Psychomotor,Functional,and Cognitive Profiles in Older People with and without Dementia:What Connections?

Abstract

Background

In typical aging, it is possible to observe a decline in psychomotor domains, such as balance or global and fine motor skills as well as a cognitive and functional decline. Although, it is not clear which psychomotor domains are mostly affected in elderly with dementia and the association with the cognitive and functional level.

Objective

To identify the correlation between psychomotor, cognitive, and functional skills, and seeking whether there are differences among persons with and without dementia.

Design and Methods

A total of 120 persons with dementia (ages between 61 and 99 years old; mean age 80.6 ± 7.4) and 377 persons without dementia (ages between 60 and 99 years old; mean age 77.2 ± 8.7) were recruited from nursing homes, day-care centers, and home care. Consenting participants were assessed in psychomotor, cognitive, and functional domains using the Mini Mental State Examination (MMSE) to assess cognitive impairment, the Barthel Index (BI), and Lawton Index (LI) to identify basic and instrumental activities of daily living and a Portuguese Version of Éxamen Geronto-Psychomoteur (P-EGP) to evaluate psychomotor skills.

Results

People with dementia showed a higher percentage of cognitive deficit and higher level of dependency in basic and instrumental activities of daily living. Further, findings also showed significant differences in psychomotor domains and total of P-EGP, with exception of Joint Mobilizations of Upper and Lower Limbs. There were moderate to strong correlations between the totals of the scales, and between the totals and domains.

Conclusions

The population with dementia has higher percentage of cognitive deficit, higher dependency on the performance of basic and instrumental activities of daily living and poorer psychomotor performance, except in joint mobilizations. It was also possible to find strong correlations between the total of P-EGP and the total of cognitive and functional scales. Implications for future research and practice are discussed.

Keywords

aging dementia psychomotor skills cognitive abilities functional capacity

Introduction

Human aging is an inevitable progressive process that produces irreversible changes depending on biological, psychological, and social factors (Spirduso, Francis, & MacRae, 2005). In typical aging, senescence involves a gradual decline of body systems and their functions which may have implications on individual’s psychomotor domains (Albaret & Aubert, 2001). Along with many physical changes that occur as a part of the normal aging process, psychosocial tasks include accepting and adjusting to a changing body image, family roles, lifestyle, and facing the inevitability of death. In what concerns the cognitive abilities, older people usually retain their cognitive abilities until late in life, although memory shows changes particularly in short-term memory.

The psychomotor domain, recognizing the interaction between the mind (psycho) and human movement (motor) is particularly useful for referring to domains that involves human movement initiated by the higher brain centers, for example, the motor cortex since most human movement is the result of such stimulation. For instance, the reduction of speed and range of motion or the increase in simple reaction time to stimulus (Spirduso et al., 2005). The motor retardation appears to be mainly due to changes in the ability to process information related to deficits in attention, the central selection process, and programming of motor response (Spirduso et al., 2005; Woods, Wyma, Yund, Herron, & Reed, 2015). Regarding muscle tonus, in normal aging, a decrease in the contraction capacity of skeletal muscle can lead to a general state of physical frailty (Miller, Callahan, & Toth, 2014). Changes in muscular tonus in aging seem to affect more dynamic than isometric functions, influencing skills such as walking and dynamic balance (Degens, Erskine, & Morse, 2009). Since most psychomotor skills are strongly dependent on the sensory system, particularly the vision and proprioceptive system, since they facilitate information of the involvement and the relationship with the individual himself, implies that gross and fine motor skills are also affected (Spirduso et al., 2005).

There are a number of special health concerns and health-related issues for elderly people, including dementia which refers to a loss in cognitive functioning. The symptoms of dementia include memory loss, disorientation, and confusion. Also, it is possible to observe concomitantly with a decline in cognitive abilities, changes in emotional control, and social behavior (Bergh & Selbæk, 2012). These deficits affect the person’s ability to perform the basic and instrumental activities of daily life (Helvik, Engedal, Benth, & Selbæk, 2014). However, few studies describe psychomotor symptoms as an important part of the clinical profile of the people with dementia. Most of the research refers to these aspects in three clusters: as a part of behavioral and psychological symptoms (e.g., psychomotor agitation or inhibition) (Kazui et al., 2016; Trivedi et al., 2013); as related to a decline in executive functions (e.g., presence of dysgraphia; decline of praxis and visuospatial abilities) (Kuzmickienė & Kaubrys, 2016; Onofri, Mercuri, Donato, & Ricci, 2015); and as a goal of non-pharmacological therapies (e.g., balance, gait speed) (Inskip, Mavros, Sachdev, & Fiatarone Singh, 2016). Few studies mention the differences in psychomotor competences, such as static and dynamic balance or fine motor abilities of upper and lower limbs, in people with and without dementia. Also, it is very difficult to find in the literature connections between psychomotor domains, functional capacity, and cognitive abilities.

In our perspective, it is important to establish relations between these three domains, since it will enrich the profile of the person with dementia and will provide information to plan interventions. Further, current research refers to a close relation of motor and cognitive changes as early signs or predictors of functional decline in people with dementia (Boyle, Cohen, Paul, Moser, & Gordon, 2002; Scherder et al., 2007).

