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Assessing Processing Speed and Executive Functions in low educated older adults: the use of the Five Digit Test in patients with Alzheimer’s disease, Mild Cognitive Impairment and Major Depressive Disorder


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OObjective: Executive functions and processing speed assessment in subjects diagnosed with Alzheimer’s disease (AD), Mild Cognitive Impairment (MCI), and Major Depressive Disorder (MDD) are often made by use of classical neuropsychological tasks (e.g.: Stroop Color Word Test). Drawbacks in instruments like the chromatic and linguistic properties of the SCWT have limited its application in elderly. An alternative are the Mini-Verbal Tests (MVT) where language content is kept on a minimum. We evaluate the use of a MVT version of the Stroop paradigm in the assessment of a mixed clinical group of older adults and its relation with global cognitive impairment. Method: In a case-control study, we examined 114 subjects divided in four groups: 30 AD, 30 MCI, 24 MDD, and 30 community-dwelling normal aged controls (NAC) with the Five Digit Test (5D) a MVT adaptation of the SCWT, in low educated older adults. The four groups were compared by one-way ANOVA in the processing speed, inhibition and cognitive shifting components of 5D. Results: Our results suggest that the processing speed impairments may be a more consistent finding in diffuse neurological damage cases as dementia, or chronic mood disorders, although the inhibition deficits may be a more specific feature of the dementia. The shifting component of the 5D have also shown good clinical validity in the characterization of MDD patients (which shown a slower performance when compared to NAC) and AD (where an expressive amount of patients were unable to perform the task and error were more frequently). Conclusion: The 5D seems a valuable tool for the assessment of processing speed and executive functions in the clinical population of Brazilians low educated older adults, being an alternative to the classic SCWT.
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Clinical Neuropsychiatry (2011) 8, 6,
© 2011 Giovanni Fioriti Editore s.r.l.
Jonas Jardim de Paula, Rafaela Teixeira de Ávila, Danielle de Souza Costa, Edgar Nunes de Moraes, Maria
Aparecida Bicalho, Rodrigo Nicolato, Humberto Corrêa, Manuel Sedó, Leandro Fernandes Malloy-Diniz
Objective: Many studies suggest that executive dysfunction is a common characteristic of Alzheimer´s disease
(AD), mild cognitive impairment (MCI), and in elderly patients with major depressive disorder (MDD). The aim of
this study is to evaluate the applicability of Five Digits Test (5D) in the assessment of executive functions in less
educated older adults with pathological aging.
Method: We studied a total of 114 subjects divided in four groups: 30 patients with AD, 30 patients with MCI, 24
patients with MDD and 30 community-dwelling normal aged controls (NAC). All subjects were submitted to the 5D.
Results: The comparison of NAC and the mixed clinical group (AD + MCI + MDD) shows significant differences
on the 5D both in speed and errors on 3rd (inhibition) and 4th (shifting) sections of the 5D. The ANOVA indicates
significant differences for all measures, except for the total number of errors in the Decoding and Naming components
of the 5D. The Post Hoc analysis indicates that in decoding (time), the NAC group performed better than AD and
MDD but not MCI. MCI patients also performed better than AD. The analysis of components associated with executive
functions of the 5D indicates that NAC outperformed AD and MDD in Inhibition (time) but only AD in Inhibition
(errors) (p<0.016). The Shifting (time) of NAC was faster than MDD, but in the total errors of this component, NAC
the group performed better than AD and MCI.
Conclusions: Our results point to the efficiency of 5D in identifying executive dysfunctions in pathological
aging in comparison with the normal aging process. This task shows great potential for use both in research and in
clinical practices in countries as Brazil, where a great amount of the population is illiterate.
Key words: Alzheimer´s disease, mild cognitive impairment, major depressive disorder, executive dysfunction, five
digits test
Declaration of interest: none
Jonas Jardim de Paula (1), Rafaela Teixeira de Ávila (1), Danielle de Souza Costa (1), Edgar Nunes de Moraes (2), Maria
Aparecida Bicalho (2), Rodrigo Nicolato (3), Humberto Corrêa (3), Manuel Sedó (4), Leandro Fernandes Malloy-Diniz (1,3)
1) Laboratório de Investigações Neuropsicológicas do INCT em Medicina Molecular
2) Departamento de Clínica Médica  Faculdade de Medicina/UFMG
3) Departamento de Saúde Mental  Faculdade de Medicina/UFMG
4) Omnilingual Tests, Natick Boston
Corresponding author
Jonas Jardim de Paula Mental Health Department - Faculdade de Medicina da Universidade Federal de Minas Gerais
UFMG. Av. Prof. Alfredo Balena, 190
Centro 30130-100 - Belo Horizonte, MG  Brasil
shaped curve (Zelazo et al. 2004). The executive
changes are mediated by a significant decrease in
processing speed and reduced working memory
capacity (Huntley and Howard 2010), a group of
cognitive abilities named cognitive mechanics (Baltes
1997). Education is an important factor in the perfor-
mance of the executive functions among the aging
population. For instance, according to Lin et al. (2007),
although the decline of some components of executive
functions (i.e., attention allocation, planning and
Executive functions are capacities that enable a
person to engage successfully in independent,
purposive, self-serving behavior (Lezak et al. 2004).
The development of executive functions occurs during
the maturation of prefrontal networks (Fuster 2009).
This development begins in early childhood and ends
in adolescence and early adulthood, presenting a slow
but consistent decay later in life in an inverted U
Jonas Jardim de Paula et al.
Clinical Neuropsychiatry (2011) 8, 6
classified according Clinical Dementia Rating (CDR)
(Morris 1993).
