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Kiselica AM, Karr JE, Mikula CM, Ranum RM, Benge JF, Medina LD, Woods SP. Recent Advances in Neuropsychological Test Interpretation for Clinical Practice. Neuropsychol Rev 2024; 34:637-667. [PMID: 37594687 DOI: 10.1007/s11065-023-09596-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/28/2023] [Indexed: 08/19/2023]
Abstract
Much attention in the field of clinical neuropsychology has focused on adapting to the modern healthcare environment by advancing telehealth and promoting technological innovation in assessment. Perhaps as important (but less discussed) are advances in the development and interpretation of normative neuropsychological test data. These techniques can yield improvement in diagnostic decision-making and treatment planning with little additional cost. Brooks and colleagues (Can Psychol 50: 196-209, 2009) eloquently summarized best practices in normative data creation and interpretation, providing a practical overview of norm development, measurement error, the base rates of low scores, and methods for assessing change. Since the publication of this seminal work, there have been several important advances in research on development and interpretation of normative neuropsychological test data, which may be less familiar to the practicing clinician. Specifically, we provide a review of the literature on regression-based normed scores, item response theory, multivariate base rates, summary/factor scores, cognitive intraindividual variability, and measuring change over time. For each topic, we include (1) an overview of the method, (2) a rapid review of the recent literature, (3) a relevant case example, and (4) a discussion of limitations and controversies. Our goal was to provide a primer for use of normative neuropsychological test data in neuropsychological practice.
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Affiliation(s)
- Andrew M Kiselica
- Department of Health Psychology, University of Missouri, 115 Business Loop 70 W, Columbia, MO, 65203, USA.
| | - Justin E Karr
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Cynthia M Mikula
- Institute of Human Nutrition, Columbia University, New York, NY, USA
| | - Rylea M Ranum
- Department of Health Psychology, University of Missouri, 115 Business Loop 70 W, Columbia, MO, 65203, USA
| | - Jared F Benge
- Department of Neurology, University of Texas-Austin, TX, Austin, USA
| | - Luis D Medina
- Department of Psychology, University of Houston, Houston, TX, USA
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delCacho-Tena A, Christ BR, Arango-Lasprilla JC, Perrin PB, Rivera D, Olabarrieta-Landa L. Normative Data Estimation in Neuropsychological Tests: A Systematic Review. Arch Clin Neuropsychol 2024; 39:383-398. [PMID: 37950923 PMCID: PMC11042921 DOI: 10.1093/arclin/acad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/28/2023] [Accepted: 09/28/2023] [Indexed: 11/13/2023] Open
Abstract
OBJECTIVE To quantify the evolution, impact, and importance of normative data (ND) calculation by identifying trends in the research literature and what approaches need improvement. METHODS A PRISMA-guideline systematic review was performed on literature from 2000 to 2022 in PubMed, Pub-Psych, and Web of Science. Inclusion criteria included scientific articles about ND in neuropsychological tests with clear data analysis, published in any country, and written in English or Spanish. Cross-sectional and longitudinal studies were included. Bibliometric analysis was used to examine the growth, productivity, journal dispersion, and impact of the topic. VOSViewer compared keyword co-occurrence networks between 1952-1999 and 2000-2022. RESULTS Four hundred twelve articles met inclusion and exclusion criteria. The most studied predictors were age, education, and sex. There were a greater number of studies/projects focusing on adults than children. The Verbal Fluency Test (12.7%) was the most studied test, and the most frequently used variable selection strategy was linear regression (49.5%). Regression-based approaches were widely used, whereas the traditional approach was still used. ND were presented mostly in percentiles (44.2%). Bibliometrics showed exponential growth in publications. Three journals (2.41%) were in the Core Zone. VOSViewer results showed small nodes, long distances, and four ND-related topics from 1952 to 1999, and there were larger nodes with short connections from 2000 to 2022, indicating topic spread. CONCLUSIONS Future studies should be conducted on children's ND, and alternative statistical methods should be used over the widely used regression approaches to address limitations and support growth of the field.
