Dementia and Effort Test Performance

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Dementia and effort test performance

a
Andy C. Dean Ph.D. , Tara L. Victor , Kyle B. Boone , Linda M.

c
Philpott & Ryan A. Hess
Harbor-UCLA Medical Center , CA, USA
California State UniversityDominguez Hills , CA, USA
Huntington HospitalPasadena , CA, USA

Published online: 10 Jun 2009.
To cite this article: Andy C. Dean Ph.D. , Tara L. Victor , Kyle B. Boone , Linda M. Philpott & Ryan A.
Hess (2009) Dementia and effort test performance, The Clinical Neuropsychologist, 23:1, 133-152,
DOI: 10.1080/13854040701819050
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The Clinical Neuropsychologist, 23: 133152, 2009

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ISSN: 1385-4046 print/1744-4144 online
DOI: 10.1080/13854040701819050
DEMENTIA AND EFFORT TEST PERFORMANCE

Andy C. Dean1, Tara L. Victor2, Kyle B. Boone1,
Linda M. Philpott3, and Ryan A. Hess2
Downloaded by [University of North Carolina] at 20:24 07 October 2014
1
Harbor-UCLA Medical Center, 2California State UniversityDominguez Hills,
and 3Huntington HospitalPasadena, CA, USA
Research on the performance of patients with dementia on tests of effort is particularly

limited. We examined archival data from 214 non-litigating patients with dementia on 18
effort indices derived from 12 tests (WAIS-III/WAIS-R Digit Span and Vocabulary,
Dot Counting Test, Warrington Recognition Memory Test Words, WMS-III Logical
Memory, Rey Word Recognition Memory Test, Finger Tapping, b-Test, Rey 15-Item, Test
of Memory Malingering, Rey Auditory Verbal Learning Test, and Rey Complex
Figure Test). Results indicated that recommended cut-offs for Digit Span indicators
(Vocabulary Minus Digit Span and four-digit forward span time score) provided 90%
specificity across participants, while the majority of other effort tests displayed specificities
in the 3070% range. Analyses of test specificity as a function of Mini Mental Status
Examination (MMSE) score and specific dementia diagnosis are provided, as well as
adjustments to cut-offs to maintain specificity where feasible.
Keywords: Effort; Dementia; Malingering; Noncredible; Alzheimers; Geriatric.
INTRODUCTION
In some circumstances, older individuals may be motivated to feign symptoms
of dementia; for example, in evaluations for competency to stand trial in criminal
proceedings, and in personal injury cases involving toxic exposure, medical
malpractice (e.g., poor surgical outcomes), head injury, etc. However, literature
on the performance of dementia groups on tests of effort is particularly scant.
Patients with dementia are often excluded from effort test validation samples,
and even replication validity studies with mixed clinical samples typically include
few to no dementia participants. For effort test interpretation to be meaningful
with a potentially demented patient, data are needed regarding which effort tests
provide the lowest rate of false positive error, the relationship between severity
of dementia and false positive rates, and the extent to which effort cut-offs need to
be adjusted in dementia groups. Further, information regarding the typical
performance of dementia patients on effort tests is crucial: Should a patient with
a much less severe condition (e.g., mild head injury) perform similarly to patients
Address correspondence to: Andy C. Dean, Ph.D., Harbor-UCLA Medical Center,
Neuropsychology Dept., 1000 W, Carson Street, Box 495, Torrance, CA 90509, USA
E-mail: andydean1@msn.com
Accepted for publication: November 12, 2007. First published online: April 8, 2008.
2008 Psychology Press, an imprint of the Taylor & Francis group, an Informa business
134
ANDY C. DEAN ET AL.
with dementia on tests of effort, this could provide compelling evidence that his or
her effort is noncredible.
REVIEW OF DEMENTIA/EFFORT TEST LITERATURE

Studies evaluating the performance of samples or subsamples of
dementia patients on tests of effort are displayed in Table 1. In the majority
of these studies, known external incentives to feign dysfunction (e.g., in litigation)
appeared unlikely, or were specifically ruled out, as part of sample selection.
The specificity of the effort tests (i.e., the percentage of dementia
patients appropriately passing the effort test) was calculated when possible from
article data.
Of all the free-standing effort measures examined, the Test of Memory
Malingering (TOMM; Tombaugh, 1996) has received the most attention.
Across studies, the specificity of the TOMM in dementia samples has ranged
from a high of 82% (Trial 2, Greve et al., 2006) to a low of 24% (Trial 2, Teichner
& Wagner, 2004). The Digit Memory Test has shown similar variability: while
DArcy and McGlone (2000) found no false positives for a small sample of amnestic
patients on a short form of the Digit Memory Test (Hiscock & Hiscock, 1989), a
study by Prigatano and colleagues (Prigatano, Smason, Lamb, & Bortz, 1997)
evidenced numerous false positives with the long form, with the mean
performance of dementia participants falling below index cut-offs. Other forcedchoice measures have also produced high rates of false positive error. The Victoria
Symptom Validity Test (VSVT; Slick, Hopp, & Strauss, 1997) was found to have a
false positive rate of 38% in a sample of non-vascular dementia (Loring, Larrabee,
Lee, & Meador, 2007). Of concern, indices of the Word Memory Test
(WMT; Green, Allen, & Astner, 1996) demonstrated false positive rates of
9095% (Merten, Bossink, & Schmand, 2007) in a probable Alzheimers
dementia sample, and the similarly constructed forced-choice indices of the
Medical Symptom Validity Test (MSVT; Green, 2004) demonstrated specificities
of 1761% in a mixed dementia group (Howe, Anderson, Kaufman, Sachs,
& Loring, 2007). However, Green (2007) and others (Howe et al., 2007) have
provided an algorithm to discriminate dementia patients from noncredible
patients based on profile analysis including the more difficult WMT and MSVT
subtests (e.g., Free Recall). In the Howe et al. MSVT study this algorithm produced
a specificity of 9289%, in early and advanced dementia, respectively.
Free-standing measures that do not use the forced-choice paradigm
have also produced problematic specificities. Using recommended cut-offs for
the Dot Counting Test (DCT; Boone, Lu, & Herzberg, 2002c), Boone et al. (2002a)
found false positive rates of 25% and 67% for mildly and moderately
demented patients, respectively. However, these authors also reported specificity
rates associated with alternate cut-off scores in the dementia subgroup,
which can allow the clinician to select cut-offs to maintain adequate specificity
(i.e., 90%), although with some mild sacrifice in test sensitivity (i.e., from 78.8%
to 62.4%). Lastly, the Rey 15-Item test (Rey, 1964, in Lezak, 1983)
has been reported to have unacceptable specificity in individuals with dementia
using a cut-off of 59 (Schretlen, Brandt, Krafft, & Van Gorp, 1991), although
Trial 2 and
Reten. 545
Trial 2
and Reten. 545
Trial 2 and
Reten. 545
Teichner &
Wagner (2004)
Greve et al.
(2006)
Merten et al.
(2007)
56
56
56
Iverson & Tulsky

