Introduction

The rapid growth of Korea’s older adult population has led to a concurrent rise in the prevalence of dementia and its associated socioeconomic burden, underscoring the need for robust nationwide strategies for prevention and early detection [1]. In 2017, the Korean government implemented the National Dementia Responsibility System to expand dementia relief centers, long-term care services, and medical support for affected individuals [2]. These initiatives were built upon earlier frameworks, including the second and third national dementia plans, which emphasized early detection through mobile screening tools (e.g., Check Dementia), lifestyle-based prevention strategies, and broader eligibility for long-term care insurance [3].

Despite these policy advances, epidemiological and economic health indicators continue to worsen. Analyses of the National Health Insurance Service cohort data demonstrated marked increases in both the standardized prevalence and incidence of dementia between 2003 and 2015 [1]. The economic health burden of dementia also increased by approximately 1.5-fold from 2015 to 2019, reaching nearly USD 4.2 billion, driven by increases in direct (outpatient and drug) and indirect (caregiver) costs [4]. These findings suggest that the current approaches remain insufficient, highlighting the need to integrate evidence-based digital strategies, including remote cognitive screening, predictive modeling, and large-scale data-driven interventions, to slow disease progression and reduce societal costs [2,4-6].

The coronavirus disease 2019 (COVID-19) pandemic further revealed the limitations of traditional in-person neuropsychological assessments and accelerated the transition to remote and digital approaches. In Korea, widely used neuropsychological instruments include the Consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet-Korean version (CERAD-K) [7] and the Seoul Neuropsychological Screening Battery (SNSB) [8]. The CERAD-K, which can be completed in approximately 30 to 40 minutes, has been standardized across diverse demographic groups, and recent studies have confirmed meaningful concurrent validity of computerized versions of this instrument [9,10]. The SNSB offers a comprehensive, multidomain assessment but requires 90 to 120 minutes in a paper-and-pencil face-to-face format. The dementia-focused version (SNSB-D) improves diagnostic accuracy, and newer tablet-based tests, such as the Seoul Cognitive Status Test, demonstrate high diagnostic agreement with substantially shorter administration time [8,11].

Although the Korean Mini-Mental State Examination (K-MMSE) remains the most widely used screening tool owing to its brevity and accessibility, its limited scope restricts its diagnostic precision. Consequently, there is a growing demand for validated, digitally administered neuropsychological batteries that can facilitate standardized, efficient, and remote cognitive assessments [12,13].

To address these limitations, the Korean version of the Repeatable Battery for the Assessment of Neuropsychological Status (K-RBANS) was adapted into a remote tablet-based format, the electronic K-RBANS (K-eRBANS), to preserve the validated structure of the original K-RBANS, while improving accessibility, standardization, and feasibility for non–face-to-face assessment. Previous studies have demonstrated that the K-RBANS exhibits strong reliability, convergent validity, and a stable five-factor structure and that tablet-based administration has minimal format effects with acceptable discriminative performance [14,15]. However, in a prior adaptation study of the K-eRBANS, the construct validity could not be empirically verified because of the study design. Therefore, this preliminary study investigated the feasibility and construct validity of the K-eRBANS using a single-group prospective observational design.

Methods

Ethics statement: This study was approved by the Institutional Review Board (IRB) of Yeungnam University Hospital (IRB No: 2021-07-009). Written informed consent was obtained from all participants or from legally authorized representatives in accordance with the Declaration of Helsinki.

1. Participants and recruitment

The participants were recruited through public announcements across the Daegu metropolitan area between September 2021 and December 2021. Individuals who met the inclusion criteria were informed of the study procedures and provided written informed consent prior to participation.

1) Inclusion criteria

Adults aged ≥40 and <90 years who provided voluntary consent were considered. Cognitive status was assessed using the K-MMSE-2. Participants were included if they had a K-MMSE-2 total score between 10 and 30 within 1 year prior to screening or if they agreed to undergo the K-MMSE-2 during screening and obtained a score in the same range [16,17]. Dementia severity was evaluated with the Clinical Dementia Rating (CDR) scale; eligible participants had a CDR score between 0 and 2.0 (or 0.5–2.0 within 1 year prior to screening) [18,19]. For participants with dementia, consent was obtained from a legally authorized representative, and for those with suspected dementia, consent was obtained from the participant. None of the participants had significant sensory, perceptual, or motor impairments that could interfere with the testing.

2) Age-range rationale

In K-RBANS normative sampling, individuals ≥90 years of age were insufficient to establish a stable subgroup. Although relatively few studies specify a precise onset of cognitive decline “around 45 years,” emerging evidence indicates that midlife (i.e., fifth to sixth decade) may mark a transition in brain aging predictive of later cognitive health yet amenable to intervention [20,21].

2. Instruments

1) Repeatable Battery for the Assessment of Neuropsychological Status

The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is a brief standardized battery composed of 12 subtests assessing five domains (immediate memory, visuospatial/constructional, language, attention, and delayed memory) plus a total scale score. The administration time is approximately 20 to 30 minutes. The RBANS has demonstrated adequate reliability and validity across populations [22-24].

