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Application and Interpretation of Functional Outcome Measures for Testing Individuals With Cognitive Impairment

Ross, Christine, M., PT, DPT, GCS, CDP, MSCS

Topics in Geriatric Rehabilitation: January/March 2018 - Volume 34 - Issue 1 - p 13–35
doi: 10.1097/TGR.0000000000000171
Thinking About Cognition: From Advances in Neuroanatomy to Outcomes Assesment

The prevalence of individuals living with dementia worldwide is expected to increase exponentially; yet these individuals receive minimal recommended quality of care. Physical therapists are a valuable component of the comprehensive medical care team serving individuals with cognitive impairment. Utilization of evidence-based outcome measures to determine optimal care is critical to improving the effectiveness of care for individuals with cognitive impairment, decreasing the variability in the evaluation process. The purpose of this article is to describe functional outcome tools to assist skilled physical therapists with the evaluation process, essential to enhancing the quality of the individualized plan of care.

Neurorehabilitation, Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas, Nevada.

Correspondence: Christine M. Ross, PT, DPT, GCS, CDP, MSCS, Neurorehabilitation, Cleveland Clinic, Lou Ruvo Center for Brain Health, Las Vegas, NV 89106 (

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

The prevalence of individuals living with dementia worldwide is expected to increase exponentially to a projected 132 million people by 2050, due to higher rates of diagnosis and changing demography.1 The estimated financial global impact of dementia was $818 billion in 2015.2 The economic burden of dementia is significant, as the estimated worldwide cost is projected to rise to $2 trillion by 2030.2 Alzheimer disease (AD) exists along a spectrum of cognitive impairment from mild cognitive impairment (MCI) to severe dementia. For the purpose of this article, the term “individuals with cognitive impairment” (IWCI) refers to any individual on this spectrum. As the disease process continues and progression of the cognitive impairment occurs, independence with activities of daily living is reduced.3 Furthermore, according to a systematic review by Lewis et al,3 IWCI are at risk for progression of physical decline, including physical deconditioning, standing balance instability, decreased muscle strength and power, and impairments in gait mechanics and speed. On average, IWCI only receive the recommended quality of care about 35% of the time.2 Researchers have found that clinicians have a low and varied adherence to dementia best practice guidelines.4 Stronger evidence to encourage routine cognitive screening and more support for dementia education and training is needed from national and international organizations.4 Physical therapists (PTs) are a valuable component of the comprehensive medical team serving individuals with neurodegenerative disease to improve their daily functional activities and quality of life.5

Utilization of evidence-based outcome measures to determine optimal care is critical with the rise of this global health crisis. As recommended by the Dementia Work Group within the 2011 Dementia Performance Measure Set,4 improving the effectiveness of care for IWCI includes a standardized use of assessment tools. The presence of dementia makes accurate examination and effective patient education challenging.4 Standardization and implementation of appropriate outcome measures for this population will decrease the considerable variability in the evaluation of IWCI.4 , 6 Utilizing an integrated approach that relies on creative and flexible clinical decision-making, PTs can safely and effectively evaluate and treat IWCI throughout the spectrum of the disease process.7 To determine baseline level of function, monitor changes over time, and identify interventions to maximize the IWCI's independence and quality of life, initial and ongoing functional status assessments should be conducted.4 The purpose of this article is to identify and describe functional outcome tools to assist skilled PTs with the evaluation process, essential to enhancing the quality of the individualized plan of care.

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In preparation for the initial physical therapy evaluation, completing a chart review may provide the PT with good insight into how the individual may present.8 By conducting a thorough chart review, the PT may obtain a better understanding of the individual's medical history, medications, and psychosocial history.8 The medical chart may include specifics of the type of dementia diagnosis, duration of the condition, if any acute cognitive changes have occurred, or any other medical diagnoses or concerns such as cancer, diabetes mellitus, or orthostasis.8 Furthermore, it is important to take note of any high-risk medications9 for older adults, such as anticholinergics,9 psychotropics,9 , 10 antiepileptics,11 opioids,10 nonsteroidal anti-inflammatory drugs,12 diuretics,13 digoxin, and type 1a antiarrhythmic drugs,13 and to review for ruling out polypharmacy.9 , 14 These medications14 and polypharmacy15 have been associated with falls in aging. Within the medical chart, the PT may also identify any behavior or nutritional concerns or sensory impairments that should be addressed as part of the individualized comprehensive PT initial evaluation.

In addition, a chart review may identify family members or any other care partners who participate in the care of the IWCI. This may give the PT a better perception of whether it would be beneficial to have a care partner present during the evaluation, and how the PT may best carry out the examinations.8 , 16 Interviewing the IWCI and the care partner separately enables the therapist to assess the individuals' cooperation and language skills without them being masked by interruptions or assistance from the care partner.17 However, when evaluating an individual who may have moderate to severe cognitive impairment, having a care partner present during the examination may be important for corroboration and assisting in capturing the full history.7 Perhaps a combination of the 2 situations is optimal, particularly during the subjective examination.

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A thorough skilled PT evaluation for an IWCI must involve a comprehensive history intake, cognitive screening with staging, and evaluation of functional status, as well as having an understanding of the goals of the individual and the care partner.7 , 8 Careful history taking is paramount and should be completed in a quiet setting, with minimal distractions and adequate lighting to promote an optimal assessment environment.8 , 18 , 19 It is important to capture the following in the subjective examination: duration of cognitive impairment, medical history, chief complaint, prior level of function, current level of function, history of falls, pain, behavior changes, daily routine, physical activity, community activity participation, social engagements, living environment, and caregiver assistance.20 Smith et al21 recommend asking questions about daily life, memory, health, relationships, life satisfaction, and autonomy. Learning details of the individual's life story can help the PT develop a rapport, creating a connection useful during the plan of care.8 , 18 , 22 This time spent may be valuable to complete prior to progressing through the examination process. Furthermore, factors contributing to fall risk should be investigated.23 These include results from the most recent annual hearing and vision examinations, medication review and discussion for literacy and adherence, and identification of any other fall risk contributors, such as peripheral neuropathy or the presence of dysautonomia.23 Most importantly, approaching the IWCI with care, patience, and respect in an unhurried manner will yield the best outcomes.

