This study included 123 old adults, aged 65–95 years, who lived in the community. Inclusion criteria: people who were not institutionalized in social or health centers, with no severe depression according to the Geriatric Depression Scale (GDS) [31]; people who scored 14 and above in the Montreal Cognitive Assessment (MoCA) [32] and were able to understand the study purpose, procedures and to sign the informed consent form. People with chronic illnesses such as high blood pressure, diabetes, osteoporosis, osteoarthritis, or urinary incontinence were included in the study. Most participants were using medications regularly (n = 112, 91.1%). Exclusion criteria: people with severe diseases such as Parkinson’s Disease, Muscular Dystrophy, cancer, Dementia, severe and acute orthopedic limitations affecting function, significant visual impairments and those who were restraint to wheelchair or bed. Participants’ socio-demographic information is included in table 1.
Instruments
Demographic and health status questionnaire, which also included the participants' current medication uptake.
Depression and cognitive status were measured by:
The Geriatric Depression scale, GDS-15 [31]- a self-report with 15 dichotomic items (yes/no questions) for screening depression in older adults. The total score ranges between 0-15 points. A higher score indicates more symptoms of depression. A score of ≥6 indicates a need for a thorough medical/psychiatric assessment. A score of ≥11 is considered a cutoff for indication of depression, and a higher score indicates higher depression severity.
The Montreal Cognitive assessment (MoCA) [32] - this short screening tool profile cognitive status. The areas of examination are visuo-spatial abilities, executive functions, attention, language, short term memory and orientation. Total score is achieved by summing the correct answers, up to a maximum of 30 points. The test is highly sensitive in identifying people with Mild Cognitive Impairment (MCI) (83%-90%) [32]. Based on an 8411 sample, Lu [33] noted that the appropriate cut of score for people without MCI or dementia and without formal education is 13/14. Since our study included participants with and without formal education, the MoCA cutoff score in the current study was set at ≥14.
Assessment of fall risk was based on a questionnaire supported by a clinical examination:
Based on the Israeli Ministry of Health (https://www.health.gov.il/PublicationsFiles/FallPreventionNationalProgram.pdf) [34], fall risk was determined according to two parameters:
(a) A questionnaire – that gathers information about the number of falls during the last year; information about fractions and significant injuries caused by falls; information about walking or stability difficulties.
(b) Time Up and Go test (TUG) [35]– this clinical examination measures mobility and lower extremity functions and is used as a screening tool for fall risk. The subject is requested to get up from a standard chair, without using upper extremity support, and walk three meters ahead in a regular pace. Then turn around and walk back to the chair and sit down. The subject can use a walking aid if needed. Rather that, no physical assistance is given throughout the test, but the examiner follows the participant in order to avoid any falling incidence. The test is carried out twice, but only the second round is scored. The score is the performance time in seconds measured by a stopwatch. Shorter performance time indicates better performance. A performance time longer than 13.5 seconds indicates fall [36].
In the present study, the high-risk group was defined when one of the three occurs: 1-the participant fell twice or more during the last year, 2-the participant had one fall during the last year with a significant injury, 3-the participant had one fall during the last year and a TUG score longer than 13.5 seconds.
Assessment of EF by a self-report and a performance-based assessment:
(a) The Behavior Rating Inventory of Executive Function–Adult Version (BRIEF-A) [37] which screens for possible executive dysfunction and indicates individuals’ awareness of their own self-regulatory functioning. The BRIEF-A assesses everyday behaviors associated with specific domains of EF in adults that are summarized into two index scales: Behavioral Regulation Index (BRI) and Metacognition Index (MC) and a scale reflecting overall functioning (Global Executive Composite [GEC]). The BRI is composed of four scales: Inhibit, Shift, Emotional Control, and Self-Monitor. The MI is composed of five scales: Initiate, Working Memory, Plan/Organize, Task Monitor, and Organization of Materials. Behavior frequency is rated on a Likert Scale ranging from "rare" to "often". Raw scores are transferred into T scores (M=50, SD=10). T scores at or above 65 reflect executive dysfunction.
(b) The medication management subtest of The Alternate Executive Function Performance Test (aEFPT) [16]– this an addition part of the valid performance-based EFPT assessment which measures EF while carrying out a daily task. The subjects’ functional independence level and the amount of help required in these tasks are also recorded. The four original EFPT tasks are: cooking an oatmeal, telephone use, taking medication and paying a bill (Lysack, Neufeld, Mast, MacNeill, & Lichtenberg, 2003). The aEFPT has four additional tasks - similar to the four original tasks but with a novel component to prevent a learning effect from the original form. In the medication management subtest – subjects are asked to sort medications into a 7-day pill sorter instead of taking a medication as requested in the original form [16]. The instruction is to find and sort medicines in a weekly pill sorter. For a successful performance, the subject has to ignore distractors (other bottles) and use prospective memory to follow the specific sorting instructions. In this study the medication management task was chosen since it is a daily common function among older adults, which does not require special facilities (like a stove top for cooking pasta, which is one of the subtests) and is relatively short in time.
The scoring refers to five executive functions: initiation, organizing, sequencing, safety and judgment and completion. Each component is scored on a scale of 0-5 points, according to the level of assistance required in order to complete the task: 5- Doing for participant, 4- physical assistance, 3- verbal direct instruction, 2- gestural guidance, 1- verbal guidance, 0- independent. The score for the full task ranges between 0-25, a higher score indicates more required assistance [16,38].
Daily life measures:
(a) The Barthel Index of ADL [39]– which measures the performance of Basic Activities of Daily Living (BADL) in ten functional domains: eating, bathing, dressing, bowl and bladder control, personal hygiene, transfers, walking on straight surface and stair climbing. Item scores in 5-point intervals (0-15), depending on the level of assistance the participant requires. Total score range is 0-100, where higher score indicates better functional ability.
(b) Instrumental Activities of Daily Living Scale (IADL) [40]- this interview-based functional assessment consists of eight components: telephone use, shopping, food preparing, housekeeping, laundry, transportation use, responsibility for personal medication and money. Item scoring ranges between 0-3 or 0-4, according to the amount of assistance the participant requires. Total score ranges between 0-20, where higher score indicates better functional ability.
(c) The World Health Organization Quality of Life Brief questionnaire (WHOQOL-BREF) [41] – this is an abbreviated 26 item version of the WHOQOL-100 which is the gold standards for measuring quality of life in four domains: physical, psychological, social relationships and environment. Scores in each domain range from 0 to 100. Higher score represent higher quality of life.