**3. Results and interpretation**

#### **3.1. Performance in the diagnostic groups**

Significant differences in BVRT total scores—mean total number of correct reproductions and mean total number of errors—were found when the normal subjects, and the subjects with CIND were compared (p < .001) (**Table 2**). (We use the term "normal" and "healthy" subjects to distinguish between normal and pathological aging, taking into account the conditionality of its use.) There were significantly more omissions and distortions (BVRT) in CIND group than in the normal group (p < .001). These differences can also be seen in the BVRT frequency distribution data—50% of the healthy participants had between three and six correct reproductions and made between seven and 12 errors; 50% of participants with CIND reproduced correctly between two and four cards and made between 10 and 14 errors. As for the different types of


**Table 2.** BVRT mean score comparison in the diagnostic groups (t-test).

errors that showed significant differences, 50% of normal subjects made zero to two omissions (one to five in CIND subjects) and, respectively, two to four distortions (2.50 to six in CIND).

No significant differences were found between the age groups with respect to house and cube drawing tasks, as well as to Block design subtest both for healthy and CIND participants

t = 8.462 P < .001

**(SD)**

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**Z score**

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177

Chi-square = 1.880

P < .001

In the healthy group with partial testing (N = 103), age correlated positively and significantly with BVRT total errors, as well as with omissions, distortion, and rotation scores

> 37.04 21.43

> 35.86 23.57

> 37.16 21.20

**Table 4.** Mean comparison for cube and house drawing and block design.

**Mean rank Mann-Whitney U Sig.**

218.5 P = .001

265.5 P = .009

213.5 P = .001

**(Two-tailed)**

(Mann-Whitney test, p >.05).

**Table 3.** RSPM results in the diagnostic groups.

**Healthy RSPM total correct Mean**

25 19.00 29.58 50 28.00 (11.69)

25 14.00 17.87 50 16.00 (7.08)

Minimum 12 −1.505 Maximum 53 2.003

Minimum 5 −1.716 Maximum 55 4.430

**Test variables Diagnostic group**

Percentiles

**CIND**

Percentiles

75 40.00

75 20.00

Healthy CIND

Healthy CIND

**Total house score**

**Total cube score** Healthy CIND

**Block design score**

**Table 3** shows RSPM performance of the participants from both diagnostic groups (percentiles, means, and z-scores). Healthy subjects gave more correct answers than subjects with CIND (p<.001).

Performance of the house and cube drawing, as well as of the Block design tasks, was also significantly worse in the CIND group (Mann-Whitney test**,** p < .01) (**Table 4**). **Figures 1** and **2** present cube and house drawings in the diagnostic groups.

#### **3.2. Performance in the age groups**

When the healthy and CIND study participants were subdivided in age groups, healthy elders up to 70 years of age (N = 70) showed more BVRT correct reproductions and RSPM correct answers (p<.001); they made significantly fewer errors (total errors), as well as fewer omissions and distortions, than the oldest subjects from the same diagnostic group. Younger subjects with CIND (N = 48) made significantly fewer number of errors, as well as fewer omissions (BVRT). They also showed significantly better result in RSPM performance than the subjects over 70 years of age (**Table 5**).

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**Table 3.** RSPM results in the diagnostic groups.

errors that showed significant differences, 50% of normal subjects made zero to two omissions (one to five in CIND subjects) and, respectively, two to four distortions (2.50 to six in CIND). **Table 3** shows RSPM performance of the participants from both diagnostic groups (percentiles, means, and z-scores). Healthy subjects gave more correct answers than subjects with

**Criteria Diagnostic group Mean score SD t p**

4.62 3.21

8.91 12.08

1.74 3.14

2.78 4.28

1.02 0.87

1.18 1.58

1.74 1.62

0.46 0.58 1.805 1.328

3.697 3.178

1.925 2.765

1.715 2.153

1.093 1.100

1.135 1.073

1.335 1.291

0.764 0.918 6.16 < .001


−3.95 < .001

−5.22 < .001

0.93 0.35

−2.41 0.17

0.59 0.55

−0.98 0.33

Performance of the house and cube drawing, as well as of the Block design tasks, was also significantly worse in the CIND group (Mann-Whitney test**,** p < .01) (**Table 4**). **Figures 1** and **2**

When the healthy and CIND study participants were subdivided in age groups, healthy elders up to 70 years of age (N = 70) showed more BVRT correct reproductions and RSPM correct answers (p<.001); they made significantly fewer errors (total errors), as well as fewer omissions and distortions, than the oldest subjects from the same diagnostic group. Younger subjects with CIND (N = 48) made significantly fewer number of errors, as well as fewer omissions (BVRT). They also showed significantly better result in RSPM performance than the

present cube and house drawings in the diagnostic groups.

