INTRODUCTION

Social distancing has been fundamental for preventing COVID-19, especially among older people with dementia, who are considered to be a vulnerable group.1 However, physical inactivity among older adults – including those with neurological disorders, such as dementia – exposes them to greater vulnerability to harmful effects on functioning and quality of life.2,3 Healthcare providers have used telehealth as a way to mitigate the impacts of the COVID-19 pandemic. This method was used to reach more vulnerable populations and those at risk of contagion. Telehealth is defined as providing activities through information and communication technologies in health care.4 Telehealth is a low-cost method that enables the remote transmission of care and the provision of quickly accessible information through technology while adhering to prevention measures to avoid the spread of COVID-19.5,6 Although this technology was widely used during the pandemic, there is a lack of studies analyzing the reliability of remote physical assessments performed in the home environment.

Prior to engaging older people in a telehealth-based physical exercise program, it is important to investigate whether the tools to determine the effect of the intervention are reliable when performed remotely. Ways to assess human functioning include using functional mobility and muscle strength measures, such as the Short Physical Performance Battery (SPPB),7 the Timed Up and Go (TUG) test,8,9 the TUG Dual Task (TUG-DT),10,11 and the 30-Second Sit to Stand Test (SST30s).12,13,14,15 Some physical tests have demonstrated good psychometric properties when performed remotely via telehealth, but research into this aspect has been limited. Ozsoy et al.16 found good reliability in TUG and SST5x when comparing telehealth with face-to-face interactions in individuals with chronic obstructive pulmonary disease.16 Similar high reliability comparing remote vs. face-to-face assessments of the TUG test were found in a study conducted by Russell et al.17 with individuals who have Parkinson’s disease and a study carried out by Hwang et al.2 with participants with heart failure.

More recently, a study conducted by Pelicioni et al.15 found strong inter-rater reliability and good intra-rater reliability on TUG and TUG-DT in both cases when comparing face-to-face vs. real-time telehealth interactions and face-to-face vs. asynchronous telehealth.3 Although these studies have contributed to the advancement of knowledge on psychometric results of remote assessments, there is a need for studies on how functional mobility and muscle strength tests can be adapted for older people with dementia in the home environment. Most studies performed remote assessments in healthy older people,15 older people with Parkinson’s disease,17 or volunteers with heart failure2 and thus did not advance knowledge on the remote assessment of older people with dementia. Adapting physical tests for this population poses a considerable challenge8 due to their difficulty in understanding verbal commands while also ensuring their safety during the test. Thus, a detailed description of any such adaptation is necessary.

Another important point is to determine inter- and intrarater reliability for these tests. In most studies found in the literature, an examiner was present during the test2,17 and there is no clear information on the process during telehealth interactions. Within this context, the present study aimed to adapt functional mobility and muscle strength tests for remote administration to older people with dementia in the home environment; determine intra-rater and inter-rater reliability of functional mobility and strength tests thus adapted in older people with dementia; and correlate the performance of the physical tests executed remotely and the TUG, which has been validated for remote use in healthy older people.

METHODS

This is a cross-sectional study undertaken as a secondary analysis from a randomized clinical trial18 previously carried out by our laboratory. Seven hundred and forty-two volunteers were recruted through advertisements placed in newspapers, online magazines, and social media, as well as telephone contact via the database of the UFSCar Research and Health of Older People Laboratory; however, only 43 met the inclusion criteria. To estimate the sample size, two examiners will be considered, alpha of 0.05, power of 90%, intraclass correlation (ICC) estimated at 0.9 with the lower limit of the 95% confidence interval of 0.7, and one onesided test19, which resulted in a minimum sample size of 30 participants. The diagnosis of dementia was confirmed with the assistance of an expert neurologist on the team, respecting the DSM V diagnostic criteria: A) Evidence of significant cognitive decline, A1) Concern of the individual or informant, A2) Substantial impairment in cognitive performance (z score < -2), B) Interference with daily independence, C) Deficits do not only occur in the context of delirium, and D) The deficits are not better explained by another mental disorder (e.g., major depressive disorder). To classify the dementia stage, the Clinical Dementia Score (CDR) was applied, and those participants classified as having mild and moderate dementia were included.20 Additionally, it was a prerequisite for a household member or visitor to the older person’s residence to be acquainted with and have access to mobile devices (e.g., smartphone, laptop) to facilitate the proposed assessments. Older people with caregivers who had scores equal to or less than 26 points in the Mini-Mental State Examination, considering years of schooling, were excluded.21 All volunteers provided a statement of informed consent. This study received approval from the local institutional Research Ethics Committee (opinion number: 34696620 0 0000 5504).

