Making History With Vitamin C Selection Test B
Trail Making Test
The Trail Making Test (TMT) asks patients to connect consecutive "targets" (numbers and/or letters) on a page arranged in a specific geometric pattern.
From: Handbook of Clinical Neurology , 2016
Cognitive Issues in the Older Adult
Cathy Haines Ciolek , Sin Yi Lee , in Guccione's Geriatric Physical Therapy, 2020
Trail Making Test
The Trail Making Test (TMT) is a freely available, timed, neuropsychological test that involves visual scanning and working memory. The TMT has two parts; the TMT-A (rote memory) and TMT-B (executive functioning). 85 In each test the participant is asked to draw a line between 24 consecutive circles that are randomly arranged on a page. The TMT-A uses all numbers, whereas the TMT-B alternates numbers and letters, requiring the patient to switch between numbers and letters in consecutive order. The TMT is scored by how long it takes to complete the test. The time includes correction of errors prompted by the examiner. If the person cannot complete the test in 5 minutes, the test is discontinued. An average score for TMT-A is 29 seconds and a deficient score is greater than 78 seconds. For TMT-B, an average score is 75 seconds and a deficient score is greater than 273 seconds. Norms have been established based on age and education. 86 This test has been shown to be useful to indicate if a road test is required to determine continued safe driving ability. 87
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History of Research into the Acute Exercise–Cognition Interaction
Terry McMorris , in Exercise-Cognition Interaction, 2016
Trail Making Test
The Trail Making Test (TMT) (see Reitan, 1958) has two parts and the times taken to complete each part are used to measure central executive functioning. In Part A (TMT-A), the participant must draw a line to connect consecutive numbers, from 1 to 25. In Part B (TMT-B), the participant connects numbers and letters in an alternating progressive sequence, 1 to A, A to 2, 2 to B, and so on. In order to measure central executive functioning, the difference in time taken to complete TMT-B, which stresses central executive processes of task-set inhibition, cognitive flexibility, and the ability to maintain a response set (Arbuthnott & Frank, 2000; Kortte, Horner, & Windhan, 2002), and the time to complete TMT-A, which has little executive input, is calculated. The ratio of TMT-B to TMT-A can also be used (Arbuthnott & Frank, 2000; Salthouse, Atkinson, & Berish, 2003).
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Assessments in Driver Rehabilitation
Joseph M. PelleritoJr., in Handbook of Assessment in Clinical Gerontology (Second Edition), 2010
Memory Assessments
The Trail Making Test has been highly correlated with driving performance ( Hopewell, 2002). The Trail Making Test was initially designed as part of the U.S. Army Individual Test Battery (1944) and is now in the public domain. The administration instructions are provided in detail in A Compendium of Neuropsychological Tests: Administration, Norms and Commentary (Spreen & Strauss, 1998); they are reproduced in Appendix B.
Norms are available for persons aged 18 to 89 years, and it has been noted that scores decrease for individuals with advanced age or lower education levels (Tombaugh, 2004). A government study (NHTSA, 2003) suggested that a timed score of 100 seconds on the Trails B subtest would indicate a need for further testing of driving performance because it correlated with increased crash risk.
CLOX is a clock drawing test that is designed to differentiate executive function and visual-spatial praxis (Royall, Cordes, & Polk, 1998). In CLOX 1 the client is requested to draw a clock, and in CLOX 2 the client copies a clock drawn by the evaluator. Standardized instructions are provided: "Draw me a clock that says 1:45. Set the hands and numbers on the face so that a child could read them" (Royall et al., 1998, p. 589). For CLOX 2 the evaluator draws a clock in a circle printed on the scoring sheet, following a specific sequence. The client is then asked to copy the evaluator's drawing. The two drawings are then scored, and the client's performance for the two testing conditions is compared. The test is particularly valuable for clients with dementia and Alzheimer's disease.
The Rivermead Behavioral Memory Test is a test of everyday memory skills, including the ability to remember names, faces, pictures, appointments, a brief story, a short route within the room, and the location of a personal object hidden in the room. Normal performance would result in one or two errors on the 12-test items (Wilson, Cockburn, & Baddeley, 1985).
