Validity and reliability of five-times-sit-to-stand test with a dual task in older adults with mild cognitive impairment

Abstract

INTRODUCTION:

Although the five-times-sit-to-stand test (FTSST) is commonly used to analyse functional capacity, in older adults with mild cognitive impairment (MCI), many activities of daily living, such as walking while holding objects, require the simultaneous performance of motor and motor tasks. Hence, the FTSST with a secondary task has been introduced, though there is a lack of evidence on its validity and reliability. This study aimed to examine the concurrent validity and reliability of the FTSST with a dual task in older adults with MCI.

METHODS:

Twenty-eight older adults with MCI participated in the study. All participants performed the FTSST, FTSST with a dual task and Timed Up and Go (TUG) test. The concurrent validity of the FTSST with a dual task was established with the TUG.

RESULTS:

Moderate concurrent validity was found between the FTSST with a dual task and the TUG, with Pearson’s r = 0.59 (p < 0.001). The FTSST with a dual task exhibited good intra-rater (ICC _3,2 = 0.99) and inter-rater (ICC _2,2 = 0.99) reliability. The standard error of measurement and minimal detectable change of the intra- and inter-rater reliability of the FTSST with a dual task were 0.22 and 0.18, respectively.

CONCLUSION:

This study showed a significant correlation between the FTSST both with and without a dual task and the TUG as well as good inter- and intra-rater reliability when used in older adults with MCI. These findings support using these tests as outcome measures in older adults with MCI.

Keywords

Older adults mild cognitive impairment sit-to-stand reliability validity

1 Introduction

Mild cognitive impairment (MCI) is a decline in cognitive performance that is considered to be related to ageing and constitutes a stage in the transition from normal cognitive ageing to dementia [1]. Globally, the prevalence of older adults with MCI ranges between 6.7% and 71.4% [2 –6]. Impairments in cognitive ability in older adults can lead to changes in physical functions, including muscle strength [7], balance and functional mobility [8]. Changes in these areas of function are common factors found to increase the risk of falls [9]. In addition, a deficit in cognitive function has been found to be related to injuries or falls [10]. Currently, several tools are used to assess muscle strength, balance and functional mobility in older adults. One measurement tool frequently used in the clinical setting that evaluates all of these components is the five-times-sit-to-stand test (FTSST) [11].

The FTSST measures how quickly an individual can change positions from sitting to standing back to sitting five times [12]. This test has been validated and has been established to have good reliability in numerous populations, including older adults with chronic obstructive pulmonary disease [13], Parkinson’s disease [14] and cardiovascular disease [15], as well as community-dwelling older women [16]. Recently, the validity and reliability of the FTSST were studied in older adults with early cognitive loss, with results demonstrating the FTSST’s moderate validity with gait speed and good reliability in this population [17].

Typically, humans are capable of performing dual or multiple tasks in daily life, such as when standing up while holding a cup of water. In this situation, the performance of multiple tasks will either reduce the ability to execute the secondary task or decrease the execution of both the primary and secondary tasks due to limitations in information perception ability [18]. The secondary task can be either a cognitive or motor task. A previous study found that older adults with MCI had decreased gait performance under dual-task conditions [19], which might be attributed to impairments in executive function and reduced attention capacity in this population [20]. Thus, modifying the FTSST by adding a secondary task might improve the test’s ability to assess functional mobility in older adults with MCI.

In both research and clinical practice, it is critical to identify outcome measures that are reliable and valid for specific populations. Unfortunately, the validity and reliability of the FTSST with dual tasks have not yet been investigated in older adults with MCI. Therefore, the objective of this study was to evaluate the concurrent validity and reliability of the FTSST with a dual-task component in older adults with MCI. We hypothesised that (1) the FTSST with a dual task would have moderate validity to detect physical function as assessed by the Timed Up and Go (TUG) test, and (2) the FTSST with a dual task would have good inter- and intra-rater reliability.

2 Subjects and methods

2.1 Subjects

A convenience sample of twenty-eight older adults with MCI who were 60 years of age or older was recruited for this study. Participants were included if they (1) were diagnosed with MCI [1], (2) did not have a history of clinical dementia, (3) had a Montreal Cognitive Assessment score of fewer than 25 points [21] and (4) were generally independent in everyday functioning based on a Barthel Index for Activities of Daily Living score of at least 12 points. Eligible participants were excluded if they had (1) a diagnosis of a neurological condition or chronic disease that causes cognitive impairment or impaired walking ability, such as stroke, multiple sclerosis, Parkinson’s, cardiopulmonary disease, uncontrolled hypertension, rheumatoid arthritis or osteoarthritis; (2) depressive symptoms, as determined by a Thai Geriatric Depression Scale score of more than 12 [22]; (3) severe auditory and visual impairment or uncorrected auditory and visual impairment; or (4) a problem with completing the tasks required for testing. Research related to human use has complied with all relevant national regulations and institutional policies, has followed the tenets of the Declaration of Helsinki, and has been approved by the ethical board of the university. Informed consent has been obtained from all individuals included in this study or from their legal guardians. The characteristics of all participants are shown in Table 1.

