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Letter and category fluency in community-

dwelling canadian seniors: A comparison of
normal participants to those with dementia of
the Alzheimer or vascular type
a a a
Margaret Crossley , Carl D'arcy & Nigel S.B. Rawson
a
University of Saskatchewan , Saskatoon, Saskatchewan, Canada
Published online: 04 Jan 2008.

To cite this article: Margaret Crossley , Carl D'arcy & Nigel S.B. Rawson (1997) Letter and category fluency
in community-dwelling canadian seniors: A comparison of normal participants to those with dementia of
the Alzheimer or vascular type, Journal of Clinical and Experimental Neuropsychology, 19:1, 52-62, DOI:
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 Journal of Clinical and Experimental Neuropsychology 1380-3395/97/190 1-52$12.00
1997, Vol. 19, NO. 1, pp. 52-62 0 Swets & Zeitlinger

Letter and Category Fluency in Community-Dwelling

Canadian Seniors:
A Comparison of Normal Participants to those with Dementia
of the Alzheimer or Vascular Type*
Margaret Crossley, Carl D’Arcy, and Nigel S.B. Rawson
University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Downloaded by [University of California Santa Cruz] at 08:07 16 November 2014

ABSTRACT

Measures of letter (FAS) and category (Animal Naming) fluency were completed by community-dwelling,
cognitively normal seniors (n = 635), and by individuals diagnosed with dementia of the Alzheimer type
(DAT) (n = 155), or with vascular dementia (n = 39). Among normal seniors, category, but not letter flu-
ency, declined with age, females performed better than males on letter but not on category fluency, and
performance increased with education on both tasks. Among participants with DAT, letter fluency was
influenced by level of education, whereas category fluency was education-, age-, and gender-invariant.
Both measures differentiated normal seniors from those with dementia. Category fluency was more im-
paired than letter fluency at both mild and moderate stages of dementia, but neither task differentiated DAT
from vascular dementia.

In the study of normal aging some components
of language are commonly described as age-in-
variant, while other components typically un-
dergo age-associated decline (see Bayles &
Kaszniak, 1987 or Kemper, 1992 for compre-
hensive summaries of this area). For example,
comprehension of word meaning and basic read-
ing skills are generally reported as stable in nor-
mal aging. In contrast, confrontational naming
appears to be sensitive to the effects of increas-
ing age (Nicholas, Obler, Albert, & Goodglass,
1985). Similarly, verbal fluency or generative
naming tasks are differentially affected by nor-
mal aging (Tomer & Levin, 1993). Letter-flu-
ency, commonly assessed by the Controlled Oral
Word Association or FAS test (Spreen & Ben-
ton, 1977) and requiring the time-limited gener-
ation of words that begin with a given letter, is
typically found to be age-stable in cognitively
normal individuals (Benton, Eslinger, & Dama-
sio, 1981; Bolla, Lindgren, Bonaccorsky, &
Bleecher, 1990; Tomer & Levin, 1993). In con-
trast, category or semantic fluency, commonly
assessed by Animal Naming (Goodglass &
Kaplan, 1972; Rosen, 1980) and requiring the
time-limited production of exemplars of a given
category, is generally found to be age-sensitive
(Ska, 1993; Tomer & Levin, 1993), although
Perlmuter and Tun (1987) found no differences
between middle-aged (55-64 years) and older
participants (65-74 years).

