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Hand function in older adults: the relationship between performance on the Jebsen Test and ADL status

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Hand function in older adults: the relationship between performance on the Jebsen Test and ADL status

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Content HAND FUNCTION IN OLDER ADULTS: THE RELATIONSHIP BETWEEN PERFORMANCE ON THE JEBSEN TEST AND ADL STATUS by Lori Renee Max A Thesis Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF ARTS (Occupational Therapy) December 1994 Copyright 1994 Lori Renee Max UNIVERSITY O F SO U TH ER N CALIFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES, CALIFO RNIA 9 0 0 0 7 This thesis, 'written by .Lox:LJRsn.as...M ax............................................. under the direction of Aer. Thesis Committee, and approved by all its members, has been pre sented to and accepted by the Dean of The Graduate School, in partial fulfillment of the requirements for the degree of m £TM ...Q F„M TS........................................... Dean D ate 2 L.M ay...l3.9 .4. TH 'Chairman TABLE OF CONTENTS ii ABSTRACT................................................................................................. vii ACKNOWLEDGEMENTS........................................................................... ix CHAPTER I. THE PROBLEM............................................................................. 1 Purpose of the Study.........................................................................1 Relevance of Study to Occupational Therapy............................... 1 Research Questions......................................................................... 2 Significance & Rationale of the Study.......................................... 3 Research Design............................................................................ 4 Assumptions and Limitations......................................................... 4 II. A REVIEW OF THE LITERATURE............................................ 6 Prevalence and Growth of the Number of Older Adults in the U.S............................................................. 6 Hand Function of Older Adults.................................................... 7 Assessment of Hand Function of Older Adults by the Jebsen T est......................................................... 1 1 Measurement of Hand Function with the Jebsen Test..................................................................20 Correlation of Hand Function with Functional Status............................................................. 22 Research Questions........................................................................28 Relevance to Occupational Therapy............................................. 28 III. METHODOLOGY....................................................................... 29 Subjects........................................................................................ 29 Instruments.................................................................................. 30 Experimental Procedure.............................................................. 31 Data Analysis............................................................................... 32 IV. RESEARCH FINDINGS.............................................................. 34 Characteristics of the Sample 34 iii V. DISCUSSION............................................................................... 79 Overview of the Study..................................................................79 Research Question 1......................................................................82 Research Question 2 .....................................................................82 Research Question 3 .....................................................................84 Research Question 4 .................................................................... 84 Future Studies............................................................................... 86 Implications for Occupational Therapy...................................... 87 REFERENCES.................................................................................... 89 APPENDIX A. Jebsen-Taylor Hand Function T est........................................... 92 B. OARS- Multidimensional Functional Assessment................. 98 C. OARS- Spanish Questionnaire...................................................104 D. Informed Consent........................................................................110 E. Infomed Consent- Spanish Translation......................................114 LIST OF TABLES 1. Demographic Characteristics of the Sample.......................... 36 2. Mean Age and SD for the Six Age Subgroups.................... 37 3. Educational Level for the Six Age Subgroups..................... 38 4. Ethnicity Percentages for the Six Age Subgroups............... 38 5. LADL & ADL Capacity of Angelus Plaza Participants by Age G roup.............................................. 39 6. LADL & ADL Capacity of JHA Participants....................... 39 7. Mean ± SD Hand Performance Subtest Scores, by Age Group and Sex (in seconds)........................................... 42 8. Main Effects for Age Group for Performance on the Jebsen Test...............................................................44 9. Main Effects for Sex for Performance on the Jebsen T est..............................................................45 10. Interaction Between Sex and Age Group for Performance on the Jebsen T est.......................................46 11. Mean + SD Hand Performance Subtest Scores, by Age Group (in seconds)...............................................47 12. Mean + SD Hand Performance Subtest Scores, for Decade, by Sex (in seconds).................................... 53 13. Main Effects for Age Group by Decade for Performance on the Jebsen T est.......................................55 14. Main Effects for Sex by Decade for Performance on the Jebsen T est................................... 56 15. Interaction Between Sex and Age Group for Performance on the Jebsen T est................................... 57 16. Mean ± SD Hand Performance Subtest Scores, by Age Group Decade (in seconds).................................58 17. Differences in Hand Performance Between 90 year olds from Angelus Plaza vs The Jewish Home for the Aging (JH A )...................................................... 59 18. Mean ± SD Performance of Right-handed Participants Compared to that of Left-handed Participants................60 19. Correlation Between Instrumental Activities of Daily Living (LADL), Activities of Daily Living (ADL) and Jebsen Subtest Scores............................................... 61 20. Activities of Daily Living (ADL) as a Covariate............... 62 21. IADL as a Covariate with Age G roup.................................. 64 22. Main Effects for Age Group for Caucasian Participants 69 V 23. Main Effects for Age Group for Latino/a Participants 70 24. Main Effects for Age Group for Asian Participants 71 25. Education as a Covariate with Age G roup............................72 vi LIST OF FIGURES 1. "Writing" Subtest Scores Using Nondominant Hand, as a Function of A g e........................................................ 74 2. "Small Objects" Subtest Scores Using Nondominant Hand, as a Function of A g e............................................ 74 3. "Checkers" Subtest Scores Using Nondominant Hand, as a Function of A g e........................................................ 75 4. Age Group x Sex Interaction on "Card Turning" Subtest Scores, Using Dominant H and...................................... 75 5. Interaction Between Age Group x Mean Summed IADL Scores on "Simulated Feeding," Using Dominant H and................................................................................... 76 6. Interaction Between Age Group x Mean Summed IADL Scores on "Heavy Objects," Using Dominant Hand 76 7. Interaction Between Age Group x Mean Summed IADL Scores on "Small Objects," Using Nondominant Hand 77 8. Interaction Between Age Group x Mean Summed IADL Scores on "Simulated Feeding," Using Nondominant H and......................................................... 77 9. Interaction Between Age Group x Mean Summed ADL Scores on "Simulated Feeding," Using Nondominant H and........................................................ 78 Abstract Older adults (N = 238) between 65 to 98 years old were administered the Jebsen Hand Function test and self-care section of the OARS (Older Americans' Resources and Services) Multidimensional Functional Assessment Questionnaire (OMFAQ). Normative values on the Jebsen test were obtained by grouping older adults in five-year age intervals: 65-69; 70-74; 75-79; 80-84; 85-89; and 90-98 years. This study examined the main effects for sex and main effects for age group. This study also examined the interaction between age group and sex and examined the correlation between older adults' hand function on the Jebsen subtests with their scores on the OMFAQ ADL assessment. There were no sex differences between hand function ability among older adults 65-98 years old in all fourteen subtests; therefore, data on males and females were combined. Results of the 2x6 analysis of variance for the main effects for age group were found in 12 out of the 14 subtests; exceptions were "moving, light objects" and "moving, heavy objects" using the dominant hand. There was only one interaction between age group and sex, as females in the 85-89 and 90-98 year age groups performed faster compared to the 80-84 year olds. Likewise, males in the 85-89 year age group performed faster compared to the male participants in their 90's. A linear relationship was found; hand performance decreased as a function of age. There were breaks in the pattern; however, as participants in the 70-74 year age group performed faster on all fourteen subtests compared to participants in the 65-69 year age group. Also, participants in the 85-89 year age group performed faster compared to participants in the 80-84 year age group. viii The breaks from this linear pattern could have been related to confounding variables, as this study found that the participants’ IADL, ADL status and educational level covaried with age group to impact older adults' speed of performance on the Jebsen test. The participants' ethnicity was also related to their hand functioning ability; as statistically significant main effects for age group in Caucasians, Latino/a's, or Asians were found in several subtests. Participants' performance on the Jebsen test was correlated to their functional status. All seven IADL’ s and ADL’s showed statistically significant negative correlations with all the Jebsen subtests. Thus, higher IADL or ADL scores related to lower hand speed or faster performances. This correlation is a valuable finding as occupational therapists or other health-care professionals could use the OMFAQ ADL assessment as a screening device in the older adult community to help detect functional impairments at an early stage and recommend intervention before an older adults’ functioning declines. The findings from this study also argue against ageism and indicate that older adults should not be stereotyped as a group whose hand functioning declines with age. ix Acknowledgements A number of persons were instrumental in helping with my thesis. I would like to thank those colleagues, professors, computer consultants, and family members for their support, guidance, and understanding. First, I would like to thank my colleague, Monica Godinez for her generous assistance with the translation of the OARS questionnaire from English to Spanish. Also, Mama Ghiglieri, another colleague, for her time and patience in explaining the basics of SAS and writing SAS programs. I am very grateful to both for their valuable time, assistance, and for being such good friends over the years in school. Besides colleagues, two very special co-workers Marie Cortez and Javier Villota, who worked at the USC health clinic at Angelus Plaza, were tremendous in their contributions with the data collection. Their help in recruiting participants and providing Spanish translations helped alleivate stress and provided a smoother administration of the Jebsen test for the Latino/a participants. Also, I am thankful for their friendly and easy going personalities, as their demeanor gave me the strength and energy to survive driving to downtown Los Angeles for three weeks, consistently. A number of professors helped with my thesis as their constructive comments and helpful suggestions made the process smoother. Dr. Carlson for his assistance in explaining statistical procedures and interpreting the results of statistical tests. Dr. Zemke for her knowledge about occupational therapy topics and making me feel comfortable at the committee meetings. Dr. Pynoos for his knowledgable suggestions and assistance with resources in the areas of gerontology. Also, for his easy going manner and for suggesting the Gerontology Computer Lab to assist with my SAS difficulties. The consultants at the Gerontology Lab, Sami Khedhiri and Alexander Bucur for both their patience and understanding in solving my SAS errors. Their pleasant disposition and helpful suggestions with programming saved me many hours of frustration and time; they were lifesavers! Dr. Hedricks for her guidance and support over the past year, for returning my drafts in a timely manner, and for patiently correcting all my grammar mistakes. Also, for helping with the SAS programming and for making the thesis a valuable and rewarding learning process. My boyfriend, Robert for his assistance with basic computer questions and for showing me those helpful shortcuts. Also, for helping me become more knowledgable about computers and for being understanding for the weekends I was at the library or computer lab. Lastly, I would like to thank my parents, Jan and Joe Gendell for their generosity, love, and support over the past six years and especially during the past few years at graduate school. 1 CHAPTER 1 THE PROBLEM Purpose of the Study The purpose of this study was to obtain a greater understanding of the relationship between age and hand function. The Jebsen-Taylor Hand Function Test (Jebsen, Taylor, Trieschmann, Trotter, and Howard, 1969) (See Appendix A) was administered to older adults 65 to 98 years old, to measure their hand function. Another purpose of this study was to examine sex differences in older adults with respect to their hand function. Thirdly, this study examined whether there was an interaction between age and sex in older adults' performance on the Jebsen test. In addition, this study investigated older adults' functional status in relation to their hand dexterity by correlating scores on the OARS (Older Americans' Resources and Services) Multidimensional Functional Assessment Questionnaire (OMFAQ) (See Appendix B) with performance on the Jebsen- Taylor Hand Function Test (Jebsen et al., 1969). Relevance of Study to Occupational Therapy Studies on older adults, persons who are 65 years or above, will increase the knowledge base of occupational therapists, which in turn should enhance their ability to serve this growing population group. Additionally, obtaining normative data on the elderly will provide occupational therapists with preliminary assessments for comparison in hand function, which acknowledges age related changes and which may help to document the progress of an older adult patient. The first step towards enhancing the occupational therapist's knowledge base in geriatrics is to obtain normative data on the elderly for all standardized tests used. Jebsen et al. (1969) attempted to obtain normative data about the hand functioning ability of 60 older adults on the Jebsen test. The subjects were between the ages of 60 to 94, and were treated as one broad age group. This treatment failed to differentiate hand functioning ability between younger and older persons within this wide age range. In addition, the researchers did not measure how older adults' activities of daily living (ADL) and instrumental activities of daily living (IADL) status might be correlated with hand function. These ADL and IADL factors are important to investigate, as Jebsen et al. (1969) claimed that the Jebsen test broadly measures functional status, which needs to be validated. Hackel, Wolfe, Bang, & Canfield (1992) also used the Jebsen test to obtain normative data on older adults. They grouped 121 subjects into ten-year intervals: a) 60-69, b) 70-79, and c) 80-89 years. They found that subjects of both sexes in their 70's and 80's demonstrated slower hand functioning ability than the