The composite physical tests used in the evaluation were the SPPB,7 TUG test,8,9 TUG-DT8,9,22 and SST30s.23,24 These tests were chosen as they are considered safe and reliable.12,17,25 Details, additional information, and descriptions of the adaptations made to the SPPB, 30-Second Sit to Stand Test, simple TUG, and dual task (addition of cognitive element) TUG-DT are shown in Table 1.2,13,14,16,26,27,28

All older participants underwent remote assessment via the Google Meet platform, conducted in real time by a previously trained physiotherapist having 5 years of experience in telehealth. A link to the videocall was sent to the caregiver approximately 30 minutes before starting the assessment.

The order in which the physical tests were performed was randomized for each participant. Before conducting each test, participants underwent an initial familiarization immediately preceding its execution.

Tests were considered inappropriate or incorrect when they were disrupted by the following situations:

1. 1. Lag or slow Internet connection; and
2. 2. External distractions, such as pets and family members.

In instances where signs of tiredness, malaise, or mood changes were observed, rendering the tests impractical, the assessment was rescheduled for another day.

Considering the population studied, the following instruments were used remotely for cognitive assessment of the participants: Mini-Mental State Examination,5 which evaluates seven categories of specific cognitive functions (orientation to time, orientation to place, memory, attention and calculation, evocation, language and constructive visual capacity); the Clock Drawing Test, which evaluates executive functions (planning, logical execution sequence), visuospatial organization, visuo-constructive praxis and psychomotor coordination;29 and the Semantic Verbal Fluency test, which assesses semantic memory, language and executive functions.30

To ensure the safety of the participants and their best performance, adaptations were made to the tests, and caregivers were instructed on their positioning and the position of the mobile device for adequate image capture. For all tests, the caregiver was instructed to place the mobile device on the floor, 1.5 m away from the initial marking, and directly in front of the participant (Figure 1). Additionally, the caregiver was advised to remain very attentive alongside the older person during the execution of all tests, to minimize the risk of falls. Finally, verbal commands were given during the tests, which are also described in Table 1.

Timekeeping, counting of repetitions, and test recording were performed by the physiotherapist/investigator responsible for the real-time assessment.

To assess the intra-rater reliability, the same investigator/ physiotherapist assessed the physical tests in real time and, after a minimum period of 14 days, watched the recordings and reassessed each of the tests. The inter-rater reliability was assessed by two independent and blinded physiotherapists to each other. After the first physiotherapist, the second independent and blinded investigator/physiotherapist also watched the recordings and assessed each of the physical tests performed by the participants.

For the intra-rater and inter-rater reliability analyses, we used a two-way mixed ICC test with absolute agreement and reported the confidence interval (CI) for the comparisons. For SPPB (seconds), SPPB (total score), TUG, TUG-DT, and SST30s values, the ICC was used to determine reliability. For the SPPB score values (two-foot balance, semi-tandem balance, tandem balance, gait speed, and 5 times sit and stand test), the kappa coefficient was used to determine the level of agreement. ICC values were interpreted as follows: excellent (ICC > 0.90), good (ICC = 0.75 – 0.90), or moderate (ICC = 0.50 – 0.74)31. Data were analyzed in IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp, Armonk, NY).

To ensure maximum standardization for reliability testing, the environment, the physical tests, and individuals were controlled through instructions, tutorials, and prior environment preparation. Moreover, the examiners were previously trained to ensure that there was no divergence during the execution and assessment of the remote tests.

RESULTS

The number of raters was two. The profile of the sample of participants is described in Table 2.

Intra-rater reliability was good for the total SPPB score (ICC = 0.862) and excellent for the TUG, TUG-DT, SST30s, and SPPB (seconds) (ICC = 0.957-1.000). Kappa agreement was nearly perfect for all SPPB score values (K = 0.838-1.000). On the other hand, inter-rater reliability was moderate for the tandem balance item (ICC = 0.685), and good for the two-foot balance (time) items and SPPB total score (ICC = 0.831-0.860). Excellent reliability was found for the semi-tandem balance, gait speed, and SST5x (time), as well as for all components of the TUG, TUG-DT, and SST30s (ICC = 0.952-0.999). Inter-rater Kappa agreement was substantial for the semi-tandem balance, tandem balance and SST5x score (K = 0.706-0.801). Agreement was fair for gait speed (K = 0.223) and almost perfect for the two-foot balance score (K = 1.000) (Table 3).