**3.2. Performance in the age groups**

subjects over 70 years of age (**Table 5**).

CIND (p<.001).

**Total correct** Healthy

176 Gerontology

**Total errors** Healthy

**Omissions** Healthy

**Distortions** Healthy

**Perseverations** Healthy

**Rotations** Healthy

**Misplacements** Healthy

**Size errors** Healthy

Note: results from partial testing group.

CIND

CIND

CIND

CIND

CIND

CIND

CIND

CIND

**Table 2.** BVRT mean score comparison in the diagnostic groups (t-test).

No significant differences were found between the age groups with respect to house and cube drawing tasks, as well as to Block design subtest both for healthy and CIND participants (Mann-Whitney test, p >.05).

In the healthy group with partial testing (N = 103), age correlated positively and significantly with BVRT total errors, as well as with omissions, distortion, and rotation scores


**Table 4.** Mean comparison for cube and house drawing and block design.

**Figure 1.** Examples of cube drawings in the diagnostic groups.

**Figure 2.** Examples of house drawings in the diagnostic groups.

(r between .213 and .520, p < .05). As expected the relation between age and BVRT total correct score was negative (r = −.397, p < .001).

In the CIND group, age correlated positively and significantly only with BVRT omissions (r = .359, p = .001). The relation between age and size errors score did not reach acceptable significance (r = − .202, p = .064). Negative moderate significant correlation existed between MMSE (r CIND = −.257 and r healthy = −.385) and RSPM total score (r CIND = −.340 and r healthy = −.535) on the one hand and the age, on the other, in both diagnostic groups.

In the group with complete testing, age correlated only with RSPM score, both in the whole group (Pearson correlation), N = 62, and in the diagnostic groups (Spearman correlation) moderate significant negative correlation (p < .001 and p < .05, respectively).

> In the CIND group, results showed a different picture, probably affected by the heterogeneity of cognitive impairments, which is characteristic of this early stage of pathological decline [56, 68]. BVRT total correct and total errors correlate moderately between them (r = −.447, p = .037), and there is no significant correlation between them and RSPM. The cube total score correlates only with the Block design score (r = .470, p = .027). The house total score also correlates with Block design score and with Benton total errors(r = −.644, p = .001). Benton total

1.037 P=.303

Moderate significant correlation was found between BVRT omissions and the cube drawing score (r = −.378, p = .016) and between BVRT distortions and the Block design score (r = −.485, p = .002), as well as the RSPM score (r = −.480, p = .002), in healthy participants. In CIND group the scores for the different types of errors did not correlate with the outcome measures from other tests.

errors correlate with Block design score as well (r = −.607, p = .003).

**Healthy BVRT total correct**

**60-70 years N=70**

**>70 years N=33**

**CIND 60-70 years N=48**

**>70 years N=37**

**T-test** 1.515

P=.133

**T-test 3.378**

**P=.001**

**BVRT total errors**

**−3.686 P<.001**

**−2.178 P=.032** **BVRT O**

**−2.347 P=.023**

**−3.236 P=.002** **BVRT D**

Mean 5.01 8.04 1.40 2.34 1.04 1.06 1.74 0.46 32.97 SD 1.77 3.56 1.61 1.63 1.03 1.13 1.29 0.77 11.53

Mean 3.79 10.76 2.45 3.70 0.97 1.45 1.73 0.45 22.39 SD 1.60 3.37 2.33 1.53 1.24 1.12 1.44 0.75 8.37

Mean 3.40 11.44 2.33 4.21 0.98 1.54 1.67 0.69 20.04 SD 1.45 3.32 2.36 2.15 1.10 1.09 1.21 1.05 8.06

Mean 2.97 12.92 4.19 4.38 0.73 1.62 1.57 0.43 15.05 SD 1.12 2.81 2.92 2.18 1.10 1.06 1.40 0.69 4.21

> **−.**359 P=.720

Note: O. omissions; D. distortions; P. perseverations; R. rotations; M. misplacements; SE. size errors.