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Affiliation(s)
- Ana delCacho-Tena
- Department of Health Science, Public University of Navarre, Pamplona, Navarre, Spain
| | - Bryan R Christ
- School of Data Science and Department of Psychology, University of Virginia, Charlottesville, VA, USA
| | | | - Paul B Perrin
- School of Data Science and Department of Psychology, University of Virginia, Charlottesville, VA, USA
| | - Diego Rivera
- Department of Health Science, Public University of Navarre, Pamplona, Navarre, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Laiene Olabarrieta-Landa
- Department of Health Science, Public University of Navarre, Pamplona, Navarre, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
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Zhang W, Yuan Y, Cui X, Chen S, Zhuang X. The level of serum retinol-binding protein is associated with diabetic mild cognitive impairment. Brain Res 2024; 1822:148670. [PMID: 37944571 DOI: 10.1016/j.brainres.2023.148670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Several studies have shown that retinol-binding protein (RBP) is linked to diabetes and neurodegenerative diseases. However, no studies have elucidated the relationship between RBP and diabetic cognitive disorders. OBJECTIVE To determine whether the change characteristics of serum RBP are associated with alterations in cognitive functioning in type 2 diabetes mellitus (T2DM). METHODS In this study, 252 patients with T2DM and 34 people as healthy controls were included. According to the Montreal Cognitive Assessment (MoCA), the diabetic subjects were divided into the mild cognitive impairment (MCI) group and the Non-MCI group. Demographic characteristics and clinical indicators as well as serum RBP levels were analyzed. RESULTS The serum RBP levels in the MCI group were lower compared with the Non-MCI group (P = 0.02). The level of RBP was higher in the diabetes without MCI group than in the healthy control (P < 0.001). Serum RBP levels were positively correlated with MoCA scores (r = 0.178, P = 0.003). Binary Logistic regression model analysis showed that low RBP [odds ratio (OR) = 0.936], old age (OR = 1.074), high fasting blood glucose (OR = 1.164), and low fasting C-peptide (OR = 0.722) may be independent risk factors for diabetic MCI. The ROC curve of serum RBP for predicting diabetic MCI showed that the area under the curve was 0.630. CONCLUSIONS Our study revealed an association between serum RBP and diabetic MCI. Serum RBP levels in diabetic MCI are lower and correlated with cognitive function.
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Affiliation(s)
- Wenjie Zhang
- Department of General Practice, The Second Hospital of Shandong University, Jinan 250000, China
| | - Yuqi Yuan
- Department of Clinical Epidemiology and Evidence-based Medicine, The Second Hospital of Shandong University, Jinan 250000, China
| | - Xiaoxia Cui
- The Second Hospital of Shandong University, Jinan 250000, China
| | - Shihong Chen
- Department of Endocrinology, The Second Hospital of Shandong University, Jinan 250000, China.
| | - Xianghua Zhuang
- Department of Endocrinology, The Second Hospital of Shandong University, Jinan 250000, China.
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Villalobos D, Torres-Simón L, Pacios J, Paúl N, Del Río D. A Systematic Review of Normative Data for Verbal Fluency Test in Different Languages. Neuropsychol Rev 2023; 33:733-764. [PMID: 36098929 DOI: 10.1007/s11065-022-09549-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 07/04/2022] [Indexed: 01/04/2023]
Abstract
Verbal fluency tests are easy and quick to use in neuropsychological assessments, so they have been counted among the most classical tools in this context. To date, several normative data for verbal fluency tests have been provided in different languages and countries. A systematic review was carried out with studies that provide normative data for verbal fluency tests. Studies were collected from Scopus, PubMed and Web of Science. 183 studies were retrieved from the database search, of which 73 finally met the inclusion criteria. An analysis of the risk of bias regarding samples selection/characterization and procedure/results reports is conducted for each article. Finally, a full description of the normative data characteristics, considering country and language, verbal fluency task characteristics (type of task) and sample characteristics (number of subjects, gender, age, education) is included. The current systematic review provides an overview and analysis of internationally published normative data that might help clinicians in their search for valid and useful norms on verbal fluency tasks, as well as updated information about qualitative aspects of the different options currently available.