(2003)
Heinly et al.
(2005)
Babikian et al.
(2006)
Digit Span ACSS
Trial 2 and
Reten. 545
Cut-off
Tombaugh
(1997)
TOMM
Measure/Study
228
38
20
22
21
40
Unknown
Unknown
1823
18 Mean 22.2

SD 2.9
Unknown
1128
Mean 19.9
SD 5.0
Unknown
MMSE range
A mixed dementia sample
An undefined sample of memory

disorder patients
Patients with Alzheimers disease

from the WAIS-III standardization
sample
Probable Alzheimers dementia

based on NINCDS-ADRA criteria
Memory disorder patients

suspected of having Alzheimers
disease, vascular dementia, or both

diagnosed with DSM, ADRANINDS, or ADDTC ischemic
vascular dementia criteria
A mixed DSM-diagnosed sample

of dementia
Sample composition
Table 1 Studies of effort measure performance and dementia
No
No
Unlikely
(continued )
1 false positive
90%
95%
Trial 2 70%
Reten. 50%
Trial 2 82%
Reten. 77%
No
Unlikely
Trial 2 24%
Reten. 29%
Trial 2 73%
Reten. 82%
Specificityb
Unlikely
Unlikely
Incentive
to feign?a

135
57
58
Babikian et al.
(2006)
Merten et al.
(2007)
595% on
trials 13
595%
DArcy &
McGlone
(2000)
36-item
version
45
Prigatano et al.
(1997)
Digit Memory Test
Iverson & Tulsky

(2003)
Vocabulary - Digit Span ACSS
57
Cut-off
Heinly et al.
(2005)
Reliable Digit Span
Measure/Study
14
38
20
228
Unknown
Unknown
1823
18
Mean 22.2
SD 2.9
Unknown
Unknown
MMSE range
Patients with chronic amnesia, at

least four of which likely met
criteria for dementia
Patients meeting ADRDA criteria

for probable Alzheimers disease
Patients with probable Alzheimers

disease from the WAIS-III
standardization sample

based on NINCDS-ADRA
criteria
An undefined sample of
memory disorder patients
Sample composition
Table 1 Continued
Low, mean performance

below cut-offs
100%
Unlikely
No
97%
30%
Unlikely
Unlikely
1 false positive
68%
Specificityb
No
No
Incentive
to feign?a
136
ANDY C. DEAN ET AL.
521 Hard
items
Slick et al.
(2003)
534 on IR,
DR, or Consis.
Merten et al.
(2007)
IR and DR
585%
German Oral
Version
IR, DR and
CNS 585%
Profile algorithm
Richman et al.
(2006)
Howe et al.
(2007)
Howe et al.
(2007)
Medical Symptom Validity Test
82.5% on
IR, DR, or
Consis.
Green
(2007)
Word Memory Test
521 Hard
items
Loring et al.
(2007)
Victoria Symptom Validity Test
31
31
62
20
25
50
Unknown
Unknown
Unknown
18
Mean 22.2
SD 2.9
Unknown
Unknown
Unknown
Early dementia patients (N 13)

with Logical Memory (WMS-III)
scaled scores 5.
Advanced dementia patients
(N 18) with Logical Memory
scores 5 5.
Early dementia patients (N 13)

with Logical Memory (WMS-III)
scaled scores 5.
Advanced dementia patients
(N 18) with Logical Memory
scores 5 5.
An unspecified German sample

with early dementia (N 48) and
advanced dementia (N 14)

Undefined early dementia

patients
Male patients with profound

memory impairment
A mixed dementia sample, without

clear cases of vascular dementia
Early dementia 92%

Advanced dementia 89%
No
(continued )
Early dementia 61%

Advanced dementia 17%
Unknown, means above cut-offs

for early dementia, below cut-offs
for advanced dementia
IR 10% DR 10%
Consis. 5%
Mean performance near or

below cut-offs
No false positives
62%
No
Unlikely
Unlikely
Unlikely
No
Unlikely

137
Cut-off
533 Words
Graham,
Becker,
& Hodges
(1997)
Arnold et al.
(2005)
Finger Tapping
Boone et al.
(2002a)
Dominant
Hand
35 men
28 women
17 comb.
score
57
DArcy &
McGlone
(2000)
Dot Counting
59
Schretlen
et al.
(1991)
Rey 15-item Test
534 on
Words or
Faces
Diesfeldt
(1990)
Warrington Recognition Memory Test
Measure/
Study
31
37
14
44
Unknown
10
Unknown
Mean 25.8
SD 5.2
Unknown
Unknown
MMSE range
A mixed DSM-diagnosed sample

of dementia
Inpatients and outpatients with

DSM-diagnosed probable
Alzheimers dementia of mild and
moderate severity
Patients with chronic amnesia, at

least four of which likely met
criteria for dementia
Two patients with early

Alzheimers disease and three with
semantic dementia
Patients meeting NINCDSADRDA criteria for probable

