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1. SAGE Open
July-September 2016: 1–10
© The Author(s) 2016
DOI: 10.1177/2158244016665693
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Article
Language impairment, especially naming difficulty, occurs
frequently in many dementias and may be present even prior
to clinical diagnosis (Cummings & Benson, 1992; Jelcic
et al., 2012; E. Miller, 1989). The severity of naming deficits
is more pronounced in some dementias such as Alzheimer’s
disease (AD), primary progressive aphasia (PPA) temporal
lobe variant of frontotemporal lobar degeneration, and
dementia with Lewy bodies (DLB) than in others such as
subcortical vascular dementia (VaD) or Huntington’s disease
(Brandt, Bakker, & Maroof, 2010) or in amnestic mild cogni-
tive impairment (aMCI; Duong, Whitehead, Hanratty, &
Chertkow, 2006). Naming deficits are not a clinical feature
of behavioral variant frontotemporal dementia (FTD;
Laforce, 2013). Hence, detection of these naming deficits
may be important in the differential diagnosis of dementia or
in distinguishing dementias such as AD from possible pre-
dementia states such as aMCI.
Our understanding of the neural networks that underlie
naming is informed by studies with both normal participants
and patients suffering from neurological disorders (Baldo,
Arévalo, Patterson, & Dronkers, 2013; Gleichgerrcht,
Fridriksson,&Bonilha,2015;Hamberger,Habeck,Pantazatos,
Williams, & Hirsch, 2014; Hamberger & Seidel, 2003).
Naming of objects or abstract entities is a multimodal process
of cortical networks that include visual processing and recog-
nition, both intentional and automatic semantic processing,
abstract representation, and execution of speech output (Duong
et al., 2006; Gleichgerrcht et al., 2015). Brain regions sub-
served include the visual cortex in the occipital lobe (bilater-
ally), the occipitotemporal/fusiform regions (bilaterally),
anterior temporal cortices (bilaterally), left posterior superior
temporal gyrus, left angular gyrus, left inferior frontal gyrus,
the left posterior inferior frontal gyrus, and subcortical struc-
tures. Pathology in one or more of these regions gives rise to
the characteristic naming difficulties of different disorders
665693SGOXXX10.1177/2158244016665693SAGE OpenHirsch et al.
research-article2016
1
Weill Medical College of Cornell University at the Burke Rehabilitation
Center, White Plains, NY, USA
2
U.S. Department of Veterans Affairs, New York, NY, USA
Corresponding Author:
Joseph A. Hirsch, Memory Evaluation and Treatment Service, Burke
Rehabilitation Hospital, 785 Mamaroneck Ave., White Plains,
NY 10605, USA.
Email: jhirsch@burke.org
The Auditory Naming Test Improves
Diagnosis of Naming Deficits in Dementia
Joseph A. Hirsch1
, George M. Cuesta2
, Barry D. Jordan1
,
Pasquale Fonzetti1
, and Leann Levin1
Abstract
Many patients with presumptive Alzheimer’s disease (AD) or other dementias may show minimal impairment on the Boston
Naming Test (BNT), a visual confrontation naming measure. We sought to determine whether a semantic naming test, the
Auditory Naming Test (ANT), would improve accuracy for identifying naming deficits in patients diagnosed with dementia
(N = 458) at an outpatient memory disorders clinic. Factor analysis revealed that both tests measured the same broad
construct. Frequency of naming impairment with the ANT was significantly greater than with the BNT for patients with
AD, regardless of dementia severity or levels of education (p < .01). Effect size was moderate (φ = 0.45). BNT but not ANT
performance declined with age in patients with AD. Sex differences were found for the BNT, but not the ANT, in the AD
population. Accuracy rate of naming impairment diagnosis with the ANT in patients with AD was good (72%). Specificity
(81%) and positive predictive value (PPV) (89%) with the ANT in AD were excellent, whereas sensitivity (69%) and negative
predictive value (NPV) (58%) were modest. Receiver operating characteristic with area under the curve (ROC AUC) was
excellent (0.958). A similar pattern was seen in patients with vascular dementia (VaD) or mixed AD/VaD. There was no
significant effect in patients with amnestic mild cognitive impairment (aMCI). It is concluded that the ANT substantially
improves the ability to diagnose naming impairment in patients with AD, VaD, and mixed AD/VaD dementia, and should be
included in a neuropsychological battery administered to elderly patients with suspected dementia.
Keywords
assessment of cognitive disorders/dementia, Alzheimer’s disease, naming, anomia, neuropsychology
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2. 2 SAGE Open
including specific dementias (Gleichgerrcht et al., 2015). For
example, the visual agnosia common to posterior cortical atro-
phy may be present in advanced, but not early-stage AD.
Pathology in more anterior regions (i.e., in the temporal cor-
tex) may impair word meaning or word retrieval—including
the popularly known phenomenon of tip-of-the tongue.
These impairments are common in AD, PPA variant of fron-
totemporal lobar degeneration, and focal strokes
(Gleichgerrcht et al., 2015).
The Boston Naming Test (BNT; Kaplan, Goodglass, &
Weintraub, 1983), a visual confrontation naming test, is the
most frequently used instrument for assessing naming disor-
ders. Until recently, the BNT was the only used naming test
in a typical neuropsychological dementia battery (Hobson
et al., 2011; B. W. Williams, Mack, & Henderson, 1989).
