Psychology
2012. Vol.3, No.6, 485-488
Published Online June 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.36068
Boston Naming Test: Gender Differences in Older Adults with
and without Alzheimer’s Dementia
James R. Hall1,2, Hoa T. Vo2, Leigh A. Johnson3, April Wiechmann1, Sid E. O’Bryant 1,3
1Institute of Aging and Alzheimer’s Disease Research,
University of North Texas Health Sciences Center, For t Worth, USA
2Department of Psychiatry, Behavioral Health and Neuroscience,
University of North Texas Health Sciences Center, For t Worth, USA
3Department of Internal Medicine, University of North Texas Health Sciences Ce nt e r,
Fort Worth, USA
Received April 5th, 2012; revised April 30th, 2012; accepted May 28th, 2012
The study clarifies the relationship between gender and performance on the BNT by controlling for the
effects of demographic and health risk factors. Participants were 468 outpatient individuals (153 diag-
nosed with probable Alzheimer’s Disease (AD) and 318 cognitively intact) enrolled in the Texas Alz-
heimer’s Research and Care Consortium cohort. Participants under went evaluations including medical
examination, interview, neuropsychological testing, and blood draw. The neuropsychological assessment
consisted of the Wechsler Digit Span, Logical Memory, and Visual Reproduction, along with the Trail
Making Test, Boston Naming Test (60-item version), verbal fluency (FAS), and the Geriatric Depression
Scale (GDS-30). To control for severity of cognitive impairment only mild AD as shown by a CDR
global score of 0.5 or 1.0 were used. Control males outperformed females (F = 10.81, p < .000, ES = .20).
AD males also performed significantly better than AD females (F = 17.13, p < .000, ES = .25). Gender
differences remain after covarying for estimated IQ, age, education, and presence of hyperlipidemia and
hypertension. Overall, within-group and between-group comparisons support prior findings that males
perform significantly better compared to females on the BNT even after controlling for health and level of
decline. Findings have implications for clinical practice and prospective test norm considerations.
Keywords: Boston Naming; Alzheimer’s Disease; Cardiovascular Risks; Gender
Introduction
Naming has long been recognized as one of the most sensi-
tive aspects of underlying aphasic disturbances. The Boston
Naming Test (BNT; Kaplan, Goodglass, &Weintraub, 1983)
has been used predominantly in older adults to assess the de-
gree of language disturbances. Studies have demonstrated that
the BNT (a measure of confrontational naming) is useful for
detecting progressive aphasia (Rogalski, Rademaker, & Wein-
traub, 2007) and can also serve as a clinical tool for differential
diagnosis of dementia (Randolph, Lansing, Ivnik et al., 1999;
Tsolaki, Tsantali, Lekka et al., 2003). Impaired performance on
the BNT has been implicated in Alzheimer’s disease (AD), an
amnestic dementia that impairs linguistic abilities leading to
eventual complete loss of language (Taler & Phillips, 2008).
The majority of the research on the BNT and dementia has
examined the effects of a number of variables including intel-
lectual capacity or intelligence quotient (IQ) (VanGorp, Satz,
Kiersch, & Henry, 1986), age (Albert, Heller, & Milberg, 1988;
Morrison, Ellis, & Quinlan, 1992), education (Welch, Doineau,
Johnson, & King, 1996; Zec, Burkett, Markwell, & Larsen,
2007), and ethnicity (Roberts & Hamsher, 1984; Ross & Lich-
tenberg, 1997). Welch and colleagues (1996), found that nam-
ing ability is slightly decreases with age after controlling for
education, with high school graduates demonstrating more ro-
bust abilities. To date, only a few studies have examined gender
differences in combination with age, education and level of
cognitive impairment (Zec et al., 2007; Randolph et al., 1999;
Ripich, Petrill, Withhouse, & Ziol, 1995). The study by Ran-
dolph et al. (1999) is the only research we are aware of that
examined gender differences in BNT performance in both cog-
nitively intact individuals and demented patients. The method-
ology used to determine level of decline or the severity of im-
pairment for the AD patient was not clearly delineated in the
Randolph et al. study.
