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Repeat and Point, Differentiating semantic dementia from progressive non-fluent aphasia.
Repeat and Point, Differentiating semantic dementia from progressive non-fluent aphasia.
available at www.sciencedirect.com
Note
Article history: To determine whether a new, simple, quick measure, the Repeat and Point test, reliably
Received 17 January 2007 differentiates between semantic dementia (SD) and progressive non-fluent aphasia (PNFA).
Reviewed 29 May 2007 Fifteen patients with SD, six patients with PNFA and 18 healthy controls were adminis-
Revised 28 June 2007 tered the Repeat and Point test. Participants were required to repeat 10 multi-syllabic
Accepted 31 August 2007 concrete nouns and, following each repetition, to point to the word’s pictorial referent
Action editor Ria De Bleser amongst an array of six semantically and perceptually similar foils.
Published online 27 December 2007 Patients with SD were consistently impaired relative to PNFA patients and controls on
the comprehension (pointing) component of the task, whereas patients with PNFA showed
Keywords: no significant deficit on pointing but were impaired at the production (repeating) compo-
Semantic dementia nent. Discriminant function analysis confirmed perfect classification of the individual
Progressive non-fluent aphasia patients into their respective groups: criteria involving a ratio of the two scores are
Frontotemporal dementia provided.
The Repeat and Point test is particularly appropriate for routine use in a clinical context:
it is quick and easy to administer and score; it reliably discriminated between the two
patient groups, SD and PNFA; and it offers a simple rule of thumb, i.e., the Repeat-to-Point
ratio, to aid in the diagnosis of these two language variants of frontotemporal dementia
(FTD).
ª 2007 Elsevier Srl. All rights reserved.
5
Disclosure: the authors have reported no conflicts of interest.
* Corresponding author. Prince of Wales Medical Research Institute, Barker Street, Randwick, Sydney, NSW 2031, Australia.
E-mail address: j.hodges@powmri.edu.au (J.R. Hodges).
0010-9452/$ – see front matter ª 2007 Elsevier Srl. All rights reserved.
doi:10.1016/j.cortex.2007.08.018
1266 cortex 44 (2008) 1265–1270
In a pilot version of the test, participants were asked to to the ‘‘stethoscope’’, to minimise working memory demands.
define the repeated item prior to pointing at its pictorial ref- The experimenter/clinician can provide the target word
erent. A four point system was adopted for scoring defini- more than once at any stage of the test if the patient requests
tions according to the detail and specificity of the response it. In our assessment study, all sessions were tape-recorded
(from 0 ¼ incorrect, or no response, to 3 ¼ referent reliably for scoring of repetition attempts, but this is not necessary
identifiable from the verbal description given). After a num- for routine use of the test.
ber of attempts to refine and simplify the scoring criteria it
was decided to exclude this component from the final test. 2.4.1. Repeat
Both the PNFA and SD patients had difficulty generating def- Only the first repetition attempt was scored, and was given
initions, but for different reasons. For example, a PNFA pa- a score of 1 if correct and a score of 0 otherwise.
tient having difficulty expressing the meaning of a word,
such as caterpillar, might concurrently demonstrate an un- 2.4.2. Point
derstanding of the concept using pantomime, whereas an Participants were shown an array of seven pictures and asked
SD patient failing to define caterpillar accurately would to point to the target item named by the examiner, which was
rarely even attempt to gesture its meaning. As gesture was presented in a random location. All six foils were chosen to be
not part of the instruction, this could not ‘count’ for or semantically close to the target (e.g., for the target item ostrich
against a patient’s performance. Because the goal was to pro- all distractors were large wild birds), and in some cases, per-
duce a test with a simple scoring system, the (otherwise ceptually similar (see Fig. 1 for an example). Participants
rather fascinating) definition component of the test was were not given any feedback on their performance. Again,
dropped. only first responses were scored: 1 for a correctly identified
item, 0 otherwise.
2.4. Repeat and Point test administration
2.5. Statistical analyses
The final version of the Repeat and Point test takes between 5
and 10 min to complete. Each word is read aloud by the exam- Scores (percent correct) were analysed with three by two
iner for each task in turn, e.g., repeat ‘‘stethoscope’’ then point ANOVAs by both subjects (Fs) and items (Fi), with
Fig. 1 – An example from the pointing task. The participant is required to point to the ostrich (target) amongst the six
semantically related and, in some cases, perceptually similar foils.
