Oral trail making test

Oral trail making test DEFAULT

Abstract

The Trail Making Test (TMT) is a useful measure of executive dysfunction in elderly subjects. This study aims to investigate the discriminative validity of the oral version of the TMT (OTMT), which can be administered to subjects with visual or motor disabilities, in elderly patients with Mild Cognitive Impairment (MCI; n = 30), Alzheimer's disease (AD; n = 30), and healthy controls (HCs; n = 25). The WAIS-R Digit Span Backwards Subscale, written form of the Trail Making Task, the Clock Drawing Test, the AD Assessment Scale-Cognitive Subscale, and the OTMT were also administered to all participants in order to examine the concurrent validity of the OTMT. The OTMT part B discriminated between patients with MCI, AD, and HC correctly. The OTMT completion time was not correlated with age, but was negatively correlated with education. In conclusion, the OTMT (mostly part B) is a valid and practical measurement tool for different levels of cognitive impairment, especially for patients with visual or motor disabilities for whom the classical written form is not feasible.

Mild Cognitive Impairment, Alzheimer's disease, Dementia, Aging, Executive functions

Introduction

Mild Cognitive Impairment (MCI) is considered a transitional state between dementia and normal cognitive aging (Petersen & Morris, 2005). Individuals with MCI are at a higher risk for Alzheimer's disease (AD) conversion with annual rates ranging between 10% and 54% (Jack et al., 2005; Petersen et al., 2001). Differentiating healthy elderly people from subjects with MCI is particularly important in determining normative data for cognitive tests (Hashimoto et al., 2006).

The Trail Making Task (TMT) has been widely used in order to evaluate executive functions and the speed of cognitive processing (Arbuthnott & Frank, 2000). The TMT, particularly part B, which is considered to be a sustained attention and sequencing task, requires subjects to alternate their responses to number-letter sequencing. The TMT has two forms; the TMT-A measures attention and processing speed, whereas the TMT-B evaluates switching on mental sets, in other words “cognitive flexibility” and it is considered an executive task (Cullum & Lacritz, 2009). Since 1944, several versions of the task have been developed (Cangöz, Karakoç, & Selekler, 2007). The TMT is sensitive to mild cognitive deterioration and it has been regarded as one of the major neuropsychological tests which identifies patients with MCI. Brief cognitive screening tools for MCI, such as the Montreal Cognitive Assessment, also include a modified version of the TMT-B (Nasreddine et al., 2005). However, it is hard to administer the classical, written form of the TMT which requires intact visual and motor functions. Since some elderly patients have physical restrictions, computerized or paper-pencil tasks have limited use in this group. An oral version of the TMT (OTMT) which was developed by Ricker and Axelrod (1994) removes the visual and motor components of the task in order to allow for the assessment of those who are unable to complete the standard written form. Furthermore, the OTMT is a practical tool and requires shorter time for administration than the classical written form (Ricker and Axelrod, 1994).

Several validity studies were carried out for the OTMT in both normal and clinical samples. It was demonstrated that the OTMT was able to discriminate between patients with different lesion sites at a similar level of sensitivity as the TMT (Ricker, Axelrod, & Houtler, 1996). However, the OTMT was not validated in patients with MCI. In this study, we aimed to examine whether the OTMT discriminated between elderly patients with amnestic type of MCI, AD, and healthy elderly controls (HCs).

Methods

Participants

The study sample consisted of 30 patients with AD (diagnostic and statistical manual of mental disorders-text revised fourth edition) and 30 patients with amnestic type of MCI (Petersen–Mayo Diagnostic Criteria, Petersen et al., 2001) who were consecutively admitted to the Geriatric Psychiatry outpatient clinic of a university hospital between September 2010 and September 2011. According to the Petersen–Mayo Diagnostic Criteria, the patient with amnestic type of MCI should have memory complaint, which is preferably corroborated by an informant, impaired memory function for age and education, preserved general cognitive function, and intact daily activities of living (Petersen et al., 2001). The HCs (n = 25) were elderly people who were admitted to the geriatrics outpatient clinic of the same university hospital for other medical disorders (such as hypertension, diabetes mellitus, congestive heart disease, osteoarthritis). Uneducated subjects (<5 years of education), subjects with other neuropsychiatric disorders (with a history of head trauma, cerebrovascular disorder, seizure disorder, etc.), and subjects who could not complete neuropsychological tests (written form of the TMT, the AD Assessment Scale-Cognitive Subscale [ADAS-Cog], the Clock Drawing Test [CDT], etc.) due to advanced cognitive impairment, hearing loss, or visual or motor deficit were excluded. The Bradykinesia subscale of Unified Parkinson Disease Rating Scale (UPDRS; Akbostancı, Balaban, & Atbasoglu, 2003; Stern, 1988) was applied to all participants and subjects with bradykinesia scores above 2 (moderate–severe bradykinesia) were excluded, because significant bradykinesia can confound tasks like the TMT and the OTMT which assess completion time. The Mini-Mental State Examination (MMSE), the CDT, the ADAS-Cog, the WAIS-R Digit Span Backwards (DSB) Subscale, the TMT-A and B, and the OTMT-A and B forms were administered to all participants. The MMSE, the CDT, and the ADAS-Cog were administered for the diagnosis of dementia and MCI in the outpatient clinic by the clinicians (the authors ETO-K, AS, OA, and UA). Other cognitive tests were administered by the clinical psychologists (the authors GB and SK). Concurrent validity of the OTMT was evaluated by the correlation between the scores of the OTMT, the TMT, the DSB, the ADAS-Cog, and the CDT. In order to control the bias due to sequence/practice effect, the application orders of the tasks (the TMT and the OTMT) were counter balanced (random integers were generated by using a computer program). Application of the whole battery lasted for about 45–60 min. Informed consent was taken from the subjects or their caregivers and the study was approved by the ethics committee of the university. Detailed information about the cognitive battery is given below.

Mini-Mental State Examination

The scale was developed by Folstein, Folstein, and McHugh (1975) as a screening test for the evaluation of cognitive impairment. Turkish standardization of the scale was carried out by Güngen, Ertan, Eker, Yaşar, and Engin (2002). The subscales include time and space orientation, immediate and delayed memory, attention, and language. The maximum score possible on the MMSE is 30. A lower MMSE score means impaired cognitive functioning.

Clock Drawing Test

The CDT has been widely used in dementia screening as a practical and valid tool for assessing various neuropsychological domains like executive and visuospatial functions. The CDT was developed by Goodglass and Kaplan (1983) and many scoring systems requiring different instructions and methodologies were proposed. Turkish versions of the three scoring methods of the CDT (drawing a 10 past 11 clock within a given circle) has been validated and Shulman's method of scoring has been suggested by Can, Özel Kızıl, Varlı, Turan, and Atlı (2010). In the present study, Shulman's scoring method (0, no clock; 1, severe visuospatial disorganization; 2, moderate visuospatial disorganization of numbers such that accurate denotation of “10 after 11” is impossible; 3, inaccurate representation of 10 after 11 when the visuospatial organization is well done; 4, minor visuospatial errors; 5, perfect clock) was used. The CDT score of ≤3 corresponds to “impaired cognition.”

The Alzheimer's Disease Assessment Scale-Cognitive Subtest

This scale was developed by Rosen, Mohs, and Davis (1984) which is used for the diagnosis and course of AD and the evaluation of the treatment response. The ADAS-Cog has 11 subtests: word recall, naming objects/fingers, commands, constructional praxis, ideational praxis, orientation, word recognition, spoken language ability, comprehension of spoken language, word-finding difficulty in spontaneous speaking, and remembering test instructions. The validity and reliability study of the Turkish version of the scale was performed by Mavioglu, Gedizlioglu, Akyel, Aslaner, and Eser (2006). The maximum score possible on the ADAS-Cog is 70 and a higher score means more cognitive impairment.