However, the BNT suffers from a high false negative rate
(Domoto-Reilly, Sapolsky, Brickhouse, & Dickerson, 2012;
Lansing, Ivnik, Cullum, & Randolph, 1999). Conversely,
there is age-related decline on the BNT in normal partici-
pants (Lansing et al., 1999; MacKay, Connor, & Storandt,
2005; Randolph, Lansing, Ivnik, Cullum, & Hermann, 1999)
resulting in relaxed cutoff scores and unintentionally missed
diagnoses in patients with mild dementia (B. W. Williams
et al., 1989). BNT total scores are positively correlated with
education in both normal and AD populations (Lansing et al.,
1999; Randolph et al., 1999).
The BNT has been criticized on a number of grounds
including poor psychometric properties, inadequate standard-
ization, inadequate norms, inadequate sampling of categories,
and insufficiently encompassing all the processes involved in
the multifaceted construct known as naming (Harry & Crowe,
2014). Severity of anomia measured on the BNT varies with
the specific type of dementia and with visual perceptual prob-
lems that are sometimes contributory (Braaten, Parsons,
McCue, Sellers, & Burns, 2006; Harnish et al., 2010; Harry &
Crowe, 2014; Lukatela, Malloy, Jenkins, & Cohen, 1998;
Stern, Richards, Sano, & Mayeux, 1993; V. G. Williams et al.,
2007). The utility of the BNT in the diagnosis of dementia of
theAlzheimer’s type has been criticized because naming defi-
cits are typically only evident in moderate-to-severe AD, but
not in mild AD or mild cognitive impairment (MCI; Testa
et al., 2004). As high as 59% of patients with very mild or
mildAD performed in the normal range on the BNT (Domoto-
Reilly et al., 2012). The BNT is also susceptible to deficits in
visual recognition (Baldo et al., 2013).
In recent years, another naming test has become available.
Hamberger and Seidel (2003) developed the Auditory
Naming Test (ANT) as an alternative to visual naming tests.
The ANT requires participants to respond directly to seman-
tic cues while bypassing the initial steps of visual perception
and recognition, as is required with the BNT. Thus, rather
than presenting a patient with a line drawing of an object or
animal as on the BNT, he or she is provided with a verbal cue
(e.g., “what a king wears on his head”). The ANT may be
less susceptible than the BNT to limited vocabulary because
items are more familiar to most participants (Hamberger &
Seidel, 2003; Yochim, Rashid, Raymond, & Beaudreau,
2013). Like the BNT, total correct item-response scores may
be quantified on the ANT. The ANT also allows for determi-
nation of two other measures that are even more sensitive
than total word response scores: tip-of-the tongue extended
latency scores and reactions times per response.
Functionally, there are both similarities and differences
between the ANT and BNT: Both tests share common left
temporal lobe neural networks involved in lexical–semantic
naming (Hamberger et al., 2014). However, the ANT, but not
the BNT, specifically activates the left hemisphere. Unlike
the BNT, the ANT activates left frontal regions but not the
left parietal lobe.
The ANT has been found to be a reliable, valid, and sensi-
tive instrument for revealing naming deficits in non-geriatric
patients with left temporal lobe epilepsy (Hamberger &
Seidel, 2003). It was of interest to us to consider the ANT as
an alternative to the BNT in diagnosing naming deficits in an
older sample of patients with dementia. Considering both the
overlap but also the very real differences in these two tests
we were curious to determine if the ANT would be more
revealing than the BNT for naming deficits in dementia.
Indeed, research indicates that cognitively intact elderly par-
ticipants (Hanna-Pladdy & Choi, 2010) and those with
dementia are more likely to show impairment on auditory
naming tests than on visual naming tests (Brandt et al., 2010;
K. M. Miller, Finney, Meador, & Loring, 2010). However,
these studies used either another auditory naming tests or an
abbreviated form of the ANT with less well-characterized
psychometrics than the complete ANT. Population samples
were of limited size. The contribution of age, education, and
sex were not considered with the dementia population.
Preliminary research with the full ANT demonstrated its
clinical utility in the diagnosis of dementia (Cuesta, Hirsch,
& Jordan, 2004; Hirsch, Cuesta, & Jordan, 2008). We sought
to more fully explore this relationship with a larger popula-
tion. Our goals were to determine (a) whether the ANT was
more likely than the BNT to identify naming difficulties in
patients with cognitive impairment, (b) which naming test
was more likely to reveal naming deficits in amnestic MCI or
specific subgroups of dementia, and (c) the role of age, edu-
cation, and sex or degree of cognitive impairment on audi-
tory versus visual naming in patients with dementia. Last, we
sought to develop norms on the ANT for a normal older
population and to determine whether normal aging influ-
ences auditory naming.
Method
Participants
Five-hundred fifty-nine patients with memory or other cogni-
tive complaints were referred by their physicians to our out-
patient Memory Evaluation and Treatment Service for
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3. Hirsch et al. 3
assessment. All were native English speakers or learned
English before age 5. Two-hundred forty-nine were male, and
310 were female. Mean age was 76.9 (± 8.3) years, and educa-
tion was 14.5 (± 3.1) years. Patients were evaluated over the
course of a 10-year period by an interdisciplinary team of neu-
rologists, geriatricians, and neuropsychologists using diagnos-
ticcriteriaconsistentwiththeNationalInstituteofNeurological
and Communicative Disorders and Stroke and theAlzheimer’s
Disease and Related Disorders Association (NINCDS-
ADRDA; Dubois et al., 2007; see below).