Alzheimers disease of moderate
severity
Sample composition
Table 1 Continued
No
Unlikely
No
Unknown
Men 87%
Women 75%
Mild dementia 75%

Mod. dementia 33%
86%
Unknown, obtained a mean of

approximately 9 items
3 false positives
Unlikely
16% Mean Words 33.8

Mean Faces 27.8
Specificity
Unlikely
Incentive
to feign? a
138
ANDY C. DEAN ET AL.
51.50
20
18 Mean 22.2

SD 2.9
25
41.39
3
585
20
28
19
19
18
Mean 22.2
SD 2.9
Unknown
Unknown
Unknown

Patients with vascular dementia
Patients with Alzheimers dementia
Patients with Alzheimers dementia

Unlikely
Unlikely
No
No
Unlikely
10%
32%
74%
95%
95%
TOMM Test of Memory Malingering; ACSS Age Corrected Scaled Score; WMS-R Wechsler Memory Scale Revised; aIncentive to feign was estimated as
accurately as possible based on available article data; bSpecificity was often derived by the current authors from available article data.
Merten et al.
(2007)
Amsterdam Short-Term Memory Test
Milanovich &
Axelrod
(1995)
Simulation Index Revised
Hilsabeck
et al.
(2003)
WMS-R Discriminant Function
Mittenberg
et al.
(1993)
Hilsabeck
et al.
(2003)
WMS-R General Memory Attention/Concentration Difference Score
Merten et al.
(2007)
Trials B to Trials A Ratio

139
140
ANDY C. DEAN ET AL.
a second study observed nearly acceptable specificity values (i.e., 86%) when the
cut-off was adjusted to six or fewer items (DArcy & McGlone, 2000).
Of the available literature on embedded effort measures (using indices
derived from traditional neuropsychological tests) in dementia, the Digit Span AgeCorrected Scaled Score (ACSS) has been found to be most robust against false
positive identifications. Using a cut-off of less than 6, both Iverson and Tulsky
(2003) and Heinly and colleagues (Heinly, Greve, Bianchini, Love, & Brennan,
2005) observed specificity in dementia or memory disordered samples of 90%
or greater. In contrast, the specificity for Reliable Digit Span was found to be
much lower (3068%, Merten et al., 2007; see also Heinly et al., 2005), possibly
reflective of the fact that Reliable Digit Span is not adjusted for
age. Other embedded indices that have provided promising specificities in dementia
are Vocabulary Minus Digit Span (97%, Iverson & Tulsky, 2003), Trails B to Trails
A Ratio (95%, Merten et al., 2007), and the WMS-R Memory Attention/
Concentration Difference Score (95%, Hilsabeck et al., 2003). Recommended cutoffs for dominant-hand finger tapping have been associated with
suboptimal specificities in dementia (7587%, Arnold et al., 2005), but the
provision of performance data on specific diagnostic subgroups (including
dementia) allows for selection of alternative cut-offs to increase specificity
in dementia groups.
Embedded measures with unacceptable false positives rates in dementia
include the Mittenberg, Azrin, Millsaps, and Heilbronner (1993) WMSR Discriminant Function (specificity 74%, Hilsabeck et al., 2003) and the
WAIS-R/WMS Simulation Index Revised (specificity 32%, Milanovich &
Axelrod, 1995). The specificity of the Warrington Recognition Memory Test (RMT;
Warrington, 1984) was noted to be particularly low in an Alzheimers
dementia sample (16%, Diesfeldt, 1990), although this was calculated
from performance on both the Words and Faces subtests, leaving unanswered
the question as to how the subtests operate independently.
In summary, relatively few effort indices have been adequately
researched in dementia samples, and of those that have, false positive rates
have been unacceptable perhaps with the exception of indicators involving Digit
Span, the Medical Symptom Validity Test (profile analysis), and Trailmaking.
To further investigate the performance of multiple effort tests in dementia,
we examined a large archival sample of mixed dementia patients on 18 effort indices
derived from 12 tests (WAIS-III/WAIS-R Digit Span and Vocabulary,
Dot Counting, Warrington Recognition Memory Test Words, WMS-III
Logical Memory, Rey Word Recognition Memory Test, Finger Tapping,
b-Test, Rey 15-Item, TOMM, Rey Auditory Verbal Learning Test [RAVLT], and
Rey Complex Figure Test), the results of which are presented below.
METHOD
Participants
Archival neuropsychological data were obtained from a total of 214
patients with dementia. Potential participants were excluded from the original
141
pool if there was indication of identifiable motive to feign (i.e., if they were applying
for disability compensation or in litigation at time of testing). As an additional
check on patient credibility, the following forced-choice measures were analyzed for
the possibility of significantly below chance levels of responding: WMS-III Logical
Memory Recognition, WMS-III Visual Reproduction Recognition, Warrington
Recognition Memory Test Words, Warrington Recognition Memory Test
Faces, TOMM Trial 1, and TOMM Trial 2 (TOMM Retention was not
administered). The lowest forced-choice scores were an 11/30 (Logical Memory
Recognition) obtained by a patient with dementia NOS and schizophrenia, and a
20/50 (Warrington Recognition Memory Test Words) obtained by a patient with
probable Alzheimers dementia and schizophrenia. Because both of these scores
have a 10% chance of occurring in random responding (see Frederick & Speed,
2007, for computing forced-choice probabilities), these patients were not excluded
from the sample. Further, none of the participants retained in the study were
determined to be malingering or otherwise noncredible from a clinical standpoint,
and any observed neuropsychological impairments were entirely consistent with
behavioral observations and information regarding how patients functioned in
activities of daily living.
Patient data were obtained from two settings: Sample # 1 (N 172) was drawn
from a large municipal county hospital tertiary care neuropsychology service
located within a department of psychiatry, and sample # 2 (N 42) consisted of
dementia patients in a residential placement.
Most diagnoses were ascertained clinically using DSM-III-R (American
Psychiatric Association, 1987) or IV-TR (American Psychiatric Association, 2000)
criteria. However, in contrast to DSM criteria, significant memory impairment
was not required in the clinical diagnosis of frontotemporal dementia, given that the
typical early symptoms of the disorder involve behavioral/social disturbance
(memory impairment was often present, but did not need to be for diagnostic
inclusion). Instead, other non-memory DSM criteria for dementia were followed in
making a frontotemporal diagnosis (e.g., disturbance in executive functioning
and significant impairment in social or occupational functioning), and FTD
participants met Lund-Manchester criteria (Brun et al., 1994). Patients suspected of
delirium and patients with isolated memory disorders without other concomitant
cognitive dysfunction (i.e., amnestic patients not meeting criteria for dementia)
were excluded.
Patients from Sample # 1 were diagnosed with various types of dementia;
patients in Sample # 2 were all diagnosed with probable Alzheimers dementia,
and did not have a severe psychiatric disturbance, current alcohol/substance abuse
problems, or any other medical disturbance that could impair central nervous
system function.1 In the combined sample, the frequencies of dementia diagnoses
were as follows: probable Alzheimers dementia (34%, N 73), dementia NOS
(23%, N 49; including dementia due to multiple etiologies and probable mixed
1
Data from Clinic # 2 was collected for L. Philpotts (1993) doctoral dissertation. The Dot Counting data
was subsequently published by Boone et al. (2002a) and comprises approximately 41% of the Dot
Counting data currently described. The Rey 15-Item data have not been published outside of the
dissertation manuscript.
142
ANDY C. DEAN ET AL.
dementiaAlzheimers and Vascular dementia), probable frontotemporal

