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Chilean version of the INECO Frontal Screening (IFS-Ch): Psychometric

properties and diagnostic accuracy

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Dement Neuropsychol 2013 March;7(1):40-47 Original Article

Chilean version of the INECO

Frontal Screening (IFS-Ch)
Psychometric properties and diagnostic accuracy
Josefina Ihnen1, Andrés Antivilo2, Carlos Muñoz-Neira1, Andrea Slachevsky3

ABSTRACT. Objective: This study sought to analyze the psychometric properties and diagnostic accuracy of the Chilean
version of the INECO Frontal Screening (IFS-Ch) in a sample of dementia patients and control subjects. Methods: After
adapting the instrument to the Chilean context and obtaining content validity evidence through expert consultation, the IFS-
Ch was administered to 31 dementia patients and 30 control subjects together with other executive assessments (Frontal
Assessment Battery [FAB], Modified version of the Wisconsin Card Sorting Test [MCST], phonemic verbal fluencies [letters A
and P] and semantic verbal fluency [animals]) and global cognitive efficiency tests (Mini mental State Examination [MMSE]
and Addenbrooke’s Cognitive Examination-Revised [ACE-R]). Caregivers of dementia patients and proxies of control subjects
were interviewed with instruments measuring dysexecutive symptoms (Dysexecutive Questionnaire [DEX]), dementia severity
(Clinical Dementia Rating Scale [CDR]) and functional status in activities of daily living (Activities of Daily Living Scale [IADL]
and Technology-Activities of Daily Living Questionnaire [T-ADLQ]). Convergent and discriminant validity, internal consistency
reliability, cut-off points, sensitivity and specificity for the IFS-Ch were estimated. Results: Evidence of content validity was
obtained. Evidence of convergent validity was also found showing significant correlations (p<0.05) between the IFS-Ch
and the other instruments measuring: executive functions (FAB, r=0.935; categories achieved in the MCST, r=0.791;
perseverative errors in the MCST, r= –0.617; animal verbal fluency, r=0.728; A verbal fluency, r=0.681; and P verbal
fluency, r=0.783), dysexecutive symptoms in daily living (DEX, r= –0.494), dementia severity (CDR, r= –0.75) and functional
status in activities of daily living (T-ADLQ, r= –0.745; IADL, r=0.717). Regarding reliability, a Cronbach’s alpha coefficient
of 0.905 was obtained. For diagnostic accuracy, a cut-off point of 18 points (sensitivity=0.903; specificity=0.867) and an
area under curve of 0.951 were estimated to distinguish between patients with dementia and control subjects. Discussion:
The IFS-Ch showed acceptable psychometric properties, supported by evidence of validity and reliability for its use in the
measurement of executive functions in patients with dementia. The diagnostic accuracy of the IFS-Ch for detecting dementia
patients was also considered acceptable.
Key words: INECO Frontal Screening, executive functions, neuropsychological tests, dementia

VERSÃO CHILENA DO RASTREIO FRONTAL INECO: PROPRIEDADES PSICOMÉTRICAS E UTILIDADE DIAGNÓSTICA

RESUMO. Objetivo: Analisar as propriedades psicométricas e utilitário de diagnóstico da versão chilena do rastreio frontal
INECO (IFS-Ch) em uma amostra de pacientes com demência e controles. Métodos: Após a adaptação do instrumento
para o contexto chileno e obtenção de evidências de validade de conteúdo, o IFS-Ch foi administrado a 31 pacientes com
demência e 30 indivíduos do grupo controle, além de outros testes de eficiência cognitiva global e executiva. Cuidadores
de pacientes com demência e informantes de indivíduos controles foram entrevistados com instrumentos de medidas de
sintomas disexecutivos, gravidade da demência e estado funcional nas atividades da vida diária. Validade convergente
e discriminante, consistência interna, pontos de corte, sensibilidade e especificidade para o IFS-Ch foram estimados.
Resultados: A evidência de validade de conteúdo foi obtida através de consulta a um especialista. Evidências de validade
convergente foram encontrados, bem como, descritas correlações significativas entre o IFS-Ch e outros instrumentos de