* The data reported in this article were collected as part of the Canadian Study of Health and Aging. This was
funded by the Seniors Independence Research Program of Health and Welfare Canada. This multi-centred na-
tional study was coordinated through the University of Ottawa and Health Canada’s Laboratory Centre for Dis-
ease Control. The authors would like to thank all of the participants and staff from across Canada who were
involved in the CSHA.
Address correspondence to: Margaret Crossley, Department of Psychology, Arts Bldg, 9 Campus Drive, Univer-
sity of Saskatchewan, Saskatoon, Saskatchewan, Canada, S7N 5A5.
Accepted for publication: July 7, 1996.
 LETTER AND CATEGORY FLJJENCY IN THE CSHA
Both letter-generation and category fluency
tasks are frequently included in neuropsycholog-
ical test batteries to assess language and retrie-
val skills (Benton & Hamsher, 1989) and are
considered sensitive measures for early detec-
tion of dementia of the Alzheimer type (Bayles,
Tomoeda, & Trosset, 1993; Hart, Smith, &
Swash, 1988; Huff, Corkin, & Growdon, 1986;
Martin & Fedio, 1983; Monsch et al., 1992;
Ober, Dronkers, Koss, Delis, & Friedland, 1986;
Rosen, 1980). Consistent with the superiority of
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category fluency in detecting normal age-related
cognitive change, category fluency is generally
found to be superior to letter fluency in discrimi-
nating early stage dementia from normal aging
(Butters, Granholm, Salmon, Grant, & Wolf,
1987; Monsch et al., 1992), although others have
not demonstrated this difference (Bayles et al.,
1989; Ober et al., 1986; Rosen, 1980).
Category and letter fluency differences are
usually attributed to the relative preservation, in
both normal aging and in early stage dementia,
of cognitive processes thought to underlie letter
fluency as compared to those associated with
category fluency. For example, Jorm (1986) ar-
gued that the letter-sound associations or phono-
logical knowledge necessary for letter fluency
may be well preserved compared to semantic-
exemplar associations necessary for category
fluency. Similarly, Butters et al. (1987) and
Monsch et al. (1992) concluded that the superior
sensitjvity of category fluency is due to its de-
pendence on the structure of semantic knowl-
edge. This store of semantic information is
thought to deteriorate in early stages of demen-
tia, and may be increasingly difficult to access
or retrieve in normal aging. Differences between
letter and category fluency may also reflect re-
duced general processing capacity or attentional
resources in normal aging and in early-stage
dementia, such that accessing semantically cued
versus phonemically cued exemplars may be
relatively difficult or resource-demanding (Hart-
man, 1991; Huff et al., 1986).
Moscovitch (1995) proposed a neuropsycho-
logical explanation for differences in perfor-
mance on letter and category fluency tasks. Ac-
cording to his model, category or semantic flu-
ency tasks may be carried out by the mesial-
53
temporal lobe structures, whereas letter-gener-
ated fluency may be primarily mediated by the
frontal lobes. In a logical extension of Mosco-
vitch’s model, age-associated differences in per-
formance on the two fluency tasks may reflect
differences in the way that normal aging affects
the biological substrate underlying these tasks.
Similarly, differences among subgroups of indi-
viduals with dementia may also reflect differ-
ences in the way pathological processes affect
the brain. For example, both normal aging and
early-stage dementia of the Alzheimer type are
known to affect the mesial temporal lobe struc-
tures, with relative sparing in the frontal brain
areas (see Kolb & Whishaw, 1996 for a brief
review); dementias described as subcortical or
vascular may interfere with both temporal and
frontal functions.
Recently category and letter fluency tasks
have been used to differentiate dementias that
are considered primarily cortical (e.g., Pasquier,
Lebert, Grymonprez, & Petit, 1995), and to dis-
tinguish cortical from subcortical dementias
(e.g., Monsch et al., 1994; Randolph, Braun,
Goldberg, & Chase, 1993; Stern & Richards,
1993; Troster, Salmon, McCullough, & Butters,
1989). For example, Monsch et al. (1994) com-
pared category and letter fluency in groups of
individuals with dementia of the Alzheimer type
(DAT) or Huntington’s disease (HD) and found
that the participants with HD were equally im-
paired on both tasks, whereas those with DAT
were proportionally more impaired on the cate-
gory task. Differences were attributed to a
breakdown in the structure of semantic knowl-
edge in DAT in contrast to difficulties in initia-
tion and retrieval in HD.
Although current research suggests that corti-
cal and subcortical dementias may be distin-
guishable using letter and category fluency
tasks, these tasks do not consistently distinguish
among patients who suffer different types of
cortical dementia. For example, Pasquier et al.
(1995) compared category and letter fluency
performance in groups of individuals with fron-
tal lobe dementia or DAT. They found that pa-
tients had lower word fluency than age- and gen-
der-matched controls on both tasks, and that cat-
egory fluency was more impaired than letter flu-
 54 MARGARET CROSSLEY ET AL
ency for both dementia types. Neither category
nor letter fluency differentiated frontal lobe de-
mentia and DAT. Finally, Margolin, Pate, Frie-
drich, and Elia (1990) compared naming ability
in individuals with DAT and anomic stroke pa-
tients using letter fluency and a semantic naming
(Boston Naming Test) task. Both patients with
DAT and anomic stroke were impaired on the
semantic naming task as compared to normals,
but those with DAT were significantly more im-
paired than those with anomic stroke. A very
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different pattern occurred for the letter fluency
task. The patients with anomic stroke were im-
paired as compared to both normal participants
and patients with DAT, whereas the DAT group
did not differ from normal controls. These find-
ings at least tentatively suggest that fluency
measures may successfully differentiate individ-
uals with DAT from those with vascular demen-
tia; however, to date, no studies have compared
the performance of these two groups on letter
and category fluency.
The current study was conducted in order to
replicate previous findings with normal older
adults and those with DAT using a large com-
munity-dwelling sample identified as part of the
Canadian Study on Health and Aging (CSHA;
Canadian Study of Health and Aging Work
Group, 1994a). In addition, we aimed to extend
the use of category and letter fluency tasks in the
investigation of dementia subtypes by including
the sample of participants from the CSHA with
vascular dementia.
The CSHA was a nationwide epidemiological
study of the cognitive status of adults aged 65
years and older that provided estimates of the
prevalence of dementia in Canada (CSHA
Working Group, 1994a), identified risk factors
for dementia (CSHA Working Group, 1994b),
and described the impact on caregivers of per-
sons with dementia (CSHA Working Group,
1 9 9 4 ~ ) .The epidemiological nature of the
CSHA allowed us to address a number of meth-
odological issues associated with the study of
verbal fluency in normal and pathological aging.
For example, normal aging studies have typi-
cally compared young, middle-aged, and older
individuals, and have seldom differentiated
young-old, moderately-old, and old-old age
groups (although see Benton, Eslinger, & Dama-
sio, 1981). The current study included a large
sample of community-dwelling older adults di-
vided into young-old (65-74 years), moderately-
old (75-84 years) and old-old (85+ years) age
groups.
Both above- and below-average educational
levels can confound the assessment of normal
elderly and the diagnosis of those with early-
stage dementia (see Lezak, 1995 for a discussion
of this issue). In addition, gender differences are
frequently observed in measures of verbal flu-
ency with normal individuals (Bolla et al., 1990;
Lezak, 1995), but few have investigated these
differences in individuals with dementia
(although see Monsch et al., 1992). In the cur-
rent study, we systematically examined educa-
tional and gender effects on verbal fluency per-
formance for both normal participants and indi-
viduals diagnosed with DAT.
As suggested by Butters et al. (1987) and
Margolin et al. (1990), lack of consistency
across studies designed to investigate letter and
category fluency performance in dementia may
be partially explained by differences in level of
severity in the patient groups. For example, let-
ter fluency may diminish later in the course of
DAT than category fluency (Margolin et al.,
1990). In an attempt to control for the effect of
illness severity, we subgrouped participants with
vascular dementia and DAT into mild and mod-
erate impairment categories.
METHOD
Participants
As part of the CSHA, 9,008 community-dwelling
seniors from 18 centres across Canada were
screened for cognitive impairment using the Modi-
fied Mini-Mental State Examination (3MS; Teng
& Chui, 1987). Individuals ( n = 1,165) who fell
below a predetermined cut-off score for normal
performance (i.e., 78/100 on the 3MS), and a sub-
sample of individuals (n = 494) who performed
above the cut-off score, were invited to participate
in the clinical component of the study. The clinical
component was designed to confirm the presence
or absence of cognitive impairment, and, in the
former case, to identify the type of impairment.
For individuals scoring above 50 on the 3MS, the
 LETTER AND CATEGORY FLUENCY IN THE CSHA 55