**Table 5.** Mean comparison for BVRT and RSPM results in the age groups for healthy subjects and CIND.

.315 P=.753

**−4.007 P<.001** **BVRT P**

**BVRT R**

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**−**1.672 P=.098

**−.**339 P=.736 .055 P=.956

.349 P=.728

**BVRT M**

**BVRT SE**

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.016 P=.987

1.275 P=.206 **5.273 P<.001**

**3.684 P<.001**

**RSPM total correct**

179

#### **3.3. Relationships between test measures**

#### *3.3.1. Correlation*

Most of the measures assessing the performance of the drawing tasks correlate moderately and significantly (Pearson correlation), except for cube total score and BVRT correct and error scores (**Table 6**). As expected Block design and RSPM measures are in a significant relation with all other variables (r between .326 and .591) as well as between them (p < .001). Further analyses (Spearman correlations) were accomplished for the same variables in each diagnostic group separately. In the group of healthy participants, the cube total score correlates only with the house total score (r = .345, p = .029). BVRT total correct and total errors correlate highly between them (r = −.886, p < .001) and moderately with RSPM (p < .001). There is a significant correlation between BVRT total errors and Block design score (r = −.318, p = .046).


**Figure 1.** Examples of cube drawings in the diagnostic groups.

**Figure 2.** Examples of house drawings in the diagnostic groups.

correct score was negative (r = −.397, p < .001).

**3.3. Relationships between test measures**

*3.3.1. Correlation*

178 Gerontology

p = .046).

(r between .213 and .520, p < .05). As expected the relation between age and BVRT total

In the CIND group, age correlated positively and significantly only with BVRT omissions (r = .359, p = .001). The relation between age and size errors score did not reach acceptable significance (r = − .202, p = .064). Negative moderate significant correlation existed between MMSE (r CIND = −.257 and r healthy = −.385) and RSPM total score (r CIND = −.340 and r

In the group with complete testing, age correlated only with RSPM score, both in the whole group (Pearson correlation), N = 62, and in the diagnostic groups (Spearman correlation)—

Most of the measures assessing the performance of the drawing tasks correlate moderately and significantly (Pearson correlation), except for cube total score and BVRT correct and error scores (**Table 6**). As expected Block design and RSPM measures are in a significant relation with all other variables (r between .326 and .591) as well as between them (p < .001). Further analyses (Spearman correlations) were accomplished for the same variables in each diagnostic group separately. In the group of healthy participants, the cube total score correlates only with the house total score (r = .345, p = .029). BVRT total correct and total errors correlate highly between them (r = −.886, p < .001) and moderately with RSPM (p < .001). There is a significant correlation between BVRT total errors and Block design score (r = −.318,

healthy = −.535) on the one hand and the age, on the other, in both diagnostic groups.

moderate significant negative correlation (p < .001 and p < .05, respectively).

Note: O. omissions; D. distortions; P. perseverations; R. rotations; M. misplacements; SE. size errors.

**Table 5.** Mean comparison for BVRT and RSPM results in the age groups for healthy subjects and CIND.

In the CIND group, results showed a different picture, probably affected by the heterogeneity of cognitive impairments, which is characteristic of this early stage of pathological decline [56, 68]. BVRT total correct and total errors correlate moderately between them (r = −.447, p = .037), and there is no significant correlation between them and RSPM. The cube total score correlates only with the Block design score (r = .470, p = .027). The house total score also correlates with Block design score and with Benton total errors(r = −.644, p = .001). Benton total errors correlate with Block design score as well (r = −.607, p = .003).

Moderate significant correlation was found between BVRT omissions and the cube drawing score (r = −.378, p = .016) and between BVRT distortions and the Block design score (r = −.485, p = .002), as well as the RSPM score (r = −.480, p = .002), in healthy participants. In CIND group the scores for the different types of errors did not correlate with the outcome measures from other tests.


low positive correlation for omissions—more errors, made by females). Dependent variables were the outcome measures that correlated with age in both diagnostic groups. As it could be seen from **Table 7**, age predicted significantly the variance in BVRT omissions, together with fluid intelligence for healthy participants and together with education and fluid intelligence for the participants with CIND. For the other BVRT outcome measures, age is no more significant performance predictor when other demographic variables and fluid intelligence are included in

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Fluid intelligence contributed to the variance in all the variables analyzed, except for BVRT rotation in the healthy group. Education was a significant predictor only for the total errors,

