Blackwell Publishing AsiaMelbourne, AustraliaPCNPsychiatry and Clinical Neurosciences1323-13162006 Folia Publishing Society2006604422428Original ArticleEffect of age and education on TMTR.

Hashimoto et al.

Psychiatry and Clinical Neurosciences (2006), 60, 422–428 doi:10.1111/j.1440-1819.2006.01526.x

Regular Article
Effect of age and education on the Trail Making Test and
determination of normative data for Japanese elderly
people: The Tajiri Project
RYUSAKU HASHIMOTO, phd,1,2 KENICHI MEGURO, md, phd,2,3 EUNJOO LEE, msc,1,2
MARI KASAI, phd,1 HIROSHI ISHII, md, phd1,4 AND SATOSHI YAMAGUCHI, md, phd2
Departments of 1Behavioral Neurology and Cognitive Neuroscience, and 3Geriatric Behavioral Neurology,
Tohoku University Graduate School of Medicine, Sendai, 2Tajiri SKIP Center, Tajiri and 4Kawasaki-Kokoro
Hospital, Kawasaki, Japan

Abstract The Trail Making Test (TMT) is a common two-part neuropsychological test, in which visuospatial
ability (TMT-A) and executive function (TMT-B) are evaluated. Normative data for this test have
not been reported for Japanese subjects; therefore, the purpose of the present paper was to inves-
tigate the effect of age and education on the TMT in 155 healthy elderly adults with clinical demen-
tia rating 0 (healthy). The participants were classified into three groups based on age (70–74 years,
75–84 years and ≥85 years), and also into three groups based on educational level (6 years, 8 years
and ≥10 years). The time to complete TMT-A and TMT-B were measured, and the difference in
score between TMT-A and TMT-B (B–A) and the ratio of the score (B/A) were calculated as indi-
ces of executive function. The time for completion of both parts of the TMT increased markedly in
the ≥85-years group. For TMT-A, there was a significant difference between the 6-years and 8-years
groups, and between the 6-years and ≥10-years groups, and for TMT-B, there was a significant dif-
ference between the 6-years and ≥10-years groups, and between the 8-years and ≥10-years groups.
The difference and ratio scores increased in the ≥85-years group, but the educational level did not
significantly influence these scores. Our data suggest that cognitive functions evaluated by TMT-A
and TMT-B are not affected by aging until the subjects are ≥85 years old. For TMT-A, an educa-
tional effect becomes apparent when the population includes poorly educated subjects, but this
part of the test is not affected by educational level provided that the subjects have some education
(>6 years). The time to complete TMT-B is affected by educational level, consistent with previous
reports. However, when adjusted using the results for TMT-A [(B-A) or (B/A)], the educational
effect on executive function disappeared. Thus, the effect of educational level on executive func-
tion was unclear in normal elderly subjects.

Key words aging effect, educational effect, normal aging, Trail Making Test.

INTRODUCTION general mental disorder,1,2 although recent studies

have suggested that subjects with MCI have mild
The concept of mild cognitive impairment (MCI) is of
impairment in executive function3,4 and visuospatial
importance in normal aging and dementia.1 Subjects
ability.5,6 Because mixing of MCI subjects with healthy
with MCI have some memory disorder, but no marked
elderly people may result in underestimation of the
ability of the healthy elderly, distinguishing healthy
elderly people from subjects with MCI is particularly
Correspondence address: Kenichi Meguro, MD, PhD, Department
important in determining normative data for cognitive
of Geriatric Behavioral Neurology, Tohoku University Graduate
School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575,
tests.7
Japan. Email: k-meg@umin.ac.jp The Trail Making Test (TMT) is a frequently used
Received 7 June 2005; revised 17 January 2006; accepted 22 screening test for brain damage or dementia. The TMT
January 2006. consists of parts A and B (TMT-A and TMT-B). The

