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Normative data of Fuld Object Memory Evaluation test for brazilian elderly population

OBJECTIVE
This study aims to present normative data for Fuld Object Memory Evaluation test stratified by sex, gender, age, and education for the Brazilian elderly population.


METHOD
We evaluated 2.132 healthy elderly both genders, with a mean age of 70.30 years (± 7.28) from two community-based samples in Brazil drawn from different economic areas who were screened with cognitive and functional tests and the memory test. Statistical analyses were performed by independent t-test, one-way analysis of variance and multiple linear regression.


RESULTS
Statistical analyses showed that memory scores tend to improve significantly with increasing years of education and decrease significantly as age increased.


CONCLUSION
We conclude that gender, education and age had effect on the Fuld Object Memory Evaluation performance in this Brazilian community-based sample.

The Fuld Object Memory Evaluation (FOME) 2,3 is an instrument that assesses learning and memory and incorporates selective-reminding procedures. It has been incorporated in dementia research in different countries in populations with different durations of formal education as a measure of overall recall because it has simple instructions and seems easier to the patients because they touch and see the objects that must be memorised, and the objects are very simple and well known 4,5,6,7,8 .
In an interesting study, FOME was one of the 4 instruments used in a combination of cognitive tests and informant reports of dementia screening in low educated older people. The combination of these 4 instruments, FOME, Mini-Mental State Examination (MMSE), Informant Questionnaire of Cognitive Decline (IQCODE) and Bayer-Activities of Daily Living Scale (B-ADL); with the mixed rule correctly classified 100% and the logistic regression classified 95.7% of a Brazilian sample subjects. This combination proved useful to improve the screening of mild to moderate dementia in low educated older people 9 .
The objective of the present study was to provide normative data on the FOME test for the Brazilian elderly population and to investigate the influence of education, age and sex on episodic memory performance. Our hypothesis was that subjects who had less education would perform worse than those who had more years of education, younger subjects would perform better than older subjects, and sex would have no effect on performance.

METHOD
The normative sample consisted of 2,132 older subjects with normal cognitive performance selected as part of a two-phase epidemiological study to investigate the prevalence of dementia in a community-based sample in Sao Paulo and Ribeirao Preto, Brazil. Data for this study were select between 2002 and 2003 10 .

