Comparison of motor strategies in sit-to-stand and back-to-sit motions between healthy and Alzheimer's disease elderly subjects

An Assessment of Physical Activity and Risk Factors in People Living with Dementia: Findings from a Cross-Sectional Study in a Long-Term Care Facility in Vietnam

BACKGROUND

People living with dementia (PLWD) may experience substantial cognitive decline as the disease progresses, which interferes with their daily activities. This study aimed to assess physical activity (PA) performance and care dependency (CD) and identify factors related to PA among PLWD.

METHODS

We conducted a cross-sectional study in 63 PLWD from National Geriatrics Hospital, Vietnam, from 2021 to 2023. We used the Mini Nutritional Assessment (MNA), International Physical Activity Questionnaire (IPAQ), and Care Dependency Scale (CDS) to assess the nutritional status and the levels of PA and CD, respectively. We used the Mann-Whitney test to compare the differences in the PA types and CD levels between dementia levels and a multivariable logistics regression model to analyze factors related to PA.

RESULTS

More than half of the subjects had mild dementia. In total, 35% of the PLWD had a low level of PA, and 46.3% were completely independent of care. The mean score in each CDS aspect of the subjects with moderate/severe dementia was statistically significantly lower than that of those with mild dementia (p ≤ 0.05). Lower dependency (OR = 0.9; 95% CI = 0.88-0.99) and malnutrition (OR = 15.4; 95% CI = 1.18-20.21) were associated with insufficient PA in the PLWD.

CONCLUSION

Formal caregivers and healthcare workers should encourage PLWD to perform physical activities at any level and personalize the development of tailored and nutritional care strategies for each individual.

A Canonical Scheme of Bottom-Up and Top-Down Information Flows in the Frontoparietal Network

Goal-directed behavior often involves temporal separation and flexible context-dependent association between sensory input and motor output. The control of goal-directed behavior is proposed to lie in the frontoparietal network, but the computational architecture of this network remains elusive. Based on recent rodent studies that measured and manipulated projection neurons in the frontoparietal network together with findings from earlier primate studies, we propose a canonical scheme of information flows in this network. The parietofrontal pathway transmits the spatial information of a sensory stimulus or internal motor bias to drive motor programs in the frontal areas. This pathway might consist of multiple parallel connections, each controlling distinct motor effectors. The frontoparietal pathway sends the spatial information of cognitively processed motor plans through multiple parallel connections. Each of these connections could support distinct spatial functions that use the motor target information, including attention allocation, multi-body part coordination, and forward estimation of movement state (i.e., forward models). The parallel pathways in the frontoparietal network enable dynamic interactions between regions that are tuned for specific goal-directed behaviors. This scheme offers a promising framework within which the computational architecture of the frontoparietal network and the underlying circuit mechanisms can be delineated in a systematic way, providing a holistic understanding of information processing in this network. Clarifying this network may also improve the diagnosis and treatment of behavioral deficits associated with dysfunctional frontoparietal connectivity in various neurological disorders including Alzheimer's disease.

Effects of Different Assistive Seats on Ability of Elderly in Sit-To-Stand and Back-To-Sit Movements

The ability to perform sit-to-stand (STS) and back-to-sit (BTS) movements is important for the elderly to live independently and maintain a reasonable quality of life. Accordingly, this study investigated the STS and BTS motions of 28 healthy older adults (16 male and 12 female) under three different seat conditions, namely nonassisted, self-designed lifting seat, and UpLift seat. The biomechanical data were acquired using a three-dimensional (3D) motion analysis system and force plates, and were examined by one-way repeated-measures ANOVA to investigate the effects of the different seat conditions on the joint angle, joint moments, and movement duration time (α = 0.05). No significant difference was observed in the STS duration among the three test conditions. However, the BTS duration was significantly increased in the UpLift seat condition. Moreover, the peak flexion angle of the hip during STS motion was also significantly higher in the UpLift condition. For both motions (STS and BTS), the lifting seats significantly decreased the knee and hip joint moments, but significantly increased the ankle joint moment. Moreover, compared to the nonassistive seat, both assistive lifting seats required a greater ankle joint strength to complete the STS and BTS motions.

Variáveis psicomotoras, cognitivas e funcionais em idosas saudáveis e com doença de Alzheimer

RESUMO A teoria da retrogênese descreve os declínios apresentados na doença de Alzheimer a partir dos estágios do desenvolvimento neuropsicomotor de Piaget. O objetivo deste estudo transversal é avaliar e descrever aspectos psicomotores, cognitivos e quedas, investigando a relação de dependência entre essas variáveis de acordo com a teoria da retrogênese. A amostra foi composta por 45 idosas (27 saudáveis e 18 com Alzheimer fase leve), residentes em São Paulo entre 2016 e 2017. Para a avaliação foram utilizados: anamnese, Escala de Depressão Geriátrica de Yesavage (GDS-30), Montreal Cognitive Assessment (MoCA), Cambridge Cognitive Exam-Revised (CAMCOG-R), Escala de Equilíbrio de Berg (EEB), timed up and go test (TUGT), Avaliação Direta do Estado Funcional (DAFS-BR), teste U de Mann-Whitney, coeficiente de correlação de Spearman e análise de regressão múltipla com p<0,05. Observou-se ordem de perda semelhante à sugerida pela teoria da retrogênese nos dois grupos estudados. Quanto menor o índice CAMCOG-R, maior o número de quedas (p=0,03). Itens praxia (p<0,00) e funções executivas (p<0,00) do CAMCOG-R mostraram-se altamente correlacionados com o TUGT e a EEB. Sugere-se relação de dependência entre funcionalidade e cognição e equilíbrio e cognição, bem como correlação entre risco de queda e desempenho cognitivo nos dois grupos estudados. As perdas observadas estão de acordo com o que a teoria da retrogênese propõe, mas com diferentes intensidades entre os grupos. Estudos longitudinais são necessários, com uso de exames de imagem para validar a teoria nos padrões de perda em idosos com e sem doença de Alzheimer.

Evaluation of the Skeleton Avatar Technique for Assessment of Mobility and Balance Among Older Adults

Background: Mobility and balance is essential for older adults' well-being and independence and the ability to maintain physically active. Early identification of functional impairment may enable early risk-of-fall assessments and preventive measures. There is a need to find new solutions to assess functional ability in easy, efficient, and accurate ways, which can be clinically used frequently and repetitively. Therefore, we need to understand how functional tests and expert assessments (EAs) correlate with new techniques.

