Deficits in explicit theory of mind: a possible early indicator of pathological aging

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This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8010643/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Traditionally, the evaluation and intervention of cognitive abilities in aging have focused on intellectual cognition, particularly executive functions such as working memory, attention, and processing speed. In contrast, social cognition—crucial for effective daily social functioning, such as following conversations, participating in group interactions, or understanding complex social situations—has received considerably less attention. Scientific evidence suggests that brain and cognitive functioning follow different trajectories in normal and pathological aging. The present study aimed to examine how age and the presence of pathological cognitive impairment predict deficits in the ability to attribute mental states through verbal cues (explicit Theory of Mind, ToM), as well as to analyze differences in this ability between normative and pathological aging. Thirty older adults (aged 58–88) participated, divided into two age- and gender-matched groups: those with normative aging (n = 15) and those with pathological aging (n = 15). Explicit ToM was assessed using an extended version of the Faux Pas Test (Baron-Cohen et al., 1999 ), which evaluates not only the detection of faux pas but also the attribution of both cognitive and emotional mental states to different characters within complex social situations. Results showed that, among older adults, only the presence of pathological cognitive impairment—and not age—predicted deficits in explicit ToM. When analyzing groups separately, age was associated with improvements in explicit ToM only in normative aging; this effect disappeared in pathological aging, where participants showed marked difficulties in verbally reasoning about social scenarios. These findings may contribute to the early identification of pathological cognitive decline and support the refinement of neuropsychological assessment and intervention protocols for older adults with both normative and pathological aging profiles. Psychology aging age cognitive impairment explicit Theory of Mind Figures Figure 1 Introduction Aging is a natural and continuous process that affects all individuals (Arkin, 1991 ) and is characterized by the structural and functional deterioration of the organism (Ito & Barnes, 2009 ). The central nervous system also undergoes changes (Raz & Kennedy, 2009 ) as a result of various processes that occur at the molecular level and in the neuronal environment, ultimately leading to neuronal damage, among them oxidative stress (Mattson & Magnus, 2006 ). When these processes persist over time, they may give rise to the cognitive and motor problems associated with aging (Farkas & Luiten, 2001 ). Consequently, even in the absence of pathology, older adults exhibit cognitive decline characterized by the deterioration of various information-processing mechanisms—such as processing speed, encoding, or attention—which underlies the memory problems they commonly experience (Tisserand & Jolles, 2003 ). However, other psychological processes appear to be preserved in normative aging (Hedden & Park, 2003 ), among them the ability to attribute mental states to others (Theory of Mind; Fromholt et al., 2003 ), although the evidence regarding the evolution of this ability remains contradictory (López-Montilla et al., 2021 ). Although cognitive decline is characteristic of normative aging, Petersen et al. ( 1999 ) defined mild cognitive impairment (MCI) as a set of memory and other cognitive function alterations that exceed what would be expected for a given age, yet do not compromise functional independence. Not all individuals with MCI develop dementia; however, a proportion of cases progress to Alzheimer’s disease (AD; Fischer et al., 2007 ; Ritchie et al., 2001 ). Therefore, MCI is considered a transitional phase between normative aging and dementia, or, in other words, a risk factor for its development. Consequently, the early detection of MCI is crucial for the management of AD and other types of dementia (Petersen et al., 2001 ). Evolution of the conceptualization of Theory of Mind Theory of Mind (ToM) is defined as the ability to attribute mental states—such as intentions, knowledge, or beliefs—in order to predict and understand behavior (Premack & Woodruff, 1978 ). It is referred to as a “theory” because such mental states are not directly observable and may be subject to errors of inference, although they remain useful for anticipating others’ behavior (Premack & Woodruff, 1978 ). Although research on ToM has traditionally focused on the early stages of child development, interest in studying it during adulthood and old age has increased in recent years. Its conceptualization has evolved from an initial, unidimensional definition—according to which it was understood as a single cognitive ability responsible for reasoning about one’s own and others’ mental states (Westby & Robinson, 2014 )—to a more holistic perspective that conceives it as a multidimensional capacity comprising different components. This latter view is supported by neuroimaging studies that have revealed its neurophysiological and neuroanatomical bases (Abu-Akel & Shamay-Tsoory, 2011 ; Frith & Frith, 2003 ; Northoff et al., 2006 ; Shamay-Tsoory, 2001). According to the type of mental state being attributed, Dvash and Shamay-Tsoory ( 2014 ) distinguish between cognitive Theory of Mind (ToM), which refers to knowledge-related mental states, and affective ToM, which refers to emotional mental states. Moreover, two levels of ToM recursion have been identified (Morin, 2006 ), depending on the depth of representation: first-order ToM, which involves attributing mental states from a single perspective (e.g., I think that my sister believes that...), and second-order ToM, which refers to metarepresentations integrating two or more perspectives (e.g., my sister believes that my mother thinks that...). Other authors have proposed distinguishing between intrapersonal ToM, when mental states are attributed to oneself, and interpersonal ToM, when they are attributed to another person (Lucariello et al., 2007 ; Northoff et al., 2006 ; Tine & Lucariello, 2012 ). In addition, Low ( 2010 ) proposed the existence of two distinct reasoning systems within Theory of Mind (ToM) according to their level of complexity: implicit ToM and explicit ToM, which are differentiated by the use of nonverbal or verbal cues, respectively, to make attributions about mental states. Consequently, López-Montilla ( 2021 ) emphasized the need to employ different assessment tools for each type of reasoning, such as the Reading the Mind in the Eyes Test (Baron-Cohen et al., 1997 ) for implicit ToM, and the Faux Pas Test (Baron-Cohen et al., 1999 ) for explicit ToM. Inconsistencies in research on Theory of Mind decline To date, research on Theory of Mind (ToM) decline in both normative and pathological aging has yielded contradictory results. With regard to normative aging, Happé et al. ( 1998 ) found that ToM remains stable and may even continue to improve with age. Similarly, Fromholt et al. ( 2003 ) reported that ToM is one of the cognitive abilities that remain stable in old age. However, Duval et al. ( 2011 ) concluded that older adults obtain lower scores on both cognitive and affective ToM tasks compared to younger adults, suggesting that ToM performance is affected by age. Likewise, Cabinio et al. ( 2015 ) found a significant inverse relationship between age and implicit ToM, that is, poorer performance as age increases. Finally, Cavallini et al. ( 2013 ) determined that ToM begins to deteriorate at approximately 60 years of age. In the case of pathological aging, Pezzutti et al. ( 2011 ) observed that cognitive decline in older adults affects ToM abilities, hindering performance on related tasks and compromising the cognitive skills necessary for making mental state attributions. However, studies by El Haj et al. ( 2016 ) and Heitz et al. ( 2016 ) indicate that affective ToM remains relatively intact. Similarly, Fernández-Duque et al. ( 2009 ) demonstrated that only complex cognitive ToM tasks deteriorate, while performance on simple tasks is preserved. According to Kemp et al. ( 2012 ), inconsistent results have begun to emerge as the different dimensions of ToM have been more clearly delineated. It is also important to note that these studies have not employed the same methods or assessment tools when addressing these contradictions, nor have they made the same distinctions regarding ToM dimensions—some focus on specific components, while others consider ToM