clinical component comprised a nurse’s evaluation,
a standardized medical examination, and a detailed
neuropsychological assessment. Those scoring be-
low 50 on the 3MS were assessed by the physician
and the nurse, but were considered to be too im-
paired to complete neuropsychological testing.
A consensus diagnosis by the clinical research
team in each centre was derived using the criteria
for primary degenerative dementia from the Diag-
nostic and Statistical Manual of Mental Disorders,
third edition, revised (DSM-111-R; American Psy-
chiatric Association, 1987) and the criteria for
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by gender, age, education, and consensus diagno-
sis. Almost half the sample had less than 10 years
of formal education.
The consensus diagnosis, by definition, re-
flected a consideration of the neuropsychological
test results, including the results of the category
and letter fluency measures. To address any con-
cern about circularity, all analyses in the current
study were repeated on groups formed by the phy-
sicians’ preliminary diagnosis. There were no sig-
nificant differences between the two sets of analy-
ses. Since the groupings generated by consensus

DAT developed by the National Institute of Neu-
rological and Communicative Disorders and
Stroke and the Alzheimer’s Disease and Related
Disorders Association (NINCDS-ADRDA;
McKhann et al., 1984). Participants were classi-
fied as having either no cognitive loss, cognitive
loss but no dementia, or some form of dementia
(i.e., Possible or Probable Alzheimer type, Vascu-
lar, Mixed, Other, or Unclassifiable). Table 1 sum-
marizes the demographic characteristics of the
community-dwelling participants of CSHA who
completed the neuropsychological component of
the clinical assessment. Participants are grouped
diagnosis better reflect the criteria for diagnosis as
set out by DSM-111-R and by NINCDS-ADRDA,
that specifically require a consideration of neuro-
psychological test performance, the results report-
ed in this study are based on the consensus group-
ings.
The Canadian Study of Health and Aging
(1994a) provides a detailed overview of the study
participants, methods, and findings, and Tuokko,
Kristjansson, and Miller (1995) describe the neuro-
psychological component of the CSHA. The large-
scale survey and sampling procedures of the
CSHA provided an unusually broad and represen-

Table I . Demographic and Diagnostic Summary for Community-DwellingParticipants in the Neuropsychologi-

cal Assessment Phase of the Canadian Study of Health and Aging.

