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Normative study of the Token Test (short version): Preliminary data for a
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Article  in  Archives of Clinical Psychiatry (São Paulo) · January 2011

DOI: 10.1590/S0101-60832011000300003

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 Original article

Normative study of the Token Test (short version): preliminary data for a sample of
Brazilian seniors
Estudo normativo do Token Test versão reduzida: dados preliminares para uma população de idosos brasileiros
Lafaiete Moreira1,2, Carlos Guilherme Schlottfeldt2,3, Jonas Jardim de Paula2,3,4, Marisa Teixeira Daniel5, Andreza
Paiva5, Viviane Cazita5, Gabriel Coutinho2,6, João Vinícius Salgado7,8,9, Leandro Fernandes Malloy-Diniz1,2,3,4
1 Departamento de Psicologia da Faculdade de Filosofia e Ciências Humanas da Universidade Federal de Minas Gerais (FAFICH/UFMG).
2 Laboratórios Integrados de Neuropsicologia (Lineu).
3 Psicólogo.

4 Programa de Pós-Graduação em Neurociências da UFMG.

5 Fonoaudióloga.

6 Centro de Neuropsicologia Aplicada – Rio de Janeiro.

7 Médico.

8 Departamento de Morfologia do Instituto de Ciências Biológicas (ICB) da UFMG.

9 Fundação Hospitalar do Estado de Minas Gerais (FHEMIG) – Hospital de Ensino Instituto Raul Soares.

Received: 27/6/2010 – Accepted: 9/11/2010

Abstract
Introduction: The preservation of oral comprehension in the elderly is correlated with the preservation of their cognitive functions. Oral comprehension is a
key feature for communication and its evaluation allows for the identification of more specific cognitive deficits, in addition to facilitating the development of
more effective, early intervention strategies. Objective: Provide contemporary standards for the use of an instrument to assess oral comprehension, the Token
Test, in a sample of healthy seniors. Method: A sample of 120 patients (76 women) with mean age of 71.1 years and 6.9 years of formal education, was assessed
using the Mini Mental State Examination to identify the existence of cognitive impairment, and the Token Test to assess oral comprehension. Results: There were
significant correlations (p < 0.01) between the token test scores for education and age, which accounted for 5% and 21% of shared variance, respectively. These
two variables were considered on the normative data tables. Discussion: The data obtained indicate that the standards provided here are sufficiently representa-
tive. This study identifies the need for future studies comparing the Token Test performance in elderly people either healthy or in the process of cognitive decline.

Moreira L, et al. / Rev Psiq Clín. 2011;38(3):97-101

Keywords: Oral comprehension, cognitive functions, evaluation, Token Test.

Resumo
Introdução: A preservação das habilidades de compreensão da fala nos idosos está correlacionada com a preservação das funções cognitivas. Essa habilidade é
característica fundamental para a comunicação e sua avaliação possibilita a identificação de déficits cognitivos mais específicos, além de facilitar o desenvolvimento
de estratégias de intervenção mais precoces e eficientes. Objetivo: Disponibilizar normas contemporâneas para a utilização de um instrumento de avaliação da
compreensão verbal, o Token Test, para idosos brasileiros saudáveis. Método: Uma amostra 120 idosos (76 mulheres), com médias de 71,1 anos para idade e de
6,9 anos de educação formal para escolaridade, foi avaliada utilizando o Miniexame de Estado Mental, para identificação da existência de comprometimento
cognitivo, e o Token Test, para avaliação da compreensão da fala. Resultados: Foram encontradas correlações significativas (p < 0,01) entre o escore do Token
Test e a educação formal e a idade, os quais corresponderam respectivamente a 5% e 21% da variância compartilhada. Tais variáveis foram consideradas nas
tabelas normativas. Conclusão: Nossos dados indicam que as normas disponibilizadas aqui são suficientemente representativas. Este trabalho abre caminho
para estudos futuros de comparação entre o desempenho no Token Test de idosos saudáveis e daqueles em processos de declínio cognitivo.

Moreira L, et al. / Rev Psiq Clín. 2011;38(3):97-101

Palavras-chave: Compreensão verbal, funções cognitivas, avaliação, Token Test.