WAIS-R DSB Subscale

This subscale was reviewed by Wechsler (1981). Subjects are given sets of digits to repeat backwards. The score is the number of the correctly recalled trials under each condition. Lower scores indicate more cognitive impairment. The DSB task has been commonly used to assess attention and working memory in both clinical and non-clinical samples. This is a test of immediate auditory recall and freedom from distraction.

Trail Making Test

The TMT was first developed in 1944, as a part of the Army Individual Test Battery. Reitan (1955) used it for organic brain damage studies. Cangöz and colleagues (2007) conducted the standardization study of the Turkish version of the TMT in elderly people above 50 years of age. This scale has two paper/pencil forms (A and B) and aims to measure several cognitive features such as complex visual screening, cognitive flexibility, motor speed, and sustained attention. For the TMT-A, the participant is asked to sequentially connect a series of 25 numbered targets that are placed in a quasi-random order on a page as quickly as possible. The TMT-B differs in that the participant is asked to alternate between connecting 25 numbers and letters in a progressive sequential order (such as 1, A, 2, B, 3, C, … ). The major dependent variable for this measure is completion time. Before each application, a short trial is applied and the application time for each form is recorded by a chronometer. If there is an error, it is corrected by either the participant or the executive and recorded as an error score. In the present study, we applied the classical, paper–pencil form of the test and also the oral form of the TMT. The OTMT also has two forms (A and B). In the OTMT-A, participants are asked to count numbers from 1 to 25. In the OTMT-B, the participants are asked to count numbers and letters as in the written form. Before each application, a short trial for the OTMT is applied and the application time for each form is recorded by a chronometer. If there is an error, it is corrected by either the participant or the executive and recorded as an error score (Ricker & Axelrod, 1994).

For the analysis of the TMT scores, we used the difference between the completion time for the TMT-A and the TMT-B (TMT B − A) and the sum of the completion time for the TMT-A and the TMT-B (TMT A + B) by referring to the original study (Cangöz et al., 2007).

Statistical Analysis

According to the distribution of the data, either one-way analysis of variance or Kruskal–Wallis tests were used for the comparison of continuous variables (age, years of education, cognitive test scores). Post hoc tests were Bonferroni or Mann–Whitney U-tests. The correlation analysis was carried out by the Spearman rank correlation test. All statistics were carried out using SPSS.

Results

Table 1 presents the comparison of the clinical characteristics of the groups. Patients with AD were older than those with MCI and HC. There was no significant difference between groups in terms of the total years of education. The MMSE, the CDT, and the ADAS-Cog scores of three groups were significantly different. The TMT-B and the OTMT-B also differentiated between three groups. The TMT-A and the OTMT-A scores of the patients with AD were higher than the patients with MCI and HC. However, the TMT-A and the OTMT-A scores of the patients with MCI and HC were similar. The TMT (B − A) and the TMT (B + A) scores, as well as the OTMT (B − A) and the OTMT (B + A) scores of the three groups were significantly different (AD > MCI > HC).

Table 1.

Statistical comparison of the clinical characteristics of the groups

Healthy controls . Patients with MCI . Patients with AD . Statistical significance . Post hoc tests . 
Age (mean) 70 ± 6.3 72.6 ± 8.8 76.3 ± 4.54 F = 5.8, p = .004aAD > MCI = HC 
Years of education (median) 7.5 6.5 χ2 = 0.08, p = .95 NS 
MMSE (median) 28 26 24.5 χ2 = 23.5, p < .001bAD < MCI < HC 
CDT (median) 2.5 χ2 = 25.7, p < .001 AD < MCI < HC 
ADAS-cog (total; median) 9.6 10.8 15.4 χ2 = 28.7, p < .001 AD > MCI > HC 
WAIS-R DBS (mean) 3.56 ± 1.45 4.10 ± 1.47 3.17 ± 1.74 F = 2.68, p = .074 NS 
TMT-A (s; median) 67 85.5 128.5 χ2 = 19, p < .001 AD > MCI = HC 
TMT-B (s; median) 156 253 510 χ2 = 27, p < .001 AD > MCI > HC 
OTMT-A (s; median) 10 χ2 = 16.6, p < .001 AD > MCI = HC 
OTMT-B (s; median) 42 63 111 χ2 = 25, p < .001 AD > MCI > HC 
TMT B − A (s; median) 82 178 334 χ2 = 26.9, p < .001 AD > MCI > HC 
TMT B + A (s; median) 218 328 596 χ2 = 26.3, p < .001 AD > MCI > HC 
OTMT B − A (s; median) 36 53 102 χ2 = 23.1, p < .001 AD > MCI > HC 
OTMT B + A (s; median) 48 76 120 χ2 = 26.3, p < .001 AD > MCI > HC 
Healthy controls . Patients with MCI . Patients with AD . Statistical significance . Post hoc tests . 
Age (mean) 70 ± 6.3 72.6 ± 8.8 76.3 ± 4.54 F = 5.8, p = .004aAD > MCI = HC 
Years of education (median) 7.5 6.5 χ2 = 0.08, p = .95 NS 
MMSE (median) 28 26 24.5 χ2 = 23.5, p < .001bAD < MCI < HC 
CDT (median) 2.5 χ2 = 25.7, p < .001 AD < MCI < HC 
ADAS-cog (total; median) 9.6 10.8 15.4 χ2 = 28.7, p < .001 AD > MCI > HC 
WAIS-R DBS (mean) 3.56 ± 1.45 4.10 ± 1.47 3.17 ± 1.74 F = 2.68, p = .074 NS 
TMT-A (s; median) 67 85.5 128.5 χ2 = 19, p < .001 AD > MCI = HC 
TMT-B (s; median) 156 253 510 χ2 = 27, p < .001 AD > MCI > HC 
OTMT-A (s; median) 10 χ2 = 16.6, p < .001 AD > MCI = HC 
OTMT-B (s; median) 42 63 111 χ2 = 25, p < .001 AD > MCI > HC 
TMT B − A (s; median) 82 178 334 χ2 = 26.9, p < .001 AD > MCI > HC 
TMT B + A (s; median) 218 328 596 χ2 = 26.3, p < .001 AD > MCI > HC 
OTMT B − A (s; median) 36 53 102 χ2 = 23.1, p < .001 AD > MCI > HC 
OTMT B + A (s; median) 48 76 120 χ2 = 26.3, p < .001 AD > MCI > HC 

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Table 1.

