2013. Vol.4, No.10A, 19-22
Published Online October 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.410A004
Copyright © 2013 SciRes. 19
The Impact of Cognitive Reserve on the Neuropsychological
Functioning of Hispanic Patients with
Minor Neurocognitive Disorder
Jorge A. Herrera Pino1,2, Nora Dieguez1,3, Jose Armas1,2
1Medical Care Consortium, Inc., Miami, USA
2Herbert Wertheim College of Medicine, Florida International University, Miami, USA
3Neurobehavioral Institute of Miami, Coral Gables, Miami, USA
Received August 7th, 2013; revised September 9th, 2013; accepted September 28th, 2013
Copyright © 2013 Jorge A. Herrera Pino et al. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
The purpose of this study was to explore the impact of cognitive reserve, on the neuropsychological status
of a sample of otherwise healthy Hispanic patients, who complained of memory difficulties, and thus
were suspected to present minor neurocognitive disorder. To this effect, 100 consecutive cases referred
for neuropsychological evaluation by their primary care physicians comprised the initial sample. Two
groups of 32 patients were formed on the basis of their scores in the Cognitive Reserve Questionnaire
(CRQ) that was administered to all participants. The results obtained by both groups in an eclectic battery of
neuropsychological instruments were compared. The results indicated that the CRQ High Score group had
significantly better performance than the CRQ Low Score group in the tests administered, except those
tapped into memory processes. This was interpreted, to be related to the fact that all of these patients fell
into the category of mild cognitive impairment of the amnestic type, as neither group performed well in
these specific instruments. The findings of this study were interpreted to lend support to the notion that
better cognitive reserve was associated with better cognitive status in the later years of life.
Keywords: Cognitive Reserve; Neuropsychological Evaluation; Mild Neurocognitive Disorder; Mild
The seminal work of Yaakov Stern (2002) opened the doors
to a whole field of scientific endeavor related to the concept of
cognitive reserve. In this regard, this concept has been the focus
of a significant amount of research in recent years (cf. Stern,
2006, 2009; Stern et al., 2003). At the center of the notion of
cognitive reserve is the assumption that there are things people
can do, to better their cognitive health, and to improve the
chances of maintaining an adequate cognitive status throughout
the aging process, or even when assailed by disease that would
otherwise lead to impaired cognition (Vasile, 2013).
Patients who present to their primary care physicians or to
specialists complaining of memory difficulties, have often been
placed within the category of mild cognitive impairment, as per
the original ideas proposed by Petersen (2004), Petersen et al.
(2001), and Petersen et al. (1999). They were even diagnosed
with mild cognitive impairment (MCI) of the amnestic type.
There was also great concern regarding the rate of conversion
of these patients to a full blown dementing disorder of primary
degenerative type, such as Alzheimer’s disease.
However, the term mild cognitive impairment, as such, while
being a useful concept, was never made a diagnosis, even
though some authors referred to it (cf. Albert et al., 2013). Re-
cently, the fifth edition of the Diagnostic and statistical manual
of mental disorders of the American Psychiatric Association
(DSM-5; APA, 2013) includes the diagnosis of minor neuron-
cognitive impairment, within which mild cognitive impairment
has been included. This is the term used throughout this paper
to refer to the participants of this study.
This study was approved by the Institutional Review Board
of the Medical Care Consortium, Inc., (MCCI) as an archival,
cross-sectional, quasi-experimental research.
The participants of this study were 100 consecutive, other-
wise healthy, Hispanic patients seen at the Cognitive Health
Program of MCCI, who were referred by their primary care
physicians for presenting memory complaints. MCCI is a
multi-center organization that provides primary and specialized
medical care in out-patient settings. The initial sample of 100
patients included 62 females and 38 males.
Two samples were derived on the bases of the scores ob-
tained in the Cognitive Reserve Questionnaire (CRQ; Alberca
Serrano, 1998) described below. The 32 patients with the high-
J. A. HERRERA PINO ET AL.
est scores in the CRQ (CRQH) had an average score of 12.75
(sd = 1.98), an average chronological age of 73.02 years (sd =
8.65), and an average of 13.78 years of education (sd = 4.03).
The 32 patients with the lowest scores in the CRQ (CRQL)
obtained an average score of 4.00 (sd = 2.07), they had an av-
erage chronological age of 70.19 years (sd = 7.28), and an av-
erage level of education of 4.63 years (sd = 3.49). As seen in
Table 1, the means of both groups differed significantly in the
scores obtained in the CRQ and in the level of education, but
not in chronological age.
Instruments and Procedures
All participants were administered the CRQ, as well as an
eclectic battery of neuropsychological instruments described
The Cognitive Reserve Questionnaire (CRQ; Alberca Ser-
rano, 1998) was administered in its original version in Spanish.
