Scandinavian Journal of Occupational Therapy. 2015; 22: 33–42
ORIGINAL ARTICLE
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Associations between performance of activities of daily living and everyday technology use among older adults with mild stage Alzheimer’s disease or mild cognitive impairment
CHARLOTTA RYD1, LOUISE NYGÅRD1, CAMILLA MALINOWSKY1, ANNIKA ÖHMAN2 & ANDERS KOTTORP1,3 1
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden, 2Division of Health, Activity and Care and National Institute for the Study of Ageing and Later Life (NISAL), Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden, and 3Department of Occupational Therapy, Zurich University of Applied Sciences, Winterthur, Switzerland
Abstract Background: The use of everyday technology (ET) is important for many activities in daily life (ADL) and can be especially challenging for older adults with cognitive impairments. Objective: The aim was to explore associations between ADL performance and perceived ability to use ET among older adults with mild stage Alzheimer’s disease (AD) and mild cognitive impairment (MCI). ADL motor and process ability, and ability to use ET were also compared between the groups. Methods: Participants with AD (n = 39) and MCI (n = 28) were included. Associations and group differences were explored with nonparametric statistics. Results: Significant correlations were found between ADL process ability and ET use in both groups (Rs = 0.44 and 0.32, p < 0.05), but for ADL motor ability and ET use, correlations were only found in the MCI group (Rs = 0.51, p < 0.01). The MCI group had significantly higher measures of ADL process ability (p < 0.001) and ET use (p < 0.05). Conclusion: ADL performance ability and perceived ability to use ET are important to consider in evaluations of older adults with cognitive impairments. Group differences indicate that measures of ADL performance ability and ET use are sensitive enough to discriminate the MCI group from the AD group with individually overlapping measures.
Key words: occupational therapy, dementia, cognitive impairments, assessments of functional ability, ADL
Introduction The physical environment is of major importance for the performance of daily activities (1) and this environment contains a growing proportion of technological artefacts and systems (2). The increasing use of everyday technology (ET), such as mobile phones, household appliances, and automated ticket-vending machines, has also changed how our daily activities are performed. To a large extent, ET has facilitated performance of daily activities but also made them more complex and demanding (3). Older adults with cognitive impairments such as mild cognitive
impairment (MCI) or mild stage Alzheimer’s disease (AD) have demonstrated greater difficulty using ET in daily activities than older adults without known cognitive impairments (4-6). Moderate to strong associations between engagement in activities in daily living (ADL) and perceived difficulty in ET use among older adults with mild AD or MCI have been found, indicating the significance of ET in daily activities for these groups (5,7). Thus the ability to use ET may be an important aspect to consider when evaluating ability to perform daily activities. However, there is a lack of knowledge about associations between the actual performance of ADL and ability
Correspondence: Charlotta Ryd, Division of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Fack 23200, 141 83 Huddinge, Sweden. E-mail: [email protected] (Received 10 June 2014; accepted 5 September 2014) ISSN 1103-8128 print/ISSN 1651-2014 online 2015 Informa Healthcare DOI: 10.3109/11038128.2014.964307
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to use ET. Therefore, empirical evidence is needed to support or refute such associations in order to offer targeted support in daily life. Moreover, limitations in ADL process skills (8), for example organizing or sequencing steps and actions in a logical order, may affect the use of ET in daily activities differently than limitations in ADL motor skills (8), such as moving in the environment or manipulating objects. Impairments in different ADL skills are likely to require different types of interventions; therefore, it is also important to know what specific aspects of ADL ability are associated with difficulties in ET use, in order to guide interventions. A dementia disease such as AD implies a decrease of cognitive function that is severe enough to increase limitations in the ability to perform daily activities (9). Instrumental activities of daily living (IADL), such as handling finances, handling medication, and doing household work, are affected earlier in the course of the disease than more basic activities of daily living (bADL) (10,11). Mild cognitive impairment (MCI) refers to a zone of cognitive decline between normal ageing and dementia (12). Persons with MCI are generally independent in daily life even if the performance of daily activities may be less efficient, take more time, or include more errors (13). Prevalence of MCI is hard to estimate due to variations in definitions that have been used to describe mild forms of cognitive impairments and in a systematic review the prevalence of MCI varied between 3% and 42% (14). Many of those diagnosed with MCI convert to dementia with time and the annual conversion rate is 5–10%. Among those who convert the most common cause of dementia is AD (15). The conversion from MCI to AD is a gradual process without fixed events that define the onset of dementia and the extent of impairment in ADL is often used to draw the line between MCI and dementia (13,16). This implies that evaluation of ability to perform ADL is important not just for identifying individuals in need of support in daily life activities but also for distinguishing between early stage dementia and MCI. However, these evaluations might be challenging due to the subtle character of the functional impairments; therefore sensitive instruments that include complex activities are required (16). Many ADL assessments today only evaluate ADL ability in relation to level of dependence in bADL (8). As many persons with MCI or early stage dementia are independent in performing such tasks, it is crucial that tools addressing ADL functioning focus on (a) other aspects of importance in everyday functioning (e.g. safety, efficiency, degree of effort), and (b) include more challenging ADL tasks (e.g. IADL and tasks incorporating ET use). More knowledge of ADL performance ability and ability to use ET, and
how these are related among older adults with mild stage AD or MCI, is important for identifying how to support these individuals in daily life. Such knowledge could also contribute to the diagnosing of MCI and AD. Therefore, the main aim of this study was to explore associations between ADL performance ability, divided into ADL motor and process ability, and perceived ability to use ET among older adults with mild stage AD or MCI. To further investigate the degree of impaired ADL performance ability and perceived ability to use ET a secondary aim of this study was to compare the MCI group and the AD group with regard to level of ADL motor and ADL process ability and level of perceived ability to use ET. Material and methods Study design In order to investigate the aims of the study, a crosssectional, non-experimental, quantitative design was used. Participants Older adults with AD (n = 39) in a mild stage or MCI (n = 28) were recruited through three different investigation units for memory deficits in the Stockholm area. Based on an earlier empirical study by Kottorp and Nygård using SETUQ with similar diagnostic samples (17), an estimated sample size of n = 18 per group is needed to secure a mean difference of 5.0 logits (p < 0.05) with a power of 0.90. Diagnoses were set by physicians according to the criteria for AD based on NINCDS-ADRDA (18) and the MCI criteria described by Petersen (19) and Winblad et al. (12). Inclusion criteria were: (a) being 55 years or older, (b) a need to use relevant ET in daily life (thus not being totally dependent on another person in daily life), (c) that any visual or hearing impairments could be compensated for with technical aids, and (d) a MMSE score of at least 18/30 for participants with AD and 25/30 for participants with MCI when recruited. Description of the groups regarding sex, age, years of education, and living conditions is presented in Table I. Significant differences between groups were not found regarding those variables. Instruments The Everyday Technology Use Questionnaire (ETUQ) ETUQ is an evaluation of perceived relevance and difficulty to use ET in daily activities, which has been developed and validated for older adults with or
ADL and ET use among older adults with Alzheimer’s or mild cognitive impairment Table I. Characteristics of the participants.
