Verbal Fluency Tests – Czech Normative Study for Older Persons

Authors: T. Nikolai 1;  H. Štěpánková 2;  J. Michalec 2,3;  O. Bezdíček 1,2;  K. Horáková 2;  H. Marková 4;  E. Růžička 1;  M. Kopeček 2
Authors‘ workplace: Neurologická klinika a Centrum klinických neurověd 1. LF UK a VFN v Praze 1;  Národní ústav duševního zdraví, Klecany 2;  Psychiatrická klinika 1. LF UK a VFN v Praze 3;  Mezinárodní centrum klinického výzkumu, LF MU a FN u sv. Anny v Brně 4
Published in: Cesk Slov Neurol N 2015; 78/111(3): 292-299
Category: Original Paper
doi: 10.14735/amcsnn2015292


The aim of the study was to report normative data on letter (LF; letters K, P, S) and semantic fluency (SF; animals and vegetables).

Verbal fluency (VF) is one of the most frequently used neuropsychological methods for the assessment of cognitive performance in clinical and experimental neuropsychology. However, representative normative data for the Czech population of older and very old adults are so far lacking.

We administered VF as part of neuropsychological battery to 540 (292 women, 248 men) healthy older adults (60–96 years of age). In LF, the letters K, P, S and their total score were used as analogous to the original Controlled Oral Word Association Test (COWAT/FAS). In SF, we evaluated performance in two categories – animals and vegetables.

Age was significantly (p < 0.001) related to a sum of K + P + S (r = –0.236) as well as animals (r = –0.359) and vegetables (r = –0.264). However, the association was moderate. Education was also moderately related (p < 0.001) to the sum of K + P + S (r = 0.297) and animals (r = 0.357). However, we did not find a significant relationship between age and vegetables (r = 0.028; p = 0.523). Vegetables were also the only measure that showed highly significant sex differences (p < 0.001). We present normative Czech data for 60–75, 70–85 and 80–96 age groups.

The results of our study confirm a significant moderate influence of age and education (with the exception of vegetables for the latter) on all VF measures. There were highly significant sex differences in the vegetable category.

Key words:
verbal fluency – normative data – neuropsychological assessment

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manu­script met the ICMJE “uniform requirements” for biomedical papers.


1. Strauss E, Sherman E, Spreen O. A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary. 3rd ed. New York: Oxford University Press 2006.

2. Preiss M. Verbální fluence, metoda vyšetření poškození mozku u dětí a dospělých. Csl Psychol 1997; 3: 244– 249.

3. Topinková E, Jirák R, Kožený J. Krátká neurokognitivní baterie pro screening demence v klinické praxi: Sedmiminutový screeningový test. Neurol Praxi 2002; 6: 323– 328. [online]. Dostupné z URL:   http:/ / pdfs/ neu/ 2002/ 06/10.pdf.

4. Tůma I, Lenderová Z. Schizofrenie a kognitivní funkce. Psychiatrie 2001; 4: 275– 282.

5. Kučerová H, Přikryl R, Čéšková E, Kašpárek T, Perna M. Vlastní zkušenosti s vyšetřováním kognitivních funkcí u depresivní poruchy (Část 2.). Čes a Slov Psychiat 2003; 99: 442– 445.

6. Preiss M, Bartoš A, Čermáková R, Nondek M, Benešová M, Rodriguez M et al. Neuropsychologická baterie Psychiatrického centra Praha, Klinické vyšetření základních kognitivních funkcí. 3. přepracované vydání. Praha: Psychiatrické centrum Praha 2012.

7. Weintraub S, Salmon D, Mercaldo N, Ferris S, Graff‑ Radford NR, Chui H et al. The Alzheimer’s Disease Centers‘ Uniform Data Set (UDS): the neuropsychologic test bat­tery. Alzheimer Dis Assoc Disord 2009; 23(2): 91– 101. doi: 10.1097/ WAD.0b013e318191c7dd.

8. Delis D, Kaplan E, Kramer J. Delis‑ Kaplan executive function system. San Antonio, TX: The Psychological Corporation 2001.

9. Greenaway MC, Smith GE, Tangalos EG, Geda YE, Ivnik RJ. Mayo older americans normative studies: factor analysis of an expanded neuropsychological battery. Clin Neuropsychol 2009; 23(1): 7– 20. doi: 10.1080/ 13854040801891686.

10. Lezak M, Howieson D, Bigler E, Tranel D. Neuropsychological assessment. 5th ed. New York: Oxford University Press 2012.

11. Baldo J V, Schwartz S, Wilkins D, Dronkers NF. Role of frontal versus temporal cortex in verbal fluency as revealed by voxel‑based lesion symp­tom mapping. J Int Neuropsychol Soc 2006; 12(6): 896– 900.

