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Home-based evaluation of executive function (Home-MET) for older adults with mild cognitive impairment
Archives of Gerontology and Geriatrics 87 (2020) 104012
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Home-based evaluation of executive function (Home-MET) for older adults with mild cognitive impairment
T
Frank Ho-yin Laia,*, Elaine Wai-hung Yanb, Kathy Ka-ying Yuc a
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong Occupational Therapy Department, Kowloon Hospital, Hong Kong c The Salvation Army Tai Po Integrated Service for Senior Citizens, The Salvation Army Hong Kong and Macau Command, Hong Kong b
A R T I C LE I N FO
A B S T R A C T
Keywords: Home-based Mild cognitive impairment Performance-based executive function
Introduction: Executive function helps older adults maintain their activities of daily living by making plans, setting goals, and carrying them out successfully. It is important for their independence in community living. Methods: With a carefully match-group of 80 mild cognitive impaired with 80 health control subjects. The homebased evaluation of executive function (Home-MET) was validated in subjects’ own living environment. Results: This Home-MET showed significant correlation in the assessment of attention control that was assessing by Test of Everyday Attention (TEA) (r = .86, p < .01), with working memory that was assessed with Trail Making Test (TMT) (r = .72, p < .01), with inhibitory control that was assessing with Stroop Test (r = .86, p < .01), with individuals’ functional disability was assessed by Chinese Disability Assessment of Dementia (CDAD) (r = .77, p < .01) and cognitive assessment was assessed by Hong Kong Montreal Cognitive Assessment (HK-MoCA) (r = .88, p < .01). By benchmarking with the validated performance-based executive function assessment, the Home-MET shows significant correlation (r = .92, p < .05) with the executive function test in a standard environment in hospital, i.e. the Chinese Multiple Errands Test (the Chinese-MET). The two-stage hierarchical linear regression model with backward method showed functional disability was a marginally significant predictor (p < .059) for the Home-MET with regression model showed with R2 = .93. Conclusion: Results indicated the Home-MET, can provide an objective measure of executive function for subjects with mild cognitive impairment in participants’ own home environment.
1. Introduction Memory impairment was considered as the chief complaint of deterioration in daily living by older adults with mild cognitive impairment, MCI in short (Avila et al., 2015). The underlying deficits in executive function (EF) also significantly contributed to their functional disabilities (Brandt et al., 2009; Kirova, Bays, & Lagalwar, 2015). EF has shown to be important, especially in the fast and complicated contemporary world, because it has been considered as central to independent daily living (Garcia-Alvarez, Gomar, Sousa, Garcia-Portilla, & Goldberg, 2019), solve problems (Leyhe, Saur, Eschweiler, & Milian, 2011; Rainville, Lepage, Gauthier, Kergoat, & Belleville, 2012), and resolve conflicts (Seo, Kim, Lee, & Choo, 2016). EF was considered as a vital part of the independent living skills of older adults with dementia in community living (Marshall et al., 2011). Some researchers commented that executive function is the core psychological deficit underlying dysfunction of mild cognitive impairment (Zhang et al., 2018).
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The resulting functional disabilities were the major cause of extended hospital stays (Bettcher, Giovannetti, Macmullen, & Libon, 2008) and protracted residential care (Avila et al., 2015). Theoretically, Miyake and colleagues proposed a valid and well known 3-components model of EF that included updating working memory, inhibition, and shifting (Miyake et al., 2000). Updating working memory is the continuous monitoring with quick addition or deletion of contents within one's working memory. Inhibition is defined as one's capacity to supersede responses that are prepotent in a given situation. Shifting is one's cognitive flexibility to switch between different tasks or mental states. The cornerstone of their theoretical model is the understanding of individual differences in executive functions reflect both unity (i.e., common executive function skills) and diversity of each component (i.e. updating -specific, inhibition-specific or shifting-specific), that is these aspects are related, yet each remains a distinct entity. Clinically, EF was considered as a fluid functional ability construct
Corresponding author. E-mail addresses: [email protected] (F.H.-y. Lai), [email protected] (E.W.-h. Yan), [email protected] (K.K.-y. Yu).
https://doi.org/10.1016/j.archger.2020.104012 Received 6 October 2019; Received in revised form 29 December 2019; Accepted 14 January 2020 Available online 16 January 2020 0167-4943/ © 2020 Elsevier B.V. All rights reserved.
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mild cognitive impaired subjects. Health control subjects would be recruited by purposeful sampling through volunteer service in local volunteer service for older adults with dementia.
(Marshall et al., 2011), a collective term referring to a set of cognitive functions that includes attention control, working memory, and inhibitory control (Faria, Alves, & Charchat-Fichman, 2015; Seo et al., 2016). Attention control allows us to shift our attention when necessary, directing it to the most important tasks and sustaining it while we are working on other tasks (Silveri, Reali, Jenner, & Puopolo, 2007). It enables individuals to switch focus quickly from one thing to another. Working memory is the ability to store information relevant to this ongoing task; it allows us to store important information so we can access it when needed (Royall et al., 2002). Inhibitory control is the ability to restrict incompatible thoughts. It helps us resist impulses, keeps us on task, and enables us to set goals and carry them out (Kaiser, Kuhlmann, & Bosnjak, 2018). For the purpose of specific executive function training for older adults with MCI, a clearer understanding of these fluid constructs in EF needs to be further examined and studied. The use of hospital environment had provided an objective environment in evaluating the EF of subjects (Lai et al., 2019). However, the unfamiliar and busy environment in hospital with the inclusion of social interactions with unfamiliar others in hospital involved subjects’ social-cognition ability and personal confidence. Literatures suggested individuals’ EF performance would be better in their familiar environment (Avila et al., 2015; Lai et al., 2019). However, just very few studies tried to accomplish this goal (Yu et al., 2012).
4. Instruments 4.1. Performance-based executive function The Home Multiple Errands Test (The Home-MET) is modeled from The Chinese Multiple Errands Test (The Chinese MET; Lai et al., 2019). The Chinese MET is a performance-based evaluation of EF by using realworld daily living activities in a hospital environment. Like its original English version, the Chinese-MET is an examiner rated measurement for executive function. Chinese-MET demonstrated excellent inter-rater reliability (ICC = .95, with 95 % CI: 0.88–.98), good test-retest reliability, with an ICC value of 0.92; with individual items’ ICC values ranging from 0.90 to .95 (95 % CI: 0.84–.96), and good to excellent internal consistency, with a Cronbach’s a of 0.94 (Lai et al., 2019). To facilitate the rating process, the authors made an administration manual that was designed to assist assessors in performing the HomeMET rating easily. Moreover, a standard rating form was designed for raters. During the testing of Home-MET, the examiner followed the subjects through five different parts of their own home (includes entrance to the house, living area, kitchen, toilet and bedroom) and used the scoring template to document each subject’s performance as depicted in Fig. 1. Instructions were also prepared in Chinese to ensure that all subjects were given the same instructions. An assessment form would be used to record the number of locations visited and the path subjects took to complete those assigned tasks. Rule breaks would be identified as an action taken by the subject that violated rules enlisted. As in its buddy version of Chinese-MET, performance efficiency in the ratio of the tasks completed to the total number of locations visited would be collected in the Home-MET. A higher performance efficiency score represents better executive function. In the work by Lai et al. (2019), the performance efficiency score of older adults with mild to moderate dementia was 0.98 + 0.11; while 2.28 + 0.04 for normal healthy older adults (Lai et al., 2019).
