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.
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.
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.
COGNITIVE SCREENING AND DISEASE STAGING SYSTEMS
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.
FUNCTIONAL OUTCOME MEASURE TESTING
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.
ACTIVITIES OF DAILY LIVING AND INSTRUMENTAL ACTIVITIES OF DAILY LIVING
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.
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
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.
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
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.
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.
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
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.
AEROBIC CAPACITY/ACTIVITY TOLERANCE
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.
CONSIDERATIONS FOR PROMOTING SUCCESSFUL TEST ADMINISTRATION
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.
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.
1. Wimo A, Prince M. The global economic impact of dementia
. In: World Alzheimer Report 2010. London, England: Alzheimer's Disease International; 2010.
2. Taylor ME, Lord SR, Delbaere K, Kurrie SE, Mikolaizak AS, Close JCT. Reaction time and postural sway modify the effect of executive function on risk of falls in older people with mild to moderate cognitive impairment
. Am J Geriatr Psychiatry. 2017;25:4:397–406.
3. Lewis M, Peiris CL, Shields N. Long-term home and community-based exercise programs improve function in community-dwelling older people with cognitive impairment
: a systematic review. J Physiother. 2017;63,23–29.
4. American Medical Association. Dementia
Performance Measure Set. https://www.aan.com
.pdf. Published 2011. Accessed August 1, 2016.
5. Nash J, Ross C. Application and interpretation of functional outcome measures
for testing individuals with cognitive impairment
. Geri Notes. 2016;23(6).
6. California Work Group on Guidelines for Alzheimer's Disease Management. Guidelines for Alzheimer's Disease Management. Los Angeles, CA: Alzheimer's Disease and Related Disorders Association, Inc; 2008.
7. Bottomley J, Thompson M. Topics in Geriatrics 2004; Independent Home Study Course for Individual Continuing Education, Alzheimer Disease: Assessment, Evaluation, and Treatment Approaches. La Crosse, WI: American Physical Therapy Association, Section on Geriatrics.
8. Loehr J, Malone ML. Here's How to Treat Dementia
. San Diego, CA: Plural Publishing, Inc; 2014.
9. American Geriatric Society 2015 Beers Criteria Update Expert Panel. American Geriatric Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11).
10. Takkouche B, Montes-Martinez A, Gill SS, Etminan M. Psychotropic medications and the risk of fracture: a meta-analysis. Drug Saf. 2007;30(2):171–184.
11. Ensrud KE, Blackwell TL, Mangione CM, et al Central nervous system-active medications and risk for falls in older women. J Am Geriatr Soc. 2002;50(10):162937.
12. Woolcott JC, Richardson KJ, Wiens MO, et al Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169(21):1952–1960. doi:10.1001/archinternmed.2009.357.
13. Leipzig RM, Cumming RC, Tinetti ME. Drugs and falls in older people: a systemic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc. 1999;47(1):40–50.
14. Allali G, Verghese J. Management of gait changes and fall risk in MCI and dementia
. Curr Treat Options Neurol. 2017;19:29.
15. Sterke CS, Verhagen AP, van Beeck EF, van der Cammen TJ. The influence of drug use on fall incidents among nursing home residents: a systematic review. Int Psychogeriatr. 2008;20(5):890–910. doi:10.1017/S104161020800714X.
16. Hugo J, Ganguli M. Dementia
and cognitive impairment
: epidemiology, diagnosis, and treatment. Clin Geriatr Med. 2014;30(3):421–442.
17. Cooper S, Greene JDW. The clinical assessment of the patient with early dementia
. J Neurol Neuro Surg Psychiatry. 2005;76(suppl V):v15–v24.
18. Alsawy S, Mansell W, McEvoy P, Tai S. What is good communication for people living with dementia
? A mixed-methods systematic review. Int Psychogeriatr. 2017;29(11):1785–1800.
19. Alzheimer's Society. Communicating. London, England: Alzheimer's Society; 2016. https://www.alzheimers.org.uk
/download/downloads/id/1789/factsheet_communicating.pdf. Accessed February 13, 2017.
20. Bottomley JM. Alzheimer's disease: rehabilitation, considerations in the examinations, evaluation and interventions. Advanced Clinical Practice. Paper presented at: APTA Annual Conference and Exposition, June 5-6, 2012.
21. Smith SC, Lamping DL, Banerjee S, et al Measurement of HRQOL for people with dementia
: development of a new instrument (DEMQOL). Health Technol Assess. 2005;9:73–76.
22. McKeown J, Clarke A, Ingleton C, Ryan T, Repper J. The use of life story work with people with dementia
to enhance person-centered care. Int J Older People Nurs. 2010;5:148–158.
23. Taylor ME, Delbaere K, Close JCT, Lord SR. Managing falls in older patients with cognitive impairment
. Aging Health. 2012;8(6):573–588.
24. Weirather RR. Communication strategies to assist comprehension in dementia
. Hawaii Med J. 2010;69(3):72–74.
25. Savundranayagam MY, Sibalija J, Scotchmer E. Resident's reactions to person-centered communication by long term care staff. Am J Alzheimer's Dis Dementias. 2016;31,530–537.
26. Jootun D, McGhee G. Effective communication with people who have dementia
. Nurs Standard. 2011;25,25:40–46.
27. Haak NJ. Maintaining connections: understanding communication from the perspective of persons with dementia
. Alzheimer's Care Q. 2002;3(2):116–131.
28. Alzheimer's Association. Types of dementia
.asp. Accessed August 20, 2017.
29. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383:911–922.
30. Kalish VB, Gillham JE, Unwin BK. Delirium in older persons: evaluation and management. Am Fam Phys. 2014;90(3):150–158.
31. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941–948.
32. Inouye SK. Delirium in hospitalized older patients: recognition and risk factors. J Geriatr Psychiatry Neurol. 1998;11(3):118–125.
33. National Institute for Health and Clinical Excellence. Delirium: Diagnosis, Prevention, and Management. http://http://www.nice.org.uk
/cg103. Published July 2010. Accessed March 19, 2014.