© 2006 The Authors

Journal compilation © 2006 Folia Publishing Society
Effect of age and education on TMT
first, TMT-A, requires an individual to connect ran-
domly located numbers in numerical order as rapidly
as possible, whereas TMT-B contains both numbers
and letters, and the subject is required to connect the
numbers and letters alternately (e.g. 1-A-2-B-3-C). The
score on each part of the TMT is the amount of time
required to complete the task. The TMT-A score
reflects visual search ability and motor skills, whereas
the TMT-B score additionally reflects the ability for
cognitive alternation.8–10 Thus, the time for completion
of TMT-B is usually used as an index of executive
function.
The influences of age and educational level on the
time to complete the TMT have been widely reported.
Most studies have examined how age affects the time
to complete TMT-A and TMT-B;11–18 these studies have
concluded that the time for TMT completion increases
with age. In contrast, conclusions regarding the influ-
ence of educational level on the TMT have been incon-
sistent between studies; some studies have shown that
educational level affects both parts of the TMT,11–14,16,19
with the time for completion of TMT-A and TMT-B
being shorter for persons of higher educational level,
but four studies have found that education affects only
TMT-B.15,17,18,20 However, these latter studies included
participants with relatively high educational levels
only, suggesting that the effects in a population with
a relatively low educational level were not fully
investigated.
Because motor speed is affected by the aging pro-
cess,21 there may be effects of age on TMT-A and B.
However, simply regarding the TMT-B score as the
index of executive function may overestimate or
underestimate the effects of aging and educational
level. Thus, to adjust for the influence of motor speed
and visual search, we used the difference between
TMT-A and TMT-B (B–A) and the ratio (B/A) as indi-
ces of executive function in the present study. Using
this procedure, we were able to use TMT-B to evaluate
executive function more accurately. Hence, the pur-
pose of the study was to examine the influence of age
and educational effect on the time for TMT completion
and to assess executive function in healthy elderly
people, thereby obtaining normative TMT data for
Japanese subjects.
METHODS
Participants
Since 1988, we have been conducting a community-
based project on stroke, dementia, and bed-
confinement prevention in Tajiri, a typical agricultural
area in northern Japan (the so-called Tajiri Project).
423
Based on data from this project, we published the
results of a survey on the prevalence of dementia in
1998.22 Five years later, we provided an analysis of 284
subjects who were rated as healthy or as having ques-
tionable dementia using the Clinical Dementia Rating
(CDR) scale (CDR 0 and CDR 0.5, respectively).23,24
In the current study, neuropsychological tests were
conducted on these 284 subjects and their CDR was re-
assessed. A clinical team of medical doctors and public
health nurses, independent of those performing the
neuropsychological assessment, determined the CDR
in the following manner: (i) before the participants
were interviewed by doctors, public health nurses vis-
ited the participants’ homes to evaluate their daily
activities; (ii) observations by family members regard-
ing the participants’ lives were obtained using a semi-
structured questionnaire; (iii) the participants were
examined by doctors to assess episodic memory, orien-
tation and judgment; and (iv) with reference to the
information provided by family members, the doctors
and public health nurses held a joint meeting to deter-
mine the CDR for each participant.
Among the 284 participants, 160 subjects were rated
as CDR 0 (healthy) and were included in the assess-
ment of the effects of age and educational level on the
TMT test. The 160 subjects met the following criteria:
(i) they were assessed as normal from neurological and
psychiatric perspectives; (ii) they showed no signs of
active central nervous system or psychiatric conditions
that might adversely affect cognitive function; (iii) they
were not taking psychoactive medication; and (iv) they
had no past history of disorders which might have
affected cognition, such as head injury, alcohol or drug
abuse, or stroke. Demographic data for the subjects are
shown in Table 1. Ultimately, four of the 160 subjects
were unable to perform the TMT due to physical prob-
lems, and therefore 156 subjects were included in the
data analysis. Written informed consent was obtained
from all the participants and from their family mem-
bers, and the study was approved by the Ethics Com-
mittee of Tajiri.
Table 1. Study population
Age group (years)
70–74 75–84 ≥85
n 90 53 17
% female 53 57 65
Age (years) 72.1 ± 1.4 77.7 ± 2.6 87.7 ± 2.2
Years of education 8.9 ± 1.8 8.1 ± 1.7† 8.8 ± 1.9
†
Mean years of education of the 75–84-years group is
different from that of the 70–74-years group (P = 0.016).
© 2006 The Authors
Journal compilation © 2006 Folia Publishing Society
424 R. Hashimoto et al.