Age Education

M SD n M SD n
Gender
Males 78.8 6.7 545 8.7 4.4 544
Females 80.5 6.9 764 9.0 3.9 763

Age Group (years)

65-74 69.6 2.8 252 8.2 3.9 252
75--84 79.0 2.8 673 9.1 4.2 673
85 + 87.8 2.7 384 8.8 4.0 382

Education (years)
0-6 79.2 7.1 37 1 4.1 1.7 37 1
7-9 79.8 6.9 378 8.0 0.7 378
10--12 80.1 6.7 368 11.0 0.8 368
13+ 80.0 6.4 190 15.7 2.6 190

Consensus Diagnosis
Normal 78.8 6.8 645 9.5 4.1 644
Cognitive loss 80.1 7.1 420 8.1 4.0 420
Alzheirner 82.5 5.9 164 8.4 3.9 163
Vascular 80.8 6.0 40 9.6 4.3 40
OtherlLinident. 80.0 6.4 40 8.2 4.3 40
All participants 79.8 6.8 1309 8.8 4.1 1307
 56 MARGARET CROSSLEY ET AL.
tative sample of older Canadian adults. The sample
included large numbers of seniors in the rarely
studied old-old group, as well as many with lim-
ited formal schooling. As well, the sample in-
cluded those with the full range of health problems
typically found in the aging population. All partici-
pants were considered to be fluent in either English
or French.
The current study investigated the performance
on tests of letter and category fluency, of those
community-dwelling participants assessed to be
cognitively normal (n = 635), or as suffering from
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possible or probable Alzheimer disease (n = 155),
or vascular dementia (n = 39). Mixed, other, and
unidentifiable dementia were excluded from the
current study due to the small sample size and het-
erogenous nature of these groups. Although indi-
viduals with “cognitive loss but no dementia”
were numerous (n = 420), this grouping was also
highly heterogenous, and includedindividuals with
impairment secondary to such things as mental
retardation, stroke, substance abuse, or psychiatric
illness. Performance by members of this group on
tests of fluency was anticipated to be highly vari-
able and difficult to interpret, and consequently
these data were not included in the current study.
Participants with dementia were subdivided into
mild and moderate impairment categories based on
their performance on the 3MS administered during
the clinical assessment. Mild impairment was de-
fined as a score of > 70, and moderate impairment
as > 50 and I 7 0 on the 3MS. This admittedly arbi-
trary division into mild and moderate subgroups
was based on the observation that a score of 70
was approximately 1.5 standard deviations below
the average score of the cognitively normal partici-
pants.
Materials and Procedures
The CSHA neuropsychological test battery was
administered by trained psychometrists and con-
tained standardized measurements of letter (Spreen
& Benton, 1977) and category (Animal Naming;
Rosen, 1980) fluency. Letter fluency was assessed
by summing the number of words orally produced
in response to letter cues (“F”,“A”,“S”) in three
60-s trials. Participants were instructed that giving
proper nouns or the same word with a different
suffix (e.g., send, sending) was not permitted. Cat-
egory fluency was assessed by recording the num-
ber of words produced in 60 s when participants
were asked to report as many words as they could
think of that were animals. The scores used for
analyses were the total numbers of correct respon-
ses on each fluency task.
RESULTS
Letter and Category Fluency in Community-
dwelling Normal Elderly
Table 2 summarizes the letter (FAS) and cate-
gory (Animal Naming) fluency scores for nor-
mal community-dwelling participants according
to age, gender, and education. Results for the
two fluency tasks were analyzed separately us-
ing 3 (Age Group) x 2 (Gender) x 4 (Education)
analyses of variance (ANOVAs). Participants in
the three age-groups (i.e., 65-74; 75-84; 85+)
performed equivalently on letter-generation
word fluency, F(2, 582) = 1.57, p = .21. As
shown by Table 2 there was a statistically signif-
icant effect for age-group on the category flu-
ency task (Animal Naming), F(2, 604) = 12.63,
p < .OO 1, that was explained by a decline in per-
formance in the oldest group.
The only statistically significant effect for
gender occurred on the letter fluency task, F( 1,
582) = 7.92, p = .005, during which females pro-
duced significantly more words (M= 26.2) than
did males (M = 23.2). The educational level of
participants had a highly significant effect on
both fluency tasks, F(3, 582) = 66.22, p < .001
for FAS, and F(3, 604) = 31.23, p < .001, for
Animal Naming. Performance increased directly
with education for both letter and category flu-
ency, but letter fluency appeared particularly
sensitive to education effects, with those in the
highest level (13 yrs +) producing over twice as
many words as those in the lowest level (0-6
yrs). No statistically significant interactions
were found among age group, gender, and edu-
cational level.
Letter and Category Fluency in Participants
with DAT
Table 3 describes the letter and category fluency
performance of community-dwelling partici-
pants diagnosed with possible or probable DAT,
according to age, gender, education, and level of
impairment. A 3(Age Group) x 2(Gender) x
4(Education) x 2(Level of Impairment) ANOVA
was conducted for each of the fluency tasks. As
shown in Table 3, age group and gender had no
statistically significant effect on either task as
performed by participants diagnosed with DAT.
 LETTER AND CATEGORY FLUENCY IN THE CSHA 57