34. Qiyun S, Warren L, Saposnik G, MacDermid J. Confusion Assessment Method: a systematic review and meta-analysis of diagnostic accuracy. Neuropsychiatr Dis Treat. 2013;9:1359–1370.
35. Wei LA, Fearing MA, Stemberg EJ, Inouye SK. The Confusion Assessment Method (CAM): a systematic review of current usage. J Am Geriatr Soc. 2008;56(5):823–830.
36. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
37. Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157–1165.
38. Nagaraj G, Burkett E, Hullick C, Carpenter CR, Arendts G. Is delirium the medical emergency we know least about? Emerg Med Australas. 2016;28(4):456–458.
39. Sheehan B. Assessment scales in dementia
. Ther Adv Neurol Disord. 2012;5(6):349–358.
40. Lokko HN, Stern TA. Sadness: diagnosis, evaluation, and treatment. Prim Care Companion CNS Disord. 2014;16(6):10.
41. Yesavage J, Brink T, Rose T, et al Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1983;17:37–49.
42. Alexopoulos G, Abrams R, Young RC, Shamoian CA. Cornell scale for depression in dementia
. Biol Psychiatry. 1988;23:271–284.
43. McKhann G, Drachman D, Folstein M, et al Clinical diagnosis of Alzheimer's disease: report of the NINCDS ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's disease. Neurology. 1984;34:939–944.
44. Pedrosa JG, Sala I, Obradors N. Effectiveness of cognition-focused interventions in activities of daily living performance in people with dementia
: a systematic review. Br J Occup Ther. 2017;80(7):397–408.
45. Boustani M, Peterson B, Hanson L, Lohr KN. Screening for dementia
in primary care: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2003;138(11):927–937.
46. Cullen B, O'Neill B, Evans JJ, et al A review of screening tests for cognitive impairment
. J Neurol Neurosurg Psychiatry. 2007;78(8):790–799.
47. Zec RF, Wilson RS, eds. Neuropsychology of Alzheimer's Disease and Other Dementias. Oxford, England: Oxford University Press; 1993:3–80.
48. Padovani A, Di Piero V, Bragoni M, et al Patterns of neuropsychological impairment in mild dementia
: a comparison between Alzheimer's disease and multi-infarct dementia
. Acta Neurol Scand. 1995;92:433–442.
49. Pachana NA, Boone KB, Miller BL, et al Comparison of neuropsychological functioning in Alzheimer's disease and frontotemporal dementia
. J Int Neuropsychol Soc. 1996;2:505–510.
50. Hansen L, Salmon D, Galasko D, et al The Lewy Body variant of Alzheimer's disease: a clinical and pathologic entity. Neurology. 1990;40:1–8.
51. Yu F, Evans LK, Sullivan-Marx EM. Functional outcomes for older adults with cognitive impairment
in a comprehensive outpatient rehabilitation facility. J Am Geriatr Soc. 2005;53:1599–1606.
52. Luxemberg JS, Feigenbaum LZ. Cognitive impairment
on a rehabilitation service. Arch Phys Med Rehabil. 1986;67:796–798.
53. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Program memorandum intermediaries/carriers: transmittal AB-01-135. http://www.hcfa.gov
/pubforms/transmit/ab01135.pdf. Accessed May 15, 2002.
54. Folstein MF, Folstein SF, McHugh PR. “Mini-Mental State.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198.
55. Nasreddine ZS, Phillips NA, Bédirian V, et al The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment
. J Am Geriatr Soc. 2005;53(4):695–699.
56. Trzepacz PT, Hochstetler H, Wang S, Walker B, Saykin AJ. Relationship between the Montreal Cognitive Assessment and Mini Mental State Exam for assessment of mild cognitive impairment
in older adults. VMC Geriatr. 2015;15:107–115.
57. Spencer RJ, Wendell CR, Giggey PP, et al Psychometric limitations of the Mini-Mental State Examination among non-demented older adults: an evaluation of neurocognitive and magnetic resonance imaging correlates. Exp Aging Res. 2013;39(4):382–397.
58. Lonie JA, Tierney KM, Ebmeier KP. Screening for mild cognitive impairment
: a systematic review. Int J Geriatr Psychiatry. 2009;24(9):902–915.
59. Beatty WW, Goodkin DE. Screening for cognitive impairment
in multiple sclerosis. An evaluation of the Mini-Mental State Examination. Arch Neurol. 1990;47(3):297–301.
60. Swirsky-Sacchetti T, Field HL, Mitchell DR, et al The sensitivity of the Mini-Mental State Exam in the white matter dementia
of multiple sclerosis. J Clin Psychol. 1992;48(6):779–786.
61. Moser DJ, Cohen RA, Clark MM, et al Neuropsychological functioning among cardiac rehabilitation patients. J Cardiopulm Rehabil. 1999;19(2):91–97.
62. Tombaugh TN, McInntyre NJ. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc. 1992;40(9):922–935.
63. Tsai JC, Chen CW, Chu H, et al Comparing the sensitivity, specificity, and predictive values of the Montreal Cognitive Assessment and Mini-Mental State Examination when screening people for mild cognitive impairment
in Chinese population. Arch Psychiatr Nurs. 2016;30(4):486–491.
64. Segal-Gidan F. Cognitive screening tools. Clin Rev. 2013;23(1):12–18.
65. Smith T, Gildeh N, Holmes C. The Montreal Cognitive Assessment: validity and utility in a memory clinic setting. Can J Psychiatry. 2007;52(5):329–332.
66. Bernstein IH, Lacritz L, Barlow CE, Weiner MF, DeFina LF. Psychometric evaluation of the Montreal Cognitive Assessment (MoCA) in three diverse samples. Clin Neuropsychol. 2011;25(1):119–126.
67. Poytner L, Kwan J, Sayer AA, Vassallo M. Does cognitive impairment
affect rehabilitation outcome? J Am Geriatr Soc. 2011;59:2108–2111.
