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Chavan PB and Akulwar-Tajane I. Correlation between Executive Function and Manual Dexterity in
Community-Dwelling Older Adults. Clin Neuro Neurological Res Int J 2021, 4(1): 180020.
Copyright © 2021 Chavan PB and Akulwar-Tajane I.
Clinical Neuroscience & Neurological Research International Journal
ISSN: 2689-6001
Research Article Volume 4 Issue 1
Correlation between Executive Function and Manual Dexterity in
Community-Dwelling Older Adults
Chavan PB1 and Akulwar-Tajane I2*
1MPT in Neuro Physiotherapy, KJ Somaiya College of Physiotherapy, India
2MPTh in Neurosciences, Assistant Professor in Neuro Physiotherapy, KJ Somaiya College of Physiotherapy, India
*Corresponding author: Isha Akulwar Tajane, MPTh in Neurosciences, Assistant Professor in Neuro Physiotherapy, KJ Somaiya
College of Physiotherapy, Mumbai, India, Email: drishasa@yahoo.co.in
Received Date: May 03, 2021; Published Date: July 21, 2021
Abstract
Background: The normal process of aging involves decline in cognitive and sensorimotor functions that affect performance of
activities of daily living. Cognitive decline & motor system decline can coexist in elderly. Previous studies have indicated that
cognitive factors in addition to peripheral changes are involved in dexterity decline. However, these studies have used either
global measures of cognition or a selective domain of executive function. The purpose of the present study is to further explore
adults.
Design: Cross-sectional, observational.
Setting: Physiotherapy department in a tertiary care center, Mumbai, India.
Participants: Community-dwelling older adults between 65-84 years of age (n= 35).
Main Outcome Measures: Executive functions were assessed for various domains using neuropsychological tests viz. TMT A &
(semantic processing). Manual dexterity was assessed using Purdue pegboard test (assembly task).
Results:
s =-0.5496),
TMT B (rs = -0.6128), Stroop test (rs s s
Conclusion:
mechanisms constitutes a crucial component of hand motor function in this population. This study provides a reasonable basis
for implementing cognitive intervention strategies for manual dexterity impairment and new insights for hand rehabilitation in
community-dwelling older adults.
Keywords:
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Introduction
In Asia as a whole, the proportion of the elderly is expected
According to the population census in India, 104 million
people are elderly (aged 65 years above) in which 53 million
are females and 51 million are males. The normal process
of aging involves decline in cognitive and sensorimotor
functions that affect performance of activities of daily living
[1]. Affection of hand dexterity in elderly is interpreted in the
context of sensori-motor and other peripheral changes only.
Cognitive decline and motor system decline can coexist in
elderly. Neurocognitive decline as a normal process of ageing
Cognition is an overarching term whereas executive function
processes responsible for planning, assembling, coordinating,
sequencing, and monitoring other cognitive operations” [2].
Executive functions (EF) refer to abilities involved in
formulating goals, planning, executing plans effectively,
and self-monitoring and correction. The primary difference
between EFs and other cognitive functions is that the latter
are related to “what” or “how much” a person knows [3].
With EF however, the focus is more on “how” an individual
goes about performing tasks. These functions encompass the
skills that enable individuals to successfully become engaged
in independent, objective and self-monitored behavior, and
thus involve the more complex aspects of human cognition
[4].
and develop strategies to achieve goals, a process calling for
and manage multiple sources of information, in coordination
with the use of previously acquired knowledge [5]. The
executive system is also responsible for adapting behavior in
order to solve problems of everyday living [6].
This multidimensional construct encompasses several other
inhibitory control, processing speed, etc. Planning refers
alternatives and choosing the most effective one. Mental
sets or tasks and changing the strategies within the same
with active maintenance and manipulation of information
that is used to guide ongoing and intended actions, and its
capacity declines with aging, especially in tasks that also
involve executive control [8]. Inhibitory control refers to
the inhibition of a prepotent response, which facilitates
the choice of an adequate response and avoids errors [9].
