CABPad Neuropsychological Test Battery for iPad


CABPad Start Screen

CABPad (Cognitive Assessment at Bedside for iPad) is a short neuropsychological test battery for bedside screening for cognitive dysfunctions after stroke. It was developed for a neurological research project studying remission of symptoms in subacute stroke. It may also - with caution - be used to screen stroke patients for cognitive symptoms before discharge from hospital.

WARNING: CABPad SHOULD NOT be used with an iPad Mini as norming and validation was done with at 9.7 inch screen.

PLEASE NOTE: CABPad is intended to be used only by qualified staff supervised by a neuropsychologist and the results should always be interpreted in collaboration with a neuropsychologist or behavioral neurologist.

The aims for the test battery require:

  1. That the entire battery does not take too long.
  2. That it measures the symptoms that typically appear after stroke.
  3. That as many patients as possible are able to cooperate to the test. This is especially challenging when it comes to stroke patients, as they suffer from such a wide range of symptoms which can influence the test, such as:
    1. Hemiparalysis of the dominant hand, which can interfere with the manual responses or lead to longer response times.
    2. Aphasia, which can make it difficult to understand instructions.
    3. Neglect, which can mean that the patient overlooks stimuli to the left side of the screen.

CABPad is NOT intended to measure all neuropsychological symptoms after stroke, just the most common and significant symptoms. CABPad is structured so that it is possible to select individual tasks if you have limited time available or if you do not need to take the whole battery. You can select and deselect tasks on the introduction screen or skip tasks as one proceeds with the test.

CABPad automatically saves test results as a readable text and as a semicolon separated file that can be opened in Excel, R or SPSS. Results are saved not only when a test is completed but also if the program f or some reason completely stops.

The results are shown as soon as a test battery is completed. You can also access test results by pressing the "Saved data" button on the introduction screen. You can also print results from this page.

A result assessment is provided on the basis of norms collected from 43 elderly healthy controls from an age group that is relevant with regards to stroke (average 69 years). Test results that are normally distributed within the healthy group are provided as T-scores. With regards to anosognosia, aphasia, and neglect, it does not make sense to increase the task difficulties to such an extent that they lead to a normal distribution within a healthy control group. Instead, for these tasks, the program reports whether the results are under or over the cut-off point.

Results are saved on the iPad in two formats: 1) as a readable text format that you can open in a text editing program, 2) as a semicolon separated CSV file that can used for research. You can print results directly from CABPad using AirPrint. must be linked to the same network. Data (CSV and text) can be transferred to a Mac or Windows computer via iTunes.

The battery includes the following tests and assessments (click names to jump to section):

  1. Rating of Anosognosia (Lack of Awareness of Symptoms)
  2. Motor Speed for Hands
  3. Speech Comprehension
  4. Picture Naming
  5. Verbal Fluency (A, F, S, Animals, Clothing)
  6. Timed Neglect Test
  7. The Baking Tray Test (Visual Hemineglect)
  8. Attention Span (for symbols)
  9. Working Memory (for symbols)
  10. Arrow Stroop (Executive Control of Attention)
  11. Memory for Pattern Locations
  12. Symbol Digit Coding (Mental and Visuo-Motor Speed)
  13. Depression - GDS Short Form

The app contains English, German, Italian, Portuguese, Brazilian Portuguese, Norwegian, and Danish language. Translators are invited for other languages.

A preliminary validation of the test battery was presented at The International Stroke Conference, Feb 2015:
L Willer, PM Pedersen, A Gullach, HB Forchhammer, HK Christensen: Assessment Of Cognitive Symptoms In Sub-acute Stroke With An iPad Test-battery. Stroke 2015; 46: ATP415.

Available on the App Store

Download user guides (pdf)


Descriptions of the tests

Rating of anosognosia

Purpose

To assess symptom awareness for all common stroke symptoms.

Background

Anosognosia (missing or reduced awareness of symptoms or illness) can be important with regards to participation in rehabilitation and long term outcome. It can also lead to accidents (e.g. when a hemiplegic patient with anosognosia attempts to get out of bed). When used as an outcome measure, it is only relevant for the symptoms that the patient has. Moreover, the assessor must know about these symptoms prior to testing.

Traditionally, anosognosia has only been rated for hemianopia and hemiplegia. Anosognosia has also been described with Wernicke's aphasia and neglect, but one could expect that it exists in relation to other symptoms as well. Therefore, for experimental purposes, anosognosia is also rated here for a series of other acute stroke symptoms. If the assessment turns out to work on a practical level, it could potentially lead to the description of something novel.

It seems that there can be differences in the level of awareness of symptoms described verbally by the patient and the level of awareness demonstrated in the behavior of the patient (some patients acknowledge hemiplegia verbally, but still attempt to leave their bed, while others deny hemiplegia verbally, but stay in bed). Unfortunately, it is not possible to include this differentiation in this rating tool, as it would require extended systematic observations. This test comes first in the battery as the other tasks can reveal some of the symptoms in question to the patient.

Test description

The assessor asks the patient questions, and if necessary, asks the patient to follow commands. Anosognosia is rated according to Bisach et al.:

  1. A symptom is reported spontaneously (when asked in a general way about what symptoms the patient has)
  2. A symptom is reported when asked specifically about it.
  3. A symptom is reported after demonstration (e.g. with hemiplegia: "Please raise your left arm")
  4. A symptom is not reported at all.

One can also register if the symptom is not present (in which case an anosognosia rating of the symptom is not relevant) or if it is not possible to rate it (e.g. because of aphasia).

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Motor Speed for Hands

Purpose

This test assesses fine motor speed for the hands.

