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Remembering a name: Neuropsychological validity studies and a computer proposal for detection of anomia

LEMBRANDO UM NOME: ESTUDOS DE VALIDADE NEUROPSICOLÓGICA E UMA PROPOSTA COMPUTADORIZADA PARA DETECÇÃO DE ANOMIA

ABSTRACT

There are contradictory results or lack of validity studies concerning the naming function and brain laterality. Although anomia is a frequent symptom of memory impairment, and the most relevant symptom of aphasia, few studies have been conducted to evaluate its validity for detecting patients with left-hemisphere damage (LD), as per the MeSH definition.

Objective:

To validate a paper-and-pencil confrontation naming test (CNT) according to side of brain injury; to select a valid and reliable abbreviated CNT wherein the effect of demographic variables is minimized; and to use the selected CNT to develop a computer-aided confrontation-naming evaluation (CACNE).

Methods:

Control data were obtained from 213 healthy participants (HP) aged 15 to 89 years. A subsample of 106 HP was demographically matched to 39 patients with LD and 40 patients with right-hemisphere damage (RD). Anomia definition and CNT cues were considered for the CACNE.

Results:

Test-retest and inter-rater reliability, internal consistency, and validity for detecting LD were demonstrated. A significant age effect was observed in HP. The CACNE was developed to detect anomia in interaction with environmental interventions.

Conclusion:

The inconsistencies observed in the CNT studies were probably due to the presence of anomia in almost 50% of the RD patients.

Key words:
Alzheimer’s disease; anomia; cognitive impairment; diagnosis; neuropsychological tests; reliability and validity

RESUMO

Existem resultados contraditórios ou falta de estudos de validade relativos à função de nomeação e lateralidade cerebral. Embora a anomia seja um sintoma frequente de comprometimento da memória e o sintoma mais relevante da afasia, poucos estudos foram realizados para avaliar sua validade na detecção de pacientes com lesão no hemisfério esquerdo (LHE) conforme definição do MeSH.

Objetivo:

Validar um teste de nomeação por confrontação (TNC) do tipo papel-e-lápis de acordo com o lado da lesão cerebral. Selecionar um TNC abreviada válida e confiável, na qual o efeito de variáveis ​​demográficas seja minimizado. Usar o TNC selecionado para desenvolver uma avaliação de nomeação por confrontação auxiliada por computador (CACNE).

Métodos:

Os dados de controle foram obtidos de 213 participantes saudáveis ​​(PS) com idades entre 15 e 89 anos. Uma subamostra de 106 PS foi demograficamente pareada com 39 LHE e 40 pacientes com lesão no hemisfério direito (LHD). A definição de anomia e as pistas do TNC foram consideradas para a CACNE.

Resultados:

A confiabilidade teste-reteste e interexaminador, consistência interna e validade para a detecção de LHE foram demonstradas. Um efeito significativo da idade foi observado na PS. CACNE foi desenvolvida para detectar anomia em interação com intervenções ambientais.

Conclusão:

As inconsistências observadas nos estudos do TNC devem-se provavelmente à presença de anomia em quase 50% dos pacientes com LHD.

Palavras-chave:
doença de Alzheimer; anomia; comprometimento cognitivo; diagnóstico; testes neuropsicológicos; confiabilidade e validade

According to the MeSH, anomia is defined as “A language dysfunction characterized by the inability to name people and objects that are correctly perceived. The individual is able to describe the object in question, but cannot provide the name. This condition is associated with lesions of the dominant hemisphere…”.11 Adams RD, Victor M, Ropper AH. Disorders of speech and language. In: Principles of neurology, 6th ed. New York: McGraw-Hill;1997:472-93. [Note: in this study we will only refer to the inability to name objects, not people].11 Adams RD, Victor M, Ropper AH. Disorders of speech and language. In: Principles of neurology, 6th ed. New York: McGraw-Hill;1997:472-93.

Although anomia is considered a common early sign in primary progressive aphasia (PPA)22 Webb WG. Adult Disorders of Language. In: Webb WG, Adler RK (Eds), Neurology for the Speech-Language Pathologist- E-Book (6th Ed.). St. Louis: Mosby/Elsevier; 2016:206-33. and the most relevant symptom of acute aphasia,33 Vigliecca NS. Validity and features of spontaneous speech in acute aphasia as evaluated with the Brief Aphasia Evaluation: is fluent aphasia more severe than nonfluent aphasia? CoDAS. 2019; 31(1):e20180048. it is also considered a common symptom in most types of dementia and non-focal brain disease.22 Webb WG. Adult Disorders of Language. In: Webb WG, Adler RK (Eds), Neurology for the Speech-Language Pathologist- E-Book (6th Ed.). St. Louis: Mosby/Elsevier; 2016:206-33.,44 Budson AE, Solomon PR. Evaluating the Patient with Memory Loss or Dementia. In: Budson AE, Solomon PR (Eds), Memory Loss, Alzheimer's Disease, and Dementia: A practical guide for clinicians, 2nd ed. London: Elsevier; 2016:5-38.

5 Hernandez A, Bates E. Interactive activation in normal and brain-damaged individuals: Can context penetrate the lexical module? In: Hillert D (Ed), Linguistics and Cognitive Neuroscience. (Linguistische Berichte, Special Edition). Wiesbaden: VS Verlag für Sozialwissenschaften / Springer Fachmedien; 1994:145-67.
-66 Casarin FS, Branco L, Pereira N, Kochhann R, Gindri G, Fonseca RP. Rehabilitation of lexical and semantic communicative impairments: An overview of available approaches. Dement Neuropsychol. 2014;8: 266-77. Milder forms of anomia are among the most common complaints in normal aging55 Hernandez A, Bates E. Interactive activation in normal and brain-damaged individuals: Can context penetrate the lexical module? In: Hillert D (Ed), Linguistics and Cognitive Neuroscience. (Linguistische Berichte, Special Edition). Wiesbaden: VS Verlag für Sozialwissenschaften / Springer Fachmedien; 1994:145-67. and, when memory is affected, anomia is one of the most frequent symptoms associated with the underlying syndrome.

Likely based on the above assumptions, and in spite of the definition of anomia, few studies have been conducted to evaluate the validity of this measure for detecting lesions in the left hemisphere. In any case, contradictory findings have been reported when confrontation naming tests (CNT), in particular, have been employed (see reports).77 Busch RM, Frazier TW, Iampietro MC, Chapin JS, Kubu CS. Clinical utility of the Boston Naming Test in predicting ultimate side of surgery in patients with medically intractable temporal lobe epilepsy: A double cross-validation study. Epilepsia. 2009;50:1270-3.

8 Newcombe F, Oldfield RC, Ratcliff GG, Wingfield A. Recognition and naming of object-drawings by men with focal brain wounds. J Neurol Neurosurg Psychiatry. 1971;34:329-40.

9 Hamberger MJ, Tamny TR. Auditory naming and temporal lobe epilepsy. Epilepsy Res. 1999;35:229-43.

10 Cheung RW, Cheung MC, Chan AS. Confrontation naming in Chinese patients with left, right or bilateral brain damage. J Int Neuropsychol Soc. 2004;10:46-53.

11 Miozzo M, Hamberger MJ. Preserved meaning in the context of impaired naming in temporal lobe epilepsy. Neuropsychology. 2015;29:274-81.

12 Trebuchon-Da Fonseca A, Guedj E, Alario FX, Laguitton V, Mundler O, Chauvel P, et al. Brain regions underlying word finding difficulties in temporal lobe epilepsy. Brain. 2009;132(Pt 10):2772-84.
-1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501.

Regarding the influence of demographic variables on these tests, results are also contradictory and highly dependent on participant recruitment.1414 Vigliecca NS, Aleman GP. [Adaptation and validation of a naming test in Spanish speakers. Do demographic variables show the evolutive pattern towards Alzheimer's disease?]. Neurologia. 2007;22:285-91.

Most of the validity studies based on CNT have been carried out in patients with Alzheimer’s disease (AD) and, within this framework, clinical studies indicate that AD disproportionately affects women in terms of both disease prevalence and rate of symptom progression.1515 Fisher DW, Bennett DA, Dong H. Sexual dimorphism in predisposition to Alzheimer's disease. Neurobiol Aging. 2018;70:308-24.,1616 Laws KR, Irvine K, Gale TM. Sex differences in cognitive impairment in Alzheimer's disease. World J Psychiatry. 2016;6:54-65. However, little work has been done to determine the validity of the relationship among gender (or demographic variables in general), aging, and anomia.