Processing speed refers to the time required to process a
Executive dysfunction is characterized by the inability to
carry out adaptive tasks and dissociation between volition
switching between tasks, controlling impulses, planning
and time sequencing, as well as impatience and emotional
limitations in the performance of activities of daily living
and also instrumental activities of daily living, which reduces
autonomy and quality of life [10,11]. Thus, stimulation and
preserving this cognitive domain is crucial for this population
group [12].
Structural basis of executive functioning became associated
with the frontal lobes [13-16,3]. Within the frontal lobes, the
motor strips control motor functions, the premotor areas are
associated with planning and execution of complex motor
sequences, and prefrontal areas are associated with intent,
area has numerous connections with the other cortical
structures, thalamic nuclei and basal ganglia forming frontal
lobe systems. In addition the cortical portions of these
systems have connections with different posterior cortical
regions [14]. Changes in EFs are suggestive of impairment
to the frontal lobes or disconnection of the lobes from other
functions. Changes in the front striatal circuit (neural circuit
integrated to the lateral prefrontal cortex which accesses
information related to working memory) are possibly the
elderly with no dementia.
Executive dysfunction in aging can be measured objectively
with neuropsychological tests [13]. There are several
executive function tests which vary according to the domains
assessed.
hands” [18,19]. It is the ability to make coordinated hand and
muscular, skeletal, and neurological functions to produce
dexterity it is evident that there are cognitive, sensorimotor,
neurophysiological elements involved in the preparation,
control and execution of a functional movement. In normal
aging, changes in hand dexterity have been demonstrated
in gripping, pinching, grasping, lifting, and manipulation of
objects, which limit older adults’ ability to perform activities
ability experienced by elderly adults are handling small
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objects such as coins or buttons, telephoning, and preparing
meals [20]. Previous studies have found that loss of hand or
declines observed in subjects over 65 years of age [21,22]. A
recent study has demonstrated that declines in grip strength
have a deleterious effect on hand steadiness, aiming, tapping
decline in aging have been attributed to, morphological
[23], lack of tactile sensation, and cognitive deterioration
[24,25]. Although the role of peripheral changes in dexterity
has been established, these changes cannot consistently
account for dexterity decline in elderly [26-28]. Study done
adults’ performance on an object-lifting task when they were
deprived of tactile information. Similarly, some researchers
changes are involved in dexterity decline.
Among the above causes for dexterity decline, the role of
cognitive decline is the least understood. Cognitive factors
are increasingly being recognized as important for motor
control. However, currently little is known about the
cognitive constraints underlying manual dexterity decline in
ageing. Previous studies targeted elderly with mild cognitive
impairment or dementia while reduced EF is prevalent
even among healthy older adults without overt cognitive
impairment. Another methodological limitation of these
studies is that they either used either global cognition or
a selective domain of EF as performance measures. There
is limited empirical evidence evaluating the connection
dexterity in normal aging. Taking into account that declines
in attention and dexterity happen in the normal course of
executive function is associated with dexterity. Unraveling
the role of executive function, we thus aimed to determine
the correlation of manual dexterity with core EF functions
Methods
It was a cross sectional study conducted in the Physiotherapy
department of a tertiary care center. Institutional review
board approved design and conduct of the study. The
procedures followed protocol and accord with the ethical
standards of the institutional review board. Informed written
consent was obtained from all the participants before their
participation in the study.
Baseline evaluation for eligibility entailed sociodemographic
and clinical data which included age, income, years of
schooling, marital status, general health status, presence
of other clinical disease and use of medications. Inclusion
criteria of the study was
• Age: 65 years to 84 years,
• Male or female,
•
homes),
• Able to follow three-step commands,
• Able to read basic English,
•
Individuals were excluded from participation if they had
• Central or peripheral neurological disorders,
• Symptomatic musculoskeletal condition in upper limb
or neck,
• Hand tremors,
•
• Uncorrected visual impairments,
• Hearing impairments,
• Speech related impairment,
• Unstable medical condition,
•
Scale), or
•
dexterity.