A volunteer group of older orthopedic patients with no
cognitive complaints was also evaluated. Using a cutoff
score of 27 on the Mini Mental State Exam (MMSE), 31 par-
ticipants were retained to serve as a non-demented normal
sample (“ortho normal”) for normative and comparative pur-
poses according to the procedure of O’Bryant et al. (2008).
Mean age was 72.9 (± 6.4) years, and education was 16 (±
3.2) years.
Standard Protocol Approvals, Registration, and
Consents
An ethical standards committee of the Independent Review
Board for clinical research at our institution approved (a) the
retrospective analysis of data presented in this article for
determination of the effectiveness of tests used to identify
naming deficits in a population presenting with complaints
of cognitive impairment and (b) conducting a study on a nor-
mal sample of volunteers with no memory complaints.
Procedures
The diagnosis of dementia and specific subtypes was based
on the clinical team’s consensus. Factors considered were
clinical presentation, course of illness, neuroimaging, labo-
ratory results, ratings on activity of daily living scales
(Lawton & Brody, 1969; Pfeffer, Kurosaki, Harrah, Chance,
& Filos, 1982), informants’ reports of behavior, and perfor-
mance on neuropsychological tests. The neuropsychological
battery, a modification of the one used by Stern et al. (1992),
consisted of tests of mental status (MMSE), Standardized
Assessment of Concussion (SAC), verbal memory (Buschke
Selective Reminding Test, Logical Memory Test from the
Wechsler Memory Test–Third Edition or WMS-III), visuo-
spatial ability and visual memory (Rey Complex Figure Test,
Benton Visual Retention Test: matching and recognition),
visual confrontation naming (BNT), auditory naming (ANT),
letter fluency (Controlled Oral Word Association Test),
semantic fluency (Animal Naming), repetition of phrases,
verbal comprehension (Complex Ideational Material), verbal
abstract reasoning (Similarities subtest from the Wechsler
Adult Intelligence Scales–Third Edition or WAIS-III), visual
abstract reasoning (Identity and Oddities subtest from the
Mattis Dementia Rating Scale), verbal attention (Digit Span
subtest from the WAIS-III), visual attention (Digit Symbol
Coding subtest from the WAIS-III; Trail Making Test part
A), and mental flexibility (Trail Making Test part B).
Patients were considered cognitively impaired on spe-
cific tests if they performed below recommended cutoff
scores, or in the absence of cutoff scores, were at least two
standard deviations below the means from published norms.
To clinically diagnose a patient with dementia, there had to
be impairment in verbal memory and at least one other cog-
nitive domain (e.g., visuospatial ability, executive function,
language) as well as impairment in activities of daily living.
Impairment in memory only resulted in a clinical diagnosis
of aMCI. Volunteer orthopedic patients who scored 27 or
above on the MMSE served as an additional matched con-
trol normal sample of non-demented participants (O’Bryant
et al., 2008).
Statistical Method
The data were analyzed with the SPSS, Version 23 for Mac
(IBM, Armonk, New York) or JMP statistical discovery soft-
ware, Version 12 (SAS, Cary, North Carolina). Descriptive
analyses were run to determine frequencies and distributions
of all variables. For the current article, only demographic
variables and performance on the MMSE, BNT total score
(correct spontaneous responses plus stimulus cued
responses), andANT total score responses are shown for spe-
cific dementia groups, patients with aMCI, and non-demented
normal patients. Norms are also shown for a non-demented
orthopedic sample. Because MMSE, ANT, and BNT raw
scores were not normally distributed, non-parametric statis-
tics were used for ANOVA (Kruskal–Wallis), matched pairs
comparisons (Mann–Whitney U), and correlation coeffi-
cients (Spearman’s rho).
To delineate the differences in performance on the ANT
and BNT, raw scores for each patient or participant were
converted to dichotomous impairment scores (1 = impaired;
0 = not impaired) at the time of diagnosis using cutoff
scores reported in the literature adjusted for age and educa-
tion (Hamberger & Seidel, 2003; Spreen & Strauss, 1998;
Table 1). These impairment scores were compared among
groups using the McNemar test for paired samples or
Cochran’s Q test for multiple matched samples.
During the course of this evaluation and diagnosis of
patients, two studies were published with improved stratifi-
cation of elderly participants administered the BNT
(Gangulia et al., 2013; Zec, Burkett, Markwell, & Larsen,
2007). Concerned that some of our patients may have been
misdiagnosed as having no naming impairment on the BNT,
these data were re-analyzed utilizing these stricter cutoff
scores and are also reported in this study (Table 1). Logistic
regression analyses, receiver operating characteristic curves
with area under the curve (ROC AUC), sensitivity, selectiv-
ity, positive predictive value (PPV), and negative predictive
value (NPV) were determined for the major groups with
dementia.
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4. 4 SAGE Open
Exploratory factor analysis with dementia patients was
conducted on the entire battery to determine factor structure
and thus more fully delineate the characteristics of our neu-
ropsychological tests on this population. (Performances on
the MMSE and SAC were excluded from this analysis
because they are omnibus screening tests rather than instru-
ments measuring distinct cognitive domains). Initially, prin-
cipal components analysis was conducted. This was followed
by scree plot and eigenvalues examination. The final stage
involved rotation utilizing the ProMax procedure.
