Applied Neuropsychology: Adult

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Toulouse-Piéron Cancellation Test: Normative

scores for the portuguese population

Marisa Lima, Élia Baeta, Diana Duro, Miguel Tábuas-Pereira, Daniela Valério,
Sandra Freitas, Mário R. Simões & Isabel Santana

To cite this article: Marisa Lima, Élia Baeta, Diana Duro, Miguel Tábuas-Pereira, Daniela
Valério, Sandra Freitas, Mário R. Simões & Isabel Santana (2023) Toulouse-Piéron Cancellation
Test: Normative scores for the portuguese population, Applied Neuropsychology: Adult, 30:2,
169-175, DOI: 10.1080/23279095.2021.1918694

To link to this article: https://doi.org/10.1080/23279095.2021.1918694

Published online: 13 May 2021.

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APPLIED NEUROPSYCHOLOGY: ADULT
2023, VOL. 30, NO. 2, 169–175
https://doi.org/10.1080/23279095.2021.1918694

ron Cancellation Test: Normative scores for the

Toulouse-Pie
portuguese population
Marisa Limaa,b,c ,
Elia Baetad, Diana Duroa,b,c , Miguel T
abuas-Pereirab,c, Daniela Val
erioa ,
Sandra Freitasa,e , M
ario R. Simo~esa,e , and Isabel Santanab,c,f
a
Center for Research in Neuropsychology and Cognitive Behavioral Intervention (CINEICC), Faculty of Psychology and Educational Sciences,
University of Coimbra, Coimbra, Portugal; bNeurology Department, Centro Hospitalar e Universit
ario de Coimbra (CHUC), Coimbra, Portugal;
c
Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Portugal; dNeurology Department, Hospital Garcia de
Orta, Almada, Portugal; eFaculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal; fFaculty of Medicine,
University of Coimbra, Coimbra, Portugal

ABSTRACT KEYWORDS
The Toulouse-Pi
eron Cancelation Test (TP) is a classic psychometric tool for the assessment of Healthy adults; normative
selective/sustained attention, processing speed and visuo-perceptual abilities. It is commonly used scores; processing speed;
in neurological disorders such as epilepsy, multiple sclerosis or Alzheimer’s disease. It encompasses psychometric tests;
selective/sustained
two main indexes: Work-Efficiency (WE) and Dispersion-Index (DI). The aim of this study is to pro- attention
vide normative scores for the TP in a sample of Portuguese healthy adults. The TP was adminis-
tered to a convenience sample of 357 cognitively-dwelling subjects aged between [45 and 86]
years old, following a standard assessment protocol. The normative scores were adjusted for age
and education. Education was the main predictor of TP-WE (R2 ¼ .310), whereas the influence of
age on this score was lower (R2 ¼ .191). These two variables explained 50.1% of the variance of
the results. Regarding TP-DI, education was also the main predictor of the results (R2 ¼ .039),
whereas age was responsible for R2 ¼ .011 and together, they explained 5% of the variance of TP-
DI. TP performances are strongly influenced by age and education. This is the first study focused
on the establishment of normative data after the age of 45 in the Portuguese population, allowing
a reliable assessment in both clinical and research contexts.

Introduction
Attention is one of the basic and more relevant domains of
neurocognitive functioning. The presence of attentional defi-
cits has a personal and social impact in daily living, hence
the need to develop precise and accurate attention assess-
ment tools (Alberto, 2003; Muller et al., 2016). Attentional
deficits impair information processing at several levels, being
involved in the more relevant deficits associated with normal
aging. An accurate characterization of possible attentional
deficits is crucial for its diagnosis and understanding
(Chauvin et al., 2016; Cohen, 2014). Despite several defini-
tions and subdivisions of attention capacity, this cognitive
domain is usually divided in sub-domains regarding the type
of processing that is mainly involved: alertness/arousal, div-
ided, selective and sustained attention (Strauss et al., 2006).
There is also controversy about the accurate meaning of
each one of these terms and some of them end up overlap-
ping. As a consequence, the accuracy of attention-tools to
singly evaluate a specific domain is questionable and many
of them involve other cognitive abilities such as motor and
information processing speed (Strauss et al., 2006). The
Toulouse-Pi
eron Cancelation Test (TP), first developed in