Therefore, our goal is to study the psychomotor, cognitive, and functional profiles of elderly with and without dementia and the correlations between these three areas. It is our purpose to add knowledge for the theoretical and empirical development achieved in this field.

Method

Design

This transversal study involved people with and without dementia, from different regions of Portugal. A quasi-experimental study design was used. Participants were recruited from different settings: nursing homes (in short, average or long stays units), day-care centers, and home care (with or without a support of the community health center, according to the level of autonomy in daily activities). Data were collected through the application of Portuguese versions of four instruments.

Participants

For this study, the participants had to have 60 or more years old, with or without dementia, living in their homes or in residential or nursing homes, located on the Portuguese regions of the north, center, metropolitan area of Lisbon, south, and Madeira Island. The exclusion criteria were the existence of motor, sensory, or learning disability as well as a non-stable psychiatric diagnosis. Also those who were unable to communicate or understand Portuguese were excluded.

Material

Procedures and measures

The ethical board of the Centre Garcia de Orta approved the research protocol, according to the Helsinki Declaration (World Medical Association, 2013). All participants were provided an informed consent for participation in this study, with a brief description of the study, goals, issues of confidentiality, and rights to withdraw from the study.

The Mini Mental State Examination (MMSE), Barthel Index, Lawton Index, and Portuguese Version of Éxamen Geronto-Psychomoteur (P-EGP) were applied by psychomotor therapists previously trained by the researchers on how to administer and score each instrument in accordance with the scales administration guidelines. Additionally, socio-demographic data and medical history were collected, including age, gender, education level, morbidity, support needs, non-pharmacological therapies (e.g., psychomotor therapy, occupational therapy, physiotherapy), physical activity routine, and the use of support devices (divided in sensorial devices such as glasses, hearing aids, or motor devices such as walking stick, tripod, and wheelchair). Data collection took place between January 2013 and September 2014 in therapeutic rooms or offices.

Assessment of mental status

The MMSE, developed in 1975 by Folstein, Folstein, and McHugh and adapted to the Portuguese population in 1994 by Guerreiro et al. (Sequeira, 2010), is one of the most widely instruments used for the screening of cognitive impairment in clinical settings and research (Morgado, Rocha, Maruta, Guerreiro, & Martins, 2009). The MMSE evaluates orientation, retention, attention and calculation, recall, language, and visual-constructional abilities. Each item is scored binomially with 0 or 1 point, and the total score ranges from 0 to 30 (the latter corresponding to the best performance). Morgado et al. (2009) indicates a good accuracy of the instrument and a moderate internal consistency (Cronbach α = 0.464). Although this study proposes new “cutoff” scores distinguishing the subjects according to the score and educational level, in our research, we used the proposed values of Guerreiro et al. (1994) (in Sequeira, 2010).

Assessment of functional capacity (basic and instrumental activity of daily living)

The Barthel Index evaluates the subject's level of independence to perform 10 basic activities of daily living (ADL): feeding, personal hygiene, use of the toilet, bathing self, dressing and undressing, sphincter control, walking on level surface, moving from the wheelchair to bed and return, and ascending and descending stairs (Hugonot-Diener, Barbeau, Michel, Thomas-Antérion, & Robert, 2010). Each activity is listed between 0, 5, 10, and 15 points, with a progressive autonomy. The total score ranges from 0 to 100 points, with the maximum score corresponding to a greater degree of autonomy. This instrument assesses the functional independence of the elderly in a global and specific way for each activity (Sequeira, 2010). Although so far validation studies for the Portuguese population and its psychometric characteristics are not available, Sequeira (2010) identified three factors that explain 75% of the total variance, mobility, hygiene, and control of sphincters. In this analysis, Barthel Index showed a good internal consistency (Cronbach's α = 0.89).

The Lawton Index evaluates elderly functioning and autonomy in eight instrumental activities of daily living (IADL—taking care of the house, washing clothes, preparing meals, shopping, using of telephone, using of transportation, using of money, and medication management). Each activity is listed 1 to 3, 1 to 4, or 1 to 5, where the higher score represents a higher degree of dependence. The total result varies from 8 to 30 points (Hugonot-Diener et al., 2010). There are no validation studies to the Portuguese population, although Sequeira (2010) conducted an analysis of psychometric properties, where a good internal consistency (Cronbach's alpha = 0.92) and a single factor that explains 65% of the total variance were identified.

Assessment of psychomotor performance

The EGP is an instrument that assesses psychomotor skills of people older than 60 years aiming to establish individual psychomotor profiles. This instrument may contribute, along with additional medical diagnosis, to guide individualized intervention plans and evaluate the effectiveness of intervention, particularly in the area of dementia care (Michel, Soppelsa, & Albaret, 2011, 2010). EGP consists of 17 items that assess the following dimensions: static and dynamic balance, joint mobilizations, praxis, fine motor skills of upper and lower limbs, knowledge of body parts, vigilance, perception, verbal and perceptive memory, spatial and temporal domain, and verbal and nonverbal communication. Each item is scored on a six-point scale, some with a set of sub-items. The order of application can be modified, with the exception of three items assessing memory that must be applied in a specific sequence and time interval. A pause is recommended if the subject is feeling tired, in pain, or uncomfortable (Michel et al., 2011, 2010). EGP also involves clinical observation with reporting qualitative aspects such as posture, problems with balance and walking, functional aspects, tonic-emotional reactions, the quality of the movement, laterality, coordination/dissociation of upper and lower limbs, tremors, and involuntary movements observed during the application (Michel et al., 2011, 2010). It is recommended an application time of about 60 minutes.