Background

Motor function is frequently affected in stroke. With a mild impact, the degree of reduction in fine motor speed is by itself important to know. Reduction in simple fine motor speed can also have consequences regarding the interpretation of performance in other tests that measure the speed of response. It is important not to interpret reduced speed in the other tests as a reduction of higher cognitive functions when they could be a consequence of a general slowing of motor speed.

Test description

The patient must alternate between pressing two buttons with his/her index finger as quickly as possible. A star is shown in the frame that needs to be pressed. First, four practice tasks are presented, and then, there is a 30 second test for each hand. Handedness must be entered. If it is known in advance that the patient cannot use the hand at all, then one can enter this into the program. This can also be registered if it only later becomes apparent during the practice trial. The test will then not be carried out for the hand in question. The dominant hand is always tested first. If the patient is ambidextrous or if hand dominance is unknown, the right hand is tested first.

Help allowed

During the practice trials, the instructions can be repeated and elaborated as needed. They can also be accompanied by gestures.

During the test itself, the instructions can be repeated when the test starts and can be accompanied by gestures. However, no help or encouragement is allowed after this.

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Speech Comprehension

CABPad Comprehension Test

Purpose

To assess the comprehension of spoken language: single words as well as short sentences.

Background

Language comprehension is often (but not always) affected when a patient has aphasia after left middle cerebral artery stroke.

Test description

The iPad says some words or sentences and the patient has to select the corresponding picture. When a picture has been selected, the frame around it becomes darker and the non-selected pictures disappear a bit quicker that the selected one, in order to indicate which picture has been selected. No feedback is provided regarding the accuracy of the response (as it would cause a distraction and would not have a purpose for the testing).

The spoken word or sentence may be repeated once by touching the button at the bottom of the screen.

The first set of pictures have large semantic distances with one another and depict ordinary objects. The following two sets show objects that are more closely semantically related, first vegetables and then insects, which are a bit more difficult. The next part is similar to the Token-test as it requires the comprehension of words for geometrical shapes, colors, and sizes. The last part tests sentence comprehension.

In a test like this, it is impossible to avoid any kind of ceiling effect. A comprehension test without any ceiling effect would be rather sensitive to educational background and also rather time-consuming.

Help allowed

The assessor can show and explain to the patient that he or she has to select a picture by pressing it, but may not show which picture the patient must choose.

The assessor can show and explain to the patient that the task instructions (what is said by the iPad) can be repeated (once) by pressing the button at the bottom of the screen.

The assessor cannot repeat the task instructions to the patient by saying the same word or sentence again (unless there has been a disturbance that has impeded the patient in hearing the task).

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Picture Naming

Purpose

To assess naming in patients with aphasia.

Background

Naming difficulties (anomia) can be seen in all types of aphasia, and in mild aphasia, they can be the only symptom (anomic aphasia). The subtasks have different levels of difficulty because of differences in the each word’s frequency in language. The test has a ceiling effect. If a larger number of pictures and more difficult pictures had been included in the test, the test would have been too time consuming and very sensitive to educational background.

Test description

Twenty pictures are shown that must be named. The patient has 20 seconds to name each picture. The picture disappears after 20 seconds and responses that are given after a picture has disappeared should not be scored as correct. As soon as the patient has provided a response, the assessor touches a button leading to a scoring page so you don't have to wait the full 20 seconds to move on. Responses are scored as follows:

  1. Correct naming (no errors at all, not even dysarthria)
  2. Incorrect, but can be understood as an attempt to say the correct word (responses with phonemic paraphasias, pronunciation problems and dysarthria are OK)
  3. Incomprehensible or wrong word (including semantic paraphasias, stereotypical repeated utterances or grunts)
  4. No response (i.e. no sound at all)

The test can be aborted after each of the 20 tasks. This can be done in cases where patients say nothing at all but should not be done if one is planning to use the data for research.

Help allowed

The only help the assessor is allowed to provide is to repeat to the patient that he/she is supposed to say what the picture depicts.

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Verbal Fluency

Purpose

To assess verbal productivity in aphasia and mental dynamics related to executive disorders.

Background

The test can be used to assess aphasia as well as dysexecutive symptoms. However, it can only be used to assess dysexectutive symptoms if there is no sign of aphasia. Verbal fluency with semantic categories is most relevant in regards to aphasia. Verbal fluency with letters is most relevant for the executive function "mental dynamics".

Test description

The patient is asked to say as many words as possible that begin with a certain letter or that are within a certain category. The test counts the number of words that are mentioned within one minute for each task. The time is displayed (to the assessor) on a timer. The assessor registers each time a word is produced. One registers whether the word is:

  1. Correct (comprehensible paraphasia and pronunciation errors are accepted)
  2. Incomprehensible (totally incomprehensible: note that pronunciation errors and paraphasia are accepted as correct)
  3. Rule breaking (e.g. words with the wrong first letter or not in the correct category)
  4. Repetition (note that the assessor has to remember words that have already been mentioned!)

It is possible to abort the test between each of the five tasks, but not during the minute that each task lasts. The assessor should avoid aborting the test, even if there has been a task with no responses, as the following trial might be easier for the patient.

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Timed Neglect Test

CABPad Timed Neglect Test

Purpose

To measure visual hemineglect with a high level of sensitivity by measuring response times in different areas of the screen.

Background

The level of sensitivity can be limited in traditional paper-and-pencil tests for hemineglect, as they usually do not have time limits and do not measure response times. On the other hand, the iPad neglect test loses sensitivity because of the small screen size.

