Applied Neuropsychology: Adult

ISSN: 2327-9095 (Print) 2327-9109 (Online) Journal homepage: http://www.tandfonline.com/loi/hapn21

Validation of the PASAT in Argentina

Sandra Vanotti, Maria Barbara Eizaguirre, Evangelina Valeria Cores, Cecilia

Yastremis, Orlando Garcea, Pablo Salgado & Fernando Cceres

To cite this article: Sandra Vanotti, Maria Barbara Eizaguirre, Evangelina Valeria Cores, Cecilia
Yastremis, Orlando Garcea, Pablo Salgado & Fernando Cceres (2016): Validation of the PASAT
in Argentina, Applied Neuropsychology: Adult, DOI: 10.1080/23279095.2015.1092150

To link to this article: http://dx.doi.org/10.1080/23279095.2015.1092150

Published online: 15 Mar 2016.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=hapn21

Download by: [Sandra Vanotti] Date: 22 March 2016, At: 15:13

 APPLIED NEUROPSYCHOLOGY: ADULT
http://dx.doi.org/10.1080/23279095.2015.1092150

Validation of the PASAT in Argentina

Sandra Vanottia,b, Maria Barbara Eizaguirrea,b, Evangelina Valeria Coresb, Cecilia Yastremisb, Orlando Garceab,
Pablo Salgadoc, and Fernando Cceresa
a
Multiple Sclerosis Clinic, Institute of Neurosciences of Buenos Aires, Buenos Aires, Argentina; bMS Clinic, Ramos Mejia Hospital, Buenos Aires,
Argentina; cPopulation Health Research Center, Durand Hospital, Buenos Aires, Argentina

ABSTRACT KEYWORDS
The Paced Auditory Serial Addition Test (PASAT) is one of the most used neuropsychological tests Normative data;
to assess information processing speed and working memory in brain injured patients. This study neuropsychological test;
was carried out with the purpose of obtaining normative data for the PASAT-3 in a healthy PASAT-300 ; processing speed;
working memory
Argentinean population, which would result in a reference control population. The PASAT-3 was
administered in a sample of 296 healthy voluntary subjects, born and living in Argentina. The age
range went from 20 to 70 years-old. The level of education was 0 to 13 or more years of schooling.
The sample obtained a mean of 44.60 (SD 10.72) in the PASAT-3. It was found that the score
obtained in the PASAT-3 was related to the age and the level of instruction of the participants.
Downloaded by [Sandra Vanotti] at 15:13 22 March 2016

Their performance diminished as age increased and, conversely, it increased as the level of
instruction was higher. Normative data was obtained for a Latin American population from
Argentina. Percentile distributions obtained by decades of age and different levels of education
should be considered as useful reference values for clinicians and investigators when applying the
PASAT-3 to assess cognitive function in different pathologies.