2. Methods This is a validation study of a home-based performance-based evaluation of executive function – The Home-MET. The study procedures included (a) inter-rater reliability is applying the Home-MET, (b) testretest reliability in older adults with MCI, (c) exploratory analysis by correlating EF performance in subjects’ own living environment with their EF performance in hospital situation, (d) constructs comparison, by comparing this Home-MET with functional disability assessment by Chinese Disability of Dementia (CDAD; Mok et al., 2005), with cognitive ability by Hong Kong Montreal Cognitive Assessment (HK-MoCA; Wong et al., 2009); with attention control was assessing by Test of Everyday Attention (TEA; Robertson, Ward, Ridgeway, & NimmoSmith, 1996); with working memory was assessing with Trail Making Test (TMT; Gaudino, Geisler, & Squires, 1995); with inhibitory control was assessing by Stroop Test (Lu, Boone, Jimenez, & Razani, 2004)). Sample size estimation was calculated based on the effect size reported in some recent studies of neuropsychological test in measuring older adults with MCI. With alpha = .05 and with power = .8, the reported Cohen’s d for attention control is 0.66 (van der Leeuw et al., 2017), working memory is 0.66 (Setti, Loughman, Savva, & Kenny, 2015) and inhibitory control is 0.67 (Gunner, Miele, Lynch, & McCaffrey, 2012). Based on an alpha level of 0.05, a statistical power of 0.8 with two groups, collectively, it is estimated that a sample size of 58 subjects in experimental group and 58 are required for the control. With the consideration of 15 % attrition rate, 65 subjects will be recruited in both groups. 3. Subjects Subjects were recruited from a local hospital with different functional disabilities due to cognitive impairment. All of them should be aged 65–80 and diagnosed with MCI by psychiatrists using the ICD-11 diagnostic criteria (World Health Organization, 2018) and should have a MoCA-HK score between 18–21. They provided an informed consent with the presence of their first-degree relatives. Moreover, recruited older adults should have with a Clinical Dementia Rating (CDR) level 1 (mild). Subjects with a history of a prior cerebrovascular accident (CVA) or were excluded. The health control group composed of a group of older adults (with a MoCA-HK score above 25). Their age and demographic characteristics like socio-economic status, family structure, and time of family caring would be carefully-matched with those of the
Fig. 1. The Home-MET. 2
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4.2. Attention control
4.6. Cognitive assessment
The Test of Everyday Attention (TEA; Robertson et al., 1996) was developed to assess individuals with attentional deficits. Attention control in older adults was explored by an examiner on three subsets of everyday living in an ecological experimental setting (Silveri et al., 2007). These subsets consist of 1) selective attention by map search and to collect the number of correct responses in 2 min; 2) attentional switching by visual elevator and to calculate the number of correct switches and the ratio between the number of correct switches (up and down) and execution time (seconds) of correct switches (time per switch) and 3) visual selective attention and to document the ratio between the number of correctly detected targets and execution time (seconds) for correct targets (time per target).
The Hong Kong- Montreal Cognitive Assessment (HK-MoCA; Wong et al., 2009) is an examiner rated cognitive screening test covering a comprehensive set of cognitive domains. These include visuospatial functions, naming, attention and working memory, language, abstraction and orientation, which are affected in common cognitive disorders. Its validation study showed that sensitivity in detecting early cognitive impairment reached 90 % and its specificity reached 87 %. It is a validated tool for detecting cognitive impairment of Chinese people at an early stage. A score below 22 should prompt further diagnostic assessment. The test’s sensitivity is comparable with that of the Cantonese version of the Mini-Mental State Examination for detection of MCI. It is practical test to conduct in the clinical setting and can be completed in less than 15 min. The MoCA scores range from 0 to 30. A higher score represents better cognitive function.
4.3. Working memory The Trail Making Test (TMT) is a neuropsychological assessment on working memory (Allen, Haderlie, Kazakov, & Mayfield, 2009; Sanchez-Cubillo et al., 2009). The TMT is an examiner-rated test, the goal of which is to complete the tests as accurately and quickly as possible. Literature suggested that TMT-A requires mainly visuo-perceptual abilities, TMT-B reflects primarily working memory and secondarily task-switching ability, while B-A minimizes visuo-perceptual and working memory demands, providing a relatively pure indicator of executive control abilities (Sanchez-Cubillo et al., 2009).
4.7. Procedures The Home-MET for this study was administered in subject’s own home within three days of their discharge from hospital. Certificated occupational therapists rated individual subjects’ performance and would instruct subjects to stop when they reach the 30 min limit. The set of neuropsychological tests like TEA, TMT, Stroop test, the disability assessment CDAD and cognitive assessment HK-MoCA would be conducted on the same day at subjects’ own home. To facilitate rating of raters, subjects’ performance would be videotaped. This same set of assessments would be conducted in a three months interval. The three months interval was chosen because this was considered as an optimal period of evaluation with the consideration of resources and drop-out rate as experienced by the research team.
4.4. Inhibitory control The Stroop Color-Word Test is an examiner-rated test in cognitive psychology (Koss, Ober, Delis, & Friedland, 1984) and was used to assess for the inhibitory control (Fernandez-Duque & Black, 2008; Klekociuk, Summers, Vickers, & Summers, 2014). For easier reading of subjects, both control and experimental Stroop cards were printed in A3 size paper with font size 40 for each word. The experimental card consisted of ten columns and ten rows printed in five different colors. Colors used were red, blue, green, brown, and purple. For control card, errors were checked by similar card written in black ink whereas for incongruent card the check card was substituted with word matching the color subject had to speak. The subjects were asked to correct the error if they made it. Individuals’ time of completion and error rates will be documented.
4.8. Statistical analysis In evaluating inter-rater reliability, subjects’ performance on the Home-MET was scored by two independent occupational therapists at the same time, while they were remaining blinded to the subjects’ status. Their scores were based on the given standardized observation form and scoring protocol. The intra-class correlation coefficient (ICC) and 95 % confident intervals were calculated. Standard descriptive statistics were computed for continuous data and frequency distributions for non-continuous data. We used Student’s t tests to compare MCI subjects with control subjects regarding their Chinese-MET, Home-MET scores, Chinese DAD, TEA test, TMT, MoCAHK and Stroop test scores. For construct comparison, Pearson correlation coefficients were computed to compare scores on these parameters. We used p values less than .05 and applied Bonferroni corrections for multiple comparisons as the criteria for significance. The univariate analyses would be performed with all subjects grouped together as well as with a sub-group that was limited to older adults with MCI. Hierarchical linear regression model was used to determine the group difference for the cognitive tests, neuropsychological tests and performance-based executive function measurements. Two time points were treated as the within-subjects factor (effect over time) and the differences between the health control and MCI groups were treated as the between-subjects factor. Moreover, demographic information of subjects was collected for analysis. Covariates such as age, sex, educational level, and the intervention group were included in the logistic model. Moreover, hierarchical linear regression model with backward method would be used for predictive analyses of the HomeMET.
4.5. Disability assessment The Chinese version of the Disability Assessment for Dementia (CDAD; Mok et al., 2005) is modeled from its original version - the Disability Assessment for Dementia Scale (Gelinas, Gauthier, McIntyre, & Gauthier, 1999). This is an examiner-rated test aimed at evaluating functional disability in people with dementia for community dwelling (Mok et al., 2005). It has 11 subscales: personal hygiene, dressing, continence, eating, meal preparation, telephoning, going on an outing, handling finances, medications, housework and leisure. In the study of convergent validity, the IADL sub-scores of the CDAD was found to have a high correlation with the Instrumental Activities of Daily Living Scale (r = 0.94, p < .001). The internal consistency of the scale was high (Cronbach’s a = 0.91). Estimated from a sample of 30 subjects, test-retest reliability (ICC = 0.99) and inter-rater reliability (ICC = 0.98) were excellent. The CDAD assesses subjects’ ability to initiate, organize and execute the identified daily activities. The CDAD score ranges from 0 to 40. The CDAD is an examiner-rated measure; a higher CDAD score represents better functional performance with lesser disability. 3
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Table 1 Reliability Testing of the Home-MET (n = 20). Home MET
Interrater Reliability (ICC) (n = 20)
Test-retest Reliability (ICC) (n = 20)
1. 2. 3. 4. 5. 6.