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Neuropsychological Testing
Glenn T. Stebbins , in Textbook of Clinical Neurology (Third Edition), 2007
TRAIL MAKING TEST. 34
There are two forms to this test: Trail Making Tests A and B. Trail Making Test A provides an assessment of complex attention. This test requires the patient to connect randomly positioned numbered circles in numeric order as quickly as possible. Form B presents the patient with numbered circles and circles with letters. The patient is required to connect the circles in numeric and alphabetic order as quickly as possible, alternating between numbers and letters. Both Forms A and B require focused attention for successful performance. In addition, Form B requires the patient to switch cognitive sets between numbers and letters. Both forms of the Trail Making Test are highly dependent upon motoric speed, and may not be appropriate for patients with marked motor impairment (e.g., Parkinson's disease).
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Dementias and the Frontal Lobes
Michał Harciarek , ... Anna Barczak , in Executive Functions in Health and Disease, 2017
Assessment of Executive Function in Dementia
More than 60% of patients with dementia cannot complete standard executive measures such as Stroop test or TMT-B (Enright et al., 2015). The choice of executive tasks to be used in a dementia clinic is made based on their simplicity and their minimal reliance upon the basic cognitive processes, such as language, visuospatial, and memory functions. The task instruction should be short, straightforward, and easy to remember, and the test material needs to be easily handled. In patients with movement disorders accuracy scores should not be time-dependent. The examples of tests/tasks of executive processes feasible in a dementia clinic are provided in Table 19.2. Of note, whereas most traditional executive tasks engage mostly dorsolateral frontal pathways, the presence of environmental dependency syndrome, frequently seen in both bvFTD (Ghosh, Dutt, Bhargava, & Snowden, 2013) and PSP (Ghika, Tennis, Growdon, Hoffman, & Johnson, 1995), may alert the clinician to the potential involvement of other frontal areas (i.e., mesial, orbitofrontal, frontostriatal, or frontothalamic tracts) (Archibald, Mateer, & Kerns, 2001). Importantly, both EDS and disinhibition may be examples of environmentally driven rather than internally generated patterns of behavior.
Table 19.2. Assessment of Executive Function in Dementia
| Observed/Assessed Aspect of Executive Function | Observable Sign/Psychometric Test/Clinical Task |
|---|---|
| Inhibition |
|
| |
| |
| Initiation and generation |
|
| |
| Mental set-shifting |
|
| |
| Planning and sequencing |
|
| |
| Executive screening tasks |
|
| Proxy report of executive/behavioral symptoms in daily life |
|
BRIEF-2, Behavior Rating Inventory of Executive Function-2; CBI, Cambridge Behavioural Inventory; DEX, Dysexecutive Questionnaire; D-KEFS, Delis–Kaplan Executive Function System; FBI, Frontal Behavioral Inventory; FrSBe, The Frontal Systems Behavior Scale; INECO, The Institute of Cognitive Neurology; IRSPC, Iowa Rating Scale for Personality Change; NPI, Neuropsychiatric Inventory; TMT, Trail Making Test; WCST, Wisconsin Card Sorting Test.
Motor impersistence assessment can also be sometimes useful for the differential diagnosis. For instance, inability to sustain tongue protrusion (>10 s) is one of the typical signs of HD. In the context of predominant psychiatric symptoms and lack of family history, the presence of this sign should alert the clinician to look out for other HD symptoms.
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Vitamin D and the Association with Cognitive Performance, Cognitive Decline, and Dementia
Elske M. Brouwer-Brolsma MSc , ... Ondine van de Rest PhD , in Diet and Nutrition in Dementia and Cognitive Decline, 2015
Prospective Studies
Prospective associations have been investigated in three studies [26,28,32] , which all included the trail making test-B (TMT-B), often referred to as a measure of executive function. The only prospective study indicating a role for 25(OH)D in maintaining cognitive performance was the InCHIANTI study. Elderly persons with serum 25(OH)D levels below 25 nmol/L had a 31% increased probability of experiencing cognitive impairment when compared to those with levels of 75 nmol/L and over, after an average follow-up time of 5.2 years [26].
In brief, up to now only very few observational studies have investigated the possible link of 25(OH)D with compound scores of domain-specific cognitive performance and individual tests for domain-specific cognitive functions. Although these few studies point towards a more pronounced association with executive function [42], future studies are needed to provide additional evidence.