We studied a total of 114 subjects divided in four
groups: 30 patients with AD, 30 patients with MCI, 24
patients with MDD and 30 community-dwelling normal
aged controls. The participants were Brazilian older
adults assessed in a secondary public healthcare center
specializing in gerontology. In the city of Belo
Horizonte, where this study was performed, a primary
care physician who assesses older adults in his or her
daily practice could request a specialized assessment
if cognitive decline or dementia was suspected. In the
secondary unit center, the patient was assessed by at
least two gerontologists (ENM and MAB) and one
clinical neuropsychologist (JJP). After the assessments
and complementary exams were performed, clinical
conferral confirms the diagnosis of each patient.
After the diagnosis, the patients were invited to
participate in this study, and there was an interval of no
more than one week between the diagnosis and research
participation. Inclusion criteria were the following: at
least 60 years old, no history of vascular or previous
neurological disorders; no history of depressive disorder
prior 60 years and no confusional status or psychotic
illness. Diagnoses were determined by a consensus
following a multidisciplinary assessment, according to
the DSM-IV (American Psychiatric Association 1994),
NINCDS-ADRDA (McKhann et al. 1984) and NINDS-
AIREN (Román et al. 1993) criteria. For the MCI
diagnosis, the Petersen et al. (2001) criteria were used.
All MDD patients scored above the recommended
cutoff for depression in the Brazilian version of the
Geriatric Depression Scale (Paradela et al. 2005).
All MCI, MDD and AD participants followed their
treatment plans, which included taking cholinesterase
inhibitors, and they were free from typical or atypical
antipsychotic drugs.
All subjects were classified according to the
Clinical Dementia Ratting (0 (NAC), 0.5 (MCI and
MDD) or 1 (mild AD). In the present study, only MDD
patients with self-reported cognitive deficits and
functional impairment were included (CDR=0.5). The
MCI group was composed of 17 amnestic and 13 mul-
tiple domain (amnestic-executive) patients. Patients
with MCI or AD who were also diagnosed with MDD
according to the DSM-IV criteria or another mood
disorder were excluded from the study. All subjects were
assessed in accordance with the Declaration of Helsinki,
and the Research Ethics Committee of the Federal
University of Minas Gerais (334/06) gave written
consent and approval. For AD patients, a relative
(usually spouse) also gave written consent.
All subjects performed a protocol composed of a
cognitive and humor screening test and the 5D.
1) Cognitive and mood screening. Cognitive
initiation) is correlated with the aging process,
educational level is more significantly correlated with
the decline of initiation, switching and flexibility, and
online updating.
Many studies suggest that executive dysfunction
is a common characteristic of Alzheimer´s Disease
(AD), even in the early phase (Baudic et al. 2006),
which is associated with episodic memory impairment.
In mild cognitive impairment (MCI), the executive
deficit is a diagnostic criteria for both single domain
executive MCI and multiple domain MCI involving
executive functions. Nonetheless, even in amnestic
MCI, executive deficits may play an important role
because the performance in executive tests may be
affected by the atrophy of medial temporal structures
(Nagata 2010). Executive function deficits are also
observed in elderly patients with major depressive
disorder (MDD), which is associated with gray and
white matter signal abnormalities in the frontal and
medial temporal regions of the brain (Sheline et al.
Executive function assessment is frequently
performed using classical neuropsychological tools,
such as the Stroop Color Word Test (SCWT) (Stroop
1935), the Trail Making Test (Hervey et al. 2004) or
the Frontal Assessment Battery (Oguro et al. 2006).
These tests are good measures of the executive functions
in subjects with AD, MCI and MDD (Pachana et al.
1996). However, these tasks are influenced by reading
abilities (Johnson et al. 2006) and formal education
(Lucas et al. 2005, Steinberg et al. 2005).
In these situations, an alternative is the Mini-
Verbal Test (MVT), which is designed to be as
independent as possible from the previous experience,
education, and culturally acquired routines of the
subjects. In MVT, the verbal content is limited to a few
familiar concepts, which are presented to the subject
as series of visual images. The main value of this
assessment framework is its use in conditions in which
subjects lack the automatic reading routines that are
absolutely necessary for its validity in the assessment
of illiterate subjects or subjects with very low levels of
The Five Digit Test (5D), proposed by Sedó
(2004), is an MVT adaptation of the SCWT. When
performing this test, the subject must know only the
first five numbers and their corresponding symbols. The
test measures continuous verbal performance at
different levels of the attentional network because it
tests both a more automatic process (i.e., reading
numbers and counting figures) and a more controlled
process, in which the subject must inhibit an
automatized routine of processing in favor of a
secondary, non-intuitive mode of processing (i.e.,
speaking rather than reading the number of digits).
The aim of this study is to evaluate the applicability
of 5D in the assessment of executive functions in less
educated older adults with AD, MCI and MDD by
evaluating the following hypothesis: (1) the 5D test will
be a useful task in the assessment of executive functions
in elderly population. Therefore, we expect that subjects
affected by AD, MCI or MDD will perform poorly on
the 5D compared to normal aged controls; (2) the per-
formance in the 5D will be associated with a greater
degree of general cognitive and functional impairment
Use of the Five Digit Test in Alzheimers disease, Mild Cognitive Impairment and Major Depressive Disorder
Clinical Neuropsychiatry (2011) 8, 6
We considered as statistically significant results where
p 0.05. The statistical analysis was conducted using
the SPSS 17.0 software.
We studied a total of 114 subjects divided in four
groups: 30 patients with AD (12 males, age: 74.36 years
± 6.79, education: 3.85 years ± 3.0), 30 patients with
MCI (13 males, age: 74.07 years ± 6.33, education: 4.57
years ± 3.00), 24 patients with MDD (5 males, age:
70.12 years ± 8.54, education 4.13 years ± 3.0) and 30
community-dwelling normal aged controls (10 males,
age: 74.10 years ± 6.80, education: 4.27 years ± 2.25).