The EGP, validated for the Portuguese population (P-EGP; Morais, Santos, & Lebre, 2016), showed moderate to excellent indexes for content validity. The detailed description of procedures related with the translation and adaptation of EGP for the Portuguese context are already described in a previous paper (Morais et al., 2016). Concerning the reliability, the instrument demonstrated excellent internal consistency (all domain reliabilities exceeding .90). The total score of P-EGP (α = .92) was superior to the original study (α=.83). A strong stability demonstrated by the Pearson’s values, were all tanged above .60 with a coefficient of P-EGP total score of r=.97 (p<.01). Three main components from exploratory factor analysis were obtained, “Physical Constraints,” “Motor Prevalence,” and “Cognitive Prevalence.”

Data analysis

Statistical analyzes were undertaken using the Statistical Package for Social Sciences, version 23.0 (SPSS, 2015). Descriptive statistics and categorical variables are presented as counts or percentages. Categorical data were analyzed using χ² (Chi-square) and scale score data with independent t-test. There were no distributional assumptions violated. Differences between the two groups are described as Cohen’s effect size (d), where d ≤ 0.2 represents a small effect, d = [0.2; 0.5] a moderate effect, d = [0.5; 1.0] a high effect, and d >1.0 a very high effect (Marôco, 2014). The relationship between the four scales (MMSE, Barthel Index, Lawton Index, and P-EGP) was analyzed using parametric correlations with Pearson’s coefficient. It was considered the strongest correlations above 0.75 and the weaker below 0.25 (Marôco, 2014).

Results

This non-normative sample comprised evaluations of 497 participants, in which 120 had dementia. Table 1 provides a comparison of the demographic profiles between people with and without dementia. There were significant differences by age, gender, education level, environment, socioeconomic status, living arrangement, and frequency of non-pharmacological therapies. The persons with dementia, in this sample, are older, are more males, have higher education and socioeconomic status, and essentially come from urban areas. Also, most of those with dementia are institutionalized or in a day-care center and have more support of non-pharmacological therapies.

Table 1.

Socio-demographic description of participants with (D) and without dementia (WD).

	D(n = 120)	WD(n = 377)	Statistics
Age (mean, SD)	80.6 (7.4)	77.2 (8.7)	t(230) = 4.13, p < .001, d = .42
60–74 years (%)	20.2	37.2
74–85 years (%)	52.9	39.8
≥85 years (%)	26.9	23.0	χ² (2) = 12.06, p = .002
Gender
Female (%)	67.5	76.7
Male (%)	32.5	23.3	χ² (1) = 4.01, p = .045
Education
Illiterate or < 4 years (%)	20.2	33.8
4–9 years (%)	44.5	46.8
9–12 years (%)	14.3	9.6
Higher	21.0	9.8	χ² (3) = 16.46, p = .001
Environment
Rural (%)	4.2	36.6
Urban (%)	95.8	63.4	χ² (1) = 28.51, p < .001
Socioeconomic status
High	29.2	13.0
Average	35.0	35.1
Low	35.8	51.9	χ² (2) = 18.85, p < .001
Living arrangement
Home-based (%)	4.3	21.6
Day center (%)	33.6	26.4
Short-term institution (%)	6.0	5.3
Long-term institution (%)	56.0	46.6	χ² (3) = 18.38, p < .001
Physical activity
No (%)	75.8	66.3
Yes (%)	24.2	33.7	χ² (1) = 3.83, p = .050
Non-pharmacological Therapy
No (%)	42.5	72.9
Yes (%)	57.5	27.1	χ² (1) = 37.38, p < .001
Support devices
No (%)	43.6	39.8
Sensorial (%)	29.8	31.9
Motor (%)	26.6	28.3	χ² (2) = 0.43, p = .805

Regarding the cognitive and functional profiles of these two groups (Table 2), the scores indicate significant statistical differences between people with and without dementia (p<0.001). People with dementia have lowest results in MMSE and higher percentage of cognitive deficit, lowest results in Barthel Index, higher levels of dependency in basic ADL, and higher results in Lawton Index showing more dependency in instrumental ADL. The differences in the results of MMSE and Lawton Index have a very high effect size (d>1.0).

Table 2.

Cognitive and functional profiles of people with (D) and without dementia (WD).