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Groups Older adults with mild stage AD (n = 39)
Older adults with MCI (n = 28)
Age, M (SD)
75.74 (7.41)
76.9 (7.19)
Females; n (%)
21 (54)
12 (43)
Years of education, M (SD)
11.08 (3.27)
12.20 (3.41)
Living conditions: single/cohabiting; n (%)
17 (43.6)/ 22 (56.4)
17 (60.7)/ 11 (39.3)
Notes: AD = Alzheimer’s disease; MCI = mild cognitive impairment; SD = standard deviation.
without cognitive impairments (20,21). It has shown potential to discriminate between older adults with no known cognitive impairment and those with mildstage AD or MCI (4-6) indicating potential to discover functional limitations among those groups. In addition ETUQ has demonstrated evidence of unidimensionality, internal scale validity, rating scale validity, and person response validity (5,6,22). The S-ETUQ is a shortened version of the ETUQ that generates statistically similar measures to those of the original version supporting the validity of the short version (17). Details of the procedure of developing the S-ETUQ have been presented elsewhere (17). The items in S-ETUQ are ETs that range from very easy to very difficult to use and include both newly developed and well-known technological artefacts and systems, e.g. the coffee machine, radio, cell-phone, and internet-banking. S-ETUQ is administered in a face-to-face interview and for each item the respondent specifies if the technology is available and relevant to him or her. Those ETs perceived as relevant are then graded on a six-step scale indicating the respondent’s perceived difficulty using them (17). The scale ranges from “uses the ET without perceived difficulties” to “does not use the ET even if it’s available and perceived as relevant” (21)”. Using S-ETUQ requires a one-day training course held by one of the developers of the instrument (LN) and colleagues. S-ETUQ generates a measure of the respondent’s perceived difficulty using ET that can also be expressed as the respondent’s perceived ability to use ET. The term used in this article will primarily be perceived ability to use ET. Assessments of Motor and Process Skills (AMPS) The AMPS is a standardized, performance-based assessment that evaluates the quality of a person’s performance of personal or instrumental activities of
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daily living (ADL) by measuring ADL motor and process performance ability. It has been proven to identify activity limitations in persons with dementia (23-25) but knowledge of AMPS usability among older adults with MCI is still limited. The AMPS can be used by occupational therapists who have attended a training course and been calibrated as users. The assessment is initiated by an interview conducted by the occupational therapist where the client identifies two ADL tasks that are familiar and of appropriate challenge on a list of 121 standardized activities. The client is then observed during performance of the self-chosen tasks and the occupational therapist scores the quality of performance on 36 ADL motor and process performance skills defined as the smallest units of observable actions in the performance of an ADL task. Each observed skill is graded on a four-point rating scale where a score of 4 reflects competent performance and a score of 1 reflect severely deficient performance. A Raschbased computerized scoring program is then used to convert these raw scores into linear measures of ADL motor ability and ADL process ability adjusting for task challenge and rater severity. The ADL tasks in AMPS are graded on a scale ranging from very easy to much harder than average to perform, and it is critical for the sensitivity and validity of the assessment that the chosen tasks are sufficiently challenging for the person performing them (8). Data-gathering procedures All participants were interviewed with S-ETUQ and evaluated with AMPS. For 53 (79%) of the participants both assessments were completed in the same day. For the rest of the participants data-gathering was carried out on to two occasions according to the participant’s individual wishes and needs. There was a maximum of 19 days between data-gathering occasions (median: 0, range: 0–19). Data were collected by four experienced occupational therapists with training in using the AMPS and the S-ETUQ. If the participants agreed, data collection took place in their homes. Otherwise, data collection took place in the clinic where the participants went through memory investigation. Some participants preferred to include a significant other during the S-ETUQ interview and this was the case for significantly more participants in the AD group than in the MCI group (see Table II). The role of the significant other was to provide support while the participant answered the questions. This procedure has been recommended and discussed elsewhere (26). During the AMPS observation significant others could be present but could not provide support. The ADL tasks chosen in the AMPS
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C. Ryd et al. ability to use ET use with the Mann–Whitney U-test. The level of significance was set at p < 0.05.
Table II. Conditions during data collection. Groups Older adults with mild-stage AD (n = 39)
Older adults with MCI (n = 28)
Data collection at participants home: n (%)
36 (92.3)
23 (89.3)
Significant other present during S-ETUQ interview: n (%)
20 (51.3)
7 (30.4)
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Notes: AD = Alzheimer’s disease; MCI = mild cognitive impairmen.
assessments in this study were, for most participants (92%), averagely or above averagely challenging to perform (8) indicating that they were sufficiently challenging for the sample (see Table II for details of the data-gathering). Before the study was initiated, ethical approval was obtained from the regional Ethical Committee (D-n [journal number] 2010/120-31/5). The participants received both written and verbal information about the study before agreeing to participate. Written informed consent was given by the participants. Data analysis Preparatory analysis The first step in the data analysis was to transform the raw ordinal data from the S-ETUQ and the AMPS into individual linear interval measures (logits). For the AMPS assessments this was done by use of the Rasch-based AMPS computerized scoring program, which generated measures of ADL process ability and ADL motor ability for each participant. The data from S-ETUQ were analysed using the WINSTEPS computer software program version 3.69.1 (27) and this analysis generated measures of each person’s perceived ability to use ET. This specific process has been described in more detail elsewhere (5). Primary analysis Next, the primary statistical analysis was performed using the Statistical Package for Social Sciences (SPSS), version 22. Non-parametric tests were used since the variables did not demonstrate a normal distribution. Associations between ADL process and motor ability and perceived ability to use ET were explored with the Spearman rank correlation coefficient (RS). The groups were compared regarding ADL motor and process ability and perceived
Results Associations between ADL motor and process ability and perceived ability to use ET The correlation coefficient (Rs) between ADL motor ability and perceived ability to use ET among persons with MCI was 0.51 (p < 0.01). In the group consisting of older adults with AD the association was weaker and non-significant, Rs = 0.21 (p = 0.17) (see Figure 1A and B). The correlation coefficient between ADL process ability and perceived ability to use ET among persons with MCI was 0.44 (p < 0.05). In the group of older adults with AD the association was weaker but also significant, Rs = 0.32(p < 0.05) (see Figure 2A and B). Based on a visual inspection, two individuals (A and B, see Figures 1A and 2A) within the AD group and one individual (C, see Figures 1B and 2B) within the MCI group had unexpectedly high measures of perceived ability to use ET in relation to their ADL process and motor ability measures. A more in-depth analysis revealed that these individuals also differed from the rest of the sample by having much higher individual standard errors on their measures of perceived ability to use ET (9.74–10.17 logits) compared with the mean of the rest of the sample (2.04 logits). Artificially high and imprecise measures indicate that these could be questioned from a validity perspective. Hence, we decided to explore the relationship by excluding these potentially invalid responses. When individual A, B, and C were removed all associations became stronger (Table III). Group comparison of ADL motor and process ability and ability to use ET Overall the participants with MCI had higher measures of both ADL motor and process ability and perceived ability to use ET compared with the participants with mild AD. The groups differed significantly regarding ADL process ability (p < 0.001) and perceived ability to use ET (p < 0.05) but not regarding ADL motor ability (p = 0.166). Measures of ADL motor and process ability and perceived ability to use ET are illustrated in Figure 3A, B, and C. Finally, the groups also differed significantly regarding number of ETs perceived as relevant (p < 0.001). The MCI group perceived on average 18 of the 33 items (SD 4.25; range 9–25) in S-ETUQ as relevant compared with the AD group who perceived on average 15 of 33 items (SD 3.95; range 7– 25) as relevant.
