construct validity of the rbans forms a and b

CONSTRUCT VALIDITY OF THE RBANS FORMS A AND B

A Thesis Presented to the Faculty

of

California State University, Stanislaus

In Partial Fulfillment

of the Requirements for the Degree

of Master of Arts in Psychology

By

Erica Lopez

May 2018

CERTIFICATION OF APPROVAL

CONSTRUCT VALIFITY OF THE RBANS FORMS A AND B

by

Erica Lopez

Dr. Dawn L. Strongin

Professor of Psychology

Dr. Gary A. Williams

Assistant Professor of Psychology

Dr. Kelly A. Cotter

Assistant Professor of Psychology

Date

Date

Date

Signed Certification of Approval page is

on file with the University Library

© 2018

Erica Lopez

ALL RIGHTS RESERVED

iv

DEDICATION

To my family and friends, thank you for all of your love and support.

v

ACKNOWLEDGEMENTS

To my parents, my brother, and Catherine, thank you for your love, support,

and understanding throughout the process of completing my thesis. It is because of all

of you that I had the strength and capacity to take on this endeavor.

To Dr. Dawn L. Strongin, my teacher, mentor, advisor, and my friend. I

couldn’t have done this without you! Thank you for giving me the opportunity to join

your lab and for your guidance all along the way. I am truly grateful to have had you

as my mentor and role model.

To Dr. Gary A. Williams and Dr. Kelly A. Cotter, my advisors, mentors,

thesis committee members, and my friends. Thank you for your patience, guidance,

and support. You have both gone above and beyond to help me succeed and I am

truly grateful.

To Michelle L. Velazquez, my best friend, who encouraged and supported me

when I felt overwhelmed. Thank you for always being there for me, for listening to

me complain, and for sticking by my side through long days of thesis edits. Thank

you for cheering me on and for always being my source of moral support. I honestly

couldn’t have one this without you.

To the Nadine and Galdina, thank you for your patience and support. You

have both helped me in so many ways and I am truly grateful.

vi

To the research assistants in the physio lab, thank you for all of your hard

work and support. Thank you for the countless hours you spent scoring and entering

data, and for your encouragement as I completed my thesis.

To my boyfriend Carson, who has encouraged me and supported me

throughout this process. Thank you for believing in me when I didn’t believe in

myself.

To Bella, Little Bear, and Mia, thank you for being my emotional support

animals throughout this journey.

My sincerest appreciation to you all, I am grateful to have you in my life.

Thank you.

vii

TABLE OF CONTENTS

PAGE

Dedication ............................................................................................................... iv

Acknowledgements ................................................................................................. v

List of Tables .......................................................................................................... viii

List of Figures ......................................................................................................... ix

Abstract ................................................................................................................... x

CHAPTER

I. Literature Review.................................................................................. 1

II. Methods................................................................................................. 13

Participants ................................................................................ 13

Exclusion Criteria ..................................................................... 14

Measures ................................................................................... 14

RBANS ..................................................................................... 15

WAIS-IV ................................................................................... 21

Scoring ...................................................................................... 29

Procedures ................................................................................. 29

Data Analysis ............................................................................ 31

III. Results ................................................................................................... 33

RBANS A five-factor Structure ................................................ 33

RBANS A four-factor Structure ............................................... 35

RBANS A three-factor Structure .............................................. 37

RBANS B five-factor Structure ................................................ 43

RBANS B four-factor Structure................................................ 45

RBANS B three-factor Structure .............................................. 48

RBANS A and B Combined five-factor Structure .................... 53

RBANS A and B Combined four-factor Structure ................... 55

RBANS A and B Combined three-factor Structure .................. 58

RBANS A and WAIS-IV Combined ........................................ 60

RBANS B and WAIS-IV Combined ........................................ 66

WAIS-IV ................................................................................... 73

viii

FSIQ .......................................................................................... 77

IV. Discussion ............................................................................................. 79

Previous Studies and Results .................................................... 79

Limitations ................................................................................ 83

Future Studies ........................................................................... 84

References ............................................................................................................... 86

Appendices

A. Permission to conduct Study at CVOT ....................................................... 96

B. Explanation of larger longitudinal study..................................................... 97

C. Demographics ............................................................................................. 98

D. Informed Consent........................................................................................ 115

E. MMSE ......................................................................................................... 118

F. Initial Debriefing Form ............................................................................... 121

G. Final Debriefing Form ................................................................................ 122

H. Factor structure comparison from the current study to Garcia et al. .......... 123

ix

LIST OF TABLES

TABLE PAGE

1. RBANS proposed five-factor structure ............................................................. 16

2. WAIS-IV proposed four-factor structure .......................................................... 22

3. RBANS Form A: Extracted five-factor structure ............................................. 35

4. RBANS Form A: Extracted four-factor structure ............................................. 37

5. Cumulative percent of variance for extracted three-factor solution ................. 39

6. Factor Loadings for Confirmatory Factor Analysis with Varimax Rotation of

RBANS Form A: Three-factor solution ............................................................ 40

7. RBANS Form A: Extracted three-factor structure............................................ 41

8. RBANS Form B: Extracted five-factor structure .............................................. 45

9. RBANS Form B: Extracted four-factor structure ............................................. 47

10. Cumulative percent of variance for extracted three-factor solution ................. 49

11. Factor Loadings for Confirmatory Factor Analysis with Varimax Rotation of

RBANS Form B: Three-factor solution ............................................................ 50

12. RBANS Form B: Extracted three-factor solution ............................................. 51

13. RBANS Forms A and B combined: Extracted five-factor structure ................. 55

14. RBANS Forms A and B combined: Extracted four-factor structure ................ 58

15. RBANS Forms A and B combined: Extracted three-factor structure ............... 60

16. Cumulative % of variance for RBANS Form A and WAIS-IV combined .... 62

17. Factor Loadings for Confirmatory Factor Analysis of RBANS Form A and

WAIS-IV ........................................................................................................... 63

x

18. RBANS Form A and WAIS-IV combined ....................................................... 64

19. Cumulative percent of variance for RBANS Form B and WAIS-IV .............. 68

20. Factor Loadings for Confirmatory Factor Analysis of RBANS Form B and

WAIS-IV ........................................................................................................... 69

21. RBANS Form B and WAIS-IV combined........................................................ 70

22. Cumulative percent of variance for WAIS-IV without extraction.................... 74

23. Factor Loadings for Confirmatory Factor Analysis of the WAIS-IV ............... 75

24. WAIS-IV: Three-factor structure without extraction ....................................... 76

25. Descriptive Statistics of WAIS-IV FSIQ scores ............................................... 78

26. Factor loadings in Garcia et al. (2008).............................................................. 123

xi

LIST OF FIGURES

FIGURE PAGE

1. Bifactor Model Torrence et al. (2016) .............................................................. 10

xii

ABSTRACT

The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS;

Randolph, 1998) is a standardized assessment that was designed to measure cognitive

function in older adults. The RBANS is a commonly used neuropsychological

assessment with moderate support of its clinical utility. However, the RBANS was

developed theoretically without the use of factor analytic studies. Previous studies

evaluating the factor structure of the RBANS failed to provide significant support for

Randolph’s proposed five-factor structure. The purpose of this study was to evaluate

the proposed five-factor structure of the RBANS Forms A and B, using a

Confirmatory Factor Analysis (CFA), in a homogeneous geriatric population of

‘healthy’ adults. Results of the RBANS Form A suggest a three-factor solution. The

first factor was defined as a Memory and Attention index, Factor two was defined as

a Learning index, and Factor Three was defined as a Visuospatial Function and

Language index. An additional CFA was conducted on the RBANS Forms A and B

combined to determine if combining forms would yield the proposed five-factor

structure. Results found the combined forms to also fit a three-factor structure.

Additionally, the current study conducted a CFA on the RBANS and WAIS-IV

combined to evaluate if similar subtests loaded together in the same factors

(convergent validity).

1

CHAPTER I

LITERATURE REVIEW

The development of neuropsychological assessments gave clinicians an

inexpensive, and noninvasive, method to evaluate a patient’s cognitive function prior

to conducting invasive treatments, such as neurosurgery. Given the importance of

these types of assessments, it is crucial to evaluate both the validity and reliability of

each test developed, such that the assessments should significantly correlate with

invasive tools, such as PET scans. In theory, performance on valid

neuropsychological assessments reflects an individual’s true cognitive function.

Neuropsychological assessments are used in clinical settings to track and

identify the current status of an individual’s cognitive functioning. In most cases, an

individual’s level of cognition will remain relatively stable throughout one’s life, with

only slight decline occurring with age (Duff et al., 2003; Duff et al., 2008; Thaler et

al., 2014). In other cases, there is a significant drop in the individual’s level of

cognitive function, which could be an indication of a neurodegenerative disorder

(Duff et al., 2008).

There are a number of complex assessments that have been developed over

the years that are specifically designed to measure and track cognitive function. The

Wechsler Memory Scale-Fourth Edition (WMS-IV) and the Wechsler Adult

Intelligence Scale - Fourth Edition (WAIS-IV) are considered among the “gold

2

standard” assessments by which new neuropsychological assessments are compared

in validity tests (Frazier, 2011; Hartman, 2009; Stano, 2004). These complex

assessments identify specific domains of cognitive strength and impairment, which

aids in the development of a treatment plan. Although there are many benefits to an

extensive battery, they may be too lengthy for some individuals. Older individuals for

example, may experience cognitive fatigue, such that they lack cognitive stamina to

put forth full and sustained effort throughout the testing session. Consequently,

performance scores potentially fail to represent the individual’s “true” function.

The Repeatable Battery for the Assessment of Neuropsychological Status

(RBANS; Randolph, 1998) is a standardized assessment that was developed in

response to lengthier batteries. The RBANS is a brief neuropsychological assessment

(i.e., 30 minutes) designed to measure cognitive function in older adults. It consists of

four purported equivalent forms to allow for retesting without the risk of test retest

effects. Its content consists of pieces of several strongly supported

neuropsychological assessments such as the Boston Naming Test (Kaplan,

Goodglass, and Weintraub, 1983), the Judgment of Line Orientation Test (Benton,

Sivan, Hamsher, Varney, & Spreen, 1983), the Wechsler Memory Scale- Third

Edition (WMS-III; Wechsler, 1997b), the Wechsler Adult Intelligence Scale-Third

Edition (WAIS-III; Wechsler 1997a), and the Controlled Oral Word Association test

(COWA; Benton, Hamsher, & Sivan, 1994).

The RBANS was designed to measure five cognitive constructs: Immediate

Memory (Subtests: List Learning, Story Memory), Visuospatial

3

Function/Constructional (Subtests: Figure Copy, Line Orientation), Language

(Subtests: Picture Naming, Semantic Fluency), Attention (Subtests: Digit Span,

Coding), and Delayed Memory (Subtests: List Recall, List Recognition, Story Recall,

and Figure Recall) (Randolph, 1998). Subtest scores are converted into one of five

index scores using a table provided in the Appendix of the RBANS stimulus book.

The sum of the index scores is converted into a total scale score using a table

provided in the Appendix of the RBANS stimulus book (Lezak, 2012). Those scores

are then compared to the normative data of individuals ages 20-89, to determine if the

clients score falls within a “normal” range (Lezak, 2012).

Suggested benefits of the RBANS clinical utility include its inclusion of four

forms (Forms A-D) and its suggested ability to predict mortality. The inclusion of

four forms of the RBANS allows for retesting without the risk of test retest effects.

Research by Duff et al. (2005) confirmed this theory by providing evidence for no

test retest effects in a community dwelling geriatric sample. Furthermore, Duff, Mold,

and Gidron (2009) discovered evidence of the RBANS’ sensitivity in predicting

participant mortality, such that nine of twelve subtests significantly correlated with

participant mortality.

The clinical utility of the RBANS has been supported in many studies,

however construct validity was not determined prior to the release of the tool (Duff et

al., 2006). The factor structure of the RBANS was developed theoretically without

the use of factor analytic studies (Schmitt et al., 2010). Support for the reliability of

the assessment stems from a series of intercorrelation and correlation studies. For

4

example, significant correlations of .78 and .77 were found between the RBANS

Total Scale Score and the Full-Scale Intelligence Quotient (FSIQ) of the Wechsler

Adult Intelligence Scale-Revised (WAIS-R) and the Wechsler Adult Intelligence

Scale-Third Edition, respectively (WAIS-III; Wechsler, 1981; Randolph, 1998; Gold,

Queern, Iannone, & Buchanan, 1999). Furthermore, Gold et al. (1999) found a

moderate correlation of .67-.69 between the RBANS and the indices of the Wechsler

Memory Scale- Third Edition (WMS-III) in a study involving participants with a

diagnosis of schizophrenia. A study by Hobart, Goldberg, Bartko, and Gold (1999)

provided additional support of the RBANS Total Scale Score. This study compared

the Total Scale Score of the RBANS to various measures (subtests) of IQ such as:

memory, language, motor attention, and executive function. Researchers found a

significant correlation (.79) between the RBANS Total Scale Score and the

previously mentioned measures of IQ. (Hobart et al., 1999). Furthermore, Randolph

(1998), the developer of the RBANS, conducted an intercorrelation study comparing

the proposed five factors of the RBANS. He found that the variability in factor

loadings (several factors appeared) suggests that each factor is measuring a different

area of cognitive function. The strongest correlation in this study was found between

Immediate and Delayed Memory factors.

The process of establishing validity for an assessment is ongoing (Schmitt et

al., 2010). Previous research suggests that the RBANS has adequate construct and

convergent validity in several clinical populations, including individuals with

traumatic brain injury (McKay, Casey, Wertheimer, & Fichtenberg, 2007)

5

Alzheimer’s Disease (Randolph, Tierney, Mohr, & Chase,1998), Huntington’s

Disease (Randolph et al., 1998), stroke (Larson et al., 2003), Parkinson’s Disease

(Beatty et al., 2003) and multiple sclerosis (Aupperle, Beatty, Shleton, &

Gontkovsky, 2002; Beatty, 2004). Furthermore, numerous studies have investigated

the RBANS sensitivity and discriminant validity, such that they assessed whether the

RBANS could accurately diagnose those with (true positive) and without (true

negative) a cognitive disorder (Duff et al., 2008; Freilich & Hyer, 2007; Gontkovsky,

Hillary, & Scott, 2002; Randolph et al., 1998).

Research conducted by Randolph et al. (1998), the author of the RBANS,

found that the RBANS was sensitive to mild impairment, such that it was able to

‘accurately’ diagnose individuals who failed to meet clinical criteria on the Dementia

Rating Scale (DRS, Mattis, 1988) and Mini Mental Status Exam (MMSE, Folstein,

Folstein, & McHugh, 1975). That is, the RBANS identified dementia earlier, before

the disease progressed enough for the DRS and MMSE to detect (sensitivity). He also

found the RBANS to have strong discriminant validity, such that its domain measures

are unrelated to each other. Although this study appears to provide support for the

clinical utility of the RBANS, it compared the RBANS to less sensitive screening

measures, such as the Dementia Rating Scale (DRS) and the Mini Mental Status

Exam (MMSE). Assessments such as the DRS and MMSE are known as screening

assessments that don’t purport to provide a complex understanding of cognitive

function, whereas the RBANS proposes to be a bit more complex. Therefore, the

6

significance of these findings doesn’t provide significant support for the assessments

sensitivity or discriminant validity.

