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BRAIN AND COGNITION 33, 343–356 (1997)

ARTICLE NO. BR970877

Estimation of Premorbid Intelligence in Spanish People with


the Word Accentuation Test and Its Application to the
Diagnosis of Dementia

Teodoro Del Ser,* Juan-Ignacio González-Montalvo,†


Susana Martı́nez-Espinosa,* Carlos Delgado-Villapalos,*
and Félix Bermejo‡
*Sección de Neurologı́a, Hospital Severo Ochoa, Leganés, Madrid; †Equipo de Valoración
Geriátrica, Hospital la Paz, Madrid; and Servicio de Neurologı́a,
Hospital 12 de Octubre, Madrid, Spain

The Word Accentuation Test assesses the accentuation of 30 infrequent Spanish


words written without the accentuation mark and is an easy-to-use tool for estimat-
ing premorbid intelligence of Spanish-speaking people. Its intraobserver (0.97) and
interobserver (0.93) reliabilities and its correlation with the Wechsler Adult Intelli-
gence Scale (.837) and Raven’s Progressive Matrices (.655) are high, offering a
good prediction of general intelligence. It is resistant to mental deterioration; 20
demented and 40 controls matched by sex, age, and education obtained similar
scores. The discrepancies between current and predicted scores in Raven’s scale can
diagnose mild-moderate dementia with 0.79 accuracy (sensitivity, 0.78; specificity,
0.82).  1997 Academic Press

INTRODUCTION
The estimation of previous intelligence is useful for the clinical and neuro-
psychological study of cognitive decline (Delgado & Del Ser, 1994), in aging
(Brayne & Beardsall, 1990), schizophrenia (Crawford, Besson, Bremner, Eb-
meier, Cochrane, & Kirkwood, 1992; O’Carroll, Walker, Dunan, Murray,
Blackwood, Ebmeier, & Goodwin, 1992b), depression (Evans & Katona,
1993), Korsakoff ’s syndrome (O’Carroll, Moffoot, Ebmeier, & Goodwin,
1992a), chronic intoxication (Bolla, Briefel, Spector, Schwartz, Weiler, Her-
ron, Gimenez, 1992), head injury (Moss & Dowd, 1991), AIDS (Egan, Craw-

This study was done in part with the support of two grants from the Fondo de Investigaciones
Sanitarias of the Ministerio de Salud y Consumo of Spain (88/2014 y 89/0203). We are in-
debted to D. Del Ser for English translation and to J. B. Murphy for reviewing the final English
version. Correspondence and requests for reprints should be addressed to Dr. Teodoro Del
Ser Quijano, Sección de Neurologı́a, Hospital Severo Ochoa, Avda. Orellana s/n, Leganés,
28911 Madrid, Spain. Fax: 91-6940717.
343
0278-2626/97 $25.00
Copyright  1997 by Academic Press
All rights of reproduction in any form reserved.
344 DEL SER ET AL.

ford, Brettle, & Goodwin, 1990), and, especially, the diagnosis and classifi-
cation of demented patients (Grober & Sliwinski, 1991; Sharpe & O’Carroll,
1991; Beardsall & Huppert, 1994).
Methods of estimating premorbid intellectual level have been based on
the assessment of vocabulary (Martin & Fedio, 1983; Kendrick, 1964), be-
cause this cognitive function, representative of ‘‘crystallized intelligence,’’
is rather stable and highly correlated with general intelligence. These meth-
ods have usually been unsatisfactory (Miller, 1977; Fuld, 1983; Delgado &
Del Ser, 1994), however, because vocabulary performance declines with age
and brain pathology. In the last decade word reading tests have proved to
be more useful than vocabulary for the estimation of premorbid intelligence
(Delgado & Del Ser, 1994; O’Carroll & Gilleard, 1986). Reading ability is
closely related to intellectual level in both children (Fransella & Gerver,
1965) and adults (Ruddle & Bradshaw, 1982) and is also resistant to mental
deterioration of organic cause (Cummings, Darkins, Mendez, et al., 1988).
The first reading tests designed to estimate premorbid intelligence were
the Schonell Graded Word Reading Test (Nelson & McKenna, 1975) and
the National Adult Reading Test (NART) (Nelson & O’Conell, 1978). The
task in the NART is to read 50 irregular and infrequent English words. Nel-
son & O’Conell (1978) and other authors have demonstrated the resistance to
deterioration of the NART in mild-moderate dementia of different etiologies
(O’Carroll & Gilleard, 1986; Nebes, Martin, & Horn, 1984; Hart, Smith, &
Swash, 1986) and the stability of its scores after 1 year of progressive deterio-
ration in other cognitive functions (O’Carroll, Baikie, & Whittick, 1987).
Since there is no similar tool in Spanish, we have tried to design a reading
test for Spanish-speaking subjects that would be useful in the estimation of
premorbid intelligence and in the diagnosis of mild-moderate dementia.

