©— 7 FFEgEEE Pu Sagr-s1 7797000954 Normative Data Stratified by Age and Education for Two Measures of Verbal Fluency: FAS and Animal Naming Tom N.Tombaugh Caton Unerty Jean Kozak ‘Sits of Chany Heath Senices aura Rees sande le hn hon ‘Se of 0 ogi ht as ‘angel fram 01031 The tal munerof won| mate foreach of the en FA and 8 lar = 52 ith he uber of nial names pened nce, grin aa far kowel that FAS war moreno the effec of ection (IKO% of the vrs) than ge (120% ofthe vatane). The oppo rlatowhip cred for Ana Nae Phonemic snd semantic verbal fhency, as measured hy an individuals ability to gener- fe (e4., FAS and CFL) and semantic category {e.g animals) have played prominent roe in ncuropsychological research, Verbal fh ene has been demonstrated to be sensitive to lesions inthe fontal lobe, temporal lobe, and caudate nucleus (Benton, 1968: Buters, Granholm, Salmon, Grant, & Wolfe, 1987 Miceli, Caltagirone, Gainoti, Masullo, & Silver, 1981; Milne, 1964: Perret, 197: Ram: fer & Hecaen, 1970}: Alticimers disease (Appell, Kertesz, & Fisman, 1982; Bayles & ate words beginning with a specific lt ‘Ain cnenpnens Toy Tomo, Dearne of Pato. Caton Unie Onan Oni 167 Paar,168 TN. Tombaugh Koval an L Ros ‘Tomoeda, 1983; Butters eta, 1987; Chertko & Bub, 199 Cummings, Benson, Hill, & Read, 1085; Hodges, Salmon, & Butters, 1992; Martin & Fedio, 185: Ober. Dronkes, Koss, Delis, & Friedland, 1986; Pachans, Boone, Miller, Cummings, & Berman, 1996, Rosen, 1980): Huntington's disease (Butters, Sax, Montgomery, & Tatlow, 1978: Buters tal, 1987); amnesia (Butters etal, 1987; Weingariner, Grafman, Boutelle, Kaye, & Martin, 198), and traumatic brain injury (Raskin & Rearck, 1990). ‘Carrent time-limited, verbal fueney tess ean be traced to the Thurstone’s Word Fhi- cency Test. which formed part of the Primary Mental Abilities Test (Thurstone, 1938 ‘Thurston & Thurstone, 1989). This test required individuals to write words beginning with a specific letter over relatively long period of time (ea, 5 minutes to write all pos sible words that began with the letter S). Benton and colleagues are generally credited ‘with developing # verbal counterpart for Thursione’s procedure (Bechtold, Benton. & Fogel, 1962: Benton, 1968: Fogel, 1962) The letters FAS were used in these experiments with I minute of responding allowed for cach eter. The fist attempt to develop norms Tor letter fluency was by Borkowski, Benton, and Spreen (1967). All letters ofthe alpha: bet except X and Z were normed using [minute test interval with 66 maternity pa tients, The letters were divided into throe difficulty levels: haed (Q. J, V, ¥,K, U} mou rate (1. O. N.E. G.L. R): and easy (H.D,M.W. A. BFP... 8), Eventually this Tead to the verbal fluency test deed in the Multilingual Aphasia Examination (MAE: Benton & Hamsher, 976; Benton, Hamsher, & Sivan, 1994). Two parallel sets of letter teins (CFL and PRW) were used rather than FAS, However according to Rot Light Parker, and Levin (1996), the name of the test was changed to Controlled Oral Word Association Test (COWA or COWAT) 10 avoid confusing the phrase "word fluency” ‘ith the “uentnonfluent” dimension of aphasia. The letters FAS have continued to be sed as a measure of verbal fueney inthe Neurosensory Center Comprehensive Exami- nation for Aphasia (NCCEA: Benton, 1967; Spreen & Benton, 1960, 1977), The other popular procedure for assessing Verbal fucney is semantic Nueney. whe individuals are asked to generate names from i specified category (e.g. animals frit, cities). For example, the Western Aphasia Battery (WAB: Kertesr, 1982) and Boston Dignostic Aphasia Examination (BDAE; Goodglass & Kaplan, 1983) uses Animal [Naming as ts word fueney test, the Mattis Dementia Rating Seale (Matty, 1988) uses, the Supermarket Test, where the person namcs items found in a supermarket and the Set Test (ssies & Kenn, 1973) uses color, anil, towns, and Eris A review ofthe Tteratue shows that the eategory of “animals” is most frequently employed. Recent, 77: 11 = 122 for 3MS 78) by phsicians and clinical nuropsychologisis on the bass of history. clinical and neurologi- ‘al examination, and an extensive battery of newropaychological tests (see Twokk, Krisjannson, & Miller, 1995; Tuokko & Woodward, 1996 for aldtional details about ‘neuropsychological protocol and results). Ages ranged from 65 to 