reported norms for older adults (Jebsen et al., 1969). Subjects who were in their 60’ s, however, required less time to complete several of the subtests than the reported nonnative values (Hackel et al., 1992). These investigators concluded that Jebsen et al.'s (1969) wide age grouping underestimated hand functioning in the 60-69 year old subjects, but overestimated it in the older adult subjects. Though Hackel et al.'s (1992) study identified important differences in hand function between individuals 60 to 89 years old, they did not collect measurements on individuals in their 90's, nor did they include an ADL assessment to investigate how ADL status correlated with hand function. Research Questions The research questions of this study were: (1) Are there sex differences in hand function ability among older adults?; (2) How do the six subgroups (65-69, 70-74, 75-79, 80-84, 85-89, 90-98) differ from one another with respect to hand function?; (3) Is there an interaction between age and sex in older adults' performance on the Jebsen test?; and (4) Across all subtests, does hand function correlate with the OMFAQ ADL assessment? Significance & Rationale of the Study Due to the discrepancies in hand function which Hackel et al. (1992) found among all three age groups when compared to Jebsen et al.'s (1969) data, their failure to study 90 year olds, and their lack of measuring ADL status, a further study of hand function in older adults seemed warranted. For example, assessment of hand functioning in five-year age increments may be useful to make more accurate assessments of older adults. In addition, neither Jebsen et al. (1969) nor Hackel et al. (1992) examined how hand performance on the Jebsen test was correlated with functional status, which is an important variable to investigate, as the developers of the Jebsen test claimed that the Jebsen test broadly measures functional ability. Finally, the inclusion of individuals 90 years old and above is necessary due to the increased longevity in the elderly population. According to the Bureau of the Census (1988) a greater number of people are living to their 80's and 90's and there are more than 32,000 seniors over 100 years old in the United States. One consequence of an increase in the elderly population is that occupational therapists and other health professionals need to focus more of their research and clinical efforts on older adults. For example, occupational therapists will need to assess hand function more frequently, as hand function is correlated with a person's ability to function independently and early screening could help an older adult stay in the community setting longer by identifying hand dysfunction and intervening before additional complications arise. There is currently a paucity of research examining hand function abilities of older adults (Shiftman, 1992). Research Design This quasi-experimental study used the Jebsen test to measure hand function of older adults between 65 and 94 years of age. Subjects were grouped into six age categories: 1) 65-69, 2) 70-74, 3) 75-79, 4) 80-84, 5) 85-89, and 6) 90-98. This procedure detected whether there were significant differences in hand mobility, sex differences, and interactions between age and sex among individuals grouped into each five-year age period. Additionally, this procedure detected whether older adults’ hand mobility was correlated with their ADL and IADL status. These data should enable occupational therapists to more accurately assess an older adult's level of impairment and thus to develop more appropriate treatment programs for older adults, as using the norms established by Jebsen et al.'s (1969) study is inadequate. Subjects were recruited from Angelus Plaza, a federally-funded housing project in downtown Los Angeles and Jewish Home For the Aging (JHA), both a board-and-care nursing home facility in the San Fernando Valley. The Jebsen test was administered to 20 female and 16-20 male subjects in each of the six age groups. Subjects were able to read and write at a third grade level and closely represented the percentage of ethnicities in the city of Los Angeles. Both the dominant and nondominant hands of these 238 subjects were tested. Subjects also completed a questionnaire which consisted of basic demographic information and questions from the OMFAQ ADL (See Appendix B). Assumptions and Limitations of the Study Assumptions were that: 1) subjects in this study were willing to volunteer 15 minutes of their time; 2) subjects were able to comprehend English or Spanish; and 3) subjects were able to write or print, as completing the first subtest of the Jebsen test required writing a sentence (See Appendix A, Subtest 1). Because the majority of this study was conducted on low income older adults (excluding the JHA population), these results may not be generalizable to elderly populations of other economic groups. 6 CHAPTER II A REVIEW OF THE LITERATURE The purpose of this study was fourfold: (1) To obtain normative data on older adults 65-98 years old on the Jebsen Hand Function Test (See Appendix A) in five-year increments; (2) to examine if there were sex differences in older adults’ hand functioning abilities; (3) to examine if there was an interaction between sex and age group in the performance of older adults on the Jebsen test; and (4) to examine how the hand function of older adults correlated with their functional status, as measured by the self-care section of the OARS Multidimensional Functional Assessment Questionnaire (OMFAQ), see Appendix B. Prevalence & Growth of the Number of Older Adults in the United States This study examined the hand function of older adults and how it correlated with their functional status, as the importance of studying the elderly population is evident due to the demographic shifts in our society. The U.S. Bureau of the Census (1988) projects that there will be 34.9 million persons aged 65 and older by the year 2000. By the year 2030, the Bureau predicts there will be 65.6 million older adults, almost double the number in only 30 years. If these predictions are accurate, persons aged 65 years and older will make up 21.8 percent of the total population in 2030. As of 1980, only 11.3 percent of persons aged 65 and above comprised the U.S. population (U.S. Bureau of the Census, 1984). Because the percentage of older adults is expected to almost double in 30 to 40 years, health care professions must expand their knowledge of this older adult population. 7 In addition to increasing in size, the older adult population has also increased its longevity. According to the Bureau of the Census (1988) a greater number of older adults are living to their 80's and 90's and there are more than 32,000 seniors over 100 years old in the U.S. Hand Function of Older Adults A person with independent functional status is defined as one who does not require any physical (excluding use of a cane, crutch, walker, or other assistive device) or verbal assistance in activities of daily living (ADL), such as dressing, grooming, eating, bathing, and instrumental activities of daily living (IADL), such as meal prepartion, transportation use, and money management. Hand function is defined as the ability to use one's hands in everyday activities such as writing, turning on the faucet, pressing buttons or dialing the phone, opening drawers, unscrewing the toothpaste cap, or pouring a glass of water. Hand function and functional status are often interdependent; if one required assistance in bathing, one might also have impaired hand functioning and vice versa. Hand function is important in older adults, helping to maintain quality of life by preventing dependency or institutionalization, as there is a consistent, positive relationship between manual dexterity and functional independence (Falconer, Hughes, Naughton, Singer, Chang, & Sinacore, 1991; Ostwald, Snowdon, Rysavy, Keenan, & Kane, 1989; Williams, Hadler, & Earp, 1982). Williams et al. (1982) recruited 56 Caucasian women over 63 years of age who lived in one of three sites (i.e., nursing home, own home with assistance, or totally independent). They investigated factors which might be responsible for predicting the woman's state of dependency, such as age, socioeconomic status, education, strength of social network, mental status, manual ability, morale and X medical problems (Williams et al., 1982). They found that hand function was the best marker of dependency. Williams et al. (1982) measured hand function, which they called the manual ability index, by using the Jebsen-Taylor Hand Function test (Jebsen et al., 1969) (See Appendix A) and a new test they developed, the Williams Test of Hand Function (Williams et al., 1982). The Williams test consists of timing subjects opening a variety of nine fasteners and then closing eight fasteners on a plywood panel (e.g., a bolt latch, screen door latch, padlock). The investigators administered five subtests from the Jebsen test to both the dominant and nondominant hand, omitting subtests six and seven (i.e., moving light objects and heavy objects). Williams et al. (1982) concluded that the timed performance of any one of the 27 manual skills was the best discriminating factor in accounting for group differences among nursing home residents, retirement home residents, and residents living independently in the community (r = .86, p < .0001). Ostwald et al. (1989) tested Williams et al.'s (1982) findings that poor manual dexterity is correlated with functional dependency. Their subjects consisted of 128 elderly Catholic nuns who lived in one of three different sites (i.e., nursing home, retirement home, or living in community). Manual dexterity was measured only by timing the subjects on the Williams Board (opening and closing a variety of fasteners); however, Williams et al. (1982) had used the Jebsen test also, referred to as the Williams Test of Hand Function. This indicates that Ostwald and colleagues did not replicate Williams et al.’ s (1982) study with the same hand function assessments and in turn they would be measuring only 17 manual skills as compared to 27 skills. In addition, the Williams Board does not consist of everyday tasks as does the Jebsen test, so the Williams Board may evaluate an individual’ s hand function differently. Furthermore, the Williams y Board focuses on fine motor and cognitive ability, whereas the Jebsen test assesses, along with the skills mentioned above, a wider range of skills such as dexterity, grasp, strength, coordination. In spite of these differences, Ostwald et al.'s (1989) finding that the nuns living in the community completed the manual dexterity test 9 seconds (1.2 times) faster than the sisters in the retirement home, and 67 seconds (2.5 times) faster that the sisters living in a nursing home, support those of Williams et al. (1982). Manual dexterity, age and mental status explained 62% of the variance in residential living site among the sisters, while manual dexterity alone explained 51% of the variance (Ostwald et al., 1989). These findings indicate that manual ability is a good predictor of an older adult's dependency level and that the addition of age and mental status only slightly increases the predictability. In turn, occupational therapists and other health-care professionals can use an older adult's manual ability to identify those at a risk for long term care, and this preventive measure should help increase the quality of life of these older adults. Falconer et al. (1991) also conducted a study which tested Williams et al.'s hypothesis that poor hand function is a correlate of dependency in older adults. They recruited 764 older adults who were from one of three populations: community dwelling; residents of a continuing care retirement community; or chronically impaired homebound adults. They assessed the subjects’ hand function abilities by using five different tests: Williams Test of Hand Function; Williams Board test; Jebsen test; self-reported Dexterity Scale of the Geriatrics-Arthritis Impact Measurement Scale (GERI-A1MS) measure of hand function; and self- reported multidimensional functional status (GERI-AIMS). ID All five hand function measures correlated significantly with dependency, although the Williams Board test, which consists of the nine fasteners to open and eight fasteners to close, correlated best with dependency (Falconer et al., 1991). The Williams Board determined the subjects’ dependency level or living site at 12.5% and the Jebsen test explained a 7.9% variance. In addition, the GERI- AIMS comprehensive functional status measure which assesses seven areas: mobility, physical activity, household activities, ADL, pain, anxiety, and depression was the best instrument to determine variability in the subjects' living site at 16.9% (Falconer et al., 1991). The importance of hand function has been reliably demonstrated by three studies (Falconer et al., 1991; Ostwald et al., 1989; Williams et al., 1982); all three found a positive correlation between hand function and living independently in older adults. However, a limitation of these studies is that the researchers based the subject’ s state of dependency on his or her living site and not by an ADL functional assessment. An older adult's living site may not accurately represent his or her functional level, as other variables such as economic and social factors may influence an older adult's living site. So one who resides in a board-and-care facility could be functioning at an independent level; maybe they did not get along with their family or could not afford hired help for assistance in transportation and running errands. Likewise, an older adult living at home could have functional impairments, but with a supportive network like family, assistance could be provided in areas such as transportation, homemaking and bathing. Thus, judging an older adult's dependency level should be assessed by an ADL questionnaire and not by living site, as too many confounding variables are involved. In addition to the lack of studies which examined older adults' dependency level by ADL status, there is a paucity of research in hand function of older adults according to the Jebsen test (Falconer et al., 1991; Hackel et al., 1992; Jebsen et al., 1969; Williams et al., 1982). This limited amount of studies, four across a twenty year span, is one possible reason why other researchers who study geriatrics have developed new hand tests, such as the Physical Performance Test (PPT) (Reuben & Siu, 1990) and the Timed Manual Performance Test (TMP) (Williams, Gaylord, & Gerrity, 1994). Development of additional hand tests may not be warranted; however, as Lynch & Bridle (1989) found that the Jebsen test predicts an individual's ADL status, which is a key finding. Further studies are needed to verify Lynch & Bridle's (1989) findings, along with studies which investigate the Jebsen test's clinical applicability. Assessment of Hand Function of Older Adults by the Jebsen Test Jebsen et al.(1969) developed the Jebsen test, which expanded the knowlege base of health-care professionals on the hand function abilities of clients. The Jebsen-Taylor Hand Function Test (Jebsen et al., 1969) measures the speed of performance in simulating everyday activities, which broadly assesses one's functional dexterity. The Jebsen test includes seven subtests which consist of writing, simulated page turning, moving small objects, simulated feeding, stacking checkers, picking up light cans, and picking up heavy cans (see Appendix A). The Jebsen test assesses an individual's independence in hand function, which assists occupational therapists in selecting a treatment program which will best facilitate a client's needs. Occupational therapists find the Jebsen test to be a quick and efficient assessment device, as it can be administered within 15 minutes. Jebsen et al. (1969) collected normative values of hand functioning in both adults and older adults on the performance on the Jebsen te st. They administered the Jebsen test to 300 participants who were described as not having any hand 12 dysfunctions. Other characteristics besides age and sex were not described. The researchers originally placed 30 male and 30 female participants into each of the following age groups: 20-29; 30-39; 40-49; 50-59; and 60-94, although they only reported normative values for two broad age groups: the 20-59 year olds and the 60-94 year olds (Jebsen et al., 1969). Jebsen et al. (1969) chose these two broad age categories as they found that the differences between the means of the two age groups by subtest and dominant or nondominant hand was statistically significant in all cases except for simulated feeding for women with both hands (p < .05). In addition, the researchers found that at about 60 years of age in both sexes, the length of time taken to perform each subtest increased significantly, except for simulated feeding in women. Additionally, in the 60 to 94 year age group, less than 10 percent of the subjects fell above two standard deviations from the means except for the large light objects subtest in females (Jebsen et al., 1969). In general, the researchers found significant differences between men and women on several of the subtests and found a trend for the oldest age group to require more time on the subtests than the younger age groups (Jebsen et al., 1969). Hackel et al. (1992) investigated Jebsen et al.'s (1969) findings of hand function in older adults for the 60 to 94 year age group. They were interested in whether hand function declines every decade for both men and women between the ages of 60-89 years. The sample consisted of 15-20 subjects in each of the three age groups: 60-69; 70-79; and 80-89. They recruited 121 men and women who were living independently in the community. Subjects were obtained from a number of different settings: senior centers; churches; retirement homes; and the residence of the subjects. 