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Current Aging Science, 2019, 12, 00-00 1
SYSTEMATIC REVIEW ARTICLE

A Hypothetical Link Between Verbal Fluency and Functionality in Aging:

A Systematic-review and Paths for Future Research

José R. Wajman1,*

1
Behavioral Neurology Sector, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNI-
FESP), Brazil

Abstract: Background: Verbal fluency (VF) tasks are known as multimodal measures clinically
useful for monitoring cognitive decline during the aging process. Considering that the executive
control observed along VF tasks calls for a set of functions directing the behavior toward a general
goal, it may be assumed that there is a correspondence between VF ability and functional capacity
(FC).
Methods: With this assumption in mind, the author aimed at performing literature research on VF
ARTICLE HISTORY
ability and FC within aging.

Received: July 20, 2019

Revised: August 20, 2019
Accepted: August 28, 2019
DOI:
10.2174/1874609812666190917151043
Keywords: Neuropsychology, cognition, verbal fluency, executive functions, functional capacity, aging.
Results: Only four studies whose title/abstract presented the target key-terms, partially fulfilled the
adopted criteria and were selected for discussion. Taken together, these articles attempted to corre-
late cognitive material to aspects of functionality, one of which not doing so directly with the eld-
erly and another with no specific association with VF abilities.
Conclusion: Theories suggest that VF might be associated with complex executive mechanisms.
Still, a theoretical scheme and controlled researches possibly able to shed light on the underlying
balance among the VF abilities and functionality within aging are, as yet, unknown.

1. INTRODUCTION of executive mechanisms [5]. Findings further suggest that

Verbal fluency (VF) tasks are known as multimodal
measures clinically useful to monitor cognitive decline dur-
ing the aging process [1]. Concisely, VF tests are time-
saving, economical, reliable, and ecological, providing valu-
able information about semantic memory, lexical access abil-
ity, executive strategies (e.g. initiation, efficient intrinsic
organization, and self-monitoring), attention-shifting, and
processing speed [2]. In turn, functional capacity (FC) may
be defined as one’s ability to maintain physical and mental
integrity, being able to live without assistance for basic and
instrumental activities of daily living (BADL and IADL) [3].
Functionality is a multifactorial product of the aging process,
including sensory perception loss, impaired mobility, and
increased frailty risk leading to BADL/IADL restrictions [4].
However, there is a dearth of research regarding FC during
the aging course in terms of its relationships with cognitive
resources.
Considering that the executive control observed along VF
tasks requires a set of functions regulating one’s thoughts
and direct behavior toward a general goal, there is a concep-
tual assumption that VF abilities might demand a wide range
*
Address correspondence to this author at the Rua Itapeva 518, conjuntos:
401-402. Bela vista. São Paulo - SP. Zip code: 01332-000, Brazil;
E-mail: jrwajman@gmail.com
all fluency tasks (semantic, phonological and verbal) involve
executive control to some degree, while those with an added
executive component (e.g., switching and shifting between
internal subcategories) are less dependent on semantic
knowledge, ultimately being more related to superior cortical
functions, such as the supervisory attentional system, a con-
tention scheduling, and strategy activation [6]. Still, a theo-
retical scheme possibly explaining the underlying balance
among the VF abilities and functionality within aging is un-
known to date.
Considering a potential synergy between neuropsy-
chological domains broadly taken as cognition and function-
ality, and given that it is not clear which components of ex-
ecutive control most strongly impact performance through-
out fluency tasks, the present systematic review aimed at
performing a literature research on VF ability and FC during
the aging process, in an attempt to identify underlying asso-
ciations between these constructs, as hypothesized in
Fig. (1).
2. METHODS
2.1. Selection of Studies
For this study, a computerized search for VF and FC
within aging was systematically conducted in MED-
LINE/PubMed database from January 1980 until 2018. A