.97 .94 .96 .95 .95 .96
.95 .92 .89 .93 .91 .93
Total Time to Complete Total Number of Locations Visited Total Number of Tasks Completed Total Number of Passes Total Number of Rule Breaks Performance Efficiency Score
(95 (95 (95 (95 (95 (95
% % % % % %
C.I. = .91–.98) C.I. = .89–.96) C.I. = .92–.98) C.I. = .91–.98) C.I. = .92–.98) C.I. = .91–.97)
5. Results
(95 (95 (95 (95 (95 (95
% % % % % %
C.I. = .91–.96) C.I. = .84–.91) C.I. = .86–.94) C.I. = .84–.95) C.I. = .86–.97) C.I. = .87–.94)
There is significant correlation between the performance efficiency score in hospital-based performance-based executive function as measured by the Chinese-MET and the home-based evaluation of HomeMET, with correlation coefficient = .95 as shown in Table 3. Examination of the mean scores of the subjects’ time to complete, number of locations visited, number of tasks completed, total number of passes, total number of rule breaks, and performance efficiency on the Home-MET result in the data listed in Table 4. Differences between the control subjects and the MCI group are significant for the majority of the Home-MET component scores, including total time to complete (p < .05), total number of locations visited (p < .05), total number of tasks completed (p < .05), total number of passes (p < .01), total number of rule breaks (p < .01), and performance efficiency (p < .01). These results support the discriminant validity of the HomeMET for people with MCI. Thus, deficiencies of executive function can be identified by the Home-MET. Subjects’ performance efficiency scores from the Home-MET has a moderate to high correlation with those from the MoCA-HK (r = .88, p < .01), the Chinese DAD (r = .77, p < .01), the TEA (r = .86, p < .01), the TMT time (r = .72, p < .01), and the Stroop Test (r = .86, p < .01) as in Table 5. When we compare those results with the other standards of disability and cognitive measures, the Home-MET shown to be reliable and valid in assessing the executive function of community-residing older adults with MCI. The analysis of the relationship indicates the Home-MET is not correlated with sociodemographic factors, Kruskal–Wallis Test was conducted to examine the differences on Home-MET to sex, there is no significant differences shown with Chi square = 6.35, p > .05; and years of education (r = .48, p > .05), but there is significant but low correlation with age (r = .35, p < .05). To elucidate the clinical prediction rules and for further classification of executive function, a two-stage hierarchical linear regression model with backward method was used. Taken age and gender in stage one and other potential candidate predictors like attention control,
5.1. Reliability of the Home-MET ratings The reliability testing was completed with 20 subjects comprised 11 males and 9 females, with ages ranging from 66 to 79 (mean age = 71.38, SD = 3.81), and with educational levels from 6 years to 10 years (mean = 6.98, SD = 3.59). They received their initial assessment on their third day after discharge from hospital and one week after the initial assessment. Results shows excellent inter-rater reliability for the Home-MET (ICC = .95, with 95 % CI: 0.89–.98), with individual items’ ICC values ranging from 0.94 to .97 (95 % CI: .89–.98), as shown in Table 1. Moreover, there is good test-retest reliability, with an ICC value of 0.95 (with individual items’ ICC values ranging from 0.89 to 0.95 (95 % CI: .84–.97), and good to excellent internal consistency, with a Cronbach’s α of 0.93. 5.2. Validity of the Home-MET Among the 80 MCI participants, there were 53 males and 27 females, with ages ranging from 66 to 82 (mean age = 71.34, SD = 6.82), and with educational levels ranging from 6 years to 11 years (mean = 7.45, SD = 2.39). Eighty matched control subjects comprised 52 males and 18 females, with ages ranging from 66 to 82 (mean age = 71.35, SD = 11.34), and with educational levels from 6 years to 12 years (mean = 8.89, SD = 2.12) were included in this study. With the careful matching, neither the control group subjects nor the subjects with MCI show a significant difference in their socio-demographics, with respect to age, sex, race, or years of education (p > .05). Results support the premise that subjects with MCI had overt deficits in cognitive function, attention control, working memory, inhibitory control and disability assessment, as shown in their HK-MoCA score, TEA tests, TMT time and error score, Stroop test and CDAD performance, all with p < .05, as shown in Table 2. Table 2 Measurement of between Control and Experimental Group (N = 160). Variables
Performance Efficiency Score of Home-MET Performance Efficiency Score of the Chinese-MET MoCA-HK TEA attention control TEA attention switching TEA Visual Selective Attention TEA Sustained and Divided Attention TMT B (errors) TMT B (time in second) TMT B – TMT A Stroop Test (time in second) Stroop Test (errors) Chinese DAD_ADL Executive Chinese DAD_IADL Executive Chinese DAD
Control Group (n = 80)
MCI (n = 80)
Initial
3 months
Initial
3 months
.98 + .04 .98 + .04 28.32 + 1.41 72.76 + 3.63 7.42 + .49 14.44 + 3.42 19.36 + 6.05 .65 + .32 76.66 + 6.90 51.36 + 4.43 161.02 + 20.88 1.12 + .96 .87 + .05 .85 + .04 .88 + .12
.98 + .04 .99 + .04 28.29 + 1.33 72.74 + 3.65 7.38 + .52 14.54 + 3.39 19.20 + 6.13 .75 + .47 76.62 + 6.76 51.34 + 4.42 162.62 + 22.23 1.20 + .86 .86 + .05 .84 + .04 .87 + .13
.63 + .07 .56 + .11 20.96 + 1.32 38.26 + 11.83 3.82 + 1.13 9.46 + 2.56 17.72 + .86 2.39 + 1.23 206.28 + 37.31 114.90 + 39.92 277.18 + 32.11 5.20 + 1.48 .72 + .07 .53 + .08 .31 + .12
.62 + .06 .56 + .10 20.88 + 1.29 38.22 + 11.82 3.80 + 1.14 9.42 + 2.72 17.68 + .96 2.51 + 1.42 205.34 + 37.93 113.96 + 51.34 277.29 + 33.45 5.14 + 1.48 .71 + .07 .53 + .07 .31 + .12
Note. * p < .05, ** p < .01. 4
p
Cohen’s d
.01** .01** .02* .01** .02* .02* .06 .02* .01** .03* .04** .01* .05* .01** .02*
6.15 5.08 4.57 3.97 4.13 1.67 .38 4.98 4.88 2.26 4.18 3.32 2.66 5.34 5.98
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Table 3 Correlation Analysis of the Home-MET and Chinese-MET in MCI subjects (n = 160).