1904 by Edouard Toulouse for the evaluation of perception
and both selective and sustained attention is a very popular
psychometric test, largely dependent on the frontal lobe (do
Amaral, 1967; see also Sim~ oes et al., 2016). The first studies
in Portugal were conducted by do Amaral in 1967, for the
evaluation of attentional components and followed by Baeta
(2002), when the test was included in a neuropsychological
battery for the assessment of adults with epilepsy. According
to a recent Portuguese study (Almeida, Sim~ oes, Almiro &
Santos, 2018), the TP is also currently the third most used
neuropsychological instrument after the Rey Complex Figure
Test (Esp
ırito-Santo, Lemos, Ventura, et al., 2015; Rey, 1959,
1998) and the D2 Test of Attention (Brickenkamp, 1981;
Brickenkamp & Schmidt-Atzert, 2019), with studies in
healthy adults (Alchieri et al., 2002; Ara
ujo, 2011; Montiel
et al., 2006) or even in children between 10 and 15 years old
(Sim~ oes et al., 2016). Its clinical utility has been shown in
several studies, in a wide range of neurological and psychi-
atric disorders such as multiple sclerosis (MS) (Cunha,
2013), epilepsy (Baeta, 2002), depression (Kennedy, 2015;
Rock et al., 2014) and neurodegenerative and vascular disor-
ders (McGuinness et al., 2010). It was also investigated in

CONTACT Marisa Lima marisalima5@hotmail.com Serviço de Neurologia – Hospitais da Universidade de Coimbra, Centro Hospitalar e Universit
ario de
Coimbra, Praceta Mota Pinto, Coimbra 3000-075, Portugal.
ß 2021 Taylor & Francis Group, LLC
170 M. LIMA ET AL.
the spectrum of Alzheimer’s disease (AD), namely mild cog-
nitive impairment (MCI) (Lima et al., 2019). In this context,
the rating of TP is based on the comparison of patient’s
scores with standardized data or percentiles, leading to
results that are higher or below the average of the corres-
pondent normative cluster (Lezak et al., 2012). This high-
lights the need to provide normative scores since in our
country robust normative values are still missing after the
age of 45. The main goals of this study are to demonstrate
the validity of this test, and further establish normative
scores. For this, we explored its psychometric properties
and investigated the influence of sociodemographic variables
on the TP scores, using such results as criteria for stratifica-
tion and establishment of normative values for the
Portuguese population.
Materials and methods
Participants and procedures
A community-based convenience sample of volunteers aged
45 years and older was recruited from aging support groups
and senior universities. Caregivers and relatives of ambula-
tory patients with dementia followed at the Memory Clinic
of a Portuguese tertiary hospital also contributed to our
study. Several demographic and clinical inclusion criteria
were considered in the initial subject selection: aged 45 years
and older; Portuguese as their native language and formal
schooling in Portugal; absence of significant motor, visual,
or auditory deficits that could influence performance on
tests; autonomy in daily living activities; no history of alco-
holism or substance abuse; absence of neurological or psy-
chiatric diseases, as well as of chronic unstable systemic
disorders with impact on cognition; absence of significant
depressive complaints and medication with possible impact
on cognition. In order to implement and ensure these gen-
eral criteria, the recruited subjects were interviewed by a
neuropsychologist using a standard clinical interview. This
interview included a sociodemographic questionnaire and
data collection on habits, medical history and current medi-
cation intake. For further inclusion in the study, all subjects
were required to display normal performance on other tools
of the cognitive assessment battery specifically composed for