Test description

A butterfly is show in various places on the screen, and the aim is to touch it as quickly as possible after it has appeared. If a response is not given within 5 seconds, the butterfly disappears and the time-score is set at 5 seconds (this is done in order for the test not to be too time consuming and in order to help patients with severe neglect move on). A total of 30 butterflies are displayed in all areas of the screen in a pseudo random order. It is easier to notice the butterfly at the top part of the screen on the blue sky background than at the bottom on green vegetation background. This graded difficulty has been added in order to reduce floor and ceiling effects. The program reports average response times for the left, middle, and right part of the screen, as well as the number of positive responses. A response-time ratio for left vs. right (middle not included) is also reported.

Help allowed

The assessor can only help by prompting during the practice session. During the practice session, the assessor can explain to the patient that he/she must look for a butterfly and touch it. If necessary, one can point out the butterfly and encourage the patient to touch it. The assessor may not help or prompt the patient during the test itself.

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The Baking Tray Test (Visual Hemineglect)

Purpose

To assess hemineglect in the peripersonal space using a test that is sensitive to visuospatial as well as intentional hemineglect.

Background

Some studies have shown that the hands-on version of the baking tray test is more sensitive to hemineglect than other traditional (paper-and-pencil) neglect tests, probably because performance can be affected by intentional as well as visuospatial neglect.

Test description

The patient has to distributed twelve buns evenly on a backing tray. In order to place buns on the tray, one simply touches the intended positions on the screen. As soon as a bun has been placed on the tray, it cannot be moved (during pilot testing of the app, it proved to be confusing for some patients that buns could be removed by being touched). Before the test itself, there is a training exercise with three buns. Patients with neglect often place too many buns on the right side of the tray. Performance can also be affected by executive difficulties such as poor planning.

Help allowed

  1. The assessor may prompt the patient to begin the task by saying: "Touch the baking tray to place a bun".
  2. The assessor may prompt the patient to continue the task: "You haven't put all 12 buns on the backing tray yet".
  3. The assessor may answer questions concerning the way the buns are placed: "You touch the baking tray in order to place a bun. Once placed, it cannot be moved".
  4. The assessor is not allowed to comment on the distribution of the buns.
  5. The assessor is not allowed to explain or show the entire baking tray using gestures.
  6. The assessor is not allowed to help the patient in orienting his/her attention toward the left or right side of the screen.

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Attention Span

Purpose

To assess simple attention span, i.e. how many items can be kept in mind at the same time with no restructuring required.

Background

The test measures attention span, which is an aspect of working memory (with little demand on the executive component, which is challenged more in the next test: Working Memory). The test is not sensitive to a reduction of episodic memory (which has to do with what can be remembered after a distraction). There is a test in the CABPad that is specially designed to test episodic memory: Memory for Pattern Locations.

In order to increase the chance that aphasia patients can manage the test, symbols (pictures of objects) are used instead of digits. The response buttons are grouped in the shape of a square in the middle of the screen in order to increase the chance that neglect patients can perform the test.

Test description

The task involves remembering symbols and the order in which they are presented. First, the symbols are shown on the screen and then, the patient has to select them from a larger selection of symbols, in the correct order. In the first trial, two symbols must be reported in the correct order, then three, then four, etc. There are two trials for each amount of symbols. The test stops when two errors have been made on the same level (e.g. if both trials with three symbols are incorrect). A single trial proceeds as follows:

  1. Each symbol is shown for 1.5 seconds.
  2. The patient enters his/her response by pressing the symbols in the order they were shown.
  3. The test moves on to the next trial when the patient has entered the amount of symbols that were included in the trial.
  4. If the patient cannot remember all of the symbols, he/she can press the button: "Cannot remember any more symbols".
  5. The test begins with a practice session.

Help allowed

Instructions can be repeated and elaborated upon (also using gestures) during the practice session but not during the test itself. During the test itself, the assessor can draw the patient’s attention to the "Cannot remember any more symbols" button, if the patient cannot remember all symbols or if the patient freezes.

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Working Memory

Purpose

To assess working memory, i.e. the ability to keep and process several items simultaneously in the mind.

Background

Working Memory is an important executive function. The prefrontal areas of the brain are important when it comes to maintaining and processing several items simultaneously in the mind. The elements themselves are held in the posterior brain areas (towards the back), which are involved in the perception of the type of information in question. The prefrontal component contributes by fending off distractors and manipulating elements, e.g. when inverting the order of the elements.

Two tests measuring working memory have been included in the battery. In the Attention Span test, the order of the elements does not have to inversed, so the contribution of the prefrontal/executive component is far weaker.

The test cannot be used to measure episodic memory (in other words, it cannot be used to measure whether a patient is able to create new memories after brain damage). There is another test included in the battery which is specifically aimed at measuring episodic memory: Memory for Pattern Locations.

Test description

This test is similar to the "Attention Span" test, but here, the symbols must be entered in reverse order. The test starts with two symbols, then three, and so on. There are two trials for each amount of symbols. The test stops when two errors have been made on the same level (e.g. if both trials with three symbols are incorrect). A single trial proceeds as follows:

  1. Each symbol is shown for 1.5 seconds.
  2. The patient enters his/her response by pressing the symbols in the reverse order than that, which they were shown in.
  3. The test moves on to the next trial when the patient has entered the amount of symbols that were included in the trial.
  4. If the patient cannot remember all of the symbols, he/she can press the button: "Cannot remember any more symbols".

The test begins with a practice session.

Help allowed

The assessor may repeat and elaborate instructions (also using gestures) during the practice session, but not during the test itself. During the test itself, the assessor can draw the patient’s attention to the "Cannot remember any more symbols" button if the patient cannot remember all symbols or if the patient freezes.