**Healthy** Total correct Age 11.848\*\*\* −.025 −.097 −.967 .264

**CIND** Omissions Age 9.353\*\*\* .075 .206 **2.001\*** .319

**Table 7.** Multiple regression analyses of demographic factors and fluid intelligence contributing to BVRT results.

Education −.337 −.330 −.**3.059\*\*** RSPM −.082 −.211 −.**2.077\*** Gender −.007 −.014 −.138

**Dependent Predictor F B Beta t R2**

Education .110 .163 1.738 RSPM .057 .372 **3.479\*\*** Total errors Age 24.401\*\*\* .087 .162 1.839 .425 Education −.250 −.180 −**2.170\*** RSPM −.146 −.463 −**4.896\*\*\***

Omissions Age 11.954\*\*\* .092 .329 **3.302\*\*** .266 Education .020 .028 .297 RSPM −.045 −.274 −**2.564\*** Distortions Age 10.529\*\*\* .025 .102 1.036 .301 Education −.109 −.170 −1.848 RSPM −.052 −.354 −**3.379\*\*** Gender −.790 −.218 −**2.556\*** Rotations Age 3.973\* .003 .020 .183 .107 Education −.080 −.189 −1.826 RSPM −.019 −.193 −1.640

made by healthy participants and for the number of omissions in CIND subjects.

the analyses.

**Diagnostic group**

Note: \* p<.05; \*\*p<.01; \*\*\*p < .001.

**Table 6.** Intercorrelations between age and visuospatial/visuoconstructive test scores.

In the group with partial testing, we found high significant negative correlation between BVRT total correct and total errors both for healthy and for CIND participants. As for the types of errors, (1) in the group of healthy subjects, the total number correct and total errors correlated moderately and significantly with all types of errors. (2) In CIND group BVRT total correct score correlated moderately and significantly only with the number of omissions and distortions (p=.001) and BVRT total errors—with omissions and distortions (p<.001) as well as with misplacement (p = .016).

#### *3.3.2. Multiple regression analysis*

Multiple regression analyses were performed to determine if age continued to predict BVRT score, when education and RSPM (fluid intelligence) score were taken into account. Gender was added as a possible predictor only for BVRT distortions (in healthy group) and for BVRT omissions in CIND group. These were the only variables that correlated with the gender of participants (low negative correlation for distortions, which means more errors in male subjects, and low positive correlation for omissions—more errors, made by females). Dependent variables were the outcome measures that correlated with age in both diagnostic groups. As it could be seen from **Table 7**, age predicted significantly the variance in BVRT omissions, together with fluid intelligence for healthy participants and together with education and fluid intelligence for the participants with CIND. For the other BVRT outcome measures, age is no more significant performance predictor when other demographic variables and fluid intelligence are included in the analyses.

Fluid intelligence contributed to the variance in all the variables analyzed, except for BVRT rotation in the healthy group. Education was a significant predictor only for the total errors, made by healthy participants and for the number of omissions in CIND subjects.


In the group with partial testing, we found high significant negative correlation between BVRT total correct and total errors both for healthy and for CIND participants. As for the types of errors, (1) in the group of healthy subjects, the total number correct and total errors correlated moderately and significantly with all types of errors. (2) In CIND group BVRT total correct score correlated moderately and significantly only with the number of omissions and distortions (p=.001) and BVRT total errors—with omissions and distortions (p<.001) as well as

**Variables Age Block design Cube score House score RSPM BVRT correct BVRT errors**

Coefficient r 1 −.071 −.124 −.035 **−.437** −.113 .130 Sig. −.071 .335 .788 **.000** .382 .315

Coefficient r −.071 1 **.400 .448 .505 .352 −.529** Sig. .586 **.001 .000 .000 .005 .000**

Coefficient r −.124 **.400** 1 **.437 .326** .213 −.204 Sig. .335 **.001 .000 .010** .097 .112

Coefficient r −.035 **.448 .437** 1 **.332 .400 .420** Sig. .788 **.000 .000 .008 .001 .001**

Coefficient r **−.437 .505 .326 .332** 1 **.573 −.591** Sig. **.000 .000 .010 .008 .000 .000**

Coefficient r −.113 **.352** .213 **.400 .573** 1 **−.864** Sig. .382 **.005** .097 **.001 .000 .000**

Coefficient r .130 **−.529** −.204 **−.420 −.591 −.864** 1

Sig. .315 **.000** .112 **.001 .000 .000**

**Table 6.** Intercorrelations between age and visuospatial/visuoconstructive test scores.

Multiple regression analyses were performed to determine if age continued to predict BVRT score, when education and RSPM (fluid intelligence) score were taken into account. Gender was added as a possible predictor only for BVRT distortions (in healthy group) and for BVRT omissions in CIND group. These were the only variables that correlated with the gender of participants (low negative correlation for distortions, which means more errors in male subjects, and

with misplacement (p = .016).