this study and with accessible Portuguese-validated data (see
section “Materials”). To avoid circularity, the TP was never
used as a criterion for selection or classification. Informed
consent was obtained from all subjects after the aims and
procedures of the investigation and confidentiality require-
ments were fully explained. In order to evaluate test-retest
reliability a sub-sample (n ¼ 70) was assessed at six-month
follow-up, randomly selected from the caregivers/relatives of
out-patients with dementia followed at our center. The pre-
sent research complied with the ethical guidelines for human
experimentation stated in the Declaration of Helsinki and by
the Faculty of Psychology and Educational Sciences of
University of Coimbra Scientific Committee.
Materials
 A sociodemographic questionnaire and a medical history
and habits’ inventory.
 The Mini Mental State Examination (MMSE; Folstein
et al., 1975; Guerreiro et al., 1994; Freitas et al., 2015)—
Portuguese normative values were used for sample inclu-
sion. Subjects were excluded if their scores were
below 1SD.
 The Montreal Cognitive Assessment (MoCA; Nasreddine
et al., 2005; Sim~oes et al., 2008; Freitas et al., 2011), was
used applying the normative scores proposed for the
Portuguese population according to age and education.
Subjects were excluded if their scores were below 1SD.
 The depressive symptoms were measured through the
Geriatric Depression Scale—30 items, with a score of  11
points being indicative of the presence of depressive symp-
tomatology and consequently as study exclusion criteria
(GDS-30; Yesavage et al., 1982, Sim~ oes et al., 2013; Sim~
oes
et al., 2017).
 Neuropsychological measures:
 The Trail Making Test (part A and B) (Cavaco et al.,
2008, 2013), a measure of global cognitive dysfunction.
Form A provides information about attention, visual
search, eye-hand coordination, processing speed,
sequencing capability and cognitive flexibility. Form B
additionally evaluates executive functions, namely the
ability to switch between sequences. For this test we
recorded the total time (in seconds) to complete both
part A and B, according to the Portuguese normative
study of Cavaco et al. (2013).
 The Stroop Color Test (conditions C and CW) (Esp
ırito-
Santo, Lemos, Fernandes, et al., 2015; Fernandes, 2013;
Trenerry et al., 1995). Condition C allows the assessment
of selective attention and processing speed, whereas con-
dition CW adds the evaluation of inhibitory and fluid
abilities as well as cognitive flexibility, and it is related
with the semantic system. For this test we recorded the
total number of words correctly read (condition C), and
the total number of stimuli correctly referred (condition
CW), according to the Portuguese normative data of
Esp
ırito-Santo et al. (2015).
The TP can be administered individually or in group and
the completion time is exactly 10 minutes. The test consists
of a blank sheet of paper with twenty-five lines and forty
small squares per line. The squares are distinguished from
each other through the orientation of the rows on the outer
surface: in each square the stroke is oriented in eight pos-
sible directions, similar to the wind rose. The subject is
required to cross out three targets presented in the header.
For each line the evaluator must register the total number of
hits (H), i.e., the number of targets correctly crossed out by
the subject, errors (E), i.e., when irrelevant targets are
crossed out in violation of the instructions (false-positives),
and omissions (O), i.e., when the targets are not crossed out
(false-negatives). The test presents two main outcomes:
Work Efficiency (WE), which sets up a measure of both the
attentional and perceptual abilities of the subject with a
maximum score of 375 points calculated by the following

