ISSN (Print) ISSN (Online) Commun Sci Disord 2014;19(4): Original Article Utility of t

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1 ISSN (Print) ISSN (Online) Commun Sci Disord 2014;19(4): Original Article Utility of the Boston Naming Test in Differentiating between Mild Cognitive Impairment and Normal Elderly: A Meta-Analysis Yun Kyung Hwang a, HyangHee Kim a,b a Graduate Program in Speech-Language Pathology, Yonsei University, Seoul, Korea b Department & Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea Correspondence: HyangHee Kim, PhD Graduate Program in Speech-Language Pathology, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul , Korea Tel: Fax: h.kim@yonsei.ac.kr Received: August 20, 2014 Revised: September 18, 2014 Accepted: October 12, 2014 This work was supported by the Students Association of the Graduate School of Yonsei University funded by the Graduate School of Yonsei University. Objectives: The Boston Naming Test (BNT) is a widely used neuropsychological test for evaluating language ability and mild cognitive impairment (MCI). Several different abbreviated forms of the BNT have been used in previous research and clinical settings. For efficiency, valid and sensitive abbreviated forms of the BNT are useful. However, there has been no study that focused on comparison among various forms of the BNT and MCI. Thus, we conducted a meta-analysis of studies that assessed subjects with MCI alongside normal elderly with one of three different forms of the BNT: 60 items (BNT-60), 30 items (BNT-30), and 15 items (BNT-15). Methods: A total of 41 studies (19 for BNT-60, 5 for BNT-30, and 17 for BNT-15) were included in the present meta-analysis. Effect sizes were obtained by Hedges s g with a 95% confidence interval. Results: The random-effects meta-analysis model composite with all forms of the BNT showed that MCI subjects performed lower than the normal elderly on the BNT. Additionally, MCI subjects acquired significantly lower scores than normal elderly in all different forms of the BNT. Conclusion: MCI subjects show significantly lower performance even in the shortest form of the BNT (BNT-15). Therefore, it seems reasonable to conclude that an abbreviated form of the BNT can be used effectively in clinical settings. Keywords: Boston Naming Test (BNT), Naming ability, Mild cognitive impairment (MCI) 주요노인질환중증가율 1위를차지하는치매는가정및사회적부담을증가시키는요인이다 (Cha & Hwang, 2014). 치매는퇴행성질환으로조기발견및진단을통한적극적인치료가매우중요하다. 