This instrument yields a total score of 25 and includes assess-
ment of the following dimensions:
Level of education
Highest level of education of one of the parents
Additional training or courses taken
Occupation or profession
Formal musical training or education
Languages spoken at a conversational level
Intellectual games or pastime
In addition to the CRQ, all participants were administered an
eclectic battery of neuropsychological instruments based on a
process oriented, evidence based paradigm. The instruments
included in this battery were the written (SDW); and oral (SDO)
administrations of the Symbol Digit Modalities Test (Smith,
1973, 1982, 2002), the Controlled Oral Word Association Test
(COW; Lezak, Howieson, & Loring, 2004; Spreen & Strauss,
1998), the Boston Naming Test (BNT; Kaplan, Goodglass, &
Weintraub, 1983, 1996), the administrations RAI (recall of the
list in the first trial), RAV (recall of the list in the fifth trial),
and RAD (recall of the list with a 20 minute delay) of the Rey
Auditory Verbal Learning Test (Schmidt, 1996), the copy
(ROC) and delayed (30 minute) (ROM) administrations of the
Rey Osterrieth Complex Figure Test (Rey, 2003; Meyers &
Meyers, 1995), and the Revised Benton Visual Retention Test
(BVR; Benton, 1974, 2002; Sivan, 1992). All neuropsycho-
logical tests were administered in Spanish, as this was the pre-
ferred language of all participants.
Differences between the mean values obtained, by the two
Demographic data by group.
Groups by CRQ score
CRQLS N = 32CRQHS N = 32 Student t
CRQ 4.00 (2.07) 12.75 (1.98) −17.224*
Age 70.19 (7.28) 73.03 (8.65) −1.422
Education (years) 4.62 (3.49) 13.781 (4.030) −9.705*
CRQLS = Cognitive Reserve Questionnaire Low Scoring, CRQHS = Cognitive
Reserve Questionnaire High Scoring, ( ) standard deviation, *p ≤ 0.000.
groups of patients with high and low scores in the CRQ in the
different measures included in this study, were analyzed by
means of the Student-t statistical procedure.
As noted above, Table 1 includes the differences between
both groups of participants in the variables of scores in the
CRQ, chronological age, and level of education. Table 2 shows
the mean values obtained by both groups in the different in-
struments included in the neuropsychological battery adminis-
tered to all participants.
An inspection of this table reveals that the mean score ob-
tained by the CRQ High Scoring (CRQHS) group in the written
administration of the Symbol Digit Modalities Test (SDW) was
26.59 (sd = 9.70), while the corresponding value obtained by
the CRQ Low Scoring (CRQLS) group was 12.78 (sd = 9.05).
The difference between these two means was found to be sig-
nificant at the level of p < 0.000, Relative to the oral admini-
stration of this instrument (SDO), the mean score obtained by
the CRQHS group was 29.68 (sd = 10.92), whereas the CRQLS
group obtained a mean value of 15.25 (sd = 10.31). Once again,
the difference between the means of both groups was found to
be significant at the level of p < 0.000.
The results obtained by both groups in the Controlled Oral
Word Association Test (COW) are as follows. The CRQHS
group obtained a mean value of 24.65 (sd = 8.61). The CRQLS
group obtained a mean score of 15.68 (sd = 7.68). The differ-
ence between these two means is statistically significant at the
level of p < 0.000.
A 30 item version of the Boston Naming Test (BNT; Saxton
et al., 2000) was used as part of the neuropsychological test
battery administered to all the participants of this study. The
Means and standard deviations in neuropsychological tests by group.
Groups by CRQ score
CRQLS N = 32 CRQHS N = 32 Student t
SDO 15.25 (10.31) 29.68 (10.920 −5.436*
SDW 12.78 (9.05) 26.59 (9.70) −5.887*
COW 15.68 (7.68) 24.65 (8.61) −4.393*
BNT 16.87 (3.94) 22.68 (4.27) −5.654*
RAI 3.71 (1.08) 4.28 (1.44) −1.763
RAV 6.00 (2.40) 7.87 (2.12) −3.304**
RAD 4.40 (2.48) 5.87 (2.70) −2.259***
ROC 22.01 (7.40) 30.23 (4.44) −5.383*
ROM 6.29 (3.35) 10.71 (5.40) −3.933*
BVR 2.12 (1.56) 3.75 (1.79) −3.863*
NP Tests = Neuropsychological Tests, CRQLS= Cognitive Reserve Questionnaire
Low Scoring, CRQHS = Cognitive Reserve Questionnaire High Scoring, SDO =
Symbol Digit Modalities Oral, SDW = Symbol Digit Modalities Written, COW =
Controlled Oral Word Association, BNT = Boston Naming Test, RAI = Rey
Auditory Verbal Learning (I), RAV= Rey Auditory Verbal Learning (V), RAD =
Rey Auditory Verbal Learning (D), ROC= Rey Osterrieth Complex Figure Copy,
ROM = Rey Osterrieth Complex Figure Memory, BVR = Benton Visual Reten-
tion, ( ) standard deviation, *p ≤ 0.000, **p ≤ 0.002, ***p ≤ 0.027.
Copyright © 2013 SciRes.