12. Birn RM, Kenworthy L, Case L, Caravella R, Jones TB, Bandettini PA et al. Neural systems supporting lexical search guided by letter and semantic category cues: a self‑ paced overt response fMRI study of verbal fluency. Neuroimage 2010; 49(1): 1099– 1107. doi: 10.1016/ j.neuroimage.2009.07.036.

13. Dick AS, Bernal B, Tremblay P. The Language Connectome: New Pathways, New Concepts. Neuroscientist 2014; 20(5): 453– 467. doi: 10.1177/ 1073858413513502.

14. Duncan J, Owen AM. Common regions of the human frontal lobe recruited by diverse cognitive demands. Trends Neurosci 2000; 23(10): 475– 483.

15. Tekin S, Cummings JL. Frontal‑ subcortical neuronal circuits and clinical neuropsychiatry: an update. J Psychosom Res 2002; 53(2): 647– 654.

16. Yuan P, Raz N. Prefrontal cortex and executive functions in healthy adults: a meta‑analysis of structural neuroimaging studies. Neurosci Biobehav Rev 2014; 42: 180– 192. doi: 10.1016/ j.neubio­rev.2014.02.005.

17. Green J, McDonald WM, Vitek JL, Evatt M, Freeman A, Haber M et al. Cognitive impairments in advanced PD without dementia. Neurology 2002; 59(9): 1320– 1324.

18. Jessen F, Amariglio RE, van Boxtel M, Breteler M, Ceccaldi M, Chételat G et al. A conceptual framework for research on subjective cognitive decline in preclinical Alzheimer’s disease. Alzheimers Dement 2014; 10(6): 844– 852. doi: 10.1016/ j.jalz.2014.01.001.

19. Levy G, Jacobs DM, Tang MX, Côté LJ, Louis ED, Alfaro B et al. Memory and executive function impairment predict dementia in Parkinson’s disease. Mov Disord 2002; 17(6): 1221– 1226.

20. Palmer K, Bäckman L, Winblad B, Fratiglioni L. Detection of Alzheimer’s disease and dementia in the preclinical phase: population-based cohort study. BMJ 2003; 326(7383): 245.

21. Santangelo G, Trojano L, Vitale C, Ianniciello M, Amboni M, Grossi D et al. A neuropsychological longitudinal study in Parkinson’s patients with and without hallucinations. Mov Disord 2007; 22(16): 2418– 2425.

22. Libon DJ, McMillan C, Gunawardena D, Powers C, Massimo L, Khan A et al. Neurocognitive contributions to verbal fluency deficits in frontotemporal lobar degeneration. Neurology 2009; 73(7): 535– 542. doi: 10.1212/ WNL.0b013e3181b2a4f5.

23. Rascovsky K, Salmon DP, Ho GJ, Galasko D, Peavy GM, Hansen LA et al. Cognitive profiles differ in autopsy‑ confirmed frontotemporal dementia and AD. Neurology 2002; 58(12): 1801– 1808.

24. Clark LJ, Gatz M, Zheng L, Chen YL, McCleary C, Mack WJ. Longitudinal verbal fluency in normal aging, preclinical, and prevalent Alzheimer’s disease. Am J Alzheimers Dis Other Demen 2009; 24(6): 461– 468. doi: 10.1177/ 1533317509345154.

25. Murphy KJ, Rich JB, Troyer AK. Verbal fluency patterns in amnestic mild cognitive impairment are characteristic of Alzheimer’s type dementia. J Int Neuropsychol Soc 2006; 12(4): 570– 574.

26. Rinehardt E, Eichstaedt K, Schinka JA, Loewenstein DA, Mattingly M, Fils J et al. Verbal fluency patterns in mild cognitive impairment and Alzheimer’s disease. Dement Geriatr Cogn Disord 2014; 38(1– 2): 1– 9. doi: 10.1159/ 000355558.

27. Rogers TT, Ivanoiu A, Patterson K, Hodges JR. Semantic memory in Alzheimer’s disease and the frontotemporal dementias: a longitudinal study of 236 patients. Neuropsychology 2006; 20(3): 319– 335.

28. Henry JD, Crawford JR, Phillips LH. A meta‑analytic review of verbal fluency deficits in Huntington’s disease. Neuropsychology 2005; 19(2): 243– 252.

29. Jacobs DM, Marder K, Côté LJ, Sano M, Stern Y, Mayeux R. Neuropsychological characteristics of preclinical dementia in Parkinson’s disease. Neurology 1995; 45(9): 1691– 1696.

30. Larsson MU, Almkvist O, Luszcz MA, Wahlin TB. Phonemic fluency deficits in asymp­tomatic gene car­riers for Huntington’s disease. Neuropsychology 2008; 22(5): 596– 605. doi: 10.1037/ 0894‑ 4105.22.5.596.

