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Fidedignidade e validade de construto do Teste de Aprendizagem Auditivo-Verbal de Rey em idosos brasileiros

Authors:

Abstract

CONTEXTO: O Teste de Aprendizagem Auditivo-Verbal de Rey (RAVLT) é amplamente utilizado para a avaliação da memória episódica. Suas propriedades psicométricas, porém, não foram bem analisadas no Brasil. OBJETIVOS: Buscar evidências de fidedignidade e validade de construto do RAVLT e analisar a influência de idade, gênero, escolaridade e sintomas depressivos no desempenho. MÉTODOS: Cento e vinte e seis idosos saudáveis realizaram o RAVLT, o Miniexame do Estado Mental (MEEM), o Desenho do Relógio (DR) e a Escala de Depressão Geriátrica. A fidedignidade foi avaliada pela análise de consistência interna e a validade de construto, pela estrutura fatorial e correlações com o MEEM e o DR. A influência da idade, escolaridade e sintomas depressivos foi estimada mediante regressão linear, enquanto diferenças de gênero foram avaliadas comparando o desempenho de homens e mulheres. RESULTADOS: O teste apresenta alta consistência interna e estrutura bifatorial relacionada aos processos de armazenamento e evocação da memória episódica. O teste mostrou, em geral, correlações fracas com o MEEM e o DR. Apenas a idade e o gênero influenciaram o desempenho na tarefa. CONCLUSÃO: Nossos resultados indicam que a versão do RAVLT analisada apresenta bons indícios de fidedignidade e validade de construto, atestando sua aplicabilidade em contextos clínicos e de pesquisa para a população estudada.
Original article
Reliability and construct validity of the Rey-Auditory Verbal Learning Test in Brazilian
elders
Fidedignidade e validade de construto do Teste de Aprendizagem Auditivo-Verbal de Rey em idosos brasileiros
Jonas Jardim de Paula1, Larissa Pacheco Cunha Melo1, Rodrigo Nicolato2, Edgar Nunes de Moraes3,
Maria Aparecida Bicalho3, Amer Cavalheiro Hamdan4, Leandro Fernandes Malloy-Diniz2
1 Laboratório de Investigações Neuropsicológicas do Instituto Nacional de Ciência e Tecnologia de Medicina Molecular (INCT-MM) da Universidade Federal de Minas Gerais (UFMG).
2 Departamento de Saúde Mental da UFMG.
3 Departamento de Clínica Médica da UFMG.
4 Departamento de Psicologia da Universidade Federal do Paraná (UFPR).
Received: 7/6/2011 – Accepted: 31/10/2011
Abstract
Background: e Rey Auditory-Verbal Learning Test (RAVLT) is widely used for the assessment of episodic memory. However, there are few studies in Brazil
assessing its psychometric properties. Objectives: To search for evidence of reliability and construct validity of the RAVLT, and to assess the inuence of age,
schooling, gender, and depressive symptoms on test performance. Methods: One hundred twenty-six healthy older adults (aged 60 and over) performed the
RAVLT, Mini-Mental State Exam (MMSE), Clock Drawing Test (CDT) and the Geriatric Depression Scale. Reliability was assessed by analysis of internal
consistency, and construct validity by factor analysis and correlations with the MMSE and CDT. e inuence of age, schooling and depressive symptoms was
estimated by conducting linear regression analysis, and the role of gender by comparing the performance of males and females. Results: e RAVLT showed
a high internal consistency, weak correlations with the MMSE and CDT, and a bifactorial structure, which is related to the processes of learning and episodic
memory retrieval. Only age and gender aected test performance. Discussion: Our results provide evidence of reliability and construct validity in the tested
RAVLT version, attesting its potential for clinical and research purposes for the Brazilian elderly population.
Paula JJ, et al. / Rev Psiq Clín. 2012;39(1):19-23
Keywords: Rey Auditory-Verbal Learning Test, RAVLT, validity, reliability, episodic memory, verbal learning.