13 They reported significant differences in hand functioning among the three groups. In two subtests: simulated feeding (dominant hand); and simulated feeding (nondominant hand), females in their 60's performed the hand test significantly faster compared to females in their 70’ s (p < .01). The speed of performance of females in their 60's compared to females in their 80's differed significantly in six subtests: writing; card turning; (dominant hand) and writing; simulated feeding; light objects; heavy objects; (nondominant hand; p < .01). Females in their 60's were also faster in completing five subtests compared to females in their 80’ s: simulated feeding; checkers; light cans; (dominant hand) and card turning; small common objects; (nondominant hand; p < .05). Females in their 70’s performed two subtests faster compared to females in their 80's: writing; (dominant hand) and writing (nondominant hand; p < .01). Females in their 70's also perfomed four subtests faster compared to females in their 80's: card turning; checkers; (dominant hand) and card turning; small common objects (nondominant hand; p < .05). Hackel et al. (1992) also reported significant differences in hand functioning among the three age groups for males. Males in their 60's compared to males in their 70's were faster in completing one subtest: light objects (dominant hand; p < .05). Males in their 60's performed eleven subtests faster compared to males in their 80's: writing; card turning; common objects; simulated feeding; checkers; light objects; heavy objects (dominant hand) and writing; card turning; light objects, heavy objects (nondominant hand; p < .01). Males in their 60's were also faster compared to males in their 80's in two subtests: simulated feeding; checkers (nondominant hand; p < .05). Males in their 70's were faster in eight subtests compared to males in their 80's: card turning; common objects; simulated feeding; checkers; light objects; 14 heavy objects (dominant hand) and checkers; and heavy objects (nondominant hand; p < .01). Males in their 70's compared to their 80's were faster in five subtests: writing; (dominant hand) and writing; card turning; simulated feeding; light objects (nondominant hand; £ < .05). Another finding of Hackel et al. (1992) was that there was a significant difference between men and women on only two out of the 14 subtests: "writing" with the dominant hand and "moving small objects" with the nondominant hand. In these two subtests, females performed faster than the males. This finding that sex had a minimal influence on hand performance contradicts Jebsen et al.'s (1969) finding, perhaps because in the 1990's a greater number of older adult women had occupied the workforce than older adult women from the late 1960's. Thus, over the past two decades women have worked in the same fields as men, such as in accounting, architecture, medicine, psychiatry, dentistry, and business. Thus, their hand use should be comparable to that of men. Lastly, when Hackel et al. (1992) compared their subjects' mean scores to Jebsen et al.'s (1969) "normative" values, they found both males and females in their 70's and 80's were slower in completing the subtests than the normative values, though this finding was predominantly for eighty year olds. Additionally, subjects in their 60's completed the subtests in less time than the reported normative values. However, Hackel et al. (1992) did not perform any statistical tests when comparing their normative values to the normative values of Jebsen et al. (1969). In summary, the results of Hackel et al. (1992) were discrepant in a number of ways with those of the Jebsen et al. (1969) study. By narrowing the 60-94 year group into three age groups by decade, Hackel et al. (1992) found the hand performance within the three age groups differed. Both men and women in their 1 5 80's were slower in completing several subtests compared to subjects in their 60’ s and 70’ s. Additionally, when Hackel et al. (1992) compared their mean scores to Jebsen et al.'s "normative" values, in general both men and women in their 70's and 80's were slower in completing the subtests than the "normative" values. In addition, subjects in their 60's completed the subtests in less time than the reported "normative" values. Although Hackel et al. (1992) found differences in hand function across the decades, they found sex to be a minor influence on the decrease of hand function, which was inconsistent with Jebsen et al.'s (1969) finding. Jebsen et al.'s and Hackel et al.'s studies are valuable to occupational therapists and other health professionals as they increase the knowledge base of hand function performance in older adults. However, there were limitations to these studies. Jebsen et al. (1969) originally planned to obtain normative data on five age groups; however, because they did not find significant differences in hand performance among the four groups less than 60 years of age, they established norms for only two groups: 20-59 year olds and 60-94 year olds. One limitation of Jebsen et al.'s (1969) study is that they did not further subdivide the sample of 60-94 year olds, which may result in occupational therapists making inaccurate assessments of an older adult's hand function ability or a client's potential for improvement in hand function. For instance, a client in his or her 80’ s whose score on the Jebsen test represents moderate impairment in hand function might be mildly impaired, else "normal" for an 80 year old for his or her age, as the mean scores for the 60-94 year group more closely represent a 60 or 70 year old's hand function ability. In effect, the client's hand performance would be documented at a lower functional level and he or she would then receive 16 occupational therapy, although the client would probably need few, if any, treatment sessions to return to his or her prior functional level. Another limitation of Jebsen et al.'s (1969) study was that they did not include an ADL assessment which could have been correlated with hand performance on the Jebsen test. Since Jebsen et al. (1969) claimed that the Jebsen test broadly assesses an individual's hand function in ADL's, their lack of including an ADL instrument was critical, in order to validate the functional correlation of the test. One other limitation of Jebsen et al.'s (1969) study was that they did not test whether hand function decreases with age, by decade. Instead they only reported values of one broad age group: 60-94 year olds. Because the Jebsen test includes the components necessary to hand function: dexterity; strength; coordination; fine motor skills; and cognitive processing, it is an ideal test to investigate the effects of age on hand function. However, Jebsen et al. (1969) did not test this possibility, perhaps because in the 1960's the older adult population comprised a smaller percentage of the population than it does today, and older adults in the 1960's had shorter life spans than today's older adults. Hackel et al.'s (1992) study examined the performance of 60 to 89 year olds on the Jebsen test by collecting data on three different age groups by decade. They investigated one limitation from Jebsen et al.'s (1969) study: the effect of whether further subdividing the broad age group (60-94 year olds) into three age groups by decades would lead to the detection of differences in hand function ability. One major limitation of Hackel et al.'s (1992) study was that they excluded 90-year-old subjects, an age group which was included in Jebsen et al.'s (1969) 17 study. It is important to assess hand functioning ability of ninety year olds, as the older adult population is increasing in both size and longevity. Another limitation of this study was that Hackel et al. (1992) did not include a statisical test to compare their subjects' mean subtest scores from the Jebsen test with Jebsen et al.’ s (1969) normative values. This was a critical missing element, as Hackel et al. (1992) found statistically significant differences on hand performance scores in the three age groups by decade, providing support that the normative values of Jebsen et al. (1969) were inaccurate. Another possible limitation of this study was that a 10-year interval might not be a small enough breakdown to determine flucuations in older adults' hand functioning abilities, as studies, not related to disease, have found changes in hand functioning of individuals within the same decade of age (Fillenbaum, 1985; Shiffman, 1992; Spector et al., 1987). Fillenbaum (1985) measured the instrumental activities of daily living (IADLs) in older adults by using the OMFAQ ADL section. Secondary analyses were conducted on 4,137 subjects, 65 years old and above, based on data from three previous studies: a random sample of 1,609 population-based older adults from "The Well-Being of Older People in Cleveland, Ohio" (Comptroller General of the U.S., 1977); a random sample of 998 community-based older adults from Durham, North Carolina (Blazer, 1978); and a statewide random sample of 1,530 older adults from Virginia (Virgina Center on Aging, 1980). The three samples of subjects were grouped into five age subgroups, by five-year intervals, from 65 to to 85 years of age. Fillenbaum (1985) found that a decline in functional ability tended to occur between 80 and 84 years of age. Additionally, Fillenbaum concluded that an older adult's functioning frequently declined five years earlier than the 80 to 84 age group, suggesting that 75 to 79 year olds also show a decline in functional ability. Similar to Fillenbaum , Spector et al. (1987) investigated the functional status of older adults, 65 years and above, using ADL scales. Spector et al. (1987) examined the relationship between ADL and IADL based on secondary analyses from three previous studies: "Study of the Well-Being of Older People in Cleveland, Ohio", (Cleveland-GAO) (Comptroller General of the U.S., 1977); the "Alternative Health Services Project" (Georgia-Medicaid) (Skellie, Mobley, & Coan, 1982); and the "Section 222 Homemaker-Day Care Study" (Weissert, Wan, & Livieratos, 1980). The Cleveland-GAO sample consisted of 1,609 population- based older adults, the highest functioning group of the three studies. The Georgia-Medicaid sample consisted of 1,141 lower functioning older adults who had either applied for nursing home admission within the last month, needed skilled nursing home care, or had been previously institutionalized. The Homemaker-Day Care sample consisted of 1,755 dysfunctional older adults, requiring homemaker and day care services. Spector et al. (1987) analyzed two IADL items (shopping and transportation) from the OARS questionnaire and four ADL items (bathing, dressing, transferring, and feeding) from "The Index of ADL" (Katz, 1963). After analyzing the association between level of function and age from the Cleveland- GOA study, Spector et al. (1987) found over 80% of older adults aged 65-75 were independent in their IADL and ADL and 70% of those aged 75-79 were independent in their IADL-ADL. The proportion decreases to 50% of 85-89 year olds were independent in their ADL's and declining to 25% of 90 year olds and above were independent in both functional levels. Thus, as older adults increased 19 in age, their functional independence in ADL's and IADL's decreased within the five-year age groupings. Shiffman (1992) studied the effects of aging on hand function in a nonrandom sample of 20 women and 20 men divided into four age groups. There were five women and five men in each group with age determining which group the subjects were placed: 77 to 87 years; 67 to 74 years; 46 to 64 years; and 24 to 40 years. The hand function of subjects was measured by testing their strength, using the Jamar dynamometer and B&L pinch gauge, and performance on a functional task (pouring a glass of milk and removing money from a wallet). Shiffman (1992) found that hand function diminished slowly after age 65; however, differences in performance were most apparent after age 75, in the 77 to 87 year age group. The evidence of varied hand functioning abilities in older adults within the same decade of age, and both Fillenbaum (1985) and Spector et al.'s (1987) use of grouping older adults into five year intervals, illustrates the need for grouping older adults in five-year increments for the Jebsen-Taylor Hand Function Test (Jebsen et al., 1969). In addition, there is evidence of varied hand function in younger adults. Agnew & Maas (1982) investigated whether Jebsen et al.'s (1969) reported normative values were valid on 20-59 year olds' speed of performance on the Jebsen test. They subdivided the sample by collecting data on five age groups in ten-year intervals: 1) 16-25; 2) 26-35; 3) 36-45; 4) 46-55; and 5) 56-65. These researchers found significant differences in scores on four of Jebsen's subtests, when using a 2-factor analysis that included age and sex (Agnew & Maas, 1982). Based on their results, they suggested that Jebsen et al.'s (1969) single set of norms for 20-59 year olds was not sufficient and recommended that the norms be 20 replaced with at least five age groupings. Thus, variation in hand function in both younger adults and older adults within the same decade of age has been demonstrated. What is now needed is an analysis of hand function in older adults between the ages of 65-94 years, grouped into five-year intervals, as researchers have found differences in hand functioning abilities in older adults whose ages are within the same decade (Fillenbaum, 1985; Hackel, 1992; Shiffman, 1992; Spector, 1987). In addition, health care workers are seeing an increase in their elderly clientele, as well as an increase in the number of 80 and 90 year olds who are candidates for therapy. This study is also important because it includes an ADL and IADL assessment, which is valuable information to occupational therapists and other allied health professionals. Previous researchers who have measured hand function with the Jebsen test have not included the use of an ADL assessement, except for Lynch and Bridle (1989); however, their sample size was small (n = 18) and IADL items were not included in the questionnaire. Measurement of Hand Function with the Jebsen Test Jebsen-Taylor Hand Function Test (Jebsen et al., 1969) includes seven subtests which are used to obtain an overall evaluation of an individual's hand function. The subtests consist of writing, simulated page turning, moving small objects, simulated feeding, stacking checkers, picking up light cans, and picking up heavy cans (Jebsen et al., 1969); see Appendix A. Occupational therapists use the Jebsen test, as it can quickly and efficiently evaluate an individual's impairment in hand function. In addition, it has be proven reliable and valid. Test-retest reliability for the Jebsen test ranges from r = .60 to r = .99 (Jebsen et al., 1969). The reliability of the Jebsen test was further investigated by Stem (1991), who studied the stability of the Jebsen test for the dominant hand across three test sessions. There were 20 right-handed female subjects ranging in age from 18-33 years. After the subject's performance was assessed using five different orthotic conditions or hand splints, each test four days apart, Stem (1991) found five of the seven subtests had strong test-retest reliability. The writing and simulated feeding subtests; however, demonstrated less stable results. One possible reason for the increased variability in both of these subtests is that they use a tool (i.e., pen and spoon) which allows subjects to refine their grasp pattern over repeated sessions (Stem, 1991). In addition to reliability, the validity of the Jebsen test has been demonstrated by Lynch & Bridle (1989). They found the Jebsen test was correlated with the Klein-Bell ADL Scale (Klein & Bell, 1982), which measures activities of daily living. The Klein-Bell scale consists of six self-care areas: mobility; dressing; emergency communications; elimination; bathing/hygiene; and eating (Lynch & Bridle, 1989). A low score on the Jebsen test indicates good hand function, whereas a low score on the Klein-Bell scale indicates poor performance, thus a negative correlation between scores on the two scales would be expected. Lynch & Bridle (1989) assessed the functional status of 18 subjects on both the Jebsen test and Klein-Bell test. The subjects were between 26-70 years old with a mean age was 52 years (Lynch & Bridle, 1989). These authors reported strong, negative correlations between the Jebsen test and three subscales of the Klein-Bell that reflect hand function: dressing (r = -.69, p < .01); bathing/hygiene (r = -.57, p < .01); and eating (r = -.45, p < .05). The correlations between these two instruments provides evidence that the Jebsen test is correlated to an individual's functional hand use in activities of daily living (ADL). 