No significant differences were found between age
(p=0.093), education (p=0.793), and sex (p=0.335)
between the groups. The demographics and
neuropsychological tests results are shown in table 1.
Table 1 shows the mean and standard deviations for
the demographics, GDS, MMSE, the four components
of 5D, and the significance of ANOVA and effect size
for each group comparison.
The comparison of NAC and the mixed clinical
group shows no differences in age (p=0.481), education
(p=0.889) and gender (p=0.815). Significant differences
(p<0.001) were found in MMSE and GDS-15 with large
effect sizes (1.45, and 0.79, respectively). On the 5D,
the Decoding (p<0.001; d=0.73) and Describing
(p<0.001; d=0.72) times were different, but the number
of errors was not different (p=0.169 and p=0.109).
Considering both time and errors on 3rd (inhibition) and
4th (shifting) sections of the 5D, we also found
statistically significant differences between groups with
large effect sizes [Inhibition time (p<0.001 d=0.62) and
errors (p=0.001 d=056); Shifting time (p<0.003 d=0.52)
and errors (p<0.001 d=0.66)].
In the AD group, 1 patient was unable to execute
the Inhibition component of the 5D, and 10 patients
were unable to execute the Flexibility component
(χ²=22.5 p<0.001), a pattern different from each of the
other three groups, in which all the patients performed
all of the 5D components. The ANOVA indicates
significant differences for all of the neuropsychological
measures, except for the total number of errors in the
Decoding and Naming components of the 5D. The effect
sizes of the comparisons were moderate to large,
ranging from 0.081 (Inhibition Errors) to 0.190
(Describing Time). These results are shown in table 1
and figure 2.
The Post Hoc analysis of the 5D indicates that in
Decoding (time), the NAC group performed better than
AD (p<0.001) and MDD (p<0.018) but not MCI
(p=0.687). MCI patients also performed better than AD
(p=0.036). In the Decoding (errors) analysis, no group
differences were found. In Describing (time) the NAC
group showed a similar pattern, with faster times than
AD (p=0.005) and MDD (p=0.027) but not MCI
(p=0.920). No differences were found between
Describing (errors). The analysis of components
associated with executive functions of the 5D indicates
that NAC outperformed AD (p=0.020) and MDD
(p=0.014) in Inhibition (time) but only AD in Inhibition
(errors) (p<0.016). The Shifting (time) of NAC was
faster than MDD (p=0.005), but in the total errors of
screening was performed by the use of Mini-Mental
State Exam (MMSE), a widely used screening test
developed by Folstein, Folstein and McHugh (1975).
Using 11 simple tasks, the MMSE evaluates temporal
orientation, spatial memory, attention, language and
praxia. The current study employed a Brazilian version
with different cutoffs based on education (Brucki et al.
2003). The Geriatric Depressive Scale (GDS) was used
for screening depressive symptoms in our sample. In
this study, we used the Brazilian version of the GDS-
15 (Paradela et al. 2005).
2) The five Digit Test: 5D is divided into four suc-
cessive parts: 1) decoding, 2) describing, 3) inhibiting
and 4) shifting. Each part involves the production of
four identical verbal lists, using the activities of reading,
describing, choosing, and switching. All parts of the
test were preceded by a training session containing 10
items. After the instructions, the subject had four trials
to correctly respond to the items. If the subject was
unable to perform at the training session, these data are
registered, and the test components that followed the
interruption were excluded from the statistical analysis.
The items of each parts were presented in pages
of 50 items (10 rows of five items), and each item was
surrounded by a rectangular frame. On the first section,
in the decoding section of the test, the subject is
presented with a series of 50 boxes that require the
automatic reading of the items inside each box, which
are in groups of one to five congruous digits (one 1,
two 2s, three 3s, etc.) that must be read. In the second
section (the retrieving section), the subject is presented
with a series of 50 boxes, in which one to five stars
must be counted. In the third section (the inhibition
section), digits are presented in incongruous forms (one
4, two 3s, five 1s, etc.), and the subject is asked to report
the number of digits, and so must inhibit his or her
immediate reaction (reading) and resolve to count the
number of digits presented and continue counting them
throughout the page. Finally, in the fourth section (the
shifting section), of the test, the subject is presented
with an additional difficulty: he or she must switch from
counting to reading in 20% of the items of the page
(the items marked by a much darker frame), demanding
the more executive process of shifting. In each of the
four sections of the 5D, we measured the subjects speed
of information processing (reading time in seconds) and
the efficiency of their responses (number of errors).
Figure 1 shows the four test components.
For the test of Hypothesis 1, the comparisons of
the NAC group and the mixed clinical group (MCG)
were carried out by independent-samples paired t tests,
and a modified Cohens d appropriated for unequal
sample sizes (Hartung et al. 2008) was used as a
measure of effect size. The statistical analyses of
Hypothesis 2 consisted of a One-Way Analysis of
Variance (ANOVA) for the group comparisons, using
Sidaks Post Hoc to evaluate specific group differences
because it offers a more conservative approach,
minimizing the chance of type 1 errors in multiple
comparisons (Ruxton and Beauchamp 2008). The
squared eta was calculated as an estimate of effect size.
Jonas Jardim de Paula et al.
Clinical Neuropsychiatry (2011) 8, 6
Figure 1. Examples of 5d components
Figure 2. Comparison among NAC, MCI, AD and MDD in 5D (time to complete Decoding, Retrieving, Inhibiting
and Shifting parts)
Use of the Five Digit Test in Alzheimers disease, Mild Cognitive Impairment and Major Depressive Disorder
Clinical Neuropsychiatry (2011) 8, 6
Table 1. Demographics and neuropsychological tests results and comparisons among MCG, NAC, AD, MCI AND
this component, NAC the group performed better than
AD (p=0.022) and MCI (p=0.046). No other group
differences were found.