Resumo
Contexto: O Teste de Aprendizagem Auditivo-Verbal de Rey (RAVLT) é amplamente utilizado para a avaliação da memória episódica. Suas propriedades psico-
métricas, porém, não foram bem analisadas no Brasil.Objetivos: Buscar evidências de dedignidade e validade de construto do RAVLT e analisar a inuência de
idade, gênero, escolaridade e sintomas depressivos no desempenho. Métodos: Cento e vinte e seis idosos saudáveis realizaram o RAVLT, o Miniexame do Estado
Mental (MEEM), o Desenho do Relógio (DR) e a Escala de Depressão Geriátrica. A dedignidade foi avaliada pela análise de consistência interna e a validade
de construto, pela estrutura fatorial e correlações com o MEEM e o DR. A inuência da idade, escolaridade e sintomas depressivos foi estimada mediante regres-
são linear, enquanto diferenças de gênero foram avaliadas comparando o desempenho de homens e mulheres. Resultados: O teste apresenta alta consistência
interna e estrutura bifatorial relacionada aos processos de armazenamento e evocação da memória episódica. O teste mostrou, em geral, correlações fracas com
o MEEM e o DR. Apenas a idade e o gênero inuenciaram o desempenho na tarefa. Conclusão: Nossos resultados indicam que a versão do RAVLT analisada
apresenta bons indícios de dedignidade e validade de construto, atestando sua aplicabilidade em contextos clínicos e de pesquisa para a população estudada.
Paula JJ, et al. / Rev Psiq Clín. 2012;39(1):19-23
Palavras-chave: Teste de Aprendizagem Auditivo-Verbal de Rey, RAVLT, validade, dedignidade, memória episódica, aprendizagem verbal.
Introduction
e Brazilian elderly population has increased signicantly since last
century and should surpass the 20 million inhabitants mark in this
decade¹. With a larger number of elderly people and higher life expec-
tancy the prevalence of dementia increases, as well as its prodromal
stage, the mild cognitive impairment, since aging is one of the main
risk factors for the development of such cases. A population study
in the Brazilian context2 found a dementia prevalence of 7.1%, being
the Alzheimer disease type the most commonly diagnosed (about
55% of the cases). e prevalence of mild cognitive impairment is
still under debate, oscillating from 3% to 20% in elderly patients3.
In dementia or mild cognitive impairment the cognitive as-
sessment is fundamental for early and clinical diagnosis. e use of
neuropsychological testing is one of the main tools for this assessment
as it allows the patient to be compared to a group or an appropriate
normative reference, leading to an objective examination of memory.
is posture is essential, since patients oen have signicant dicul-
ties in reporting their cognitive diculties, as shown in a literature
review of Dourado et al.4, and the perception of these diculties is
inuenced by dierent factors such as cognitive impairment and
anxiety symptoms5.
e Rey Auditory-Verbal Learning Test (RAVLT) was originally
proposed as a neuropsychological tool for the assessment of the
processes of learning and memory 6. It was adapted for the Brazilian
population by Malloy-Diniz et al.7 with a second version published
later by the same author8, with some changes that favor its use in
the elderly brazilian population, such as a change in the original
list of words to a new one, containing high frequency disyllables in
Brazilian Portuguese. In a recent study9 that estimated the relation-
ship between age, gender, educational level and test performance,
Address correspondence to: Jonas Jardim de Paula. Faculdade de Filosoa e Ciências Humanas, Universidade Federal de Minas Gerais. Av. Antônio Carlos, 6627, Pampulha – 31270-901 –
Belo Horizonte, MG. E-mail: jonasjardim@gmail.com / malloy-diniz@gmail.com
20 Paula JJ, et al. / Rev Psiq Clín. 2012;39(1):19-23
signicant correlations were found between these three variables
and the processes of learning and memory assessed.
In populational studies of other countries the RAVLT tends to
have strong psychometric properties. Internal consistency is gene-
rally above 0.9 and it has high correlations with other instruments
for episodic memory evaluation, such as the California Verbal
Learning Test10.
Fichman et al.11 conducted the rst study of the RAVLT’s cons-
truct validity in the elderly population in the Brazilian context. Using
convergent correlations (cognitive test instruments with positive
correlations tend to measure, at some level, similar constructs) and
a learning picture test that is independent from formal education, the
authors correlated the components “A7”, “REC”, “ Total” and an index
compound by the total number of words mentioned in A5 minus the
total of words evoked in A1 (in which the total of words memorized
is considered, being short-term memory pondered). eir ndings
showed moderate correlations (r = 0.528 p < 0.01) in the recall com-
ponent and weak ones (r = 0.197, p < 0.01) in recognition.