ADL and ET use among older adults with Alzheimer’s or mild cognitive impairment A
37
Mild stage AD
3.00
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ADL motor ability
2.50
2.00
A B
1.50
1.00
0.50
0.00 40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
Perceived ability to use ET
B
MCI
3.00
ADL motor ability
2.50
2.00 C 1.50
1.00
0.50
0.00 40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
Perceived ability to use ET Figure 1. Relationships between measures of ADL motor ability and perceived ability to use ET among older adults with (A) mild stage AD and (B) MCI. Notes: AD = Alzheimer’s Disease, MCI = Mild Cognitive Impairment, ET = Everyday Technology. Higher measures indicate higher ability. Individual A: ADL motor ability = 1.80 logits, perceived ability to use ET = 71.6 logits. Individual B: ADL motor ability = 1.55 logits, perceived ability to use ET = 63.05 logits. Individual C: ADL motor ability = 1.65 logits, perceived ability to use ET = 72.55 logits.
Discussion This study was intended primarily to explore associations between ADL performance and perceived
difficulty of ET use for older adults with MCI or mild-stage AD. Significant correlations were found between ADL process ability and perceived ability to use ET in both groups. ADL motor ability was
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C. Ryd et al. A
Mild stage AD
2.50
2.00
ADL process ability
1.00 A 0.50 B 0.00 –0.50
–1.00 40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
Perceived ability to use ET
B
MCI
2.50
2.00
1.50 ADL process ability
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1.50
C
1.00
0.50
0.00
–0.50
–1.00 40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
Perceived ability to use ET Figure 2. Relationships between measures of ADL process ability and perceived ability to use ET among older adults with (A) mild stage AD and (B) MCI. Notes: AD = Alzheimer’s Disease, MCI = Mild Cognitive Impairment, ET = Everyday Technology. Higher measures indicate higher ability. Individual A: ADL process ability = 0.74 logits, perceived ability to use ET = 71.60 logits. Individual B: ADL process ability = 0.15 logits, perceived ability to use ET = 63.05 logits. Individual C: ADL process ability = 1.05 logits, perceived ability to use ET = 72.55 logits.
associated with perceived ability to use ET in the MCI group but not in the AD group. Overall the findings indicate that perceived ability to use ET is
clearly related to performance of ADL but also that they are different aspects of functioning in daily life.
ADL and ET use among older adults with Alzheimer’s or mild cognitive impairment
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Table III. Correlations (Rs) between ADL motor and ADL process ability measures and perceived ability to use ET use with and without outliers. All participants included
Outliers excluded
AD (n = 39)
MCI (n = 28)
AD (n = 37)
MCI (n = 27)
Motor ability – ET use
0.22 (NS)
0.50**
0.27(NS)
0.60**
Processability –ET use (r)
0.32*
0.44*
0.41*
0.51**
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Notes: AD = Alzheimer’s disease, MCI = Mild cognitive impairment, ET = everyday technology. *p < 0.05; **p < 0.01.
Regarding ADL process ability and ability to use ET, associations were somewhat stronger in the group of older adults with MCI than among those with AD. This could reflect the different approaches for datagathering in the S-ETUQ and the AMPS. Persons with AD are more likely to under-report functional status than persons with MCI (28) and when comparing the rater’s assessments of observed ability to use ET with the participants’ own perceptions of their ability, older adults with AD were found to overestimate their ability to a greater extent than older adults with MCI (29). These differences between the groups make it likely that the observational evaluation of ADL performance corresponds to a greater extent to the perceived ability to use ET among older adults with MCI than among those with mild-stage AD. An alternative explanation for the group differences in correlation strength between ADL ability and ability to use ET could be a decrease in the numbers of ETs perceived as relevant associated with cognitive decline. The numbers of ETs perceived as relevant was significantly higher in the MCI group than in the AD group in this sample. Earlier studies show similar findings where older adults without known cognitive impairments perceived significantly more ETs as relevant than older adults with AD or MCI (5,6) and older adults with MCI perceive significantly more ETs as relevant than older adults with AD (5). These differences in the number of relevant ETs between the groups might be due to a gradual adaptation to decreased ability to use ET in daily life where the person stops using ETs that are perceived as difficult; hence, these difficulties are not captured in the S-ETUQ interview and are not reflected in the measure of perceived ability to use ET. This process is likely to have progressed further among the older adults with AD than the older adults with MCI and could possibly explain the difference in correlation strength between the groups regarding perceived difficulty in ET use and ADL process ability. The finding that ability to use ET is more strongly correlated with ADL in the MCI group (Rs = 0.51 and 0.44) than in the AD group (Rs = 0.21 and 0.32) is not in line with earlier findings investigating correlations between ADL and ET use. On the contrary, Nygård
and Kottorp (7) found stronger correlations between frequency of engagement in activities (ADL, social and leisure activities) and ET use among older adults with AD (R = 0.49) than among older adults with MCI (R = 0.37). These contradictory findings indicate that the quality of the actual doing of ADL tasks is related to ability to use ET in a different way than frequency of engagement in ADL. The combination of findings from these two studies therefore indicates the need for occupational therapists to use various approaches and foci when evaluating ADL ability (including the use of ET), as different approaches can generate different responses. Regarding correlations between ADL motor ability and perceived ability to use ET, there were more evident differences between the groups. The significant and relatively strong correlation between those variables in the MCI group is somewhat surprising since motor skills are not usually expected to be significant for functional performance for persons with MCI, who are expected primarily to have cognitive limitations. ADL motor ability was even more strongly correlated with ability to use ET than ADL process ability in the MCI group, highlighting the importance of also addressing ADL motor limitations when evaluating ADL ability in this population. Otherwise, problems in daily-life activities caused by ADL motor limitations might not be detected and addressed when planning support for people with MCI. However, in the AD group motor ability was not associated with ability to use ET. This might partially be for the same reasons that differences were found between groups regarding correlation strength between ADL process ability and difficulty in ET use, as described earlier. However, the differences were so distinct that alternative explanations related to characteristics of the sample are more likely. As older adults often have agerelated ADL motor limitations (8) this was probably the case for some participants in this study, and due to the sample size even a few of these individuals could have had an effect on the correlation coefficient, especially in the MCI group. A few individuals differed from the rest of the group by perceiving unexpectedly high ability to use ET in relation to their observed ability to perform ADL.
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C. Ryd et al. A
B 3.00
ADL process ability
2.00
1.00
0.00
1.00
0.00
–1.00 Mild stage AD Group
Mild stage AD Group
MCI
MCI
C
70.00
Perceived ability to use ET
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ADL motor ability
2.00
60.00
50.00
40.00 Mild stage AD
MCI
Group Figure 3. Boxplots of measures of (A) observed ADL motor ability, (B) observed ADL process ability and (C) perceived ability to use ET. AD = Alzheimer’s Disease, MCI = Mild Cognitive Impairment, ET = Everyday Technology. Higher measures indicate higher ability.