Additional research has provided evidence of the RBANS ability to

differentiate between disorders. For example, it was capable of distinguishing

between disorders with similar etiologies such as, Mild Cognitive Impairment (MCI)

and probable/possible Alzheimer’s Disease (Karantzoulis, Novitski, Gold, and

Randolph, 2013). Randolph et al. (1998), developer of the RBANS, also found the

RBANS was capable of differentiating between dissimilar disorders such as probable

Alzheimer’s Disease and Huntington’s Disease. Furthermore, Karantzoulis et al.

(2013) found the RBANS was able to differentiate between clinical and nonclinical

individuals.

Although there is moderate support for the clinical utility of the RBANS,

there is a lack of factor analytic studies to support the theoretically developed five-

factor solution of the assessment. Factor analytic studies are necessary to support the

construct validity of an assessment, such that the assessment should accurately

measure what it is purported to measure. That is, the factor structures should reflect

the intended cognitive domains (index scores). Factor analytic studies are also

beneficial for data reduction when conducting a confirmatory factor analysis.

Essentially, the goal of a factor analysis is to identify the weight of each subtest score

and condense it into smaller factors that are more closely related, and thus more

reliable. (Schmitt et al., 2010)

7

To date, ten factor analytic studies have been published on the RBANS. A

majority of the studies have discovered a two-factor solution (Carlozzi, Horner, Yang,

& Tilley, 2008; Duff et al., 2006; King, Bailie, Kinney, & Nitch, 2012; Schmitt et al.,

2010; Wilde, 2006; Yang, Garrett-Mayer, Schneider, Gollomp, & Tilley, 2009). Duff

et al. (2006) conducted a factor analysis on 824 “normal” elderly individuals and

discovered a two-factor solution. The two factors they found included, Verbal

Memory and Visual Processing. RBANS subtests Semantic Fluency and Digit Span

had low correlations with all other subtests, and therefore were excluded from the

final analysis. Furthermore, Picture Naming was not significant and was therefore

excluded from the final analyses. Wilde (2006) conducted an analysis and found a

two-factor solution in 210 individuals with acute stroke. His analyses divided all

verbal subtests into a Language/Verbal Memory factor and all visual subtests into a

Visuospatial Function/Visual Memory factor. Carlozzi et al. (2008) conducted a

factor analysis on 175 military veterans and found a two-factor solution. The two

factors included Memory and Visuospatial Reasoning. Digit Span was eliminated due

to insignificant loadings. Yang et al. (2009) found a two-factor solution in 383/315

(baseline/12 month follow up) individuals with untreated early Parkinson’s Disease.

The factors found include a Verbal Learning/Verbal Memory factor and a Memory

for Verbal Information with Semantic and Syntactic Content factor. In this study, six

of the twelve subsets were excluded from the final analyses due to low correlations

with the remaining six subtests and subtests overall. Schmitt et al. (2010) utilized

archival data and conducted a factor analysis on 636 individuals who had been

8

referred by physicians for a dementia screening. They found a two-factor solution

consisting of Memory/Learning and Visuospatial Function. King et al. (2012)

conducted a factor analysis with 167 forensically committed psychiatric patients. All

participants had a primary diagnosis of schizophrenia or schizoaffective disorder. A

majority of participants also had a secondary diagnoses of substance abuse or

substance dependence. This study found a two-factor solution comprised of Memory

and Visual Perception/Speed of Information Processing. In this study, Digit Span was

found to be non-significant. Researchers then conducted a higher-order factor

analysis and found that interpretations of the indices alone, without the inclusion of a

total scale score, would likely lead to misleading interpretations of the factor

structure. Although these studies found a two-factor solution, the subtests loaded very

differently among the studies.

Of the ten published studies on the factor analyses of the RBANS, only three

found a factor structure greater than two (Cheng et al., 2011; Emmert, Schwarz,

Vander Wal, & Gfeller, 2016; Garcia, Leahy, Corradi, & Forchetti, 2008). Garcia et

al. (2008) conducted a factor analysis on 351 individuals diagnosed with a memory

disorder(s) and found a three-factor solution. The factors in this study consisted of

Memory, Visuomotor Processing, and Verbal Processing. Cheng et al. (2011) found a

five-factor solution in a sample of 236 community-dwelling elderly individuals in

Shanghai, China. The factors found include Immediate Memory, Visuospatial

Function/Constructional, Language, Attention, and Delayed Memory. These findings

9

are consistent with the proposed theoretically based Five Factor structure of the

RBANS.

The latest factor analytic studies have continued to find dissimilar factor

loadings. Most recently, Emmert et al. (2016) conduced an analysis on 150 geriatric

individuals referred for a clinical neuropsychological evaluation. Researchers

conducted four separate Exploratory and Confirmatory Factor Analyses (two-factor,

three-factor, two-factor based on previous studies) and found the five-factor structure

to be the most practical and significant. However, in order to achieve a five-factor

analysis, Emmert et al. lowered the factor loading cutoff to .32 instead of 4.0. That is,

the correlation cutoffs were lowered to allow subtests with less significant

correlations to load in a factor. In the same year, Torrence, John, Gavett, and

O’Bryant (2016) utilized archival data from the Project FRONTIER study to conduct

a factor analysis on 341, cognitively heathy or impaired, elderly individuals. The

purpose of their study was to explore a factor model (bifactor model) previously

proposed by Duff et al. (2006). As suggested by the model, they included the RBANS

subtest scores and the Total Scale Score to evaluate how the Total Scale score effects

the factor loadings. They found a bifactor model, such that they found support for a

first order factor, such as the subtest factors, and a higher order factor, such as the

Total Scale Score. A visual representation of the higher order factor and the first

order factor can be found in Figure 1.

10

Figure 1: Visual representation of the Bifactor Model found by Torrence et al. (2016)

The Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV; Wechsler,

2008) is a neuropsychological assessment that was developed to identify dementia

related disorders. To date, there have been three revisions of the original WAIS,

which was developed in 1955. The WAIS-IV’s revisions consisted of additional

subtests, deleted subtests, and modified administration and/or scoring criteria. Picture

Arrangement and Object Assembly, both found in the previous WAIS-III, were

deleted in this revision. The subtests which were added in this revision include:

Visual Puzzles, Figure Weights, and Cancellation. Of the 15 subtests included in the

WAIS-IV (supplemental included-subtests not required to calculate Full Scale IQ

score (FSIQ)), 12 underwent changes in administration and/or scoring criteria. The

proposed Four Factor structure of the WAIS-III has been strongly supported in

numerous studies (Dickinson, Iannone, and Gold, 2002; Kaufman, Lichtenberger, and

McLean, 2001; Ryan and Paulo, 2001; Saklofske, Hildebrand, and Gorsuch, 2000).

Total Scale Score

(Higher Order Factor)

Immediate Memory

Viuospatial Function

Language AttentionDelayed Memory

Five-Factors

(First Order Factor)

11

However, the WAIS-IV has had little support for the proposed Four Factor structure.

Many studies which have examined the factor structure of the WAIS-IV have found

support for a Five Factor structure instead (Benson, Hulac, & Kranzler, 2010;

Niileksela, Reynolds, and Kaufman, 2013; Staffaroni, Eng, Moses, Zeiner, &

Wickham, 2018; Ward, Bergman, & Hebert, 2012).

The present study is a factor analysis of the RBANS, in comparison to the

WAIS-IV, in a geriatric population. The RBANS is a commonly used assessment for

the measurement of cognitive function in older adults. Given that there has been some

support for the clinical utility of the assessment, it is often used without hesitation.

However, despite the moderate support for the clinical utility, there is still a lack of

support for the construct validity of the assessment. Factor analytic studies are

necessary to validate that an assessment’s subtests are loading in its proposed factors.

Such that, if different researchers and participants yield different results, the tool is

not reliable and therefore not valid. Additional factor analyses are also needed to

evaluate the convergent validity of the RBANS. That is, correlational analyses will

compare RBANS subtests to other neuropsychological batteries which assess similar

cognitive constructs. Previous factor analytic studies compared the RBANS factor

structure to outdated versions of the WAIS. To date, no known study has compared

the RBANS to the current WAIS-IV. Moreover, when evaluating the factor structure,

each of the previous studies used a single form of the RBANS (Form A). This study

focuses on a homogeneous sample of “healthy” elderly individuals, such that the

individuals are capable of living independently. The goal of this study is to evaluate

12

the construct validity of the RBANS and convergent validity of the RBANS

compared to the WAIS-IV.

13

CHAPTER II

METHODOLOGY

Participants

Participants were recruited from an independent living facility in Stanislaus

County, California. Facility consent can be found in Appendix A. A presentation on

healthy cognitive aging was given to residents at the facility as a way of recruiting

participants. Those who could not physically attend the event could watch the

presentation from their televisions and sign up later. My study is part of a larger

longitudinal study taking place at Covenant Village Retirement Community in

Turlock, California, an independent living facility for older adults. For additional

information on the larger study, see appendix B. A total of 44 participants were

recruited for the current study. Of the 44 initial participants, three were excluded from

the final data analysis (see exclusion criteria). The final analysis consisted of 41

participants with a mean age of 80.74 (SD = 6.22). Participant’s age range spanned 22

years with a Minimum of 67 and a maximum of 89. The sample consisted of 28

females (68.3%) and 13 males (31.7%). One hundred percent of participants

identified as White/Caucasian, of which, 95 percent identified English as their native

language (4.9 percent identified German and/or Chinese as their native language).

Moreover, 92.7 % of participants attended some college or achieved higher

educational status (7.3 % graduated from high school). There were no means of

compensation in place for the participants in this study. Some possible benefits to

14

participants included learning about how research studies are conducted and learning

about factors that are related to health in later life.

Exclusion Criteria

In the current study, three participants data were excluded from data analysis.

Participants who scored below 25 on the Mini Mental Status Exam (MMSE) were

excluded from the study. Anything below this cutoff score indicates that they lack the

cognitive capacity to participate in the study. From the original 44 participants, one

was excluded for scoring below the MMSE cutoff score. Furthermore, one individual

was excluded from the data analyses due to severe visual impairment and another

exceeded the age limit of the WAIS-IV and RBANS.

Measures

Demographics

A demographics questionnaire was given to inquire about participants, health,

social, and exercise behaviors. Participants completed questionnaires using paper-

and-pencil surveys in the presence of research assistants who were available to

answer questions and clarify survey items. A majority of demographics data will be

used for the larger longitudinal research study. For the purpose of the current study,

age and language of origin was the only information utilized from this data. Please

see Appendix C for a complete list of survey items.

MMSE

The Mini Mental Status Exam (MMSE) (Folstein et al., 1975) is a 30-item

screening tool that takes approximately 10 minutes to administer. The MMSE is a

15

commonly used screening tool to assess cognitive function. In order for a participant

to continue in the study they must receive a score of 25 or higher. A score of 24 or

below indicates cognitive impairment, such that the examinee does not have the

cognitive capacity to complete more complex assessments. Lezak (2012) categorized

MMSE scores below the cutoff as follows: a score of 21-24 points indicates mild

impairment, 10-20 indicates moderate impairment, and nine or below indicates severe

cognitive impairment. Participants who do not meet the criterion score on the MMSE

will skip the cognitive assessments described below. When the participant fell below

the cutoff score, he/she was only given the demographics and psychosocial

questionnaires (this assessment will

be used in the larger study).

RBANS

The RBANS is a cognitive assessment (Randolph, 2012) which measures

Immediate and Delayed Memory, Visuospatial Function, Processing Speed,

Language, and Attention. The RBANS provides a brief, individually administered

battery to measure cognitive decline or improvement (if administered consistently

over time). The RBANS has four forms and is only intended to be used on adults ages

12 to 89. The four forms are similar in structure and procedure but contain different

stimuli. Each form is comprised of 12 subtests that make up five intended domains.

The List Learning and Story Memory subtests make up the Immediate Memory

domain; Figure copy and Line Orientation make up the Visuospatial

Function/Constructional domain; Picture Naming and Semantic Fluency make up the

16

Language domain; Digit Span and Coding make up the Attention domain; and List

Recall, List Recognition, Story Recall, and Figure Recall make up the Delayed

Memory domain. A visual representation of the RBANS subtests and intended

domains can be found in Table 1.

The total administration time of the RBANS ranges between 20 and 30

minutes. The highest score one can achieve is a score of 160. The scores of each

subtest in a given domain are added to make up each domain score. The scores of the

five domains are then added to make up the total RBANS assessment score. The

score is then compared to the RBANS norms to determine the percentile rank. A

higher score on each subtest and/or overall global index score represents high

Table 1

RBANS proposed five-factor structure

Immediate

Memory

Visuospatial

Functioning

Language Attention Delayed

Memory

List Learning Figure Copy Picture

Naming

Digit Span List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List

Recognition

Story Recall

Figure Recall

17

cognitive functioning. Overall, this assessments’ global index score has proven to

have high internal consistency reliability r = .93 and construct validity (Randolph,

2012). Additionally, it has been known to have high sensitivity for detecting dementia

(Randolph, 2012).

List learning. The List Learning subtest is designed to measure immediate

memory. The administrator verbally recites a list of ten unrelated words. The

participant is then asked to repeat back as many words as possible. This procedure is

repeated over four trials. Each item in all trials are worth one point, making this

subtest worth a possible 40 points. At the completion of this test the sum of each trial

is added to calculate the total list learning score.

Story Memory. The Story Memory subtest is designed to measure immediate

memory. The administrator verbally recites a short story. The participant is then

asked to repeat back as many words as possible. The story is repeated a second time

and the participant is asked to recall the story once more. The short story is divided

into 12 items, each worth one point. Each item is worth a total of two points, one

point for the first recall and a second point for the second recall. The scores of both

trial one and two are then added to make up the total score.

Figure Copy. The Figure Copy subtest is designed to measure Visuospatial

Function skills. The participant is presented with an illustration from a stimulus book

and asked to replicate it. The illustration remains in front of the participant for the

duration of the test. There is a four-minute time limit in which the participant must

complete the illustration. The illustration is divided into ten parts for scoring. For

18

each shape, the participants are scored based on shape and placement. The participant

is awarded one point for shape and one point for placement, making each item worth

two points. At the completion of this test all item scores are added to make up the

total score.