Table 17. Letter and Category Fluency Performance for Cognitively Normal Participants according to Age,
Gender, and Educational Level

Fluency Task
FASa (letter fluency) Animal Namingb (category fluency)
Group M SD n M SD n
Age Group (years)
65-74 24.0 12.4 139 14.2 4.3 144
75-84 25.8 11.5 343 14.2 3.8 343
85 + 24.0 10.8 146 12.5** 3.8 148
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Gender
Male 23.2 12.1 258 14.2 4.2 258
Female 26.2* 11.0 370 13.6 3.9 317

Education (years)
0-6 16.2 6.9 140 12.1 3.1 149
7-9 23.7 9.9 170 13.4 3.8 169
10-12 27.0 10.2 202 14.1 3.9 203
13+ 34.2** 12.6 115 16.3** 4.1 113
Sample 25.0 11.6 628 13.8 4.3 635

Note. Values for fluency tasks are compared vertically, in table columns, according to age, gender, and educa-
tional level.
a The values are the total number of words beginning with specified letters reported orally in three 1 min. trials.
The values are the number of animal names reported orally in I-min.
*p<.o1.**p<.oo1.

Level of education did not influence perfor- A Comparison of Normal Participants to

mance on Animal Naming, F(3, 127) < 1, p =
.45.In contrast, there was a statistically signifi-
cant effect for education on the FAS task, F(3,
116) = 8.48, p < .001. Similar to cognitively
normal participants, highly educated individuals
with AD produced twice as many words on the
FAS task as did their least educated cohorts ( M
= 22.6 words vs. 11.9 words, respectively).
When mild (3MS > 70) and moderately im-
paired (3MS 5 70) participants with DAT were
compared on the two fluency tasks, a statisti-
cally significant effect for impairment was
found for Animal Naming, F( 1, 127) = 4 . 5 5 , ~=
.035, with the mildly impaired DAT group pro-
ducing more words (M= 9.5 words) during the
1-min trial than the moderately impaired indi-
viduals ( M = 8.1 words). Level of impairment
did not significantly influence performance on
the FAS task, F(1,116) = 1 . 8 5 , ~= .176.
those with Mild and Moderate DAT and Vas-
cular Dementia on Letter and Category Flu-
ency
In Table 4, letter and category fluency data are
reported for the normal community-dwelling
participants, and for the two dementia groups
(Le., DAT and vascular dementia) subdivided
into mild and moderate impairment levels. Four
3-way ANOVAs compared normal participants
to those with mild DAT and mild vascular de-
mentia on letter and category fluency tasks, and
normal participants to those with moderate DAT
and moderate vascular dementia on the two flu-
ency tasks. Both mildly impaired dementia
groups produced significantly fewer words than
did normal participants during both letter flu-
ency, F(2,655) = 6.72, p = .001, and category
fluency, F(2,655) = 37.84, p c .001, tasks. Pre-
dictably, both moderately impaired dementia
groups also produced significantly fewer words
 58 MARGARET CROSSLEY ET AL.

Table 3. Letter and Category Fluency Performance for Community-Dwelling Elderly Diagnosed with Dementia
of the Alzheimer Type.

Fluency Task

FASa (letter fluency) Animal Namingb (category fluency)

Group M SD n M SD n
Age Group (years)
65-74 17.0 8.4 13 8.2 2.1 13
75-84 16.4 10.6 73 8.7 3.9 75
85+ 16.0 9.1 66 8.3 3.4 67
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Gender
Male 15.5 10.1 56 9 .O 4.6 58
Female 16.8 9.6 96 8.2 2.7 97
Education (years)
0-6 11.9 7.4 48 9.1 3.7 49
7-9 14.6 8.9 45 7.9 3.5 46
10-12 20.1 10.0 39 8.3 2.9 40
13+ 22.6** 10.3 19 8.7 4.2 19
Impairment
Mild 19.5 10.1 46 9.5 3.5 46
Moderate 14.9 9.4 105 8.1* 3.5 108
Total N 16.3 9.8 152 8.5 3.5 155

Note. Values for fluency tasks are compared vertically, in table columns, according to age, gender, and education,
and impairment.
a The values are the total number of words beginning with specified letters reported orally in three I-min trials.
The values are the number of animal names reported orally in 1-min.
p < .05. ** p c .001.

Table 4. Letter and Category Fluency Performance for Community-Dwelling Cognitively-Normal Elderly and
for Elderly with Dementia of the Alzheimer or Vascular Type at Mild and Moderate Levels of Impair-
ment.