in a global manner. Theory of Mind and the Default Mode Network Regarding the neuroanatomical correlates of ToM, Mars et al. ( 2012 ) identified using functional magnetic resonance imaging (fMRI) that most of the neural bases of social cognition overlap with the Default Mode Network (DMN). This network comprises brain regions that are active during low-demand cognitive tasks, that is, during the resting state (Gusnard & Raichle, 2001 ). Among the most prominent structures within this network are the medial prefrontal cortex (mPFC), the posterior cingulate cortex (PCC), the precuneus, the anterior cingulate cortex (ACC), the parietal cortex, and, to a lesser extent, the hippocampus (Buckner et al., 2008 ). In normative aging, a decrease has been observed both in the functional connectivity of the DMN and in the ability to deactivate it during tasks requiring focused attention (Grady et al., 2006 ). In individuals with mild cognitive impairment (MCI), several studies have also documented reduced functional connectivity within the DMN (Drzezga et al., 2011 ; Sorg et al., 2007 ; Gili et al., 2011 ; Bai et al., 2008 ; Han et al., 2011 ; Petrella et al., 2011 ), particularly in the mPFC, PCC, ACC, and hippocampus (Petrella et al., 2011 ). In fact, Rombouts et al. ( 2005 ) and Pihlajamäki and Sperling ( 2009 ) concluded that performance on tasks involving decreased brain activity tends to decline along the continuum from normative aging to Alzheimer’s disease (AD). Considering all of the above, it can be concluded that there is no consensus regarding how the different components of ToM deteriorate during aging, especially when distinguishing between normative and pathological aging. The multidimensional nature of ToM, together with the neurocognitive differences observed between the two types of aging, provides a basis for questioning whether ToM decline manifests differently in each case. Based on the above, the present study has two main objectives: to examine the influence of age on explicit ToM decline in normative and pathological aging, and to analyze potential differences in performance on this component between the two types of aging. Method Participants The sample consisted of 30 older adults, 16 women and 14 men, aged between 58 and 88 years (M = 76, SD = 7.38). The sample was divided into two groups: one consisting of 15 individuals with normative aging and the other of 15 individuals with early-stage pathological cognitive impairment, that is, pathological aging. The participant selection process and exclusion criteria, described in detail below, differed for each group. Efforts were made to ensure that both groups were as comparable as possible in terms of age and gender (see Tables 1 and 2 ). The normative aging group was recruited from healthy aging centers in Málaga, within the Department of Preventive Sports Medicine. The presence of diagnosed psychological disorders or neurodegenerative diseases was considered an exclusion criterion. Table 1 Descriptive statistics of participants’ age. Age N Mean SD Minimum Maximum Normative 15 76.1 8.37 58 88 Pathological 15 75.9 6.53 64 87 Total 30 76 7.38 58 88 Table 2 Descriptive statistics of participants’ gender Gender Frequency Percentage Normative Female 8 53.3 Male 7 46.7 Pathological Female 8 53.3 Male 7 46.7 The pathological aging group was recruited from the Association of Relatives of Patients with Alzheimer’s Disease and Other Dementias (AFA) in Fuengirola–Mijas Costa, specifically from the “Workshop 0,” which corresponds to the group with the mildest cognitive impairment at the center, although some heterogeneity was observed even within this group. Exclusion criteria included the presence of psychological disorders and/or moderate to severe cognitive impairment. Materials and Instruments For this study, two assessment instruments were used, administered in the same order as presented below. Demographic Questionnaire A custom-made data collection sheet was used to gather demographic information for each participant, including age and gender. The data were obtained through direct interviews and recorded both quantitatively and qualitatively. In the case of participants with pathological aging, age was confirmed with the responsible psychologist to minimize possible errors due to memory deficits. Faux Pas Test (Baron-Cohen et al., ) A selection of five stories was used to assess participants’ ability to understand that a person can make a comment that generates a negative emotion in another, due to a lack of information about the latter. The evaluation consisted of presenting social situations in which someone committed a social blunder and assessing whether the participant was able to identify it. The original instrument by Baron-Cohen et al. ( 1999 ) consisted of only two questions, aimed at assessing the detection of the faux pas and the identification of the character who made the inappropriate comment. In the present study, these questions were reformulated and new items were added, so that each story included seven items. These evaluated both the identification of the faux pas and the attributions of different mental states of the speaker (the character committing the faux pas) and the listener (the character to whom the faux pas was directed). The maximum total score of the instrument is 50 points, with a maximum of 10 points per story. Participants’ responses were evaluated following the corresponding guidelines (see Table 3 ). Table 3 Coding and Scoring Criteria for the Faux Pas Test Example Question Assessed Aspect Level of Recursivity Coding 1. Did someone say something they shouldn’t have said, or something inappropriate? Who was it? Faux Pas Identification Complex 0 points. Faux pas no detected 1 Point. Faux pas detected 2. Why shouldn’t they have said it, or why was it inappropriate? Attribution of Ignorance to the Speaker Complex 0 points. G ives an irrelevant response or does not attribute any mental state. 1 point. Implicitly attributes ignorance to the speaker who commits the faux pas, referring to the effect produced on the listener or to the situation itself. 2 points : refers to the perspective of the speaker who commits the faux pas or explicitly mentions the mental state. 3. Why do you think they said it? Attribution of Motivation to the Speaker Complex 0 points . attributes a motivation to cause harm. 1 point. Attributes any other type of motivation. 4. Did Alice know who had bought the curtains? Attribution of Ignorance to the Speaker Simple 0 points. Does not attribute ignorance to the speaker. 1 point . Attributes ignorance to the speaker. 5. How Julia felt when she heard Alice’s comment?? Attribution of Emotion to the Listener Simple 0 points. Does not predict an emotional effect on the listener. 1 point. Predicts an emotional effect on the listener. 6. Does Alice know that Julia is feeling upset by her words? Why? Attribution of Knowledge to the Speaker about the Listener’s Emotion Complex 0 points. Does not attribute to the speaker an epistemic perspective of ignorance regarding the emotion produced in the listener. 1 point. Implicitly attributes such knowledge to the speaker. 2 points. Explicitly attributes to the speaker an epistemic perspective of ignorance regarding the emotion produced in the listener. 7. Did Alice want Julia to feel upset? Attribution of the Speaker’s Intention regarding the Listener’s Emotion Complex 0 points. Does not attribute to the speaker a lack of intention to cause an emotional effect. 