68. Chen P, Yu ES, Zhang M, et al ADL dependence and medical conditions in Chinese older persons: a population-based survey in Shanghai, China. J Am Geriatr Soc. 1995;43:378–383.
69. Mulrow CD, Gerety MB, Cornell JE, et al The relationship between disease and function and perceived health in very frail elders. J Am Geriatr Soc. 1994;42:374–380.
70. Aguero-Torres H, Fratiglioni L, Guo Z, et al Dementia
is the major cause of functional dependence in the elderly: 3-year follow up data from a population based study. Am J Public Health. 1998;88:1452–1456.
71. Mini-Cog. Screening for cognitive impairment
in older adults. http://mini-cog.com. Accessed August 20, 2017.
72. Borson S. The Mini-Cog: a cognitive “vitals signs” measure for dementia
screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021.
73. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia
: validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451–1454.
74. Brodaty H, Low LF, Gibson L, Burns K. What is the best dementia
screening instrument for general practitioners to use? Am J Geriatr Psychiatry. 2006;14(5):391–400.
75. Eknoyan D, Hurley RA, Taber KH. The clock drawing task: common errors and functional neuroanatomy. J Neuropsychiatry Clin Neurosci. 2012;24(3):260–265.
76. Auer S, Reisberg B. The GDS/FAST staging system. Int Psychogeriatr. 1997;9(suppl 1):161–171.
77. Reisberg B, Jamil IA, Khan S, et al Staging dementia
. Principles Pract Geriatr Psychiatry. 2010;3:162–169.
78. Sclan SG, Reisberg B. Functional Assessment Staging (FAST) in Alzheimer's disease: reliability, validity, and ordinality. Int Psychogeriatr. 1992;4(suppl 1):55–69.
79. Rikkert MG, Tona KD, Janssen L, et al Validity, reliability, and feasibility of clinical staging scales in dementia
: a systematic review. Am J Alzheimers Dis Other Demen. 2011;26(5):357–365.
80. Foster JR, Sclan S, Welkowitz J, et al Psychiatric assessment in medical long-term care facilities: reliability of commonly used rating scales. Int J Geriatr Psychiatry. 1998;3:229–233.
81. Gottlieb GL, Gur RE, Gur RC. Reliability of psychiatric scales in patients with dementia
of the Alzheimer type. Am J Psychiatry. 1988;45:857–859.
82. Reisberg B, Ferris SH, Steinberg G, et al Longitudinal study of dementia
patients and aged controls: an approach to methodologic issues. In: Lawton MP, Herzog AR, eds. Special Research Methods for Gerontology. Amityville, NY: Baywood Publishers; 1989;195–231.
83. Dura JR, Haywood-Niler E, Kiecolt-Glaser JK. Spousal caregivers of persons with Alzheimer's and Parkinson's disease dementia
: a preliminary comparison. Gerontologist. 1990;30:332–336.
84. Hartmaier SL, Sloan PD, Guess HA, et al The MDS cognition scale: a valid instrument for identifying and staging nursing home residents with dementia
using the minimum data set. J Am Geriatr Soc. 1994;42:1173–1179.
85. Monteiro IM, Boksay I, Auer SR, et al The reliability of routine clinical instruments for the assessment of Alzheimer's disease administered by telephone. J Geriatr Psychiatry Neurol. 1998;11:18–24.
86. Reisberg B, Ferris SH, de Leon MJ, et al Stage-specific behavioral, cognitive, and in vivo changes in community residing subjects with age-associated memory impairment and primary degenerative dementia
of the Alzheimer type. Drug Dev Res. 1988;15:101–114.
87. Reisberg B, Franssen E, Bobinski M, et al Overview of methodologic issues for pharmacologic trials in mild, moderate, and severe Alzheimer's disease. Int Psychogeriatr. 1996;8:159–193.
88. Overall JE, Scott J, Rhoades HM, et al Empirical scaling of the stages of cognitive decline in senile dementia
. J Geriatr Psychiatry Neurol. 1990;3(4):212–220.
89. Reisberg B, Sclan S, Franssen E, et al The GDS staging system: Global Deterioration Scale (GDS), Brief Cognitive Rating Scale (BCRS), Functional Assessment Staging (FAST). In: Rush AJ, First MB Jr, Blacker D, eds. Handbook of Psychiatric Measures, 2nd ed. Washington, DC: American Psychiatric Publishing; 2008;431–435.
90. Franssen EH, Reisberg B. Neurologic markers of the progression of Alzheimer's disease. Int Psychogeriatr. 1997;9(suppl 1):297–306.
91. Reisberg B, Sclan S G, de Leon M J, et al The GDS staging system. In: Rush AJ, ed. Handbook of Psychiatric Measures. Washington, DC: American Psychiatric Publishers; 2007;431–435.
92. Reisberg B, Ferris SH. Brief Cognitive Rating Scale (BCRS). Psychopharmacol Bull. 1988;24:629–636.
93. American Physical Therapy Association. Outcome measures in patient care. http://http://www.apta.org
/OutcomeMeasures/. Accessed August 31, 2017.
94. Suttanon P, Hill KD, Dodd KJ, Said CM. Re-test reliability of balance and mobility measurements in people with mild to moderate Alzheimer's disease. Int Psychogeriatr Assoc. 2011;23(7):1152–1159.
95. Muir-Hunter SW, Graham L, Montero-Odasso M. Reliability of the Berg Balance Scale as a clinical measure of balance in community-dwelling older adults with mild to moderate Alzheimer's disease: a pilot study. Physio Therapy Canada. 2015;67(3):255–262.
96. Tappen RM, Roach KE, Buchner D, et al Reliability of physical performance measures in nursing home residents with Alzheimer's disease. J Gerontol A Biol Sci Med Sci. 1997;52(1):M52–M55.
97. Ries JD, Echternach JL, Nof L, et al Test-retest reliability and minimal detectable change scores for the “Timed Up & Go” test, the Six-Minute Walk test, and gait speed in people with Alzheimer's disease. Phys Ther. 2009;89(6):569–579.
98. Alzheimer's Association. What is Dementia
.asp. Accessed August 20, 2017.