Scales	D(n = 120)	WD(n = 377)	Statistics
Mini Mental State Examination (mean, SD)	15.6 (6.9)	23.1 (6.2)	t(180)=−10.42, p<.001, d=1.14
With cognitive deficit (%)	87.2	33.9
Without cognitive deficit (%)	12.8	66.1	χ² (1) = 100.68, p<.001
Barthel (mean, SD)	69.7 (27.9)	86.2 (21.3)	t(165)= −5.94, p<0.001, d=.66
Independent (%)	15.8	46.7
Slightly dependent (%)	52.5	42.2
Moderately dependent (%)	13.3	5.6
Severe/Totally dependent (%)	18.3	5.6	χ² (3) = 48.76, p<.001
Lawton (mean, SD)	25.8 (5.5)	18.2 (7.2)	t(262)=12.24, p<.001, d=1.19
Independent (%)	0.8	11.9
Moderately dependent (%)	14.2	44.3
Severely dependent (%)	85.0	43.8	χ² (2) = 63.25, p<.001

Comparing the psychomotor profile of people with and without dementia, the results (presented in table 3) show significant differences in all domains and total of P-EGP, with exception of Joint Mobilizations of Upper and Lower Limbs. The higher effects (d>1.0) are for the Perceptive memory, the Space domain, the Time domain, and the total score of P-EGP.

Table 3.

Psychomotor profile of people with (D) and without dementia (WD).

EGP Domains	D(n = 120)(mean, SD)	WD(n = 377)(mean, SD)	Statistics
Static balance I	5.0 (1.8)	5.4 (1.3)	t(166)= −2.15, p=.033, d=.24
Static balance II	1.8 (1.6)	3.0 (1.6)	t(207)= −7.06, p<.001, d=.73
Dynamic balance I	4.8 (2.0)	5.4 (1.5)	t(163)= −3.06, p=.003, d=.34
Dynamic balance II	2.5 (2.5)	4.0 (2.3)	t(188)= −6.01, p<.001, d=.64
Joint mobilization upper limbs	4.6 (1.4)	4.7 (1.4)	t(206)= −0.57, p=.568, d=.06
Joint mobilization lower limbs	4.1 (1.8)	4.4 (1.6)	t(185)= −1.36, p=.175, d=.15
Fine motor upper limbs	3.0 (1.6)	4.1 (1.5)	t(187)= −6.90, p<.001, d=.74
Fine motor lower limbs	4.5 (1.5)	5.4 (1.1)	t(164)= −6.09, p<.001, d=.68
Praxis	2.8 (1.5)	4.1 (1.4)	t(183)= −8.81, p<.001, d=.95
Knowledge of body parts	3.6 (1.6)	4.9 (1.1)	t(155)= −7.87, p<.001, d=.89
Vigilance	3.7 (1.9)	5.2 (1.2)	t(147)= −7.80, p<.001, d=.91
Perceptive memory	1.3 (1.2)	3.4 (1.6)	t(268)= −15.79, p<.001, d=1.52
Space domain	2.8 (1.8)	4.7 (1.3)	t(164)= −10.76, p<.001, d=1.20
Verbal memory	2.5 (1.4)	3.9 (1.4)	t(196)= −9.41, p<.001, d=.99
Perception	3.4 (1.6)	4.4 (1.3)	t(171)= −5.86, p<.001, d=.65
Time domain	2.3 (1.8)	4.5 (1.6)	t(185)= −12.31, p<.001, d=1.32
Communication	3.2 (2.4)	5.0 (1.6)	t(157)= −7.64, p<.001, d=.87
P-EGP Total	56.0 (19.2)	76.6 (16.0)	t(175)= −10.62, p<.001, d=1.16

Pearson correlations were carried out to study the possible relations between all scales. The results are shown in Tables 4 to 8. In general, it is possible to find moderate to strong correlations between the totals of cognitive (MMSE), functional (Barthel’s and Lawton’s Index), and psychomotor (P-EGP) assessments, and between the totals and domains of each scale. The MMSE Orientation domain is highly related with P-EGP Space and Time domains and Lawton Using Telephone. The P-EGP domains concerning static and dynamic balance are well related with Barthel Ascending and Descending Stairs, Transfer from the Wheelchair, and Walking on level surface. One more time the P-EGP domains of Joint Mobilizations of Upper and Lower Limbs have different results compared with other domains, since they show week or no correlations with the domains and totals of the other scales. The same happens with the domain of Retention of MMSE. Also the MMSE Recall and Visual-Constructional Ability have poor correlations with Barthel and Lawton domains. The Barthel and Lawton domains have moderate correlations and the strongest are between Lawton Taking care of the House and Barthel Dressing and Bathing.

Table 4.

Correlations between the P-EGP and MMSE domains and totals.