To further analyze the differences in executive
functions among the groups, an interference score was
computed subtracting the Decoding time from the
Inhibition and Shifting time. The aim of this procedure
was to minimize the influence of processing speed on
executive performance, creating a more one-
dimensional measure. No differences between the
Interference-Inhibition (p=0.573) and Interference-
Shifting (p=0.326) were found in the test of H1 or in
Interference-Inhibition (p=0.096) and Interference-
Shifting (p=0.201) in H2.
This study evaluated the efficiency of 5D in the
assessment of executive functions in less educated older
adults with AD, MCI and MDD. Our findings show
that the 5D may be a useful neuropsychological
assessment tool for elderly patients with cognitive
impairments. When a mixed clinical group is compared
with the 5D, differences among the task components
appear to be more related to processing speed (Decoding
and Describing time), with large effect sizes,
corroborating the discrepancy between the speed of
performance of patients and controls. Processing speed
declines with age (Salthouse 2000, Salthouse 2003,
Brown et al. 2011), and older individuals tend to present
a greater variability in performance (Salthouse 1998).
Differences among clinical groups and healthy subjects
are usually related (Wadley et al. 2011). As suggested
by Boone et al. (1998), the performance results of mul-
tiple executive functions tend to show a moderate
association, indicating a common structure and the
presence of more specific components. In Boones
analysis, the SCWT had shared factorial loadings with
the Digit Symbol task of the Wechsler Intelligence
Scales, indicating that processing speed is related to
the Inhibition process of the Stroop task.
The effect sizes of executive components were
moderate to high, and differences in efficiency were
found, suggesting that the executive process may also
be compromised. Similar results were found using the
SCWT in head-injury patients (Rios et al. 2004,
Felmingham et al. 2004) and patients with Alzheimers
Disease (Spieler et al. 1996, Bondi et al. 2002);
however, in MCI and MDD, recent studies have found
no difference in the Inhibition time in Stroop Tasks
(Zhang et al. 2007, Kertzman et al. 2010). It is important
D' E  D/ D  
D  ^ D  ^ D  ^ D  ^ D  ^ EKs
^ 
       
         
'^        
DD^          
 d           
         
 d           
         
/  d           
/          
^  d            
^       
D' D  ' EE     D/ D  / DD
 
Jonas Jardim de Paula et al.
Clinical Neuropsychiatry (2011) 8, 6
to emphasize that interference scores from Stroop tasks
may not be simple measures of inhibition. Salthouse
and Meinz (1995) found that different measures of
inhibition share most of their age-related variance with
other measures of processing speed. Despite the
proportion of shared age-related variance, they
suggested that specific effects could be accurately
estimated when the effects associated with the common
influence are first controlled. As previously mentioned,
the impairment of executive functions is not the core
neuropsychological impairment found in MCI, AD and
MDD, so a severe impairment was not expected in our
sample, which may explain the more significant
processing speed impairments.
Our data suggest that the processing speed
impairments may be a more consistent finding in dif-
fuse neurological damage, dementia or chronic mood
disorders (Selnes and Vinters 2006, Duering et al. 2011,
Brown et al. 2011, Burdick et al. 2010). As previously
argued, the three clinical conditions examined in our
study show white matter abnormalities (Alexopoulos
et al. 2008, Douaud et al. 2011), which may mediate
this cognitive deficit. According to this hypothesis,
some evidence is provided by studies that show that
processing speed may be secondary to a loss of integrity
in white matter connection fibers (Fry and Hale 2000,
Hansell et al. 2005, Rypma et al. 2005, Jung and Haier
2007, Turken et al. 2011). Penke et al. (2010) has shown
that the general integrity factor of white matter is
associated with a series of cognitive abilities, including
processing speed, intelligence, and memory. Turken et
al. (2011) also found a positive correlation between the
structure of white matter pathways and processing speed
in a healthy population and left hemisphere lesion
patients. Although processing speed is not correlated
with a specific brain region, the role of white matter in
integrating information across spatially distinct brain
regions suggests that cognitive slowing is related to
neuronal efficiency. This hypothesis shows significant
ecological validity because the impairments in
processing speed are associated with greater functional
deficits and may be used as estimates of MCI
conversion to dementia (Tabert et al. 2002, Devanand
et al. 2008).
When comparing the degrees of general cognitive
and functional impairment, the performance in the 5D
was not associated with a higher CDR score. Different
clinical conditions can imply a marked slowness of
performance in all test situations, especially controlled
situations that require further use of voluntary self-
direction, persistence and mental effort, and a greater
resilience to the presence of stress and fatigability
(Nathan et al. 2001). Normally, healthy older adults
show declined performances in processing speed,
inhibition and flexibility (Zelazo et al. 2004), three
components of the 5D. This pattern may be influenced
by general slowing difficulties associated with aging
but tends to be more accentuated in clinical conditions,
such as dementia. In AD patients, as suggested by Bondi
et al. (2002), the slowness and magnitude of interference
increases with the severity of dementia. The analysis
of our second hypothesis revealed a discrepancy in
performance of the four groups studied in all of the 5D
components, excluding the total errors in Decoding and
Describing, with moderate to high effect sizes. The Post
Hoc analysis indicating that the CDR associated
declines, however, was not supported by our data. In
the Decoding and Describing Times, no differences
were found between the NAC and MCI groups, but
differences were present in NAC and MDD. MCI
patients also performed better than AD. NAC patients
were no faster than MCI in Inhibition and Shifting times
but again had better performance than AD and MDD in
Inhibition Time and better performance than MDD in
Shifting Time. The efficiency of Inhibition of AD
patients was inferior compared to the NAC group but
not MCI and MDD, although in Flexibility, NAC
outperformed MCI and AD patients. These results do
not support our second hypothesis, but the Shifting
differences encountered in terms of efficiency should
be better evaluated in future studies. It must be
considered that in the present study, the MCI sample is
predominantly of the amnestic type, minimizing the
degree of impairment expected in executive functions
and processing speed. The small sample size may also
be an important bias for these observations.