22 Correlation of Hand Function with Functional Status Hand function is an important necessity of life, as it is essential for engagement in the activities of daily living (ADL) and the instrumental activities of daily living (IADL). ADL, which includes dressing, grooming, eating, and IADL, which are activities requiring complex cognitive processing such as money management and transportation, are an occupational therapist's primary focus of treatment. One main concern of occupational therapists is to maximize an individual's self-sufficiency in both ADL's and IADL's. Both types of ADL require hand mobility, which leads to the question of whether an older adult's hand function, as measured on the Jebsen test correlates with functional ability. Previous studies have found that poor manual dexterity is correlated with dependency in older adults (Falconer et al., 1991; Ostwald et al., 1989; Williams et al., 1982); however, functional status was based on the subject's living site and not by an ADL measure. These three studies classified an older adults dependency based upon his or her living site. Nursing home placement would be on one end of a continuum, living independently would be at the other end, whereas, requiring assistance at home would be an intermediate level. Functional assessments are valuable as they help an occupational therapist determine an individual's ADL status and safety awareness. Occupational therapists need to assess a client's functional status early in the acute phase of a hospital stay, in order to help specify the appropiate treatment and to help document progress. In addition, as occupational therapists are moving towards community settings, functional assessments could be administered as a preventive measure, in prolonging or postponing dependency in older adults; for example, older adults who attend senior centers and health care clinics. The importance of early 23 assessment of older adults is that it can enable the occupational therapist to help maintain or improve the independence of the older adult, which should improve the latter's quality of life. The OARS Multidimensional Functional Assessment Questionnaire (OMFAQ) (Duke University, 1988) is a widely-used instrument in geriatric studies. It is divided into two sections. Part A provides an overall assessment of an older adult's functioning, whereas Part B assesses the services utilized by an older adult. Part A of the OMFAQ assesses an older adult's functioning through self- report within five categories: social; economic; mental health; physical health; and self-care (Fillenbaum & Sinyer, 1981). However, the self-care questionnaire is the only dimension which will be administered, as it is the only dimension which assesses ADL's. The self-care section of the OMFAQ has 14 questions which include level of independence in both physical activities of daily living (PADL) or ADL and IADL. It can be administered within 5 minutes and provides occupational therapists with a quick and efficient method for assessing an individual's functional ability. The PADL section consists of questions regarding eating, dressing, bathing, toileting, bed mobility, and ambulation. The IADL section consists of seven items: telephone use; shopping; travel; housework; meal prepartion; taking own medication; and handling personal finances. According to Fillenbaum & Smyer (1981), the self-care part of the OMFAQ has demonstrated reliability. Interrater reliability was examined; eleven raters rescored 30 questionnaires (r = .87, p < .001). Test-retest reliability was computed on a subsample of 30 subjects reinterviewed after an interval of five weeks, gave similar responses to their ADL and IADL status: IADL (r = .71, p < .001); ADL 24 (r = .82, g <.001) (Fillenbaum, 1978). In addition to being reliable, the OMFAQ ADL is also valid. Criterion validity was investigated, physical therapists, after a period of 2 years, reassessed the ADL status of 30 subjects by personal observation. Their observations closely agreed with the item-based summary ratings of the questionnaires ( Tau = .83, r = .89, g < .001). It is important that occupational therapists begin integrating ADL assessments into all settings where older adults reside, as studies have found that impaired functioning ability, as measured by an ADL scale, is predictive of mortality (Fillenbaum, 1985; Reuben, Siu, & Kimpau, 1992; Spector, Katz, Murphy, & Fulton, 1987; Williams, Gaylord, & Gerrity, 1994). Fillenbaum (1985) examined the validity of using a brief IADL questionnaire to assess an older adult's functional ability. The questionnaire was adapted from the OMFAQ IADL section and consists of five questions instead of seven (excluding telephone use and taking medicine). The respondents described their functional level as being either with or without some help. Based on data from the Cleveland sample (N= 1,609; 65 years and above), Fillenbaum (1985) was able to assess the predictive validity of subjects' IADL, as the Cleveland study provides longitudinal information for the entire sample (Comptroller General of the U.S., 1977). He found that subjects between the age of 65 to 74 years old who required assistance in all five of their IADL's had a deathrate of 27%. Subjects between the age of 65 to 74 who required assistance in three IADL's had a deathrate of 9%, compared to 2% of those 65 to 74 years old who performed all their IADL’ s independently. The death rate of these subjects who required assistance in performing all five of their activities was 5.4 times greater than that of the entire sample. In comparison, for the entire sample a death rate of 0.4 was found for subjects who could perform all their activities. Spector et al. (1987) examined the hierarchical relationship between ADL and IADL by analyzing three previous studies on the elderly: the Cleveland-GOA, the Georgia-Medicaid, and The Homemaker-Day Care study. Their functional measure was based on two IADL items (shopping and transportation) and four ADL's (bathing, dressing, transferring, and feeding). The Cleveland-GOA sample was the highest functioning group; 23% of the subjects needed assistance with shopping or transportation, compared to the other two studies where 90% and 80% of the subjects required help with shopping and transportation. On the other hand, the Homemaker-Day Care sample consisted of older adults with the lowest functional level of the three studies. Fifty-nine percent of the older adults were dependent in bathing, compared to 40% in the Georgia-Medicaid sample and 10% in the Cleveland-GOA sample. When analyzing subjects' functional status with their death rate within a one year time frame, they found that in all three studies, older adults who showed dependency on both ADL and IADL measures had a significantly higher mortality rate (p < .05), as compared to older adults who were less dependent (Spector et al., 1987). The researchers also examined the risk of hospitalization among the older adults' functional levels from the Cleveland-GOA study. Spector et al. (1987) found that following a one year time span, an older adult’ s risk of hospitalization increases as his or her independence in a functional activity decreases. They found that only 18% of older adults who were independent were hospitalized, compared to 27% of older adults dependent in their IADL's were hospitalized. To an even greater extent, 37% of older adults dependent in both ADL and IADL were hospitalized. Additionally, they found the difference between the risk of 26 hospitalization for independent older adults and older adults dependent in their IADL’ s was statistically significant (p = .01). Reuben et al. (1992) examined the function of older adults in predicting mortality and nursing home placement. Their longitudinal study consisted of 149 older adults from one of four sites: a senior citizens housing unit, two ambulatory- based geriatric practices, and a board-and-care facility. The Katz ADL is one self- report instrument which the researchers used to measure the function of the subjects which includes: bathing; dressing; toileting; transferring; maintaining continence; and feeding (Katz, 1970). After follow-up, averaging 22 months, 11% of the subjects had died and 5% were placed in a nursing home. Reuben et al. (1992) found through logistic regression that impaired ADL's were predictive of both mortality and institutionalization (r = -1.09 and r = -.73; p < .05). Williams et al. (1994) examined the functional ability of 1,286 community- based older adults and investigated the usefulness of older adults' manual ability and IADL status in predicting mortality and hospitalization. This prospective study began in October, 1986, and ended in June, 1988. Subjects were reassessed two years later, beginning in October, 1988, and ending in September, 1990. Manual ability was measured by the Williams Board, renamed the Timed Manual Performance (TMP) test, which consists of 27 separate measurements: opening a variety of nine doors, closing eight doors, dominant hand skills from five subtests of the Jebsen test (excluding picking up light cans and heavy cans), and nondominant hand skills from Jebsen’ s five subtests (Williams, Gaylord, & McGaghie, 1990). All 27 measurements were timed in seconds and summed to produce a total score. The other variable, IADL, was measured by using the Instrumental Activities of Daily Living Scale (IADLS). This self-report measure examines six 27 areas: shopping, preparing meals, doing heavy housework or yard work, cutting toenails, using the telephone, and managing money (National Health Interview Survey, 1984). Subjects' scores for each of the six IADL's were computed as follows: one point if subject had some difficulty in performance, two points if there was considerable difficulty and three points if they were totally unable to perform. Thus, a low score of 0 indicates excellent IADL status and a high score of 18 indicates completely unable to perform any IADL tasks. Williams et al. (1994) found subjects who took longer to complete the TMP test were more likely to die during the two-year follow-up period. Subjects who took the longest (more than 224.6 seconds) to complete the 27-item TMP test had approximately a 2.5 higher mortality rate compared to subjects who completed the TMP the fastest (less than or equal to 142.0 seconds). Williams et al. (1994) also found that subjects' scores on the IADLS predicted mortality over the two-year follow-up period after controlling for age. Subjects who scored 6 had a 1.95 higher mortality rate compared to subjects who scored 0. Subjects who scored 12 had a 3.79 higher mortality rate, on average. In addition to subjects' IADL predicting mortality, IADL also predicted hospitalization after controlling for age. Subjects who scored 6 were 1.69 times as likely to be hospitalized than subjects who scored 0. Subjects who had scores of 12 were 2.85 times as likely to be hospitalized, on average. Because hand use is believed to be correlated with functional status, it would be benefical if the Jebsen test proved to be correlated with the OMFAQ ADL section,as then an occupational therapist would have two options for assessment. 28 Research Questions In this study, hand function of older adults age (65-98) years was measured with the Jebsen test (see Appendix A). In addition, the scores from the Jebsen test were correlated with the OMFAQ ADL scores. The research questions of this study were: (1) Are there sex differences in hand function ability among older adults?; (2) How do the six subgroups (65-69, 70-74, 75-79, 80-84, 85-89, 90-98) differ from one another with respect to hand function?; (3) Is there an interaction between sex and age group in older adults' performance on the Jebsen test?; and (4) Across all subtests, does hand function correlate with the OMFAQ ADL assessment? Relevance to Occupational Therapy Obtaining normative data on older adults' performances on the Jebsen test, when the values are grouped into five-year increments, should increase an occupa tional therapist's knowledge base on the relationship of age to hand function. In a clinical setting these data should help guide treatment programs, as they provide occupational therapists with obtainable goals in older adults' hand dexterity. If the Jebsen test and OMFAQ are highly correlated, then this study would provide further data to support hand function as measured by the Jebsen test, as a predictor of an older adult's functional level. The Jebsen test; however, could never replace an ADL evaluation given by an occupational therapist, as the performance of an activity is most important. By observing an ADL activity, occupational therapists can see what is interfering. Whether it be a cognitive or perceptual impairment, range of motion limitation, impaired coordination or fine motor ability, OT's can improve or compensate for a client's limitations. 2'J Chapter III METHODOLOGY Subjects The initial objective was to recruit older adults (N = 238) between 65 and 94 years of age to participate in this study; however, older adults above 94 years were included due to the unavailability of older adults between 90-94 years of age. Participants were recruited from Angelus Plaza, a federally-funded housing project in downtown Los Angeles and Jewish Home For the Aging (JHA), a board-and- care nursing facility in the San Fernando Valley. Fliers were distributed throughout Angelus Plaza and placed underneath the residents' doors. Fliers stated that the participants understand English or Spanish and be willing to volunteer 15 minutes of their time. JHA participants were randomly selected from a computer printout of all the residents. The Spanish version of the questionnaire was translated by a colleague of Spanish descent and was then reread and edited by a Latino doctor, who worked in the Health Clinic at Angelus Plaza. The ethnicity of the participants was diverse, similar to the population in Los Angeles. The City Planning Department (1991) reported that the citywide population in 1990 consisted of 40.2% Hispanic/Latino/a, 37.3% Caucasian, 17.0% African-American, 9.2% Asian, and 0.6% Native American. Neither Jebsen et al. (1969) nor Hackel et al. (1992) indicated the ethnicities of their subjects. However, the ethnicity of the participants was merely being used to characterize this sample; it was not a focus of this study. An effect size was computed based upon Hackel et al.'s (1992) data on mean subtest scores on the Jebsen test. Effect size was calculated by randomly choosing 14 subtest scores of two different decade groups for each gender. The difference of the means of the subtests were divided by the average of the standard 30 deviations. Using the data, an effect size of .74 was found for males and .65 for females, using a two-tailed test at the .05 alpha level with 80% power. According to Cohen (1977), a sample size of 16 male subjects and 20 female subjects was needed, based on that effect size. Thus, a sample size of 16-20 males and 20 females in each five-year age interval was used. There were 98 male participants and 104 female participants (n — 202) from Angelus Plaza. Only four males and four females in their 90's were recruited; however, due to the low population of 90 year olds residing at Angelus Plaza. Participants from JHA (n = 36) were between 90 and 98 years of age; 20 female (ages 65 to 94) and 16 male (ages 65 to 98) participants. Both sexes were equally divided into