Tasks Analysis 2: educational effect

Trail Making Test-A and TMT-B were administered by
clinical psychologists and a trained occupational ther-
apist who were blinded to the CDR score. The tests
were conducted according to the standard adminis-
tration procedure described by Spreen and Strauss.25
During the tests, the examiner corrected each error
immediately. The time to complete each part of the
TMT was recorded, and raw time scores were used as
the dependent variables. In the Japanese version of the
TMT-B, the test is revised by changing letters from
the Roman alphabet (A B C . . .) into Kana letters
Kana is the Japanese phonogram. The
test–retest reliability for TMT-A and TMT-B was 0.737
and 0.595, respectively,18 and the time limits for per-
forming TMT-A and TMT-B were set at 180 s and 480 s,
respectively.
Analysis 1: aging effect
The 156 healthy elderly subjects were classified into
three groups according to age: 70–74 years (n = 88), 75–
84 years (n = 51), and ≥85 years (n = 17), respectively.
Using spss 11.5 J for Windows (spss Japan Inc., Tokyo,
Japan), analysis of covariance (ancova) was performed
to examine the effect of aging on the TMT, with the
educational level of the subjects used as a covariate.
The 156 subjects were classified into three groups
according to educational level: 6 years (n = 15), 8 years
(n = 101), and ≥10 years (n = 40). Based on the old
Japanese educational system, 6 years corresponds to
elementary school, 8 years corresponds to junior high
school, and ≥10 years corresponds to high school or
college. ancova in spss 11.5 J was performed to identify
the educational effect on the TMT, with the age of
subjects used as a covariate.
RESULTS
One subject exceeded the time limit for completing
TMT-A, and a second subject exceeded the time limit
for TMT-B. Eleven subjects (approx. 7% of all sub-
jects) could not perform the TMT-B because they
could not follow the rules for the test. Three of these
subjects were in the 6-years education group (20% of
the 6-years group) and eight were in the 8-years edu-
cation group (8% of the 8-years group).
Analysis 1: aging effect
The results of analysis 1 are given in Fig. 1. Both parts
of the TMT were affected by normal aging (TMT-A,
P = 0.002; TMT-B, P < 0.001). The time to complete

(a) (b) (c) (d)

110 375 300 5.5
* * * *
* * 5.0
100 * 325 250 *
4.5
275
Time (s)

90
Time (s)

Time (s)

200 4.0

80 225 150 3.5

3.0
70 175 100
2.5
60 125 50 2.0
70–74 75–84 85+ 70–74 75–84 85+ 70–74 75–84 85+ 70–74 75–84 85+

Age groups (years)

Figure 1. Means and standard errors for (a) Trail Making Test (TMT)-A, (b) TMT-B, (c) difference of the two scores and (d)
ratio of the two scores, *P < 0.05. (a) For TMT-A, ancova showed a significant effect of age (F = 6.687, P = 0.002), and the cova-
riate of years of education was significant (F = 10.757, P < 0.001). Post-hoc tests showed that the ≥85-years group was significantly
different from the 70–74-years (P < 0.001) and 75–84-years groups (P = 0.017). (b) For TMT-B, ancova also showed a significant
effect of age (F = 9.095, P < 0.001), and the covariate of years of education was significant (F = 7.155, P = 0.008). Post-hoc tests
showed that the ≥85-years group was significantly different from the 70–74-years (P < 0.001) and 75–84-years groups (P = 0.006).
(c) For the difference of the two scores, ancova showed a significant effect of age (F = 7.507, P < 0.001), and the covariate of years
of education was significant (F = 5.196, P < 0.024). Post-hoc tests showed that the ≥85-years group was significantly different from
the 70–74-years (P < 0.001) and 75–84-years groups (P = 0.003). (d) For the ratio of the two scores, ancova showed a significant
effect of age (F = 4.12, P = 0.018), but the covariate of years of education was not significant. Post-hoc tests showed that the ≥85-
years group was significantly different from the 70–74-years (P = 0.006) and 75–84-years groups (P = 0.01).