The poor performance of AD patients in Stroop
Tasks is well documented in the neuropsychological
literature (Bondi et al. 2002, Spieler et al. 1996, Perry
and Hodges 1999, Perry et al. 2000). Our result, using
an MVT task variation, corroborates this pattern,
indicating convergence validity of the two tasks in a
clinical sample. These results are consistent with those
presented by Sedó and DeCristoforo (2001), where
moderate to high correlations were found between the
SCWT and the 5D in a healthy North American older
adult sample, and those obtained by Hsieh et al. (1996)
and Hsieh and Tori (2007) in a Chinese elderly
population. In our sample, an important fact that may
be used as a clinical guideline for older adults
assessment is that NAC, MCI and MDD patients
matched by age, education and gender to AD patients
were able to complete all of the 5D components,
although 10 of 30 AD patients were unable to perform
the Shifting component and only one the Inhibition
component. This cognitive shifting deficit may be a
more specific feature of the AD neuropsychological
deficits, which is also corroborated by the greater
efficiency impairment with relative preservation of
speed, in a fast but inaccurate performance, typical of
executive impairments (Kogan 1971). Balota et al.
(2010) showed, for example, that the errors on
incongruent trials were the best discriminator of those
who converted and those who did not convert to AD
over a 14-year period.
Our results point to the efficiency of 5D in
identifying executive dysfunctions in pathological aging
in comparison with the normal aging process.
Furthermore, the assessment of cognition in less
educated elderly subjects needs to consist of appropriate
stimuli (i.e., stimuli that do not require reading or
writing abilities). This task shows great potential for
use both in research and in clinical practices. Drawbacks
in instruments, such as the chromatic (Lezak et al.
2004), visual (Dyer 1973, Spreen and Strauss 1998),
and linguistic (Cox et al. 1997) properties of the SCWT,
have limited their application in clinical special-needs
contexts, where difficulties in color perception, visual
impairments, specific reading problems, and language
disorders are presented. This is the recurrent profile of
Use of the Five Digit Test in Alzheimers disease, Mild Cognitive Impairment and Major Depressive Disorder
Clinical Neuropsychiatry (2011) 8, 6
the elderly in Brazil, where 26% of the population is
illiterate (IBGE 2009). In these contexts, the MVT tests
appear to be an appropriate choice for the assessment
of processing speed and executive functions.
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... The assessment of processing speed and executive functions in Bipolar Disorder (BD) is an important aspect on their clinical evaluation. Deficits in selective attention (a component of one Executive Function called "Inhibitory Control") is related to several clinical outcomes including impairments in everyday life activities (O'Shea et al. 2010), psychosocial functioning (Solé et al. 2012), and suicide behavior (Malloy-Diniz et al. 2011). One of the most used paradigms for this cognitive function is the interference control, assessed by Stroop-like tests, as the Stroop Color-Word Test (SCWT). ...
... Her results indicated that the FDT along with the SCWT and other tests of attention composed a latent factor related to interference control, a subcomponent of the inhibitory control system. A study with mood disorders carried in older adults with major depressive disorders also revealed significant group differences between patients and controls, with moderate to high effect sizes (de Paula et al. 2011). ...
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Objective: to analyze the validity of the Five Digits Test (FDT), an adapted version of the Stroop Color-Word Test (SCWT) on Bipolar Disorder patients (BD). Methods: we assessed 35 BD patients diagnosed in a clinical interview by a psychiatrist using the MINI-Psychiatric Interview. The participants were euthymic on during the cognitive assessment. Besides the FDT the participants performed the SCWT, the Five Points Test (FPT) and the Rey Auditory Verbal Learning Test (RAVLT) as measures of criterion related, convergent and divergent validity, respectively. We adopted partial correlations, controlling for age, education, sex and symptoms of depression and mania, assessed the association between the FDT times and errors with the other cognitive measures. Group comparisons with a paired control sample assessed the FDT discriminant validity. Results: we found significant correlations between the FDT and the SCWT and between the FDT and the FPT, but not between the Five Points Test and the RAVLT. The shared variance of the measures sustained the construct validity for the assessment of processing speed and executive functions. Group comparisons indicate large effect sizes for the FDT timed measures and the errors in the executive functions components. The test accuracy for group classification was 90%. Conclusion: the results suggests that the FDT is a valid measure of processing speed and executive functions for the assessment of BD patients, and might be an alternative to the SCWT for patients with low formal education.
... Estudos com populações clínicas sugerem que a desregulação do controle de interferência característica dos transtornos mentais e de algumas doenças neurológicas pode ser documentada com o FDT. Até o momento encontramos estudos com pacientes diagnosticados com transtorno bipolar 8 , depressão 14 , transtorno neurocognitivo 14,15 , abuso de substâncias 16 , acidente vascular encefálico 17 e obesidade 18 . ...
... Estudos com populações clínicas sugerem que a desregulação do controle de interferência característica dos transtornos mentais e de algumas doenças neurológicas pode ser documentada com o FDT. Até o momento encontramos estudos com pacientes diagnosticados com transtorno bipolar 8 , depressão 14 , transtorno neurocognitivo 14,15 , abuso de substâncias 16 , acidente vascular encefálico 17 e obesidade 18 . ...