The Paced Auditory Serial Addition Test (PASAT) is one
of the neuropsychological tests most widely used for
assessing information-processing speed and working
memory at an auditory/verbal level (Spreen & Strauss,
1998). Initially, the PASAT was designed to evaluate
the decline in information-processing speed in patients
with traumatic brain injury (TBI; Gronwall, 1977;
Sampson, 1956), but then clinicians began to implement
it in patients with other pathologies, such as systemic
lupus erythematosus (Shucard et al., 2004). Clinicians
also started to administer the PASAT to college
football players 24 hr after suffering a mild concussion
(Macciocchi, Barth, Alves, Rimel, & Jane, 1996).
Tombaugh (2006) conducted an extensive study on the
scope of administering the PASAT to patients with
TBI and concluded that the test is highly sensitive for
patients with severe TBI. The PASAT is also considered
to be one of the most sensitive tools for evaluating
cognitive dysfunction in multiple sclerosis (MS; Forn,
Belenguer, Parcet-Ibars, & vila, 2008).
There have been several adaptations of the test. One is
the PASAT-2the version used by Levin, Benton, and
Grossman (1982)which was developed to reduce
patient fatigue and practice effects after trials. Another
adaptation is the PASAT-3a version developed by
Rao (1990)which is recommended for inclusion in a
clinical assessment measure of MS such as the
Multiple Sclerosis Functional Composite (Rudick et al.,
1997).
In the neuropsychological clinical practice, to classify
the performance of a patient with cerebral damage as
normal or pathological, it is necessary to count on
reliable normative data. Also, normative studies should
take into account several variables that may affect test
performance. However, it is not adequate to use popu-
lation-based normative data from other countries, as
specific cultural variables influence test performance
(Ardila, 2005). These variables affect not only verbal
tasks, but also nonverbal tests (Rosselli & Ardila,
2003). It has been recognized that the subjective values
affected by culturesuch as processing speedplay an
important part in performance during the assessment
of cognitive function (Ardila, 2005). Because in
Argentina there is a lack of updated normative data
for the PASAT, the aim of the present study was to
obtain normative data for the PASAT-3 in a healthy
population in Argentina and to analyze the impact of
variables such as age and level of instruction. The second
aim was to compare the performance of healthy parti-
cipants in the first half and the second half of the test.

CONTACT Sandra Vanotti svanotti@ineba.net Clinic of Multiple Sclerosis, INEBA Neurosciences Institute of Buenos Aires, Guardia
Vieja 4435, Buenos Aires, C1192AAW, Argentina.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/hapn.
2016 Taylor & Francis
 2 S. VANOTTI ET AL.

Method and materials
A sample of 296 healthy participants was analyzed: 105
men and 191 women aged 20 to 70 years old. Parti-
cipants mean age was 43.95 years (SD 16.31), and
the mean instruction level was 11.69 years (SD 4.42).
Participation was voluntary; all participants resided in
Buenos Aires, Argentina, and spoke Spanish. The
inclusion criteria stated that the participants should
possess a Mini Mental State Examination score greater
than 26 points (Folstein, Folstein, & McHugh, 1975),
whereas the exclusion criteria included substance abuse,
systemic pathologies that could cause cognitive degener-
ation, or a history of mental disorder. Variables such as
age and level of instruction were taken into consider-
ation. The former was divided into five groups, each
one representing one decade: 20 to 30 years old, 31 to
40 years old, 41 to 50 years old, 51 to 60 years old, and
61 to 70 years old. The latter was classified into three
Downloaded by [Sandra Vanotti] at 15:13 22 March 2016
was employed for paired samples. For all analyses, the
established alpha level was .05.
Results
The sample obtained a mean score of 44.60 (SD 10.72)
on the PASAT-3. Means and standard deviations for
each group of age and level of instruction are shown
in Table 1.
As shown in Figure 1, the probability density
distribution of the data observed in the PASAT-3,
smoothed due to adjustments in the Kernell function,
does not obey any usual parametric function, but rather
appears to be right-censored. In fact, the construct to be
measured is, theoretically, a non-negative number that
the tool produces by counting values with a maximum
observed value (60) as reference, a limit beyond which
the construct appears to be censored.