However, an important methodological question arises when
u sing convergent and divergent correlations with other instru-
ments for the analysis of construct validity: although signicant,
the magnitude of eect obtained by such correlations tends to be
low. In Fichman et al.11 study, moderate correlation of the stages of
recall represents approximately 27% of the variance (r²), while the
recognition task represents only 4%. us, respectively 73% and 96%
of common variance between the two instruments are explained by
other factors rather than the latent construct to be validated. One
possible explanation for the unexplained variance in that study is
that the RAVLT has verbal stimuli while the other analyzed instru-
ment has visual ones. Intercorrelation of age on these tests (the total
variance explained by this variable may dier from instrument to
instrument, masking the correlations) and other variables such as
education, general intelligence and gender should also be considered.
Given these biases, the construct validity performed using convergent
correlations should be complemented by other forms of validation,
seeking convergent evidence of such propriety.
When performances on several neuropsychological tests are
correlated, the results are usually grouped into a single component
which is responsible for most of the variance found12. is methodo-
logy aims to identify a latent structure, in other words, a cognitive
construct related to the performed tasks that can be inferred from
the association of performance in dierent cognitive tasks. e
identication of latent structures has been historically associated
with the development of the psychology of individual dierences
and studies about intelligence and personality. e most commonly
used method in such research is the exploratory factor analysis,
a multivariate statistical procedure that deals with the pattern of
correlations or covariance presented by the items of a particular
set of data, seeking for latent patterns of intercorrelations13. is
methodology is one of the most appropriate ones to assess the
construct validity of psychological and neuropsychological tests,
since it allows the testing of hypotheses about the latent features as-
sessed by the instruments. In a recent study14 the latent structure of
a cognitive examination protocol that consisted of several cognitive
tests was evaluated in a clinical population of the Brazilian elderly
population, and only one factor was responsible for more than 58%
of the total variance.
e RAVLT is a test that assesses episodic memory, with com-
ponents related to short-term memory, learning, immediate and
delayed recall and recognition memory. Its factorial structure, how-
ever, is heterogeneous and dependent on the studied population. In
clinical groups of patients with epilepsy or psychiatric disorders15 the
test tends to show a bi-factorial model, with a component related to
short-term memory and the other to long-term memory. It is usually
found two or three factors in the general population: short-term
memory, long-term memory and recognition memory16. is test
has been widely used in clinical and research contexts in several
countries, being considered as a valid and eective measurement of
episodic memory and sensitive to memory decits found in several
clinical conditions such as Alzheimer’s disease17, Mild Cognitive
Impairment17 and major depression18, demonstrating strong crite-
rion validity.
is study aims to evaluate the reliability and construct validi-
ty of the RAVLT. e following hypotheses will be investigated: 1)
e items of episodic memory of the RAVLT will present high internal
consistency (Cronbach’s alpha > 0.8), 2) the components of the RAVLT
will present weak to moderate correlations with the Mini-Mental State
Exam total score and the Clock Drawing, 3) its factor structure will
present a bi or tri-factorial model, with components related to learning
and retrieving processes and 4) age, education, gender and depressive
symptoms will signicantly inuence task performance.
is study is associated with the project Depression and Demen-
tia in the Elderly, approved by the Ethics Committee of Universidade
Federal de Minas Gerais (334/06).
Method
Participants
One hundred twenty-six healthy elderly people were evaluated. ey
were recruited through local advertisements in the metropolitan
region of Belo Horizonte, totaling 63 women and 63 men. e mean
age of the sample was 71.74 (SD = 7.9, Min = 60 and Max = 89) years
and the mean education of 6.74 (SD = 2.3, Min = 4 and Max = 17)
years. Age showed normal distribution in the sample, conrmed by
Kolmogorov-Smirnov test (Z = 1.031 p = 0.239), while education
was polarized in 4 (35%) and 8 (50%) years. Inclusion criteria for
the control group were: age above 60 years, at least 4 years of formal
education, Mini-Mental State Exam (MMSE) total score above the
cut-o proposed for education19 (27.96, SD = 1.57), absence of func-
tional impairment attested by the Katz et al.20 and Lawton-Brody21
inventories of daily living activities, score below the proposed
cut-o for major depressive disorder on the Geriatric Depression
Scale22 (average = 3.07, SD = 2.01), no history of neuropsychiatric
symptoms or neurological impairments and score 0 on the Clinical
Dementia Rating Scale (CDR)23. e evaluations were performed
by neuropsychologists of the Laboratory of Neuropsychological
Investigations (LIN-UFMG). e participants lled out the term of
free and informed consent of the project.