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Late Aging Associated Changes in Alcohol Sensitivity, Neurobehavioral Function, and Neuroinflammation
Sara Jo Nixon , Ben Lewis , in International Review of Neurobiology, 2019
3.2 Behavioral outcomes
Gilbertson et al. (2009) examined performance on a common test of set-shifting (i.e., Trail Making Test, Form B; Reitan & Wolfson, 1993) on both the ascending and descending limbs of the BrAC curve. As expected, there was an age main effect with the younger cohort completing the task more quickly than did the older group. Of greater relevance was the differential effect of alcohol in the two age groups. On the ascending limb, older adults receiving low dose alcohol (targeted peak BrAC = 0.04 g/dL) performed more poorly than their age- cohorts receiving placebo. There was no effect of alcohol for older adults at an equivalent BrAC on the descending limb. Interestingly, self-reported ratings of perceived impairment indicated that older adults were relatively unaware of their impairment on the ascending limb. On the descending limb, where alcohol did not impact performance, older adults receiving alcohol reported higher levels of perceived impairment than their cohorts receiving placebo. The younger group was unaffected by alcohol on either limb and reported no differences in perceived impairment.
At peak BrAC, in this same study, participants completed a covert visual attention task (Luck et al., 1994), previously shown to be sensitive to both age (e.g., see Carriere, Cheyne, Solman, & Smilek, 2010) and alcohol (Acons, Chan, Drummond, & Tiplady, 2006). Cognitive efficiency, as reflected in the ability to respond both quickly and accurately, was ascertained (Sklar, Gilbertson, Boissoneault, Prather, & Nixon, 2012). The construct has demonstrated sensitivity to both age (Salthouse, Matlaga, & Wykoff, 1977) and acute alcohol administration (Tiplady et al., 2001) and has been widely applied in studies of alcohol use disorder (Nixon, 1993; Oscar-Berman & Marinkovic, 2007). Efficiency ratios were equivalent for the two age groups in the placebo condition. Alcohol benefitted performance in the younger cohort with those receiving alcohol being more efficient than their age-cohort receiving placebo. Unexpectedly, alcohol did not affect cognitive efficiency in the older group. Further analyses revealed that unlike the other groups, older adults receiving alcohol sacrificed speed for accuracy in maintaining efficient performance.
In an independent sample, similarly selected participants were assigned to one of three groups; targeted BrAC of 0, 0.04, or 0.065 g/dL. Participants completed a working memory (WM) task (Boissoneault, Sklar, Prather, & Nixon, 2014; Gazzaley, Clapp, Kelley, McEvoy, Knight, & D'Esposito, 2008) at peak BrAC. The task involved presentation of a short series of individually presented faces and scenes followed by a short delay (WM maintenance period) and then the presentation of a probe stimulus, which was judged as being either present or absent in the previous series. Instructions to remember the faces or the scenes were counterbalanced within participants. Efficiency ratios for "hits" (accurately identifying a stimulus as appearing in the previous series) and "correct rejections" (accurately identifying a stimulus as being novel) were derived. Alcohol had no effect on performance in the younger cohort. For hit efficiency, the older group was inferior to the younger group at both placebo and moderate alcohol doses. Interestingly, the low dose benefitted performance in the older group and resulted in hit efficiency ratios equivalent to that of the younger cohort. Analysis of correct rejections, where detection of novelty is critical, revealed a different pattern. Among older participants, performance was negatively affected at both alcohol doses relative to placebo. For the younger group, performance for the placebo and low dose groups was equivalent, while there was a trend for enhanced efficiency at the moderate dose. The data for Hit and CR efficiency are shown in Fig. 2.
Fig. 2. Efficiency ratios for working memory (WM) performance. Age-contingent alcohol effects on WM (Means ± SE). For hit efficiency (triangles), low dose alcohol benefitted older adults (open symbols) relative to placebo (P = 0.03). Younger adults were unaffected by alcohol. For CRs (circles), older adults exhibited a dose related decline (P = 0.04, at moderate dose). There was an opposite trend for younger adults (P = 0.07).