groups: participants who had 7 years of instruction or First, the simultaneous relationship between age and
less, those who had 8 to 12 years of instruction, and level of instruction (in years) and the PASAT-3 score
lastly, those with more than 12 years of instruction. was analyzed for exploratory purposes. A structured
Ten professionals specially trained in psychometric additive regression model was used to assess the
testing implemented the PASAT-3 in standard, independent effect of each variable and the way these
homogeneous conditions. The study was approved by variables interacted with one another.
the local Ethics Committee and all the participants Figures 2 and 3 show the results of the structured
signed an informed consent. additive regression model, where the relationship
Raos (1990) version was used in the administration between level of instruction (in years) and age can be
of the test. The required materials were an audio player observed as S(level of instruction) and S(age), respect-
and a recording with PASAT-3 stimuli. The test result ively, where S(level of instruction) centered additive
was the number of correct sums obtained by the partici-
pant (out of 60 possible); the total score of answers was Table 1. Paced Auditory Serial Addition Test score by level of
taken as the main outcome measure. The total correct education and age (in decades), number of participants, means,
responses for the first half and the second half of the test and standard deviations.
were calculated (Rao, 1990). 95% Confidence interval
Age Educational Lower Upper
For assessing the data obtained, Version 19.0 of the group level N M SD band band
Statistical Package for the Social Sciences (IBM SPSS) 2030 07 15 44.000 8.90 39.339 48.661
was used, in addition to the Segmented and Tolerance 812 18 46.722 9.27 42.467 50.977
>13 41 50.439 6.90 47.620 53.258
packages in the R.3.0.15 programming environment. Total 74 48.23 8.26 46.32 50.14
The relationship between age, instruction level, and 3140 07 17 42.294 9.47 37.916 46.672
PASAT score was explored with a structured additive 812 18 50.111 5.96 45.856 54.366
>13 27 50.519 8.85 47.044 53.993
regression model with the aim of evaluating the separate Total 62 48.15 8.94 45.87 50.42
effects of the variables and the interaction between them, 4150 07 15 36.867 11.56 32.206 41.528
812 17 51.000 8.56 46.622 55.378
without imposing any restriction on the relationship. >13 20 49.600 11.66 45.563 53.637
Afterward, the effect of the level of instruction was Total 52 46.38 12.17 43.00 49.77
5160 07 14 39.429 11.33 34.604 44.253
analyzed with a multiple regression model. To analyze 812 15 40.600 10.80 35.939 45.261
whether there were differences among the sample based >13 16 47.125 7.01 42.612 51.638
Total 45 42.56 10.19 39.49 45.62
on sex, a students t test was carried out for independent 6170 07 27 34.148 7.46 30.674 37.622
samples. A univariate analysis of variance (ANOVA) was 812 19 36.211 8.66 32.069 40.352
used to analyze the influence of sex, age, and level of >13 17 41.824 12.80 37.445 46.202
Total 63 36.84 9.87 34.35 39.33
instruction variables and how they interacted with one Total 07 88 38.70 10.05 36.58 40.83
another in the PASAT. Lastly, to compare the first 812 87 44.91 10.30 42.71 47.10
>13 121 48.67 9.55 46.95 50.39
half and the second half of the test, a students t Total 296 44.60 10.72 43.37 45.83