dementia2 (17%, N 36), vascular dementia (12%, N 26), dementia due to head
trauma (5%, N 10; including closed and penetrating injuries), dementia
NOS with psychosis/schizophrenia (5%, N 10), dementia due to substance
abuse or Korsakoffs disease (2%, N 4), probable Lewy body dementia
(1%, N 3), dementia due to AIDS (1%, N 2), and finally, dementia due to
lupus (51%, N 1).
Age of the total sample ranged from 23 to 97, with a mean of 63.5 years
(SD 15.1). Mean education was 13.1 years (SD 2.9), and 49% were female.
Approximately 58% of the sample were Caucasian, while 18% were African
American, 9% were Hispanic, 5% were Asian, 51% were Middle Eastern,
and 10% were unknown/other. All patients were fluent in English; a minority of the
sample (11%) learned English concurrent with another language or spoke English
as a second language. Of those who spoke English as a second language, the mean
age of learning English was 12.0 years old (SD 6.9). ESL/bilingualism was equally
distributed across the range of MMSE (2 5.11; p 0.28).
Available MMSE scores (N 125) ranged from 1 to 29, with a mean
of 18.5 (SD 6.0). In the 121 participants administered enough subtests on the
WAIS-III or WAIS-R to provide a Full Scale IQ (i.e., at least five Verbal
and four Performance), mean FSIQ was 77.2 (SD 14.3). Excluding patients
with frontotemporal dementia, the mean delayed recall on WMS-R or WMS-III
subtests fell at approximately the third%tile (including frontotemporal dementia
M 4%tile). Excluding frontotemporal patients, the mean number of words on
delayed free recall of the RAVLT was less than one word (M 0.90, SD 1.5;
N 67).
Procedure/Measures
Approval to utilize archival neuropsychological data was obtained from
both institutional review boards. MMSE and effort indicators were typically
administered in the context of more comprehensive neuropsychological assessments
(i.e., covering multiple domains including language, visuospatial functioning,
memory, executive functioning, and motor function). The effort indices examined
(citations for cut-offs reproduced in Table 2) were: Digit Span Age-Corrected
Scaled Score (ACSS; Babikian, Boone, Lu, & Arnold, 2006); Reliable Digit Span
(Babikian et al., 2006); Timed Digit Span (3- and 4- digits forward; Babikian et al.,
2006); Vocabulary Minus Digit Span (Iverson & Tulsky, 2003; Mittenberg, Fichera,
Zielinksi, & Heilbronner, 1995; Mittenberg et al., 2001); Dot Counting Test
E-score (Boone et al., 2002c); TOMM Trial 2 (Tombaugh, 1996); Warrington
Recognition Memory Test Words (Iverson & Franzen, 1994); Rey 15-Item Test
(free recall, Lezak, 1983, p. 619; Recognition Equation, Boone, Salazar, Lu,
Warner-Chacon, & Razani, 2002d); WMS-III Logical Memory Rarely
Missed Index (RMI; Killgore & DellaPietra, 2000); Finger Tapping dominant
2
Approximately 60% of the current frontotemporal participants were previously used in studies by
Boone et al. (1999) and Razani, Boone, Miller, Lee, and Sherman (2001). See these articles for further
neuroimaging data and criteria for assignment to right/left cases of frontotemporal dysfunction.
143
Table 2 Effort test specificity in patients with dementia
Effort test
Digit span ACSS
Reliable digits
Three digits timed
Four digits timed
Vocabulary digit span
Dot counting
TOMM
Warrington words
Rey 15-Item free recall
Rey 15-Item recognition
equation
Logical memory RMI
Fingertapping
b-Test
Rey word recognition
equation
RAVLT equation
Rey-O equation
Rey-O/RAVLT equation
Mean MMSEa
Specificity
Cut-off
Sample Size
5
6
42.0 s
44.0 s
45
escore 517
Trial 2 5 45
533
59
520
N 172
N 172
N 50
N 48
N 149
N 80
N 20
N 39
N 105
N 50
20.2
20.2
20.0
20.3
20.4
18.8
19.2
20.7
17.5
20.5
(4.6)
(4.6)
(4.3)
(4.2)
(4.4)
(5.0)
(4.4)
(4.2)
(6.6)
(4.2)
73%
70%
82%
90%
97%
50%
45%
59%
26%
14%
136
Men 35
Women 28
160
Men 5
Women 7
9
N 43
N 55
20.5 (4.0)
20.6 (3.5)
77%
69%
N 34
N 32
20.2 (4.0)
20.5 (4.2)
47%
78%
N 32
20.5 (4.2)
56%
12
47
0.40
N 64
N 51
N 56
20.9 (4.6)
20.7 (4.3)
22.0 (3.9)
13%
37%
48%
ACSS Age corrected scaled score; TOMM Test of Memory Malingering; RMI Rarely Missed
Index; RAVLT Rey Auditory Verbal Learning Test; Rey-O Rey-Osterreith Complex Figure Test;
a
Because not all patients received the MMSE, mean MMSE scores only represent sample estimates based
on available data.
hand (Arnold et al., 2005); b-Test E-score (Boone et al., 2002b); Rey Word
Recognition Test (Nitch, Boone, Wen, Arnold, & Alfano, 2006); Rey Auditory
Verbal Learning Test (RAVLT) Effort Equation (Boone, Lu, & Wen, 2005); ReyOsterreith (Rey-O) Effort Equation (Lu, Boone, Cozolino, & Mitchell, 2003); and
the Rey-Osterreith/RAVLT (Rey-O/RAVLT) discriminant function (Sherman,
Boone, Lu, & Razani, 2002).
It is important to note that, given the clinical setting of the assessments, not
all tests were administered to all participants. Patients in Sample # 2 only were given
the MMSE, Rey 15-Item Test (free recall), and the Dot Counting Test. A total
of 80% (N 172) of patients completed some subtests from the WAIS, and of those,
54% (N 93) were administered the WAIS-R and 46% (N 79) were given the
WAIS-III. Because the WAIS-R only provides normative data up to age 74, the
Mayo Older Americans Normative Studies (MOANS) norms (Ivnik et al., 1992)
were used for WAIS-R scores of patients 75 years and older. No patient
administered the WAIS-III exceeded the WAIS-III manuals normative age range.
Of patients evaluated with the WAIS-R, 69% (N 64) were administered the
Satz-Mogel short form. (The Satz-Mogel short form does not alter administration
of Digit Span, but only every third item is administered on Vocabulary.) Thus, for
144
ANDY C. DEAN ET AL.
the calculation of the Vocabulary minus Digit Span effort index, 42% (N 64) were
calculated with regular administration WAIS-III data, 16% (N 24) with regular
administration WAIS-R data, and 42% (N 64) with WAIS-R data using the
Satz-Mogel procedure for the calculation of Vocabulary.
Of patients given subtests from the Weschler Memory Scale (WMS; N 140),
57% were administered the WMS-R and 43% were administered the WMS-III.
Only the WMS-III allows calculation of the Logical Memory Rarely Missed Index.
Lastly, because patients with dementia often took excessive time in the completion
of the b-Test, 44% (N 15) of the b-Test data are based on prorated scores
(i.e., testing was discontinued early and with scores extrapolated from existing data).
Of those that were prorated, the mean number of stimulus pages completed was 5.0
pages (SD 3.9).
RESULTS
Table 2 provides the specificity of the various effort indictors per published
cut-offs. Mean MMSE scores and standard deviations are provided to illustrate the
typical level of severity of dementia in the subsample completing each test; however,
because not all patients completed the MMSE, mean scores should be interpreted as
estimates only. Examination of the table reveals that the majority of effort indices
had unacceptable false positive rates in dementia patients, with particularly poor
specificity values observed for Rey 15-item plus recognition and the RAVLT effort
equation (i.e., 520%), but with substantially higher specificity rates (i.e., 475%)
observed for Digit Span 3-digit time (82%), Digit Span 4-digit time (90%),
Vocabulary minus Digit Span (97%), Logical Memory RMI (77%), and Rey Word
Recognition (78%).
In order to investigate the effect of dementia severity on effort test specificity,
we divided MMSE scores into three bands of severity: mild (MMSE 420),
mild to moderate (MMSE 1520), and moderate to severe (MMSE 515).
We then calculated the percentage of effort tests failed by each participant
(e.g., if administered three effort tests and the patient failed cut-offs on one, he/she
was considered to fail 33% of the tests administered). Out of the possible effort
measures listed in Table 2, the following five measures were excluded from this
calculation because they were highly similar and/or overlapped with other indices
(shown in parentheses): Reliable Digit Span (ACSS), Digit Span 3-digit time (4-digit
time), Rey 15-Item plus recognition (Rey 15-item), Rey Word Recognition
Equation (Rey Word Recognition total), and the Rey-O/RAVLT discriminant
function (RAVLT equation). Examination of the remaining 13 indicators revealed
that patients with MMSE scores 420 failed an average of 36% of the measures
administered to them (N 58; mean number of tests administered 4.7; SD 3.7),
those with MMSE 1520 failed an average of 47% (N 40; mean tests
administered 4.3; SD 3.1), and those with MMSE 515 failed an average of
83% (N 27; mean tests administered 2.6; SD 2.5).
For further examination of specificity by dementia severity, Table 3 provides
the specificity of each effort indicator by MMSE band. Although small sample sizes
point to the need for caution in interpretation, it can be seen that only Four Digits
Time and Vocabulary Minus Digit Span had acceptable specificity in mild dementia
145
Table 3 Effort test specificity by Mini Mental Status Examination (MMSE) band
Effort test
Digit span ACSS
Reliable Digits
Three digits Timed
Four digits Timed
Vocabulary Digit span
Dot Counting
TOMM
Warrington words
Rey 15-Item Recognition equation
Logical Memory RMI
Finger tapping
b-Test
Rey word recognition equation
RAVLT equation
Rey-O equation
Rey-O/RAVLT equation
MMSE 2130
(Mean 23.5, SD 2.1)
N 44
N 44
N 15
N 16
N 35
N 26
N8
N 15
N 33
N 14
N 17
N 20
N 10
N 11
N 11
N 20
N 16
N 18
84%
86%
73%
94%
94%
77%
63%
73%
33%
21%
82%
70%
50%
64%
46%
15%
44%
44%
MMSE 1520
(Mean 17.6, SD 1.8)
N 30 67%
N 30 60%
N 14 86%
N 12 83%
N 21 100%
N 18 44%
N 9 33%
N 5 20%
N 19 5%
N 8 0%
N 10 50%
N 12 83%
N 8 38%
N 6 83%
N 6 50%
N 9 0%
N 13 15%
N 7 29%
MMSE 5 15
(Mean 9.4, SD 4.1)
N 9 33%
N 9 22%
N 2 100%
N 2 100%
N 7 100%
N 13 8%
N 2 0%
N 3 0%
N 23 0%
N 3 0%
N 2 100%
N 2 100%
N 2 0%
N 2 50%
N 2 50%
N 3 0%
N 1 0%
N 1 0%
Index; RAVLT Rey Auditory Verbal Learning Test; Rey-O Rey-Osterreith Complex Figure Test.
(MMSE 2130), while only the Vocabulary Minus Digit Span maintained
acceptable specificity with MMSE scores of 20 or less.
In order to consider the possible influence of specific dementia diagnosis
on effort test performance, as shown in Table 4, we also calculated the specificity
of each test by the following diagnoses: probable Alzheimers dementia, probable
vascular dementia, and probable frontotemporal dementia. However,
it should be noted that these diagnostic groups were not equivalent on a number
of relevant dimensions, with the exception of gender (2 4.03; p .13),
although some of the differences are in fact expected for disease characteristics
(i.e., age, MMSE scores). The Alzheimers patients (M 72.5; SD 11.4) were
significantly older than both the FTD patients (M 62.4; SD 9.5; p 5 .001) and
the vascular patients (M 62.1; SD 12.9; p 5 .001). The FTD patients (M 15.0;
SD 2.9) had more years of education than both the Alzheimers patients
(M 13.2; SD 2.8; p .01) and the vascular patients (M 11.4; SD 3.4;
p 5 .001), and the Alzheimers patients in turn had more education than
vascular patients (p .03). However, the Alzheimers patients (M 16.3;
SD 7.0) had significantly lower MMSE scores than the FTD patients (M 20.9;
SD 5.5; p .05), while other MMSE group comparisons did not differ (p4.05).
Data are reproduced in the table only for those tests in which sample size was 10
in at least one diagnostic category. Given the overall small ns, the data contained
in Table 4 should be viewed as preliminary.
Lastly, using the total dementia sample (irrespective of dementia severity
and diagnosis), cut-offs were adjusted to achieve 90% specificity: Digit Span
146
ANDY C. DEAN ET AL.

