Skip to main content Accessibility help

An abbreviated version of Silhouettes test: a brief validated mild cognitive impairment screening tool

  • Lin Huang (a1), Ke-Liang Chen (a1), Bi-Ying Lin (a1), Le Tang (a1), Qian-Hua Zhao (a1), Fang Li (a2) and Qi-Hao Guo (a1)...



To revise an abbreviated version of the Silhouettes subtest of the Visual Object and Space Perception (VOSP) battery in order to recognize mild cognitive impairment (MCI) and determine the optimal cutoffs to differentiate among cognitively normal controls (NC), MCI, and Alzheimer’s Disease (AD) in the Chinese elderly.


A cross-sectional validation study.


Huashan Hospital, Shanghai, China.


A total of 591 participants: Individuals with MCI (n = 211), AD (n = 139) and NC (n = 241) were recruited from the Memory Clinic, Huashan Hospital, Shanghai, China.


Baseline neuropsychological battery (including VOSP) scores were collected from firsthand data. An abbreviated version of silhouettes test (Silhouettes-A) was revised from the original English version more suitable for the elderly, including eight silhouettes of animals and seven silhouettes of inanimate objects, with a score ranging from 0 to 15.


Silhouettes-A was an effective test to screen MCI in the Chinese elderly with good sensitivity and specificity, similar to the Montreal cognitive assessment and superior to other single tests reflecting language, spatial, or executive function. However, it had no advantage in distinguishing MCI from AD. The corresponding optimal cutoff scores of Silhouettes-A were 10 for screening MCI and 8 for AD.


Silhouettes-A is a quick, simple, sensitive, and dependable cognitive test to distinguish among NC, MCI, and AD patients.


Corresponding author

Correspondence should be addressed to: Fang Li, Department of Gerontology, Fuxing Hospital, Capital Medical University, No.20 A, Fuxingmenwai Street, Beijing 100038, China. Phone: +86 18510859856; Fax: +861088062032. Email:


