|Year : 2021 | Volume
| Issue : 3 | Page : 109-115
Influence of simulated functional task to improve executive function, functional balance and activities of daily living in elderly people with mild cognitive impairment: A one-arm interventional study
K Sanjeevkumar, S Sakthi Srija
Deportment of Occupational Therapy, KMCH College of Occupational Therapy, Coimbatore, Tamil Nadu, India
|Date of Submission||26-Jan-2021|
|Date of Acceptance||20-Sep-2021|
|Date of Web Publication||12-Oct-2021|
No. 6/142.A, Vetrayan Nagar, A. Jettihalli (P.O.), Dharmapuri - 636 807, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Elderly patients with mild cognitive impairment (MCI) have decline in executive functions, functional balance, and impact on the ability to perform activities of daily living (ADL). The simulated functional task (FcTSim) program may provide standard benefits on the cognitive function of elderly patients with MCI. Objective: This study aimed to find the effectiveness of FcTSim to improve executive functions, functional balance, and ADL in elderly patients with MCI. Study Design: A one-arm interventional study. Method: An interventional study was conducted on elderly patients with MCI and balance impairment. They were selected for the study on the basis of the Mini-Mental Status Examination score 18–23, Berg Balance Scale (BBS) score of <45 (indicate the greatest risk of falling), and age group between 65–85 years. FcTSim program was given for 4 weeks, a total of 12 sessions (3 sessions per week). Addenbrooke's Cognitive Examination-Revised (ACE-R), BBS, and Canadian Occupational Performance Measure (COPM) scales were used as the outcome measures. Results: The mean posttest scores of ACE-R was 11.53 ± 3.62; P < 0.00; 95% confidence interval (CI): 9.52 to 13.54, BBS 8.80 ± 2.36; P < 0.00; 95% CI: 7.49 to 10.11, it shows significant difference and COPM performance 1.00 ± 0.84; P < 0.00; 95% CI: 0.53 to 1.46 satisfaction 1.53 ± 0.91; P < 0.00; 95% CI: 1.02 to 2.04. Conclusion: The findings of this study suggest that after 4 weeks encompassing 12 sessions of FcTSim, the elderly patients with MCI showed improvement in their executive functions, functional balance, and ADL such as eating, bathing, dressing, and grooming.
Keywords: Daily Living Activities, Executive Function, Functional Balance, Mild Cognitive Impairment, Simulated Functional Task
|How to cite this article:|
Sanjeevkumar K, Srija S S. Influence of simulated functional task to improve executive function, functional balance and activities of daily living in elderly people with mild cognitive impairment: A one-arm interventional study. Indian J Occup Ther 2021;53:109-15
|How to cite this URL:|
Sanjeevkumar K, Srija S S. Influence of simulated functional task to improve executive function, functional balance and activities of daily living in elderly people with mild cognitive impairment: A one-arm interventional study. Indian J Occup Ther [serial online] 2021 [cited 2021 Dec 2];53:109-15. Available from: http://www.ijotonweb.org/text.asp?2021/53/3/109/328125
| Introduction|| |
Executive functioning consists of complex attention, working memory, verbal and visual organization, planning, judgment, and reasoning. Various cognitive factors affect the functional decline in elderly people, such as global cognitive status, visuospatial ability, memory, and executive functioning. Executive deficit and gait abnormalities present in elderly patients with mild cognitive impairment (MCI). Functional balance focus on the maintenance of posture (static balance and dynamic balance). Recent studies suggested that the brain can be considered to be an organized, integrated network of ﬁxed functional systems specialized to manage speciﬁc types of information (e.g. language, visual-spatial, etc.) These systems are located primarily in the posterior regions of the cortex, with each having connections to the prefrontal cortex. The performance of simple motor tasks such as moving ﬁngers on both hands simultaneously in sequence showed activation of brain areas involved in higher cognitive executive functions, suggesting that control of routine movement requires continued input from posterior sensory systems and integration of this information with previously learned motor programs. Executive skills are required to perform activities of daily living (ADL), even mild executive dysfunction could have an impact on functional ability and the risk of ADL dependence among older adults with MCI to moderate cognitive impairment.
The simulated functional task (FcTSim) program may be more meaningful and practical for the individual with cognitive impairment. According to “Occupational Therapy Practice Frame-Work” the use of meaningful occupation as a means of therapeutic intervention promotes cognitive functioning and occupational performance.
Individual with MCI may represent problems in their executive function, gait and are more susceptible to fall. The rationale for using FcTSim is said to have improvement in executive function and functional balance.