9S years (M = 792, SD = 65). Number of years of edeation varied fron 1021 years (M = 103,SD = 33) ‘The male to female ratio was 162 10243, All persons stated that English was thir first language Proceiture The total number of words generated in | minute forthe letters F, A, and S (phone- ‘mic flueney) was obtained from all 1300 participants. The number of words generated for each individual letter was available only fom the 895 participants from the fist eX- periment, The instrictions were identical to those used by Spreen and Benton (1977) And described in detail by Spreen and Straus (1991), Participants were instructed that proper nouns and multiple words using the same stem with a diferent surfs (e. rend, Triends. friendly) Were not acceptable. The ages forthe FAS sample ranged trom 16 10 95 years (W = 607, SD = 198), Years of education ranged from 11021 (M = 12.1,D = 32), The male to femal ratio was 550 to 741 “The number of animal names generated in 1 minute (semantic ueney) was obtained ‘roma subset of 735 individuals (33 from the frst study nd fom the second study), Instructions followed those of Rosen (1980) and required individuals to say “the names ‘of as many animals that they could think of” in a minute perio. The ages forthe Ani ‘mal Naming sample range from 16 10 95 years(M = 67.0, SD = 19.8). Years of educa tion ranged from 10 21 (M = 11-4, SD = 34). The male to Female ratio was 310 0 435rm TEN. Tombaugh J Koza, and L- Reet ‘Meats (Man Stand Destin (SD) fe nd or Edt, Se, Fas Eiiaton eas) : er ae ae Ow RESULTS, Phonemic Fuency (FAS) For descriptive purposes, years of education was divided int four groups, and ages were divided into nine age ranges, Table I shows the mean numberof words generated for each of these two variables as wel as for gender. Inspection of Table 1 shows that AS scores tended! to increase with increasing education, sith the least amount of change ooeurring between the lst te eategories (13-16 years and 17-21 years). FAS. Scores decreased with advancing age with the i occurring from, ages 161059 years, Females generated slightly more words than male, Simultaneous re jression analyses further explored the effects of these three variables. Education ac- ‘counted fr 186% ofthe variance. while age accounted for only 11.0% Gender wa not Significant and therefore didnot enter the equation. Comparable values were obtained from a subst of individuals who were administered both verbal fluency tests, Education accounted for 2.7% anlage accounted for 11.8%, Vocabulary scores (WAIS-R) corre- lated r= 25 (p <0) with overall FAS sco (On the basis of these analyses and visual inspection ofthe data, it was decided t0 stratify the norms onthe bass of age (16-59, 60-79, and 80-95 years) and years of educa tion (0-8,9-12, and 13-21), Normative data for total FAS scores are provided in Table 2 “Table 2 shows that within each age level FAS scores inerease with increased education When education is used as the major variable of interest, FAS scores decrease within any given educational category as ge ineeased. An analysis of variance (ANOVA) ap propriate for a3 (education) x 3 (age) factorial design showed that both age and educa tion were statistically significant with a small but statistically significant interaction, Age: FL2, 1291) = 56.6, p < 001: Education: F2, 291) = 812, p <.001: Age Eaucation: FIs, 1291) =26,p-=.08.m Verbal Fiueney om @ rr as woos stg wa 7 a= or Ce RPA SSRN Tae SERN Kara 1-51 BOE TI-6 8) WHIP YD PS 56-8 "WD WG-9) BV) POMBE SV 1 SPN rantm TEN. Tombaugh J Koza, and L- Reet “Two measures of reliability were obtained. The frst measure assessed the degree of, internal consistency that existed among the three letters. A coefficient alpha (Cronbach Alpha) was computed using the total number of words generated for each leer 38 indi= vidual tems (Letter F: M™= LMA, SD = 45: Letier A: M= 11.9,5D ~ 44 Letter S: M_ 15.0,D = 47). The coefficient alpha of r= 83 was suiciently high to insure high tem homogeneity even though t-tests showed the number of worl was significantly ciferent (= 001) among the three letters (F vs. A: (1.893) = 19.0 F ys, S:1(1893) = 52: Avs S:1(.893) = 230) The second measure of reliability was obtained from 38 older participants who had taken the FAS on to accasions separated by 5 6 years (SD =.76). The mean