Figure 1. Distribution density of Paced Auditory Serial
Addition Test (PASAT-3) scores in healthy participants.
Downloaded by [Sandra Vanotti] at 15:13 22 March 2016
Figure 2. Relationship between age and the Paced Auditory
Serial Addition Test (PASAT-3) scores.
effects of level of instruction, and S(age) centered
additive effect of years.
Thus, based on the observations made in the explora-
tory trial, the relationship between the PASAT-3 and
age and level of instruction (in years) was assessed
through a multiple regression model. It was found that
these variables accounted for 26% of the variance on
the PASAT, F(2, 293) 55.4, p .000, and that the
age (b .343, p .000) and level of instruction
(b .322, p .000) of the participants significantly
affected the total score. The differences based on sex
were analyzed in the total scores of the PASAT-3. It
was found that men (M 46.36, SD 9.73) and women
Figure 3. Relationship between level of instruction and the
Paced Auditory Serial Addition Test (PASAT-3) scores.
APPLIED NEUROPSYCHOLOGY: ADULT 3
Figure 4. Effects of the interaction between the variables of
sex and age on the Paced Auditory Serial Addition Test.
(M 43.63, SD 11.13) presented significant differ-
ences, t(294) 2.10, p .036.
Finally, a univariate ANOVA was carried out to
analyze the influence of sex, age, and level-of-
instruction variables and how they interacted with one
another in the PASAT. The results obtained highlight
that there was an important adjustment of the model,
F(29, 296) 5.77, p .000, 2 .38, and that sex, F(1,
296) 7.43, p .007, 2 .27, age, F(4, 296) 15.98,
p .000, 2 .19, and level of instruction, F(2,
296) 14.79, p .000, 2 .10, had significant effects
on the test; the same can be stated for the interaction
between the variables of sex and age, F(4, 296) 3.14,
p .01, 2 .04, as shown in Figure 4. On the contrary,
the interaction between the variables of sex and level of
instruction did not produce significant effects, F(2,
Figure 5. Error bar diagram showing Paced Auditory Serial
Addition Test (PASAT-3) performance during the first half and
second half of the test by age. Note. CI confidence interval.
 4 S. VANOTTI ET AL.
Figure 6. Error bar diagram showing Paced Auditory Serial
Addition Test (PASAT-3) performance during the first half
and second half of the test by years of schooling. Note. CI
confidence interval.
Downloaded by [Sandra Vanotti] at 15:13 22 March 2016
296) 1.57, p .20, 2 .01, nor did the interaction
between age and level of instruction, F(8, 296) 1.12, p
.34, 2 .03.
Regarding the second aim of this study, a significant
statistical difference, t(295) 6.73, p > .001, was found
in PASAT-3 performance between the correct answers
in the first half (M 23.07, SD 5.53) and the correct
answers in the second half (M 21.57, SD 5.8) of
the test, with the latter being fewer than the former.
Such difference in performance occur independent of
the number of years of instruction or the age of the
participant, as shown in Figures 5 and 6.
Discussion
The PASAT-3 is a useful test for assessing cognitive
decline and, specifically, working-memory alterations
and a slow processing speed. With this research, it was
possible to obtain normative data of a representative
sample of participants from Argentina. In addition, the
study was able to demonstrate and characterize the
relationship between performance on the PASAT-3
and demographic variables (namely, age and level of
instruction). The samples mean score was 44.60
(SD 10.72); this result matches other published data.
Normative data for the PASAT-3 have been pre-
viously published, though based on smaller samples
(Amato et al., 2006; Boringa et al., 2001). Boringa et al.
(2001) presented a sample of 140 healthy controls and
obtained a mean of 48.7 (SD 10.7), whereas Amato
et al. (2006) obtained a mean of 44.9 (SD 12.1) in a
sample of 200 participants.
It was found that the score obtained on the PASAT-3
was related to participants age and level of instruction.
Their performance diminished as age increased, and
conversely, it increased as the level of instruction
increased.
These results are in accordance with the results of
Diehr, Heaton, Miller, and Grant (1998), who found a
relation between the PASAT, level of instruction, and
age. On the contrary, the results of the present study
differ from those of Brittain, La Marche, Reeder, Roth,
and Boll (1991) and Wiens, Fuller, and Crossen (1997),
who found that only age and IQ affected performance,
not the level of instruction of the participants (however,
they do not take into consideration a level of instruction
of less than 12 years). Other authors (Amato et al., 2006;
Boringa et al., 2001) did not report any influence of age
on test performance but found significant differences
based on the participants level of instruction.
The effects of the variables of age, sex, and level of
instruction on the PASAT were analyzed, in addition
to the way they interacted with one another. It was found
that each variable had important effects on the test and
that the interaction of the variables of sex and age also
affected participants performance. Regarding the influ-
ence of the sex variable on PASAT performance, the
findings are contradictory: Brittain et al. (1991) reported
that sex affected performance, as opposed to Boringa et
al. (2001) and Amato et al. (2006).
One of the strengths of this study is that it was able to
obtain a normative sample with an adequate degree of
representation of different levels of instruction and ages.
Regarding the second aim of this study, it was found
that a significant decline in performance occurs between
the first half and the second half of the test, which could
be evidence of fatigue. Other authors (Rosti, Hamalainen,
Koivisto, & Hokkanen, 2006; Schwid et al., 2003) have
found a significant decline in performance along the test
in patients with MS but not in healthy controls. Kos,
Kerckhofs, Nagels, and Geentjes (2004) found some
evidence of cognitive fatigue in healthy controls, but it
was less marked than in patients with MS.
It is worth emphasizing that this report of normative
data is the first for the PASAT-3 in Argentina and in
Spanish. It could prove very helpful to clinicians, who
would be able to use an appropriate neuropsychological
tool based on the demographic characteristics of their
patients. It may be necessary to study a larger group
of participants to improve the representation of the
sample.
Finally, there are performance analyses in this test that
could be sources for future research. Given that there is
an important percentage of patients who do not follow
instructions correctly, different authors have carried out
other types of analyses such as grouping responses called
chunkings (Coo, Hopman, Edgar, McBride, & Brunet,