Thus, as per these criteria, broadly speaking participants
were physically and mentally healthy older adults. Eighty
individuals were screened, out of which forty-four individuals
met the eligibility criteria. As per the estimated sample size
randomization using a computer generated table.
For the outcome measures of the study, subjects were assessed
function was assessed using six neuropsychological tests viz.
different brain processes (table 1). These are standardized,
reliable and validated tests; and are simple paper and pencil
tests in clinical context [29,34]. Whereas Purdue pegboard
equipment. The subjects were assessed by two different
assessors for cognitive and manual dexterity tests and in an
identical manner for all the subjects. To negate the effect of
fatigue and practice, rest period of 1 minute was given after
every neuropsychological test and the order of testing was
randomized for every subject.
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Statistical Analysis
as given in Table 2. In this association model, The EF test
values served as the independent variables whereas the
manual dexterity served as the dependent variable. Variable
distribution was tested using Kolmogorov-Smirnov test
and therefore non-parametric tests were used for all
for correlation analysis between Purdue pegboard test and
3) The result showed that the PPT (Purdue pegboard test)
descending order with TMT B (rs -0.6128, p <0.0001), Verbal
s 0.5503 p = 0.0006), TMT A (rs -0.5496, p= 0.0006),
Clock drawing test (rss
s=
s= 0.2988 at p 0.0813) [30-33].
Variable Domain Test Unit
Executive function
Visuomotor tracking, Cognitive
Trail making test A & B Time (sec)
Selective attention, Inhibitory control Stroop test Interference score
Working memory (verbal) Number of responses
Planning Clock drawing test Number of errors
Semantic processing Number of responses
Execution of controlled movements Purdue pegboard test
(Bimanual Assembly task) Number of pins inserted
Table 1:
Age (in years) (Mean ± SD)
Gender: Male/Female (%)
Dominance: Right/Left (%)
GDS score
MMSE score (Mean ± SD) 28.88 ± 1.40
Lateral Pinch Strength (lb)
Table 2:
Test Mean SD p value r value Interpretation
TMT A 54.32 0.006 -0.5496
TMT B < 0.0001 -0.6128
Stroop Interference 52.19 0.0094
4.94 0.96 0.0813 0.2988
3.4 0.0906 0.2904
Clock drawing test 3.14 2.61 -0.5432
12.28 4 0.0006 0.5503
Table 3: Correlation analysis of Executive function tests with Purdue pegboard test
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Discussion
This cross-sectional study aimed to determine the correlation
dexterity in community-dwelling older adults between the
function assessment consisted of neuropsychological tests
whereas manual dexterity was assessed by assembly task of
grooved Purdue pegboard test.
except working memory. This provides direct evidence for
underlying common cause which drives this association. The
rationale for this association resides in that hand dexterity
requires cognitive engagement and processes such as visual
search, speed of processing, attention, judgment, task
in line with the previous studies and thus the null hypothesis
is rejected.
TMT and Manual Dexterity
correlation with the assembly task. (for TMT-A rs= -0.5496
at p= 0.0006; for TMT-B rs=-0.6128 at p < 0.0001). TMT A is
a measure of psychomotor speed, selective attention, visual
scanning and visual-motor tracking [12]. Whereas Part B is
stimulus at a time, set-shifting and inhibition. In addition,
Part B assesses visual scanning, number recognition, numeric
sequencing and motor speed, working memory. TMT A &
B both provide visuomotor tracking, however, cognitive
part B increases the executive demands of this subtask. In
the present study, older adults showed longer completion
time for part B relative to part A. Prolonged time in TMT-B
performance in assembly tasks. PPT involves visually guided
performance of pegboard test with executive functioning on
TMT was found [35].
scores on Purdue pegboard tests may be due to cognitive
the relationship between manual dexterity and executive
function in elderly using kinematic analysis. Along with
increased movement variability in dexterity and lower
executive functioning on Trail making test B. In another
study by Mari LE, et al. [36], strong association for
variability in the assembly task and cognitive performance
as measured by TMT was found in healthy elderly. Also
the measurement of angular displacement and not on the
angular velocities. Authors suggested that processing speed
and executive function (as measured by TMT) as well as
general appropriate mental status may explain the limited
performance in the elderly.
