Montreal Communication Evaluation Battery - Portuguese version: age and education effects

ABSTRACT

Purpose:

To verify age and education effects on communication performance of healthy adults in the Montreal Communication Evaluation Battery, Portuguese version (MAC-PT).

Methods:

The sample comprised 90 healthy adults from Portugal, European Portuguese speakers, divided into nine groups according to educational level (4-9, 10-13, and >13 years of formal schooling) and age (19-40, 41-64, and 65-80 years). The influence of age and education was assessed by comparing mean scores between groups, using a two-way analysis of variance followed by Bonferroni post hoc tests (p ≤0.05).

Results:

The results showed that participants' performance was influenced by age in pragmatic-inferential, discursive, and prosodic tasks. Education had the greatest influence on the performance in all processes evaluated by the MAC-PT.

Conclusion:

Age and education seem to influence the communicative performance and should be considered in the assessment of neurological patients.

Keywords:
Evaluation; Communication; Adults; Age; Education

RESUMO

Objetivos:

Verificar o efeito das variáveis idade e escolaridade no desempenho de adultos saudáveis na Bateria Montreal de Avaliação da Comunicação, versão portuguesa (MAC-PT).

Métodos:

A amostra foi composta por 90 indivíduos portugueses, falantes do Portugês Europeu, distribuídos em 9 grupos de acordo com a escolaridade (4 a 9; 10 a 13; e mais de 13 anos de ensino formal) e com a idade (19 a 40; 41 a 64; e 65 a 80 anos). Para análise de comparação entre grupos, utilizou-se o testetwo-way ANOVA, com post-hoc Bonferroni (p≤0,05).

Resultados:

Verificou-se que o desempenho dos indivíduos foi influenciado pela variável idade nas tarefas pragmático-inferencial, discursiva e prosódica. Já a escolaridade influenciou o desempenho em todos os processamentos avaliados pela MAC-PT.

Conclusão:

As variáveis idade e escolaridade influenciaram o desempenho comunicativo e devem ser consideradas no processo de avaliação de pacientes neurológicos.

Descritores:
Avaliação; Comunicação; Adultos; Idade; Escolaridade

INTRODUCTION

Nearly a century ago, studies described the important role of the left hemisphere in cognition, emphasizing language, in the data analytical processing, and in verbal memory. However, only from the 1970s on, with the advance in researches on cognitive, psycholinguistic, and neuroanatomical functional models, more systemic researches have been initiated about the functional linguistic components related to the right hemisphere (RH) - nonliteral semantic, discursive, and pragmatic components. In this same period, with the evolution of behavioral and neuroimaging studies, it became possible to verify that a lesion in the right hemisphere (LRH) may cause communication disorders1 2 3 4.

Patients with LRH may also present difficulties in other competences, such as temporal-spatial orientation, attention, perception (anosognosia, hemineglect, and prosopagnosia)5, memory (visual amnesia and working memory)6, and emotional processing (comprehension and expression of prosodic stimuli with emotional intonation, emotional processing of faces)7. The damage to one or more of the identified components generates distinct profiles of alterations in the expression and verbal comprehension, impairing the quality of life of the individual and their family8. This way, the process of language evaluation becomes extremely important after neurological lesions, being fundamental in cases of stroke and traumatic brain injury8 9.

The main relevance of the evaluation and the diagnosis by the speech language therapist after the stroke is to draw the profile of the cognitive and communicative functions preserved and in deficit, in comparison with the premorbid state of the subject. The evaluation is essential for the prognosis and design of appropriate treatments for the patients8 9 10. Besides that, the incidence of communicative deficit in individuals with LRH depends on personal characteristics such as age, school education, post-lesion time, and nature of the lesion11, such factors must be considered during the whole evaluation process.

In this sense, the Protocole Montréal d'Évaluation de la Communication - Protocole MEC12 - provided basis for the development of the Montreal Communication Evaluation Battery, Portuguese version (MAC-PT Battery, submitted for publication in Audiology Communication Research), which was adapted from its Brazilian version (Montreal Communication Evaluation Battery - MAC Battery)13. Such adaption occurred in six stages: comparative analysis of the MAC batteries and Protocole MEC ; adaptation and development of new stimuli by specialists; analysis by non-expert evaluators; analysis by expert evaluators; pilot study 1 and pilot study 2; agreement among evaluators, with evidence of content validity; and final adjustments and development of the MAC-PT Battery. It is important to highlight that all stages were intermediated and analyzed by both the authors of the Portuguese adaptation and the authors of the MAC Battery and theProtocole MEC . The instrument kept the same amount of items of the French and Brazilian versions. Chart 1 has the alterations performed in the adaptation based on the Brazilian version.

Chart 1:
Initial and final stimuli of the Montreal Communication Evaluation Battery, Portuguese version, in comparison to the Brazilian version.