Communicating with an IWCI requires use of conversational strategies to promote successful comprehension, creating an environment of ease and safety.18 , 24 , 25 While the individual's level of communication skills will vary depending on severity, poor communication may compromise care.26 Being a skilled communicator enables the PT to engage with the IWCI on a therapeutic level.24 Communication strategies include introductions as a PT and explaining the PT's role in individual's care, maintaining good eye contact, increasing the use of friendly nonverbal communication, using multisensory cues and reassuring touch, allowing time for processing with a slowed rate of speech in simple phrases, minimizing environmental distractions, minimizing instructions to 3 steps or less when appropriate, demonstrating the test again if necessary, and listening to the emotions behind what the individual is saying.8 , 18 , 26 Taking a person-centered approach by acknowledging the uniqueness and individuality of each person may empower and promote the person's communication strengths. Furthermore, the PT will want to determine whether the IWCI has any sensory deficits that may impact testing and should be accommodated.8 If the IWCI wears hearing aids, ensure the hearing aids are correctly donned and working properly.8 If the IWCI is visually impaired, ensure the individual is donning his or her clean personal eyeglasses. It may be necessary for the PT to modify the education materials or home exercise program illustrations by enlarging the print size.8

Encouragement and neutral feedback may be given to assist in decreasing the individual's anxiety. Allowing for rest breaks and monitoring for fatigue, especially between challenging tasks, will assist with the individual's participation. Being attentive to, and documenting, how the individual communicates will greatly assist the PT in promoting understanding and a successful delivery of interventions throughout the individual's plan of care.8

During the subjective examination, conversation with the individual may be as important as any formal cognitive assessment. According to a 2017 systematic review by Alsawy and colleagues,18 problems with communication arise across all types of dementia. In the early stages of dementia, a PT may observe problematic communication including aphasia and anomia (difficulty finding the right word), challenge with writing, and difficulties with understanding complex language such as analogies.18 , 27 As an IWCI progresses to the middle stages of the disease, communication impairments include echolalia (repetition of the same words and phrases); verbigeration (repetition of meaningless words or sentences); perseveration (continued repetition of the same movement or repetition of the same words and phrases); paraphrasia (word substitution or disorderly arrangement of words); apraxic speech (ie, hearing the word “chicken” when the individual may mean to speak the word “kitchen”); difficulty with sentence formation and understanding written information; and following and conceptualizing multistep commands.7 , 18 , 27 In the later stages of dementia, deterioration of language and communication may further occur and individuals may become unable to communicate their needs due to the production of nonsensical language or they may even become mute.18 , 28 This warrants the need to monitor the use of nonverbal expressions, verbal reassurance, and possible use of appropriate physical contact. However, caution must be taken when attempting to interpret nonverbal expressions, as these may not be an accurate portrayal of the person's experiences.18

In addition, the individual's level of alertness and the ability to maintain appropriate behavior throughout the examination should be assessed.17 If the level of alertness is decreased, it would be important to look into the medication history and sleeping habits, and delirium should be considered if the individual appears poorly responsive. The subjective examination should also give the PT insight into any impairments that may be affecting memory and cognition, such as depression and delirium. If delirium is suspected due to the patient's level of confusion, disorientation, and alertness, the PT should inquire further into identifying any recent hospitalizations, acute cognitive changes, possible recent diagnosis of any infections (ie, urinary tract infections), central nervous system pathology, withdrawals, acute metabolic changes, toxins, drugs, hypoxia, trauma, acute vascular cause, endocrine issues, and possible improper catheter positioning, as the cause of delirium is multifactoral.29 , 30

The Confusion Assessment Method (CAM)31 is the most effective tool to identify delirium.31–34 Designed and validated to be used based on observations made during examination, the CAM has been adapted for use for multiple health care settings.35 During this 5-minute assessment, the PT will assess for the presence of acute cognitive change, fluctuations in behavior during the day, difficulty focusing attention, presence of disorganized rambling or irrelevant speech, and their overall consciousness.30 , 36 Assessment and prevention of delirium should be ongoing and completed throughout the individual's plan of care.30 Clinicians often do not recognize the signs and symptoms of delirium.30 , 32 , 37 Once delirium is detected, it should be seen as a medical emergency and warrants prompt intervention to identify and treat the cause.38

Attentiveness to signs of depression is also important. Depression is commonly experienced by individuals with dementia39 and may be contributing to an individual's cognitive impairment. The PT may inquire into “sadness” as opposed to “depression,” as the individual may more identify with feeling sad versus feeling depressed.40 Signs of depression include changes in sleeping habits, loss of interest, guilt, lack of energy, difficulty concentrating, loss of appetite, psychomotor changes like agitation and lethargy, and suicidal thoughts.36 If any of these signs are identified, the PT should follow up with questions to guide recommendations for additional care and referral. Follow-up questions may include (1) “If you could make two things better, what would they be?”, (2) “Do you have someone else to speak with about these concerns?”, and (3) “Have you ever thought about harming yourself?”. Specific documentation on all of these findings is very important. The Geriatric Depression Scale41 is the most commonly used outcome tool to assess mood and depression among older adults.39 Both sensitive to change and reliable, this quick self-rated tool has been validated for individuals with mild dementia, but not for those with moderate-severe to severe dementia.39 , 41 The Geriatric Depression Scale is usually self-rated but can be rated by an assessor.39 On the other hand, the Cornell Scale for Depression in Dementia is completed by the individual and care partner, yet for its use, the individual does not need to be able to answer questions.39 The Cornell Scale for Depression in Dementia is validated for individuals with and without dementia and is considered the gold standard for quantifying depressive symptoms in individuals with dementia.39 , 42 Based on clinical judgment, the Geriatric Depression Scale score, and individual subjective report, the PT may indicate that referral to social and/or behavior health services may be warranted.

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Dementia is the process of gradual cognitive decline, with progressive limitations in one or more cognitive domains including memory, executive function, language, judgment, and spatial abilities, and may be accompanied by aphasia and apraxia.16 , 36 , 43 , 44 A review by the US Preventive Services Task Force reported that between 50% and 60% of individuals presenting to physicians in the primary care setting were found to have dementia, but had no such diagnosis in their medical notes.45 Cognitive screening, as part of the objective examination, assists the clinician in establishing the individual's baseline orientation, communication, spatial awareness, and ability to follow instructions. However, the cognitive screen is not intended to take the place of a full neuropsychological assessment.46 Usually completed by a neuropsychologist, the comprehensive neuropsychological testing examines at least 6 core domains: attention/working memory, new verbal learning and recall, expressive language, visual construction, executive function, and abstract reasoning.46 Examination of these core domains assists to identify characteristics of different subtypes of dementia: AD, vascular dementia, frontotemporal dementia (FTD), and Lewy body dementia (LBD).46 Information about characteristics of these subtypes and impairments in cognitive domains is beyond the scope of this article and may be found elsewhere in the literature.46–50 Performing cognitive screening provides objective documentation on cognition and communication abilities that will guide successful delivery of physical therapy interventions. Payers look for justification into why each IWCI in the care of a PT needs skilled PT services.51–53 Providers and payers have often perceived cognitive impairment as a barrier to rehabilitation services utilization and reimbursement.51–53 Data collected during cognitive screening may give the PT guidance as to what outcome measures and educational interventions would be most appropriate. Cognitive screening is necessary for the development of a skilled PT plan of care and is considered billable time.