이를위해최근임상에서는정상적인노화와치매의중간단계로인지기능의저하가나타나는경도인지장애 (mild cognitive impairment, MCI) 단계가주목받고있다. Petersen 등 (1999) 은 MCI 의진단기준을 (1) 기억손상에관한주관적인보고, (2) 경도의전반적인기능적손실, (3) 정상적인전반적인지기능의저하, (4) 정상적인일상생활유지, (5) 치매진단기준에부합하지않는자로제시하였다. MCI는초기치매단계라고도일컬어지며, 알츠하이머형치매로이행할수있는고위험군으로지목된다 (Alom, Llinares, & Fajardo, 2012; Griffith et al., 2006; Jacova et al., 2008; Petersen et al., 1999, 2001). 역학연구에따르면, 매년평균정상노인의치매발병률은 1%-2% 인데비해, MCI 환자는 14% 이며 (Petersen et al., 2001), MCI 환자의치매전환율은 1년후 41%, 2년후 64% 에육박한다 (Geslani, Tierney, Herrmann, & Szalai, 2005). 이와같이 MCI는치매를가장이른시기에발견하여치료효과를극대화할수있는임상적으로매우중요한단계이다 (Apostolova & Cummings, 2007). 간이정신상태검사 (Mini-Mental State Examination, MMSE) 는대표적인치매선별검사로서널리사용되고있다. 그러나 MMSE 의단독평가만으로는 MCI를선별하기에임상적으로낮은신뢰도를보인다 (Lee, Cheong, Oh, & Hong, 2009). 또한 MMSE만시행했을경우언어수행력저하에관한정보를충분하게제공하지못한다는제한점이있다 (Park & Chey, 2000). 따라서 MCI 환자를선별 Copyright 2014 Korean Academy of Speech-Language Pathology and Audiology This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited

2 Yun Kyung Hwang, et al. Utility of the Boston Naming Test in MCI 하거나진단함에있어더욱심층적인신경심리평가가필요하다. MCI 환자를대상으로실시하는신경심리평가는언어능력평가항목을포함하고있다. 언어기능은인지기능의정도를반영하기때문에진단시매우중요한평가요소로서, 특히치매초기부터기능저하가보고되는의미처리능력 (Balthazar, Cendes, & Damasceno, 2008; Taler & Phillips, 2008) 을필수적으로평가한다. 대표적인의미언어평가과제는대면이름대기 (confrontational naming) 이다. 대면이름대기의대표적인과제는본연구에서다루어진보스턴이름대기검사 (Boston Naming Test, BNT) 이다. 60개의그림자극을보고그이름을말하도록하는이과제는 Kaplan, Goodglass와 Weintraub (1983) 이개발하여치매를비롯한다양한신경손상장애환자의변별과예측에민감한지표로서유용하게사용되어왔다. 국내에서도문항개발과표준화작업을거친한국판보스턴이름대기검사 (Korean version of Boston Naming Test, K-BNT; Kim & Na, 1997, 1999) 가연구와임상에서대표적으로널리사용되고있다 (Kang, Kim, & Na, 1999). 60개문항으로개발된표준 BNT (BNT-60) 는 60문항전체를평가하도록개발되었으나, 인지기능이나주의집중에저하를보이는환자를대상으로전체문항을평가하기에는어렵다는문제가제기되었다 (Kim & Kim, 2013). 이에따라검사의효율성을위해 BNT- 60과높은상관관계를유지하는단축형 BNT의개발이활발히이루어졌다. BNT-60의항목을순서에따라축소구성하거나새로운문항개발을통한 30문항 (BNT-30) 혹은 15문항 (BNT-15) 등의다양한단축형 BNT가개발되었고치매환자와정상노인의수행력을변별하는도구로서 60개문항의 BNT (BNT-60) 와높은상관관계가검증된단축형 BNT는 MCI 환자에게도평가도구로활용되어왔다 (Arlt et al., 2013; Beinhoff, Hilbert, Bittner, Grön, & Riepe, 2005; Bélanger & Belleville, 2009; Bigler et al., 2003; Brunet et al., 2011; Deason, Hussey, Budson, & Ally, 2012; De Jager, Hogervorst, Combrinck, & Budge, 2003; Devanand et al., 2010; Fillenbaum et al., 2005; Griffith et al., 2006; Guo, Zhou, Zhao, Wang, & Hong, 2012; Jefferson et al., 2006, 2007; Johns et al., 2012; Joubert et al., 2010; Kramer et al., 2006; Laakso et al., 2009; Pa et al., 2010; Price et al., 2010; Vliet et al., 2003; Yeh et al., 2011). 치매환자는선행연구에서일관적으로낮은 BNT 수행력이보고된반면, MCI 환자의경우에는상반된연구결과가혼재한다 (Taler & Phillips, 2008). 