31. Gorno‑ Tempini ML, Dronkers NF, Rankin KP, Ogar JM, Phengrasamy L, Rosen HJ et al. Cognition and anatomy in three variants of primary progressive aphasia. Ann Neurol 2004; 55: 335– 346.

32. Wilson SM, Brambati SM, Henry RG, Handwerker DA, Agosta F, Miller BL et al. The neural basis of surface dyslexia in semantic dementia. Brain 2009; 132(1): 71– 86. doi: 10.1093/ brain/ awn300.

33. Elias MF, Elias PK, D’Agostino RB, Silbershatz H, Wolf PA. Role of age, education, and gender on cognitive performance in the Framingham Heart Study: com­munity‑based norms. Exp Aging Res 1997; 23(3): 201– 235.

34. Gladsjo JA, Schuman CC, Evans JD, Peavy GM, Miller SW, Heaton RK. Norms for letter and category fluency: demographic corrections for age, education, and ethnicity. Assessment 1999; 6(2): 147– 178.

35. Kavé G. Phonemic fluency, semantic fluency, and difference scores: normative data for adult Hebrew speakers. J Clin Exp Neuropsychol 2005; 27(6): 690– 699.

36. Kosmidis MH, Vlahou CH, Panagiotaki P, Kios­seoglou G. The verbal fluency task in the Greek population: normative data, and clustering and switching strategies. J Int Neuropsychol Soc 2004; 10(2): 164– 172.

37. Loonstra AS, Tarlow AR, Sellers AH. COWAT metanorms across age, education and gender. Appl Neuropsychol 2001; 8(8): 161– 166.

38. Lucas JA, Ivnik RJ, Smith GE, Ferman TJ, Willis FB, Petersen RC. Mayo’s Older African Americans Normative Studies: norms for Boston Naming Test, Controlled Oral Word Association, Category Fluency, Animal Naming, Token Test, WRAT‑ 3 Reading, Trail Making Test, Stroop Test, and Judgment of Line Orientation. Clin Neuropsychol 2005; 19(2): 243– 269.

39. Tombaugh TN, Kozak J, Rees L. Normative data stratified by age and education for two measures of verbal fluency: FAS and animal naming. Arch Clin Neuropsychol 1999; 14(2): 167– 177.

40. Troyer AK. Normative data for clustering and switch­ing on verbal fluency tasks. J Clin Exp Neuropsychol 2000; 22(3): 370– 378.

41. Acevedo A, Loewenstein DA, Barker WW, Harwood DG, Luis C, Bravo M et al. Category fluency test: normative data for English‑  and Spanish‑ speaking elderly. J Int Neuropsychol Soc 2000; 6(7): 760– 769.

42. Fillenbaum GG, Heyman A, Huber MS, Ganguli M, Unverzagt FW. Performance of elderly African American and White community residents on the CERAD Neuropsychological Battery. J Int Neuropsychol Soc 2001; 7(4): 502– 509.

43. Harrison JE, Buxton P, Husain M, Wise R. Short test of semantic and phonological fluency: normal performance, validity and test‑ retest reliability. Br J Clin Psychol 2000; 39 (2): 181– 191.

44. Lucas JA, Ivnik RJ, Smith GE, Bohac DL, Tangalos EG, Graff‑ Radford NR et al. Mayo’s older Americans normative studies: category fluency norms. J Clin Exp Neuropsychol 1998; 20(2): 194– 200.

45. Brickman AM, Paul RH, Cohen RA, Williams LM, Mac­Gregor KL, Jefferson AL et al. Category and letter verbal fluency across the adult lifespan: relationship to EEG theta power. Arch Clin Neuropsychol 2005; 20(5): 561– 573.

46. Crossley M, D’Arcy C, Rawson NS. Letter and category fluency in community‑ dwelling Canadian seniors: a comparison of normal participants to those with dementia of the Alzheimer or vascular type. J Clin Exp Neuropsychol 1997; 19(1): 52– 62.

47. Mathuranath PS, George A, Cherian PJ, Alexander A, Sarma SG, Sarma PS. Effects of age, education and gender on verbal fluency. J Clin Exp Neuropsychol 2003; 25(8): 1057– 1064.

48. Ravdin LD, Katzen HL, Agrawal P, Relkin NR. Letter and semantic fluency in older adults: effects of mild depressive symp­toms and age‑ stratified normative data. Clin Neuropsychol 2003; 17(2): 195– 202.

49. Preiss M. Příspěvek k validizaci testu verbální fluence a kognitivního odhadu v běžné populaci. Psychiatrie 2002; 6 (Suppl 4): 28– 34.

50. Preiss M, Kalivodová Z, Kundrátová I, Mrlinová L, Ježková T, Kubů M et al. Test verbální fluence –  vodítka pro všeobecnou dospělou populaci. Psychiatrie 2002; 6(2): 74– 77.