Table 1
Characteristics of study participants (n = 28)

Characteristic Mean (SD)/N (%)

Age (years); mean (SD) 67.67 (5.56)

Gender; n (%)

Female 19 (67.86)

Male 9 (32.14)

Weight (kg); mean (SD) 62.88 (8.96)

Height (cm); mean (SD) 159.61 (8.08)

Education level; n (%)

No education 1 (3.57)

Primary school/elementary school

Lower-secondary 1 (3.57)

Upper-secondary 8 (28.57)

Secondary school/high school

Lower-secondary 6 (21.43)

Upper-secondary 5 (17.86)

Bachelor’s degree or higher 7 (25.00)

MoCA (score); mean (SD) 20.68 (2.16)

Characteristic	Mean (SD)/N (%)
Age (years); mean (SD)	67.67 (5.56)
Gender; n (%)
Female	19 (67.86)
Male	9 (32.14)
Weight (kg); mean (SD)	62.88 (8.96)
Height (cm); mean (SD)	159.61 (8.08)
Education level; n (%)
No education	1 (3.57)
Primary school/elementary school
Lower-secondary	1 (3.57)
Upper-secondary	8 (28.57)
Secondary school/high school
Lower-secondary	6 (21.43)
Upper-secondary	5 (17.86)
Bachelor’s degree or higher	7 (25.00)
MoCA (score); mean (SD)	20.68 (2.16)

Note: Montreal Cognitive Assessment score (MoCA), Standard deviation (SD).

The sample size was calculated based on the result of a previous study showing that FTSST times correlated with TUG times in older adults (r = 0.64; p < 0.001) [16]. For a Pearson’s correlation coefficient of r = 0.60 and an alpha of 0.05, 19 people had to be examined to achieve 80% power.

2.2 Procedures

Data collection was conducted by two licensed physiotherapists who were trained in the testing procedures by the senior author before data collection began. Participants were asked to perform three tests: the FTSST, the FTSST with a dual task and the TUG test. The testing sequence was randomly assigned to the participants using a simple random sampling technique.

During the FTSST, the participants began by sitting in an upright trunk position with their arms across their chests in an armless chair with a seat height of 46 cm from the ground. They were then instructed to achieve a full standing position five successive times as quickly as possible without using their arms. Timing began when the tester spoke the word ‘Go’ and stopped when the participants returned to sitting with their buttocks contacting the chair after the fifth repetition.

During the FTSST with a dual task, the participants were asked to hold a cup filled with water on a tray in their dominant hand and achieve a full standing position five consecutive times as quickly as possible without using their arms or spilling water from the cup. The tester informed the participants, ‘You must not choose to prioritise either the FTSST or the second task, and please perform both tasks as well as possible’.

During the TUG test, the participants were asked to sit in the chair in the starting position, stand, walk forward 3 m as quickly and safely as possible, turn at the traffic cone, walk back and sit down at the starting position.

The participants were evaluated by one assessor (assessor A) twice, on the first day and seven days later, to assess intra-rater reliability. Two assessors (assessors A and B) evaluated the participants on the same day to determine inter-rater reliability. Both assessors were unaware of the other’s findings. The participants were allowed to rest for five minutes between the tests to prevent physical fatigue. Each participant was permitted to practice each test one time prior to data collection. The average values of the two trials from the first and second sessions were used for analysis.

2.3 Statistical analysis

Data were analysed using SPSS version 28.0 (SPSS Inc., 233 S Wacker Dr, 11th Fl, Chicago, IL 60606). Pearson’s correlation coefficient (r) was computed to test the concurrent validity of the FTSST and FTSST with a dual task relative to the TUG test. Correlation strength was determined as follows: little-none (r < 0.25), poor (r = 0.25–0.50), moderate (r = 0.50–0.75) and good-excellent (r > 0.75) [23].

Intraclass correlation coefficient (ICC) with a 95% confidence interval was applied to examine the intra-rater (ICC _3,2) and inter-rater (ICC _2,2) reliability of time to complete the FTSST and FTSST with a dual task. The ICC was interpreted as follows: an ICC > 0.75 indicated good reliability and an ICC of 0.5–0.75 indicated moderate reliability [23]. In addition, the standard error of measurement (SEM) and minimal detectable change (MDC), which determine absolute reliability, were calculated using the equations $\begin{matrix} SEM = Standart deviation (SD) \times \sqrt{(1 - ICC)} \\ and MDC = 1 . 96 \times \sqrt{2} \times SEM . \end{matrix}$

3 Results

In the concurrent validity analysis, both the FTSST and the FTSST with a dual task were significantly correlated with the TUG test. Analysis using Pearson’s correlation coefficient revealed a moderate relationship between the FTSST and the TUG test (r = 0.51, p < 0.001) and between the FTSST with a dual task and the TUG test (r = 0.59, p < 0.001).