method: [WE ¼ H–(E þ O)]; and Dispersion Index (DI), cor-
responding to the percentage of mistakes committed during
the test, calculated by the following formula: [DI ¼ (E þ O)/
H  100]. This index allows a more precise and specific
interpretation of the scores obtained on TP-WE, namely if
they were primarily influenced by a pattern of global
response slowing or by selection mistakes, i. e., impulsivity
(errors) or distractibility (omissions). Usually, lower per-
formances in the TP-WE are related with inattention and
global response slowing and high scores in TP-DI are
explained by distractibility or impulsivity patterns. When
there is a disturbance in flexibility, impairment in informa-
tion processing or motor integration, the two indexes are
typically affected (Baeta, 2002). So, better performances in
the TP are a combination of high scores in TP-WE with
lower scores in TP-DI.
Statistical analysis
Statistical analyses were performed using the Statistical
Package for the Social Sciences (SPSS), version 22.0 for
Windows. Normal distribution was assumed (n > 30), and
multicollinearity was analyzed and showed to be adequate for
all statistical procedures (Pallant & Manual, 2007). Descriptive
statistics were used for the sample’s characterization.
Differences between subgroups according to sociodemographic
variables were examined using one-way between-groups ana-
lysis of variance (ANOVA) and Pearson’s v2 test, for numer-
ical and nominal data, respectively. All tests were 2-tailed and
a p value < .05 was assumed to be statistically significant. Post
hoc Bonferroni and Tukey SD corrections were used to adjust
for multiple pairwise comparisons (Cohen, 1988). Convergent
validity was assessed by Pearson (r) correlation coefficients
between the TP total scores and MMSE, MoCA, TMT (part A
and B) and Stroop test conditions (C and CW) total scores.
Test-retest reliability was also assessed with Pearson’s correl-
ation coefficient between the baseline and the six-month fol-
low-up data. Multiple linear regression (MLR) analysis (enter
method) was performed to examine the influence of age (in
years) and education (years of formal schooling successfully
completed). The coefficient of determination (R2) was consid-
ered in the analysis of effect size in the regressions (Cohen,
1988). Finally, normative values of TP were stratified and
determined according to the sociodemographic variables most
significantly associated with TP scores showed by MLR ana-
lysis. The normative values are presented as means ± standard
deviations (SD), and the distributions of means below (TP-
WE) and above (TP-DI) 1 SD, 1.5 SD, and 2 SD.
Results
From the initial community-based sample of 407 volunteers,
3% (12 participants) were excluded following the interview
(the most frequent reasons were history of psychiatric or
neurological disorder), and 9% (38 participants) were
excluded due to their performance on the assessment bat-
tery, suggesting the presence of possible cognitive impair-
ment or depressive symptomatology according to the
APPLIED NEUROPSYCHOLOGY: ADULT 171
Table 1. Sociodemographic description (n ¼ 357).
Total sample 1–4 years 5–9 years 10
(n ¼ 357) (n ¼ 112) (n ¼ 99) (n ¼ 146)
n % n % n % n %
Gender
Male 152 42.6 49 43.8 48 48.5 62 40.2
Female 205 57.4 63 56.2 51 51.5 86 59.8
Years old
45–64 153 42.8 28 25.0 38 38.4 87 59.6
65–74 103 22.8 39 34.8 28 28.3 36 24.7
75 101 22.4 45 40.2 33 33.3 23 15.7
Source
Senior universities 282 79.0 – – –
Aging support groups 49 13.7 – – –
Caregivers of ambulatory patients 26 7.3 – – –
Portuguese cut-off points. The final sample is composed by
357 cognitively healthy volunteers and the sociodemographic
characterization is presented in Table 1. One of the essential
challenges of this study was to obtain the best representa-
tiveness of the real distribution of the Portuguese population
throughout the selected variables. Participants were stratified
according to age and education. The sample was then div-
ided in three age groups: [45–64] (mean age ¼ 52.86 ± 5.44),
[65–74] (mean age ¼ 69.71 ± 3.60), and 75 (mean age ¼
78.29 ± 3.21) and three education groups: [1–4] (mean edu-
cation ¼ 3.96 ± 0.2) (primary school), [5–9] (mean education
¼ 8.02 ± 1.50) (middle school), and 10 (mean education ¼
14.81 ± 2.89) (high school/university), since there were no
differences between groups on the TP performances after
10 years or more of formal education. The cognitive charac-
terization of the sample can be found in Tables 2 and 3.
The TP showed good convergent validity properties,
obtained by Pearson’s correlation coefficient with MMSE,
MoCA, TMT and Stroop Test (Table 4).
Test-retest reliability was assessed with Pearson’s correl-
ation coefficient between the baseline and six-month follow-
up data of a sub-sample (n ¼ 70) of our study population.
The obtained values were r ¼ .865 (TP-DI) and r ¼ .908
(TP-WE), both p < .01.
The analysis of differences between groups regarding
sociodemographic variables showed that there were statis-
tical significant differences between the three age groups in
both TP-WE (F(2, 355) ¼ 23.57, p < .001) and TP-DI (F(2,
355) ¼ 18.67, p < .001). Bonferroni and Tukey SD post hoc
tests revealed that the younger group [45–64 years old],
performed significantly better than the other two groups
(p < .001), although the older groups did not differ from
each other (p > .05). Statistical significant differences were
also found for education in both TP indexes: TP-WE
(F(2, 355) ¼ 77.96, p < .001) and TP-DI (F(2, 355) ¼ 49.57,
p < .001). Post hoc tests showed that the three groups sig-
nificantly differed from each other, with the most schooled
group ( 10 years), performing significantly better than the
others (p < .001). No statistically significant differences
between groups were found for gender (TP-WE: (v2(1) ¼
4.500, p ¼ .051) and TP-DI: (v2(1) ¼ 9.500, p ¼ .060).
We found significant correlations between the total scores
of TP indexes (WE and DI), age and education. Statistically
significant correlations were observed between the TP-WE
and age (r ¼ –.598) and education (r ¼ .626), both p < .01.
172 M. LIMA ET AL.

