Full text of DOI:10.1093/geronb/57.2.P187

Journal of Gerontology: PSYCHOLOGICAL SCIENCES
Copyright 2002 by The Gerontological Society of America
2002, Vol. 57B, No. 2, P187–P191
Usefulness of a 15-Item Version of the Boston Naming
Test in Neuropsychological Assessment of
Low-Educational Elders With Dementia
M. Dolores Calero,1 M. Luisa Arnedo,1,2 Elena Navarro,1 Mónica Ruiz-Pedrosa,1
and Cristobal Carnero3
1Faculty of Psychology, University of Granada, Spain.
2Neurosciences Institute, Granada, Spain.
3Traumatology Hospital, Granada, Spain.
The purpose of this study was to validate a reduced version (15 items) of the Boston Naming Test (BNT) in a sam-
ple of 78 low-educational elderly persons with or without dementia, as determined by independent assessment
with a battery of cognitive tests. The reduced version was found to be equivalent to the complete BNT, and to
have criterion validity with respect to other measures of dementia. We conclude that the reduced version is a use-
ful instrument for assessing patients who require shorter testing methods because of severe cognitive deteriora-
tion or their low level of education.
HE Boston Naming Test (BNT; Kaplan, Goodglass, &
Weintraub, 1978) is the most widely used test of visual
plete 60-item test. They therefore emphasized the need for
independent validation of each version to verify its useful-
ness for the clinical diagnosis of dementia.
T
confrontation naming. The standard 60-item version has
been used to assess language performance in participants
with aphasia or dementia (Goodglass, Wingfeld, & Hyde,
1998). Deficits in naming performance frequently appear in
the first stages of Alzheimer’s disease and increase with
time. For this reason the BNT is one of the tests most fre-
quently used to detect the disease and follow its course
(Williams, Mack, & Henderson, 1989).
Many studies have shown that the BNT is useful in dis-
criminating normal elderly persons and those with dementia
(LaBarge, Edwards, & Knesevish, 1986; Lansing, Ivnik,
Cullum, & Randolph, 1999; Martin & Fedio, 1983; Welch,
Doineau, Johnson, & King, 1996). However, the particular
characteristics of the latter population, including the limited
attention span, together with the need to shorten testing time
in daily clinical practice, have led different researchers to
suggest the possibility of giving reduced versions of the test.
Williams and colleagues (1989) constructed two reduced
versions of 30 items each (the even-numbered and the odd-
numbered versions), and found that both were equivalent to
each other and showed a significant correlation with the
complete version both in patients with dementia and in
healthy subjects.
In a more recent study the same researchers (Mack,
Freed, Williams, & Henderson, 1992) proposed four equiv-
alent forms of 15 items each, obtained by assigning each
item consecutively to one of four series. The interseries
equivalence analysis showed that all four versions corre-
lated significantly with one another, and each version ap-
peared to discriminate subjects with and without dementia
as effectively as did the complete test. However, as the
authors discussed, the scores on each version were obtained
by dividing up the items in the global analysis of the com-
In 1999, Lansing and colleagues validated the four short-
ened versions proposed by Mack and colleagues (1992),
confirming the tests’ discriminative capacity for the detec-
tion of anomia in dementia. Like the full version of the
BNT, all shortened versions show significant correlations
with demographic variables such as age, gender, and educa-
tion. However, as the authors indicated in their article, the
influence of these variables on short-form performance has
not been thoroughly investigated.
There have likewise been few studies of the influence of
these demographic variables on populations different from
those in the original sample (such as the Spanish popula-
tion), for which the BNT has been adapted. Moreover, the
few comparative studies of norms in Spanish and English
have concentrated on the American Hispanic population,
whose sociocultural and lexical characteristics differ from
those of the indigenous population of Spain (Kohnert,
Hernández, & Bates, 1998).