Chinese-MET Time of completion Location visited Tasks completed Number of Rule Breaks Performance Efficiency Score
Time of Completion in Home-MET
Location visited in Home-MET
Tasks Completed in Home-MET
Number of Rule Breaks in Home-MET
Performance Efficiency Score in Home-MET
.83 ** .34** .96** .80** −.89**
.52 ** .84** .44** .60** .42**
.80** .31** .96** −.73** .77**
.85** .45** −.68** .92** −.89**
−.90** .42** .77** −.89** .95**
Correlation Analysis between Chinese-MET and Home-MET (N = 160). Note. * p < .05, ** p < .01. Table 4 Measurement of Home-MET between Health Control and MCI subjects (N = 160). Variables
Control Group (n = 80)
MCI (n = 80)
Home-MET
Pre
Post
Pre
Post
Total Time to Complete Total Number of Locations Visited Total Number of Tasks Completed Total Number of Rule Breaks Performance Efficiency Score
22.92 + 1.96 5.00 + .00 11.80 + .45 .52 + .47 .98 + .04
22.98 + 1.95 4.95 + .05 11.28 + .78 .54 + .48 .97 + .04
29.52 + .54 5.48 + .50 7.84 + 1.48 4.20 + 1.21 .63 + .07
29.56 + .56 5.40 + .61 7.52 + 1.31 4.08 + 1.14 .62 + .06
p
Cohen’s d
.03* .05* .01** .01** .01*
4.68 4.10 3.66 4.42 6.15
Note. * p < .05, ** p < .01, *** p < .001.
evaluation in the home of older adults. The Home-MET showed significant correlation with selection attention, attentional switching and visual selection. This finding supports attention control is very important in performing their activities of daily living. Our attention selection system is required to select relevant processes or stimuli and to inhibit irrelevant ones and maintain preparedness in the absence of external signs for our activities of daily living (van der Leeuw et al., 2017). Visual search is also one of the domains of visual processing that deteriorates with ageing in a manner that relates to visual attention decline (Madden, 2007). The natural decline in visual processing in ageing has a number of consequences on the ability to perform daily living tasks such as navigating the environment, including the possibility of suffering a fall in older adults (Anstey, Wood, Kerr, Caldwell, & Lord, 2009) and looking for a particular object or a person among others (Sekuler & Ball, 1986). These processes also mediate the successful training of visual capacities to improve daily living activities (Edwards, Ruva, O’Brien, Haley, & Lister, 2013). The Home-MET showed its correlation with working memory as assessed by TMT. This also indicate working memory crucial for their executive function, the deterioration can indicate their pacing of deterioration. Working memory is consequently one of the general processes targeted by the new generation of process-based cognitive training. The assumption that working memory is trainable is based on evidence of the plasticity of our cognitive system across the whole life span (Hertzog, Kramer, Wilson, & Lindenberger, 2008). According to the continuity model (Cornoldi & Vecchi, 2003), working memory is characterized by different processes that depend on the type of content processed (verbal vs. spatial) and also on the involvement of executive control. By improving working memory, its related processes can also theoretically be enhanced. Literature showed the working memory model distinguished between a “basic structure” (a sort of personal biological equipment), and a “used ability” determined by the way in which individuals use their working memory (Vecchi, Monticellai, & Cornoldi, 1995). Another well-cited meta-analysis focusing on aging (Karbach & Verhaeghen, 2014), showed that working memory training for MCI could promote significant gains both in the trained tasks and in other similar tasks (near transfer effects). There also seemed to be some improvements in untrained tasks that shared some cognitive processes with the task used in the training (far transfer effects), though they
working memory and inhibitory control as in stage 2. The regression model shows with R2 = .93 with functional disability of CDAD shows to be a marginally significant predictor (p < .059) for the Home-MET. When the analyses were limited to subjects with a MCI, a two groups pretest-posttest ANOVA with repeated-measures for Home-MET showed a significant effect of group (p = .01) and there is no significant group × time interaction in Home-MET (p = .06) indicating there is no change in home-based executive function performance over three months. Tests of simple main effects shows that the health control group exhibited steady home-based executive function (p < .05) scores compared to baseline, but not in the MCI group. The repeatedmeasures ANOVA for selective attention and working memory (p = .03) shows a significant effect of time. However, there are no main effects of group and no group × time interactions. The repeated-measures ANOVA shows a significant group × time interaction (p < .05) in inhibitory control. There are no main effects of group or time. Tests of simple main effects reveal that the subjects in the control group showed increased executive function (p = .01) over time, compared with their baseline scores 6. Discussion The present study examined the association of multiple executive function elements (i.e., attention control, working memory, inhibitory control), functional disability and cognitive function in older adults with and without cognitive impairment. There is significant correlation (r = .95, p < .01) between the Home-MET and the hospital-based measure Chinese MET. This high correlation result indicated these two sets of instruments are measuring the same dimension. The performance efficiency score Home MET in MCI subject is .63 + .06, that is comparatively higher than the Chinese MET score (.56 + .10) and with lesser rule breaks when compared with their executive function performance in the same hospital environment. Home environment is a more familiarized environment- when compared with the original version of Chinese-MET. The Home-MET provides a more familiar environment of subjects in performing the functional test. With lesser disturbance and distraction from environment, subject can more concentrate on his / her own tasks performance. This validated home-based evaluation can help domiciliary health care professionals to implement performance-based executive function 5
Archives of Gerontology and Geriatrics 87 (2020) 104012
were usually small in terms of effect size. Moreover, our present findings echoed the work by Jefferson, Paul, Ozonoff, and Cohen (2006) that working memory correlated with the activity of daily living in older adults with cognitive impairment. Interestingly, the card-reading version of the Stroop task has already been reported in a number of previous conversion studies, although there appear to be some inconsistencies in the results from these studies (Sarazin et al., 2007). In our present study, with attention control and working memory, inhibitory control formulated a good regression model with R2 = .93. There was significant correlation between executive function with inhibitory control as measured by Stroop test with r = .86, p < .01. Moreover, there is a highly significant correlation between inhibitory control and selective attention with r = .94, p < .01. This remarkable correlation can be explained by inhibitory control is defined as a mechanism of attentional selection, which comprises three aspects: an access function, a deletion function, and a restraint function (Albert, Blacker, Moss, Tanzi, & McArdle, 2007). While the access function prevents irrelevant information from entering the working memory system, the deletion function supports the updating of momentarily important information by suppressing the activation of no longer relevant information. Finally, the restraint function aims at suppressing strong, but irrelevant, information in order to enable the activation of weaker, but potentially more important, information. Acting in concert, the three functions ensure a proper functioning of working memory. To our knowledge, this is the first study that directly examines the influence of inhibitory control on performance-based executive function. Therefore, the present results are of particular theoretical relevance as they are consistent with the inhibitory deficit view and its predictions concerning age-related working memory functioning and to performance-based executive function measures. Some literature comments executive function comprises of more factors like mental flexibility, verbal fluency, planning and processing speed as reported by (Cercy, 2012). However, it is believed that too lengthy assessment would increase the mental loading of subjects that would jeopardize the quality of assessment results.
.73** .85* .58* .71** .71** .58** .85** .73**
.57** .70** .83**
.77** .70**
.94** .77** .82**
.94**
.82** .83** .57*
.77** .83** .68* .59* .82** .82** .81** .82**
.85** .76**
.86** .72** .86** .86** .77** . 88 **
.62**
TEA Test Attentional Switching TEA Test Selective Attention Disability Assessment Chinese DAD Cognitive Assessment HK-MoCA
.83**
This study indicates the Home-MET can provide an objective measure of executive function for subjects with MCI in their real-life daily living tasks and in their own real-life situation. This validated homebased evaluation can help domiciliary health care professionals to implement performance-based executive function evaluation in participants’ own daily living and use their own everyday home materials.