These discrepancies indicate the advisability of using alternative methods to get a more valid and comprehensive evaluation of ability to use ET among those individuals. The Management of Everyday Technology Assessment (META) is an observationbased assessment of ability to use ET that has been
evaluated for older adults with MCI and AD as well as for older adults without cognitive impairments (4,30). The META could be a useful complement to the S-ETUQ, both clinically and in research when ability to use ET is evaluated among older adults with cognitive impairments.
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ADL and ET use among older adults with Alzheimer’s or mild cognitive impairment This study also had a second aim of comparing ADL motor and process ability and perceived ability to use ET. When examining the distribution of measures no ceiling effects were found either for the AMPS measures of ADL motor and process ability or for the S-ETUQ’s measure of perceived ability to use ET. This is a potential problem in those relatively high-functioning groups (31). The ADL process ability measure and the measure of perceived ability to use ET were also sensitive enough to separate the groups from each other, further supporting the validity of both the AMPS and the S-ETUQ when used on older adults with different levels of cognitive decline. Interestingly, the perceived relevance of number of ETs differed significantly between groups. This indicate that the S-ETUQ can also separate groups based on the numbers of ETs perceived as relevant, which has not been explored before using the shortform version. This is despite the relatively few ETs included in S-ETUQ: 33 compared with 93 in the full version. As stated earlier, knowledge of AMPS usability among older adults with MCI has been limited. The findings of this study support the usefulness of the AMPS among older adults with MCI. In combination with the extensive evaluations of the AMPS’ validity in other populations (8) this further supports validity of the AMPS when used among older adults with MCI. The major methodological consideration in this study is the relatively small sample size. A small sample makes the statistical analyses sensitive to outliers, which is evident when the exclusion of outliers increased the correlation coefficient in all correlation analyses (Table III). Hence, generalizations of the findings should be made with caution, especially regarding older adults with MCI. Another methodological consideration is that significantly more participants with AD had support from a significant other during the S-ETUQ interview than participants with MCI. Having a significant other as support during the interview could have the benefit of increasing the quality of the data, since the participants with AD might have been less able to estimate their functional ability than the participants with MCI (28). Hence, one benefit of this could be that ability to use ET was captured to a greater extent in the AD group. On the other hand it could be questioned whether it actually was the participant’s perceptions that were captured or those of the significant other. Taken together, the advantages of including significant others when possible were considered to outweigh the disadvantages in this study. This is also supported in the literature describing the development of ETUQ (26). Conclusion and clinical implications To conclude, the positive associations between ADL performance and perceived ability to use ET found in
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this study support the significance of ET in daily-life activities among older adults with mild-stage AD or MCI. Despite the general perception that cognitive limitations and ADL process ability are the primary causes of decreased functional performance in these groups, ADL motor ability was more associated with perceived ability to use ET than ADL process ability in the MCI group. The finding implies that use of ET is an aspect of functioning in daily life that should be included when evaluating ADL ability in these populations in order to discover activity limitations related to the increasing use of ET in our homes and in society. In addition ADL motor ability as well as ADL process abilityisimportant toconsiderwhen evaluating function in daily-life activities among older adults with cognitive impairments. ADL process ability and perceived ability touse ETdifferedsignificantlybetween thegroups.This implies that the AMPS and the S-ETUQ are sensitive enough to separate older adults with mild stage AD from those with MCI; hence both instruments’ validity when used in those groups is further supported. For clinicians the findings highlight the importance of considering ability to use ET when evaluating functional ability and planning support in daily life for older adults with cognitive impairments. They also highlight the importance of using different datagathering methods (i.e. interview and observation) and make suggestions for instruments to use when evaluating functional ability in daily life. Based on the findings of this study and of previous research the ability to use ET can be assumed to be of importance for the performance of daily-life activities. However, to target individuals in need of support, future research also needs to address if and how ability to use ET is related to a person’s ability to function independently in the community. Acknowledgements The authors wish to thank the participants, who generously shared their daily lives. They also wish to thank the OTs who performed the data gathering; Monica Pantzar, Pernilla Lundh, and Sofia Starkhammar, as well as the OTs engaged in the recruitment of participants. The research was supported by the Health Care Science Postgraduate School and the Strategic Research Program in Care Sciences (SFO-V) at Karolinska Institutet, Swedish Brainpower, and the Stockholm County Council through the agreement on medical training and clinical research (ALF) between Stockholm County Council and the Karolinska institutet. Declaration of interest: The authors report no conflict of interests and are alone responsible for the content and writing of the paper.
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References 1. Kielhofner G. A model of human occupation: Theory and practice. Maryland: Lippincot Williams & Wilkins; 2008. 2. Emiliani PL. Assistive Technology (AT) versus Mainstream Technology (MST): The research perspective. Technol Disabil 2006;18:19–29. 3. Patomella A-H, Kottorp A, Nygård L. Design and management features of everyday technology that challenge older adults. Br J Occup Ther 2013;76:390–8. 4. Malinowsky C, Almkvist O, Kottorp A, Nygard L. Ability to manage everyday technology: A comparison of persons with dementia or mild cognitive impairment and older adults without cognitive impairment. Disabil Rehabil Assist Technol 2010;5:462–9. 5. Nygard L, Pantzar M, Uppgard B, Kottorp A. Detection of activity limitations in older adults with MCI or Alzheimer’s disease through evaluation of perceived difficulty in use of everyday technology: A replication study. Aging Ment Health 2012;16:361–71. 6. Rosenberg L, Kottorp A, Winblad B, Nygard L. Perceived difficulty in everyday technology use among older adults with or without cognitive deficits. Scand J Occup Ther 2009;16: 216–26. 7. Nygård L, Kottorp A. Engagement in IADLs, social activities and use of everyday technology in older adults with and without cognitive imapirment. Br J Occup Ther; Accepted. 8. Fisher AG. Assessment of Motor and Process Skills Volume 1: Development, standardization and administration manual. 7th ed. Forth Collins, CO: Three Star Press; 2012. 9. Kelley BJ, Petersen RC. Alzheimer’s disease and mild cognitive impairment. Neurol Clin 2007;25:577–609. 10. Arrighi HM, Gélinas I, McLaughlin TP, Buchanan J, Gauthier S. Longitudinal changes in functional disability in Alzheimer’s disease patients. Int Psychogeriatr 2013;25:929– 37. 11. Suh GH, Ju YS, Yeon BK, Shah A. A longitudinal study of Alzheimer’s disease: Rates of cognitive and functional decline. Int J Geriatr Psych 2004;19:817–24. 12. Winblad B, Palmer K, Kivipelto M, Jelic V, Fratiglioni L, Wahlund LO, et al. Mild cognitive impairment – beyond controversies, towards a consensus: Report of the International Working Group on Mild Cognitive Impairment. J Intern Med 2004;256:240–6. 13. Albert MS, DeKosky ST, Dickson D, Dubois B, Feldman HH, Fox NC, et al. The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging–Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s Dementia 2011;7:270–9. 14. Ward A, Arrighi HM, Michels S, Cedarbaum JM. Mild cognitive impairment: Disparity of incidence and prevalence estimates. Alzheimer’s Dement 2012;8:14–21. 15. Mitchell AJ, Shiri-Feshki M. Rate of progression of mild cognitive impairment to dementia: Meta-analysis of 41 robust inception cohort studies. Acta Psychiatr Scand 2009;119: 252–65.
