JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY

2011, iFirst, 1–8

Comparing the clinical usefulness of the Institute of

Cognitive Neurology (INECO) Frontal Screening (IFS)
and the Frontal Assessment Battery (FAB) in
frontotemporal dementia
Ezequiel Gleichgerrcht1,3 , María Roca1,2,3 , Facundo Manes1,3 , and Teresa Torralva1,3
1
Institute of Cognitive Neurology (INECO), Buenos Aires, Argentina
2
Laboratory of Neuroscience, Universidad Diego Portales, Santiago, Chile
3
Institute of Neurosciences, Favaloro University, Buenos Aires, Argentina

We compared the utility of two executive-function brief screening tools, the Institute of Cognitive Neurology
(INECO) Frontal Screening (IFS) and the Frontal Assessment Battery (FAB), in their ability to detect executive
dysfunction in a group of behavioral variant frontotemporal dementia (bv-FTD, n = 25) and Alzheimer’s disease
(AD, n = 25) patients in the early stages of their disease and in comparison to a group of age-, gender-, and educa-
tion-matched controls (n = 26). Relative to the FAB, the IFS showed (a) better capability to differentiate between
types of dementia; (b) higher sensitivity and specificity for the detection of executive dysfunction; (c) stronger cor-
relations with standard executive tasks. We conclude that while both tools are brief and specific for the detection of
early executive dysfunction in dementia, the IFS is more sensitive and specific in differentiating bvFTD from AD,
and its use in everyday clinical practice can contribute to the differential diagnosis between types of dementia.

Keywords: Behavioral variant frontotemporal dementia; Alzheimer’s disease; Institute of Cognitive Neurology
Frontal Screening; Frontal Assessment Battery; Executive functions; Cognitive screening.

During the past decade, assessment in the field of demen- (Torralva, Roca, Gleichgerrcht, Bekinschtein, & Manes,
tia has aimed to improve the sensitivity and specificity 2009) or an abbreviated version of it (Gleichgerrcht,
of neuropsychological tests for the detection of sub- Torralva, Roca, & Manes, 2010) can detect the subtle
tle and/or early cognitive deficits, which can lead to a executive deficits that go unnoticed in a group of patients
more reliable diagnosis of neurodegenerative conditions. in the early stages of behavioral variant frontotemporal
Strong focus has been placed on two primary approaches dementia (bvFTD).
towards meeting this goal. On the one hand, some The other popular approach towards attaining this
research groups have designed “ecological” tasks and objective has been the development of brief screening
assessment batteries that recreate everyday-life scenarios tools that are easy and quick to administer. This has been
more closely than standard cognitive tests. As a result, especially important because the detection of a dysexec-
patients can now be evaluated with tasks that pose cogni- utive syndrome typically requires an extensive neuropsy-
tive demands that resemble real life more closely. This is chological battery that has to be administered by trained
especially true for the assessment of executive functions, neuropsychologists. Because of their popular use at bed-
which are essential in achieving a particular goal in a side, these brief screening tools must not only be able to
flexible manner and, thus, a fundamental skill for success- detect cognitive deficits, but it also should ideally be able
fully carrying out our activities of everyday living. For to reliably discriminate between different types of dis-
instance, we have recently demonstrated that administer- eases, such as Alzheimer’s disease (AD). Of the various
ing an “ecological” executive and social cognition battery brief screening tools that have been designed to specially

The present study was funded by a Fundación INECO grant.

Address correspondence to Ezequiel Gleichgerrcht, Pacheco de Melo 1860, Capital Federal, Buenos Aires 1126, Argentina (E-mail:
egleichgerrcht@ineco.org.ar).
© 2011 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/jcen DOI: 10.1080/13803395.2011.589375
2 GLEICHGERRCHT ET AL.