1 point. Xorrectly attributes to the speaker the lack of intention to cause an emotional effect. Procedure Prior to conducting the assessments, informed consent was obtained from all participants and, in the case of the pathological aging group, also from their family members. The instruments were administered individually in a quiet, interruption-free environment. Assessments for the normative aging group were conducted in a dedicated laboratory at the Faculty of Psychology and Speech Therapy, University of Málaga, whereas the pathological aging group was evaluated in a room at the AFA center, at a time agreed upon with the responsible psychologist so as to interfere as little as possible with their daily activities. During the assessments, flexible breaks were offered to prevent participant fatigue. Participants were also encouraged to ask any questions that arose, and the items or instructions were repeated as many times as necessary. All responses were recorded in writing on scoring sheets. Additionally, during the administration of the Faux Pas Test, custom-made storyboards corresponding to each story were used to help participants follow the narratives. However, when it was observed that these storyboards hindered rather than supported comprehension, they were removed. Data Analysis Initially, multiple linear regression analyses were conducted to evaluate the potential predictive effect of the variables “age” and “with/without pathological cognitive impairment” on explicit Theory of Mind (ToM). Subsequently, once the sample was divided into normative and pathological aging groups, Spearman’s correlation coefficient was applied to examine the relationship between age and the scores obtained on the Faux Pas Test within each group. Next, a detailed analysis of each component of the Faux Pas Test was conducted, comparing the scores obtained by each group. According to normality tests, for values with a normal distribution (total Faux Pas Test score), Student’s t-test was applied, whereas for values that did not follow a normal distribution (scores for individual items), the Mann–Whitney U test was used, with the aim of determining whether significant differences existed between the means of both groups. Results Relationship between Age, Cognitive Impairment, and Explicit ToM The results of the regression analysis examining the predictive variables “age” and “with/without pathological cognitive impairment” on the criterion variable explicit ToM indicate a statistically significant relationship between the presence of pathological cognitive impairment and explicit ToM ( R² = .158; p = .043). In contrast, no significant relationship was found between age and this component ( R² = .158; p = .611; Table 4 ). These results suggest that performance in explicit ToM is determined by the presence of pathological cognitive impairment, independently of age (Fig. 1). Table 4 Linear Regression Analysis ( R² ) and Its Significance: Age, Cognitive Impairment, and Explicit ToM Predictors R R2 p Explícit ToM Age .397 .158 .611 With/Without Impairment .043* *p < .05 Significant Relationship; Non Significant Relationship When the sample was divided into groups according to the variable “with/without pathological cognitive impairment” and the relationship between age and explicit ToM was analyzed, the results for the pathological aging group did not show a significant relationship. In contrast, in the normative aging group, a significant relationship was observed, specifically with the identification of the faux pas ( r = .597; p = .015). This indicates that, in these adults, there is a direct relationship between age and faux pas identification, such that higher age is associated with better identification (Table 5 ). Table 5 Relationship between Age and Explicit ToM in Normative Aging Adults (Spearman’s ρ Coefficient) Age Total Faux Pas – Question 1 (Faux Pas Identification) Spearman’s ρ .597 gl 14 p .015* *p < .05 Relationship between Impairment and Explicit ToM To specifically analyze explicit ToM in relation to the variable “with/without pathological cognitive impairment,” a detailed analysis of the results for each group was conducted for each item of the Faux Pas Test, with the aim of identifying possible significant differences between them. The results indicated (Table 6 ) significant differences between the two groups in the total score ( t = 2.177; p = .038), in Question 2 ( U = 32; p = .001), and in Question 3 ( U = 47.5; p = .007). In all cases, the normative aging group presented higher means than the pathological aging group. Table 6 Relationship between Impairment and Explicit ToM (Student’s t and Mann–Whitney U ) Test Statistic p Total Faux Pas Student’s t 2.177 .038 Faux Pas Identification – Q1 Mann–Whitney U 96 .681 Attribution of Ignorance to the Speaker – Q2 Mann–Whitney U 32 .001 Attribution of Motivation to the Speaker – Q3 Mann–Whitney U 47.5 .007 Attribution of Ignorance to the Speaker – Q4 Mann–Whitney U 81 .273 Attribution of Emotion to the Listener – Q5 Mann–Whitney U 87.5 .398 Attribution of Knowledge to the Speaker about the Listener’s Emotion – Q6 Mann–Whitney U 89.5 .503 Attribution of the Speaker’s Intention regarding the Listener’s Emotion – Q7 Mann–Whitney U 93.5 .595 Discussion Influence of Age on the Progression of Explicit ToM Considering the objectives of this research, the influence of age on the deterioration of explicit ToM in normative and pathological aging was first examined. The results for the complete sample indicate that performance in explicit ToM among older adults is predicted solely by the presence of pathological cognitive impairment; that is, the greater the pathological cognitive impairment, the lower the ability to make attributions about mental states based on verbal cues. In contrast, age does not appear to predict a decline in this ability. When the sample was divided into normative and pathological aging groups, it was observed that age is related differently to explicit ToM in each case. In normative aging, age is directly associated with explicit ToM; that is, in the absence of pathological cognitive impairment, this ability is maintained or may even improve with age, consistent with the findings of Fromholt et al. ( 2003 ) and Happé et al. ( 1998 ). In contrast, in pathological aging, age is not associated with explicit ToM, losing its predictive effect. This suggests that once pathological cognitive impairment is present, explicit ToM deteriorates independently of age, adding to the generalized and progressive decline of other cognitive abilities that accompany it. Influence of Pathological Cognitive Impairment on the Progression of Explicit ToM Regarding the second objective, differences between the normative and pathological aging groups in relation to explicit ToM were analyzed, observing that this component deteriorates in the presence of pathological cognitive impairment. It was found that the greater the cognitive impairment, the greater the difficulties in understanding social situations in which someone makes a mistake or expresses something inappropriate. Specifically, older adults with pathological aging show greater difficulty in identifying faux pas and correctly attributing states of ignorance and motivation to the speaker who causes them. This finding is particularly relevant, as, when considered together with the previous results—which indicate that explicit ToM is preserved in normative aging—it suggests that early detection of deficits in explicit ToM could be useful for identifying the onset of pathological cognitive impairment at an early stage. Conclusion This study examined the relationship between explicit ToM, age, and type of aging in older adults. The results show that, in the full sample, only the presence of pathological cognitive impairment predicts performance in explicit ToM, in an inverse manner. When the groups were analyzed separately, it was observed that in normative aging, age is associated with the maintenance of this ability, whereas in pathological aging, age loses its predictive effect. Furthermore, when both groups were compared using an explicit ToM assessment tool, it was concluded that individuals with pathological aging show greater difficulties in understanding inappropriate comments in social situations. Although this study involves a small sample, the results are considered relevant. They provide the scientific literature with a more precise delineation of ToM deterioration, both in normative and pathological aging, focusing specifically on explicit ToM. This contributes to clarifying the impact of age on this ability and the characteristic pattern of decline in both types of aging. These findings may guide changes in clinical practice, as ToM is an aspect that is often overlooked in interventions for older adults, where intellectual cognition is prioritized over social cognition. It is suggested that these data serve as a basis for including ToM training and preservation in intervention programs for older adults, both with and without pathological impairment. This would allow for improving the quality of social relationships, enhancing social competence, and reducing unwanted loneliness. In the clinical setting, the results may also be applied to the early diagnosis of pathological cognitive impairment, specifically in the detection of deficits in explicit ToM, which should not appear in normative aging. The main limitation is the small sample size, due to the complexity of evaluating older adults, which involves delays in administration and unavailability due to unforeseen circumstances or health problems. In addition, the specificity of the pathological group made it difficult to select participants within the age range who met the exclusion criteria. Although the AFA Fuengirola-Mijas Costa center provided part of the sample, even within the group with impairment, cognitive heterogeneity remained notable. Therefore, it is suggested that future research study explicit ToM with larger samples and include additional predictive variables. This would allow for the identification of statistically more robust relationships, expanding knowledge about the course of deterioration, which remains unclear when comparing different studies. Furthermore, the findings could contribute to considering deficits in explicit ToM as early indicators of pathological cognitive impairment, incorporating them into neuropsychological assessments and interventions for older adults. In conclusion, the study provides relevant information for both research and clinical settings and aims to promote a more multidimensional approach in interventions with older adults. 