1874-6098/19 $58.00+.00 © 2019 Bentham Science Publishers

2 Current Aging Science, 2019, Vol. 12, No. 0
Fig. (1). Hypothetical synergy between cognition and functionality.
systematic search of English articles was conducted as fol-
lows: verbal fluency AND functional capacity AND ag-
ing/ageing. The concepts for the present research once estab-
lished, the following MeSH descriptors (variants) were com-
bined to aging/ageing: “verbal fluency” OR “verbal fluency
ability” OR “verbal fluency tasks” OR “semantic verbal flu-
ency” OR “phonemic verbal fluency” OR “action fluency”
OR “verb fluency”, AND “functional capacity”. Search
variations for functional capacity were as follows: “func-
tionality” OR “capability”. In addition, hand searching of
references and prior citations were also performed.
Finally, papers meeting the eligibility criteria (quality
index considering aspects of methodology, selection of sam-
ples, comparability of populations, adopted diagnostic crite-
ria, and clinical instruments used) were descriptively ana-
lyzed with regard to their importance to the topic, main re-
sults and final discussion. These articles were then exported
to Mendeley Software (1.17.10), where all the manuscripts
were analyzed according to the adopted criteria. Methodo-
logical searching was performed by the main researcher
(JRW). The final compilation of the searches was illustra-
tively converted into a PRISMA flow diagram (Fig. 2).
3. RESULTS
As expected, even the expanded search revealed a limited
amount of studies in this field of research. As a matter of
fact, seeking to cross VF (of any modality) with aspects of
FC within aging, no indexed study was found to be in the
adopted platform. However, four papers (Table) partially
fulfilled the inclusion criteria admitted for this research and
these, given the absence of studies based on the initial objec-
tives of this review, will be presented and discussed below.
3.1. Study 1
The first article [7] main goal was to investigate whether
or not the performance in different cognitive domains could
longitudinally predict life satisfaction (LS) in an elderly
sample. Measured through a self-reported quality of life
scale, authors considered LS to be the result of five compo-
nents: initiative, resolution, achieved goals, self-concept, and
mood. Main findings suggest a significant correspondence
José R. Wajman
between both, phonological and semantic verbal fluency [11]
and LS three-years on. Employing linear regression models,
authors ascribe the positive correlations among cognition and
LS to the processing speed performance achieved both at
baseline and during follow-up.
3.2. Study 2
The second article [8] examined the effects of a gist rea-
soning training in cognitively normal seniors between the
ages of 64-85 years. Authors’ main goal rested upon the as-
sumption that high-order cognitive skills possibly maximize
the cognitive capacity in later life. As part of the gist reason-
ing program, four strategies were included in the training:
inhibiting unimportant information, organizing by focusing
on concepts, inferencing, and generalizing (integrating data
into the context). Findings suggest that the top-down strat-
egy-based training significantly improved abstraction ability
measured through the Similarities Test [12] (p = 0.04), the
cognitive switching weighted by part B of the Trail Making
Test – TMT [13] (p = 0.02), and the phonological verbal
fluency [14] (p = 0.002) highlighting the value of engaging
in cognitive activities in later-life.
3.3. Study 3
The third article [9] studied the relationship between
adaptive life skills (ALS) comparing The Performance-
Based Skills Assessment – UCSD [15] with objective scor-
ing on neuropsychological tests of older (age 50-85) schizo-
phrenia patients. Authors conclude that neuropsychological
scores do not independently predict ALS. On the other hand,
according to the main outcomes, real-world ALS (e.g., inter-
personal skills, work skills, and community activities) may
be predicted in conjunction with cognitive performance,
mood symptoms, and FC between these individuals. For the
present study, a composite cognitive score was calculated
and there was no specific association with VF abilities.
3.4. Study 4
In the fourth study [10], authors administered a battery of
neuropsychological tasks assessing broader cognitive abili-
ties and executive functions (e.g., verbal fluency, working
A Hypothetical Link Between Verbal Fluency and Functionality in Aging
Fig. (2). PRISMA flow diagram of the systematic search.
memory, and response inhibition) to 25 patients with
Huntington’s disease (HD) and 20 healthy controls. Re-
searchers looked to investigate the effect of cognitive deficits
on patients’ daily functioning. Results show that patients
with HD exhibited deficits on all timed neuropsychological
tasks but not on measures of accuracy. Poorer functional
capacity [16] was related to cognitive deficits, and category
fluency scores alone predicted 54% of the variance in func-
tional capacity. Authors also highlight that performance on
neuropsychological tasks may be influenced by motor and/or
psychiatric symptoms among these patients.
Considering only the “verbal fluency” AND “functional
capacity” terms, twelve articles were found, four of which
being part of the material presented above and another four
articles not related to the core theme suggested for this sys-
tematic review (e.g., motor symptoms, sympathetic skin re-
sponse, transcranial direct current stimulation, and clinical
trial in HD). Even though, taken together, the four papers
presented above attempted to correlate cognitive material to
Current Aging Science, 2019, Vol. 12, No. 0 3
aspects of functionality, one of which not doing so directly
with the elderly [10] and another with no specific association
with VF abilities [9].
CONCLUSION
The present study proposed a systematic search for spe-
cialized literature on VF ability and FC during the aging
process, through the most renowned database available in the
medical-scientific scenario. Authors’ main assumption re-
ferred to the possible correspondence between verbal ability
(based on executive functions prerequisites) and aspects of
functionality, as a predictive hallmark with advancing age.
Regrettably, despite the importance of the matter, virtually
nothing was found that could objectively base the hypotheses
through controlled studies, by means of verification proce-
dures.
Albeit preliminarily, results from studies included in this
review suggest that cognition and functionality share certain
aspects that could be possibly driven by the influence of ex-
4 Current Aging Science, 2019, Vol. 12, No. 0 José R. Wajman

Table 1. Articles partially related to the correspondence between verbal fluency ability and functional capacity within aging.