Domains	MMSE
P-EGP	Orientation	Retention	Attention	Recall	Language	Visual	Total
SB I	.23**	.07	.13**	.07	.17**	.18**	.21**
SB II	.42**	.17**	.34**	.28**	.34**	.27**	.45**
DB I	.28**	.12*	.16**	.16**	.21**	.19**	.27**
DB II	.36**	.17**	.28**	.16**	.31**	.20**	.37**
JMUL	.18**	.03	.15**	.12**	.11*	.13**	.18**
JMLL	.18**	.03	.16**	.03	.19**	.18**	.19**
FMUL	.53**	.28**	.43**	.34**	.42**	.33**	.56**
FMLL	.47**	.20**	.30**	.18**	.38**	.26**	.45**
PR	.68**	.37**	.60**	.41**	.57**	.47**	.74**
KBP	.66**	.39**	.49**	.34**	.56**	.41**	.69**
V	.66**	.43**	.54**	.31**	.56**	.38**	.70**
PM	.66**	.21**	.47**	.50**	.41**	.34**	.65**
SD	.75**	.43**	.61**	.38**	.58**	.46**	.78**
VM	.65**	.36**	.42**	.42**	.45**	.29**	.64**
P	.59**	.34**	.54**	.33**	.54**	.46**	.66**
TD	.84**	.35**	.64**	.44**	.57**	.47**	.83**
C	.56**	.28**	.40**	.28**	.44**	.35**	.57**
Total	.75**	.36**	.58**	.41**	.59**	.46**	.77**

*Correlations are significant at p<.05; **Correlations are significant at p<.01.

Note: SB I: Static balance I; SB II: Static balance II; DB I: Dynamic balance I; DB II: Dynamic balance II; JMUL: Joint mobilization upper limbs; JMLL: Joint mobilization lower limbs; FMUL: Fine motor upper limbs; FMLL: Fine motor lower limbs; PR: Praxis; KBP: Knowledge of body parts; V: Vigilance; PM: Perceptive memory; SD: Space domain; VM: Verbal memory; P: Perception; TD: Time domain; C: Communication.

Table 5.

Correlations between the P-EGP and Barthel domains and totals.

DomainsP-EGP	BarthelFeeding	Dressing	Bathing	Use toilet	Personal hygiene	Bowels	Bladder	Stairs	Transfer	Walking	Total
SB I	.38	.48	.30	.49	.35	.40	.41	.56	.62	.68	.63
SB II	.37	.53	.48	.50	.37	.44	.45	.54	.51	.50	.62
DB I	.36	.59	.38	.58	.46	.42	.47	.62	.70	.74	.71
DB II	.28	.52	.47	.48	.36	.41	.38	.55	.52	.46	.59
JMUL	.15	.19	.27	.18	.20	.22	.25	.24	.24	.22	.28
JMLL	.13	.21	.15	.22	.17	.23	.21	.25	.28	.24	.28
FMUL	.42	.50	.41	.48	.41	.43	.43	.36	.40	.38	.54
FMLL	.39	.56	.38	.59	.42	.44	.47	.48	.51	.52	.63
PR	.36	.46	.39	.42	.38	.42	.38	.32	.33	.31	.48
KBP	.41	.56	.41	.53	.46	.49	.46	.34	.36	.32	.56
V	.37	.48	.35	.47	.42	.40	.40	.27	.28	.31	.48
PM	.25	.41	.31	.38	.36	.36	.38	.28	.29	.29	.43
SD	.37	.50	.41	.47	.44	.42	.45	.31	.32	.33	.51
VM	.28	.42	.37	.36	.34	.34	.37	.26	.30	.30	.43
P	.26	.36	.36	.33	.36	.36	.34	.25	.28	.29	.41
TD	.31	.48	.46	.44	.41	.41	.42	.30	.30	.29	.49
C	.24	.37	.26	.37	.28	.36	.34	.23	.25	.22	.38
Total	.46	.66	.54	.63	.53	.56	.57	.54	.56	.55	.73

AllCorrelations are significant at p<.01.

DomainsP-EGP	LawtonHouse	Washing clothes	Preparing meals	Shopping	Using telephone	Using transportation	Using money	Medication management	Total
SB I	.35	.23	.24	.29	.30	.30	.26	.26	.32
SB II	.57	.49	.47	.54	.52	.53	.50	.50	.59
DB I	.43	.35	.34	.39	.36	.41	.34	.33	.43
DB II	.53	.46	.44	.52	.46	.52	.45	.45	.55
JMUL	.26	.21	.21	.23	.20	.21	.20	.13	.24
JMLL	.21	.17	.16	.20	.17	.19	.17	.08*	.20
FMUL	.51	.42	.44	.46	.49	.47	.45	.40	.52
FMLL	.42	.36	.37	.41	.46	.42	.43	.38	.47
PR	.48	.44	.42	.45	.57	.49	.52	.46	.55
KBP	.52	.45	.42	.50	.58	.50	.55	.49	.57
V	.43	.40	.37	.45	.58	.45	.52	.45	.52
PM	.48	.47	.48	.47	.55	.47	.55	.52	.57
SD	.49	.45	.45	.49	.65	.52	.58	.54	.59
VM	.45	.40	.42	.46	.55	.45	.52	.46	.53
P	.41	.37	.37	.40	.50	.40	.47	.40	.47
TD	.52	.47	.47	.53	.66	.54	.65	.56	.63
C	.40	.34	.35	.38	.50	.40	.44	.41	.46
Total	.65	.57	.56	.63	.70	.64	.66	.60	.72