Statistical comparison of the clinical characteristics of the groups

Healthy controls . Patients with MCI . Patients with AD . Statistical significance . Post hoc tests . 
Age (mean) 70 ± 6.3 72.6 ± 8.8 76.3 ± 4.54 F = 5.8, p = .004aAD > MCI = HC 
Years of education (median) 7.5 6.5 χ2 = 0.08, p = .95 NS 
MMSE (median) 28 26 24.5 χ2 = 23.5, p < .001bAD < MCI < HC 
CDT (median) 2.5 χ2 = 25.7, p < .001 AD < MCI < HC 
ADAS-cog (total; median) 9.6 10.8 15.4 χ2 = 28.7, p < .001 AD > MCI > HC 
WAIS-R DBS (mean) 3.56 ± 1.45 4.10 ± 1.47 3.17 ± 1.74 F = 2.68, p = .074 NS 
TMT-A (s; median) 67 85.5 128.5 χ2 = 19, p < .001 AD > MCI = HC 
TMT-B (s; median) 156 253 510 χ2 = 27, p < .001 AD > MCI > HC 
OTMT-A (s; median) 10 χ2 = 16.6, p < .001 AD > MCI = HC 
OTMT-B (s; median) 42 63 111 χ2 = 25, p < .001 AD > MCI > HC 
TMT B − A (s; median) 82 178 334 χ2 = 26.9, p < .001 AD > MCI > HC 
TMT B + A (s; median) 218 328 596 χ2 = 26.3, p < .001 AD > MCI > HC 
OTMT B − A (s; median) 36 53 102 χ2 = 23.1, p < .001 AD > MCI > HC 
OTMT B + A (s; median) 48 76 120 χ2 = 26.3, p < .001 AD > MCI > HC 
Healthy controls . Patients with MCI . Patients with AD . Statistical significance . Post hoc tests . 
Age (mean) 70 ± 6.3 72.6 ± 8.8 76.3 ± 4.54 F = 5.8, p = .004aAD > MCI = HC 
Years of education (median) 7.5 6.5 χ2 = 0.08, p = .95 NS 
MMSE (median) 28 26 24.5 χ2 = 23.5, p < .001bAD < MCI < HC 
CDT (median) 2.5 χ2 = 25.7, p < .001 AD < MCI < HC 
ADAS-cog (total; median) 9.6 10.8 15.4 χ2 = 28.7, p < .001 AD > MCI > HC 
WAIS-R DBS (mean) 3.56 ± 1.45 4.10 ± 1.47 3.17 ± 1.74 F = 2.68, p = .074 NS 
TMT-A (s; median) 67 85.5 128.5 χ2 = 19, p < .001 AD > MCI = HC 
TMT-B (s; median) 156 253 510 χ2 = 27, p < .001 AD > MCI > HC 
OTMT-A (s; median) 10 χ2 = 16.6, p < .001 AD > MCI = HC 
OTMT-B (s; median) 42 63 111 χ2 = 25, p < .001 AD > MCI > HC 
TMT B − A (s; median) 82 178 334 χ2 = 26.9, p < .001 AD > MCI > HC 
TMT B + A (s; median) 218 328 596 χ2 = 26.3, p < .001 AD > MCI > HC 
OTMT B − A (s; median) 36 53 102 χ2 = 23.1, p < .001 AD > MCI > HC 
OTMT B + A (s; median) 48 76 120 χ2 = 26.3, p < .001 AD > MCI > HC 

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The percentages of errors for TMT-A and OTMT-A are presented in Table 2. Table 2 presents the error rates (percentages) of the groups for the TMT and the OTMT. Table 3 presents the correlations between the OTMT-A and B with other executive tasks in the whole sample. The OTMT-A and the OTMT-B scores were also positively correlated with each other (R = .47, p < .001).

Table 2.

Error rates of the groups for the TMT and the OTMT

Healthy controls (%) . Patients with MCI (%) . Patients with AD (%) . 
TMT-A 20 20 36 
TMT-B 76 86 93 
OTMT-A 
OTMT-B 72 90 93 
Healthy controls (%) . Patients with MCI (%) . Patients with AD (%) . 
TMT-A 20 20 36 
TMT-B 76 86 93 
OTMT-A 
OTMT-B 72 90 93 

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Table 2.

Error rates of the groups for the TMT and the OTMT

Healthy controls (%) . Patients with MCI (%) . Patients with AD (%) . 
TMT-A 20 20 36 
TMT-B 76 86 93 
OTMT-A 
OTMT-B 72 90 93 
Healthy controls (%) . Patients with MCI (%) . Patients with AD (%) . 
TMT-A 20 20 36 
TMT-B 76 86 93 
OTMT-A 
OTMT-B 72 90 93 

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Table 3.

Correlations between the OTMT and other executive tasks

OTMT-A completion time . OTMT-B completion time . 
TMT-A R = .46, p < .001 — 
TMT-B — R = .69, p < .001 
CDT R = −.55, p < .001 R = −.60, p < .001 
WAIS-R DBS R = −.19, p = .08 R = −.23, p = .04 
OTMT-A completion time . OTMT-B completion time . 
TMT-A R = .46, p < .001 — 
TMT-B — R = .69, p < .001 
CDT R = −.55, p < .001 R = −.60, p < .001 
WAIS-R DBS R = −.19, p = .08 R = −.23, p = .04 

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Table 3.

Correlations between the OTMT and other executive tasks

OTMT-A completion time . OTMT-B completion time . 
TMT-A R = .46, p < .001 — 
TMT-B — R = .69, p < .001 
CDT R = −.55, p < .001 R = −.60, p < .001 
WAIS-R DBS R = −.19, p = .08 R = −.23, p = .04 
OTMT-A completion time . OTMT-B completion time . 
TMT-A R = .46, p < .001 — 
TMT-B — R = .69, p < .001 
CDT R = −.55, p < .001 R = −.60, p < .001 
WAIS-R DBS R = −.19, p = .08 R = −.23, p = .04 

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Age was not correlated with the TMT-A, the TMT-B, the OTMT-A, or the OTMT-B completion times in HC (R = .02, p = .94; R = −.01, p = .95; R = .30, p = .14; R = −.07, p = .74, respectively). However, education was negatively correlated with the TMT-A, the TMT-B, and the OTMT-B scores, but not with the OTMT-A scores in HC (R = −.57, p = .003; R = −.49, p = .01; R = −.45, p = .02; R = −.30, p = .14, respectively).

Discussion

These results indicate that the OTMT, especially part B, is useful for discriminating between patients with MCI, patients with AD, and healthy elderly subjects. The high correlations between the scores of the OTMT and other neuropsychological tests further support the validity of the task. We also found strong correlations between the OTMT-A and the OTMT-B as in the previous studies (Strauss, Sherman, & Spreen, 2006). However, the OTMT-A and the TMT-A did not discriminate between healthy elderly and patients with MCI. Only part B of the TMT and the OTMT differentiated between the groups. In a large sample of 526 subjects, Ashendorf and colleagues (2008) had similar results in favor of the TMT-B. Cercy, Simakhodskaya, and Elliott (2010) studied the diagnostic accuracy of a brief cognitive measure consisting of several tasks including the OTMT. In their study, a receiver operating curve (ROC) analysis revealed that the diagnostic accuracy of the OTMT-B (area under the curve value was 0.911) was the highest, whereas the diagnostic accuracy of the OTMT-A was not significant. Also, they specified cut-off values for the completion times. For the OTMT-B, a cut-off value of >55 s had a sensitivity of 75% and a specificity of 100%, whereas a cut-off value of >42 s had a sensitivity of 85% and a specificity of 75%. We did not perform ROC analysis; however, median values for the OTMT-B completion times in our study were similar to their results (for MCI patients, median = 63 s; for AD patients median = 42 s). Besides, Cercy, Simakhodskaya, and Elliott (2010) took the presence of cognitive impairment instead of exact clinical diagnoses as an inclusion criterion. In a recent study, Bezdicek and colleagues (2012) also reported that TMT indices, with the exception of the TMT-A, might be useful clinical indicators in distinguishing patients with AD and MCI. The discrepancy between the results for parts A and B is probably due to the hierarchical ordering of attention. Patients with severe cognitive impairment often have difficulty with all levels of attention processing beyond the most basic of tasks like forward digit span or sustained attention tasks like the Continuous Performance Test (which measures target–non-target discrimination ability, e.g., mark the letter “X” followed by the letter “A”) and the TMT-A/OTMT-A. However, patients with MCI demonstrate little difference in simple/sustained attention, even though they have difficulty in alternating their attentional focus (Cullum & Lacritz, 2009).