Data reported in Boissoneault, J., Sklar, A., Prather, R., & Nixon, S. J. (2014). Acute effects of moderate alcohol on psychomotor, set shifting, and working memory function in older and younger social drinkers. Journal of Studies on Alcohol and Drugs, 75(5), 870–879.Lewis, Garcia, Boissoneault, Price, and Nixon (2019) conducted a replication study using identical selection criteria and the same WM task. Both studies showed that older cohorts in the placebo and moderate doses had significantly lower hit efficiency than their younger cohorts receiving these doses, with the older group receiving the low dose achieving performance equivalent to younger cohorts. Similarly, the moderate alcohol dose was associated with reduced correct rejection efficiency in the older cohort as compared to the younger cohorts in both studies. Age-related compromise in correct rejection efficiency at the low dose was observed only in the original study. Taken together, these studies demonstrate differential effects of acute alcohol with age. Furthermore, they suggest that processes related to "attending" and those related to "ignoring" may be impacted differently. Notably, the association between alcohol dose and performance was not linear, and may be facilitatory at some doses. In short, low and moderate alcohol doses are associated with divergent patterns of outcomes in older versus younger drinkers.
Often, there are insufficient women to allow analysis of sex differences (e.g., Boissoneault et al., 2014; Lewis, Boissoneault, Gilbertson, Prather, & Nixon, 2013). The Lewis et al. (2019) paper is an exception. Given identical selection criteria, doses and tasks, participants in the Boissoneault et al., 2014 and Lewis et al., 2019 were combined, permitting sufficient power for analysis of sex differences. Importantly, means for the four groups (2 age by 2 sex) were equivalent on key demographic variables with all groups reporting typical alcohol consumption of between ½ to 1 drink/day. Fig. 1, presented earlier, illustrates the absence of age or sex effects in alcohol metabolism at these doses. It might be noted that the absence of group differences in the BrAC curves is consistent with other reports from this group (Gilbertson et al., 2009; Sklar et al., 2012; Sklar, Boissoneault, Fillmore, & Nixon, 2014). Given earlier discussion, only sex main and interaction effects will be discussed. Hit efficiency was not impacted by the inclusion of sex. To the contrary, complex interactions including sex, age, dose and instruction set were obtained for correct rejection efficiency. The most striking outcome was an age-related divergence with older women in the moderate dose group being disproportionately disadvantaged. In contrast, younger women receiving this dose performed far better than all other groups. Furthermore, the magnitude of this difference was largest when the task demanded that faces be ignored. This pattern eludes ready explanation, but suggests that future work may benefit from greater consideration of (a) existing literature on age differences in face processing (Sullivan, Ruffman, & Hutton, 2007; Wong, Cronin-Golomb, & Neargarder, 2005), and (b) potential age differences in alcohol's effects on cognitive control processes.
Importantly, ~ 15% of drivers aged 45–64% and 8% of those 65 + report a current (30 day) history of driving after drinking (National Highway Traffic Safety Administration, 2011). Thus, understanding the behavioral outcomes associated with drinking and driving among older adults is of high import. Toward that end, Sklar et al. (2014) examined the age by alcohol interaction in a simulated driving task where driving demands were minimized. They found that core driving skills such as consistency in maintaining speed were compromised in older adults receiving low/moderate doses of alcohol. More recently, Price, Lewis, Boissoneault, Frazier, and Nixon (2018) examined performance in complex scenarios (i.e., country or city settings) and explored drivers' responses when presented with either relevant (e.g., a pedestrian crossing the street) or irrelevant (e.g. a pedestrian walking on a parallel sidewalk) stimuli. These analyses showed that older adults altered their response strategy contingent on dose and scenario. In less complicated scenarios, the older cohort receiving alcohol became more conservative, decelerating more and braking earlier to relevant stimuli than their cohorts receiving placebo and producing a response pattern largely opposite to that of younger drinkers. In the more complicated metropolitan scenario, those receiving alcohol extended this strategy to irrelevant stimuli, braking and decelerating unnecessarily. There were no sex main or interaction effects with dose. It should be mentioned that to better approximate conditions under which older adults commonly drive after drinking, e.g., after a social event or dinner, the driving task was conducted on the descending BrAC limb in both the Sklar et al. (2014) and Price et al. (2018) studies. Thus, these age-contingent differences in alcohol effects occurred at very low BrACs; ~ 0.05 and ~ 0.28 g/dL for the moderate and low dosed groups, respectively.