As Kohnert and colleagues (1998) indicate, adapted
BNTs have been undertaken without taking into account the
demographic variables and lexical peculiarities of the popu-
lation to which the new version is applied. Specifically, for
the Spanish adaptation, the same validation criteria were fol-
lowed as for the English version (Goodglass & Kaplan,
1986). The test was administered to 84 adults between 18
and 59 years old, arranged in two groups according to level
of education: one group with 12 or more years of schooling
and the other group with 12 years or fewer. The range of
this second group is too broad, including both completely il-
literate participants and functional illiterates (able to read
and write, but not fluently), who have limited access to the
lexicon owing to their low level of education. Currently,
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CALERO ET AL.
Table 2. Sociodemographic Data of the Sample
these two subgroups raise important issues for the Spanish
elderly population (with and without dementia).
Characteristic
Percentage
Because of sociopolitical circumstances during their
childhood and adolescence (Spanish Civil War and postwar
period), many members of this generation did not have ac-
cess to formal schooling, and thus attained only a low level
of education. These subjects usually make more mistakes on
the BNT than subjects with a moderate to high level of edu-
cation; the errors are not due to anomic deficits, but rather to
their ignorance of the exact name that the test scores as the
correct response. Under these conditions, validation of the
reduced form of the BNT could be especially relevant. Ad-
ministering the complete test would prolong the testing pe-
riod needlessly and would increase the participant’s feelings
of failure and frustration, which might in turn affect his or
her motivation and performance.
Age, y
60–69
70–79
80–93
Education
Illiterate
Functionally illiterate
Primary education
Dementia
MMSE ꢁ 24
MMSE ꢂ 24
Gender
22.11
49.99
27.90
18.80
45.90
35.30
51.16
48.84
Women
Men
48.90
51.10
Note: MMSE ꢀ Mini-Mental State Examination.
The purpose of our research was threefold:
1. To find out whether one of the reduced versions of the
BNT, the Shortened Boston Version-15 (SBV-15) pro-
posed by Mack and colleagues (1992; specifically, Ver-
sion 2; see Table 1), correlated with the complete 60-
item version, and could therefore substitute for the latter
in clinical situations in which time limitations, special
characteristics of the participant, or both, make use of a
shortened version necessary.
2. To find out whether the SBV-15 is useful in detecting
dementia in a population with a low educational level, in
whom attention is limited by dementia and lexical capac-
ity by low level of education.
diagnosed with possible dementia as well as the normal con-
trols were selected from among the residents of retirement
centers (67.5%) and the outpatients at a hospital neurology
clinic (32.5%). The sample’s demographic and clinical fea-
tures are summarized in Table 2. Since Spain’s current gen-
eration of elderly persons with and without dementia have a
low level of education (especially those people who grew up
in southern Spain), we created three groups: (a) those who
were completely illiterate (Group 1); (b) those who were
functionally illiterate, that is, able to read and write, although
not fluently (Group 2); and (c) those with primary education,
with an average of 6 to 8 years of schooling (Group 3). Other
categories of educational level were not used because very
few participants in our sample had received education be-
yond the primary school level.
3. To analyze the differences between participants with and
without dementia in performance on the SBV-15 and the
BNT, and to examine the influence of age, education, and
gender on performance.
METHODS
Instruments
Participants
BNT.—Developed by Goodglass and Kaplan (1986).
The complete 60-item version consists of figures represent-
ing everyday objects arranged in increasing order of diffi-
culty. The subject was asked to name each object correctly
within a maximum of 20 s. Semantic or phonemic cues were
provided as necessary. According to the standard test crite-
ria, the score was calculated from those items that were cor-
rectly named spontaneously plus additional items named
correctly after semantic cues.