Table 4 Effort test specificity by probable dementia diagnosis
Effort test
Digit span ACSS
Reliable digits
Three digits timed
Four digits timed
Vocabulary digit span
Dot counting
TOMM
Warrington words
Rey 15-Item recognition
equation
Logical memory RMI
Finger tapping
b-Test
equation
RAVLT equation
Rey-O equation
Rey-O/RAVLT
equation
Alzheimers
Vascular
73%
58%
100%
100%
100%
27%
Frontotemporal
N 31 74%
N 31 74%
N 7 100%
N 7 100%
N 26 92%
N 39 54%
N 47 6%
N 5 20%
N 26
N 26
N 12
N 10
N 21
N 11
N 15
N 14
N 7 100%
N 14 43%
N 2 100%
N 8 0%
N 6 50%
N 6 33%
N 13 15%
N 13 23%
N 10 50%
N 4 25%
N 3 33%
N 4 25%
27%
7%
N 36
N 36
N3
N3
N 35
N4
N4
N3
75%
75%
33%
67%
91%
50%
25%
33%
Index; RAVLT Rey Auditory Verbal Learning Test; Rey-O Rey-Osterreith Complex Figure Test.
Age-Corrected Scaled Score 53 (95% specificity); Reliable Digit Span 54 (95%),