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Cognitive and affective theory of mind in dementia with Lewy bodies and Alzheimer’s disease. Alzheimer's Research & Therapy, 8 , 1–15. https://doi.org/10.1186/s13195-016-0179-9 Ito, K., & Barnes, P. J. (2009). COPD as a disease of accelerated lung aging. Chest, 135 (1), 173–180. https://doi.org/10.1378/chest.08-1419 Kemp, J., Després, O., Sellal, F., & Dufour, A. (2012). Theory of mind in normal ageing and neurodegenerative pathologies. Ageing Research Reviews, 11 (2), 199–219. https://doi.org/10.1016/j.arr.2011.12.001 López-Montilla, N. (2021). Teoría de la mente implícita en adultos mayores: El papel de la reserva cognitiva y del perfil de actividad social y cognitiva. http://dx.doi.org/10.24310/mumaedmumaed.5315 López-Montilla, N., Barajas, C., & Nielsen, A. (2021). Teoría de la mente en adultos mayores: El papel de la actividad social y cognitiva. http://dx.doi.org/10.17060/ijodaep.2021.n2.v2.2242 Low, J. (2010). 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Default mode network connectivity in stable vs progressive mild cognitive impairment. Neurology, 76 (6), 511–517. https://doi.org/10.1212/WNL.0b013e31820af94 Pezzutti, L., Longobardi, E., Milletti, K., & Ovidi, A. (2011). A study about theory of mind in primary and secondary aging. Life Span and Disability, 14 (1), 31–34. http://doi.org/2011-16541-002 Pihlajamäki, M., & Sperling, R. A. (2009). Functional MRI assessment of task-induced deactivation of the default mode network in Alzheimer’s disease and at-risk older individuals. Behavioural Neurology, 21 (1–2), 77–91. https://doi.org/10.3233/BEN-2009-0231 Premack, D., & Woodruff, G. (1978). Does the chimpanzee have a theory of mind? Behavioral and Brain Sciences, 1 (4), 515–526. https://doi.org/10.1017/s0140525x00076512 Raz, N., & Kennedy, K. M. (2009). A systems approach to the aging brain: Neuroanatomic changes, their modifiers, and cognitive correlates. In Oxford University Press eBooks (pp. 43–70). https://doi.org/10.1093/acprof:oso/9780195328875.003.0004 Ritchie, K., Artero, S., & Touchon, J. (2001). Classification criteria for mild cognitive impairment: A population-based validation study. Neurology, 56 (1), 37–42. https://doi.org/10.1212/WNL.56.1.37 Rombouts, S. A., Barkhof, F., Goekoop, R., Stam, C. J., & Scheltens, P. (2005). Altered resting state networks in mild cognitive impairment and mild Alzheimer's disease: An fMRI study. Human Brain Mapping, 26 (4), 231–239. https://doi.org/10.1002/hbm.20160 Shamay-Tsoory, S. G. (2011). The neural bases for empathy. The Neuroscientist, 17 (1), 18–24. https://doi.org/10.1177/1073858410379268 Sorg, C., Riedl, V., Muhlau, M., Calhoun, V. D., Eichele, T., Läer, L., Drzezga, A., Förstl, H., Kurz, A., Zimmer, C., & Wohlschläger, A. M. (2007). Selective changes of resting-state networks in individuals at risk for Alzheimer's disease. Proceedings of the National Academy of Sciences, 104 (47), 18760–18765. https://doi.org/10.1073/pnas.0708803104 Tine, M., & Lucariello, J. (2012). Unique theory of mind differentiation in children with autism and Asperger syndrome. Autism Research and Treatment, 2012 , 505393. https://doi.org/10.1155/2012/505393 Tisserand, D. J., & Jolles, J. (2003). On the involvement of prefrontal networks in cognitive ageing. Cortex, 39 (4–5), 1107–1128. https://doi.org/10.1016/S0010-9452(08)70880-3 Westby, C., & Robinson, L. (2014). A developmental perspective for promoting theory of mind. Topics in Language Disorders, 34 (4), 362–382. https://doi.org/10.1097/tld.0000000000000035 Additional Declarations The authors declare no competing interests. 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1","display":"","copyAsset":false,"role":"figure","size":28796,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRelationship of Age and Presence of Impairment with Explicit ToM\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8010643/v1/d4f4711e240951665cc325ed.png"},{"id":95224764,"identity":"f2ecdf31-cbd3-4b55-b024-ce79289fa4f9","added_by":"auto","created_at":"2025-11-05 16:24:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":842370,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8010643/v1/b62bed2a-11be-48e2-8bc0-5fe55ba91635.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eDeficits in explicit theory of mind: a possible early indicator of pathological aging\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAging is a natural and continuous process that affects all individuals (Arkin, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1991\u003c/span\u003e) and is characterized by the structural and functional deterioration of the organism (Ito \u0026amp; Barnes, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). The central nervous system also undergoes changes (Raz \u0026amp; Kennedy, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) as a result of various processes that occur at the molecular level and in the neuronal environment, ultimately leading to neuronal damage, among them oxidative stress (Mattson \u0026amp; Magnus, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). When these processes persist over time, they may give rise to the cognitive and motor problems associated with aging (Farkas \u0026amp; Luiten, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConsequently, even in the absence of pathology, older adults exhibit cognitive decline characterized by the deterioration of various information-processing mechanisms\u0026mdash;such as processing speed, encoding, or attention\u0026mdash;which underlies the memory problems they commonly experience (Tisserand \u0026amp; Jolles, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). However, other psychological processes appear to be preserved in normative aging (Hedden \u0026amp; Park, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), among them the ability to attribute mental states to others (Theory of Mind; Fromholt et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), although the evidence regarding the evolution of this ability remains contradictory (L\u0026oacute;pez-Montilla et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough cognitive decline is characteristic of normative aging, Petersen et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) defined \u003cem\u003emild cognitive impairment\u003c/em\u003e (MCI) as a set of memory and other cognitive function alterations that exceed what would be expected for a given age, yet do not compromise functional independence. Not all individuals with MCI develop dementia; however, a proportion of cases progress to Alzheimer\u0026rsquo;s disease (AD; Fischer et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Ritchie et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Therefore, MCI is considered a transitional phase between normative aging and dementia, or, in other words, a risk factor for its development. Consequently, the early detection of MCI is crucial for the management of AD and other types of dementia (Petersen et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eEvolution of the conceptualization of Theory of Mind\u003c/h3\u003e\n\u003cp\u003eTheory of Mind (ToM) is defined as the ability to attribute mental states\u0026mdash;such as intentions, knowledge, or beliefs\u0026mdash;in order to predict and understand behavior (Premack \u0026amp; Woodruff, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1978\u003c/span\u003e). It is referred to as a \u0026ldquo;theory\u0026rdquo; because such mental states are not directly observable and may be subject to errors of inference, although they remain useful for anticipating others\u0026rsquo; behavior (Premack \u0026amp; Woodruff, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1978\u003c/span\u003e). Although research on ToM has traditionally focused on the early stages of child development, interest in studying it during adulthood and old age has increased in recent years.