16. Marshall GA, Amariglio RE, Sperling RA, Rentz DM. Activities of daily living: Where do they fit in the diagnosis of Alzheimer’s disease? Neurodegener Dis Manag 2012;2: 483–91. 17. Kottorp A, Nygard L. Development of a short-form assessment for detection of subtle activity limitations: Can use of everyday technology distinguish between MCI and Alzheimer’s disease? Expert Rev Neurother 2011;11:647–55. 18. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease Report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology 1984;34:939–44. 19. Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med 2004;256:183–94. 20. Nygård L. The meaning of everyday technology as experienced by people with dementia who live alone. Dementia 2008;7:481–502. 21. Nygård L. Manual to the questionnaire about everyday technology in home and society: Everyday Technology Use Questionnaire (ETUQ II) & Short ETUQ (S-ETUQ). Stockholm Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Occupational Therapy; 2012. 22. Rosenberg L, Nygård L, Kottorp A. Everyday technology use questionnaire: Psychometric evaluation of a new assessment of competence in technology use. OTJR: Occup. Particip Health 2009;29:52. 23. Oakley F, Duran L, Fisher A, Merritt B. Differences in activities of daily living motor skills of persons with and without Alzheimer’s disease. Aust Occup Ther J 2003;50: 72–8. 24. Oakley F, Sunderland T. Assessment of motor and process skills as a measure of IADL functioning in pharmacologic studies of people with Alzheimer’s disease: A pilot study. Int Psychogeriatr 1997;9:197–206. 25. Hartman ML, Fisher AG, Duran L. Assessment of functional ability of people with Alzheimer’s disease. Scand J Occup Ther 1999;6:111–18. 26. Rosenberg L. Navigating through technological landscapes: Views of people with dementia or MCI and their significant others. Stockholm: Karolinska Institutet; 2009. 27. Linacre JM. WINSTEPS Rasch measurement computer program. Chicago: Winsteps; 2006. 28. Farias ST, Mungas D, Jagust W. Degree of discrepancy between self and otherreported everyday functioning by cognitive status: Dementia, mild cognitive impairment, and healthy elders. Int J Geriatr Psych 2005;20:827–34. 29. Malinowsky C. Managing technology in everyday activities: A study of older adults with dementia, MCI, and no cognitive impairment. Stockholm: Karolinska Institutet; 2011. 30. Malinowsky C, Nygard L, Kottorp A. Psychometric evaluation of a new assessment of the ability to manage technology in everyday life. Scand J Occup Ther 2011;18:26–35. 31. Rockwood K. The measuring, meaning and importance of activities of daily living (ADLs) as an outcome. Int Psychogeriatr 2007;19:467–82.
ORIGINAL ARTICLE
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Associations between performance of activities of daily living and everyday technology use among older adults with mild stage Alzheimer’s disease or mild cognitive impairment
CHARLOTTA RYD1, LOUISE NYGÅRD1, CAMILLA MALINOWSKY1, ANNIKA ÖHMAN2 & ANDERS KOTTORP1,3 1
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden, 2Division of Health, Activity and Care and National Institute for the Study of Ageing and Later Life (NISAL), Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden, and 3Department of Occupational Therapy, Zurich University of Applied Sciences, Winterthur, Switzerland
Abstract Background: The use of everyday technology (ET) is important for many activities in daily life (ADL) and can be especially challenging for older adults with cognitive impairments. Objective: The aim was to explore associations between ADL performance and perceived ability to use ET among older adults with mild stage Alzheimer’s disease (AD) and mild cognitive impairment (MCI). ADL motor and process ability, and ability to use ET were also compared between the groups. Methods: Participants with AD (n = 39) and MCI (n = 28) were included. Associations and group differences were explored with nonparametric statistics. Results: Significant correlations were found between ADL process ability and ET use in both groups (Rs = 0.44 and 0.32, p < 0.05), but for ADL motor ability and ET use, correlations were only found in the MCI group (Rs = 0.51, p < 0.01). The MCI group had significantly higher measures of ADL process ability (p < 0.001) and ET use (p < 0.05). Conclusion: ADL performance ability and perceived ability to use ET are important to consider in evaluations of older adults with cognitive impairments. Group differences indicate that measures of ADL performance ability and ET use are sensitive enough to discriminate the MCI group from the AD group with individually overlapping measures.
Key words: occupational therapy, dementia, cognitive impairments, assessments of functional ability, ADL
Introduction The physical environment is of major importance for the performance of daily activities (1) and this environment contains a growing proportion of technological artefacts and systems (2). The increasing use of everyday technology (ET), such as mobile phones, household appliances, and automated ticket-vending machines, has also changed how our daily activities are performed. To a large extent, ET has facilitated performance of daily activities but also made them more complex and demanding (3). Older adults with cognitive impairments such as mild cognitive
impairment (MCI) or mild stage Alzheimer’s disease (AD) have demonstrated greater difficulty using ET in daily activities than older adults without known cognitive impairments (4-6). Moderate to strong associations between engagement in activities in daily living (ADL) and perceived difficulty in ET use among older adults with mild AD or MCI have been found, indicating the significance of ET in daily activities for these groups (5,7). Thus the ability to use ET may be an important aspect to consider when evaluating ability to perform daily activities. However, there is a lack of knowledge about associations between the actual performance of ADL and ability
Correspondence: Charlotta Ryd, Division of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Fack 23200, 141 83 Huddinge, Sweden. E-mail: [email protected] (Received 10 June 2014; accepted 5 September 2014) ISSN 1103-8128 print/ISSN 1651-2014 online 2015 Informa Healthcare DOI: 10.3109/11038128.2014.964307
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C. Ryd et al.