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Arrow Stroop (Executive Control of Attention)

CABPad Arrow Stroop Test

Purpose

To investigate executive control of attention, more specifically cognitive impulse control.

Background

Selective dysexecutive syndromes are rarely seen after stroke, but after severe stroke, mild executive difficulties are commonly seen together with other symptoms. These symptoms can be expected to have implications for the patient’s outcome. In CABPad, only one aspect of executive symptoms has been included, as the battery would be too time consuming if it had to cover all aspects (e.g. cognitive flexibility and planning ability). The task measures the added reaction time that results from response conflict. Other tasks that can reflect dysexecutive disorders are Working Memory and Verbal Fluency (but performance on these tasks can also be a ffected by more basic cognitive disorders, such as aphasia).

Test description

Two buttons are placed above one another. Arrows are shown (one on each side in order to support neglect patients) pointing upwards or downwards. In the test, one must press the top button as quickly as possible if the arrow is pointing upwards and the bottom button if the arrow is pointing downwards. Nine out of ten arrows are placed in a position that is congruent with the direction that the arrow is pointing towards, i.e. beside the top button (that is to be pressed), if the arrow is pointing upwards. One out of ten trials is incongruent. The test stops after two minutes.

If the correct button is pressed, a green tick appears quickly in the middle of the screen. If the wrong button is pressed, a red cross appears, and an unpleasant sound is produced.

Before the test begins, there is a practice session.

Results are measured as the difference in reaction times between the congruent and incongruent trials. The number of errors is also indicated, but it is not a good measure of performance, as patients do not all reach the same amount of trials within the two minute limit. This would require that all patients were given the same amount of trials regardless of their reaction times, in which case the test could take a very long time for the slowest patients.

Help allowed

The assessor can help the patient understand the test by repeating and elaborating explanations, as well as by using gestures during the practice trials, but not during the test itself.

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Memory for Pattern Locations

Purpose

To evaluate episodic memory using a test that can be carried out by patients with aphasia.

Background

Severe memory deficits (amnestic syndrome) are rarely seen in patients with aphasia but can occur, specially if the posterior cerebral arteries are affected. Patients do, however, often describe more discrete memory problems. It can be difficult to differentiate language problems and memory problems in patients with aphasia. This test is designed to evaluate episodic memory, i.e. what one can remember after a disturbance has occurred after learning (information that one can keep in mind as long as no disturbance occurs is called working memory; working memory can be measured using other tests in the CABPad). The test requires memory for spatial locations and for abstract patterns, which are difficult to verbalize. In the first version of the test, drawings of real objects were used, but there was an evident ceiling effect among healthy controls. There should not be a floor effect as one should be able to remember the location of at least one pattern within ten attempts. The fact that some patterns look very much alike means that a ceiling effect is unlikely.

Test description

The patient has to remember where the abstract patterns are shown. There are 10 positions and their 10 associated patterns, and 10 attempts are given. In the first trial, a pattern is shown. When the pattern has been hidden, one has to point at the frame where the pattern was shown. If a mistake is made, the pattern is shown again. If one answers correctly, the next trial includes two patterns. If a mistake is made, both patterns are shown again. A point is given for each correct answer, with 55 as the maximum score.

Each time a pattern is shown, an arrow appears in the middle of the screen pointing towards it. This is intended to help neglect and hemianopia patients in seeing the patterns.

Help allowed

  1. The assessor may remind the patients that they are being shown patterns that they must remember.
  2. The assessor may prompt the patients to answer by pressing the field with the question mark, but may not show the patient which frame they need to choose.

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Symbol Digit Coding (Mental and Visuo-Motor Speed)

Purpose

To measure mental and visuo-motor speed in a complex task that requires good communication between different parts of the brain and that also requires a high level of concentration.

Background

This test is included in the battery because it is highly sensitive to cognitive disturbances. It is, however, not very specific, as it challenges a number of cognitive functions including visual search, working memory, concentration, and learning. The high sensitivity and good level of reliability make it very well-suited for research regarding outcome, and since it lasts only a few minutes, a lot of important information can be gained in a short timespan.

Test description

A coding system is displayed at the top of the screen, showing digits and their associated symbols. At the bottom of the screen, there is a "symbol keyboard", which the patient uses to provide responses. Single digits are shown, one at a time, in the middle of the screen, and one has to press the associated symbols as quickly as possible. If a mistake is made, a red frame appears instead of a grey frame around the digit in the middle of the screen. The test starts with five practice trials. The test itself takes two minutes.

Help allowed

The assessor may repeat and elaborate explanations (also using gestures) during the practice session.

During the test itself, the patient can be prompted to start at the beginning of the test, but no other explanations or help may be given.

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Depression - GDS Short Form

Purpose

To assess depression using a scale that can be used with elderly and hospitalized patients.

Background

Depression is common after stroke. It should probably be treated as early as possible, in part because it can affect the amount of energy the patient has for rehabilitation. Depression can also affect a patient’s performance on cognitive tests. There is also an overlap between depression and stroke symptoms (e.g. loss of energy or concentration difficulties). The scale that has been included in this test battery was chosen because it was considered to be least affected by stroke symptoms.

Test description

The test is simply a computerized form of the short version of the Geriatric Depression Scale. The assessor reads the questions aloud and enters the patient’s yes-no answers. The questions can also be read aloud by the app. It is also possible to register whether the patient is able to understand the questions and respond to them. Any form of yes-no answers are accepted.

Help allowed

All 15 questions may be repeated as many times as needed, but they may not be rephrased.

Any type of support that can help the patient provide a positive or negative answer is allowed. The assessor must be sure, however, that what is typed in the form is a true expression of the patient’s answer.

