Aging, Neuropsychology, and Cognition

A Journal on Normal and Dysfunctional Development

ISSN: 1382-5585 (Print) 1744-4128 (Online) Journal homepage: http://www.tandfonline.com/loi/nanc20

Object decision test (BORB): normative data for

the adult Quebec population and performance in
Alzheimer’s disease and the semantic variant of
primary progressive aphasia

Alexandre St-Hilaire, Marie-Claude Blackburn, Maximiliano A. Wilson, Robert

Jr. Laforce, Carol Hudon & Joël Macoir

To cite this article: Alexandre St-Hilaire, Marie-Claude Blackburn, Maximiliano A. Wilson,

Robert Jr. Laforce, Carol Hudon & Joël Macoir (2017): Object decision test (BORB): normative
data for the adult Quebec population and performance in Alzheimer’s disease and the
semantic variant of primary progressive aphasia, Aging, Neuropsychology, and Cognition, DOI:
10.1080/13825585.2017.1319901

To link to this article: http://dx.doi.org/10.1080/13825585.2017.1319901

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 Object decision test (BORB): Normative Data for the Adult Quebec

Population and Performance in Alzheimer’s Disease and the Semantic Variant

of Primary Progressive Aphasia

Alexandre St-Hilaire1,2, Marie-Claude Blackburn1,2, Maximiliano A. Wilson2,3,

Robert Jr. Laforce4,5, Carol Hudon1,2, Joël Macoir2,3

1
École de psychologie, Université Laval, Québec, QC, Canada
2
Centre de recherche de l’Institut universitaire en santé mentale de Québec, Québec, QC,

Canada
3
Département de réadaptation, Université Laval, Québec, QC, Canada
4
Clinique Interdisciplinaire de Mémoire (CIME), CHU de Québec, Québec, QC, Canada
5
Département des Sciences Neurologiques, Université Laval, Québec, QC, Canada

Corresponding author: Joël Macoir; Département de réadaptation, Faculté de médecine,

Pavillon Ferdinand-Vandry, Université Laval; 1036, rue de la Médecine, Bureau 4453; Québec,

QC, Canada, G1V 0A6; email: joel.macoir@fmed.ulaval.ca

ASH: alexandre.st-hilaire.1@ulaval.ca; MCB: marie-claude.blackburn.1@ulaval.ca;

MAW: maximiliano.wilson@fmed.ulaval.ca; RJL: robert.laforce@fmed.ulaval.ca;

CH: carol.hudon@psy.ulaval.ca; JM: joel.macoir@fmed.ulaval.ca

1
Acknowledgements

CH was supported by a salary award from the FRQ-S [26809].

Funding

This work was funded by the Réseau québécois de recherche sur le vieillissement, the Canadian Institutes

of Health Research (CIHR), the Alzheimer Society of Canada, the Natural Sciences and Engineering

Research Council of Canada, the Canadian Institutes of Health Research, the Fonds de recherche du

Québec – Société et culture [FRQ-SC-2013-NP-168556] and the Fonds de Recherche du Québec – Santé

(FRQ-S).

2
 Object decision test (BORB): Normative Data for the Adult Quebec

Population and Performance in Alzheimer’s Disease and the Semantic Variant

of Primary Progressive Aphasia

Abstract

Objectives: Object decision (OD) test is one subtest of the Birmingham Object Recognition
Battery (BORB). It is useful for differential diagnosis among several neurodegenerative diseases.
However, normative data provided with this battery count on very few subjects and do not
control for the effect of age, which limits interpretability. The purpose of Study 1 was to provide
normative data for the OD test of the BORB (version A - hard). The objectives of Study 2 were to
establish the diagnostic validity of this task and predictive validity of the normative data in the
case of the semantic variant of primary progressive aphasia (svPPA) and Alzheimer’s disease
(AD). Methods: Based on multiple linear regressions, equations to calculate Z-scores corrected
for age were provided for 130 participants aged from 47 to 89 years. Performance of 20 healthy
participants was compared to that of 14 individuals with svPPA and 18 with AD. Results: After
controlling for confounders, participants with svPPA had a lower total score than controls and
AD participants. AD participants had a poorer performance than controls only when chimeric
objects were considered. Among those with a deficit on the total score of the test, 94% (17/18,
including 12 with svPPA) were correctly identified as having a pathological condition (svPPA or
AD). Discussion: This test could help refine differential diagnosis between svPPA and AD
patients, especially before the deficits of episodic memory show up.