In order to clarify the role of gender differences on BNT
performance it is important to take into account specific health
risk factors that may affect the cognitive processes involved in
object naming. To our knowledge, the potentially confounding
effects of vascular health have not been controlled for in any of
the research on BNT performance and gender. Vascular func-
tioning has been shown to have a significant impact on cogni-
tive processes related to naming. Processing speed and im-
paired executive functioning has been associated with cognitive
declines in diseases with vascular etiologies (Prins, Dijk, Heijer
et al., 2005). Although the BNT is not a timed sensitive meas-
ure and therefore not directly impacted by processing speed,
proficient performance on the task requires sufficient encoding
and processing of a visual stimulus (Grossman, McMillan,
Moore et al., 2004) within a relatively limited time frame
(typically 20 seconds Diseases due to vascular impairment lead
to subcortical and white-matter changes (Levy & Chelune,
2007), which contribute to the deterioration of visual perceptual
processes and hence may impair the ability to recognize and

J. R. HALL ET AL.
process the visual stimuli effectively. Additionally, gender di-
fferences have been noted in the literature suggesting that men
are at increased vascular risk compared to women (Barrett-
Connor & Bush, 1991; White, Rivera, & Davison, 2000). The
present study attempts to clarify the relationship between gen-
der and performance on the BNT by controlling for the effects
of education, age, and most importantly, vascular risks in cog-
nitively impai red and cognitively intact elder ly.
Method
468 individuals (153 diagnosed with probable AD and 318
determined to be cognitively intact) enrolled in the Longitudi-
nal Research Cohort of the Texas Alzheimer’s Research and
Care Consortium (TARCC), a well characterized cohort of AD
and normal controls assessed annually were analyzed. The
methodology of the TARCC project has been described in de-
tail elsewhere (Waring, O’Bryant, Reich et al., 2008). Briefly,
each participant undergoes an annual evaluation that includes a
medical examination, interview, neuropsychological testing,
and blood draw. AD patients met consensus based diagnosis for
probable AD based on NINCDS-ADRDA criteria (McKhann,
Drachman, Folstein et al., 1984). To control for the confound-
ing effect of severity of impairment and stage of disease the AD
sample was limited to individuals with mild AD as shown by a
CDR global score of .5 or 1.0.
The final AD sample consisted of 82 males and 71 females.
Controls (110 males; 208 females) performed within normal
limits on psychometric assessment and received a CDR global
score of .0. The breakdown of the CDR global scores was as
follows: 0 = 318 (controls), .5 = 61, (AD), 1.0 = 92 (AD). Par-
ticipants in the probable AD group were 54 to 102 years of age
(Males M = 75.17, SD = 7.95; Females M = 76.81, SD = 8.09)
and from 52 to 93 (Males M = 72.78, SD = 8.47; Females M =
69.98, SD = 8.70) for the control group. The characteristics of
the participants are presented in Table 1. Majority of partici-
pants were Caucasian (93%), black or African American was
the next largest group accounting for 4% of the sample. The
TARCC project received Institutional Review Board approval
and all participants and/or caregivers signed written informed
consent documents.
The neuropsychological assessment battery used in the
TARCC core battery consists of the following instruments: We-
chsler digit span, Logical Memory, and Visual Reproduction,
along with the Trail Making Test, Boston Naming Test (60-
item version), the FAS measure of verbal fluency, the Geriatric
Depression Scale (GDS-30), the AMNART to estimate verbal
Table 1.
Demographic characteristics of the sample.
AD (N = 153) NC (N = 318) p
Gender (M, F) 82 71 110 208 .000
Age (M, SD) 75.173
(7.95) 76.81 (8.09) 72.78 (8.47) 69.98 (8.70) .001
Education 15.27
(3.04) 14.20 (6.33) 16.24 (2.75) 15.29 (6.12) .212
Estimated IQ 109.12
(12.12) 109.13 (12.90) 117.44 (8.99) 115.34 (10.47) .000
M = Male, F = Female, M = Mean, SD = Standard Deviation, IQ = Intelligence
Quotient.
IQ and the Clinical Rating scale (CDR). The cognitive evalua-
tion was administered under controlled testing setting according
to standardized instructions.