Stroop Interference Effect and Manual Dexterity
Stroop test creates cognitive interference and predominantly
assesses active inhibitory control over more automated
responses and selective attention. Stroop color and word
test assess the ability to inhibit cognitive interference, which
occurs when the processing of stimulus features affects the
simultaneous processing of another attribute of the same
stimulus. i.e. (in the third test C-W) the participants are
required to perform a less automated task (i.e. naming the
ink color) while inhibiting the interference arising from a
in inhibiting the more automated process is called the Stroop
effect, while Stroop test widely measures the ability to inhibit
cognitive interference; previous literature also reports its
application to measure other cognitive functions such as
cognitive attributes are also important for manual dexterity
tasks.
negative correlations with assembly task (rs
at P=0.0094). Similarly Mari Lise Eriksen, 2012 found a
strong association between dexterity task and cognitive
tests measured by Stroop and TMT test and suggested that
the executive functions and attention play a role in elderly
to execute the dexterity task. When compared to young
adults, old adults (those over age 60) tend to show large
strop interference effects which may indicate an age related
selective attention impairment.
Digit Span Test and Manual Dexterity
promotes active short term maintenance of information for
later access and manipulation. Forward digit span primarily
measures attention and storage while backward digit span
may affect both storage and processing because it requires
that a person must maintain a number in memory and
manipulation of those numbers. According to Joel Mayerson,
only shows small decline in normal aging as mentioned by
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Clinical Neuroscience & Neurological Research International Journal
older adults who indicate that the elderly group had good
performance in the short term and working memory by Choi
HJ, et al. [31].
backward, however, requires an active reorganization and
manipulation of the information held in short term memory
which requires working memory and shows impairment
Arnanda., et al 2016 the elderly group was particularly
able to execute immediate recall of serial numbers forward
part that relied on the higher levels of active manipulation
of information. However, some studies by Jacques G, et al.
on the difference between digit span forward and backward.
As because aging is characterized by a decline in the
central executive while automatic processes (phonological
loop) remain intact. In the working model, a phonological
loop is arranged to maintain a string of verbal items in a
given temporal order while, Backward digit span is a more
extensive involvement of the central executive [39]. Thus,
previous studies evaluating working memory in elderly as
well as those comparing forward versus backward digit span
s=
s= 0.2988 at p 0.0813). It was
observed in this sample that older adults showed a trend of
reduced ability in backward digit span progressively from the
age of 65 years to 84 years however, were able to remember
the sequence of assembling pins, collars and washers in
the dexterity task. It is important to mention that previous
study, both these factors were not considered for analysis.
Previous studies evaluating working memory in elderly as
well as those comparing forward versus backward digit span
need to be explored further considering all the confounding
factors in future studies.
Clock Drawing Test and Manual Dexterity
Clock drawing test measures visuo-constructive & visuo-
spatial skills, along with executive functions which include
planning, organization & parallel processing. Gunten AV,
et al. [40] suggested that normal elderly subjects often
differentiating the clock hands correctly. The studies have
shown that the older age and fewer years of education
are typically associated with poorer clock drawing test
performance by Hubbard EJ, et al. [41] In the present study,
negative correlation (rs
studies have also demonstrated spatial and planning errors
in visuo-constructional abilities. PPT has certain spatial
and temporal task rules. In the assembly task, different
movements and pegs are required to be handled at faster
rates. Thus, proper manipulation of various pegs is required
as well as coordination of type of movements in the right
order. Therefore, low manual dexterity score of assembly
tasks may be due to cognitive delay rather than or in addition
other tests concluded that visual perceptual impairment
older adults [42].