Sample selection
According to the Brazilian Institute of Geography and Statistics (IBGE) in 2000, São Paulo is the largest city in Brazil, and the city's population is 10,426,384, of whom 9.3% are 60 years old or older. Ribeirao Preto is a city in southeastern Brazil with a population of approximately 500,000, and 10.1% of the population is aged sixty years and older.
A clustered random sampling of a population of individuals aged 60 years old and older from three different socioeconomic classes (upper, middle and low) was used, following official census data 11,12 . This strategy aimed to evaluate a sample containing city districts that represent the area universe context of elderly individuals living in Sao Paulo and Ribeirao Preto. Initially, the 96 city districts were ranked from the wealthiest to the poorest according to data from the 2000 Census, provided by IBGE. The following parameters were applied: income, education, proportion of elderly living in each district and sanitation. Subsequently, the districts were divided into three groups, and a district that was representative of each socioeconomic stratum was chosen to represent the upper, middle and lower group.
In Sao Paulo, those three selected districts (upper, middle and lower class) had 17,186; 17,738 and 14,443 elderly individuals, respectively. Then, blocks of 10 homes were randomly chosen in each of the 90 selected census sectors. Following local media (newspaper, radio, television) and mail advertisement, a trained team started a systematic door-knocking survey, visiting 8,042 homes to find elderly subjects. After the identification of elderly subjects, a sample of 2,233 subjects older than 60 years of age was approached in the community, and a total of 1,563 subjects who agreed to be visited by a trained interviewer (response rate = 70%) were assessed. The interviewers tried at least three times to evaluate the elderly subjects at home before they were considered to have refused. The socio-demographic characteristics of the sample assessed at home have been presented in greater detail recently 13 , but the mean age was 71.4 years (60 to 102; SD = 8.03), 68.7% were female, 16.6% were illiterate, and 71.0% had up to 8 years of education.
In Ribeirao Preto, a sample of 1,828 subjects were approached, of whom 1,145 agreed to participate (683 subjects refused to participate; rate of attrition: 37.3%). The sample came from three socio-economic levels in the following fashion: upper class: 369 subjects (32.2% of the total sample); middle class: 439 subjects (38.3%); lower class: 332 subjects (29%); data were missing for five subjects.
The sample had a mean age of 70.9 years (60 to 100; SD = 7.7), 63.4% were female, 10.1% were illiterate, and 62.2% had up to 8 years of education 14 .
In the first phase of this study, subjects were screened for dementia with a combination of cognitive tests and functional scales: the MMSE 15 , the Brazilian version of the FOME and a semantic verbal fluency examination were administered to the patients. The IQCODE 16 and the B-ADL 17 were also administered to the informants. Depressive symptoms were evaluated with a 10-item instrument, the D-10 (scores from 0 to 10), which contains questions related to the presence of depressive symptoms most of the time during the past 2 weeks 18 .
The following instruments were also used: socio-demographic questionnaire and socioeconomic classification scale (allowing five levels of classification). Data were obtained directly from the cognitively intact elderly subjects and/or from an informant, who was usually a close relative, when the subject was cognitively impaired. Data were collected at the participants' homes between July, 2002 and August, 2003.
All individuals with positive screenings for dementia and depression and a random sample of negative screenings were invited for the second phase, where clinical evaluation and diagnosis were achieved by the consensus of at least two physicians and consistency with the DSM-IV (American Psychiatric Association, 1994) 19 criteria for psychiatric diagnosis.
All subjects considered negative after screenings in the community phase and all subjects evaluated in the second phase who were considered free of psychiatric diagnoses were considered for the present investigation. Moreover, to guarantee the inclusion of normal cognitive subjects, we excluded subjects with a MMSE ≤ 18 20,21 and IQCODE ≤ 3.37 22 , resulting in a sample of 2,132 elderly subjects. This sample was then stratified for education, age and sex. Education was categorized into four groups: no formal education, 1 to 4 years of formal education, 5 to 8 years, and 9 and above years of formal education. Age was divided into three groups: 60 to 69, 70 to 79, and above 80 years of age.
The investigation was approved by the local ethics committee, and all of the subjects agreed to participate in the study by signing the informed consent.

Fuld Object Memory Evaluation
The FOME is an instrument used to evaluate several components of learning and memory in elderly people, and it also provides information about tactile recognition, right-left discrimination, and verbal fluency. Ten common objects in a bag (ball, button, matchbox, pacifiers, spoon, toothbrush, pencil, comb, catch, cup) are presented to the subjects to determine whether he can identify objects by touch, alternating systematically right and left hand. The patient name each object and then pulls it out of the bag to see if he was right. After conducting a distracting task by asking the patient to say words rapidly from a semantic category, "things that make people happy" (1 minute), the subject is asked to recall the items from the bag. After each recall, he is slowly and clearly reminded verbally of each item omitted in that trial, for a total of 5 trials. A 30-sec rapid semantic retrieval trail comes after each learning trail as a distractor for the next recall trial. The categories for these distractor trials are respectively, "animals", "fruits", "food", "give name" (same sex as the patient) and "things that make people sad". After a 15 minutes interval filled by other tests, an unexpected final recall is requested. Then, a multiple choice recognition task is elicited only for those items not recalled.
The Brazilian version of the test uses all the same semantic categories of the original version, with the exception of "vegetables ", which was changed to "fruits". In the original version the ten objects in the bag are; ball, bottle, button, card, cup, key, matches, nail, ring, scissors, that were changed by the previously listed objects.
The data collected during the test are classified as follows: Immediate retrieval is determined by the total sum of items remembered in all trials; the storage efficiency is determined by the number of different items recalled over the 5 trials and the retrieval efficiency is determined by the total number of items recalled in successive trails without any reminding. Delayed recall is the number of items remembered spontaneously after an interval.

Statistical analysis
The statistical analysis was based on the crude means and standard deviations (SD) of the FOME scores and on the frequencies and percentages of socio-demographic variables. The comparisons of FOME performance by sex was carried out by independent t-test and the comparison by age and educational level were carried out by one-way Analysis of Variance (ANOVA) followed by Tukey's post-hoc tests. Normality of distribution was verified using the Kolmogorov-Smirnov test.
The factors associated with memory score were analysed by multiple linear regression models with FOME score as dependent variable and education, age and sex as independent variables. The initial multivariate model included all variables and its interactions. In the final model, only those variables/interactions that maintained an association with FOME score at a level of 0.05 or less were retained. Same significance level of a = 0.05 was used for all other comparisons, and the statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) for Windows, version 14.0.