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Objetivo O presente estudo analisou a confiabilidade do Teste dos Cinco Dígitos (FDT), um instrumento de avaliação dos processos atencionais baseado no paradigma Stroop. O teste usa números e quantidades para avaliação do efeito de interferência atencional. Métodos Avaliamos 49 adultos brasileiros por meio do FDT. Os participantes realizaram o teste em dois momentos, com aproximadamente duas semanas de intervalo. A confiabilidade do teste foi estimada pela consistência interna (método das metades) e pela avaliação da estabilidade teste-reteste (coeficiente de correlação intraclasse e teste de Wilcoxon para amostras repetidas). Resultados O tempo de resposta médio dos participantes apresentou discreta melhora nas etapas mais simples do teste e mais acentuada nas etapas mais complexas. A consistência interna do teste foi superior a 0,9. A estabilidade teste-reteste variou em função da etapa do teste, e todas as correlações foram significativas (p < 0,01) e explicaram entre 60% e 90% da variância encontrada. Conclusão O FDT apresenta evidências robustas de confiabilidade na amostra avaliada. Esse foi o primeiro estudo brasileiro a avaliar essa propriedade pelo método de teste-reteste. Os resultados propiciam melhor aplicabilidade do FDT nos contextos de clínica e pesquisa.
... go/no go tasks) were associated with HI (Polner et al., 2014). It is important to note, for example, that studies using Stroop Color-Word Test found correlations with FDT performance (De Paula, Abrantes, Neves, & Malloy-Diniz, 2014;De Paula et al., 2011). Interestingly, a study aimed at parsing ADHD-related heterogeneity in its underlying neurobiology by investigating functional connectivity across multiple brain networks found that clusters within the visual networks were primarily related to inattention and reaction time variability. ...
Symptoms of inattention and hyperactivity/impulsivity, arranged along a continuum, are commonly associated with neuropsychological and academic deficits, even in the general population. The aim of this study is to analyze how Attention Deficit Hyperactivity Disorder (ADHD) symptoms are associated with the performance in neuropsychological and academic abilities (phonological processing, processing speed/automatic attention, executive functions, reading, and spelling) in school-age children. The sample consisted of 216 children from 3rd and 4th grades (M = 8.94 years old, SD =.71) from public elementary schools of two Brazilian capitals. Pearson correlation and Multiple Linear Regression analysis were performed. Inattention symptoms were the only predictors of performance in phonological processing (phoneme suppression and rapid automatized naming of letters), processing speed/automatic attention, executive functions, such as inhibitory control and cognitive flexibility, and reading fluency. Beta values ranged from .14 to .27, and the largest value was related to an inhibitory control task. Inattention, and not hyperactivity/impulsivity symptoms, seems to affect neuropsychological functions even in non-clinical diagnosed children. Contributions and future directions are discussed.
... 23 The executive function score was built using the inverse digit span 20 and the inhibitory control and cognitive flexibility measures of the Five Digit Test (FDT). 24 The visuoconstruction score was built using the DRS constructional subscale and a copy of the simplified version of the Taylor Complex Figure (TCF). 25 The processing speed score was based on the first part (number reading) of the FDT. ...
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Objective: Aging studies regularly assume that years of education are a protective factor for baseline cognition. In developing countries with specific sociocultural issues, this relationship may not work as expected, and an unmet need remains for alternative resilience factors. This study aimed to analyze different moderators for the relationship between aging and general cognition that could reflect better protective factors. Methods: One hundred and fourteen Brazilian older adults, deemed healthy by global cognition, absence of psychiatric symptoms, or neurological history, participated in this cross-sectional study. Moderators for the relationship between age and global cognition included education, intelligence, and occupational factors. Semantic memory was added as a protective factor reflecting culturally acquired conceptual knowledge. Results: As expected, age alone is a predictor of global cognitive scores; surprisingly, however, education, intelligence, and occupation were not moderators of the association. Semantic memory was a significant moderator (p = 0.007), indicating that knowledge acquired during life may be a protective factor. Conclusion: In developing countries, the use of resilience factors based only on years of education may be misleading. Sociocultural issues influence the educational system and achievement and, consequently, affect the use of this simple measure. Resilience-factor studies should consider using crystallized abilities when studying populations with sociocultural particularities.
... Some of the tasks were grouped into composite scores. The executive function score was composed by Digit Span task 23 , and parts three and four of the Five Digits Test 24 . The episodic memory score was composed by the learning, retrieval and recognition parts of the Rey Auditory Verbal Learning Test 25 . ...
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Background: Semantic memory is a cultural influenced cognitive domain that is responsible for our knowledge about words and the world. Semantic Memory Battery (BAMS) is a new battery that evaluate semantic memory based on a compendium of tasks, including verbal fluency, naming, conceptualization, categorization, general questions, and word definitions, and was designed to consider cultural aspects. Objectives: We aimed to evaluate the BAMS psychometrics structure comprising classical and modern analysis, and also evaluate a clinical subdivision of the battery. Methods: 114 Brazilian cognitively healthy older adults BAMS performance provided data for psychometric analysis using validity tests, item response theory analysis and confirmatory factor analysis for goodness-of-fit measures. Results: BAMS results revealed good validity and good-fit measures in each subtest, total score (X² = 20.684, p = 0.110) and a hierarchical structure with clinical subdivision of the battery (X² = 20.089, p = 0.093). Discussion: BAMS is a new compendium of tasks that evaluate distinct aspects of semantic memory and can clinically consider the impact of executive function. This battery evaluates verbal fluency, naming, conceptualization, categorization, general knowledge and word definitions. The BAMS has clinical importance once semantic memory is mostly influenced by culture and language, and there is an absence of broadly semantic memory tests in our scenario, especially with older adults that can have a pathological aging condition that affects primarily or secondarily this domain.