Results
Characteristics of Clinical Groups
The vast majority of our patient population satisfied the clin-
ical criteria for a diagnosis of dementia (n = 458; 81.9%).
The most frequent diagnoses were probable AD (n = 269;
48.1%). Other diagnoses were mixed AD vascular dementia
(mixed AD/VaD; n = 91; 16.3%), vascular dementia (VaD; n
= 26; 4.7%), DLB (n = 12; 2.1%), FTD (n = 5; 0.9%),
Parkinson’s disease (PD; n = 3; 0.5%), posttraumatic or
chronic traumatic encephalopathy (n = 4; 0.8%), and cogni-
tive disorder not otherwise specified (n = 48; 8.5%). A large
number of patients were diagnosed with aMCI (n = 62;
11.1%) whereas very few were diagnosed as normal (n = 13;
2.3%). Last, some patients never received a formal diagnosis
because they failed to follow up with necessary neuroimag-
ing or blood work (n = 26).
The characteristics of the AD, VaD, mixed AD/VaD, and
aMCI patients are shown in Table 2. Also included for demo-
graphic comparisons only are normal patients with memory
complaints and normal orthopedic volunteers. AD patients
were slightly older and less educated than normal patients or
normal orthopedic volunteers. The AD and mixed AD/VaD
groups were generally the most similar in terms of overall
scores on the MMSE, BNT, and ANT. The normal patients
and MCI patients were indistinguishable on any of the
variables.
Relationship Between ANT and BNT
Because the major focus of this study was a comparison of
the ANT with the BNT, we examined the relationship
between the two tests and then determined how the same
patients performed on both tests. First, we determined that
the correlation between the ANT and BNT was moderate for
normal patients (ρ = 0.45, p < .01) to high in orthopedic nor-
mal participants (ρ = 0.61, p < .05). These correlations were
no higher than those we found for some other pairs of tests in
our battery that also measure a similar construct (e.g., the
verbal memory tests: Buschke Selective Reminding Test
total score vs. Logical Memory I from the WMS-III; r = .59;
p < .05). Consequently, we felt justified in adding the ANT to
our test battery despite the gross similarities between the two
measures, and then sought to determine the characteristics of
these instruments in our clinical populations of interest. The
first step in this determination was factor analysis.
Factor Analysis
Factor analysis of neuropsychological test score performance
was conducted on our sample of patients diagnosed with
dementia. On the basis of scree plot and eigenvalues exami-
nation, a four-factor solution was derived (Table 3). As can
be seen, the ANT and BNT total scores loaded highly on
Factor 3, demonstrating that they are grossly measuring a
similar construct, naming, in dementia patients. Other factors
revealed were a visual factor (Factor 1), a verbal memory
factor (Factor 2), and a visual memory factor (Factor 4).
Frequency of Impairment
The McNemar test was performed for the entire dementia
sample, as well as specific dementia subgroups, using cutoff
scores from published norms at the time of initial diagnosis
(Hamberger & Seidel, 2003; Spreen & Strauss, 1998). For
the entire dementia sample, twice as many scored impaired
on the ANT (68.3%) as the BNT (34.6%; Table 4; p < .001).
The effect size was moderate (φ = 0.44). The findings were
almost identical for the specific group AD: ANT (68.4%)
versus BNT (34.9%; Table 5). The effect size was again
moderate (φ = 0.45). There were proportionately more
patients with VaD who scored in the impaired range on the
ANT (65.4%) than those with BNT (38.5%), χ2
(1, N = 26) =
4.35, p < .05; φ = 0.45. A similar ratio was also evident for
patients diagnosed with mixed AD/VaD: ANT (72.4%) ver-
sus BNT (27.5%). There were too few patients diagnosed
with DLB (n = 12), FTD (n = 5), or PD (n = 3) to analyze
Table 1. Cutoff Scores for ANT and BNT Correct Total Scores.
Variable Age
Education
(years)
Cutoff
score
ANTa
19-64 8-15 45
16+ 47
BNT (at diagnosis)b
57-65 51
66-70 47
71-75 44
76-85 37
BNT (post analysis)c
60-69 <12 46
>12 50
70-79 <12 39
>12 47
80-89 <12 37
>12 43
Note. ANT = Auditory Naming Test–total score transformed; BNT =
Boston Naming Test–total score transformed.
a
Hamberger and Seidel (2003).
b
Spreen and Strauss (1998).
c
Zec, Burkett, Markwell, and Larsen (2007).
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5. Hirsch et al. 5
statistically. There was an insignificant effect size (φ < 0.1)
for the aMCI patient sample with very few patients scoring
in the impaired range on either test: ANT (17.7%) and BNT
(4.8%). Neither the patients diagnosed as normal nor the
orthopedic non-demented volunteers scored in the impaired
range on the BNT or ANT.
As a check against misdiagnosis and possible spurious
statistical effects, the BNT data were re-analyzed using more
stringent cutoff scores from norms that were not available at
the time of the initial diagnoses of many of these patients
(Gangulia et al., 2013; Zec et al., 2007). These analyses
revealed that there was a significant shift in diagnoses from
less to more impaired on the BNT regardless of which set of
newer norms were used (p < .001, Table 6). The two newer
sets of norms were indistinguishable from one another.