Line Orientation. The Line Orientation subtest is designed to measure

Visuospatial Function skills. The participant is presented with an illustration of 13

equal lines, which meet at a single point, in the shape of a semi-circular fan. Each line

is numbered from one to thirteen. Beneath the illustration are two lines that match

two of the lines from the main illustration. The participant is tasked with choosing

which lines from the main illustration match the two lines beneath. There is a total of

ten trials, each with new lines. Every trial is worth a total of two points, one point for

each correct response. The item scores are then added to make up the total line

orientation score.

Picture naming. The picture naming subtest is designed to measure language

skills. The participant is presented with a series of photos from a stimulus book. They

are asked to name each picture, on a single item, within a 20 second time limit. If the

participant misperceives a photo, the researcher provides a stimulus cue. There is a

total of ten items, each worth one point. The scores are then added to make up the

total subtest score.

Semantic fluency. The semantic fluency subtest is designed to measure

language skills. The participant is given one minute to recite as many fruits and

vegetables (Form A), or animals in a zoo (Form B) that come to mind. The scoring

19

criteria for acceptable responses were vague, which left room for interpretation. Each

“valid” answer is awarded one point. All points are added to calculate the total subtest

score.

Digit span. The digit span subtest is designed to measure attention. This

subtest requires the participant to verbally repeat numbers previously recited by the

administrator. Each item is made up of two sets of numbers. The second set is only

read if the participant fails the first set. There are 16 sets of numbers for a total of

eight items. If the participant correctly recites the item in the first set, they are

awarded two points. If the participant fails to correctly recite the first set but

accurately recites the second set, they are awarded one point. If they fail both strings,

they are given a score of zero and the subtest is discontinued. All item scores are

added to calculate the total score.

Coding. The Coding subtest is designed to measure attention. The participant

is presented with a sheet with rows of boxes. At the top of the page is a key with 9

boxes. At the top of each box is a symbol with a corresponding number beneath.

There is a total of nine symbols with coded numbers between one and nine. Beneath

the key are rows of boxes with symbols but lack the corresponding number. The

participant is then tasked with filling in the number that corresponds to each shape.

They are given 90 seconds to complete as many boxes as they can without skipping.

There is a total of 89 boxes with a possible score of 89 points. At the end of 90

seconds the participant is awarded one point for each correctly coded item. All points

are then added to make up the total subtest score.

20

List Recall. The List Recall subtest is designed to measure delayed memory.

The participant is asked to recall the list of ten words from the list learning subtest,

which was administered at the beginning of the assessment. Each correctly recalled

word is awarded one point, making this test worth ten possible points.

List Recognition. The List Recognition subtest is designed to measure

delayed memory. The participant is asked recall the list of ten words from the list

learning subtest, which was administered at the beginning of the assessment. The

participant is read 20 words and asked to identify which words were a part of the list

learning subtest. The list contains ten correct answers and ten distractors. Each item is

worth one point, making it worth a possible 20 points.

Story Recall. The Story Recall subtest is designed to measure delayed

memory. The participant is asked to retell the story from the story memory subtest.

This subtest splits the story up into ten items. Each correct recollection of the item

results in one point, making it worth total possible ten points. All points are then

added to compute the total subtest score.

Figure Recall. The Figure Recall subtest is designed to measure delayed

memory. The participant is asked to draw the illustration from the figure copy subtest

from memory. The illustration is divided into ten parts for scoring. For each shape,

the participants are scored based on shape and placement. The participant is awarded

one point for shape and one point for placement, making each item worth two points.

All points are added to calculate the total subtest score.

21

WAIS-IV

The Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV; Wechsler,

2008) is a commonly used neuropsychological assessment. The WAIS-IV measures

Visuospatial Function, Processing Speed, Attention, and Intelligence. The WAIS-IV

provides a complex, individually administered battery to measure cognitive decline or

improvement (if given periodically over a moderate time period). The total

administration time has a range between 60 and 90 minutes. It is comprised of 15

subtests that make up four domains. The Verbal Comprehension domain consists of

the similarities, vocabulary, information, and comprehension (supplemental subtest,

not required to calculate FSIQ) subtests. The Perceptual Reasoning domain consists

of Block Design, Matrix Reasoning, Visual Puzzles, Figure Weights (supplemental;

ages 16-69 only), and picture completion (supplemental). The Working Memory

domain consists of Digit Span, Arithmetic, and Letter-Number Sequencing

(supplemental; ages 16-69 only) subtests. Lastly, the Processing Speed domain

consists of Symbol Search, Coding, and Cancellation (supplemental; ages 16-69 only)

subtests. A visual representation of the WAIS-IV subtests and intended domains can

be found in Table 2.

22

Table 2

WAIS-IV Proposed four-factor Structure

Verbal

Comprehension

Perceptual

Reasoning

Working

Memory

Processing

Speed

Similarities Block Design Digit Span Symbol Search

Vocabulary Matrix Reasoning Arithmetic Coding

Information Visual Puzzles

Participants can receive a maximum score of 160 which is representative of

their cognitive function. A higher score on each subtest and/or overall global index

score represents high cognitive functioning. The scores of the subtests are added to

make up each domain score. The scores of the four domains are added to make up the

full-scale IQ score. The highest score one can achieve on the WAIS-IV is a full scale

(total) IQ score of 160. The score is then compared to full scale IQ normative sample

to determine the where the participant falls on the bell curve. A higher score on each

subtest and/or overall global index score represents high cognitive functioning.

Overall, this assessments’ full-scale IQ score has proven to have high internal

consistency reliability (r = .98) and validity (Wechsler, 2008), such that the

assessment is accurately measuring what is purported to measure.

Block Design. The Block Design subtest is designed to measure perceptual

reasoning and Visuospatial Function skills. The subtest requires the use of nine red

and white blocks. Each block has two sides that are all red, two all-white, and two

23

diagonally split half red and white sides. Participants are shown a design from a

stimulus book and asked to replicate the design with the blocks. The designs vary in

difficulty and are designed to get increasingly difficult as the participant progresses.

The researcher begins by replicating the construction of a simple design using only

two blocks. After acknowledging that the blocks resemble the design, the participant

is asked to replicate the design themselves. If completed correctly, the participant can

move on to item 5 (The starting point if the participant gets the sample correct). The

first design utilizes four blocks and allows 60 seconds for completion. The following

five designs follow the same protocols as the previous. If the participant reaches item

11 without two consecutive scores of zero, the participant is given five additional

blocks. The remaining four designs will require the use of all nine blocks and will

allows 120 seconds for completion. This subtest consists of 14 items, with a possible

total point value of 66. Each design has a corresponding point value that increases as

difficulty increases. Items five through eight awards four points if the design is

completed under the designated time limit. Items nine through ten award extra points

for faster completion times. Items nine thru ten scores are as follows: 31-60 seconds:

four points, 21-30 seconds: five points, 11-20 seconds: six points, and 1-10 seconds:

seven points. Items 11-14 distribute scores as follows: 76-120 seconds: four points,

61-75 seconds: five points, 31-60 seconds: six points, 1-30 seconds: seven points. The

scores are added up to calculate the block design total raw score.

Similarities. The Similarities subtest is designed to measure verbal

comprehension, conceptual thinking, and abstract reasoning (Groth-Marnat, 2009).

24

The similarities assessment has 18 items, with a total possible point value of 36. This

subtest is untimed and is designed to get increasingly difficult as it progresses. Each

participant is required to describe how two words, either objects or concepts, are

similar. The WAIS-IV administration and scoring manual contains both the item

words and acceptable answers. The more precise the answer the higher the score,

such that the answer must match one of the acceptable answers provided in the

scoring manual (Groth-Marnat, 2009). Answers that are precise will earn two points,

less precise answers receive one point, and answers that are far off receive a score of

zero. Vague answers require the researcher to provide a neutral inquiry, such as “tell

me more.” The subtest must be discontinued after three consecutive scores of zero. At

the completion of the subtest the scores are added up to calculate the similarities total

raw score.

Digit Span. The Digit Span subtest is designed to measure working memory,

attention, concentration, pattern shifting competency, and mental flexibility (Groth-

Marnat, 2009). This subtest is comprised of three tests: digit forward, digit backward,

and digit sequencing. There is a total of 24 items across all three tests, eight items

each, with a possible total point value of 48. Each of the three subtests are worth 16

possible points, two points per item. The first test administered is the digit forward

test. This section of the subtest requires the participant to verbally repeat back the

numbers previously verbalized by the administrator. This test is designed to become

increasingly difficult. Each item is made up of two sets of numbers, worth two points,

one point for each number set. Participants receive a point if he or she recalls the

25

exact numbers in the correct order. The subtest is to be discontinued if the participant

receives a score of zero on both sets of numbers on a single item. The second test

within the digit span subtest is the digit backwards. This test maintains the same

scoring and discontinuation rules as digit forward. However, this test requires the

participant to say the numbers from last to first. This test is also designed to become

increasingly difficult. The researcher will verbally present the participant with a list

of numbers and are asked to repeat back the list in reverse order. The last test

included in the digit span subtest is digit sequencing. This test maintains the same

scoring and discontinuation rules as digit forward and digit backward. This test

ranges from two to nine numbers and is designed to become increasingly difficult.

Digit sequencing requires the participant to repeat the numbers in order from lowest

to highest value. At the end of all three tests, the scores are added to calculate the

digit span raw score.

Matrix Reasoning. The Matrix Reasoning subtest is designed to measure

perceptual reasoning and nonverbal abstract reasoning. Participants are presented

with an illustration of an incomplete matrix or series from a stimulus book. The

participant is asked which of five illustrated options bests completes the matrix or

series. Each item is worth one point for a correct response. There is a total of 26 items

worth a possible 26 points total. The item scores are added to calculate the matrix

reasoning raw score.

Vocabulary. The Vocabulary subtest is designed to measure verbal

comprehension, verbal intelligence, and language development. This subtest is

26

untimed and is designed to get increasingly difficult as it progresses. The participant

is verbally presented with a word and asked to describe what each word means. The

WAIS-IV administration and scoring manual contains both the item words and

possible answers. The more precise the answer the higher the score (Groth-Marnat,

2009), such that the answer matches an acceptable answer provided by the scoring

manual. Answers that are precise will earn two points, less precise answers receive

one point, and answers that are far off receive a score of zero. Vague answers require

the researcher to provide a neutral inquiry such as, “tell me more.” There is a total of

30 items, with a total possible score of 57. The subtest must be discontinued after

three consecutive scores of zero. At the completion of the subtest the scores are added

up to calculate the vocabulary total raw score.

Arithmetic. The Arithmetic subtest is designed to measure working memory,

short-term memory, sequencing, and mental alertness (Groth-Marnat, 2009). The

items in this subtest require basic mathematic skills and concentration from the

participant (Groth-Marnat, 2009). Moreover, they are designed to get increasingly

difficult. The researcher begins by informing the participant that he/she will be

verbally presented with a problem and asked to solve it. He or she will only be

allowed one repeat of the question. Participants are to solve the problems in their

head without the use of paper or pencils. This subtest consists of 22 items worth total

possible 22 points. Each item is worth one point and has a 30 second time limit. In the

event that the participant receives three consecutive scores of zero, the test must be

27

discontinued. The points of each item are added up to calculate the arithmetic total

raw score.

Symbol Search. The Symbol Search subtest is designed to measure

processing speed. The participant is presented with a booklet of symbols. Each item

consists of two target symbols, five search group symbols, and one “No” box. The

participant is tasked with determining if any of the two target symbols can be found

in the search group. If either of the target symbols are in the search group they must

strike a line through the symbol with a pen. If the target symbol is not included in the

search group the participant must strike a line through the box labeled no. The

participant is given two minutes to complete as many items as possible from left to

right (like reading) without skipping. There is a total of 60 items, one point per item,

with a total possible score of 60. Once complete the number incorrect is subtracted

from the number correct to calculate the symbol search total symbol search raw score.

Visual Puzzles. The Visual Puzzles subtest is designed to measure perceptual

reasoning. Participants are presented with an illustration in a stimulus book and asked

to choose three symbols that make up the main illustration. The main illustration is

seen at the top of the page with six illustration shape options beneath. The three

symbols must fit together like a puzzle side by side to make up the illustration. There

is only one correct answer per item, worth one point each. This is a timed test that

must be completed within 20 (items 5-7) or 30 seconds (items 8-26). The subtest is to

be discontinued after three consecutive scores of zero. There is a total of 26 items,

28

one point per item, worth 26 points total possible. At the completion of the subtest the

points are added up to calculate the visual puzzles total raw score.

Information. The Information subtest is designed to measure verbal

comprehension. The participant is verbally presented with a question that may be

common knowledge, such that the question was likely learned at some point in the

individual’s life. There are 26 items, one point each, worth 26 possible points. The

WAIS-IV administration and scoring manual contains both the item questions and

acceptable answers. The more precise the answer the higher the score, such that the

answer must match one of the acceptable answers provided in the scoring manual

(Groth-Marnat, 2009). The test is designed to get increasingly difficult and requires a

discontinuation after three consecutive scores of zero. The scores are added to

calculate the information total raw score.

Coding. The Coding subtest is designed to measure processing speed and

attention. The participant is presented with a sheet with rows of boxes. At the top of

the page is a key with 9 boxes. In the top half of each box is a symbol with a

corresponding number beneath. There is a total of nine symbols with (coded)

corresponding numbers to each symbol ranging between one and nine (every symbol

has a corresponding number). Beneath the key are rows of boxes with symbols that

lack the corresponding number. The participant is then tasked with filling in the

number that corresponds to each symbol. They are given 120 seconds to complete as

many boxes as they can without skipping. This subtest has a total possible score of

29

135 points. At the end of 120 seconds the participant is awarded one point for each

correctly coded item. All points are added to make up the total coding score.

Scoring

Each neuropsychological assessment (MMSE, RBANS, WAIS-IV) was

partially scored (subtests) three times by three different research assistants. Research

assistants were trained on the scoring criteria of each assessment. Inconsistencies

between scoring on any item and/or subtest was looked over by a research assistant or

a primary investigator. That is, the research assistant or primary investigator would

determine the final score of the item and/or subtest which was flagged for

inconsistencies. For example, subtests Figure Copy and Figure Recall from the

RBANS were frequently flagged for inconsistencies in scoring. The inconsistencies in

these subtests were a result of vague scoring criteria provided by the RBANS manual.

As a result, this study is likely to have lower interrater reliability. Index scores, Total

Scale Scores, and FSIQ scores were calculated by one of two lead research assistants.

For the purpose of this study, subtest scores, index scores, and total scores were

entered into an Excel sheet by trained research assistants. All entered data were triple

checked by two different research assistants and saved on a lab computer.

Procedures

During the first session/encounter, participants were presented with an

informed consent form (Appendix D). Researchers explained that as participants they

would be administered a battery of neuropsychological assessments. If they chose to

participate in the study, they were required to sign the consent form. The signed copy

30

was then stored in a locked lab and the participant was given an unsigned copy for

their records.