... 47 However, there are few tools available to specifically assess cognitive functions that are suitable for the neuropsychological evaluation of less educated or illiterate populations. [48][49][50][51][52] To assess episodic memory, a few tools have been adapted or specifically developed, for example, in India, 19 the Netherlands, 27 and Brazil, 18,53 but very few in French-speaking countries. [54][55][56] To fill this gap, we also developed the TNI-93. ...
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The present study aimed at validating the Memory Associative Test of the district of Seine-Saint-Denis (TMA)-93, a new test of episodic memory. The TMA-93 was proposed to mostly less educated and multicultural elderly population composed of 376 healthy controls (HC) and 94 patients with Alzheimer’s disease (AD). The construct validity was checked by studying correlations with a widely used memory test (the Free and Cued Selective Reminding Test [FCSRT]) in the subsample of literate patients. Results showed that (i) all the TMA-93 scores of the patients with AD were lower than those of the HC, (ii) the TMA-93 total score identified patients with AD with a high sensitivity (88%) and very high specificity (97%), and (iii) the TMA-93 total score was strongly correlated with both free recall and total recall scores of the FCSRT. Taken together, results showed that the TMA-93 is a reliable tool to assess episodic memory in a multicultural, less educated, or illiterate population, with good construct validity for AD diagnostic accuracy.
... Previous studies suggest this test is adequate for assessment of older adults. 5, 6 For statistical analyses, nonparametric data were normalized by logarithmic transformation. Partial correlations (controlling for age, gender, and education) were used to assess the relationship between cognitive measures. ...
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Neuropsychological tests related to verbal fluency para-digms are among those most frequently used to assess executive functions in older adults. These tasks are quick and easy to administer and widely used for clinical assessment. However, despite their apparent simplicity, these tests involve different cognitive demands and are influenced by sociodemographic factors. 1 Two cognitive domains are particularly related to verbal fluency perfor-mance: executive functions and processing speed. Performance on these two cognitive domains declines with age and mediates the effect of other cognitive and demographic factors on verbal fluency scores. 2 The objective of the present report is to investigate the contribution of executive functions and processing speed on category fluency performance. We hypothesize that these two cognitive domains will be related to test performance, suggesting that verbal fluency may not be used as a unidimensional measure of executive functions.
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Introduction In the assessment of older adults with very low formal education, typical tests of selective attention and inhibitory control are biased by reading abilities. In this sense, we aim to assess the psychometric characteristics of the Five Digits Test (FDT), a numerical Stroop paradigm, in older adults without cognitive disorders, with mild cognitive impairment, and with dementia. Methods We assessed 211 Brazilian older adults with low formal education using the FDT and other cognitive measures. Construct validity and reliability were assessed by correlations and internal consistency. Results The FDT test had weak correlations with crystalized intelligence tests and moderate-high correlations with fluid intelligence measures and tests of global cognitive status and executive functions. The split-half coefficient of reliability showed high internal consistency (>0.900). Conclusion Together, the results suggest that the FDT is a valid and reliable measure for the assessment of processing speed and executive functions in older adults with low formal education.
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Introduction: The Frontal Assessment Battery (FAB) is a for the assessment of executive functions. We investigated its validity and reliability and proposed normative data in a representative sample of older adults. Method: 391 healthy elderly subjects and 93 Alzheimer’s disease (AD) patients performed the FAB. Internal consistency, convergent correlations, ROC curve and logistic regression were used to assess its psychometric properties. Results: We found good internal consistency, significant correlations with other tests and moderate accuracy (64%) for AD diagnosis. The use of specific subtests increased diagnostic potential (75%). Normative data stratified by age and education were proposed. Conclusion: The FAB showed adequate psychometric properties. The normative values stratified by age and education can improve its clinical use for neuropsychological assessment.
The development of cholinergic therapies for Alzheimer's disease (AD) has highlighted the importance of understanding the role of attentional de®cits and the relationship between attention and memory in the earliest stages of the disease. Variability in the tasks used to examine aspects of attention, and in the disease severity, between studies makes it dicult to determine which aspects of attention are a€ected earliest in AD, and how attentional impairment is related to other cognitive modules. We tested 27 patients in the early stages of the disease on the basis of the MMSE (minimal 24±30 corresponding to minimal cognitive impairment, very mild or possible AD in other classi®cations; and mild 18±23) on a battery of attentional tests aimed to assess sustained, divided, and selective attention, plus tests of episodic memory, semantic memory, visuoperceptual and visuospatial function, and verbal short-term memory. Although the mildly demented group were impaired on all attentional tests, the minimally impaired group showed a preserved ability to sustain attention, and to divide attention based on a dual-task paradigm. The minimally demented group had particular problems with response inhibition and speed of attentional switching. Examination of the relationship between attention and other cognitive domains showed impaired episodic memory in all patients. De®cits in attention were more prevalent than de®cits in semantic memory suggesting that they occur at an earlier stage and the two were partially independent. Impairment in visuoperceptual and visuospatial functions and verbal short-term memory were the least common. Although attention is impaired early in AD, 40% of our patients showed de®cits in episodic memory alone, con®rming that amnesia may be the only cognitive de®cit in the earliest stages of sporadic AD. #