Table 1 shows the sociodemographic data of the sample and the
neuropsyhcological tests performance. For better sample description
the participants were segregated by age (60-69, 70-79, 80-89 years)
and education (less than 8 years and more than 8 years).
Neuropsychological assessment
RAVLT: We used the adapted version for the Brazilian elderly popula-
tion8. e een words are read slowly to the subject, requesting him/
her to repeat them aer the reading, independently from the order
they were said (A1). e same procedure is repeated in steps A2, A3,
A4 and A5, pointing out that the subject must always remember all
the words, including those said previously. en a second list of words
(B1) is read as a distractor, and the subject must only recall these new
words. Aer that, the words of the rst list are asked (A6), without
being exposed, in a task of immediate recall from episodic memory.
Twenty-ve minutes aer this stage the subject must again recall
the words of the rst list (A7) in order to assess the delayed recall of
episodic memory. Finally, a recognition list (REC) containing y
words, the een ones from the rst list, een from the second and
twenty other words phonetically or semantically related (totalling 35
distractors) are are presented, and the subject must judge whether
each word belonged or not to the rst list. e scores of each stage are
computed according to the number of words correctly recalled, except
for REC, where 35 (total of distractors) is subtracted from the total
score (words correctly classied). In order to avoid negative outcomes
in later analysis, the negative results were subtracted, generating a
score ranging from 0 to 50 points. e Total score (ΣA1-A5) in the
learning steps is also computed.
21
Paula JJ, et al. / Rev Psiq Clín. 2012;39(1):19-23
Table 1. Participants description and performance on neuropsychological assessment
60-69
years
(n = 51) 70-79
years
(n = 43) 80-89
years
(n = 32)
< 8 years
n = 26, F = 12
> 8 years
n = 25, F = 15
< 8 years
n = 8, F = 5
> 8 years
n = 35, F = 18
< 8
years
n = 24, F = 14
> 8
years
n = 8, F = 3
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
MEEM
29,1 (1,1) 29,1 (1,0) 27,7 (0,5) 27,4 (0,9) 26,0 (1,3) 26,5 (1,4)
CDT 4,7 (0,8) 4,8 (0,6) 4,3 (0,8) 4,0 (0,5) 3,4 (0,6) 3,3 (0,5)
GDS-15
2,0 (1,8) 1,5 (1,7) 3,3 (1,6) 3,8 (1,1) 5,2 (1,2) 4,4 (1,8)
A1
5,1 (1,1) 5,3 (0,9) 5,2 (2,6) 5,0 (0,7) 3,9 (1,7) 3,5 (0,5)
A2
7,4 (1,8) 7,8 (1,0) 6,7 (2,1) 6,7 (0,9) 5,8 (1,7) 5,5 (0,8)
A3
8,7 (2,0) 8,8 (1,6) 7,8 (2,1) 7,5 (1,4) 7,1 (1,7) 6,9 (2,2)
A4
9,9 (2,0) 10,2 (1,4) 8,7 (2,6) 9,3 (1,6) 8,0 (2,1) 8,5 (1,7)
A5
11,1 (2,0) 11,1 (1,8) 8,8 (1,3) 10,7 (1,2) 9,9 (2,5) 9,4 (2,1)
B1
4,7 (1,1) 4,5 (1,3) 4,0 (0,6) 4,0 (0,7) 2,9 (1,5) 3,5 (1,2)
A6
9,8 (2,6) 9,3 (2,3) 9,0 (1,3) 8,7 (1,1) 8,4 (1,9) 8,0 (1,8)
A7
9,1 (2,8) 9,0 (2,0) 7,7 (2,4) 8,4 (1,2) 7,0 (2,0) 7,4 (2,0)
REC
31,7 (5,8) 28,9 (9,0) 29,7 (2,8) 28,7 (4,7) 26,9 (8,2) 25,8 (8,5)
RAVLT – Total
42,2 (7,2) 43,2 (4,9) 37,2 (9,2) 39,3 (4,1) 34,6 (8,2) 33,8 (5,6)
MMSS: Mini-Mental State Exam; CDT: Clock Drawing Test; GDS-15: Geriatric Depression Scale; RAVLT: Rey Auditory-Verbal Learning Test; SD: Standard Deviations; F: female.