Objective: To explore whether the skeleton avatar technique (SAT) can predict the results of functional tests (FTs) of mobility and balance: Timed Up and Go (TUG), the 30-s chair stand test (30sCST), the 4-stage balance test (4SBT), and EA scoring of movement quality.

Methods: Fifty-four older adults (+65 years) were recruited through pensioners' associations. The test procedure contained three standardized FTs: TUG, 30sCST, and 4SBT. The test performances were recorded using a three-dimensional SAT camera. EA scoring was performed based on the video recordings of the 30sCST. Functional ability scores were aggregated from balance and mobility scores. Probability theory-based statistical analyses were used on the data to aggregate sets of individual variables into scores, with correlation analysis used to assess the dependency between variables and between scores. Machine learning techniques were used to assess the appropriateness of easily observable variables/scores as predictors of the other variables included.

Results: The results indicate that SAT data of the fourth 4SBT stage could be used to predict the aggregated results of all stages of 4SBT (with 7.82% mean absolute error), the results of the 30sCST (11.0%), the TUG test (8.03%), and the EA of the sit-to-stand movement (8.79%). There is a moderate (significant) correlation between the 30sCST and the 4SBT (0.31, p = 0.03), but not between the EA and the 30sCST.

Conclusion: SAT can predict the results of the 4SBT, the 30sCST (moderate accuracy), and the TUG test and might add important qualitative information to the assessment of movement performance in active older adults. SAT might in the future provide the means for a simple, easy, and accessible assessment of functional ability among older adults.

The development of sit-to-stand in typically developing children aged 4 to 12 years: Movement time, trunk and lower extremity joint angles, and joint moments

BACKGROUND

Sit-to-stand (STS) movement is an important transition movement for daily life. STS movement is typically seen in children aged 1 year and older. According to the motor development process, the ability of children in different age groups to perform STS movement would be different before they meet the mutuality. However, it is still unclear whether there are changes in the STS movement of growing children and adults.

RESEARCH QUESTION

Are there any differences in the movement time, joint angles, and peak joint moments of STS in typically developing (TD) children?

METHODS

Motion analysis and the force plate system were used to analyze the STS movement in 77 healthy participants. All participants were asked to perform the STS movement using an adjustable bench with a self-selected pattern. Statistical analysis was done with respect to age (4-6, 7-9, 10-12, 18-25 years) and body height (1.00-1.20, 1.20-1.40, 1.40-1.60, 1.60-1.80 meters).

RESULTS

Children aged 4-6 years (or 1.0-1.20 m height) took less time to accomplish STS movement than adults (or 1.60-1.80 m height). Children aged 4-9 years performed STS movement by using more trunk and hip flexion and anterior pelvic tilt, but less knee flexion and ankle dorsiflexion than children aged 10-12 years and adults. At the final standing position, children aged 4-12 years exhibited more knee extension and more ankle plantar flexion than adults. In addition, children aged 4-12 years had more peak trunk-pelvic extension and less peak knee extension moments than adults.

SIGNIFICANCE

Different strategies to achieve the STS task were found among children aged 4-12 years in terms of total movement time, joint angle, and joint moments. Adult-like kinematic and kinetic STS patterns were not seen in children up to 12 years old.

Electrophysiological Processes on Motor Imagery Mediate the Association Between Increased Gray Matter Volume and Cognition in Amnestic Mild Cognitive Impairment

Motor imagery is considered as an ideal window to observe neural processes of action representations. Behavioral evidence has indicated an alteration of motor imagery in amnestic mild cognitive impairment (aMCI). However, it still remains unclear on the altered neurophysiological processing mechanism of motor imagery and whether this mechanism links the abnormal biological basis of motor imagery with impaired cognition in aMCI. This study was to investigate the altered neurophysiological processing mechanism of motor imagery and to examine the relationships between this knowledge and the altered structural basis of motor imagery with impaired cognition in aMCI. A hand mental rotation paradigm was used to manipulate the processing of motor imagery while event-related brain potentials (ERPs) were recorded and gray matter (GM) voxel-based morphometry was performed in 20 aMCI and 29 healthy controls. Compared with controls, aMCI exhibited lower ERP amplitudes in parietal cortex and higher ERP amplitudes in frontal cortex during motor imagery. In addition, aMCI showed reduced GM volumes in cerebellum posterior lobe, insula and hippocampus/parahippocampal gyrus, and increased GM volumes in middle cingulate gyrus and superior frontal gyrus. Most importantly, increased ERP amplitude significantly mediated the association between increased GM and cognition. This study provided a novel evidence for the relationships between the electrophysiological processing mechanism and structural basis of motor imagery with impaired cognition in aMCI. It suggests that improving neural activity by stimulating the frontal lobe can potentially contribute to acquire motor imagery skills for neurological rehabilitation in aMCI subjects.

Recommended motor assessments based on psychometric properties in individuals with dementia: a systematic review

Background

Motor assessments are important to determine effectiveness of physical activity in individuals with dementia (IWD). However, inappropriate and non-standardised assessments without sound psychometric properties have been used. This systematic review aims to examine psychometric properties of motor assessments in IWD combined with frequency of use and effect sizes and to provide recommendations based on observed findings.We performed a two-stage systematic literature search using Pubmed, Web of Science, Cochrane Library, ALOIS, and Scopus (inception - July/September 2018, English and German). The first search purposed to identify motor assessments used in randomised controlled trials assessing effectiveness of physical activity in IWD and to display their frequency of use and effect sizes. The second search focused on psychometric properties considering influence of severity and aetiology of dementia and cueing on test-retest reliability. Two reviewers independently extracted and analysed findings of eligible studies in a narrative synthesis.

Results

Literature searches identified 46 randomised controlled trials and 21 psychometric property studies. While insufficient information was available for validity, we observed sufficient inter-rater and relative test-retest reliability but unacceptable absolute test-retest reliability for most assessments. Combining these findings with frequency of use and effect sizes, we recommend Functional Reach Test, Groningen Meander Walking Test (time), Berg Balance Scale, Performance Oriented Mobility Assessment, Timed Up & Go Test, instrumented gait analysis (spatiotemporal parameters), Sit-to-Stand assessments (repetitions> 1), and 6-min walk test. It is important to consider that severity and aetiology of dementia and cueing influenced test-retest reliability of some assessments.