Introduction One of the most valuable fields of research concerning the effects
of aging on seniors’ quality of life and autonomy is the study of the
According to the Synthesis of Social Indicators of IBGE , the Brazilian1
neuropsychological aspects of cognition9, especially, language and
population aged 60 or older is approximately 19 million [people]. other functions involved in the communication process10. Language
The notable increase in life expectancy at birth, owing to significant is the basis of the social and cultural evolution of mankind. It is
improvements in the structure of the health system and the advan- primarily responsible for the abilities to transfer knowledge and to
cement of health sciences, has led to the growth of the proportion communicate11-13. Some authors consider it as the cognitive function
of seniors in the population2-4. that is most closely linked to the whole complexity of thought, the
Guerreiro and Caldas reported that aging predisposes various basic processes of organization and categorization of stimuli, and
conditions of illness, with direct impact on functional capacity5. The even creativity14-16.
number of medical diagnoses and medications used tend to increase Language assessment difficulties in elderly patients are likely
sharply after 60 years of age6-8. due to the fact that the nature of language itself directly affects other

Institutional type of work: Departamento de Psicologia da FAFICH/UFMG.

Address correspondence to: Leandro Fernandes Malloy-Diniz. Universidade Federal de Minas Gerais (UFMG). Faculdade de Filosofia e Ciências Humanas. Departamento de Psicologia.
Av. Antônio Carlos, 6627, São Luiz – 31270-901 – Belo Horizonte, MG, Brasil. E-mail: [email protected]
98 Moreira L, et al. / Rev Psiq Clín. 2011;38(3):97-101

cognitive functions such as attention and memory. The maintenance Method

of linguistic and communicative abilities in the elderly is correlated
with the preservation of cognitive functions17-19. In advanced stages Sample
of cognitive impairment, patients may have a mean reduction in
The sample was comprised of 120 elderly subjects, selected from
specific aspects of communication, such as initiative, spontaneity the authors’ social network. The mean age was 71.1 years and
and speech recognition, even though they may still have some ability average education was 6.9 years. The group included 76 women,
to communicate and to adapt to their environment20. Other studies which represented 63.3% of the total. The sample description is
have reported that aspects such as attention and working memory shown in table 1.
(phonological loop) would be particularly affected in patients with The Exclusion Criteria employed in this study were: presence
language impairments, especially oral comprehension, defined as of pathological cognitive decline assessed by the Mini-Mental State
the ability to process and manipulate information received through Examination (MMSE)30, complaints of depression, neurological or
speech20-23. psychiatric diagnoses (prior or current), sensorial impairment related
As speech recognition is one of the key features of communica- to anamnesis. No subjects were receiving psychopharmacological
tion, its evaluation allows the examiner to identify more specific cog- therapy.
nitive deficits, facilitating the development of intervention strategies,
making them more effective and also contributing to the differential
diagnosis in cases of pathological cognitive decline24. Instruments
De Renzi e Vignolo25 stated that a oral comprehension test should
The sample was subjected to the MMSE30 and to the Token Test short
have the following characteristics: a) it should have a fast application;
version29. The MMSE, associated with anamnesis, score was one of
b) it should not require any complex material; c) the tasks should be
the factors used as exclusion criteria to select the sample. Different
short in order to avoid defects of memory, and so that any normal cut-off scores were used based on education: 13 for illiterate, 18 for
adult, regardless of age, would have no difficulty completing them; elementary and high school and 26 for post-secondary education.
d) it should not include intellectual difficulties, whereby, until some MMSE was also used for cognitive screening in the sample. This
acceptable limit, any person would be able to answer the questions, neuropsychological test is widely used as it can be adapted to many
independent of their intelligence quotient; and e) difficulties encoun- different cultures, it provides good psychometrics characteristics