Key words: Norms; Object recognition; Alzheimer’s disease; Primary progressive aphasia;

Assessment

3
Introduction

The object decision task assesses perceptual knowledge of the visual form of objects (“I know

this to be a real/familiar thing”), i.e. the structural description that would be a gateway to the

conceptual knowledge of an object. The difficulty in associating a percept to a concept is called

“associative agnosia” and it may lead to poor performance on an object decision task. For

instance, compared to healthy controls, impaired performance on object decision has been found

in the case of the semantic variant of primary progressive aphasia (svPPA) (Patterson et al., 2006;

Rogers, Lambon Ralph, Hodges, & Patterson, 2004; Zannino et al., 2014) and, to a lesser extent,

in Alzheimer’s disease (AD) (Tippett, 2004; Zannino et al., 2014). However, the tasks used in

most of these studies (Patterson et al., 2006; Rogers et al., 2004; Zannino et al., 2014), and

particularly those used in svPPA, are experimental so the stimuli are not always available for

clinical use. The sole set of published normative data for an object decision test are those of the

Birmingham Object Recognition Battery (BORB) (Humphreys & Riddoch, 1993). This test of the

BORB battery is of interest for differential diagnosis among neurodegenerative disorders,

especially when performance is considered in relation with other cognitive test scores. Indeed, the

object decision test of the BORB has a significant predictive value and increases specificity (i.e.,

reducing false positive) in the identification of older individuals at greater risk to progress to AD

(Belleville, Fouquet, Duchesne, Collins, & Hudon, 2014; Belleville, Gauthier, Lepage, Kergoat,

& Gilbert, 2014).

The BORB is composed of 14 subtests that assess neuropsychological disorders of visual

object recognition (Humphreys & Riddoch, 1993). These subtests assess low-level aspects of

visual perception (using same-different matching of basic perceptual features such as orientation,

length, position, and object size), intermediate-level visual processes (e.g., overlapping figures

4
task), higher-level visual processes (e.g., matching objects from different viewpoints), access to

stored perceptual knowledge about objects (object decision test), access to semantic knowledge

(functional and associative matching), and access to names of objects (picture naming). Each of

these steps can be selectively impaired, thus leading to a particular type of visual agnosia. The

BORB has been validated among patients with left brain damage which have a poor performance

compared to right brain damaged individuals. Nonetheless, because these normative data were

derived from a very small sample of healthy participants (n = 13), which may not be

representative of the healthy population, these norms present several limitations. First, due to the

small sample, data are presented as a whole, and are not adjusted for the influence of

sociodemographic variables. Second, normative data are presented in the form of means and

standard deviations only, which leads to a non-normal distribution and difficulties to interpret

extreme values.

In regard to the above-mentioned limitations, normative data were derived for the object

decision test of the BORB (subtest 10; version A – hard), tailored for a large sample of adults

from Quebec (Canada; Study 1). Also, in order to accurately discriminate between normal and

pathological cognitive functioning in this population, we aimed to examine the diagnostic

validity of this test and the predictive validity of the normative data for two clinical populations,

svPPA and AD (Study 2).

STUDY 1: NORMATIVE DATA

Methods

Participants

5
Researchers from Quebec City (Canada) were invited to share anonymized data from French-

speaking healthy volunteers whose mother tongue was French and who had completed the object

decision test of the BORB as part of other research studies approved by local Research Ethics

Boards. We had consent to use the data presented in this article for secondary analyses, as

stipulated in the information and consent documentation given to participants of the primary

studies.

All participants scored within normal range on the Montreal Cognitive Assessment

(MoCA ≥ 26) (Nasreddine et al., 2005) or the Mini-Mental State Examination (MMSE ≥ 26)

(Folstein, Folstein, & McHugh, 1975), indicating normal cognition. Participants had no

significant depressive symptomatology based on screening results from the Geriatric Depression

Scale (cut-offs were ≤ 10 for the 30-item GDS) (Yesavage, 1988). All participants self-reported

good mental and physical health (i.e., no history of neurological disease, current untreated

psychiatric illness, traumatic brain injury, and untreated medical conditions that could interfere

with cognitive performance).

The normative sample consisted of 130 community-dwelling participants (66 women and

64 men), aged between 47 and 89 years (mean age = 67.2 years; SD = 8.2) and having between 5

and 23 years of formal education (mean education level = 14.5 years; SD = 3.5). Highly educated

men and women aged over 55 were overrepresented in our sample compared with actual Quebec

demographics (Institut de la statistique du Québec, 2006) (Table 1). The number of women in our

sample was similar to Quebec demographics (50.8% vs. 50.3% in Quebec) (Government of

Canada, 2015).

Material and Procedure

6
The object decision task of the BORB (version A – hard) is a 32-item subtest in which

participants are asked to look carefully at black and white line drawings of animals (n = 28) and

tools (n = 4). Half the pictures are constructed by combining parts of two different animals (e.g.,

the body of a cow with the head of a donkey) or tools (e.g., the handles of pliers with the blades

of a scissor) and thus, they represent chimeric objects. The other half of the pictures consists in

real objects. Each picture was presented one at a time on separate pages. Items were administered

in the order predefined by the authors of the battery. For each item, participants were asked

whether or not each picture depicted a real animal or object. Each participant had to reply ‘yes’

(real) or ‘no’ (unreal) as the examiner presented the drawings. They did not have to provide the

names of the animals/objects. Correct answers were credited one point each. There was no time

limit and it took participants about two minutes to complete the test. Figure 1 shows an example

of the items of the task. The scoring sheet is available in the Appendix.