© 2006 The Authors

Journal compilation © 2006 Folia Publishing Society
Effect of age and education on TMT 425

both parts of the test was especially long in the ≥85-
years group. The difference and ratio scores were also
affected by normal aging (difference score: P < 0.001,
ratio score: P < 0.018) and were higher in the ≥85-years
group.
Analysis 2: educational effect
The results of analysis 2 are shown in Fig. 2. Both parts
of the TMT were affected by educational level (TMT-
A, P = 0.006; TMT-B, P = 0.027), and the time to com-
plete TMT-A was particularly long in the 6-years
group. There was no difference in the completion time
between the 8-years and ≥10-years groups. For TMT-B,
there was no difference in completion time between
the 6-years and 8-years groups, but the time to com-
plete TMT-B was shorter in the ≥10-years group.
Although the effect of educational level on the differ-
ence score was not significant, P approached statistical
significance (P = 0.056). The educational effect on the
ratio score was not significant (P = 0.309).
DISUCUSSION
A summary of the mean values and standard devia-
tions is given for each age and educational-level sub-
group for both parts of the TMT in Table 2. These are
normative TMT data for Japanese healthy elderly sub-
jects (CDR 0) in a population properly distinguished
from subjects with questionable dementia (CDR 0.5).
Significant aging and educational effects were found
for both TMT-A and TMT-B. Almost all healthy sub-
jects were able to perform TMT-A, while approxi-
mately 7% could not complete TMT-B.
In TMT-A, a person is required to connect randomly
arranged numbers as fast as possible, and the main cog-
nitive functions required for this part of the test are
rapid visual searching and motor speed. In TMT-B, the
subject is required to connect numbers and letters in an
alternate manner, which requires simultaneous reten-
tion of two sequences and flexible exchange between
these sequences. Therefore, the TMT-B score is
thought to reflect executive function, while the TMT-A
score reflects visuospatial function.
Previous studies have indicated that the time for
completion of the TMT is affected by aging, and that
the time for TMT-B completion is affected by educa-
tional level.11–20 There is inconsistency in previous
reports regarding the effect of educational level on
TMT-A times.
Aging effect on the TMT
Only limited normative TMT data are available for
older elderly people.15,17 The sample size in our ≥85-
years group was relatively small (n = 17), but subjects
with MCI were carefully excluded using the CDR
scale, and therefore we believe that our data are rep-
resentative of the functional ability of normal older
elderly people. We found that the times for completion
of the two parts of the TMT were affected by normal
aging, consistent with previous reports.11–18 The time for

(a) (b) (c) (d)

100 300 300 5.5
5.0
90 260 250
4.5
Time (s)
Time (s)

80 220
Time (s)

200 4.0

70 180 150 3.5

* 3.0
60 140 *
100
* * 2.5
50 100 50 2.0
6 8 10+ 6 8 10+ 6 8 10+ 6 8 10+

Educational levels

Figure 2. Means and standard errors for (a) Trail Making Test (TMT)-A, (b) TMT-B, (c) difference of the two scores and (d)
ratio of the two scores, *P < 0.05. (a) For TMT-A, ancova showed a significant effect of educational level (F = 5.259, P = 0.006),
and the covariate of age was significant (F = 18.187, P < 0.001). Post-hoc tests showed significant differences between the 6-years
and 8-years groups (P = 0.019) and between the 6-years and ≥10-years groups (P = 0.002). (b) For TMT-B, ancova also showed
a significant effect of education (F = 3.852, P = 0.024), and the covariate of age was significant (F = 18.699, P < 0.001). Post-hoc
tests showed a significant difference between the 6-years and ≥10-years groups (P = 0.017) and between the 8-years and ≥10-
years groups (P = 0.027). (c) For the difference of the two scores, ancova did not show a significant effect of education (F = 2.939,
P = 0.056), but the covariate of age was significant (F = 13.167, P < 0.001). (d) For the ratio of the two scores, ancova also did not
show a significant effect of education (F = 1.185, P = 0.308), but again the covariate of age was significant (F = 4.068, P = 0.046).

© 2006 The Authors

Journal compilation © 2006 Folia Publishing Society
426 R. Hashimoto et al.

Table 2. Normative data for the TMT in Japanese subjects

TMT-A time (s) TMT-B time (s)

Age group Years of
(years) education Mean ± SD n Mean ± SD n

70–74 6 83.1 ± 39.3 7 259.8 ± 97.0 5

8 63.4 ± 23.1 53 190.6 ± 86.0 49
≥10 57.3 ± 16.2 28 154.4 ± 71.7 27
Total 63.0 ± 23.5 88 182.8 ± 85.2 81
75–84 6 84.9 ± 29.8 7 234.7 ± 81.2 6
8 73.9 ± 26.0 35 229.1 ± 94.9 35
≥10 61.0 ± 22.0 8 182.0 ± 43.8 8
Total 73.3 ± 26.3 50 222.1 ± 87.6 49
≥85 6 121.0 ± 0. 1 295.0 ± 0. 1
8 89.7 ± 41.5 12 289.7 ± 96.8 9
≥10 75.0 ± 33.8 4 276.3 ± 112.8 4
Total 88.1 ± 38.8 17 286.2 ± 93.5 14
Total 6 86.5 ± 33.7 15 250.2 ± 82.3 12
8 70.2 ± 27.9 100 214.7 ± 94.6 93
≥10 59.8 ± 19.6 40 172.6 ± 79.1 39
Total 69.1 ± 27.5 155 206.2 ± 92.0 144

TMT, Trail Making Test.