tered in the test should occur mainly due to linguistic challenges, but and it is sensitive to Alzheimer diagnosis31. In the current study, the
progressively ordered with a lexicon of everyday life. MMSE provides an overview of cognitive functions, establishing a
The Token Test is among the instruments most commonly baseline for the language examination done by the Token Test short
used in the clinical neuropsychological assessment of language version.
comprehension. This instrument has been highly accepted in clini- The Token Test was first developed by De Renzi and Vignolo25 in
cal practice over the last decades, as evidenced by the emergence order to evaluate mild disorders of language comprehension. The first
of multiple versions and various studies. This acceptance is prob- version of the test had 62 commands. Since then, it has undergone
ably linked to its simplicity, objectivity, fast application and high various changes, resulting in several versions. The short version
sensitivity10,26-28. used in this study29 contains 36 commands (scored 1 if correct and
When the Token Test was originally designed, its developers 0 if incorrect) and it is simpler and faster to apply when compared
identified the issues that could affect its level of sensitivity25,29: (1) with the original version, which explains its inclusion in any neu-
artificiality of the testing environment , it being impossible to recon- ropsychological assessment protocol32.
struct the command by the examiner in the context; (2) influence The Token Test short version is divided into six parts (Figure
of disturbances in concentration, motivation, and either auditory or 1): part 1 consists of seven items, parts 2, 3, 4 and 5 have four
visual-motor fatigue; (3) lack of redundancy of the transmitted mes- items each and part 6 has 13 items. In parts 1, 3 and 5, all ite-
sage, requiring the subject to decode each element from command ms are used, in parts 2, 4 and 6, only the big pieces (the small
to fulfill it properly; (4) specific language difficulties of late acquisi- pieces are covered).
tion, like the identification of geometric shapes, with ambiguous The items within a section have the same level of complexity.
distinction between adjective and noun; (5) abstract nature of the The score is calculated by assigning 1 point for each item answered
tokens, detached from the context of the subject; (6) aspects of verbal completely correct, ranging from 0 to 36 points. The cut-off score was
memory, especially short-term memory; (7) cognitive aspects such 29 in the original study, representing less than 5% of the population.
as the ability of the subject to analyze the command as a whole; and The pieces are arranged in a specific order and the subject must
(8) difficulties inherent to completing tests which require choices answer exactly as the item requests33.
between sequences and the similars.
In a previous study, we published normative data for the Token
Test’s short form for Brazilian children between 7 and 10 years of Procedure
age28. According to PubMed and other databases (Lilacs and SCI- The tests were conducted in the subjects’ homes, in the absence of
ELO), a search for the term “Token Test” revealed that the latest auditory and/or visual distraction. The MMSE was conducted first,
Brazilian normative data for this test for elderly people were provided followed by the Token Test.
by Fontanari26. Considering the significant changes in the Brazilian
senior population over the last 20 years, the need for new normative
studies is essential. Statistical analysis
The statistical methods used in large-scale studies of standardi-
Objective zation of neuropsychological instruments were followed34-36. The
procedures were:
The purpose of this study is to provide contemporary normative 1. Overlapping cell strategy37 was adopted to maximize the sample
data for the use of the Token Test with a healthy senior population. size for each age group. Thus, the standards for each age group (mean
age plus or minus 2 years) were built on a broader age group (mean
Ethical committee age plus or minus 5 years).
2. In order to verify age and education influences on the overall
All participants signed the terms of consent. This study was approved results of the Token Test, a bivariate correlation was conducted
by the Ethics Committee of Hospital Felício Rocho under the protocol between the Token Test raw scores and measures of schooling. The
CAAE – 006.0.240.000-07. point-biserial correlation was used to verify the effect of gender on
 Moreira L, et al. / Rev Psiq Clín. 2011;38(3):97-101 99