The WAIS-R DSB, which is a commonly used attention task, was also taken as a measure of concurrent validity in our study. There was a negative correlation between the WAIS-R DSB and the OTMT scores as suggested by Kortte, Horner, and Windham (2002). However, the WAIS-R DSB did not discriminate between the groups.

In this study, we also examined whether the OTMT and the TMT performances were correlated with age or education. Although there was a difference between the groups in terms of age (patients with AD were older), the samples were similar in terms of age intervals (all of them were ∼70) and neither the OTMT nor the TMT scores were correlated with age. Some of the previous studies did not find an association between age and the TMT-B performance, either (Abraham, Axelrod, & Ricker, 1996; Ricker & Axelrod, 1994). The result in the present study may also be due to the exclusion of participants with higher UPDRS scores in order to prevent the confounding effects of Parkinsonism which may have occurred in other studies, as previous research has shown greater deficits on the TMT in AD patients with Parkinsonian features than Alzheimer's patients without these features (Merello et al., 1994). On the other hand, some of the previous studies found that the TMT and the OTMT completion times increased with increasing age (Ashendorf et al., 2008; Bezdicek et al., 2012; Cangöz et al., 2007; Mrazik, Millis, & Drane, 2010). However, until the age of 80, normative data for TMT completion times failed to identify significant age-related decrement (Stuss, Binns, Murphy, & Alexander, 2002; Wardill & Anderson, 2008).

In the current study, the OTMT-A scores were not correlated with education, but the OTMT-B scores were negatively correlated with education. This is probably because the OTMT-A is a simple task consisting of only numbers, whereas the OTMT-B has a greater working memory load. Moreover, the error percentages were quite lower for the OTMT-A than the TMT-A, whereas the error percentages were similar for the B forms of the TMT and the OTMT. This is probably because the OTMT-A is a quite easy task of counting numbers sequentially. In addition, the mean education level of the subjects in the present study was also low (corresponding to a primary school degree); therefore, the correlation between education and the OTMT-B scores may be due to such a low levels of education. In other words, subjects with little education may not have perfect knowledge of the alphabet. For samples with higher levels of education such a correlation seems unlikely as reported by Mrazik and colleagues (2010).,Hashimoto and colleagues (2006) also had similar findings; cognitive functions evaluated by the TMT-A and the TMT-B were not affected by aging until the subjects were ≥85 years old. For the TMT-A, an educational effect became apparent when the population included poorly educated subjects, but this part of the test was not affected by the educational level provided that the subjects had some education (>6 years). The completion time for the TMT-B was affected by the educational level; however, when adjusted using the results for the TMT-A (B − A or B/A), the educational effect on executive function disappeared. Thus, the effect of the educational level on executive function was reported as unclear in healthy elderly subjects (Hashimoto et al., 2006). Some of the previous studies reported correlations between education and the TMT/OTMT scores (Ashendorf et al., 2008; Bezdicek et al., 2012; Drane, Yuspeh, Huthwaite, & Klingler, 2002; Ruchinskas, 2003). Ashendorf and colleagues (2008) and Bezdicek and colleagues (2012) reported a negative correlation between both parts of the TMT and education. Ruchinskas (2003) found an impact of education on OTMT-B performance in a sample of older medical patients. However, the authors acknowledged a significant difference in the education levels among the groups, with the control group having almost three more years of education than one of the experimental groups (consisting of neurological patients).

Some of the previous research examined the ratios between the TMT and the OTMT completion times in order to detect whether these tasks were identical. Axelrod and Lamberty (2006) suggested an oral-to-written ratio of 2.5 and the study by Mrazik and colleagues (2010) revealed an overall ratio of 2.1 for the entire sample, with a range 1.7–2.3 for different age groups. Ricker and Axelrod (1994) demonstrated that the OTMT yielded results consistent with an individual's written performance in normal subjects, regardless of age. Although we found high correlations between the completion times of the TMT-B and the OTMT-B and similar error rates, the working memory load seems to be higher in the OTMT-B than in the written form of this task. Because, participants can use the visual cues to track the last number/letter marked in the written form, whereas in the oral form, they must rely on their own memory to do so. Moreover, there were differences between the error rates of the oral and written forms of part A in our study. The written form of part A requires sustained attention and visual search; therefore, there is no doubt that this situation in the TMT-A differs from simply counting from 1 to 25 in the OTMT-A. The idea that the OTMT-A is not an equivalent task to the TMT-A, probably due to the relative simplicity of the task, has also been reported by Mrazik and colleagues (2010). Taken together, the results of the present study and our experience suggest that the OTMT and the TMT should be considered as two independent tasks. High correlations between these tasks are not sufficient to conclude that they are identical and that their scores can be converted. Inconsistent results from the previous studies further support the idea that they are independent. Therefore, we did not calculate the oral-to-written ratio in our sample.

Although the results of the present study support the OTMT (mostly part B) as a valid and practical screening tool for different levels of cognitive impairment like MCI and AD, there are some limitations. For example, in previous studies, TMT-B performance was reported as a significant predictor of time to progression from mild impairment to a clinical diagnosis of AD (Blacker et al., 2007; Rozzini et al., 2007). However, the present study is a cross-sectional one and this should be taken as the major limitation. Therefore, future studies should be carried out by a longitudinal method in order to address the prognostic value of the OTMT. Additionally, the patients with hearing loss or visual/motor deficits were excluded, although this is the subgroup of patients for whom the OTMT will be most useful and applicable. However, we had to perform such a exclusion in order to administer other tasks requiring intact visuomotor abilities. Furthermore, in order to minimize the practice effects, we counterbalanced the administration sequence of the TMT and the OTMT. However, these tasks consist of the same verbal material and we could not completely control the practice effect. This should also be taken as a limitation of the current study.

In conclusion, the OTMT seems to have many advantages. First of all, the OTMT takes less time. Completion times for the OTMT were shorter than those for the TMT. This finding is in parallel with the original study of the OTMT by Ricker and Axelrod (1994) and the study by Mrazik and colleagues (2010), which also reported similar completion times for the OTMT-A (mean = 7 s) and the OTMT-B (mean = 34 s). Second, it is affected by the aging process less than its written counterpart and it can be more suitable for functional imaging research as it requires lesser time and motor activity. A recent study by Jacobson, Blanchard, Connolly, Cannon, and Garavan (2011) showed significantly greater activation in fMRI during the TMT-B relative to the TMT-A in right inferior/middle frontal cortices, right precentral gyrus, left angular gyrus/left middle temporal gyrus. However, the computerized version of the TMT in that study was quite different from the original task. Finally, the OTMT can also be administered via telephone for longitudinal neuropsychological assessment, as performed by Mitsis and colleagues (2010).

We recommend the usage of the OTMT-B, the OTMT (A + B), or the OTMT (B − A) scores instead of the OTMT-A score both for clinical practice and future research. Moreover, although the TMT and the OTMT seem to be similar tests, they are not identical; therefore, the scores of the OTMT cannot be converted to the TMT scores and norm studies for the OTMT should be carried out.

Conflict of Interest

None declared.

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Sours: https://academic.oup.com/acn/article/28/5/411/6000

The Oral Trail Making Test: Effects of Age and Concurrent Validity

Marty Mrazik,1,*Scott Millis,2 and Daniel L. Drane3,4

Marty Mrazik

1University of Alberta, Edmonton, Alberta, Canada

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Scott Millis

2Department of Physical Medicine & Rehabilitation, Wayne State University School of Medicine, Detroit, MI, USA

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Daniel L. Drane

3Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA

4Department of Neurology, Regional Epilepsy Center, University of Washington, School of Medicine, Seattle, Washington DC, USA

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Author informationArticle notesCopyright and License informationDisclaimer

1University of Alberta, Edmonton, Alberta, Canada

2Department of Physical Medicine & Rehabilitation, Wayne State University School of Medicine, Detroit, MI, USA

3Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA

4Department of Neurology, Regional Epilepsy Center, University of Washington, School of Medicine, Seattle, Washington DC, USA

*Corresponding author at: University of Alberta, 6-135 Education Building North, Edmonton, AB, Canada, T6G 2G5. Tel.: +1-780-492-8052; fax: +1-780-492-1318. E-mail address:[email protected] (M. Mrazik).