six different age groupings: 1) 65-69; 2) 70-74; 3) 75-79; 4) 80-84; 5) 85-89; and 6) 90-98. Instruments The Jebsen-Taylor Hand Function Test (Jebsen, et al., 1969) measures speed of performance in simulating everyday activities, broadly assessing an individual's functional dexterity. All subtests were used to obtain an overall evaluation of an individual's manual ability. The subtests consist of writing, card turning, picking up small objects, simulated feeding, stacking checkers, picking up light cans, and picking up heavy cans. Speed was measured in seconds; a high score on the Jebsen test indicates impaired hand function. Both dominant and nondominant hands were tested and the test was completed within ten to fifteen minutes. The OARS Multidimensional Functional Assessment Questionnaire (OMFAQ) (Duke University, 1988) assesses overall functioning in older adults through self-report. The instrument assesses five areas: social; economic; mental health; physical health; and self-care. Self-care, however, was the only dimension 31 which was evaluated, as this study was specifically interested in investigating the relationship between hand functioning ability and functional ADL status in older adults. The self-care section includes questions on both activities of daily living (ADL) and instrumental activities of daily living (IADL). There are seven ADL questions which cover five areas: eating; dressing; bathing; toileting; bed mobility; and mobility. There are also seven IADL questions which include: telephone use; travel; shopping; preparing meals; housework; taking medication; and money management (See Appendix B). Participants responded to the questions by choosing: without help= 2, with some help= 1, or unable= 0. A high score on the OMFAQ ADL section indicates functional independence. Experimental Procedure After signing an informed consent form (Appendix D), participants completed a brief questionnaire (See Appendix B). The questionnaire included 15 questions which were available in both English and Spanish, and took approximately five minutes to complete. A medical student and a receptionist, both Latino/a and long-term employees of the Health Clinic at Angelus Plaza, helped with translation and communication. They provided assistance recruiting Latino/a participants, helped to answer questions when participants filled out questionnaires, and helped with verbal instruction during the Jebsen test. The questions included: 1) basic demographic information such as age, sex, marital status, years of schooling, and race; 2) previous occupation worked; 3) seven ADL questions; and 4) seven questions on IADL's. The Jebsen test was administered according to the standardized procedure (See Appendix A), although the writing subtest was administered last instead of first, on occasion, due to a participant's unpleasant response to writing with his or her nondominant hand. Additionally, during the writing subtest, two participants 32 used a magnifying glass, four participants copied the sentences with enlarged letters, and two participants had their sentences read aloud, on account of visual impairment. The Jebsen test was administered to the Angelus Plaza population in various locations; the majority of participants were tested in the Health Clinic. T n addition, the test was administered in residents' apartments, lobby areas, the nutrition room, the library, and outside on the patio. The JHA population was also tested in a number of locations: conference room, lounge area, office area, and a few in the residents' rooms. Participants began each of the seven subtests with their nondominant hand, followed by their dominant hand. Their performance was timed with a stopwatch. Instructions were given in Spanish for those who preferred or indicated Spanish as a primary language. These participants were given two sentences to copy in Spanish for the writing subtest, along with a Spanish translation of the OARS (See Appendix C). Data Analysis This study measured hand function of older adults between 65 and 98 years old with the Jebsen test and investigated how their performance in hand function correlated with their ADL status. Descriptive statistics were used to characterize the sample with respect to the demographic variables and to compute mean subtest scores and standard deviations. A 2x6 analysis of variance (ANOYA) was computed to test for main effects for sex, main effects for age group, and the interaction between age group and sex. One expectation was that main effects for age group should be found; participants who were in their 60's and 70's were expected to perform faster on several of the subtests compared to the participants who were in their 80's and 90's. Scheffe"post hoc tests were used to determine how the six subgroups (65- 69, 70-74, 75-79, 80-84, 85-89, 90-98) differed from one another with respect to hand function. Scheffe post hoc tests were also used to determine how the four subgroups arranged by decade (65-69, 70-79, 80-89, 90-99) differed ffom one another with respect to hand function. T-tests compared hand function by 90 year old participants from Angelus Plaza to 90 year old participants ffom JHA and right-handed participants to left-handed participants ffom the entire sample. When the null hypothesis that variances were equal was rejected, the Welch t-test was used (Afifi & Azen, 1979). Pearson correlation coefficients were used to calculate relationships between the participants' IADL and ADL scores with their scores on the Jebsen test. Scores of IADL, ADL, and both IADL and ADL together were each correlated to the fourteen subtest scores. In addition, analysis of covariance (ANCOVA) was computed to examine if the participants’ IADL or ADL status contributed to their speed of performance on the Jebsen test. The summed scores of the IADL's and ADL’ s were the covariates; interactions between IADL x age group and ADL x age group were examined. One expectation was that a high score on the ADL questionnaire should correlate with a low score on the Jebsen test, as functional independence should signify good hand function. In addition, a low score on the ADL questionnaire should correlate with a high score on the Jebsen test, as dependency should signify poor hand function. All tests were two-tailed at alpha = .05 level of significance. 34 Chapter IV RESEARCH FINDINGS Characteristics of the Sample Older adults (N = 238) between 65 and 98 years of age, residing at Angelus Plaza and Jewish Home For the Aging (JHA) participated in this study. Angelus Plaza participants (n = 202) were tested after signing informed consent, between June 1993 and July 1993. JHA participants (n = 36) included only 90 year olds, as only eight participants in their 90's were available from Angelus Plaza. Testing occurred between October 1993 and January 1994. The characteristics of the sample are presented in Table 1. The number of male and female participants was almost equal, 52.1% female (M = 79.62 years, SD = 8.62) and 47.9% male (M = 79.22 years, SD = 9.42). The mean ages for males and females in the six age subgroups are shown in Table 2. Almost half of the subjects (43.8%) were widowed, over one-fifth (23.2%) were married, and for five cases marital status was missing. The majority of the participants, almost half (46.6%) were Caucasian. Over a fifth (23.5%) of the participants were high school graduates. Income for over one-third of the sample (35.5%) was between S600-S700; the JHA participants (n = 36) had an income of $0, as most of their money was donated to the home. Income data were missing for 21 cases. The majority of the subjects (96.2%) were right-handed. The percentage of left-handed participants (3.8%) in this study was below the average percentage (10%) of left-handers in the population (Myers, 1986). The smaller percentage of left-handed participants in this study could be attributed from society's pressures against left-handedness when these participants were growing up. The means and standard deviations for age in each of the six subgroups are shown in Table 2. The percentages of the educational levels and ethnicities represented by the six age subgroups are shown in Tables 3 and 4. Over half (54.6%) of the 90-98-year-old participants only had a junior high education. Over three-fourths (88.6%) of the 90-98-year-old participants were Caucasian. Table 5 shows the instrumental activities of daily living (IADL) and activities of daily living (ADL) capacity of the Angelus Plaza participants (n = 202) broken down by age group. A total score of 28 points indicated independent functioning or excellent/good IADL/ADL capacity, 25 to 27 points was mildly impaired, 24 points was moderately impaired, and 23 points or less was severely impaired. The 80-84-year-old participants' IADL/ADL capacity was the most severely impaired group at 16.7%. The IADL/ADL capacity for the Jewish Home for the Aging (JHA) participants (n = 36) are shown in Table 6. A total score of 26 points was calculated, omitting the meal preparation question, as all their meals are prepared and served by the dietary employees. Over half (52.7%) of JHA participants in their 90's were severely impaired in their IADL/ADL functioning. Table 1 Demographic Characteristics of the Sample (N = 238) Characteristic n % Sex Male 114 47.9 Female 124 52.1 Marital Status Married 54 23.2 Single 38 16.3 Divorced 39 16.7 Widowed 102 43.8 Ethnicity Caucasian 111 46.6 Hispanic 50 21.0 Asian 43 18.1 African-American 30 12.6 Pacific Islander 01 0.4 Other 03 1.3 Education < 7 yrs of school 22 9.2 7-9th grade 45 18.9 10-11th grade 31 13.0 High school graduate 56 23.5 1-3 yrs college 41 17.2 College graduate 24 10.1 Post graduate PhD., M. A. 19 8.0 77 T able 1. continued Characteristic n % Income per month 0-$ 1 0 0 02 0.9 $100-$200 02 0.9 $300 - $400 05 2.3 $400 - $500 09 4.1 $500-$600 35 16.1 $600 - $700 77 35.5 $700 - $800 14 6.5 $800 or more 37 17.1 JHA participants, 36 16.6 donated money to home Hand Right-handed 229 96.2 Left-handed 09 3.8 Table 2 Mean Age and SD for the Six Age Subgroups Males Females Age group mean SD mean SD 65-69 66.60 1.31 66.60 1.23 70-74 71.70 1.26 72.15 1.53 75-79 76.20 1.40 77.10 1.55 80-84 82.12 1.54 81.85 1.46 85-89 86.82 1.51 86.40 1.31 90-98 93.45 3.00 91.29 1.16 T able 3 Educational Level for the Six Age Subgroups 65-69 70-74 Education % (n = 40) (n = 40) < 7yrs school 15.0 5.0 7-9th grade 12.5 0.0 10-11th grade 15.0 15.0 High school graduate 17.5 35.0 1 -3yrs college 15.0 22.5 College graduate 10.0 15.0 Post graduate 15.0 7.5 Age group 75-79 80-84 85-89 90-98 (n = 40) (n = 37) (n = 37) (n = 44) 5.0 8.1 10.8 11.4 20.0 16.2 18.9 43.2 7.5 16.2 13.5 11.4 20.0 24.3 27.0 18.2 20.0 21.6 16.2 9.1 17.5 5.4 8.1 4.5 10.0 8.1 5.4 2.3 Table 4 Ethnicity Percentages for the Six Age Subgroups 65-69 70-74 75-79 80-84 85-89 90-98 (n = 40) (n = 40) (n = 40) (n= 3 7 ) (n = 3 7) (n = 4L Ithnicity % Caucasian 17.5 35.0 30.0 54.1 51.4 88.6 Hispanic 22.5 22.5 30.0 27.0 18.9 6.8 Asian 45.0 25.0 20.0 10.8 8.1 2.3 African-American 15.0 15.0 17.5 8.1 18.9 2.3 Table 5 IADL & ADL Capacity of Angelus Plaza Participants by Age Group Age Group (n = 40) (n = 40) 65-69 70-74 IADL/ADL Capacity n % n % Excellent/Good 25 62.5 30 75.0 Mildly impaired 12 30.0 06 15.0 Moderately impaired 00 00.0 01 2.5 Severely impaired 03 7.5 03 7.5 (n = 40) (n = 37) (n = 37) (n = 8) 75-79 80'-84 85-89 90-98 n % n % n % n % 23 57.5 23 63.9 20 54.1 06 75.0 11 27.5 07 19.4 13 35.1 01 12.5 03 7.5 00 00.0 01 2.7 00 00.0 03 7.5 06 16.7 03 8.1 01 12.5 Table 6 IADL & ADL Capacity of JHA Participants Age Group (n — 36) 90-98 IADL/ADL Caoacitv n % Excellent/Good 06 16.7 Mildly impaired 09 25.0 Moderately impaired 02 5.6 Severely impaired 19 52.7 Note, Excellent/Good = performs all IADL/ADL independently Mildly impaired = needs assistance with one to three I ADL/ADL Moderately impaired = needs assistance with four IADL/ADL Severely impaired = needs assistance with five or more IADL/ADL -1 0 Mean subtest scores and standard deviations for both sexes in each age group are shown in Table 7. As one can see, performance became slower with age; however, the pattern was broken for the 65-69, 85-89, and 90-98 year age groups on a few of the subtests. Both male and female participants in the 65-69 year age group performed faster in eight subtests compared to the 70-74 year age group. Female participants in the 85-89 year age group performed faster on nine subtests compared to females in the 80-84 year age group. Females in their 90's were faster on five subtests compared to females in the 85-89 year age group. Likewise, males in their 90's were faster on three subtests compared to males in the 85-89 year age group. Results of the 2x6 analysis of variance found main effects for age group in 12 of the 14 subtests, except "moving, light objects" and "moving, heavy objects" using the dominant hand (see Table 8). The three subtests which showed the highest age group effects were: "writing" F (5,226) = 9.13, g = .005; "small objects" F (5,226) = 10.06, g = .005; and "checkers" F (5,226) - 13.95, g - .005, using the nondominant hand. Although, main effects for age group were found in many of the subtests, the percent of variance was small. The highest variance was for the "checkers" subtest, using the nondominant hand, explaining 23% of the variance. There were no main effects for sex (see Table 9). There was only one sex/age group interaction (see Table 10); it was for "card turning", using the dominant hand F (1, 226) = 2.47, g = .04 (refer to Figure 4). As one can see, the mean subtest scores of the females were slower until the 80-84 year age group, then the average performance for the 85-89 and 90-98 year age group was faster. The mean subtest scores of the males were slower in speed from the 70-74 year age group until the 85-89 year age group, then the hand performance of the 90 year olds was faster. Means and standard deviations on the Jebsen subtest scores for each age group are shown in Table 11. Sex was collapsed into each age group because there were no main effects for sex and only one sex/age group interaction. As one can see, the linear pattern of a decrease in hand function as an older adult increases in age was more closely followed compared to the mean subtest scores when sex was not collapsed. However, in all subtests, participants in the 65-69 year age group had slower hand function speeds compared to the participants in the 70-74 year age group. In addition, participants in the 90-98 year age group were faster in speed of performance compared to the 85-89 year age group in five subtests. Table 11 also shows the results of a one-way ANOVA with Scheffe post hoc tests. For the dominant hand, participants 65-69 years old performed significantly faster compared to the 90-98 year group in only one subtest, "checkers" (p < .05). Participants in the 70-74 year age group were significantly faster compared to the 90-98 year age group in "writing," "small objects," "simulated feeding," and "checkers" (p < .05). For the nondominant hand, participants in the 65-69, 70-74, 75-79, and 80- 84 year age groups were significantly faster compared to the 90-98 year age group in "writing," "small objects," "simulated feeding," and "checkers" (p < .05) (see Figures 1,2,3). Participants in the 65-69 and 70-74 year age groups performed significantly faster compared to the 85-89 year age group in "writing" and "light objects" (p < .05). In addition, 85-89-year-old participants performed significantly faster compared to the 90-98-year-old participants in "checkers" (p < .05). Table 7 42 Mean ± SD Hand Performance Subtest Scores, by Age Group and Sex (in seconds) Age Group 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 90 - 98 (n = 20) (n = 20) (n = 20) (n=17) (n=17) (n = 20) Males Dominant Hand Subtest Write 23.8 ± 15.6 19.6 ± 07.4 22.6 ± 09.4 25.0 ± 11.8 36.4 ± 12.3 41.0 ± 21.7 Cards 06.0 ±01.9 05.2 ±01.1 05.5 ± 01.3 06.5 ±02.1 08.1 ±04.5 07.2 ± 02.4 Obj. 07.7 ±01.2 07.8 ±01.3 08.4 ±01.9 08.3 ±02.1 10.3 ± 02.7 12.6 ±06.2 Feed 09.1 ±02.2 08.6 ±01.5 09.5 ± 02.6 10.6 ± 04.6 10.9 ±03.2 21.9 ± 27.1 Check 05.2 ±01.3 05.3 ±01.3 06.5 ± 02.3 06.0 ± 02.2 07.3 ±02.1 08.4 ± 02.4 Ltobj. 04.6 ± 00.8 04.4 ±01.1 04.5 ± 00.9 04.7 ±01.0 05.5 ±02.1 05.5 ±01.1 Hvyobj. 04.5 ± 00.8 04.4 ±01.1 04.5 ± 00.9 04.7 ± 00.9 05.4 ±01.6 05.5 ±01.1 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 90 - 98 (n = 20) (n = 20) (n = 20) (n = 20) (n = 20) (n = 24) Females Dominant Hand Subtest Write 29.4 ±39.3 19.3 ±08.0 26.0 Cards 06.2 ±03,6 06.3 ±01.1 06.8 Obj. 09.7 ± 09.5 07.7 ±01.3 09.6 Feed 12.0 ± 16.1 08.6 ±01.2 11.3 Check 06.4 ±05.1 05.4 ±01.2 06.2 Ltobj. 05.3 ± 04.4 04.1 ±00.7 05.3 Hvyobj. 