1
Unidad de Neurología Cognitiva y Demencias, Servicio de Neurología, Hospital del Salvador. Santiago, Región Metropolitana, Chile. Universidad de Chile. 2De-
partamento de Psicología, Facultad de Ciencias Sociales, Universidad de Chile. Departamento de Psicología, Facultad de Ciencias Sociales, Universidad de Chile.
3
Unidad de Neurología Cognitiva y Demencias, Servicio de Neurología, Hospital del Salvador. Santiago, Región Metropolitana, Chile. Universidad de Chile. Departa-
mento de Psicología, Facultad de Ciencias Sociales, Universidad de Chile. Centro de Investigación Avanzada en Educación, Universidad de Chile. Departamento de
Farmacología Molecular y Clínica, ICBM y Departamento de Ciencias Neurológicas Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile. Servicio
de Neurología, Clínica Alemana de Santiago, Región Metropolitana, Chile.

Andrea Slachevsky. Unidad de Neurología Cognitiva y Demencias, Servicio de Neurología, Hospital del Salvador – Avenida Salvador 364 – Santiago – Región
Metropolitana – Chile. E-mail: [email protected]

Disclosure: The authors report no conflicts of interest.

Received November 04, 2012. Accepted in final form January 08, 2013.

40 INECO Frontal Screening: Chilean version    Ihnen J, et al.

 Dement Neuropsychol 2013 March;7(1):40-47

medidas: de funções executivas (FAB, r=0,935; categorias alcançadas no MCST, r=0,791; erros perseverativos na MCST,
r= –0,617; fluência verbal animais, r=0,728; “A” de fluência verbal, r=0,681; gravidade de demência e fluência verbal de
“P”, r=0,783), sintomas disexecutivos na vida diária (DEX, r= –0,494), (CDR, r= –0,75) e estado funcional nas atividades da
vida diária (T-ADLQ, r= –0,745; AIVD, r=0,717). Quanto à confiabilidade, coeficiente alfa de Cronbach de 0,905 foi obtido.
Quanto a utilidade de diagnóstico, um ponto de corte de 18 pontos (sensibilidade=0,903, especificidade=0,867) e uma área
sob a curva de 0,951 foi estimada para distinguir entre pacientes com demência e sujeitos controles. Discussão: O IFS-Ch
mostra propriedades psicométricas aceitáveis, apoiadas por evidências de validade e confiabilidade para sua utilização
como medida de funções executivas em pacientes com demência. Sua utilidade diagnóstica para detectar pacientes com
demência também é considerada aceitável.
Palavras-chave: INECO triagem frontal, funções executivas, testes neuropsicológicos, demência.