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Affiliation(s)
- Dolores Villalobos
- Department of Experimental Psychology, School of Psychology, Complutense University of Madrid, Madrid, Spain
- Center for Cognitive and Computational Neuroscience, Complutense University of Madrid, Madrid, Spain
- Department of Psychology, Cardenal Cisneros University Center, Alcalá de Henares University. Madrid, Madrid, Spain
- European Neuroscience Center, Madrid, Spain
| | - Lucia Torres-Simón
- Department of Experimental Psychology, School of Psychology, Complutense University of Madrid, Madrid, Spain
- Center for Cognitive and Computational Neuroscience, Complutense University of Madrid, Madrid, Spain
| | - Javier Pacios
- Department of Experimental Psychology, School of Psychology, Complutense University of Madrid, Madrid, Spain
- Center for Cognitive and Computational Neuroscience, Complutense University of Madrid, Madrid, Spain
| | - Nuria Paúl
- Department of Experimental Psychology, School of Psychology, Complutense University of Madrid, Madrid, Spain
| | - David Del Río
- Department of Experimental Psychology, School of Psychology, Complutense University of Madrid, Madrid, Spain.
- Center for Cognitive and Computational Neuroscience, Complutense University of Madrid, Madrid, Spain.
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Espenes J, Lorentzen IM, Eliassen IV, Hessen E, Waterloo K, Timón-Reina S, Fladby T, Walhovd KB, Fjell AM, Kirsebom BE. Regression-based normative data for the D-KEFS Color-Word Interference Test in Norwegian adults ages 20-85. Clin Neuropsychol 2023:1-27. [PMID: 37974044 DOI: 10.1080/13854046.2023.2276967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
Objective: The Delis-Kaplan Executive Function System (D-KEFS) Color-Word-Interference Test (CWIT; AKA Stroop test) is a widely used measure of processing speed and executive function. While test materials and instructions have been translated to Norwegian, only American age-adjusted norms from D-KEFS are available in Norway. We here develop norms in a sample of 1011 Norwegians between 20 and 85 years. We provide indexes for stability over time and assess demographic adjustments applying the D-KEFS norms. Method: Participants were healthy Norwegian adults from Center for Lifespan Changes in Brain and Cognition (LCBC) (n = 899), the Dementia Disease Initiation (n = 77), and Oslo MCI (n = 35). Using regression-based norming, we estimated linear and non-linear effects of age, education, and sex on the CWIT 1-4 subtests. Stability over time was assessed with intraclass correlation coefficients (ICC). The normative adjustment of the D-KEFS norms was assessed with linear regression models. Results: Increasing age was associated with slower completion on all CWIT subtests in a non-linear fashion (accelerated lowering of performance with older age). Women performed better on CWIT-1&3. Higher education predicted faster completion time on CWIT-3&4. The original age-adjusted norms from D-KEFS did not adjust for sex or education. Furthermore, we observed significant, albeit small effects of age on all CWIT subtests. ICC analyses indicated moderate to good stability over time. Conclusion: We present demographically adjusted regression-based norms and stability indexes for the D-KEFS CWIT subtests. US D-KEFS norms may be inaccurate for Norwegians with high or low educational attainment, especially women.