99. Johnson N, Barion A, Rademaker A, Rehkemper G, Weintraub S. The validation of the activities of daily living questionnaire. Alzheimer Dis Assoc Disord. 2004;18:223–230.
100. Mahoney F, Barthel D. Functional evaluation: the Barthel Index. Maryland State Med J. 1965;14:61–65.
101. Katz S, Down TD, Cash HR, Grotz RC. Progress in the development of the index of ADL. Gerontologist. 1970;10(1):20–30.
102. Giebel C, Challis D, Montadli D. The newly Revised Interview for Deteriorations in Daily Living Activities in Dementia
(R-IDDD2): distinguishing initiative from performance at assessment. Int Psychogeriatr. 2017;29(3):497–507.
103. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–186.
104. Blankevoort CG, van Heuvelen MJ, Boersma F, et al Review of effects of physical activity on strength, balance, mobility and ADL performance in elderly subjects with dementia
. Dement Geriatr Cogn Disord. 2010;30:392–402.
105. Bossers WJR, Lucas HV, Froukje B, Erik JAS, Marieke JG. Recommended measures for the assessment of cognitive and physical performance in older patients with dementia
: a systematic review. Dement Cogn Dis Extra. 2012;2(1):589–609.
106. Qian H. Correlation of walking speed and Time Up to Go (TUG) with dementia
. Alzheimers Dement. 2014;10(4):891.
107. Gras LZ, Kanaan SF, McDowd JM, Colgrove YM, Burns J, Pohl PS. Balance and gait of adults with very mild Alzheimer's disease. J Geriatr Phys Ther. 2015;38(1):1–7.
108. Telenius EW, Engedal K, Bergland A. Inter-rater reliability of the Berg Balance Scale, 30 s chair stand test and 6 m walking test, and construct validity of the Berg Balance Scale in nursing home residents with mild-to-moderate dementia
. BMJ Open. 2015;5:e008321.
109. van Iersel MB, Benraad CE, Olde Rikkert MG. Validity and reliability of quantitative gait analysis in geriatric patients with and without dementia
. J Am Geriatr Soc. 2007;55:632–634.
110. Podsialdo D, Richardson S. The Timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142–148.
111. Herman T, Giladi N, Hausdorff JM. Properties of the “Timed Up and Go” test: more than meets the eye. Gerontology. 2011;57(3):203–210.
112. Farrell MK, Rutt RA, Lusardi MM, Williams AK. Are scores on the physical performance test useful in determination of risk of future falls in individuals with dementia
? J Geriatr Phys Ther. 2011;34(2):57–63.
113. Vidoni ED, Billinger SA, Lee C, Hamilton J, Burns JM. The physical performance test predicts aerobic capacity sufficient for independence in early-stage Alzheimer disease. J Geriatr Phys Ther. 2011;34:1–7.
114. Whitney JC, Lord SR, Close JC. Streamlining assessment and intervention in a falls clinic using the Timed Up and Go Test and Physiological Profile Assessments. Age Ageing. 2005;34:567–571.
115. Bossers WJR, van der Woude LHV, Boersma F, et al The Groningen Meander Walking Test: a dynamic walking test for older adults with dementia
. Phys Ther. 2014;94:262–272.
116. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34:119–126.
117. McGough EL, Logsdon RG, Kelly VE, Teri L. Functional mobility limitations and falls in assisted living residents with dementia
: physical performance assessment and quantitative gait analysis. J Geriatr Phys Ther. 2013;36(2):78–86. doi:10.1519/JPT.0b013e318268de7f.
118. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83(suppl 2):S7–S11.
119. Hill K, Schwarz J, Flicker L, Carroll S. Falls among healthy, community-dwelling, older women: a prospective study of frequency, circumstances, consequences and prediction accuracy. Aust NZ J Public Health. 1999;23:41–48.
120. Isles RC, Choy NL, Steer M, Nitz JC. Normal values of balance tests in women Aged 20-80. J Am Geriatr Soc. 2004;52:1367–1372.
121. Okumiya K, Matsubayashi K, Nakamura T, et al The Timed “Up & Go” Test is a useful predictor of falls in community-dwelling older people. J Am Geriatr Soc. 1998;46:928–930.
122. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80:896–903.
123. Janssen WG, Bussmann HB, Stam HJ. Determinants of the sit-to-stand movement: a review. Phys Ther. 2002;82:866–879.
124. Mirelman A, Weiss A, Buchman AS, Bennett DA, Giladi N, Hausdorff JM. Association between performance on Timed Up and Go subtasks and mild cognitive impairment
: further insights into the links between cognitive and motor function. J Am Geriatr Soc. 2014;62(4):673–678.
125. Donoghue OA, Horgan NF, Savva GM, Cronin H, O'Regan C, Kenny RA. Association between Timed Up-and-Go and memory, executive function, and processing speed. J Am Geriatr Soc. 2012;60(9):1681–1686.
126. Pettersson AF, Engardt M, Wahlund LO. Activity level and balance in subjects with mild Alzheimer's disease. Dement Geriatr Cogn Disord. 2002;13:213–216.
127. Pettersson AF, Olsson E, Wahlund LO. Motor function in subjects with mild cognitive impairment
and early Alzheimer's disease. Dement Geriatr Cogn Disord. 2005;19:299–304.
128. Guralnik JM, Ferrucci L, Simonsick EM, Salive ME, Wallace RB. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med. 1995;332:556–561.
129. Maranhao-Filho PA, Maranhao ET, Lima MA, Silva MM. Rethinking the neurological examination II: dynamic balance assessment. Arq Neuropsiquiatr. 2011;69(6):959–963.
130. Lundin-Olsson L, Nyberg L, Gustafson Y. Attention, frailty, and falls: the effect of a manual task on basic mobility. J Am Geriatr Soc. 1998;758–761.
131. Hofheinz M, Schusterschitz C. Dual task interference in estimating the risk for falls and measuring change: a comparative, psychometric study of four measurements. Clin Rehabil. 2010;24(9):831–842.