INTRODUCTION (Luria Motor Series, Conflicting Instructions and Go-no

E xecutive functions constitute a group of higher or-

der abilities that coordinate basic cognitive process-
es in order to regulate, control and execute goal-orient-
go). In addition, the IFS includes new subtests, most of
them assessing various dimensions of working memo-
ry. Figure 1 shows the detailed structure of the IFS, de-
ed behaviors that require new and creative solutions.1-3 scribes the variables assessed by the test, its indicators
These include a wide range of cognitive processes such and sub-indicators, and the subtests that measure each
as inhibition, working memory, shifting, verbal reason- indicator or subindicator.
ing, multitasking and planning,4,5 all of which involve Since the IFS has only been validated in Argentina
significant activity of the frontal lobes and “frontal lobe and to the best of our knowledge neither content valid-
systems”, i. e. those areas with direct connections with ity nor correlation of the IFS with functionality and dys-
the frontal lobes.6 executive behaviors in daily living have been examined,
This cognitive domain is impaired in numerous neu- it would be valuable to consider these aspects in order
rological and neuropsychiatric pathologies, such as focal to complement the study of the instrument. Therefore,
lesions involving the frontal lobes (abscesses, strokes or the aim of the present study was to adapt the IFS to the
tumors), inflammatory diseases, neurodegenerative dis- Chilean cultural context and evaluate its psychometric
orders, schizophrenia, obsessive compulsive disorder, properties and diagnostic accuracy in a sample of con-
etc.7 Executive dysfunction has also been observed early trol subjects and dementia patients.
in most types of dementia, to the point where some au-
thors have defined it as its core symptom.8 Accordingly, METHODS
the assessment of executive functions contributes to an Subjects. The study was carried out in a convenience sam-
early diagnosis of dementia. Moreover, executive defi- ple, which included participants of both sexes, Spanish
cits are prominent symptoms of some dementia syn- speakers, aged 52 or older, with at least three years of
dromes, such as frontotemporal dementia (behavioral formal education. All subjects had a proxy that gave rel-
variant)9 and vascular dementia10,11 Hence, the assess- evant information about their everyday activities and
ment of this cognitive domain also contributes to the behavior. Subjects were divided into two groups:
differential diagnosis of the specific type of dementia. A clinical sample, including 31 patients recruited
The above-mentioned facts, together with the high from the Cognitive Neurology and Dementias Unit
and increasing prevalence of dementia,12 have prompted (Unidad de Neurología Cognitiva y Demencias) of the
the development of executive screening tests to be ap- Neurology Service at the Hospital del Salvador in San-
plied in neurological and general medical practice with tiago, Chile. The diagnosis of dementia was provided
elderly patients that can provide brief and quick as- by a Neurologist based on detailed neurological, neu-
sessment of this cognitive domain. The INECO Frontal ropsychological, laboratory, and neuroimaging data
Screening (IFS) is an executive screening test that as- from each participant. The first step in the diagnostic
sesses several executive processes using a few tasks.13 It process was to determine the presence of dementia
comprises three of the subtests included in the Frontal using the DSM-IV-TR criteria.17 When these criteria
Assessment Battery (FAB) - another executive screening were met, the Neurologist determined the specific type
test that has shown good characteristics for assessing of dementia using multiple diagnostic criteria for AD
executive dysfunctions:14,15 those which have shown the (i. e., NINCDS-ADRDA), vascular dementia (i. e., AD-
highest sensitivity according to the test author’s every- DTC, NINDS-AIREN), Dementia with Lewy Bodies (i.
day clinical experience13 as well as empirical evidence16 e., third report of the DLB Consortium) or frontotem-

Ihnen J, et al.    INECO Frontal Screening: Chilean version 41

 Dement Neuropsychol 2013 March;7(1):40-47

Groups of tasks
Variable Indicators Subindicators Subtests
(executive processes)

Motor Luria motor

programming series

Response inhibition Resistance to Conflicting

and set shifiting interference instructions

Motor inhibitory
Go- no go
control
Inhibitory
control
Verbal inhibitory Modified
control Hayling test

Verbal working Months

memory backwards
Executive Verbal working
functions memory
Numerical working Backwards
Working memory memory digit span

Spatial working Modified Corsi

memory tapping test

Capacity of Capacity of Proverb

abstraction abstraction interpretation

Figure 1. Structure of the INECO Frontal Screening.

poral dementia (i.e. Consensus for FTD diagnosis).18-21 points), Months backwards (2 points), Backwards digit
All patients had a Clinical Dementia Rating Scale (CDR) span (6 points), Modified Corsi tapping test (4 points),
≥1. More specifically, 10 patients with AD, 3 with VD, 2 Proverb interpretation (3 points) and Modified Hayling
with mixed dementia, 5 with LBD, 5 with bvFTD, 2 with Test (6 points). Thus, the IFS has a maximum possible
SD and 4 dementia patients with non-specified etiol- score of 30 points. High scores indicate preservation
ogy, were included in the sample. of the executive functions. In this study, the IFS was
The control sample comprised 30 subjects with simi- adapted to the Chilean cultural context (IFS-Ch) and
lar socio-demographic characteristics (age, sex and years then administered to all subjects.
of education) to those of the clinical sample. All partici- All subjects were assessed with the following ex-
pants included in this group had CDR=0 and presented ecutive tests to estimate convergent validity. [1] The
no symptoms or history of neurological or psychiatric Modified version of the Wisconsin Card Sorting Test
diseases. (MCST),22 a brief version of the widely known Wiscon-
Finally, exclusion criteria for both groups were: sin Card Sorting Test23,24 designed originally to study
[1] presence of depression as measured by the Geriat- “abstract behavior” and “set-shifting ability” and later
ric Depression Scale (score ≥5 points); [2] presence of proposed as being sensitive for assessing frontal dam-
Anxiety Disorder as measured by the Zung Scale (score age.24 The MCST is a classification task in which the sub-
≥51 points); and [3] presence of severe sensory deficits ject must find the sorting criteria and maintain it for a
(loss of vision and/or hearing) that could impede test number of trials.14 This particular version was used as
administration. it simplifies and reduces ambiguity in administration,
making it more suitable for elderly patients.25 [2] Ver-
IFS and other neuropsychological tests. As outlined above, bal fluency tasks, or controlled oral word-association, in
the IFS is a screening test for executive dysfunctions. which subjects have to generate words following a given
The tasks included in the IFS are: Luria motor series (3 criteria. This test is sensitive for assessing executive
points), Conflicting instructions (3 points), Go-no go (3 dysfunction24,26 and semantic memory impairment.24