다수의연구에서 MCI가정상노인에비해저하된수행력을보였다 (Alom et al., 2012; Arsenault-Lapierre, Bergman, & Chertkow, 2012; Beinhoff et al., 2005; Beversdorf et al., 2007; Bigler et al., 2003; Brunet et al., 2011; De Jager et al., 2003; Devanand et al., 2010; Duong, Whitehead, Hanratty, & Chertkow, 2006; Fillenbaum et al., 2005; Guo et al., 2012; Harel et al., 2011; Jacova et al., 2008; Jefferson et al., 2006, 2007; Johns et al., 2012; Kramer et al., 2006; Laakso et al., 2009; Malek-Ahmadi, Raj, & Small, 2011; Malek-Ahmadi, Small, & Raj, 2011; Pa et al., 2010; Rami et al., 2008; Schmitter-Edgecombe & Creamer, 2010; Schmitter-Edgecombe & Sanders, 2009; Weakley, Schmitter-Edgecombe, & Anderson, 2013; Yeh et al., 2011). 그러나두집단간유의한차이를보이지않았다는연구도있다 (Arlt et al., 2013; Balthazar et al., 2008, 2010; Bélanger & Belleville, 2009; Deason et al., 2012; Griffith et al., 2006; Grönholm- Nyman, Rinne, & Laine, 2010; Grönholm, Rinne, Vorobyev, & Laine, 2007; Harel et al., 2011; Joubert et al., 2010; Price et al., 2010; Schmitter-Edgecombe, Woo, & Greeley, 2009; Vliet et al., 2003). MCI 환자와정상노년층의수행력차이는 BNT-60을실시한연구보다단축형 BNT를실시한연구에서더욱비일관적으로보고되었다. 문헌고찰을통해 MCI 환자와정상노년층의 BNT 수행력에따른변별력과치매전환예측력을살펴본 Taler와 Phillips (2008) 는단축형 BNT를사용하거나대상자의수가적을수록 MCI 환자의변별력과예측력이낮게나타났다고언급하며 MCI 환자를대상으로한단축형 BNT의유용성에의문을제기하기도하였다. 이에, 본연구에서는 MCI 환자와정상노인의수행력의차이를보고한기존의상반된연구결과들로부터종합적인결과를도출하기위해메타분석 (meta-analysis) 을실시하였다. 이를통해연구및임상현장에서근거기반에기초한평가도구로서표준형및다양한단축형 BNT의유용성을검증하고, 검사의효율성증대및활용방안을모색하고자한다. 구체적인연구목적은다음과같다. 첫째, MCI와정상노년층의 BNT 수행력차이의효과크기 (effect size) 를산출한다. 둘째, 문항수에따라 BNT를유형별로분류하고, MCI와정상노년층의수행력차이의효과크기를각각산출한다. 연구방법자료수집문헌검색다양한단축형 BNT를이용한 MCI 환자와정상노년층의이름대기수행력차이를알아보기위해 2014년 4월에 PubMed 와 Pro- Quest 데이터베이스에서문헌검색을실시하였다. 문헌수집에사용된검색어로는 PubMed에서는 ( mild cognitive impairment OR MCI) AND ( boston naming test OR BNT OR naming OR flu

3 경도인지장애변별을위한보스턴이름대기검사의유용성 : 메타분석 황윤경외 ency), ProQuest에서는 ( mild cognitive impairment OR MCI) AND BNT가사용되었다. PubMed 데이터베이스에서는 MCI 환자를대상으로널리쓰이는신경심리검사인생성이름대기 (fluency) 를검색어에포함하여선정에적합한논문이누락되는것을최소화하고자하였다. 반면 ProQuest 검색결과에서는 BNT 이외의이름대기검사가다수포함되어있어, 검색의효율성을위해과제관련검색어를 BNT 로한정하여재검색하였다. 논문의선정기준 PubMed 에서 350편, ProQuest에서 229편으로총 579편의연구가검색되었다. 논문의선정기준및제외기준을통해최종 41편의문헌이메타분석을위해수집되었다. 논문선정과정은 Figure 1과같다. 선정된개별논문의특성은 Table 1에요약하여제시하였다. 신뢰도평가논문선정과정에서의신뢰도검증을위하여연구자 1인과연구보조원 1인의논문선정일치도를평가하였다. 전문이용이가능한논문중약 50% 에해당하는 20편을무선표집 (random sampling) 한후, 연구보조원이 Figure 1에제시한논문의선정기준및제외기준근거에따라논문을선정하고비교하였다. 그결과, 검사자간논문선정의일치도는 95% 였으며, 불일치는재검토를통해추가논의하여선정여부를결정하였다. 자료분석방법론적질적평가횡단적연구 (cross-sectional study) 에적합한질적평가를위해 Gersten 등 (2005) 의필수질적지표 (essential quality indicator) 를차용및수정하여측정하였다 (Table 2). 그결과본연구에서수집된논문은분석에적합한것으로평가되었다. 자료의코딩연구자, 게재연도, BNT 문항수, BNT 문항인용출처, 대조군과 MCI 두집단의표본크기, BNT 수행력의평균과표준편차, 두집단간효과크기를기록하였다. 