All testing was done in a quiet room with a table and two chairs to minimize

any potential distractions. Researchers met each participant individually at a

designated time and place at the facility. Participants attended two separate sessions

in order to reduce cognitive fatigue effects. The first session lasted an estimated

ninety minutes on average. At the first, session participants were asked to complete

demographic and psychosocial questionnaires (this assessment will be used in the

larger study). During the same session, they were also administered the MMSE

(Appendix E) and the RBANS. There are four forms of the RBANS, intended for

measuring change over time. Participants were administered two of four forms (A, B,

C, or D) in a counter-balanced fashion, such that 50% were given form A and 50%

were given form B. The second session, approximately a week later, lasted an

estimated sixty minutes on average. During the second session participants were

administered the WAIS-IV and WMS-IV (The WMS-IV is included in the larger

study).

All test data were scored and filed in a locked research lab. After each session,

participants were given a partial debriefing form that was verbally clarified by the

researcher (Appendix F). The full debriefing form will be given to each participant at

the conclusion of the larger longitudinal study (Appendix G).

31

Data Analysis

Confirmatory Factor Analysis is a tool that is used to confirm or reject a

measurement theory. For the purpose of this study, I conducted a Confirmatory

Factor Analysis (CFA). The reason for conducting this type of analysis is because we

are provided with presumed factor loadings by the developer of the RBANS,

Randolph

(1998). Therefore, I have the ability to extract the proposed number of factors to

determine if the subtests load as purported. The purpose of extracting variations of

factors is to determine which factor loading results in the best fit of the subtests into

each factor.

A CFA, with a Varimax rotation, was conducted on the RBANS Form A in

order to extract Randolph’s proposed five-factor solution. Similarly, a CFA with a

Varimax rotation was conducted on the RBANS Form B to extract Randolph’s

proposed five-factor solution. Additional CFA’s, with extractions, were conducted on

the RBANS Forms A and B to evaluate which factor loading was the best fit. A CFA

with a Varimax rotation was conducted on the RBANS Form A, extracting four

factors. A CFA, with a Varimax rotation, was also conducted on the RBANS Form B

extracting four factors. A CFA, with a Varimax rotation, was conducted on the

RBANS Form A extracting three factors. Similarly, a CFA with a Varimax rotation

was conducted on the RBANS Form B extracting three factors.

A Confirmatory Factor Analyses was conducted on the RBANS Forms A and

B combined to see if combining forms would result in Randolph’s proposed five-

factor solution. Additional CFA’s, with extractions, were conducted on the RBANS

Forms A and B combined to evaluate which factor loading was the best fit. A CFA,

32

with a Varimax rotation, was conducted on the RBANS Form A and B combined

extracting the proposed five-factor solution of the RBANS. A CFA, with a Varimax

rotation, was conducted on the RBANS Form A and B combined extracting four

factors. A CFA, with a Varimax rotation, was conducted on the RBANS Form A and

B combined extracting three factors.

A CFA, without extraction, was conducted on the WAIS-IV and RBANS,

Forms A and B, because they contain similar subtests and purport to measure similar

cognitive constructs. Lastly, a CFA, with and without extraction, was conducted on

the WAIS-IV data to verify the presence of the proposed four-factor solution of the

WAIS-IV. All analyses were conducted using IBM SPSS software.

33

CHAPTER III

RESULTS AND INITIAL DISCUSSION

RBANS

RBANS Form A: Five-factor Solution

A Confirmatory Factor Analysis was conducted on the RBANS Form A with

a Varimax Rotation. The Kaiser-Meyer-Olkin measure of sampling adequacy was

.616, above the commonly recommended value of .6, and Bartlett’s test of sphericity

was significant (χ2 (66) = 133.48, p < .05). Communalities on all ten subtests were

1.00, such that the subtests’ percent of variance could be explained by those factors.

These findings indicate that the data were suitable for a factor analysis.

A Confirmatory Factor Analysis with a Varimax Rotation was conducted on

the RBANS Form A extracting the proposed five-factor Solution. A CFA of the

RBANS Form A, involving an examination of factor eigenvalues (> 1.0) and a scree

plot, resulted in a five-factor solution, with combined factors accounting for 86.33%

of the variance. The extracted five-factor solution resulted in three subtests loaded on

factor one, three subtests loaded on factor two, two subtests loaded on factor three,

two subtests loaded on factor four, and one subtest loaded on factor five. Figure Copy

was moderately double loaded in factors three (.592) and four (.563). Moreover, Line

Orientation loaded independently in the fifth factor. Given that a factor cannot consist

of a single subtest, the fifth factor is not a true factor. Therefore, I chose to extract

four factors in the following analyses. A visual representation of the proposed factor

34

structure of the RBANS and the current loadings of RBANS Form A can be found in

Table 3 for a visual comparison of the factor loadings.

Table 1

Recap; Proposed five-factor Structure of the RBANS

Immediate

Memory

Visuospatial

Functioning


Memory


Naming

Digit

Span

List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List

Recognition

Story Recall

Figure Recall

35

RBANS Form A: Four-factor Solution








the RBANS Form A extracting a four-factor Solution. A CFA of the RBANS Form

A, involving an examination of factor eigenvalues (> 1.0) and a scree plot, resulted in

Table 3

RBANS Form A: Extracted five-factor Structure

Learning Memory Attention Language Not a Factor

List Learning

(.947)

Story

Memory

(.876)

Figure Recall

(.816)

Picture

Naming

(.899)

Line

Orientation

(.966)

List

Recognition

(.924)

Digit Span

(-.812)

Coding

(.806)

Semantic

Fluency

(.641)

List Recall

(.829)

Story Recall

(.770)

36

a four-factor solution, with combined factors accounting for 79.26% of the variance.

The extracted four-factor solution resulted in four subtests loaded on factor one, three

subtests loaded on factor two, four subtests loaded on factor three, and one subtest

loaded on factor four. Line Orientation loaded independently in the fourth factor.

Given that a factor cannot consist of a single subtest, the fourth factor is not a true

factor. Therefore, I chose to extract three factors in the following analyses of the

RBANS Form A. A visual representation of the proposed factor structure of the

RBANS and the current loadings of RBANS Form A can be found in Table 4 for a

visual comparison of the factor loadings.

Table 1


Immediate

Memory

Visuospatial

Functioning


Memory


Naming

Digit

Span

List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List

Recognition

Story Recall

Figure Recall

37

Table 4

RBANS Form A: Extracted four-factor Structure

Memory and

Attention

Learning Visuospatial

Function and

Language

Not a Factor

Story Memory

(.888)

List Learning

(.944)

Figure Copy

(.855)

Line Orientation

(.955)

Story Recall

(.847)

List Recognition

(.928)

Picture Naming

(.725)

Digit Span

(-.772)

List Recall

(.819)

Figure Recall

(.690)

Coding

(.594)

Semantic Fluency

(.667)

RBANS Form A: Three-factor Solution







38

A Confirmatory Factor Analysis of the RBANS Form A, involving an

examination of factor eigenvalues (> 1.0) and a scree plot, resulted in a three-factor

solution, with combined factors accounting for 69.25% of the variance (see Table 5).

Loadings over 4.0 were considered significant and were grouped accordingly. A

three-factor solution was extracted and resulted in four subtests loaded on factor one,

three subtests loaded on factor two, and four subtests loaded on factor three (see

Table 6). Line Orientation was found to be nonsignificant and therefore failed to load

in any factor. These findings are not consistent with the proposed five-factor structure

of the RBANS. A visual representation of the proposed factor structure of the

RBANS and the current loadings of RBANS Form A can be found in Table 7 for a


39

Table 5

Cumulative percent of variance for extracted three-factor solution

Componen

t

Initial Eigenvalues Rotation Sums of Squared

Loadings

Total % of

Varianc

e

Cumulativ

e %

Total % of

Varianc

e

Cumulativ

e %

1 4.19

6

34.969 34.969 2.88

1

24.006 24.006

2 2.25

1

18.756 53.726 2.84

9

23.744 47.750

3 1.86

2

15.521 69.246 2.58

0

21.497 69.246

4 1.20

2

10.014 79.260

5 .848 7.065 86.325

6 .533 4.444 90.769

7 .465 3.874 94.643

8 .211 1.759 96.403

9 .176 1.465 97.867

10 .121 1.005 98.872

11 .090 .752 99.624

12 .045 .376 100.000

40

Table 6

Factor Loadings for Confirmatory Factor Analysis with Varimax

Rotation of RBANS Form A: Three-factor solution

Subtest Component

1 2 3

Story Memory .831 .248 .104

Story Recall .818 .312 .279

Digit Span -.805 .365 .300

Coding .611 .068 .341

List Recognition -.013 .935 -.122

List Learning -.006 .930 .183

List Recall .342 .838 .172

Line Orientation .144 .166 -.015

Figure Copy -.110 .089 .855

Picture Naming .017 -.120 .723

Figure Recall .391 .122 .700

Semantic Fluency .443 .215 .681

Note. Factor Loadings > .50 are in boldface.

41

Table 7

RBANS Form A: Extracted three-factor structure

Memory and Attention Learning Visuospatial and

Language

Story Memory List Recognition Figure Copy

Story Recall List Learning Picture Naming

Digit Span (Neg.) List Recall Figure Recall

Coding Semantic Fluency

Table 1


Immediate

Memory

Visuospatial

Functioning


Memory


Naming

Digit

Span

List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List

Recognition

Story Recall

Figure Recall

42

The four subtests which loaded on Factor one consisted predominantly of

Memory and Attention measures (i.e., Story Memory, Story Recall, Digit Span, and

Coding). These subtests comprise the Attention, Immediate and Delayed Memory

indices of the RBANS. These findings suggest that these subtests load as a single

factor, rather than three separate factors. Digit Span and Coding loaded in the same

factor as expected. However, additional loadings of memory measures were

inconsistent with proposed indices. Moreover, Digit Span loaded negatively (-.805) in

this factor, such that as Digit Span scores go up all others go down. Most of these

subtests require retention of newly acquired information, such that the examiner will

verbally present the individual with information and ask him/her to recall it.

The three subtests which loaded on Factor Two consisted of Learning

measures (i.e., List Recognition, List Learning, and List Recall). The list learning

subtest strongly grouped together and alone. These subtests comprise the Immediate

and Delayed Memory indices of the RBANS. These findings suggest that these

subtests load as a single factor, rather than two separate factors. Each of these subtests

require retention of newly acquired information, such that the examiner will verbally

present the individual with information and ask them to recall it verbally.

The four subtests which loaded highest in Factor Three consisted of

Visuospatial Function and Language measures (i.e., Figure Copy, Picture Naming,

Figure Recall, and Semantic Fluency). These subtests comprise the Language,

Visuospatial Function, and Delayed Memory indices of the RBANS. These findings

suggest that these subtests load as a single factor, rather than three separate factors.

43

Theoretically, these subtests don’t appear to be a unified construct, therefore making

these findings difficult to interpret. Two of the subtests, Figure Copy and Figure

Recall, require visuospatial processing in the form of a paper and pencil response.

Whereas the other two subtests which loaded in this factor, Semantic Fluency and

Picture Naming, rely on information that an individual already possesses.

RBANS Form B: Five-factor Solution

A Confirmatory Factor Analysis was conducted on the RBANS Form B with a

varimax rotation. The Kaiser-Meyer-Olkin measure of sampling adequacy was .399,

below the commonly recommended value of .6, and Bartlett’s test of sphericity was

significant (χ2 (66) = 97.64, p = .007). Communalities on all ten subtests were 1.00,

such that the subtests’ percent of variance could be explained by those factors. These

findings indicate that the data was not suitable for a factor analysis. Although initial

assumptions were not met, I still looked at the way in which the subtests loaded.


the RBANS Form B extracting the proposed five-factor Solution. A CFA of the

RBANS Form B, involving an examination of factor eigenvalues (> 1.0) and a scree

plot, resulted in a five-factor solution, with combined factors accounting for 77.88%

of the variance. The extracted five-factor solution resulted in three subtests loaded on

factor one, three subtests loaded on factor two, two subtests loaded on factor three,

three subtests loaded on factor four, and one subtest loaded on factor five. Figure

Copy loaded independently in the fifth factor. Given that a factor cannot consist of a

single subtest, the fifth factor is not a true factor. Therefore, I chose to extract four

44

factors in the following analyses of RBANS Form B. A visual representation of the

proposed factor structure of the RBANS and the current loadings of RBANS Form B

can be found in Table 8 for a visual comparison of the factor loadings.

Table 1


Immediate

Memory

Visuospatial

Functioning


Memory


Naming

Digit

Span

List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List

Recognition

Story Recall

Figure Recall

45

Table 8

RBANS Form B: Extracted five-factor Structure

Learning Attention Language? Memory Not a Factor

List Recall

(.851)

Figure Recall

(.902)

Picture

Naming (.888)

Semantic

Fluency

(.739)

Figure Copy

(.939)

List Learning

(.839)

Line

Orientation

(.695)

Story Recall

(-.608)

Digit Span

(.714)

List

Recognition

(.719)

Coding

(.604)

Story Memory

(.608)

RBANS Form B: Four-factor Solution








46


the RBANS Form B extracting a four-factor Solution. A CFA of the RBANS Form B,

involving an examination of factor eigenvalues (> 1.0) and a scree plot, resulted in a

four-factor solution, with combined factors accounting for 69.28% of the variance.

The extracted four-factor solution resulted in three subtests loaded on factor one, two

subtests loaded on factor two, three subtests loaded on factor three, and three subtests

loaded on factor four. The complex loadings of these subtests made labeling each

factor impossible. Furthermore, List Recall was moderately double loaded in factors

one (.638) and two (.649). Given that List Recall failed to load in a single factor, I

chose to extract three factors in the following analyses of RBANS Form B. A visual

representation of the proposed factor structure of the RBANS and the current loadings

of RBANS Form B can be found in Table 9 for a visual comparison of the factor

loadings.

47

Table 1


Immediate

Memory

Visuospatial

Functioning


Memory


Naming

Digit

Span

List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List

Recognition

Story Recall

Figure Recall

Table 9

RBANS Form B: Extracted four-factor Structure

Unknown Unknown Unknown Attention

List Learning

(.780)

Story Recall

(.816)

Figure Recall

(.901)

Semantic Fluency

(.738)

List Recognition

(.711)

Picture Naming

(-.775)

Coding

(.701)

Digit Span

(.696)

Figure Copy

(.504)

Line Orientation

(.621)

Story Memory

(.625)

48

RBANS Form B: Three-factor Solution








A Confirmatory Factor Analysis of the RBANS Form A, involving an

examination of factor eigenvalues (> 1.0) and a scree plot, resulted in a three-factor

solution, with combined factors accounting for 57.69% of the variance (see Table 10).

Loadings over 0.4 were considered significant and were grouped accordingly. A

Rotated Component Matrix of the three-factor solution found four subtests loaded on

factor one, five subtests loaded on factor two, and three subtests loaded on factor

three (see Table 11). These findings are not consistent with the proposed five-factor

structure of the RBANS. A visual representation of the proposed factor structure of

the RBANS and the current loadings of RBANS Form B can be found in Table 12 for

a visual comparison of the factor loadings.

