Testing of Verbal Fluency in Egyptians: Cultural and Educational Challenges

Background: The importance of verbal fluency tasks as a cornerstone in cognitive assessment is now well acknowledged, as they provide fast, reliable tools for assessment of both verbal and executive function abilities. Objectives: To investigate the effect of age and education on verbal fluency and to develop a verbal fluency task that is culture-oriented and non-education-based to overcome the problem of illiteracy in Egypt. Methods: Two groups of participants were recruited, a normal cognition control group (n=79) and a clinically demented group (n=32). Phonemic verbal fluency was tested by asking participants to generate as many words as they could think of starting with the Arabic letter Haa; category fluency was evaluated using four semantic categories (animals, fruits, vegetables, and names). Results: Animal, vegetable, and name fluency tasks (unlike phonemic fluency and fruit) were not related to age and education, and they had better criterion validity (area under the receiver operating characteristic curve [AUC]=0.96, 0.91, and 0.92, respectively) than did letters and fruits (AUC=0.74 and 0.86, respectively). Our suggested cutoff points are 11 for the animal fluency task (sensitivity=94%, specificity=93%), 11 for vegetables (sensitivity=84%, specificity=88%), and 18 for names (sensitivity=91%, specificity=82%). Conclusions: Animals, vegetables, and names are reliable and appropriate categories to be used for culture-oriented and non-education-based verbal fluency tests.