42 INECO Frontal Screening: Chilean version    Ihnen J, et al.

 Dement Neuropsychol 2013 March;7(1):40-47

Semantic verbal fluency (animals) and phonemic ver- scores, for which the Spearman rank correlation test
bal fluencies (letters A and P)27 were specifically used. was employed. Reliability was assessed using the Cron-
[3] The FAB, a screening test for executive dysfunction bach’s alpha coefficient. The sensitivity and specificity of
that assesses conceptualization, mental flexibility, mo- the IFS-Ch for detecting the presence of dementia were
tor programming, resistance to interference, inhibitory evaluated using the receiver operating characteristic
control and environmental autonomy.14 (ROC) analysis.
All participants were also tested with global cog-
nitive efficiency measures: [1] the Mini Mental State Ethical concerns. The study was approved by the Eth-
Examination (MMSE),28 the most commonly used cog- ics Committee at the Servicio de Salud Metropolitano
nitive screening test internationally;29 and [2] the Ad- Oriente. Informed consent was obtained from control
denbrooke’s Cognitive Examination Revised-Chilean subjects, dementia patients and their closest relatives.
Version (ACE-R-Ch),30 a test that assesses five cognitive
domains: orientation and attention, memory, verbal flu- RESULTS
ency, language and visuospatial abilities. Adaptation. Given its sociocultural nature, the proverb in-
Proxies were interviewed with instruments to assess terpretation subtest of the IFS was adapted to the Chil-
dysexecutive symptoms in daily life (Dysexecutive Ques- ean cultural context. Using a four-point Likert scale, six
tionnaire [DEX]),31 dementia severity (CDR)32 and func- experts in the neuropsychological field were consulted
tional capacity in activities of daily living (Instrumental about the capacity of the three proverbs included in the
Activities of Daily Living Scale [IADL]33 and Technology- original test and three proverbs proposed as relatively
Activities of Daily Living Questionnaire [T-ADLQ]).34 common in Chile to assess executive function and their
level of familiarity in the Chilean cultural context. The
Procedure. The IFS was first adapted to the Chilean cul- three proverbs that presented the highest means and
tural context and its content validity was assessed by the lowest standard deviations were selected. Table 1
consultation with experts through a content validity summarizes the statistical parameters for the experts’
questionnaire. All subjects were assessed by the modi- responses. Only minor modifications were made to the
fied IFS (IFS-Ch) and the other instruments previously rest of the test administration procedure and scoring in-
described. structions in order to standardize the assessment proce-
dure as much as possible.
Statistical analysis. All statistical analyses were performed
with significance level set at 0.05. Data analysis was per- Demographic and neuropsychological data. Table 2 shows de-
formed with PASW Statistics 18 software. Differences mographic and neuropsychological data for the clinical
in sex were analyzed using the χ² test. Differences in and control samples. No significant differences in sex,
age, years of education and test scores between groups age or years of education were found among the groups
were analyzed using the t test for independent samples. (p>0.05). In contrast, the scores of all the instruments
A one-way MANOVA analysis was conducted to com- administered to subjects and their informants differed
pare results across subtests of the IFS-Ch by diagnostic significantly between the studied groups (p<0.05).
category. The correlations between scores of two tests
were evaluated using the Pearson coefficient, with the Influence of socio-demographic variables on IFS-Ch perfor-
exception of the association between CDR and IFS-Ch mance. In order to determine the influence of demo-