05.3 ±03.4 04.5 ±01.2 05.5 ± 18.7 29.8 ± 30.0 25.9 ± 09.1 30.8 ± 13.3 ± 02.5 08.1 ± 03.3 06.9 ± 02.6 06.0 ± 01.4 ± 04.3 09.3 ± 05.5 09.1 ± 02.8 09.8 ± 02.3 ± 07.9 11.2 ± 06.5 13.9 ± 19.0 15.0 ± 12.7 ± 02.6 06.4 ± 04.2 06.7 ± 01.5 07.8 ± 02.9 ± 02.0 05.6 ± 03.8 05.2 ± 01.0 05.0 ± 00.9 ± 03.3 05.9 ± 04.1 05.5 ± 01.3 05.1 ± 00.8 Note. Obj. = small objects Ltobj. = light objects Hvyobj. = heavy objects Table 7, continued 43 Age Group 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 90 - 98 (n = 20) (n = 20) (n = 20) (n=17) (n=17) (n = 20) Males Nondominant Hand Subtest Write 47.5 ± 28.9 39.5 ± 13.9 52.5 ±20.8 42.2 ± 18.1 78.8 ±35.3 83.9 ±40.2 Cards 06.7 ±01.3 06.2 ±01.8 06.5 ±01.9 06.5 ± 02.2 09.4 ±05.4 08.6 ± 03.6 Obj. 08.7 ±02.3 08.1 ±01.2 08.9 ±01.9 09.0 ± 03.8 10.8 ±02.1 12.9 ±04.6 Feed 10.7 ±03.2 10.3 ±01.9 12.4 ± 04.5 12.4 ±05.9 15.8 ±08.0 23.1 ±22.4 Check 05.9 ±01.9 05.8 ±01.0 06.6 ± 02.0 06.8 ±01.3 08.2 ± 02.3 09.9 ± 03.0 Ltobj. 04.6 ± 00.6 04.3 ± 00.6 04.8 ±01.0 04.9 ± 00.9 06.1 ±01.8 05.6 ±01.4 Hvyobj. 04.7 ± 00.9 04.5 ± 00.6 04.9 ±01.0 05.0 ±01.0 05.8 ±01.6 06.0 ±01.5 (n = 20) (n = 20) (n = 20) (n = 20) (n = 20) (n = 24) 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 90 - 98 Females Nondominant Hand Subtest Write 48.9 ± 16.8 49.7 ± 30.0 55.2 ±20.9 60.9 ± 45.9 65.4 ±34.2 73.3 ±26.8 Cards 06.9 ±02.2 07.1 ±01.6 08.3 ±02.8 08.1 ±04.1 07.9 ± 04.0 07.6 ±01.8 Obj. 08.1 ±01.8 08.1 ±01.7 09.5 ± 03.2 10.0 ± 04.2 09.8 ± 02.4 11.6 ±04.4 Feed 11.2 ±03,9 10.7 ± 02.9 13.7 ± 12.0 12.9 ±05.5 16.8 ± 17.3 24.1 ±22.0 Check 06.2 ±01.8 05.9 ±01.4 07.0 ± 02.5 06.8 ± 02.6 07.1 ±01.9 08.9 ±03.7 Ltobj. 04.7 ±01.2 04.6 ±01.0 05.1 ±01.1 05.7 ± 02.5 05.3 ±00.9 05.3 ±01.2 Hvyobj. 05.0 ±01.2 04.8 ± 00.9 05.2 ±01.2 06.0 ±03.3 05.7 ± 01.0 05.7 ±01.2 Note. Obj. = small objects Ltobj. = light objects Hvyobj. = heavy objects Table 8 M ain E ffects for A g e G roup fo r P erfo rm a n ce on the J eb sen T est Subtest F ratio Dominant Hand Writing 3.70 Card Turning 3.04 Small Objects 3.22 Simulated Feeding 3.49 Checkers 5.52 Moving, light objects 1.56 Moving, heavy objects 1.17 Nondominant Hand Writing 9.13 Card Turning 2.60 Small Objects 10.06 Simulated Feeding 7.08 Checkers 13.95 Moving, light objects 5.46 Moving, heavy objects 4.89 df p-value 5,226 .003 .07 5,226 .01 .06 5,226 .007 .06 5,226 .004 .07 5,226 .0001 .11 5,226 .17 .03 5,226 .32 .03 5,226 .0001 .16 5,226 .03 .05 5,226 . .0001 .17 5,226 .0001 .14 5,226 .0001 .23 5,226 .0001 .10 5,226 .0003 .10 T ab le 9 M a in E ffe c ts fo r S ex fo r P e r fo r m a n c e on th e J e b se n T e s t Subtest F ratio df p-value Dominant Hand Writing 0.24 1,226 .63 Card Turning 0.71 1,226 .40 Small Objects 0.00 1,226 .99 Simulated Feeding 0.02 1,226 .88 Checkers 0.00 1,226 .97 Moving, light objects 0.71 1,226 .41 Moving, heavy objects 3.02 1,226 .09 Fondominant Hand Writing 0.16 1,226 .70 Card Turning 0.71 1,226 .41 Small Objects 0.31 1,226 .58 Simulated Feeding 0.23 1,226 .63 Checkers 0.47 1,226 .50 Moving, light objects 0.08 1,226 .78 Moving, heavy objects 1.51 1,226 .22 46 T able 10 In te ra ctio n B etw een S ex an d A g e G ro u p fo r P e r fo r m a n c e on th e J eb sen T e st Subtest F ratio df p-value Dominant Hand Writing 1.50 5,226 .20 Card Turning 2.47 5,226 .04 Small Objects 1.88 5,226 .10 Simulated Feeding 1.01 5,226 .42 Checkers 0.66 5,226 .66 Moving, light objects 0.87 5,226 .51 Moving, heavy objects 1.00 5,226 .42 [ondominant Hand Writing 1.66 5,226 .15 Card Turning 2.15 5,226 .07 Small Objects 0.88 5,226 .50 Simulated Feeding 0.01 5,226 1.00 Checkers 0.85 5,226 .52 Moving, light objects 1.65 5,226 .15 Moving, heavy objects 0.93 5,226 .46 Table 11 47 Mean ± SD for Hand Performance Subtest Scores, by Age Group (in seconds) Age Group 65-69 70-74 75-79 80-84 85-89 90-94 (n = 40) (n = 40) (n = 40) (n = 37) (n = 37) (n = 44) Dominant Hand Subtest Write 26.6 ±29.6 19.4 ±07.6“ 1 24.3 ± 14.7 27.6 ±23.3 30,7 ± 11.8 35.4 ± 18.1 Cards 06.1 ±02.8 05.7 ±01.2 06.1 ±02.1 07.3 ± 02.9 07.5 ± 03.6 06.5 ± 02.0 Obj. 08.7 ±06.7 07.7 ±01.3“ 09.0 ± 03.4 08.9 ± 04.3 09.6 ± 02.8 11.0 ±04.7 Feed 10.5 ± 11.5 08.6 ±01.3“ 10.4 ± 05.9 11.0 ±05.6 12.6 ± 14.0 18.1 ±20.6 Check 05.8 ± 03.7“ 05.3 ±01.2“ 06.3 ± 02.4 06.2 ±03.4 07.0 ±01.8 08.1 ±02.7 Ltobj. 04.9 ±03.1 04.2 ± 00.9 04.9 ±01.6 05.2 ± 02.9 05.4 ±01.6 05.2 ±01.0 Hvyobj. 04.9 ± 02.4 04.5 ±01.1 05.0 ±02.4 05.4 ±03.1 05.4 ±01.4 05.3 ±01.0 Nondominant Hand Subtest Write 48.2±23.4“ '6 4.6 ±23.6“ ' 53.9 ± 20.6“ 52.3 ± 36.7“ 71.6 ±34.9 78.1 ±33.6 Cards 06.8 ±01.8 06.6 ±01.7 07.4 ± 02.5 07.4 ±03.4 08.6 ± 04.7 08.0 ±02.8 Obj. 08.4 ±02.1“ 08.1 ±01.4“ 09.2 ± 02.6“ 09.5 ± 04.0“ 10.2 ±02.3 12.2 ± 04.5 Feed 11.0 ±03.5" 10.5 ± 02.4“ 13.1 ±09.0“ 12.7 ±05.6“ 16.3 ± 13.6 23.6 ±21.9 Check 06.0 ±01.8“ 05.9 ±01.2“ 06.8 ± 02.2“ 06.8 ±02.1“ 07.6 ±02.1" 09.4 ± 03.4 Ltobj. 04.7 ± 00.9* 4.5 ± 00.8“ ' 04.9 ±01.1 05.3 ± 02.0 05.7 ±01.4 05.4 ±01.3 Hvyobj. 04.8 ±01.1 4.6 ± 00.8“ ’ 05.1 ±01.1 05.7 ± 02.6 05.7 ±01.3 05.8 ±01.3 "Significantly different from 90-98 year age group, p < .05. b Significantly different from 85-89 year age group, p < .05. Note. Obj. = small objects, Ltobj. = light objects Hvyobj. = heavy objects 4X Data were next analyzed by dividing the age groups by decade (65-69, 70-79, 80-90, and 90-99 years). Mean subtest scores and standard deviations for both sexes in each of the four subgroups are shown in Table 12. As one can see, there was a decrease in speed of performance with age; however, the pattern was broken for both sexes, as participants in their 70's and 90's performed faster on several of the subtests compared to their younger counterparts, participants in their 60's and 80's. Compared to male participants in their 60's, male participants in their 70's performed faster on six subtests and performed equally as fast on four subtests. Likewise, female participants in their 70's performed faster on six subtests compared to female participants in their 60's. Male participants in their 90's performed faster on one subtest compared to male participants in their 80's. Female participants in their 90's performed faster on six subtests compared to female participants in their 80's. Results of the 2x6 analysis of variance for the main effects for age group by decade were found in 12 out of the 14 subtests; exceptions were "moving, light objects" and moving, heavy objects" using the dominant hand (see Table 13). The three subtests which showed the highest age group effects were: "simulated feeding" F (3,230) = 10.98, p = .0001; "small objects" F (3,230) = 15.33, P = .0001; and "checkers" F (3,230) = 20.95, p = .0001. There were no main effects for sex (see Table 14). Likewise, there were no sex x age group interactions (see Table 15 ). The results for the main effects for age group and main effects for sex were similar to those obtained with 2x6 ANOVA’ s computed on data arranged into five year age groupings. There was one difference, however, for the sex x age group interaction from analyses of the five- year age intervals compared to analyses on the ten-year age intervals. When data 4'J were grouped by five-year intervals, there was one significant sex x age group interaction, "card turning" using the dominant hand (F (5,226) = 2.47, p = .04), compared to no significant interactions when data were grouped by ten-year age intervals. Table 16 shows the results of a one-way ANOVA with Scheffe^post hoc tests. Sex was collapsed into each of the four age subgroups, because there were no main effects for sex nor any sex/age group interactions. For the dominant hand, participants in their 60's and 70's performed significantly faster compared to participants in their 90's in "small objects," "simulated feeding," and "checkers" (p < .05). Participants in their 80’ s were significantly faster compared to participants in their 90's in "checkers" (p < .05). In addition, participants in their 70's were significantly faster compared to participants in their 80’ s in "card turning" (p < .05). For the nondominant hand, participants in their 60’ s, 70's, and 80's were significantly faster compared to the participants in their 90's in "writing," "small objects," "simulated feeding," and "checkers." In addition, participants in their 70's performed faster compared to participants in both their 80's and 90f s in "light objects" and "heavy objects" (p < .05). With the dominant hand, there was not a linear pattern of a decrease in hand performance as a function of age. That is, participants in their 70’ s performed faster in six out of the seven subtests compared to participants in their 60's. In addition, participants in their 90's performed faster in three subtests compared to participants in their 80's. For performance with the nondominant hand, a linear pattern of a decrease in speed of performance with age was more closely followed. The pattern was only broken in four subtests: participants in their 90's performed faster in one subtest and performed with the same speed in one subtest compared to participants in their 80's. In addition, participants in their 60's performed at the same speed in two subtests compared to participants in their 70's. When comparing 90-year-old participants from Angelus Plaza to 90-year- old participants from JHA, the 90-year-old participants from Angelus Plaza were significantly faster in six of the fourteen subtests: "writing;" "small objects;" "simulated feeding;" "stacking checkers," using the dominant hand, and "simulated feeding;" "moving heavy objects," using the nondominant hand (see Table 17). This result was expected as the Angelus Plaza residents were more self-sufficient in their IADL's compared to the JHA residents; unlike Angelus Plaza, JHA provides laundry service, housekeeping, and meal preparation, unless requested otherwise. The subtest "small objects" showed the greatest difference in performance between the two 90-year-old samples (Welch t (39.1) = -3.35, P<01). When comparing right-handed participants (n = 229) to left-handed participants (n = 9), there were no statistically significant differences in speed of performance in all fourteen subtests (see Table 18). Table 19 shows the results of Pearson correlations between mean subtest scores from the Jebsen test compared to the IADL and ADL status of the participants. There were statistically significant correlations between all subtests in the Jebsen test and instrumental activities of daily living (IADL), activities of daily living (ADL), and the sum total of IADL and ADL. It is noteworthy that the significant correlations were partially due to the large sample size, thus the power of these tests was small. Another finding relating to the participants' IADL and ADL status was that participants in the 65-69 year age group were slightly more dependent in their 51 IADL (23.14), ADL (24.19), and IADL + ADL (47.33) mean summed scores compared to the 70-74-year-old participants IADL (23.08), ADL (25.95), and IADL + ADL (49.03) mean summed scores. Recall that a high score on the OMFAQ ADL questionnaire indicates independence, whereas a lower score indicates dependence. Likewise, participants in the 80-84 year age group were more dependent in their functional status compared to those participants in the 85-89 year age group. Mean summed scores for the 80-84-year-old participants were; IADL (22.41), ADL (23.44), and IADL + ADL (45.85). Mean summed scores for the 85-89 year old participants were; IADL (23.76), ADL (25.44), and IADL + ADL (49.20). Summed scores for the 90-98 year age group were not compared with the 85-89 year age group due to the unequal sample sizes. However, the results of a 2x6 analysis of variance for the dependent variable ADL found statistically significant main effects for age group F (5,226) = 6.29, p = .0002. Scheffe'post hoc tests revealed that participants in the 90-98 year age group were more independent in their ADL status compared to participants in the 65-69, 70-74, 75-79, and 85-89 year age groups. This high functional independence of these 90-year-old participants relates to their faster hand function speeds on several of the subtests compared to the 85-89-year-old participants. These data reveal an active 90-year-old population, less active or dependent 60-year-old population, and a 85-89-year-old population that was more dependent compared to the 80-84-year-old population. Table 20 shows the results of ANCOVA using mean summed ADL scores as the covariate. After controlling for ADL, significant main effects for age group were found in two subtests. Additionally, after controlling for age group, ADL was still significantly significant for main effects in six subtests, thus predicting 52 the participants' speed of performance on the Jebsen subtests. The highest effect was for "heavy objects," using the dominant hand F (3,234) = 15.95, p = .0001. Also, on the "simulated feeding" subtest, when participants used their nondominant hand there was an interaction between age group and mean summed ADL scores F (3,234) = 7.27, p = .008; see Figure 9. As one can see, participants in the 70-74 and 80-84 year age groups performed faster on the subtest and were more independent in their ADL status compared to participants in the 65-69 and 75-79 year age groups. Using mean summed IADL scores as the covariate, an ANCOVA found that after controlling for IADL, effects of age group were still significantly significant in seven out of the fourteen subtests (see Table 21). Thus, the participants' age group impacted the participants' speed of performance on the Jebsen subtests. In addition, an interaction between age group and IADL scores were found in four subtests, see Figures 5, 6, 7, 8. The highest interaction was on "simulated feeding," using the nondominant hand F (3,199) = 8.57, p = .004. As one can see, participants in the 70-74 year age group performed faster and were more independent in their IADL status compared to participants in the 65-69 year age group. Likewise, participants in the 80-84 year age group performed faster, but were less independent in their IADL status, compared to the participants in the 75- 79 year age group. Table 12 53 Mean ± SD Hand Performance Subtest Scores for Decade, by Sex (in seconds) Age Group 65-69 70-79 80 -89 90-99 (n = 20) (n = 40) (n = 34) (n = 20) Males Dominant Hand Subtest Write 23.8 ± 15.6 21.1 Cards 06.0 ±01.9 05.4 Obj. 07.7 ±01.2 08.1 Feed 09.1 ±02.2 09.1 Check 05.2 ±01.3 05.9 Ltobj. 04.6 ±00.8 04.4 Hvyobj. 04.5 ± 00.8 04.5 ± 08.5 30.7 ± 13.2 41.0 ± 21.7 ± 01.2 07.3 ± 03.5 07.2 ± 02.4 ± 01.7 09.3 ± 02.6 12.6 06.2 ± 02.1 10.8 ± 04.0 21.9 ± 27.1 ± 01.9 06.6 ± 02.6 08.4 02.4 ± 01.0 05.1 ± 01.7 05.5 i 01.1 01.0 05.0 ± 01.4 05.5 01.1 65-69 70-79 80-89 90-99 (n = 20) (n = 40) (n = 40) (n = 24) Females Dominant Hand Subtest Write 29.4 ± 39.3 22.6 ± 14.6 27.8 ±22.0 30.8 ± 13.3 Cards 06.2 ±03.6 06.5 ± 02.0 07.5 ±03.0 06.0 ±01.4 Obj. 09.7 ±09.5 08.6 ±03.3 09.2 ± 04.3 09.8 ± 02.3 Feed 12.0 ± 16.1 10.0 ±05.7 12.6 ± 14.1 15.0 ± 12.7 Check 06.4 ±05.1 05.8 ± 02.0 06.5 ±03.1 07.8 ±02.9 Ltobj. 05.3 ± 04.4 04.7 ±01.6 05.4 ± 02.8 05.0 ±00.9 Hvyobj. 05.3 ± 03.6 05.0 ±02.5 05.7 ±03.0 05.1 ±00.8 Note. Obj. = small objects Ltobj, = light objects Hvyobj. = heavy objects Table 12, continued Age Group 65-69 70-79 80 -89 90-99 (n = 20) (n = 40) (n = 34) N D I I to o Males Nondominant Subtest Write 47.5 ± 29.0 46.0 ± 18.6 60.5 ±33.3 83.9 ±40.2 Cards 06.7 ±01.3 06.3 ±01.8 08.0 ± 04.3 08.6 ±03.6 Obj. 08.7 ±02.3 08.5 ±01.6 09.9 ±03.2 12.9 ±04.6 Feed 10.7 ±03.2 11.4 ±03.6 14.1 ±07.1 23.1 ±22.4 Check 05.9 ±01.9 06.2 ±01.6 07.5 ± 02.0 09.9 ±03.0 Ltobj. 04.6 ±00.6 04.6 ± 00.9 05.5 ±01.5 05.6 ±01.4 Hvyobj. 04.7 ±00.9 04.7 ±00.8 05.4 ±01.4 06.0 ±01.5 65-69 70-79 80-89 90-99 Females Nondominant Subtest (n = 20) (n = 40) (n = 40) (n = 24) Write 48.9 ± 16.8 52.5 ±25.7 63.2 ±40.0 73.3 ± 26.8 Cards 06.9 ± 02.2 07.7 ± 02.3 08.0 ±04.0 07.6 ±01.8 Obj. 08.1 ±01.8 08.8 ±02.6 09.9 ±03.4 11.6 ±04.4 Feed 11.2 ±03.9 12.2 ±08.8 14.8 ± 12.8 24.1 ±22.0 Check 06.2 ±01.8 06.5 ±02.1 06.9 ± 02.2 08.9 ±03.7 Ltobj, 04.7 ±01.2 04.8 ±01.1 05.5 ±01.9 05.3 ±01.2 Hvyobj. 