Part of this paper was presented at the 21st Annual Meeting of the National Academy of Neuropsychology, San Francisco, CA.

Accepted 2010 Jan 28.

Copyright © The Author 2010. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected]

This article has been cited by other articles in PMC.

Abstract

The oral version of the Trail Making Test (OTMT) is a neuropsychological measure that provides an assessment of sequential set-shifting without the motor and visual demands of the written TMT (WTMT). Originally purposed to serve as an oral analog of the WTMT, the OTMT provides a means to evaluate patients with physical restrictions. However, formal validity studies and available normative data remain sparse. In a sample of healthy adults (n = 81), a strong correlation was observed between OTMT-B and its written counterpart (r = .62), but the correlations were weak between OTMT-A and either written version of the TMT. OTMT-B was significantly correlated with age but not with education or gender, whereas OTMT-A was not significantly correlated with demographic factors. The WTMT to OTMT ratios observed in the current study were generally lower than previously reported and varied across age groups, suggesting that the recommended use of a uniform conversion factor to predict one performance based on the other should be cautiously undertaken. Normative data that have been stratified by age are provided as well as suggestions for using both versions of the TMT in tandem to better elucidate the nature of cognitive deficits and to aid in the localization of cerebral dysfunction.

Keywords: Neuropsychology, Normative data, Cognitive tests, Trail Making Tests, Neuropsychological assessment

Introduction

The written Trail Making Test (WTMT; Army Individual Test Battery, 1944; Reitan, 1955) is a visuomotor speeded task consisting of two parts that is a widely used neuropsychological measure among clinicians (Rabin, Barr, & Butler, 2005). WTMT-A is a simple visual scanning task that requires one to draw a line connecting consecutive numbers from 1 to 25. WTMT-B adds the dimension of dividing one's attention between unrelated conceptual sets, requiring one to draw a line connecting numbers and letters in alternating sequence. Factor analytic studies have indicated that rapid visual search, contextual set shifting, and visuospatial sequencing are major components of WTMT-B performance (Des Rosier & Kavanaugh, 1987; Fossum, Holmberg, & Reinvang, 1992). However, non-cognitive factors such as poor vision and impaired motor functioning are known to impact performance and can preclude test administration in some instances. This problem is commonly encountered among older patients, persons who have sustained orthopedic injuries, and patients experiencing certain neurologic conditions (e.g., individuals whose dominant limbs are hemiparetic following a stroke).

An oral version of the TMT (OTMT) developed by Ricker and Axelrod (1994) removes the visual and motor components of the task in order to allow for the assessment of those who are unable to complete the standard written form. The sample in the original study included 58 healthy adults who were divided into three age-groups. Results suggested significant between-group age differences using analysis of variance (ANOVA). Subsequent post hoc analysis revealed significant differences between the youngest and oldest age groups on both OTMT-A and OTMT-B, although no statistically significant differences were detected between the younger and the middle age groups. Further, correlational analyses revealed significant relationships between these two versions of the TMT. Overall, the authors presented the OTMT as a promising addition to the assessment of attention by acting as an oral analog for WTMT.

Although years have passed, validity studies and normative data remain sparse for this measure despite evidence that it continues to be routinely employed by many neuropsychologists (Strauss, Sherman, & Spreen, 2006). In a recent book chapter, the original authors cite only a handful of validity studies for the OTMT, with most completed by their own group (Axelrod & Lamberty, 2006). Validity studies have been completed in a sample of 58 healthy adults (Ricker & Axelrod, 1994), 85 cerebrovascular accident patients (Ricker, Axelrod, & Houtler, 1996), 86 older medical patients (Ruchinskas, 2003), and a mixed clinical sample of 112 subjects with a wide variety of neurologic, medical, and psychiatric diagnoses (Abraham, Axelrod, & Ricker, 1996). Results of these validity studies suggested that the OTMT was able to discriminate between patients with different lesion sites at a similar level of sensitivity as the WTMT and established some of the basic psychometric properties of this measure (e.g., preliminary exploration of the statistical relationship between OTMT and WTMT, some demographic factors, and concurrent validity).

Arguments that the OTMT and the WTMT are analogous measures have been based on the congruence of results found in these preliminary studies. In the original study, correlations between the two versions of the TMT were large and statistically significant (r = .68 for TMT-A and r = .72 for TMT-B). Further evidence came when using the OTMT and WTMT in various clinical populations. The Abraham and colleagues (1996) study found an age-related effect for both the OTMT and the WTMT (with older subjects performing significantly worse than younger subjects) regardless of the patient group (normal, medical, or psychiatric diagnosis). Demographic variables including intelligence, education, and gender were not found to yield significant differences for either OTMT or WTMT among the groups. In addition, the authors found both OTMT-B and WTMT-B did not correlate well with measures of expressive language but did correlate well with measures of executive control. One study has reported an impact of education on OTMT performance in a sample of older medical patients (Ruchinskas, 2003). However, the authors in this study acknowledged a significant difference in the education levels among the three groups, with the control group having almost three more years of education than one of the experimental groups (neurologic patients). Results yielded the level of education as a significant predictor of passing or failing the OTMT-B.

In contrast, there are enough differences between these measures in terms of obvious perceptual and motor demands to question whether they measure the same underlying constructs. The differences in the demands of these measures are backed by a failure to observe a relationship between the oral and written versions of the TMT in some studies. For example, the Ricker and colleagues (1996) study found no significant correlation between the OTMT-B and the WTMT-B for one group of subjects (anterior strokes). This could reflect that motor deficits only hinder performance on the WTMT.

Similarly, although the initial OTMT publication found a large correlation (r = .68; Ricker & Axelrod, 1994) between Part A of the OTMT and the WTMT, subsequent studies have demonstrated only a weak to mild relationship (r = .10–.29; Axelrod & Lamberty, 2006). Although WTMT-A requires visual scanning and psychomotor speed, the OTMT-A is really more of an overlearned, mental control task that places no demands on visual or motor functions. Creating a true analog of WTMT-A appears virtually impossible, as one cannot develop an oral sequencing task that parallels the written version.

There have also been some limitations in the existing validity studies primarily due to restrictions in sample characteristics, and normative data for the OTMT remain scant. The three groups used in the original Ricker & Axelrod (1994) study had a narrow demographic profile that placed considerable limitations on its normative properties. More specifically, Ricker and Axelrod's (1994) sample had a significant gap in the middle to older age ranges, with the age range from 40 to 70 years not well represented (i.e., the sample included college students and persons living in a retirement community). Because they were comparing groups at extreme ends of the age spectrum, it appears that this could bias their sample toward finding age-related correlations. The 112 subjects used in the Abraham and colleagues (1996) study suffered from a breadth of medical conditions with relative small sample sizes within each group to yield a very heterogeneous population, making the generalization of findings difficult. Although the convergent validity of OTMT appears promising in clinical populations, its psychometric properties within the normal population are tenuous given the limited normative information.