There are several cognitive screening instruments available for detecting dementia. The Mini-Mental Status Examination (MMSE)54 is used extensively in clinical and research settings and widely performed by frontline physicians for general cognitive evaluation.55 , 56 Administered in 10 minutes, the MMSE screens 7 cognitive domains of cognitive function.51 , 54 With a possible total 30 points for the sum of all correct answers, a score of 23 or less points indicates the presence of cognitive impairment.51 , 54 However, the MMSE has a limited dynamic performance range for individuals without cognitive impairment.57 , 58 This ceiling effect increases the likelihood that individuals within the predementia stages score a 24/30 or above within the range of normal, no cognitive impairment.56 The MMSE has poor sensitivity for distinguishing MCI, causing difficulty in detecting early dementia. This is likely due to the absence of executive function items and lack of complexity within the cognitive assessment tool.56 , 59–62 Yet on the other hand, the MMSE is superior when testing IWCI in the more advanced stages of AD.55 , 63 There have been proprietary changes limiting access to the MMSE, thus the utilization of other noncopyrighted cognitive screening instruments has increased.64

The Montreal Cognitive Assessment(MoCA)55 is a brief cognitive screening tool that assesses 11 cognitive domains within 10 minutes of skilled time. Like the MMSE, the MoCA is feasible to use in a clinical setting where assessment time is often limited. In contrast to the MMSE, the MoCA has excellent sensitivity and specificity and is a better predictor of progression from MCI to mild AD.55 , 65 , 66 Individuals screened and found to have an MoCA score lower than 26/30 and/or an MMSE of 26-21/30 or lower would be more likely to meet clinical and neuropsychological criteria for extensive evaluation. This lends quick guidance to refer for further investigation with a neurologist.33 , 55 , 56 With lower total scores, both cognitive screening tools indicate higher likelihood of institutionalization, mortality, extended length of stay, and adverse incidents. More information is discussed in other research literature.67–70

The Mini-Cog71 is a simple 3-minute cognitive screening tool that includes a 3-item recall and a clock-drawing test.71–74 With a total potential score of 5, a cutoff point of less than 3 has been validated for dementia screening.72 Eknoyan and colleagues75 detail more information on the interpretation of the clock-drawing errors and changes in functional neuroanatomy. The Mini-Cog is recommended by the Academy of Geriatric Physical Therapy Cognitive and Mental Health Special Interest Group of the American Physical Therapy Association. The strong predictive value and sensitivity of this tool may assist clinicians in detecting cognitive impairment and identify individuals in need of more thorough cognitive evaluation.71 , 72 Table 1 shows more details on the selected cognitive screening tools, test characteristics, cutoff scores, and psychometrics properties. Results from the cognitive screening provide the clinician with documentation of the IWCI's current cognitive status, selecting the most appropriate delivery method for interventions, and assist in identifying their disease stage severity.



Staging systems are helpful tools that allow clinicians to categorize disease severity in progressive cognitive illness.4 , 76–78 Dementia severity can be assessed using a number of valid and reliable instruments, which include the Global Deterioration Scale (GDS), the Functional Assessment Staging Tool (FAST), the Clinical Dementia Rating, and the Dementia Severity Rating Scale.4 , 76 , 77 , 79 The GDS Staging System, which includes the FAST76 and the Brief Cognitive Rating Scale (BCRS),77 is one of the most widely used and extensively studied systems proven to be reliable80–85 and valid77 , 86–90 for staging dementia in AD. The GDS spans the entire course of normal aging and progressive AD, enhancing the ability to track the longitudinal course, while providing differential diagnostic and prognostic information.78 , 91 In an effort to expand the 7-level staging system of the GDS, a 16-level FAST was developed, providing more clinicopathologic observations, substages at the final levels of the disease process, and enhanced diagnostic and prognostic information.76 Table 2 presents the GDS and FAST Staging Scales and levels of cognitive impairment severity with reference to MMSE scores. To identify the appropriate stage, the BCRS is used to evaluate functional and cognitive abilities within 5 questions to assess a variety of domains.77 There are 5 axes in which the examiner identifies the appropriate level of ability using one of the objective ratings given.77 After all 5 axes are completed, the total is added up and divided by 5 to get the stage on the GDS, with the decimal point indicating the substage within the level.92 Staging using the GDS helps the health care team, families, and care partners understand the cognitive deficits and set realistic goals for living situations and therapy care.



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As with any individual in the care of a PT, outcome measures serve as the basis for assessing functional performance and fall risk, identifying treatment goals, developing plans of care, recommending other discipline referrals, and selecting proper treatment interventions.93 The American Physical Therapy Association states that “measuring outcomes is an important component of physical therapist practice.”93 Individuals with cognitive impairment can present to the initial PT evaluation each with unique challenges and potential barriers to the assessment of physical function and mobility. Each IWCI's presentation and the distinctive symptoms among the different types of dementia are important to understand, as the physical and cognitive performances vary between subtypes of dementia.46 , 94 The variability of impairments and the progressive nature of the disease can make selection and administration of the functional outcome measures challenging.95 These hallmark changes in memory and language begin during the earliest stages of the disease, and as the disease progresses, create difficulty in comprehending multistep commands. It is very important for the selected functional outcome measures, utilized to assess IWCI, to demonstrate acceptable reliability. Delivery and content of test instructions should be administered in a way that is consistent with successful communication strategies in IWCI. The increase in disease severity progresses over time and adversely affects the performance of functional outcome measures, compromising the ability of these tools to accurately quantify or detect change.94–97 Functional outcome measures performed on this population must demonstrate retest reliability in order for clinicians to be able to interpret changes, especially as the disease progresses.94 , 95 Of upmost importance is to ensure that the functional outcome measure is safe and feasible to implement to maintain the safety of the IWCI under the care of the PT.94 As AD is the most common type of dementia,94 , 98 the particular interest of this article will be highlighting AD and the functional outcome measures used to assess individuals with AD, unless otherwise indicated.

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The Dementia Performance Measure Set, developed by the Physician Consortium for Performance Improvement (PCPI), serves to identify and define quality measures toward improving outcomes for individuals with dementia and ultimately enhance the quality of care.4 The PCPI states that an assessment of functional status should include, at minimum, an evaluation of the individual's ability to perform instrumental activities of daily living (IADLs) and activities of daily living (ADLs).4 Understanding and assessing how cognitive impairment affects an IWCI's performance of ADL and IADL tasks and how that ability to perform competently declines over time is difficult to assess. Functional status can be assessed using a valid and reliable tool including, but not limited to, ADL measurements such as ADL-Questionnaire99, Barthel ADL Index100, Katz Index of Independence in ADL,101 or IADLs measurements, like the Revised Interview for Deterioration in Daily Living Activities in Dementia (R-IDDD2)102 or Lawton IADL Scale.4 , 103 The Katz, Barthel, and Lawton tools are sufficient in generating measures for function in the elderly, but for detecting cognitive impairment and how it affects the decline in function, a combination of instruments would most likely provide better results.21 However, the ADL-Questionnaire is sensitive to functional and communication changes and used for a wide variety of types of dementia.99 The R-IDDD2 is an IADL assessment tool that is valid and reliable for individuals with dementia.102 Lower scores on these tools warrant functional training within the physical therapy plan of care and possible referral to occupational therapy services.