The correlation of performance on the physical tests performed remotely was also determined (Table 4).

DISCUSSION

The present study demonstrated that functional mobility and muscle strength tests for older people with dementia could be adapted for remote utilization, with excellent intra-rater reliability for the SPPB, TUG, TUG-DT, and SST30 when performed in the telehealth modality (real-time vs. recorded). Furthermore, when compared between raters, these tests proved to be reliable. Moreover, the tests were considered safe to be performed remotely in individuals with mild to moderate dementia and ongoing caregiver assistance.

Good intra-rater reliability was found for the SPPB score in the present study. Similar results were reported by Olsen and Bergland,28 who tested the reliability of the SPPB in the face-to-face assessment modality in older people with and without dementia. The authors employed test-retest analysis for older people with dementia, obtaining good reliability (ICC = 0.840).28 Thus, it is understood that SPPB performed remotely is reliable and does not differ significantly from face-to-face assessments, corroborating our findings. In previous studies, Fox et al.25 analyzed each of the SPPB subtests, obtaining poor reliability for the balance subtest (ICC = 0.490), moderate reliability for gait speed (ICC = 0.676), and excellent reliability for the SST5x subtest (ICC = 0.966).25 In contrast, we found good reliability for gait speed and SST5x and excellent reliability for the balance test. The study by Fox et al.25 included participants diagnosed with dementia regardless of stage, while only older people with mild to moderate dementia were included in the present study. Furthermore, the mean age of participants was 83 years in the study by Fox et al.25 and 78 years in the present investigation. Thus, the stage of dementia and age of the participant (but especially the former) may influence the scores obtained. Regarding inter-rater reliability on the SPPB test, no study performed this analysis, whether face-to-face or remotely via telehealth.

The reliability of several face-to-face mobility tests for older people with Alzheimer’s disease (AD), including the TUG test, has been discussed in the literature. Ries et al.32 found excellent reliability on the TUG test. Furthermore, they noted considerable variability in the individual performance of the participants, as well as differences between individuals with mild and moderate AD.32 Another study by Pelicioni et al.15 used the simple TUG test to compare remote and face-to-face reliability in a study of 15 community-dwelling older people.15 Reliability was considered good for both the real-time and face-to-face assessment and the recorded and face-to-face assessment. Compared with the present study, the reliability of the present study conducted remotely was excellent and similar to that found in the study by Ries et al.32 As the present study considered older people with greater cognitive impairment and had a larger sample size, the difference in our reliability values may be attributed to these factors, despite being excellent. Our literature search found no studies that analyzed the reliability and other measurement properties of the TUG test for older people with dementia remotely.

The TUG-DT has been adapted and used for the remote assessment of older people with dementia. No studies with TUG-DT among older people with dementia were found in our search. The only relevant literature was the study of Åhman et al.,10 which also used naming of animals during performance of the dual task to assess the test-retest reliability of the TUG-DT in healthy older people through face-to-face assessments and reported good reliability (ICC = 0.86).10 These findings are in line with the results obtained in the present study, in which the reliability of the TUG-DT was considered excellent (ICC = 1.00) when comparing real-time assessment and subsequent review of its recording, as well as in the comparison between examiners. The difference in the results can perhaps be explained by methodological differences, as the assessment was only conducted once in the present study (in real time) and was compared asynchronously. In summary, all evaluations were conducted remotely in the present study, and the results were similar to those found in the existing literature, reinforcing the reliability of the TUG-DT for the remote environment.

Reliability for the SST30s was considered excellent in the present study for comparing real-time and asynchronous assessments, as well as for the inter-rater comparisons. These values were higher than those originally described by Ricki and Jones23 and updated by the same authors in 2012,24 in which reliability, evaluated by the modified kappa coefficient, was 0.79 when tested in older people without cognitive impairment.23,24 Blankevoort et al.33 found results similar to those of the previous study, showing good reliability for older people with mild and moderate cognitive impairment (ICC = 0.79 and ICC = 0.88, respectively).33 Our ICC values were higher than those found in the recent literature due to how the test was applied. Blankevoort et al.33 allowed individuals to use their hands to stand up. In contrast, the participants in the present study performed the tests with their arms folded across their chest, relying more on lower limb strength and balance, thus making the test more difficult, which can reduce the number of repetitions and, consequently, facilitate counting by examiners.33 To the best of our knowledge, no previous studies have been conducted on the reliability of the remote form of the SST30s.