Hide All
Albert, M. S. et al. (2011). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 270279. doi: 10.1016/j.jalz.2011.03.008.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Association.
Amieva, H. et al. (2008). Prodromal Alzheimer’s disease: successive emergence of the clinical symptoms. Annals of Neurology, 64, 492498. doi: 10.1002/ana.21509.
Belleville, S., Fouquet, C., Hudon, C., Zomahoun, H. T. V. and Croteau, J. (2017). Neuropsychological measures that predict progression from mild cognitive impairment to Alzheimer’s type dementia in older adults: a systematic review and meta-analysis. Neuropsychology Review, 3, 126. doi: 10.1007/s11065-017-9361-5.
Benton, A. L. (1983). Contributions to Neuropsychological Assessment: A Clinical Manual. New York: Oxford University Press.
Binetti, G., Cappa, S. F., Magni, E., Padovani, A., Bianchetti, A. and Trabucchi, M. (1996). Disorders of visual and spatial perception in the early stage of Alzheimer’s disease. Annals of the New York Academy of Sciences, 777, 221225. doi: 10.1111/j.1749-6632.1996.tb34422.x.
Boyd, C. D. et al. (2014). Visuoperception test predicts pathologic diagnosis of Alzheimer disease in corticobasal syndrome. Neurology, 83, 510519. doi: 10.1212/WNL.0000000000000667.
Calderon, J., Perry, R. J., Erzinclioglu, S. W., Berrios, G. E., Dening, T. and Hodges, J. R. (2001). Perception, attention, and working memory are disproportionately impaired in dementia with Lewy bodies compared with Alzheimer’s disease. Journal of Neurology, Neurosurgery & Psychiatry, 70, 157164. doi: 10.1136/jnnp.70.2.157.
Calvo, L. et al. (2013). Spanish normative studies in young adults (NEURONORMA young adults project): norms for the Visual Object and Space Perception Battery and Judgment of Line Orientation tests. Neurologia, 28, 153159. doi: 10.1016/j.nrl.2012.03.007.
Chen, Q., Weidner, R., Vossel, S., Weiss, P. H. and Fink, G. R. (2012). Neural mechanisms of attentional reorienting in three-dimensional space. Journal of Neuroscience, 32, 1335213362. doi: 10.1523/JNEUROSCI.1772-12.2012.
Eckerstrom, C. et al. (2013). A combination of neuropsychological, neuroimaging, and cerebrospinal fluid markers predicts conversion from mild cognitive impairment to dementia. Journal of Alzheimer’s disease, 36, 421431.
Fukui, T. and Lee, E. (2009). Visuospatial function is a significant contributor to functional status in patients with Alzheimer’s disease. American Journal of Alzheimer’s Disease & Other Dementias, 24, 313321. doi: 10.1177/1533317509333903.
Hachinski, V., Oveisgharan, S., Romney, A. K. and Shankle, W. R. (2012). Optimizing the Hachinski ischemic scale. Archives of Neurology, 69, 169175. doi: 10.1001/archneurol.2011.1698.
Haxby, J. V., Duara, R., Grady, C. L., Cutler, N. R. and Rapoport, S. I. (1985). Relations between neuropsychological and cerebral metabolic asymmetries in early Alzheimer’s disease. Journal of Cerebral Blood Flow & Metabolism, 5, 193200. doi: 10.1038/jcbfm.1985.25.
Herrera-Guzman, I., Peña-Casanova, J., Lara, J. P., Gudayol-Ferre, E. and Böhm, P. (2004). Influence of age, sex, and education on the Visual Object and Space Perception Battery (VOSP) in a healthy normal elderly population. The Clinical Neuropsychologist, 18, 385394.
Jack, C. J. et al. (2011). Introduction to the recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 257262. doi: 10.1016/j.jalz.2011.03.004.
Kaplan, E., Goodglass, H. and Weintraub, S. (1983). Boston Naming Test. Philadelphia: Lea & Febiger.
Kusne, Y., Wolf, A. B., Townley, K., Conway, M. and Peyman, G. (2017). Visual system manifestations of Alzheimer’s disease. Acta Ophthalmologica, 95, e668e676. doi: 10.1111/aos.13319.
Lin, K. N., Wang, P. N., Liu, C. Y., Chen, W. T., Lee, Y. C. and Liu, H. C. (2002). Cutoff scores of the cognitive abilities screening instrument, Chinese version in screening of dementia. Dementia and Geriatric Cognitive Disorders, 14, 176182. doi: 10.1159/000066024.
Mandal, P. K., Joshi, J. and Saharan, S. (2012). Visuospatial perception: an emerging biomarker for Alzheimer’s disease. Journal of Alzheimer’s Disease, 31, S117S135. doi: 10.3233/JAD-2012-120901.
Mendez, M. F., Mendez, M. A., Martin, R., Smyth, K. A. and Whitehouse, P. J. (1993). Complex visual disturbances in Alzheimer’s disease. Neurology, 40, 439443. doi: 10.1212/WNL.40.3_Part_1.439.
Morris, J. C. (1993). The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology, 43, 24122414. doi: 10.1212/WNL.43.11.2412-a.
Patricia, J. and Bonello, L. J. R. (1997). Psychometric properties of the visual object and space perception battery in normal older adults. The Clinical Neuropsychologist, 11, 436442. doi: 10.1080/13854049708400475.
Petersen, R. C. (2000). Mild cognitive impairment: transition between aging and Alzheimer’s disease. Neurologia, 15, 93101. doi: 10.1002/0470846453.ch14.
Petersen, R. C., Smith, G. E., Waring, S. C., Ivnik, R. J., Tangalos, E. G. and Kokmen, E. (1999). Mild cognitive impairment: clinical characterization and outcome. Archives of Neurology, 56, 303308. doi: 10.1001/archneur.56.3.303.
Possin, K. L. (2010). Visual spatial cognition in neurodegenerative disease. Neurocase, 16, 466487. doi: 10.1080/13554791003730600.
Quental, N. B., Brucki, S. M. and Bueno, O. F. (2013). Visuospatial function in early Alzheimer’s disease—the use of the Visual Object and Space Perception (VOSP) battery. PLoS One, 8, e68398. doi: 10.1371/journal.pone.0068398.
Rapport, L. J., Millis, S. R. and Bonello, P. J. (1998). Validation of the Warrington theory of visual processing and the Visual Object and Space Perception Battery. Journal of Clinical and Experimental Neuropsychology, 20, 211220. doi: 10.1076/jcen.
Rey, A. (1964). The Clinical Exam in Psychology. Paris, France: Press Universitaire de France.
Rey, A. (1983). Reativo of Complex Figure A and B. Florence, Italy: Organizzazioni Speciali.
Rizzo, M., Anderson, S. W., Dawson, J., Myers, R. and Ball, K. (2000). Visual attention impairments in Alzheimer’s disease. Neurology, 54, 19541959. doi: 10.1212/WNL.54.10.1954.
Salmon, D. P. and Bondi, M. W. (2009). Neuropsychological assessment of dementia. Annual Review of Psychology, 60, 257282. doi: 10.1146/annurev.psych.57.102904.190024.
Thiyagesh, S. N. et al. (2009). The neural basis of visuospatial perception in Alzheimer’s disease and healthy elderly comparison subjects: an fMRI study. Psychiatry Research, 172, 109116. doi: 10.1016/j.pscychresns.2008.11.002.
Warrington, E. K. and James, M. (1991). The Visual Object and Space Perception Battery. Bury St. Edmunds, UK: Thames Valley Test Company.
Wechsler, D. (1981). Adult Intelligence Scale- Revised. New York: Psychological Corporation.
Worboys, M. (2013). The Hamilton rating scale for depression: the making of a “gold standard” and the unmaking of a chronic illness, 1960-1980. Chronic Illness, 9, 202219. doi: 10.1177/1742395312467658.
Zhang, M. Y. et al. (1990). The prevalence of dementia and Alzheimer’s disease in Shanghai, China: impact of age, gender, and education. Annals of Neurology, 27, 428437. doi: 10.1002/ana.410270412.
Zhao, Q., Guo, Q., Li, F., Zhou, Y., Wang, B. and Hong, Z. (2013). The Shape Trail Test: application of a new variant of the Trail Making Test. PLoS One, 8, e57333. doi: 10.1371/journal.pone.0057333.


Related content

Powered by UNSILO
Type Description Title
Supplementary materials

Huang et al. supplementary material
Tables S1-S4 and Figure S1

 Word (112 KB)
112 KB

An abbreviated version of Silhouettes test: a brief validated mild cognitive impairment screening tool

  • Lin Huang (a1), Ke-Liang Chen (a1), Bi-Ying Lin (a1), Le Tang (a1), Qian-Hua Zhao (a1), Fang Li (a2) and Qi-Hao Guo (a1)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.