.77**
.81** .82** .68** .85**
.87**
.82** .82** .59* .76**
.87**
7. Conclusion
Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
.86**
.86** .86** .62** .72**
.88** .77**
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Home-MET Performance Efficiency Cognitive Assessment HK-MoCA Disability Assessment Chinese DAD TEA Test Selective Attention TEA Test Attentional Switching TEA Test Visual Selection Working Memory Trail Making Test Inhibitory Control Stroop Test (time)
Home-MET Performance Efficiency
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TEA Test Visual Selection
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Home-based evaluation of executive function (Home-MET) for older adults with mild cognitive impairment
T
Frank Ho-yin Laia,*, Elaine Wai-hung Yanb, Kathy Ka-ying Yuc a
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong Occupational Therapy Department, Kowloon Hospital, Hong Kong c The Salvation Army Tai Po Integrated Service for Senior Citizens, The Salvation Army Hong Kong and Macau Command, Hong Kong b
A R T I C LE I N FO
A B S T R A C T
Keywords: Home-based Mild cognitive impairment Performance-based executive function
Introduction: Executive function helps older adults maintain their activities of daily living by making plans, setting goals, and carrying them out successfully. It is important for their independence in community living. Methods: With a carefully match-group of 80 mild cognitive impaired with 80 health control subjects. The homebased evaluation of executive function (Home-MET) was validated in subjects’ own living environment. Results: This Home-MET showed significant correlation in the assessment of attention control that was assessing by Test of Everyday Attention (TEA) (r = .86, p < .01), with working memory that was assessed with Trail Making Test (TMT) (r = .72, p < .01), with inhibitory control that was assessing with Stroop Test (r = .86, p < .01), with individuals’ functional disability was assessed by Chinese Disability Assessment of Dementia (CDAD) (r = .77, p < .01) and cognitive assessment was assessed by Hong Kong Montreal Cognitive Assessment (HK-MoCA) (r = .88, p < .01). By benchmarking with the validated performance-based executive function assessment, the Home-MET shows significant correlation (r = .92, p < .05) with the executive function test in a standard environment in hospital, i.e. the Chinese Multiple Errands Test (the Chinese-MET). The two-stage hierarchical linear regression model with backward method showed functional disability was a marginally significant predictor (p < .059) for the Home-MET with regression model showed with R2 = .93. Conclusion: Results indicated the Home-MET, can provide an objective measure of executive function for subjects with mild cognitive impairment in participants’ own home environment.
1. Introduction Memory impairment was considered as the chief complaint of deterioration in daily living by older adults with mild cognitive impairment, MCI in short (Avila et al., 2015). The underlying deficits in executive function (EF) also significantly contributed to their functional disabilities (Brandt et al., 2009; Kirova, Bays, & Lagalwar, 2015). EF has shown to be important, especially in the fast and complicated contemporary world, because it has been considered as central to independent daily living (Garcia-Alvarez, Gomar, Sousa, Garcia-Portilla, & Goldberg, 2019), solve problems (Leyhe, Saur, Eschweiler, & Milian, 2011; Rainville, Lepage, Gauthier, Kergoat, & Belleville, 2012), and resolve conflicts (Seo, Kim, Lee, & Choo, 2016). EF was considered as a vital part of the independent living skills of older adults with dementia in community living (Marshall et al., 2011). Some researchers commented that executive function is the core psychological deficit underlying dysfunction of mild cognitive impairment (Zhang et al., 2018).
⁎
The resulting functional disabilities were the major cause of extended hospital stays (Bettcher, Giovannetti, Macmullen, & Libon, 2008) and protracted residential care (Avila et al., 2015). Theoretically, Miyake and colleagues proposed a valid and well known 3-components model of EF that included updating working memory, inhibition, and shifting (Miyake et al., 2000). Updating working memory is the continuous monitoring with quick addition or deletion of contents within one's working memory. Inhibition is defined as one's capacity to supersede responses that are prepotent in a given situation. Shifting is one's cognitive flexibility to switch between different tasks or mental states. The cornerstone of their theoretical model is the understanding of individual differences in executive functions reflect both unity (i.e., common executive function skills) and diversity of each component (i.e. updating -specific, inhibition-specific or shifting-specific), that is these aspects are related, yet each remains a distinct entity. Clinically, EF was considered as a fluid functional ability construct
Corresponding author. E-mail addresses: [email protected] (F.H.-y. Lai), [email protected] (E.W.-h. Yan), [email protected] (K.K.-y. Yu).
https://doi.org/10.1016/j.archger.2020.104012 Received 6 October 2019; Received in revised form 29 December 2019; Accepted 14 January 2020 Available online 16 January 2020 0167-4943/ © 2020 Elsevier B.V. All rights reserved.
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mild cognitive impaired subjects. Health control subjects would be recruited by purposeful sampling through volunteer service in local volunteer service for older adults with dementia.
(Marshall et al., 2011), a collective term referring to a set of cognitive functions that includes attention control, working memory, and inhibitory control (Faria, Alves, & Charchat-Fichman, 2015; Seo et al., 2016). Attention control allows us to shift our attention when necessary, directing it to the most important tasks and sustaining it while we are working on other tasks (Silveri, Reali, Jenner, & Puopolo, 2007). It enables individuals to switch focus quickly from one thing to another. Working memory is the ability to store information relevant to this ongoing task; it allows us to store important information so we can access it when needed (Royall et al., 2002). Inhibitory control is the ability to restrict incompatible thoughts. It helps us resist impulses, keeps us on task, and enables us to set goals and carry them out (Kaiser, Kuhlmann, & Bosnjak, 2018). For the purpose of specific executive function training for older adults with MCI, a clearer understanding of these fluid constructs in EF needs to be further examined and studied. The use of hospital environment had provided an objective environment in evaluating the EF of subjects (Lai et al., 2019). However, the unfamiliar and busy environment in hospital with the inclusion of social interactions with unfamiliar others in hospital involved subjects’ social-cognition ability and personal confidence. Literatures suggested individuals’ EF performance would be better in their familiar environment (Avila et al., 2015; Lai et al., 2019). However, just very few studies tried to accomplish this goal (Yu et al., 2012).
4. Instruments 4.1. Performance-based executive function The Home Multiple Errands Test (The Home-MET) is modeled from The Chinese Multiple Errands Test (The Chinese MET; Lai et al., 2019). The Chinese MET is a performance-based evaluation of EF by using realworld daily living activities in a hospital environment. Like its original English version, the Chinese-MET is an examiner rated measurement for executive function. Chinese-MET demonstrated excellent inter-rater reliability (ICC = .95, with 95 % CI: 0.88–.98), good test-retest reliability, with an ICC value of 0.92; with individual items’ ICC values ranging from 0.90 to .95 (95 % CI: 0.84–.96), and good to excellent internal consistency, with a Cronbach’s a of 0.94 (Lai et al., 2019). To facilitate the rating process, the authors made an administration manual that was designed to assist assessors in performing the HomeMET rating easily. Moreover, a standard rating form was designed for raters. During the testing of Home-MET, the examiner followed the subjects through five different parts of their own home (includes entrance to the house, living area, kitchen, toilet and bedroom) and used the scoring template to document each subject’s performance as depicted in Fig. 1. Instructions were also prepared in Chinese to ensure that all subjects were given the same instructions. An assessment form would be used to record the number of locations visited and the path subjects took to complete those assigned tasks. Rule breaks would be identified as an action taken by the subject that violated rules enlisted. As in its buddy version of Chinese-MET, performance efficiency in the ratio of the tasks completed to the total number of locations visited would be collected in the Home-MET. A higher performance efficiency score represents better executive function. In the work by Lai et al. (2019), the performance efficiency score of older adults with mild to moderate dementia was 0.98 + 0.11; while 2.28 + 0.04 for normal healthy older adults (Lai et al., 2019).