The MAC-PT Battery is an expanded battery, relatively easy to be applied, with an average duration of 90 minutes divided into two sessions of 45 minutes each, which evaluate the four processings of communicative competences (discursive, pragmatic-inferential, lexical-semantic, and prosodic)13.

To date, there are no reports in Portuguese of a single instrument that evaluates the four competences mentioned earlier. Thus, it has created the necessity of developing and/or adapting an instrument of evaluation of the communicative competences performed by the RH, adapted to the linguistic and sociocultural reality of Portugal. So that the psychometric rigor obtained in the study with the Brazilian version13 is kept, being necessary empirical studies with the Portuguese version. This way, this study tried to verify the effect of variables such as age and school education on the performance of healthy adults in the MAC-PT Battery, in addition to contributing with performance normative data for the Portuguese population.

METHODS

Participants

Ninety neurologically healthy individuals took part in this study, aged between 18 and 80 years - mean (M) 50.48 years and standard deviation (SD) 19.82 years - and having between 4 and 19 years of formal education (M=11.27 years; SD=4.31 years), which were selected by the non-random convenience method, in college, school, business, hospital, day centers environments, among others, in the region of Great Lisbon, Portugal. As inclusion criteria, the individuals who took part in the study were those who had European Portuguese as the mother language; no sensory disorders (uncorrected hearing and/or visual); no sign of cognitive decline measured by the Clock Test14 associated with the Mini-Mental State Examination (MMSE), adapted version for the Portuguese population15; and no signs of depression measured through the 15-item Geriatric Depression Scale16, which was used in all individuals to obtain the same measure for youngsters, adults, and the elderly9. Also, in order to take part in the sample, the adults could not have a history of alcoholism and/or current or previous abuse of illicit drugs or benzodiazepines and antipsychotics (data collected by the sociocultural and health aspects questionnaire)17.

The initial sample consisted of 101 individuals. Of those subjects, 11 were excluded from the studies because: 3 subjects did not want to proceed with the evaluation claiming exhaustion, 4 subjects scored above cutoff points in the Geriatric Depression Scale, 2 subjects scored below the cutoff point of the MMSE, and 2 subjects had history of neurological diseases. This way, the final sample consisted of 90 individuals.

After the use of the MAC-PT Battery, the participants were distributed into nine subgroups according to age (18-40, 41-65, and 65-80 years) and school education (4-9, 9-13, and more than 13 years of formal study). Regarding the distribution by gender, the sample consisted of 26.7% male individuals and 76.3% female individuals (Table 1).

Table 1:
Demographic characteristics of the sample by age and education range

• ^Caption:
  M = male; F = female

Instruments and procedures

The participation of the individuals was voluntary, and therefore, not remunerated. All of them signed the informed consent. The individuals were assessed individually, in a silent, well lit, and ventilated environment. The evaluation was performed in one single session, lasting about 1 h and 30 min.

After the administration of all instruments needed to fulfill the inclusion criteria, the Portuguese version of the MAC Battery was applied, which has the objective of evaluating four components of the communicative processing: discursive, pragmatic-inferential, lexical-semantic, and prosodic18, through the following tasks:

• • conversational speech,

• • interpretation of metaphors,

• • verbal fluency,

• • linguistic prosody, (e) emotional prosody, (f) narrative speech, (g) interpretation of speech acts, and (h) semantic judgment.

The data were registered and recorded using a digital audio recording equipment for later transcription. Two examiners, speech language therapists, specialized and trained, applied the tasks in the MAC-PT Battery supported by its scoring manual, being 27% (30) of the evaluation judged by a blind specialist evaluator, concordance coefficient higher than 75%.

Analysis of the data

The data were analyzed using the SPSS statistical software, version 17.0, for Windows. For the performance comparison among the nine groups, we used the two-way analysis of variance test, with Bonferroni post hoc (p≤0.05).

RESULTS

Table 2 has the means and standard deviations obtained by the participants in each MAC-PT Battery according to age and school education.

Table 2:
Means and standard deviations in the 16 scores regarding the tasks in the Montreal Communication Evaluation Battery, Portuguese version

• ^Caption:
  SD = standard deviation; MS = maximum score of the task

In general, it is observed that the participants with low school education have underperformed in the MAC-PT Battery when compared to those with high education. The same happens with the elderly, among which a decrease in performance is observed in relation to young adults. Table 3 shows the effect of the variables of age and school education on the tasks of the MAC-PT Battery.

Table 3:
Effect of the variables of age and school education on the tasks of the Montreal Communication Evaluation Battery, Portuguese version

• ^Caption:
  F = F-statistics

An effect of school education was observed on 12 of the 16 scores regarding the analyzed tasks (orthographic verbal fluency, free verbal fluency, semantic judgment, production of emotional prosody, comprehension of linguistic prosody, repetition prosody, interpretation of metaphors, interpretation of speech acts, narrative speech - partial and full recount and questions).

