Item-Level Analysis of Category Fluency Test Performance: A Systematic Review and Meta-Analysis of Studies of Normal and Neurologically Abnormal Ageing

Abstract

While Category Fluency (CF) is widely used to help profile semantic memory, item-level scoring (ILS) approaches to this test have been proposed to obtain indices that are less influenced by non-semantic supportive functions. We systematically reviewed the literature to test the hypotheses that (1) compared with healthy adults, individuals with a clinical diagnosis suggestive of neurodegeneration generate words of lower semantic complexity; (2) compared with young adults, older adults generate words of higher semantic complexity. We searched six databases (date of search: 8 December 2023) for studies that relied on CF and ILS methods, in normal ageing and in age-associated neurodegeneration. Thirty-four studies were shortlisted: 27 on neurodegenerative conditions; 7 on normal ageing. Risk of bias was evaluated via a published checklist. Data were presented via qualitative synthesis. Most studies reported words of lower semantic complexity in relation to at least one item-level feature in individuals with mild cognitive impairment (MCI), Alzheimer's dementia (AD), and other neurodegenerative diseases. Post-hoc meta-analyses focussing on the MCI/AD continuum confirmed an effect on words' frequency (385 MCI/AD individuals and 350 controls; Hedges's G = 0.59) and age-of-acquisition (193 MCI/AD individuals and 161 controls; Hedges's G = - 1.51). Studies on normal ageing, conversely, failed to demonstrate any overall effect. Most studies on MCI and AD have not relied on neurobiological diagnostic criteria. Moreover, only a small number of studies analysed ILS controlling for quantitative CF performance. Despite these two limitations, this study suggests that ILS can contribute to an in-depth characterisation of semantic memory in neurological ageing.

Keywords: Dementia; Item-based; Qualitative scoring; Semantic complexity; Semantic fluency; Semantic memory.