In addition to identifying limitations in functional and community participation, impairments in areas such as aerobic capacity, strength, balance, and gait should also be evaluated to track changes over time. Mobility, lower extremity strength, balance, and walking endurance are highly trainable in IWCI.104 Improvements in these body functions can lead to an improvement in ADLs.104 A review of the literature found over 20 functional outcome measure tools used to cover the domains of aerobic capacity, strength, balance, and mobility when testing IWCI; more information can be found about these elsewhere.94 , 95 , 97 , 104–117 However, none of these tests were used frequently enough in randomized control trials among the IWCI populations.105

The Timed Up and Go Test (TUG),94 , 97 , 107 , 109 Groningen Meander Walking Test (GMWT), Berg Balance Scale (BBS),108 , 109 Tinetti-Performance Oriented Measure (Tinetti-POMA),105 , 109 sharpened Romberg with eyes open,107 6-m walk,97 , 107 , 108 5-time sit-to-stand test,94 30-second chair rise test,108 and 6-minute walk test (6MWT)97 , 105 were proven to have excellent reliability when testing in IWCI. Table 3 presents the reliability and minimal detectable changes (MDCs) of functional outcome measures recommended for assessing mobility, balance, gait speed, aerobic capacity, and leg strength for IWCI.



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Measuring lower extremity function, mobility and fall risk, the TUG110 is a quick and widely used clinical performance measure. The TUG has been studied in older adult populations109–111 , 118–122 and in various pathological conditions.109 The TUG can be viewed as a sequence of complex multiple tasks, despite its apparent simplicity.123 Combining several serial movements relying on strength, balance, mobility, and coordination, the TUG requires appropriate sit-to-stand transfer, stability upon standing, initiating of stepping and forward acceleration during gait, preparation for turning at end line, and then performing these tasks in reverse for preparation to sit.123 Ries et al found the TUG to be a reliable outcome measure that showed excellent test-retest values for IWCI, with mild to moderate AD and moderately severe to severe AD.97 , 105 , 106 Results from Ries et al97 also indicated an MDC with 90% confidence interval of 4.09 seconds to be used when testing IWCI. Gras et al107 in 2015 also identified MDC for this population as 2.77 seconds with confidence interval of 98%. Mirelman et al124 found that, although times to complete the TUG between individuals with MCI or without MCI were not significantly different, findings indicated higher step irregularity when walking, less axial rotation during turns, and less forward trunk movement during transitions. Due to the transition and turning subtasks and the processing of different visual and afferent inputs during the test performance, perhaps TUG components may be particularly sensitive to serve as predictors of future cognitive decline, more so than just the overall time to complete the test.124 These findings may suggest the importance of consideration of feasibility and use of an instrumented walking mat for assessing gait parameters in more physical therapy clinics.107 Additional studies on this population indicate slower TUG time is linked to poor cognitive function performance.97 , 125 Despite consisting of everyday common motor tasks and basic movements, tasks of the TUG require planning, orientation in space, and organization.109 Within later stages of dementia, to facilitate participation of the test, modifications such as using a cone at the end line to distinguish a more visible target, modeling actual task performance, and/or 1- to 2-step commands may be beneficial. The everyday mobility components of the TUG and its relationship to cognitive function109 , 126 , 127 may perhaps explain why the inability to perform the test has been associated with institutionalization, impaired functioning and mobility, and even death.109 , 123 , 128 Nevertheless, to date, there are no functional outcome tools that measure fall risk in IWCI.

The TUG Cognitive (TUGC) and TUG Manual (TUGM) tests serve as additional opportunities to assess the IWCI's dual-task performance. When the PT is requesting completion of the TUG, individuals are given the verbal instructions to stand up from the chair, walk 3 m as quickly and safely as possible, cross the line marked on the floor, turn around, walk back, and sit down.94 In the TUGC, individuals are asked to begin counting backward by 3s from any number between 20 and 100. Then, while counting when sitting, the PT instructs the individual to begin walking to complete the original TUG test task, and to maintain counting. Alternatively, Maranhao-Filho et al129 report that reciting aloud alternating letters of the alphabet (“A-C-E”) may serve as the cognitive dual-task TUG challenge. PTs will assess and document performance of TUGC while monitoring success with counting/reciting (eg, Did the patient stop counting? Were there counting/reciting errors?), successful completion of exact test instructions (ie, Was line crossed fully prior to returning or did IWCI continue walking and require cue to turn around?), sit-to-stand transfer skill, and gait mechanics and balance while ambulating during the test. Suttanon and colleagues94 did identify an MDC95 for TUGC of 4.69 seconds within a small population of individuals with mild to moderate dementia; yet, these authors found the TUGC to be least feasible.94 Twenty-eight percent of the study's participants were not able to complete the test because of its level of difficulty, counting backward by 3s starting from a random number.94 This may suggest the need to select a more appropriate cognitive task, such as reciting the months of the year backward or a cognitive calculation task that may correlate with the individual's GDS level on the BCRS within “Axis 1: Concentration.”77

Although a manual dual task utilizes a different skill and level of difficulty, performing the TUGM in addition to the TUGC would present another way to assess an IWCI's ability to perform a dual task requiring dynamic balance. When the PT is requesting completion of the TUGM, individuals begin sitting and upon start, pick up a full glass of water129 , 130 in 1 hand from a table beside them, walk to the line, turn around, walk back, place the water back down on the table, and sit down. Conflicting research indicates that the water in the glass is filled 1, 2, or 5 mm from the top of the cup.129–131 PTs will assess and document performance of the TUGM regarding any spilling of the water from the glass or required cues during performance. Shumway-Cook et al122 in 2000 identified cutoff scores for the community-dwelling older adult population for the TUGC as greater than or equal to 15 seconds with overall prediction rate of 86.7%, and for the TUGM as greater than or equal to 14.5 seconds with 90% overall prediction rate. These authors concluded that the difference in scores between dual-task TUG (TUGC or TUGM) did not increase the ability to detect community-dwelling older adults who are prone to falls.122 With conflicting results, Lundin-Olsson and colleagues130 did find that comparing the TUG with the TUGM or TUGC was a useful way of predicting future falls in institutionalized older adults. In addition, if the TUGM score was greater than the TUG by 4.5 seconds, this indicated an increased risk for falls.130 Suttanon and colleagues94 found an MDC95 of 2.83 seconds with the TUGM when studying a small group of individuals with mild to moderate dementia. To date, dual-task gait assessment as it compares to fall risk in IWCI has not been thoroughly studied, warranting further research.23 , 132 , 133