J. A. HERRERA PINO ET AL.
mean score obtained by the CRQHS group in the BNT was
22.68 (sd = 4.27), while the corresponding value obtained by
the CRQLS group was 16.87 (sd = 3.94). The difference be-
tween these means was found to be statistically significant at
the level of p < 0.000.
The mean score obtained by the CRQHS group in the first
administration of the list of words of the Rey Auditory Verbal
Learning Test (RAI) was 4.28 (sd = 1.44), while the mean score
for the CRQLS group was 3.71 (sd = 1.08). The difference
between these two means was not found to be statistically sig-
nificant (p = 0.083). In the fifth administration of the list of
words of this instrument (RAV), the mean score value for the
CRQHS group was 7.86 (sd = 2.12) and for the CRQLS group
the mean score was 6.00 (sd = 2.40). This difference in mean
values was found to be significant at the level of p = 0.002.
The mean score obtained by the CRQHS group in the de-
layed (20 minutes) administration of the list of words of the
Rey Auditory Verbal Learning Test (RAD) was 5.87 (sd =
2.70), with a corresponding mean value of 4.40 (sd = 2.48) for
the CRQLS group. The difference between these means was
found to be statistically significant at the level of p = 0.027.
Relative to the Rey Osterrieth Complex Figure Test, the
findings were as follows. The CRQHS group obtained a mean
score of 30.23 (sd = 4.44) in the copy administration (ROC).
The CRQLS group obtained an average score of 22.01 (sd =
7.40). The difference between these means was found to be
highly significant (p < 0.000). In the delayed (30 minutes) re-
call administration of this instrument (ROM), the CRQHS
group obtained a mean value of 10.71 (sd = 5.40), and the
CRQLS group obtained a mean value of 6.29 (sd = 3.35). Once
more, the difference between these two means was found to be
highly significant (p < 0.000).
In the Revised Benton Visual Retention Test (BVR), the
CRQHS group obtained an average score of 3.75 (sd = 1.79).
The corresponding value for the CRQLS group was 2.12 (sd +
1.56). The difference between these two means was also found
to be highly significant (p < 0.000).
It is evident, on the bases of the results described above, that
the level of cognitive reserve attained by the participants in this
study has a significant and measurable impact on their neuro-
cognitive status, as measured by an eclectic battery of neuro-
psychological instruments. This impact was seen clearly on the
attentional and incidental memory abilities measured by the
written and oral administrations of the Symbol Digit Test. The
results obtained in this study also revealed the impact of cogni-
tive reserve on the verbal fluency and word finding abilities
measured by the Controlled Oral Word Association Test.
The level of cognitive reserve was also noted to have an im-
pact on the naming function of language, as measured by the
Boston Naming Test. In addition to this, the level of cognitive
reserve was also found to have an impact on the visual con-
structional praxis abilities measured by the copy administration
of the Rey Osterrieth Complex Figure Test, as well as the inci-
dental memory functions assessed by the delayed memory ad-
ministration of this instrument.
On the other hand, the impact of the level of cognitive re-
serve, as measured by the CRQ did have a clear impact on tasks
in which memory was an important function. The results of the
recall of the initial presentation of the supra-span list of words
(RAI) of the Rey Auditory Verbal Learning Test did not differ
significantly between the two groups of patients.
Even though the mean values obtained by both groups in the
fifth administration of the word list (RAV) and the delayed
administration (RAD) showed statistical significance, the actual
values differed by less than two (2) points. It is very difficult to
make clinical decisions on the bases of such a narrow margin of
difference. The same may be said of the visual memory func-
tions assessed by the Revised Benton Visual Retention Test
The interpretation of these findings brings out the ever pre-
sent concern of the difference between statistical significance
and clinical significance. Whereas these results show statistical
significance, once again, it is very difficult to translate them
into the clinical setting.
It should be noted that both groups did not perform well in
measures related to memory processes. One possible explana-
tion is the fact that these patients can be characterized as pre-
senting what has been described as mild cognitive impairment
of the amnestic type (now referred to as minor neurocognitive
disorder), as they were referred to the Cognitive Health Pro-
gram of MCCI, by their primary care physicians, for having
reported to them memory difficulties to begin with..
Conclusion and Recommendations
The findings of this study clearly support the initial premise
that there are things that can be done throughout the life cycle,
to improve overall cognitive functioning in the later years of
life. It is important to note that the sample included in this study
is a referred sample, that is, patients referred for neuropsy-
chological evaluation due to memory complaints. In this regard,
it would be important to explore the impact of cognitive reserve
on neuropsychological status of healthy, non-referred individu-
als, as well. It would also be important to replicate this study
with patients that have begun to show symptoms of probable
The knowledge gained through this research can help in the
development of life long strategies to improve or increase cog-
nitive reserve. It can also point the way to the need for devel-
oping and implementing neurobehavioral interventions to
lessen the impact of the aging process or the presence of medi-
cal conditions that may accelerate cognitive decline and result
in functional impairments.
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