assess executive functions (Ettlin & Kischka, 1999; for mood symptoms, all participants completed the Beck
Rothlind & Brandt, 1993; Royall, Mahurin, & Gray, Depression Inventory II (BDI–II; Beck, Steer, Ball, &
1992), the Frontal Assessment Battery (FAB; Dubois, Ranieri, 1996), and only patients with a score of 13 points
Slachevsky, Litvan, & Pillon, 2000) was probably one or below were included in the study.
of the most extensively used (Guedj et al., 2008; Lima,
Meireles, Fonseca, Castro, & Garrett, 2008; Oguro et al.,
Procedure
2006; Santangelo et al., 2009; Yoshida et al., 2009). While
the authors of the FAB have argued this is an easy-to-
The study was initially approved by the ethics commit-
administer battery, sensitive to frontal dysfunction test
tee at INECO following international regulations estab-
for the evaluation of different kinds of frontal dysfunc-
lished for human research subjects. All participants were
tion (Dubois et al., 2000), and capable of differentiating
evaluated with an extensive neuropsychological battery.
between neurological pathologies such as bvFTD and
Data for this study were obtained from the follow-
AD (Slachevsky et al., 2004), some studies have not been
ing tests: the INECO Frontal Screening (IFS; Torralva,
able to replicate the sensitivity and specificity of the FAB
Roca, Gleichgerrcht, López, et al., 2009); the Frontal
and, in particular, its ability to actually differentiate types
Assessment Battery (FAB; Dubois et al., 2000); the
of dementia, such as AD and FTD (Castiglioni et al.,
Addenbrooke’s Cognitive Examination–Revised (ACE–
2006; Lipton et al., 2005) in the early stages.
R; Mioshi, Dawson, Mitchell, Arnold, & Hodges,
In order to overcome these caveats, our group has
2006), which also incorporates the Mini Mental State
more recently developed the Institute of Cognitive
Examination (MMSE; Folstein, Folstein, & McHugh,
Neurology (INECO) Frontal Screening (IFS; Torralva,
1975); and classical executive measures, including the ver-
Roca, Gleichgerrcht, López, & Manes, 2009), which
bal phonological fluency (Lezak, Howieson, & Loring,
showed high sensitivity and specificity to detect executive
2004), Trail Making Test–Part B (TMT–B; Partington &
impairment in less than 10 min.
Leiter, 1949), and the adapted version of the Wisconsin
The goal of the present study was to compare the
Card Sorting Test (WCST; Nelson, 1976).
clinical usefulness of the IFS and the FAB in detecting
patients with dementia and, furthermore, in their capac-
ity to differentiate patients with bvFTD from patients Frontal Assessment Battery (Dubois et al., 2000)
with AD. Based on our clinical experience with both
tools, we hypothesized that the IFS would show higher The FAB consists of six subtests, which assess concep-
sensitivity for the detection of executive deficits and better tualization, conflicting instructions, motor programming,
capability to distinguish between types of dementia. sensitivity to interference, motor inhibitory control, and
prehension behavior. Each subtest is scored on a maxi-
mum of 3 points, rendering a total maximum score of 18.
METHOD Although no cutoff score was suggested by the authors of
the FAB, the original publication reported a discriminant
Participants validity of 89.1% using the total score.

A total of 76 subjects were included in this study, 26

INECO Frontal Screening (Torralva, Roca,
of which were healthy controls, and 50 of which were
Gleichgerrcht, López, et al., 2009)
diagnosed with dementia. Within the dementia group,
25 patients presented with the bvFTD and 25 with a The IFS included three subtests from the FAB
diagnosis of probable AD. Healthy controls were exam- (motor programming, conflicting instructions, and motor
ined with a comprehensive neuropsychological and neu- inhibitory control) and added new subtests that have been
ropsychiatry evaluation and had no history of either shown to be sensitive to executive dysfunction: numerical
neurological or psychiatric disorder. All patients with working memory (backward digit span), verbal working
AD diagnosis fulfilled National Institute of Neurological memory (months backwards), spatial working memory
and Communicative Disorders and Stroke–Alzheimer’s (modified Corsi tapping test), abstraction capacity (infer-
Disease and Related Disorders Association (NINCDS- ring the meaning of proverbs), and verbal inhibitory
ADRDA) criteria (Varma et al., 1999), while all patients control (modified Hayling test). The IFS has a maxi-
in the bvFTD group fulfilled Lund and Manchester crite- mum possible total score of 30 points. The test takes less
ria (Neary et al., 1998). Participants underwent a stan- than 10 minutes to be administered and scored. A 25-
dard examination battery including neurological, neu- point cutoff score has shown a sensitivity of 96.2% and
ropsychiatric, and neuropsychological examinations and a specificity of 91.5% in detecting patients with dementia
magnetic resonance imaging (MRI). The bvFTD patients (Torralva, Roca, Gleichgerrcht, López, et al., 2009).
showed frontal atrophy on MRI on visual examination.
Patterns of cortical atrophy were visually inspected by
two experts in dementia (F.M. and T.T.). Severity of Statistical analysis
dementia was determined with the Clinical Dementia
Rating (CDR). Patients with a CDR value of two points Demographic and clinical information, as well as test
or higher were excluded from this study (Hughes, Berg, performance scores, were compared between the groups
Danziger, Coben, & Martin, 1982). In order to control using one-way analyses of variance (ANOVAs) with
 COMPARING IFS AND FAB 3