Naming tests can be considered language indicators of semantic memory: in visual CNT, the interviewee is usually assessed through pictures, in which he/she must recognize their function or meaning, involving visual knowledge, and retrieve their names, involving verbal knowledge.1717 Vigliecca N, Aleman GP, Jaime MP. [Adaptation and validation of a naming test for Spanish speakers: reliability and discrimination of patients with dementia and unilateral brain lessions]. Neurologia. 2007;22:147-52. Although a correlation between naming and cognitive impairment has been observed,22 Webb WG. Adult Disorders of Language. In: Webb WG, Adler RK (Eds), Neurology for the Speech-Language Pathologist- E-Book (6th Ed.). St. Louis: Mosby/Elsevier; 2016:206-33.

3 Vigliecca NS. Validity and features of spontaneous speech in acute aphasia as evaluated with the Brief Aphasia Evaluation: is fluent aphasia more severe than nonfluent aphasia? CoDAS. 2019; 31(1):e20180048.

4 Budson AE, Solomon PR. Evaluating the Patient with Memory Loss or Dementia. In: Budson AE, Solomon PR (Eds), Memory Loss, Alzheimer's Disease, and Dementia: A practical guide for clinicians, 2nd ed. London: Elsevier; 2016:5-38.

5 Hernandez A, Bates E. Interactive activation in normal and brain-damaged individuals: Can context penetrate the lexical module? In: Hillert D (Ed), Linguistics and Cognitive Neuroscience. (Linguistische Berichte, Special Edition). Wiesbaden: VS Verlag für Sozialwissenschaften / Springer Fachmedien; 1994:145-67.
-66 Casarin FS, Branco L, Pereira N, Kochhann R, Gindri G, Fonseca RP. Rehabilitation of lexical and semantic communicative impairments: An overview of available approaches. Dement Neuropsychol. 2014;8: 266-77.,1717 Vigliecca N, Aleman GP, Jaime MP. [Adaptation and validation of a naming test for Spanish speakers: reliability and discrimination of patients with dementia and unilateral brain lessions]. Neurologia. 2007;22:147-52. questions remains regarding the validity of the CNT total score for the detection of anomia in some disorders which supposedly have this symptom (see papers).99 Hamberger MJ, Tamny TR. Auditory naming and temporal lobe epilepsy. Epilepsy Res. 1999;35:229-43.,1212 Trebuchon-Da Fonseca A, Guedj E, Alario FX, Laguitton V, Mundler O, Chauvel P, et al. Brain regions underlying word finding difficulties in temporal lobe epilepsy. Brain. 2009;132(Pt 10):2772-84.,1818 Willers IF, Feldman ML, Allegri RF. Subclinical naming errors in mild cognitive impairment: A semantic deficit? Dement Neuropsychol. 2008; 2:217-22.

Considering brain laterality and naming, some new perspectives have emerged (focused mainly on specific brain areas or pathologies), and there is now a substantial body of work about this issue.1212 Trebuchon-Da Fonseca A, Guedj E, Alario FX, Laguitton V, Mundler O, Chauvel P, et al. Brain regions underlying word finding difficulties in temporal lobe epilepsy. Brain. 2009;132(Pt 10):2772-84.,1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501.,1919 Marshall CR, Hardy CJD, Volkmer A, Russell LL, Bond RL, Fletcher PD, et al. Primary progressive aphasia: a clinical approach. J Neurol. 2018;265:1474-90.

20 Mesulam MM, Thompson CK, Weintraub S, Rogalski EJ. The Wernicke conundrum and the anatomy of language comprehension in primary progressive aphasia. Brain. 2015;138(Pt 8):2423-37.

21 Skipper-Kallal LM, Lacey EH, Xing S, Turkeltaub PE. Functional activation independently contributes to naming ability and relates to lesion site in post-stroke aphasia. Hum Brain Mapp. 2017;38:2051-66.

22 Skipper-Kallal LM, Lacey EH, Xing S, Turkeltaub PE. Right Hemisphere Remapping of Naming Functions Depends on Lesion Size and Location in Poststroke Aphasia. Neural Plast. 2017;2017:8740353.

23 Unadkat P, Fumagalli L, Rigolo L, Vangel MG, Young GS, Huang R, et al. Functional MRI Task Comparison for Language Mapping in Neurosurgical Patients. J Neuroimaging. 2019;29:348-56.

24 Ni B, Wang X, Yu T, Wu R, Wang B. Pre-surgical Language Mapping in Epilepsy: Using fMRI in Chinese-Speaking Patients. Front Hum Neurosci. 2019;13:183.

25 Stowe LA, Haverkort M, Zwarts F. Rethinking the neurological basis of language. Lingua 2005;115:997-1042.

26 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18

27 Trébuchon-Da Fonseca A, Bénar CG, Bartoloméi F, Régis J, Démonet JF, Chauvel P, Liégeois-Chauvel C. Electrophysiological study of the basal temporal language area: a convergence zone between language perception and production networks. Clin Neurophysiol. 2009;120:
-2828 Rice GE, Lambon Ralph MA, Hoffman P. The roles of the left vs. right anterior temporal lobes in conceptual knowledge: an ALE meta-analysis of 97 functional neuroimaging studies. Cereb Cortex. 2015. 25:4374-91. Despite using a different approach to the one employed in the present study, these perspectives aid understanding and encourage validity studies. For example, there are a number of areas involved in aspects of language comprehension and production in both hemispheres and neuroimaging results suggest that various cognitive tasks that make use of similar representations or processes frequently share component sub-functions with other tasks including non-linguistic ones.2525 Stowe LA, Haverkort M, Zwarts F. Rethinking the neurological basis of language. Lingua 2005;115:997-1042. The interaction between different inputs and outputs,1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501. and the dissociation between left brain areas for lexical retrieval and right brain areas for visual recognition,2626 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18 have been reported in these perspectives.

Semantic memory has been linked to the anterior temporal lobes (ATLs) in both hemispheres, in patients with temporal lobe epilepsy (TLE).1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501. Alternatively, semantic verbal memory in particular, has also been linked to the inferior part of the left temporal lobe1212 Trebuchon-Da Fonseca A, Guedj E, Alario FX, Laguitton V, Mundler O, Chauvel P, et al. Brain regions underlying word finding difficulties in temporal lobe epilepsy. Brain. 2009;132(Pt 10):2772-84.,2727 Trébuchon-Da Fonseca A, Bénar CG, Bartoloméi F, Régis J, Démonet JF, Chauvel P, Liégeois-Chauvel C. Electrophysiological study of the basal temporal language area: a convergence zone between language perception and production networks. Clin Neurophysiol. 2009;120: in patients with TLE, as well as to the tip of the left ATL in patients with PPA.2626 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18

A previous fMRI meta-analysis showed that visual semantic concept tasks exhibit strong bilateral activation across the ATLs in healthy participants.2828 Rice GE, Lambon Ralph MA, Hoffman P. The roles of the left vs. right anterior temporal lobes in conceptual knowledge: an ALE meta-analysis of 97 functional neuroimaging studies. Cereb Cortex. 2015. 25:4374-91. In addition, the speech production system in the prefrontal cortex has been shown to be highly left lateralized in neuroimaging studies, i.e. the left ATL seems to be more strongly connected to regions involved in speech production than the right, and thus is likely to assume some specialization for naming tasks.1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501. Miozzo and Hamberger,1111 Miozzo M, Hamberger MJ. Preserved meaning in the context of impaired naming in temporal lobe epilepsy. Neuropsychology. 2015;29:274-81. suggested that when picture meaning is preserved, the probable cause of word-finding difficulty in the left TLE relates to processes that involve lexical/phonological information.

These views are relevant for the present study because the current CNT deals with both linguistic and non-linguistic stimuli, as well as with the concept of semantic cognition.

The present study involves a CNT which was initially based on that of Oldfield and Wingfield,2929 Oldfield RC, Wingfield A. Response latencies in naming objects. Quart. J. Exp. Psychol 1965;17:273- 81. which had validity studies associated with lesions of the verbal dominant hemisphere,88 Newcombe F, Oldfield RC, Ratcliff GG, Wingfield A. Recognition and naming of object-drawings by men with focal brain wounds. J Neurol Neurosurg Psychiatry. 1971;34:329-40. but their results were obtained from a sample of men only. In a preceding study with this test and a sample of healthy participants (HP) aged 9 to 90 years,1414 Vigliecca NS, Aleman GP. [Adaptation and validation of a naming test in Spanish speakers. Do demographic variables show the evolutive pattern towards Alzheimer's disease?]. Neurologia. 2007;22:285-91. women of greater age and lower education level were mainly affected in their naming performance. Although these results are in agreement with findings observed in AD, further study is necessary to ascertain whether they were associated with some artifactual effect, such as the sample of participants or items selected or, considering that AD involves both sides of the brain, the contribution of one of these sides in particular. The study of unilateral focal brain lesions may help elucidate this issue.