Statistical Analyses

To identify the possible confounders influencing performance, a multiple linear regression

analysis was performed for the object decision test with age, education, and gender as predictors.

Residuals for the object decision test were normally distributed (skewness and kurtosis values

between -1 and 1 in absolute value) (Tabachnick & Fidell, 2013).

Age and education were entered in the analyses as continuous variables, while gender was

coded 0 for men and 1 for women. Interactions between predictors were tested (continuous

variables were centered and interaction terms were created by multiplication: age*education,

age*gender, education*gender, age*education*gender). None of the interactions were significant

so they were not retained in the final models. Visual and statistical analyses were conducted to

7
verify the underlying assumptions of the regression models (normality of residuals, homogeneity

of variance, linearity, multicollinearity and outliers using common criteria) (Tabachnick & Fidell,

2013). Inspection of the data revealed that two items of the object decision test (items 3 and 30;

i.e., deer/goat and snake/tortoise) tended to have very high error rates (96.2% and 88.5%,

respectively). It seems that these items are too discrete and thus go undetected even by healthy

adults. However, more than 50% of participants gave good responses to all other items. Thus,

these two items were excluded from the data set and the regression analysis was repeated. Both

regressions with and without items 3 and 30 are presented in Table 3. All statistical analyses were

performed using SPSS software (version 21.0) with the alpha level set at .05.

Results

Table 2 shows the characteristics of the normative sample according to its demographic variables.

Table 3 illustrates the regression coefficients and intercepts for each condition. Correlations were

significant between total performance on the object decision test and age (r = -.392; p < .001), but

not with education (r = .063; p = .478) or gender (rpb = -.134; p = .130). With respect to

performance on the object decision test without items 3 and 30, correlations were also significant

with age (r = -.391; p < .001), but not with education (r = .063; p = .478) or gender (rpb = -.119; p

= .177). Since education and gender did not significantly correlate with any conditions, the

effects of these variables were not taken into account in the regression equations.

The final model accounted for 15.3% of the variance of the total performance on the object

decision test and only included age, R² = .153, F (1, 128) = 23.207, p < .001. The final model for

performance on the object decision test without items 3 and 30 also accounted for 15.3% of the

variance of performance (age: R² = .153, F (1, 128) = 23.056, p < .001). Based on the results

8
from the regression models, Table 4 reports equations to calculate Z-scores for performance on

the object decision test of the BORB, according to the effect of age. In order to ease calculation

of Z-scores based on the regression formulas, a Microsoft Excel® spreadsheet containing

automatic formulas has been prepared. Clinicians and researchers can download the file from the

website of the journal (see Supplementary materials) or by writing to the corresponding author of

the manuscript.

Discussion

The main objective of this study was to establish normative data for the object decision test of the

BORB. To that end, we used a sample of 130 adults aged 47 to 89 years from Quebec (Canada).

The results of linear multiple regression models indicated that neither education nor gender

explained a significant proportion of the total score on the object decision test. Nevertheless, the

age of participants was a significant predictor of the total score of the test. More precisely, as the

age of participants increased, performance decreased. We cannot rule out the possibility that

performance declines in elderly participants because the sensory system undergoes age-related

changes and also is often affected by eye diseases (e.g., cataracts, glaucoma). Moreover, as other

authors alleged (McKendrick, Weymouth, & Battista, 2010; Robnett, 2013), we can argue that

the elderly have more difficulty to focus attention to visual details. Indeed, it has been described

that, compared to younger adults, the elderly generally identify more readily global features

before local ones when presented in a stimulus containing both global and local features (Gottlob

& Madden, 1999). This effect, called the global interference effect, would be more pronounced

during aging due to an inhibitory breakdown (Roux & Ceccaldi, 2001). Thus, it is possible that

the elderly base more their judgment (real vs. chimeric object) on coarse visual information

instead of details. When stimuli require attention to more fine visual details in order to decide

9
whether or not the object is real, the elderly would fail to recognize them as non-existing

chimeric objects. Finally, in regard to the object decision test, a study showed that performance

involving stored perceptual knowledge deteriorates when age increases, especially beyond 40

years of age, while semantic knowledge is preserved in older participants (Ehrle, Goudour,

Legrand, & Bakchine, 2008). It was argued by these authors that the decrease in visual acuity due

to aging could lead to a gradual decline in the sharpness of the stored perceptual knowledge in

long-term memory.