\u003c/p\u003e\u003cp\u003eIts conceptualization has evolved from an initial, unidimensional definition\u0026mdash;according to which it was understood as a single cognitive ability responsible for reasoning about one\u0026rsquo;s own and others\u0026rsquo; mental states (Westby \u0026amp; Robinson, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)\u0026mdash;to a more holistic perspective that conceives it as a multidimensional capacity comprising different components. This latter view is supported by neuroimaging studies that have revealed its neurophysiological and neuroanatomical bases (Abu-Akel \u0026amp; Shamay-Tsoory, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Frith \u0026amp; Frith, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Northoff et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Shamay-Tsoory, 2001).\u003c/p\u003e\u003cp\u003eAccording to the type of mental state being attributed, Dvash and Shamay-Tsoory (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) distinguish between cognitive Theory of Mind (ToM), which refers to knowledge-related mental states, and affective ToM, which refers to emotional mental states. Moreover, two levels of ToM recursion have been identified (Morin, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), depending on the depth of representation: first-order ToM, which involves attributing mental states from a single perspective (e.g., I think that my sister believes that...), and second-order ToM, which refers to metarepresentations integrating two or more perspectives (e.g., my sister believes that my mother thinks that...). Other authors have proposed distinguishing between intrapersonal ToM, when mental states are attributed to oneself, and interpersonal ToM, when they are attributed to another person (Lucariello et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Northoff et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Tine \u0026amp; Lucariello, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, Low (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) proposed the existence of two distinct reasoning systems within Theory of Mind (ToM) according to their level of complexity: implicit ToM and explicit ToM, which are differentiated by the use of nonverbal or verbal cues, respectively, to make attributions about mental states. Consequently, L\u0026oacute;pez-Montilla (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) emphasized the need to employ different assessment tools for each type of reasoning, such as the Reading the Mind in the Eyes Test (Baron-Cohen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1997\u003c/span\u003e) for implicit ToM, and the Faux Pas Test (Baron-Cohen et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) for explicit ToM.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eInconsistencies in research on Theory of Mind decline\u003c/h2\u003e\u003cp\u003eTo date, research on Theory of Mind (ToM) decline in both normative and pathological aging has yielded contradictory results.\u003c/p\u003e\u003cp\u003eWith regard to normative aging, Happ\u0026eacute; et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1998\u003c/span\u003e) found that ToM remains stable and may even continue to improve with age. Similarly, Fromholt et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) reported that ToM is one of the cognitive abilities that remain stable in old age. However, Duval et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) concluded that older adults obtain lower scores on both cognitive and affective ToM tasks compared to younger adults, suggesting that ToM performance is affected by age. Likewise, Cabinio et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) found a significant inverse relationship between age and implicit ToM, that is, poorer performance as age increases. Finally, Cavallini et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) determined that ToM begins to deteriorate at approximately 60 years of age.\u003c/p\u003e\u003cp\u003eIn the case of pathological aging, Pezzutti et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) observed that cognitive decline in older adults affects ToM abilities, hindering performance on related tasks and compromising the cognitive skills necessary for making mental state attributions. However, studies by El Haj et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and Heitz et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) indicate that affective ToM remains relatively intact. Similarly, Fern\u0026aacute;ndez-Duque et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) demonstrated that only complex cognitive ToM tasks deteriorate, while performance on simple tasks is preserved.\u003c/p\u003e\u003cp\u003eAccording to Kemp et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), inconsistent results have begun to emerge as the different dimensions of ToM have been more clearly delineated. It is also important to note that these studies have not employed the same methods or assessment tools when addressing these contradictions, nor have they made the same distinctions regarding ToM dimensions\u0026mdash;some focus on specific components, while others consider ToM in a global manner.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTheory of Mind and the Default Mode Network\u003c/h3\u003e\n\u003cp\u003eRegarding the neuroanatomical correlates of ToM, Mars et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) identified using functional magnetic resonance imaging (fMRI) that most of the neural bases of social cognition overlap with the Default Mode Network (DMN). This network comprises brain regions that are active during low-demand cognitive tasks, that is, during the resting state (Gusnard \u0026amp; Raichle, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Among the most prominent structures within this network are the medial prefrontal cortex (mPFC), the posterior cingulate cortex (PCC), the precuneus, the anterior cingulate cortex (ACC), the parietal cortex, and, to a lesser extent, the hippocampus (Buckner et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn normative aging, a decrease has been observed both in the functional connectivity of the DMN and in the ability to deactivate it during tasks requiring focused attention (Grady et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). In individuals with mild cognitive impairment (MCI), several studies have also documented reduced functional connectivity within the DMN (Drzezga et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Sorg et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Gili et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Bai et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Han et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Petrella et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), particularly in the mPFC, PCC, ACC, and hippocampus (Petrella et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). In fact, Rombouts et al. (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) and Pihlajam\u0026auml;ki and Sperling (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) concluded that performance on tasks involving decreased brain activity tends to decline along the continuum from normative aging to Alzheimer\u0026rsquo;s disease (AD).\u003c/p\u003e\u003cp\u003eConsidering all of the above, it can be concluded that there is no consensus regarding how the different components of ToM deteriorate during aging, especially when distinguishing between normative and pathological aging. The multidimensional nature of ToM, together with the neurocognitive differences observed between the two types of aging, provides a basis for questioning whether ToM decline manifests differently in each case.\u003c/p\u003e\u003cp\u003eBased on the above, the present study has two main objectives: to examine the influence of age on explicit ToM decline in normative and pathological aging, and to analyze potential differences in performance on this component between the two types of aging.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eThe sample consisted of 30 older adults, 16 women and 14 men, aged between 58 and 88 years (M\u0026thinsp;=\u0026thinsp;76, SD\u0026thinsp;=\u0026thinsp;7.38).\u003c/p\u003e\u003cp\u003eThe sample was divided into two groups: one consisting of 15 individuals with normative aging and the other of 15 individuals with early-stage pathological cognitive impairment, that is, pathological aging. The participant selection process and exclusion criteria, described in detail below, differed for each group. Efforts were made to ensure that both groups were as comparable as possible in terms of age and gender (see Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe normative aging group was recruited from healthy aging centers in M\u0026aacute;laga, within the Department of Preventive Sports Medicine. The presence of diagnosed psychological disorders or neurodegenerative diseases was considered an exclusion criterion.