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CABPad Neuropsychological Test Battery for iPad


CABPad Start Screen

CABPad (Cognitive Assessment at Bedside for iPad) is a short neuropsychological test battery for bedside screening for cognitive dysfunctions after stroke. It was developed for a neurological research project studying remission of symptoms in subacute stroke. It may also - with caution - be used to screen stroke patients for cognitive symptoms before discharge from hospital.

WARNING: CABPad SHOULD NOT be used with an iPad Mini as norming and validation was done with at 9.7 inch screen.

PLEASE NOTE: CABPad is intended to be used only by qualified staff supervised by a neuropsychologist and the results should always be interpreted in collaboration with a neuropsychologist or behavioral neurologist.

The aims for the test battery require:

  1. That the entire battery does not take too long.
  2. That it measures the symptoms that typically appear after stroke.
  3. That as many patients as possible are able to cooperate to the test. This is especially challenging when it comes to stroke patients, as they suffer from such a wide range of symptoms which can influence the test, such as:
    1. Hemiparalysis of the dominant hand, which can interfere with the manual responses or lead to longer response times.
    2. Aphasia, which can make it difficult to understand instructions.
    3. Neglect, which can mean that the patient overlooks stimuli to the left side of the screen.

CABPad is NOT intended to measure all neuropsychological symptoms after stroke, just the most common and significant symptoms. CABPad is structured so that it is possible to select individual tasks if you have limited time available or if you do not need to take the whole battery. You can select and deselect tasks on the introduction screen or skip tasks as one proceeds with the test.

CABPad automatically saves test results as a readable text and as a semicolon separated file that can be opened in Excel, R or SPSS. Results are saved not only when a test is completed but also if the program f or some reason completely stops.

The results are shown as soon as a test battery is completed. You can also access test results by pressing the "Saved data" button on the introduction screen. You can also print results from this page.

A result assessment is provided on the basis of norms collected from 43 elderly healthy controls from an age group that is relevant with regards to stroke (average 69 years). Test results that are normally distributed within the healthy group are provided as T-scores. With regards to anosognosia, aphasia, and neglect, it does not make sense to increase the task difficulties to such an extent that they lead to a normal distribution within a healthy control group. Instead, for these tasks, the program reports whether the results are under or over the cut-off point.

Results are saved on the iPad in two formats: 1) as a readable text format that you can open in a text editing program, 2) as a semicolon separated CSV file that can used for research. You can print results directly from CABPad using AirPrint. must be linked to the same network. Data (CSV and text) can be transferred to a Mac or Windows computer via iTunes.

The battery includes the following tests and assessments (click names to jump to section):

  1. Rating of Anosognosia (Lack of Awareness of Symptoms)
  2. Motor Speed for Hands
  3. Speech Comprehension
  4. Picture Naming
  5. Verbal Fluency (A, F, S, Animals, Clothing)
  6. Timed Neglect Test
  7. The Baking Tray Test (Visual Hemineglect)
  8. Attention Span (for symbols)
  9. Working Memory (for symbols)
  10. Arrow Stroop (Executive Control of Attention)
  11. Memory for Pattern Locations
  12. Symbol Digit Coding (Mental and Visuo-Motor Speed)
  13. Depression - GDS Short Form

The app contains English, German, Italian, Portuguese, Brazilian Portuguese, Norwegian, and Danish language. Translators are invited for other languages.

A preliminary validation of the test battery was presented at The International Stroke Conference, Feb 2015:
L Willer, PM Pedersen, A Gullach, HB Forchhammer, HK Christensen: Assessment Of Cognitive Symptoms In Sub-acute Stroke With An iPad Test-battery. Stroke 2015; 46: ATP415.

Available on the App Store

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Descriptions of the tests

Rating of anosognosia

Purpose

To assess symptom awareness for all common stroke symptoms.

Background

Anosognosia (missing or reduced awareness of symptoms or illness) can be important with regards to participation in rehabilitation and long term outcome. It can also lead to accidents (e.g. when a hemiplegic patient with anosognosia attempts to get out of bed). When used as an outcome measure, it is only relevant for the symptoms that the patient has. Moreover, the assessor must know about these symptoms prior to testing.

Traditionally, anosognosia has only been rated for hemianopia and hemiplegia. Anosognosia has also been described with Wernicke's aphasia and neglect, but one could expect that it exists in relation to other symptoms as well. Therefore, for experimental purposes, anosognosia is also rated here for a series of other acute stroke symptoms. If the assessment turns out to work on a practical level, it could potentially lead to the description of something novel.

It seems that there can be differences in the level of awareness of symptoms described verbally by the patient and the level of awareness demonstrated in the behavior of the patient (some patients acknowledge hemiplegia verbally, but still attempt to leave their bed, while others deny hemiplegia verbally, but stay in bed). Unfortunately, it is not possible to include this differentiation in this rating tool, as it would require extended systematic observations. This test comes first in the battery as the other tasks can reveal some of the symptoms in question to the patient.

Test description

The assessor asks the patient questions, and if necessary, asks the patient to follow commands. Anosognosia is rated according to Bisach et al.:

  1. A symptom is reported spontaneously (when asked in a general way about what symptoms the patient has)
  2. A symptom is reported when asked specifically about it.
  3. A symptom is reported after demonstration (e.g. with hemiplegia: "Please raise your left arm")
  4. A symptom is not reported at all.

One can also register if the symptom is not present (in which case an anosognosia rating of the symptom is not relevant) or if it is not possible to rate it (e.g. because of aphasia).

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Motor Speed for Hands

Purpose

This test assesses fine motor speed for the hands.