연구자이외의검사자가코딩을검토한결과, 일치율은 98.2% 였으며, 불일치한자료는재검토와논의를거쳐수정하였다. Total 579 searched PubMed (N= 350), ProQuest (N=229) Full text available (N=506) [Inclusion criteria] 1. Design: cross-sectional 2. Participants: include both control and MCI group, specified diagnostic criteria (ex: CDR=0.5) 3. Methods & Results: full & short form of BNT, mean and standard deviation of BNT score in two groups, or effect size were provided. Eligible articles (N=41) Full text unavailable (N=73) [Exclusion criteria] 1. Design: (N=111): review, prepost comparison, single subject research 2. Participants: (N=201): unspecified diagnostic criteria for MCI (ex: predementia stage), no control group, multiple disability, same participants across studies 3. Methods & Results (N=125): naming test other than BNT, no BNT score Duplicates (N=28) Figure 1. Flowchart of studies included from database search. BNT = Boston Naming Test; MCI= mild cognitive impairment. 출판편향표준오차에대한출판편향 (publication bias) 을퍼넬플롯 (funnel plot) 으로확인하였다. 여기서 출판편향 이란, 메타분석의결과가과대추정되어왜곡될위험성을일컫는데 (Borenstein, Hedges, Higgins, & Rothstein, 2009) 높은효과크기를보고한연구들이낮은효과크기를보고한연구들보다상대적으로출판될확률이높으며메타분석에서는기출판된연구들이주로포함되기때문에출판편향의위험성을보고하는일이필요하다. 무선효과모형 (random effect model) 에서 trim-and-fill (Duval & Tweedie, 2000) 방법을이용한헤지의표준화된평균차 (Hedges s g) 값이삽입된도표는 Figure 2와같다. 이도표에서빈원 ( ) 은본메타분석에실제사용된값을, 검은원 ( ) 은보정되어삽입된값을의미한다. 또한도표아래의다이아몬드는각각실제사용된값 () 과보정된값 () 의전체효과크기와 95% 신뢰구간의표준오차를나타낸다. 출판편향을확인하는추가적인방법으로 Classic fail-safe N (Rosenthal, 1979) 계수는 4,075로출판편향의영향이매우적은것으로나타났다. 이는본메타분석의효과크기를무효화하기위해추가적으로필요한문헌의수를나타내며, 이계수가클수록연구결과가출판편향에의한영향을적게받는것을의미한다 (Borenstein et al., 2009)

4 Yun Kyung Hwang, et al. Utility of the Boston Naming Test in MCI Table 1. Study characteristics Study (Language) Arlt et al. (2013) German Bélanger & Belleville (2009) French Beinhoff et al. (2005) German Bigler et al. (2003) Brunet et al. (2011) French Deason et al. (2012) Devanand et al. (2010) Fillenbaum (2005) Japanese Fillenbaum (2005) Japanese Griffith et al. (2006) Johns et al. (2012) French, Joubert et al. (2010) French Kramer et al. (2006) Laakso et al. (2009) Pa et al. (2010) Price et al. (2012) Vliet et al. (2003) De Jager et al. (2003) Guo et al. (2012) Chinese Jefferson et al. (2006) Jefferson et al. (2007) Yeh et al. (2011) Chinese Alom et al. (2012) Spanish Arsenault-Lapierre (2012) Age of participants (yr) No. of participants BNT MCI type Normal MCI Normal MCI No. of items Form 67.6 (5.7) 70.6 (6) Amnestic 15 N/S N/A (age matched) Amnestic-single 15 Kaplan et al. (1983) 63.5 (7.5) 66.4 (7.1) N/S 15 Lezak (1995) (6.48) (6.79) N/S 15 Kaplan et al. (1978) 72.7 (5.3) (7.4) Amnestic 15 Calero et al. (2002) 73.5 (7.54) 73 (8.6) Amnestic-single 80.2 (5.7) (6.07) Amnestic Non-amnestic 15 N/S 15 N/S 79.6 (7.2) 83.5 (7.8) N/S 15 Kaplan et al. (1978) 80.6 (5.2) 82.5 (5.4) N/S 