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eDescriptive statistics of participants\u0026rsquo; age.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eMean\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eMinimum\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eMaximum\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePathological\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eDescriptive statistics of participants\u0026rsquo; gender\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eFrequency\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ePercentage\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePathological\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe pathological aging group was recruited from the Association of Relatives of Patients with Alzheimer\u0026rsquo;s Disease and Other Dementias (AFA) in Fuengirola\u0026ndash;Mijas Costa, specifically from the \u0026ldquo;Workshop 0,\u0026rdquo; which corresponds to the group with the mildest cognitive impairment at the center, although some heterogeneity was observed even within this group. Exclusion criteria included the presence of psychological disorders and/or moderate to severe cognitive impairment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eMaterials and Instruments\u003c/h2\u003e\u003cp\u003eFor this study, two assessment instruments were used, administered in the same order as presented below.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDemographic Questionnaire\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA custom-made data collection sheet was used to gather demographic information for each participant, including age and gender. The data were obtained through direct interviews and recorded both quantitatively and qualitatively. In the case of participants with pathological aging, age was confirmed with the responsible psychologist to minimize possible errors due to memory deficits.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eFaux Pas Test (Baron-Cohen et al., )\u003c/h3\u003e\n\u003cp\u003eA selection of five stories was used to assess participants\u0026rsquo; ability to understand that a person can make a comment that generates a negative emotion in another, due to a lack of information about the latter. The evaluation consisted of presenting social situations in which someone committed a social blunder and assessing whether the participant was able to identify it.\u003c/p\u003e\u003cp\u003eThe original instrument by Baron-Cohen et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) consisted of only two questions, aimed at assessing the detection of the faux pas and the identification of the character who made the inappropriate comment. In the present study, these questions were reformulated and new items were added, so that each story included seven items. These evaluated both the identification of the faux pas and the attributions of different mental states of the speaker (the character committing the faux pas) and the listener (the character to whom the faux pas was directed).\u003c/p\u003e\u003cp\u003eThe maximum total score of the instrument is 50 points, with a maximum of 10 points per story. Participants\u0026rsquo; responses were evaluated following the corresponding guidelines (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eCoding and Scoring Criteria for the Faux Pas Test\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExample\u003c/p\u003e\u003cp\u003eQuestion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssessed Aspect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLevel of Recursivity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCoding\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Did someone say something they shouldn\u0026rsquo;t have said, or something inappropriate? Who was it?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFaux Pas Identification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e0 points.\u003c/em\u003e Faux pas no detected\u003c/p\u003e\u003cp\u003e\u003cem\u003e1 Point.\u003c/em\u003e Faux pas detected\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Why shouldn\u0026rsquo;t they have said it, or why was it inappropriate?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttribution of Ignorance to the Speaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e0 points.\u003c/em\u003eG ives an irrelevant response or does not attribute any mental state.\u003c/p\u003e\u003cp\u003e\u003cem\u003e1 point.\u003c/em\u003e Implicitly attributes ignorance to the speaker who commits the faux pas, referring to the effect produced on the listener or to the situation itself.\u003c/p\u003e\u003cp\u003e\u003cem\u003e2 points\u003c/em\u003e: refers to the perspective of the speaker who commits the faux pas or explicitly mentions the mental state.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Why do you think they said it?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttribution of Motivation to the Speaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e0 points\u003c/em\u003e. attributes a motivation to cause harm.\u003c/p\u003e\u003cp\u003e\u003cem\u003e1 point.\u003c/em\u003e Attributes any other type of motivation.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Did Alice know who had bought the curtains?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttribution of Ignorance to the Speaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSimple\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e0 points.\u003c/em\u003e Does not attribute ignorance to the speaker.\u003c/p\u003e\u003cp\u003e\u003cem\u003e1 point\u003c/em\u003e. Attributes ignorance to the speaker.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. How Julia felt when she heard Alice\u0026rsquo;s comment??\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttribution of Emotion to the Listener\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSimple\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e0 points.\u003c/em\u003e Does not predict an emotional effect on the listener.\u003c/p\u003e\u003cp\u003e\u003cem\u003e1 point.\u003c/em\u003e Predicts an emotional effect on the listener.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Does Alice know that Julia is feeling upset by her words? Why?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttribution of Knowledge to the Speaker about the Listener\u0026rsquo;s Emotion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e0 points.\u003c/em\u003e Does not attribute to the speaker an epistemic perspective of ignorance regarding the emotion produced in the listener.\u003c/p\u003e\u003cp\u003e\u003cem\u003e1 point.\u003c/em\u003e Implicitly attributes such knowledge to the speaker.\u003c/p\u003e\u003cp\u003e\u003cem\u003e2 points.\u003c/em\u003e Explicitly attributes to the speaker an epistemic perspective of ignorance regarding the emotion produced in the listener.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. Did Alice want Julia to feel upset?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttribution of the Speaker\u0026rsquo;s Intention regarding the Listener\u0026rsquo;s Emotion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e0 points.\u003c/em\u003e Does not attribute to the speaker a lack of intention to cause an emotional effect.\u003c/p\u003e\u003cp\u003e\u003cem\u003e1 point.\u003c/em\u003e Xorrectly attributes to the speaker the lack of intention to cause an emotional effect.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eProcedure\u003c/h2\u003e\u003cp\u003ePrior to conducting the assessments, informed consent was obtained from all participants and, in the case of the pathological aging group, also from their family members. The instruments were administered individually in a quiet, interruption-free environment. Assessments for the normative aging group were conducted in a dedicated laboratory at the Faculty of Psychology and Speech Therapy, University of M\u0026aacute;laga, whereas the pathological aging group was evaluated in a room at the AFA center, at a time agreed upon with the responsible psychologist so as to interfere as little as possible with their daily activities.\u003c/p\u003e\u003cp\u003eDuring the assessments, flexible breaks were offered to prevent participant fatigue. Participants were also encouraged to ask any questions that arose, and the items or instructions were repeated as many times as necessary. All responses were recorded in writing on scoring sheets. Additionally, during the administration of the Faux Pas Test, custom-made storyboards corresponding to each story were used to help participants follow the narratives. However, when it was observed that these storyboards hindered rather than supported comprehension, they were removed.