2) Korean version of the Repeatable Battery for the Assessment of Neuropsychological Status

The culturally adapted K-RBANS shows good convergent validity with intelligence and other neuropsychological tests (r=0.41–0.81, p<0.001) and a stable second-order factor structure (comparative fit index [CFI], 0.949; goodness-of-fit index [GFI], 0.942). Receiver operating characteristic analysis revealed an area under the curve (AUC) of 0.837 (95% confidence interval, 0.760–0.896), sensitivity of 77.66%, and specificity of 78.12% in clinical settings [15].

3) Korean version of the Electronic Repeatable Battery for the Assessment of Neuropsychological Status

A tablet-based digital adaptation preserving the K-RBANS structure, subtest ordering, and norms was designed for remote administration and called K-eRBANS. Format equivalence work indicated minimal format effects (≤0.20 for most subtests) and acceptable discriminative performance (AUC, approximately 0.827) when distinguishing clinical from control groups [16].

3. Administration procedures

Each enrolled participant was assigned a unique research ID (RXXX). Two tablets running the K-eRBANS application (the examiner and participant devices) were connected using a secure wireless network. After confirming the connectivity, the examiner launched the application on both devices, entered the participant ID, positioned the participant device at the testing station, and initiated the assessment. The subtests were administered in the fixed order specified in the manual. If an interruption occurred, testing was resumed from the place of pausing.

4. Statistical analysis

Analyses were performed using IBM SPSS ver. 25.0 and IBM AMOS ver. 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize the demographic and clinical variables (means, standard deviations [SDs], and frequencies). Data were checked for normality, linearity, and outliers, and variables with significant non-normality were transformed or analyzed using nonparametric methods as appropriate.

Concurrent validity was evaluated using Pearson correlations between the K-eRBANS subtest/index scores and K-MMSE-2 and CDR scores. Effect sizes followed Cohen’s (1988) conventions (small, |r|≥0.10; medium, |r|≥0.30; and large, |r|≥0.50) [25]. Construct validity was examined using confirmatory factor analysis with maximum likelihood estimation. Model fit indices included χ² and χ²/degree of freedom (CMIN/df), standardized root mean square residual (sRMR), root mean square error of approximation (RMSEA), GFI, CFI, and Tucker-Lewis index (TLI). Acceptable thresholds were CMIN/df≤3, sRMR≤0.08, RMSEA≤0.10, GFI≥0.90, and CFI≥0.90. Two-tailed tests used α=0.05.

Results

1. Demographic and clinical characteristics

A total of 150 participants were included (male, 37 [24.7%]; female, 113 [75.3%]). The mean age was 55.0 years (SD, 6.5 years). The largest age groups were 46 to 50 years (31.3%) and 51 to 55 years (22.7%). All participants were literate; their mean education was 14.3 years (SD, 3.2 years). Nearly half (48.7%) had 13 to 16 years of education, and 20.0% had ≥17 years of education. Previous drug treatment was reported by 20.0%, alcohol use within 24 hours by 5.3%, and smoking within 24 hours by 13.3%. Mean height and weight were 162.8 cm (SD, 7.6 cm) and 63.3 kg (SD, 11.0 kg), respectively; mean body mass index was 23.8 kg/m² (SD, 3.2 kg/m²). A history of medication use was documented in 10.7% of the participants, and a medical history in 11.3%.

The mean K-MMSE-2 was 28.5 (SD, 1.9). The CDR distribution was 0 (73.3%), 0.5 (24.7%), and 1 (2.0%), indicating that most participants had no or very mild impairment (Table 1).

2. Raw and index scores of the Korean version of the Electronic Repeatable Battery for the Assessment of Neuropsychological Status

Participants generally showed preserved performance across domains. The average immediate memory and delayed memory index scores were ≥95; the visuospatial/constructional score was somewhat lower (mean, 83.66; SD, 21.95). Language and attention indices ranged from the high 80s to the high 90s. The total scale score averaged 90.32 (SD, 22.11), and the sum of all index scores averaged 462.81 (SD, 74.30) (Table 2).

3. Correlations with the Mini-Mental State Examination and Clinical Dementia Rating

The K-MMSE-2 scores correlated positively with most K-eRBANS subtests (r=0.223–0.577, all p≤0.01) and composite indices (e.g., sum of subtests 9+11+12: r=0.590, p<0.001). The CDR scores correlated negatively with most subtests and indices (e.g., spatial orientation: r=−0.414, p<0.001; delayed memory: r=−0.310, p<0.001), indicating worse cognition with higher dementia severity (Table 3).

4. Confirmatory factor analysis

The hypothesized five-factor model demonstrated an overall acceptable fit to the data (χ²=104.44, p<0.001; CMIN/df, 2.13; sRMR, 0.057; RMSEA, 0.089; GFI, 0.901; CFI, 0.910; and TLI, 0.879). Most indices satisfied the conventional criteria for adequate model fit, whereas the TLI value was marginally below the recommended cutoff of 0.90, indicating the potential for minor model refinement (Table 4).