3 Digits Timed 43 seconds (98%), 4 Digits Timed 44 seconds (90%; 45
seconds 94%), Vocabulary Minus Digit Span 43 (93%), Dot Counting escore
442 (90%), TOMM Trial 2 5 28 (95%), Warrington Recognition Memory Test
Words 526 (90%), Rey 15-Item free recall (51 still associated with 81%
specificity), Rey 15-Item with Recognition Equation 53 (90%), Logical Memory
Rarely Missed Index 5104 (91%), Finger Tapping dominant hand 521 taps (91%,
genderless), b-Test escore 43000 (91%), Rey Word Recognition Test 55 (91%;
genderless), Rey Word Recognition Test Equation 57 (91%; genderless), RAVLT
Equation 5 2 (95%), Rey-Osterreith Equation 516 (92%), and the
Rey-Osterreith/RAVLT discriminant function 5 2.62 (91%).
DISCUSSION
In a large heterogeneous sample of patients with dementia, the majority
of effort tests examined displayed unacceptably high false positive rates of error.
This occurred despite the fact that the patients did not have an external incentive to
feign deficits and any observed neuropsychological impairments were consistent
with behavioral observations and activities of daily living (i.e., there was no clinical
suspicion of poor effort). In particular, specificities for the total sample ranged
from a high of 97% (Vocabulary minus Digit Span) to a low of 13% (RAVLT effort
147
equation), with most effort test specificities falling in the range of 30% to 70%.
Out of the 18 different effort measures examined, only published cut-offs
for Vocabulary minus Digit Span and Four Digits Forward Timed achieved
specificities 90%. In contrast, several other effort tests were prone to
misclassify half or more of the patients examined, including the RAVLT effort
equation (13% specificity), Rey 15-Item Test (1426%), Rey-Osterreith Effort
Equation (37%), TOMM Trial 2 (45%), and the Rey-Osterreith/RAVLT
Discriminant Function (48%). This suggests that, using traditional cut-offs,
commonly used effort indices are generally unacceptable in assessing effort in
potentially demented samples.
When effort test specificity was examined according to stage of dementia
severity, unacceptable false positive rates continued to be the norm. Even in cases
where severity of dementia was relatively mild (MMSE 420), only Vocabulary
minus Digit Span and Four Digits Forward Timed provided adequate levels
of specificity (i.e., greater than 90%). Furthermore, as MMSE scores dropped, most
test specificities likewise fell. In fact, some measures correctly classified none of
the patients within more severe MMSE bands (Rey 15-Item Test, TOMM, b-Test,
RAVLT equation, Rey-Osterreith equation, Rey-Osterreith/RAVLT equation),
although these data should be interpreted with caution given exceedingly
small sample sizes. Only the Vocabulary minus Digit Span index maintained
greater than 90% specificity across MMSE bands, although Four Digits Forward
Timed also performed reasonably well (specificity dropping to 83% in only the
mild to moderate range of dementia). When the percentage of non-redundant effort
tests failed by each patient was analyzed by MMSE band, we found that
those with MMSE scores 420 failed an average of 36% of the tests administered
to them, those with MMSE 1520 failed an average of 47%, and patients
with MMSE scores 515 failed 83% of administered effort tests. This clearly
illustrates that lower MMSE scores are associated with increased effort test failure.
In actual practice, dementia patients with low MMSE scores are not likely to be
misidentified as noncredible due to their obvious limitations on behavioral
parameters (i.e., they require residential placement for 24-hour supervision,
they cannot manage IADLs, etc.). In contrast, the group with MMSE 420 is of
particular interest in that the question of actual versus feigned dementia is most
likely to occur in this subset. We realize that a MMSE band of 21 to 30 encompasses
a fairly wide range of function, but due to small sample size we could not
further subdivide this group. Future research should explore effort test performance
as a function of MMSE scores 420.
When effort test cut-offs were adjusted to provide 90% specificity in
our sample, it became apparent that several of the effort measures are
likely inappropriate for use in a demented population. The significant adjustment
to cut-offs required by several measures would likely make them too insensitive,
including the Digit Span Age-Corrected Scaled Score, Reliable Digits, ReyOsterreith Effort Equation, Rey-Osterreith/RAVLT Effort Equation, b-Test,
Rey 15-Item measures, Dot Counting, and the RAVLT Effort Equation. For
example, lowering the cut-off for the free recall portion of the Rey 15-Item test to
less than one item still resulted in a specificity of only 81%! Clearly, lowering
148
ANDY C. DEAN ET AL.
cut-offs in this manner would sacrifice sensitivity (the ability to detect noncredible
performance) to such an extent as to be useless.
In contrast, a few of the measures did provide some promise for use in
demented groups. The Vocabulary minus Digit Span index cut-off could actually be
lowered to a cut score of greater than 3, while still maintaining 93% specificity in our
sample. While such a cut-off score may not be appropriate for use in other clinical
situations, it does suggest that large Vocabulary scores relative to Digit Span
are uncommon in demented groups. Further, in addition to the acceptable
specificity found for the traditional cut-off of Four Digits Timed (90%), Three
Digits Timed resulted in a 98% specificity when the cut-off was only raised 1 second.
Likewise, Finger Tapping (521, genderless) and the Rey Word Recognition
Test (55, genderless) required relatively minor cut-offs adjustments to maintain
adequate specificity. Although the forced-choice measures of the Warrington
Recognition Memory Test Words and the TOMM required substantial cut-off
changes to maintain specificity, it should be mentioned that both retained 90%
specificity with cut-offs slightly higher than 50% correct (Warrington 526; TOMM
Trial 2 5 28). This suggests that even in demented groups, correctly identifying half
or less of the items is quite uncommon. Thus, when chance or worse
performance occurs in, for example, a mild head injury case without gross
impairments in activities of daily living, this would be nearly incontrovertible
evidence that the patients effort was noncredible.
Several of our findings are similar to those found in previous research
on effort testing in dementia. Previous specificities for demented groups on
the second trial of the TOMM ranged from a high of 82% (Greve et al., 2006) to a
low of 24% (Teichner & Wagner, 2004)our specificity fell in between
these findings at 45%. Similarly, our specificities for Reliable Digit Span (70%)
and Vocabulary minus Digit Span (97%) were nearly identical to those previously
reported (68%, Heinly et al., 2005; 97%, Iverson & Tulsky, 2003; respectively).
Merten et al. (2007) found a much lower specificity for Reliable Digit Span (30%),
but this was based on a more stringent cut-off than used currently or by Heinly
and colleagues (Merten et al. cut-off 58; Heinly et al. and current study 57).
Previous findings from our lab on the Dot Counting Test were also similar to those
found currently with a larger dementia sample (current mild dementia 77%,
previous mild dementia 75%, Boone et al., 2002a), but it should be noted that
the samples in these two analyses overlapped in slightly less than half of the cases
examined. Our specificity for the Warrington Recognition Memory Test Words
(59%) was actually much better than previously described by Diesfeldt (1990; 16%),
but since the Diesfeldt calculation was based on a cut-off for both the Words
and Faces subtests, our results are likely to be more representative of the Words
subtest in isolation.
Compared to the specificities found by Iverson and Tulsky (2003; 95%)
and Heinly and colleagues (2005; 90%) for the Digit Span Age-Corrected Scaled
Score, our specificity was considerably worse (73%). Because the Heinly et al. study
was comprised of undefined memory disorder patients, it is possible that some
or many of their participants did not meet the full criteria for dementia.
The participants for the Iverson and Tulsky study were Alzheimers outpatients
from the WAIS-III standardization sample with MMSE scores no less than 18 and a
149
mean full scale IQ of 86 (see WAIS-III/WMS-III Technical Manual; Psychological