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Affiliation(s)
- Jacob Espenes
- Department of Psychology, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - Ingrid Myrvoll Lorentzen
- Department of Psychology, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
| | - Ingvild Vøllo Eliassen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Erik Hessen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Knut Waterloo
- Department of Psychology, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - Santiago Timón-Reina
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Departamento de Inteligencia Artificial, Universidad Nacional de Educación a Distancia, Madrid, Spain
| | - Tormod Fladby
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway
| | - Kristine B Walhovd
- Center for Lifespan Changes in Brain and Cognition, University of Oslo, Norway
- Computational Radiology and Artificial Intelligence, Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway
| | - Anders M Fjell
- Center for Lifespan Changes in Brain and Cognition, University of Oslo, Norway
- Computational Radiology and Artificial Intelligence, Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway
| | - Bjørn-Eivind Kirsebom
- Department of Psychology, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
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Zhou A, Britt C, Woods RL, Orchard SG, Murray AM, Shah RC, Rajan R, McNeil JJ, Chong TTJ, Storey E, Ryan J. Normative Data for Single-Letter Controlled Oral Word Association Test in Older White Australians and Americans, African-Americans, and Hispanic/Latinos. J Alzheimers Dis Rep 2023; 7:1033-1043. [PMID: 37849629 PMCID: PMC10578329 DOI: 10.3233/adr-230089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/24/2023] [Indexed: 10/19/2023] Open
Abstract
Background The Controlled Oral Word Association Test (COWAT) is a commonly used measure of verbal fluency. While a normal decline in verbal fluency occurs in late adulthood, significant impairments may indicate brain injury or diseases such as Alzheimer's disease. Normative data is essential to identify when test performance falls below expected levels based on age, gender, and education level. Objective This study aimed to establish normative performance data on single-letter COWAT for older community-dwelling adults. Methods Over 19,000 healthy men and women, without a diagnosis of dementia or a Modified Mini-Mental State Examination score below 77/100, were recruited for the ASPREE trial. Neuropsychological assessments, including the COWAT with letter F, were administered at study entry. Results Median participant age was 75 years (range 65-98), with 56.5% being women. The majority of participants had 9-11 years of education in Australia and over 12 years in the U.S. The COWAT performance varied across ethno-racial groups and normative data were thus presented separately for 16,335 white Australians, 1,084 white Americans, 896 African-Americans, and 316 Hispanic/Latinos. Women generally outperformed men in the COWAT, except for Hispanic/Latinos. Higher education levels consistently correlated with better COWAT performance across all groups, while the negative association with age was weaker. Conclusions This study provides comprehensive normative data for the COWAT stratified by ethno-racial groups in Australia and the U.S., considering age, gender, and education level. These norms can serve as reference standards for screening cognitive impairments in older adults in both clinical and research settings.
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Affiliation(s)
- Aoshuang Zhou
- Division of Epidemiology, Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Carlene Britt
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Robyn L. Woods
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Suzanne G. Orchard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Anne M. Murray
- Division of Geriatric and Palliative Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Berman Center for Outcomes and Clinical Research, Minneapolis, MN, USA
| | - Raj C. Shah
- Department of Family and Preventive Medicine and the Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - Ramesh Rajan
- Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - John J. McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Trevor T.-J. Chong
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Clinical Neurosciences, St Vincent’s Hospital, Melbourne, VIC, Australia
| | - Elsdon Storey
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Joanne Ryan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Dassanayake TL, Hewawasam C, Baminiwatta A, Ariyasinghe DI. Regression-based, demographically adjusted norms for Victoria Stroop Test, Digit Span, and Verbal Fluency for Sri Lankan adults. Clin Neuropsychol 2021; 35:S32-S49. [PMID: 34499569 DOI: 10.1080/13854046.2021.1973109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Lack of test norms is a major limitation in neuropsychological assessment in many non-English-speaking countries. Our objective was to generate sex-, age-, and education-adjusted, regression-based norms for three pen-and-paper-based executive function/working memory tests, viz. Victoria Stroop Test (VST), Digit Span, and Verbal Fluency, for Sinhala-Speaking Sri Lankan adults. METHOD Six-hundred and six healthy, community-living, Sinhala-speaking adults (273 men) aged 19-83 years completed VST, Digit Span (forward and backward), and Phonemic (Sinhala phonemes "N," "P," and "S") and Category (animals and vegetables) Fluency tests. We conducted multiple linear regression analyses with sex, age, and years of education fitted as predictors to model the test outcome variables. RESULTS Younger age was associated with better performance in all tests except in Phonemic Fluency. Longer education was associated with better performance in all outcomes except VST errors and interference. Women had a significant but small advantage over men in VST Neutral and Color Word tests, and Phonemic Fluency. We report regression equations to predict norms for the test performance measures based on sex, age, and years of education; and the test variances accounted by these factors. CONCLUSIONS We propose demographically adjusted norms for VST, Digit Span, and Verbal Fluency for Sinhala-speaking Sri Lankans aged 19-83 years, and supplement the regression formulae with a calculator that produces predicted and standard scores. These norms would help in interpreting the results of clinical samples in the future, taking into account the variability introduced by sex, age, and education.