Given the lack of validity studies and presence of contradictory results with the naming function regarding brain laterality, the main objective of the present study was to validate a CNT according to the side of brain injury.

Since the present study is part of a bigger research project developing brief, efficient and/or easy-to-apply neuropsychological techniques, the complementary objectives of the present study were:

To abbreviate the initial CNT from 60 to 30 items by developing two parallel forms from the test and selecting one of them.

To verify the internal consistency and reliability of the abbreviated scales and how they were influenced by demographic variables

To verify the validity of the abbreviated scales to discriminate patients with left hemisphere damage and, if possible, select a valid and reliable abbreviated scale wherein the effect of demographic variables is minimized.

To use the selected abbreviated scale to develop a computer-aided confrontation-naming evaluation (CACNE).

METHODS

Material

We used the CNT from the battery of Neuropsychological Tests Abbreviated and Adapted to Spanish Speakers (NTAASS).3030 Vigliecca NS, Báez S. Verbal Neuropsychological Functions in Aphasia: An Integrative Model. J Psycholinguist Res. 2015;44:715-32.

31 Vigliecca NS. Relationship between the caregiver's report on the patient's spontaneous-speech and the Brief Aphasia Evaluation. Codas. 2017;29(5):e20170035.

32 Vigliecca NS. Neurocognitive implications of tangential speech in patients with focal brain damage. In: D'Onofrio G, Sancarlo D, Greco A (Eds), Gerontology. London: InTechOpen; 2018:191-220.
-3333 Vigliecca NS. [Neuropsychological tests abbreviated and adapted to Spanish speakers: review of previous findings and validity studies for the discrimination of patients with anterior vs. posterior lesions]. Rev Neurol. 2004;39:205-12. This paper-and pencil-CNT, with black-and-white drawings, consists of 60 items, of which 36 were translated and adapted from the Oldfield and Wingfield’s scale.2929 Oldfield RC, Wingfield A. Response latencies in naming objects. Quart. J. Exp. Psychol 1965;17:273- 81.

Since in a previous study (using 45 items instead of the original 36), a gender effect was observed which was significant from the age of 60 years for any level of education,1414 Vigliecca NS, Aleman GP. [Adaptation and validation of a naming test in Spanish speakers. Do demographic variables show the evolutive pattern towards Alzheimer's disease?]. Neurologia. 2007;22:285-91. we predominantly recruited participants in this age range for the present study. Also, the number of items was increased from 45 to 60 to create two abbreviated and parallel forms of 30 items, and select one of these forms to develop a simpler evaluation of anomia. The last 15 items of the extended scale were designed to be as neutral as possible to the effect of demographic variables (e.g.to avoid an unintentional biased selection of items favoring males).1414 Vigliecca NS, Aleman GP. [Adaptation and validation of a naming test in Spanish speakers. Do demographic variables show the evolutive pattern towards Alzheimer's disease?]. Neurologia. 2007;22:285-91.,3434 Randolph C, Lansing AE, Ivnik RJ, Cullum CM, Hermann BP. Determinants of confrontation naming performance. Arch Clin Neuropsychol. 1999;14:489-96.

Since the overlapping effects of stimulus characteristics (frequency, acquisition age, decline age, etc.) are ultimately related to accuracy (i.e. item difficulty), we first used face validity to avoid, e.g. the selection of items favoring males, and then the effect of each item on the scales was verified case-by-case, according to the demographic variables for this particular sample and context. We also added items of lower frequency, such as geometric figures, with the intention of achieving a wide range of difficulty. Regarding the age at acquisition, it is worth noting that picture naming is a current approach to establish this word property, which relates to familiarity, frequency of use, etc. (see articles3535 Barbarotto R, Laiacona M, Capitani E. Objective versus estimated age of wordacquisition: a study of 202 Italian children. Behav Res Methods. 2005;37:644-50.,3636 Izura C, Ellis AW. Age of acquisition effects in word recognition and production in first and second languages. Psicológica. 2002; 23:245-81. and below the procedure for parallel forms, where the item-difficulty approach was also used).

We used the Oldfield and Wingfield’s scale because the battery of the NTAASS3030 Vigliecca NS, Báez S. Verbal Neuropsychological Functions in Aphasia: An Integrative Model. J Psycholinguist Res. 2015;44:715-32.

31 Vigliecca NS. Relationship between the caregiver's report on the patient's spontaneous-speech and the Brief Aphasia Evaluation. Codas. 2017;29(5):e20170035.

32 Vigliecca NS. Neurocognitive implications of tangential speech in patients with focal brain damage. In: D'Onofrio G, Sancarlo D, Greco A (Eds), Gerontology. London: InTechOpen; 2018:191-220.
-3333 Vigliecca NS. [Neuropsychological tests abbreviated and adapted to Spanish speakers: review of previous findings and validity studies for the discrimination of patients with anterior vs. posterior lesions]. Rev Neurol. 2004;39:205-12. was developed in around 1998 when validity studies were even scarcer. Thus, this CNT was selected in view of its validity studies regarding both lesion side88 Newcombe F, Oldfield RC, Ratcliff GG, Wingfield A. Recognition and naming of object-drawings by men with focal brain wounds. J Neurol Neurosurg Psychiatry. 1971;34:329-40. and the relationship between item frequency and response speed.2929 Oldfield RC, Wingfield A. Response latencies in naming objects. Quart. J. Exp. Psychol 1965;17:273- 81.,3434 Randolph C, Lansing AE, Ivnik RJ, Cullum CM, Hermann BP. Determinants of confrontation naming performance. Arch Clin Neuropsychol. 1999;14:489-96. Moreover, this test was taken as a reference to develop other naming tests. Regarding our research resources, we tried to improve this test in particular, because of our previous experience with its content and the material collected.

Participants and procedures

Data were obtained from a sample of 292 Argentine right-handed volunteers, who were all native Spanish speakers.

Control data were obtained from 213 healthy participants (HP), who were community-dwellers, without any known neurological or psychiatric disease. The recruitment method is further described elsewhere.3030 Vigliecca NS, Báez S. Verbal Neuropsychological Functions in Aphasia: An Integrative Model. J Psycholinguist Res. 2015;44:715-32.,3131 Vigliecca NS. Relationship between the caregiver's report on the patient's spontaneous-speech and the Brief Aphasia Evaluation. Codas. 2017;29(5):e20170035.,3737 Vigliecca NS, Peñalva MC, Molina SC, Voos JA. Brief aphasia evaluation (minimum verbal performance): concurrent and conceptual validity study in patients with unilateral cerebral lesions. Brain Inj. 2011;25:394-400.

38 Vigliecca NS, Penalva MC, Castillo JA, Molina SC, Voos JA, Ortiz MM, et al. Brief Aphasia Evaluation (minimum verbal performance): psychometric data in healthy participants from Argentina. J Neurosci Behav Health. 2011;3:16-26.

39 Vigliecca NS, Aleman GP. A novel neuropsychological assessment to discriminate between ischemic and nonischemic dementia. J Pharmacol Toxicol Methods. 2010;61:38-43.
-4040 Vigliecca NS, Baez S. Screening executive function and global cognition with the Nine-Card Sorting Test: healthy participant studies and ageing implications. Psychogeriatrics. 2015;15:163-70.

Clinical data were obtained from 79 consecutive preoperative inpatients with focal and unilateral cerebral lesions. The sample was recruited from the Neurological and Neurosurgery Service of the Cordoba Hospital, a public hospital for adults. Lesions were confirmed by CT scan and/or MRI techniques, as well as by complementary diagnostic studies. None of the patients suffered from any other (previous or simultaneous) associated neurological disease.

We excluded patients who were unable to understand the test instructions or who had visual agnosia, hemianopia, hemineglect, or sensory or motor difficulties which might affect visual perception. We also excluded patients who answered less than 50% of the first ten pictures of the initial scale correctly,1414 Vigliecca NS, Aleman GP. [Adaptation and validation of a naming test in Spanish speakers. Do demographic variables show the evolutive pattern towards Alzheimer's disease?]. Neurologia. 2007;22:285-91. or who had a severe impairment in describing the pictures when anomia was present (i.e. patients were excluded if they had unintelligible or severely distorted expressions on more than 15% of all pictures).

The initial sample consisted of 83 patients, from which one patient was excluded for probable visual agnosia, another for having hemianopia with hemineglect, a third one because of difficulty understanding the test instructions and answering less than 50% of the first ten pictures of the initial scale correctly; finally, another patient was excluded for producing severely distorted descriptions on more than nine pictures of the initial scale.