Table 1. Mean and standard deviation of the proverbs’ capacity to assess executive functions and level of familiarity in Chilean population.
Proverbs Capacity to assess executive functions Level of familiarity in Chile
Perro que ladra no muerde 3.67±0.516 3.67±0.516
A mal tiempo, buena cara 3.5±0.837 3.83±0.408
En casa de herrero, cuchillo de palo 3.83±0.408 3.67±0.516
Más vale pájaro en la mano que cien volando 3.83±0.408 3.67±0.516
Camarón que se duerme se lo lleva la corriente 3.67±0.516 3.5±0.548
Si el río suena es porque piedras trae 3.67±0.516 3.33±0.516
Results expressed in Mean±Standard Deviation.

Ihnen J, et al.    INECO Frontal Screening: Chilean version 43

 Dement Neuropsychol 2013 March;7(1):40-47

Table 2. Demographic and neuropsychological data.

Descriptive statistics by group Comparison
Parameters Control (n=30) Dementia (n=31) Significance
Age 70.9±8.2 74.1±9.2 n. s.
Years of education 11.9±4.5 9.7±4.7 n.s.
Sex* %Men (n) 46.7% (14) 54.8% (17) n.s.
%Women(n) 53.3% (16) 45.2% (14)
IFS-Ch 21.7±3.4 9.8±5.7 **
FAB 16±1.6 9.1±3.9 **
MCST (categories achieved) 4.9±1.4 2.2±1.4 **
MCST (perseverative errors) 2.5±3.1 7.7±4.5 **
“A” verbal fluency 11.7±4.4 5.3±4.3 **
“P” verbal fluency 15.1±4.5 6.6±5.2 **
Animals verbal fluency 17.2±5.4 4.8±3.1 **
DEX 8.7±8.3 33.8±16.2 **
CDR 0±0 1.6±0.8 **
IADL 7.7±0.6 3.5±1.9 **
T-ADLQ 4.1±5.9 49.5±18.8 **
ACE-R-Ch 90.9±7.1 49.4±18.7 **
MMSE 28.9±1.3 18.1±6.6 **
Results expressed in Mean±Standard Deviation. *Chi-Square, all other comparisons were carried out with a t test for independent
samples. **Significant difference, p<0.05. n.s.: non-significant difference, p>0.05.

graphic variables on IFS-Ch performance, the correla- For 5 of the 8 subtests, all the experts considered that
tion between demographic characteristics and IFS-Ch the instructions were formulated clearly, while for the
total scores was estimated. No significant association 3 remaining subtests, one expert considered that the
was found between IFS-Ch total scores and age (r= instructions were formulated poorly. The latter expert
–0.197; p>0.05), whereas a significant correlation was suggested changes to clarify the instructions, which
found between IFS total scores and years of education were later incorporated into the test. A new version of
(r=0.48; p<0.001). Regarding sex, no significant gender the IFS-Ch was then devised according to these observa-
differences were found on IFS performance (t= –0.25; tions. This new version had only minor differences com-
p>0.05). In summary, only years of education showed pared with the original test.
an influence on IFS performance.
Discriminant validity. The performance of the two groups
Evidence of validity. Content validity. Five experts with at differed significantly (p<0.05). Average total scores
least two years of experience in the field of neuropsy- on the IFS-Ch and each of its subtests were signifi-
chology answered a content validity questionnaire de- cantly lower in the clinical sample (Table 3). A one-way
signed for the IFS-Ch. In this questionnaire, the concep- MANOVA revealed a significant multivariate main ef-
tual and operational definitions of executive functions fect for diagnosis, Wilks’ Lambda=0.225, F(8, 52)=22.398,
and its indicators were presented. The definition of each p<0.001, partial eta squared=0.775. The power to detect
indicator was followed by the administration and scor- the effect was 1.00.
ing instructions for the corresponding subtest. Subse- The standardized mean differences between the de-
quently, the experts were asked about the capacity of mentia and control groups showed a Cohen’s d value (ef-
each subtest to assess executive function, its capacity to fect size r) of 2.54 (0.79) for the IFS-Ch.
measure the corresponding indicator, and the clarity of
the administration and scoring instructions, leaving a Convergent and divergent validity. The total IFS-Ch scores
space for any other observations. All the experts agreed significantly correlated (p<0.05) with other measures of
that each of the subtests measured executive functions executive functions (categories achieved in the MCST,
and that each subtest assessed its respective indicator. perseverative errors on the MCST, phonemic verbal flu-