Seventy-eight participants (37 women and 41 men) were
included in the study. They ranged in age from 60 to 93
years old, with an average age of 74 years. The participants
Table 1. Items in the SBV-15
English
Spanish
Árbol
Tree
Watch
Reloj
Escoba
Percha
Careta
Raqueta
Corona
Rinoceronte
Zancos
Escalera Mecánica
Bozal
Acordeón
Compás
Papiro
Reduced 15-Item version of the BNT (SBV-15).—
Developed by Mack and colleagues (1992). We used Ver-
sion 2 of the SBV-15. Each of the 60 items was assigned
consecutively to one of four series, and one series of 15
items was used. Five items were easy, five were moderately
difficult, and five were difficult. The criteria used to ap-
ply and correct the items were the same as for the com-
plete BNT.
Broom
Hanger
Mask
Racquet
Wreath
Rhinoceros
Stilts
Escalator
Muzzle
Accordion
Compass
Scroll
Mini-Mental State Examination (MMSE).— Developed
by Folstein, Folstein, and McHugh (1975), translated and
adapted by Lobo, Escobar, Ezquerra, and Seva Diaz (1979).
In the adapted version the maximum score is 35 points. To
Abacus
Ábaco
Note: SBV-15 ꢀ Shortened Boston Version-15.

SHORTENED VERSION OF THE BOSTON NAMING TEST
P189
Table 3. Mean, Average Score, and Standard Deviation of the
MMSE, SBV-15, and BNT
establish criteria for the presence or absence of dementia we
used standards developed by Manubens and colleagues
(1997) for the Spanish population.
Parameter
MMSE
SBV-15
BNT
Mean
Average Score
SD
24.218
24
5.42
10.035
10
3.11
36.790
34
12.17
Rey’s Auditive Verbal Learning Test.—This test con-
sisted of 15 common words presented in five trials (Rey,
1964). Recall was required after each presentation.
Notes: MMSE ꢀ Mini-Mental State Examination; SBV-15 ꢀ Shortened
Boston Version-15; and BNT ꢀ Boston Naming Test.
Benton’s Visual Retention Test.—This multiple-choice
identification task tests short-term visual memory (Benton,
1953).
tia by age and sex. If a factor was found to be statistically
significant, post-hoc comparisons were done.
Luria’s Motor Test.—In this test the participant is asked
to learn and reproduce a sequence of movements (fist/edge/
palm; Christensen, 1979).
RESULTS
The means and standard deviations of the MMSE, SBV-
15 version, and the BNT scores are summarized in Table 3.
On the basis of these results and in accordance with a previ-
ous study estimating the cut-off points of greatest sensitivity
and specificity for this population (Calero, Navarro, Robles,
& García-Berben, 2000), we used a score of 24 points in the
MMSE, 10 items in the SBV-15 version, and 36 items in the
BNT as a cut-off to classify the participants as having or not
having dementia.
The results of our analysis of criterion validity for the
SBV-15 are summarized in Table 4. Specificity (agreement
in the identification of dementia between the two versions
of the BNT) reached 1, positive predictive value was 1, and
complete agreement between the two versions was 0.855.
The MMSE yielded a higher positive predictive value for
the identification of participants without dementia (0.913),
although complete diagnostic agreement was slightly lower
(0.835).
As shown in Table 5, there was a highly significant corre-
lation between the complete and the reduced versions of the
BNT (r ꢀ .83, p ꢂ .001). The correlation between the
MMSE and each version of the BNT was also significant
(r ꢀ .68, p ꢂ .001 for the BNT; r ꢀ .65, p ꢂ .001 for the
SBV-15).
Table 5 also shows the correlations between the SBV-15
and some of the other tests traditionally included in the bat-
tery of instruments used to detect dementia. In all cases the
correlations were highly significant.
Digit Span and Block Design Subtests.—Taken from the
Wechsler Adult Intelligence Scale (Wechsler, 1974).
Verbal Fluency Test.—Tested with semantic (mainly
nouns) and phonetic cues (words that begin with the letter p;
Goodglass & Kaplan, 1986).
Procedure
The complete battery of tests for neuropsychological as-
sessment was administered in three sessions. Each partici-
pant took both versions of the BNT (complete and SBV-15)
independently in different sessions, normally one week
apart.