Fig. 1 illustrates the standardized factor loadings and structural relationships among the five latent domains: immediate memory, visuospatial/constructional, language, attention, and delayed memory. Each domain was represented by its corresponding subtest (e.g., Word List Learning and Story Memory for immediate memory; Figure Copy and Line Orientation for visuospatial/constructional). All factor loadings were statistically significant (p<0.001) and ranged from 0.54 to 0.82, supporting the theoretical construct consistency between the K-eRBANS and original K-RBANS structures.

Fig. 1 further shows moderate correlations among latent domains, particularly between immediate memory and delayed memory (r=0.71), reflecting the interconnected nature of episodic memory processes. This pattern indicates that despite minor deviations in the TLI, the five-factor model preserves the conceptual integrity of the original instrument and provides psychometrically sound measurements across the digital administration.

Discussion

In this study, we evaluated both the construct validity and clinical applicability of the K-eRBANS, a tablet-based and remotely administered adaptation of the K-RBANS, to determine its psychometric robustness among middle-aged and older adults. The results demonstrated that the K-eRBANS preserves the theoretical and structural integrity of the original K-RBANS, while providing distinct advantages in digital accessibility and standardized administration. A confirmatory factor analysis supported the hypothesized five-factor structure of immediate memory, visuospatial/constructional, language, attention, and delayed memory. Model fit indices, including the CFI, GFI, and RMSEA, indicated adequate model fit, confirming that the digital version maintains the factorial stability of the original instrument. These findings are consistent with those of prior studies reporting that computerized versions of the RBANS yield minimal format effects and psychometric properties comparable to those of traditional paper-based administration.

Significant positive correlations between the K-eRBANS subtests and K-MMSE-2 scores, together with negative correlations with CDR ratings, further support the concurrent and construct validity of the digital tool. The strongest associations were observed for Word List Recall and Story Recall, subtests that are highly sensitive to early episodic memory decline, a hallmark feature of prodromal dementia. This correlation pattern indicates that the K-eRBANS effectively captures both global cognitive functioning and dementia severity. Thus, the K-eRBANS can be regarded as a valid and efficient instrument for detecting subtle cognitive changes in both the community-based and clinical contexts.

From a clinical perspective, the digital transformation of the K-RBANS into the K-eRBANS represents a major step forward in the modernization of neuropsychological assessments within Korea’s healthcare system. The tablet-based platform enables standardized, efficient, and remote administration, thereby reducing examiner burden and minimizing human scoring errors. These advantages are particularly valuable in non-face-to-face contexts such as those necessitated by the COVID-19 pandemic, where accessibility and reliability are essential. Moreover, the K-eRBANS can be integrated into large-scale dementia databases or Clinical Data Interchange Standards Consortium-compliant infrastructures to support longitudinal cognitive monitoring and evidence-based policymaking under the National Dementia Responsibility System. By bridging traditional neuropsychological expertise with digital innovation, the K-eRBANS contributes to Korea’s transition toward proactive, preventive, and data-driven dementia management.

Despite these strengths, several limitations of this study must be acknowledged. The present sample consisted primarily of women who were middle-aged and relatively well-educated, reflecting the demographic characteristics of voluntary participants in community-based cognitive studies. However, this composition may limit the generalizability of the findings to older adults, individuals with lower educational attainment, and male participants. Considering the potential effects of gender and education on cognitive performance and digital test engagement, future research should include more balanced and demographically diverse samples to enhance external validity. Furthermore, normative data should be expanded across broader demographic strata, and diagnostic performance should be evaluated in clinically diagnosed dementia groups. Although digital administration enhances efficiency, factors such as device familiarity, visual–motor comfort, and Internet stability can affect performance outcomes. Subsequent studies should address these variables and further examine test–retest reliability, cross-device equivalence, and sensitivity to longitudinal cognitive changes.

In conclusion, the present findings provide robust evidence of the validity, reliability, and feasibility of the K-eRBANS as a digital neuropsychological assessment tool. By retaining the psychometric rigor of the K-RBANS while leveraging the flexibility of tablet-based delivery, the K-eRBANS has emerged as a practical and scalable solution for early cognitive screening, remote monitoring, and dementia prevention. Its integration into clinical and preventive frameworks may substantially advance national efforts toward early detection and continuous cognitive health management in the aging Korean population.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Fig. 1.

Comparison of factor structures between (A) Korean version of the Repeatable Battery for the Assessment of Neuropsychological Status (K-RBANS) and (B) Korean version of the Electronic Repeatable Battery for the Assessment of Neuropsychological Status (K-eRBANS). All paths shown are standardized loadings (p<0.001). The five-factor model for K-eRBANS demonstrates factorial stability and high correspondence with the established structure of the K-RBANS.

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Figure & Data

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