SUBJECTS AND METHODS


In this study we followed four steps:
1. Design of an easy reading test for subjects of different intellectual levels and occasionally
with cognitive deterioration.
2. Validation of the test in relation to other general intelligence tests, selection of the best
items, and assessment of its reliability.
3. Determination of an empirical law to estimate the intellectual level by the scores of the
reading test.
4. Application of the test to diagnosis of dementia.

Elaboration of the First Version of the Word Accentuation Test (WAT)


Nelson designed a reading test for adults by selecting English words with an irregular pro-
nunciation whose proper reading would depend on the previous knowledge of the subject
(Nelson & O’Conell, 1978). In the Spanish language this cannot be done, because every word
is read in a regular way. Therefore we decided to assess a reading task with an ambiguous
graphic clue for the Spanish reader: the accentuation of infrequent words written without
accent mark. We hypothesized that the correct accentuation would depend on previous knowl-
WORD ACCENTUATION TEST 345

edge of those words, and that the higher the intellectual level of the subject the better the
result.
We selected 238 Spanish words with difficult accentuation. Subsequently we eliminated the
words that had ambiguous accentuation, were too infrequent, and/or were technical jargon.
Finally, 40 words were selected, with a frequency below 1/70.000 (Juilland & Chang-Rodrí-
guez, 1964), that we considered suitable for the objectives of the test (WAT-40).
The feasibility of the WAT-40 was assessed in 17 inpatients of the geriatric ward of the
Hospital Central de la Cruz Roja in Madrid. In this pilot study we examined whether cogni-
tively normal patients could read the words, the examiner could discriminate the proper accen-
tuation, and the obtained scores had a normal distribution according to the Kolmogorov–
Smirnov test.

Validation of the Final Version of the WAT


In a second step the WAT-40 was validated and shortened. This study was made in a sample
of 81 healthy elders living in their homes, selected from a population survey of dementia
prevalence (Bermejo, 1993). Their mean age was 72.2 6 5.1 years, 42 were women (52%),
and they had 5.8 6 4.3 years of formal education. An extensive clinical assessment was made
in all subjects to exclude mental impairment due to brain disease (Bermejo, 1993). The diag-
nostic workup included neurological examination, CT scan, laboratory tests, and neuropsycho-
logical assessment: Folstein’s Mini-Mental State Examination (Folstein, Folstein, & McHugh,
1975), vocabulary and picture completion of the WAIS (Wechsler, 1958), Raven’s Progressive
Matrices (Raven, 1985), and an extensive mental status examination based on Strub and
Black’s (1985) methodology.
The following tests were selected for this study:
Word Accentuation Test. The WAT assesses the ability of Spanish speakers to stress the
correct syllable in a series of uncommon words. The words are printed on white paper in bold
black capital letters, large enough for clear perception by the subject, and they are presented
without any accent mark. The subject is asked to read aloud each word, without worrying
about its meaning. The total score is the number of words correctly read. The application is
individual and takes 3 to 5 min.
Vocabulary and picture completion subtests of the Wechsler Adult Intelligence Scale (WAIS)
(Wechsler, 1958). Only two subtests of the WAIS were applied to make the study easier for
both control elders and demented patients (see below). We selected the subtests that best
predict verbal and performance total WAIS scores (Wechsler, 1958). The direct scores ob-
tained in each subtest were transformed into standard scores according to Spanish standard
rules (Wechsler, 1982) and subsequently added.
Raven’s Progressive Matrices (RAVEN). Series A and B were applied to each subject indi-
vidually and untimed (Raven, 1985). This test is a better measure of general intelligence than
WAIS subtests and can be applied without time limitations, making it easier for the elders.
Folstein’s Mini-Mental State Examination (MMSE). A Spanish translation (Tolosa, Alom, &
Forcadell, 1987) of the MMSE was applied (Folstein et al., 1975). This short cognitive scale
is frequently used in the study of demented patients. It has 11 items assessing orientation to
place and time, attention, memory, arithmetic, language, and visuoconstructive ability.
The validity of the WAT for estimating intellectual level was calculated by means of its
Pearson’s correlation coefficient with two tests of general intelligence: WAIS (subtests of
vocabulary and incomplete figures) and RAVEN.
Once the WAT-40 was validated an item analysis was performed. Every item correlating
less than .400 with the total score of the WAT (internal consistency) or with the scores of
the WAIS and RAVEN (external validity) was dropped from the test. Tetrachoric correlation
was used as the most suitable for a dichotomous and a continuous variable.
After item analysis and shortening of the WAT the internal consistency, test–retest reliabil-
346 DEL SER ET AL.