2005; Cores, Vanotti, Osorio, Politis, & Garcea, 2011;
Fisk & Archibald, 2001), which could be more sensitive
than the original scores (Fisk & Archibald, 2001). The
development of regulations for implementing these find-
ings in the clinic is still pending.
Acknowledgements
We would like to thank Manuel Lago and Oscar Ianovsky, the
Methodology Research and Biostatistics Department,
Committee for Teaching and Research from J. M. Ramos
Meja Hospital, for supervising the statistical analysis.
References
Amato, M. P., Portaccio, E., Goretti, B., Zipoli, V., Ricchiuti,
L., De Caro, . . . Trojano, M. (2006). The Raos Brief Repeat-
able Battery and Stroop test: Normative values with age,
education and gender corrections in an Italian population.
Downloaded by [Sandra Vanotti] at 15:13 22 March 2016
Multiple Sclerosis Journal, 12, 787793. doi:10.1177/135245
8506070933
Ardila, A. (2005). Cultural values underlying psychometric
cognitive testing. Neuropsychology Review, 15, 185195.
doi:10.1007/s11065-005-9180-y
Boringa, J. B., Lazeron, R. H. C., Reuling, I. E. W., Adr, H. J.,
Pfennings, L., Lindeboom, J., . . . Polman, C. H. (2001). The
Brief Repeatable Battery of Neuropsychological Tests:
Normative values allow application in multiple sclerosis
clinical practice. Multiple Sclerosis Journal, 7, 263267.
doi:10.1191/135245801680209385
Brittain, J. L., La Marche, J. A., Reeder, K. P., Roth, D. L., & Boll,
T. J. (1991). Effects of age and IQ on Paced Auditory Serial
Addition Task (PASAT) performance. The Clinical Neuropsy-
chologist, 5, 163175. doi:10.1080/13854049108403300
Coo, H., Hopman, W. M., Edgar, C. M., McBride, E. V., &
Brunet, D. G. (2005). The Paced Auditory Serial Addition
Test: To what extent is it performed as instructed, and is
it associated with disease course? Multiple Sclerosis Journal,
11, 8589. doi:10.1191/1352458505ms1124oa
Cores, E. V., Vanotti, S., Osorio, M., Politis, G. D., & Garcea,
O. (2011). Estrategias de resolucin del PASAT en pacientes
con Esclerosis Mltiple y viabilidad de una versin corta del
test [Resolution strategies of the PASAT in Multiple Scler-
osis patients and viability of a short version of the test].
Revista Chilena de Neuropsicologa, 6, 8185.
Diehr, M. C., Heaton, R. K., Miller, W., & Grant, I. (1998).
The Paced Auditory Serial Addition Task (PASAT): Norms
for age, instruction, and ethnicity. Assessment, 5, 375387.
doi:10.1177/107319119800500407
Fisk, J. D., & Archibald, C. J. (2001). Limitations of the Paced
Auditory Serial Addition Test as measure of working
memory in patients with multiple sclerosis. Journal of the
International Neuropsychological Society, 7, 363372.
doi:10.1017/s1355617701733103
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-
mental state: A practical method for grading the cognitive
state of patients for the clinician. Journal of Psychiatric
Research, 12, 189198.
Forn, C., Belenguer, A., Parcet-Ibars, M. A., & vila, C. (2008).
Information-processing speed is the primary deficit
APPLIED NEUROPSYCHOLOGY: ADULT 5
underlying the poor performance of multiple sclerosis