2. Methods This is a validation study of a home-based performance-based evaluation of executive function – The Home-MET. The study procedures included (a) inter-rater reliability is applying the Home-MET, (b) testretest reliability in older adults with MCI, (c) exploratory analysis by correlating EF performance in subjects’ own living environment with their EF performance in hospital situation, (d) constructs comparison, by comparing this Home-MET with functional disability assessment by Chinese Disability of Dementia (CDAD; Mok et al., 2005), with cognitive ability by Hong Kong Montreal Cognitive Assessment (HK-MoCA; Wong et al., 2009); with attention control was assessing by Test of Everyday Attention (TEA; Robertson, Ward, Ridgeway, & NimmoSmith, 1996); with working memory was assessing with Trail Making Test (TMT; Gaudino, Geisler, & Squires, 1995); with inhibitory control was assessing by Stroop Test (Lu, Boone, Jimenez, & Razani, 2004)). Sample size estimation was calculated based on the effect size reported in some recent studies of neuropsychological test in measuring older adults with MCI. With alpha = .05 and with power = .8, the reported Cohen’s d for attention control is 0.66 (van der Leeuw et al., 2017), working memory is 0.66 (Setti, Loughman, Savva, & Kenny, 2015) and inhibitory control is 0.67 (Gunner, Miele, Lynch, & McCaffrey, 2012). Based on an alpha level of 0.05, a statistical power of 0.8 with two groups, collectively, it is estimated that a sample size of 58 subjects in experimental group and 58 are required for the control. With the consideration of 15 % attrition rate, 65 subjects will be recruited in both groups. 3. Subjects Subjects were recruited from a local hospital with different functional disabilities due to cognitive impairment. All of them should be aged 65–80 and diagnosed with MCI by psychiatrists using the ICD-11 diagnostic criteria (World Health Organization, 2018) and should have a MoCA-HK score between 18–21. They provided an informed consent with the presence of their first-degree relatives. Moreover, recruited older adults should have with a Clinical Dementia Rating (CDR) level 1 (mild). Subjects with a history of a prior cerebrovascular accident (CVA) or were excluded. The health control group composed of a group of older adults (with a MoCA-HK score above 25). Their age and demographic characteristics like socio-economic status, family structure, and time of family caring would be carefully-matched with those of the
Fig. 1. The Home-MET. 2
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4.2. Attention control
4.6. Cognitive assessment
The Test of Everyday Attention (TEA; Robertson et al., 1996) was developed to assess individuals with attentional deficits. Attention control in older adults was explored by an examiner on three subsets of everyday living in an ecological experimental setting (Silveri et al., 2007). These subsets consist of 1) selective attention by map search and to collect the number of correct responses in 2 min; 2) attentional switching by visual elevator and to calculate the number of correct switches and the ratio between the number of correct switches (up and down) and execution time (seconds) of correct switches (time per switch) and 3) visual selective attention and to document the ratio between the number of correctly detected targets and execution time (seconds) for correct targets (time per target).
The Hong Kong- Montreal Cognitive Assessment (HK-MoCA; Wong et al., 2009) is an examiner rated cognitive screening test covering a comprehensive set of cognitive domains. These include visuospatial functions, naming, attention and working memory, language, abstraction and orientation, which are affected in common cognitive disorders. Its validation study showed that sensitivity in detecting early cognitive impairment reached 90 % and its specificity reached 87 %. It is a validated tool for detecting cognitive impairment of Chinese people at an early stage. A score below 22 should prompt further diagnostic assessment. The test’s sensitivity is comparable with that of the Cantonese version of the Mini-Mental State Examination for detection of MCI. It is practical test to conduct in the clinical setting and can be completed in less than 15 min. The MoCA scores range from 0 to 30. A higher score represents better cognitive function.
4.3. Working memory The Trail Making Test (TMT) is a neuropsychological assessment on working memory (Allen, Haderlie, Kazakov, & Mayfield, 2009; Sanchez-Cubillo et al., 2009). The TMT is an examiner-rated test, the goal of which is to complete the tests as accurately and quickly as possible. Literature suggested that TMT-A requires mainly visuo-perceptual abilities, TMT-B reflects primarily working memory and secondarily task-switching ability, while B-A minimizes visuo-perceptual and working memory demands, providing a relatively pure indicator of executive control abilities (Sanchez-Cubillo et al., 2009).
4.7. Procedures The Home-MET for this study was administered in subject’s own home within three days of their discharge from hospital. Certificated occupational therapists rated individual subjects’ performance and would instruct subjects to stop when they reach the 30 min limit. The set of neuropsychological tests like TEA, TMT, Stroop test, the disability assessment CDAD and cognitive assessment HK-MoCA would be conducted on the same day at subjects’ own home. To facilitate rating of raters, subjects’ performance would be videotaped. This same set of assessments would be conducted in a three months interval. The three months interval was chosen because this was considered as an optimal period of evaluation with the consideration of resources and drop-out rate as experienced by the research team.
4.4. Inhibitory control The Stroop Color-Word Test is an examiner-rated test in cognitive psychology (Koss, Ober, Delis, & Friedland, 1984) and was used to assess for the inhibitory control (Fernandez-Duque & Black, 2008; Klekociuk, Summers, Vickers, & Summers, 2014). For easier reading of subjects, both control and experimental Stroop cards were printed in A3 size paper with font size 40 for each word. The experimental card consisted of ten columns and ten rows printed in five different colors. Colors used were red, blue, green, brown, and purple. For control card, errors were checked by similar card written in black ink whereas for incongruent card the check card was substituted with word matching the color subject had to speak. The subjects were asked to correct the error if they made it. Individuals’ time of completion and error rates will be documented.
4.8. Statistical analysis In evaluating inter-rater reliability, subjects’ performance on the Home-MET was scored by two independent occupational therapists at the same time, while they were remaining blinded to the subjects’ status. Their scores were based on the given standardized observation form and scoring protocol. The intra-class correlation coefficient (ICC) and 95 % confident intervals were calculated. Standard descriptive statistics were computed for continuous data and frequency distributions for non-continuous data. We used Student’s t tests to compare MCI subjects with control subjects regarding their Chinese-MET, Home-MET scores, Chinese DAD, TEA test, TMT, MoCAHK and Stroop test scores. For construct comparison, Pearson correlation coefficients were computed to compare scores on these parameters. We used p values less than .05 and applied Bonferroni corrections for multiple comparisons as the criteria for significance. The univariate analyses would be performed with all subjects grouped together as well as with a sub-group that was limited to older adults with MCI. Hierarchical linear regression model was used to determine the group difference for the cognitive tests, neuropsychological tests and performance-based executive function measurements. Two time points were treated as the within-subjects factor (effect over time) and the differences between the health control and MCI groups were treated as the between-subjects factor. Moreover, demographic information of subjects was collected for analysis. Covariates such as age, sex, educational level, and the intervention group were included in the logistic model. Moreover, hierarchical linear regression model with backward method would be used for predictive analyses of the HomeMET.