05.0 ±01.2 05.0± 01.1 05.8 ± 02.4 05.7 ±01.2 Note. Obj. = small objects Ltobj. = light objects Hvyobj. = heavy objects T able 13 M ain E ffects for A g e G ro u p by D eca d e fo r P er fo rm a n ce on th e J eb sen T est Subtest Dominant Hand Writing Card Turning Small Objects Simulated Feeding Checkers Moving, light objects Moving, heavy objects Nondominant Hand Writing Card Turning Small Objects Simulated Feeding Checkers Moving, light objects Moving, heavy objects F ratio df p-value R2 5.47 3,230 .001 .06 4.78 3,230 .003 .06 4.51 3,230 .004 .05 5.64 3,230 .001 .06 7.78 3,230 .0001 .09 1.81 3,230 .15 .02 1.54 3,230 .21 .02 10.94 3,230 .0001 .12 2.62 3,230 .05 .03 15.33 3,230 .0001 .16 10.98 3,230 .0001 .13 20.95 3,230 .0001 .21 7.42 3,230 .0001 .09 7.40 3,230 .0001 .09 T able 14 M a in E ffects fo r S ex b y D ec a d e fo r P e r fo r m a n c e on th e J e b se n T est Subtest F ratio df p-value Dominant Hand Writing 0.33 1,230 .57 Card Turning 0.05 1,230 .83 Small Objects 0.03 1,230 .86 Simulated Feeding 0.04 1,230 .84 Checkers 0.05 1,230 .83 Moving, light objects 0.49 1,230 .48 Moving, heavy objects 2.03 1,230 .16 Nondominant Hand Writing 0.00 1,230 1.00 Card Turning 0.11 1,230 .74 Small Objects 0.94 1,230 .33 Simulated Feeding 0.22 1,230 .64 Checkers 0.56 1,230 .46 Moving, light objects 0.00 1,230 .99 Moving, heavy objects 0.65 1,230 .42 57 Table 15 In tera ctio n B etw een Sex and A g e G roup fo r P erfo rm a n ce on th e J eb sen T est Subtest F ratio d£ p-val Dominant Hand Writing 1.42 3,230 .24 Card Turning 2.13 3,230 .10 Small Objects 2.54 3,230 .06 Simulated Feeding 1.61 3,230 .19 Checkers 0.80 3,230 .49 Moving, light objects 0.58 3,230 .63 Moving, heavy objects 0.87 3,230 .46 Nondominant Hand Writing 0.78 3,230 .51 Card Turning 1.62 3,230 .19 Small Objects 0.73 3,230 .53 Simulated Feeding 0.00 3,230 .10 Checkers 1.07 3,230 .36 Moving, light objects 0.57 3,230 .64 Moving, heavy objects 0.67 3,230 .57 Table 16 Mean ± Hand Performance Subtest Scores, By Age Group Decade (in seconds) Age Group (n = 40) (n = 80) (n = 74) (n = 44) 65-69 70-79 80 -89 90-99 Dominant Hand Subtest Write 26.6 ± 29.6 21.9± 11.9 29.2 ± 18.4 35.4 ± 18.1 Cards 06.1 ±02.8 05.9 ±01.76 07.4 ±03.2 06.5 ± 02.0 Obj. 08.7 ±06.7° 08.3 ± 02.6" 09.3 ± 03.6 11.0 ±04.7 Feed 10,5 ± 11.5° 09.5 ± 04.3" 11.8 ± 10.7 18.1 ±20.6 Check 05.8 ± 03.7" 05.8 ±02.0" 06.6 ± 02.7" 08.1 ±02.7 Ltobj. 04.9 ± 03. r 04.6 ±01.3 05.3 ± 02.3 05.2 ±01.0 Hvyobj. 04.9 ± 02.4 04.7 ±01.9 05.4 ± 02.4 05.3 ±01.0 Nondominant Hand Subtest Write 48.2 ±23.4" 49.3 ± 22.5“ 61.9 ±36.9" 78.1 ±33.6 Cards 06.8 ±01.8 07.0 ± 02.2 08.0 ±04.1 08.0 ± 02.8 Obj. 08.4 ±02.1° 08.7 ± 02.2" 09.9 ± 03.3" 12.2 ±04.5 Feed 11.0 ± 03.5" 11.8 ±06.7" 14.5 ± 10.5" 23.6 ±21.9 Check 06.0 ±01.8" 06.4 ±01.8" 07.2 ±02.1" 09.4 ± 03.4 Ltobj. 04.7 ± 00.9* 04.7 ± 01.0"’ 6 05.5 ±01.7 05.4 ±01.3 Hvyobj. 04.8 ± 01.1"'6 04.8 ±01.0"’ 6 05.7 ± 02.0 05.8 ±01.3 " Significantly different from 90-99 year age group, p < .05. b Significantly different from 80-89 year age group, p < .05. Note. Ltobj = light objects, Hvyobj = heavy objects Obj. = small objects Table 17 Differences in Hand Performance Between 90yr Olds from Angelus Plaza vs JHA Angelus Plaza JHA fn = 8) (n = 36J t 2 Dominant Hand Subtest Write 26.0 ± 06.7 37.5 ± 19.2 -2.91* <.01 Cards 06.0 ± 00.8 06.6 ±02.1 1.43 <.16 Sm Obj. 08.4 ±01.4 11.6 ±05.0 -3.35* <.01 Feed 10.2 ±03.5 19.9 ±22.4 -2.46* <.05 Check 06.2 ±01.3 08.5 ± 02.8 -2.26** <.05 Ltobj. 05.1 ±00.8 05.3 ±01.0 -0.43 <.68 Hvyobj. 04.8 ± 00.7 05.4 ±01.0 -1.45 <.16 Nondominant Hand Subtest Write 62.2 ±21.0 81.7 ± 35.0 -1.50 <.15 Cards 07.6 ±01.7 08.1 ±03.0 -0.48 <.64 Obj. 11.3 ±04.8 12.4 ±04.5 -0,63 <.54 Feed 12.8 ±03.3 26.0 ±23.6 -3.22* <.01 Check 07.7 ±03.2 09.8 ±03.4 -1.60 <.12 Ltobj. 04.9 ±01.2 05.6 ±01.3 -1.31 <.20 Hvyobj. 05.3 ± 00.7 06.0 ±01.4 -2.14* <.05 *Welch t-test used, unequal variances, p < .05. **T-test used, p > .05. Note. Obj. = small objects Ltobj. = light objects Hvyobj. = heavy objects Table 18 60 Mean ± SD Performance of Right-Handed Participants Compared to that of Left-Handed Participants Right Left t £ (N = 229) (n-9) Dominant Hand Subtest Write 26.3 ± 16.2 57.2 ±52.1 -1.78* <.12 Cards 06.4 ± 02.3 09.0 ± 05.8 -1.31* <.23 Sm Obj. 08.8 ± 02.9 17.8 ± 15.1 -1.77* <.12 Feed 11.5 ± 11.3 23.8 ±24.0 -1.53 <.17 Check 06.3 ± 02.4 10.3 ± 07.3 -1.62 <.15 Ltobj. 04.9 ±01.6 07.9 ± 06.4 -1.42* <.20 Hvyobj. 04.9 ±01.6 08.2 ±06.2 -1.55 <.16 Nondominant Hand Subtest Write 58.9 ±31.2 44.7 ±42.1 1.32 <.19 Cards 07.5 ± 03.0 06.4 ±01.8 1.14 <.26 Sm Obj. 09.7 ±03.3 09.0 ±04.1 0.61 <.55 Feed 14.8 ±12.7 12.9 ±07.0 0.45 <.66 Check 07.2 ± 02.6 06.3 ±01.6 0.94 <.35 Ltobj. 05.1 ±01.4 04.9 ±01.3 0.45 <.66 Hvyobj. 05.3 ±01.5 05.0 ±01.2 0.62 <.54 * Welch t-test used for unequal variances, g < .05. Note. Obj. = small objects Ltobj. = light objects Hvyobj. = heavy objects Table 19 Correlation Between Instrumental Activities of Daily Living (IADL), Activities of Daily Living (ADL) and Jebsen Subtest Scores (n=203) (n=238) (n=203) Subtest IADL ADL IADL+ADL Dominant Hand Writing -0.22* -0.28** -0.23* Card Turning -0.31** -0.28** -0.31** Small Objects -0.27** -0.38** -0.31** Simulated Feeding -0.29** -0.25** -0.29** Checkers -0.26** -0.44** -0.32** Light Objects -0.29** -0.34** -0.33** Heavy Objects -0.40** -0.40** -0.43** Nondominant Hand Writing -0.21* -0.22** -0.19* Card Turning -0.26** -0.21** -0.24** Small Objects -0.40** -0.41** -0.42** Simulated Feeding -0.31** -0.32** -0.28** Checkers -0.29** -0.40** -0.30** Light Objects -0.32** -0.32** -0.33** Heavy Objects -0.37** -0.39** -0.39** Note. The higher the score on each Jebsen subtest, the slower the speed. Higher scores equals independence for ADL questions from OMFAQ. p < .01* T ab le 2 0 62 A ctivities o f D aily L iving (A D L ) as a C ovariate Subtest Variable df R2 Dominant Hand Writing age group adlsum agegrp*adlsum 0.10 2.29 0.01 (3,234) .76 .13 .91 Card Turning age group adlsum agegrp*adlsum 0.25 5.03 0.39 (3,234) .62 .03 .53 Small Objects age group adlsum agegrp* adlsum 0.15 5.01 0.05 (3,234) .70 .03 .83 Simulated Feeding age group adlsum agegrp*adlsum 0.14 1.48 0.03 (3,234) .70 .22 .86 Checkers age group adlsum agegrp*adlsum 1.93 3.40 1.23 (3,234) .17 .07 .27 Light Objects age group adlsum agegrp*adlsum I.43 II.02 1.60 (3,234) .23 .001 .21 Heavy Objects age group adlsum agegrp*adlsum 1.95 15.95 2.10 (3,234) .16 .0001 .15 .10 .09 ,16 .09 .24 .12 .17 63 Table 20, continued Subtest Nondominant Hand Writing Card Turning Small Objects Simulated Feeding Checkers Light Objects Heavy Objects Variable age group adlsum agegrp*adlsum age group adlsum agegrp*adlsum age group adlsum agegrp*adlsum age group adlsum agegrp*adlsum age group adlsum agegrp*adlsum age group adlsum agegrp* adlsum age group adlsum agegrp*adlsum F df 1.05 (3,234) 0.24 0.36 0.51 (3,234) 0.48 0.28 1.19 (3,234) 3.62 0.42 9.28 (3,234) 0.38 7.27 5.03 (3,234) 0.61 2.97 0.02 (3,234) 4.95 0.20 0.00 (3,234) 6.72 0.05 E R2 .31 .15 .62 .55 .48 .07 .49 .60 .27 .26 .06 .52 .003 .20 .54 .008 .03 .30 .44 .09 .88 .15 .03 .66 .95 .20 .01 .83 Subtest Dominant Hand Writing Card Turning Small Objects Simulated Feeding Checkers Light Objects Heavy Objects 64 Table 21 IADL as a Covariate with A ge Group Variable F df E R2 age group 0.67 (3,199) .41 .06 ladlsum 0.39 .53 agegrp*Iadlsum 0.46 .50 age group 2.49 (3,199) .12 .13 ladlsum 0.32 .57 agegrp*Iadlsum 1.76 .19 age group 1.91 (3,199) .17 .09 ladlsum 0.16 .69 agegrp* ladlsum 1.65 .20 age group 8.54 (3,199) .004 .13 ladlsum 0.73 .39 agegrp*ladlsum 8.01 .005 age group 4.10 (3,199) .04 .10 ladlsum 0.02 .88 agegrp*Iadlsum 3.30 .07 age group 3.07 (3,199) .08 .11 ladlsum 0.05 .82 agegrp*Iadlsutn 2.64 .11 age group 4.44 (3,199) .04 .18 ladlsum 0.38 .54 agegrp* ladlsum 3.97 .05 Table 21, continued Subtest Nondominant Hand Writing Card Turning Small Objects Simulated Feeding Checkers Light Objects Heavy Objects Variable age group ladlsum agegrp* ladlsum age group ladlsum agegrp*Iadlsum age group ladlsum agegrp*Iadlsum age group ladlsum agegrp*Iadlsum age group ladlsum agegrp* radlsum age group ladlsum agegrp*Iadlsum age group ladlsum agegrp*Iadlsum F d f 0.12 (3,199) 1.50 0.00 2.09 (3,199) 0.15 1.40 9.46 (3,199) 0.00 6.97 10.35 (3,199) 0.70 8.57 0.94 (3,199) 1.44 0.28 4.68 (3,199) 0.07 3.20 4.60 (3,199) 0.32 3.27 E R 2 .73 .10 .22 .96 .15 .10 .69 .24 .002 .25 .98 .009 .002 .17 .40 .004 .33 .16 .23 .60 .03 .17 .79 .08 .03 .19 .57 .07 66 Supplemental Findings Ethnicity / race. For the dominant hand, main effects for ethnicity were found; there was a significant difference in speed of performance for the "writing" subtest F (3,330) = 4.52, p = .004. However, ethnicity only accounted for 5.6% of all the variance in this "wiiting" subtest. Scheffe'post hoc tests revealed that Asian participants were significantly slower in writing compared to the Latino/a participants (p < .05). Similarly, for the "writing" subtest using the nondominant hand, there was a significant difference in speed of performance among the ethnicities F (3,330) = 4.03, p = .008. A Scheffe test found that the Asian participants were significantly slower in writing compared to the Lationo/a participants (p < .05). Ethnicity, however, only accounted for 5.0% of all the variance for the "writing" subtest with the nondominant hand. Three separate ANOVA's for Caucasians, Latino/a's, and Asians were computed to determine age group effects for each ethnic group, separately. Main effects for age group in Asians were found in six subtests (see Table 24). The subtests which showed the highest age group effects were: "moving, light objects" F (4,38) = 3.78, p = .01; "moving, heavy objects" F (4,38) = 3.59, p = .01, using the dominant hand; "moving, light objects" F (4,38) = 3.72, p = .01; and "moving, heavy objects" F (4,38) = 3.87, p = .01, using the nondominant hand. Main effects for age group in Caucasians were found in five subtests (see Table 22). The highest main effects were found in "writing" with the nondominant hand F (5,105) = 6.98, p = .0001 and in "checkers" with the nondominant hand F (5,105) = 7.30, P = .0001. Main effects for age group in Latino/a's were found in two subtests (see Table 23). The subtest which showed the highest age group effect was "moving, light objects" F (5,44) = 4.37, p = .003. 61 It thus appears as if the main effects for age group resulted from data collected from the Asian and Caucasian participants. The only two subtests in which two ethnic groups contributed to the main effects for age group were the Caucasian and Asian participants on "checkers," using the dominant and nondominant hand. Also, the Latino/a and Asian participants both showed age group effects for "light objects," using the nondominant hand. Educational level. For the dominant hand on the "writing" subtest, main effects were found for the educational level of the participants (F (6,231) = 4.51, p = .0002); educational level accounted for 10.5% of the variance. Scheffe'post hoc tests found that participants with less than seven years of schooling were significantly slower compared to participants with 1-3 years of college or a college degree < fi < -05). For the nondominant hand on the "writing" subtest, main effects were also found for the educational level of the participants (F (6,231) = 9.31, p = .0001); educational level accounted for 19.5% of all the variance in the participants’ speed of performance on the "writing" subtest. Scheffe^comparisons revealed that participants with less than seven years o f schooling were significantly slower compared to participants who completed tenth through eleventh grade, high school graduate participants, participants with partial college training, and participants with post-graduate degrees (p < .05). Participants who completed seventh through ninth grade were also significantly slower compared to participants with partial college training, those with a college degree, and those with post-graduate degrees (p < .05). Analysis of covariance with education as the covariate was computed to determine the impact of educational level on the speed of performance of older f> 8 adults. The results are shown in Table 25. After controlling for educational level, age group was still predictive for older adults' speed of performance on the Jebsen test on ten out of the fourteen subtests. The three highest effects were for "writing," nondominant hand (F (3,234) = 10.40, p = .001); "simulated feeding," nondominant hand (F (3,234) = 11.64, g = .0008); and "checkers," nondominant hand (F (3,234) = 15.43, g = .0001). Table 22 M ain E ffects for A g e G roup for C au casian P articip an ts Subtest F Dominant Hand Writing 5.06 Card Turning 0.92 Small Objects 1.64 Simulated Feeding 1.23 Checkers 3.08 Moving, light objects 1.46 Moving, heavy objects 1.22 Nondominant Hand Writing 6.98 Card Turning 1.14 Small Objects 3.52 Simulated Feeding 2.03 Checkers 7.30 Moving, light objects 1.66 Moving, heavy objects 2.06 df e R2 5,105 .0003 .19 5,105 .47 .04 5,105 .15 .07 5,105 .30 .06 5,105 .01 .13 5,105 .21 .06 5,105 .31 .05 5,105 .0001 .25 5,105 .35 .05 5,105 .006 .14 5,105 .08 .09 5,105 .0001 .26 5,105 .15 .07 5,105 .08 .09 M ain E ffects for A ge G roup for L atino/a P articip an ts Subtest F Dominant Hand Writing 0.77 Card Turning 3.37 Small Objects 0.90 Simulated Feeding 0.55 Checkers 0.97 Moving, light objects 1.25 Moving, heavy objects 0.93 Nondominant Hand Writing 1.19 Card Turning 2.17 Small Objects 1.59 Simulated Feeding 2.21 Checkers 0.46 Moving, light objects 4.37 Moving, heavy objects 1.52 df p R2 5.44 .57 .08 5.44 .01 .28 5.44 .49 .09 5.44 .74 .06 5.44 .44 .10 5.44 .30 .12 5.44 .47 .10 5.44 .33 .12 5.44 .07 .20 5.44 .18 .15 5.44 .07 .20 5.44 .80 .05 5.44 .003 .33 5.44 .20 .15 T able 2 4 M a in E ffe c ts fo r A g e G ro u p fo r A sia n P a r tic ip a n ts Subtest £ df E R2 Dominant Hand Writing 1.22 4,38 .32 .11 Card Turning 0.58 4,38 .68 .06 Small Objects 0.40 4,38 .80 .04 Simulated Feeding 0.83 4,38 .52 .08 Checkers 3.24 4,38 .02 .25 Moving, light objects 3.78 4,38 .01 .28 Moving, heavy objects 3.59 4,38 .01 .27 Nondominant Hand Writing 1.20 4,38 .32 .11 Card Turning 0.47 4,38 .76 .05 Small Objects 0.65 4,38 .63 .06 Simulated Feeding 0.51 4,38 .73 .05 Checkers 3.41 4,38 .02 .26 Moving, light objects 3.72 4,38 .01 .28 Moving, heavy objects 3.87 4,38 .01 .29 Table 25 E d u cation as a C o v a ria te w ith A g e G rou p 72 Subtest Variable df R2 Dominant Hand Writing Card Turning age group 3.25 (3,234) .07 education 1.35 .25 agegrp*educ 0.69 .41 age group 2.29 (3,234) .13 education 0.20 .66 agegrp*educ 0.68 .41 . 1 1 .05 Small Objects age group education agegrp*educ Simulated Feeding age group education agegrp *educ Checkers Light Objects Heavy Objects age group education agegrp*educ age group education agegrp *educ age group education agegrp*educ 5.05 0.04 1.33 5.92 0.19 1.63 5.16 0.08 0.19 0.94 0.24 0.13 0.45 0.62 0.00 (3,234) (3,234) (3,234) (3,234) (3,234) .03 .84 .25 .02 .66 .20 .02 .77 .66 .33 .63 .72 .50 .43 .96 .06 .06 .09 .03 .03 Table 25, continued Subtest Nondominant Hand Writing Card Turning Small Objects Simulated Feeding Checkers Light Objects Heavy Objects Variable F df £ R2 age group 10.40 (3,234) .001 .26 education 3.27 .07 agegrp*educ 1.47 .23 age group 4.15 (3,234) .04 .06 education 0.00 .10 agegrp*educ 1.08 .30 age group 9.21 (3,234) .002 .16 education 0.01 .91 agegrp *educ 0.13 .72 age group 11.64 (3,234) .0008 .12 education 0.40 .53 agegrp* educ 1.92 .17 age group 15.43 (3,234) .0001 .21 education 0.01 .92 agegrp* educ 0.99 .32 age group 7.05 (3,234) .009 .11 education 0.12 .73 agegrp* educ 1.03 .31 age group 5.13 (3,234) .02 .11 education 0.38 .54 agegrp* educ 0.29 .60 Figure 1 "VJriting" Subtest Scores Using Nondominant Hand, as a Function of Age F(5,232) = 8.68, P4..0002 00 c= c o •r-» CJ - P OJ * r * H to s - c a t o ' —■ c to a> e no 3 o ZD 1 ------1 ------1 ------j ------1 ------ 1 ---- 70^4 75 -7 < ] ea^tj g ^ -g t} Age Group (yrs) Figure 2 "Small Objects" Subtest Scores Using Nondominant Hand, as a Function of Age F(5,232) = 9.84, p^.0002 to < D s- o o to to -t-> u o > — > ■ n to 0 c o o 1 - i o) (O to to o to to Q J IS IL w 4 11 -- 8 - - i T 1 ------1 ------! ------ 1 ------j ------ I ---- 7o-7V 75"-7¥ ?S"-^ ?