Mini-Mental State Exam: screening instrument commonly used
for identifying cognitive impairment in the diagnosis of dementia19.
It contains questions that assess temporal orientation, spatial orien-
tation, calculation, short-term memory, motor praxis, naming, lan-
guage and constructive praxis. e total score ranges from 0 to 30,
where the cuto points 16, 22 and 26 are used for the identication
of signicant cognitive impairment in illiterate, educated and college
graduated, respectively.
Clock Drawing Test: used to assess the constructive praxis and
executive functions. It is a test of quick and simple application and
it is sensitive to cognitive impairment. In this study we used a score
ranging from 0 (worst) to 5 (best)24.
Statistical analysis
e reliability analysis is the evaluation of the stability or precision of
a test measurement. One method for the analysis of this characteristic
is the internal consistency, performed in this study by calculating
Cronbach’s Alpha (Pasquali, 2006) with the components A1, A2, A3,
A4, A5, B1, A6, A7, and REC of the RAVLT. e construct validity
of the RAVLT was attained through its correlations with other two
neuropsychological tests (MMSE and CDT) and an exploratory factor
analysis, using the principal axis factoring and oblique rotation (direct
oblimin). ese methods were selected because of the theoretical fo-
cus of this study and the probable dependence relationship between
the components of the RAVLT13. Kaiser-Meyer-Olkin measure of
sampling adequacy (KMO) and Bartletts test of sphericity were
calculated to demonstrate the viability of the analysis in the selected
sample. e proportion of observations and variables (ten to one)
recommended by Hair et al.13 was satised. Finally the relationships
between the dierent components of the RAVLT and age, education,
depressive symptoms and gender were assessed. For the rst three
factors we opted for stepwise linear regression models, with the
components of the RAVLT as dependent variables and other varia-
bles as independent. Considering the variable gender, performance
of men and women was compared by Student’s t test, including the
calculation of Cohens d eect magnitude.
Results
e nine components of the RAVLT showed high level of intercor-
relations, generating a Cronbach’s alpha of 0.831, an evidence of
good internal consistency. e correlations between the dierent
components of the test with the MMSE and the CDT oscillated be-
tween not signicant (r = 0.08 p = 405) to weak (r = 0.448, r² = 0.20
p < 0.001). e correlation between the MMSE and the CDT (r =
0.713, r2 = 0.50, p < 0.001) can be considered high. Table 2 shows
the correlations between tests.
KMO´s test (0.856) and Bartlett’s sphericity test (χ² = 458.8, p
< 0.001) indicate sample adequacy for exploratory factor analysis.
Based on the factor extraction, rotation and interpretation of the
eigenvalues and screeplot a two-factor solution was considered most
appropriate (Eigenvalues : 4.411 and 1.139) to the sample, responsible
for 59% of the total variance. e pattern analysis indicates factor
loads predominantly on the items A1 (0.704), A2 (0.763), A3 (0.742)
and A4 (0.776) for factor 1 while the second factor was related to
the items A6 (0.816), A7 (0.714) and REC (0.485). A5 component
exhibited substantial loads on both factors (0.393 in the rst and
0.478 in the second). e factors showed a strong correlation (r =
0.752 r² = 0.56). ese results are shown in gure 1.
e stepwise linear regression analysis, with the components of
the RAVLT as dependent variables and age, education (and presence
of depression symptoms (GDS-15) as independent variables led to
models where only age was a predictor of performance on the RAVLT
(signicant in all stages), while education and depressive symptoms
did not show signicance. Table 2 summarizes these results. Women
had higher performance levels than men in A1 (p < .001 d = 0.66),
A3 (p = 0.031, d = 0.41), A5 (p = 0.015, d = 0.48), A6 (p = 0.032, d
= 0.49) and total (p = 0.008, d = 0.51).