Bonferroni post hoc analyses when appropriate. When education, F(73, 2) = 1.76, p = .18, or gender (χ 2 = 0.18,
data were not normally distributed (as assessed by means p = .98). The dementia groups did not differ on their
of Kolmogorov–Smirnoff tests), U Mann–Whitney tests severity, as measured by the CDR (U = 275.0, p = .75),
were used to compare two groups at a time. When ana- or the intensity of their mood symptoms, as measured by
lyzing categorical variables (e.g., gender), the Freeman– BDI–II scores (U = 300.5, p = .82).
Halton extension of the Fisher exact probability test for As expected, significant differences were found
2 × 3 contingency tables was used. between the groups on the general cognitive status
In order to compare the usefulness of the IFS and FAB, screening tests, including the MMSE, F(73, 2) = 42.8,
initially, we determined the sensitivity and specificity of p < .001, the ACE–R, F(73, 2) = 58.6, p < .001, and the
each test to discriminate between (a) healthy controls and classical executive function tasks including phonological
patients with dementia, and (b) patients with AD from fluency, F(73, 2) = 38.6, p < .001, latency to complete
bvFTD. This was done by means of a receiver-operating the TMT–B, F(73, 2) = 24.5, p < .001, and the number
characteristic (ROC) curve, detecting the cutoff score at of categories achieved, F(73, 2) = 37.9, p < .001, and
which sensitivity was highest and 1-specificity was lowest perseverative errors made, F(73, 2) = 38.6, p < .001,
(i.e., higher specificity). The area under the ROC curve on the WCST. In all cases, controls outperformed both
(AuC) was used as a measure of discriminatory accuracy, dementia groups. Remarkably, no significant differences
and the AuC values were compared between each other were found between bvFTD and AD patients on the
in order to test statistical differences following Hanley classical tests of executive functioning (phonological
and McNeil (1983) algorithms. Correlations were sought fluency: p = .99; TMT–B: p = .45; WCST: p = .62).
between the total scores of the IFS and the FAB and of
performance scores on classical tests of executive func-
tioning using Spearman’s correlation coefficient. In order IFS versus FAB performance
to avoid increasing the risk of a Type I error due to mul-
tiple comparisons, Bonferroni correction was applied for As shown by Figure 1A, significant differences were
correlation analyses. found between the groups on both the IFS, F(73, 2) =
All statistical analyses were performed using the SPSS 64.2, p < .001, and FAB, F(73, 2) = 5.38, p < .01, total
18.0 statistical package, and the α value was set at .05, scores. Post hoc comparisons revealed that on the IFS,
two-tailed. controls outperformed both groups of dementia patients
(p < .001 for both) and that AD differed significantly
from bvFTD patients (p < .001). On the contrary, the
RESULTS FAB showed more subtle significant differences between
controls and both AD (p = .01) and bvFTD (p = .04),
Clinical, demographic, and neuropsychological while the dementia groups showed a very similar perfor-
profile mance (p = .99). This is likely because of the large portion
of overlapping individual scores between AD and bvFTD
Table 1 summarizes the clinical, demographic, and neu- on the FAB (Figure 1B).
ropsychological profile of the groups included in this A cutoff score of 25 points (out of 30) on the IFS
study. No significant difference was found between the was associated with a sensitivity of 92.2%, CI = [81.1,
groups on age, F(73, 2) = 3.63, p = .24, years of formal 97.8], and a specificity of 96.2%, CI = [80.4, 99.9], for

TABLE 1
Demographic, clinical, and neuropsychological performance of controls, patients with behavioral variant frontotemporal
dementia, and patients with Alzheimer’s disease

Control bvFTD AD

Mean SD Mean SD Mean SD

Age (years) 69.23 8.9 70.00 6.8 72.64 5.3

Education (years) 14.46 2.2 15.92 3.5 14.48 3.6
Gender (F:M) 14:12 13:12 13:12
CDR — — 0.81 0.4 0.91 0.2
BDI–II 1.54 1.4 7.67 8.1 5.82 4.7
MMSE 29.65 0.5 27.36 2.3 24.36 2.6
ACE–R 95.54 3.0 80.06 11.6 68.56 9.9
Phonological fluency 22.15 6.6 11.11 5.2 9.88 4.4
TMT–B (s) 61.88 25.7 199.91 109.7 169.46 63.1
WCST categories 5.88 0.3 2.55 2.0 3.08 1.6
WCST perseverative errors 1.15 1.2 13.04 7.1 7.12 4.4

Note. bvFTD = behavioral variant frontotemporal dementia. AD = Alzheimer’s disease. F = female; M = male. CDR =
Clinical Dementia Rating Scale; BDI–II = Beck Depression Inventory II; MMSE = Mini-Mental State Examination; ACE–R =
Addenbrooke’s Cognitive Examination–Revised; TMT–B = Trail Making Test Part B; WCST = Wisconsin Card Sorting Test.
4 GLEICHGERRCHT ET AL.