The biological age factor seems to have less influence on the performance of the sample, being present in only six scores (emotional prosody - comprehension and repetition, linguistic prosody - comprehension and repetition, interpretation of metaphors, and conversational speech). It was observed in only one age versus school education interaction - in the semantic verbal fluency task -, indicating that there was a higher effect of education in the group of younger adults with a peak in the intermediate range of education, while for the elderly the peak was given after 14 years of study. Table 4 presents the post hoc analysis that compares the scores of the three age groups and the three school education groups.

Table 4:
Comparison of the scores between age range and school education groups

• ^Caption:
  ns = not significant

The performance of the participants with low education was found to be worse than those with intermediate to high ­education in most tasks. The individuals with intermediate education differ from those with high education in only one task of lexical recall with spelling criterion.

Age influences in an important way the scoring of individuals in some tasks of the MAC-PT Battery (Table 4). This influence occurs mainly when comparing the age group of young adults (18-40 years) with the group of elderly adults (65-80 years), that is, extreme groups.

DISCUSSION

This study aimed at investigating the role of individual factors of age and sociocultural school education from the comparison of base groups for the generation of normative data of the MAC-PT Battery for the Portuguese population. As well as in other studies, the results showed that the communicative tasks were discriminating to the variables of school education and age, considering the effect of education is more frequent than the effect of age10 12 19. These similarities between studies carried out in different languages allow important translinguistic studies.

As for education, the subjects with more than one year of study had better performance, in most tasks of the MAC-PT Battery, than those with lower education. Thus, the lower the education level, the worse the performance in communicative tasks. These findings are consistent with the hypothesis that education increases the level of acquired knowledge of the individuals, promotes greater maturation of brain structures, and, hence, improves language skills20.

Regarding the effect of age, the difference between the age groups was less evident, showing that this factor influences the performance of participants to a lesser extent, at least until the age range limit of 80 years. This happens because the human brain is able to adapt to aging keeping the functionality of its processing throughout the years, even when there are adaptive changes21. However, age seems to influence the scoring of individuals evaluated by the MAC-PT Battery, to the extent that the groups with elder adults had lower scores in relation to the other groups in the task forming the pragmatic-inferential, discursive, and, especially, the prosodic processing. The age factor in the performance of cognitive behavioral tasks has been drawing the interest from the scientific community, considering that some authors observed a decline in the performance of elder adult subjects22 23, whereas other researchers argued that the execution of many functions is kept stable or improves, as language itself24.

From the 16 variables analyzed in the MAC-PT Battery, a school education versus age interaction was evidenced in only one of them (semantic verbal fluency). This indicates that for most of the evaluated subtests, education and age represent relatively independent factors10. This reinforces the hypothesis that such variables represent better performance of the MAC-PT Battery when analyzed independently.

The patterns verified in this study, regarding age end education, were similar to those present in the original instrument Protocole MEC12, in the Montreal Communication Evaluation Battery (MAC-BR)13, and in the short version of the Montreal Communication Evaluation Battery (MAC-Brief Battery)19, showing that the population of Portugal, as well as the one from Canada and Brazil, perform language tasks in a different way according to their age and education level and indicate that the education variable influences more the other communicative processing evaluated by the instruments mentioned than the age variable, at least in a sample of individuals aged up to 80 years.

The size of the sample and the absence of analysis of the gender variable may have limited our results. Some standardization studies of neuropsychological instruments consider that the gender variable influences the performance25, while other researches show no significant differences13. This way, the influence of gender on the performing of cognitive and language tasks is not a consensus in literature. Besides that, the use of the Geriatric Depression Scale in youngsters and adults may limit the results, once that it is indicated for the elderly population. However, it is important to note that there is no valid tracking instrument for these populations.

The MAC-PT Battery came to fill a gap in the evaluation of patient speakers of European Portuguese. This fact makes MAC-PT an instrument capable of providing clear directions in the evaluation process, being easy to apply and analyze.

CONCLUSION

This study allows us to verify the influence of school education in the performance of most tasks in the MAC-PT Battery, considering that the difference in the performance between age range groups was less evident when compared to the effect of education. This way, school education and age must be considered in the evaluation of neurological patients, avoiding false-positive or false-negative results.

ACKNOWLEDGMENTS

The authors thank the participants of this research and the scholarship granted by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) to the second author of this work.

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• 4
  Study carried out at the Health Institute of theUniversidade Católica Portuguesa, Lisbon - Portugal.

Publication Dates

• Publication in this collection
  Dec 2015

History

• Received
  11 Feb 2015
• Accepted
  11 June 2015