Discussion
is study investigated some psychometric properties of the RAVLT,
a neuropsychological test for memory assessment commonly used
in Brazil. e test of the rst hypothesis proposed, which was about
its internal consistency, indicates that the dierent items of the
RAVLT present a consistent pattern of intercorrelations, an evidence
of reliability. Although there is a robust evidence of such property,
there are no other Brazilian studies evaluating the reliability of the
RAVLT by other methodologies, such as test-retest.
e hypothesis about the construct validity of the RAVLT shows
converging evidences of such characteristic for the studied popula-
tion. e test had weak correlations, but generally signicant, with
two classical tests for global cognitive assessment of elderly patients,
the MMSE and the CDT. is nding suggests that, although they
share variance, the RAVLT measures distinct constructs from those
assessed by the two other tests, an indication of construct validity.
Accordingly, the two screening instruments showed a strong cor-
relation, highlighting the distinction between their constructs and
those measured by the RAVLT.
22 Paula JJ, et al. / Rev Psiq Clín. 2012;39(1):19-23
Figure 1. Factor loadings of the RAVLT.
1,000
0,800
0,600
0,400
0,200
0,000
-0,200
Factor loadings
A1 A2 A3 A4
Factor 1 Factor 2
A5 A6 A7 REC
Table 2. Linear regression analysis and correlations of the RAVLT with
MMSE and CDT
RAVLT βModel Sig. Ajusted
Cor. MMSE Cor. CDT
A1 -0,417 Age p < 0,001 0,17 0,244
(p = 0,010)
0,370
(p < 0,001)
A2 -0,491 Age p < 0,001 0,23 0,370
(p < 0,001)
0,377
(p < 0,001)
A3 -0,396 Age p < 0,001 0,15 0,372
(p < 0,001)
0,377
(p < 0,001)
A4 -0,441 Age p < 0,001 0,29 0,349
(p < 0,001)
0,390
(p < 0,001)
A5 -0,269 Age p = 0,005 0,07 0,193
(p < 0,001)
0,319
(p < 0,001)
B1 -0,448 Age p < 0,001 0,19 0,260
(p < 0,006)
0,335
(p < 0,001)
A6 -0,241 Age p < 0,001 0,05 0,153
(p < 0,110)
0,345
(p < 0,001)
A7 -0,338 Age p < 0,001 0,10 0,289
(p = 0,002)
0,344
(p < 0,001)
REC -0,300 Age p = 0,001 0,08 0,080
(p = 0,405)
0,180
(p = 0,059)
Total -0,493 Age p < 0,001 0,24 0,381
(p < 0,001)
0,448
(p < 0,001)
RAVLT: Rey Auditory Verbal Learning Test; Sig.: Signicance; Cor.: Person Correlation; MMSE:
Mini-Mental State Exam; CDT > Clock Drawing Test.
e factor structure of the RAVLT in the studied population is
consistent with the one found in the literature15,16. In healthy elderly,
with the sociodemographic prole of this study, a two-factor structure
was sucient to explain more than half of the variance presented in
the test. A detailed analysis of the factor loads of each item indicates
a change on the cognitive processes involved in the task: while the
loads of items A1, A2, A3 and A4 on factor one suggest a process
related to learning , the items A6, A7, and partly REC, suggest a search
for a content already stored in the memory system. e component
REC had a lower factor loading than the two components of Factor
2.We conjecture that in a larger and more heterogeneous population
this task forms, by itself, an isolated factor, as pointed out by other
authors16, considering that such component diers from the structure
of other components of the RAVLT.
Based on this information these results we named the two fac-
tors found, respectively, learning and retrieving. is solution is
supported by A5 factor loading, the last item in the learning phase
of the RAVLT, related to the two factors, as a transition between
processes. e factor structure found is supported by both classi-
cal neuropsychological models of episodic memory25 and the most
recent26,27, brain-function correlations28 and studies with clinical
populations16,17,26. e high correlation shown between the two
factors still supports the interdependence of the episodic memory
system. Huijbers et al.26 demonstrated in a functional neuroimaging
study that processes relatively independent from and retrieving share
overlapping hippocampal activation, a structure that would act as a
synthesis and transition element for dierent memory processes, a
view shared by other authors.
e inuence of sociodemographic variables on the RAVLT
conrms some previous ndings, such as the signicant inuence
of age and gender10 on test performance (the Brazilian population
standards are divided by age and sex). Age, the only signicant pre-
dictor in linear regression models, explained between 5% and 29%
of the variance found in the dierent components of the RAVLT,
while gender was related to components A1, A3, A5, A6 and to the
total number of words stored, with better performance of women
over men. e magnitudes were close to half standard deviation. e
clinical relevance of these dierences is signicant, since in some
clinical settings (such as mild cognitive impairment or mild AD) the
quantitative interpretation of the neuropsychological performance
is central to the diagnosis3.