**Age**

180 Gerontology

**Block design**

**Cube score**

**House score**

**BVRT correct**

**BVRT errors**

**RSPM**

*3.3.2. Multiple regression analysis*

**Table 7.** Multiple regression analyses of demographic factors and fluid intelligence contributing to BVRT results.


Grossi [51], specific studies are needed to reveal the relations between visuospatial disorders

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We found that the global BVRT outcome measures (numbers of correct reproductions and number of errors) can significantly differentiate normal from pathological aging. Our work regarding the qualitative characteristics of BVRT performance is consistent with the view that it is necessary to study the specific patterns of this test results in different diagnostic groups [70, 71]. Most existing studies with BVRT analyze only the number of correct reproductions [71, 72] or the total number of errors [73]. The data about the profiles of errors in different groups, including geriatric, are scarce [74], and as far as they exist, they do not refer to CIND. We can assume that the types of errors that differ significantly in the two studied diagnostic groups—omissions and distortions—reflect the cognitive decline profile

House and cube drawing tasks, as well as Block design subtest, also showed good discriminant capacity for differentiation of normal elders from persons with CIND. We compare the results reported here with studies of healthy individuals and dementia, as we were unable to find data on the use of these tests in subjects with cognitive impairment, no dementia. The house drawing test results are consistent with those obtained in Moore and Wyke [52] study, which found a statistically significant difference between the score from house drawing of patients with dementia and control group of healthy subjects. Similar results are reported by Gragnaniello et al. [53], who found mainly omissions of elements and simplification of the drawings of a house by persons with Alzheimer's dementia. Assessment criteria used in our study take into consideration omissions of elements, three-dimensionality, distortion, and

Our results confirm the classic model of cognitive aging, showing a significant decline in fluid intelligence, measured by RSPM, with age, in both diagnostic groups. Concerning the other

**1.** Healthy participants up to 70 years of age showed more accurate BVRT reproductions than these over 70 (number correct, number errors, omissions, and distortions). When the education, fluid intelligence, and gender (where correlated with our variables) were included in the model, age was a significant predictor only for BVRT omissions. In age groups over 70, Coman et al. [70] found the greatest decline in mean total number corrects. The error profile was not analyzed in their study. In another study of normal non-demented subjects from 20 to 102 years of age, significant age-related changes in omissions, distortions, and rotations for both genders were found. This made the authors suppose different brain regions involved in the different types of BVRT errors. When longitudinal analyses were performed, authors found more rapid increase of omissions and distortions for the oldest

**2.** Number of omissions was the only variable upon which age showed a significant effect in subjects with CIND before and after taking into account the other demographic features and RSPM scores. In normals with memory concerns, a negative correlation between age

and constructional apraxia.

in CIND.

cohesion of the figures.

tests used in this study:

age groups [74].

and BVTR total correct was reported [70].

**Table 8.** Principal component pattern matrix for the sample with complete testing.

#### **3.4. Principal component analysis**

To explore the different dimensions in the visuospatial and visuoconstructive abilities in old age, a principal component analysis was performed with oblimin rotation, because of the comparatively small data set (N = 62) and the postulated interrelations between variables used. A four-factor structure, with eigenvalues bigger than 1, was established, all four factors explaining around 71% of the variance. Item loading above 0.3 on each factor is taken into consideration (**Table 8**). Most of the variables load high on the first factor, which could mean that the same kind of abilities is included in the tasks measured by many of our variables. That is why my suggestion for the name of this factor is "general cognitive ability." I would name the second factor extracted "executive functioning" (planning and executing visuoconstructive and visuospatial tasks). This factor is strongly associated with cube and house drawing, Block design performance, and planning and organization of the BVRT figures on the sheet of paper. It is the second factor on which RSPM score loads (coefficient = .237), and RSPM is proven as an executive test. Factor 3 includes BVRT omissions and distortions, together with house drawing and Block design scores and could be named "visuospatial memory." The characteristics of item loading on factor 4 give reason to label it "visuospatial analysis and visual perception."