Corp., 2002). Because our dementia patients were of mixed diagnosis with
the possibility of more severe MMSE scores (and a mean FSIQ of 77), our
sample was likely more severely impaired in comparison. In fact, even the Digit
Span specificity from our probable Alzheimers dementia sample was much lower
(74%) than that reported by these authors. Lastly, previous findings from our
lab on the Finger Tapping test produced better specificities (8775%, Arnold et al.,
2005) than found currently (69%), probably reflective of the more stringent
exclusion criteria implemented in the former study (cases with motor
impairment were excluded).
Because of particularly small sample sizes and a lack of demographic
equivalence between groups, our specificity results for different types of dementia
should be viewed as preliminary. Nonetheless, it is interesting to note possible
patterns of performance. While probable vascular patients performed poorly on the
traditional cut-offs for the Finger Tapping test (43%), no false positives were found
on this test for those with probable Alzheimers dementia. This is likely reflective
of the relative sparing of motor cortex in mild to moderate stage Alzheimers
disease.
In conclusion, data from the current study indicate that a minority of existing
effort indicators appear to be useful in the differential between actual and feigned
dementia. Hopefully these findings will provide an impetus for additional validation
studies on other effort indicators in dementia samples and the development of
new effort measures that are insensitive to even the most severe forms of cognitive
impairment. Until that time, we suggest that existing effort tests be administered
and carefully compared for consistency with the wealth of other data available
in clinical evaluations, including other cognitive scores, behavioral observations,
self and collateral report, historical records, and the clinicians
knowledge of dementia and typical brainbehavior relationships. Further,
the data from this study regarding cut-off adjustments and effort score/severity
relationships can be used as guidelines in interpreting effort test scores obtained
in clinical practice.
ACKNOWLEDGMENT
This study was graciously supported by a grant from the
Borchard Center for Law and Aging. We would also like to thank Jill
Razani, Ph.D., and Ashley R. Curiel, M.A. for their contributions to data
collection/entry.
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The Clinical Neuropsychologist