	MMSE
Barthel
Feeding	.39**	.30**	.29**	.14**	.40**	.14**	.41**
Dressing	.54**	.26**	.33**	.25**	.38**	.27**	.51**
Bathing	.44**	.22**	.31**	.24**	.31**	.32**	.44**
Use toilet	.50**	.29**	.32**	.22**	.40**	.21**	.48**
Personal hygiene	.47**	.24**	.30**	.24**	.33**	.24**	.45**
Bowels	.44**	.11*	.28**	.18**	.32**	.25**	.41**
Bladder	.40**	.10*	.22**	.20**	.26**	.23**	.36**
Stairs	.30**	.16**	.22**	.19**	.26**	.23**	.32**
Transfer	.34**	.17**	.19**	.18**	.28**	.17**	.33**
Walking	.33**	.18**	.21**	.15**	.26**	.13**	.32**
Total	.52**	.25**	.33**	.26**	.40**	.28**	.51**
Lawton
House	.53**	.23**	.34**	.30**	.36**	.35**	.51**
Washing clothes	.46**	.19**	.34**	.30**	.31**	.33**	.47**
Preparing meals	.49**	.23**	.34**	.31**	.30**	.31**	.48**
Shopping	.54**	.23**	.37**	.35**	.36**	.34**	.53**
Using telephone	.67**	.31**	.49**	.37**	.48**	.42**	.67**
Using transportation	.55**	.25**	.40**	.31**	.38**	.34**	.55**
Using money	.63**	.26**	.43**	.36**	.43**	.38**	.62**
Medication management	.58**	.26**	.39**	.34**	.36**	.34**	.56**
Total	.63**	.28**	.44**	.37**	.42**	.40**	.62**

DomainsBarthel	LawtonHouse	Washing clothes	Preparing meals	Shopping	Using telephone	Using transportation	Using money	Medication management	Total
Feeding	.35	.25	.25	.30	.31	.31	.27	.22	.33
Dressing	.62	.49	.50	.54	.54	.57	.54	.50	.62
Bathing	.62	.51	.53	.58	.53	.58	.56	.52	.64
Use toilet	.53	.41	.43	.46	.48	.49	.47	.42	.53
Personal hygiene	.49	.41	.41	.43	.48	.47	.43	.40	.51
Bowels	.46	.39	.37	.41	.46	.42	.43	.39	.48
Bladder	.47	.39	.40	.42	.47	.42	.44	.41	.49
Stairs	.52	.41	.41	.48	.39	.45	.41	.40	.50
Transfer	.49	.38	.40	.43	.42	.44	.40	.38	.48
Walking	.42	.33	.34	.36	.36	.39	.35	.34	.42
Total	.64	.52	.52	.57	.57	.59	.56	.52	.65

Table 6.
Correlations between the P-EGP and Lawton domains and totals.

DomainsP-EGP LawtonHouse Washing clothes Preparing meals Shopping Using telephone Using transportation Using money Medication management Total

SB I .35 .23 .24 .29 .30 .30 .26 .26 .32

SB II .57 .49 .47 .54 .52 .53 .50 .50 .59

DB I .43 .35 .34 .39 .36 .41 .34 .33 .43

DB II .53 .46 .44 .52 .46 .52 .45 .45 .55

JMUL .26 .21 .21 .23 .20 .21 .20 .13 .24

JMLL .21 .17 .16 .20 .17 .19 .17 .08* .20

FMUL .51 .42 .44 .46 .49 .47 .45 .40 .52

FMLL .42 .36 .37 .41 .46 .42 .43 .38 .47

PR .48 .44 .42 .45 .57 .49 .52 .46 .55

KBP .52 .45 .42 .50 .58 .50 .55 .49 .57

V .43 .40 .37 .45 .58 .45 .52 .45 .52

PM .48 .47 .48 .47 .55 .47 .55 .52 .57

SD .49 .45 .45 .49 .65 .52 .58 .54 .59

VM .45 .40 .42 .46 .55 .45 .52 .46 .53

P .41 .37 .37 .40 .50 .40 .47 .40 .47

TD .52 .47 .47 .53 .66 .54 .65 .56 .63

C .40 .34 .35 .38 .50 .40 .44 .41 .46

Total .65 .57 .56 .63 .70 .64 .66 .60 .72

*No Correlations found; All Correlations are significant at p<.01.

Note: SB I: Static balance I; SB II: Static balance II; DB I: Dynamic balance I; DB II: Dynamic balance II; JMUL: Joint mobilization upper limbs; JMLL: Joint mobilization lower limbs; FMUL: Fine motor upper limbs; FMLL: Fine motor lower limbs; PR: Praxis; KBP: Knowledge of body parts; V: Vigilance; PM: Perceptive memory; SD: Space domain; VM: Verbal memory; P: Perception; TD: Time domain; C: Communication.

Table 7.
Correlations between Barthel, Lawton, and MMSE domains and totals.