Conclusion

This review establishes an important foundation for future investigations. Sufficient relative reliability supports the conclusiveness of recommended assessments at group level, while unacceptable absolute reliability advices caution in assessing intra-individual changes. Moreover, influences on test-retest reliability suggest tailoring assessments and instructions to IWD and applying cueing only where it is inevitable. Considering heterogeneity of included studies and insufficient examination in various areas, these recommendations are not comprehensive. Further research, especially on validity and influences on test-retest reliability, as well as standardisation and development of tailored assessments for IWD is crucial.This systematic review was registered in PROSPERO (CRD42018105399).

Mobility assessment in people with Alzheimer disease using smartphone sensors

Background

Understanding the functional status of people with Alzheimer Disease (AD), both in a single (ST) and cognitive dual task (DT) activities is essential for identifying signs of early-stage neurodegeneration. This study aims to compare the performance quality of several tasks using sensors embedded in an Android device, among people at different stages of Alzheimer and people without dementia. The secondary aim is to analyze the effect of cognitive task performance on mobility tasks.

Methods

This is a cross-sectional study including 22 participants in the control group (CG), 18 in the group with mild AD and 22 in the group with moderate AD. They performed two mobility tests, under ST and DT conditions, which were registered using an Android device. Postural control was measured by medial-lateral and anterior-posterior displacements of the COM (MLDisp and APDisp, respectively) and gait, with the vertical and medial-lateral range of the COM (Vrange and MLrange). Further, the sit-to-stand (PStand) and turning and sit power (PTurnSit), the total time required to complete the test and the reaction time were measured.

Results

There were no differences between the two AD stages either for ST or DT in any of the variables (p > 0.05). Nevertheless, people at both stages showed significantly lower values of PStand and PTurnSit and larger Total time and Reaction time compared to CG (p < 0.05). Further, Vrange is also lower in CDR1G than in CG (p < 0.05). The DT had a significant deleterious effect on MLDisp in all groups (p < 0.05) and on APDisp only in moderate AD for DT.

Conclusions

Our findings indicate that AD patients present impairments in some key functional abilities, such as gait, turning and sitting, sit to stand, and reaction time, both in mild and moderate AD. Nevertheless, an exclusively cognitive task only influences the postural control in people with AD.

Recommendations for assessing motor performance in individuals with dementia: suggestions of an expert panel - a qualitative approach

Background

Recommendations for assessing motor performance in individuals with dementia (IWD) are rare, and most existing assessment tools previously applied in IWD were initially developed for healthy older adults. However, IWD and their healthy counterparts differ in motor and cognitive capabilities, which needs to be considered when designing studies for this population. This article aims to give recommendations for motor assessments for IWD and to promote standardisation based on a structured discussion of identified assessment tools used in previous trials.

Methods

Appropriateness and standardisation of previously applied motor assessments for IWD were intensively discussed using a qualitative approach during an expert panel. Furthermore, the use of external cues and walking aids, as well as psychometric properties were considered. Starting with a comprehensive overview of current research practice, the discussion was gradually specified and resulted in the elaboration of specific recommendations.

Results

The superior discussion emphasised the need for tailoring motor assessments to specific characteristics of IWD and attaching importance to standardised assessment procedures. Specific recommendations include the use of sequential approaches, which incorporate a gradual increase of complexity from simple to more difficult tasks, a selection of motor assessments showing sufficient relative reliability and appropriateness for IWD, as well as allowing external cues and walking aids when restricted to repeated instructions and commonly used devices, respectively.

Conclusions

These are the first recommendations for assessing motor performance in IWD based on a comprehensive qualitative approach. Due to limited evidence, it was not possible to address all existing questions. It is therefore important to evaluate these recommendations in studies with IWD. Besides tailoring and evaluating available assessments, future research should focus on developing specific tools for IWD. Moreover, further progress in standardisation is necessary to enhance comparability between different trials. This article provides initial approaches for overcoming existing limitations in trials with IWD by giving recommendations and identifying future research questions, and therefore contributes to enhancing evidence regarding efficacy and effectiveness of physical activity interventions.

The effect of time restricted visual sensory input on asymmetry of ground reaction force components in female children

The association between visual sensory and the asymmetry index of sit-to-stand ground reaction force characteristics is not fully understood. Therefore, the purpose of this study was to investigate asymmetry index of sit-to-stand ground reaction forces, their times-to-peak, vertical loading rate, impulses, and free moment in blind and sighted children. 15 female children with congenital blindness and 30 healthy girls with no visual impairments volunteered to participate in this study. The girls with congenital blindness were placed in one group and the girls with no visual impairments were randomly divided into two groups of 15. The two condition groups consisted of, one eyes open and the other, eyes closed. The participants in the eyes closed group were asked to close their eyes for 20 min before the test, whereas those in the eyes open group kept their eyes open. Kinematic and kinetic data were collected using an eight-camera motion analysis system synchronized with two force plates embedded in the floor. A MANOVA test was run for between-group comparisons. There were no distinctive biomechanical alternations in all axes of ground reaction forces and their times-to-peak, vertical loading rate, impulses and free moments in congenital blindness and eyes closed groups compared with the eyes open group. However, eyes closed was associated with increased total time and second phase duration of sit-to-stand performance by 69% (p = 0.008) and 62% (p = 0.008), respectively. These findings reveal that individuals who are visually restricted in the short term, do not develop stereotypical movement strategies for sit-to-stand.

A model based analysis of optimality of sit-to-stand transition

Objective assessment of mobility and effectiveness of interventions remains an open issue. Timed Up and Go (TUG) and 30 Second Chair Stand (30SCS) tests are routinely used in assessing mobility of subjects, but they provide a single parameter. Instrumenting subjects with wearable sensors enables a detailed mobility assessment. Specifically, we argue that instrumented sit-to-stand (S2ST) posture transitions during the TUG and 30SCS tests can be used to assess the strength and balance of subjects. In this paper we develop a personalized three-segment model that quantifies torques/forces on the body and assesses optimality of each sit-to-stand transition. To characterize a S2ST transition we calculate action defined as an integral of mechanical energy over time. The theoretical optimal transition time can thus be determined for each person by finding the minimum action necessary for a S2ST transition. Our model assesses action during the S2ST transition using inputs from smartphone's inertial sensors, and calculates optimum S2ST transition time for a given body composition of a subject. Our experimental evaluation shows that healthy young subjects have posture transition times close to the optimal transition time generated by the model. We hypothesize that the optimality of posture transition provides an objective and potentially more accurate estimation of the mobility. We tested the model by evaluating optimum action and optimum S2ST transition time for 10 geriatric patients undergoing a mobility improvement program by comparing their performance with the optimum performance generated by the model. This paper presents the model and possible use of the results to assess long-term changes in mobility of users.