to use ET. Therefore, empirical evidence is needed to support or refute such associations in order to offer targeted support in daily life. Moreover, limitations in ADL process skills (8), for example organizing or sequencing steps and actions in a logical order, may affect the use of ET in daily activities differently than limitations in ADL motor skills (8), such as moving in the environment or manipulating objects. Impairments in different ADL skills are likely to require different types of interventions; therefore, it is also important to know what specific aspects of ADL ability are associated with difficulties in ET use, in order to guide interventions. A dementia disease such as AD implies a decrease of cognitive function that is severe enough to increase limitations in the ability to perform daily activities (9). Instrumental activities of daily living (IADL), such as handling finances, handling medication, and doing household work, are affected earlier in the course of the disease than more basic activities of daily living (bADL) (10,11). Mild cognitive impairment (MCI) refers to a zone of cognitive decline between normal ageing and dementia (12). Persons with MCI are generally independent in daily life even if the performance of daily activities may be less efficient, take more time, or include more errors (13). Prevalence of MCI is hard to estimate due to variations in definitions that have been used to describe mild forms of cognitive impairments and in a systematic review the prevalence of MCI varied between 3% and 42% (14). Many of those diagnosed with MCI convert to dementia with time and the annual conversion rate is 5–10%. Among those who convert the most common cause of dementia is AD (15). The conversion from MCI to AD is a gradual process without fixed events that define the onset of dementia and the extent of impairment in ADL is often used to draw the line between MCI and dementia (13,16). This implies that evaluation of ability to perform ADL is important not just for identifying individuals in need of support in daily life activities but also for distinguishing between early stage dementia and MCI. However, these evaluations might be challenging due to the subtle character of the functional impairments; therefore sensitive instruments that include complex activities are required (16). Many ADL assessments today only evaluate ADL ability in relation to level of dependence in bADL (8). As many persons with MCI or early stage dementia are independent in performing such tasks, it is crucial that tools addressing ADL functioning focus on (a) other aspects of importance in everyday functioning (e.g. safety, efficiency, degree of effort), and (b) include more challenging ADL tasks (e.g. IADL and tasks incorporating ET use). More knowledge of ADL performance ability and ability to use ET, and
how these are related among older adults with mild stage AD or MCI, is important for identifying how to support these individuals in daily life. Such knowledge could also contribute to the diagnosing of MCI and AD. Therefore, the main aim of this study was to explore associations between ADL performance ability, divided into ADL motor and process ability, and perceived ability to use ET among older adults with mild stage AD or MCI. To further investigate the degree of impaired ADL performance ability and perceived ability to use ET a secondary aim of this study was to compare the MCI group and the AD group with regard to level of ADL motor and ADL process ability and level of perceived ability to use ET. Material and methods Study design In order to investigate the aims of the study, a crosssectional, non-experimental, quantitative design was used. Participants Older adults with AD (n = 39) in a mild stage or MCI (n = 28) were recruited through three different investigation units for memory deficits in the Stockholm area. Based on an earlier empirical study by Kottorp and Nygård using SETUQ with similar diagnostic samples (17), an estimated sample size of n = 18 per group is needed to secure a mean difference of 5.0 logits (p < 0.05) with a power of 0.90. Diagnoses were set by physicians according to the criteria for AD based on NINCDS-ADRDA (18) and the MCI criteria described by Petersen (19) and Winblad et al. (12). Inclusion criteria were: (a) being 55 years or older, (b) a need to use relevant ET in daily life (thus not being totally dependent on another person in daily life), (c) that any visual or hearing impairments could be compensated for with technical aids, and (d) a MMSE score of at least 18/30 for participants with AD and 25/30 for participants with MCI when recruited. Description of the groups regarding sex, age, years of education, and living conditions is presented in Table I. Significant differences between groups were not found regarding those variables. Instruments The Everyday Technology Use Questionnaire (ETUQ) ETUQ is an evaluation of perceived relevance and difficulty to use ET in daily activities, which has been developed and validated for older adults with or
ADL and ET use among older adults with Alzheimer’s or mild cognitive impairment Table I. Characteristics of the participants.
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Groups Older adults with mild stage AD (n = 39)
Older adults with MCI (n = 28)
Age, M (SD)
75.74 (7.41)
76.9 (7.19)
Females; n (%)
21 (54)
12 (43)
Years of education, M (SD)
11.08 (3.27)
12.20 (3.41)
Living conditions: single/cohabiting; n (%)
17 (43.6)/ 22 (56.4)
17 (60.7)/ 11 (39.3)
Notes: AD = Alzheimer’s disease; MCI = mild cognitive impairment; SD = standard deviation.
without cognitive impairments (20,21). It has shown potential to discriminate between older adults with no known cognitive impairment and those with mildstage AD or MCI (4-6) indicating potential to discover functional limitations among those groups. In addition ETUQ has demonstrated evidence of unidimensionality, internal scale validity, rating scale validity, and person response validity (5,6,22). The S-ETUQ is a shortened version of the ETUQ that generates statistically similar measures to those of the original version supporting the validity of the short version (17). Details of the procedure of developing the S-ETUQ have been presented elsewhere (17). The items in S-ETUQ are ETs that range from very easy to very difficult to use and include both newly developed and well-known technological artefacts and systems, e.g. the coffee machine, radio, cell-phone, and internet-banking. S-ETUQ is administered in a face-to-face interview and for each item the respondent specifies if the technology is available and relevant to him or her. Those ETs perceived as relevant are then graded on a six-step scale indicating the respondent’s perceived difficulty using them (17). The scale ranges from “uses the ET without perceived difficulties” to “does not use the ET even if it’s available and perceived as relevant” (21)”. Using S-ETUQ requires a one-day training course held by one of the developers of the instrument (LN) and colleagues. S-ETUQ generates a measure of the respondent’s perceived difficulty using ET that can also be expressed as the respondent’s perceived ability to use ET. The term used in this article will primarily be perceived ability to use ET. Assessments of Motor and Process Skills (AMPS) The AMPS is a standardized, performance-based assessment that evaluates the quality of a person’s performance of personal or instrumental activities of
35
daily living (ADL) by measuring ADL motor and process performance ability. It has been proven to identify activity limitations in persons with dementia (23-25) but knowledge of AMPS usability among older adults with MCI is still limited. The AMPS can be used by occupational therapists who have attended a training course and been calibrated as users. The assessment is initiated by an interview conducted by the occupational therapist where the client identifies two ADL tasks that are familiar and of appropriate challenge on a list of 121 standardized activities. The client is then observed during performance of the self-chosen tasks and the occupational therapist scores the quality of performance on 36 ADL motor and process performance skills defined as the smallest units of observable actions in the performance of an ADL task. Each observed skill is graded on a four-point rating scale where a score of 4 reflects competent performance and a score of 1 reflect severely deficient performance. A Raschbased computerized scoring program is then used to convert these raw scores into linear measures of ADL motor ability and ADL process ability adjusting for task challenge and rater severity. The ADL tasks in AMPS are graded on a scale ranging from very easy to much harder than average to perform, and it is critical for the sensitivity and validity of the assessment that the chosen tasks are sufficiently challenging for the person performing them (8). Data-gathering procedures All participants were interviewed with S-ETUQ and evaluated with AMPS. For 53 (79%) of the participants both assessments were completed in the same day. For the rest of the participants data-gathering was carried out on to two occasions according to the participant’s individual wishes and needs. There was a maximum of 19 days between data-gathering occasions (median: 0, range: 0–19). Data were collected by four experienced occupational therapists with training in using the AMPS and the S-ETUQ. If the participants agreed, data collection took place in their homes. Otherwise, data collection took place in the clinic where the participants went through memory investigation. Some participants preferred to include a significant other during the S-ETUQ interview and this was the case for significantly more participants in the AD group than in the MCI group (see Table II). The role of the significant other was to provide support while the participant answered the questions. This procedure has been recommended and discussed elsewhere (26). During the AMPS observation significant others could be present but could not provide support. The ADL tasks chosen in the AMPS
36
C. Ryd et al. ability to use ET use with the Mann–Whitney U-test. The level of significance was set at p < 0.05.
Table II. Conditions during data collection. Groups Older adults with mild-stage AD (n = 39)
Older adults with MCI (n = 28)
Data collection at participants home: n (%)
36 (92.3)
23 (89.3)
Significant other present during S-ETUQ interview: n (%)
20 (51.3)
7 (30.4)
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Notes: AD = Alzheimer’s disease; MCI = mild cognitive impairmen.