1268 cortex 44 (2008) 1265–1270
a between-subjects and within-items factor of group (control, 3.3. Repeat and Point
SD, PNFA) and a within-subjects and within-items factor of
task (Repeat, Point). Significant interactions were followed- Performance of the three groups for each item is provided in
up by using paired-samples t-tests for the within-item anal- Table 3, with averaged data displayed in Fig. 2. Analyses
ysis and independent groups t-tests for the between-subjects revealed a highly significant group by task interaction by both
analysis. Discriminant function analysis was also used to in- subjects (Fs(2,36) ¼ 139.34, p < .0005) and items (Fi(2,18) ¼ 47.61,
vestigate how well the test discriminated between the two p < .0005). As predicted, performance (a) in the control group
patient groups. was at ceiling in both conditions, (b) in the SD group was signif-
icantly lower for Point than Repeat (ts(14) ¼ 12.82, p < .0005;
ti(9) ¼ 8.14, p < .0005), and (c) in the PNFA group was significantly
3. Results poorer for Repeat than Point (ts(5) ¼ 4.84, p ¼ .005; ti(9) ¼ 2.89,
p ¼ .018).
3.1. Demographics Multiple comparisons exploring the group effect for each
task revealed the following significant contrasts. For the Re-
The demographic characteristics of the patient and the control peat component, control > SD (ts(15) ¼ 2.67, p ¼ .017; ti(9) ¼ 2.44,
groups completing the Repeat and Point test are shown in p ¼ .038), control > PNFA (ts(5) ¼ 4.82, p ¼ .005; ti(9) ¼ 6.34, p <
Table 1. The groups did not differ in age at test (F(3,55) ¼ 1.77, .0005) and SD > PNFA (ts(6) ¼ 3.83, p ¼ .009; ti(9) ¼ 6.48, p <
p > .05) or years of education (F(3,43) ¼ .56, p > .05), and disease .0005). For the Point component, control > SD and PNFA > SD
duration did not significantly differ between patient groups (ts(5) ¼ 9.63, p < .0005; ti(9) ¼ 6.63, p < .0005) (ts(14) ¼ 14.33,
(t(18) ¼ 1.04, p > .05). p < .0005; ti(9) ¼ 8.80, p < .0005); PNFA patients differed from
controls only in the by-items but not the by-subjects analysis
3.2. General neuropsychology (ts(5) ¼ 1.92, p ¼ .111; ti(9) ¼ 5.93, p < .0005).
In order to explore whether a combination of Repeat and
As shown in Table 2, a series of independent groups t-tests Point scores would effectively classify patients as having
revealed that, consistent with their deficits in auditory verbal either SD or PNFA, we conducted a discriminant function
short-term memory and phonological processing (Hodges and analysis on the patient data. The discriminant function we
Patterson, 1996; Grossman et al., 1996; Croot et al., 1998; Tree obtained was as follows: y ¼ 1.916 þ (.057 Repetition)
et al., 2001), the PNFA group was only impaired relative to con- þ (.057 Point). The predictive capacity of this function was
trols on the measures of fluency (letter and category) and digit highly significant (c2 ¼ 35.34, p < .005) and accounted for
span (forwards and backwards). The SD patients, however, 100% of the available variance, indicating perfect classification
were impaired relative to controls on all measures except for of patients into their respective groups on the basis of the dis-
the copy of the Rey figure and the dot counting test. The SD criminant scores using the cut-off point of 1.916. Clinically,
patients were also impaired relative to the PNFA patients on this function may be applied in the following way. For some-
picture naming and word–picture matching, but, as expected, one obtaining equal scores on Repeat and Point, the ratio be-
performed significantly better than the PNFA patients on the tween the two scores would of course ¼ 1. In the present
non-word repetition test and the forward condition of the sample of SD patients, this ratio never fell below 1.25, and in
digit span test. the present sample of PNFA patients, this ratio never fell
above .9. Hence, for the ratio Repeat/Point, the rule PNFA < .9
and SD > 1.25 may be applied for patient classification
purposes.
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