132. Yamada M, Aoyama T, Arai H, et al Dual task walk is a reliable predictor of falls in robust elderly adults. J Am Geriatr Soc. 2011;59(1):163–164.
133. Muir SW, Speechley M, Wells J, Borrie M, Gopaul K, Montero-Odasso M. Gait assessment in mild cognitive impairment
and Alzheimer's disease: the effect of dual-task challenges across the cognitive spectrum. Gait Posture. 2012;35(1):96–100.
134. Buchner DM, Larson EB. Falls and fractures in patients with Alzheimer-type dementia
. JAMA. 1987;257(11):1492–1495.
135. van Doom C, Cruber-Baldini AL, Zimmerman S, et al Dementia
as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc. 2003;51(9):1213–1218.
136. Makizako H, Shimada H, Doi T, et al Six-minute walking distance correlated with memory and brain volume in older adults with mild cognitive impairment
: a voxel-based morphometry study. Dement Geriatr Cogn Dis Extra. 2013;3(1):223–232.
137. Ogama N, Sakurai T, Shimizu A, Toba K. Regional white matter lesions predict falls in patients with amnestic mild cognitive impairment
and Alzheimer's disease. J Am Med Dir Assoc. 2014;15(1):36–41.
138. Eshkoor SA, Hamid TA, Nudin SS, Mun CY. A research on functional status, environmental conditions, and risk of falls in dementia
. Int J Alzheimers Dis. 2014;2014:769062. doi:10.1155/2014/769062.
139. Chen PY, Chiu HT, Chiu HY. Daytime sleepiness is independently associated with falls in older adults with dementia
. Geriatr Gerontol Int. 2016;16(7):850–855.
140. Allan LM, Ballard CG, Rowan EN, Kenny RA. Incidence and prediction of falls in dementia
: a prospective study in older people. PLoS One. 2009;4(5):e5521. doi:10.1371/journal.pone.0005521.
141. Allali G, Annweiler C, Blumen HM, et al Gait phenotype from mild cognitive impairment
to moderate dementia
: results from the GOOD Initiative. Eur J Neurol. 2016;23(3):527–541.
142. Eriksson S, Strandberg S, Gustafson Y, Lundin-Olsson L. Circumstances surrounding falls in patients with dementia
in a psychogeriatric war. Arch Gerontol Geriatr. 2009;49(1):80.
143. Kato-Narita EM, Nitrini R, Radanovic M. Assessment of balance in mild and moderate stages of Alzheimer's disease: implications on falls and functional capacity. Arq Neuropsiquiatr. 2011;69(2-A):202–207.
144. Scandol JP, Toson B, Close JC. Fall-related hip fracture hospitalisations and the prevalence of dementia
within older people in New South Wales, Australia: an analysis of linked data. Injury. 2013;44:776–783.
145. Gruber-Baldini AL, Zimmerman S, Morrison RS, et al Cognitive impairment
in hip fracture patients: timing of detection and longitudinal follow-up. J Am Geriatr Soc. 2003;51:1227–1236.
146. Magaziner J, Simonsick EM, Kashner TM, et al Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol. 1990;45:M101–M107.
147. Franchignoni F, Horak F, Godi M, et al Using psychometric techniques to improve the Balance Evaluation Systems Test: the Mini-BESTest. J Rehabil Med. 2010;42:323–331.
148. Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther. 2009;89:484–494.
149. Roaldsen KS, Wakefield E, Opheim A. Pragmatic evaluation of aspects concerning validity and feasibility of the Mini Balance Evaluation System Test in a specialized rehabilitation hospital. Int J Rehab Res. 2015;1:104.
150. Godi M, Franchignoni F, Caligari M, Giordano A, Turcato AM, Nardone A. Comparison of reliability, validity, and responsiveness of the Mini-BESTest and Berg Balance Scale in patients with balance disorders. Phys Ther. 2013;93(2):158–167.
151. King LA, Priest KC, Salarian A, Pierce D, Horak FB. Comparing the Mini-BESTest with the Berg Balance Scale to evaluate balance disorders in Parkinson's disease. Parkinsons Dis. 2012;2012:375419. doi:10.1155/2012/375419.
152. Chinsongkram B, Chaikeeree N, Saengsirisuwan V, Viriyatharakij N, Horak FB, Boonsinsukh R. Reliability and validity of the Balance Evaluation Systems Test (BESTest) in people with subacute stroke. Phys Ther. 2014;94(11):1632–1643. doi:10.2522/ptj.20130558.
153. Nordin E, Rosendahl E, Lundin-Olsson L. Timed “Up & Go” test: reliability in older people dependent in activities of daily living—focus on cognitive state. Phys Ther. 2006;86(5):646–655.
154. Sterke CS, Huisman SL, vanBeeck EF, Caspar WML, van der Cammen TJM. Is the Tinetti Performance Oriented Mobility Assessment (POMA) a feasible and valid predictor of short-term fall risk in nursing home residents with dementia
? Int Psychogeriatr. 2010;22(2):254–263.
155. Uhlmann RF, Larson EB, Koepsell TD, Rees TS, Duckert LG. Visual impairment and cognitive dysfunction in Alzheimer's disease. J Gen Intern Med. 1991;6:126–132.
156. Gordon B, Carson K. The basis for choice reaction time slowing in Alzheimer's disease. Brain Cogn. 1990;13:148–166.
157. Manckoundia P, Pfitzenmeyer P, d'Athis P, Dubost V, Mourey F. Impact of cognitive task on the posture of elderly subjects with Alzheimer's disease compared to healthy elderly subjects. Mov Disord. 2006;21:236–241.
158. Moreland JD, Richardson JA, Goldsmith CH, Clase CM. Muscle weakness and falls in older adults: a systematic review and metaanalysis. J Am Geriatr Soc. 2004;52:1121–1129.
159. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35:ii37–ii41.
160. Lord SR, Menz HB, Tiedemann AA. Physiological profile approach to falls risk assessment and prevention. Phys Ther. 2003;83(3):237–252.