Although the current study used an incidental sampling method, the normative data

presented here were built from a respectable sample of adults and older adults living in

community. Since there were fewer participants with a low level of education, greater variability

in scores may be present in these subsamples. Nevertheless, this seems unlikely since education

did not affect performance in the present sample. More importantly, our sample did not comprise

people aged 90 years and older. Thus, the application of regression formulas for people over this

age should be interpreted with caution since it represents estimated scores. One should note,

however, that the extent of ages of the current normative data exceeds that of Humphreys and

Riddoch (1993) (which was between 50 and 80 years). Overall, contrarily to the present

normative study, it is noteworthy that the effect of age was not taken into account in the original

normative data (Humphreys & Riddoch, 1993), probably because of the small size of their

sample (13 participants). Finally, we present normative data for the object decision test with and

without the two items that were extremely error-prone for the normative sample. We argue that

this limits the number of errors due to visual discrimination rather than to difficulties in

associating the percept to a concept.

10
 The use of regression equations to calculate Z-scores for performance on the object

decision test has the advantage of better estimating the expected performance of a participant

given his personal characteristics. To illustrate the difference between these two methods, let us

imagine four participants aged 50, 60, 70, and 80, respectively. Based on the regression equations

from Table 4, the participants would have a deficient performance for raw scores of 24, 23, 22,

and 21, respectively (Z ≤ -1.65; 5th percentile). If we use the normative data from Humphreys and

Riddoch (1993), which are not corrected for the effect of age, all participants, no matter their age,

would have a deficient performance for a raw score of 23 (Z ≤ -1.65; 5th percentile), increasing

the rate of false-positives for older adults. The present data seem therefore to better suit the

specific effects of the age of the participants.

STUDY 2: DIAGNOSTIC AND PREDICTIVE VALIDITY

In order to accurately discriminate between normal and pathological cognitive functioning, the

aim of Study 2 was to establish the diagnostic validity of the object decision test and the

predictive validity of the normative data. Diagnostic validity refers to the magnitude of the

deficits that can be found in clinical populations on the object decision test, by comparing their

performance to those of control participants. Predictive validity is the usefulness of the test to

classify participants on a binary classifier system (e.g., healthy, not healthy).

Methods

Participants

11
To establish the diagnostic validity of the test, data from 18 participants with probable AD and

14 participants with svPPA were compared to those of a subsample of 20 healthy participants. To

establish the predictive validity, data from the same three groups were compared.

The subsample of healthy participants was randomly generated using the SPSS

COMPUTE command, which selected a random sample among participants of Study 1

approaching the assigned value (n = 20), considering the number of subjects in the clinical

conditions. These 20 healthy people were not included in the normative data in Study 1. They

were between 50 and 84 years old and had between 4 and 23 years of formal education. One

should note that these participants did not differ significantly from the normative sample in terms

of age (p = .741), education (p = .350), gender (p = .827), general cognition on MoCA (p = .972),

and raw score for total performance on the object decision test with all 32 items (p = .664) and

without items 3 and 30 (p = .613).

AD is a neurodegenerative disease characterized by a disproportionate atrophy in the

medial, basal, and lateral temporal lobe, and in the medial parietal cortex (McKhann et al., 2011).

Probable AD was determined according to current diagnostic criteria (McKhann et al., 2011) and

based on medical records and history (e.g., diagnosis of AD from a medical doctor and/or

participants taking an approved pharmacological treatment for dementia [memantine, donepezil,

galantamine, or rivastigmine]), consensus among clinicians and results from a comprehensive

neuropsychological assessment. The neuropsychological battery comprised tests of verbal (16-

item Free and Cued Recall (Dion et al., 2014; Van der Linden et al., 2004)) and non-verbal (Rey–

Osterrieth or Taylor Complex Figure Tests (Osterrieth, 1944; Tremblay et al., 2015)) episodic

memory, language (Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1983; Mack, Freed,

Williams, & Henderson, 1992)), semantic memory (Pyramids and Palm Trees Test (Callahan et

12
al., 2010; Howard & Patterson, 1992)), visuoperceptual skills (Rey–Osterrieth or the Taylor

Complex Figure Tests (Osterrieth, 1944; Tremblay et al., 2015), Clock Drawing Test (Yamamoto

et al., 2004), Size Match Task of the BORB (Humphreys & Riddoch, 1993)), executive functions

(verbal fluency (Canadian Study of Health and Aging Working Group, 1994; St-Hilaire et al.,

2016), D-KEFS Trail Making Test and Color-Word Interference Test (Delis, Kaplan, & Kramer,

2001)), and working memory/attention (WAIS-III Letter-Number Sequencing and Digit Symbol-