The purpose of the present study was to further examine the potential clinical use of the OTMT. The relative ease of administration, coupled with its potential applicability to populations with visual and/or motor limitations, makes it a viable instrument for use in a variety of clinical contexts. Yet to date, there have been no follow-up studies evaluating its psychometric properties in a nonclinical sample that is more evenly stratified by age. Therefore, we sought to explore relations between demographic variables (i.e., age, education, and gender) and performance on the OTMT. In addition, concurrent validity of the OTMT with WTMT was evaluated, and normative performance provided for the OTMT to make is useful for clinical comparison.

Materials and Methods

Participants

Participants included 81 adults (22 males, 59 females) who were participating in a comprehensive neuropsychological normative project. All participants were without history of known psychiatric or neurologic disorder and were living independently in their respective communities. No participant had a history of substance abuse or treatment, and none was currently receiving psychotropic medications. Participants were volunteers recruited from a variety of sources. They included family members of patients seen clinically at a couple of major medical centers, members of various civic organizations, and individuals recruited through the use of flyers in public locations. All participants provided written informed consent and the study was approved by an institutional review board. Participants were screened for exclusionary factors through the use of a careful, in-depth clinical interview. All participants performed within the normal range on a cognitive screening measure (i.e., Modified Cognistat, Drane, Yuspeh, Klingler, Huthwaite, & Mrazik, 2002, February, 2002; Drane et al., 2003) and on the 2nd edition of the Beck Depression Inventory (Beck, Steer, & Brown, 1996). Participants ranged in age from 20 to 90 years (M = 48.47, SD = 19.56), and education level ranged from 6 to 20 years (M = 14.20, SD = 2.15). The mean education level is somewhat high compared with the general population. Table 1 presents the demographic characteristics and OTMT performance for the entire sample.

Table 1.

Demographic characteristics and means (SD) for OTMT performance for the entire sample (n = 81)

Mean (SD)Range
Age49.62 (19.56)20–90 years
Education14.20 (2.15)6–20 years
OTMT-A6.88 (1.89)2–12 s
OTMT-A errors0.02 (0.15); mode = 00–1 errors
OTMT-B33.91 (17.58)12–90 s
OTMT-B errors0.51 (0.36); mode = 00–3 errors
WTMT-A29.85 (14.09)13–85 s
WTMT-B72.33 (35.57)29–187 s
Gender composition22 men, 59 women

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Procedures

Test instructions

The OTMT (Ricker & Axelrod, 1994) and the WTMT (Army Individual Test Battery, 1944; Reitan & Wolfson, 1993) were administered according to standardized procedures as part of a comprehensive neuropsychological normative project. Test administration was counterbalanced in order to control for order effects.

Specifically, participants were given the following instructions prior to administration of the oral version of TMT.

For OTMT-A:

“I would like you to count from 1 to 25 as quickly as you can – 1, 2, 3, and so on. Are you ready? Begin.”

For OTMT- B:

“Now I would like you to count again, but this time you are to switch between number and letter, so you would say 1-A-2-B-3-C, and so on, until I say ‘stop’. Are you ready? Begin.” (Ricker & Axelrod, 1994, pp. 48–49).

Although not mentioned in their original article (Ricker & Axelrod, 1994), Ricker and Axelrod have also reportedly redirected patients who lose their place on either of these tasks (Axelrod & Lamberty, 2006). We have found this to be a necessary procedure, as it is nearly impossible for patients to recover from a set loss error on OTMT-B without any kind of prompt. For the current study, we added the following instructions to be presented when errors were made on the OTMT:

  • If the patient makes an error on Part A, the examiner is to reorient them to the last correct number by saying: “You last said ‘[specific number],’ please continue from there.”

  • If the patient makes an error on Part B, the examiner is to reorient them to the last correct pair by saying: “You said ‘[specific number] [specific letter];’ Continue from there.”

Timing is continued uninterrupted for both versions of the OTMT when instructions are given to keep them on task as described. For part B, timing is discontinued once subjects reach the number 13, identical to instructions for WTMT.

Analysis

Analyses included calculating Pearson product–moment correlations in order to examine the association of OTMT time to completion scores with demographic variables including age, gender, and education, as well as with the WTMT, Parts A and B (Army Individual Test Battery, 1944).

Results

OTMT-A time for the entire sample ranged from 2 to 12 s (M = 6.88, SD = 1.89), and OTMT-B time ranged from 12 to 90 s (M = 33.91, SD = 17.58). With respect to demographic characteristics, small and non-significant correlations were observed between OTMT-A time and age, education, and gender (rs ranged from −.01 to .17). Correlations were non-significant between OTMT-B time and education and gender. However, a significant correlation was observed between age and OTMT-B time (r = .40, p = .0001), with age accounting for 16% of the total variance in OTMT-B performance.

Correlational analyses revealed significant relationships between OTMT, Parts A and B, and their written counterparts (rs were .29 and .62, respectively), although the relationship was small between OTMT-A and WTMT-A. Interestingly, the correlation between the OTMT-A and the OTMT-B was also small, whereas the correlation between WMT-A and WMT-B appeared large. Table 2 presents the correlations among the demographic characteristics, oral TMT times, and written TMT times.

Table 2.

Correlation coefficients between demographic characteristics, OTMT performance, and WTMT performance

EducationGenderOTMT-AOTMT-BWTMT-AWTMT-B
Age.04.05.17.40**.61***.69***
Education−.16−.01−.13−.14−.19
Gender.08.08.03.03
OTMT-A.22*.29*.31**
OTMT-B.54***.62***
WMT-A.81***

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Given the impact of age on the OTMT, we decided to stratify our sample by age when presenting normative data. Therefore, participants were divided into six collapsed age groups with midpoint ages following the procedures outlined by Pauker (1988), as this method is recommended to maximize the clinical usefulness of normative data, especially when there is a wide range of normal subjects. Table 3 presents the mean performance of these six age groups on the OTMT and the WTMT. In addition, percentile distribution scores were established to outline the cumulative frequencies of test score performance for OTMT-A and OTMT-B for each of the collapsed age groups (Table 4).

Table 3.

Means (SD) for collapsed groups on education level and time to completion performance on parts A and B of the WTMT and the OTMT (measured in seconds)

Age groups (years) (midpoint)20–39 (29)29–49 (39)39–59 (49)49–69 (59)59–79 (69)69–90 (79)
Age28.8 (5.7)38.3 (6.6)48.2 (5.8)59.2 (6.7)69.3 (5.6)76.3 (6.11)
Group size313131272318
Education14.61 (2.33)14.48 (2.36)14.29 (2.28)14.19 (2.22)13.65 (1.77)14.28 (2.40)
WTMT-A21.53 (7.24)22.44 (6.49)24.05 (5.12)31.48 (11.23)38.73 (16.04)43.63 (18.90)
WTMT-B46.72 (17.04)53.14 (18.62)59.02 (17.62)78.26 (36.96)96.85 (36.39)109.42 (38.25)
OTMT-A6.25 (1.32)6.56 (1.42)7.02 (2.01)7.16 (2.34)6.98 (2.27)7.48 (2.07)
OTMT-A err0.00 (0.00)0.01 (0.18)0.01 (0.18)0.00 (0.00)0.01 (0.21)0.01 (0.24)
OTMT-B27.77 (14.80)29.97 (15.19)30.65 (14.18)35.27 (16.24)42.25 (19.16)46.78 (20.55)
OTMT-B err0.42 (0.62)0.52 (0.85)0.61 (0.92)0.00 (0.75)0.51 (0.73)0.67 (0.69)

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Table 4.