Unlike previous studies9,11, there has not been found signicant
inuence of formal education on test scores. is fact can be ex-
plained by the homogeneity of the participants assessed in terms of
formal education, and the unequal distribution of subjects at 4 and
8 years of education, which is a limitation of this study. e study
of such variable in populations with predominantly low (0-3 years)
and high education (> 14 years) is essential for the proper use of the
test, in order to investigate the performance at dierent educational
levels, considering it is important for diagnostic purposes. Although
the GDS score did not show inuence on the various stages of the
RAVLT, low scores on the scale do not indicate intensive depressive
symptoms, since it was one of the inclusion criteria for this study. In
a clinical group with more apparent depressive symptoms, this factor
could negatively inuence test performance, as evidenced studies that
used the RAVLT in patients with major depression18.
The analysis of the psychometric properties of the RAVLT
conducted in this study provides signicant evidence of reliability
(through analysis of internal consistency), construct validity (through
the use of divergent correlations and analysis of the factorial struc-
ture), besides it investigates the inuence of sociodemographic
variables, such as age, education and gender and the clinical varia-
ble of depressive symptoms. However, this study has the methodo-
logical limitations pointed out by Delis et al.29. e RAVLT is an
instrument marked by learning processes, where each component
of the the test depends crucially on the previous one, which tends
to increase the variance shared by each component. ese authors
argue that the assessment of construct validity through correlations
with other neuropsychological tests and analysis of the factorial
structure is overly biased by the characteristics of the participants.
In an experimental design they demonstrated that the clinical prole
of episodic memory of patients with Alzheimer’s disease and Hun-
tingtons disease (marked by dissociation of performance between
immediate and delayed memory recall) is not supported by analysis
of test correlations and factor structure in that population. However,
Larrab e e’s30 comment about these evidences suggests that factorial
analysis can be a useful tool for construct validity when conducted
in samples of adequate size and homogeneity, and preferably in
combination with other similar cognitive measures (for example,
using RAVLT delayed recalls together with Rey Complex Figure and
CERAD battery praxis recalls).
Comparing the factorial structure of each specic clinical group
can also bring important evidence about patterns of variance pre-
sented by the sample, allowing inferences about the specicity of the
constructs assessed and clinical applicability. Larrabee30 concludes
that the use of these methods by itself, does not exhaust the construct
validity analysis of neuropsychological tests, but along with clinical
studies of well characterized populations and specic case studies it
is essential for the analysis.
23
Paula JJ, et al. / Rev Psiq Clín. 2012;39(1):19-23
e present study provides evidences of validity and reliability
considering the psychometric properties of the RAVLT. In favor of
this, there is a multi-methodological convergence of such evidence,
the homogeneity of the sample (based on a series of objective criteria
for inclusion) and adequate sample size for analysis. erefore, with
the rst analysis of the construct validity of the test11, it provides
convergent evidence of reliability and construct validity. However,
the present results cannot be generalized to the entire elderly popu-
lation, being required further studies about the inuence of factors
such as education and depressive symptoms in more heterogeneous
samples in order to increase the external validity of these ndings.
In this regard, we emphasize that the growing volume of studies to
obtain normative parameters and applicability of neuropsychological
tests for dierent segments of the Brazilian population7,8,11,14,19 must
be accompanied by studies on the psychometric properties of these
instruments. is initiative will support the renement of the use of
these instruments for both clinical practice and research.
Conclusions
e RAVLT showed strong internal consistency, weak correlations
with global neuropsychological testing instruments and factorial
structure composed of two components, encoding and retrieving.
e analysis of sociodemographic variables suggests a signicant
inuence of age in all the test components and gender in A1, A3, A5,
A6 and total. e results showed reliability and construct validity of
the test, endorsing its potential for clinical use.
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