ity, and interrater agreement were determined. The internal consistency of the WAT was calcu-
lated with Cronbach’s α coefficient. Test–retest reliability was examined in a sample of 10
elderly inpatients from the Hospital de la Cruz Roja, with a mean age of 87 years. The WAT
was applied twice by the same rater with a delay of 30 days. Interrater agreement was examined
in a sample of 23 consecutive elderly outpatients from the geriatric clinic of the Hospital of
Guadalajara, with a mean age of 78 years. The WAT was applied the same day by a geriatric
practitioner and a clinical assistant.

Estimation of Intellectual Level using the WAT


Three linear regression equations were obtained to define the best estimate of the scores
achieved by the 81 healthy elders in the intelligence tests (WAIS and RAVEN), using their
WAT and vocabulary scores as predictors:
WAIS (predicted) 5 a ⋅ WAT 1 b (1)
RAVEN (predicted) 5 a ⋅ WAT 1 b (2)
RAVEN (predicted) 5 a ⋅ Vocabulary 1 b (3)

Application of the WAT to the Diagnosis of Dementia


Twenty patients with mild-moderate dementia were studied with the same protocol used
for the healthy elders referred to above. Fourteen lived in their homes [8 came from a popula-
tion study of dementia prevalence (Bermejo, 1993) and 6 were outpatients at the geriatric
clinic of the Hospital Central de la Cruz Roja] and 6 lived in geriatric residences. The dementia
diagnosis was established by independent experts (neurologists and geriatricians), other than
the authors of this paper, according to DSM-III criteria (American Psychiatric Association,
1987), following the extensive neuropsychological and clinical evaluation previously de-
scribed (Bermejo, 1993). All cases met NINCDS–ADRDA criteria for possible or probable
Alzheimer’s disease (McKhann, Drachman, Folstein, et al., 1984). Their demographic charac-
teristics are listed in Table 3.
A control group of 40 healthy elders were selected, and matched by age, sex, years of
education, and type of residence with the demented cases.
The mean scores of each group on the WAT, WAIS, RAVEN, and MMSE were compared
with Student’s t test. The equations previously derived for estimating the WAIS and RAVEN
from performance on the WAT and the vocabulary subtest were applied and the discrepancies
between the empirical and predicted scores were calculated for every case. The mean discrep-
ancies of each group were compared with the hypothesis that they should be greater in the
demented group because of the recent mental deterioration.
Finally the receiver operating characteristic (ROC) curves for the MMSE and for the discrep-
ancies in the WAIS and RAVEN were performed following the standard rules for diagnostic
tests (Sackett, Haynes, Guyatt, & Tugwell, 1991). The areas under the curve were compared
and the validity of the diagnosis of dementia was calculated. The optimum cutoff scores were
established looking for the greatest accuracy, and the sensitivity, specificity, and negative and
positive predictive values were determined.