MMSE

Domains Orientation Retention Attention Recall Language Visual Total

Barthel

Feeding .39** .30** .29** .14** .40** .14** .41**

Dressing .54** .26** .33** .25** .38** .27** .51**

Bathing .44** .22** .31** .24** .31** .32** .44**

Use toilet .50** .29** .32** .22** .40** .21** .48**

Personal hygiene .47** .24** .30** .24** .33** .24** .45**

Bowels .44** .11* .28** .18** .32** .25** .41**

Bladder .40** .10* .22** .20** .26** .23** .36**

Stairs .30** .16** .22** .19** .26** .23** .32**

Transfer .34** .17** .19** .18** .28** .17** .33**

Walking .33** .18** .21** .15** .26** .13** .32**

Total .52** .25** .33** .26** .40** .28** .51**

Lawton

House .53** .23** .34** .30** .36** .35** .51**

Washing clothes .46** .19** .34** .30** .31** .33** .47**

Preparing meals .49** .23** .34** .31** .30** .31** .48**

Shopping .54** .23** .37** .35** .36** .34** .53**

Using telephone .67** .31** .49** .37** .48** .42** .67**

Using transportation .55** .25** .40** .31** .38** .34** .55**

Using money .63** .26** .43** .36** .43** .38** .62**

Medication management .58** .26** .39** .34** .36** .34** .56**

Total .63** .28** .44** .37** .42** .40** .62**

MMSE: Mini Mental State Examination.

*Correlations are significant at p<.05; **Correlations are significant at p<.01.

Table 8.
Correlations between Barthel and Lawton domains and totals.

DomainsBarthel LawtonHouse Washing clothes Preparing meals Shopping Using telephone Using transportation Using money Medication management Total

Feeding .35 .25 .25 .30 .31 .31 .27 .22 .33

Dressing .62 .49 .50 .54 .54 .57 .54 .50 .62

Bathing .62 .51 .53 .58 .53 .58 .56 .52 .64

Use toilet .53 .41 .43 .46 .48 .49 .47 .42 .53

Personal hygiene .49 .41 .41 .43 .48 .47 .43 .40 .51

Bowels .46 .39 .37 .41 .46 .42 .43 .39 .48

Bladder .47 .39 .40 .42 .47 .42 .44 .41 .49

Stairs .52 .41 .41 .48 .39 .45 .41 .40 .50

Transfer .49 .38 .40 .43 .42 .44 .40 .38 .48

Walking .42 .33 .34 .36 .36 .39 .35 .34 .42

Total .64 .52 .52 .57 .57 .59 .56 .52 .65

All Correlations are significant at p<.01.

Discussion

This study compared the psychomotor, cognitive, and functional profiles of people with and without dementia.

First, it is possible to state that the two groups had different socio-demographic characteristics. In this case, we consider that these differences may have been expected since, from epidemiological studies, age is one of the major risk factors for dementia (van Alphen et al., 2016). However, the results about the education level were somehow surprising. Recent studies indicate that cognitive reserve can constitute a protective factor for the appearance of cognitive impairment and dementia (Kadlec, Dujela, Beattie, & Chappell, 2016). In the case of our sample, the participants with dementia had a higher education level. We hypothesize that, since the elderly with dementia in our sample were essentially from urban areas, they had a higher economic status and thus more study years. Nevertheless, we interpret these results as particular characteristics of the participants of our study and not as representative of people with dementia in general. As expected, the elderly with dementia received more non-pharmacological therapies and have more support in institutions.

In what concerns the cognitive and functional profiles, as expected, elderly with dementia had a higher percentage of cognitive deficit and higher dependency on the performance of basic and instrumental daily living activities, which confirms previous research that says dementia is one of the most common causes of functional disability (Yoshida et al., 2012). The highest effect sizes are for the results of MMSE and Lawton Index, related with abilities that involve mainly cognitive areas. As it is well known, dementia is characterized by progressive loss of cognitive and functional abilities (Bökberg, Ahlström, Karlsson, Hallberg & Janlöv, 2014). The Lawton domains have in general stronger correlations with MMSE domains than the Barthel and MMSE domains, indicating the importance of the cognitive functioning to perform more complex daily activities. Studies have been showing that cognitive abilities are related with, and even can be predictors of everyday functional abilities (Gross, Rebok, Unverzagt, Willis, & Brandt, 2011).

Comparing the psychomotor profile of people with and without dementia, the results showed significant differences in all domains and total of P-EGP, with exception of Joint Mobilizations of Upper and Lower Limbs. As already mentioned in a previous paper (Morais et al., 2016), these domains seem to constitute a “separate” construct, as they can be more connected with physical deterioration (associated with aging and/or the presence of morbilities) of the subject than with the presence of dementia. Also, these results are in accordance with the study of Hesseberg, Bentzen, Ranhoff, Engedal, and Bergland (2016), which found significant associations between the performance of persons with mild cognitive impairment or dementia in different areas of physical fitness and cognition, except for the items related with flexibility. Hesseberg, Bergland, Rydwik, and Brovold (2016) also have not found significant differences for the upper body flexibility between persons with cognitive impairment and older people recently discharged from hospital.