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eInitially, multiple linear regression analyses were conducted to evaluate the potential predictive effect of the variables \u0026ldquo;age\u0026rdquo; and \u0026ldquo;with/without pathological cognitive impairment\u0026rdquo; on explicit Theory of Mind (ToM). Subsequently, once the sample was divided into normative and pathological aging groups, Spearman\u0026rsquo;s correlation coefficient was applied to examine the relationship between age and the scores obtained on the Faux Pas Test within each group.\u003c/p\u003e\u003cp\u003eNext, a detailed analysis of each component of the Faux Pas Test was conducted, comparing the scores obtained by each group. According to normality tests, for values with a normal distribution (total Faux Pas Test score), Student\u0026rsquo;s t-test was applied, whereas for values that did not follow a normal distribution (scores for individual items), the Mann\u0026ndash;Whitney U test was used, with the aim of determining whether significant differences existed between the means of both groups.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eRelationship between Age, Cognitive Impairment, and Explicit ToM\u003c/h2\u003e\u003cp\u003eThe results of the regression analysis examining the predictive variables \u0026ldquo;age\u0026rdquo; and \u0026ldquo;with/without pathological cognitive impairment\u0026rdquo; on the criterion variable explicit ToM indicate a statistically significant relationship between the presence of pathological cognitive impairment and explicit ToM (\u003cem\u003eR\u0026sup2;\u003c/em\u003e = .158; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.043). In contrast, no significant relationship was found between age and this component (\u003cem\u003eR\u0026sup2;\u003c/em\u003e = .158; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.611; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). These results suggest that performance in explicit ToM is determined by the presence of pathological cognitive impairment, independently of age (Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eLinear Regression Analysis (\u003c/em\u003eR\u0026sup2;\u003cem\u003e) and Its Significance: Age, Cognitive Impairment, and Explicit ToM\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eR\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eR2\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExpl\u0026iacute;cit ToM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.397\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.611\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWith/Without Impairment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.043*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e*p\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eSignificant Relationship; Non Significant Relationship\u003c/h2\u003e\u003cp\u003eWhen the sample was divided into groups according to the variable \u0026ldquo;with/without pathological cognitive impairment\u0026rdquo; and the relationship between age and explicit ToM was analyzed, the results for the pathological aging group did not show a significant relationship. In contrast, in the normative aging group, a significant relationship was observed, specifically with the identification of the faux pas (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.597; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.015). This indicates that, in these adults, there is a direct relationship between age and faux pas identification, such that higher age is associated with better identification (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eRelationship between Age and Explicit ToM in Normative Aging Adults (Spearman\u0026rsquo;s\u003c/em\u003e ρ \u003cem\u003eCoefficient)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eTotal Faux Pas \u0026ndash; Question 1 (Faux Pas Identification)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eSpearman\u0026rsquo;s\u003c/em\u003e ρ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.597\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003egl\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.015*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003e*p\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eRelationship between Impairment and Explicit ToM\u003c/h2\u003e\u003cp\u003eTo specifically analyze explicit ToM in relation to the variable \u0026ldquo;with/without pathological cognitive impairment,\u0026rdquo; a detailed analysis of the results for each group was conducted for each item of the Faux Pas Test, with the aim of identifying possible significant differences between them. The results indicated (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) significant differences between the two groups in the total score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.177; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.038), in Question 2 (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;32; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001), and in Question 3 (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;47.5; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.007). In all cases, the normative aging group presented higher means than the pathological aging group.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eRelationship between Impairment and Explicit ToM (Student\u0026rsquo;s\u003c/em\u003e t \u003cem\u003eand Mann\u0026ndash;Whitney\u003c/em\u003e U\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTest Statistic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Faux Pas\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudent\u0026rsquo;s \u003cem\u003et\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.038\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFaux Pas Identification \u0026ndash; Q1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.681\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttribution of Ignorance to the Speaker \u0026ndash; Q2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttribution of Motivation to the Speaker \u0026ndash; Q3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttribution of Ignorance to the Speaker \u0026ndash; Q4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.273\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttribution of Emotion to the Listener \u0026ndash; Q5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.398\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttribution of Knowledge to the Speaker about the Listener\u0026rsquo;s Emotion \u0026ndash; Q6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.503\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttribution of the Speaker\u0026rsquo;s Intention regarding the Listener\u0026rsquo;s Emotion \u0026ndash; Q7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.595\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eInfluence of Age on the Progression of Explicit ToM\u003c/h2\u003e\u003cp\u003eConsidering the objectives of this research, the influence of age on the deterioration of explicit ToM in normative and pathological aging was first examined. The results for the complete sample indicate that performance in explicit ToM among older adults is predicted solely by the presence of pathological cognitive impairment; that is, the greater the pathological cognitive impairment, the lower the ability to make attributions about mental states based on verbal cues. In contrast, age does not appear to predict a decline in this ability.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen the sample was divided into normative and pathological aging groups, it was observed that age is related differently to explicit ToM in each case. In normative aging, age is directly associated with explicit ToM; that is, in the absence of pathological cognitive impairment, this ability is maintained or may even improve with age, consistent with the findings of Fromholt et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) and Happ\u0026eacute; et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). In contrast, in pathological aging, age is not associated with explicit ToM, losing its predictive effect. This suggests that once pathological cognitive impairment is present, explicit ToM deteriorates independently of age, adding to the generalized and progressive decline of other cognitive abilities that accompany it.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eInfluence of Pathological Cognitive Impairment on the Progression of Explicit ToM\u003c/h2\u003e\u003cp\u003eRegarding the second objective, differences between the normative and pathological aging groups in relation to explicit ToM were analyzed, observing that this component deteriorates in the presence of pathological cognitive impairment. It was found that the greater the cognitive impairment, the greater the difficulties in understanding social situations in which someone makes a mistake or expresses something inappropriate.