Statistical Methods
Data were analyzed using the statistical packages BMDP (BMDP Statistical Software Inc.,
Los Angeles, CA, PC Version, 1984) and SPSS (SPSS Inc., 1986). The statistical methods used
were the Kolmogorov–Smirnov test to check the normal distribution of a variable, Student’s
t to compare normal quantitative variables, Spearman’s correlation to determine test–retest
WORD ACCENTUATION TEST 347

TABLE 1
Correlationsa of the Word Accentuation Test with External Criteria
WAT-40 WAT Vocabulary

WAIS
Vocabulary 0.842 0.835
Figure completion 0.722 0.712 0.750
Vocabulary 1 figure completion 0.835 0.837 0.952
RAVEN 0.580 0.655 0.663
Mini-Mental State Examination 0.604 0.576 0.632
Years of education 0.571 0.591 0.603

WAT-40, first version of the Word Accentuation Test; WAT, final version of the Word
Accentuation Test; WAIS, Wechsler Adult Intelligence Scale; RAVEN, Raven’s Progressive
Matrices.
a
Pearson’s correlation coefficients; all are statistically significant, p , .0001.

reliability and interrater agreement, Cronbach’s α coefficient to determine the WAT’s internal
consistency, Pearson’s correlation to measure the relation of quantitative variables, tetrachoric
correlation to the item analysis of the WAT-40, and simple linear regression to obtain experi-
mental laws.

RESULTS
Elaboration of the First Version of the WAT
In its initial application to 17 cognitively normal elders, it was verified
that the words could be read, that the examiner could value the correct accen-
tuation, and that the scores had a normal distribution, according to the Kol-
mogorov–Smirnov test (p 5 1).

Validation of the Final Version of the WAT


In the sample of 81 mentally healthy elders the WAT score reached high
and significant correlations with the vocabulary (r 5 .842) and figure com-
pletion scores (r 5 .722) and with the sum of both standardized scores
(r 5 .835). The correlations of the WAT with RAVEN (r 5 .580) and MMSE
(r 5 .604) were somewhat lower but also significant. These high correlations
with general intelligence tests were considered to indicate the concurrent
validity of the WAT-40 as an estimate of the intellectual level.
Ten items had a tetrachoric correlation with the total test score or with
the WAIS or RAVEN scores below 0.400 and were eliminated. The WAT
was shortened by 25%, but it maintained similar correlations with vocabulary
(.842) and figure completion (.712) subtests (vocabulary 1 incomplete fig-
ures 5 .837), RAVEN (.655), and MMSE (.576) (Table 1). The WAT and
the vocabulary subtest had about the same correlation with the number of
years of education (.591 and .603).
The final version of the WAT included 30 infrequent and difficult to accen-
348 DEL SER ET AL.

TABLE 2
Word Accentuation Test
ACULLA ABOGACIA ANOMALO CELIBE
ALELI RABI APATRIDA HUSAR
ALEGORIA MANCHU DIAMETRO MOARE
CONCAVO AMBAR PUGIL POLIGAMO
ACME SILICE GRISU ALBEDRIO
CANON PIFANO TACTIL VOLATIL
DESCORTES DISCOLO BULGARO BALADI
ACOLITO CUPULA

tuate words: 9 with the stress on the last syllable, 9 with stress on the penulti-
mate, and 12 with the stress on the antepenultimate (Table 2).
The test–retest reliability of the WAT applied in 10 elderly subjects with
a delay of 30 days was 0.97. The interrater agreement between a geriatric
physician and a clinical assistant in a sample of 23 patients assessed the
same day was 0.93. Cronbach’s α coefficient of internal consistency was
0.91.