Results
ANCOVA was applied to assess within group gender diffe-
rences. Comparisons were made within group to assess for
gender differences using ANCOVAs. The BNT scale scores
were used in all analyses. Covariates included age, estimated
IQ, level of formal education, existing hypertension and hyper-
lipidemia, and number of years smoked. As expected, in the
control group, males outperformed females (F = 10.81, p < .000,
ES = .20) with means (M = 13.46; SD = 2.89) for males and (M
= 11.76; SD = 3.10) for females. Males performed significantly
better than females in the AD group (F = 17.13, p < .000, ES
= .25) with means of (M = 8.43; SD = 3.82) for males and (M =
8.20; SD = 3.16) for females. Overall, within-group and be-
tween-group comparisons support prior findings that males
perform significantly better compared to females on the BNT
(F = 68.06, p < .000) even after covarying for level of estimated
IQ (F = 54.24, p < .000), age, (F = 11.27, p < .001), education
(F = 1.56, p = .212), and the presence of hyperlipidemia (F
= .18, p = .67) and hypertension (F = .22, p = .640). After con-
trolling for level of decline (using CDR scores) and covariates,
gender differences remain significant (F = 11.30, p < .000; ES
= .19) with robust naming abilities among AD males (M = 7.63;
SD = 3.65) compared to females (M = 6.60; SD = 3.45). Effect
size for gender difference in both normal controls and probable
AD groups was above 0.49. Overall, performance was best
among control males and worst among females with probable
AD (see Figure 1).
Discussion
The current finding provides support for gender differences
in performance on the Boston Naming Test for both cognitively
impaired and intact elderly. Prior studies have implicated the
role of age, education, and minority status, suggesting interac-
tions between these variables (Connor, Spiro, Obler, & Albert,
2004; Zec et al., 2007). Similar to previous findings (Randolph
et al., 1999), males generally out-performed females in both
control and AD groups. The present study, after controlling all
previously indicated relevant factors in addition to cardiovas-
cular health variables, found a consistent and nontrivial effect
0
2
4
6
8
10
12
14
16
Males Females
Sex
Bost on Naming Scale Score
AD
N
C
AD = Alzheimer’s, NC = Normal Controls
Figure 1.
Sex differences in group means.
486

J. R. HALL ET AL.
suggesting that both the control and the diagnostic group with
males scoring higher than females. Due to the relatively small
body of literature that have examined the current topic, it re-
mains unclear why males perform better than females on the
BTN. It can be speculated that, first and most simply, males
start a higher baseline as observed in cognitively intact indivi-
duals in the present sample. The present study did not demon-
strate educational differences as reported in several other stu-
dies (Albert et al., 1988; Fastenau, Denburg, & Mauer, 1998;
LaBarge, Edwards, & Knesevich, 1986; Nicholas, Obler, Albert,
& Goodglass, 1985). Other studies have suggested that educa-
tion is an important variable (Borod, Goodglass, & Kaplan,
1980; Hawkins, Sledge, Orleans et al., 1993; Henderson, Frank,
& Pigatt et al., 1998; Kent & Luszcz, 2002; Welch et al., 1996;
Zec et al., 2007). Despite not finding significant effects of edu-
cation, our study was consistent with previous studies (Albert et
al., 1988; Henderson et al., 1998; VanGorp et al., 1986) sup-
porting the role of IQ in BNT performance. The absence of a
significant education effect in our study may be due to the re-
stricted range of education in both controls and AD groups.
The effects of the presence hypertension and hyperlipidemia
were not significantly associated with performance on BNT. It
has been hypothesized that confrontational naming may be
impacted by subcortical white-matter changes effected by vas-
cular risks producing inefficient processing of visual stimuli
(Prins et al., 2005). The current findings suggest that co-morbid
vascular risks generally do not impact performance on the BNT.
However, additional research is warranted in this area because
it remains unclear whether gender differences will be detected
in patients with dementia of vascular etiologies at various
stages of decline.
There are a number of limitations that may effect generalize-
bility of the findings including sample size and the cross-sec-
tional nature of the study. The sample was also relatively highly
educated and predominately urban and Caucasian. Despite
these limitations, the overall findings demonstrate the impor-
tance of accounting for gender differences and advocates for
the use of gender as a factor when evaluating performance on
the BNT. Among the factors that impact performance, includ-
ing IQ, level of formal education, age, vascular health status
and cognitive status, the present data suggests that gender is the
most robust variable associated with performance on the BNT.
Prospective and longitudinal designs may contribute to under-
stand of progression and changes in confrontation naming ca-
pacity among elderly men and women.
Acknowledgements
This study was made possible by the Texas Alzheime r’s Re-
search Consortium (TARC) funded by the state of Texas
through the Texas Council on Alzheimer’s Disease and Related
Disorders.
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