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The presence of dementia is an independent risk factor for falls in older adults.13 , 134 , 135 The occurrence of a fall in IWCI rarely results from a single risk factor, but rather multifactorial cause. Older adults with cognitive impairment experience more than 60% falling annually.2 , 3 Makizako and colleagues136 compared the balance and gait speed performance of individuals with MCI and baseline gray matter densities and found that individuals with lower baseline gray matter densities in both the superior and middle frontal gyrus were assisted with falls. Numerous research articles found that polypharmacy,137 functional status,137 , 138 daytime sleepiness,139 white matter lesions,138 presence of depression,140 orthostatic hypotension,140 autonomic symptoms,140 and low physical activity activity140 are all associated with falls in IWCI as major risk factors.13 Most falls occur when performing ADLs or walking, and functional limitations during daily activities increase the fall risk of IWCI.18 Poor balance, slowing processing speed, postural instability, decreased reaction time, and inability to complete sit-to-stand chair transfer have also been associated with falls in IWCI.2 , 23 When walking, slowed cognitive processing speed fails to compensate for sensorimotor system impairments and compromise motor planning and the necessary responses required to improve ability to maintain balance in challenging environments.23 Older adults with better executive functioning skills may be better able to appropriately allocate attention and cognitive sources to maintain both voluntary movement and reactive responses.2 However, IWCI with poor executive function are not as able to counter decrements in balance performance due to impaired cognitive compensatory strategies.2 As the incidence of falls in IWCI is more than twice141 to 3 times142 that of individuals who are cognitively intact, it is clear that cognition and attentiveness are factors contributing to falls.6 , 143 More commonly, IWCI experience fall-related injury, institutionalization, morbidity, and mortality compared with peers with normal cognition.143–146

Assessing balance in IWCI will help determine both potential risk for falling and balance challenges experienced during ADLs. The Mini-Balance Evaluation Systems Test (Mini-BESTest) developed by Franchignoni and colleagues147 in 2010 was designed to include 4 of the 6 balance domains originally included in the comprehensive balance assessment tool, called the BESTest.148 The Mini-BESTest has excellent psychometric characteristics.147 Through a 14-item series of static and dynamic balance tasks on either firm, incline, or foam surface, the Mini-BESTest measures anticipatory postural adjustments, reactive postural control, sensory orientation, and dynamic gait. The Mini-BESTest test items include multidirectional reactive balance compensatory stepping, single-leg stance, standing heel raise, narrowed base of support, gait with speed changes, and gait with horizontal head turns, as well as stepping over an obstacle.147 , 149

The Mini-BESTest may only be appropriate for individuals with MCI and early-middle stages of AD, due to the level of complexity of the test tasks, although not yet proven to be valid and reliable when testing IWCI. Typically, when testing community-dwelling older adults without cognitive impairment, the Mini-BESTest takes about 10 to 15 minutes to administer.147 , 149 However, additional time may be required as IWCI may require various types and levels of cues and time for processing instructions, and time to minimize distractions. The Mini-BESTest has been found to be reliable and able to predict falls; however, research on validity of the Mini-BESTest for assessing fall risk in IWCI has not been completed. In addition, the Mini-BESTest has excellent concurrent validity with the BBS according to Godi and colleagues150 in 2013 when testing individuals with balance disorders, and according to King et al151 in 2012 when testing individuals with Parkinson disease. Researchers have suggested that, when used alone, the Mini-BESTest may not be sufficient to develop a comprehensive balance intervention. This may be even more evident when evaluating the balance of IWCI.149 , 152

To further assess dynamic balance, the GMWT was created by Bossers et al115 and was found to be a feasible and reliable test for IWCI. On a 20-ft curvilinear track, starting 1 m prior to the course, the PT asks the individual to walk over the path as fast and accurately as possible without stepping of the line, recording the time and oversteps. The Figure from Bossers and colleagues115 depicts the dimension of the GMWT walking path. An assistive device can be used when ambulating over the path, yet this may negatively affect the assessment of change over time. The MDC for IWCI using a 4-wheeled walker was 10.35 seconds, while IWCI not using an assistive device the MDC is 2.96 seconds. The MDC for the oversteps off the curvilinear line is 4.38 steps.



Clinicians may encounter situations when appropriately being able to perform tests, like the Mini-BESTest and GMWT, with IWCI due to the test's level of complexity of tasks, multiple step commands, and the IWCI's ability to perform the tasks.153 The BBS 108 , 150 or the Tinetti-POMA105 , 122 , 154 may be more appropriate for individuals with moderate to severe levels of cognitive impairment, as the items can be completed predominantly with 1-step instructions. On the other hand, a skilled and creative clinician may be able to assist the IWCI with participation in higher complexity level test items, with the use of creative equipment setup, single-step instruction commands, utilization of additional other types of cuing such as modeling/mirroring, feed-forward instruction, and hand-over-hand physical guidance, all within in a quiet environment free of distractions. Creative solutions to facilitate participation in balance measure tasks of the Mini-BESTest may include the following: (1) When assessing test item, “Eyes Closed, Foam Surface” or “Incline-Eyes Closed,” there may be times where individuals may not recall the need to keep their eyes closed for 30 seconds, a pair of sunglasses with tape over lenses may assist in simulating the eyes closed for testing. (2) Using 2 equal-sized boxes side by side during the item, “Stepping Over Obstacles” task to encourage the understanding of stepping over the obstacle rather than walking around the box. (3) When individuals may have difficulty understanding standing narrowed base of support, lead the individual to walk and position their feet between 2 boxes positioned like a “V” and direct them toward the point until their feet are positioned together. The clinician must be certain to document such cues and modifications accordingly.154

The BBS108 , 110 , 111 and the Tinetti-POMA122 , 154 evaluate an individual's static balance in various positions with eyes open or eyes closed, and selected similarities in functional performance tasks such as sitting balance, sit to stand, and turning in a full circle, despite the known differences with the gait section of the Tinetti-POMA. A disadvantage of completing the BBS and Tinetti-POMA in place of the Mini-BESTest and GMWT is that these tests are predominantly static balance measures versus dynamic balance outcome tools. The Mini-BESTest items assess compensatory stepping strategy postural responses, sensory orientation on compliant or inclined surfaces, and balance during gait, each important aspects of dynamic balance control, not included in BBS or Tinett-POMA.147 , 150 Telenius and colleagues utilized the BBS to investigate a group of older adults with dementia living in nursing homes and found that the BBS had high interrater and intrarater reliability as well as an MDC of 2.7 points.108 van Iersel et al109 did find moderate to high retest reliability among the BBS and Tinetti-POMA in a population of individuals with dementia. However, when assessing individuals in the later stages of AD, test modifications may be required; therefore, results may not be applicable to tests using standard procedures.98 Bossers and colleagues105 in 2012 found the Tinetti-POMA to be a measure that is sensitive to change when testing IWCI. However, there are very few studies available that investigated the psychometric properties or the feasibility of the Tinetti-POMA.105 , 109 , 154 Sterke et al154 found that 41% of the individuals with moderate-severe dementia had difficulty following one or more instructions due to their cognitive impairment. On the other hand, van Iersel and colleagues109 revealed that this test is “suitable” for assessing balance and mobility in individuals with mild to moderate dementia. As performance of the test is dependent on how well the individual can understand the instructions and many of the test items require the ability to perform executive functions, given the low feasibility of the Tinetti-POMA when testing individuals with moderate-severe dementia, Sterke and colleagues report that “alternatives should be considered...”.154