Before the results were analyzed, we used multiple com-
parisons between groups of participants recruited from the
retirement home or hospital to rule out statistically signifi-
cant differences in age, gender, or level of education related
with the variable setting.
Statistical Analysis
We first classified the participants as having or not having
dementia depending on neurological diagnosis and their
performance in the battery. We used the methodology com-
monly used in epidemiological studies (Agrimon & Jiménez
Villa, 1991; González de Rivera, Rodríguez Pulido, & Si-
erra López, 1993; Sackett, 1979) to show that the reduced
version of the BNT showed criterion validity with regard to
the complete version and the MMSE.
In accordance with these methods, to establish the crite-
rion validity of measurement instruments and diagnostic
tests (understood as the ability of a test to identify subjects
who have a certain characteristic or diagnostic status and
differentiate them from those who do not), we took into ac-
count the test’s sensitivity (the proportion of persons with a
certain characteristic who are correctly classified) and spec-
ificity (the proportion of persons who do not have the given
characteristic and are correctly classified), as well as the
agreement between the two (criterion agreement).
ANOVA between the groups with and without demen-
tia depending on their MMSE scores (above or below 24
points) revealed significant differences in performance on
Table 4. Criterion Validity of the SBV-15 Compared With the BNT
and the MMSE
Criterion
SBV-15 ꢃ BNT
SBV-15 ꢃ MMS
Sensitivity
Specificity
0.760
1
0.823
1
We then used the SPSS program (SPSS Inc., Chicago, IL)
to test the correlation between the shortened version and the
60-item BNT. Correlations between the SBV-15 and the other
tests used to detect dementia were calculated with the Pear-
son Product-Moment Test. We used analysis of variance
(ANOVA) to compare the groups with and without demen-
Positive Predictive Value
Negative Predictive Value
Complete Agreement
1
0.913
0.727
0.835
0.733
0.855
Notes: SBV-15 ꢀ Shortened Boston Version-15; BNT ꢀ Boston Naming
Test; MMSE ꢀ Mini-Mental State Examination.

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CALERO ET AL.
Table 5. Bivariate Correlations Between the SBV-15, the BNT,
Research into adapting the BNT and its shortened versions
to the characteristics of this group could therefore improve
diagnoses of dementia for this population.
and Cognitive Tests Used to Assess the Degree of
Cognitive Deterioration
The results we obtained show a high degree of equiva-
lence between the complete version of the BNT and the re-
duced version of only 15 items in subjects with a low educa-
tion level. Criterion validity for the SBV-15, diagnostic
agreement with the MMSE, and the significant correlations
between the results of the reduced version and other tests
traditionally used to detect and follow dementia, all suggest
that the SBV-15 can be used instead of the BNT to assess
dementia in situations in which time limitations or the spe-
cial characteristics of the patient so require.
Test
MMSE
SBV-15
BNT
Benton Visual Retention
BNT
Block Design
Digit Span
Age
Education
Verbal Fluency
MMSE
Luria Motor
REY Verbal Learning
0.597**
0.685**
0.657**
0.503**
ꢅ0.383**
0.369**
0.358*
1.000
0.528**
0.534**
0.597**
0.834**
0.658**
0.420**
ꢅ0.389**
0.361**
0.283**
0.651**
0.441**
0.350**
0.660**
1.000
0.729**
0.420**
ꢅ0.341**
0.199
0.420**
0.685**
0.577**
0.525**
Our analyses revealed significant differences between the
complete and the reduced versions of the BNT with regard
to the results for the MMSE and all other battery tests in
participants with and without dementia. This is further con-
firmation of the usefulness of the reduced version and its
equivalence to the complete form of the test.
Notes: MMSE ꢀ Mini-Mental State Examination; SBV-15 ꢀ Shortened
Boston Version-15; BNT ꢀ Boston Naming Test.
*p ꢂ .05; **p ꢂ .01.