However, although the magnitude of relative impairment on
the ANT versus the BNT changed after using these newer
cutoff scores, the direction and significance of the effect
favoring theANT over the BNT were still evident. For exam-
ple, the percentage of patients identified with a naming dis-
order on the BNT now increased from 34.9 to 53.2 in the AD
sample, but the ANT still identified significantly more
patients with a naming disorder than the BNT (68.4%), χ2
(1,
N = 269) = 58.84, p < .001. There was still a moderate effect
size (φ = 0.45) and a high odds ratio (OR = 9.61). Table 7
shows the details of the logistic regression analysis. The
resultant ROC curve generated is shown in Figure 1. The
overall accuracy rate of correctly identifying naming deficits
when both tests were administered was good (72.9%).
Sensitivity was modest (69.0%) whereas specificity was high
(81.1%). PPV was excellent (88.8%) whereas NPV was
modest (54.8%).
The pattern of greater frequency of detecting naming dis-
orders with the ANT versus the BNT in the VaD sample with
the McNemar test was virtually indistinguishable from that
in AD: χ2
(1, N = 26) = 5.49, p < .05; φ = 0.43, OR = 10.
Overall accuracy rate (72.0%), sensitivity (62.5%), specific-
ity (88.8%), PPV (90.9%), and NPV (58.1%) were also com-
parable with theAD group. ROCAUC was excellent (0.958).
The pattern in the mixed AD/VaD sample was similar
qualitatively, but far less pronounced in all parameters: χ2
(1,
N = 87) = 6.75, p < .01, φ = 0.28, OR = 3.6; overall accuracy
rate (66.3%), sensitivity (52.6%), specificity (75.9%), PPV
(81.1%), and NPV (44.9%). ROC AUC was good (0.885).
Table 2. Clinical Groups Analyzed.
Variable AD VaD Mixed AD/VaD aMCI
Normal
patients
Orthopedic
controls
n 269 26 91 62 13 31
Age 78.4 (6.5)†
79.8 (7.4)†
79.1 (6.2)†
74.5 (7.2) 70.0 (11.1) 72.90 (6.4)
Education 14.1 (3.2)†,‡
14.3 (3.0)†,‡
14.1 (2.7)†,‡
16 (2.7) 16.4 (2.53) 16.0 (3.15)
MMSE 22.2 (4.9)‡
22.9 (4.1)‡
22.0 (4.7)‡
27.9 (1.9) 29.3 (0.95) 28.9 (0.73)
BNT total 40.6 (12.6)‡
43.1 (11.8) 41.6 (12.4)‡
52.6 (6.2) 56.5 (3.04) 55.8 (2.16)
ANT total 40.7 (8.2) 41.7 (6.0) 41.3 (8.1) 47.0 (1.8) 48.6 (1.2) 46.81 (1.90)
Note. AD = Alzheimer’s disease; VaD = vascular dementia; aMCI = amnestic mild cognitive impairment; MMSE = Mini Mental State Exam; BNT = Boston
Naming Test–total score transformed; ANT = Auditory Naming Test–total score transformed.
‡
p < .001 versus aMCI. †
p < .001 versus Normal.
Table 3. Rotated Factor Loadings of the Neuropsychological
Battery.
Factor 1 Factor 2 Factor 3 Factor 4
SRT: Total Score .21 .77 .09 −.13
SRT: LTS −.07 .87 −.02 −.01
SRT: CLTR −.04 .80 −.13 −.04
SRT: LDR −.10 .60 −.02 .27
SRT: Recognition .07 .43 .16 .14
Log Memory I .16 .43 .20 .17
Log Memory II −.02 .52 .06 .30
Rey Copy .64 −.13 .04 .22
Rey Immediate Recall .01 .12 .01 .78
Rey Delayed Recall .01 .12 −.06 .81
BVRT Matching .30 .12 −.02 .05
BVRT Recognition .51 .08 .12 .07
BNT Total Score −.06 −.01 .87 .08
ANT Total Score −.03 −.09 .98 −.04
ANT Tip of Tongue −.36 −.17 .13 .08
Literal Fluency .48 −.01 .22 −.08
Semantic Fluency .30 .16 .32 −.03
Repetition High .25 .21 .17 −.15
Repetition Low .27 .24 .25 −.18
Complex Ideation .31 .15 .34 .01
Dig Span Forward .18 .03 .17 −.14
Digit Span Backward .52 . 01 .14 −.04
Digit Symbol .70 −.10 −.01 .04
Similarities .12 −.02 .27 .02
Identities and Oddities .19 −.00 .07 .03
Trails A −.64 .06 .10 .01
Trails B −.45 −.01 −.10 −.12
Note. Procedure consisted of principal components analysis, eigenvalue
and scree plot inspection, and ProMax oblique rotation with four factors.
Shown is the final factor solution. BNT = Boston Naming Test–total score
transformed; ANT = Auditory Naming Test–total score transformed; SRT
= Buschke Selective Reminding Test; LTS = long-term storage; CLTR =
consistent long-term rerieval; LDR =long-delayed recall; BVRT= Benton
Visual Retention Test. Factor loadings >0.35 are in bold.