The Physiological Profile Assessment (PPA) includes a variety of tasks to assess physiologic risk for falls in older adults. Several studies have confirmed that impaired vision,155 slowed reaction time,156 increased postural sway,157 peripheral sensory loss, and muscle weakness are strongly associated with impaired balance and increased fall risk.158 , 159 Lord and colleagues160 studied the PPA among older adults and showed a 75% accuracy for predicting falls over a 12-month period. The PPA includes testing of high- and low-contrast visual acuity, contrast sensitivity, visual field dependence, tactile sensitivity, vibration sense, proprioception, muscle force, reactive time, and postural sway using the coordinated stability test. The coordinated stability test uses the Lord Swaymeter, a simple device comprising of a 40-cm rod that is attached to the individual's waist by a firm belt. The individuals are then asked to adjust balance by moving their center of mass by bending or rotating the body without moving the feet. The individuals follow a convoluted track while a pen mounted vertically at the end of the rod traces their movements on a piece of paper attached to an adjustable height table. More details on test specifics may be found in the literature.161 Within a cohort of individuals with mild to moderate AD, Lorbach and colleagues161 identified a correlation between MMSE scores and PPA results.161 The coordinated stability test indicates that the higher degree of cognitive impairment on the MMSE, the greater number of errors when performing this test. Furthermore, the coordinated stability test had excellent test-retest reliability, high feasibility, and discriminated between AD and control groups.161 Whitney and colleagues114 found that the PPA falls risk score was significantly higher in a cohort of community-dwelling IWCI compared with older adults who were cognitively intact. Lorbach et al161 concluded that the coordinated stability test may be the most beneficial balance test, identifying people with mild to moderate AD who are at risk for falling. However, a limitation to these findings would include that the sample size was relatively small and may not be generalizable to the broader population of people with AD.161 In addition, obtaining and utilizing the Lord Swaymeter for completion of the coordinated stability test may not be feasible for many physical therapy clinics, thus limiting participation of the PPA in its entirety.

Functional outcome measure testing completed on individuals with moderate to severe cognitive impairment has been understudied and may be very challenging26 Every attempt needs to be made to promote participation of the IWCI in outcome measure testing. The following functional outcome measures may serve as a way to evaluate IWCI in the moderate to severe stages of the disease. The Modified Berg Balance Scale (Modified BBS) is an abbreviated version of the original 14-item scale. The modified 11-item version excludes 3 items found in the original BBS: chair-to-chair transfer, forward reach with outstretched arm, and alternate stepping on-off stool. The score on this test is adjusted to 0 out of 44 instead of 56 on the original BBS, with higher scores still indicating better balance.117 , 162 , 163 The 3 items were excluded to allow for “brevity, consistency, safety, and ability to convey instructions when testing participants with cognitive impairment.”117 , 162 , 163 Kenny and colleagues162 studied the performance of the Modified BBS on older adults with dementia residents of a dementia-specific assisted living facility reporting findings of a hazard ratio of 0.91 with 95% confidence interval. The Modified BBS was predictive of transfers from assisted living to skilled nursing care. Thus, the Modified BBS may best serve as an alternative test to measure IWCI in the moderate to severe stages of the disease, as these findings suggest potential utility of this outcome measure.

The 4-Stage Balance Test is a functional outcome measure that can be used to assess an IWCI balance and mobility.164 Serving as a fall risk screen as described in the Centers for Disease Control and Prevention's Stopping Elderly Accidents and Deaths and Injuries (STEADI) Tool Kit,165 the 4-Stage Balance Test comprises narrowed stance, near-tandem stance, tandem stance, and single-leg stance. A community-dwelling older adult is at increased risk for falls if the individual cannot hold tandem stance for 10 seconds.164 Ries et al97 identified an MDC score of 15.52 seconds for individuals of mild AD performing sharpened Romberg (tandem) with eyes open. Vellas and colleagues166 found that the inability to perform single-leg stance leg unassisted for 5 seconds predicts injurious falls. In addition, Lord and colleagues167 found that static standing balance positioning in near tandem with eyes closed is significantly associated with falls for community-dwelling older adults. When assessing IWCI in later stages of AD while performing these static balance tests, utilization of visual cues on the ground with colored place markers/spots therapy equipment may assist with placement of feet.

The Functional Reach Test is a functional measure of limits of stability and a marker of physical frailty.168 Weiner and colleagues168 established a cutoff score for community-dwelling older adults at 7 inches, while Thomas and Lane169 found 7 inches indicated fall risk for frail older adults. Suttanon and colleagues94 established excellent test-retest reliability for older adults with mild to moderate AD. The Modified Functional Reach Test is adapted for individuals who are unable to stand.170 Although not studied in IWCI, the Modified Functional Reach Test has excellent test-retest reliability among a population of individuals after acute stroke.170 Success with these tests may be facilitated by visual demonstration through modeling and 1-step instructions, which are further discussed elsewhere.162

Having 2 clinicians present during the assessment, such as the treating PT and assistance from another PT or PT assistant or physical therapy aide/technician (if appropriate), may be beneficial when testing individuals with severe physical and/or cognitive impairments.149 This additional clinician or assistant may be able to help with positioning or retrieving alternate equipment while the lead PT is working to maintain attention and participation in testing.

Transferring is considered a standard part of any aging adult's physical functional assessment, as it is considered a basic activity of daily living.171 Among older adult nursing home residents older than 65 years, 60% of these individuals have difficulty with bed mobility.172 In the setting of assessing an individual with moderate to severe cognitive impairment, the supine-to-sit transfer is a functional assessment that allows the individual to utilize implicit memory to facilitate understanding of test instructions.171 The supine-to-sit transfer may be an alternative criterion-referenced assessment. During an individual's performance with the supine-to-sit transfer, the PT will assess trunk functional strength; trunk, hip, and leg range of motion; functional transfer stability; and if required physical assistance is needed.171 Within a population of 116 nursing home residents requiring assistance with at least 1 mobility-related ADL, the mean score in completing the supine-to-sit test was 6.8 seconds, with the head of bed at 0°.171 Alexander and colleagues171 also include a score for head of bed positioning at 30° or 45° for a supine-to-stand transfer, with a mean score of 15.2 to 18.8 seconds.