The home environment could have influenced the participants’ performance, as 3 to 4 meters of space were needed to perform the test. The home is a familiar environment for older people with dementia, facilitating familiarization and safety when performing the test, but the absence of an investigator present could lead to a more cautious performance of the tests, or even a lack of confidence by the participant to perform the test. It is important to point out that the home space was often inappropriate for administering the assessments (e.g., a narrow hallway). Thus, participants and examiners often had to improvise and adjust the environment (e.g., tests performed outdoors). Furthermore, although motor impairment is clearer in the moderate and advanced stages of dementia, studies in the literature demonstrate that, even in the early stages, there may already be motor impairments that can modify family dynamics and activities of daily living, especially in those with progressive pathophysiological processes.34,35,36 Individuals with more advanced stages of dementia may have difficulty executing and understanding commands given by a family member or remotely by a therapist, which may affect the reliability of assessment of the test findings.36,³⁷

In this discussion, we highlighted some points that may have contributed to the present findings, which we consider as strengths of the present study. The presence of the caregiver alongside the participant, which may have contributed to satisfactory performance on the tests; carrying out tests in the older person’s home environment and not in a laboratory or other controlled environment; the previous training given by the therapists to the caregiver; the real-time presence of the therapist during the tests to address any questions; and the adaptations made to each test to ensure preparation and suitability of the environment and, above all, patient safety.

Our study also had limitations. Some participants experienced Internet connectivity issues; thus, the execution time of the tests could have been longer than if we had assessed these participants face-to-face. Nevertheless, it is crucial to highlight that data collection occurred at the height of the COVID-19 pandemic, and it was thus impossible to compare remote performance to that of face-to-face assessments, as some previous studies had done.5 Therefore, future studies should explore this reliability assessment (face-to-face vs. remote). In addition, remote contact and general health guidance may have reduced variability in exercise performance during the pandemic. To enable application of the proposed tests, the mobility and muscle strength tests were adapted for remote use in older people with dementia. Such adaptations are scarce and have rarely been reported in studies with this population; no previous studies were found which reproduced these tests through the videoconferencing modality. However, this study demonstrates the inter- and intra-rater reliability of functional mobility tests for older people with dementia. Finally, only two raters, who were not randomly sampled, participated in the present study. This may limit the generalizability of our findings.

As practical implications, reliable and adapted functional mobility and muscle strength tests could be an additional alternative for assessment of this population, facilitating delivery of this type of service to individuals who are not financially or physically able to travel to a clinic or in situations that prevent individuals from leaving their homes, as occurred during the COVID-19 pandemic.

CONCLUSION

The physical tests used in the present study (SPPB, 30-second Sit to Stand, and single and dual-task TUG) appear reliable and feasible for administration in home environments when assessing older people with dementia, as long as a caregiver is present to provide assistance. These findings have important clinical implications, offering healthcare providers reliable, appropriately adapted means for the remote assessment of older people with dementia who were affected by COVID-19 containment measures or who otherwise have difficulties accessing healthcare services, e.g., those who live in remote areas or have comorbidities that prevent their travel to health facilities.

This study provides important information for coping with COVID-19, as few studies have evaluated the exercise performance of Brazilian community-dwelling older adults with dementia during the pandemic. We recommend that future studies sample Brazilian older adults from different regions, and with specific types of dementia, to understand and compare the consequences of exercise performance after the COVID-19 pandemic, its long-term social constraints, and possible actions to minimize its impact in the country.

ACKNOWLEDGEMENTS

We thank the participants and their families for their involvement and Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) for supporting this study (code: 2020/08779-0).

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Notes

Notes

Author notes

Correspondence data Larissa Pires de Andrade – Rodovia Washington Luís, km 235 – Monjolinho – CEP: 13565-905 – São Carlos (SP), Brazil. E-mail: larissa.andrade@ufscar.br

Conflict of interest declaration