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6. 6 SAGE Open
Table 6. Frequency of Impairment on the Boston Naming Test
as a Function of Normative Data Used.
Variable Sum % not impaired % impaired
Spreen and Strauss
Norms
94 65.1 34.9
Zec Norms 143 46.8 53.2
Gangulia Norms 142 47.2 52.8
Note. Cochran’s Q Test (2) = 66.28; p < .001.
There were no significant differences in impairment fre-
quencies on the ANT versus BNT in the DLB group or the
aMCI group. There was no impairment with either the BNT
or ANT in either of the two samples of normal individuals
(i.e., normal patients seen at our memory evaluation clinic or
an orthopedic control sample).
Interaction Effects
Normal sample. Correlation coefficients between ANT total
score and age or education in the orthopedic control group (n
= 31) were small and not significant. There was no signifi-
cant relationship between age and performance on the BNT,
but there was a modest but significant relationship between
education and BNT scores (ρ = 0.56, p < .001). MMSE
scores were not considered because they were arbitrarily set
at 27 or above for retention of participants. For the smaller
sample of normal patients from our clinic (n = 13), a
somewhat different pattern emerged: There were modest but
significant correlations between ANT total score and educa-
tion (ρ = 0.56, p < .05) and between ANT total score and
MMSE score (ρ = 0.56, p < .05). There were no significant
correlations between BNT score and MMSE scores or educa-
tion. Age did not correlate highly with either ANT or BNT
scores for this sample.
AD sample. BNT total scores (spontaneous responses and
response to stimulus cues) were directly related to level of
education. The Kruskal–Wallis H test showed that there was
a statistically significant difference in BNT scores per level
of education, χ2
(2, N = 269) = 23.16, p ≤ .001, with a mean
BNT score of 44.52 for 16 years of education or greater,
39.07 for 12 to 15 years of education, and 35.74 for less than
16 years of education. The relationship between age and
BNT score was not demonstrated with the Kruskal–Wallis H
test, χ2
(2, N = 269) = 7.10, p ≤ .13, but was with the median
test, χ2
(2, N = 269) = 10.31, p ≤ .035. That was because there
was a progressive decline in BNT scores from ages 50 to 80
that then began to rise again in a mostly highly educated
sample of nonagenarians (n = 7).
The Kruskal–Wallis H test also demonstrated an educa-
tion-related relationship with theANT, χ2
(2, N = 269) = 21.76,
p ≤ .001, with a mean ANT total score of 42.93 for 16 years
of education or greater, 39.85 for 12 to 15 years of education,
and 37.47 for less than 16 years of education. The decline in
performance on the ANT with increasing age was not statisti-
cally significant with either the Kruskal–Wallis test or the
median test.
Last, we sought to determine whether education or level
of cognitive impairment attenuated or conversely accentu-
ated the relative differences between the ANT and the BNT
in each test’s ability to reveal a naming deficit in our largest
group, those who were diagnosed with AD. To this end, we
again determined the frequencies of impairment on the BNT
versus ANT, using the cutoff scores of Zec et al. (2007) and
Hamberger and Seidel (2003), but this time performed the
analyses per stratum of each education level (discussed
above) or range of scores on the MMSE. The latter was cho-
sen as a proxy for dementia severity. Although not without
controversy in terms of its sensitivity to detect dementia,
especially in a highly educated sample, there is nevertheless
some precedent for using different scores on the MMSE as a
crude measure of dementia severity (Perneczky et al., 2006;
Reisberg et al., 2011). Because we were analyzing these
data in patients that we had already diagnosed as having
dementia, we made slight modifications in the labels used
that were associated with specific MMSE score ranges: very
mild = 25-30; mild-to-moderate = 19-24; severe = ≤ 18.
These data are presented in Tables 8 and 9. As can be seen,
regardless of level of education, patients with AD were
more likely to demonstrate a naming impairment on the
ANT than on the BNT. Also, regardless of severity of cogni-
tive impairment, patients with AD were more likely to fall
Table 5. Observed Frequencies of Impairment With ANT
Versus BNT in AD.
BNT
impaired
ANT impaired
No Yes Total
No 82 93 175
Yes 03 91 94
Total 85 184 269
Note. χ2
(1) = 53.95, p < .001. McNemar Test = p < .001. ANT = Auditory
Naming Test–total score transformed; BNT = Boston Naming Test–total
score transformed; AD = Alzheimer’s disease.
Table 4. Observed Frequencies of Impairment With ANT
Versus BNT in All Dementias.
BNT impaired
ANT impaired
No Yes Total
No 139 160 299
Yes 6 152 158
Total 145 312 457
Note. χ2
(1) = 86.97, p < .001. McNemar Test = p < .001. ANT = Auditory
Naming Test–total score transformed; BNT = Boston Naming Test–total
score transformed.
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7. Hirsch et al. 7
below cutoff on the ANT than the BNT. There was a rela-
tively strong association at each stratum for education or
dementia severity (ϕ = 0.4 − 0.6).
Discussion
The present study supported our rationale for inclusion of the
ANT in a neuropsychological battery for diagnosing patients
for possible naming deficits in dementia. Using two instru-
ments with well-defined reliability and validity, the ANT and
the BNT, our research revealed that the ANT was more sensi-
tive than the BNT to detect naming difficulties in most patients
with dementia, especially those withAD, VaD, and mixedAD/
VaD but not those with a possible pre-morbid state, aMCI.
