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Neurol Sci
DOI 10.1007/s10072-015-2158-5
ORIGINAL ARTICLE
Disentangling the relationship between cognitive estimation
abilities and executive functions: a study on patients
with Parkinsons disease
Guido Edoardo DAniello1 Federica Scarpina2,4 Giovanni Albani2
Gianluca Castelnuovo1,3 Alessandro Mauro2,4
Received: 2 September 2014 / Accepted: 9 March 2015
Springer-Verlag Italia 2015
Abstract The cognitive estimation test (CET) measures
cognitive estimation abilities: it assesses the ability to ap-
ply reasoning strategies to answer questions that usually
cannot lead to a clear and exact reply. Since it requires the
activation of an intricate ensemble of cognitive functions,
there is an ongoing debate in the literature regarding
whether the CET represents a measurement of global
cognitive abilities or a pure measure of executive func-
tions. In the present study, CET together with a neu-
ropsychological assessment focused on executive functions
was administered in thirty patients with Parkinsons disease
without signs of dementia. The CET correlated with mea-
sures of verbal working memory and semantic knowledge,
but not with other dimensions of executive domains, such
as verbal phonemic fluency, ability to manage real-world
interferences, or visuospatial reasoning. According to our
results, cognitive estimation abilities appeared to trigger a
defined cognitive path that includes executive functions,
namely, working memory and semantic knowledge.
& Guido Edoardo DAniello
g.daniello@auxologico.it
1
Psychology Research Laboratory, IRCCS Istituto Auxologico
Italiano, Ospedale San Giuseppe, Via Cadorna,
90 28824 Piancavallo (VCO), Italy
2
Division of Neurology and Neuro-Rehabilitation, IRCCS
Istituto Auxologico Italiano, Ospedale San Giuseppe,
Piancavallo (VCO), Italy
3
Department of Psychology, Universita Cattolica del Sacro
Cuore, Milan, Italy
4
Rita Levi Montalcini Department of Neuroscience, plete and pure frontal syndrome [10] at various stages of
University of Turin, Turin, Italy
Keywords Executive functions
Parkinsons disease

Cognitive estimation
Neuropsychological tests
Introduction
Cognitive estimation refers to the ability to apply reasoning
strategies to answer questions that usually cannot lead to an
exact reply, but just to an acceptable approximation. It
requires the activation of an intricate ensemble of cognitive
functions, such as planning abilities, attention, abstract
reasoning, semantic and working memory [1].
Since frontal damaged patients showed a coarse im-
pairment in this ability, the cognitive estimation test (CET)
was assumed to be directly linked to executive functions
[13]. However, the effective reliability of the CET in re-
ferring to executive functions is more controversial [4]: it
could be considered as a measurement of global cognitive
abilities since the recruitment of cognitive domains which
go beyond the executive domains (attention, verbal learn-
ing, and naming abilities) [4], as suggested by studies
relative to right temporal lobe epilepsy patients [5] and
Alzheimers disease [6, 7]; however, other studies argue in
favor of a consistent relationship between the CET and
executive skills in Alzheimers disease [8].
In the present study, we deepened the relationship be-
tween the CET and executive skills focusing on Parkin-
sons disease (PD) patients performance. We studied PD
patients because the investigation of cognitive functions
related to estimation abilities would be particularly inter-
esting in patients with a more selective dysfunction of the
frontal lobes [9]; in fact, a frequent neuropsychological
complication of idiopathic PD was reported to be a com-
this disease [11], even in the absence of signs of dementia
123
 Neurol Sci