4.5. Disability assessment The Chinese version of the Disability Assessment for Dementia (CDAD; Mok et al., 2005) is modeled from its original version - the Disability Assessment for Dementia Scale (Gelinas, Gauthier, McIntyre, & Gauthier, 1999). This is an examiner-rated test aimed at evaluating functional disability in people with dementia for community dwelling (Mok et al., 2005). It has 11 subscales: personal hygiene, dressing, continence, eating, meal preparation, telephoning, going on an outing, handling finances, medications, housework and leisure. In the study of convergent validity, the IADL sub-scores of the CDAD was found to have a high correlation with the Instrumental Activities of Daily Living Scale (r = 0.94, p < .001). The internal consistency of the scale was high (Cronbach’s a = 0.91). Estimated from a sample of 30 subjects, test-retest reliability (ICC = 0.99) and inter-rater reliability (ICC = 0.98) were excellent. The CDAD assesses subjects’ ability to initiate, organize and execute the identified daily activities. The CDAD score ranges from 0 to 40. The CDAD is an examiner-rated measure; a higher CDAD score represents better functional performance with lesser disability. 3
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Table 1 Reliability Testing of the Home-MET (n = 20). Home MET
Interrater Reliability (ICC) (n = 20)
Test-retest Reliability (ICC) (n = 20)
1. 2. 3. 4. 5. 6.
.97 .94 .96 .95 .95 .96
.95 .92 .89 .93 .91 .93
Total Time to Complete Total Number of Locations Visited Total Number of Tasks Completed Total Number of Passes Total Number of Rule Breaks Performance Efficiency Score
(95 (95 (95 (95 (95 (95
% % % % % %
C.I. = .91–.98) C.I. = .89–.96) C.I. = .92–.98) C.I. = .91–.98) C.I. = .92–.98) C.I. = .91–.97)
5. Results
(95 (95 (95 (95 (95 (95
% % % % % %
C.I. = .91–.96) C.I. = .84–.91) C.I. = .86–.94) C.I. = .84–.95) C.I. = .86–.97) C.I. = .87–.94)
There is significant correlation between the performance efficiency score in hospital-based performance-based executive function as measured by the Chinese-MET and the home-based evaluation of HomeMET, with correlation coefficient = .95 as shown in Table 3. Examination of the mean scores of the subjects’ time to complete, number of locations visited, number of tasks completed, total number of passes, total number of rule breaks, and performance efficiency on the Home-MET result in the data listed in Table 4. Differences between the control subjects and the MCI group are significant for the majority of the Home-MET component scores, including total time to complete (p < .05), total number of locations visited (p < .05), total number of tasks completed (p < .05), total number of passes (p < .01), total number of rule breaks (p < .01), and performance efficiency (p < .01). These results support the discriminant validity of the HomeMET for people with MCI. Thus, deficiencies of executive function can be identified by the Home-MET. Subjects’ performance efficiency scores from the Home-MET has a moderate to high correlation with those from the MoCA-HK (r = .88, p < .01), the Chinese DAD (r = .77, p < .01), the TEA (r = .86, p < .01), the TMT time (r = .72, p < .01), and the Stroop Test (r = .86, p < .01) as in Table 5. When we compare those results with the other standards of disability and cognitive measures, the Home-MET shown to be reliable and valid in assessing the executive function of community-residing older adults with MCI. The analysis of the relationship indicates the Home-MET is not correlated with sociodemographic factors, Kruskal–Wallis Test was conducted to examine the differences on Home-MET to sex, there is no significant differences shown with Chi square = 6.35, p > .05; and years of education (r = .48, p > .05), but there is significant but low correlation with age (r = .35, p < .05). To elucidate the clinical prediction rules and for further classification of executive function, a two-stage hierarchical linear regression model with backward method was used. Taken age and gender in stage one and other potential candidate predictors like attention control,
5.1. Reliability of the Home-MET ratings The reliability testing was completed with 20 subjects comprised 11 males and 9 females, with ages ranging from 66 to 79 (mean age = 71.38, SD = 3.81), and with educational levels from 6 years to 10 years (mean = 6.98, SD = 3.59). They received their initial assessment on their third day after discharge from hospital and one week after the initial assessment. Results shows excellent inter-rater reliability for the Home-MET (ICC = .95, with 95 % CI: 0.89–.98), with individual items’ ICC values ranging from 0.94 to .97 (95 % CI: .89–.98), as shown in Table 1. Moreover, there is good test-retest reliability, with an ICC value of 0.95 (with individual items’ ICC values ranging from 0.89 to 0.95 (95 % CI: .84–.97), and good to excellent internal consistency, with a Cronbach’s α of 0.93. 5.2. Validity of the Home-MET Among the 80 MCI participants, there were 53 males and 27 females, with ages ranging from 66 to 82 (mean age = 71.34, SD = 6.82), and with educational levels ranging from 6 years to 11 years (mean = 7.45, SD = 2.39). Eighty matched control subjects comprised 52 males and 18 females, with ages ranging from 66 to 82 (mean age = 71.35, SD = 11.34), and with educational levels from 6 years to 12 years (mean = 8.89, SD = 2.12) were included in this study. With the careful matching, neither the control group subjects nor the subjects with MCI show a significant difference in their socio-demographics, with respect to age, sex, race, or years of education (p > .05). Results support the premise that subjects with MCI had overt deficits in cognitive function, attention control, working memory, inhibitory control and disability assessment, as shown in their HK-MoCA score, TEA tests, TMT time and error score, Stroop test and CDAD performance, all with p < .05, as shown in Table 2. Table 2 Measurement of between Control and Experimental Group (N = 160). Variables
Performance Efficiency Score of Home-MET Performance Efficiency Score of the Chinese-MET MoCA-HK TEA attention control TEA attention switching TEA Visual Selective Attention TEA Sustained and Divided Attention TMT B (errors) TMT B (time in second) TMT B – TMT A Stroop Test (time in second) Stroop Test (errors) Chinese DAD_ADL Executive Chinese DAD_IADL Executive Chinese DAD
Control Group (n = 80)
MCI (n = 80)
Initial
3 months
Initial
3 months
.98 + .04 .98 + .04 28.32 + 1.41 72.76 + 3.63 7.42 + .49 14.44 + 3.42 19.36 + 6.05 .65 + .32 76.66 + 6.90 51.36 + 4.43 161.02 + 20.88 1.12 + .96 .87 + .05 .85 + .04 .88 + .12
.98 + .04 .99 + .04 28.29 + 1.33 72.74 + 3.65 7.38 + .52 14.54 + 3.39 19.20 + 6.13 .75 + .47 76.62 + 6.76 51.34 + 4.42 162.62 + 22.23 1.20 + .86 .86 + .05 .84 + .04 .87 + .13
.63 + .07 .56 + .11 20.96 + 1.32 38.26 + 11.83 3.82 + 1.13 9.46 + 2.56 17.72 + .86 2.39 + 1.23 206.28 + 37.31 114.90 + 39.92 277.18 + 32.11 5.20 + 1.48 .72 + .07 .53 + .08 .31 + .12
.62 + .06 .56 + .10 20.88 + 1.29 38.22 + 11.82 3.80 + 1.14 9.42 + 2.72 17.68 + .96 2.51 + 1.42 205.34 + 37.93 113.96 + 51.34 277.29 + 33.45 5.14 + 1.48 .71 + .07 .53 + .07 .31 + .12
Note. * p < .05, ** p < .01. 4
p
Cohen’s d
.01** .01** .02* .01** .02* .02* .06 .02* .01** .03* .04** .01* .05* .01** .02*
6.15 5.08 4.57 3.97 4.13 1.67 .38 4.98 4.88 2.26 4.18 3.32 2.66 5.34 5.98
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Table 3 Correlation Analysis of the Home-MET and Chinese-MET in MCI subjects (n = 160).