Although word-finding difficulty may be the first cognitive
difficulty reported by many patients with suspected dementia,
it may not be revealed in a battery that uses only the BNT, the
most commonly used visual confrontation naming test.
The failure to consistently demonstrate a naming diffi-
culty with the BNT may be a consequence of the less than
desirable ecological validity of this test. Thus, visual con-
frontation naming test performance does not correlate as well
with subjective complaints of word-finding difficulties as
does auditory naming (Hamberger & Seidel, 2003). In part,
this is related to the inclusion of low-frequency (harder)
items on the BNT, such that what might be measured is less
anomia than a limited expressive vocabulary. The ANT con-
trols for this confound.
Another potentially significant consideration is the inter-
action between task and neuroanatomical demand. There are,
indeed, distinctions in this regard between visual confronta-
tion naming versus auditory naming. However, the findings
have been inconsistent with regard to neuroanatomical
regional localization, choice of participants (e.g., temporal
lobe epilepsy patients vs. normal participant), or experimen-
tal design. Earlier research suggested that auditory naming
was more diffusely localized than visual confrontation nam-
ing (Hamberger, Seidel, McKhann, & Goodman 2010;
Tomaszewski, Harrington, Broom, & Seyel, 2005). However,
a more recent study by Hamberger et al. (2014) demonstrated
that the two modalities tapped both unique and overlapping
brain regions. The authors suggest that auditory naming,
which involves frontal activation, might reflect a higher level
of response competition and resolution than visual confron-
tation naming. They also argue that the ANT may be more
language-specific and left (dominant) hemisphere–focused.
We posit that this greater neuronal and cognitive demand
may contribute to the greater sensitivity of the ANT than the
BNT in patients with specific dementias. However, the more
extensive bilateral activation required in visual confrontation
may not significantly interfere with performance in patients
with mild AD or some other dementias when the integrity of
these pathways have not been compromised through
neuropathology.
Thus, the distinction between the auditory and visual con-
frontation naming tests is yet another example of the well-
recognized phenomenon in neuropsychological assessment
that few, if any cognitive constructs, are unitary and, there-
fore justify inclusion of two or more instruments that mea-
sure the same broad construct. Indeed, certain omnibus tests
such as the WMS contain several highly inter-correlated but
nevertheless distinct subtests of both verbal and visual mem-
ory. Therefore, rather than being redundant with two naming
tests in our battery, the inclusion of the ANT for assessing
patients with suspected dementia actually improved clinical
utility and supported that very argument by Hamberger et al.
(2014). The latter concluded that using only one naming test
runs the risk of failing to detect a genuine naming deficit
(i.e., false negative). Such was our rationale for both clinical
and research purposes as it has been our observation prior to
such inclusion that, despite patient complaints of naming dif-
ficulties, we were often not able to demonstrate this impair-
ment psychometrically when we administered the BNT
alone.
Table 7. Logistic Regression: BNT Impaired Scores Versus ANT Impaired Scores.
Coefficient b SE Wald p value Exp(b) Lower Upper
Intercept −0.191055237 0.178987746 1.139387088 0.285781876 0.826086957
Zec Norms
Impaired
2.262653601 0.320016607 49.99091761 1.54459E-12 9.608552632 5.131677357 17.99105385
Note. BNT = Boston Naming Test–total score transformed; ANT = Auditory Naming Test–total score transformed.
Figure 1. ROC curve for impairment with BNT and ANT in AD.
Note. Impairment scores for matched AD patient administered both
BNT and ANT. Empiric ROC Area = 0.941. ROC = receiver operating
characteristic; BNT = Boston Naming Test–total score transformed; ANT =
Auditory Naming Test–total score transformed; AD = Alzheimer’s disease.
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8. 8 SAGE Open
Table 9. Impairment in BNT or ANT Versus Level of Dementia.
Level Variable n % not impaired % impaired χ2
df p level φ
1 BNT 45 11.1 88.9 16.75 1 .01 0.61
ANT 4.4 95.6
2 BNT 129 43.4 56.6 23.42 1 .001 0.43
ANT 32.6 67.4
3 BNT 95 42.1 57.9 14.89 1 <.000 0.40
ANT 31.6 68.4
Note. MMSE stratified: 1 = <18; 2 = 19-24; 3 = 25-30. Significance determined with McNemar test. BNT = Boston Naming Test–total score transformed;
ANT = Auditory Naming Test–total score transformed; MMSE = Mini Mental State Exam.
Inclusion of theANT to our battery substantially improved
the odds of detecting naming deficits in patients with AD,
VaD, and mixed AD/VaD dementia. Sensitivity, specificity,
and PPV in diagnosing naming impairments in dementia
were respectable when the ANT was added to our battery.
Because the ANT failed to reveal significant naming deficits
in our aMCI and normal samples, the false positive rate asso-
ciated with the ANT was minimal.