Fluency Task

FAS' (letter fluency) Animal Namingb (category fluency)

Group M SD n M SD n

Normals 25.0' 11.6 628 13.8** 4.0 635

Alzheimer
Mild' 19.5 10.1 46 9.5 3.5 46
Moderated 14.9 9.4 105 8.1 3.5 108
Vascular
Mild 18.3 10.1 14 8.4 2.8 13
Moderate 13.2 8.0 25 8.2 3.4 25

Note. Values for fluency tasks are compared vertically, in table columns, according to cognitive group and level
of impairment.
a The values are the total number of words beginning with specified letters reported orally in three 1-min trials.
The values are the number of animal names reported orally in 1 min.
Mild impairment refers to 3MS scores > 70.
Moderat:*impairment refers to 3MS scores I 70.
p < .01. p < .001.
 LETTER AND CATEGORY FLUENCY IN THE CSHA 59

than the normal participants while performing
letter fluency, F(2,714) = 38.57, p < .001, and
category fluency, F(2,714) = 97.12, p < .001,
tasks. In summary, both fluency measures suc-
cessfully distinguished between the cognitively
normal group and the two dementia groups at
both mild and moderate levels of impairment,
but failed to differentiate DAT from vascular
dementia at either impairment level. Level of
performance on the two tasks was significantly
correlated for normal participants (Spearman’s
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both measures to standard scores (i.e., z scores),
expressed in standard deviations from the mean
of the normal seniors’ performance (see Figure
1). A 2 (DAT vs. vascular dementia) x 2 (mild
vs. moderate severity) x 2 (letter vs. category
fluency) ANOVA was performed on these stan-
dard scores. A significant main effect for level
of severity, F(1, 374) = 1 3 . 8 5 , <
~ .001, revealed
that moderately impaired participants performed
more poorly than mildly impaired participants
for both fluency tasks, regardless of diagnosis.

rho = .44, p < .001), for those with DAT (Spear-
man’s rho = .29, p < .OOl), and for those with
vascular dementia (Spearman’s rho = .36, p =
.014).
Letter Versus Category Fluency in DAT and
Vascular Dementia
Letter and category scores were directly com-
pared by converting each participant’s score on
A significant main effect for fluency task, F(1,
374) = 44.17, p < .001, confirmed that category
fluency was significantly more affected than
letter fluency at both mild and moderate levels
of impairment, regardless of diagnosis. There
were no significant effects for dementia type
(DAT vs. vascular dementia), nor were there any
significant interactions among the three factors.