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Affiliation(s)
| | - Chandana Hewawasam
- Department of Physiology, Faculty of Medicine and Allied Health Sciences, Rajarata University of Sri Lanka, Saliyapura 50008, Sri Lanka
| | - Anuradha Baminiwatta
- Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Peradeniya 20400, Sri Lanka
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Poptsi E, Moraitou D, Tsardoulias E, Symeonidisd AL, Tsolaki M. Is the Discrimination of Subjective Cognitive Decline from Cognitively Healthy Adulthood and Mild Cognitive Impairment Possible? A Pilot Study Utilizing the R4Alz Battery. J Alzheimers Dis 2021; 77:715-732. [PMID: 32741834 DOI: 10.3233/jad-200562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The early diagnosis of neurocognitive disorders before the symptoms' onset is the ultimate goal of the scientific community. REMEDES for Alzheimer (R4Alz) is a battery, designed for assessing cognitive control abilities in people with minor and major neurocognitive disorders. OBJECTIVE To investigate whether the R4Alz battery's tasks differentiate subjective cognitive decline (SCD) from cognitively healthy adults (CHA) and mild cognitive impairment (MCI). METHODS The R4Alz battery was administered to 175 Greek adults, categorized in five groups a) healthy young adults (HYA; n = 42), b) healthy middle-aged adults (HMaA; n = 33), c) healthy older adults (HOA; n = 14), d) community-dwelling older adults with SCD (n = 34), and e) people with MCI (n = 52). RESULTS Between the seven R4Alz subtasks, four showcased the best results for differentiating HOA from SCD: the working memory updating (WMCUT-S3), the inhibition and switching subtask (ICT/RST-S1&S2), the failure sets (FS) of the ICT/RST-S1&S2, and the cognitive flexibility subtask (ICT/RST-S3). The total score of the four R4Alz subtasks (R4AlzTot4) leads to an excellent discrimination among SCD and healthy adulthood, and to fare discrimination among SCD and MCI. CONCLUSION The R4Alz battery is a novel approach regarding the neuropsychological assessment of people with SCD, since it can very well assist toward discriminating SCD from HOA. The R4Alz is able to measure decline of specific cognitive control abilities - namely of working memory updating, and complex executive functions - which seem to be the neuropsychological substrate of cognitive complaints in community dwelling adults of advancing age.
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Affiliation(s)
- Eleni Poptsi
- Laboratory of Psychology, Section of Cognitive and Experimental Psychology, Faculty of Philosophy, School of Psychology, Aristotle University of Thessaloniki (AUTh), Macedonia, Hellas.,Lab of Neurodegenerative Diseases, Center for Interdisciplinary Research and Innovation, Aristotle University of Thessaloniki (LND, CIRI - AUTh) Macedonia, Hellas.,Greek Association of Alzheimer's Disease and Related Disorders (GAADRD), Thessaloniki, Macedonia, Hellas
| | - Despina Moraitou
- Laboratory of Psychology, Section of Cognitive and Experimental Psychology, Faculty of Philosophy, School of Psychology, Aristotle University of Thessaloniki (AUTh), Macedonia, Hellas.,Lab of Neurodegenerative Diseases, Center for Interdisciplinary Research and Innovation, Aristotle University of Thessaloniki (LND, CIRI - AUTh) Macedonia, Hellas.,Greek Association of Alzheimer's Disease and Related Disorders (GAADRD), Thessaloniki, Macedonia, Hellas
| | - Emmanouil Tsardoulias
- School of Electrical and Computer Engineering, Faculty of Engineering, Aristotle University of Thessaloniki (AUTh), Macedonia, Hellas
| | - Andreas L Symeonidisd
- School of Electrical and Computer Engineering, Faculty of Engineering, Aristotle University of Thessaloniki (AUTh), Macedonia, Hellas
| | - Magda Tsolaki
- Lab of Neurodegenerative Diseases, Center for Interdisciplinary Research and Innovation, Aristotle University of Thessaloniki (LND, CIRI - AUTh) Macedonia, Hellas.,Greek Association of Alzheimer's Disease and Related Disorders (GAADRD), Thessaloniki, Macedonia, Hellas.,1st Department of Neurology, School of Medicine, Aristotle University of Thessaloniki (AUTh), Macedonia, Hellas
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