[12]. As a result, we hypothesized that the investigation of
cognitive estimation abilities in patients at risk of a subtle
executive impairment would increase the understanding of
this particular cognitive skill.
The unique study relative to the performance at the CET
in patients with PD appeared to reinforce the hypothesis
that it could be viewed as a non-specific screening tool for
global cognition [9]: the authors argued against a rela-
tionship between cognitive estimation abilities and ex-
ecutive functions.
In the present study, the relationships between cognitive
estimation abilities and executive functions were explored
using a wider set of neuropsychological tests to find out
which cognitive domains are involved in the process of
cognitive estimation.
Methods
Participants
30 patients (m = 17, f = 13. Mean age in years: m = 64;
sd = 11. Mean education in years: m = 11; sd = 4) were
included in the present study. They had been diagnosed as
having PD (mean years from diagnosis m = 8, sd = 4) and
they were consecutively admitted to the Division of Neu-
rology and Neurorehabilitation of the involved hospital for
clinical purposes.
SPECT scans data showed reduced activity of dopa-
mine-secreting cells of the basal ganglia system (striatum,
putamen and caudate nucleus); a lack of dopamine was
detected bilaterally in most of the patients. All patients
were under anti-parkinsonian treatment (L-Dopa) at an
optimized daily dosage. According to the Hoehn and
Yahrs classification [13], our group of patients were
mainly between the 1st and the 3rd stage of the disease
(mean = 2.7; sd = 0.8). The classification data were ob-
tained for 29 out of 30 patients: only 3 patients were at the
4th stage (10 %), 3 patients were at the 1st stage (10 %), 4
patients were at the 2nd stage (14 %) and 19 patients were
at the 3rd stage (66 %). None showed signs of dyskinesia
or hyperkinesia at the time of the cognitive examination.
A threshold of 24 for MMSE was set as an inclusion
criterion, suggesting the absence of dementia among the
selected patients [14].
Cognitive measures
Patients were assessed using a neuropsychological test
battery (Table 1) which included measures of global cog-
nitive functioning, as Mini Mental State Examination
(MMSE) [15] and the clock drawing test [16].
Executive functions were assessed using a set of se-
lected standardized tests.
The frontal assessment battery (FAB) [17] was included
as a reliable measure of frontal lobe dysfunction [18]. It is
widely used in clinical contexts, having been recently
recommended to detect the first symptoms of cognitive
decline among patients with a diagnosis of neurodegen-
erative diseases [19, 20]. We also administered the digit
span backward [21]: this is a measure of verbal working
memory, requiring the activation of a rehearsal process
using the so-called phonological loop [22, 23].
The screening of executive functions also comprised the
verbal phonemic and semantic fluency tasks [24] to eval-
uate phonological and semantic-based word retrieval skills,
and the Weigl color-form sorting test [25] that assesses
abstract and symbolic reasoning [26]. Finally, we admin-
istered the Stroop Test [27] since the error index represents
a measure ability of resistance to interferences.
Cognitive estimation test
The Italian version of the CET [28] consists of 21 questions
which rely on the estimation of the dimensions of: time,
weight, size, quantity and speed estimation. The scoring
procedure assigns a score of 0 for estimations between 0
and 30 % above or below the ideal answer; 1 (between 31

Table 1 Results on the Cognitive testing (minimum and maximum scores) Mean Standard deviation Range
neuropsychological tests of PD
participants Mini mental state examination (030) 27.1 2 2430
Clock drawing test (010) 8.9 1.9 310
Frontal assessment battery (018) 14.7 3 818
Digit span backward (08) 3.4 0.7 25
Verbal phonemic fluency task (075) 31.4 10 1054
Verbal semantic fluency task (075) 38.4 9.5 1958
Weigl color-form sorting test (015) 11.3 3.3 315
Stroop testerror index 3.1 7.4 054.5
Cognitive estimation test (042) 15.7 2.8 1123

123
Neurol Sci
and 90 % above or below); and 2 (more than 90 % above
or below). A total score above 18 suggests the presence of a
deficit.
Analysis
The relationship between the cognitive estimation ability
measured by the CET and the demographical variables of
age and education was investigated using the Pearson
product-moment correlation coefficient and an indepen-
dent-samples t test was performed to investigate the effect
of gender on the variance of the CET performances. Each
neuropsychological tests score was corrected according to
the corresponding Italian standardization and the Pearson
product-moment correlation coefficient was also applied to
investigate the relationship between the CET and the raw
scores of the administered neuropsychological tests.
Results
Neuropsychological testing
Table 1 reports the means and standard deviations relating
to raw scores at the neuropsychological tests. Rates of
normal, borderline and impaired performancesaccording
to corresponding Italian standardizationsat tests of
global cognitive functioning (MMSE and clock drawing
test) and executive domains (FAB, Digit Span Backward,
Verbal Fluencies) have been reported in Fig. 1.
Performances on certain neuropsychological tests
(Fig. 1) showed higher rates of impaired scores at a
screening test of executive functions (FAB) and at a verbal
working memory task (Digit span backward); rates of
Fig. 1 Neuropsychological tests: score distributions according to Italian standardizations
impaired scores at global cognitive tests (MMSE and clock
drawing test) were generally lower. Taken together, the
group seems to present a very mild/mild overall cognitive
impairment, mainly characterized by subtle executive
deficits, as we might expect from a group of Parkinsons
disease patients without dementia [11].
Cognitive estimation test
Rates of patients with normal (score \16), borderline
(17 C score C 18) and impaired (score [18) performances
are displayed in Fig. 1.
No relationship between the cognitive estimation abil-
ity and general demographical variables appeared (age:
r = 0.19; n = 30; p = 0.31; Education: r = -0.15;
n = 30; p = 0.42); no gender effect was found
(p = 0.29).
No significant correlation was found between the
MMSE and the CET score; however, a significant corre-
lation was found with the Clock Drawing Test and with
performance on the FAB. Significant correlations were also
found with the Digit Backward Task and the Verbal Se-
mantic Fluency Task. Since the scoring system adopted for
the CET implies that higher scores correspond to poorer
performance, the correlation is negatively signed. No sig-
nificant correlations were found between the CET and the
remained neuropsychological measures (Table 2).
Discussion
The aim of the present study was to identify which cog-
nitive domains appeared to be related to the cognitive es-
timation ability in a group of Parkinsons disease patients
123