161. Lorbach ER, Webster KE, Menz HB, Wittwer JE, Merory JR. Physiological falls risk assessment in older people with Alzheimer's disease. Dement Geriatr Cogn Disord. 2007;24:260–265.
162. Kenny AM, Bellantonio S, Fortinsky RH, Walsh SJ. Factors associated with skilled nursing facility transfers in dementia
-specific assisted living. Alzheimer Dis Assoc Disord. 2008;22(3):255–260.
163. Dawson N, Judge KS, Gerhart H. Improved functional performance in individuals with dementia
after a moderate-intensity home-based exercise program: a randomized controlled trial [published online ahead of print March 1, 2017]. J Geriatr Phys Ther. doi:10.1519/JPT.0000000000000128-
164. Rossiter-Fornoff JE, Wolf SL, Wolfson LI, et al A cross-sectional validation study of the FICSIT common database static balance measures. Frailty and injuries: cooperative studies of intervention techniques. J Gerontol A Biol Sci Med Sci. 1995;50:M291–M297.
165. Centers for Disease Control and Prevention. STEADI-Older Adult Fall Prevention. https://www.cdc.gov
/steadi/index.html. Accessed January 20, 2017.
166. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45(6):735–738.
167. Lord SR, Rogers MW, Howland A, Fitzpatrick R. Lateral stability, sensorimotor function, and falls in older people. J Am Geriatr Soc. 1999;47(9):1077–1081.
168. Weiner DK, Duncan PW, Chandler J, Studenski SA. Functional reach: a marker of physical frailty. J Am Geriatr Soc. 1992;40(3):203–207.
169. Thomas JI, Lane JV. A pilot study to explore the predictive value of 4 measures of falls risk in frail elderly patients. Arch Phys Med Rehab. 2005;86(6):1636–1640.
170. Katz-Leurer M, Fisher I. Reliability and validity of the modified functional reach test at the sub-acute stage post-stroke. Disabil Rehabil. 2009;31(3):243–248.
171. Alexander NB, Galecki AT, Nyquist LV, et al Chair and bed rise performance in ADL-impaired congregate housing residents. J Am Geriatr Soc. 2000;48:526–533.
172. Mehr DR, Fries BE, Williams BC. How different are VA nursing homes residents? J Am Geriatr Soc. 1993;41:1095–1101.
173. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services task force on Alzheimer's disease. Neurology. 1984;34(7):939–944.
174. Boyle PA, Buchman AS, Wilson RS, Leurgans SE, Bennett DA. Association of muscle strength with the risk of Alzheimer's disease and the rate of cognitive decline in community-dwelling older persons. Arch Neurol. 2009;66(11):1339–1344.
175. Wang L, Larson EB, Bowen JD, van Belle G. Performance-based physical function and future dementia
in older people. Arch Intern Med. 2006;166:1115–1120.
176. Louis ED, Tang MX, Mayeux R. Parkinsonian signs in older people in a community-based study: risk of incident dementia
. Arch Neurol. 2004;61:1273–1276.
177. Waite LM, Grayson DA, Piguet O, Creasey H, Bennett HP, Broe GA. Gait slowing as a predictor of incident dementia
: 6-year longitudinal data from the Sydney older persons study. J Neurol Sci. 2005;229/230:89–93.
178. Buchman AS, Boyle PA, Wilson RS, Tang Y, Bennett DA. Frailty is associated with incident Alzheimer's disease and cognitive decline in the elderly. Psychosom Med. 2007;69(5):483–489.
179. Beauchet O. Gait analysis in demented subjects: interests and perspectives. Neuropsychiatr Dis Treatment. 2008;4(1):155–160.
180. Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital sign. J Aging Phys Act. 2015;23(2):314–322.
181. Afilalo J, Eisenberg MJ, Morin JF, et al Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010;56(20):1668–1676.
182. Castell MV, Sanchez M, Julian R, Queipo R, Martin S, Otero A. Frailty prevalence and slow walking speed in persons age 65 and older: implications for primary care. BMC Fam Pract. 2013;14(1):86.
183. Elbaz A, Sabia S, Brunner E, et al Association of walking speed in late midlife with mortality: results from the Whitehall II cohort study. Age (Dordr). 2013;35(3):943–952.
184. Matsuzawa Y, Konishi M, Akiyama E, et al Association between gait speed as a measure of frailty and risk of cardiovascular events after myocardial infarction. J Am Coll Cardiol. 2013;61(19):1964–1972.
185. Studenski S, Perera S, Patel K, et al Gait speed and survival in older adults. JAMA. 2011;305(1):50–58.
186. Cesari M, Kritchevsky SB, Penninx BW, et al Prognostic value of usual gait speed in well-functioning older people—results from the health, aging and body composition study. J Am Geriatr Soc. 2005;53(10):1675–1680.
187. Alfaro-Acha A, Al Snih S, Raji MA, Markides KS, Ottenbacher KJ. Does 8-foot walk time predict cognitive decline in older Mexican Americans? J Am Geriatr Soc. 2007;55(2):245–251.
188. Inzitari M, Newman AB, Yaffe K, et al Gait speed predicts decline in attention and psychomotor speed in older adults: the health aging and body composition study. Neuroepidemiology. 2007;29(3/4):156–162.
189. Montero-Odasso M, Schapira M, Soriano ER, et al Gait velocity as a single predictor of adverse events in healthy seniors aged 75 years and older. J Gerontol A Biol Sci Med Sci. 2005; 60(10):1304–1309.
190. Chu LW, Chi I, Chiu AY. Incidence and predictors of falls in the Chinese elderly. Ann Acad Med Singapore. 2005;34(1):60–72.
191. Ng SS, Ng PC, Lee CY, et al Assessing the walking speed of older adults: the influence of walkway length. Am J Phys Med Rehabil. 2013;92(9):776–780.
192. Nascimento LR, Caetano LC, Freitas DC, Morais TM, Polese JC, Teixeira-Salmela LF. Different instructions during the ten-meter walking test determined significant increases in maximum gait speed in individuals with chronic hemiparesis. Rev Bras Fisioter. 2012;16(2):122–127.