Sit-to-stand ground reaction force characteristics in blind and sighted female children

BACKGROUND

The association between visual sensory and sit-to-stand ground reaction force characteristics is not clear. Impulse is the amount of force applied over a period of time. Also, free moment represents the vertical moment applied in the center of pressure (COP).

RESEARCH QUESTION

How the ground reaction force components, vertical loading rate, impulses and free moment respond to long and short term restricted visual information?

METHODS

Fifteen female children with congenital blindness and 45 healthy girls with no visual impairments participated in this study. The girls with congenital blindness were placed in one group and the 45 girls with no visual impairments were randomly divided into three groups of 15; eyes open, permanently eyes closed, and temporary eyes closed. The participants in the permanently eyes closed group closed their eyes for 20 min before the test, whereas temporary eyes closed group did tests with their eyes closed throughout, and those in the eyes open group kept their eyes open.

RESULTS

Congenital blindness was associated with increased vertical loading rate, range of motion of knee and hip in the medio-lateral plane. Also, medio-lateral and vertical ground reaction force impulses. Similar peak negative and positive free moments were observed in three groups.

SIGNIFICANCE

In conclusion, the results reveal that sit-to-stand ground reaction force components in blind children may have clinical importance for improvement of balance control of these individuals.

Cognitive, functional and physical activity impairment in elderly with Alzheimer's disease

Alzheimer's Disease (AD) is a progressive degenerative disorder that negatively affects quality of life of patients and family members.

Objective

The aim of this study is to compare the cognition, level of physical activity and functioning of elderly individuals with mild AD and those without dementia.

Methods

The study comprised 24 elderly with mild AD (mean age = 76.9 ± 5.3 years) and 30 elderly without dementia (mean age = 74.1 ± 5.6 years). The following instruments were applied to evaluate cognitive functions: MMSE; Frontal Assessment Battery; Clock Drawing Test; Corsi Blocks, and Verbal Paired Associates. Event-related potential P300 was used to evaluate cognitive processing. The Modified Baecke Questionnaire For Older Adults was applied to evaluate the level of physical activity together with use of a pedometer for 7 consecutive days. For the evaluation of the functioning, the Direct Assessment of Functional Status-Revised scale and functional tests were used.

Results

There was a significant difference between the groups in level of physical activity and functioning, except on the test evaluating flexibility.

Conclusion

Elderly with AD had cognitive, functional and physical activity deficits which can manifest even in the early stages of the disease.

Increased Physical Fitness Is Associated with Higher Executive Functioning in People with Dementia

Physical fitness (PF) has been associated with improved cognition in older age, but less is known about its effects on different cognitive domains in individuals diagnosed with dementia. We explored the associations between PF and cognitive performance in 40 healthy elderly and 30 individuals with dementia. Participants completed a battery of standardized cognitive tests (Mini-Mental State Exam, Verbal Fluency, Prospective and Retrospective Memory Questionnaire, Clock Drawing, and California Verbal Learning Test) and were classified into high versus low levels of PF based on their score on the Physical Fitness Questionnaire. Analyses took into account age, gender, education, occupation, head injury, Internet use, brain training, and past levels of exercise and revealed overall benefits of PF, in particular for the people with dementia. Discriminant analysis showed high accuracy of reclassification, with most errors being due to the misclassification of dementia cases as healthy when they had high PF. The first discriminant function accounted for 83% of the variance. Using individual estimates of this function, which reflected global cognitive performance, confirmed the beneficial role of PF in dementia, even when taking into account age, past level of exercise, and the number of years since the dementia diagnosis. Finally, univariate analyses confirmed the differential sensitivity of the cognitive tests, with MMSE and clock drawing showing reliable interaction effects. This work shows that PF is associated with a reduced level of cognitive deterioration expected with dementia, especially in executive functioning and provides empirical support for the cognitive benefits of interventions promoting PF for individuals with dementia.

Determination of Aerobic Capacity via Cycle Ergometer Exercise Testing in Alzheimer's Disease

BACKGROUND

Older adults with Alzheimer's disease (AD) may be unable to perform treadmill testing due to balance issues. We investigated whether older adults with AD could successfully complete a peak cycle ergometer test.

METHODS

Peak oxygen consumption (peak [Formula: see text]) assessed via a cycle ergometer test in 44 participants with AD (age 78.4 ± 6.8). Physical function was assessed via the incremental shuttle walk, 6-minute walk, and the Short Physical Performance Battery (SPPB).

RESULTS

All participants completed the cycle ergometer test successfully. Peak [Formula: see text] was correlated with SPPB ( r = .35, P = .023), shuttle walk ( r = .35, P = .024), 6-minute walk ( r = .31, P = .05), and inversely with age ( r = -.4, P = .009). There was no correlation between peak [Formula: see text] and cognition.

CONCLUSION

Older adults with AD are able to safely complete a peak cycle ergometer exercise testing protocol. We provide an individualized cycle ergometer test for determining aerobic capacity in older adults with AD who may be unable to perform treadmill testing due to balance or gait issues.

People with Dementia Can Learn Compensatory Movement Maneuvers for the Sit-to-Stand Task: A Randomized Controlled Trial

BACKGROUND

A complex motor skill highly relevant to mobility in everyday life (e.g., sit-to-stand [STS] transfer) has not yet been addressed in studies on motor learning in people with dementia (PwD).

OBJECTIVE

To determine whether a dementia-specific motor learning exercise program enables PwD to learn compensatory STS maneuvers commonly taught in geriatric rehabilitation therapy to enhance patients' STS ability.

METHODS

Ninety-seven patients with mild-to-moderate dementia (Mini-Mental State Examination: 21.9±2.9 points) participated in a double-blinded, randomized, placebo-controlled trial with 10-week intervention and 3-month follow-up period. The intervention group (IG, n = 51) underwent a motor learning exercise program on compensatory STS maneuvers specifically designed for PwD. The control group (CG, n = 46) performed a low-intensity motor placebo activity. Primary outcomes were scores of the Assessment of Compensatory Sit-to-stand Maneuvers in People with Dementia (ACSID), which covers the number of recalled and initiated, and of effectively performed compensatory STS maneuvers. Secondary outcomes included temporal and kinematic STS characteristics measured by a body-fixed motion sensor (BFS, DynaPort® Hybrid).

RESULTS

The IG significantly improved in all ACSID scores compared to the CG (p < 0.001). Secondary analysis confirmed learning effects for all BFS-based outcomes (p < 0.001-0.006). Learning gains were sustained during follow-up for most outcomes.