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Neuroepidemiology
P. Palta , ... M.C. Carlson , in Handbook of Clinical Neurology, 2016
Incorporation of cognitive assessments in research studies
Cognitive tests, although often times categorized as domain-specific, are broad and multifactorial. For example, cognitive demands for TMT, Part B involve working memory, visual-spatial skills, and motor and executive functions. When considering what test instruments to include in a research study, several factors should be considered, including length and ease of administration, participant burden, psychometric properties, generalizability to population under study, and availability of norms to infer appropriate comparisons (Mitrushina et al., 2005). In some cases, a predetermined comprehensive neuropsychologic test battery, such as the Halstead–Reitan Battery, which includes a set of well-validated and reliable cognitive test instruments with available norms, may be used. These batteries are typically administered in clinical vs. epidemiologic settings given the time and resources required to implement, score, and interpret the patterns of performance. Established norms, although important for the interpretation of cognitive test scores, are limited in their generalizability beyond the clinic samples for which the norms were established. Cost constraints and availability of resources (e.g., test administrators) often limit the use of such a full neuropsychologic test battery, therefore encouraging the use of a select battery of tests.
To aid the inclusion of cognitive test assessments into research practice, the National Institutes of Health (NIH) charged an expert panel of neuropsychologists, neurologists, and practitioners to identify a brief and convenient set of validated cognitive tests for use in epidemiologic and longitudinal research, as well as clinical trials (Table 7.2) (Weintraub et al., 2013). This test battery, NIH Toolbox, can be administered in a computerized format and has been nationally standardized to provide a "common currency" among researchers, therefore facilitating the appropriate use of cognitive tasks into epidemiologic studies and clinical trials.
Table 7.2. Psychometric properties of neuropsychologic tests
| Characteristic | Definition |
|---|---|
| Validity | Effectiveness of the test to measure what it is purposed to measure (e.g., distinguishing individuals with and without cognitive impairment) |
| Sensitivity | Probability that the test correctly classifies cases or individuals with impaired cognitive functioning (or disease) |
| Specificity | Probability that the test correctly classifies individuals with normal cognition (or without disease) |
| Reliability | Repeatability of a test and its ability to produce consistent results |
| Standard deviation (SD) | Measure of dispersion for test scores, indicating on how far from the mean, on average, are the scores in a distribution |
Several other computerized neurocognitive test batteries have been proposed to aid these research and clinical efforts, including the CANTAB (Cambridge Neuropsychologic Test Automated Battery) and COGSTATE. These standardized batteries are simple, fast, and reliable and have several additional desirable characteristics, including: (1) minimization of participant burden; (2) providing comprehensive information on key domains of cognition (e.g., executive control function, memory); (3) translatable across ages (e.g., could be used for children and adults so that one could track trajectories of cognitive decline from childhood to adulthood); (4) previously published and validated, hence comparable across other studies; and (5) ease of administration and reliability of scoring.
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Screening Instruments and Brief Batteries for Dementia
Benjamin T. Mast , Adam Gerstenecker , in Handbook of Assessment in Clinical Gerontology (Second Edition), 2010
Fuld Object Memory Evaluation
The Fuld Object Memory Evaluation (FOME) is a neuropsychological test that was originally developed to assess episodic memory function in an elderly population (Fuld, 1981). The FOME is unique from most other instruments used as dementia screens due to its multi-modal process of encoding: tactile; auditory; and visual. The tested person is initially instructed to place their hand into a bag that contains ten common objects (e.g., key, mug, playing card) and asked to name the object using only their sense of touch. The tested person then removes the object from the bag, visually confirms the selection, and verbally names the object with mistakes being corrected by the test administrator. This process is repeated one by one until all ten objects have been identified and removed from the bag. The objects are then removed from sight, and a verbal fluency distracter task is initiated for approximately 60 seconds. Next, the tested person is given 60 seconds to name as many objects as they can remember that were initially contained in the bag. This is followed by a selective reminding procedure and the process is repeated four more times for a total of five trials. A total of 50 points is possible on the FOME (one point for each correctly recalled item during each trial) with scores of 30 or lower deemed indicative of cognitive impairment.