Estimation of Intellectual Level Using the WAT


To estimate the intellectual level measured with WAIS and RAVEN with
the WAT results, three linear regression equations were obtained for the
sample of 81 healthy subjects:
WAIS (predicted) 5 0.730 WAT 1 2.057 (1)

RAVEN (predicted) 5 0.371 WAT 1 7.400 (2)

RAVEN (predicted) 5 0.731 Vocabulary 1 7.958 (3)


Here, WAIS and RAVEN are the best estimates of each subject’s score that
can be predicted from the subject’s score on the WAT or the vocabulary
subtest.

Application of the WAT to the Diagnosis of Dementia


The results of comparing the 40 controls and the 20 patients are shown
in Table 3. The WAIS, RAVEN, and MMSE scores are significantly lower
in the demented patients than in the healthy elders; however, the WAT scores
are not statistically different between groups.
The regression equations described above were applied to every subject,
and the differences, or ‘‘discrepancies,’’ between the predicted and empirical
scores on the WAIS and RAVEN were calculated. The ‘‘discrepancies’’ are
WORD ACCENTUATION TEST 349

TABLE 3
Comparison of Demented and Control Subjects
Demented Controls
(N 5 20) (N 5 40) χ 2 test

Sex
Male 8 (40%) 16 (40%)
Female 12 (60%) 24 (60%) N.S.
Institutionalized 6 (30%) 12 (30%) N.S.

Mean SD Mean SD Student’s t

Age 78.8 1.6 78.2 1.0 N.S.


Years of education 5.1 1.3 5.5 0.9 N.S.
WAIS
Vocabulary 4.1 4.2 6.9 4.3 ,.05
Figure completion 2.3 2.2 5.3 2.8 ,.001
RAVEN 6.9 3.8 12.5 3.9 ,.0001
Mini-Mental State Examination 16.3 6.2 24.0 4.2 ,.0001
WAT 12.7 7.3 14.6 7.8 N.S.
Discrepanciesa (predictor)
WAISp–WAISe (WAT) 4.7 3.9 0.4 3.5 ,.001
RAVENp–RAVENe (WAT) 5.3 3.6 0.4 2.6 ,.001
RAVENp–RAVENe (Vocabulary) 4.2 2.7 0.4 3.0 ,.001

WAIS, Wechsler Adult Intelligence Scale; WAT, Word Accentuation Test


a
Discrepancies between predicted (p) and empirical (e) scores.

significantly higher in the demented group (Table 3). The ‘‘discrepancies’’


for the RAVEN are higher when the estimation is made with the WAT rather
than with the vocabulary subtest (Table 3).
The magnitude of the ‘‘discrepancy’’ between the predicted and empirical
scores indicates the amplitude of mental decline, and can be applied to the
diagnosis of dementia. Figure 1 shows the ROC curves for the MMSE and
for the ‘‘discrepancies’’ in the WAIS and RAVEN. The area under the curve
is 0.86 6 0.05 for the MMSE, 0.83 6 0.06 for the ‘‘discrepancy’’ in the
WAIS, and 0.87 6 0.05 for the ‘‘discrepancy’’ in the RAVEN; when these
areas under the curve were compared no significant differences were found.
To establish a dementia diagnosis, the validity of the MMSE and these
‘‘discrepancies’’ is very similar. The sensitivity, specificity, diagnostic accu-
racy, and positive and negative predictive values of these three variables are
shown in Table 4. The ‘‘discrepancy’’ between the scores obtained in the
RAVEN test and the scores predicted by the WAT is the best diagnostic
parameter.

DISCUSSION
The estimation of premorbid intellectual level is useful in the study of
patients with slight or mild mental deterioration (Delgado & Del Ser, 1994;
350 DEL SER ET AL.

FIG. 1. The receiver operating characteristic curves of the Mini-Mental State Examination
(MMSE), and the discrepancies between predicted and obtained scores on the WAIS (dWAIS)
and RAVEN (dRAVEN). SENS., sensitivity; SPEC., specificity. ■, MMSE; 1, dWAIS; ✴,
dRAVEN.