assessments in this study were, for most participants (92%), averagely or above averagely challenging to perform (8) indicating that they were sufficiently challenging for the sample (see Table II for details of the data-gathering). Before the study was initiated, ethical approval was obtained from the regional Ethical Committee (D-n [journal number] 2010/120-31/5). The participants received both written and verbal information about the study before agreeing to participate. Written informed consent was given by the participants. Data analysis Preparatory analysis The first step in the data analysis was to transform the raw ordinal data from the S-ETUQ and the AMPS into individual linear interval measures (logits). For the AMPS assessments this was done by use of the Rasch-based AMPS computerized scoring program, which generated measures of ADL process ability and ADL motor ability for each participant. The data from S-ETUQ were analysed using the WINSTEPS computer software program version 3.69.1 (27) and this analysis generated measures of each person’s perceived ability to use ET. This specific process has been described in more detail elsewhere (5). Primary analysis Next, the primary statistical analysis was performed using the Statistical Package for Social Sciences (SPSS), version 22. Non-parametric tests were used since the variables did not demonstrate a normal distribution. Associations between ADL process and motor ability and perceived ability to use ET were explored with the Spearman rank correlation coefficient (RS). The groups were compared regarding ADL motor and process ability and perceived
Results Associations between ADL motor and process ability and perceived ability to use ET The correlation coefficient (Rs) between ADL motor ability and perceived ability to use ET among persons with MCI was 0.51 (p < 0.01). In the group consisting of older adults with AD the association was weaker and non-significant, Rs = 0.21 (p = 0.17) (see Figure 1A and B). The correlation coefficient between ADL process ability and perceived ability to use ET among persons with MCI was 0.44 (p < 0.05). In the group of older adults with AD the association was weaker but also significant, Rs = 0.32(p < 0.05) (see Figure 2A and B). Based on a visual inspection, two individuals (A and B, see Figures 1A and 2A) within the AD group and one individual (C, see Figures 1B and 2B) within the MCI group had unexpectedly high measures of perceived ability to use ET in relation to their ADL process and motor ability measures. A more in-depth analysis revealed that these individuals also differed from the rest of the sample by having much higher individual standard errors on their measures of perceived ability to use ET (9.74–10.17 logits) compared with the mean of the rest of the sample (2.04 logits). Artificially high and imprecise measures indicate that these could be questioned from a validity perspective. Hence, we decided to explore the relationship by excluding these potentially invalid responses. When individual A, B, and C were removed all associations became stronger (Table III). Group comparison of ADL motor and process ability and ability to use ET Overall the participants with MCI had higher measures of both ADL motor and process ability and perceived ability to use ET compared with the participants with mild AD. The groups differed significantly regarding ADL process ability (p < 0.001) and perceived ability to use ET (p < 0.05) but not regarding ADL motor ability (p = 0.166). Measures of ADL motor and process ability and perceived ability to use ET are illustrated in Figure 3A, B, and C. Finally, the groups also differed significantly regarding number of ETs perceived as relevant (p < 0.001). The MCI group perceived on average 18 of the 33 items (SD 4.25; range 9–25) in S-ETUQ as relevant compared with the AD group who perceived on average 15 of 33 items (SD 3.95; range 7– 25) as relevant.
ADL and ET use among older adults with Alzheimer’s or mild cognitive impairment A
37
Mild stage AD
3.00
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ADL motor ability
2.50
2.00
A B
1.50
1.00
0.50
0.00 40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
Perceived ability to use ET
B
MCI
3.00
ADL motor ability
2.50
2.00 C 1.50
1.00
0.50
0.00 40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
Perceived ability to use ET Figure 1. Relationships between measures of ADL motor ability and perceived ability to use ET among older adults with (A) mild stage AD and (B) MCI. Notes: AD = Alzheimer’s Disease, MCI = Mild Cognitive Impairment, ET = Everyday Technology. Higher measures indicate higher ability. Individual A: ADL motor ability = 1.80 logits, perceived ability to use ET = 71.6 logits. Individual B: ADL motor ability = 1.55 logits, perceived ability to use ET = 63.05 logits. Individual C: ADL motor ability = 1.65 logits, perceived ability to use ET = 72.55 logits.
Discussion This study was intended primarily to explore associations between ADL performance and perceived
difficulty of ET use for older adults with MCI or mild-stage AD. Significant correlations were found between ADL process ability and perceived ability to use ET in both groups. ADL motor ability was
38
C. Ryd et al. A
Mild stage AD
2.50
2.00
ADL process ability
1.00 A 0.50 B 0.00 –0.50
–1.00 40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
Perceived ability to use ET
B
MCI
2.50
2.00
1.50 ADL process ability
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1.50
C
1.00
0.50
0.00
–0.50
–1.00 40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
Perceived ability to use ET Figure 2. Relationships between measures of ADL process ability and perceived ability to use ET among older adults with (A) mild stage AD and (B) MCI. Notes: AD = Alzheimer’s Disease, MCI = Mild Cognitive Impairment, ET = Everyday Technology. Higher measures indicate higher ability. Individual A: ADL process ability = 0.74 logits, perceived ability to use ET = 71.60 logits. Individual B: ADL process ability = 0.15 logits, perceived ability to use ET = 63.05 logits. Individual C: ADL process ability = 1.05 logits, perceived ability to use ET = 72.55 logits.
associated with perceived ability to use ET in the MCI group but not in the AD group. Overall the findings indicate that perceived ability to use ET is
clearly related to performance of ADL but also that they are different aspects of functioning in daily life.
ADL and ET use among older adults with Alzheimer’s or mild cognitive impairment
39
Table III. Correlations (Rs) between ADL motor and ADL process ability measures and perceived ability to use ET use with and without outliers. All participants included
Outliers excluded
AD (n = 39)
MCI (n = 28)
AD (n = 37)
MCI (n = 27)
Motor ability – ET use
0.22 (NS)
0.50**
0.27(NS)
0.60**
Processability –ET use (r)
0.32*
0.44*
0.41*
0.51**
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Notes: AD = Alzheimer’s disease, MCI = Mild cognitive impairment, ET = everyday technology. *p < 0.05; **p < 0.01.