Table 2. Cognitive characterization of the study sample.

MMSE MoCA TMT A TMT B
Final sample
(M ± SD) (29.43 ± 0.74) (25.96 ± 2.19) 55.81 ± 26.46 138.11 ± 84.86
[Min–Max] [28–30] [23–30] [21–174] [48–400]
Note. MMSE ¼ Mini Mental State Examination (Maximum score ¼ 30); MoCA ¼ Montreal Cognitive Assessment (Maximum score
¼ 30); TMT ¼ Trail Making Test.

Table 3. Cognitive characterization of the study sample. Table 5. Multiple Linear Regression (MLR) analysis for age and education.
Stroop C Stroop CW GDS Variable B SEB b p value
Final sample WE
(M ± SD) (61.89 ± 15.87) (181.84 ± 63.36) (6.86 ± 3.46) Education 5.038 .683 .456 < .001
[Min–Max] [48–80] [130–297] [1–11] Age –2.048 .285 –.311 < .001
Note. Stroop Color (C); Stroop Color-Word (CW); GDS ¼ Geriatric Depression DI †
Scale (Maximum score ¼ 30). Education –2.311 .928 –.156 < .001
Age 1.470 .805 .115 .021
Note. R2 ¼ .501; F(2,355) ¼ 99.314, p < .01; †R2 ¼ .050; F(2,355) ¼ 7.300, p <
Table 4. Summary of significant Pearson correlations obtained between the
.01. WE ¼ Work Efficiency; DI ¼ Dispersion Index; SEB ¼ Standard Error of B.
TP indexes and the remaining cognitive tests.
Neuropsychological measures TP-WE TP-DI
MMSE r ¼ .717 r ¼ –.617 Table 6. Normative scores of the TP-WE according to age and education.
MoCA r ¼ .520 r ¼ –.620
Work-efficiency (WE) Education
TMT A r ¼ –.565 r ¼ .486
Primary middle High
TMT B r ¼ –.524 r ¼ .422
Age (1–4) (5–9) (10) All education
Stroop C r ¼ –.551 r ¼ .451
Stroop CW r ¼ –.440 r ¼ .326 [45–64]
n 32 37 43 112
Note. p < .01; MMSE ¼ Mini Mental State Examination; MoCA ¼ Montreal
M ± SD 140 ± 47 167 ± 46 191 ± 46 170 ± 50
Cognitive Assessment; TMT ¼ Trail Making Test.
SD 93, 70, 46 121, 98, 75 145, 122, 99 120, 95, 70
[65–74]
The opposite pattern was found for TP-DI: r ¼ .123, with n 36 24 39 99
M ± SD 92 ± 23 106 ± 24 147 ± 44 115 ± 30
age and r ¼ –.360, with education, both p < .01. No statis- SD 69, 52, 36 82, 70, 58 103, 79, 56 85, 69, 54
cally significant correlations were found between gender and 75
the total scores of TP indexes (WE and DI), all p > .5. We n 85 42 19 146
M ± SD 80 ± 20 95 ± 25 125 ± 41 100 ± 29
then proceeded with a MLR analysis (enter method) in SD 60, 50, 40 70, 57, 45 84, 63, 43 71, 56, 41
order to examine the contribution of the significant sociode- All age
n 153 103 101 357
mographic variables (age and educational level), to the M ± SD 104 ± 30 123 ± 32 154 ± 44 128 ± 36
indexes of the TP and to assess the added contributions of SD 74, 59, 44 91, 74, 58 110, 88, 66 92, 74, 56
their interactions. The intercorrelations of the predictive var- Note. WE values are presented below 1 SD, 1.5 SD, and 2 SD, respectively.
iables can be found on Table 5. For TP-WE, age and educa-
tion are responsible for 50.1% of the results variance
Table 7. Normative scores of the TP-DI according to age and education.
(education: 31% and age: 19.1%). For TP-DI, these two vari-
Dispersion Index (DI) (%) Education
ables together explain 5% of the results variance (education: Primary Middle High
3.9% and age: 1.1%). Age (1–4) (5–9) (10) All education
In line with the obtained results, we considered age and [45–65]
n 32 37 43 112
education for the development of normative scores for the M ± SD 21 ± 9 15 ± 12 12 ± 9 16 ± 10
TP in the Portuguese population. Normative scores were SD 30, 35, 39 27, 33, 39 21, 26, 30 26, 31, 36
stratified according to the distributional properties of each [65–75]
n 36 24 39 99
variable. We considered the referred three educational M ± SD 26 ± 10 25 ± 8 21 ± 10 24 ± 9
groups (1–4 years, 5–9 years and 10 years) and three age SD 36, 41, 46 33, 37, 41 31, 37, 41 33, 38, 42
groups: 45–64, 65–74, and 75 years old. The TP scores are  75
n 85 42 19 146
expressed as the M ± SD); values below (TP-WE) and above M ± SD 28 ± 16 25 ± 14 25 ± 10 26 ± 13
(TP-DI) 1 SD, 1.5 SD and 2 SD can be indicated as cutoff SD 44, 52, 60 34, 41, 53 35, 40, 45 39, 46, 52
points for possible cognitive impairment (Tables 6 and 7). All age
n 153 103 101 357
Finally, we established the same norms to all education lev- M ± SD 25 ± 12 22 ± 11 19 ± 10 22 ± 11
els and all age to enable its use in cases where sociodemo- SD 37, 43, 49 33, 39, 44 29, 34, 39 33, 39, 44
graphic information is missing or uncertain. Note. DI values are presented above 1 SD, 1.5 SD, and 2 SD, respectively.