A
35 CONTROL
p < .001
bvFTD
30
p < .001 AD
25
p = .01
20 p = .04

15

10

0
IFS FAB

B
30 18

25 16
IFS Total Score

FAB Total Score

14
20

12
15

10
10
8
5
CTR bvFTD AD CTR bvFTD AD

Figure 1. A. Group performance on the Institute of Cognitive Neurology (INECO) Frontal Screening (IFS) and Frontal Assessment
Battery (FAB). Error bars represent standard deviations. B. Individual performance on the IFS and FAB. CTR = controls. bvFTD =
behavioral variant frontotemporal dementia. AD = Alzheimer’s disease.

the detection of dementia (both AD and bvFTD). On Analysis of subtests

the FAB, a cutoff score of 14 (out of 18) showed a speci-
ficity of 100%, CI = [86.6, 100], but a sensitivity of as In order to determine the potential usefulness of particu-
low as 51.0%, CI = [36.6, 65.2]. As shown by Figure 2A, lar subtests of the IFS and the FAB, we compared scores
the discriminatory accuracy (patients with dementia vs. obtained by AD and FTD patients on individual tasks of
healthy controls) of the IFS (AuC = .97, SE = .02) was each screening tool (Figure 3).
superior to that of the FAB (AuC = .77, SE = .06),
and this difference was statistically significant (z = 3.69,
p < .001). Subtests shared by both the IFS and the FAB
In comparing the capacity to discriminate between No significant differences were found between AD and
types of dementia (AD vs. bvFTD), the FAB showed a FTD patients on the motor programming (U = 306.0,
specificity of 96.2%, CI = [80.4, 99.9], but a very low sen- p = .89) and conflicting instructions (U = 284.0, p =
sitivity of 16.0%, CI = [4.5, 36.1], using a cutoff score .50) test. Performance on the motor inhibitory control
of 10 points. On the contrary, a 21-point cutoff score task (go/no-go), on the other hand, was significantly
on the IFS showed 92.0%, CI = [74.0, 99.0], sensitivity diminished in FTD patients (U = 209.0, p = .036).
and 67.7%, CI = [52.2, 73.8], specificity. Again, the IFS
showed superior discriminatory accuracy (AuC = .77,
SE = .07) than the FAB (AuC = .50, SE = .08), and this Subtests unique to the IFS
difference was statistically significant (z = 4.32, p < .001), Performance on the backward digit span test (U =
as revealed by Figure 2B. 233.5, p = .10) and the spatial working memory test (U =
 COMPARING IFS AND FAB 5

A B
1.0 1.0

0.8 0.8

0.6 0.6
Sensitivity

Sensitivity
0.4 0.4

0.2 IFS 0.2 IFS

FAB FAB
Reference Line Reference Line
0.0 0.0
0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity 1 - Specificity

Figure 2. Institute of Cognitive Neurology (INECO) Frontal Screening (IFS) and Frontal Assessment Battery (FAB) receiver operating
characteristic (ROC) curves in comparing (A) healthy controls versus patients with dementia, and (B) Alzheimer’s disease (AD) versus
behavioral variant frontotemporal dementia (bvFTD) patients.

4.50
FTD AD
4.00 *
3.50
3.00
Subtest Score

2.50 *
* *
2.00
1.50
1.00
.50
.00
MP CI MIC BDS VWM SWM AC VIC C PB VF

Shared by IFS & FAB Unique to the IFS Unique to the FAB

Figure 3. Performance of Alzheimer’s disease (AD) and frontotemporal dementia (FTD) patients on subtests shared by both the Frontal
Assessment Battery (FAB) and the Institute of Cognitive Neurology (INECO) Frontal Screening (IFS; MP = motor programming; CI
= conflicting instructions; MIC = motor inhibitory control), unique to the IFS (BDS = backward digit span; VWM = verbal working
memory; SWM = spatial working memory; AC = abstraction capacity; VIC = verbal inhibitory control), and unique to the FAB (C =
conceptualization; PB = prehension behavior; VF = verbal fluency). The asterisk represents tasks for which a significant difference was
found between AD and FTD patients (p < .05).

