables, but not with
gender. RAVLT performance improved with increasing
education and declined with increasing age.
In healthy elderly subjects, RAVLT performance has been
previously shown to be affected by age, an effect attributable
to functional and anatomical changes (Brockway et al., 1998;
Janowsky et al., 1996). However, Janowsky et al. (1996)
showed that this decline is not linear with age and that it
predominates within the verbal memory domain. Moreover,
aging promotes deterioration of other cognitive domains, such
as executive function (Lin, Chan, Zheng, Yang, & Wang, 2007;
Scuteri, Palmieri, Lo Noce, & Giampaoli, 2005), which can
be associated with learning performance possibly through its
influence with search strategies (Ratcliff et al., 1998). Another
hypothesis is that highly educated elderly people have more
possibilities to exercise this function because they are more
exposed to intellectual stimuli than minimally educated people.
A few studies have shown a gender effect on RAVLT
performance, with women presenting higher scores than
men (Knight et al., 2006; Malloy-Diniz et al., 2007;
Messinis et al., 2007; Van Der Elst et al., 2005). Despite
these results, however, we did not find significant
differences in performance between genders, consistent
with a study by Foss et al. (2005).
N∑A1-A5 A5-A1 A7Rec A
≤ 75 years12037.1 (11.5)** 4.6 (2.6)5.7 (4.0)**10.2 (4.7)
> 75 years 6330.7 (8.3)4.2 (2.6) 4.2 (3.6)8.1 (4.5)
< 8 years8831.6 (9.8)**4.1 (2.4)4.1 (3.5)**8.5 (4.8)
≥ 8 years 8938.8 (10.6) 4.9 (2.5)6.2 (3.9)10.8 (4.2)
Female11836.01 (10.63)4.51 (2.58)5.34 (3.98)9.71 (4.65)
Male6532.81 (11.08)4.43 (2.26)4.45 (3.51)9.16 (4.88)
**p < .01.
Table 2. Mean (SD) of age, education, and gender groups
The Rey Auditory Verbal Learning Test83
Few validation studies on these tests have been
conducted. One such report was a case-control study
by Takada et al. (2006), in which the accuracy of two
dementia diagnostic tests (DR-BCSB and DR-CERAD)
was compared. The DR-BCSB showed higher accuracy
than the DR-CERAD among illiterate subjects, similar
accuracy among literate subjects, and a statistical trend
toward higher accuracy in the entire population.
We also found a positive correlation between
performance on the RAVLT and BCSB on both the
delayed recall and recognition tasks. The two tests
evaluate memory function, but they have some
differences. The RAVLT is a verbal episodic memory
test and involves auditory-verbal coding, which requires
more elaborate encoding and search information
strategies than the BCSB. People use a hearing input,
and semantic clues are not available in the task; such
associations must be established by the subject. The
BCSB test, in contrast, has a visual input, and semantic
encoding is possible. The DR-BCSB is also a task that
shows less educational and age influences than the
CERAD (Nitrini et al., 2004). For these reasons, the
correlation observed in the present study to investigate
construct validity was significant, although the level of
significance was not robust.
The present findings represent an important
contribution for clinicians because it expands the data
on the effects of education on RAVLT performance,
demonstrating an association between episodic
memory and sociodemographic variables. This feature
is particularly relevant in a country like Brazil, which
has wide variability in education levels. Moreover, the
confirmation of construct validity of the RAVLT in our
setting may also be important to neuropsychologists and
Further research is necessary to investigate the
effects of age and education in greater detail by
considering different groups according to these variables.
Other aspects of the test can also be evaluated, such as
different trials. Additional studies can verify the effects
of education and age on RAVLT performance in people
with dementia and determine the test’s clinical validity
by comparing healthy elderly subjects with elderly
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