49

Table 10

Cumulative percent of variance for extracted three-factor solution RBANS Form A

Componen

t


Loadings

Total % of

Varianc

e

Cumulativ

e %

Total % of

Varianc

e

Cumulativ

e %

1 3.07

0

25.585 25.585 2.97

3

24.778 24.778

2 2.14

2

17.853 43.438 2.14

6

17.887 42.665

3 1.71

1

14.255 57.693 1.80

3

15.029 57.693

4 1.39

0

11.584 69.278

5 1.03

2

8.598 77.875

6 .860 7.168 85.044

7 .703 5.861 90.904

8 .415 3.455 94.360

9 .338 2.815 97.174

10 .170 1.418 98.593

11 .100 .837 99.430

12 .068 .570 100.000

50

Table 11

Factor Loadings for Confirmatory Factor Analysis with Varimax

Rotation of RBANS Form B: Three-factor solution

Component

1 2 3

List Learning .908 .111 -.080

List Recall .858 -.429 .066

List Recognition .600 -.085 -.368

Story Memory .522 .066 .064

Picture Naming -.064 .678 -.367

Coding .514 .670 .297

Semantic Fluency -.131 .662 .138

Story Recall .463 -.571 .244

Digit Span .141 .509 .248

Line Orientation -.019 .064 .867

Figure Recall .419 .023 .575

Figure Copy .289 -.038 -.457


51

Table 1


Immediate

Memory

Visuospatial

Functioning


Memory


Naming

Digit

Span

List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List

Recognition

Story Recall

Figure Recall

Table 12

RBANS Form B: Extracted three-factor structure

Learning and Memory Language and Attention Visuospatial Function

List Learning Picture Naming Line Orientation

List Recall Coding Figure Recall

List Recognition Semantic Fluency Figure Copy

Story Memory Story Recall

Digit Span

52

The four subtests which loaded in factor 1 consisted predominantly of

Learning and Memory measures (List Learning, List Recall, List Recognition, and

Story Memory). These subtests comprise the Immediate and Delayed Memory indices

of the RBANS. These findings suggest that these subtests load as a single factor,

rather than two separate factors. Most of these subtests require retention of newly

acquired information, such that the examiner will verbally present the individual with

information and ask them to recall it. While Memory factors did load together, they

do not load as Immediate and Delayed Memory indices, as proposed by the RBANS.

The five subtests which loaded on factor two consisted of Language and

Attention measures (Picture Naming, Coding, Semantic Fluency, Story Recall, and

Digit Span). These subtests comprise the Language, Attention, and Delayed Memory

indices of the RBANS. These findings suggest that these subtests load as a single

factor, rather than three separate factors. A majority of these subtests contain a

language aspect. That is, the individual has to provide verbal responses to various

tasks. Coding however, requires visual attention and concentration with a paper and

pencil response. Despite this difference, Coding was still expected to load in the same

factor as Digit Span since they both belong to the proposed Attention index of the

RBANS.

The three subtests which loaded highest in factor three consisted of

Visuospatial Function measures (Line Orientation, Figure Recall, and Figure Copy).

These subtests comprise the Visuospatial Function/Constructional, and Delayed

Memory indices of the RBANS. These findings suggest that these subtests load as a

53

single factor, rather than two separate factors. Two of the subtests, Figure Copy and

Figure Recall, require visuospatial processing in the form of a paper and pencil

response. While Figure Recall failed to load in its proposed Delayed Memory factor,

it is still ultimately a visuospatial task.

RBANS Forms A and B Combined: Five-factor Solution

A Confirmatory Factor Analysis was conducted on the RBANS Forms A and

B with a Varimax Rotation. The purpose of this analysis was to determine if a five-

factor structure would emerge when combining RBANS Forms A and B. The Kaiser-

Meyer-Olkin measure of sampling adequacy was .536, slightly below the commonly

recommended value of .6, and Bartlett’s test of sphericity was significant (χ2 (66) =

184.57, p < .05). Communalities on all ten subtests were 1.00, such that the subtests’

percent of variance could be explained by those factors. These findings indicate that

the data were moderately suitable for a factor analysis.


the RBANS Forms A and B combined extracting the proposed five-factor Solution. A

CFA of the RBANS Forms A and B, involving an examination of factor eigenvalues

(> 1.0) and a scree plot, resulted in a five-factor solution, with combined factors

accounting for 76.37% of the variance. The extracted five-factor solution resulted in

three subtests loaded on factor one, three subtests loaded on factor two, two subtests

loaded on factor three, two subtests loaded on factor four, and two subtests loaded on

factor five. In this analysis, the Visuospatial Functioning, and Language factors

loaded as proposed by the RBANS. Therefore, I chose to extract four factors in the

54

following analyses to evaluate whether the subtests load closer to their proposed

loadings. A visual representation of the proposed factor structure of the RBANS and

the current loadings of RBANS Forms A and B combined can be found in Table 13

for a visual comparison of the factor loadings.

Table 1


Immediate

Memory

Visuospatial

Functioning


Memory


Naming

Digit

Span

List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List

Recognition

Story Recall

Figure Recall

55

Table 13

RBANS Forms A and B Combined: Extracted five-factor structure

Learning Memory Attention Language Visuospatial

Functioning

List Learning

(.917)

Story

Memory

(.815)

Figure Recall

(.895)

Semantic

Fluency

(.809)

Line

Orientation

(-.789)

List

Recognition

(.879)

Story Recall

(.783)

Coding

(.665)

Picture

Naming

(.742)

Figure Copy

(.711)

List Recall

(.776)

Digit Span

(-.673)

RBANS Forms A and B Combined: Four-factor Solution



.536, slightly below the commonly recommended value of .6, and Bartlett’s test of

sphericity was significant (χ2 (66) = 184.57, p < .05). Communalities on all ten

subtests were 1.00, such that the subtests’ percent of variance could be explained by

those factors. These findings indicate that the data were moderately suitable for a

factor analysis.

56


the RBANS Forms A and B combined extracting a four-factor Solution. A CFA of

the RBANS Forms A and B, involving an examination of factor eigenvalues (> 1.0)

and a scree plot, resulted in a four-factor solution, with combined factors accounting

for 68.05% of the variance. The extracted four-factor solution resulted in three

subtests loaded on factor one, four subtests loaded on factor two, three subtests

loaded on factor three, and two subtests loaded on factor four. In this analysis, factors

three and four proved difficult to name given their complex loadings. Therefore, I

chose to extract three factors in the following analyses to evaluate whether the

subtests load closer to their proposed loadings. A visual representation of the

proposed factor structure of the RBANS and the current loadings of RBANS Forms A

and B combined can be found in Table 14 for a visual comparison of the factor

loadings.

57

Table 1


Immediate

Memory

Visuospatial

Functioning


Memory


Naming

Digit

Span

List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List

Recognition

Story Recall

Figure Recall

58

Table 14

RBANS Forms A and B Combined: Extracted four-factor structure

Learning Memory

List Learning

(.910)

Figure Recall

(.734)

Story Memory

(.784)

Picture Naming

(.715)

List Recognition

(.871)

Coding

(.707)

Story Recall

(.767)

Figure Copy

(.627)

List Recall

(.809)

Line Orientation

(.672)

Digit Span

(-.701)

Semantic Fluency

(.590)

RBANS Forms A and B Combined: Three-factor Solution



.536, slightly below the commonly recommended value of .6, and Bartlett’s test of

sphericity was significant (χ2 (66) = 184.57, p < .05). Communalities on all ten

subtests were 1.00, such that the subtests’ percent of variance could be explained by

those factors. These findings indicate that the data were moderately suitable for a

factor analysis.


the RBANS Forms A and B combined extracting a three-factor Solution. A CFA of

59

the RBANS Forms A and B, involving an examination of factor eigenvalues (> 1.0)

and a scree plot, resulted in a three-factor solution, with combined factors accounting

for 57.12% of the variance. The extracted three-factor solution resulted in three

subtests loaded on factor one, three subtests loaded on factor two, and five subtests

loaded on factor three. Line Orientation was not significant in any factor. A visual

representation of the proposed factor structure of the RBANS and the current loadings

of RBANS Forms A and B combined can be found in Table 15.

Table 1


Immediate

Memory

Visuospatial

Functioning


Memory


Naming

Digit

Span

List Recall

Story Memory Line

Orientation

Semantic

Fluency

Coding List Recognition

Story Recall

Figure Recall

60

RBANS Form A and WAIS-IV Combined

A CFA of the RBANS Form A combined with the WAIS-IV was conducted

to see if similar subtests loaded together in the same factors (convergent validity). A

Confirmatory Factor Analysis of the RBANS Form A combined with the WAIS-IV,

involving an examination of factor eigenvalues (> 1.0) and a scree plot, resulted in a

six-factor solution, with combined factors accounting for 82.45% of the variance (see

Table 16). Loadings over 4.0 were considered significant and were grouped

Table 15

RBANS Forms A and B Combined: Extracted three-factor structure

Learning Memory Language and Attention

List Learning

(.913)

Story Recall

(.767)

Picture Naming

(.670)

List Recognition

(.865)

Story Memory

(.728)

Semantic Fluency

(.654)

List Recall

(.818)

Digit Span

(-.587)

Coding

(.517)

Figure Recall

(.517)

Figure Copy

(.511)

61

accordingly. A Rotated Component Matrix of the six-factor solution found six

subtests loaded on factor one, four subtests loaded on factor two, two subtests loaded

on factor three, three subtests loaded on factor four, three subtests loaded on factor

five, and two subtests loaded on factor six (see Table 17). A visual representation of

the RBANS Form A and WAIS-IV combined can be found in Table 18 for a visual

comparison of the factor loadings.

62

Table 16

Cumulative percent of variance for RBANS Form A and WAIS-IV combined

Compone

nt


Loadings

Total % of

Variance

Cumul

ative

%

Tot

al

% of

Varianc

e

Cumulati

ve %

1 6.793 30.876 30.876 4.78 21.711 21.711

2 3.787 17.214 48.090 3.48 15.834 37.545

3 2.547 11.576 59.665 2.65 12.034 49.579

4 2.164 9.837 69.503 2.55 11.566 61.145

5 1.608 7.311 76.814 2.51 11.389 72.534

6 1.240 5.634 82.448 2.18 9.914 82.448

7 .955 4.341 86.789

8 .793 3.602 90.391

9 .638 2.898 93.289

10 .431 1.959 95.248

11 .386 1.754 97.002

12 .241 1.094 98.096

13 .211 .959 99.054

14 .115 .524 99.578

15 .071 .321 99.899

16 .022 .101 100.00

17 4.867E-

16

2.212E-15 100.00

18 2.499E-

16

1.136E-15 100.00

0

19 9.153E-

17

4.160E-16 100.00

20 -9.958E-

17

-4.526E-

16

100.00

0

21 -4.490E-

16

-2.041E-

15

100.00

0

22 -5.875E-

16

-2.671E-

15

100.00

0

63

Table 17

Factor Loadings for Confirmatory Factor Analysis of RBANS Form A and WAIS-IV

Component

1 2 3 4 5 6

List Recall (RBANS) .865 .188 .161 .091 .000 .061

List Learning (RBANS) .856 .020 -.020 .161 -.174 .300

Story Memory

(RBANS)

.832 -.180 .086 .211 .317 -.129

Story Recall (RBANS) .829 .001 .064 .301 .271 -.192

List Recognition

(RBANS)

.742 -.001 .493 -.213 .096 -.052

Coding (RBANS) .555 .417 .536 -.055 -.097 .190

Visual Puzzles (WAIS-

IV)

.095 .936 .035 .197 .024 -.086

Block Design (WAIS-

IV)

-.134 .784 -.267 .235 .025 .140

Line Orientation

(RBANS)

-.055 .729 .204 .017 .018 -.456

Matrix Reasoning

(WAIS-IV)

.182 .682 .084 .286 .101 .476

Coding (WAIS-IV) .201 -.011 .841 .080 .082 .099

Digit Span (WAIS-IV) .057 .524 -.673 -.107 .277 .261

Figure Recall (RBANS) .317 .322 .421 .400 .290 .286

Picture Naming

(RBANS)

.093 .196 -.205 .800 -.041 .143

Figure Copy (RBANS) -.019 .061 .242 .714 -.080 .515

Semantic Fluency

(RBANS)

.382 .332 .300 .707 .031 -.185

Symbol Search (WAIS-

IV)

.289 .243 .464 .514 .414 -.081

Arithmetic (WAIS-IV) -.272 -.018 -.014 .098 .885 .203

Vocabulary (WAIS-IV) .396 -.023 .114 -.121 .773 .307

Information (WAIS-IV) .369 .379 -.142 -.079 .641 -.163

Similarities (WAIS-IV) .145 -.098 .177 .137 .342 .676

Digit Span (RBANS) -.472 .104 -.389 .095 .121 .654


64

The first factor was defined by six subtests (List Recall, List Learning, Story

Memory, Story Recall, List Recognition, and Coding). All subtests that loaded in this

factor were derived from the RBANS. These findings are not surprising considering

Table 18

Factor Structure of RBANS Form A and WAIS-IV combined

Learning

and

Memory

Visuospatial

Function

Processing

Speed

Language

and

Attention

Verbal Comp. Working

Memory

List Recall Visual

Puzzles

Coding Picture

Naming

Arithmetic Similarities

List

Learning

Block

Design

Digit Span

(WAIS-

IV)

Figure

Copy

Vocabulary Digit Span

(RBANS)

Story

Memory

Line

Orientation

Semantic

Fluency

Information

Story

Recall

Matrix

Reasoning

List

Recognition

Coding

65

the subtests consist predominately of learning and memory measures. Coding, a

proposed Attention index subtest of the RBANS, loaded moderately (.555) into this

factor. Given that Coding assesses incidental learning, it’s loading in this Learning

index is understandable.

The four subtests which loaded on factor two consisted of Visuospatial

Function measures (Visual Puzzles, Block Design, Line Orientation, Matrix

Reasoning). Visual Puzzles, Block Design, and Matrix Reasoning were derived from

the WAIS-IV and Line Orientation was derived from the RBANS. All highly loaded

subtests in this factor were grouped as expected.

The two subtests which loaded in factor three consisted of Processing Speed

and Attention measures (Coding and Digit Span). Both subtests were derived from

the WAIS-IV and loaded as expected. Moreover, Digit Span was moderately

negatively loaded (-.673), such that as Digit Span scores increase Coding scores

decrease.

The three subtests which loaded in factor four consisted of Language and

Attention measures (Picture Naming, Figure Copy, and Semantic Fluency). All

loaded subtests were derived from the Language and Visuospatial

Function/Constructional indices of the RBANS. Despite their proposed loadings,

these subtests fit well into the factor listed above.