However, there is no research evidence on the implementation of FcTSim on ADL. Hence, this study focused on the implementation of FcTSim on ADL to improve executive function and functional balance in elderly patients with MCI.
| Methods|| |
A one-arm interventional study was conducted. The elderly patients who were fulfilling the inclusion criteria were selected by convenient sampling technique into a single group. Elderly patients with both gender and age ranging from 60 to 85 were included. The patients were selected on the basis of: Screened as MCI with Mini-Mental Status Examination (MMSE) scores between 18 and 23, Berg Balance Scale (BBS) score of <45 (indicate the greatest risk of falling). People who had comorbid physical dysfunction and psychiatric causes of cognitive dysfunctions were excluded. The study was conducted adhering to the principles of Declaration of Helsinki guidelines and written informed consent was sought from all patients before recruiting them in the study.
Addenbrooke's Cognitive Examination-Revised (ACE-R)
It is used to assess the components of executive function such as attention, memory, verbal fluency, language, visuospatial ability, planning, judgment, and reasoning. Total score out of 100, higher scores indicate better cognitive functioning. Inter-rater reliability is reported as (0.99), test-retest reliability as (0.88), sensitivity as (0.97), and specificity as (0.81).
Berg Balance Scale
BBS is used to measure (static and dynamic) balance among older adults with the performance of predetermine tasks. It is a 14-item list, the components are sitting and transferring chair, standing with feet apart, and feet together, in single-leg stance, feet in the Romberg position with the eye open or closed, reaching, stooping down to pick something off floor. The administration of the test takes 10–15 min. A 5-point rating scale, ranging from 0 = lowest level of function, 4 = highest level of function, total score = 56. Reliability is reported as (0.86) and validity as (0.97).
Canadian Occupational Performance Measure
The Canadian Occupational Performance Measure (COPM) is a measure of patient's self-perception of occupational performance in the area of self-care, productivity, and leisure. In the study self-care component (eating, bathing, dressing, and grooming) of COPM is only used. COPM is used as an outcome measure only. The rating was using a 10-step numeric Likert scale from 1 (not important at all) to 10 (extremely important). Two scores for performance and satisfaction. Mean score is obtained for satisfaction and performance with ranging from 1 to 10. Reliability of 0.86 and validity of 0.93 are reported in the literature.
During each session, the patient performed tasks, a set of 1–3 repetition with 1–2 min of rest between each set. Each session started off with 5–10 min of warm-up, next 30–40 min with core exercise, and winded off with cool-down activities for 5–10 min and feedback about client's performance were also given [Appendix I]. Interventions were given for 4 weeks (12 sessions, 3 days per week, 1 h per session) [Appendix II]. Posttest assessment was done by Addenbrooke's Cognitive Examination-Revised (ACE-R) (higher score indicates better cognitive functioning), BBS, COPM at the end of the last session.
Level Core Movement
A structured functional task exercise program, involving the performance of tasks (object placing and collection) following speciﬁc patterns of movement and sequence incorporated with a sit-stand movement. The program has ﬁve levels, including unilateral movement, bimanual movement, task switching, and body midline crossing.
Drinking and Eating
- Level 1: First place the things (plate, tumbler, bowl, cups, and water bottle) from forward along crossing midline and to collect backward direction
- Level 2: Prepare to washing the utensils, circularly place the things (plate, tumbler, bowl, cups, and water bottle) from clockwise direction along cross midline reaching and to collect the utensils counter clockwise. Washing the things before eating
- Level 3: Preparing for serving food, alternate direction to place the things (plate, tumbler, bowl, cups, and water bottle) along with cross midline reach both placing/collecting with both left and right hand alternatively. Originally doing serving and drink/eat food
- Level 4: After eating ready to wash the utensils, from repeatedly placing the things (plate, tumbler, bowl, cups, and water bottle) along with cross midline reach placing and to collecting with 1 point of repetition. Washing plate and cups things and keep it correctly
- Level 5: Thing ready to dry it, from bimanually alternate placing collecting the utensils, along with cross midline reach Placing and to collect bimanually in opposite direction. Things keep it on the table or floor to dry it.
- Level 1: Initially placing cloths on table and collecting from the floor. Separate upper body cloths (UB) and lower body (LB) clothes
- Level 2: Circularly placing the clothes, before done buttoning and hooking. Along with Cross midline reaches and place it in the clockwise direction and finally collect it in the counter clockwise direction
- Level 3: Alternate direction to placing the clothes Along with Cross midline reaches, before matching the colors of clothes of UB and LB
- Level 4: Repeatedly placing and collecting the matching clothes. Along with Cross midline reach place and collect with 1 point of repetition and place it on the table
- Level 5: Bimanually alternate placing and collecting and along with Cross midline reach place the clothes on cupboard/slab.
