Digitally generated Trail Making Test data: Analysis using hidden Markov modeling

Abstract

The Trail Making Test (TMT) is a neuropsychological test used to assess cognitive dysfunction. The TMT consists of two parts: TMT‐A requires connecting numbers 1 to 25 sequentially; TMT‐B requires connecting numbers 1 to 12 and letters A to L sequentially, alternating between numbers and letters. We propose using a digitally recorded version of TMT to capture cognitive or physical functions underlying test performance. We analyzed digital versions of TMT‐A and ‐B to derive time metrics and used Bayesian hidden Markov models to extract additional metrics. We correlated these derived metrics with cognitive and physical function scores using regression. On both TMT‐A and ‐B, digital metrics associated with graphomotor processing test scores and gait speed. Digital metrics on TMT‐B were additionally associated with episodic memory test scores and grip strength. These metrics provide additional information of cognitive state and can differentiate cognitive and physical factors affecting test performance.

Dysexecutive difficulty and subtle everyday functional disabilities: the digital Trail Making Test

“…Greater time spent with the pen lifted from the iPad could be associated with additional problems, including deficits revolving around visual scanning for successive target items and/or struggling to maintain the assigned mental set for this test, i.e., to draw a line alternating between numbers and letters. The prior studies of Du et al ( 14 ) and Fellows et al ( 39 ) tend to support this supposition. In research examining participants from the Framingham Heart Study, De Anda-Duran et al ( 47 ) found that paper and pencil Trail Making Part B pen lifts was associated with subtle but statistically significant MRI gray and white matter alterations involving frontal, parietal, and temporal lobe brain regions—regions known to be involved in working memory functions [see ( 48 )].…”

“…Second, errors that may have been made on the dTMT-B, data from the dTMT-B practice portion of the test, and data from the companion digital Trail Making-Part A test condition were not available for analysis. As reported by other researchers ( 14 , 39 ), these data need to be presented in order to obtain a fuller appreciation of the relations between FAQ-defined IADL activities and neuropsychological problems using the dTMT-B. Third, we acknowledge that the decision to create subtle and mildly impaired FAQ groups, as described above, is somewhat arbitrary and may have affected the results as reported.…”

“…In addition to time to completion, the traditional metric used to define impairment with the paper and pencil version of the Trail Making Test-Part B, a panel of six, comparatively new novel process-based measures ( 14 , 39 ) was examined in relation to FAQ groups. A wide number of between-group differences were revealed.…”

“…In addition to total time to completion, a corpus of six comparatively new digitally produced process variables was used in the current research. Several of the outcome measures used in the current research have been described by other researchers ( 14 , 39 , 42 ).…”

“…Moreover, successful performance on the TMT-B has consistently been shown to be related to relatively intact IADL, functional abilities ( 23–25 ). Indeed, the wide number of neurocognitive abilities underlying TMT-B time to completion ( 14 ) is a major reason why this test is so sensitive to brain illness.…”