We excluded patients with visual agnosia or with visual-perception difficulties, because we sought to assess genuine word retrieval failures or anomic states.1212 Trebuchon-Da Fonseca A, Guedj E, Alario FX, Laguitton V, Mundler O, Chauvel P, et al. Brain regions underlying word finding difficulties in temporal lobe epilepsy. Brain. 2009;132(Pt 10):2772-84. As we assessed word retrieval in the spontaneous performance of the CNT, which was the first participants’ response, if participants answered with only a description of the object, this response was considered wrong (see statistical analysis below and also the CACNE for an analysis of this failure using an approach in which the description of the object is computed using visual and auditory inputs).

As we needed interviewees to recognize CNT pictures, when the presence of conceptual blurring was suspected (i.e. disruptions in single-word association and comprehension2626 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18 or in visual-perception) we administered the optional card from the Brief Aphasia Evaluation.33 Vigliecca NS. Validity and features of spontaneous speech in acute aphasia as evaluated with the Brief Aphasia Evaluation: is fluent aphasia more severe than nonfluent aphasia? CoDAS. 2019; 31(1):e20180048.,3030 Vigliecca NS, Báez S. Verbal Neuropsychological Functions in Aphasia: An Integrative Model. J Psycholinguist Res. 2015;44:715-32.,3131 Vigliecca NS. Relationship between the caregiver's report on the patient's spontaneous-speech and the Brief Aphasia Evaluation. Codas. 2017;29(5):e20170035.,3737 Vigliecca NS, Peñalva MC, Molina SC, Voos JA. Brief aphasia evaluation (minimum verbal performance): concurrent and conceptual validity study in patients with unilateral cerebral lesions. Brain Inj. 2011;25:394-400.,3838 Vigliecca NS, Penalva MC, Castillo JA, Molina SC, Voos JA, Ortiz MM, et al. Brief Aphasia Evaluation (minimum verbal performance): psychometric data in healthy participants from Argentina. J Neurosci Behav Health. 2011;3:16-26. In this card, not only can real objects be matched with pictures of the same objects (picture-picture recognition), but also interviewers can say the words of the pictures on the card while interviewees point at the corresponding picture (word-picture recognition). Interestingly, this card includes pictures of the same family of objects (e.g. pen, pencil; matches, lighter; car key, house key) and/or semantically associated representations (e.g. remote control for car key; school accessories for pen and pencil, etc.), both of which could produce semantic interference.2626 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18

Regarding clinical intervening variables, no significant differences were observed between patients with left and right-hemisphere damage (LD and RD, respectively) for disease duration (mean months: LD: 33.44±82.72, RD: 34.05±84.99 (F(1,77)=0.00, p=0.97); risk factors for cognitive impairment (mean number: LD: 1.28±1.12, RD: 1.42±1.17 (F(1,77)=0.30, p=0.58); site of lesion (frequency: anterior (frontal): LD=9, RD=13, posterior (temporal, parietal or occipital): LD=19, RD=19, antero-posterior: LD=5, RD=5, and subcortical: LD=6, RD=3 (Chi2=1.71; df: 3; p=0.63)); and type of lesion (see Table 1 for specific types, and for the difference between malignant tumors and rest of lesions, which numbered 23 for LD and 26 for RD (Chi2=0.30; df: 1; p=0.58)); no significant differences were found when specific lobe lesions were also compared (results available on request).

Table 1
Frequency of focal brain lesions by type and patient group.

For entry to this study, all participants (or their caregivers) signed the informed consent form. The pertinent institutional review board approved the project and the study, which was carried out in accordance with the ethical standards established in the Declaration of Helsinki.4141 World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310:2191-4.

We developed the parallel forms from the initial CNT and verified the internal consistency of these abbreviated scales, along with the effect of demographic variables in a sample of 213 HP (see Table 2) aged 15 to 89 (mean±SD: 54.96±19.38) years.

Table 2
HP - sample demographic data.

From this total sample, a sub group of 37 participants was re-evaluated for test-retest and inter-rater reliability. In this subsample of 17 to 84-year-olds (45.41±20.66), 62% (N=23) of the participants were females and 38% (14) males; 40% (15) had first level education, 38% (14) second level and 22% (8) third level.

In this study, all the participants, either HP or patients, received the original 60 items (the initial scale) at the time of testing in any step of the research. With the data provided by the participants, we then developed the abbreviated scales by analyzing and modeling two parallel forms and selecting one of them. Subsequently, the CACNE was developed using the selected scale.

We developed the two parallel forms of the initial scale (i.e., form 1 (F1) and form 2 (F2)) by verifying that they were comparable in terms of difficulty and relationship with demographic variables. The parallel forms were selected by considering the items of the initial scale which contributed most to attenuate both demographic differences in general, and the effect of gender and its interactions in particular.1414 Vigliecca NS, Aleman GP. [Adaptation and validation of a naming test in Spanish speakers. Do demographic variables show the evolutive pattern towards Alzheimer's disease?]. Neurologia. 2007;22:285-91. Items with these properties were distributed between the scales in an effort to achieve parallelism and the study objectives. The selection of one of the scales was finally based on the fulfillment of most of the criteria that arose from the different analyses of this study (including studies of demographic variables, validity and reliability), with particular emphasis on the criterion for side of brain lesion (see below).

For test-retest reliability, at least 30 days of inter-test interval was established, with a maximum of 120 days. For inter-rater reliability, two trained interviewers acting independently evaluated the spontaneous (uncued) performance of the same interviewee. Specifically, the second rater interpreted the first rater’s written records of the administration protocol, in which multiple variables were registered.

A subsample of HP was matched with LD and RD, according to demographic variables (see Table 3). With these subjects we determined the validity of the scales for discriminating between non-LD (RD and HP) and LD on the one hand, and among LD, RD and HP on the other hand.

Table 3
Demographic data for the three matched samples.

In developing the CACNE, we took into account the definition of anomia11 Adams RD, Victor M, Ropper AH. Disorders of speech and language. In: Principles of neurology, 6th ed. New York: McGraw-Hill;1997:472-93. and the cues usually implemented to help remedy anomia. To this end, previous findings about CNT were reviewed,4242 Kaplan E, Goodglass H, Weintraub S. Test de vocabulario de Boston. In: Goodglass H, Kaplan E (Eds), Evaluación de la afasia y de trastornos relacionados, 2nd ed. Adaptación española. Madrid: Editorial Médica Panamericana; 1996:186-90.

43 Kohnert KJ, Hernandez AE, Bates E. Bilingual performance on the Boston naming test: preliminary norms in Spanish and English. Brain Lang. 1998;65:422-40.

44 Lopez MN, Arias GP, Hunter MA, Charter RA, Scott RR. Boston Naming Test: problems with administration and scoring. Psychol Rep. 2003;92:468-72.

45 Meteyard L, Bose A. What Does a Cue Do? Comparing Phonological and Semantic Cues for Picture Naming in Aphasia. J Speech Lang Hear Res. 2018;61:658-74.
-4646 Harry A, Crowe SF. Is the Boston Naming Test still fit for purpose? Clin Neuropsychol. 2014;28:486-504. particularly those regarding the type of performance errors (see articles).4747 McKinnon ET, Fridriksson J, Basilakos A, Hickok G, Hillis AE, Spampinato MV, et al. Types of naming errors in chronic post-stroke aphasia are dissociated by dual stream axonal loss. Sci Rep. 2018;8:14352.

48 Lin CY, Chen TB, Lin KN, Yeh YC, Chen WT, Wang KS, et al. Confrontation naming errors in Alzheimer's disease. Dement Geriatr Cogn Disord. 2014;37(1-2):86-94.
-4949 Ellis AW, Kay J, Frankling S. Anomia: Differentiating Between Semantic and Phonological Deficits. In: Margolin DI (Ed), Cognitive Neuropsychology in Clinical Practice. New York, NY: Oxford University Press, Inc.; 1992:207-28. We make available the CACNE as a free CNT to be tested using researchers’ particular samples and objectives.

Statistical analysis

The correlation between the two parallel forms, and of these forms with the initial CNT, was analyzed by the Pearson correlation coefficient (r). The internal consistency for either F1 or F2 was analyzed by Cronbach’s alpha coefficient, while the difference between the two forms was explored by - Student’s t-test for dependent samples.

A gender × age × education ANOVA was carried out to determine the effect of demographic variables on the spontaneous performance of CNT, which was the number of correct responses (correct=1, error=0) on any of the three scales. Age was recoded into five levels (see Table 2); education was recoded into two levels (first level versus higher levels) to avoid the presence of empty cells and/or lack of variance, particularly for the third level of education.