Chinese-MET Time of completion Location visited Tasks completed Number of Rule Breaks Performance Efficiency Score
Time of Completion in Home-MET
Location visited in Home-MET
Tasks Completed in Home-MET
Number of Rule Breaks in Home-MET
Performance Efficiency Score in Home-MET
.83 ** .34** .96** .80** −.89**
.52 ** .84** .44** .60** .42**
.80** .31** .96** −.73** .77**
.85** .45** −.68** .92** −.89**
−.90** .42** .77** −.89** .95**
Correlation Analysis between Chinese-MET and Home-MET (N = 160). Note. * p < .05, ** p < .01. Table 4 Measurement of Home-MET between Health Control and MCI subjects (N = 160). Variables
Control Group (n = 80)
MCI (n = 80)
Home-MET
Pre
Post
Pre
Post
Total Time to Complete Total Number of Locations Visited Total Number of Tasks Completed Total Number of Rule Breaks Performance Efficiency Score
22.92 + 1.96 5.00 + .00 11.80 + .45 .52 + .47 .98 + .04
22.98 + 1.95 4.95 + .05 11.28 + .78 .54 + .48 .97 + .04
29.52 + .54 5.48 + .50 7.84 + 1.48 4.20 + 1.21 .63 + .07
29.56 + .56 5.40 + .61 7.52 + 1.31 4.08 + 1.14 .62 + .06
p
Cohen’s d
.03* .05* .01** .01** .01*
4.68 4.10 3.66 4.42 6.15
Note. * p < .05, ** p < .01, *** p < .001.
evaluation in the home of older adults. The Home-MET showed significant correlation with selection attention, attentional switching and visual selection. This finding supports attention control is very important in performing their activities of daily living. Our attention selection system is required to select relevant processes or stimuli and to inhibit irrelevant ones and maintain preparedness in the absence of external signs for our activities of daily living (van der Leeuw et al., 2017). Visual search is also one of the domains of visual processing that deteriorates with ageing in a manner that relates to visual attention decline (Madden, 2007). The natural decline in visual processing in ageing has a number of consequences on the ability to perform daily living tasks such as navigating the environment, including the possibility of suffering a fall in older adults (Anstey, Wood, Kerr, Caldwell, & Lord, 2009) and looking for a particular object or a person among others (Sekuler & Ball, 1986). These processes also mediate the successful training of visual capacities to improve daily living activities (Edwards, Ruva, O’Brien, Haley, & Lister, 2013). The Home-MET showed its correlation with working memory as assessed by TMT. This also indicate working memory crucial for their executive function, the deterioration can indicate their pacing of deterioration. Working memory is consequently one of the general processes targeted by the new generation of process-based cognitive training. The assumption that working memory is trainable is based on evidence of the plasticity of our cognitive system across the whole life span (Hertzog, Kramer, Wilson, & Lindenberger, 2008). According to the continuity model (Cornoldi & Vecchi, 2003), working memory is characterized by different processes that depend on the type of content processed (verbal vs. spatial) and also on the involvement of executive control. By improving working memory, its related processes can also theoretically be enhanced. Literature showed the working memory model distinguished between a “basic structure” (a sort of personal biological equipment), and a “used ability” determined by the way in which individuals use their working memory (Vecchi, Monticellai, & Cornoldi, 1995). Another well-cited meta-analysis focusing on aging (Karbach & Verhaeghen, 2014), showed that working memory training for MCI could promote significant gains both in the trained tasks and in other similar tasks (near transfer effects). There also seemed to be some improvements in untrained tasks that shared some cognitive processes with the task used in the training (far transfer effects), though they
working memory and inhibitory control as in stage 2. The regression model shows with R2 = .93 with functional disability of CDAD shows to be a marginally significant predictor (p < .059) for the Home-MET. When the analyses were limited to subjects with a MCI, a two groups pretest-posttest ANOVA with repeated-measures for Home-MET showed a significant effect of group (p = .01) and there is no significant group × time interaction in Home-MET (p = .06) indicating there is no change in home-based executive function performance over three months. Tests of simple main effects shows that the health control group exhibited steady home-based executive function (p < .05) scores compared to baseline, but not in the MCI group. The repeatedmeasures ANOVA for selective attention and working memory (p = .03) shows a significant effect of time. However, there are no main effects of group and no group × time interactions. The repeated-measures ANOVA shows a significant group × time interaction (p < .05) in inhibitory control. There are no main effects of group or time. Tests of simple main effects reveal that the subjects in the control group showed increased executive function (p = .01) over time, compared with their baseline scores 6. Discussion The present study examined the association of multiple executive function elements (i.e., attention control, working memory, inhibitory control), functional disability and cognitive function in older adults with and without cognitive impairment. There is significant correlation (r = .95, p < .01) between the Home-MET and the hospital-based measure Chinese MET. This high correlation result indicated these two sets of instruments are measuring the same dimension. The performance efficiency score Home MET in MCI subject is .63 + .06, that is comparatively higher than the Chinese MET score (.56 + .10) and with lesser rule breaks when compared with their executive function performance in the same hospital environment. Home environment is a more familiarized environment- when compared with the original version of Chinese-MET. The Home-MET provides a more familiar environment of subjects in performing the functional test. With lesser disturbance and distraction from environment, subject can more concentrate on his / her own tasks performance. This validated home-based evaluation can help domiciliary health care professionals to implement performance-based executive function 5
Archives of Gerontology and Geriatrics 87 (2020) 104012
were usually small in terms of effect size. Moreover, our present findings echoed the work by Jefferson, Paul, Ozonoff, and Cohen (2006) that working memory correlated with the activity of daily living in older adults with cognitive impairment. Interestingly, the card-reading version of the Stroop task has already been reported in a number of previous conversion studies, although there appear to be some inconsistencies in the results from these studies (Sarazin et al., 2007). In our present study, with attention control and working memory, inhibitory control formulated a good regression model with R2 = .93. There was significant correlation between executive function with inhibitory control as measured by Stroop test with r = .86, p < .01. Moreover, there is a highly significant correlation between inhibitory control and selective attention with r = .94, p < .01. This remarkable correlation can be explained by inhibitory control is defined as a mechanism of attentional selection, which comprises three aspects: an access function, a deletion function, and a restraint function (Albert, Blacker, Moss, Tanzi, & McArdle, 2007). While the access function prevents irrelevant information from entering the working memory system, the deletion function supports the updating of momentarily important information by suppressing the activation of no longer relevant information. Finally, the restraint function aims at suppressing strong, but irrelevant, information in order to enable the activation of weaker, but potentially more important, information. Acting in concert, the three functions ensure a proper functioning of working memory. To our knowledge, this is the first study that directly examines the influence of inhibitory control on performance-based executive function. Therefore, the present results are of particular theoretical relevance as they are consistent with the inhibitory deficit view and its predictions concerning age-related working memory functioning and to performance-based executive function measures. Some literature comments executive function comprises of more factors like mental flexibility, verbal fluency, planning and processing speed as reported by (Cercy, 2012). However, it is believed that too lengthy assessment would increase the mental loading of subjects that would jeopardize the quality of assessment results.
.73** .85* .58* .71** .71** .58** .85** .73**
.57** .70** .83**
.77** .70**
.94** .77** .82**
.94**
.82** .83** .57*
.77** .83** .68* .59* .82** .82** .81** .82**
.85** .76**
.86** .72** .86** .86** .77** . 88 **
.62**
TEA Test Attentional Switching TEA Test Selective Attention Disability Assessment Chinese DAD Cognitive Assessment HK-MoCA
.83**
This study indicates the Home-MET can provide an objective measure of executive function for subjects with MCI in their real-life daily living tasks and in their own real-life situation. This validated homebased evaluation can help domiciliary health care professionals to implement performance-based executive function evaluation in participants’ own daily living and use their own everyday home materials.
.77**
.81** .82** .68** .85**
.87**
.82** .82** .59* .76**
.87**
7. Conclusion
Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
.86**
.86** .86** .62** .72**
.88** .77**
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