The three subtests which loaded in factor five consisted of Verbal

Comprehension measures (Arithmetic, Vocabulary, and Information). All loaded

subtests were derived from the Verbal Comprehension and Working Memory indices

66

of the WAIS-IV. Despite their proposed loadings, these subtests measure the same

verbal comprehension skills.

The two subtests which loaded in factor six consisted of Attention and

Working Memory measures (Similarities and Digit Span). In this factor, Similarities

was derived from the WAIS-IV and Digit Span was derived from the RBANS. Both

subtests require working memory to perform each task. For example, Similarities

requires working memory to look for similarities and concepts between two words

and Digit Span requires the individual to retain a list of numbers and verbally repeat

each series back to the examiner.

Two subtests were found to be moderately double loaded in this Factor

Analysis (Figure Recall and Symbol Search). Figure recall, derived from the RBANS,

was moderately double loaded in Factors three (.421) (Working Memory and

Attention) and four (.400) (Language and Attention). Symbol Search, derived from

the WAIS-IV, was also moderately double loaded in Factors three (.464) and four

(.514). The nature of these loadings made it difficult to categorize them in either

factor. Moreover, including them in either factor made it impossible to accurately

identify the latent content. Given that the subtests failed to load in a single factor, this

is an argument for extracting (forcing data into fewer factors) fewer factors.

RBANS Form B and WAIS-IV Combined

A Confirmatory Factor Analysis of the RBANS Form B combined with the

WAIS-IV, involving an examination of factor eigenvalues (> 1.0) and a scree plot,

67

resulted in a six-factor solution, with combined factors accounting for 76.78% of the

variance (see Table 19). Loadings over 4.0 were considered significant and were

grouped accordingly. A Rotated Component Matrix of the six-factor solution found

five subtests loaded on factor one, five subtests loaded on factor two, four subtests

loaded on factor three, two subtests loaded on factor four, two subtests loaded on

factor five, and three subtests loaded on factor six (see Table 20). A visual

representation of the RBANS Form B and WAIS-IV combined can be found in Table

21 for a visual comparison of the factor loadings.

68

Table 19

Cumulative percent of variance for RBANS Form B and WAIS-IV combined

Compone

nt


Loadings

Total % of

Varianc

e

Cumulativ

e %

Tota

l

% of

Varianc

e

Cumulativ

e %

1 5.830 26.501 26.501 3.91 17.783 17.783

2 3.411 15.503 42.004 3.33 15.145 32.928

3 2.420 11.000 53.004 2.78

8

12.671 45.599

4 1.876 8.529 61.533 2.30 10.468 56.068

5 1.798 8.171 69.704 2.16 9.828 65.896

6 1.557 7.076 76.780 2.12 9.649 75.545

7 1.250 5.680 82.460 1.52 6.915 82.460

8 .962 4.372 86.832

9 .852 3.874 90.706

10 .641 2.915 93.621

11 .400 1.818 95.439

12 .290 1.317 96.755

13 .280 1.274 98.030

14 .159 .723 98.752

15 .114 .516 99.268

16 .081 .366 99.635

17 .046 .210 99.845

18 .034 .155 100.000

19 6.024E

-16

2.738E-

15

100.000

20 2.853E

-16

1.297E-

15

100.000

21 3.938E

-17

1.790E-

16

100.000

22 -

2.774E

-16

-

1.261E-

15

100.000

69

Table 20

Factor Loadings for Confirmatory Factor Analysis of RBANS Form B and WAIS-

IV

Component

1 2 3 4 5 6 7

Coding (WAIS-IV) .842 .050 -

.053

.009 .344 -

.033

.032

Coding (RBANS) .817 .088 .169 .110 .226 -

.227

-.069

Arithmetic (WAIS-IV) .773 .254 -

.024

-

.130

-

.131

.115 .144

Symbol Search (WAIS-

IV)

.730 .129 .407 .340 .134 -

.129

.042

Figure Recall (RBANS) .607 -

.211

.267 .560 -

.271

.025 -.040

Information (WAIS-IV) .013 .855 -

.089

-

.250

-

.187

-

.013

-.154

Digit Span (RBANS) .122 .818 -

.127

.244 .114 -

.166

-.075

Similarities (WAIS-IV) .209 .798 .130 .132 .067 .314 .200

Vocabulary (WAIS-IV) -.022 .712 .251 .119 .216 -

.175

-.002

Semantic Fluency

(RBANS)

.489 .626 -

.129

-

.145

-

.032

.009 -.091

List Recognition

(RBANS)

-.047 -

.097

.810 -

.048

.106 .002 .035

List Learning (RBANS) .304 .146 .798 .095 .151 .120 .161

List Recall (RBANS) -.002 -

.115

.722 .213 .117 .555 .117

Matrix Reasoning

(WAIS-IV)

.502 .195 .536 .117 .090 .121 -.141

Digit Span (WAIS-IV) .080 .207 .193 .882 .152 -

.118

.204

Line Orientation

(RBANS)

.368 -

.105

-

.238

.588 .322 .243 -.461

Visual Puzzles (WAIS-

IV)

.110 .074 .161 .018 .885 .066 -.140

70

Table 21

Factor Structure of RBANS Form B and WAIS-IV combined

Processing

Speed

Verbal

Comp.

Learning Unknown Perceptual

Reasoning

Verbal

Memory

Coding

(WAIS-IV)

Information List

Recognition

Digit Span Visual

Puzzles

Story

Recall

Coding

(RBANS)

Digit Span List Recall Line

Orientation

Block

Design

Picture

Naming

Arithmetic Similarities List

Learning

Story

Memory

Symbol

Search

Vocabulary Matrix

Reasoning

Figure

Recall

Semantic

Fluency

Block Design (WAIS-

IV)

.182 -

.022

.314 .232 .730 -

.187

.354

Story Recall (RBANS) -.097 -

.151

.253 -

.078

-

.051

.811 -.185

Picture Naming

(RBANS)

.314 -

.024

.065 -

.581

.146 -

.642

-.144

Story Memory

(RBANS)

.303 .283 .044 -

.253

.510 .604 .236

Figure Copy (RBANS) .046 -

.114

.089 .120 .046 .006 .919


71

The first factor was defined by five subtests (Coding (WAIS-IV), Coding

(RBANS), Arithmetic, Symbol Search, and Figure Recall). Coding, Arithmetic, and

Symbol Search were derived from the WAIS-IV, while Coding, and Figure Recall

were derived from the RBANS. A majority of these factor loadings measure

Processing Speed and Attention; however, Figure Recall doesn’t fit the same criteria.

Figure Recall loaded moderately in Factor one (.607) and appears to be double loaded

in Factor four (.560). Given that this subtest loaded in multiple factors, it poses an

argument for extracting fewer factors in future analyses.

The five subtests which loaded on factor two consisted of Verbal

Comprehension measures (Information, Digit Span, Similarities, Vocabulary, and

Semantic Fluency). Information, Similarities, and Vocabulary were derived from the

WAIS-IV, and Digit Span Semantic Fluency were derived from the RBANS. All

highly loaded subtests in this factor were grouped as expected.

The four subtests which loaded in factor three consisted of predominately

Learning measures (List Recognition, List Recall, List Learning, and Matrix

Reasoning). List Recognition, List Recall, and List Learning were derived from the

RBANS and Matrix Reasoning was derived from the WAIS-IV. The loading of Matrix

Reasoning in this factor comes as a surprise and makes labeling this factor impossible.

Matrix Reasoning loaded moderately with this factor (.536) and also co-loaded

moderately in Factor one (.502).

The two subtests which loaded in factor four consisted of factors which

measure very different constructs (Digit Span and Line Orientation). Digit Span was

72

derived from the WAIS-IV and Line Orientation was derived from the RBANS.

Given that the subtests intended measures were vastly different, an index name could

not be given.

The two subtests which loaded in factor five consisted of Perceptual

Reasoning measures (Visual Puzzles and Block Design). All loaded subtests were

derived from the Perceptual Reasoning index of the WAIS-IV. These subtests were

strongly loaded and loaded as expected.

The three subtests which loaded in factor six consisted of Verbal Memory

measures (Story Recall, Picture Naming, and Story Memory). All subtests included in

this factor were derived from the RBANS. While these loadings don’t follow the

proposed factor loadings of the RBANS, they all measure a similar cognitive

construct.

A seventh factor, consisting of one factor loading, was found in this analysis.

The subtest loaded in the seventh factor was proposed to measure a Visuospatial

Function construct (Figure Copy). Figure Copy, derived from the RBANS, failed to

load with any other subtest and therefore was excluded as a viable factor.

73

WAIS-IV

Table 2

Recap: WAIS-IV Proposed Factor Structure

Verbal

Comprehension

Perceptual

Reasoning

Working

Memory

Processing

Speed




WAIS-IV: A Confirmatory Factor Analysis was conducted on the WAIS-IV

without rotations. The purpose of this analysis was to confirm the proposed four-

factor structure of WAIS-IV, which was used in conjunction with the RBANS in

earlier analyses. The Kaiser-Meyer-Olkin measure of sampling adequacy was .628,

above the commonly recommended value of .6, and Bartlett’s test of sphericity was

significant (χ2 (45) = 119.05, p < .05). That is, the data was significant and had

enough variability to form factors. Communalities on all ten subtests were 1.00, such

that the subtests’ percent of variance could be explained by those factors. These

findings indicate that the data was suitable for a factor analysis.

A Confirmatory Factor Analysis of the WAIS-IV, involving an examination

of factor eigenvalues (> 1.0) and a scree plot, resulted in a three-factor solution, with

combined factors accounting for 52.0% of the variance (see Table 22). Loadings over

0.4 were considered significant and were grouped accordingly. A Rotated Component

74

Matrix (correlation table) of the three-factor solution found four subtests loaded on

factor one, four subtests loaded on factor two, and two subtests loaded on factor three

(see Table 23). These findings are not consistent with the proposed Four Factor

structure of the WAIS-IV. However, these factor loadings made the most sense with

the data from the current study. A visual representation of the proposed factor

structure of the WAIS-IV and the current loadings can be found in Table 24 for a


Table 22

Cumulative percent of variance for WAIS-IV without extractions

Componen

t


Loadings

Total % of

Varianc

e

Cumulativ

e %

Total % of

Varianc

e

Cumulativ

e %

1 3.45

3

34.531 34.531 2.35

6

23.563 23.563

2 1.75

0

17.504 52.036 2.31

6

23.162 46.725

3 1.36

5

13.655 65.691 1.89

7

18.966 65.691

4 .865 8.651 74.342

5 .733 7.332 81.674

6 .616 6.164 87.838

7 .438 4.382 92.221

8 .370 3.697 95.918

9 .242 2.417 98.335

10 .166 1.665 100.000

75

Table 23

Factor Loadings for Confirmatory Factor Analysis of the

WAIS-IV

Component

1 2 3

Block Design .854 -.020 .166

Visual Puzzles .817 -.009 .158

Digit Span .719 .238 -.161

Matrix Reasoning .533 .267 .499

Vocabulary .151 .808 .134

Information .032 .790 -.166

Similarities .106 .680 .274

Arithmetic .012 .628 .223

Coding -.085 .070 .892

Symbol Search .341 .223 .777


Table 2

Recap: WAIS-IV Proposed Factor Structure

Verbal

Comprehension

Perceptual Reasoning Working

Memory

Processing Speed




76

Table 24

WAIS-IV: Three-factor structure without extractions

Perceptual Reasoning Verbal Comprehension Processing Speed

Block Design Vocabulary Coding

Visual Puzzles Information Symbol Search

Digit Span Similarities

Matrix Reasoning Arithmetic

The four subtests which loaded in factor one consisted predominantly of

Perceptual Reasoning measures (Block Design, Visual Puzzles, Matrix Reasoning,

and Digit Span). Each of these measures focuses on a visuospatial task, such that the

individual must visually interpret information and respond verbally or in block

designs. While Digit Span loaded highly (.719) with the Perceptual Reasoning index,

these findings differ from its proposed loading in the Working Memory index of the

WAIS-IV.

The four subtests which loaded on factor two consisted of Verbal

Comprehension measures (Vocabulary, Information, Similarities, and Arithmetic).

These measures examine an individual’s breadth of knowledge in several areas. Each

measure requires the examiner to ask the individual a question which elicits a verbal

response. Once again, a subtest from the proposed Working Memory index of the

77

WAIS-IV loaded highly in a different factor. In this case, Arithmetic loaded highly

(.628) in the Verbal Comprehension index.

The third factor consisted of two loaded subtests which made up the

Processing Speed index (Coding and Symbol Search). These findings are consistent

with the proposed loading of the WAIS-IV.

An additional Confirmatory Factor Analysis was run on the WAIS-IV,

however this time we extracted the proposed four-factor Structure. The factors

remined the same however, Digit Span loaded independently in Factor Four.

Therefore, I determined the three-factor solution found in the previous analyses was a

better fit.

FSIQ

A Descriptive Statistics analysis was conducted on the WAIS-IV data to

determine how participants preformed relative to their age group. The WAIS-IV

FSIQ score ranges from 40 to 160, with higher scores indicating higher cognitive

function. FSIQ scores are converted into an age-based percentile score to provide a

qualitative description of an individual’s performance. Based on the data from this

analysis, participants scored ‘average’ to ‘high average’ relative to their age group.

The FSIQ statistics can be found in Table 25.

78

Table 25

Descriptive Statistics of WAIS-IV FSIQ Scores

Mean 114.71

Median 114.50

Mode 110.00

Standard Deviation 9.72

Minimum 99.00

Maximum 139.00

Note. FSIQ = Full Scale Intelligence Quotient.

79

CHAPTER IV

DISCUSSION

Previous Studies and Results

The clinical utility of the RBANS has been somewhat supported in

many studies, however construct validity was not determined prior to the release of

the tool (Duff et al., 2006). That is, the factor structure of the RBANS was developed

theoretically without the use of factor analytic studies (Schmitt et al., 2010). Without

support for the construct validity of the RBANS we cannot purport that the data is

measuring the intended constructs. Despite the lack of support for the construct

validity of the assessment, it is still a commonly used neuropsychological battery for

the measurement of cognitive function in various neurological populations (Aupperle

et al., 2002; Beatty et al., 2003; Beatty, 2004; Larson et al., 2003; McKay et al., 2007,

Randolph et al., 1998; Randolph et al.,1998).

The RBANS consists of twelve subtests (i.e. List Learning, Story Memory,

Figure Copy, Line Orientation, Picture Naming, Semantic Fluency, Digit Span,

Coding, List Recall, List Recognition, Story Recall, and Figure Recall) which make

up five proposed domains (i.e., Immediate Memory, Visuospatial

Function/Constructional, Language, Attention, and Delayed Memory). The five

domain scores are converted into a Total Scale Index Score which is representative of

an individual’s global cognitive ability. Ten previous factor analytic studies have

attempted to validate the proposed five-factor structure of the RBANS (Carlozzi et

80

al., 2008; Cheng et al., 2011; Duff et al.2006; Emmert et al., 2016; Garcia et al.,

2008; King et al., 2012; Schmitt et al., 2010; Torrence et al., 2016; Wilde, 2006;

Yang et al., 2009). Of the ten previous studies, only two found support for the

proposed Five Factor structure (Cheng et al., 2011; Emmert et al., 2016). Six of the

previous factor analytic studies found support for a two-factor solution (Carlozzi et

al., 2008; Duff et al., 2006; King et al., 2012; Schmitt et al., 2010; Wilde, 2006; Yang

et al., 2009) and one for a three-factor solution (Garcia et al., 2008).