Discussion
In this study we analyzed the influence of sociodemographic
variables on TP scores and were able to determine the nor-
mative values for the Portuguese population. The results
reflect a community-based sample of cognitively healthy vol-
unteers that were stratified according to the most significant
sociodemographic variables. Besides, this study highlights the
importance of having both validity and normative studies of

more than a single neuropsychological test that allows the
assessment of the same cognitive domain, namely attention.
Despite the worldwide use of the TP as a primary meas-
ure of attentional, perceptual and processing speed abilities,
few studies have analyzed the wide variety of sociodemo-
graphic and health variables that might influence its results.
Our study allows to expand the knowledge about the test,
leading to a more accurate and reliable use of this psycho-
metric tool. In order to demonstrate the clinical value of the
instrument, we firstly explored its psychometric properties.
As expected, we observed significant positive correlations
between TP-WE total scores and both MMSE and MoCA
total scores, and between TP-DI and both TMT-A and B
and Stroop C and CW total scores. Moreover, significant
negative correlations were found between TP-WE and TMT
A and B and Stroop C and CW total scores as well as
between TP-DI and MMSE and MoCA total scores. All
together, these results support the convergent validity of this
test (Cohen, 1988). Regarding common measures of reliabil-
ity, we explored test-retest reliability through Pearson’s cor-
relation coefficient between the baseline and six-month
follow-up data of 70 individuals, and obtained high values
for both TP-WE and TP-DI indexes. Interrater reliability
was not assessed in this study since TP has a single standard
instruction before the beginning of the test and no further
prompting is required throughout the 10 minutes.
Similar to previous studies conducted with the TP in our
country (Baeta, 2002; do Amaral, 1967) TP-WE total scores
increased with higher education and the opposite occurs
with the TP-DI. Furthermore, we found that the educational
level was a better predictor of the TP scores than age (31%
vs. 19.1% for TP-WE and 3.9% vs 1.1% for TP-DI). The
higher influence of education compared to age was an
expected result considering our previous experience with
other screening tests in our country, such as the MMSE and
MoCA, where education has been the strongest predictor,
followed by age (Freitas et al., 2011, 2015). For this reason,
in Portugal, we need to develop normative data considering
age and education groups instead of international standard
cut-off points for cognitive decline. Considering the greater
contribution of education to the total scores of the neuro-
psychological scoring in our country (Baeta, 2002; Cavaco
et al., 2013; Faustino et al., 2020), it is known that the
Portuguese society a few decades ago was critically influ-
enced by the achieved educational level which was determin-
ant of the attained socio-economic status, job access, culture
and long-life learning. More recently, the educational setting
has quickly changed as result of the rearrangement of the
school system and the definition of higher mandatory edu-
cational levels for all. Those changes are already reflected in
the youngest groups of our study sample. However, the
older group remains characterized by lower educational lev-
els. Our sample distribution could not fully remove this dis-
similarity in terms of number of participants per group,
however, the achieved partition is quite close to the real
one. Considering age, other international studies reported
no influence of this variable on the subject’s performance:
Maureira et al. (2019) in a sample of 125 students of
APPLIED NEUROPSYCHOLOGY: ADULT 173
physical education found no differences for sex or age in
any of two evaluated indexes (TP-WE and TP-DI), corrobo-
rating the previous study of Maureira et al. (2014) with a
small sample of 15 students, where the same pattern was
primarily described. In 2011, Ara
ujo conducted a normative
study with 701 participants and observed that the ANOVA
analysis based on age, gender and education showed statis-
tically significant differences in TP-WE on basis of educa-
tion only. Also, Montiel et al. (2006) found no differences
between subjects according to age on the TP-DI, and the
differences found for TP-WE were not corroborated by
Tukey SD post hoc analysis. Alchieri et al. (2002), stated that
there were no differences between the age groups on TP