44 INECO Frontal Screening: Chilean version    Ihnen J, et al.

 Dement Neuropsychol 2013 March;7(1):40-47

Table 3. Performance of dementia patients and control subjects in the IFS-Ch and its subtests.
Descriptive statistics by group Comparison
Subtest Dementia patients (n=31) Control subjects (n=30) t Significance
Luria motor series 1.3±1.1 2.8±0.5 7.33 **
Conflicting instructions 1.7±1 2.9±0.3 6.24 **
Go- No go 1.2±0.8 2.3±0.8 5.51 **
Backwards digit span 1.8±1.3 2.9±1 3.92 **
Months backwards 0.6±0.8 1.7±0.7 5.64 **
Modified Corsi tapping test 1.1±0.6 1.7±1 3.16 **
Proverb interpretation 0.7±0.8 2.5±0.5 10.78 **
Modified Hayling test 1.5±1.9 4.8±1.2 8.3 **
Total IFS-Ch 9.8±5.7 21.7±3.4 9.91 **
Results expressed in Mean±Standard Deviation. **Significant difference, p<0.05. All comparisons were carried out with a t test for independent samples.

Table 4. Association coefficients between the IFS-Ch and the rest of the administered measures.
IFS-Ch
Instrument rxy Significance
Executive functions FAB 0.935 **
MCST (categories achieved) 0.791 **
MCST (perseverative errors) –0.617 **
A verbal fluency 0.681 **
P verbal fluency 0.783 **
Animals verbal fluency 0.728 **
Global cognitive efficiency ACE-R-Ch 0.9 **
MMSE 0.874 **
Dysexecutive symptoms DEX –0.494 **
Dementia severity CDR –0.75 **
Functional capacity T-ADLQ –0.745 **
IADL 0.717 **
**Significant association, p<0.05. All associations were estimated using a Pearson coefficient, with the exception of the correlation between IFS-Ch and CDR
scores, which was executed using a Spearman rank correlation test.

ency with letters A and P, semantic verbal fluency of Diagnostic accuracy. A ROC curve analysis on the IFS-Ch
animals and the FAB); global cognitive efficiency (ACE- total score between control subjects and dementia pa-
R-Ch and MMSE); dysexecutive symptoms (DEX); de- tients generated several cut-off points, with 18 points
mentia severity (CDR); and functionality (IADL and T- being the best balance between sensitivity and specific-
ADLQ). The coefficients estimated for each association ity (sensitivity=0.903; specificity=0.867). The area un-
are given in Table 4. The association between IFS-Ch der the curve (AUC) was 0.951 (Figure 2). There were no
and measures of global cognitive efficiency indicates no significant differences among the areas under the curve
evidence of divergent validity. of the IFS-Ch, FAB, categories completed on the MCST,
Animals verbal fluency, A verbal fluency, and P verbal
Evidence of reliability. The Cronbach’s alpha coefficient cal- fluency (p>0.05).35
culated for the total test was 0.901. Regarding the sub-
tests that included more than one item, the Cronbach’s DISCUSSION
alpha coefficient was 0.577 for the Modified Corsi tap- In this paper, the IFS-Ch has shown good psychometric
ping test, 0.781 for the Proverb interpretation task, and properties and diagnostic accuracy. First, it has shown
0.836 for the Modified Hayling test. validity evidence from multiple sources: content validity