First Author [ref], Enkvist Å [7], 2013, Eddy CM [10], 2015, United
Anand R [8], 2011, USA Bowie CR [9], 2006, USA
Year, Country Sweden Kingdom

Explore whether abilities
in six different cognitive
Study main objective
domains could predict life
satisfaction 3 years latter
Test the effectiveness of cogni-
tive training that target higher-
order cognitive skills to maxi-
mize cognitive capacity
Investigate the relationship be-
Investigate the effect of cogni-
tween adaptive life skills and
tive deficits on Huntington’s
performance on neuropsy-
disease daily functioning
chological tests

20 healthy controls (Mean age

681 individuals (Mean age 26 cognitively normal seniors 78 patients with Schizophrenia
Sample characteristics = 49 years) and 25 HD pa-
= 83 years) (Mean age  =  74 years) (Mean age = 58 years)
tients (Mean age = 54 years)

Included verbal flu- (+) Letter and Category (+) Letter and Category (+) Letter and Category
(+) Category fluency
ency assessment (+/-) fluencies fluencies fluencies

Included functional (+) Unified Huntington’s

(+) Performance-Based Skills
capacity assessment (-) (-) Disease Rating Scale -
Assessment - UCSD
(+/-) UHDRS

The training significantly im-

Significant correlations
between all verbal fluency
Main outcome(s)
modalities and processing
speed with life satisfaction
proved abstraction ability as
Neuropsychological performance Poorer functional capacity was
well as measures of executive
predicted functional capacity related to cognitive deficits
function including verbal flu-
ency

Mixed urban and rural Patients involved in rehabilita-

Motor and psychiatric symp-
living participants, school- No control group or neutral tion programs, negative and
toms may have influenced the
Comments ing variation, missing conditions, small sample and depressive symptoms influenced
results, concomitant use of
partial data, and high non-random sampling design performance, and concomitant
medications and sample size
drop-out rate use of medications

ecutive mechanisms not fully understood yet. Main out-
comes may implicate in a probable interface between differ-
ent domains of human behavior already demonstrated in the
literature. Consistent with these observations, neuroimaging
data have demonstrated the involvement of overlapping, but
not identical brain circuits [17]. In this study, the author
showed that additional analyses of executive control abilities
to VF performance could be gleaned by scoring not only the
number of correct responses but also the timing of the re-
sponses (a proceeding driven by the self-control in starting,
maintaining and achieving the goals inherent to the task).
According to cognitive theories preconized in basic psy-
chology, there are at least two systems that could shed some
light on this subject: working memory – WM [18] and the
hybrid model – HM [19]. WM construct combines elements
of the processing of information with the storage of interme-
diate traits of that series of actions. In essence, this mecha-
nism is crucial to higher level cognition because measures of
WM capacity reliably predict performance in a wide variety
of ecological tasks. In turn, HM refers to sub-modules of
mental information processing, once termed “cognits”. Cog-
nits might be understood as portions of memory, which are
organized as widely distributed neural sub-networks insepa-
rably associated with others [20]. In theory, at its highest
level, cognitive combined to previous experience will pro-
mote hetero-modal frontal, parietal and temporal associa-
tions, representing complex networks, and ultimately hosting
higher conceptual concepts.
Alternatively, researchers have suggested the concept of
brain reserve to describe some individuals with an increased
‘‘baseline adaptive neuroplasticity’’ [21]. These authors have
hypothesized that brain reserve may have neuroprotective
effects against psychiatric symptoms later, during the aging
process. In addition, other researchers have pointed to the
effect of potentially neuroinflammatory conditions closely
linked with multiple neurodegenerative pathways and their
impact on late-life functionality, recovering this relationship
between cognitive reserve and brain reserve [22]. Some at-
tempts were also made in search of possible associations
between cognition and functionality among the elderly. A
cross-sectional study involving 461 elderly subjects has
found that functional cognitive impairment is a prevalent
condition in Brazilian community-dwelling older adults and
its occurrence is associated with age, number of drugs used,
and vascular morbidities [23].
Although the vast majority of these studies did not spe-
cifically focus on verbal fluency abilities (as observed along
the present systematic literature search), in a test of verbal
fluency, authors have found that children tended to activate
cortex - more specifically right inferior frontal gyrus - more
widely than adults, but activation patterns for fluency appear
to be established by middle childhood. In this scenario,
Functional Magnetic Resonance Imaging (fMRI) using ver-
bal fluency paradigms may be applied to compare popula-
tions for determining possible links between language abili-
ties and brain capacity also in future studies including older
people [24].
A Hypothetical Link Between Verbal Fluency and Functionality in Aging Current Aging Science, 2019, Vol. 12, No. 0 5