Figure 1: Correlation analysis of TMT A test with Purdue pegboard test.
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Clinical Neuroscience & Neurological Research International Journal
Figure 2: Correlation analysis of TMT B test with Purdue pegboard test.
Figure 3: Correlation analysis of Stroop test with Purdue pegboard test.
Figure 4: Correlation analysis of Clock drawing test with Purdue pegboard test.
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Figure 5:
Figure 6:
Figure 7:
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executive function variables and hand dexterity.
Verbal Fluency and Manual Dexterity
information in memory. Phenomic and semantic verbal
category (animal category). In the present study semantic
dexterity (rs= 0.5503 at P 0.0006). Literature search
conducted for the present study could not identify any study
on elderly. A study done in preschool children by Smirni P, et
al. [43] found that manual dexterity correlated with verbal
and visuo-spatial performances.
Apart from this functional connectivity the neural basis can
which suggest similarity of the prefrontal brain activities
postulated between executive function and manual dexterity
studies have also demonstrated the potential involvement
of a network of several brain areas related to EF, including
the parietal cortex, cerebellum, and two prefrontal cortices:
the anterior cingulate cortex and the dorsolateral prefrontal
cortex [44]. In elderly, prefrontal brain activities are altered
[45].
An important highlight of this study is more comprehensive
which provide additional information about this relationship
in addition to existing evidence. Also, in contrast to the
previous studies, the age appropriate handgrip strength
set as a cut off in inclusion try to disentangle sensorimotor
affection from manual dexterity decline.
However, we acknowledge some limitations in the present
study. Though it is speculated that cognitive decline has
affected the manual dexterity performance; due to the
cross-sectional nature of the study, this cause and effect
relationship could not be established. Also, considering
the dynamic relationship of both of these attributes in the
mediating effect of age, a longitudinal design would have
been more appropriate. Potential confounding factors such
in the literature), were not adjusted or eliminated in the
to determine the extent of affection in cognition and manual
not analyzed. With regards to generalizability, results are
applicable to community-dwelling elderly only and may not
be extrapolated to or include institutionalized elderly.
Conclusion
Executive function (all the domains, except working
in community-dwelling older adults aged 65- 84 years.
mechanisms constitute a crucial component of hand
motor function and thus provide a reasonable basis for
implementing cognitive intervention strategies and new
insights for hand rehabilitation. Thus, there are cognitive,
sensorimotor, neurophysiological elements involved in the
preparation, control and execution of a functional movement
in older adults.
Implications for Rehabilitation
Findings of the study provide clinical evidence of functional
connectivity between EF and manual dexterity in elderly. The
this study need to be targeted for training dexterity function.
each other, therapeutic strategies for elderly with hand
dexterity affection should be differently mediated for those
with cognitive decline than those with intact cognition.
New technological devices designed to improve hand
functions should consider the cognitive demands for their
application by the elderly. Correlation of cognitive skills with
dexterity tasks assessed using Purdue Pegboard test further
strengthen the evidence of neuro psychomotor property of
Purdue Pegboard test.
Implications for Research
This study provides empirical evidence about the role of EF
in execution of hand dexterity in elderly. Future research is
required to establish causal relationships and considering the
dynamic relationship, a longitudinal design is recommended.
It will be worth exploring if performance of manual dexterity
can predict cognitive deterioration in elderly. Also, this will
serve to formulate therapeutic strategies to direct cognitive-
based approach to motor rehabilitation.
Acknowledgement
The authors would like to acknowledge the valuable
contribution of the participants and support of the principal
and faculty of the institute in the conduct of the study.
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Funding
in the conduct or publication of this research.
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