Ihnen J, et al.    INECO Frontal Screening: Chilean version 45

 Dement Neuropsychol 2013 March;7(1):40-47

1.0 years and 14.5 years, respectively. These differences are

coherent with our finding that years of education exhib-
ited a significant association with IFS-Ch total scores
0.8 and with results of studies showing that education is
an important variable in executive test performance in
general.38-40 Overall, these data suggest that it is impor-
0.6 tant to formulate local norms in order to interpret IFS-
Sensitivity

Ch scores accurately.
One of the main findings of this study was that the
0.4 Source of the curve IFS-Ch showed a good association with functionality
IFS-Ch
measures such as the IADL and T-ADLQ. This is coher-
FAB
Phonemic verbal fluency (letter A) ent with the findings of previous studies which sug-
0.2 Phonemic verbal fluency (letter P) gest that executive tests predict functional impairment
Semantic verbal fluency (Animals) more accurately than tests that assess other cognitive
MCST (categories achieved)
domains,41-43 which is expected given that daily life ac-
0.0 tivities are mainly goal-oriented behaviors. Thus, the
0.0 0.2 0.4 0.6 0.8 1.0 described association contributes with evidence of con-
1 – Specificity vergent validity for the IFS-Ch.
Diagonal segments are produced by ties. Similarly, a good association was found between
IFS-Ch total scores and the DEX, a questionnaire that
Figure 2. ROC curve for controls vs. patient groups (bvFTD and depression).
The superior discriminatory accuracy of the IFS over the MMSE and ACE-R assesses dysexecutive symptoms. In other words, the
is revealed by its larger area under the curve. IFS-Ch, despite the fact that it is a non-ecological mea-
sure - i. e. it is a standardized test administered in a
laboratory type setting - correlates significantly with
through expert consultation, discriminant validity by the presence of dysexecutive behaviors in everyday life.
comparing the means of IFS-Ch scores between groups, The latter constitutes not only evidence of convergent
and convergent validity through associations between validity for the test, but also suggests that it presents
IFS-Ch scores and other executive and related measures. good ecological validity, a relevant and highly desirable
Second, the IFS-Ch demonstrated evidence of reliabil- feature for an executive assessment instrument.4,44
ity, exhibiting a good internal consistency coefficient. One limitation of our study is the small number of
This is relevant given that reliability is a common weak- subjects by category of dementia, a situation preclud-
ness of executive tests.36,37 With regard to diagnostic ac- ing proper assessment of the capacity of the IFS-Ch
curacy, the selected cut-off point produced an excellent to discriminate between different types within the pa-
AUC as well as a very good balance between sensitivity thology. Moreover, the greater number of patients with
and specificity for detecting dementia. AD compared with patients with bvFTD or VD, meant
Although the test and two subtests (Modified Hay- that most of our clinical group presented a multideficit
ling test and Proverb interpretation) showed evidence of clinical profile, a situation that could explain the sig-
very good reliability, the Modified Corsi tapping subtest nificant correlation found between IFS-Ch total scores
had a poor internal consistency coefficient. Further stud- and measures of global cognitive efficiency (ACE-R-Ch
ies are needed to determine whether this subtest pro- and MMSE). Evidence of divergent validity for the IFS-
vides an accurate measure of spatial working memory. Ch should be studied with patients presenting deficits
It is noteworthy that the cut-off point found in mainly in the executive domain. Further research is
this study (18) was much lower than that found in the needed to determine whether the IFS-Ch can differenti-
original publication (25). This fact is probably due to the ate between different forms of dementia and to obtain
socio-demographic differences between both samples, further evidence of divergent validity.
particularly in relation to years of education. In our
study, the mean of this parameter was 11.93 and 9.65 Acknowledgements. This study was supported by grants:
years for the control and clinical groups, respectively, Project FONDECYT No. 1100975 CONICYT and PIA-
whereas in the Argentinian investigation the mean for CONICYT Project CIE-05. We thank Constanza Ihnen
bvFTD, AD and control subjects was 16.3 years, 14.5 for her English review of the manuscript.

46 INECO Frontal Screening: Chilean version    Ihnen J, et al.

 Dement Neuropsychol 2013 March;7(1):40-47

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