patients in the Paced Auditory Serial Addition Test
(PASAT). Journal of Clinical and Experimental Neuropsy-
chology, 30, 789796. doi:10.1080/13803390701779560
Gronwall, D. (1977). Paced Auditory Serial-Addition Task: A
measure of recovery from concussion. Perceptual and
Motor Skills, 44, 367373. doi:10.2466/pms.1977.44.2.367
Kos, D., Kerckhofs, E., Nagels, G., & Geentjes, L. (2004).
Cognitive fatigue in multiple sclerosis (Letter). Multiple
Sclerosis Journal, 10, 337.
Levin, H. S., Benton, A. L., & Grossman, R. G. (1982). Neuro-
behavioral consequences of closed head injury. New York,
NY: Oxford University Press.
Macciocchi, S. N., Barth, J. T., Alves, W., Rimel, R. W., & Jane,
J. A. (1996). Neuropsychological functioning and recovery
after mild head injury in collegiate athletes. Neurosurgery,
39, 510514. doi:10.1097/00006123-199609000-00014
Rao, S. M. (1990). Cognitive Function Study Group, NMSS. A
manual battery for the Brief Repeatable Battery of Neurop-
sychological Tests in MS. New York, NY: National Multiple
Sclerosis Society.
Rosselli, M., & Ardila, A. (2003). The impact of culture and
instruction on non-verbal neuropsychological measure-
ments: A critical review. Brain and Cognition, 52, 326333.
doi:10.1016/S0278-2626(03)00170-2
Rosti, E., Hamalainen, P., Koivisto, K., & Hokkanen, L.
(2006). The PASAT performance among patients with
multiple sclerosis: Analyses of responding patterns using
different scoring methods. Multiple Sclerosis Journal, 12,
586593. doi:10.1177/1352458506070624
Rudick, R., Antel, J., Confavreux, C., Cutter, G., Ellison, G.,
Fischer, J., & Rao, S. (1997). Recommendations from the
National Multiple Sclerosis Society Clinical Outcomes
Assessment Task Force. Annals of Neurology, 42, 379382.
doi:10.1002/ana.410420318
Sampson, H. (1956). Pacing and performance on a serial
addition task. Canadian Journal of Psychology/Revue
canadienne de psychologie, 10, 219225. doi:10.1037/
h0083679
Shucard, J. L., Parrish, J., Shucard, D. W., McCabe, D. C.,
Benedict, R. H. B., & Ambrus, J. (2004). Working memory
and processing speed deficits in systemic lupus erythemato-
sus as measured by the Paced Auditory Serial Addition Test.
Journal of the International Neuropsychological Society, 10,
3545. doi:10.1017/S1355617704101057
Schwid, S. R., Tyler, C. M., Scheid, E. A., Weinstein, A.,
Goodman, A. D., & Mc Dermott, M. P. (2003). Cognitive
fatigue during a test requiring sustained attention: A pilot
study. Multiple Sclerosis Journal, 9, 503508. doi:10.1191/
1352458503ms946oa
Spreen, O., & Strauss, E. (1998). A compendium of
neuropsychological tests (2nd ed.). New York, NY: Oxford
University Press.
Tombaugh, T. N. (2006). A comprehensive review of the
Paced Auditory Serial Addition Test (PASAT). Archives
of Clinical Neuropsychology, 2, 153176. doi:10.1016/j.
acn.2005.07.006
Wiens, A. N., Fuller, K. H., & Crossen, J. R. (1997). Paced
Auditory Serial Addition Test: Adult norms and moderator
variables. Journal of Clinical and Experimental
Neuropsychology, 19, 473483. doi:10.1080/01688639708
403737