In this review we summarize the progress that has been made in the research on attentional and executive deficits in Alzheimer's disease. Like memory, attention is now recognized as consisting of subtypes that differ in their function and anatomical basis. We base our review upon a classification of three subtypes of attention: selective, sustained and divided. This model derives from lesion studies, animal electrophysiological recordings and functional imaging. We examine how these sub-components of attention can be reconciled with neuropsychological models of attentional control, particularly the Supervisory Attentional System and the Central Executive System of Shallice and Baddeley, respectively. We also discuss the relationship of attention to the concept of executive function. Current evidence suggests that after an initial amnesic stage in Alzheimer's disease, attention is the first non-memory domain to be affected, before deficits in language and visuospatial functions. This is consistent with the possibility that
Criteria for the diagnosis of vascular dementia (VaD) that are reliable, valid, and readily applicable in a variety of settings are urgently needed for both clinical and research purposes. To address this need, the Neuroepidemiology Branch of the National Institute of Neurological Disorders and Stroke (NINDS) convened an International Workshop with support from the Association Internationale pour la Recherche et l'Enseignement en Neurosciences (AIREN), resulting in research criteria for the diagnosis of VaD. Compared with other current criteria, these guidelines emphasize (1) the heterogeneity of vascular dementia syndromes and pathologic subtypes including ischemic and hemorrhagic strokes, cerebral hypoxic-ischemic events, and senile leukoencephalopathic lesions; (2) the variability in clinical course, which may be static, remitting, or progressive; (3) specific clinical findings early in the course (eg, gait disorder, incontinence, or mood and personality changes) that support a vascular rather than a degenerative cause; (4) the need to establish a temporal relationship between stroke and dementia onset for a secure diagnosis; (5) the importance of brain imaging to support clinical findings; (6) the value of neuropsychological testing to document impairments in multiple cognitive domains; and (7) a protocol for neuropathologic evaluations and correlative studies of clinical, radiologic, and neuropsychological features. These criteria are intended as a guide for case definition in neuroepidemiologic studies, stratified by levels of certainty (definite, probable, and possible). They await testing and validation and will be revised as more information becomes available.
The present review summarizes empirical findings and theoretical views related to the Stroop color-word test. Lyperimental findings were emphasized in contrast to the results of correlational studies, and the bulk of the material was produced since the 1966 review of Jensen and Rohwer. One purpose of the review was to illustrate use of the Stroop paradigm as a too! for the stud)' of other psychological processes. The incompleteness, and in some cases the mappropnateness, of existing explanatisons of the Stroop phenomenon also were discussed. nt]mis|The author is grateful to E. C. Dalrymple-Alford. George S. Harker, and Anne Treisman for their comments on an earlier draft of the paper.
The Stroop Color and Word Test is used clinically to assess a specific aspect of executive function, that is, selective inhibition. It requires a subject to inhibit an automatized reading response in favor of a less well-rehearsed, competing color-naming response. Although it is necessary to the interpretation of the Stroop effect observed during the interference condition, the degree of automaticity of the reading response is usually assumed in an adult population rather than being defined by any standard reading measures. The present investigation demonstrated that, in a group of 306 parents of children with learning disabilities, the best indicator of reading automaticity was not simply a standard word-reading score within normal limits, but rather a score that was at least equal to the individual's Full Scale IQ. In those subjects who satisfied this reading criterion, the Stroop Interference score correlated significantly with other measures of response inhibition. No such correlation was observed in subjects who did not satisfy the reading automaticity criterion.
Neuropsychological changes distinguishing mild Alzheimer's disease (AD) from frontotemporal dementia (FTD) have been described, but empirical verification of differential cognitive characteristics is lacking. Archival neuropsychological data on 15 FTD patients, 16 AD patients, and 16 controls were compared. Controls outperformed both patient groups on measures of verbal and nonverbal memory, executive ability, and constructional skill, with AD patients showing more widespread memory decline. No differences were found between the 3 groups in confrontation naming, recognition memory, or basic attention. Patient groups differed only in nonverbal memory, with FTD patients performing significantly better than AD patients. However, patient groups also differed in pattern of performance across executive and memory domains. Specifically, AD patients exhibited significantly greater impairment on memory than executive tasks, whereas the opposite pattern characterized ther FTD group. These findings suggest that examination of relative rankings of scores across cognitive domains, in addition to interpretation of individual neuropsychological scores, may be useful in differential diagnosis of FTD versus AD. (JINS, 1996, 2, 505–510.)
Background: Some previous research has hypothesized that executive dysfunction in patients with early Alzheimer's disease (AD) occurs as a result of a disconnection between different cerebral areas. The aim of the present study was to evaluate how the hippocampal volume influences executive function as a non-memory cognitive function. Methods: From 157 consecutive patients with AD or amnestic mild cognitive impairment (A-MCI), we recruited 107 subjects who had a global Clinical Dementia Rating (CDR) of 0.5 or 1.0 and whose degree of hippocampal atrophy had been measured using magnetic resonance imaging (MRI); the severity of atrophy was assessed using the voxel-based specific regional analysis for Alzheimer's disease (VSRAD) system. We divided the subjects into three groups: mild atrophy, 0 < Z-score < 1.0 (N = 21); moderate atrophy, 1.0 ≤ Z-score < 2.0 (N = 46); or severe atrophy, 2.0 ≤ Z-score < 4.0 (N = 40) according to the Z-score and compared the Frontal Assessment Battery (FAB) and its subtest scores between each atrophy group. Results: The results demonstrated that age, sex ratio, duration of illness, education years, MMSE score, Behave-AD score, and proportion of atrophy area in total brain (%) were not significantly different among the three groups. Only the go/no-go score among the six subtests was significantly lower for increasing atrophy severity (P < 0.05). Furthermore, hippocampal atrophy significantly influenced the go/no-go score independently of interactions from whether the diagnosis was early AD or A-MCI (P < 0.05). Conclusion: These results support a significant association between hippocampal atrophy and executive dysfunction as a non-memory cognitive impairment in patients with early AD and A-MCI.