Background

Motor function is frequently affected in stroke. With a mild impact, the degree of reduction in fine motor speed is by itself important to know. Reduction in simple fine motor speed can also have consequences regarding the interpretation of performance in other tests that measure the speed of response. It is important not to interpret reduced speed in the other tests as a reduction of higher cognitive functions when they could be a consequence of a general slowing of motor speed.

Test description

The patient must alternate between pressing two buttons with his/her index finger as quickly as possible. A star is shown in the frame that needs to be pressed. First, four practice tasks are presented, and then, there is a 30 second test for each hand. Handedness must be entered. If it is known in advance that the patient cannot use the hand at all, then one can enter this into the program. This can also be registered if it only later becomes apparent during the practice trial. The test will then not be carried out for the hand in question. The dominant hand is always tested first. If the patient is ambidextrous or if hand dominance is unknown, the right hand is tested first.

Help allowed

During the practice trials, the instructions can be repeated and elaborated as needed. They can also be accompanied by gestures.

During the test itself, the instructions can be repeated when the test starts and can be accompanied by gestures. However, no help or encouragement is allowed after this.

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Speech Comprehension

CABPad Comprehension Test

Purpose

To assess the comprehension of spoken language: single words as well as short sentences.

Background

Language comprehension is often (but not always) affected when a patient has aphasia after left middle cerebral artery stroke.

Test description

The iPad says some words or sentences and the patient has to select the corresponding picture. When a picture has been selected, the frame around it becomes darker and the non-selected pictures disappear a bit quicker that the selected one, in order to indicate which picture has been selected. No feedback is provided regarding the accuracy of the response (as it would cause a distraction and would not have a purpose for the testing).

The spoken word or sentence may be repeated once by touching the button at the bottom of the screen.

The first set of pictures have large semantic distances with one another and depict ordinary objects. The following two sets show objects that are more closely semantically related, first vegetables and then insects, which are a bit more difficult. The next part is similar to the Token-test as it requires the comprehension of words for geometrical shapes, colors, and sizes. The last part tests sentence comprehension.

In a test like this, it is impossible to avoid any kind of ceiling effect. A comprehension test without any ceiling effect would be rather sensitive to educational background and also rather time-consuming.

Help allowed

The assessor can show and explain to the patient that he or she has to select a picture by pressing it, but may not show which picture the patient must choose.

The assessor can show and explain to the patient that the task instructions (what is said by the iPad) can be repeated (once) by pressing the button at the bottom of the screen.

The assessor cannot repeat the task instructions to the patient by saying the same word or sentence again (unless there has been a disturbance that has impeded the patient in hearing the task).

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Picture Naming

Purpose

To assess naming in patients with aphasia.

Background

Naming difficulties (anomia) can be seen in all types of aphasia, and in mild aphasia, they can be the only symptom (anomic aphasia). The subtasks have different levels of difficulty because of differences in the each word’s frequency in language. The test has a ceiling effect. If a larger number of pictures and more difficult pictures had been included in the test, the test would have been too time consuming and very sensitive to educational background.

Test description

Twenty pictures are shown that must be named. The patient has 20 seconds to name each picture. The picture disappears after 20 seconds and responses that are given after a picture has disappeared should not be scored as correct. As soon as the patient has provided a response, the assessor touches a button leading to a scoring page so you don't have to wait the full 20 seconds to move on. Responses are scored as follows:

  1. Correct naming (no errors at all, not even dysarthria)
  2. Incorrect, but can be understood as an attempt to say the correct word (responses with phonemic paraphasias, pronunciation problems and dysarthria are OK)
  3. Incomprehensible or wrong word (including semantic paraphasias, stereotypical repeated utterances or grunts)
  4. No response (i.e. no sound at all)

The test can be aborted after each of the 20 tasks. This can be done in cases where patients say nothing at all but should not be done if one is planning to use the data for research.

Help allowed

The only help the assessor is allowed to provide is to repeat to the patient that he/she is supposed to say what the picture depicts.

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Verbal Fluency

Purpose

To assess verbal productivity in aphasia and mental dynamics related to executive disorders.

Background

The test can be used to assess aphasia as well as dysexecutive symptoms. However, it can only be used to assess dysexectutive symptoms if there is no sign of aphasia. Verbal fluency with semantic categories is most relevant in regards to aphasia. Verbal fluency with letters is most relevant for the executive function "mental dynamics".

Test description

The patient is asked to say as many words as possible that begin with a certain letter or that are within a certain category. The test counts the number of words that are mentioned within one minute for each task. The time is displayed (to the assessor) on a timer. The assessor registers each time a word is produced. One registers whether the word is:

  1. Correct (comprehensible paraphasia and pronunciation errors are accepted)
  2. Incomprehensible (totally incomprehensible: note that pronunciation errors and paraphasia are accepted as correct)
  3. Rule breaking (e.g. words with the wrong first letter or not in the correct category)
  4. Repetition (note that the assessor has to remember words that have already been mentioned!)

It is possible to abort the test between each of the five tasks, but not during the minute that each task lasts. The assessor should avoid aborting the test, even if there has been a task with no responses, as the following trial might be easier for the patient.

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Timed Neglect Test

CABPad Timed Neglect Test

Purpose

To measure visual hemineglect with a high level of sensitivity by measuring response times in different areas of the screen.

Background

The level of sensitivity can be limited in traditional paper-and-pencil tests for hemineglect, as they usually do not have time limits and do not measure response times. On the other hand, the iPad neglect test loses sensitivity because of the small screen size.