Table 2 Pearson product-moment correlations between tests of global cognitive functioning, executive functions and the cognitive estimation
test
MMSE Clock Frontal Digit span
drawing assessment backward
test battery
Cognitive r = -0.11 r = -0.36 r = -0.53 r = -0.46
Estimation test * ** * *
** p \ 0.001; * p\ 0.05
whose subtle cognitive deficitswhere presentwere
mostly limited to the executive domain.
Cognitive estimation abilities are related to a definite
pattern of cognitive skills, including the efficiency of
working memory and semantic knowledge. This pattern of
results is in line with the model proposed by Brand et al.
[29], which describes working memory as a crucial link
between the recovering of semantic information and the
strategies involved in the estimation task [8].
The significant relationship between the CET and per-
formance at the semantic verbal fluency task [24]that
investigated the extension of the semantic knowledge and
the ability to access itsupports the hypothesis regarding
the crucial role of semantic knowledge in cognitive esti-
mation [30]. On the other hand, the CETs performance
appeared unrelated to the phonemic verbal fluency task
[24]. Both tasks are related to retrieval processes and
showed similar sensitivity to executive control skills [31].
However, while the semantic verbal fluency task appears to
have a stronger sensitivity to the effective degradation of
the semantic store [32], its phonemic counterpart is usually
associated with less specific executive skills such as re-
trieval processes [32, 33]. The relation between semantic
knowledge and cognitive estimation abilities seems to be
further confirmed by the significant relationship between
the CET and the clock drawing test [16]: it is a measure of
goal-directed behavior [34] and it requires access to se-
mantic knowledge and to properly recall the mental image
of the clock itself [35].
Other cognitive executive dimensions, such as the
ability to manage real-world interferences (error index of
the Stroop test) [27] and visuospatial category-shifting
reasoning (Weigl color-form sorting test) [25], do not ap-
pear to be involved in the CET as reported in anatomical
studies [36]. Moreover, the absence of a relationship be-
tween the CETs performance and the Weigl color-form
sorting test [25] within the present work confirms the strict
link between cognitive estimation abilities and semantic
knowledge: the second task relies on visuospatial reasoning
and category-shifting abilities within a novel context [37];
thus, it does not ask for specific retrieval of semantic
123
Neurol Sci
Semantic Phonemic Weigl color-form Stroop test
fluency task fluency task sorting test error index
r = -0.45 r = -0.33 r = -0.22 r = 0.10
knowledge but it could be more properly described as a
measure of fluid intelligence [38].
According to the results, higher performance at the CET
was related to the FAB, suggesting that cognitive estima-
tion abilities appeared to be related to global executive
functioning, in contrast with previous studies [9]. However,
due to the lack of specificity of the FAB global score, we
suggest the importance to study the cognitive estimation
ability with more targeted tools.
In conclusion, the CET seems to be more than a generic and
unfocused cognitive test. Instead, it is highly associated with a
certain path of executive functions, including the ability to
recover semantic knowledge. However, due to the contro-
versial results about the involvement of other cognitive do-
mains, the debate about what are the cognitive skills required
for an optimal estimation is still ongoing. Future research will
be required to disentangle such relation studying different
clinical populations and assessing Parkinsons disease pa-
tients with a more pervading cognitive impairment.
Conflict of interest None.
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