ages atthe first and second administration were 65.6 years (SD = 9.7) and 71.2 years (SD = 99) spectively. The small decrease in scores that aceurred for the second administration (G87 vs. 36.3) was not statistically significant (r= 1.97, p >.05). A corelational analysis showed the test-retest reliability was within acceptable limits (r= 74, p <0), ‘Semantic Fluency (Animal Noming) Table 3 shows the number of animal names generated in | minute for each of four levels of education, nine age ranges. and gender. Inspection of te table shows that the ‘number of snimals named increased as years of education increased. The greatest ins crease occurred between 0 108 and 9 12 yeas, and hetween 9 to [and 13 4016 years “The opposite trend occurred for ag, where the number of animals named remains re: tively constant until age 60, whe it began to decrease with advancing ated more snimals names than females. When the effects of age, education, and gender ‘on animal nami tnalyzed by regression analases, age accounted for 23.4% of| ‘variance, eduction for 136%, and gender for less than 1%, should be noted that al, ‘TaRLES Meas (and Standard Deaton (SD) Numbers in ip 3) MMS as wa, io Go at tae) Me a far tao) 138) ng gp heVerbal Fiueney vs these individuals also had been administered the FAS. Vocabulary scores (WAIS-R) correlated 7 =-17(p <.001) with total numberof animals named, Table 4 prevents normative data stratified using the same three levels of education and age as employed previously with FAS scores. As with FAS, number of animals ‘named within a specific age level progressively increased with increasing amounts of e ‘uation, and scores within any given educational level progressively decreased with in- creasing age. An ANOVA appropriate fora 3 (education) X 3 (age) factorial design hosted tht both age and education were statistically significant, Age: F(2, 726) = 8. ‘P= 001: Eduction: 2.726) = 281. p = 00: Age X Education: FU, 126) = 65. > 15). Finally a correlational analysis showed that number of animals named carelatedr = 52 (p-< 101) with FAS scores, Correlations of the numberof animals named with indi idual letters were as follows Letter F-= 31, Letter A =36, and Letter = 39. DISCUSSION “The results from the preseat study provide norms for two verbal Nueney tests that have enjoyed widespread experimental and clinical usage but have not been adequately normed. Previous norms for FAS and animal naming have used a resected age o edt cational range (Bolla ct al, 1950; Geiser & Vanderploeg, 199%: Read, 1O8T; Sees eta, 1991; Spreen & Benton, 1977; Yeudal etal 1986). By recruiting individuals having & wide range of ages (16-95 years) and years of education (0-21) the present set of norms represent substantial improvement over those previously avaiable, Evidence from a variety of sources shows that verbal fluency measures are sensitive to the effect of years of education an age, bat ar relatively insensitive to gender (Bolla tal, 1990; Borod, Goodglass, & Kaplan, 1980; Geiser & Vanderploeg, 1983; Hamsher & Benton, 1078 Ivnik et al 1096; Ruf tal, 199; Sarno, Bounaguro, & Levita, 985), “The present study confirms and extends these findings by showing that measures of pho- rnemic and semantic vernal fhtency are differentially sensitive t age and education. Re- {gression analyses performed on scores from individuals who had competed both Verbal flueney tests demonstrated that for FAS education accounted for more variance than “ranues ‘Nom or Ain Saif Ape (1-5, (0-79, and 30-98 Years) ta ears of Edoation 4,913,008 1321) ws (a) ovation (Yeas) Easton (ea) boot ho Ba id fio oh ie tea ee 6h 8b Note M= ms SD = snd vimm TN. Tombaugh Koval an L Ros ‘age (education = 21.7% vs. age = 1.8%) while for Animal Naming the apposite rela: tionship existed (education = 136% vs. age = 284%). In both analyses, gender was, ound to account for less than 19% of the variance. Consequently, the eugrent set of norms were stratified overage (16-59, 0-79, and 80-95 years) and years of education (0-8, 9-12, and 13-21) and percentile equivalents were determined. The resis from our sample may’ differ fom other normative data based exclusively fon the CSHA sample, ut contained only participants with MS scores greater than 77 (ee, Tuokko & Woodard, 196). We felt that using onl the final consensus diagnosis ‘would produce a more representative sample than combining it witha criterion 3MS. score, This decision was based on {Wo factors, Ftst the final consensts diagnosis wis ‘hased on an extensive series of elinical, neurologic, and neurapsychologc tess. Conse- ‘quently, we felt that using scores from a brief mental status examination was unwar- ranted and unnecessary. Second, results from prior research (Tombaugh, MeDovell, Kristansson,«€ Hubley, 1996) dentonstrated that scares on the SMS are sensitive to the effets of age and education, and using a 3MS eritrion score might restriet the represen tativeness of our sample. Subsequent data analyses on the CSHLA sample confirmed this suspicion, Participants scoring below a 3MS score of 78 were significantly (F140), p< A1) older (S18 vs. 798 years), ad fewer years of education (87 vs. 119) and scored. lower on FAS (238 v5, 334) and Animal Naming (11.5 vs. 129) “The mujer elnisl wilt ofthese norms is that they wil increase the ability of ne ropsychologiss to determine more precisely the dezree to which verbal ueney is im- paired in patients of varying ages and educational level. Moreover, the provision of horns for both phonemic and semantic flcney offers the additional advantage of allow ing the neuropsychologist to determine if one type of verbal fueney i affected more than the other. Such a determination hasbeen shown to be useful in making differential dlagnoses, For example, Steenhnis and! Osthye (1995) reported that phonemic thuency had greater clinical uty in identifying cognitive loss in nondemented individuals and the generation of animal names contributed more tothe diagnosis of dementia, Consi- tent with this are reports that semantic tlueney declines more in Alzheimer’ patients than does letter thiency (Crossley, D'Arcy, & Rawson, 1997; Kevora & Calm, 1995), and the inclusion ofan animal naming test significantly inereases the sensitivity of the MMSE to identify Alzheimer’s disease (Tombaugh etal, 199). Finally, Zee (1993), ia his review ofthe literature on Alzheimer’s disease (AD), concluded that semantic f= ‘ency "may be considerably more useful than phonemic word fluency inthe diferent slagnosis of patients with AD at all stages of dementia fom normal elder persons" (p. 3) “Two major factors should be kept in mind When using the eurrent norms. First the norms are applicable only when the letters F, A. and Sor the category of animals are used, A large degree of variety exists among the number of mimes generated to different letters of the alphabet. For example. in the present study, significant diferences wer found in numberof words generated with the eters F. A, and S. Thisis consistent with “Thomalke-Lomge’sfrequeney count (Thorndike & Lorge, 1944): with the dats contained {nthe original report by Borkowski el (1967): and with results from other research Us ing cognitively inact and eognitively impaited persons (Hart, Smith, & Swash, 1988; Yeudall ct al, 1986). Similarly, diferent types of semantic categories yield elfferent ‘number of exemplars (Hart, Smith, & Swash, 198; Hodges eta, 1992; Monseh eta, 1092). The lack of comparability in numberof exemplars between different types of fu ovides ample evidence that the present norms should be used exclusively semantic eategory of animals. Ruff etal (1996), ia thir normative article on Benton's Controlled Oral Word Association Test, expressed a ‘Similar aution that "despite the fet thatthe FAS and COWA (e.¢, CFL or PRW) areVerbal Fiueney vs ‘wo versions ofthe same procedures, the raw scores om the Wo Versions are not compa: sable” (p. 337). Secon, the current norms ae only appliable when the person is fluent in English “The current norms should not be wsed when the exemplars to the same letters or animals, category were generated in a ciferent language. This is clearly illustrated by Steenbuis land Osttye (1085), who reported a significant diference in verbal fueney between French and English for PAS (English = 227, French = 1501) and Animal Naming (En- lish = 12.3. French = 103) inan older population tht contained individuals diagnosed. fas demented, cognitively impaired and cognitively intact, REFERENCES Apel, Keres A. Fan, M19. A sy of neue fntoning in Ae pais Brin td Language 1775. Byles KAcdTomoodn-C. 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