Coding (Wechsler, 1997)). In accordance with McKhann et al. (2011), AD participants had

impairment (Z ≤ -1.50) in verbal and/or non-verbal total learning or total delayed recall of

recently learned information. There was also evidence of impairment in at least one other

cognitive domain. The mean performance on the MoCA was 19.6 (SD = 3.1), which is equivalent

to a MMSE score of 24-25 (Saczynski et al., 2015; Trzepacz, Hochstetler, Wang, Walker, &

Saykin, 2015). Also, all AD participants had a functional impairment as revealed by the

Alzheimer’s Disease Cooperative Study/Activities of Daily Living scale, based on the

information provided by the participant and an informant/caregiver (Galasko et al., 1997). AD

diagnosis was not applied when there was evidence of a stroke temporally related to the onset or

worsening of the cognitive impairment or prominent features of other dementia as those stated by

McKhann et al. (2011).

The svPPA is also a neurodegenerative disease characterized by atrophy, usually more

extensive in the left hemisphere, of the anterior temporal lobes (Gorno-Tempini et al., 2011). The

diagnosis of probable svPPA was based on the most recent criteria for diagnosis of PPA (Gorno-

Tempini et al., 2011) according to neuropsychological testing and clinical judgment of three

authors of this paper (JM, MAW, RJL), who are speech-language pathologist, neuropsychologist,

and behavioral neurologist, respectively. In accordance with Gorno-Tempini et al. (2011), the

13
most prominent clinical feature of svPPA was difficulty with word-finding, word meaning and

multi-modal semantic processing. Moreover, associative agnosia is commonly observed in

svPPA (Kertesz, Jesso, Harciarek, Blair, & McMonagle, 2010) and figured among the criteria for

semantic dementia (i.e., previous name of svPPA) proposed by Neary et al. (1998). The mean

score of participants with svPPA on the MoCA was 19.2 (SD = 2.9; MMSE equivalent to 24-25).

Material and procedure

The object decision test of the BORB was administered to all subjects (healthy, AD, svPPA)

using the same procedure and scoring method as in Study 1.

Statistical Analyses

We compared the total performance between healthy, AD, and svPPA participants with

ANCOVAs controlling for age, education, and general cognition as assessed with the MoCA.

Gender was not significantly correlated with any dependant variables listed in Table 5 for AD,

svPPA, or healthy participants so it was not included in the ANCOVAs. In addition to the

traditional p-values, the effect sizes (partial eta squared; ηp2) are also reported. Like R2, partial eta

squared values indicate the proportion of the variance explained by the main factor (e.g.,

diagnosis) when the effect of the other factors is controlled (e.g., age, education, global

cognition). They were computed as follow: systematic variance of a factor/(systematic variance

of a factor + error variance). Partial eta squared values ranging from 0.01 to 0.06 indicate a small

effect of the main factor while eta squared ranging from 0.06 to 0.14 and higher than 0.14

indicate moderate and strong effects, respectively (Cohen, 1988). Cohen’s d effect sizes,

calculated as the difference of the means of two groups divided by the weighted pooled standard

deviations of these groups, are also reported in Table 5, in order to quantify the magnitude of the

14
difference between conditions on the BORB’s object decision test (i.e., healthy vs. AD, healthy

vs. svPPA, AD vs. svPPA). Cohen’s d ranging from 0.20 to 0.50 indicate small effect of a factor

on performance while Cohen’s d ranging from 0.50 to 0.80 and 0.80 and higher suggest moderate

and large effects, respectively (Cohen, 1988).

Results

Sociodemographic data for the three groups appear in Table 5. AD participants were older than

the two other groups, but educational level was similar among groups. General cognition was

better for healthy participants, but very close to the two clinical groups. Post hoc analyses

following an ANCOVA controlling for the effect of age, education, and general cognition

showed a significant effect of diagnosis on performance on the object decision test (Table 5).

With respect to diagnostic validity, participants with svPPA showed a significantly poorer total

performance (raw score on 32) in comparison with those with AD or controls (mean = 19.2, 23.8,

and 26.1, respectively, F (2, 46) = 7.599, p = .001, ηp2 = 0.25). The same pattern of results was

found for the object decision test when items 3 and 30 were removed (mean = 18.9, 23.3, and

25.9, respectively, F (2, 46) = 7.770, p = .001, ηp2 = 0.25). When performance only for chimeric

objects (raw score on 16) was tested, once again, participants with svPPA had a significantly

lower performance than AD and healthy participants (mean = 6.2, 9.7, 12.4, respectively, F (2,

46) = 6.337, p = .004, ηp2 = 0.22). Although the total performance (/32) of participants with AD

did not significantly differ from that of healthy controls, the former showed a significantly lower

performance than healthy participants when only chimeric objects (/16) were considered.