Operating characteristics of the FOME are relatively unaffected by education or ethnicity and have demonstrated excellent utility in detecting dementia (Chung, 2009; La Rue, 1989; Loewenstein, Duara, Arguelles, & Arguelles, 1995; Marcopulos, Gripshover, Broshek, McLain, & Brashear, 1999; Mast, Fitzgerald, Steinberg, MacNeill, & Lichtenberg, 2001; Wall, Deshpande, MacNeill & Lichtenberg, 1998;). The FOME has demonstrated excellent utility in detecting mild dementia (sensitivity and specificity >0.95) in both English and Spanish speaking elders (Loewenstein et al., 1995) and has also demonstrated high sensitivity (0.98) in detecting dementia among older African Americans using the retrieval cutscore of 30 (Mast et al., 2001). The slope of learning over five trials has been associated with daily functioning (IADLs) (Mast & Allaire, 2006). The FOME places fewer demands on processing speed than other list learning measures such as the California Verbal Learning Test (CVLT) or the Hopkins Verbal Learning Test (HVLT). Because the learning and encoding of words occurs at a slower pace on the FOME, it may be a purer measure of memory function than other measures which may partially confound memory and processing speed, which is the ability most affected by normal aging (Salthouse, 1993, 1994).
Due to the time and materials needed to administer the FOME it is usually administered as part of a brief battery rather than a stand-alone screener. The FOME is, however, a useful dementia screen and a viable alternative for screening elders with hearing and/or visual impairment (Chung & Ho, 2009). The development of a shorter, three-trial version of the FOME may increase its use as a screener. However, when combined with other measures such as the DRS-2, the FOME can be very effective in evaluating dementia (Mast, MacNeill, & Lichtenberg, 2000).
Because the brief batteries reviewed lack a strong emphasis on executive functioning, supplemental tests of this construct should be included (e.g., Trail Making Test, Controlled Oral Word Association Test). The use of both screening measures and brief batteries is demonstrated in the case study below, along with supplementation with measures that are sensitive to executive dysfunction.
Case Study
Ms P is a 90-year-old woman whose son and primary care physician requested an evaluation of her memory and cognitive functioning. She had been living independently until a year ago when she fell and fractured her leg. Although she was reportedly living independently, medical records indicate that she has had some difficulty with balance, repetitive language, and forgetfulness over the past two to three years. Her primary care physician screened her with the MMSE two years ago and she received a score of 27 out of 30. More recently she was given the Mini-Cog. She initially recalled 3 of 3 words but could not recall any after a short delay. Her clock drawing test score was 2 out of 4. She had previously been diagnosed as having Mild Cognitive Impairment by her PCP, but the recent failure on the Mini-Cog screener prompted further testing with a brief battery.
Test results
Ms P's performance on a test of reading ability (an indicator of premorbid functioning) was average (post-high school level; Scaled Score = 110). Her general cognitive functioning was in the low average range (DRS-2 Total = 120). Her performance on the Attention subscale of the DRS-2 was high average (72nd–81st percentile) and the Construction and Conceptualization subscales were average (41st–59th percentile). Her DRS-2 Memory (3rd–5th percentile) and Initiation/Perseveration (6th–10th percentile) scores were in the moderately and mildly impaired ranges, respectively. On the FOME Ms P retrieved 24 over five trials (out of 50) which was significantly impaired. In terms of language abilities, she demonstrated average performance on tests of verbal comprehension (71st percentile), category fluency (Animal Naming 25th percentile), and lexical fluency (40th–50th percentile). Her performance on the Trail Making Test was low average (14th percentile) on Part A and mildly impaired (8th percentile) on Part B. She did not endorse any of the items on the Geriatric Depression Scale.
Conclusions
Ms P demonstrated significant cognitive strengths in several areas of functioning, but also demonstrated significant impairment in memory and executive functioning. Moreover her low average general cognitive functioning likely represents a slight decline from premorbid levels of functioning, which taken together with impairment in memory and executive functioning is consistent with a mild dementia syndrome.
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Cognitive Testing
Michael Hoffmann , in Clinical Neurotoxicology, 2009
Delis Kaplan Executive Function Systems Test 25
Delis Kaplan is a new frontal test that derives most of its subtests from those known previously but standardizes them with normative data. The nine subtests include a trail-making test, verbal fluency tests, a design fluency test, color–word interference tests, a sorting test, a 20-questions test, a tower test, and proverb interpretation tests. This test is particularly advocated for formal executive or frontal network system assessment because it combines into one test most frontal tests we use separately, for example, the Tower of London or Hanoi tests, Stroop test, FAS test and trail-making test versions.
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Making History With Vitamin C Selection Test B
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