Group means, standard deviations, and selected percentile distribution of OTMT scores (in seconds) for midpoint age groups

Age groups (years) (midpoint)20–39 (29)29–49 (39)39–59 (49)49–69 (59)59–79 (69)69–90 (79)
Group size313131272318
OTMT-A6.25 (1.3)6.56 (1.4)7.02 (2.0)7.16 (2.3)6.98 (2.3)7.48 (2.1)
 9th percentile8.08.09.69.69.19.1
 25th percentile7.47.37.68.28.98.4
 50th percentile6.06.06.46.47.18.0
 75th percentile5.05.35.75.55.35.9
OTMT-B27.77 (14.8)29.97 (15.2)30.65 (14.1)35.27 (16.2)42.25 (19.1)46.78 (20.6)
 2nd percentile55.058.058.060.073.082.3
 9th percentile44.053.053.056.069.773.0
 25th percentile33.034.134.042.052.952.9
 50th percentile22.022.924.230.132.136.1
 75th percentile16.017.220.023.625.031.4

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Axelrod and Lamberty (2006) in their summary chapter of OTMT research suggested that future research should look at the comparison of WTMT-B to OTMT-B as a means to estimate the written version from the oral score. This would allow one to take advantage of the demographically corrected scores for the WTMT-B, which would be particularly useful for patients unable to complete the written form. Their work suggested that the WTMT-B to OTMT-B ratio was approximately 2.5. However, calculations of the WTMT-B to OTMT-B ratio with our data revealed an overall ratio of 2.1 for the entire sample, with a range 1.7–2.3 for the different collapsed age groups (Table 5). These scores are substantially lower than 2.5 ratio that was previously reported and suggest that this finding may not stable enough to allow for reliable predictions from one version of the test to the other. Although there was a clear tendency for older age groups to exhibit higher ratios in our sample, the overall model did not reach statistical significance (r = .22, p = .06). Table 5 also includes the mean estimated WTMT-B score for each of the collapsed age groups, as well as a corresponding demographically corrected T-score based on the Heaton, Miller, Taylor, and Grant (2004) demographically corrected norms.

Table 5.

Summary of written-to-oral TMT-B ratio scores with estimated mean raw and demographically corrected T-scores by collapsed age groups

Age groups (years) (midpoint)
20–39 (29)29–49 (39)39–59 (49)49–69 (59)59–79 (69)69–90 (79)
WTMT-B/OTMT-B ratioa1.71.81.92.22.32.3
Mean Est. WTMT-B scoresb47.253.958.277.697.2107.6
Estimated WTMT-B T-scoresc545453484849

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Finally, cumulative frequencies were generated to address the issue of clinical significance in our population sample. Specifically, cumulative frequencies of the WTMT-B to OTMT-B ratio for each of the collapsed age groups and for the entire sample are presented in Table 6. This will allow one giving both versions of the test to get a better idea of how common disparities are between the two versions.

Table 6.

Cumulative percent of written-to-oral TMT-B ratio scores

RatiosAge groups (years)
Total
20–3929–4939–5949–6959–7969–90
6.704.89.51.5
5.505.03.63.1
4.409.514.35.65.4
4.2011.16.2
4.0016.76.9
3.407.15.014.323.810.0
3.3010.010.722.213.1
3.2014.319.033.315.4
3.1015.027.817.7
3.0023.842.919.2
2.9017.915.028.622.3
2.8021.420.033.324.6
2.7028.635.042.952.430.8
2.6047.661.944.435.4
2.5032.140.05038.5
2.4035.752.440.0
2.3039.340.8
2.2020.046.450.057.161.147.7
2.1025.050.055.061.971.472.254.6
2.0030.053.660.056.9
1.9040.060.765.071.481.063.1
1.8055.067.970.076.277.870.0
1.7065.071.481.090.583.374.6
1.6075.075.075.085.710088.981.5
1.5080.078.683.1
1.4010086.2
1.30
1.2085.085.785.090.590.8
1.1092.995.095.295.4
1.00100100.096.9
0.9095.096.498.5
0.70100.0100.0100.0100.0

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Discussion

Our results suggest that OTMT-B shows a large relationship with both Parts A and B of the WTMT, but indicate that the OTMT-A is only weakly related to either written task. In addition, OTMT-A shows little relationship with OTMT-B despite large correlations between the two written tasks both in this study and across prior studies involving the WTMT (Strauss et al., 2006). Taken together, these findings suggest that OTMT-A is not an equivalent task to WMT-A. It is probable that the OTMT-A is less strongly related to its written counterpart due to the relative simplicity of the task. It only requires patients to repeat an overlearned rote sequence, which produces a restricted range in scores. In contrast, WTMT-A requires other cognitive abilities such as planning, visual scanning and tracking, and visuomotor functioning. To some degree, these differences also exist between the OTMT-B and the WTMT versions. However, there is a strong relationship between the OTMT-B and the WTMT versions, which is perhaps due to a presumed dependence on mental flexibility and divided attention (although external validation of the shared underlying neurocognitive constructs is still lacking; Axelrod & Lamberty, 2006).

Results clearly identified the moderating effect of age on performance of both the OTMT-B and the WTMT-B, although this difference was more pronounced for the written version. There was a trend for completion times to get slower for OTMT-B and WTMT-B across each of our six age groups. It is likely that the additional visuomotor demands of WTMT-B versus OTMT-B contribute to the slightly greater impact of age on the written version. The absence of a significant impact of age on OTMT-A performance once again highlights the relative simplicity and rote nature of this task and again distinguishes it from its written counterpart.

Dissociations between performance on the OTMT-B and WTMT-B are highlighted by both the differential impact of age on these measures and by the modest correlations observed between these tasks. This is actually consistent with growing evidence that attentional functioning can vary across different sensory modalities in an individual subject (Benedict et al., 1998; Sinnett, Juncadella, Rafal, Azanon, & Soto-Faraco, 2007) and presumably reflects the activity of partially segregated neural networks. There is also ample evidence that dissociations across attentional tasks tapping varying sensory modalities may frequently be of diagnostic utility (Berger & Posner, 2000; Collier & Logan, 2000; Connor, Streissguth, Sampson, Bookstein, & Barr, 1999; Jonkman et al., 1997; Wood, Potts, Hall, Ulanday, & Netsiri, 2006). Therefore, rather than analogs, the OTMT and WTMT may actually reflect somewhat complimentary tasks and administering both versions may be helpful in patients without physical handicaps. The work of Ricker and Axelrod (1994) indicated that the order in which these versions are administered does not result in confounding effects. Order effects were also absent when examined in a small subset of our current sample. This leads us to conclude that there are no confounding effects of using both versions in a single assessment.

A clinical comparison between the oral and written administrations may also allow an examiner to better clarify factors contributing to the patient's performance in some situations. For example, combining the comparative data obtained from the OTMT and WTMT with a thorough examination of motor and visuoperceptual functions can help to elucidate the possible role of perceptual, motor, and attentional deficits on tasks requiring more complex cognitive integration. Moreover, in patients lacking perceptual and/or motor deficits, or in whom the contribution of such deficits can be controlled, it may be possible to determine if deficits in attention are limited to one or more sensory modalities (e.g., auditory versus visual).

Our results support previous research demonstrating age-related differences in performance on both the WTMT and the OTMT (Drane, Yuspeh, Huthwaite, & Klingler, 2002; Ernst, 1987; Rasmusson, Zonderman, Kawas, & Resnick, 1998; Ricker & Axelrod, 1994). These results provide additional evidence that complex processing speed may slow down and cognitive flexibility may diminish with normal aging, thereby supporting the use of appropriate normative data that controls for age when using the OTMT.