Concerning predictive validity, when using our normative data at a cut-score of -1.65 SD

(5th percentile; both with and without items 3 and 30), the detection of svPPA among healthy

15
participants was excellent (accuracy: 91%; sensitivity: 86%; specificity: 95%). In AD, specificity

was elevated, but sensitivity was poorer (accuracy: 63%; sensitivity: 28%; specificity: 95%).

Overall, among those with a deficit (Z ≤ -1.65) on the total object decision test, the percentage of

participants who were correctly identified as having a pathological condition (svPPA or AD) was

very high (positive predictive value: 94%; 17/18). Among those with a performance above -1.65

SD, 56% (19/34; negative predictive value) of participants were correctly identified as

cognitively healthy.

Discussion

The objective of Study 2 was to verify the capacity of the BORB’s object decision test and our

normative data to detect differences in performance between healthy participants, individuals

with AD, and those with svPPA. Almost all patients (12/14) with svPPA had a performance

below -1.65 SD (5th percentile). It is noteworthy that two svPPA patients achieved a score closer

to that of healthy controls (Z = -1.30 and -0.53). This could be due to the fact that only two

options (YES/NO) were available for each item. This might have facilitated a score above chance

by simply guessing. Nonetheless, our normative data detected large deficits on the object

decision test for most svPPA participants. This provides validity to the current normalization.

Patients with svPPA typically show associative agnosia and impaired object knowledge (Kertesz

et al., 2010; Neary et al., 1998). In the object decision test, after controlling for the effect of age,

education, and general cognition, participants with svPPA had poorer performance on this task in

comparison to both AD and healthy participants. Moreover, performance for chimeric objects

was clearly affected, while performance for real objects was not affected. Similar results were

found in other studies that compared svPPA and healthy controls on other object decision tasks

(Adlam et al., 2006; Patterson et al., 2006; Rogers et al., 2004). As suggested by Zannino et al.

16
(2014), performance on experimental object decision tests was impaired in svPPA, particularly

for chimeric objects. This could be explained by the fact that these patients may rely on

verbalizable rules to solve the task (e.g., items could be endorsed/rejected based on the ability to

name them or name their two component parts, meaning that if only one component can be

named, the item is endorsed as real). Nonetheless, the faulty verbally-based semantic

representations in svPPA would prevent the affected individuals to perform well. On the

opposite, in an alternative version of the object decision task in which the drawings were not an

arrangement of component parts of different objects, but rather deformed real objects, individuals

with svPPA performed better because the contribution of verbal knowledge was reduced in

solving the task (Zannino et al., 2014). Thus, it seems that patients with svPPA show difficulty in

recognizing an amalgam of combined objects, but not distorted objects. This seems to be a

consequence of the progressive semantic deterioration (or disconnection from structural

descriptions) involving atrophy of the anterior temporal lobes, especially on the left side (Adlam

et al., 2006; Patterson et al., 2006; Rogers et al., 2004; Zannino et al., 2014). An alternative

explanation comes from Postle (2015) who postulated that high-level visual perception

deterioration in svPPA may be due to the early deterioration of the anterior temporal lobes This

would, in turn, impact the functioning of the inferior and lateral temporo-occipital cortex.

However, there is still ongoing debate on whether the poor performance on object decision tasks

in svPPA is due to the degradation of stored perceptual knowledge about objects or is the indirect

result of a breakdown of semantic memory. This debate is beyond the scope of the present study

and has been addressed in previous studies (Patterson et al., 2006; Rogers et al., 2004; Zannino et

al., 2014).

17
 In the present study, AD participants showed comparable performance on the total score

of the BORB’s object decision test in comparison to healthy participants. Tippett, Blackwood,

and Farah (2003) also showed a non-significant difference between AD and healthy adults on the

object decision test of the BORB after having controlled for the effect of impairment in low-level

aspects of perception. Indeed, in AD, brain areas V4 and V2 of the visual cortex are suspected to

generate weakened or distorted visual input of basic shapes, which may slightly impact higher-

level recognition (Tippett, 2004; Tippett et al., 2003). However, when only chimeric objects were

studied, we found that the performance was affected in AD in comparison to healthy sample,

while it was preserved for the detection of real objects. Beyond the above-mentioned possible

low-level visual perceptual deficits, patients with AD often have a semantic deficit, although less

apparent or less severe than that of svPPA patients (Zannino et al., 2014). The better performance

of persons with AD on the object decision test, in comparison to svPPA, may be due to the

relative preservation of the anterior temporal and occipital lobes in the initial stages of AD, and to

a greater heterogeneity of the cognitive profiles among individuals. Indeed, the initial stages of

AD are more associated with deterioration of the medial, basal, and lateral temporal lobes

(Johnson, Fox, Sperling, & Klunk, 2012; McKhann et al., 2011). Although sensitivity was poor

in AD, the object decision test could nonetheless be useful in the detection of AD patients since it

was previously shown to be among the six tests that led to the best overall diagnostic accuracy

between progressive and stable mild cognitive impairment (MCI) when followed over 4.5 years

(Belleville, Fouquet, et al., 2014; Belleville, Gauthier, et al., 2014). Indeed, while a deficit in

episodic memory increases sensitivity for progressive MCI, deficits on the perceptual domain are

thought to increase specificity (Belleville, Gauthier, et al., 2014).