\u003c/p\u003e\u003cp\u003eSpecifically, older adults with pathological aging show greater difficulty in identifying faux pas and correctly attributing states of ignorance and motivation to the speaker who causes them. This finding is particularly relevant, as, when considered together with the previous results\u0026mdash;which indicate that explicit ToM is preserved in normative aging\u0026mdash;it suggests that early detection of deficits in explicit ToM could be useful for identifying the onset of pathological cognitive impairment at an early stage.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study examined the relationship between explicit ToM, age, and type of aging in older adults. The results show that, in the full sample, only the presence of pathological cognitive impairment predicts performance in explicit ToM, in an inverse manner. When the groups were analyzed separately, it was observed that in normative aging, age is associated with the maintenance of this ability, whereas in pathological aging, age loses its predictive effect. Furthermore, when both groups were compared using an explicit ToM assessment tool, it was concluded that individuals with pathological aging show greater difficulties in understanding inappropriate comments in social situations.\u003c/p\u003e\u003cp\u003eAlthough this study involves a small sample, the results are considered relevant. They provide the scientific literature with a more precise delineation of ToM deterioration, both in normative and pathological aging, focusing specifically on explicit ToM. This contributes to clarifying the impact of age on this ability and the characteristic pattern of decline in both types of aging.\u003c/p\u003e\u003cp\u003eThese findings may guide changes in clinical practice, as ToM is an aspect that is often overlooked in interventions for older adults, where intellectual cognition is prioritized over social cognition. It is suggested that these data serve as a basis for including ToM training and preservation in intervention programs for older adults, both with and without pathological impairment. This would allow for improving the quality of social relationships, enhancing social competence, and reducing unwanted loneliness.\u003c/p\u003e\u003cp\u003eIn the clinical setting, the results may also be applied to the early diagnosis of pathological cognitive impairment, specifically in the detection of deficits in explicit ToM, which should not appear in normative aging.\u003c/p\u003e\u003cp\u003eThe main limitation is the small sample size, due to the complexity of evaluating older adults, which involves delays in administration and unavailability due to unforeseen circumstances or health problems. In addition, the specificity of the pathological group made it difficult to select participants within the age range who met the exclusion criteria. Although the AFA Fuengirola-Mijas Costa center provided part of the sample, even within the group with impairment, cognitive heterogeneity remained notable.\u003c/p\u003e\u003cp\u003eTherefore, it is suggested that future research study explicit ToM with larger samples and include additional predictive variables. This would allow for the identification of statistically more robust relationships, expanding knowledge about the course of deterioration, which remains unclear when comparing different studies. Furthermore, the findings could contribute to considering deficits in explicit ToM as early indicators of pathological cognitive impairment, incorporating them into neuropsychological assessments and interventions for older adults.\u003c/p\u003e\u003cp\u003eIn conclusion, the study provides relevant information for both research and clinical settings and aims to promote a more multidimensional approach in interventions with older adults. It is expected that the findings will contribute to giving greater importance to social cognition, a fundamental ability for adequate social functioning during aging, but one that is often underestimated.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthical Approval\u003c/h2\u003e\u003cp\u003e The study was approved by the Ethics Committee for Experimentation of the University of M\u0026aacute;laga, Registration Number CEUMA: 154-2022-H.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research was supported by: Universidad de M\u0026aacute;laga, II Own Research and Transfer Plan, Research Initiation Grants; University of M\u0026aacute;laga Proyect PRO-B4-2025-001; Junta de Andaluc\u0026iacute;a, Project SEJ466-G-FEDER.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbu-Akel, A., \u0026amp; Shamay-Tsoory, S. (2011). 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A developmental perspective for promoting theory of mind. \u003cem\u003eTopics in Language Disorders, 34\u003c/em\u003e(4), 362\u0026ndash;382. https://doi.org/10.1097/tld.0000000000000035\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"b2dad160-b3a8-43dd-9fe8-d5e5d20570c5","identifier":"10.13039/100009473","name":"Universidad de Málaga","awardNumber":" PRO-B4-2025-001","order_by":0},{"identity":"81a74004-2b87-4cda-a3d5-61d833718798","identifier":"10.13039/501100011011","name":"Junta de Andalucía","awardNumber":"PPRO-SEJ466-G-2023","order_by":1}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Universidad de Malaga","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"aging, age, cognitive impairment, explicit Theory of Mind","lastPublishedDoi":"10.21203/rs.3.rs-8010643/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8010643/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTraditionally, the evaluation and intervention of cognitive abilities in aging have focused on intellectual cognition, particularly executive functions such as working memory, attention, and processing speed. In contrast, social cognition\u0026mdash;crucial for effective daily social functioning, such as following conversations, participating in group interactions, or understanding complex social situations\u0026mdash;has received considerably less attention. Scientific evidence suggests that brain and cognitive functioning follow different trajectories in normal and pathological aging.\u003c/p\u003e\u003cp\u003eThe present study aimed to examine how age and the presence of pathological cognitive impairment predict deficits in the ability to attribute mental states through verbal cues (explicit Theory of Mind, ToM), as well as to analyze differences in this ability between normative and pathological aging. Thirty older adults (aged 58\u0026ndash;88) participated, divided into two age- and gender-matched groups: those with normative aging (n\u0026thinsp;=\u0026thinsp;15) and those with pathological aging (n\u0026thinsp;=\u0026thinsp;15). Explicit ToM was assessed using an extended version of the \u003cem\u003eFaux Pas Test\u003c/em\u003e (Baron-Cohen et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1999\u003c/span\u003e), which evaluates not only the detection of faux pas but also the attribution of both cognitive and emotional mental states to different characters within complex social situations.\u003c/p\u003e\u003cp\u003eResults showed that, among older adults, only the presence of pathological cognitive impairment\u0026mdash;and not age\u0026mdash;predicted deficits in explicit ToM. When analyzing groups separately, age was associated with improvements in explicit ToM only in normative aging; this effect disappeared in pathological aging, where participants showed marked difficulties in verbally reasoning about social scenarios. These findings may contribute to the early identification of pathological cognitive decline and support the refinement of neuropsychological assessment and intervention protocols for older adults with both normative and pathological aging profiles.\u003c/p\u003e","manuscriptTitle":"Deficits in explicit theory of mind: a possible early indicator of pathological aging","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-04 10:23:55","doi":"10.21203/rs.3.rs-8010643/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"315460cb-f492-4dd5-896d-dfcd0efa529d","owner":[],"postedDate":"November 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57396845,"name":"Psychology"}],"tags":[],"updatedAt":"2025-11-04T10:23:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-04 10:23:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8010643","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8010643","identity":"rs-8010643","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}