Test-retest and inter-rater reliability indices were analyzed by the intra-class correlation coefficient (ICC). Differences between test and retest and differences between both raters were analyzed by Student’s t-test for dependent samples.

When HP were compared with LD and RD for demographics, data were analyzed by ANOVA for years of age or by Chi2 for education and gender.

Receiver Operating Characteristic (ROC) curve analysis was performed to determine the sensitivity and specificity of the scales for differentiating non-LD and LD. The cut-off point that produced a more uniform frequency distribution between sensitivity and specificity was considered the most satisfactory. When this was not possible, or when one of the frequencies was <70% (see below), sensitivity was prioritized. In order to select optimal cut-off points based on several criteria, ROC curve analysis was done with the “Statistica” computer program, using neural networks and a linear model.5050 StatSoft, Inc, Manual. STATISTICA: Data analysis software system (version 7). Tulsa, OK: StatSoft, 2004.

The validity of the scales for discriminating among LD, RD and HP was verified by cross-tabulation and Chi2, using the selected cut-off points.

In general, indices ≥70% (correlation, reliability, validity, etc.) were considered acceptable.

RESULTS

The r between F1 and F2 was 0.81 and between either of these forms and the initial CNT was 0.95 (N=213). The Cronbach’s alpha coefficient with 29 items in each scale (excluding items with zero variance) was 0.77 for F1 and 0.79 for F2. The difference between F1 and F2 was not significant (t=0.36, df: 212, p<0.72; F1: 24.10±3.65, F2: 24.15±3.70).

The three-way ANOVA for demographic variables indicated a significant main effect for age in both forms (F1: F(4,193)=2.96, p=0.02 [see Figure 1]; F2: F(4,193)=2.70, p=0.03) and non-significant effects for the rest of the factors or interactions between factors in either of the forms (F1: gender, education, and gender × education (all F(1,193)≤2.07, p≥0.15); gender × age, age × education, and gender × age × education (all F(4,193)≤1.87, p≥0,12)); (F2: gender, education, and gender × education (all F(1,193)≤2.36, p≥0.13); gender × age, age × education, and gender × age × education (all F(4,193)≤1.99, p≥0,10)). [Results for the initial CNT were very similar].

Figure 1
Age effect in a gender × age × education ANOVA on the sponta neous performance of the abbreviated scale (form 1). LS means effective hypothesis decomposition. Vertical bars denote 0.95 confidence intervals.

Just for descriptive purposes, and considering the three CNT, Bonferroni’s post-hoc test indicated that comparisons between age ranges were significant only for women aged 30-44 years with second level of education, who were the participants with the best performance, versus women aged 60-74 and 75-90 years with first level of education, who were the participants with the worst performance.

We observed a CCI of 0.83 for test-retest and inter-rater reliability for both F1 and F2, without significant differences between the two measures. Indices for test-retest reliability (with an inter-test interval of 61.59±27.85 days): F1: t=1.64, df: 36, p<0.12, Test: 24.76±3.27, Retest: 25.27±3.62; F2: t=1.83, df: 36, p<0.08, Test: 24.62±3.21, Retest: 25.22±3.79. Indices for inter-rater reliability: F1: t=0.80, df: 36, p<0.43, Rater 1: 24.76±3.27, Rater 2: 24.51±3.31; F2: t = 0.46, df: 36, p<0.65, Rater 1: 24.62±3.21, Rater 2: 24.49±3.09.

The optimal cut-off points for the scales are shown in Table 4 and the ROC curves for the abbreviated scales are depicted in Figure 2. The sensitivity of the initial scale to differentiate non-LD vs. LD was 77% (30/39 for LD) and the specificity was 78% (114/146 for non-LD). The sensitivity of F1 was 74% (29/39 for LD) and the specificity 75% (110/146 for non-LD). F2 had better sensitivity, but lower specificity regarding non-LD because 85% of LD (33/39) scored ≤ the cut-off point, whereas 66% (96/146) scored> the cut-off point. It was not possible to find a model with a more uniform frequency distribution between sensitivity and specificity for F2.

Table 4
Frequency by group according to cut-off points of ROC curves in spontaneous-performance total-score of the three scales.

In the matched samples, descriptive data of the total scores for the initial scale, as well as for F1 and F2 were 45.20±8.61; 22.72±4.55; and 22.48±4.37, respectively. The difference between F1 and F2 was not significant (t=1.41, df: 184, p<0.17).

Figure 2
Receiver Operating Characteristic (ROC) curves for the abbreviated scales: Form 1 (F1) and Form 2 (F2). F1 was selected for a computer-aided confrontation-naming evaluation (CACNE). Note: the area under the ROC curve for the initial scale from which F1 and F2 were modeled was 0.839.

Table 4 shows the frequency distribution according to the cut-off points of the ROC curves. The difference between LD and HP was more relevant, since most LD scored ≤ the cut-off point, whereas most HP scored > the cut-off point. By contrast, the frequency distribution for RD was more uniform since most of these patients scored between 40% and 60%of the cut-off point.

With the exception of maybe internal consistency, F1 was selected for the CACNE in view of fulfilling most of the criteria required for this purpose.

CACNE introduction, instructions, correct words, and translation (from Spanish to English) are shown in Appendix 1 APPENDIX 1 CACNE sections: introduction, instructions, translation, and list of correct words. A) INTRODUCTIONIn the present study, picture recognition matched with its corresponding name is considered a language indicator of semantic memory. As a result, we believed that spontaneous performance and the semantically cued performance should not be given the same score28-30 since, in the former case, only a visual stimulus is enough to trigger the entire process of correctly remembering the name while, in the second case, the interviewer's help is required to favor semantic (visual) recognition. Instead, we intended the CACNE to have three cycles scored differently according to the interviewer's interventions (i.e. the more attempts in remembering a name, the more performance facilitation, thus the lower the score (see below)).Moreover, from the initial 30 items, and during cued performance, each interviewee has his/her own list of difficult items visually presented with auditory cues. We propose the use of repetition priming to gradually select the items with anomia as a function of their difficulty to be remembered by each interviewee. Specifically, in the first cycle we evaluate spontaneous performance and, in the second and third cycles, we evaluate cued performance by only showing those stimuli that could not be remembered in the previous cycles. The procedure was designed based on the following premise: any previous effort that a person makes to place a perceived object into its corresponding semantic and phonological family of representations activates a memory network, which will subsequently facilitate the recall of the object name. Therefore, a semantic or phonemic cue, along with a new presentation of the object, will act like repetition (direct) priming because the same object is presented in complementary ways.Hamberger9 has suggested that the auditory presentation of the stimulus is more sensitive than the visual one for detecting anomia. Additionally, in the process of naming, which implicitly includes the process of language evolution,3 the phonemic/phonological information is considered to be the second step after picture recognition or semantic retrieval.11,31,36 Therefore, in the CACNE, after verifying and scoring with the maximum value spontaneous recall, using just visual stimuli, we successively used the semantic and phonemic cues, with decreasing scores, as complementary auditory presentations. Since the phonemic cue not only induces the recall of the name more explicitly in language terms, but has also proven to be more effective than the semantic cue to improve naming accuracy,31 then in the CACNE, phonemic cued performance is scored with the minimum value.[Note: From now on, we indistinctly use the terms 'phonemic' and 'phonetic' as well as the terms 'cues' and 'helps'.]Anomia can be inferred in the CACNE from the successive results described in each cycle, including the number of correct responses and the type of errors according to the provided cues or helps. The scores in each cycle reflect both the interviewee's accuracy and all the interviewer's interventions, together with their respective weights (the effect of priming can be inferred from the results obtained in the second and third cycles).Consequently, in one session we may observe not only if the person failed to remember a name, but also if some of the processes the brain uses to successively retrieve that name were successful; i.e., if the interviewee recalls the name after anomia, this can be taken as an indication that the name was in the interviewee's repertory and that the link between the picture and the name had probably been weakened for the reasons (or results) explained in the evaluation. Considering the limiting difficulties that may be found in public hospitals, the CACNE was designed to be administered offline, using Flash Player. B) INSTRUCTIONSb1) Instructions for the InterviewerThere are three cycles in the evaluation. Each cycle is specified in the title and in the upper left corner of the screen with a red circle, which is highlighted within the other two cycles. During the first cycle, the interviewer must register, in the bottom left corner of the screen, either if the answer was right or, otherwise, the type of cue needed in the next cycle as a function of the type of error. Specifically: in this corner there are four options, the right answer and three types of cues or helps, which have to be administered in the next cycles according to the following criteria:a) If the interviewee did not visually recognize the picture (if he/she said: "I do not know" or if the picture was misidentified or incorrectly described), a semantic cue should be offered in the second cycle, by briefly describing the object in simple words; b) If the interviewee said a similar name, i.e. a name of the same family of objects or a name with similar pronunciation, but not the exact name, a better answer should be requested in the second cycle, up to a maximum of two requests; c) If the interviewee did recognize the picture by correctly describing its meaning, but the name was not remembered (anomia), a phonetic cue should be offered in the third cycle, up to a maximum of two requests if the name has more than two syllables (the first request by saying the initial sound of the name, the second request by saying the two initial sounds). This last cue will also be offered if the interviewee failed with the previous cues. [Note: Each type of selected cue is automatically recognized by the program to be administered in the corresponding cycle]. In the second and third cycles, the interviewer will only register if the final answer was right or wrong. Additional Comments:1) Interviewee's self-corrections are not counted as errors.2) Wrong answers, which are registered verbatim in the three cycles, include picture descriptions.3) Words or expressions that are distorted or not related to the picture represent wrong answers or descriptions; the offered help will depend on the cycle in which they occur.4) Errors in the third cycle are taken as indicators that, under the current conditions, those names are unknown.5) When the last picture of each cycle has been administered, interviewers can examine the "Partial Results" in the first and second cycles, or the "Final Results" (including the partial ones) in the third cycle.6) Interviewers should never press 'New Test' unless they want to start all over again from the first picture.7) Although each researcher will have prepared in advance his/her own list of semantic cues according to the particular sample recruited, when the partial results are observed, interviewers will have the opportunity to think about the cues for the wrong answers because the time record stops at that stage.8) The list of correct names shown in part (d) of this table is tentative, based on our experience, but researchers will be able to adapt it to their language or cultures, including the corresponding cues. b2) Instructions for the IntervieweeInitial or Spontaneous PerformanceI am going to show you some pictures and I want you to tell me their names. If you cannot say the exact name, give your best answer or say "I don't know" to go to the next item. Later you will be able to tell me what you know about that object.What's this?Cued PerformanceNow you can tell me the name or what you know about those pictures that you couldn't remember the name of before. I am going to help you.What's this? C) TRANSLATION OF THE INSTRUCTIONS AND TERMS USED IN CACNE[Note: Spanish terms in italic, English terms in bold. see Fig. 2]Evaluación de Nombres, por Confrontación, Asistida por Computadora (ENCAC)Computer-Aided Confrontation-Naming Evaluation (CACNE) Test de denominación - Ciclo 1: Desempeño espontáneo/Naming test - Cycle 1: Spontaneous performance Tenga la lista de palabras correctas / Have the list of correct wordsEscriba textualmente las palabras erradas / Write the wrong words verbatim [Confirme las actividades para continuar... / Confirm the activities to continue...] 1: Desempeño espontáneo / 1: Spontaneous performance2: Desempeño con 1º ayuda / 2: Performance with 1st help3: Desempeño con 2º ayuda / 3: Performance with 2nd help Bien / GoodSemántica / SemanticMejor Resp./ Better AnswerFonética / Phonetic [Seleccione una opción... / Choose an option...] Nuevo Test / New Test[¿Desea interrumpir el test en curso? SI NO/Do you want to interrupt the test in progress? YES NO] Test de denominación / Naming testNuevo ciclo / New cycle Test de denominación - Ciclo 2: Desempeño con 1º ayuda /Naming test - Cycle 2: Performance with 1st help Ofrezca una ayuda semántica / Offer a semantic helpPida una mejor respuesta / Ask for a better answer Test de denominación - Ciclo 3: Desempeño con 2º ayuda /Naming test - Cycle 3: Performance with 2nd help Ofrezca una ayuda fonética / Offer a phonetic help Resultados Parciales / Partial ResultsResultados Finales / Final Results Test de denominación - Resultados Finales/Naming test - Final Results Tiempo Empleado: minutos (mm) y segundos (ss) /Completion Time: minutes (mm) and seconds (ss) Puntaje Total / Total Score Ciclo 1: Desempeño espontáneo / Cycle 1: Spontaneous performanceTiempo (mm:ss) / Time (mm:ss)Figuras Puntaje Correctas Semántica Mejor Resp. Fonética /Figures Score Correct Semantic Better Answer Phonetic Ciclo 2: Desempeño con ayuda / Cycle 2: Performance with helpTiempo (mm:ss) / Time (mm:ss)Figuras Puntaje Correctas Semánticas Correctas Mejor Resp. ErróneasFigures Score Correct Semantic Correct Better Answer Wrong Ciclo 3: Desempeño con ayuda / Cycle 3: Performance with helpTiempo (mm:ss) / Time (mm:ss)Figuras Puntaje Correctas ErróneasFigures Score Correct Wrong D) LIST OF CORRECT WORDS IN OUR SAMPLE OF SPANISH SPEAKERS AND TRANSLATION[Note: Items are in order of difficulty] Spanish1) reloj2) teléfono3) libro4) cama5) silla6) sobre (carta)7) rastrillo8) piano9) molino -de viento-10) cigarrillo11) lámpara (velador)12) helicóptero13) cepillo de dientes14) pulpo15) jeringa (inyección)16) dado17) cafetera18) grúa (guinche)19) caballete20) candelabro (candelero)21) verja (cerca/o)22) matafuego (extintor, extinguidor)23) guadaña24) cono25) puntilla (guarda)26) clave de sol27) yunque (bigornia)28) cilindro29) gaita30) diapasón English1) clock2) telephone3) book4) bed5) chair6) envelope (letter)7) rake8) piano9) windmill10) cigarette11) lamp12) helicopter13) toothbrush14) octopus15) syringe (injection)16) die (dice)17) coffee pot18) crane19) sawhorse (trestle)20) candelabrum (candlestick)21) fence22) fire extinguisher23) scythe24) cone25) lace (lace edging)26) treble clef27) anvil28) cylinder29) bagpipe30) tuning fork . To obtain CACNE material and procedure send an e-mail to nsvigliecca@gmail.com.

DISCUSSION

In the present study, we validated three CNT versions, according to side of brain injury. Specifically, we abbreviated the initial CNT from 60 to 30 items, by developing two parallel forms from this test and then selecting one of them. We verified the reliability and validity of the selected CNT and how it was influenced by demographic variables. By evaluating score on spontaneous performance, we demonstrated test-retest and inter-rater reliability, internal consistency, as well as its validity for detecting patients with lesions of the dominant hemisphere. Only a significant effect of age in the present sample of HP was observed in the selected CNT. Results were similar for the parallel form. Also, using the selected CNT, we developed the CACNE, in which both spontaneous performance and cued performance were designed to detect anomia in interaction with environmental interventions.

The present results also showed that the inconsistencies observed in CNT studies regarding either the involvement of the dominant hemisphere, or the detection of anomia in certain disorders,77 Busch RM, Frazier TW, Iampietro MC, Chapin JS, Kubu CS. Clinical utility of the Boston Naming Test in predicting ultimate side of surgery in patients with medically intractable temporal lobe epilepsy: A double cross-validation study. Epilepsia. 2009;50:1270-3.

8 Newcombe F, Oldfield RC, Ratcliff GG, Wingfield A. Recognition and naming of object-drawings by men with focal brain wounds. J Neurol Neurosurg Psychiatry. 1971;34:329-40.

9 Hamberger MJ, Tamny TR. Auditory naming and temporal lobe epilepsy. Epilepsy Res. 1999;35:229-43.

10 Cheung RW, Cheung MC, Chan AS. Confrontation naming in Chinese patients with left, right or bilateral brain damage. J Int Neuropsychol Soc. 2004;10:46-53.

11 Miozzo M, Hamberger MJ. Preserved meaning in the context of impaired naming in temporal lobe epilepsy. Neuropsychology. 2015;29:274-81.

12 Trebuchon-Da Fonseca A, Guedj E, Alario FX, Laguitton V, Mundler O, Chauvel P, et al. Brain regions underlying word finding difficulties in temporal lobe epilepsy. Brain. 2009;132(Pt 10):2772-84.
-1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501.,4646 Harry A, Crowe SF. Is the Boston Naming Test still fit for purpose? Clin Neuropsychol. 2014;28:486-504. were probably due to the presence of anomia in almost 50% of the patients with lesions to the right hemisphere. Thus, the CNT administered to patients with bilateral damage, which had undergone most validity studies, are more likely to have validation problems because these patients are usually compromised across a range of processes that affect naming.44 Budson AE, Solomon PR. Evaluating the Patient with Memory Loss or Dementia. In: Budson AE, Solomon PR (Eds), Memory Loss, Alzheimer's Disease, and Dementia: A practical guide for clinicians, 2nd ed. London: Elsevier; 2016:5-38.,4646 Harry A, Crowe SF. Is the Boston Naming Test still fit for purpose? Clin Neuropsychol. 2014;28:486-504.

Considering aging and bilateral damage, semantic dementia, which has been studied to reveal the individual roles of left versus right ATL in semantic function, can be asymmetric in early cases; however, the disease is inherently bilateral and it is thus hard to infer a unilateral model for this function.1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501. According to Mesulam et al.,2626 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18 semantic memory may not represent a unitary function that can be localized but, instead, the collective and interactive contributions of more fundamental networks, each of which contains modality-selective synaptic hierarchies and domain-specific transmodal hubs.2626 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18

Taking into account both the probable influence of the type of inputs and the two ATLs on the representation of semantic knowledge,1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501. in the present study we observed a significant deficit in naming for LD, despite using nonverbal inputs. This finding is consistent with the hypothesis that the left ATL has a more prominent role in word retrieval, which in turn is related with verbal outputs and the frontal lobe.1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501. Although we tried to exclude patients with visual-perception difficulties, the influence of the two hemispheres on CNT performance was evidenced not only by the presence of anomia in almost 50% of RD, but also in most LD, particularly when the two groups of patients were compared with HP. This finding is also in line with the observations of Rice et al.1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501. In their study, the right TLE group produced slower and less accurate naming responses compared with the control group, but not to the same level of the left TLE group, suggesting that this hemispheric specialization for semantic memory is graded rather than absolute.

Accordingly, Mesulam et al.2626 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18 affirmed that recent investigations of semantic dementia and patients with unilateral anterior temporal lesions have revealed functional asymmetries in the contributions of each anterior temporal lobe to verbal versus non-verbal processing domains. Such asymmetrical domain selectivity would presumably constitute a deviation from strict amodality,2626 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18 as pointed out by Rice et al.,1313 Rice GE, Caswell H, Moore P, Hoffman P, Lambon Ralph MA. The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients. Cereb Cortex. 2018;28:1487-501. based on data reported from patients with semantic dementia, functional neuroimaging, and cortical-grid neurophysiological investigations. In the view of Mesulam et al.,2626 Mesulam MM, Wieneke C, Hurley R, Rademaker A, Thompson CK, Weintraub S, et al. Words and objects at the tip of the left temporal lobe in primary progressive aphasia. Brain. 2013;136(Pt 2):601-18 temporal lobe lesions might therefore appear to generate domain-independent amodal impairments that equally disrupt verbal and non-verbal components of semantic memory, only if they are sufficiently large and bilateral to include the language network together with the inferotemporal/fusiform object recognition network (see also studies).1212 Trebuchon-Da Fonseca A, Guedj E, Alario FX, Laguitton V, Mundler O, Chauvel P, et al. Brain regions underlying word finding difficulties in temporal lobe epilepsy. Brain. 2009;132(Pt 10):2772-84.,2727 Trébuchon-Da Fonseca A, Bénar CG, Bartoloméi F, Régis J, Démonet JF, Chauvel P, Liégeois-Chauvel C. Electrophysiological study of the basal temporal language area: a convergence zone between language perception and production networks. Clin Neurophysiol. 2009;120:

Considering the objectives of the present study, in which only unilateral lesions were assessed, and comparing present findings with previous research by this laboratory,1414 Vigliecca NS, Aleman GP. [Adaptation and validation of a naming test in Spanish speakers. Do demographic variables show the evolutive pattern towards Alzheimer's disease?]. Neurologia. 2007;22:285-91. the effect of demographic variables was reduced. However, in the present study, participants older than 60 years of age were predominantly considered for recruitment, which may have influenced results. The additional items incorporated to the extended CNT, which were addressed to avoid demographic differences, may have also influenced results.

Overall, the three CNT versions in the present study are quantitative measures which are highly sensitive to procedural changes (see paper).4646 Harry A, Crowe SF. Is the Boston Naming Test still fit for purpose? Clin Neuropsychol. 2014;28:486-504. Therefore, different approaches, items, and samples produce different results, in particular when non-representative recruitment is involved or a wide range of difficulty among items is available.1414 Vigliecca NS, Aleman GP. [Adaptation and validation of a naming test in Spanish speakers. Do demographic variables show the evolutive pattern towards Alzheimer's disease?]. Neurologia. 2007;22:285-91. Nonetheless, such quantitative measures allow more possibilities to manage confounding factors and improve psychometric properties in view of the large number of items involved. For example, the development of two parallel forms as a way to abbreviate the initial scale and select one of the forms according to the study objectives, offers the possibility to identify the intended scale as the better of the two options, thus guaranteeing that either of the options represents (to a large extent) the initial scale. In addition, a CNT with culture-free visual stimuli is valuable because it allows the verbal component of the administration protocol to be adapted to different languages.

Limitations of the study: The current proposal requires that the objectives examined here be verified for the researchers’ particular approach and sample. For example, it is likely that increasing performance in older women with first level of education produces an increase in performance in younger women with higher levels of education. [Note: descriptive data for non-significant results of the present initial scale were very similar to the previously used version,1414 Vigliecca NS, Aleman GP. [Adaptation and validation of a naming test in Spanish speakers. Do demographic variables show the evolutive pattern towards Alzheimer's disease?]. Neurologia. 2007;22:285-91. except for the age range of 30 to 44 years in which women had a better performance than men for the second level of education (results available on request)]. Given we did not report lesion size because of variability of the lesions, it is worth mentioning that, when the location of the lesion is known, naming performance generally declines with lesion size among patients with the same etiology (see article2222 Skipper-Kallal LM, Lacey EH, Xing S, Turkeltaub PE. Right Hemisphere Remapping of Naming Functions Depends on Lesion Size and Location in Poststroke Aphasia. Neural Plast. 2017;2017:8740353. and its implications for laterality).

  • This study was conducted at the Instituto de Humanidades, Consejo Nacional de Investigaciones Científicas y Técnicas de la Argentina (IDH-CONICET), Universidad Nacional de Córdoba (UNC).
  • Financial support. The study was supported by funds from the CONICET, Hospital Córdoba, and UTN.
  • Errata
    In the paper Vigliecca NS, Voos JA: Remembering a name: neuropsychological validity studies and a computer proposal for detection of anomia. Dement Neuropsychol. 2019;13(4):450-462,
    Where it reads:
    1. Servicio de Neurología y Neurocirurgía del Hospital Córdoba, Argentina.
    Read:
    1. Instituto de Humanidades, Consejo Nacional de Investigaciones Científicas y Técnicas de la Argentina (IDH-CONICET), Universidad Nacional de Córdoba (UNC); Servicio de Neurología y Neurocirugía del Hospital Córdoba, Argentina.
    Dement Neuropsychol 2020 March;14(1):91

Acknowledgements. I thank my brother, Ernesto G. Vigliecca, for the CNT drawings, the neurosurgery team for patient lesion diagnoses, and all the professionals who collaborated in the data collection and registration, particularly Gretel P. Aleman.

APPENDIX 1

CACNE sections: introduction, instructions, translation, and list of correct words.

A) INTRODUCTIONIn the present study, picture recognition matched with its corresponding name is considered a language indicator of semantic memory. As a result, we believed that spontaneous performance and the semantically cued performance should not be given the same score28-30 since, in the former case, only a visual stimulus is enough to trigger the entire process of correctly remembering the name while, in the second case, the interviewer's help is required to favor semantic (visual) recognition. Instead, we intended the CACNE to have three cycles scored differently according to the interviewer's interventions (i.e. the more attempts in remembering a name, the more performance facilitation, thus the lower the score (see below)).Moreover, from the initial 30 items, and during cued performance, each interviewee has his/her own list of difficult items visually presented with auditory cues. We propose the use of repetition priming to gradually select the items with anomia as a function of their difficulty to be remembered by each interviewee. Specifically, in the first cycle we evaluate spontaneous performance and, in the second and third cycles, we evaluate cued performance by only showing those stimuli that could not be remembered in the previous cycles. The procedure was designed based on the following premise: any previous effort that a person makes to place a perceived object into its corresponding semantic and phonological family of representations activates a memory network, which will subsequently facilitate the recall of the object name. Therefore, a semantic or phonemic cue, along with a new presentation of the object, will act like repetition (direct) priming because the same object is presented in complementary ways.Hamberger9 has suggested that the auditory presentation of the stimulus is more sensitive than the visual one for detecting anomia. Additionally, in the process of naming, which implicitly includes the process of language evolution,3 the phonemic/phonological information is considered to be the second step after picture recognition or semantic retrieval.11,31,36 Therefore, in the CACNE, after verifying and scoring with the maximum value spontaneous recall, using just visual stimuli, we successively used the semantic and phonemic cues, with decreasing scores, as complementary auditory presentations. Since the phonemic cue not only induces the recall of the name more explicitly in language terms, but has also proven to be more effective than the semantic cue to improve naming accuracy,31 then in the CACNE, phonemic cued performance is scored with the minimum value.[Note: From now on, we indistinctly use the terms 'phonemic' and 'phonetic' as well as the terms 'cues' and 'helps'.]Anomia can be inferred in the CACNE from the successive results described in each cycle, including the number of correct responses and the type of errors according to the provided cues or helps. The scores in each cycle reflect both the interviewee's accuracy and all the interviewer's interventions, together with their respective weights (the effect of priming can be inferred from the results obtained in the second and third cycles).Consequently, in one session we may observe not only if the person failed to remember a name, but also if some of the processes the brain uses to successively retrieve that name were successful; i.e., if the interviewee recalls the name after anomia, this can be taken as an indication that the name was in the interviewee's repertory and that the link between the picture and the name had probably been weakened for the reasons (or results) explained in the evaluation. Considering the limiting difficulties that may be found in public hospitals, the CACNE was designed to be administered offline, using Flash Player. B) INSTRUCTIONSb1) Instructions for the InterviewerThere are three cycles in the evaluation. Each cycle is specified in the title and in the upper left corner of the screen with a red circle, which is highlighted within the other two cycles. During the first cycle, the interviewer must register, in the bottom left corner of the screen, either if the answer was right or, otherwise, the type of cue needed in the next cycle as a function of the type of error. Specifically: in this corner there are four options, the right answer and three types of cues or helps, which have to be administered in the next cycles according to the following criteria:a) If the interviewee did not visually recognize the picture (if he/she said: "I do not know" or if the picture was misidentified or incorrectly described), a semantic cue should be offered in the second cycle, by briefly describing the object in simple words; b) If the interviewee said a similar name, i.e. a name of the same family of objects or a name with similar pronunciation, but not the exact name, a better answer should be requested in the second cycle, up to a maximum of two requests; c) If the interviewee did recognize the picture by correctly describing its meaning, but the name was not remembered (anomia), a phonetic cue should be offered in the third cycle, up to a maximum of two requests if the name has more than two syllables (the first request by saying the initial sound of the name, the second request by saying the two initial sounds). This last cue will also be offered if the interviewee failed with the previous cues. [Note: Each type of selected cue is automatically recognized by the program to be administered in the corresponding cycle]. In the second and third cycles, the interviewer will only register if the final answer was right or wrong. Additional Comments:1) Interviewee's self-corrections are not counted as errors.2) Wrong answers, which are registered verbatim in the three cycles, include picture descriptions.3) Words or expressions that are distorted or not related to the picture represent wrong answers or descriptions; the offered help will depend on the cycle in which they occur.4) Errors in the third cycle are taken as indicators that, under the current conditions, those names are unknown.5) When the last picture of each cycle has been administered, interviewers can examine the "Partial Results" in the first and second cycles, or the "Final Results" (including the partial ones) in the third cycle.6) Interviewers should never press 'New Test' unless they want to start all over again from the first picture.7) Although each researcher will have prepared in advance his/her own list of semantic cues according to the particular sample recruited, when the partial results are observed, interviewers will have the opportunity to think about the cues for the wrong answers because the time record stops at that stage.8) The list of correct names shown in part (d) of this table is tentative, based on our experience, but researchers will be able to adapt it to their language or cultures, including the corresponding cues. b2) Instructions for the IntervieweeInitial or Spontaneous PerformanceI am going to show you some pictures and I want you to tell me their names. If you cannot say the exact name, give your best answer or say "I don't know" to go to the next item. Later you will be able to tell me what you know about that object.What's this?Cued PerformanceNow you can tell me the name or what you know about those pictures that you couldn't remember the name of before. I am going to help you.What's this? C) TRANSLATION OF THE INSTRUCTIONS AND TERMS USED IN CACNE[Note: Spanish terms in italic, English terms in bold. see Fig. 2]Evaluación de Nombres, por Confrontación, Asistida por Computadora (ENCAC)Computer-Aided Confrontation-Naming Evaluation (CACNE) Test de denominación - Ciclo 1: Desempeño espontáneo/Naming test - Cycle 1: Spontaneous performance Tenga la lista de palabras correctas / Have the list of correct wordsEscriba textualmente las palabras erradas / Write the wrong words verbatim [Confirme las actividades para continuar... / Confirm the activities to continue...] 1: Desempeño espontáneo / 1: Spontaneous performance2: Desempeño con 1º ayuda / 2: Performance with 1st help3: Desempeño con 2º ayuda / 3: Performance with 2nd help Bien / GoodSemántica / SemanticMejor Resp./ Better AnswerFonética / Phonetic [Seleccione una opción... / Choose an option...] Nuevo Test / New Test[¿Desea interrumpir el test en curso? SI NO/Do you want to interrupt the test in progress? YES NO] Test de denominación / Naming testNuevo ciclo / New cycle Test de denominación - Ciclo 2: Desempeño con 1º ayuda /Naming test - Cycle 2: Performance with 1st help Ofrezca una ayuda semántica / Offer a semantic helpPida una mejor respuesta / Ask for a better answer Test de denominación - Ciclo 3: Desempeño con 2º ayuda /Naming test - Cycle 3: Performance with 2nd help Ofrezca una ayuda fonética / Offer a phonetic help Resultados Parciales / Partial ResultsResultados Finales / Final Results Test de denominación - Resultados Finales/Naming test - Final Results Tiempo Empleado: minutos (mm) y segundos (ss) /Completion Time: minutes (mm) and seconds (ss) Puntaje Total / Total Score Ciclo 1: Desempeño espontáneo / Cycle 1: Spontaneous performanceTiempo (mm:ss) / Time (mm:ss)Figuras Puntaje Correctas Semántica Mejor Resp. Fonética /Figures Score Correct Semantic Better Answer Phonetic Ciclo 2: Desempeño con ayuda / Cycle 2: Performance with helpTiempo (mm:ss) / Time (mm:ss)Figuras Puntaje Correctas Semánticas Correctas Mejor Resp. ErróneasFigures Score Correct Semantic Correct Better Answer Wrong Ciclo 3: Desempeño con ayuda / Cycle 3: Performance with helpTiempo (mm:ss) / Time (mm:ss)Figuras Puntaje Correctas ErróneasFigures Score Correct Wrong D) LIST OF CORRECT WORDS IN OUR SAMPLE OF SPANISH SPEAKERS AND TRANSLATION[Note: Items are in order of difficulty] Spanish1) reloj2) teléfono3) libro4) cama5) silla6) sobre (carta)7) rastrillo8) piano9) molino -de viento-10) cigarrillo11) lámpara (velador)12) helicóptero13) cepillo de dientes14) pulpo15) jeringa (inyección)16) dado17) cafetera18) grúa (guinche)19) caballete20) candelabro (candelero)21) verja (cerca/o)22) matafuego (extintor, extinguidor)23) guadaña24) cono25) puntilla (guarda)26) clave de sol27) yunque (bigornia)28) cilindro29) gaita30) diapasón English1) clock2) telephone3) book4) bed5) chair6) envelope (letter)7) rake8) piano9) windmill10) cigarette11) lamp12) helicopter13) toothbrush14) octopus15) syringe (injection)16) die (dice)17) coffee pot18) crane19) sawhorse (trestle)20) candelabrum (candlestick)21) fence22) fire extinguisher23) scythe24) cone25) lace (lace edging)26) treble clef27) anvil28) cylinder29) bagpipe30) tuning fork

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Publication Dates

  • Publication in this collection
    09 Dec 2019
  • Date of issue
    Oct-Dec 2019

History

  • Received
    26 Mar 2019
  • Accepted
    09 Sept 2019
Academia Brasileira de Neurologia, Departamento de Neurologia Cognitiva e Envelhecimento R. Vergueiro, 1353 sl.1404 - Ed. Top Towers Offices, Torre Norte, São Paulo, SP, Brazil, CEP 04101-000, Tel.: +55 11 5084-9463 | +55 11 5083-3876 - São Paulo - SP - Brazil
E-mail: revistadementia@abneuro.org.br | demneuropsy@uol.com.br