0 LETTER
1 CATEGORY

-1

-2 I I I I
MILD DAT MOD DAT MILD VASC MOD VASC

Standard scores of participants with mild dementia of the Alzheimer type (Mild DAT), moderate de-
mentia of the Alzheimer type (Mod DAT), mild vascular dementia (Mild Vasc), and moderate vascular
dementia (Mod Vasc) on letter and category fluency tasks.
 60 MARGARET CROSSLEY ET AL.
DISCUSSION
The CSHA provided neuropsychological data
for a large, stratified random sample of commu-
nity-dwelling, cognitively normal elderly indi-
viduals. Consistent with past research, the cate-
gory fluency task (Animal Naming) was found
to be age-sensitive. The performance of the old-
est age group was significantly lower than the
performance of the moderately-old and young-
old groups. In contrast, the letter word fluency
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(FAS) task was age-stable. Females performed
better than males on the letter fluency task, but
there was no significant gender difference on the
category task. Taken together, these differential
findings provide some additional support for the
thesis that letter and category fluency tasks are
measuring unique aspects of language, and may
have different brain-based substrates that deter-
mine their vulnerability to the effects of normal
aging.
Educational level had a significant effect on
the performance of normal seniors for both the
letter and category naming tasks. Since 50% of
the elderly participants reported less than nine
years of formal education, and 21% had five or
fewer years of schooling, the importance of con-
sidering this demographic variable is clear. In
contrast to these data, studies of normal elderly
are typically based on convenience samples that
are frequently biased in the direction of relati-
vely high education and socioeconomic levels.
The relatively large sample of individuals
with DAT allowed an investigation of the effects
of age, gender, education, and level of impair-
ment (i.e., mild or moderate) on fluency perfor-
mance in the DAT group. Age and gender did
not influence performance of DAT participants
on either fluency measure. Educational level
significantly influenced performance on the let-
ter fluency task, but not on the category fluency
task. Interestingly, highly educated participants
with DAT performed similarly on the letter flu-
ency task to cognitively normal participants with
low levels of formal education. In contrast, on
the category task, even the most highly educated
participants with DAT performed well below the
level of the least well educated normal partici-
pants. Similarly, participants with dementia per-
formed significantly more poorly on the cate-
gory compared to the letter fluency task at both
mild and moderate levels of impairment. Consis-
tent with other studies (Butters et al., 1987;
Monsch et al., 1992), these results suggest that
category fluency may be particularly sensitive to
the effects of dementia, even in the earliest
stages, and may be useful in staging the progres-
sion of the illness. The usefulness of the cate-
gory fluency task is enhanced by its relative in-
sensitivity to the effects of education, age, and
gender among individuals with DAT. In con-
trast, interpretation of performance on the letter
fluency task must take into account the effects
of educational level that is highly significant for
both normal older individuals and those with
DAT.
One goal of this study was to examine the
ability of the letter and category fluency tasks to
differentiate those with DAT from vascular de-
mentia at mild and moderate stages of impair-
ment. Although the relatively small sample of
individuals with vascular dementia in the CSHA
may have limited our investigation, these results
suggest that category and letter fluency tasks are
sensitive to dementia and level of impairment,
regardless of type, but are unable to distinguish
DAT from vascular dementia.
In summary, these data provide some addi-
tional support for the thesis that category and
letter fluency tasks measure unique aspects of
cognition. In particular, syntactical or phonolog-
ical knowledge (required for letter fluency) may
be less affected than semantic knowledge (re-
quired for category fluency), both by normal
aging and by early-stage dementia. Consistent
with this thesis is the proposition that syntactical
and semantic knowledge systems may have dif-
ferent underlying biological substrates. Alter-
nately, fluency tasks may differentially draw
resources from a limited capacity store that is
affected both by normal aging and by dementia.
In any case, letter and category fluency did not
differentiate DAT and vascular dementia, sug-
gesting that both forms of dementia may simi-
larly affect the brain-based processes underlying
these tasks.
 LETTER AND CATEGORY FLUENCY IN THE CSHA
REFERENCES
American Psychiatric Association (1987). Diagnostic
and statistical manual of mental disorders (3rd ed.
rev.). Washington, DC: Author.
Bayles, K. A., & Kaszniak, A. W. (1987). Communi-
cation and cognition in normal aging and demen-
tiu. Austin: Pro-Ed.
Bayles, K. A., Salmon, D. P., Tomoeda, C. K., Jacobs,
D., Caffrey, J. T., Kaszniak, A. W., & Troster, A.
I. (1989). Semantic and letter category naming in
Alzheimer’s patients: A predictable difference.
Downloaded by [University of California Santa Cruz] at 08:07 16 November 2014
Developmental Neuropsychology, 5, 335-347.
Bayles, K. A., Tomoeda, C.K., & Trosset, M. W.
(1993). Alzheimer’s disease: Effects on language.
Developmental Neuropsychology, 9, 131-160.
Benton, A. L., Eslinger, P.J., & Damasio, A. R.
(198 1). Normative observations on neuropsycho-
logical test performances in old age. Journal of
Clinical Neuropsychology, 3, 33-42.