TABLE 4
Validity of the MMSE and the Discrepancies in the WAIS and RAVEN
for the Diagnosis of Dementiaa

Discrepancies
MMSE WAIS RAVEN

Cutoff 18 6 3
Sensitivity 0.60 0.55 0.72
Specificity 0.92 0.90 0.85
Predictive value
Positive 0.80 0.71 0.72
Negative 0.82 0.81 0.87
Accuracy 0.81 0.79 0.82

MMSE, Mini-Mental State Examination; WAIS, Wechsler Adult Intelligence Scale;


RAVEN, Raven’s Progressive Matrices.
a
Prevalence of dementia in the sample: 0.33.
WORD ACCENTUATION TEST 351

Hart et al., 1986; Baddeley, Emslie, & Nimmo-Smith, 1993). The estimated
previous level can be compared with the present level and, if a clear discrep-
ancy is observed, the diagnosis of mental deterioration can be sustained. This
estimation is also useful in some studies of demented patients needing a
retrospective control of this variable (Jorm & Korten, 1988; Oyebode,
Barker, Blessed, et al., 1986; Morales, González-Montalvo, Bermejo, & Del
Ser, 1995).
Reading aloud tests have been proven to be the most useful for the estima-
tion of premorbid intellectual level (Nelson & McKenna, 1975; Nelson &
O’Conell, 1978; Nebes et al., 1984; Hart et al., 1986; O’Carroll et al., 1987;
Baddeley et al., 1993). The best known of these tests is the National Adult
Reading Test designed by Nelson and colleagues (Nelson & O’Conell,
1978), which assesses the reading of a series of irregular English words and
offers a good estimate of the intellectual level of the subject. According to
the authors (Nelson & McKenna, 1975; Nelson & O’Conell, 1978; O’Carroll
et al., 1987), performance on this test is a good indicator of the subject’s
lexical knowledge, a variable strongly correlated to intellectual level (Rud-
dle & Bradshaw, 1982; Baddeley et al., 1993).
Recently the NART has been translated into other languages (Schmand,
Bakker, Saan, & Louman, 1991) and cultures (Grober & Sliwinski, 1991;
Beardsall & Huppert, 1994), and modified for practical purposes (Crawford,
Parker, Allan, Jack, & Morrison, 1991); however, creation of a similar test
for Spanish speakers seems impossible, because in Spanish, unlike in En-
glish, the rules of reading are always regular. Therefore we examined
whether the accentuation of infrequent words, written without accent mark,
would be a good indicator of lexical ability in Spanish and an efficient way
of estimating premorbid intellectual level.
The WAT, designed for this purpose, has proved to be easy to apply,
short, well accepted by subjects, and, most importantly, highly valid for the
estimation of intellectual level. The correlations of the WAT with external
criteria (WAT–WAIS 5 .837, WAT–RAVEN 5 .655) are higher or similar
to the correlations of these criteria with the MMSE (WAIS–MMSE 5 .491,
RAVEN–MMSE 5 .686), or between them (WAIS–RAVEN 5 .700, vo-
cabulary–RAVEN 5 0.633) (see Table 1). In this study the full WAIS was
not used for practical reasons, but we have shown in an independent study
(Martı́nez, Delgado, & Del Ser, unpublished data) that the correlation be-
tween word accentuation and total WAIS score is higher than .80. Therefore,
the first conclusion of this study is that the WAT is a valid estimate of intel-
lectual level in healthy elders.
It could be argued that the ability to correctly accentuate some infrequent
words is dependent mainly on culture and formal education; however, the
WAT correlates with the duration of education (.591) less than with the intel-
ligence tests, in the same range as the vocabulary (.603), usually considered
the most suitable test for the estimation of general intelligence (Martin &
352 DEL SER ET AL.