Our data also revealed a trend for older subjects to have higher WTMT-B to OTMT-B ratios, although results were not statistically significant between groups. A higher ratio in older individuals could suggest that performance on the written version declines at a greater rate than the oral version. This could reflect greater impact of general physical slowing that may accompany the aging process. Previous studies have not compared this ratio across age groups, and this trend bears further examination in future normative studies using the OTMT. We should also note that the calculated WTMT-B to OTMT-B ratio in our sample was lower than that reported in previous research (Axelrod & Lamberty, 2006), suggesting that conversion across forms of the TMT could potentially be problematic.

Although the sample size of the current study is modest, this represents the largest sample of normative data presented to date for this measure and provides a broader age range of subjects compared with the original normative study completed by Ricker and Axelrod (1994). In addition, the age ranges within each of the six groups used in this study enhance the clinical utility of the OTMT by allowing a better comparison of subjects to an appropriate normative group, as the only existing normative data lack subjects in the middle age ranges. Our sample was also well-defined, screened for existing cognitive and mood-related issues, and did not reflect a population of convenience. The current study includes a disproportionate number of females, yet gender has not been shown to affect performance in any prior study of the OTMT and has been shown to have minimal impact on the WTMT (Strauss et al., 2006). Despite the wide-range of education levels reflected in our current sample, most individuals tended to have had at least a high-school education. Therefore, it is possible that we could have underestimated the impact of education on this measure. Only one prior study has reported an impact of education (Ruchinskas, 2003). However, as there were significant differences in education levels across the three groups analyzed in the Ruchinskas (2003) study, a strong possibility exists that results were confounded by differences in neurologic diagnosis. Overall, all studies to date addressing this issue have been limited and lacked adequate sampling of education levels.

Further research using both versions of the TMT in various clinical populations is warranted. Likewise, factor analyzing a battery of neurocognitive tests including the WTMT and OTMT would help to elucidate the underlying constructs measured by each version of the test. Such research approaches might also reveal more about the underlying neural substrates of these different facets of attention. Functional imaging studies exploring the use of these tasks may also prove useful in this regard as well.

Overall, although the OTMT and the WTMT do not appear to be completely analogous paradigms, it appears likely that they both require set-shifting, allowing for this construct to be assessed in patients with physical and visual limitations. In addition, differences in task demands may make them useful in a complimentary manner for establishing differences in attention across sensory modalities where such dissociations are suspected. Finally, this test is available in the public domain, making it readily available to be used by clinicians without any associated cost.

Funding

This research was supported in part by the National Institute of Neurological Disorders and Stroke of the National Institute of Health (K23 NSO49100-05).

Conflict of Interest

None declared.

Acknowledgements

We would like to thank Dr Robert L. Yuspeh for his initial prompting to start this and several related projects prior to his death in 2002. This study was approved by the Institutional Review Boards of Emory University School of Medicine (application #IRB00010651) and Northeast Georgia Medical Center (application #FY01-08-30).

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Articles from Archives of Clinical Neuropsychology are provided here courtesy of Oxford University Press


Sours: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2858599/
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Administration, Scoring, and Interpretation of the Trail Making Test

The Trail Making Test (TMT) is an evaluation tool that is sometimes used to screen for dementia by assessing cognition—the ability to think, reason, and remember. The TMT has two parts that are referred to as the Trail Making Test Part A and the Trail Making Test Part B. The TMT is a timed test and the goal is to complete the tests accurately and as quickly as possible.

Parts of the Test

Part A

The TMT Part A consists of 25 circles on a piece of paper with the numbers 1-25 written randomly in the circles. The test taker’s task is to start with number one and draw a line from that circle to the circle with the number two in it to the circle with the three in it, etc. The person continues to connect the circles in numerical order until they reach number 25.

Part B

The TMT Part B consists of 24 circles on a piece of paper, but rather than all of the circles containing numbers, half of the circles have the numbers 1-12 in them and the other half (12) contain the letters A-L. The person taking the test has the more difficult task of drawing a line from one circle to the next in ascending order; however, he must alternate the circles with numbers in them (1-13) with circles with letters in them (A-L). In other words, he is to connect the circles in order like this: 1-A-2-B-3-C-4-D-5-E and so on.

Test Administration

To administer the test, give the test taker the paper with the circles on it, explain the directions and then demonstrate on a sample page how to complete Part A. Then, tell the person to begin the test and time them. Repeat the directions for Part B, again demonstrating on a sample page how to correctly complete Part B. If the person is unable to complete the test after five minutes, you can discontinue the test.

Test Taker Error

When administering the TMT test, if an error is made, the administrator should tell the person right away and moves the pencil back to the last correct circle.

Scoring

The Trail Making Test is scored by how long it takes to complete the test. If a person makes an error in the test, there’s no change in the score other than that it makes their completion time longer since the person has to go back to the previous circle, thus extending their time.

Acceptable Scores

According to the TMT directions for administration, an average score for the TMT Part A is 29 seconds and a deficient score is greater than 78 seconds.

For the TMT Part B, an average score is 75 seconds and a deficient score is greater than 273 seconds.

The results of the TMT were found to be influenced significantly by age; as people age, they require a longer time to complete the TMT. How many years of education the person received only slightly impacted the results.

Effectiveness of Screening

The TMT measures attention, visual screening ability and processing speed, and is a good measure of overall cognitive functioning.

Part A is a good measure of rote memory. Part B is generally quite sensitive to executive functioning since the test requires multiple abilities to complete it. The TMT Part B has also been suggested as a useful tool to evaluate if a loved one with dementia can safely drive since it requires visual ability, motor functioning, and cognitive processes.

The Oral Trail Making Test

The Trail Making Test can also be administered orally. Rather than giving the person a piece of paper and pen, you can simply ask the person to count from 1 to 25 (Part A). For Part B, the person is asked to verbally recite numbers and letters, alternating between numbers and letters like this: 1-A-2-B-3-C, etc. The oral version of the TMT can be a quick tool to assess cognition when the person physically is unable to perform the written test or in situations like a hospital where illness and fatigue could affect the written results.

Pros

It's free to use, while other tests incur a cost each time they're administered.

It's brief, taking only about five minutes to administer.

Part B has been shown to be a good measure of executive functioning. Tests that only measure memory or word-finding ability may miss impaired executive functioning and thus not detect some types of dementia.

Cons

Older age generally affects performance, even in the absence of any cognitive impairment, but this is not taken into account in the scoring.

Some research found that the TMT would exclude a significant number of capable drivers if it was solely relied upon to evaluate driving ability, while other studies found it missed other impairments that would endanger the driver or those around him.

A Word From Verywell

The trail making test A and B can be a useful tool in assessing cognition. As with any other cognitive test, it's important to remember that the TMT is a screening test and should generally not be used in isolation to detect dementia.

Thanks for your feedback!

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Additional Reading
  • Archives of Clinical Neuropsychology. 19 (2004) 203–214. Trail Making Test A and B: Normative data stratified by age and education.

  • National Highway Traffic Safety Institution. Physician’s Guide to Assessing and Counseling Older Drivers.

  • Papandonatos G, Ott B, Davis J, Barco P, Carr D. Clinical utility of the trail-making test as a predictor of driving performance in older adults. Journal of the American Geriatrics Society. 2015;63(11):2358–64.b doi:10.1111/jgs.13776

  • State of Alaska. Department of Administration. Trail Making Test (TMT) Parts A & B.

Sours: https://www.verywellhealth.com/dementia-screening-tool-the-trail-making-test-98624
TMT-L - Trail Making Test - Langensteinbach Version

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Test making oral trail

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TMT-L - Trail Making Test - Langensteinbach Version

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Now discussing:

He licked, bit, ate. somehow furiously. And, beloved from the 12th, he pressed tightly and repeated, quietly, quietly, you will like ". I did not resist, did not hysteria, did not kick.



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