15 Kaplan et al. (1978) (7.66) (8.65) Amnestic 15 Kaplan et al. (1983) 71.8 (5) 72.4 (8.6) Amnestic 15 Mack et al. (1992) 72.4 (7.1) 73.7 (6.3) Amnestic 15 Calero et al. (2002) 73 (5.3) 75 (6.1) Amnestic 15 N/S 71 (4) 73 (4) N/S 15 Morris et al. (1989) 65.2 (8.9) 69.8 (9.3) Amnestic single Amnestic multiple Dysexecutive MCI 15 Kaplan et al. (1983) (6.17) (7.2) Amnestic 15 Kaplan et al. (2001) 67.9 (8.2) 69.7 (10.5) N/S 15 Kaplan et al. (1983) 75 (9) 76 (10) N/S 30 Kaplan et al. (1983) (7.7) (5.06) Amnestic-single 72 (8.4) 71.4 (8.2) Amnestic-single Non-amnestic-single Non-amnestic-multiple 30 Guo et al. (2006) 30 Fisher et al. (1999) 71.9 (8.4) 71.8 (8) N/S 30 Williams et al. (1989) 76.5 (6.6) (6.15) Amnestic-single 30 Kaplan et al. (1983) 70.2 (6.9) 72.3 (7.3) N/S 60 Kaplan et al. (1983) 74.7 (9) 75 (7) N/S 60 Mack et al. (1992) (Continued to the next page) 504

5 경도인지장애변별을위한보스턴이름대기검사의유용성 : 메타분석 황윤경외 Table 1. Continued Study (Language) Balthazar (2007) Brazilian Balthazar et al. (2008) Brazilian Balthazar et al. (2010) Brazilian Beversdorf et al. (2007) Djordjevic et al. (2008), French Duong et al. (2006) Grönholm (2007) Finnish Grönholm-Nyman (2010) Finnish Harel et al. (2011) Jacova et al. (2008) Malek-Ahmadi et al. (2011a) Malek-Ahmadi et al. (2011b) Rami et al. (2008) Spanish Schmitter-Edgecombe & Sanders (2009) Schmitter-Edgecombe et al. (2009) Schmitter-Edgecombe & Creamer (2010) Weakley et al. (2013) Values of age are presented as mean (SD). BNT= Boston Naming Test; MCI= mild cognitive impairment. Age of participants (yr) No. of participants BNT MCI type Normal MCI Normal MCI No. of items Form 69.4 (7.28) (10.27) Amnestic 60 Lezak (1995) (7.77) (9.79) Amnestic 60 Modified version of Kaplan et al. (1983) (7.55) (6.33) Amnestic 60 Modified version of Kaplan et al. (1983) 68 (8.3) 67.5 (8.9) N/S 60 Kaplan et al. (1983) 73.7 (3) 75.4 (3.3) Amnestic 60 N/S (5.74) (6.28) Amnestic 60 N/S 65.5 (6.9) 68.6 (8.6) Amnestic 60 N/S 66 (7.3) 69.5 (8.2) Amnestic 60 N/S 66.2 (6.7) 67.7 (5.6) Amnestic 60 Morris et al. (1989) 72.1 (7.3) 69.2 (7.5) Amnestic 60 Kaplan et al. (1983) (5.59) 74.3 (5.19) Amnestic 60 Kaplan et al. (1983) 74.8 (5.77) 74.8 (5.77) Amnestic 60 Kaplan et al. (1983) 74.3 (5.3) 73.6 (6.8) Amnestic 60 Kaplan et al. (1983) (4.9) (5.7) Amnestic Non-amnestic (9.1) (9.55) Amnestic-single (7.8) (9.32) Amnestic-single (9.37) (9.78) Amnestic-Single Non-amnestic 60 Kaplan et al. (1983) 60 N/S 60 Kaplan et al. (1983) 60 Ivnik et al. (1996) 메타분석 Comprehensive Meta-Analysis (version 2.0) 을이용하여효과크기를산출하였다. 개별연구에서사용된 BNT 문항수에따라 BNT- 60, BNT-30, BNT-15 로분류한후, 대조군과 MCI의표본크기, 평균, 표준편차, 계산된효과크기를이용하여종합효과크기와 BNT 유형에따른각각의효과크기 (Hedges s g) 를산출하였다. 또한표준오차의역수를가중치로부여하고무선효과모형 (random effect model) 을이용하여신뢰구간 95% 를기준으로효과크기의이질성을평가하였다. 연구결과대상자총대상자는 MCI환자 2,428명, 정상노년층 3,566명이었다. 문항수에따른 BNT 유형하위집단에해당하는논문수와대상자정보는 Table 3과같다. BNT 유형에따른집단간수행력차이비교 BNT 유형을종합하여살펴보았을때, MCI와정상노년층의전반적인 BNT 수행력은효과크기 (95% CI: to -.547, p<.001) 로 505

6 Yun Kyung Hwang, et al. Utility of the Boston Naming Test in MCI Table 2. Evaluation by quality indicators Category Quality indicators Qualified Non-qualified Participants Was sufficient information provided to determine/confirm whether the participants demonstrated the disability(ies) or difficulties presented? Were appropriate procedures used to increase the likelihood that relevant characteristics of participants in the sample were comparable across conditions? Was sufficient information given characterizing examiners provided? Did it indicate whether they were comparable across conditions? Assessment procedure Were the assessment procedure and scoring system clearly described and specified? 41 0 Outcome measures Was descriptive statistics quantity provided as outcome? 41 0 Data analysis Were the data analysis techniques appropriately linked to key research questions and hypotheses? Table 3. Characteristics of participants included in the analysis by BNT types Group BNT-60 BNT-30 BNT-15 Total MCI Normal MCI Normal MCI Normal MCI Normal No. of studies No. of participants ,190 2,428 3,566 Age (yr) (7.43) (7.05) (6.81) (8.12) (4.75) (5.92) (7.15) (6.64) Values of age are presented as mean (SD). BNT= Boston Naming Test; MCI= mild cognitive impairment. Standard error Funnel plot of standard error by Hedges's g Hedges s g Figure 2. Funnel plot of standard error by Hedges s g after trim-and-fill. = Hedges s g of observed values; = Hedges s g of imputed filled values; = overall effect size and 95% CI before allowing for publication bias; = overall effect size and 95% CI after allowing for publication bias. 서 MCI 환자가정상노년층에비해낮은수행력을나타냈다 (Table 4). 단축형 BNT 유형별두집단간수행력차이를살펴보면, 첫째, BNT-60 을시행한연구에서는효과크기가 (95% CI: to -.528, p<.001) 로 MCI 환자가정상노년층에비해통계적으로유의하게낮은수행력을보였다 (Figure 3). 둘째, BNT-30 을시행하였을때효과크기는 (95% CI: to -.454, p<.001) 로 MCI의이름대기수행력이정상노년층의수행력보다유의하게낮았다 (Figure 4). 셋째, BNT-15 를시행하였을때역시효과크기는 (95% CI: to -.450, p<.001) 로 MCI 환자가정상노년층보다낮은수행력을나타냈다 (Figure 5). 요컨대, BNT 유형을종합했을때와세유형의 BNT 유형에서모두 MCI 환자가정상노년층에비해유의하게낮은수행력을보였다. 출판편향을고려한 trim-and-fill 보정을실시한결과, 모든유형의 BNT를종합한경우 MCI와정상인의 BNT 수행력은효과크기 (95% CI: to -.669) 로서 MCI 환자가정상인에비해낮은수행력을보였다. 유형별로살펴보면, BNT-60 은효과크기 (95% CI: to -.544), BNT-30 은효과크기 (95% CI: to -.453), BNT-15 는효과크기 (95% CI: to -.627) 로나타났으므로, 출판편향보정후에도앞서결과와마찬가지로모든유형의 BNT에서 MCI 환자가정상노년층에비해유의하게낮은수행력을보였다. 논의및결론본메타분석을통해 MCI가정상노년층에비해낮은 BNT 수행력을보인다는것을확인함으로써기존의개별적으로보고된상반 506