The standardized scores by age (SSA) are shown in table 2, which

also includes the percentile scores, T scores and raw scores for each
age group. To use the table just find the corresponding age group in
the columns and the score got by the subject, then the line obtained
will correspond to the classification of this subject compared to the
rest of the sample (SSA).
To construct the table with scores adjusted by schooling (Table 3),
the regression coefficient β = 0.194 was used. To use the table,
find the row that corresponds to the SSA obtained in Table 2,
and then find the column for the subject’s years of schooling.
The cell that is the intersection between the row and column
corresponds to the obtained standard score corrected for age
and education (SSAE).
However, despite the greater influence of education, the norma-
tive table was first adjusted by age, and in continuity to another lined
up by schooling. This decision was made in order to facilitate the
comparison of these results with those of other studies34-36.

Table 1. Sociodemographic and cognitive characterization of the subjects

N % Mean SD Minimum Maximum
Sex
Female 76 63.3%
Male 44 36.7%
Age (years) 71.14 7.32 60 89
Education (years) 6.89 3.89 4 18
MMSE 26.63 2.60 19 30
Token Test 28.92 3.94 15 35

Figure 1. Token Test commands.

Table 2. Standardized Scores by Age (SSA)
SSA Age (years)
 p% T-score
  63-67 68-72 73-77 78-82 83+
the Token Test score. Correlation coefficients (r), determination (r^2) 2 <1 ≤ 14 ≤ 14 ≤ 18 ≤ 18 ≤ 15 < 25
and significance (p) were then determined.
3 1 15 15 19 - - 25-28
3. In order to create an age-adjusted table for each age group,
the raw scores were transformed into a cumulative distribution 4 2 19 19 - 19 - 28-31
frequency. Therefore, these values were transformed into standard 5 3–5 23 23 23 22 16 32-35
scores (z). These scores were then weighted using two different meas- 6 6–10 24 - 24 23 22 35-38
ures: the first was a Standardized Score by Age (SSA) with a mean 7 11–18 25-26 24-25 25 24 23 39-42
of 10 and standard deviation of 3. The second (additionally), was a
8 19–28 27 26-28 26 25-26 24 42-45
T-scores column inserted as a base reference (mean 50 and SD 10)
4. In order to generate the correction values for education, the 9 29–40 29 29 27-28 27 26 45-48
following equation was used: SSA = k + (β * Educ). The coefficient β 10 41–59 30 30 29-30 28-29 28 49-51
was the basis for adjusting for education. The weighted Standardized 11 60–71 31 31 31 30 29-30 52-55
Score by Age and Education (SSAE) was obtained using the equa- 12 72–81 32-33 32 32 31 31 55-58
tion31,36: SSAE = SSA - (β * [Educ-12]). The values were truncated to 13 82–89 - 33 - - - 58-61
the lowest one in order to obtain an integer.
14 90–94 34 34 33 32 - 62-65
15 95–97 35 - - - 32 65-68
Results
16 98 - 35 34 33 - 69-72
Table 1 shows the sociodemographic characterization of participants 17 99 - - - - - 72-75
and their performance (mean and standard-deviation) in Token 18 > 99 36 36 35 34 33 > 75
Test and MMSE.
The correlations (r), shared variance (r^2) and significance Normative 60-70 65-75 70-80 75-85 80+
age (80-89)
between the Token Test score and the variables: age, gender and
education were: 0.23/0.05 (p < 0.01), 0.13/0.02 (p < 0.15) e 0.46/0.21 MMSE > 27.24 26.7 26.37 25.85 25.18
(p < 0.001), respectively Test scores showed significant correlations Mean (SD (2.41) (2.73) (2.9) (2.33) (1.84)
between education and age, which accounted for 5% and 21% of Sample size 55 52 48 40 17  
shared variance, respectively.
100 Moreira L, et al. / Rev Psiq Clín. 2011;38(3):97-101

Table 3. Standardized Scores by Age and Education (SSAE)

  Education (years)
  0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
2 4 4 3 3 3 3 3 2 2 2 2 2 2 1 1 1 1 1 0 0 0
3 5 5 4 4 4 4 4 3 3 3 3 3 3 2 2 2 2 2 1 1 1
4 6 6 5 5 5 5 5 4 4 4 4 4 4 3 3 3 3 3 2 2 2
5 7 7 6 6 6 6 6 5 5 5 5 5 5 4 4 4 4 4 3 3 3
6 8 8 7 7 7 7 7 6 6 6 6 6 6 5 5 5 5 5 4 4 4
7 9 9 8 8 8 8 8 7 7 7 7 7 7 6 6 6 6 6 5 5 5
8 10 10 9 9 9 9 9 8 8 8 8 8 8 7 7 7 7 7 6 6 6
S 9 11 11 10 10 10 10 10 9 9 9 9 9 9 8 8 8 8 8 7 7 7
S 10 12 12 11 11 11 11 11 10 10 10 10 10 10 9 9 9 9 9 8 8 8
A 11 13 13 12 12 12 12 12 11 11 11 11 11 11 10 10 10 10 10 9 9 9
12 14 14 13 13 13 13 13 12 12 12 12 12 12 11 11 11 11 11 10 10 10
13 15 15 14 14 14 14 14 13 13 13 13 13 13 12 12 12 12 12 11 11 11
14 16 16 15 15 15 15 15 14 14 14 14 14 14 13 13 13 13 13 12 12 12
15 17 17 16 16 16 16 16 15 15 15 15 15 15 14 14 14 14 14 13 13 13
16 18 18 17 17 17 17 17 16 16 16 16 16 16 15 15 15 15 15 14 14 14
17 19 19 18 18 18 18 18 17 17 17 17 17 17 16 16 16 16 16 15 15 15
18 20 20 19 19 19 19 19 18 18 18 18 18 18 17 17 17 17 17 16 16 16

Discussion sentative. This aspect contributes significantly to the field of clinical

neuropsychology in Brazil for several reasons including: providing
We calculated for normative samples, T-score, percentile and SSA, the possibility of beginning to address the lack of standardized neu-
which seek to facilitate the conversion and interpretation of the test ropsychological tests in our context; the expansion of Token Test
to several other instruments that, in general, tend to use at least one versions to provide standards for the elderly; and the application of
of these three scales. the results of the current study to future studies due to the use of a
With a weighted score of 10, the difference between age groups non-clinical population.
varied by two points. This result was also obtained in other studies34-36, Future studies comparing Token Test performance between
suggesting that, on average, oral comprehension among healthy sen- healthy seniors and those with dementia may reveal how the role
iors does not decrease dramatically with the aging process. of cognitive impairment in the neurodegenerative process. Specific
The largest association of education than age with performance profiles for each type of dementia can be developed using the stan-
on the Token test suggests that, although decline in oral comprehen- dards identified in this study as a reference.
sion is related to the process of normal individual development, for-
mal schooling plays a more significant role. This finding corroborates
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