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AD is associated with a variety of noncognitive features including impaired motor function, such as gait impairment. Gait disturbances at the onset or very early in the course of the neurocognitive disease process make the diagnosis of AD uncertain.173 However, recent data suggest that these noncognitive features may be early signs of AD, and often predict the onset of clinical AD.174–178 The origin of gait impairment in early dementia may be regarded as a central misprocessing of information that includes attention and executive functions.179

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Gait speed

Gait speed testing can be performed in a variety of settings. It is widely used alone or in combination with other measures and is considered the “sixth vital sign.”180 Research continues to uphold this classification.180–185 Gait speed is indicative of an individual's functional capacity186 and general health status,185 , 186 cognitive decline,187 , 188 and falls.180 , 189 , 190 When assessing gait speed in IWCI, it may be necessary to have landmarks at both end points, such as cones or a chair, to give the individual a visual cue for assisting in completing the test. In addition, in the later stages of dementia, more handheld guidance leading the individual down the walking path may be necessary. It may also be helpful to request that the care partner stand at the opposite end of testing area to increase success of participation. Middleton and colleagues180 recommend consideration of administering the gait speed tests on 10-m distances or less, as they are more clinically feasible. A study by Ng et al191 in 2013 found that there is no significant difference between gait speed calculated at 5-, 8-, or 10-m walkways when assessing older adults. The 6-m walk was found to be a reliable and valid test for individuals with dementia.105 Gait speed measured at self-selected speed and maximal walking speed should be part of a comprehensive evaluation, as it is an important aspect of functional mobility and safety.192 With a gait speed of less than 1.0 m/s in the presence of diagnosed MCI, the individual is twice as likely to develop dementia.124 , 193 This presentation of slowed gait speed and cognitive complaints is defined as “motoric cognitive risk syndrome” and is useful in identifying older adults at risk of dementia.13 , 141 More specifically, Dumurgier et al193 found that 1 standard deviation (0.204 m/s) lower gait speed was associated with a 59% increased hazard of dementia. Fast gait speed was found to be a more sensitive measure in differentiating cognitive levels.194 Furthermore, poor fast gait speed is more predictive of significant cognitive decline over a 3-year follow-up.193–196 Ries and colleagues97 reported an MDC90 for gait speed of 0.30 ft/s in individuals with AD, while Gras et al107 found an MDC of 0.41 ft/s in the same population. Proactive and reactive postural control,197 lower extremity strength,198 , 199 aerobic capacity,200 proprioception,201 and vision202—all contribute to gait speed. Therefore, due to the complexity of contributions to declines in gait speed, further testings of other body structures and functions as well as gait mechanics are warranted.

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Gait mechanics analysis

In a 2013 study, Nutt203 explained how gait is a complex task requiring higher control of cognitive processing that involves attention, planning, memory, and other motor, perceptual, and cognitive process. The prevalence of gait disorders such as frontal and ataxic gait in AD is between 9% and 52%.204 In vascular dementia, gait disorders appear with a prevalence of over 71%, in which hemiparetic gait, frontal gait, and unsteady gait are commonly characterized.204 A parkinsonian-type gait is observed in LBD and Parkinson disease dementia.204 , 205 However, a study conducted by Allan and colleagues206 indicated that gait and balance disorders were more common with Parkinson disease dementia (93%), vascular dementia (79%), LBD (75%), than with Parkinson disease (43%), and AD (25%). In 2015, Bridenbaugh and Kressig207 found that gait changes occur 12 years prior to MCI diagnosis. Similarly, Beauchet et al208 reported that gait impairments occur between 3 and 9 years prior, while Dumurgier et al193 reported gait is slower 7 years prior to clinical onset of dementia. These findings provide evidence for the close relationship between gait and cognitive dysfunction.208 In individuals with dementia, an increase in stride-to-stride variability while usual walking and dual-tasking has been shown to be more specific and sensitive than any change in the mean value.179

Changes in gait parameters early in the prodromal stage of MCI and early dementia, including increased stance time, decreased gait velocity, and decreased step length, were found in individuals with MCI when using the instrumented walkway.124 Gait disorders during MCI are predictive of non-AD diagnoses over AD,180 , 207 , 208 particularly supportive of vascular dementia, LBD, and Parkinson disease dementia. Abnormalities in the white matter and basal ganglia are likely the reason for this strong association.199 Rosano et al209 and de Laat210 have reported on the associations between certain gait parameters and different brain areas, such as step width and the pallidum, and step length with the sensorimotor and dorsolateral prefrontal cortex.209 , 210

A systematic review by Tian and colleagues211 indicated that step-to-step gait variability (temporal gait variability), and spacing of steps (spatial gait variability), is a major predictor of fall risk and an indicator of impaired executive function and movement control.202 , 203 Both temporal and spatial gait variabilities were associated with structural and functional differences in the hippocampus and primary sensorimotor cortex.211 MacAuley et al212 identified that the APOE-e4 gene, the strongest known genetic risk factor for AD, was linked to shorter stride length (spatial gait changes) and greater dual-task-related disturbances in stride length.213 This gait parameter has been linked to heightened fall risk, reductions in attention, and structural brain changes in older adults.212 There have been numerous associations between spatial and temporal gait characteristics, with indicators of structural brain changes and the magnitude of associations with memory and executive function and attention have been found.212

Identified as a sensitive marker for gait stability, stride time variability also reflects one of the highly integrated central nervous system pathways of gait.214 As healthy adults typically have a stride time variability of less than 3%,208 associated with efficient and safe gait patterns, frail older adults have been found to have higher stride time variability.215 Valkanova and Embeier216 reported that executive function performance has been correlated with gait mechanics and variability. Studies have indicated that decreased gait velocity,217 slower pace,218 reduced cadence,219 and a worse degree of stride time variability220 have been associated with worse executive function.216

Evidence suggests that gait speed and gait analysis captured via instrumented walkways are less variable than those calculated with a stopwatch on an overground marked pathway, despite overground gait speed measurement remaining a valid and reliable tool.180 , 221 However, the expense of instrumented walkways limits their clinical feasibility. Yet, the numerous findings on spatial and temporal gait parameters may give more reason to justify the need for more data collection utilizing instrumented walking pathways.

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Dual task

Among older adults with early signs of gait dysfunction, the gait changes that occur during performance of dual-task testing may represent an appropriate method to identify subtle gait disorders and impaired attentional mechanism related to gait control.13 Gait changes while dual tasking (dual-task cost) have been shown in IWCI, specifically MCI, AD, vascular dementia, and FTD.222 Rucco and colleagues222 reported that, when studying the performance of a group of individuals with behavior variant of FTD, the performance of the motor dual task, carrying 2 full glasses of water on tray, caused a decline in velocity, stability parameters, and worsening of stance time. However, in individuals with AD, speed and stride length were significantly different.222 When completing the cognitive dual task, counting backward from 100 by 7s, there were significantly slower gait speed changes and spatiotemporal and kinematic parameters, in both groups—AD and FTD—but the FTD group had even slower velocity and worsened stability changes and the AD group had a significant deterioration in cycle time and cadence, stride width, and stance time.222

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Muscle weakness and self-reported musculoskeletal problems limiting physical function have been associated with falls and fall-related fractures in older people with AD.134 , 223 The 5-time sit-to-stand test assesses leg power and fall risk, and in healthy older adults, it is associated with age-related normative values and an MDC of 4.2 seconds.224 This outcome measure serves as a good functional tool that may be successfully completed even in the later stages of the disease. The 5-time sit-to-stand test has yet been identified as a valid or reliable measure for testing the leg power or fall risk for IWCI. However, it may be the best lower extremity measure to perform for those IWCI who are not able to understand instructions of manual muscle testing.