RESULTS
For descriptive purposes, years of education were divided into four groups, and age was divided into three age ranges. Table 1 shows the socio-demographic characteristics of the sample. Table 2 shows the mean and standard deviation (SD) of the FOME scores, immediate total recall, delayed recall, recognition and verbal fluency scores between sex. In general, females presented higher scores (except in verbal fluency animal and sad, and recognition). Table 3 shows the mean and SD of the FOME scores, immediate total recall, delayed recall, recognition and verbal fluency scores in the three different age groups. The FOME score decreased with advancing age with statistical significance (except in recognition). Table 4 shows mean and SD for the FOME scores, immediate total recall, delayed recall, recognition and verbal fluency scores in the three different education levels. Data show that FOME scores increased with increasing years of education with statistical significance. Table 5 shows the percentiles of the FOMES' s immediate and delayed recall performance by age and by education level.
To identify the simultaneous effect of education, age and sex on the FOME scores, a multiple linear regression analysis was performed and is displayed in Table 6.
The reference groups of women (sex), younger individuals (age) and participants with higher education levels (education) were considered to provide better clinical interpretation and all these three variables presented significant influence on the FOME score.
It was observed that the variables age and education presented significant interaction (p = 0.03). However, there were no significant interactions of these variables with sex (p > 0.05).

DISCUSSION
We analysed the performance of a Brazilian community-based sample of older subjects drawn from two Brazilian cities on the FOME test. The main finding of the present study is that the FOME test is influenced by education, age and sex.
Age and education are variables known to affect cognitive performance, so the influence of these two variables on the FOME score is not surprising. Generally, aging affects fluid intelligence, including episodic memory 23 , and the influence of education on cognition is already well documented in the literature 24 .
Our results regarding memory are in accordance with previous findings from Brazilian studies, which also showed the influence of education and age on episodic memory tests. One study that assessed verbal episodic memory in a sample of older adults documented significant differences between literate and illiterate subjects 25 . Another study that assessed verbal and visual episodic memory in a sample of the Brazilian population found that age and years of education had a significant influence on the tests results. However, no significant influence of sex was observed 26 . The same influence was documented in the normative data of the word list test with a health elderly sample, but again, no influence of sex was reported 27 .      Age 60-69 * education 0 0 Age 60-69 * education 1-4 0 Age 60-69 * education 5-8 0 Age 60-69 * education ≥ 9 0 In each variable, the category with Beta = 0 indicates the reference category. Sex did not present significant interactions with sex and education. FOME: Fuld Object Memory Evaluation.
Brazilian data indicate that education has no influence on the FOME exit score, and these data might be explained by sample characteristics, such as smaller sizes and less heterogeneity regarding education attainment compared to the present community-based sample 28,29 . Regarding the influence of sex on the episode memory test, this result was not expected based on results reported in the literature 26,29 .
Therefore, although the statistical analysis indicated that education influenced FOME scores, the FOME remains suitable for use in older people with lower levels of education. Another reason supporting its use is that it is a memory test during which even very elderly patients with significant memory problems and individuals with very low formal education typically do not complain or show anxiety. On the contrary, they enjoy the test. A different reaction is frequently observed for word list tests, in that patients sometimes refuse to perform them.
Our results corroborate a previous study, which showed that the FOME was a good test for assessing older people with few years of schooling 30 . Another study in China found influences of age and education on the FOME performance but less influence of sex in the older population 31 .
The normative data are relevant due to the limited availability of memory tests standardised for the Brazilian population; moreover, the data presented can help clinicians to better interpret immediate and delayed scores on episodic memory tests in older Brazilians with varying degrees of education from community-based or primary care samples. Our results also support the notion that clinicians should carefully analyse the memory test performance in low-education elderly populations with memory complaints.
In conclusion, data presented here can help clinicians to better diagnosis Brazilian elderly with memory problems.
There is a limitation of this study, some classifications that the FOME test can provide, storage and retrieval efficiency, could not be analysed in these study because on the time of the data collect, these classifications were not tabulated.