The means and standard deviations of the time to complete the FTSST and FTSST with a dual task, which were used to determine reliability, are reported in Table 2. The time to complete both the FTSST and the FTSST with a dual task exhibited good intra- and inter-rater reliability. The SEM and MDC of the FTSST’s intra- and inter-rater reliability were 0.14 and 0.00 seconds, respectively. In addition, the SEM and MDC of the FTSST with a dual task’s intra- and inter-rater reliability were 0.22 and 0.18 seconds, respectively (Table 2).

Table 2
Intra- and inter-rater reliability of the five-times-sit-to-stand test with and without a dual task

Intra-rater reliability

Variables Time (s) ICC_3,2 95% CI p-value MDC SEM

1^st session 2^nd session

FTSST 10.71 (3.00) 10.68 (3.06) 0.99 0.99–1.00 <0.001 0.38 0.14

FTSST with dual task 11.87 (3.95) 11.84 (3.86) 0.99 0.99–1.00 <0.001 0.59 0.22

Inter-rater reliability

Variables Time (s) ICC_2,2 95% CI p-value MDC SEM

Assessor A Assessor B

FTSST 10.71 (3.00) 10.72 (2.99) 1.00 1.00–1.00 <0.001 0.00 0.00

FTSST with dual task 11.88 (3.95) 11.78 (3.88) 0.99 0.99–1.00 <0.001 0.48 0.18

Intra-rater reliability
FTSST	10.71 (3.00)	10.68 (3.06)	0.99	0.99–1.00	<0.001	0.38	0.14
FTSST with dual task	11.87 (3.95)	11.84 (3.86)	0.99	0.99–1.00	<0.001	0.59	0.22
Inter-rater reliability
Variables	Time (s)	ICC_2,2	95% CI	p-value	MDC	SEM
	Assessor A	Assessor B
FTSST	10.71 (3.00)	10.72 (2.99)	1.00	1.00–1.00	<0.001	0.00	0.00
FTSST with dual task	11.88 (3.95)	11.78 (3.88)	0.99	0.99–1.00	<0.001	0.48	0.18

Note: Intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC), and confidence interval (CI).

4 Discussion

This study aimed to investigate the validity, intra- and inter-rater reliability, SEM, and MDC of the FTSST with a dual task in older adults with MCI. To our knowledge, our study was the first to investigate the FTSST with a dual task in this population. The results indicated that the FTSST with a dual task had a moderate correlation with the TUG test, good intra- and inter-rater reliability, and low SEM and MDC values when used in older adults with MCI.

The FTSST and FTSST with a dual task were moderately correlated with the TUG test when employed in older adults with MCI, indicating that adding the secondary task during the FTSST did not change the FTSST’s correlation to the TUG. This might be attributed to the type of secondary task employed, as different types of dual tasks have been shown to have varying effects on performance in older adults with MCI [24]. However, the results in this study were consistent with previous studies investigating the validity of the FTSST against the TUG test [16 , 25–28]. Therefore, it can be inferred that the FTSST with a dual task is a valid measure for assessing functional mobility in older adults with MCI.

This study found good intra- and inter-rater reliability of the FTSST and FTSST with a dual task in older adults with MCI. These results support findings in the literature regarding the reliability of the FTSST in various populations [13 –17]. Providing the assessors with practice sessions using the laboratory procedures before data collection began may have contributed to the positive reliability results in the present study. In addition, clear and standardised instructions from the assessor may enable the participants to perform the task effectively.

Knowledge of the error in the measurement tool is critical to deciding whether a measurement is reliable enough for therapeutic choices. In previous studies on the FTSST in older adults [16] and older adults with early cognitive loss [17], it was reported that an error of 0.9 seconds and 1.20 seconds were highly likely to be considered widely acceptable. In the current study, the SEM values of the FTSST and FTSST with a dual task were less than 0.9 seconds for both inter- and intra-rater reliability; the variability in performance that occurred in this study were thus likely too small.

In addition, our study provided MDC values for the FTSST and FTSST with a dual task, which are simple tests that can be easily performed. MDC values can provide a reference point when interpreting data from other population groups. In addition, these values can be used to understand the minimum amount of change that must be observed to indicate a therapeutic change post-intervention in older adults with MCI.

There were some limitations in our study. First, the participants in this study were a convenience sample of older adults in one community, which does not reflect the overall population. Second, the secondary task employed in this study was only a motor task, holding a tray with a cup of water. Future research may evaluate other types of motor or cognitive tasks. It may present different results with the secondary task used in this study. Additionally, future studies should include an investigation of the other psychometric properties of the FTSST with a dual task, such as its accuracy in detecting falls in older adults with MCI.

5 Conclusions

This study demonstrated that the FTSST with a dual task has good intra- and inter-rater reliability and is valid in older adults with MCI. The MDC and SEM for the FTSST with a dual task were small. The findings support the use of the FTSST with a dual task to evaluate performance in this population.

Conflict of interest

The authors state no conflict of interest.

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