CONCLUSION

People with mild-to-moderate dementia can learn and retain compensatory STS maneuvers in response to a dementia-specific motor learning exercise program. This is the first study that demonstrated preserved motor learning abilities in PwD by using a motor skill highly relevant to everyday life.

Advanced 3D movement analysis algorithms for robust functional capacity assessment

OBJECTIVES

We developed a novel system for in home functional capacities assessment in frail older adults by analyzing the Timed Up and Go movements. This system aims to follow the older people evolution, potentially allowing a forward detection of motor decompensation in order to trigger the implementation of rehabilitation. However, the pre-experimentations conducted on the ground, in different environments, revealed some problems which were related to KinectTM operation. Hence, the aim of this actual study is to develop methods to resolve these problems.

METHODS

Using the KinectTM sensor, we analyze the Timed Up and Go test movements by measuring nine spatio-temporal parameters, identified from the literature. We propose a video processing chain to improve the robustness of the analysis of the various test phases: automatic detection of the sitting posture, patient detection and three body joints extraction. We introduce a realistic database and a set of descriptors for sitting posture recognition. In addition, a new method for skin detection is implemented to facilitate the patient extraction and head detection. 94 experiments were conducted to assess the robustness of the sitting posture detection and the three joints extraction regarding condition changes.

RESULTS

The results showed good performance of the proposed video processing chain: the global error of the sitting posture detection was 0.67%. The success rate of the trunk angle calculation was 96.42%. These results show the reliability of the proposed chain, which increases the robustness of the automatic analysis of the Timed Up and Go.

CONCLUSIONS

The system shows good measurements reliability and generates a note reflecting the patient functional level that showed a good correlation with 4 clinical tests commonly used. We suggest that it is interesting to use this system to detect impairment of motor planning processes.

Effectiveness of a 16-Week Multimodal Exercise Program on Individuals With Dementia: Study Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

The increasing prevalence of dementia in the next decades is accompanied by various societal and economic problems. Previous studies have suggested that physical activity positively affects motor and cognitive skills in individuals with dementia (IWD). However, there is insufficient evidence probably related to several methodological limitations. Moreover, to date adequate physical activity interventions specifically developed for IWD are lacking.

OBJECTIVE

This study aims to investigate the effectiveness of a multimodal exercise program (MEP) on motor and cognitive skills in IWD in a high-quality multicenter trial.

METHODS

A multicenter randomized controlled trial with baseline and postassessments will be performed. It is planned to enroll 405 participants with dementia of mild to moderate stage, aged 65 years and older. The intervention group will participate in a 16-week ritualized MEP especially developed for IWD. The effectiveness of the MEP on the primary outcomes balance, mobility, and gait will be examined using a comprehensive test battery. Secondary outcomes are strength and function of lower limbs, activities of daily living, and cognition (overall cognition, language, processing speed, learning and memory, and visual spatial cognition).

RESULTS

Enrollment for the study started in May 2015. It is planned to complete postassessments by the beginning of 2017. Results are expected to be available in the first half of 2017.

CONCLUSIONS

This study will contribute to enhancing evidence for the effects of physical activity on motor and cognitive skills in IWD. Compared to previous studies, this study is characterized by a dementia-specific intervention based on scientific knowledge, a combination of motor and cognitive tasks in the intervention, and high standards regarding methodology. Findings are highly relevant to influence the multiple motor and cognitive impairments of IWD who are often participating in limited physical activity.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00010538; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00010538 (Archived by WebCite at http://www.webcitation.org/6oVGMbbMD).

Influence of time restriction, 20 minutes and 94.6 months, of visual information on angular displacement during the sit-to-stand (STS) task in three planes

[Purpose] The purpose of this investigation was to assess whether or not restriction of visual information influences the kinematics of sit-to-stand (STS) performance in children. [Subjects and Methods] Five girls with congenital blindness (CB) and ten healthy girls with no visual impairments were randomly selected. The girls with congenital blindness were placed in one group and the ten girls with no visual impairments were divided into two groups of five, control and treatment groups. The participants in the treatment group were asked to close their eyes (EC) for 20 minutes before the STS test, whereas those in the control group kept their eyes open (EO). The performance of the participants in all three groups was measured using a motion capture system and two force plates. [Results] The results show that the constraint duration of visual sensory information affected the range of motion (ROM), the excursion of the dominant side ankle, and the ROM of the dominant side knee in the EC group. However, only ankle excursion on the non-dominant side was affected in the CB group, and this was only observed in the sagittal plane. [Conclusion] These results indicate that visual memory does not affect the joint angles in the frontal and transverse planes. Moreover, all of the participants could perform the STS transition without falling, indicating; the participants performed the STS maneuver correctly in all planes except the sagittal one.

Development and Validation of a Novel Motor-Cognitive Assessment Strategy of Compensatory Sit-to-Stand Maneuvers in People With Dementia

BACKGROUND AND PURPOSE

People with dementia show disease-specific sit-to-stand (STS) movement disorders, which relate to deficits of integrating cognitive aspects of motor processes into motor action organization. During STS training in rehabilitation therapy, compensatory STS movement maneuvers are taught aiming to improve patients' STS ability. Previous clinical STS measures do not address these maneuvers or assess cognitive aspects of their motor action organization. The purpose of this study was to develop and validate a motor-cognitive STS assessment instrument for people with dementia (Assessment of Compensatory Sit-to-Stand Maneuvers in People With Dementia, ACSID).

METHODS

The ACSID covers the recall, initiation, and effective performance of compensatory STS movement maneuvers. The inter- and intrarater reliability, concurrent validity, sensitivity to change, and feasibility were investigated by secondary analysis of data of 97 participants from a randomized controlled trial to improve motor-cognitive performances in people with mild to moderate dementia (mean [standard deviation] age: 82.5 [5.9] years, Mini-Mental Status Examination: 21.9 [2.9] points). Concurrent validity of the individual ACSID items was assessed against reference criteria derived from video-motion analysis.

RESULTS

Good to excellent inter- (kappa [κ] = 0.64-0.99; intraclass correlation coefficient [ICC] = 0.74-0.89) and intrarater (κ= 0.77-0.91; ICC = 0.77-0.91), concurrent validity (point-biserial correlation coefficients = |0.56|-|0.84|), and sensitivity to change (standardized response means = 0.61-1.00) were found. Feasibility was excellent with a high completion rate (96.9%), no critical events during assessment, and no floor or ceiling effects.

CONCLUSIONS

The ACSID represents the first observation-based assessment instrument to document motor and cognitive aspects in the execution of a motor key feature in people with dementia, and has been shown to be reliable, valid, feasible, and sensitive to intervention-induced changes.

Associations between physical function, dual-task performance and cognition in patients with mild Alzheimer's disease

OBJECTIVE

Alzheimer's disease (AD) causes a gradual decline in cognition, limitations of dual-tasking and physical function leading to total dependence. Hence, information about the interaction between physical function, dual-task performance and cognition may lead to new treatment strategies with the purpose of preserving function and quality of life. The objective of this study was to investigate the associations between physical function, dual-task performance and cognition in community-dwelling patients with mild AD.

METHODS

Baseline results from 185 participants (50-90 years old) in the single blinded multicenter RCT 'ADEX' (Alzheimer's disease: the effect of physical exercise) were used. Assessments included tests of physical function: 400-m walk test, 10-m walk test, Timed Up and Go test and 30-s chair stand test; dual-task performance, i.e., 10-m walk while counting backwards from 50 or naming the months backwards; and cognition, i.e., Mini Mental State Examination, Symbol Digit Modalities Test, the Stroop Color and Word Test, and Lexical verbal fluency test.

RESULTS

Results in the 30-s chair stand test correlated significantly with all tests of cognition (r = .208-.242) while the other physical function tests only randomly correlated with tests of cognition. Results in the dual-task counting backwards correlated significantly with results in all tests of cognition (r = .259-.388), which accounted for 7%-15% of the variation indicating that a faster time to complete dual-task performance was associated with better cognitive performance.

CONCLUSION

The evidence of the associations between physical function, dual-task performance and cognition is important when creating new rehabilitation interventions to patients with mild AD.

Mental Rotation as an Indicator of Motor Representation in Patients with Mild Cognitive Impairment

This internal representation of movement of part(s) of the body is involved during Implicit Motor Imagery tasks (IMI); the same representations are employed in the laterality judgment task. Few studies have looked at the consequences of aging, Alzheimer's disease (AD) and mild cognitive impairment (MCI) on the processes of motor preparation but none showed evidence of an alteration of action representation in patient with amnestic MCI. In the present study, the IMI task was used to assess the action representation abilities in MCI patients and healthy counterparts. A total of 24 elderly participants aged between 65 and 90 years old (12 women, 73.4 ± 6 years, mean ± S.D.) were recruited: 12 patients with MCI (MCI group) and 12 healthy aged adults (HAA group). The results showed that MCI patients have significantly a greater response time (RT) than HAA subjects only in IMI task and more precisely when performing their mental rotation at the challenging conditions. Furthermore, the IMI task related to the non-dominant hand induced a significant increase of RT only in MCI subjects. At the light of these results, we assume that MCI patients are able to engage themselves in IMI processes, still showing a compelling impairment of this mental ability across its complexity.

Kinematic analysis of motor strategies in frail aged adults during the Timed Up and Go: how to spot the motor frailty?

Objective

The purpose of this work was to analyze and compare the movement kinematics of sit-to-stand (STS) and back-to-sit (BTS) transfers between frail aged adults and young subjects, as well as to determine the relationship between kinematic changes and functional capacities.

Methods

We analyzed the Timed Up and Go (TUG) movements by using a 3D movement analysis system for real-time balance assessment in frail elderly. Ten frail aged adults (frail group [FG]) and ten young subjects (young group [YG]) performed the TUG. Seven spatiotemporal parameters were extracted and compared between the two groups. Moreover, these parameters were plotted with TUG test duration.

Results

The experiments revealed that there were significant differences between FG and YG in trunk angle during both STS and BTS, and in TUG duration. The trunk angle of the young subjects was more than two times higher than that of the FG. As expected, the TUG duration was higher in the FG than in YG. Trunk angles during both transfers were the most different parameters between the groups. However, the BTS trunk angle and STS ratio were more linked to functional capacities.

Conclusion

There was a relationship between kinematic changes, representing the motor planning strategies, and physical frailty in these aged adults. These changes should be taken into account in clinical practice.

An ambient assisted living approach in designing domiciliary services combined with innovative technologies for patients with Alzheimer's disease: a case study

BACKGROUND

Alzheimer's disease (AD) is one of the most disabling diseases to affect large numbers of elderly people worldwide. Because of the characteristics of this disease, patients with AD require daily assistance from service providers both in nursing homes and at home. Domiciliary assistance has been demonstrated to be cost effective and efficient in the first phase of the disease, helping to slow down the course of the illness, improve the quality of life and care, and extend independence for patients and caregivers. In this context, the aim of this work is to demonstrate the technical effectiveness and acceptability of an innovative domiciliary smart sensor system for providing domiciliary assistance to patients with AD which has been developed with an Ambient Assisted Living (AAL) approach.

METHODS

The design, development, testing, and evaluation of the innovative technological solution were performed by a multidisciplinary team. In all, 15 sociomedical operators and 14 patients with AD were directly involved in defining the end-users' needs and requirements, identifying design principles with acceptability and usability features and evaluating the technological solutions before and after the real experimentation.

RESULTS

A modular technological system was produced to help caregivers continuously monitor the health status, safety, and daily activities of patients with AD. During the experimentation, the acceptability, utility, usability, and efficacy of this system were evaluated as quite positive.

CONCLUSION

The experience described in this article demonstrated that AAL technologies are feasible and effective nowadays and can be actively used in assisting patients with AD in their homes. The extensive involvement of caregivers in the experimentation allowed to assess that there is, through the use of the technological system, a proven improvement in care performance and efficiency of care provision by both formal and informal caregivers and consequently an increase in the quality of life of patients, their relatives, and their caregivers.

Energy-related optimal control accounts for gravitational load: comparing shoulder, elbow, and wrist rotations

We permanently deal with gravity force. Experimental evidences revealed that moving against gravity strongly differs from moving along the gravity vector. This directional asymmetry has been attributed to an optimal planning process that optimizes gravity force effects to minimize energy. Yet, only few studies have considered the case of vertical movements in the context of optimal control. What kind of cost is better suited to explain kinematic patterns in the vertical plane? Here, we aimed to understand further how the central nervous system (CNS) plans and controls vertical arm movements. Our reasoning was the following: if the CNS optimizes gravity mechanical effects on the moving limbs, kinematic patterns should change according to the direction and the magnitude of the gravity torque being encountered in the motion. Ten subjects carried out single-joint movements, i.e., rotation around the shoulder (whole arm), elbow (forearm), and wrist (hand) joints, in the vertical plane. Joint kinematics were analyzed and compared with various theoretical optimal model predictions (minimum absolute work-jerk, jerk, torque change, and variance). We found both direction-dependent and joint-dependent variations in several kinematic parameters. Notably, directional asymmetries decreased according to a proximodistal gradient. Numerical simulations revealed that our experimental findings could be attributed to an optimal motor planning (minimum absolute work-jerk) that integrates the direction and the magnitude of gravity torque and minimizes the absolute work of forces (energy-related cost) around each joint. Present results support the general idea that the CNS implements optimal solutions according to the dynamic context of the action.

Describing Force Patterns: A Method for Classifying Sit-To-Stand Movement in Elderly People

The main contribution of this study is that it examined the sit-to-stand movements of elderly people and then established an assessment method to supplement the existing Berg Balance Scale for the risk of falling in elderly individuals. 36 elderly adults ( M age = 69.9 yr., SD = 4.0) volunteered to participate in this study. Three key points of the sit-to-stand movement were confirmed as aspects of the ground reaction force: the onset, maximum ground reaction force, and seat-off. Based on the characteristics indicated by the force data, the sit-to-stand movement sequences of those who were evaluated at low fall risk with a Berg Balance Scale score between 41 and 55 were classified into three patterns: typical-modal, multimodal, and incompetent-modal patterns. With this increased accuracy, medical practitioners can determine more clearly those participants who require further immediate medical consultation and those that are not at risk of falling.

Test-retest reliability and minimal detectable change of repeated sit-to-stand analysis using one body fixed sensor in geriatric patients

A majority of geriatric patients experience difficulty in performing sit-to-stand (SiSt) transitions. A detailed assessment of SiSt ability is a prerequisite for successful rehabilitation. Body fixed sensors (BFSs) are increasingly used to assess functional performances. As to date there is no system which analyzes clinically relevant phases of SiSt, the aim of this study was to determine the reliability of an automated approach for quantifying durations and angular velocities of trunk flexion and extension during repeated SiSt transitions using one BFS (DynaPort® Hybrid). Forty multimorbid geriatric patients aged 84.1 ± 6.6 years were included. Each patient participated in two test sessions with a 5 min rest period in between. Intra- and interrater reliability was assessed. Intraclass correlation coefficients (ICCs), absolute and relative standard measurement errors (SEMs, SEMs%) and minimal detectable changes (MDCs(95), MDCs(95)%) were calculated. ICCs were good to excellent for all variables in the total sample (0.80-0.94). The intraobserver group (50%) showed a higher number of excellent ICCs (≥.9) compared to the interobserver subgroup (10%). SEM% was low for all variables (6.9-12.7%). MDC(95)% ranged 19.2-34.4% and more variables ≤30% were found in the intra- (80%) compared to the inter-observer group (60%). Study results demonstrate that the BFS system provides a reliable analysis of SiSt phases in geriatric patients, and is a substantial improvement over the stopwatch approach used in clinical practice today.

The physical performance test predicts aerobic capacity sufficient for independence in early-stage Alzheimer disease

BACKGROUND

Early identification of physical impairment related to Alzheimer disease (AD) is increasingly identified as an important aspect of diagnosis and care. Clinically accessible tools for evaluating physical capacity and impairment in AD have been developed but require further characterization for their effective use.

PURPOSE

To assess the utility of the Physical Performance Test (PPT) for identifying functionally limiting aerobic capacity in older adults with AD and without dementia.

METHODS

Secondary analysis of a dataset of community dwelling older adults, 70 without dementia and 60 with early-stage AD. Participants were administered the PPT and performed a graded maximal exercise test. The clinical utility of 2 versions of the PPT was described by determining sensitivity and specificity to functionally limiting aerobic capacity.

RESULTS

The 9-item PPT is predictive of diminished aerobic capacity in older adults with AD. A score of 28 or less indicates likelihood of functionally limiting aerobic capacity that would limit independent function with 67% sensitivity and 67% specificity. The 4-item mini-PPT demonstrates improved capability for identifying impaired functional aerobic capacity with 85% sensitivity and 62% specificity. The PPT was not useful for identifying impaired functional aerobic capacity in older adults without dementia.

CONCLUSIONS

The PPT, which incorporates basic and instrumental activities of daily living as test items, and the mini-PPT which focuses on basic activities of daily living and simple physical functions, are both clinically useful tool for the evaluation for individuals in the earliest stages of AD and both provide important information about functional performance. The mini-PPT additionally inform the clinician as to whether or not individual with early-stage AD is likely to have insufficient aerobic capacity to perform instrumental daily functions.

Evidence of altered corticomotor system connectivity in early-stage Alzheimer's disease

BACKGROUND AND PURPOSE

There is increasing evidence for subtle motor dysfunction early in Alzheimer disease (AD), including common motor behaviors that were once considered unaffected early in the disease process. Our objective was to assess whether functional neural networks underlying motor behavior are altered by AD.

METHODS

We investigated AD-related differences in regional brain activation during motor performance. Nine older adults with early-stage AD and 10 without dementia underwent functional magnetic resonance imaging while performing a visually directed simple motor task (hand squeeze).

RESULTS

Despite some similarity in brain activation during motor performance, we found that individuals without dementia exhibited greater activation in accessory motor regions, supplementary motor area, and cerebellum compared with those with AD. We also assessed disease-related differences in regions where activity was functionally integrated with primary motor cortex. Using a psychophysiological interaction analysis, we found that those with AD displayed increased coactivation with primary motor cortex of bilateral motor and visual regions.

DISCUSSION AND CONCLUSIONS

These AD-related differences in regional coactivation during motor execution may represent inefficiency in the motor network as a consequence of the disease process. Alternatively, they may represent compensatory activation. These findings provide further evidence that in early stages of AD, neuromotor function is altered even during simple motor behaviors. The results may have implications for performance of more complex tasks and may be associated with the well-characterized decline in dual-task performance in those with AD.

An instrumented timed up and go: the added value of an accelerometer for identifying fall risk in idiopathic fallers

The Timed Up and Go (TUG) test is a widely used measure of mobility and fall risk among older adults that is typically scored using a stopwatch. We tested the hypothesis that a body-fixed accelerometer can enhance the ability of the TUG to identify community-living older adults with a relatively high fall risk of unknown origin. Twenty-three community-living elderly fallers (76.0 ± 3.9 years) and 18 healthy controls (68.3 ± 9.1 years) performed the TUG while wearing a 3D-accelerometer on the lower back. Acceleration-derived parameters included Sit-to-Stand and Stand-to-Sit times, amplitude range (Range), and slopes (Jerk). Average step duration, number of steps, average step length, gait speed, acceleration-median, and standard-deviation were also calculated. While the stopwatch-based TUG duration was not significantly different between the groups, acceleration-derived TUG duration was significantly higher (p = 0.007) among the fallers. Fallers generally exhibited lower Range and Jerk (p < 0.01). While TUG stopwatch duration successfully identified 63% of the subjects, an accelerometer-derived three-measure-combination correctly classified 87% of the subjects. Accelerometer-derived measures were generally not correlated with TUG duration. These findings demonstrate that fallers have difficulty with specific TUG aspects that can be quantified using an accelerometer. Without compromising simplicity of testing, an accelerometer can apparently be combined with TUG duration to provide complementary, objective measures that allow for a more complete, sensitive TUG-based fall risk assessment.

Vertical force and wrist deviation angle when using a walker to stand up and sit down

Research investigating walkers suggests that safety and assistance for the elderly with weak lower limbs were important. However, the relationship between the use of a walker and the upper limbs has received little investigation. Standing up and sitting down are important daily activities. Therefore, the aim of this study was to explore wrist deviation and vertical force among elderly individuals using a walker for assistance to stand up and sit down. In total, 64 elderly volunteers (M age = 80.22, SD = 9.36) were enrolled. Data were obtained from four load cells and a twin-axis wrist goniometer. Wrist deviation and vertical force were examined when participants used a walker with horizontal handles to assist in standing up and sitting down. Significant wrist angle deviation occurred with the use of a walker, with dorsiflexion of the right hand greater than that of the left. Males exerted significantly greater vertical force. In the sitting position, greater ulnar deviation was seen among experienced walker users, whereas during standing, experienced users exhibited greater dorsiflexion. The horizontal handles of most marketed walkers may cause user wrist deviations, suggesting researchers should pursue improvements in walker design.

Multi-parametric evaluation of sit-to-stand and stand-to-sit transitions in elderly people

The aim of this study was to extract multi-parametric measures characterizing different features of sit-to-stand (Si-St) and stand-to-sit (St-Si) transitions in older persons, using a single inertial sensor attached to the chest. Investigated parameters were transition's duration, range of trunk tilt, smoothness of transition pattern assessed by its fractal dimension, and trunk movement's dynamic described by local wavelet energy. A measurement protocol with a Si-St followed by a St-Si postural transition was performed by two groups of participants: the first group (N=79) included Frail Elderly subjects admitted to a post-acute rehabilitation facility and the second group (N=27) were healthy community-dwelling elderly persons. Subjects were also evaluated with Tinetti's POMA scale. Compared to Healthy Elderly persons, frail group at baseline had significantly longer Si-St (3.85±1.04 vs. 2.60±0.32, p=0.001) and St-Si (4.08±1.21 vs. 2.81±0.36, p=0.001) transition's duration. Frail older persons also had significantly decreased smoothness of Si-St transition pattern (1.36±0.07 vs. 1.21±0.05, p=0.001) and dynamic of trunk movement. Measurements after three weeks of rehabilitation in frail older persons showed that smoothness of transition pattern had the highest improvement effect size (0.4) and discriminative performance. These results demonstrate the potential interest of such parameters to distinguish older subjects with different functional and health conditions.

Evaluation of key points in the sit-to-stand movement using two force platforms

Three key points of the sit-to-stand (STS) movement were confirmed as aspects of the ground reaction force (GRF): the onset, maximum GRF, and seat-off. 46 healthy subjects (M age = 22.2 yr., SD = 4.4) participated. During the STS movement, two vertical force platforms were used to measure the resultant GRF, defined as the whole-body force, and its two components, the buttock and leg GRFs. The onsets of the component GRFs identified the sequence of the important time points in the STS movement more precisely than the onset of the resultant GRF. Data showed that the maximum whole-body GRF, the maximum GRF of both legs, and seat-off appeared in sequence and not simultaneously.

Follow-up for Alzheimer patients: European Alzheimer Disease Consortium position paper

BACKGROUND AND PURPOSE

Alzheimer disease (AD) is one of the leading causes of dependence in the elderly. Providing care for patients with AD is complex and the type of care required depends on the stage of the disease and varies over time. The aim of this article is to discuss available care strategies once the AD diagnosis has been made and to propose a follow-up plan as standard of care at a European level.

METHODS

The proposals developed in this article stem from the collaborative work of a panel of multidisciplinary experts involved in the care of AD patients (European Alzheimer Disease Consortium) based on the results of published scientific studies and on their experience from clinical practice.

CONCLUSION

Suggestions for follow-up frequency and easily administered and scored assessment tools are provided, thereby increasing efficiency and quality of care for patients with Alzheimer disease.

Strategies for Posture Transfer Adopted by Elders during Sit-To-Stand and Stand-To-Sit

This study investigated whether three posture-transfer strategies, No support, Chair-arm, and Cane, were associated with the smallest hip-compressed angle and the smallest ankle-compressed angle during sit-to-stand and stand-to-sit for 12 elders ( M age = 81.3 yr., SD = 5.9) who volunteered to participate. Using an optoelectronic movement analyzer, the smallest compressed angles of the hip and ankle were measured during standing up and sitting down. The adopted strategies had significant effects on the smallest hip-compressed angle, but not the smallest ankle-compressed angle. Although cane use led to a larger trunk angular displacement than did chair-arm use, a cane can provide help during the whole transfer process. These two strategies may be seen as adaptive mechanisms to decrease risk of anterior disequilibrium.

[Should all old hypertensive subjects have Mini-Mental State Examination?]

Hypertension constitutes a recognized risk factor of vascular dementia but also of Alzheimer-type dementia. Various longitudinal studies showed that midlife blood pressure level is one of the factors conditioning the onset of dementia syndrome in late life. The high risk of dementia is linked to leukoaraiosis, vascular rigidity, microcirculation disorders, oxidative stress, blood pressure fluctuations including orthostatic hypotension and strokes, all of those being associated with hypertension. Numerous clinical trials showed the positive effect of effective treatment of hypertension on the prevention of cognitive disorders and dementias. Thus, screening and early management of dementia and cognitive decline, in particular in the hypertensive subject, are essential. The Mini-Mental State Examination (MMSE) is a major first-intention screening test because it allows a full assessment of cognitive aptitudes. If cognitive decline is suspected and the MMSE score is considered to be abnormal, the elderly subject must be sent to a specialist or a referent memory centre; the MMSE is only a first stage in the diagnostic reasoning. MMSE should be included in the follow-up of all hypertensive elderly subjects and should be performed once a year by the general practitioner.