### **4. Discussion**

Constructive and visuospatial abilities are complex fluid functions that decline with advancing age [31, 45, 50, 54]. Their impairments are proven characteristics of the pathological aging related to different types of dementia [8, 47, 53], and they are not enough studied in the boundary states, posing a risk for the development of dementia. According to Guerin [69] and Grossi [51], specific studies are needed to reveal the relations between visuospatial disorders and constructional apraxia.

We found that the global BVRT outcome measures (numbers of correct reproductions and number of errors) can significantly differentiate normal from pathological aging. Our work regarding the qualitative characteristics of BVRT performance is consistent with the view that it is necessary to study the specific patterns of this test results in different diagnostic groups [70, 71]. Most existing studies with BVRT analyze only the number of correct reproductions [71, 72] or the total number of errors [73]. The data about the profiles of errors in different groups, including geriatric, are scarce [74], and as far as they exist, they do not refer to CIND. We can assume that the types of errors that differ significantly in the two studied diagnostic groups—omissions and distortions—reflect the cognitive decline profile in CIND.

House and cube drawing tasks, as well as Block design subtest, also showed good discriminant capacity for differentiation of normal elders from persons with CIND. We compare the results reported here with studies of healthy individuals and dementia, as we were unable to find data on the use of these tests in subjects with cognitive impairment, no dementia. The house drawing test results are consistent with those obtained in Moore and Wyke [52] study, which found a statistically significant difference between the score from house drawing of patients with dementia and control group of healthy subjects. Similar results are reported by Gragnaniello et al. [53], who found mainly omissions of elements and simplification of the drawings of a house by persons with Alzheimer's dementia. Assessment criteria used in our study take into consideration omissions of elements, three-dimensionality, distortion, and cohesion of the figures.

**3.4. Principal component analysis**

**Table 8.** Principal component pattern matrix for the sample with complete testing.

Block design House score Cube score BVRT correct BVRT errors BVRT omissions BVRT distortions BVRT perseverations BVRT rotations BVRT misplacements BVRT size errors RSPM total correct

182 Gerontology

analysis and visual perception."

**4. Discussion**

To explore the different dimensions in the visuospatial and visuoconstructive abilities in old age, a principal component analysis was performed with oblimin rotation, because of the comparatively small data set (N = 62) and the postulated interrelations between variables used. A four-factor structure, with eigenvalues bigger than 1, was established, all four factors explaining around 71% of the variance. Item loading above 0.3 on each factor is taken into consideration (**Table 8**). Most of the variables load high on the first factor, which could mean that the same kind of abilities is included in the tasks measured by many of our variables. That is why my suggestion for the name of this factor is "general cognitive ability." I would name the second factor extracted "executive functioning" (planning and executing visuoconstructive and visuospatial tasks). This factor is strongly associated with cube and house drawing, Block design performance, and planning and organization of the BVRT figures on the sheet of paper. It is the second factor on which RSPM score loads (coefficient = .237), and RSPM is proven as an executive test. Factor 3 includes BVRT omissions and distortions, together with house drawing and Block design scores and could be named "visuospatial memory." The characteristics of item loading on factor 4 give reason to label it "visuospatial

**Variables Factor 1 Factor 2 Factor 3 Factor 4**

.439 .405 .787 −.082 .097 −.404 .021 −.079 .037 .838 .012 .237

.435 .463 .059 .182 −.241 .572 −.915 −.086 .206 −.127 −.035 .188

.070 −.229 −.033 −.107 .058 .305 .000 −.830 −.208 .119 .664 −.186

.324 .170 .097 .840 −.896 −.482 −.050 −.386 −.788 −.371 −.208 .535

Constructive and visuospatial abilities are complex fluid functions that decline with advancing age [31, 45, 50, 54]. Their impairments are proven characteristics of the pathological aging related to different types of dementia [8, 47, 53], and they are not enough studied in the boundary states, posing a risk for the development of dementia. According to Guerin [69] and Our results confirm the classic model of cognitive aging, showing a significant decline in fluid intelligence, measured by RSPM, with age, in both diagnostic groups. Concerning the other tests used in this study:


We can conclude that age is a significant predictor of visuospatial memory decline. Accordingly Rabbit et al. [36] reported that age predicted the results from Spatial Working Memory test.