7 경도인지장애변별을위한보스턴이름대기검사의유용성 : 메타분석 황윤경외 Table 4. Summary of effect sizes for BNT score between MCI and normal elderly Type Effect size and 95% CI Homogeneity tests Hedges s g Lower limit Upper limit p Q df (Q) p I 2 Overall < < BNT < BNT < BNT < < BNT= Boston Naming Test; MCI= mild cognitive impairment. Effect sizes for BNT-60 Study name Statistics for each study Hedges's g and 95% CI Hedges's Lower Upper g limit limit p-value Alom(2012) Arsenault-Lapierre(2012) Balthazar(2007) Balthazar(2008) Balthazar(2010) Beversdorf (2007) Djordjevic(2008) Duong(2006) Gronholm(2007) Gronholm-Nyman(2010) Harel(2011) Jacova(2008) Malek-Ahmadi(2011a) Malek-ahmadi(2012) Rami(2008) Schmitter-Edgecombe(2009) Schmitter-Edgecombe(2009b) Schmitter-Edgecombe(2010) Weakley(2013) MCI Normal Figure 3. Effect sizes for BNT-60 items. BNT= Boston Naming Test; MCI= mild cognitive impairment. Effect sizes for BNT-30 Study name Statistics for each study Hedges's g and 95% CI Hedges's Lower Upper g limit limit p-value De Jager(2003) Guo(2012) Jefferson(2006) Jefferson(2007) Yeh(2011) MCI Normal Figure 4. Effect sizes for BNT-30 items. BNT= Boston Naming Test; MCI= mild cognitive impairment. 된연구결과를통합하고종합적인의미를도출할수있었다. 저하된의미처리능력이꾸준히보고되어온치매초기단계뿐만아니라치매전단계인 MCI 단계에서부터의미처리능력을반영하는대면이름대기과제인 BNT의수행력이정상노년층에비해저하된것을관찰할수있었다. 더욱이 60문항의기본형 BNT뿐만아니라 30문항, 15문항으로구성된다양한단축형 BNT를이용한간단한평가만으로도 MCI 와정상노년층의대면이름대기수행력을변별할수있다는가능성을확인하였다. 본메타분석의결과는적은문항수의단축형 BNT 를이용한평가로는 MCI와정상노년층의변별에특히어려움이있다는 Taler와 Phillips (2008) 의주장과상반되는결과이다. 이러한상반된의견의이유는 Taler와 Phillips (2008) 가통계적유의성결과에따른연구편수를세는방법 (vote counting) 으로전체적인결론을도출한반면, 본연구에서는대상자수와효과크기를고려 507

8 Yun Kyung Hwang, et al. Utility of the Boston Naming Test in MCI Effect sizes for BNT-15 Study name Statistics for each study Hedges's g and 95% CI Hedges's Lower Upper g limit limit p-value Arlt(2013) B?langer(2009) Beinhoff(2005) Bigler(2003) Brunet(2011) Deason(2012) Devanand(2010) Fillenbaum(2005A) Fillenbaum(2005B) Griffith(2006) Johns(2012) Joubert(2010) Kramer(2006) Laakso(2009) Pa(2010) Price(2012) Vliet(2003) MCI Normal Figure 5. Effect sizes for BNT-15 items. BNT= Boston Naming Test; MCI= mild cognitive impairment. 했기때문인것으로보인다. 또한문항의난이도만을고려하여문항을축소한병렬형단축형을사용한연구 (Bélanger & Belleville, 2009; Bigler et al., 2003; De Jager et al., 2003; Fillenbaum et al., 2005; Griffith et al., 2006; Pa et al., 2010; Price et al., 2010; Vliet et al., 2003; Yeh et al., 2011) 이외에도문화를고려하여번안된문항이나높은변별력을나타내는문항으로새로이단축된문항으로개발된다양한단축형 BNT의사용이 (Beinhoff et al., 2005; Brunet et al., 2011; Guo et al., 2012; Jefferson et al., 2006; Johns et al., 2012; Joubert et al., 2010) 적은문항의단축형 BNT로도 MCI와정상노년층을효과적으로변별하는결과를도출한것으로보인다. 