In a study by Boyle et al,174 muscle strength was found to be associated with the rate of cognitive decline in a cohort of 900 community-dwelling older adults without dementia. Of these 900 older adults, 138 persons later developed AD.174 The authors reported that greater muscle strength was also associated with a decreased risk of MCI and progression to dementia.174 These findings suggest that there is a link between AD and cognitive decline in older adults, and muscle strength.174 Demnitz and colleagues225 found that the 5-time sit-to-stand test, or also known as the “chair stands test,” was significantly correlated with cognitive processing speed. Thus, when necessary, successful completion of the 5-time sit-to-stand test may be facilitated between the PT and the IWCI by using the following: visual cues, such as modeling or mirroring the motion of sit-to-stand transfer; verbal cues with utilization of 1-step instructions, such as “Up” and “Down”; and tactile cues with light handhold assist only for guiding to facilitate awareness of the transfer task.226

The 30-second chair rise test227 has also been utilized when assessing lower extremity strength within community-dwelling individuals with early-onset dementia.163 The clinician may need to consider that measurements of time (5-time sit-to-stand Test) are more precise than counting repetitions (30-second chair rise test). However, IWCI with strength and functional transfer impairments may not be able to complete the required number of repetitions. Therefore, counting the number of repetitions performed in a designated time may be preferable for populations such as individuals with moderate-severe dementia, or those individuals whom may be more functionally impaired.228 Telenius and colleagues108 reported, when testing older adults with dementia living in a nursing home, the 30-second chair rise test had excellent relative interrater reliability. Santana-Sosa and colleagues229 concluded that, when testing the effects of an exercise program for individuals with dementia, the 30-second chair rise test is a successful measure.

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The 6MWT is a measure of endurance,230 yet the test has also been considered a broader measure of function and mobility, especially that of community mobility.231 , 232 This test is performed at moderate to vigorous intensity and may be useful in the classification of aerobic fitness, which is associated with health outcomes.233 In response to moderate aerobic exercise, brain regions vulnerable to age-related and disease-related atrophy have also demonstrated changes in structure and function. This suggests that physical exercise that contributes to the reduction of cardiovascular risk factors is associated with biomarkers of brain health and mediate improvements in cognitive performance.234–236

The 6MWT has not been widely used in studying individuals with dementia. However, Tappen and colleagues96 performed the TUG and 6MWT on individuals with AD and reported that these individuals were able to perform the 6MWT but unable to perform the TUG. The authors suggested that the 6MWT may be the preferred physical performance tool for individuals with AD. When studying individuals with MCI, Makizako and colleagues136 found that poor performance on the 6MWT correlated with decreased hippocampal and cerebral gray matter volume. In a study by Bossers et al,105 the 6MWT was found to be reliable, valid, and sensitive to change in IWCI. Ries et al97 identified an MDC for the 6MWT of 109.8 ft for this population.

Modifications to the test procedure may be necessary to facilitate successful participation. Providing verbal cuing when appropriate, using 2 cones as landmarks to walk around, or positioning other targets at each end point may be helpful. More specifically, placing a table at each end point, and giving instruction to move one cup (or other small easy-to-grasp item) from one table at one end of the testing area and move the cup to another table at the other end, may assist in maintaining attention to task completion.

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Practical considerations on interacting and communicating with IWCI have been reported in the literature. Every effort must be made by the clinician to maximize the success of interactions such as creating a safe and low-stress environment, with introductions using a firm but pleasant voice and friendly facial expressions.97 The purpose of the PT visit and meaningful goals for the visit should also be stated. When administering functional outcome measures to IWCI, a skilled clinician would consider a number of variables that may impact performance. First, the PT should assess the individual's sensory abilities, in regard to hearing and vision. It would be important for the clinician to determine whether there are sensory deficits and be certain to accommodate for hearing or visual impairment during testing. Ensuring the individual's glasses are clean and utilizing a room with adequate ambient lighting while attempting to reduce glare will facilitate optimal alertness for the individual are important factors that promote success within the evaluation and treatment process. Sitting on the side the person hears better from and confirming that the hearing aids are on and working will facilitate performance at the individual's highest potential. During testing be certain to maintain eye contact and use friendly nonverbal communication with clear speech.97 This can affect a person's ability to comprehend and respond and may promote improvements in feeling safe within the testing environment. When delivering instructions, the clinician must give the individual time to process the information and to respond. Repeating the instructions using a steady voice along with the possible use of cuing may be required.237 Beck et al238 developed a 7-level scale of assistance for older adults with cognitive impairments. This scale is used to classify the type of cuing or assistance required for the individual. Several studies have shown that, when administering the TUG to participants with cognitive impairment, each utilized verbal and tactile cuing to optimize performance.49 , 97 , 109 However, the cuing was carefully implemented and consistently facilitated using a script. Ries et al97 indicated that participants with moderately severe to severe AD required more substantive prompting and handheld guiding assistance during outcome measure performance than those with mild to moderate AD.

It would be essential to minimize distractions by performing the test in a quiet room; however, the evaluation may have to be conducted in the individual's home and may not be private. This may not be the optimal assessment environment, but the clinician may obtain a good representation of how the individual functions within the room. Due to possible distractions in environments, such as the private home residence or distractions from a roommate within a shared room in an assisted living facility, the clinician should monitor for understanding and may need to have the individual repeat the instructions as necessary. Allowing for rest and recognizing signs of fatigue, confusion, or frustration will be important to observe throughout the testing. The clinician needs to ensure that tests are selected based on the goal purpose. Different types of cuing and delivery of instructions may be required. But the clinician must understand that the outcome measure scores may be less reliable, as cuing during the test may negatively affect the standardization of the test. At this point, it may be necessary to use the results as criterion-referenced data.

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Translating assessment into action when effectively evaluating IWCI takes a knowledgeable and skilled PT with insight, observation skills, creativity, and flexibility using an integrated approach.5 In addition, the ability to adapt the communication process to engage with the IWCI will facilitate improved outcomes and quality of life. Given progressive impairment and function decline over time for IWCI, performing cognitive and functional outcome measures plays a pivotal role in care management plans. Performance outcome assessment, including staging, completed at the initiation of skilled PT care helps determine baseline of functional status, assists with documentation of skilled and medically necessary care, and guides the plan of care. The neuroprotective benefits associated with functional exercise for aging adults are vast.239 Thus, standardized outcome measure testing remains an important component of the plan of care and ongoing assessments are fundamental for proper management of an individual's functional status and fall risk, and measuring the neuroprotective benefits of exercise. Every attempt needs to be made by the PT to perform outcome measure testing and promote participation of the IWCI, no matter the individual's disease severity. Currently, there is no one specific outcome measure that is useful for every IWCI in every physical therapy setting. Therapists must search for and carefully select the correct set of measures appropriate for the individual in your care. There is a strong need for consensus in the use of assessment tools for IWCI. It is imperative that physical therapy professionals continue to improve their skills and utilize interventions of best practice to work effectively with the rapidly growing population of IWCIs requiring rehabilitation services.

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              cognitive impairment; dementia; functional outcome measures; physical therapy evaluation

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