Lansing and colleagues (1999) demonstrated the influ-
ence of age, education, and gender variables on all versions
of the BNT published to date. Because our participants were
generally homogeneous with regard to their low educational
level, we found that this variable was not associated with
significant differences in performance in either version of
the BNT. The gender variable was not significant either. It
could have become highly relevant if groups with a higher
educational level had been introduced, because within the
present generation of patients with dementia in Spain, men
had greater opportunity of access to education than women
did. Regarding the age variable, not surprisingly an Age ꢄ
Diagnosis interaction was detected: The greatest number of
cases of Alzheimer’s disease was found in the oldest age
subgroup.
In conclusion, even considering possible limitations due
to the reduced number of participants in the sample or to
sample characteristics, our study reveals that the SBV-15
shows high criterion validity and can thus be considered an
assessment instrument equivalent to the complete BNT for
certain patients. The validation of other reduced forms as al-
ternatives to the BNT, as well as shortening the overall neu-
ropsychological battery, may facilitate follow-up of the
course of patients with anomia, with or without dementia,
by obviating possible learning effects after the same test has
been given in repeated measures.
both versions of the BNT (F(1, 77) ꢀ 32.95, p ꢂ .001 for
the SBV-15, and F(1, 77) ꢀ 54.13, p ꢂ .001 for the BNT).
Multivariate analysis to test the influence of age, level of
education, and gender revealed significant differences only
for the variable age (F(2, 76) ꢀ 7.22, p ꢂ .001 for the SBV-
15, and F(2, 76) ꢀ 3.98, p ꢂ .05 for the BNT) and the
Age ꢄ Diagnosis interaction (F(2, 76) ꢀ 6.24, p ꢂ .001 for
the SBV-15, and F(2, 76) ꢀ 4.55, p ꢂ .05 for the BNT).
Post-hoc analyses showed that these differences were
mainly due to the oldest age subgroup, which also had the
highest prevalence of dementia.
DISCUSSION
In spite of the fact that the BNT, whether in its full ver-
sion or the versions reduced to 30 or 15 items, is one of the
most widely used clinical tests to detect the presence of ano-
mia in dementia, few studies have considered the influence
of lexical characteristics and demographic variables (age,
gender, and education) in non-English-speaking populations
subjected to adaptations of the test. Specifically, the Span-
ish version of the BNT normally used is a literal translation
of the original test, validated in a population with an upper-
age limit of 59, which falls well short of the average age of
the population with dementia. Classification of subjects ac-
cording to education level also follows the standards of the
original version, with two overly broad groups (12 or more
years of schooling as opposed to fewer than 12 years).
These groups present great variability in performance de-
pending on their lexical knowledge, which means that in
many cases the final scores need to be corrected in order to
avoid a diagnosis of anomia for what in reality is lexical ig-
norance of the evaluated item.
In the future, there is a need for a fuller validation of the
Spanish adaptation of the BNT and its shortened versions,
which should also include a frequency analysis of the items
selected, to investigate their correspondence with the partic-
ular lexical characteristics of the Spanish population. These
are probably different from those of the Hispanic popula-
tion, on which such studies have normally been based
(Kohnert et al., 1998).
This situation is especially common in subjects with a
low educational level, who currently constitute the average
population with dementia, particularly in southern Spain.
Owing to the sociocultural characteristics prevailing during
their childhood and adolescence, this population presents a
high index of total illiteracy (neither reading nor writing) or
of functional illiteracy (reading and writing without flu-
ency). There can be no doubt that such subjects have signif-
icant lexical limitations affecting the results of the BNT.
Acknowledgments
We thank Karen Shashok and Julian Bourne for translating the original
manuscript into English.
Address correspondence to Dr. M. Dolores Calero, Facultad de Psi-
cología, Universidad de Granada, Campus “La Cartuja,” 18071 Granada,
Spain. E-mail: mcalero@ugr.es

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P191
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