18
 Although the performance on object decision differs between the groups under study, the

inclusion of a lower-level visual task, such as those contained in the BORB, could have shed

some light onto the discussion about the cognitive mechanism involved in a higher level visual

processing task. Another peculiarity is that AD participants had a better performance than svPPA

when only real objects of the BORB were analysed, while healthy participants did not had a

better performance in comparison to clinical samples. This is probably a difference due to the

heterogeneity of the performance in AD. It should be kept in mind that AD and svPPA are not

homogeneous subgroups in terms of deficits, especially AD.

However, all AD and svPPA participants were administered the MoCA and we controlled

for the effect of global cognition on performance. Although the sample of AD participants is

small, the sample of svPPA is appreciable compared to previous studies (n < 10). The overall

performance of these two clinical populations on the BORB’s object decision test provided an

overview of the extent of the expected deficits and could help the clinician to guide the diagnosis

or encourage him to lead further investigations if the score falls below -1.65 SD, which was a

sign of a pathological condition for 94% of our sample.

Conclusion

In sum, the current article presents normative data for the BORB’s object decision test in Quebec

adults. This represents a valuable addition to the limited norms currently available for this test.

Moreover, the test is very quick to administer, sensitive to impairments in svPPA and could help

refine the differential diagnosis of AD patients, especially before the deficits of episodic memory

shows up.

Disclosure Statement

19
No potential conflict of interest was reported by the authors.

20
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24
Table 1. Highest education level reached (% of the population) in the present sample compared
to actual Quebec demographics

Present sample Quebec demographics

Education
At least At least
No high-school No high-school
Age high-school high-school
diploma diploma
diploma diploma

45-54 20.0 80.0 18.5 81.5

55-64 15.0 85.0 24.6 75.4

65-74 29.4 70.6 42.0 58.0

≥ 75 13.8 86.2 54.7 45.3

Note. The second and third left columns contain the proportion of participants in the sample, while the last two
columns contain the percentages of people in the Quebec population having the indicated age and education (Institut
de la statistique du Québec, 2006).

26
Table 2. Distribution of participants in the normative sample (n = 130)

Characteristics N (%)
Age
47-55 10 (7.7)
56-60 17 (13.1)
61-65 28 (21.5)
66-70 30 (23.1)
71-75 19 (14.6)
76-80 21 (16.2)
81-89 5 (3.8)

Gender (men/women) 64/66 (49.2/50.8)

Education
Elementary (5-7 years) 3 (2.3)
High-School (8-12 years) 40 (30.8)
College (13-14 years) 24 (18.5)
University undergraduate 37 (28.5)
(15-17 years)
University graduate 16 (12.3)
(18-19 years)
University postgraduate 10 (7.6)
(20-23 years)

27
Table 3. Coefficients for multiple linear regression analyses

Variable B β t p

Object decision test (subtest 10) –

All test items a
Age -0.120 -0.392 -4,817 <.001

Object decision test (subtest 10) –

Items 3 and 30 excluded b
Age -0.118 -0.391 -4.802 <.001

Notes:
a
Intercept = 34.386; Square root of the mean square residual = 2.329.
b
Intercept = 34.078; Square root of the mean square residual = 2.294; see the text for an explanation regarding
exclusion of items 3 and 30.

28
Table 4. Normative equations to calculate corrected Z-scores for age on the object decision test
of the BORB

Variable n Corrected Z-score for age

All test items (/32) 130 Raw score – [34.386 + (-0.120*Age)] / 2.329
Items 3 and 30 excluded (/30) 130 Raw score – [34.078 + (-0.118*Age)] / 2.294

Notes. Age: participant’s age (continuous variable; between 47 and 89).

Equation denominators corresponded to residual standard deviations of each models.
For example, for a 60-year-old person with a raw score of 26, the equation (/32) should be:
Z-score = 26 - [34.386 + (-0.120*60)] / 2.329 = -0.51

29
Table 5. Comparison of participants with Alzheimer’s disease, the semantic variant of primary progressive aphasia and healthy
participants on sociodemographic variables and the object decision test of the BORB

Effect size (Cohen’s d)

Healthy AD svPPA
Characteristics p
(n = 20) (n = 18) (n = 14) H vs. AD H vs. svPPA AD vs. svPPA