Benton, A. L., & Hamsher, K. deS. (1989). Multilin-
gucil Aphasia Examination: Manual of Instructions
(2nd ed.). Iowa City: AJA.
Bolla, K. I., Lindgren, K. N., Bonaccorsky, C., &
Bleecher, M. L. (1990). Predictors of verbal flu-
ency (FAS) in the healthy elderly. Journal of Clini-
cal Psychology, 46, 623-628.
Butters, N., Granholm, E., Salmon, D. P., Grant, I., &
Wolfe, J. (1987). Episodic and semantic memory:
A comparison of amnesic and demented patients.
Journal of Clinical and Experimental Neuropsy-
chology, 9, 479-497.
Canadian Study of Health and Aging Working Group
(1994a). The Canadian Study of Health and Aging:
Study methods and prevalence of dementia. Cana-
dian Medical Association Journal, 150, 899-9 13.
Canadian Study of Health and Aging Working Group
(1994b). The Canadian Study of Health and Aging:
Risk factors for Alzheimer’s Disease in Canada.
Neurology, 44,2073-2080.
Canadian Study of Health and Aging Working Group
(1994~).Patterns of caring for people with demen-
tia in Canada. Canadian Journal ofAging,l3,470-
487.
Goodglass, H., & Kaplan, E. (1972). Assessment of
aphasia and related disorders. Philadelphia: Lea &
Febiger.
Hart, S., Smith, C. M., & Swash, M. (1988). Word
fluency in patients with early dementia of Alzhei-
mer type. British Journal of Clinical Psychology,
27, 115-124.
Hartman, M. (1991). The use of semantic knowledge
in Alzheimer’s disease: Evidence for impairments
of attention. Neuropsychology, 29, 213-228.
Huff, F. J., Corkin, S., & Growdon, J. H. (1986). Se-
mantic impairment and anomia in Alzheimer’s dis-
ease. Brain and Language, 28, 235-249.
61
Jorm, A. F. (1986). Controlled and automatic infor-
mation processing in senile dementia: A review.
Psychological Medicine, 16, 77-88.
Kemper, S. (1992). Language and aging. In F. I. M.
Craik & T. A. Salthouse (Eds.), The handbook of
aging and cognition (pp. 213-270). Hillsdale, NJ:
Lawrence Erlbaum.
Kolb, B., & Whishaw, I. Q. (1996). Fundamentals of
human neuropsychology (4th ed.). New York:
Freeman.
Lezak, M. D. (1995). Neuropsychological assessment
(3rd ed.). New York: Oxford University Press.
MargoIin, D. I., Pate, D.S., Friedrich, F. J., & Elia, E.
(1990). Dysnomia in dementia and in stroke pa-
tients: Different underlying cognitive deficits.
Journal of Clinical and Experimental Neuropsy-
chology, 12, 597-612.
Martin, A., & Fedio, P. (1983). Word production and
comprehension in Alzheimer’s disease. Brain and
Language, 19, 124-141.
McKhann, G., Drachman, D. A., Folstein, M. F.,
Katzman, R., Price, D., & Stadlan, E. M. (1984).
Clinical diagnosis of Alzheimer’s Disease: Report
of the NINCDS-ADRDA work group under the
auspices of the Department of Health and Human
Services Task Force on Alzheimer’s Disease. Neu-
rology, 34, 939-944.
Monsch, A. U., Bondi, M. W., Butters, N., Salmon, D.
P., Katzman, R., & Thal, L. J. (1992). Comparisons
of verbal fluency tasks in the detection of dementia
of the Alzheimer type. Archives of Neurology, 49,
1253-1258.
Monsch, A. U.,Bondi, M. W., Butters, N., Paulsen, J.
S., Salmon, D. P., Brugger, P., & Swenson, M. R.
(1994). A comparison of category and letter flu-
ency in Alzheimer’s disease and Huntington’s dis-
ease. Neuropsychology, 8, 25-30.
Moscovitch, M. (1994). Cognitive resources and dual-
task interference effects at retrieval in normal peo-
ple: The role of the frontal lobes and medial tem-
poral cortex. Neuropsychology, 8, 524-534.
Nicholas, M., Obler, L., Albert, M., & Goodglass, H.
(1985). Lexical retrieval in healthy aging. Cortex,
21, 595-606.
Ober, B. A., Dronkers, N. F., Koss, E., Delis, D. C., &
Friedland, R. P. (1986). Retrieval from semantic
memory in Alzheimer-type dementia. Journal of
Clinical and Experimental Neuropsychology, 8,
75-92.
Pasquier, F., Lebert, F., Grymonprez, L., & Petit, H.
(1995). Verbal fluency in dementia of frontal lobe
type and dementia of Alzheimer type. Journal of
Neurology, Neumsurgev, and Psychiatry, 58, 8 1-
84.
Perlmuter, L. C., & Tun, P. (1987). Age and diabetes
related changes in verbal fluency. Experimental
Aging Research, 13, 9-14.
Randolph, C., Braun, A. R., Goldberg, T. E., & Chase,
T. N. (1993). Semantic fluency in Alzheimer’s,
 62 MARGARET CROSSLEY ET AL.
Parkinson’s,and Huntington’s disease: Dissocia-
tion of storage and retrieval failures. Neuropsycho-
logy, 7, 82-88.
Rosen, W. G . (1980). Verbal fluency in aging and de-
mentia. Journal of Clinical Neuropsychology, 2,
135-146.
Ska, B. (1993). Quelques observations a propos de
modifications lexico-semantiques lors du vieilliss-
ement normal. (1993). Revue de Neuropsychologie,
3, 157-180.
Spreen, O., & Benton, A. L. (1977). Neurosensory
centre comprehensive examination for aphasia:
Manual of instructions. Victoria, B.C.: University
Downloaded by [University of California Santa Cruz] at 08:07 16 November 2014
of Victoria.
Stem, Y., &Richards, M. (1993). Comparison of cog-
nitive changes in patients with Alzheimer’s and
Parkinson’s disease. Archives of Neurology, 50,
1040-1045.
Teng, E. L., & Chui, H. C. (1987). The modified
Mini-Mental State (3MS) Examination. Journal of
Clinical Psychiatry, 48, 314-318.
Tomer, R., & Levin, B. E. (1993). Differential effects
of aging on two verbal fluency tasks. Perceptual
and Motor Skills, 76, 465-466.
Troster, A.I., Salmon, D. P., McCullough, D., & But-
ters, N. (1989). A comparison of the category flu-
ency deficits associated with Alzheimer’s and
Huntington’s disease. Brain and Language, 37,
500-513.
Tuokko, H., Kristjansson, B., & Miller, J. (1995).
Neuropsychological detection of dementia: An
overview of the neuropsychological component of
the Canadian Study of Health and Aging. Journal
of Clinical and Experimental Neuropsychology,
17,352-373.