<M 8 Age Group (yrs) mean (SD) "Card Turning" Scores mean "checkers" Scores (in seconds) *l n seconds) F i g u r e 3 "Checkers" Subtest Scores Using Nondominant Hand, as a Function of Age F(5,232) = p^.0002 11. - - B -- 5 r 45-47 70-7V 75-77 B a - f i 7 05-87 70-76 Age Group (yrs) Figure 4 Age Group x Sex Interaction on "Card Turning" Subtest Scores, Using Dominant Hand F(5,226) = 2.47, p s .04 ---------- Fem^ t. II - lo -- 45-47 10-7*/ 75-T7 00-8*/ 65-07 Age Group (yrs) CO CD P O U CO F ig u re 5 Interaction Between Age Group x Mean Summed IADL Scores on "Simulated Feeding," Using Dominant Hand F(3,199) = 8.10, p = .005 76 Cn G •rH T3 0) 0 ) {u . W T 3 T f 0 1 c •P o n j U rH (U 3 W E • H C CO -H o CO c m 0 ) E 6 H - - S&-- m - Mo- 31' I f - K 8 - ■ o- _4 U IADL • tf/IftDL t e - U ■ no’iv eo -e4 85-8? Age Group (yrs) w 0 1 p o o to CO -p C J (1 ) • ■ n W n T 3 0 c o > 1 o > ( U m to 0 1 ffl c o CO c rt 0 1 E Figure 6 Interaction Between Age Group x Mean Summed IADL Scores on "Heavy Objects," Using Dominant Hand F(3,199) = 3.97, p = .047 -------- .LoIA D L * • Hiiadl w It 14 - ll -- lo •- 8 - 6 - 2 iK ■* <*5-m I o-ih ~i;--ft eo-64 Br-eg 9<=-ga Age Group (yrs) C O 0 ) 3 h o o C O ( 0 4 J a Q J - •I-1 C O p T j O G o 1 -t u I- I d J ( 1 3 C O E C O G = -H p C O G ( 0 03 £ Figure 7 77 Interaction Between Age Group x Mean Summed IADL Scores on "Small Objects," Using Nondominant Hand F(3,199) = 6.97, p = .009 --------- ,Lo IAPL * ’ UlIAH (.F-M 10-7Y 15-7/ 8»'S checker. The fourth checker need not stay in place. The item is repeated with the dominant hand. Instructions- "Place your left hand on the table please. When I say 'Go,' use your left hand to stack these checkers on the board in front of you as fast as you can like this, one on top of the other (demonstrate). You may begin with any checker. Do you understand? Ready? Go." Dominant Hand- "Now the same thing with the right hand. Ready? Go." Subtest 6: Large Light Objects Procedure- Five empty No. 303 cans are placed in front of a board which is clamped to the desk in front in front of the subject 5 inches from the front edge of the desk. The cans are spaced 2 inches apart with the open end of the can facing down. Timing is from the work "Go" until the fifth can has been released. The item is repeated with the dominant hand. Instructions- "Place your left hand on the table please. When I say ’ Go,' use your left hand to stand these cans on the board in front of you, like this (demonstrate). Begin with this one (indicate can on extreme left). Do you understand? Ready? Go." Dominant Hand- "Now the same thing with the right hand beginning here (indicate extreme right can). Ready? Go." Subtest 7: Heavy Objects Procedure- Five full (1 pound) No. 303 cans are placed in front of a board clamped to the desk in front of the subject 5 inches from the front edge of the desk. The cans are spaced 2 inches apart. Timing is from the word "Go" until the fifth can has been released. The item is repeated with the dominant hand. Instructions- "Now do the same thing with these heavier cans. Place your left hand on the table. When I say 'Go,' use your left hand to stand these cans on the board as fast as you can. Begin here (indicate can on extreme left). Do you understand? Ready? Go." Dominant Hand- "Now the same thing with your right hand beginning her (indicate can on far right). Ready? Go." APPENDIX B OARS M ULTIDIM ENSIONAL FUNCTIONAL ASSESSM ENT QUESTIONNAIRE (DUKE UNIVERSITY, 1988) y y O A R S M U L T ID IM E N S IO N A L F U N C T IO N A L A S S E S S M E N T Q U E ST IO N N A IR E SE L F -C A R E SE C T IO N ID #____ Birthdate: Month Day Year Sex: M A ge:_____ Marital Status: Married_ Divorced_ Race: Caucasian Hispanic Asian African-American Native American Pacific Islander other (please specify) How far did you go in school? (circle the one number that applies) 7 Less than seven years of school 6 Completed seventh through ninth grade 5 Completed tenth or eleventh grade 4 High school graduate 3 Partial college training, 1-3 years 2 Graduated from 4 year college 1 Post graduate degree (PhD, M.A., M.S.) Previous Occupation (For Pay):___________________ (Unpaid): ___________________ F____ Single, never married Widowed Instrumental ADL 1. Can you use the telephone.... (Circle only one) 2 without help, including looking up numbers and dialing; 1 with some help (can answer phone or dial operator in an emergency, but need a special phone or help in getting the number or dialing); or 0 are you completely unable to use the telephone? 2. Can you get to places out of walking distance... 2 without help (drive your own car, or travel alone on buses, or taxis); 1 with some help (need someone to help you or go with you when traveling); or 0 are you unable to travel unless emergency arrangements are made for a specialized vehicle like an ambulance? 3. Can you go shopping for groceries or clothes (Assuming subject has Transportation)... 2 without help (taking care of all shopping needs yourself, assuming you had transportation); 1 with some help (need someone to go with you on all shopping trips); or 0 are you completely unable to do any shopping? 4. Can you prepare your own meals... 2 without help (plan and cook full meals yourself); 1 with some help (can prepare some things but unable to cook full meals yourself); or 0 are you completely unable to prepare any meals? 5. Can you do your housework... 2 without help (can scrub floors, etc.); 1 with some help (can do light housework but need help with heavy work); or 0 are you completely unable to do any housework? 6. Can you take your own medicine... 2 without help (in the right doses at the right time); 1 with some help (able to take medicine if someone prepares it for you and/or reminds you to take it); or 0 are you completely unable to take your medicines? 7. Can you handle your own money... 2 without help (write checks, pay bills, etc.); 1 with some help (manage day-to-day buying but need help with managing your checkbook and paying your bills); or 0 are you completely unable to handle money? Physical ADL 8. Can you eat... 2 without help (able to feed yourself completely); 1 with some help (need help with cutting, etc.); or 0 are your completely unable to feed yourself? 9. Can you dress and undress yourself... 2 without help (able to pick out clothes, dress and undress yourself) 1 with some help; or 0 are you completely unable to dress and undress yourself? 10. Can you take care of your own appearance, for example combing your hair and and (for men) shaving... 2 without help; 1 with some help; or 0 are you completely unable to maintain your appearance yourself? 11. Can you walk... 2 without help (except from a cane); 1 with some help from a person or with the use of a walker, or crutches, etc.; or 0 are you completely unable to walk? 12. Can you get in and out of bed... 2 without any help or aids; 1 with some help (either from a person or with the aid of some device); or 0 are you totally dependent on someone else to lift you? 13. Can you take a bath or shower... 2 without help; 1 with some help (need help getting in and out of the tub, or need special attachments on the tub); or 0 are you completely unable to bathe yourself? 14. Do you ever have trouble getting to the bathroom on time? 2 No 1 Yes 0 Have a catheter or colostomy (If "YES" ASK a.} a. How often do you wet or soil yourself (either day or night)? 1 Once or twice a week 0 Three times a week or more 15. Is there someone who helps you with such things as shopping, housework, bathing, dressing, and getting around? 1 Yes ] <H 0 No {IF "YES" ASK a. AND b.} a. Who is your major helper? N am e________________ Relationship b. Who else helps you? N am e______ Relationship (CIRCLE THE LETTER WHICH IDENTIFIES YOUR CURRENT MONTHLY INCOME) A. 0 -$ 1 0 0 F. $500 -$600 B. $100-$200 G. $600-$700 C. $200-$300 H. $700-$800 D. $300 - $400 I. $800 or more E. $400-$500 A PPE N D IX C O A R S- SPA N ISH Q U E ST IO N N A IR E O A R S- SPANISH Q UESTIO NN A IR E ID#____ Fecha de Nacimiento: Edad: Sexo: M mes dia ano Estado Civil:___Casado/a Divorciado/a Soltero/a Separado/a Raza: Caucasico Hispano Asiatico Africano Americano Nativo (Indigeno) Isleno Pacifico otro (especifica por favor) Hasta que grado termineste la escuela? (marque lo que aplica) 7 Menos de siete anos de escuela 6 Complete el septimo hasta el noveno 5 Completo el decimo o el onceavo grado 4 Graduado de escuela de segunda ensenanza 3 Trenamiento de colegio partial, 1-3 anos 2 Graduado de un colegio universitario de 4 anos 1 Graduado de un facultad de altos estudious Ocupacion Previo de que gano dinero: Favor de hacer un circulo en la respuesta adecuada para usted: 106 1. Puede usar el telefono... 2 sin ayuda, incluyendo buscando numeros y marcandolos; t con alguna ayuda (puede responder el telefono o marcar la operadora encaso de emergencia, pero necesiata un t telefono especial o ayuda para marcar el numero; o 0 no puede usar totalmente el telefono? 2. Puede caminar largas distancias... 2 sin ayuda (puede ir de viaje solo/a en el autobus, taxi, o manejar su carro); 1 con alguna ayuda (necesita compania cuando viaja), o 0 no puede viajar solamente con un vehfculo de emergencia? 3. Puede ir de compras... 2 sin ayuda (puede ir de compras sin ayuda); 1 con alguna ayuda (necesita compania para ir de compras); o 0 no puede ir de compras? 4. Puede preparar su comida... 2 sin ayuda (planear y cocinar su comida sin ayuda); 1 con alguna ayuda (puede preparar algunas cosas pero no puede cocinar toda la comida); o 0 no puede preparar su comida por completo? 5. Puede hacer su trabajo de casa... 2 sin ayuda (puede limpiar los pisos, y otras cosas); 1 con alguna ayuda (puede hacer trabajo liviano pero no puede hacer trabajo pesado); o 0 no puede hacer su trabajo de casa complentamente? 6. Puede tomar su medicina... 107 2 sin ayuda (en la propia dosis en la propia hora); 1 con alguna ayuda (puede tomar su medicina si alguien se lo prepara o/y tiene alguien que lo recuerde); o 0 no puede tomar su medicina sin ayuda? 7. Puede manejar su dinero... 2 sin ayuda (escribir cheques, pagar cuentas, y otras cosas); 1 con alguna ayuda (manejar sus compras pero necesita ayuda manejando su chequera o pagando sus cuentas); o 0 no puede manejar su dinero? 8. Puede comer... 2 sin ayuda (completamente comer sin ayuda); 1 con alguna ayuda (necesita ayuda cortando la comida y otras cosas); o 0 no puede comer sin ayuda? 9. Puede vestirse o desvestirse... 2 sin ayuda (puede escojer su ropa, vestirse o desvestirse); 1 con alguna ayuda; o 0 no puede vestirse o desvestirse totalmente? 10. Puede usted quedarse de su apararencia, ejemplo penarse (hombre) rasurarse... 2 sin ayuda, 1 con alguna ayuda; o 0 necesita ayuda totalmente? 11. Puede caminar... 2 sin ayuda (excepto ayuda con muletas); 1 con alguna ayuda (de otra persona o con el uso de una caminadora o aparatos); o 0 necesita ayuda totalmente? 12. Puede subir y vajar de la cama... 2 sin ayuda o aparatos; 1 con alguna ayuda (de otra persona o con aparatos); o 0 necesita ayuda al levantarse? 13. Puede banarse o usar la ducha... 2 sin ayuda; 1 con alguna ayuda (necesita ayuda entrando o saliendo del necesita aparatos especiales para la banera); o 0 no puede banarse o usar la ducha? 14. Tiene diflcultades usando el bano a tiempo... 2 No 1 Sf 0 Tiene cateter o colostomia 15. Hay alguien quien le ayude con compras, trabajo de su casa, banarse, vestirse e ir de viaje? 1 s f 0 No { "SI" preguntar a.Y b.} a. Quien le ayudador mayor? Nombre____________ Afinidad____________ b. Quien otro le ayude? Nombre Afinidad |0Y Pongale un circulo a la letra que le coiTesponde asu salario mensul. A. 0-S100 F. $500-$600 B. $100 - $200 G. $600 - $700 C. $200 - $300 H. $700 - $800 D. $300 - $400 I. $800 o mas E .$400 - $500 A P P E N D IX D IN F O R M E D C O N S E N T I N F O R M E D C O N S E N T Title of Project: Hand Function in Older Adults: The Relationship Between Performance on the Jebsen Test and ADL Status Principal Investigator: Lori Max Department: University of Southern California, Department of Occupational Therapy 24-Hour Telephone Number: ('31(f) 306-4313 PURPOSE OF STUDY: You are invited to participate in a study that examines hand use in older adults. I hope to learn about your hand use. In addition, I hope to learn how your activities of daily living (dressing, grooming, bathing, shopping, cooking) are correlated with your hand use. You were invited as a possible participant in this study because you are between 65 to 94 years o f age. PROCEDURE: If you decide to participate, I will give you a questionnaire which includes 15 questions which ask about your ability to care for yourself at home. Next, you will complete the Jebsen-Taylor Hand Function test which includes seven subtests (writing a sentence, card turning, picking up small objects, simulated feeding, stacking checkers, picking up light cans, and picking up 1 lb. can) to both your left and right hand. The procedure will take 15 minutes of your time and will only be given one time. 1 12 RISKS: There are no expected risks from being in this study. You may, however,experience boredom, frustration, and some minor muscle fatigue in your hands. BENEFITS: There is no direct benefit to you from your participation in this study. It is hoped that this study can help improve hand function in older adults, so that they have a better quality of life. ALTERNATIVE TREATMENT: N/A CONFIDENTIALITY STATEMENT: Any information that is obtained in connection with this study and that can be identified with you will remain confidential. OFFER TO ANSWER QUESTIONS: If you have any questions relating to the study, please feel free to ask them at any time. You will be given a copy of this form to keep. COERCION AND WITHDRAWAL STATEMENT: Your decision whether or not to participate will not interfere with your future care in this health clinic. If you decide to participate, you are free to withdraw your consent and to discontinue participation at any time. PHYSICAL INJURY STATEMENT FOR MEDICAL CENTER: If you require medical treatment as a result of physical injury arising from your participation in this study, the financial responsibility for such care will be yours. AGREEMENT: YOUR SIGNATURE INDICATES THAT YOU HAVE DECIDED TO PARTICIPATE HAVING READ THE INFORMATION PROVIDED ABOVE. Signature of Participant Date Signature of Principal Investigator Date ! 14 APPEN D IX E INFO RM ED CO NSEN T- SPANISH TR AN SLA TIO N 115 IN F O R M A C IO N D E C O N S E N T IM IE N T O Titulo del Proyecto: Funcion de la Mano en Personas de Edad Avanzada: La Relacion Entre el Estudio en la Prueba de Jebsen v ADL Status. Principal Investigator: Lori Max Department: Universidad del sur de California Departamento de Terapia Ocunacional. Numero Telefonico Las 24 Horas: (310) 306-4313 PROPOSITO DEL ESTUDIO: Usted esta invitado a participar en este estudio que examina el uso de la mano. Espero aprender acerca del uso de su mano. Ademas espero aprender la relacion que existe entre las actividades diarias (vestirse, arreglarse, banarse, cocinar, ir de compras) y el uso de su mano. Usted esta invitado como un possible participante en este estudio porque su edad esta entre 65- 94 anos de edad. PROCEDIMIENTO: Si usted decide participar, le sera dado un questionario que incluye 15 preguntas, acerca de su habilidad para cuidar de usted mismo. En seguida usted completara la prueba de funcio namiento de la mano de Jebsen-Taylor que incluye siete pruebas pequenas (escribir una oracion, voltear cartas, levantar objetos pequenos, simular estar comiendo acomodar, levantar botes livianos, y un bote de lib de peso) fichas en ambos manos. El procedimiento toma 15 minutos de su tiempo y solo sera dado una sola vez. I 16 RIESGOS: No hay riesgos por participar en este estudio. Sin embargo usted puede presentar aburrimiento, frustracion y una leve fatiga muscular en sus manos. CONFIDENCIALIDAD: Cualquier informacion que sea obtenida en conexion con este estudio siempre sera confidencial. PREGUNTAS: Si usted tiene cualquier dada relacionada con el estudio, por favor sientase libre para preguntar en cualquier momento. Usted recibira una copia de esta forma al final. CAN CELACION: Su decision de participar, no interferira con su cuidado futuro en esta clinica. Si usted decide puede cancelar su participacion en cualquier momento. ACUERDO: SU FIRMA INDICA QUE USTED A DECIDIDO PARTICIPAR HABIENDO LEIDO LA INFORMATION QUE DIMOS ARRIBA. Firma del Participante Fecha Firma del Investigador Principal Fecha INFORMATION TO U SERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer. The q u a lit y of this reproduction is dependent upon the quality o f the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleed through, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Each original is also photographed in one exposure and is included in reduced form at the back of the book. Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6" x 9" black and white photographic prints are available for any photographs or illustrations appearing in this copy for an additional charge. Contact UMI directly to order. A Bell & Howell Information Company 300 North Z eeb Road. Ann Arbor. M l 48106-1346 USA 313/761-4700 800/521-0600 UMI Number: 1376482 Copyright 1994 by Max, Lori Renee All rights reserved. UMI Microform 1376482 Copyright 1995, by UMI Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103

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Asset Metadata

Creator Max, Lori Renee (author)

Core Title Hand function in older adults: the relationship between performance on the Jebsen Test and ADL status

School Graduate School

Degree Master of Arts

Degree Program Occupational Therapy

Degree Conferral Date 1994-12

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag gerontology,health sciences, occupational health and safety,OAI-PMH Harvest

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Hedricks, Cynthia A. (committee chair), Pynoos, Jon (committee member), Zemke, Ruth (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-3001

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Legacy Identifier 1376482-0.pdf

Dmrecord 3001

Document Type Thesis

Rights Max, Lori Renee

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA