ORIGINAL STUDY
Normative Data for Healthy Middle-Aged and Elderly
Performance on the Addenbrooke Cognitive
Examination-Revised
Viviane Amaral-Carvalho, MSc,* and Paulo Caramelli, MD, PhD*w
Objective: To provide normative data for healthy middle-aged
and elderly Brazilians’ performance on the Addenbrooke Cog-
nitive Examination-Revised (ACE-R) and to investigate the
effects of age, sex, and schooling on test performance.
Background: The ACE-R is a brief cognitive battery that as-
sesses various aspects of cognition. Its 5 subdomains (Attention
and Orientation, Memory, Verbal Fluency, Language, and
Visuospatial Abilities) are commonly impaired in Alzheimer
disease or frontotemporal dementia.
Methods: We evaluated 144 cognitively healthy volunteers (50%
men, 50% women) aged 50 to 93 years, with 4 to 24 years of
schooling. We divided the participants into 4 age groups, each of
which was then stratified into 3 groups according to years of
education. We assessed all participants with the ACE-R, the
Mattis Dementia Rating Scale, and the Cornell Scale for De-
pression in Dementia.
Results: Years of education affected all ACE-R subscores. Age
influenced the Verbal Fluency subscore (P < 0.001) and the
ACE-R total score (P < 0.05). Sex affected the Attention and
Orientation (P = 0.037) and Mini-Mental State Examination
subscores (P = 0.048), but not the ACE-R total score
(P > 0.05).
Conclusions: The performance of healthy middle-aged and el-
derly individuals on the ACE-R battery is strongly influenced by
education and, to a lesser extent, by age. These findings are of
special relevance in countries with populations that have marked
heterogeneity in educational levels.
Key Words: cognitive evaluation, normative data, Addenbrooke
Cognitive Examination-Revised (ACE-R), Brazil
Received for publication October 2, 2011; accepted February 8, 2012.
From the *Postgraduate Program in Neurology, University of São Paulo
School of Medicine, São Paulo, SP, Brazil; and wDepartment of
Internal Medicine, Behavioral and Cognitive Neurology Unit, Fac-
ulty of Medicine, Federal University of Minas Gerais, Belo Hori-
zonte, MG, Brazil.
P.C. is funded by the Conselho Nacional de Desenvolvimento Cientı́fico
e Tecnológico (CNPq) and the Fundac¸ão de Amparo à Pesquisa do
Estado de Minas Gerais (FAPEMIG), Brazil.
The authors declare no conflicts of interest.
Reprints: Paulo Caramelli, MD, PhD, Department of Internal Medicine,
Faculty of Medicine, Federal University of Minas Gerais, Av. Prof.
Alfredo Balena, 190 - Room 246 30130-100, Belo Horizonte (MG),
Brazil (e-mail: caramelli@ufmg.br).
Copyright r 2012 by Lippincott Williams & Wilkins
72 | www.cogbehavneurol.com
(Cogn Behav Neurol 2012;25:72–76)
T he Addenbrooke Cognitive Examination-Revised
(ACE-R) is a brief cognitive battery that is useful for
detecting dementia,1–4 differentiating Alzheimer disease
from frontotemporal dementia in their early stages,1,3,5
and diagnosing mild cognitive impairment in the general
elderly population.3,6 The ACE-R is also valuable for
detecting cognitive decline in Parkinson disease,7,8 corti-
cobasal degeneration,9 subcortical ischemic vascular de-
mentia,10 and brain injury,11 and is useful as part of an
overall neuropsychological assessment.6
The ACE-R assesses 5 cognitive domains: Attention
and Orientation (score = 18 points), Memory (26 points),
Verbal Fluency (14 points), Language (26 points), and
Visuospatial Abilities (16 points). The sum of scores on
these subscales gives the total score for the battery and also
allows a Mini-Mental State Examination (MMSE)12,13
score to be calculated separately. The ACE-R is available
in many languages, among them English,1 Spanish,5
Greek,2 German,3 Korean,10 Dutch,7 and Portuguese,14
which was the first published adaptation.
Although Mioshi et al1 have published normative
data for the English-language version of the ACE-R, their
study had several limitations. They evaluated only 63
people, and grouped them only by age (50 to 59, 60 to 69,
and 70 to 75 years). Further, all had a similar educational
level of around 12 years’ schooling. The total scores for
Mioshi’s 3 age groups were 86, 85, and 84, respectively.
In a previous study, we compared the ACE-R per-
formance of patients with mild Alzheimer disease to
healthy controls, and determined 2 cutoff points accord-
ing to educational level: mild Alzheimer disease was likely
in participants with <11 years of schooling who had a
total score <68, and in those with Z11 years of educa-
tion who scored <78. The average ACE-R total score for
the controls was 83.63 ± 7.90.15
Because demographic variables such as education,
age, sex, and cultural background may significantly in-
fluence cognitive performance,16,17 our previous study
also revealed an influence of age and schooling on Bra-
zilian ACE-R scores.15 Since Mathuranath et al’s18 orig-
inal publication of the ACE in 2000, several studies have
investigated its properties under different conditions, and
specific cutoffs have been proposed.1,19–22 However, no
Cogn Behav Neurol  Volume 25, Number 2, June 2012
Cogn Behav Neurol  Volume 25, Number 2, June 2012 Addenbrooke Cognitive Examination: Normative Data

substantial body of normative data has yet accounted for METHODS

demographic variables.
Only 3 normative studies have been published about
the original version of the ACE, and none considered age.
In 2006, Garcı́a-Caballero et al,21 using the Spanish-
language version, divided controls into <14 and Z14
years of schooling, and found mean total scores of 79.93
(standard deviation [SD] = 7.64) and 86.37 (SD = 5.83),
respectively. In 2004, Mathuranath et al,23 using a
Malayalam-language (Southern India) adaptation, div-
ided their sample into r8 and Z9 years of education,
and obtained mean scores of 59.0 (SD = 10.5) and 83.6
(SD = 6.7), respectively. In 2007, again using the
Malayalam version, Mathuranath et al22 split 519 par-
ticipants into 5 strata by schooling level: illiterate (mean
total score 42.8 ± 9.8), 1 to 4 years of formal education
(55.9 ± 12.5), 5 to 8 years (62.6 ± 11.4), 9 to 12 years
(77.0 ± 10.2), and Z12 years (83.4 ± 7.2).
It is widely acknowledged that there are too few
brief, practical, inexpensive, and sensitive cognitive tests.
Neuropsychological batteries are time-consuming and
require specialized professionals for their application. At
the other extreme, screening tests tend to be too short and
able to discriminate dichotomously only between de-
mented and nondemented patients, lacking the sensitivity
to detect mild impairment. These screening instruments
can rarely distinguish among different cognitive profiles
that are useful for predicting types of dementias and de-
termining anatomoclinical correlations. The 5 subscales
of the ACE-R provide a broader assessment, offering an
advantage over other available instruments.
Although the ACE-R has been in widespread use at
more than 150 clinical and research centers in at least 22
countries worldwide, demographic effects and normative
data for the instrument remain scarce. The primary aim
of this study was to investigate the influence of age, ed-
ucation, and sex on total scores of the Brazilian version of
the ACE-R and to propose normative data for healthy
Brazilians aged 50 and older who have at least 4 years of
schooling. We also sought to determine normative sub-
scale scores.
We evaluated 144 cognitively healthy volunteers
aged 50 years or older (50% men, 50% women), recruited
from the community, predominantly from social organ-
izations for elderly people. All participants scored Z123
points on the Mattis Dementia Rating Scale,24 had no
complaints of cognitive decline or history of neurologic or
psychiatric illness, and did not use drugs that could affect
the central nervous system. None of the participants ful-
filled the Diagnostic and Statistical Manual-IV criteria for
depression; all scored <8 points on the Cornell Scale for
Depression in Dementia.25
We stratified the participants both by age (50 to 59,
60 to 69, 70 to 79, 80 years or older) and by years of
schooling (4 to 7, 8 to 11, Z12 years).
The study was approved by the Research Ethics
Committee of the Federal University of Minas Gerais and
by the Research Ethics Committee of the Hospital das
Clı́nicas of the University of São Paulo School of Medi-
cine. All participants signed the written informed consent
form.
We used the Wilcoxon test to evaluate the effects of
sex on ACE-R scores, and the Kruskal-Wallis test to
analyze the influences of age and schooling. Monte Carlo
Simulation confirmed both nonparametric tests as achiev-
ing a 99% confidence interval. Means, SDs, median,
and percentiles were found to be dependent on age and
years of education for all the ACE-R total and subscale
scores.
RESULTS
Data on participants’ age, sex, and years of educa-
tion are shown in Table 1. Years of education strongly
influenced all ACE-R scores (P < 0.05). Age had an effect
on the Verbal Fluency and ACE-R MMSE subscales
(P < 0.001) and on the total score (P < 0.05). Sex influ-
enced only 2 subscales: Attention and Orientation
(P = 0.037) and ACE-R MMSE (P = 0.048).
Table 2 shows the normative data for each
subscale; Table 3, the total scores for the ACE-R and

TABLE 1. Age, Education, and Sex of 144 Healthy Brazilians Taking the Addenbrooke
Cognitive Examination-Revised
Mean SD Median Minimum Maximum DRS Brazilian ACE-R n
Age (y)
50-59 53.64 2.98 53.00 50 59 137.89 (4.68) 86.86 (7.62) 36
60-69 65.08 2.57 65.00 60 69 137.47 (4.78) 87.44 (8.45) 36
70-79 73.97 2.96 73.50 70 79 134.80 (5.47) 84.75 (8.07) 36
80 or older 83.81 3.64 82.00 80 93 134.27 (5.27) 82.00 (6.86) 36
Education (y)
4-7 4.73 1.12 4 4 7 132.83 (4.74) 80.25 (7.57) 48
8-11 10.10 1.22 11 8 11 135.73 (4.86) 84.75 (6.95) 48
Z12 16.54 2.58 16 12 24 139.77 (3.63) 90.79 (5.57) 48
Sex
Women 50% — — — — 136.15 (5.53) 84.82 (8.42) 72
Men 50% — — — — 136.07 (5.01) 85.71 (7.56) 72
SD indicates standard deviation; DRS, Dementia Rating Scale; ACE-R, Addenbrooke Cognitive Examination-Revised.

r 2012 Lippincott Williams & Wilkins www.cogbehavneurol.com | 73

Amaral-Carvalho and Caramelli Cogn Behav Neurol  Volume 25, Number 2, June 2012

TABLE 2. Scores on the Brazilian Addenbrooke Cognitive Examination-Revised, by Age and Education
Education (y)
Age 50-59 (y) Age 60-69 (y) Age 70-79 (y) Age 80 or Older (y)
4-7 8-11 Z12 4-7 8-11 Z12 4-7 8-11 Z12 4-7 8-11 Z12
(n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12)
Attention and Orientation
Mean 16.75 17.00 17.92 17.25 16.92 17.17 16.75 16.83 17.67 16.42 16.83 17.08
Median 17.00 18.00 18.00 17.00 17.00 17.00 17.00 17.00 18.00 17.00 17.00 17.00
SD 1.22 1.54 0.29 0.75 0.90 0.83 1.29 1.19 0.49 1.44 1.34 0.90
Minimum 15.00 14.00 17.00 16.00 15.00 16.00 14.00 15.00 17.00 14.00 14.00 15.00
Maximum 18.00 18.00 18.00 18.00 18.00 18.00 18.00 18.00 18.00 18.00 18.00 18.00
Memory
Mean 18.67 17.83 22.08 17.50 21.42 21.75 17.33 18.17 21.42 17.25 17.00 19.67
Median 17.50 17.50 23.00 18.00 21.50 23.00 17.00 18.00 22.00 17.00 18.50 20.00
SD 3.68 4.71 2.91 4.32 3.45 2.73 3.60 2.25 3.12 3.31 4.49 3.06
Minimum 15.00 10.00 15.00 10.00 17.00 16.00 11.00 16.00 15.00 13.00 8.00 13.00
Maximum 24.00 25.00 25.00 23.00 26.00 25.00 25.00 24.00 26.00 24.00 21.00 23.00
Verbal Fluency
Mean 10.67 10.75 12.17 8.58 11.33 12.58 9.00 9.92 12.25 9.42 8.92 8.75
Median 11.00 10.50 12.00 9.00 11.00 12.50 9.00 10.00 12.00 9.00 9.00 9.00
SD 2.10 1.36 0.94 1.83 1.37 1.08 2.26 1.62 1.29 1.78 2.35 1.48
Minimum 8.00 9.00 11.00 6.00 9.00 11.00 4.00 8.00 10.00 8.00 6.00 7.00
Maximum 14.00 13.00 14.00 13.00 14.00 14.00 12.00 13.00 14.00 14.00 14.00 12.00
Language
Mean 21.67 24.67 25.58 22.92 25.17 25.33 21.83 23.67 25.33 22.67 23.75 24.58
Median 23.00 25.00 26.00 24.00 25.50 26.00 22.50 24.00 25.00 22.50 25.00 25.00
SD 3.77 1.07 0.90 3.45 1.19 0.98 3.13 1.61 0.65 2.39 2.70 1.31
Minimum 15.00 23.00 23.00 15.00 22.00 23.00 16.00 21.00 24.00 18.00 18.00 21.00
Maximum 26.00 26.00 26.00 26.00 26.00 26.00 25.00 26.00 26.00 26.00 26.00 26.00
Visuospatial Abilities
Mean 14.33 14.92 15.58 14.00 14.83 15.58 13.83 14.42 15.83 14.17 14.67 14.83
Median 14.00 15.50 16.00 14.00 16.00 16.00 14.00 14.50 16.00 14.00 15.00 15.00
SD 1.07 1.31 .67 1.76 1.70 .90 1.95 1.73 0.39 1.47 1.30 1.34
Minimum 13.00 12.00 14.00 11.00 11.00 13.00 10.00 10.00 15.00 12.00 12.00 12.00
Maximum 16.00 16.00 16.00 16.00 16.00 16.00 16.00 16.00 16.00 16.00 16.00 16.00
SD indicates standard deviation.

TABLE 3. Brazilian Addenbrooke Cognitive Examination-Revised: Total Scores and MMSE Scores, by Age and Education
Education (y)
Age 50-59 (y) Age 60-69 (y) Age 70-79 (y) Age 80 or Older (y)
4-7 8-11 Z12 4-7 8-11 Z12 4-7 8-11 Z12 4-7 8-11 Z12
(n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12) (n = 12)
ACE-R total score
Mean 82.08 85.17 93.33 80.25 89.67 92.42 78.75 83.00 92.50 79.92 81.17 84.92
Median 80.00 83.00 95.00 82.00 87.50 93.50 79.50 83.50 93.00 80.00 83.00 85.00
SD 7.68 5.25 4.94 9.27 5.61 4.56 7.55 5.06 4.08 6.10 8.83 4.48
Minimum 72.00 81.00 80.00 62.00 80.00 82.00 65.00 74.00 84.00 72.00 64.00 76.00
Maximum 98.00 96.00 97.00 95.00 97.00 98.00 93.00 93.00 98.00 92.00 90.00 90.00
; 10 73.00 81.00 90.00 66.00 85.00 86.00 67.00 75.00 88.00 72.00 69.00 80.00
Percentile 25 77.00 81.00 91.50 76.00 85.50 91.00 76.00 81.50 90.50 74.50 74.50 82.00
= 75 88.50 89.00 97.00 86.50 95.00 95.50 83.00 85.50 95.50 84.00 88.50 89.00
9 90 89.00 92.00 97.00 88.00 96.00 96.00 84.00 87.00 98.00 86.00 89.00 90.00
MMSE
Mean 27.25 26.50 28.08 26.58 27.00 26.83 26.58 26.50 27.25 25.67 25.75 26.67
Median 26.00 27.00 28.00 27.00 27.00 27.00 26.50 26.00 27.00 25.00 26.50 27.00
SD 1.71 1.98 1.38 1.56 1.35 1.03 2.50 1.62 1.22 1.67 2.22 1.56
Minimum 26.00 23.00 26.00 24.00 24.00 25.00 23.00 25.00 25.00 23.00 20.00 24.00
Maximum 30.00 30.00 30.00 29.00 29.00 28.00 31.00 30.00 30.00 29.00 28.00 29.00
SD indicates standard deviation; ACE-R, Addenbrooke Cognitive Examination-Revised; MMSE, Mini-Mental State Examination; Median, percentile 50.

74 | www.cogbehavneurol.com r 2012 Lippincott Williams & Wilkins

Cogn Behav Neurol  Volume 25, Number 2, June 2012 Addenbrooke Cognitive Examination: Normative Data

TABLE 4. Addenbrooke Cognitive Examination-Revised Scores, by Education

Education (y)
4-7 (n = 48) 8-11 (n = 48) Z12 (n = 48)
Mean SD Median Mean SD Median Mean SD Median
Attention and 16.79 1.20 17 16.90 1.22 17 17.46 0.74 18
Orientation
Memory 17.69 3.67 17 18.60 4.09 18 21.23 3.01 22
Verbal Fluency 9.42 2.09 9 10.23 1.90 10 11.44 1.97 12
Language 22.27 3.17 23 24.31 1.82 25 25.21 1.03 25
Visuospatial Abilities 14.08 1.56 14 14.71 1.49 15 15.46 0.94 16
ACE-R total score 80.25 7.58 80 84.75 6.95 84,5 90.79 5.57 92
MMSE 26.52 1.92 26 26.44 1.82 27 27.21 1.38 27
ACE-R indicates Addenbrooke Cognitive Examination-Revised; MMSE, Mini-Mental State Examination; SD, standard
deviation.

ACE-R MMSE; and Table 4, the distribution of ACE-R
scores according to education, with a larger number of
participants for each level (48 vs. 36; ie, 12 participants
for each of the 4 groups stratified by age).
DISCUSSION
We report normative data for healthy people aged
50 years and older, divided into 3 subgroups of schooling.
We found all of the ACE-R scores to be dependent on
years of education. Age influenced only the Verbal Flu-
ency and ACE-R MMSE subscores and the ACE-R total
score. Sex affected the Attention and Orientation and the
ACE-R MMSE subscores, but not the ACE-R total
score.
Normative studies of diverse large populations have
confirmed a dependent relationship between cognition
and demographic data such as age, education, and
sex.26–30 In the present study, we also found the ACE-R
Verbal Fluency subscore to be dependent on both age
and education. These effects have been reported in
earlier research, with the greatest influence being educa-
tion.27 Other groups besides ours have found associations
of verbal fluency tasks with age28 and with formal
education.28,29 As mentioned, MMSE scores have also
been significantly associated with age and education.30
In their 2006 study, Mioshi et al1 failed to find a
significant interaction between age and performance on
the ACE-R, possibly because of their small sample size
(n = 63). However, Mathuranath et al22 found a sig-
nificant correlation between age and total scores on the
original version (ACE) in their study of 488 healthy elder-
ly people. Among studies investigating the relationship
between formal education and ACE-R performance,
Mathuranath et al22 and others19–21 confirmed this asso-
ciation using the original ACE.
The main clinical contribution of our study is the
provision of norms enabling clinicians to determine more
precisely the degree to which ACE-R scores truly reflect
impaired performance in persons of different ages and
educational levels. Having this capability is of special
relevance in countries whose populations have marked
heterogeneity of schooling—many developing countries
and some developed nations that have substantial immi-
gration. We also believe that normative data for in-
dividuals aged 50 and older may be useful, given that the
ACE-R was developed to differentiate frontotemporal
dementia from Alzheimer disease. Frontotemporal de-
mentia, in particular, affects many people before age 65.
Further studies should also include populations with <4
years of schooling.
ACKNOWLEDGMENTS
The authors thank Dr Eneida Mioshi-Hornberger and
Professor John R. Hodges for their continuous support of
and collaboration with our work.
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