51. Kopeček M, Kuncová A. Efekt nácviku testu generování slov a testování alternativní verze. Pilotní studie. Psychiatrie 2006; 10(4): 211– 215.

52. Štorková P, Preiss M, Kopeček M. Efekt nácviku testu verbální fluence a testování alternativní verze. Pilotní studie. Psychiatrie 2004; 8: 187– 190.

53. Štěpánková H, Nikolai T, Lukavský J, Bezdíček O, Vrajová M, Kopečel M. Mini‑Mental State Examination –  česká normativní studie. Cesk Slov Neurol N 2015; 78/ 111(1): 57– 63.

54. Folstein MF, Folstein SE, McHugh PR. “Mini‑mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12(3): 189– 198.

55. Nasreddine ZS, Phillips NA, Bédirian V, Charbon­neau S, Whitehead V, Collin I et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005; 53(4): 695– 699.

56. Wechsler D. Wechsler Memory Scale. 3rd ed. San Antonio, TX: Psychological Corporation 1997.

57. Wechsler D. Wechsler Adult Intelligence Scale. 3rd ed. San Antonio, TX: Psychological Corporation 1997.

58. Kopeček M, Štěpánková H. Test‑ retest minutové slovní produkce v kategorii zvířata a kratších variant u seniorů. Psychiatrie 2009; 13(2– 3): 61– 65.

59. Bezdicek O, Motak L, Axelrod BN, Preiss M, Nikolai T, Vyhnalek M et al. Czech version of the Trail Making Test: normative data and clinical utility. Arch Clin Neuropsychol 2012; 27(8): 906– 914. doi: 10.1093/ arclin/ acs084.

60. Mack WJ, Freed DM, Williams BW, Henderson VW. Boston Naming Test: shortened versions for use in Alzheimer’s disease. J Gerontol 1992; 47(3): 154– 158.

61. Bezdicek O, Libon DJ, Stepankova H, Panenkova E, Lukavsky J, Garrett KD et al. Development, validity, and normative data study for the 12- word Philadelphia Verbal Learning Test [czP(r)VLT‑ 12. among older and very old Czech adults. Clin Neuropsychol 2014; 28(7): 1162– 1181. doi: 10.1080/ 13854046.2014.952666.

62. Regard M. Cognitive rigidity and flexibility: A neuropsychological study. University of Victoria: unpublished Ph.D. dissertation 1981.

63. Bush S. Neurosensory Center Comprehensive Examination for Aphasia. In: Kreutzer J, DeLuca J, Caplan B (eds). Encyclopedia of Clinical Neuropsychology. New York: Springer 2011: 1772– 1773.

64. Nikolai T, Vyhnálek M, Štěpánková H, Horáková K. Neuropsychologická dia­gnostika kognitivního deficitu u Alzheimerovy choroby. Praha: Psychiatrické centrum Praha 2013.

65. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986; 5(1– 2): 165– 173.

66. Bezdíček O, Lukavský J, Preiss M. Validizační studie české verze dotazníku FAQ. Cesk Slov Neurol N 2011; 74/ 107(1): 36– 42.

67. Gourovitch ML, Kirkby BS, Goldberg TE, Weinberger DR, Gold JM, Esposito G et al. A comparison of rCBF patterns during letter and semantic fluency. Neuropsychology 2000; 14(3): 353– 360.

68. Henry JD, Crawford JR. A meta‑analytic review of verbal fluency performance following focal cortical lesions. Neuropsychology 2004; 18(2): 284– 295.

69. Duff K, Schoenberg MR, Scott JG, Adams RL. The relationship between executive functioning and verbal and visual learning and memory. Arch Clin Neuropsychol 2005; 20(1): 111– 122.

70. Higginson CI, King DS, Levine D, Wheelock VL, Khamphay NO, Sigvardt KA. The relationship between executive function and verbal memory in Parkinson’s disease. Brain Cogn 2003; 52(3): 343– 352.

71. Troyer AK, Moscovitch M, Winocur G, Alexander MP, Stuss D. Clustering and switching on verbal fluency: the effects of focal frontal‑  and temporal‑ lobe lesions. Neuropsychologia 1998; 36(3): 499– 504.

72. Marra C, Ferraccioli M, Gainotti G. Gender‑related dis­sociations of categorical fluency in normal subjects and in subjects with Alzheimer’s disease. Neuropsychology 2007; 21(2): 207– 211.

73. Richard E, Schmand BA, Eikelenboom P, Van Gool WA. MRI and cerebrospinal fluid bio­markers for predicting progression to Alzheimer’s disease in patients with mild cognitive impairment: a dia­gnostic accuracy study. BMJ Open 2013; 3(6): e002541. doi: 10.1136/ bmjopen‑ 2012‑ 002541.

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