The present study conducted a Confirmatory Factor Analysis on the RBANS

Form A, RBANS Form B, RBANS Forms A and B combined, RBANS Form A

compared to the WAIS-IV, RBANS Form B compared to the WAIS-IV, and on the

WAIS-IV. An analysis of RBANS Form A found a three-factor solution

(Memory/Attention, Learning, & Visuospatial Function/Language), as did Form B

(Learning/Memory, Language/Attention, & Visuospatial Function). These findings

are consistent with the number of factors found by Garcia and colleagues (2008).

However, subtest loadings from the current study did not match those of Garcia et al.

(2008). A visual comparison of the factor loadings can be found in Appendix H. A

Confirmatory Factor Analysis was conducted on the RBANS Form A and B

compared to the WAIS-IV. An analysis of the RBANS Form A combined with the

WAIS-IV resulted in a six-factor solution (Learning/Memory, Visuospatial Function,

Processing Speed/Attention, Language/ Attention, Verbal Comprehension, &

Working Memory/Attention). The analysis between RBANS Form B and the WAIS-

IV also found a six-factor solution (Processing Speed/Attention, Verbal

81

Comprehension, Untitled, Untitled, Perceptual Reasoning, & Verbal Memory). Given

the complex loadings of some factors, an index name could not be determined.

Furthermore, Figure Copy loaded independently in a seventh factor. Being as it is

impossible to have a factor with a single loading; Figure Copy was not considered a

factor in this analysis. Furthermore, Line Orientation (subtest) from the RBANS

continuously failed to correlate with subtests form the same assessment, suggesting

that the RBANS does not have enough visuospatial functioning tasks to measure

Visuospatial Function.

As of now, no studies have been conducted comparing multiple forms of the

RBANS to the latest revision of the WAIS (WAIS-IV). Given that the WAIS-IV’s

revisions were substantial (additional subtests, deleted subtests, and modified

administration and/or scoring criteria) from the previous version of the WAIS

(WAIS-III), I cannot compare my findings to previous studies.

The differences in my findings from a majority of previous factor analytic

studies can be attributed to several factors. Differences in sample characteristics for

example, would contribute to varying factor structures and loadings. Duff et al.

(2006) focused on “normal” elderly individuals. Wilde (2006) studied individuals

with acute stroke. Carlozzi et al. (2008) looked at military veterans. Yang et al.

(2009) focused on individuals with early untreated Parkinson’s Disease. Schmitt et al.

(2010) looked at individuals referred for dementia screening (archival). King et al.

(2012) studied forensically committed psychiatric patients who had a primary

diagnosis of schizophrenia or schizoaffective disorder (A majority of participants also

82

had a secondary diagnosis of substance abuse or substance dependence). Garcia et al.

(2008) focused on individuals diagnosed with a memory disorder(s). Cheng et al.

(2011) looked at community-dwelling elderly individuals in Shanghai, China.

Emmert et al. (2016) focused on geriatric individuals referred for a clinical

neuropsychological evaluation. Lastly, Torrence et al. (2016) focused on cognitively

heathy and impaired, elderly individuals (archival data). Given that several disorders

affect varying areas of cognitive function, the differences in sample populations will

likely result in varying performance differences on subtests. That is, individuals

scores and overall performance will vary depending on sample characteristics (i.e.

clinical vs. nonclinical). These differences may suggest that factor loadings will be

specific to the characteristics of the sample, such that the RBANS loads differently in

different populations.

Another factor that may have contributed to different factor loadings is the

exclusion of subtests in the data analysis of previous studies. That is, researchers

eliminated subtests from the final analysis, which failed to load (or were not

significant) in initial analyses. For example, Duff et al. (2006) eliminated semantic

fluency, digit span, and picture naming (skewed) from the final analysis due to low

correlations. Yang et al. (2009) eliminated six subtests due to low correlations or

severe ceiling effects (picture naming, semantic fluency, digit span, coding, line

orientation, and figure copy). Carlozzi et al. (2010) and King et al. (2012) also

eliminated digit span due to low correlations. Lastly, Torrence et al. (2016)

eliminated list recognition from their first model due to insignificant factor loadings.

83

In past factor analytic studies, Digit Span appeared to present the most problems for

factor loadings. In the current study, no subtest was excluded from the final analysis.

An additional difference between each factor analytic study, which could

determine factor loadings, is the type of analysis that was conducted. For the current

study, I chose to utilize a CFA because we are provided with presumed factor

loadings. Therefore, I had the ability to extract the proposed number of factors to

determine if the subtests load as purported. Other analyses, such as an Exploratory

Factor Analysis (EFA), have no prior presumptions of the possible factor loadings or

subsequent latent content. King et al. (2012) and Schmitt et al. (2010) ran a Principal

Component Analysis (PCA), Wilde (2006) ran a Principal Component Analysis with

orthogonal rotation, and Garcia et al. (2008) conducted a Principal Component

Analysis with oblique rotation. Yang et al. (2009), Emmert et al. (2016), Cheng et al.

(2011), and Torrence et al. (2016) conducted a Confirmatory Factor Analysis.

Carlozzi et al. (2008) ran an Exploratory Factor Analysis (EFA) with orthogonal

rotation followed by a Confirmatory Factor Analysis. Lastly, Duff et al. (2006)

utilized an Exploratory Factor Analysis with oblique and orthogonal rotations. Given

the different approaches to viewing the data and the differences in rotations,

differences in analysis techniques are sure to affect the factor loadings of the RBANS.

Limitations

The current study has several limitations. First, the present study has a

relatively low sample size. Smaller sample sizes increase the risk for outliers that may

skew the data. The preset study utilized 41 participants, which is far below the

84

recommended sample size for a factor analytic study (two participants per item on

each subtest included in the analyses). Previous studies examining the factor structure

of the RBANS utilized samples ranging from 167 to 824 individuals. A second, and

most important, limitation was the counterbalancing of RBANS Forms A and B. That

is, of my 41 participants, only half received RBANS Form A and half received

RBANS Form B, severely limiting my sample size per analyses. Furthermore, a CFA

of the WAIS-IV resulted in a three-factor structure, which is inconsistent with its

purposed four-factor structure. Given that the WAIS-IV failed to load as expected,

and that previous studies have often failed to support its proposed four-factor

structure, I cannot fully support its factor comparison to the RBANS.

A limitation of a measure used was the vague scoring criteria for Figure Copy

and Figure Recall in the RBANS manual. The scoring criteria left a lot of room for

interpretation and thus affected interrater reliability. This limitation was addressed in

the factor analytic study conducted by Duff et al. (2006), such that they developed

their own scoring criteria for the subtest. The present study however, adhered to the

standardized scoring criteria provided by the RBANS scoring manual.

Future Research

Future research should focus on methods of restructuring the RBANS to make

it a reliable and efficient tool to use in a clinical setting. Given that the RBANS

consists of subtests inspired by those in the WAIS-IV ad WMS-IV, future research

should compare the factor structure of the RBANS to both the WAIS-IV and WMS-

IV, in a larger sample. That is, future studies should see if subtests which purport to

85

measure similar cognitive constructs, load together in similar factors. Specifically,

future studies should compare nearly identical subtests between the WAIS-IV and

RBANS, such as Coding and Digit Span. Furthermore, Forms A and B loaded

differently in the current study, therefore a factor analysis of each individual form of

the RBANS (Forms A, B, C, & D) should be conducted to provide convergent

validity for the additional forms. Moreover, additional factor analytic studies should

be conducted in a variety of clinical and nonclinical populations to determine if the

RBANS loads differently in each sample. Lastly, studies should evaluate the cause of

the insignificant factor loadings of Line Orientation and effect of the vague scoring

criteria for the Figure Copy and Figure Recall subtests of the RBANS.

The purpose of this study was to evaluate the construct validity of the RBANS

to determine if it is a valid tool for cognitive assessment. Although the RBANS

appears to have face validity, it lacks sufficient information to provide a complex

understanding of cognitive function. Therefore, an assessment such as this cannot be

a replacement for more complex batteries, such as the WAIS-IV and WMS-IV.

However, with some revisions, the RBANS could possibly act as a screening tool,

such as the MMSE. Yet, as of now, the RBANS has yet to provide sufficient support

for its construct validity and is therefore inappropriate in clinical settings.

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APPENDICES

96

APPENDIX A

PERMISSION TO CONDUCT STUDY AT CVOT

97

APPENDIX B

EXPLNATION OF LARGER LONGIUDINAL STUDY

Longitudinal Study

Purpose. The purpose of the larger longitudinal study is to determine which

psychosocial factors contributed to optimal cognitive decline. Researchers

focused on social and exercise factors that contribute to healthy cognitive

aging. Participants were administered several neuropsychological tests every

year for the duration of five years. In addition to cognitive testing they were

also administered a series of psychosocial questionnaires and had their

physical activity monitored.

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APPENDIX C

DEMOGRAPHICS

Demographics

1. Age: __________________

2. Date of birth (mm/dd/yyyy): _______________________

3. Sex:

Male Female Other

4. Ethnicity (check all that apply):

Black or African American

Alaska Native or American Indian

Asian, Native Hawaiian, or Pacific Islander

White or Caucasian

Hispanic or Latino

Other: _____________________________________

5. Is English your first/native language?

Yes

No (please state your first language): _______________

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6. What is your highest level of education?

No school

Grade school

High school or equivalent

Certificate or training program

Some college

Associate's degree

Bachelor's degree

Master's degree

Doctoral degree

Other: ______________________________

7. What is your height (ft/in)? _______________________

8. What is your current weight (lbs)? ___________________

9. What is the circumference of your waist (cm)? ___________10. In general, would you say that your health is: Poor Fair Good Very good Excellent

Occupational History Please list your past job titles and the length of each title: __________________________________________________________________________________________

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Personal Medical History

Please check all problems that exist(ed) for you and describe the problem indicated (if applicable).

Health condition: Describe

Dementia

Diabetes

Heart disease

Hypertension

Cancer

Asthma

Other

Medications

Please list any medications you are currently taking and their purpose.

________________________________________________

________________________________________________

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Stress & Substance Use History

1. In the past week, how much stress have you experienced?

Extreme stress

Quite a bit of stress

Moderate stress

Little stress

No stress at all

2. I drink alcohol:

Never Rarely 1-2 days/week 3-5 days/week Daily

3. When I drink alcohol, I typically drink ___ drinks in one day:

Not applicable

1

2

3

4

5 or more

4. Do you currently smoke? YES NO

If yes, what?________________________________

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If no, have you ever smoked? YES NO

If yes, when did you quit? ____________________

If yes, what did you smoke? ___________________ When did you start smoking? _________________

5. Do you use or have you ever used any other substances?

YES NO Please explain:___________________________________

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Physical Activity

1. How many times a week do you typically engage in vigorous exercise?That is, physical activity that causes your heart to beat so rapidly that you canfeel it in your chest and you perform the activity long enough to work up agood sweat and you are breathing heavily? (E.g., rigorous bicycling, vigorousswimming, or high intensity water aerobics; digging in the garden or liftingheavy objects.)

None Once (1) per week Twice (2) per week Three (3) times per week Four (4) times per week Five (5) times per week Six (6) times per week Seven (7) or more times per week

2. When you exercise vigorously, how many minutes on average does eachexercise session last? _________________

3. What types of vigorous physical activities do you typically engage in?(e.g., swimming, walking, running, weight training, dancing, tai chi, yoga,etc.)

4. How many times a week do you typically engage in moderate exercise?That is, activity that it not physically exhausting, but causes your heart rate toincrease slightly and you work up a sweat? (E.g., leisurely sports like lighttennis, slow or light swimming, low impact aerobics, or golfing without apower cart; brisk walking, mowing the lawn with a walking lawnmower,vacuuming or other heavy housework.)


5. When you exercise at moderate intensity, how many minutes onaverage does each exercise session last? ________

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6. What types of moderate physical activities do you typically engage in?(e.g., swimming, walking, running, weight training, dancing, tai chi, yoga,etc.)

_____________________________________________

7. How many times a week do you typically engage in light exercise? (E.g.,leisurely sports like croquet; strolling; shopping; light cleaning or yard work.)


8. When you exercise at light intensity, how many minutes on average doeseach exercise session last? _________________

9. What types of light physical activities do you typically engage in? (e.g.,swimming, walking, running, weight training, dancing, tai chi, yoga, etc.)

Leisure Activities

1. Please list your hobbies/leisure activities: ____________

_____________________________________________

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Social Partners

Instructions: This questionnaire is concerned with how many people you see or talk to on a regular basis including family, friends, workmates, neighbors, etc. Please read and answer each question carefully. Answer follow-up questions where appropriate.

1. Which of the following best describes your marital status?

currently married & living together, or living with someone in marital-likerelationship

never married & never lived with someone in a marital-like relationship

separated

divorced or formerly lived with someone in a marital-like relationship

widowed (please indicate time since death of spouse): ______

_____________________________________________

2. How many children do you have? (If you don't have any children, check'0' and skip to question 3.)

0 1 2 3 4 5 6 7 or more

2a. How many of your children do you see or talk to on the phone at least once every 2 weeks?

0 1 2 3 4 5 6 7 or more

3. Are either of your parents living? (If neither is living, check 'neither' andskip to question 4.)

neither mother only father only both

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3a. Do you see or talk on the phone to either of your parents at least once every 2 weeks?


4. Are either of your in-laws (or partner's parents) living? (If you have none, check the appropriate space and skip to question 5.)


not applicable

4a. Do you see or talk on the phone to either of your partner's parents at least once every 2 weeks?


5. How many other relatives (other than your spouse, parents & children) do you feel close to? (If '0', check that space and skip to question 6.)

0 1 2 3 4 5 6 7 or more

5a. How many of these relatives do you see or talk to on the phone at least once every 2 weeks?

0 1 2 3 4 5 6 7 or more

6. How many close friends do you have? (meaning people that you feel at ease with, can talk to about private matters, and can call on for help)

0 1 2 3 4 5 6 7 or more

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6a. How many of these friends do you see or talk to at least once every 2 weeks?

0 1 2 3 4 5 6 7 or more

7. Do you belong to a church, temple, or other religious group? (If not, check'no' and skip to question 8.)

no yes

7a. How many members of your church or religious group do you talk to at least once every 2 weeks? (This includes at group meetings and services.)