본연구결과를통해 MCI 환자의대면이름대기능력평가를위한기본형 BNT의유용성뿐만아니라, 단축형 BNT가임상현장및특히대단위역학조사나외래진료등시간의제약이있는조건에서효율적으로 MCI로의심되는환자의대면이름대기수행력을짧은시간내에선별할수있는평가도구로활용될수있다는가능성을확인할수있었다. MCI 변별에있어단축형 BNT의유용성이검증됨에따라선별검사에서단축형 BNT의활용은짧은추가평가시간만으로도기존의치매선별검사보다좀더구체적인언어능력수행특징을파악할수있게할것이다. 이러한신경심리학적수행에관한추가적인정보는짧은시간내에좀더정확한 MCI의진단과변별에도움을줄수있을것이다. 본메타분석에는포함되지않았으나, 국내에서도 MCI와정상노년층을변별하기위한단축형 K-BNT의개발연구가꾸준히진행되어왔다. 단축형 Korean-Boston Naming Test (S-K-BNT) 개발의 초기단계에서는문항의난이도만을고려한병렬형단축형이제시되었으나, 이후치매환자와정상노년층의변별력을더욱높이기위한연구를통해새로운문항이선정되기도하였다. 그결과, 15개문항으로이루어진치매진단을위한단축형 K-BNT (S-K-BNT) 는기존 K-BNT 와높은상관성을유지하면서오히려 60개문항의 K-BNT 를실시하였을때보다더높은변별효용성을보인다 (Kang et al., 1999). 특히최근에는문항반응이론을적용하여단축형문항을선정한 K-BNT-15가 MCI와정상노년층의수행력을효과적으로변별할수있었다 (Kim & Kim, 2013). 이와같이 MCI 및치매환자를대상으로변별력이높은단축형문항이개발되면서, 국내연구및임상현장에서도단축형 K-BNT의유용성이한층높아졌다고할수있다. 본연구는상반된연구결과가혼재하는다양한유형의 BNT를활용한 MCI와정상노년층의대면이름대기수행력차이를종합하여 BNT의유용성을검증하고근거기반에기초한평가도구로서임상에서의활용을도모했다는점에서의의가있다. 그러나국내연구는분석에포함하지않은제한점이있으므로향후국내에서개발된 BNT를활용한연구를대상으로집단간차이에대한효과크기및두집단의변별에영향을미치는다양한매개변인을조사하는등더욱심층적인분석이필요하겠다. REFERENCES Alom, J., Llinares, I., & Fajardo, S. (2012). Clinical approach to diagnosis of 508

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12 Yun Kyung Hwang, et al. Utility of the Boston Naming Test in MCI 국문초록 경도인지장애변별을위한보스턴이름대기검사의유용성 : 메타분석 황윤경 1 김향희 1,2 1 연세대학교대학원언어병리학협동과정, 2 연세대학교의과대학재활의학교실및재활의학연구소 배경및목적 : 보스턴이름대기검사 (Boston Naming Test, BNT) 는경도인지장애 (mild cognitive impairment, MCI) 환자의이름대기능력을측정하기위하여임상에서널리시행되고있으나정상노년층과의수행력차이여부에관하여상반된연구결과가혼재한다. 이에, 본연구에서는메타분석을통해 MCI를대상으로 BNT의수행력을보고한개별연구들로부터종합적인결과를도출하고, 근거기반에기초한평가도구로서문항수에따른다양한유형의 BNT의유용성을검증하고자한다. 방법 : MCI와정상노년층의 BNT 점수를비교한연구들을 ProQuest와 PubMed 데이터베이스를이용하여수집하였다. 선정기준에적합한총 41편의문헌을수집하여메타분석을실시하였다. 결과 : 총 41개문헌중 BNT의문항수에따라 60문항 BNT (BNT-60) 를이용한연구는 19편, 30문항 BNT (BNT- 30) 는 5편, 15문항 BNT (BNT-15) 는 17편이었다. BNT의유형을종합한효과크기 (effect size) 및문항수에따른유형별효과크기를살펴본결과, 모든유형의 BNT에서 MCI가정상인에비해낮은수행력을보였다. 논의및결론 : MCI 대상 BNT 검사의종합적인유용성을검증하고문항수에따른하위유형별변별력을제시함으로써연구및임상에서의효율성을제고하는데근거를마련하였다. BNT는 MCI와정상인의이름대기능력을변별하는평가도구로유용하며, 특히단축형 BNT를활용하여임상에서검사의효율성을증대시킬수있을것으로기대된다. 핵심어 : 보스턴이름대기검사, BNT, 대면이름대기, 경도인지장애, MCI 본연구는 2014년연세대학교대학원재원으로대학원총학생회의지원을받아연구되었음. 참고문헌 강연욱, 김향희, 나덕렬 (1999). 치매진단을위한단축형 Korean-Boston Naming Test (S-K-BNT) 의개발. 한국심리학회지 : 임상, 18, 김향희, 김수련 (2013). 문항반응이론을적용한한국판보스톤이름대기검사단축형 (K-BNT-15) 개발. 한국콘텐츠학회논문지, 13, 김향희, 나덕렬 (1997). 한국판보스톤이름대기검사 (K-BNT). 서울 : 학지사. 박은희, 최진영 (2000). 한국판보스톤이름대기검사의단축형에대한노인규준연구. 인지과학, 11, 이강수, 정해관, 오병훈, 홍창형 (2009). 치매및경도인지장애에대한인지선별검사 4종의타당도비교. 신경정신과학, 48, 차신영, 황선희 (2014). 노년기환자의신경인지적특성 : 우울감이있는경도인지장애, 우울감이없는경도인지장애, 우울장애집단의비교. 한국심리학회지 : 임상, 33,