Sociodemographic
Age, mean (SD) 67.9 (8.5) 74.9 (7.6) 65.1 (10.0) .006a 0.87* 0.30 1.13*
Education, mean (SD) 13.7 (4.9) 13.9 (2.9) 16.1 (4.4) .219a 0.07 0.52 0.59
Female, n (%) 10 (50.0) 7 (38.9) 2 (14.3) .100b - - -
MoCA, mean (SD)d 27.8 (1.6) 19.6 (3.1) 19.2 (2.9) <.001a 3.34* 3.86* 0.11

Object decision test

All test items, /32, mean (SD) 26.1 (2.6) 23.8 (4.0) 19.2 (3.7) .001c 0.68 2.20* 1.19*

Items 3 and 30 excluded, /30, mean (SD) 25.9 (2.6) 23.3 (3.8) 18.9 (3.9) .001c 0.79 2.21* 1.17*

Chimeric objects, /16, mean (SD) 12.4 (1.4) 9.7 (3.6) 6.2 (2.7) .004c 1.03* 3.07* 1.08*

Real objects, /16, mean (SD) 13.6 (1.8) 14.2 (1.7) 13.0 (1.7) .046c 0.33 0.35 0.70*

Notes. H = Healthy; AD = Alzheimer’s disease; svPPA = Semantic variant of primary progressive aphasia
Cohen’s d: 0.20 to 0.50 = small effect; 0.50 to 0.80 = moderate effect; 0.80 and higher = large effect (Cohen, 1988).
a
One-way ANOVA; b Chi-square; c ANCOVA controlling for effect of age, education and general cognition (MoCA);
d
MMSE scores equivalent to 30 (healthy) and 24 (AD and svPPA) (Saczynski et al., 2015)
* = significant Sidak post-hoc analysis for one-way ANOVA and one-way ANCOVA.

30
Figure 1. Sample stimuli

The drawing on the left side represents an unreal animal while the one on the right side depicts a real animal
(Humphreys & Riddoch, 1993, pages 164 and 185). Reproduced with the permission of Psychology Press, Taylor
and Francis Group and the authors.

31
16 A. ST-HILAIRE ET AL.

Appendix
Scoring sheet for the object decision test of the BORB (version A – hard)

English
Verbatim instructions: I will show you drawings of animals and tools. Is this [animal or tool] real
or not? Does it exist in this way in real life?
[Repeat the instruction as many times as necessary to ensure that the patient understands the
task. Get the patient’s attention to the drawings to avoid perseverations in his responses.]

Français
Consignes verbales: Je vais vous montrer des dessins d’animaux et d’objets. Est-ce que cet
[animal ou outil] est réel ou non? Existe-t-il sous cette forme dans la vraie vie?
[Répétez les consignes autant de fois que nécessaire pour vous assurer de la bonne
compréhension de la tâche par le patient. Assurez-vous d’attirer l’attention du patient sur
chaque dessin pour éviter les réponses persévératives.]

Page N° Target (Cible) Yes (Oui) No (Non)

163 1 Camel (Chameau) ■ □
164 2 Cow/Donkey (Vâche/Âne) □ ■
165 3 Deer/Goat (Cerf/Chèvre) □ ■
166 4 Dog/Donkey (Chien/Âne) □ ■
167 5 Goat/Deer (Chèvre/Cerf) □ ■
168 6 Cockerel (Jeune coq) ■ □
169 7 Horse/Fox (Cheval/Renard) □ ■
170 8 Lion/Monkey (Lion/Singe) □ ■
171 9 Donkey (Âne) ■ □
172 10 Pliers/Scissors (Pinces/Ciseaux) □ ■
173 11 Scissors/Pliers (Ciseaux/Pinces) □ ■
174 12 Duck (Canard) ■ □
175 13 Giraffe (Girafe) ■ □
176 14 Horse (Cheval) ■ □
177 15 Screwdriver/Screw (Tournevis/Vis) □ ■
178 16 Seal/Sheep (Phoque/Mouton) □ ■
179 17 Kangaroo (Kangourou) ■ □
180 18 Sheep/Seal (Mouton/Phoque) □ ■
181 19 Leopard (Léopard) ■ □
182 20 Monkey (Singe) ■ □
183 21 Swan/Tortoise (Cygne/Tortue) □ ■
184 22 Mouse (Souris) ■ □
185 23 Pig (Cochon) ■ □
186 24 Rabbit (Lapin) ■ □
187 25 Rhino/Sheep (Rhinocéros/Mouton) □ ■
188 26 Screwdriver (Tournevis) ■ □
189 27 Seahorse (Hippocampe) ■ □
190 28 Tortoise/Snake (Tortue/Serpent) □ ■
191 29 Zebra/Tiger (Zèbre/Tigre) □ ■
192 30 Snake/Tortoise (Serpent/Tortue) □ ■
193 31 Squirrel (Écureuil) ■ □
194 32 Tiger (Tigre) ■ □