0 1 2 3 4 5 6 7 or more

8. Do you attend any classes (school, university, technical training, or adulteducation) on a regular basis? (If not, check 'no' and skip to question 9.)

no yes

8a. How many fellow students or teachers do you talk to at least once every 2 weeks? (This includes at class meetings.)

0 1 2 3 4 5 6 7 or more

9. Are you currently employed either full or part-time? (If not, check 'no' andskip to question 10.)

no yes, self-employed yes, employed by others

9a. How many people do you supervise?

108

0 1 2 3 4 5 6 7 or more

9b. How many people at work (other than those you supervise) do you talk to at least once every 2 weeks?

0 1 2 3 4 5 6 7 or more

10. How many of your neighbors do you visit or talk to at least once every 2weeks?

0 1 2 3 4 5 6 7 or more

11. Are you currently involved in regular volunteer work? (If not, check 'no'and skip to question 12.)

no yes

11a. How many people involved in this volunteer work do you talk to about volunteering-related issues at least once every 2 weeks?

0 1 2 3 4 5 6 7 or more

12. Do you belong to any groups in which you talk to one or more members ofthe group about group-related issues at least once every 2 weeks? Examplesinclude social clubs, recreational groups, trade unions, commercial groups,professional organizations, groups concerned with children like the PTA orBoy Scouts, groups concerned with community service, etc. (If you don'tbelong to any such groups, check 'no' and skip the section below.)

no yes

Consider those groups in which you talk to a fellow group member at least once every 2 weeks. Please provide the following information for each such group: the name or type of group and the total number of members in that group that you talk to at least once every 2 weeks.

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1. Group name/type; total number of group members you talk to at least onceevery 2 weeks: __________________________

_____________________________________________


_____________________________________________


_____________________________________________


_____________________________________________


_____________________________________________


_____________________________________________ Social Support People sometimes look to others for companionship, assistance, or other types of support. How often is each of the following kinds of support available to you if you need it? Circle one number on each line.

None of the time

A little of the time

Some of the time

Most of the

time

All of the

time Someone you can count on to listen to you when you need to talk

1 2 3 4 5

Someone to give you information to help you understand a situation

1 2 3 4 5

110

Someone to give you good advice about a crisis

1

2

3

4

5

Someone to confide in or talk to about yourself or your problems

1

2

3

4

5

Someone whose advice you really want

1

2

3

4

5

Someone to share your most private worries and fears with

1

2

3

4

5

Someone to turn to for suggestions about how to deal with a personal problem

1

2

3

4

5

Someone who understands your problems

1

2

3

4

5

Someone to help you if you were confined to bed

1

2

3

4

5

Someone to take you to the doctor if you needed it

1

2

3

4

5

Someone to prepare your meals if you were unable to do it yourself

1

2

3

4

5

Someone to help with daily chores if you were sick

1

2

3

4

5

Someone who shows you love and affection

1

2

3

4

5

Someone to love and make you feel wanted

1

2

3

4

5

Someone who hugs you 1

2

3

4

5

Someone to have a good time with

1

2

3

4

5

Someone to get together with for relaxation

1

2

3

4

5

Someone to do something enjoyable with

1

2

3

4

5

Someone to do things with to help you get your mind off things

1

2

3

4

5

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Social Exchanges In the past month, how often did the people you know do the following? Circle one number on each line, where 1 represents “Never” and 5 represents “Very often.”

Never 1 2 3 4 5 Very often

1. offer helpful advice when you needed to make important decisions? 1 2 3 4 5 2. make useful suggestions? 1 2 3 4 5 3. suggest ways that you could deal with problems you were having? 1 2 3 4 5 4. do favors and other things for you? 1 2 3 4 5 5. provide you with aid and assistance? 1 2 3 4 5 6. help you with an important task or something that you could not do on your own? 1 2 3 4 5 7. provide you with good company and companionship? 1 2 3 4 5 8. include you in things they were doing? 1 2 3 4 5 9. do social or recreational activities with you? 1 2 3 4 510. do or say things that were kind or considerate toward you? 1 2 3 4 5 11. cheer you up or help you feel better? 1 2 3 4 5 12. In the past month, how often did you discuss personal matters or concerns with someone you know? 1 2 3 4 5 13. give you unwanted advice? 1 2 3 4 5 14. question or doubt your decisions? 1 2 3 4 5 15. interfere or meddle in your personal matters? 1 2 3 4 5 16. let you down when you needed help? 1 2 3 4 5 17. ask you for too much help?

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1 2 3 4 5 18. fail to give you assistance that you were counting on? 1 2 3 4 5 19. leave you out of activities that you would have enjoyed? 1 2 3 4 5 20. forget or ignore you? 1 2 3 4 5 21. fail to spend enough time with you? 1 2 3 4 5 22. do things that were thoughtless or inconsiderate? 1 2 3 4 5 23. act angry or upset with you? 1 2 3 4 5 24. act unsympathetic or critical about a personal concern of you? 1 2 3 4 5

More Social Reactions to Physical Activity & Exercise In the past week, how often did the people you know (e.g., friend, family member, spouse) do the following? Circle one number on each line, where 1 represents “Never” and 5 represents “Very often.”

Never 1 2 3 4 5 Very often 1. exercise with you?1 2 3 4 5 2. offer to exercise with you?1 2 3 4 5 3. nag you about exercise?1 2 3 4 5 4. demand that you exercise on recreational outings?1 2 3 4 5 5. give you encouragement to stick with your exercise program?1 2 3 4 56. change his or her schedule so you could exercise together?1 2 3 4 57. demand that you discuss exercise?1 2 3 4 5 8. give you helpful reminders to exercise? 1

2 3 4 5 9. plan for exercise on recreational outings?1 2 3 4 5 10. discuss exercise with you?1 2 3 4 5 11. talk about how much they like to exercise?1 2 3 4 5 12. tell you ideas on how you can get more exercise?1 2 3 4 5 13. make negative comments about your physical appearance1 2 3 4 514. help plan activities around your exercise?1 2 3 4 5 15. ask you for ideas on how they can get more exercise?1 2 3 4 516. pressure you to exercise?1 2 3 4 5 17. take over chores so you had more time to exercise?1 2 3 4 5 18. make positive comments about your physical appearance?1 2 3 4 519. make remarks about how much you should be exercising?1 2 3 4 5

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20. give you rewards for exercising? 1 2 3 4 5 Emotions

1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most people? YES / NO 11. Do you think it is wonderful to be alive? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO

115

APPENDIX D

INFORMED CONSENT

Dear Participant:

You are being asked to participate in a research project on healthy aging. We hope to

learn about social and behavioral factors that influence health and cognition over

time. If you decide to volunteer, you will be asked to answer questions about your

health, your physical activity behavior, and your social relationships. After the survey

portion is complete, you will be given the opportunity to take a break. Then we will

do some activities together, like picture naming, figure drawing, defining words, and

remembering stories. The whole procedure should take approximately one hour.

Because we are interested in examining change over time, you will also be asked if

we can contact you again next year to participate in the study again. Finally, we

would like to access your exercise data, and so we will ask you to give us permission

to access your personal fitness information. This study will follow participants over

four years, but responses will remain completely confidential. No personal identifying

information will be collected, and data will be protected from inappropriate access.

There are no known risks to you for your participation in this study. However,

responding to some questions may make you feel uncomfortable. To guard against

this risk, you are free to skip any question or to discontinue the study at any point,

without penalty. If your participation in this study causes you any concerns, anxiety,

or distress, please contact Chaplain Paul Barnes at 209-216-5620.

It is possible that you will not benefit directly by participating in this study. However,

possible benefits include the fact that you may learn something about how research

studies are conducted and you may learn something about this area of research (i.e.,

factors that are related to health in later life). The information collected will be

protected from all inappropriate disclosure under the law. All data will be kept in a

secure location (locked file cabinet), separate from consent forms, and all materials

will be destroyed 3 years after the study is completed. Only the primary investigators

and their trained research assistants will have access to the data. Also, we are not

interested in anyone’s individual responses, only the average responses of everyone in

the study.

There is no cost to you beyond the time and effort required to complete the

procedure(s) described above. Your participation is voluntary. Refusal to participate

in this study will involve no penalty or loss of benefits. You may withdraw at any

time without penalty or loss of benefits.

116

If you agree to participate, please indicate this decision by signing below. If you have

any questions about this research project please contact me, Dr. Kelly Cotter, at (209)

664-4432 or at [email protected]. If you have any questions regarding your rights

and participation as a research subject, please contact the IRB Administrator by

phone (209) 667-3493 or email [email protected].

Sincerely,

Kelly A Cotter, PhD

Assistant Professor of Psychology & Child Development

California State University Stanislaus One University Circle Turlock, CA 952382 Email: [email protected] Phone: (209) 664-4432

I have read and understand the information provided above. All of my questions, if

any, have been answered to my satisfaction. I consent to take part in this study. I

have been given a copy of this form.

Signature Date

Name (printed)

In addition to agreeing to participate, I also consent to having the researchers contact

me again for the follow-up study in approximately one year.

Signature Date

Name (printed)

I also consent to having the researchers access my exercise data, housed on my

Covenant Village memory key in the fitness facility.

Signature Date

Name (printed)

117

Signature of person obtaining consent Date

Printed name of person obtaining consent

118

APPENDIX E

MINI MENTAL STATUS EXAM (MMSE)

Score

Maximum Score

(5)

ORIENTATION TO TIME

What: is today’s date? ____________ (______)

is the month? ____________ (______)

is the year? ____________ (______)

is the day of the week today? ____________ (______)

season is it? ____________ (______)

Total: (______)

(5)

ORIENTATION TO PLACE

What: state are we in? ____________ (______)

country are we in? ____________ (______)

town are we in? ____________ (______)

building are we in? ____________ (______)

room/floor are we on? ____________ (______)

Total: (______)

(5)

IMMEDIATE RECALL

Have the participant immediately recall: Ball, Flag, Tree. Allow 6 trials. Only 1st

trial is scored.

Trial 1: ______, ______, ______ (______) Trial 2: ______, ______, ______

Trial 3: ______, ______, ______ Trial 4: ______, ______, ______

Trial 5: ______, ______, ______ Trial 6: ______, ______, ______

Total: (______)

# of trials to get all correct: (______)

(3)

ATTENTION

I would like you to count backwards from 100 by sevens.

(93) ______, (86) ______, (79) ______, (72) ______, (65) ______

Total: (______)

(5)

Alternative

Please spell the word “world” backwards.

119

(D) ______, (L) ______, (R) ______, (O) ______, (W) ______

Score is the number of letters in correct order. Total: (______)

DELAYED RECALL

Earlier I told you three words. Can you tell me what those three words were?

Ball ______, Flag ______, Tree ______

Total: (______)

(3)

LANGUAGE

Naming

What is this:

(point to wristwatch)? ______ (______), (point to pen)? ______ (______)

Total: (______)

(2)

Repetition

Repeat the following: “No ifs, and’s or buts.” Total: (______)

(1)

3 STAGE COMMAND

Please take the paper in your right hand, fold it, and then set it on the ground

Takes (______), Folds (______), Puts (______)

Total: (______)

(3)

READING

Holding up the phrase “CLOSE YOUR EYES”, say: Read this sentence and do what

it says.

Closes eyes Total: (______)

(1)

WRITING

Give the participant a blank piece of paper. Do not dictate a sentence; it is to be

written by the subject spontaneously. Must contain a subject, verb, and make a

complete thought.

Please make up a sentence about anything and write it down.

Total: (______)

(1)

COPYING

Please copy this design exactly. All 10 angles must be present and 2 must intersect.

120

Total: (______)

(1)

Total MMSE Points: ____________

121

APPENDIX F

INITIAL DEBRIFING FORM

Purpose

The purpose of this study is to assess social and behavioral factors that relate to

exercise behavior, cognitive functioning, and health. Much of the research that has

been conducted in this area has been based on data collected at just one point in time.

We cannot draw causal inferences from these data. Therefore, we aim to collect data

from participants over several years. We will contact participants once per year for

five years in order to measure how they change over time. This will help us to

determine which behaviors are the healthiest and which behaviors may be harmful for

health and cognitive functioning.

Contact Information

The results of this study will be available by December of 2022. If you would like

further information about the study or have questions in the meantime, please contact

Kelly Cotter, PhD, at [email protected] or at 209-664-4432 at your convenience. If

you have any questions regarding your rights and participation as a research subject,

please contact the CSU Stanislaus IRB Administrator by phone (209) 667-3493 or

email [email protected].

Psychological Services

If your participation in this study causes you any concerns, anxiety, or distress, please

contact Chaplain Paul Barnes at 209-216-5620.

Thank you for participating!

Sincerely,

Kelly Cotter, Dawn Strongin, Gary Williams, and the Healthy Aging Lab

122

APPENDIX G

FINAL DEBRIEFING FORM

Purpose

The purpose of this study is to assess social and behavioral factors that relate to

exercise behavior, cognitive functioning, and health. Much of the research that has

been conducted in this area has been based on data collected at just one point in time.

We cannot draw causal inferences from these data. However, previous research has

shown links between more supportive social relationships, more frequent physical

activity participation, better health, and better cognitive functioning (e.g., Bassey,

2000; Cohen, 2004; Kramer et al., 1999). You have helped us to collect a lot of

information over a long period of time. This will help us to determine which

behaviors are the healthiest and which behaviors may be harmful for health and

cognitive functioning.

Contact Information

The results of this study will be available by December of 2022. If you would like

further information about the study, if you would like us to send you research reports

on the topics of social relations and health, or if you have questions, please contact

Kelly Cotter, PhD, at [email protected] or at 209-664-4432 at your convenience. If

you have any questions regarding your rights and participation as a research subject,

please contact the CSU Stanislaus IRB Administrator by phone (209) 667-3493 or

email [email protected].

Psychological Services

If your participation in this study causes you any concerns, anxiety, or distress, please

contact Chaplain Paul Barnes at 209-216-5620.

Thank you for participating!

Sincerely,

Kelly Cotter, Dawn Strongin, Gary Williams, and the Healthy Aging Lab

References

Bassey, E. J. (2000). The benefits of exercise for the health of older people. Reviews

in Clinical Gerontology, 10, 17-31.

Cohen, S. (2004). Social relationships and health. American Psychologist, 59, 676-

684.

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APPENDIX H

COMPARISON OF THE FACTOR LOADINGS FROM THE CURRENT STUDY

TO GARCIA ET AL. (2008)

Table 26

Factor loadings in Garcia et al. (2008)

Memory Visuomotor Processing Verbal Processing

Story Recall Figure Copy Picture Naming

List Recall Line Orientation List Learning

Figure Recall Coding

List Recognition

Story Memory

Table 9

Extracted Three-factor structure of the RBANS Form A

Memory and Attention Learning Visuospatial and

Language

Story Memory List Recognition Figure Copy

Story Recall List Learning Picture Naming

Digit Span (Neg.) List Recall Figure Recall

Coding Semantic Fluency

construct validity of the rbans forms a and b

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