Fedio, 1983; Kendrick, 1964). These data suggest that this reading ability
is based not only on cultural exposure to the lexical items but also on other
intellectual skills applied to these materials.
The WAT is a very simple but also consistent test; its test–retest and
interrater reliabilities are very high, even more than those for the NART
(O’Carroll, 1987).
The similarity of the WAT scores in demented patients and control sub-
jects indicates that this test, as other reading tests (Crawford, 1989), is resis-
tant to cognitive deterioration; however, this stability in patients with mild-
moderate dementia cannot be extrapolated to more severe degrees of demen-
tia, where reading ability also declines (Cummings, Houlihan, & Hill, 1986;
Murdoch, Chenery, Wilks, & Boyle, 1987). On the other hand, demented
patients score significantly worse than controls on the WAIS and RAVEN,
even in the vocabulary subtest, which has usually been considered a stable
cognitive function (Martin & Fedio, 1983; Kendrick, 1964; Miller, 1977).
The cognitive deterioration produced by dementia is quite heterogeneous,
and some abilities are more affected than others. Nonsemantic verbal abilities
(such as word accentuation) are better preserved than semantic abilities (vo-
cabulary test), and both of these abilities are better preserved than manipula-
tive abilities (figure completion and progressive matrices tests, in our case)
(Bayles & Boone, 1982; Code & Lodge, 1987). The automatic phonologic
component of language is better preserved because, unlike the semantic com-
ponent, it does not need the integrity of higher cognitive processes (Bayles &
Boone, 1982; Code & Lodge, 1987).
In reading aloud three different mechanisms have been described (Coslett,
Rothi, & Heilman, 1985; Katz & Sevush, 1987). (1) The ‘‘phonologic mech-
anism’’ applies regular and fixed grapheme–phoneme translation rules, is
slow, and does not require previous knowledge or actual understanding of
the read text. If this were the reading mechanism in WAT, most words would
be stressed on the penultimate syllable, because this is the most common
accentuation in Spanish. (2) The ‘‘lexical–semantic’’ mechanism uses the
meaning of the word to produce the correct pronunciation. This mechanism
requires the use of systems of high lexical integration and is impaired early
by the dementia process. (3) The ‘‘writing–sound association’’ nonsemantic
mechanism allows the subject to read correctly the words he has previously
managed, without activating their meaning or applying the slow phonologic
rules. In this way demented patients can correctly read aloud words they
were familiar with but no longer understand. In some types of dementia
(O’Carroll & Gilleard, 1986) the lexical–semantic mechanism can be selec-
tively impaired, while the phonologic and writing–sound association is pre-
served (Sevush, 1984; Rapcsak, Arthur, Bliklen, & Rubens, 1989). The in-
tegrity of this writing–sound association is the basis of the application of
word reading tests to the estimation of premorbid intelligence.
According to our results the WAT score is not affected by the dementia
WORD ACCENTUATION TEST 353

process, probably because its reading is based on the nonsemantic writing–


sound association mechanism, since the orthographic key, the tilde, is lacking
and the semantic processes (vocabulary subtest) are affected. Due to this
resistance to the effects of dementia we can suppose that the WAT is a good
estimator of premorbid intellectual level in patients with organic brain dis-
ease.
The discrepancies between empirical and predicted scores are lower when
the estimation is based on the vocabulary subtest rather than on the WAT.
This finding is similar to others previously reported (Nelson & O’Conell,
1978; Hart et al., 1986) and indicates that reading is a cognitive ability more
resistant than semantic knowledge to the dementia process (O’Carroll & Gil-
leard, 1986; Hart et al., 1986).
The fact that the WAT is a good estimate of premorbid intellectual level
is corroborated when it is applied as a diagnostic tool in light dementia and
its ability to discriminate between demented and nondemented subjects is
demonstrated. This study suggests that word accentuation discriminates mild
dementia with the same accuracy as the MMSE or other verbal tests like
naming (Bayles & Boone, 1982; Williams, Mack, & Henderson, 1989). Our
results are in accord with those of Van den Broek and Bradshaw (1994),
who used the NART and found that the discrepancies between predicted and
obtained scores were higher for the RAVEN than for the WAIS.
Therefore, estimation of previous intelligence with the WAT can be useful
in the diagnosis of mild dementia. It can also be supposed to be useful in
the detection of mental deterioration in patients with an extremely high or
low intelligence, when the usual screening tests produce the highest number
of false-positive and -negative results. It can also be applied to the classifica-
tion of demented patients according to their premorbid intellectual level and
for other diagnostic or experimental purposes.

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