Test description

A butterfly is show in various places on the screen, and the aim is to touch it as quickly as possible after it has appeared. If a response is not given within 5 seconds, the butterfly disappears and the time-score is set at 5 seconds (this is done in order for the test not to be too time consuming and in order to help patients with severe neglect move on). A total of 30 butterflies are displayed in all areas of the screen in a pseudo random order. It is easier to notice the butterfly at the top part of the screen on the blue sky background than at the bottom on green vegetation background. This graded difficulty has been added in order to reduce floor and ceiling effects. The program reports average response times for the left, middle, and right part of the screen, as well as the number of positive responses. A response-time ratio for left vs. right (middle not included) is also reported.

Help allowed

The assessor can only help by prompting during the practice session. During the practice session, the assessor can explain to the patient that he/she must look for a butterfly and touch it. If necessary, one can point out the butterfly and encourage the patient to touch it. The assessor may not help or prompt the patient during the test itself.

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The Baking Tray Test (Visual Hemineglect)

Purpose

To assess hemineglect in the peripersonal space using a test that is sensitive to visuospatial as well as intentional hemineglect.

Background

Some studies have shown that the hands-on version of the baking tray test is more sensitive to hemineglect than other traditional (paper-and-pencil) neglect tests, probably because performance can be affected by intentional as well as visuospatial neglect.

Test description

The patient has to distributed twelve buns evenly on a backing tray. In order to place buns on the tray, one simply touches the intended positions on the screen. As soon as a bun has been placed on the tray, it cannot be moved (during pilot testing of the app, it proved to be confusing for some patients that buns could be removed by being touched). Before the test itself, there is a training exercise with three buns. Patients with neglect often place too many buns on the right side of the tray. Performance can also be affected by executive difficulties such as poor planning.

Help allowed

  1. The assessor may prompt the patient to begin the task by saying: "Touch the baking tray to place a bun".
  2. The assessor may prompt the patient to continue the task: "You haven't put all 12 buns on the backing tray yet".
  3. The assessor may answer questions concerning the way the buns are placed: "You touch the baking tray in order to place a bun. Once placed, it cannot be moved".
  4. The assessor is not allowed to comment on the distribution of the buns.
  5. The assessor is not allowed to explain or show the entire baking tray using gestures.
  6. The assessor is not allowed to help the patient in orienting his/her attention toward the left or right side of the screen.

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Attention Span

Purpose

To assess simple attention span, i.e. how many items can be kept in mind at the same time with no restructuring required.

Background

The test measures attention span, which is an aspect of working memory (with little demand on the executive component, which is challenged more in the next test: Working Memory). The test is not sensitive to a reduction of episodic memory (which has to do with what can be remembered after a distraction). There is a test in the CABPad that is specially designed to test episodic memory: Memory for Pattern Locations.

In order to increase the chance that aphasia patients can manage the test, symbols (pictures of objects) are used instead of digits. The response buttons are grouped in the shape of a square in the middle of the screen in order to increase the chance that neglect patients can perform the test.

Test description

The task involves remembering symbols and the order in which they are presented. First, the symbols are shown on the screen and then, the patient has to select them from a larger selection of symbols, in the correct order. In the first trial, two symbols must be reported in the correct order, then three, then four, etc. There are two trials for each amount of symbols. The test stops when two errors have been made on the same level (e.g. if both trials with three symbols are incorrect). A single trial proceeds as follows:

  1. Each symbol is shown for 1.5 seconds.
  2. The patient enters his/her response by pressing the symbols in the order they were shown.
  3. The test moves on to the next trial when the patient has entered the amount of symbols that were included in the trial.
  4. If the patient cannot remember all of the symbols, he/she can press the button: "Cannot remember any more symbols".
  5. The test begins with a practice session.

Help allowed

Instructions can be repeated and elaborated upon (also using gestures) during the practice session but not during the test itself. During the test itself, the assessor can draw the patient’s attention to the "Cannot remember any more symbols" button, if the patient cannot remember all symbols or if the patient freezes.

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Working Memory

Purpose

To assess working memory, i.e. the ability to keep and process several items simultaneously in the mind.

Background

Working Memory is an important executive function. The prefrontal areas of the brain are important when it comes to maintaining and processing several items simultaneously in the mind. The elements themselves are held in the posterior brain areas (towards the back), which are involved in the perception of the type of information in question. The prefrontal component contributes by fending off distractors and manipulating elements, e.g. when inverting the order of the elements.

Two tests measuring working memory have been included in the battery. In the Attention Span test, the order of the elements does not have to inversed, so the contribution of the prefrontal/executive component is far weaker.

The test cannot be used to measure episodic memory (in other words, it cannot be used to measure whether a patient is able to create new memories after brain damage). There is another test included in the battery which is specifically aimed at measuring episodic memory: Memory for Pattern Locations.

Test description

This test is similar to the "Attention Span" test, but here, the symbols must be entered in reverse order. The test starts with two symbols, then three, and so on. There are two trials for each amount of symbols. The test stops when two errors have been made on the same level (e.g. if both trials with three symbols are incorrect). A single trial proceeds as follows:

  1. Each symbol is shown for 1.5 seconds.
  2. The patient enters his/her response by pressing the symbols in the reverse order than that, which they were shown in.
  3. The test moves on to the next trial when the patient has entered the amount of symbols that were included in the trial.
  4. If the patient cannot remember all of the symbols, he/she can press the button: "Cannot remember any more symbols".

The test begins with a practice session.

Help allowed

The assessor may repeat and elaborate instructions (also using gestures) during the practice session, but not during the test itself. During the test itself, the assessor can draw the patient’s attention to the "Cannot remember any more symbols" button if the patient cannot remember all symbols or if the patient freezes.