total scores. We believe that the reason why no influence of
age was found in the above-described studies is the very low
percentage of older adults on the samples, since two of them
(Maureira et al., 2014, 2019) only included young students
in their twenties and the remaining included a small number
of participants aged 50 and older. As previously described
(e.g., Fortenbaugh et al., 2015), in the process of normal
aging there is a performance peak in the early 40’s, followed
by a gradual decrease in older adults, particularly related to
execution time/processing speed. Focusing on gender, it was
not a significant predictor of the TP total scores, which is
consistent with prior studies (Baeta, 2002; Rebollo &
Montiel, 2006), where this demographic variable did not sig-
nificantly contribute to data distribution. Despite the fact
that the MLR analysis results showed a minor influence of
age on the total scores of the TP, and once we followed a
regression-based approach to calculate normative data, we
decided to consider both sociodemographic variables (age
and education) for the establishment of normative values for
the Portuguese population. Together, these variables contrib-
ute significantly to the prediction of the total scores,
explaining 50.1% of the results variance on TP-WE and 5%
on TP-DI. We further determined the means and SD for
each sub-group, crossing the three education and
age groups.
This study has some limitations. Considering the low rep-
resentativeness of illiterates in the Portuguese population
nowadays we chose not include those participants, although
the absence of a verbal component in the TP represents an
advantage for its use in this population. Besides, it is
important to point out that, although the TP is one of the
most used psychometric tests to assess attentional, percep-
tual and processing speed abilities, no clinical diagnosis
should be made based solely on its scores. This test should
be integrated in a comprehensive neuropsychological assess-
ment battery at a well-defined timepoint application,
respecting the conditions of the present study in order to
guarantee that normative data are still applicable.
This study has an important set of strengths. Our results
were obtained in a community-sample of cognitively healthy
volunteers that were stratified according to the most signifi-
cant sociodemographic variables and addressed the import-
ance of considering the influence of age and education on
test performances, reflected on the establishment of norma-
tive data for the Portuguese population according to the
174 M. LIMA ET AL.
combination of these two variables. These normative scores
will be useful in both clinical and research contexts, where
the TP has been increasingly used not only in normal aging
but also in neurological conditions such as MCI, AD, MS
and epilepsy (Baeta, 2002; Cunha, 2013; Lima et al., 2019).
It has also been widely used as part of the psychological
assessment batteries for the renewal of driving licenses
(Dora et al., 2018; Sandu, 2014), and also as a useful indica-
tive tool of subject’s performances in recruitment and selec-
tion contexts (Alchieri et al., 2002). In future studies, it
would be important to conduct specific validation studies
for neurological conditions with a known impact on atten-
tion such as MS, vascular dementia or depression, promot-
ing a more accurate use of this instrument in
clinical practice.
Conclusion
This is the first study focused on the establishment of nor-
mative data for the TP in the Portuguese population after
the age of 45. The results emphasize the association of both
education and age in TP performances. The higher influence
of education compared to age was an expected result consid-
ering our previous experience with other neuropsychological
instruments in our country, such as MMSE and MoCA,
where education has been the strongest predictor. Besides,
across the normal aging process there is a gradual perform-
ance decrease related to execution time/processing speed
abilities which may explain the effect of age on TP perform-
ance in older groups.
Disclosure statement
No potential conflict of interest was reported by the author(s).
ORCID
Marisa Lima http://orcid.org/0000-0003-4200-9284
Diana Duro http://orcid.org/0000-0002-9818-9862
Daniela Val
erio http://orcid.org/0000-0001-8062-5817
Sandra Freitas http://orcid.org/0000-0002-3022-5353
M
ario R. Sim~oes http://orcid.org/0000-0002-1311-1338
Isabel Santana http://orcid.org/0000-0002-8114-9434
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