Our research is consistent with that of other investigators
who also found auditory naming to be sensitive to naming
problems in patients with dementia. However, their findings
are neither directly comparable with one another nor to ours
due to differences in tests used or items of tests selected for
assessment, the populations contrasted, or the statistical
analyses performed. K. M. Miller et al. (2010) reported
seemingly inconsistent findings. A mixed sample of patients
with mild-to-moderate dementia of various etiologies per-
formed more poorly on theANT than on the Columbia Visual
Naming test, a visual confrontation naming test developed
by Hamberger and Seidel (2003). However, they only used a
subset of items from the ANT and the Columbia Visual
Naming test, each with unknown psychometrics. When the
abbreviated version of theANT was compared with a 15-item
version of the BNT, the results were the converse. Now the
patients from their combined dementia group showed greater
accuracy on the ANT than the BNT. It is important to note
that a methodologically questionable procedure was used,
with the full 60-item BNT administered to 10% of their
patient sample and the score was then divided by four for
comparative purposes. It is unknown what confound was
introduced by administering the full test to some of their
participants.
Brandt et al. (2010) reported that patients with mild-to-
moderate AD performed more poorly than normal controls
on an auditory naming test. Both patients and controls had
greater difficulty with auditory naming than with visual con-
frontation naming. Of note, this study was performed with an
auditory naming test that the authors themselves developed
with stimuli consisting of sound files associated with objects
(e.g., musical instrument, vehicles) or animals, not with
semantic stimuli from theANT. In addition, their comparison
with visual naming was also with their own test and not with
the BNT, although that test was also administered. In patients
with mild AD, their auditory naming test had the identical
sensitivity to their visual confrontation naming test, but with
lower specificity. Consequently, an auditory naming test did
not improve diagnostic accuracy relative to visual confronta-
tion naming. Regardless of the differences among these three
studies, auditory naming tests did show sufficient sensitivity
to reveal naming problems in a population of patients with
dementia. In that regard, the ANT serves a useful diagnostic
role when assessing patients with putative dementia. This
was apparent in our study groups with specific types of
dementia such as AD, VaD, and mixed AD/VaD dementia, a
finding consistent with the research of others (Brandt et al.,
2010; K. M. Miller et al., 2010).
Because sample sizes in patients with other types of
dementia were too small to meaningfully analyze in the pres-
ent study, it was impossible to determine how well the ANT
could reveal the presence or absence of naming problems.
Table 8. Frequency of Impairment in BNT or ANT Versus Level of Education.
Level Variable n % not impaired % impaired χ2
df p value φ
1 BNT 34 48.5 51.5 7.34 1 .008 0.47
ANT 33.3 66.7
2 BNT 124 34.6 65.4 27.88 1 <.001 0.49
ANT 29.8 70.2
3 BNT 111 58.6 41.4 24.06 1 <.001 0.47
ANT 32.4 67.6
Note. Level 1: <12 years education. Level 2: 12-15 years education. Level 3: 15-20 years education. Significance determined with McNemar test. BNT =
Boston Naming Test–total score transformed; ANT = Auditory Naming Test–total score transformed.
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9. Hirsch et al. 9
This limitation in sample size was also true for both our nor-
mal, non-demented patient group and our orthopedic controls
and did not allow for statistical comparison with our dementia
groups. Therefore, normative data for these elderly normal
populations should be considered preliminary. Perhaps future
research with larger samples will be more elucidative.
Last, consistent with previous research, both ANT and
BNT scores were positively correlated with educational level
but negatively correlated with severity of dementia in
patients with AD. Most important, regardless of education
level or severity of dementia, the relationship of greater sen-
sitivity of the ANT than the BNT remained consistent. These
findings support our contention that the ANT may be of par-
ticular diagnostic utility in revealing naming deficits in less
severely impaired and better educated individuals with
dementia, at a point where the BNT, alone, may be insensi-
tive. However, AD patients’ BNT scores were inversely cor-
related to age but ANT scores were not. The failure to
establish an age-related decline in auditory naming was sur-
prising but may reflect the relative insensitivity of accuracy
scores on the ANT to detect this phenomenon. The ANT has
two other parameters that are even more sensitive to accu-
racy scores: “tip-of-the tongue” extended latencies and
response times. We are presently exploring whether these
scores will reveal a possible education effect in patients with
dementia as well as naming difficulties on the ANT in
patients with aMCI.
Acknowledgments
The authors gratefully acknowledge Dr. Marla Hamberger for pro-
viding them with stimuli for the Auditory Naming Test. They also
thank Dr. Jessica Elder and Ms. Kristin Bonistall for assistance with
the statistical analyses.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research and/or
authorship of this article.
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Author Biographies
Joseph A. Hirsch is a pharmacologist and consultant in neuropsy-
chology at the Memory Evaluation and Treatment Service of the
Burke Rehabilitation Hospital where he performs clinical evalua-
tions and conducts clinical research in dementia. Areas of research
include memory and naming as well as the neurobiological effects
of thiamine and thiamine analogues.
George M. Cuesta is a neuropsychologist with the VA New York
Harbor Healthcare system. He provides clinical assessments and has
engaged in clinical research in dementia and neurorehabilitation.
Barry D. Jordan is a board certified neurologist and assistant med-
ical director of the Burke Rehabilitation Hospital. He is also the
director of at the Burke Rehabilitation Hospital with specialization
in sports neurology, dementia and coincussion.
Pasquale Fonzetti is a board certified neurologist and director of
the Memory Evaluation and Treatment Service of the Burke
Rehabilitation Hospital. He conducts clinical research in dementia
and stroke.
Leanne Levin is a clinical psychologist in the Outpatient Neuro-
psychology Service of the Burke Rehabilitation Hospital.
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