From a neurocognitive point of view, illustratively, there ment of these ability areas becomes a critical step in view of
is an assumption that Action Fluency (AF) may reflect en- a more accurate understanding of these intricate neuropsy-
gaging motor representations during retrieval. The AF test chological mechanisms and their interrelationships.
requires that participants rapidly generate as many verbs
Nevertheless, to date, no available data in the specialized
(e.g., “things that people do” such as eat, run, or sleep) as literature explain in a satisfactory way the relationships be-
possible within a 60-sec time limit. In this sense - although
tween complex cognitive abilities (such as VF) and FC, dur-
the following article does not meet the present review crite-
ing the aging process. The scant articles partially fulfilling
ria, authors have suggested that impaired AF may adversely
the present review criterion sought, in their own way, to cor-
impact BADL/IADL by disrupting the production and orga-
relate cognitive functions and functionality by means of per-
nization of script-based action schemas upon which success-
centage of variation, training programs or even through
ful performance depends [25]. Employing different modali- mathematical predictive models. These results suggest that,
ties of VF along with a self-report measure of BADL/IADL
at least, some headway has already been made in this field of
[26] in a sample of young adults with human immunodefi-
research. Future experimental studies would eventually pro-
ciency virus type 1 (HIV-1), enrolled in a neuroAIDS study,
vide new insights that may clarify the underlying balance
these authors found that Individuals with impaired AF per-
among the VF abilities and functionality within aging, in
formance had a fivefold risk of concurrent IADL dependence
view of a better approach to this population.
as compared to those with normal cutoffs.
Amidst the academic discussion of the differences and LIST OF ABBREVIATIONS
similarities between cognition and functionality, the concept
of cognitive abilities - CA (or skills) emerges. CA are brain- AF = Action Fluency
based skills necessary to carry out different tasks from the ALS = Adaptive Life Skills
simplest to the most complex. CA have more to do with en-
grams of how to adequately solve a problem, than with any BADL = Basic Activities of Daily Living
actual knowledge. For instance, answering the phone call CA = Cognitive Abilities
involves: perception (perceiving the ring tone), making the
FC = Functional Capacity
decision (answering or not), motor abilities (lifting the re-
ceiver), language principles (talking and understanding), and fMRI = Functional Magnetic Resonance Imaging
social-based skills (interpreting the tone of voice and inter- HD = Huntington’s Disease
acting). To focus neural resources according to the contin-
gencies of the moment, both bottom-up and top-down sys- HIV-1 = Human Immunodeficiency Virus Type 1
tems share a common neural apparatus, the frontoparietal HM = Hybrid Model
network, with regard to processes mediating the guidance of
attention based on prior knowledge, willful plans, and cur- IADL = Instrumental Activities of Daily Living
rent goals [27]. Hence, in spite of their individual particulari- LS = Life Satisfaction
ties, cognition and functionality apportion neural substrates
that must, therefore, be better understood. TMT = Trail Making Test

Future studies involving the triad: verbal fluency skills, UCSD = The Performance-Based Skills Assessment
functionality and aging should take into account the use of VF = Verbal Fluency
specific and objective tools able to comprehensively and
satisfactorily access these neurocognitive mechanisms in WM = Working Memory
elderly populations, with and without neurodegenerative
conditions that may lead to cognitive decline and dementia, CONSENT FOR PUBLICATION
seeking a better understanding of these executive systems Not applicable.
and further potential ways to build and maintain brain pro-
tection against the inexorability of aging. FUNDING

LIMITATIONS None.

The scarcity of studies found in this review could ulti- CONFLICT OF INTEREST
mately be justified by the author’s choice of searching for
articles in only one data source (MEDLINE/PubMed). Nev- The author declares no competing interests.
ertheless, since this review encompasses a complex matter,
we opted for the incorporation of quality data from an in- ACKNOWLEDGEMENTS
dexed and reliable database rather than merely accumulating
The author would like to thank his university teachers
random information. Further studies with different age strata
and colleagues, who contributed to the betterment and
and contrasting brain-injured samples will help to clarify
building of this research.
these complex cognitive systems and their concurrence re-
garding FC, especially during the aging of the brain. Per-
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