- Level 1: Initially placing the things (mirror, paste, brush, comb, oil, cream, towel, face washer/soap) along with cross midline reaching. Forward placing and backward collecting
- Level 2: Circularly place the things in clockwise direction (mirror, paste, brush, and towel) along with crossing midline reaching. And collecting the things in the counter clockwise direction. Do brushing action or do originally
- Level 3: Alternate way placing (mirror, towel, and face washer/soap) along with cross midline reaching and collecting the things with left and right hand alternatively. Washing faces do the task originally
- Level 4: Repeatedly placing things (mirror, comb, oil) along with cross midline reaching. Collecting the thing in 1 point of repetition. Combing hair/tying it
- Level 5: Bimanually alternate placing things (cream/oil) along with cross midline reaching. Collecting the tings bimanually in opposite direction. Apply moisturizing cream/oil to the body.
- Level 1: Initially place the things (mirror, towel, soap, scarab, water basket) along with cross midline reaching. Simple place it and collecting in the backward direction
- Level 2: Circularly place the things in the clockwise direction (mirror, towel, soap, scarab, and water basket) along with cross midline reaching. Collecting things in counter clockwise. Then, things set up in the bathroom
- Level 3: Alternately placing the things (mirror, towel, soap, scarab, water basket) along with cross midline reach. Collecting with left and right hand alternatively. Washing upper extremity (UE) or lower extremity (LE)
- Level 4: Repeated placing the things (mirror, towel, soap, scarab, water basket) along with cross midline reaching. Placing and collecting with 1 point of repetition. Both UE and LE washing
- Level 5: Bimanually alternately placing the things, along with cross midline reaching and Collecting the tings bimanually in opposite direction. Applying soap, rubbing, dry with towel.
Statistical analysis was performed with SPSS version 20 (IBM Corp., released 2011. Armonk, NY). Paired t-test was used to analyze whether any significant difference exists between pre and post score of ACE-R, BBS, and COPM in group. Furthermore, the study analysis was done with the setting level of confidence at α ≤ 0.05 and 95% confidence interval (CI) values were also computed.
| Results|| |
A total of 25 patients were screened, from which 15 patients were selected according to the selection criteria using MMSE (score 18–23) and BBS score of <45 (indicate the greatest risk of falling). Pre- and post-test assessments were done, using ACE-R, BBS, and COPM. Descriptive details of pretest and posttest of ACE-R, BBS, and COPM scores were analyzed [Table 1].
The result shows that their difference in pre- and post-test score of patients in the groups of ACE-R score 11.53 ± 3.62; P < 0.00; 95% CI: 9.52 to 13.54 and BBS score 8.80 ± 2.36; P < 0.00; 95% CI: 7.49 to 10.11. It represents the difference as in [Table 2]. The statistically mean difference of ACE-R and BBS in their pre- and post-test scores, indicating posttest score higher than the pretest scores of patients in the group, it shows participants improved their executive function and functional balance.
|Table 2: Descriptive Details of Pre- and Post-Test Scores of Addenbrooke's Cognitive Examination-Revised, Berg Balance Scale and Canadian Occupational Performance Measure|
Click here to view
Mean scores of COPM performance was 1.00 ± 0.84; P < 0.00; 95% CI: 0.53 to 1.46 and satisfaction 1.53 ± 0.91; P < 0.00; 95% CI: 1.02 to 2.04. Pre- and post-test score of patients in the group in [Table 3]. It shows the statistically mean difference in pretest and posttest score of COPM, indicating improvement in the ADL component (eating, bathing, dressing, and grooming) performance and satisfaction postintervention.
|Table 3: Difference in the Pre- and Post-test Scores of Addenbrooke's Cognitive Examination-Revised and Berg Balance Scale|
Click here to view
| Discussion|| |
Elderly patients with reduced executive function tend to walk slow, fall more often and have poorer performance on complex mobility tasks., A daily functional task such as cleaning or dressing involves components of stretching, balance, endurance, and strengthening as seen in a conventional therapy program. The functional task exercise program is a simple and structured program that does not require any sophisticated equipment or tool for implementation, people can do simply these activities in either clinical or home-based setting. It can be used as a means of combined cognitive and exercise intervention with specific patterns of movement and sequence in day-to-day activities.