An 80-year-old woman who had an 8-years education level could not finish within the time limit for TMT-A, and a 71-year-
old man who had a ≥10-years education level could not finish within the time limit for TMT-B.

completion of the TMT was markedly increased in the
≥85-years group (Fig. 1), suggesting that motor skills,
visual searching and executive function do not decline
very significantly in normal aging until the age of
85 years. Confirmation of this conclusion will require
accumulation of more data, including data for younger
adults.
Educational effect on the TMT
The mean time to complete TMT-A and TMT-B
decreased with higher educational level, consistent
with several previous reports.11–14,16,19 However, there is
controversy concerning the effect of educational level
on the TMT, especially for TMT-A, because other
reports have concluded that TMT-A is not influenced
by education, while still finding an influence on TMT-
B.15,17,18,20 It should be noted that the subjects in these
reports were highly educated; almost all had educa-
tional levels of ≥10 years. In contrast, the present pop-
ulation included subjects with education only up to the
elementary school level (6-years group).
The educational effects on TMT-A and TMT-B were
statistically significant for persons of low educational
level in the present subjects, but interestingly we did
not find a significant difference between the 8-years
and ≥10-years groups for TMT-A. Moreover, the mean
time to complete TMT-A was long, especially in the 6-
years group. Thus, one possible interpretation of these
data is that the threshold for influence on the TMT dif-
fers between educational levels. For TMT-A, the time
for completion may not be influenced by educational
level, provided that the subjects have at least some
education (>6 years). Therefore, for surveys targeted at
relatively highly educated participants, the influence of
educational level on TMT-A may not be detectable sta-
tistically. In contrast, a statistically significant differ-
ence in the time for completion of TMT-B was found
between educational levels 8 years and ≥10 years. This
result is consistent with previous reports, especially
those including highly educated subjects, and our data
confirm that highly educated persons (>8 years) are
likely to complete TMT-B in a shorter time than those
with less education.
Executive function
The results of analysis 1 showed that the aging effect is
significant after adjusting for the influence of motor
speed and visual search. Thus, the aging process clearly
affects executive function. Stuss et al. found a relation-
ship between TMT-B impairment and frontal lobe
damage, by comparing patients with damage to the
frontal and non-frontal regions with control subjects.26
Recently, Tisserand et al. reported a longitudinal study
using voxel-based morphometry, which showed that
the largest age-related decreases in gray matter in
healthy elderly people were found in the frontal lobe.27

© 2006 The Authors

Journal compilation © 2006 Folia Publishing Society
Effect of age and education on TMT
Thus atrophy or dysfunction in the frontal lobe may be
reflected by the TMT-B score, and hence may be an
index of executive function. In addition, our results
showed that the influence of aging is particularly
important in the ≥85 years age group.
In the present study we were unable to show a clear
educational effect on executive function, using both
the difference and the of the TMT-A and -B scores.
One of the possible explanations for this result is that
educational level did not affect executive function, as
measured by TMT-B, when the effects of motor speed
and visual searching ability were properly controlled.
Thus, our data may suggest that reduced TMT-B com-
pletion times for more educated subjects overestimate
the effect of educational level. Another possibility is
that although executive function is influenced by edu-
cational level, the effect might not have been detect-
able statistically because of the small sample size of the
low educational level group (n = 12). In addition, a rel-
atively large number of subjects with low educational
level (approx. 20% of the 6-years group) were unable
to complete TMT-B. However, differences in the indi-
ces of executive function were not found between the
8-years and ≥10-years groups, and hence further work
is needed to confirm the relationship between educa-
tion and executive function as measured by TMT-B.
ACKNOWLEDGMENTS
We are grateful to all staff members of the Tajiri SKIP
Center.
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