Regarding ADL process ability and ability to use ET, associations were somewhat stronger in the group of older adults with MCI than among those with AD. This could reflect the different approaches for datagathering in the S-ETUQ and the AMPS. Persons with AD are more likely to under-report functional status than persons with MCI (28) and when comparing the rater’s assessments of observed ability to use ET with the participants’ own perceptions of their ability, older adults with AD were found to overestimate their ability to a greater extent than older adults with MCI (29). These differences between the groups make it likely that the observational evaluation of ADL performance corresponds to a greater extent to the perceived ability to use ET among older adults with MCI than among those with mild-stage AD. An alternative explanation for the group differences in correlation strength between ADL ability and ability to use ET could be a decrease in the numbers of ETs perceived as relevant associated with cognitive decline. The numbers of ETs perceived as relevant was significantly higher in the MCI group than in the AD group in this sample. Earlier studies show similar findings where older adults without known cognitive impairments perceived significantly more ETs as relevant than older adults with AD or MCI (5,6) and older adults with MCI perceive significantly more ETs as relevant than older adults with AD (5). These differences in the number of relevant ETs between the groups might be due to a gradual adaptation to decreased ability to use ET in daily life where the person stops using ETs that are perceived as difficult; hence, these difficulties are not captured in the S-ETUQ interview and are not reflected in the measure of perceived ability to use ET. This process is likely to have progressed further among the older adults with AD than the older adults with MCI and could possibly explain the difference in correlation strength between the groups regarding perceived difficulty in ET use and ADL process ability. The finding that ability to use ET is more strongly correlated with ADL in the MCI group (Rs = 0.51 and 0.44) than in the AD group (Rs = 0.21 and 0.32) is not in line with earlier findings investigating correlations between ADL and ET use. On the contrary, Nygård
and Kottorp (7) found stronger correlations between frequency of engagement in activities (ADL, social and leisure activities) and ET use among older adults with AD (R = 0.49) than among older adults with MCI (R = 0.37). These contradictory findings indicate that the quality of the actual doing of ADL tasks is related to ability to use ET in a different way than frequency of engagement in ADL. The combination of findings from these two studies therefore indicates the need for occupational therapists to use various approaches and foci when evaluating ADL ability (including the use of ET), as different approaches can generate different responses. Regarding correlations between ADL motor ability and perceived ability to use ET, there were more evident differences between the groups. The significant and relatively strong correlation between those variables in the MCI group is somewhat surprising since motor skills are not usually expected to be significant for functional performance for persons with MCI, who are expected primarily to have cognitive limitations. ADL motor ability was even more strongly correlated with ability to use ET than ADL process ability in the MCI group, highlighting the importance of also addressing ADL motor limitations when evaluating ADL ability in this population. Otherwise, problems in daily-life activities caused by ADL motor limitations might not be detected and addressed when planning support for people with MCI. However, in the AD group motor ability was not associated with ability to use ET. This might partially be for the same reasons that differences were found between groups regarding correlation strength between ADL process ability and difficulty in ET use, as described earlier. However, the differences were so distinct that alternative explanations related to characteristics of the sample are more likely. As older adults often have agerelated ADL motor limitations (8) this was probably the case for some participants in this study, and due to the sample size even a few of these individuals could have had an effect on the correlation coefficient, especially in the MCI group. A few individuals differed from the rest of the group by perceiving unexpectedly high ability to use ET in relation to their observed ability to perform ADL.
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C. Ryd et al. A
B 3.00
ADL process ability
2.00
1.00
0.00
1.00
0.00
–1.00 Mild stage AD Group
Mild stage AD Group
MCI
MCI
C
70.00
Perceived ability to use ET
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ADL motor ability
2.00
60.00
50.00
40.00 Mild stage AD
MCI
Group Figure 3. Boxplots of measures of (A) observed ADL motor ability, (B) observed ADL process ability and (C) perceived ability to use ET. AD = Alzheimer’s Disease, MCI = Mild Cognitive Impairment, ET = Everyday Technology. Higher measures indicate higher ability.
These discrepancies indicate the advisability of using alternative methods to get a more valid and comprehensive evaluation of ability to use ET among those individuals. The Management of Everyday Technology Assessment (META) is an observationbased assessment of ability to use ET that has been
evaluated for older adults with MCI and AD as well as for older adults without cognitive impairments (4,30). The META could be a useful complement to the S-ETUQ, both clinically and in research when ability to use ET is evaluated among older adults with cognitive impairments.
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ADL and ET use among older adults with Alzheimer’s or mild cognitive impairment This study also had a second aim of comparing ADL motor and process ability and perceived ability to use ET. When examining the distribution of measures no ceiling effects were found either for the AMPS measures of ADL motor and process ability or for the S-ETUQ’s measure of perceived ability to use ET. This is a potential problem in those relatively high-functioning groups (31). The ADL process ability measure and the measure of perceived ability to use ET were also sensitive enough to separate the groups from each other, further supporting the validity of both the AMPS and the S-ETUQ when used on older adults with different levels of cognitive decline. Interestingly, the perceived relevance of number of ETs differed significantly between groups. This indicate that the S-ETUQ can also separate groups based on the numbers of ETs perceived as relevant, which has not been explored before using the shortform version. This is despite the relatively few ETs included in S-ETUQ: 33 compared with 93 in the full version. As stated earlier, knowledge of AMPS usability among older adults with MCI has been limited. The findings of this study support the usefulness of the AMPS among older adults with MCI. In combination with the extensive evaluations of the AMPS’ validity in other populations (8) this further supports validity of the AMPS when used among older adults with MCI. The major methodological consideration in this study is the relatively small sample size. A small sample makes the statistical analyses sensitive to outliers, which is evident when the exclusion of outliers increased the correlation coefficient in all correlation analyses (Table III). Hence, generalizations of the findings should be made with caution, especially regarding older adults with MCI. Another methodological consideration is that significantly more participants with AD had support from a significant other during the S-ETUQ interview than participants with MCI. Having a significant other as support during the interview could have the benefit of increasing the quality of the data, since the participants with AD might have been less able to estimate their functional ability than the participants with MCI (28). Hence, one benefit of this could be that ability to use ET was captured to a greater extent in the AD group. On the other hand it could be questioned whether it actually was the participant’s perceptions that were captured or those of the significant other. Taken together, the advantages of including significant others when possible were considered to outweigh the disadvantages in this study. This is also supported in the literature describing the development of ETUQ (26). Conclusion and clinical implications To conclude, the positive associations between ADL performance and perceived ability to use ET found in
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this study support the significance of ET in daily-life activities among older adults with mild-stage AD or MCI. Despite the general perception that cognitive limitations and ADL process ability are the primary causes of decreased functional performance in these groups, ADL motor ability was more associated with perceived ability to use ET than ADL process ability in the MCI group. The finding implies that use of ET is an aspect of functioning in daily life that should be included when evaluating ADL ability in these populations in order to discover activity limitations related to the increasing use of ET in our homes and in society. In addition ADL motor ability as well as ADL process abilityisimportant toconsiderwhen evaluating function in daily-life activities among older adults with cognitive impairments. ADL process ability and perceived ability touse ETdifferedsignificantlybetween thegroups.This implies that the AMPS and the S-ETUQ are sensitive enough to separate older adults with mild stage AD from those with MCI; hence both instruments’ validity when used in those groups is further supported. For clinicians the findings highlight the importance of considering ability to use ET when evaluating functional ability and planning support in daily life for older adults with cognitive impairments. They also highlight the importance of using different datagathering methods (i.e. interview and observation) and make suggestions for instruments to use when evaluating functional ability in daily life. Based on the findings of this study and of previous research the ability to use ET can be assumed to be of importance for the performance of daily-life activities. However, to target individuals in need of support, future research also needs to address if and how ability to use ET is related to a person’s ability to function independently in the community. Acknowledgements The authors wish to thank the participants, who generously shared their daily lives. They also wish to thank the OTs who performed the data gathering; Monica Pantzar, Pernilla Lundh, and Sofia Starkhammar, as well as the OTs engaged in the recruitment of participants. The research was supported by the Health Care Science Postgraduate School and the Strategic Research Program in Care Sciences (SFO-V) at Karolinska Institutet, Swedish Brainpower, and the Stockholm County Council through the agreement on medical training and clinical research (ALF) between Stockholm County Council and the Karolinska institutet. Declaration of interest: The authors report no conflict of interests and are alone responsible for the content and writing of the paper.
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C. Ryd et al.
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