193. Dumurgier J, Artaud F, Touraine C, et al Gait speed and decline in gait speed as predictors of incident dementia
. J Gerontol A Biol Sci Med Sci. 2017;72(5):655–661.
194. Fitzpatrick AL, Buchanan CK, Nahin RL, et al Associations of gait speed and other measures of physical function with cognition in a healthy cohort of elderly persons. J Gerontol. 2007;62(11):1244–1251.
195. Mielke MM, Roberts RO, Savica R, et al Assessing the temporal relationship between cognition and gait: slow gait predicts cognitive decline in the Mayo Clinic study of aging. J Gerontol A Biol Sci Med Sci. 2013;68:929–937.
196. Callisaya ML, Blizzard CL, Wood AG, Thrift AG, Wardill T, Srikanth VK. Longitudinal relationships between cognitive decline and gait slowing: the Tasmanian study of cognition and gait. J Gerontol A Biol Sci Med Sci. 2015;70(10):1226–1232.
197. Woollacott MH, Tang PF. Balance control during walking in the older adult: research and its implications. Phys Ther. 1997;77(6):646–660.
198. Bohannon RW. Comfortable and maximum walking speed of adults aged 20-79 years: reference values and determinants. Age Ageing. 1997;26:15–19.
199. Clark DJ, Manini TM, Fielding RA, Patten C. Neuromuscular determinants of maximum walking speed in well-functioning older adults. Exp Gerontol. 2013;48(3):358–363.
200. Fiser W, Hays N, Rogers S, et al Energetics of walking in elderly people: factors related to gait speed. J Gerontol A Biol Sci Med Sci. 2010;65A(12):1332–1337.
201. Park YH, Kim YM, Lee BH. An ankle proprioceptive control program improves balance, gait ability of chronic stroke patients. J Phys Ther Sci. 2013;25:1321–1324.
202. Aartolahti E, Hakkinen A, Lonnroos E, Kautiainen H, Sulkava R, Hartikaninen S. Relationship between functional vision and balance and mobility performance in community-dwelling older adults. Aging Clin Exp Res. 2013;25(5):545–552.
203. Nutt J. Higher-level gait disorders: an open frontier. Mov Disord. 2013;28(11):1560–1565.
204. Manckoundia P, Mourey F, Pfitzenmeyer P. Gait and dementias. Ann Readapt Med Phys. 2008;51:692–700.
205. Wilson RS, Schneider JA, Bienias JL, Evans DA, Bennett DA. Parkinsonian-like signs and risk of incident Alzheimer disease in older persons. Arch Neurol. 2003;60:539–544.
206. Allan LM, Ballard CG, Burn DJ, Kenny RA. Prevalence and severity of gait disorders in Alzheimer's and non-Alzheimer's dementias. J Am Geriatr Soc. 2005;53(10):1681–1687.
207. Bridenbaugh SA, Kressig RW. Quantitative gait disturbances in older adults with cognitive impairments. Curr Pharm Des. 2014;20(19):3165–3172.
208. Beauchet O, Annweiler C, Callisaya ML, et al Poor gait performance and prediction of dementia
: Results from a meta-analysis. J Am Med Dir Assoc. 2016;17(6):482–490.
209. Rosano C, Aizenstein H, Brach J, Longenberger A, Studenski S, Newman AB. Special article: gait measures indicate underlying focal gray matter atrophy in the brain of older adults. J Gerontol A Biol Sci Med Sci. 2008;63(12):1380–1388.
210. de Laat KF, van Norden AG, Gons RA, et al Diffusion tensor imaging and gait in elderly persons with cerebral small vessel disease. Stroke. 2011;42(2):373–379.
211. Tian Q, Chastan N, Bair WN, Resnick SM, Ferrucci L, Studenski SA. The brain map of gait variability in again, cognitive impairment
—a systematic review. Neuro Sci Bio Behav Rev. 2017;74:149–162.
212. MacAuley RK, Allaire T, Brouillette R, et al Apolipoprotein E genotype linked to spatial gait characteristics: predictors of cognitive dual task gait change. PLoS One. 2016;11(8):1–10.
213. Hausdorff JM, Gruendlinger L, Scollins L, O'Herron S, Tarsy D. Deep brain stimulation effects on gait variability in Parkinson's disease. Mov DIsord. 2009;24(11):1688–1692.
214. Hausdorff JM. Gait variability: methods modelling and meaning. J Neuro Engineering Rehabil. 2005;2:19.
215. Montero-Odasso M, Muir SW, Hall M, et al Gait variability is associated with frailty in community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2011;66:568–576.
216. Valkanova V, Ebmeier KP. What can gait tell us about dementia
? Review of epidemiological and neuropsychological evidence. Gait and Posture. 2017;53:215–223.
217. Hausdorff JM. Gait dynamics, fractals and falls: finding meaning in the stride-to-stride fluctuations of human walking. Hum Mov Sci. 2007;26:555–589.
218. Amboni M, Barone P, Hausdorff JM. Cognitive contributions to gait and falls: evidence and implications. Mov Disord. 2013;28(11):1520–1533.
219. Verghese J, Wang C, Lipton RB, Holtzer R, Xue X. Quantitative gait dysfunction and risk of cognitive decline and dementia
. J Neurol Surg Pshychiatry. 2007;78(9):929–935.
220. Montero-Odasso M, Verghese J, Beauchet O, Hausdorff J. Gait and cognition: a complementary approach to understanding brain function and the risk of falling. J Am Geriatr Soc. 2012;60(11):2127–2136.
221. Youdas JW, Childs KB, McNeil ML, Mueller AC, Quilter CM, Hollman JH. Responsiveness of 2 procedures for measurement of temporal and spatial gait parameters in older adults. PMR. 2010;2(6):537–543.
222. Rucco R, Agosti V, Jacini F. Spatio-temporal and kinematic gait analysis in patients with frontotemporal dementia
and Alzheimer's disease through 3D motion capture. Gait Posture. 2017;52:312–317.