The study suggested that the improvement in everyday problem-solving performance tasks is associated with working memory gained through the practice of functional task exercise in which participants showed significantly higher performance score, whereas in the present study ADL in their performance and satisfaction scores of COPM in patients (performance: 6.20 and 7.20, satisfaction: 6.47 and 8.0), post-FcTSim program also showed significant improvement. Additional, feedback received from the participants regarding FcTSim program and daily problem-solving tasks, also supports the results of the current study. Few patients reported that “Previously I used to have a stooped posture. After performing these activities with exercises, I am being able to reach in all directions and perform better.” Some reported that “After the program, I was able to sit, stand, and quickly bend forward to take thinks from the floor, after performing activities regularly” and “Activities like folding dresses, buttoning my shirt were difficult, but now I am able to perform it independently.” Patients feedbacks on the intervention program despite their activity perform, improved postintervention, could be because the intervention was concentrated on daily functional task based on levels of core movements.
Therefore, the significant improvement in performance and satisfaction can be considered as a significant improvement in the efficacy of FcTSim program [Table 4]. Hence, the findings of the current study encourage the use of FcTSim program on daily functional task as a mean of occupational therapy interventions for improving executive function and functional balance.
|Table 4: Difference in the Pre- and Post-test Scores of Canadian Occupational Performance|
Click here to view
Limitations and Recommendations
The current study design was single group study with small sample size, and also the duration of the study was shorter. Generalizability of the study is limited due to single geographical area.
Future studies can use other test batteries like Neurobehavioral Cognitive Status Examination or Lowenstein Occupational Therapy Cognitive Assessment to assess general cognitive function, and randomized controlled trials may be conducted for generating higher level of evidence.
| Conclusion|| |
The findings of this study suggest that after 4 weeks and 12 sessions of FcTSim, the elderly patient with MCI showed improvement in their executive function, functional balance, and ADL such as eating, bathing, dressing, and grooming.
We would like to thank the Institution, Head of the Department - KMCH College of Occupational Therapy for the kind permission to conduct this project. Thanks to all those subjects who were involved in this study.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Marshall GA, Rentz DM, Frey MT, Locascio JJ, Johnson KA, Sperling RA, et al.
Executive function and instrumental activities of daily living in mild cognitive impairment and Alzheimer's disease. Alzheimers Dement 2011;7:300-308.
Kearney C, Harwood RH, Gladman JR. The relationship between executive function and fall and gait abnormalities in older Adults: A Systemic Review. Dement Geriatr Cogn Dis 2013;36:20-35.
Unsworth CA. Cognitive and perceprual dysfunction. In: Sallivan SB, Schimtz TJ, editors. Physical Rehabilitation. 6th
ed. New Delhi: Jaypee Brothers Medical Publisher; 2019. p. 1175-1222.
Sheridan PL, Mat JS, Kowall N. Influence of executive function on locomotors function: Divided attention increase gait Variability in Alzheimer's Disease. J Am Geriatr Soc 2003;51:1633-1637.
Gill TM, Richardson ED, Tinetti ME. Valuating the risk of dependence in activities of daily among community – Living older adult with mild to moderate cognitive impairment. J Gerontol Med Sci 1995;50:235-241.
Lawla LF, Fong KN, Yau MM. Can functional task exercise improve executive function and contribute to functional balance in older adults with mild cognitive impairment? A pilot study. Br J Occup Ther 2018;81:495-502.
Occupational Therapy Practice Framework: Domain and Process. 3rd
ed. Vol. 68. Am J Occup Ther; 2017. p. 1-48.
Folstein MF, Folstein SE, 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.
Berg KO, Wood-Dauphinee S, Willliams JI, Gayton D. Measuring balance in elderly: Perliminary development of an instrument. Physiother Can 1989;41:304-311.
Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges JR. The Addenbrooke's Cognitive Examination Revised (ACE-R): A brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 2006;21:1078-1085.
Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N. The Canadian occupational performance measure: An outcome measure for occupational therapy. Can J Occup Ther 1990;57:82-87.
Jacubovski OS, Herman T, Seligmann GY. The interplay between gait, falls and cognition: Can cognitive therapy reduce fall risk? Expert Rev Neurother 2011;11:1057-1075.
Iersel MB, Kessels RP, Bloem BR. Executive functions are associated with gait and balance in community – Living elderly people. J Gerontol A Biol Sci Med Sci 2008;63:1344-1349.
[Table 1], [Table 2], [Table 3], [Table 4]