228.0, p = .09) were marginally significant. FTD patients Subtests unique to the FAB
exhibited a significantly poorer performance than AD
No significant differences were found on any of the
patients on the verbal working memory (U = 207.0,
tasks exclusive to the FAB, including conceptualization
p = .018), abstraction capacity (U = 172.5, p < .01),
(U = 235.5, p = .10), prehension behavior (U = 286.5,
and verbal inhibitory control (U = 199.5, p = .026)
p = .28), and verbal fluency (U = 301.0, p = .80).
tasks.
6 GLEICHGERRCHT ET AL.

IFS FAB PhFlu TMT-B WCSTc WCSTp

Groups
IFS CONTROL
bvFTD
AD

FAB

Figure 4. Correlation matrix showing the relationship between Institute of Cognitive Neurology (INECO) Frontal Screening (IFS)
and Frontal Assessment Battery (FAB) total scores and performance on classical executive tasks. For both executive screening tests,
significant correlations were found with executive tests. However, as revealed by the slope of the fit lines, correlations were stronger for
the IFS than for the FAB. PhFlu = phonological fluency; TMT–B = Trail Making Test–Part B; WCST = Wisconsin Card Sorting Test
(c = categories; p = perseverative errors).

Correlations between screening tools and set shifting, but depend strongly on motor performance.
executive tasks For this reason, we added a verbal inhibitory control task
(a brief, modified version of the Hayling test) that would
As shown in Figure 4, the total score on the IFS cor- provide us with both qualitative and quantitative infor-
related significantly with phonological fluency (r = .63, mation about this sphere within the executive domain.
p < .01), TMT–B (r = −.61, p < .01), and both cat- Another major component of executive function is work-
egories completed (r = .73, p < .01) and perseverative ing memory. Following Baddeley and Hitch’s (1974)
errors (r = −.69, p < .01) of the WCST. The FAB total work, we sought to tap on each component of their work-
also correlated significantly with all executive tasks, but ing memory model using three tasks: backwards digit
their relationships were not as strong as those with the span (central executive), verbal working memory (phono-
IFS (phonological fluency: r = .41, p < .01; TMT–B: logical loop), and spatial working memory (visuospatial
r = −.36, p < .01; WCST categories: r = .52, p < .01; sketchpad). Finally, because it had become evident dur-
WCST perseverative errors: r = −.34, p = .037). ing our clinical experience with bvFTD patients that
Moreover, the IFS showed a weaker (r = .42, p = .17) they systematically failed on tests of conceptual abstrac-
correlation with the ACE–R than did the FAB (r = .71, tion, we included a task involving the interpretation of
p < .01), which suggests that the latter test is not tap- proverbs.
ping on the executive domain as selectively, given that It is likely that the superior psychometric properties of
the ACE–R is indeed a general cognitive status screen- the IFS relative to the FAB in the assessment of patients
ing tool that features all domains except for the executive with bvFTD results from the incorporation of tasks that
one. A significant correlation was found between the IFS had demonstrated to us, during clinical practice, a high
and FAB total scores (r = .55, p < .01). sensitivity to detect subtle executive deficits. Evidence
to support this argument comes from the analysis per-
formed on each subtask of the FAB and the IFS: We
DISCUSSION found no significant differences between AD and FTD
patients on any of subtests unique to the FAB, yet three
Our results showed that, relative to the FAB, the INECO out of five of the subtests unique to the IFS were able
Frontal Screening (IFS) presented (a) higher sensitivity to differentiate between the two types of dementia (and
and specificity for the detection of dementia, (b) higher the remaining two showed a strong trend toward signifi-
discriminatory accuracy to differentiate bvFTD from cance). In this regard, we were not able to replicate the
AD patients, and (c) stronger correlations with executive findings of Lipton and collaborators (2005), who had
tasks. found that while the total score of the FAB was not useful
In designing the IFS, our group tried to include a set in differentiating executive performance of AD and FTD
of tasks that would tap into different executive func- patients, three subtests—namely, motor programming,
tions. We also chose those subtests originally included prehension behavior, and verbal fluency—differed signif-
in the FAB that seemed to be most sensitive for the icantly between the groups. It is likely that our inability
detection of executive deficits based on our everyday clin- to replicate such findings lies on the fact that patients
ical experience with this screening test. Accordingly, the included in the present study were in earlier stages of the
motor programming, conflicting instructions and motor disease, as revealed by the MMSE scores from our (AD:
inhibitory control (go/no-go) tests were included in the 24.4 ± 2.6, FTD: 27.4 ± 2.3) and their (AD: 20.7 ± 5.6,
IFS. The three of them demand response inhibition and FTD: 22.1 ± 6.4) study.
 COMPARING IFS AND FAB 7

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