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Arrow Stroop (Executive Control of Attention)

CABPad Arrow Stroop Test

Purpose

To investigate executive control of attention, more specifically cognitive impulse control.

Background

Selective dysexecutive syndromes are rarely seen after stroke, but after severe stroke, mild executive difficulties are commonly seen together with other symptoms. These symptoms can be expected to have implications for the patient’s outcome. In CABPad, only one aspect of executive symptoms has been included, as the battery would be too time consuming if it had to cover all aspects (e.g. cognitive flexibility and planning ability). The task measures the added reaction time that results from response conflict. Other tasks that can reflect dysexecutive disorders are Working Memory and Verbal Fluency (but performance on these tasks can also be a ffected by more basic cognitive disorders, such as aphasia).

Test description

Two buttons are placed above one another. Arrows are shown (one on each side in order to support neglect patients) pointing upwards or downwards. In the test, one must press the top button as quickly as possible if the arrow is pointing upwards and the bottom button if the arrow is pointing downwards. Nine out of ten arrows are placed in a position that is congruent with the direction that the arrow is pointing towards, i.e. beside the top button (that is to be pressed), if the arrow is pointing upwards. One out of ten trials is incongruent. The test stops after two minutes.

If the correct button is pressed, a green tick appears quickly in the middle of the screen. If the wrong button is pressed, a red cross appears, and an unpleasant sound is produced.

Before the test begins, there is a practice session.

Results are measured as the difference in reaction times between the congruent and incongruent trials. The number of errors is also indicated, but it is not a good measure of performance, as patients do not all reach the same amount of trials within the two minute limit. This would require that all patients were given the same amount of trials regardless of their reaction times, in which case the test could take a very long time for the slowest patients.

Help allowed

The assessor can help the patient understand the test by repeating and elaborating explanations, as well as by using gestures during the practice trials, but not during the test itself.

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Memory for Pattern Locations

Purpose

To evaluate episodic memory using a test that can be carried out by patients with aphasia.

Background

Severe memory deficits (amnestic syndrome) are rarely seen in patients with aphasia but can occur, specially if the posterior cerebral arteries are affected. Patients do, however, often describe more discrete memory problems. It can be difficult to differentiate language problems and memory problems in patients with aphasia. This test is designed to evaluate episodic memory, i.e. what one can remember after a disturbance has occurred after learning (information that one can keep in mind as long as no disturbance occurs is called working memory; working memory can be measured using other tests in the CABPad). The test requires memory for spatial locations and for abstract patterns, which are difficult to verbalize. In the first version of the test, drawings of real objects were used, but there was an evident ceiling effect among healthy controls. There should not be a floor effect as one should be able to remember the location of at least one pattern within ten attempts. The fact that some patterns look very much alike means that a ceiling effect is unlikely.

Test description

The patient has to remember where the abstract patterns are shown. There are 10 positions and their 10 associated patterns, and 10 attempts are given. In the first trial, a pattern is shown. When the pattern has been hidden, one has to point at the frame where the pattern was shown. If a mistake is made, the pattern is shown again. If one answers correctly, the next trial includes two patterns. If a mistake is made, both patterns are shown again. A point is given for each correct answer, with 55 as the maximum score.

Each time a pattern is shown, an arrow appears in the middle of the screen pointing towards it. This is intended to help neglect and hemianopia patients in seeing the patterns.

Help allowed

  1. The assessor may remind the patients that they are being shown patterns that they must remember.
  2. The assessor may prompt the patients to answer by pressing the field with the question mark, but may not show the patient which frame they need to choose.

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Symbol Digit Coding (Mental and Visuo-Motor Speed)

Purpose

To measure mental and visuo-motor speed in a complex task that requires good communication between different parts of the brain and that also requires a high level of concentration.

Background

This test is included in the battery because it is highly sensitive to cognitive disturbances. It is, however, not very specific, as it challenges a number of cognitive functions including visual search, working memory, concentration, and learning. The high sensitivity and good level of reliability make it very well-suited for research regarding outcome, and since it lasts only a few minutes, a lot of important information can be gained in a short timespan.

Test description

A coding system is displayed at the top of the screen, showing digits and their associated symbols. At the bottom of the screen, there is a "symbol keyboard", which the patient uses to provide responses. Single digits are shown, one at a time, in the middle of the screen, and one has to press the associated symbols as quickly as possible. If a mistake is made, a red frame appears instead of a grey frame around the digit in the middle of the screen. The test starts with five practice trials. The test itself takes two minutes.

Help allowed

The assessor may repeat and elaborate explanations (also using gestures) during the practice session.

During the test itself, the patient can be prompted to start at the beginning of the test, but no other explanations or help may be given.

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Depression - GDS Short Form

Purpose

To assess depression using a scale that can be used with elderly and hospitalized patients.

Background

Depression is common after stroke. It should probably be treated as early as possible, in part because it can affect the amount of energy the patient has for rehabilitation. Depression can also affect a patient’s performance on cognitive tests. There is also an overlap between depression and stroke symptoms (e.g. loss of energy or concentration difficulties). The scale that has been included in this test battery was chosen because it was considered to be least affected by stroke symptoms.

Test description

The test is simply a computerized form of the short version of the Geriatric Depression Scale. The assessor reads the questions aloud and enters the patient’s yes-no answers. The questions can also be read aloud by the app. It is also possible to register whether the patient is able to understand the questions and respond to them. Any form of yes-no answers are accepted.

Help allowed

All 15 questions may be repeated as many times as needed, but they may not be rephrased.

Any type of support that can help the patient provide a positive or negative answer is allowed. The assessor must be sure, however, that what is typed in the form is a true expression of the patient’s answer.

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