Dementia and effort test performance

Andy C. Dean Ph.D. , Tara L. Victor , Kyle B. Boone , Linda M.

Philpott & Ryan A. Hess

Harbor-UCLA Medical Center , CA, USA

California State UniversityDominguez Hills , CA, USA

Huntington HospitalPasadena , CA, USA

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The Clinical Neuropsychologist, 23: 133152, 2009

DEMENTIA AND EFFORT TEST PERFORMANCE

Research on the performance of patients with dementia on tests of effort is particularly

ANDY C. DEAN ET AL.

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REVIEW OF DEMENTIA/EFFORT TEST LITERATURE

Iverson & Tulsky

Digit Span ACSS

18 Mean 22.2

A mixed dementia sample

An undefined sample of memory

Patients with Alzheimers disease

Probable Alzheimers dementia

Memory disorder patients

A mixed dementia sample

A mixed DSM-diagnosed sample

Table 1 Studies of effort measure performance and dementia

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DEMENTIA AND EFFORT TEST PERFORMANCE

Digit Memory Test

Iverson & Tulsky

Vocabulary - Digit Span ACSS

Reliable Digit Span

Patients with chronic amnesia, at

Patients meeting ADRDA criteria

Patients with probable Alzheimers

Probable Alzheimers dementia

A mixed dementia sample

Low, mean performance

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Medical Symptom Validity Test

Word Memory Test

Victoria Symptom Validity Test

Early dementia patients (N 13)

Early dementia patients (N 13)

An unspecified German sample

Probable Alzheimers dementia

Undefined early dementia

Male patients with profound

A mixed dementia sample, without

Early dementia 92%

Early dementia 61%

Unknown, means above cut-offs

Mean performance near or

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DEMENTIA AND EFFORT TEST PERFORMANCE

Rey 15-item Test

Warrington Recognition Memory Test

A mixed DSM-diagnosed sample

Inpatients and outpatients with

Patients with chronic amnesia, at

A mixed dementia sample

Two patients with early

Patients meeting NINCDSADRDA criteria for probable