The differences between the two groups with and without dementia are higher (d>1.0) for the Perceptive memory, the Space domain, the Time domain, and the total score of P-EGP. Although dementia involves various sub-types and heterogeneous profiles, memory and time-space orientation seems to constitute domains affected in most of the people with dementia. However, the perceptual implicit memory is mentioned in many studies as a cognitive area that is relatively intact in patients with dementia (LaVoie, Olbinski, & Palmer, 2015); we may suppose that in these particular tasks what is mostly the cause of such performance is not the “sensory” part (identify the colors or positions of the body for Perceptive memory, identify places or objects for the Space Domain and identify a clock or details of a picture in Time Domain) but the “recognition” task necessary for the success on this performance (recall of the colors or positions of the body, explain space orientations of routes or objects, recall of dates, hours, days and months and definition of temporal sequence of actions), because it involves conceptual knowledge and recall. Literature has been reporting that the results of performance in implicit or explicit memory depend on many ways of the characteristics of the task (Deason, Hussey, Flannery, & Ally, 2015). The task of Perceptive memory demands that the subject recalls colors and recognizes or recalls with the help of cues, postural positions seen previously. What is demanded in the tasks belongs to explicit memory area and it is well-known that patients with dementia have a high deterioration of this ability (Ballesteros, Reales, & Mayas, 2007; Willems, Salmon, & van der Linden, 2008). The Space domain is evaluated by tasks of topographic orientation, which involves several cognitive abilities and executive functions, like heading, geographic, egocentric and allocentric orientations, visual attention, spatial working memory, visuospatial perception, among others (Guariglia & Nitrini, 2009). It also involves tasks of spatial orientation of static and dynamic objects. As the results of other studies (e.g., Guariglia & Nitrini, 2009), even if the spatial and visual perception are intact, the topographic orientation seems to be an area of differentiation of elderly with and without dementia (Pal et al., 2016). As for the Time Domain, it involves temporal orientation and sequential ability. Studies have shown that temporal orientation is a fundamental area that distinguishes elderly with and without dementia, since it is almost perfectly intact in older people with normal cognition, even with a low level of schooling (Fernández-Turrado et al., 2011; Tractenberg, Weiner, Aisen, Kaye, & Fuh, 2007). In our sample, we have some participants without dementia but with a cognitive impairment and even though this domain seemed to differentiate more these two sub-groups.

In what concerns the correlations between scale’s totals and domains, strong correlations between the P-EGP and other scales’ totals were found. These results confirm the close relationship between psychomotor, cognitive, and functional abilities. Studies have shown associations between deficits in fine motor skills, cognitive impairment, and functional loss (Paula et al., 2016), suggesting that using both cognitive and motor assessments can facilitate the estimation of functional performance. In our perspective, P-EGP may constitute a valid instrument to this purpose, based not only on the results of the present study but also of the previous study about P-EGP psychometric properties (Morais et al., 2016). Also the total score of Barthel has strongest correlations with the “motor” domains of P-EGP (especially the ones related with balance and fine motor skills of lower limbs), suggesting a higher dependence of the motor skills for a better performance in basic ADL. Unfortunately, the research still tends to analyze the association between cognitive abilities or psychomotor abilities and functional performance, separately (Gross et al., 2011). In our opinion, the simultaneous assessment of psychomotor abilities and functional performance measures, in older adults, would be more beneficial since it brings more complete information about the person and it allows planning interventions more suitable to prevent, maintain, or rehabilitate the functional abilities of the person (Kempen & Ormel, 1998).

There were a number of possible limitations to this study which must be acknowledged. The two samples (with and without dementia) have different socio-demographic characteristics and these variables may influence the results obtained. Also, some participants without dementia showed cognitive impairment, due to other health issues not possible to control by the researchers. So, in our opinion, these results should be replicated with two samples similar in their socio-demographic profile. In this study, it was not possible to differentiate the sub-types of dementia in our sample. We consider that information on the type and onset of a dementia diagnosis could be useful in providing a better understanding on the psychomotor, cognitive, and functional profiles.

In conclusion, the group of elderly with dementia has a higher percentage of cognitive deficit, higher dependency on the performance of basic and instrumental ADL and poorer psychomotor performance, except in joint mobilizations. It was also possible to find strong correlations between the total of P-EGP and the total of cognitive and functional scales, which allow us to conclude that there is a strong association of psychomotor skills with the cognitive and functional abilities. Interventions with persons with dementia should thus involve activities to promote psychomotor skills as well as cognitive and functional abilities.

Footnotes

Acknowledgements

We would like to thank Ana Antunes for her valuable help on inserting data and all the colleagues that applied P-EGP. Nothing would have been possible without their cooperation and excellent work. We would also like to thank the board of directors and the technical staff from the elderly care services where the data collection took place for welcoming the researchers of this study.

Declaration of Conflicting Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ana Morais, PhD student, is a psychomotor therapist specialized in the field of mental health in adults and elderly. Her research interests are on psychomotor evaluation and treatment in adults, especially in patients with dementia. She is focusing on establish the psychomotor profile of elderly with and without dementia.

Sofia Santos, PhD, is an assistant professor in psychomotor and special education field, with a background in health/education care delivery system. Her research interests focus on intellectual disability and aging, quality of life and rights, tests validation (adaptive behavior, supports, quality of life, self-determination, etc.), psychomotor development, evaluation, and intervention.

Paula Lebre, PhD, is an assistant professor in psychomotor rehabilitation and special Education, with a background in health promotion, social skills training, and expressive therapies. Her research interests focus on health promotion, resilience, evaluation, and intervention in psychomotor therapies.

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