223. Salva A, Roque M, Rojano X, et al Falls and risk factors for falls in community-dwelling adults with dementia
(NutriAlz trial). Alzheimer Dis Assoc Dis. 2012;26(1):74–80.
224. Schaubert KL, Bohannon RW. Reliability and validity of three strength measures obtained from community-dwelling elderly persons. J Strength Con Res. 2005;19(3):717–720.
225. Demnitz N, Zsoldos E, Mahmood A. Associations between mobility, cognition and brain structure in healthy older adults. Front Ageing Neurosci. 2017;9(155):1–11.
226. White L, Ford MP, Brown CJ, Peel C, Triebel KL. Facilitating the use of implicit memory and learning in the physical therapy management of individuals with Alzheimer's disease: a case series. J Geriatr Phys Ther. 2014;37:35–44.
227. Rikli RE, Jones CJ. Senior Fitness Test Manual. Champagne AIGN, IL: Human Kinetics; 2103.
228. Rehabilitation Measures Database. 30 Second Sit to Stand Test. http://http://www.rehabmeasures.org
/Lists/RehabMeasures/PrintView.aspx?ID=1122. Accessed August 21, 2017.
229. Santana-Sosa E, Barriopedro M, Lopez-Mojares LM, Perez M, Lucia A. Exercise training is beneficial for Alzheimer's patients. Int J Sport Nutr. 2008;29(10):845–850.
230. Guyatt GH, Sullivan MJ, Thompson PJ, et al The 6 minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J. 1985;132:919–923.
231. Harada ND, Chiu V, Stewart AL. Mobility-related function in older adults: assessment with a 6-minute walk test. Arch Phys Med Rehabl. 1999;80(7):837–841.
232. Lord SR, Menz HB. Physiologic, psychologic and health predictors of 6-minute walk performance in older people. Arch Phys Med Rehabl. 2002;83(7):907–911.
233. Burr JF, Bredin SS, Faktor MD, Warburton DE. The 6-minute walk test as a predictor of objectively measured aerobic fitness in healthy working-aged adults. Phys Sportsmed. 2011;39(2):133–139.
234. Kirk-Sanchez NJ, McGough EL. Physical exercise and cognitive performance in the elderly: current perspectives. Clin Interv Aging. 2014;9:51–62.
235. Colcombe SJ, Erickson KI, Scalf PE, et al Aerobic exercise training increases brain volume in aging humans. J Gerontol A Biol Sci Med Sci. 2006;61(11):1166–1170.
236. Erickson KI, Miller DL, Weinstein AM, Akl SL, Banducci SE. Physical activity and brain plasticity in late adulthood: a conceptual review. Ageing Res. 2012;3(1):34–47.
237. Kitwood T. Dementia
Reconsidered: The Person Comes First. Buckingham, England: Open University Press; 2001.
238. Beck CK, Heacock P, Rapp CG, Mercer SO. Assisting cognitively impaired elders with activities of daily living. Am J Azhiemer's Care Related Disord Res. 1993;8(6):11–20.
239. Ahlskog E, Geda YE, Graff-Radford NR, Petersen RC. Physical exercise as a preventive or disease-modifying treatment of dementia
and brain aging. Mayo Clin Proc. 2011;86(9):876–884.
240. McCarten JR, Anderson P, Kuskowski M, McPherson S, Borson S, Dysken MW. Finding dementia
in primary care: The results of a clinical demonstration project. J Am Geriatr Soc. 2012;60(2):210–217.
241. Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig M. Improving identification of cognitive impairment
in primary care. Int J Geriatr Psychiatry. 2006;21(4):349–355.
243. Roalf DR, Moberg PJ, Xie SX, Wolk DA, Moelter ST, Arnold SE. Comparative accuracies of two common screening instruments for classification of Alzheimer's diseases, mild cognitive impairment
, and healthy aging. Alzheimers Dement. 2013;9:529–537.
244. Rossetti HC, Lacritz LH, Cullum CM, et al Normative data for the Montreal Cognitive Assessment (MoCA) in a population-based sample. Neurol. 2011;77:1272–1275.
245. Chertkow H, Nasreddine Z, Johns E, Phillips N, McHenry C. The Montreal cognitive assessment (MoCA): validation of alternate forms and new recommendations for education corrections. Sci Dir. 2011; 7(4):s157.
246. Julayanont P, Phillips N., Chertkow H, Nasreddine ZS. The Montreal Cognitive Assessment (MoCA): concept and clinical review. In: Larner AJ, ed. Cognitive Screening Instruments: A Practical Approach. London, England: Springer-Verlag; 2012.
247. National Institute for Clinical Excellence. Guidance on the Use of Donepezil, Rivastigmine and Galantamine for the Treatment of Alzheimer's Disease. London, England: NICE; 2001.
248. Creavin ST, Wisniewski S, Noel-Storr AH. Mini-Mental State Examination (MMSE) for the detection of dementia
in clinically unevaluated people aged 65 and over in community and primary care populations. Cochrane Database Syst Rev. 2016;(1):CD011145.
249. Mitchell AJ. A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia
and mild cognitive impairment
. J Psychiatr Res. 2009;43(4):411–431.
250. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the mini-mental state examination by age and educational level. JAMA. 1993;269(18):2386–2391.
251. Rovner BW, Folstein MF. Mini-mental state exam in clinical practice. Hosp Pract. 1987;22(1A):99, 103, 106, 110.
252. O'Bryant SE, Humphreys JD, Smith GE, et al Detecting dementia
with the Mini-Mental State Examination (MMSE) in highly educated individuals. Arch Neurol. 2008;65(7):963–967.
253. De Silva V, Hanwella R. Why are we copyrighting science? BMJ. 2010;341:c4738.
254. Allen DN. Brief cognitive rating scale. In: Kreutzer J, ed. Encyclopedia of Clinical Neurology. New York, NY: Springer-Verlag; 2011.
255. Allen CK. Cognitive disability and reimbursement for rehabilitation and psychiatry. J Insur Med. 1991;23(4):245–247.