**5. Conclusions**

**Author details**

**References**

Radka Ivanova Massaldjieva

Medical University, Plovdiv, Bulgaria

Address all correspondence to: rapsy\_99@yahoo.com

60 years.

tasks in healthy and in CIND subjects.

The basic objective of this paper was to analyze the performance of constructive and visuospatial

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185

The results confirm our hypothesis about significant differences in the level of performance in drawing and construction between persons with CIND and normally aging individuals over

We found a prevalence of omissions and distortions in the error profile of CIND and signifi-

In both diagnostic groups, age of participants showed a significant effect on BVRT omissions,

Results proved discriminative sensitivity of BVRT general scoring criteria and the separate

We tested a modification of Moore and Wike [52] scoring system for house and cube drawing task in elders, and this study confirmed its diagnostic sensitivity. Drawing of cube and house

Results from the principal component analysis (oblimin rotation) reaffirmed the multicompo-

The main limitation of this study is the small number of participants with complete neuropsychological testing and the lack of detailed clinical and neuroimaging examination. For the future, it might be interesting to carry out a similar analysis using more detailed description of subjects, including neuroimaging with functional MRT that could give the possibility to

cant difference between CIND and normal aging regarding these two types of errors.

when fluid intelligence, education, and gender were also considered.

could be used for quick screening of CIND in subjects over 60.

nent structure of the visuospatial and constructive abilities in old age.

conclude about brain structures involved in different task performance.

Health Care Management Department, Centre for Translational Neuroscience,

Medicine. 2013;**29**(4):737-752. DOI: 10.1016/j.cger.2013.07.002

[1] Harada CN, Natelson Love MC, Triebel K. Normal cognitive aging. Clinics in Geriatric

error types (omissions and distortions) in the preclinical stages of dementia.

The two age groups did not differ significantly in the performance of house and cube drawing and of Block design task. Data exist about worse perception and presentation of three-dimensionality in cube drawing task by elders [29], but we could not find studies of house and cube drawing in different late-life groups. It could be supposed that the interindividual variability, characteristic of old age in this comparatively small sample, influenced our results. The size of the sample has also prevented the use of a more detailed statistical analysis of the performance of these three tests.

A possible explanation of the results concerning the cube drawing task score and BVTR total outcome measures could be the complexity of the tasks and in particular the three-dimensionality, as a mandatory feature of the cube drawing. These results could be partially explained as well by the structure of the BVRT task, which involves reproduction of geometric shapes by memory. The task of drawing a cube and a house also requires reproduction, but long-term memory is involved here, while Benton test assesses short-term memory. Another difference between Benton test and the drawing of cube and house is related to BVRT patterns themselves—part of them are new, unknown spatial models, and the other part are well-known figures (triangle, square, circle, trapezoid) engaging long-term representations. A comprehensive cognitive model of adults' drawing ability has not yet been developed. What is well known is its "multicomponential nature" [[51], p. 117] confirmed in this study by a principal component analysis of the results from testing healthy adults and individuals with CIND over 60 years of age (four factors extracted).

The global functioning or the intelligence together with attention, sensory, motor, and executive functions is fundamental for the visuospatial and visuoconstructive abilities, following R. Mapou's [43] hierarchical model. The correlations found reflect the relationship between these basic functions and the capabilities required for specific (constructional and spatial) cognitive functions. This explanation is supported by the principal component analysis, according to the results of which global and executive functioning are required for the performance, assessed by a large number of study variables. Interpretation of principal component analysis reveals at the same time the specificity of constructive and spatial functions, based on visuospatial analysis and perception.

As elements of the multiple regression model, education of participants predicted the total number of errors in the group of healthy subjects and the number of omissions in CIND group. In another study without consideration of type of errors, the level of performance of normal older adults aged 61–97 showed dependence on education. In the same paper, in the group of normals with memory concerns from 64 to 74, less educated had worse performance, the difference found not reaching significance over 75. As for the gender effects on BVRT performance, there are no evidences about significant differences between men and women, from most research results available [70]. Resnick et al. [74] reported sex differences for omissions and rotations in subjects from 20 to 102, but they account for very low percentage of the variance (1%). Our multiple regression results gave a gender effect only on distortions, made by healthy subjects.
