JAGS MAY 2008–VOL. 56, NO. 5 LETTERS TO THE EDITOR Queensland, Australia Paul Varghese, MD Princess Alexandra Hospital Woolloongabba Queensland, Australia Richard Wootton, DSc Centre for Online Health University of Queensland Herston Queensland, Australia Len Gray, MD, PhD Academic Unit of Geriatric Medicine University of Queensland Woolloongabba Queensland, Australia ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this letter. Author Contributions: Melinda Martin-Khan: development of study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript. Paul Varghese: advice on study design, interpretation of data from a clinical perspective, and review of manuscript. Richard Wootton: advice on study design and review of manuscript. Len Gray: advice on study concept and design, advice on analysis and interpretation of data, overall direction and extensive review of manuscript. Sponsor’s Role: No sponsors. REFERENCES 1. Martin-Khan M, Varghese P, Wootton R et al. Validation of cognitive assessments conducted by videoconference: A pilot study. J Telemed Telecare 2006; 12(Suppl 3):S3:111. 2. Saligari J, Flicker L, Loh PK et al. The clinical achievements of a geriatric telehealth project in its first year. J Telemed Telecare 2002;8(Suppl 3):S3:53–S3:55. 3. Loh PK, Ramesh P, Maher S et al. Can patients with dementia be assessed at a distance? The use of Telehealth and standardised assessments. Intern Med J 2004;34:239–242. 4. Loh P-K, Donaldson M, Flicker L et al. Development of a telemedicine protocol for the diagnosis of Alzheimer’s disease. J Telemed Telecare 2007;13:90–94. 5. Shores MM, Ryan-Dykes P, Williams RM et al. Identifying undiagnosed dementia in residential care veterans: Comparing telemedicine to in-person clinical examination. Int J Geriatr Psychiatry 2004;19:101–108. 6. Craig JJ, McConville JP, Patterson VH et al. Neurological examination is possible using telemedicine. J Telemed Telecare 1999;5:177–181. 7. Patterson V. Teleneurology. J Telemed Telecare 2005;11:55–59. 8. Chua R, Craig J, Wootton R et al. Cost implications of outpatient teleneurology. J Telemed Telecare 2001;7(Suppl 1):S1:62–S1:64. 9. Martin-Khan M, Varghese P, Wootton R et al. Successes and failures in assessing cognitive function in older adults using video consultation. J Telemed Telecare 2007;13(Suppl 3):S3:60–S3:62. 949 MEASURING FUNCTIONAL PERFORMANCE IN PERSONS WITH DEMENTIA To the Editor: Van Iersel et al.1 gave an interesting report on validity and reliability of quantitative functional assessment in persons with dementia and cautiously stated that dementia does not preclude their use. We are currently performing a large intervention trial in persons with dementia and would like to add to the comments made by van Iersel et al. Although some validation studies have been performed in the past in patients with dementia leading to validated assessment instruments, measuring functional performance still represents a challenge to all researchers in the field. Motor testing assumes that test participants are able to comprehend test commands, to develop an adequate motor action and sequence, and to recollect both during execution. Another prerequisite is that test persons show adequate motivation and attention during testing. However, decreased executive functions, memory, and attention represent frequent and early symptoms of dementia.2,3 Depending on the cause and grade of cognitive impairment or associated illness such as depression, demented persons may have difficulties in all the domains mentioned above. The decreased effectiveness of physical training in such persons4 may therefore be based substantially on measurement problems that are not all mirrored by established test quality criteria such as test– retest reliability. Van Iersel et al. report that impaired patients may depend heavily on external cues, because they may forget what task was expected from them or lose attentional focus. However, such external cueing will potentially influence qualitative tests as well as quantitative tests. In test–retest reliability measures, results ‘‘stablilized’’ by external cues may yield high intraclass correlations (ICCs) but will probably document the speed, reliability and quality of external cueing rather than the patients’ best functional result or internal performance. Test performance is substantially based on the person’s willingness to test his or her own maximum performance levels. Our experience is that cognitively impaired persons often do not understand the nature of the test situation and do not show a sense of competitiveness, which is helpful to measure maximum performance in unimpaired persons. In addition, the perception of exertion is often inadequate in cognitively impaired patients. Patients may complain during physical training or testing that workloads are too high to perform. When patients were distracted by talking to them, or when training or testing was performed another day, when the patient was in a different mood, they might not perceive the same workload as being too strenuous and could perform it successfully without much obvious exertion. Quantitative testing is partly based on complex motion sequences such as laboratory measures (e.g., machine-based strength measurement) not related to any motor experience in everyday life. Because of the decreased ability to develop and perform (new) complex motor sequences that many persons with dementia have, it is difficult to do such measurements. In such a case, testing may document constant but low performance, leading to high ICCs but inadequate documentation of an individual maximal performance level. It is therefore doubtful whether promising results in 950 LETTERS TO THE EDITOR validity and reliability testing will guarantee adequate measurement properties in persons with dementia. In measures related to activities of daily living, such as the timed up and go test and walking tests or tests that involve activities that subjects perform daily, patients may be able to follow the test instruction when it is introduced adequately (no verbal focus; presentation of the task; clear, short, repeated instructions). Despite adequate presentation quite a number of patients may forget the test task while performing it or will show inadequate attention (e.g., talking while walking during test). However, such dual tasking significantly reduces functional performance.5 Klaus Hauer, PhD P. Oster, MD Bethanien-Hospital/Geriatric Center at the University of Heidelberg Heidelberg, Germany ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this letter. Author Contributions: Both author’s participated in the preparation of letter. Sponsor’s Role: No sponsor; not applicable. REFERENCES 1. van Iersel M, Benraad CEM, Olde-Rikkert MGM. Validity and reliability of quantitative gait analysis in geriatric patients with or without dementia. J Am Geriatr Soc 2007;55:632–633. 2. Perry RJ, Hodges JR. Attention and executive deficits in Alzheimer’s disease: A critical review. Brain 1999;122:383–404. 3. Craft S, Cholerton B, Reger M. Aging and cognition: What is normal? In: Hazzard WR, Blass JP, Halter JB, Ouslander JG, Tinetti ME, eds. Principles of Geriatric Medicine and Gerontology. McGraw-Hill Professional, New York: 2003, pp 1355–1371. 4. Hauer K, Becker C, Lindemann U et al. Systematic review: Effectiveness of physical training on motor performance in cognitively impaired persons. Am J Phys Med Rehabil 2006;85:847–857. 5. Hauer K, Kliegel M, Weber C et al. Postural control deteriorates during multitasking in geriatric patients with cognitive impairment. J Am Geriatr Soc 2003;51:1–7. LAY CONCEPT OF AGING WELL: CROSS-CULTURAL COMPARISONS To the Editor: Aging wellFsuccessful aging and related concepts (healthy, optimal, active, positive, aging)Fis a relatively new domain of research in the study of aging.1 The literature on successful aging reveals a wide range of definitions, most of them reflecting only one theoretical, academic, or scientific field and therefore being partially biased. Thus, biomedical researchers mainly emphasize health and physical functioning; psychologists usually limit their interest to subjective dimensions such as life satisfaction or well-being, and social scientists usually consider socioeconomic conditions the key aspects of successful aging. Nevertheless, because aging implies a biopsychosocial process, successful aging must be considered as an interdisciplinary subject of inquiry and a multidimensional concept. MAY 2008–VOL. 56, NO. 5 JAGS But successful agingFor in lay vocabulary, ‘‘aging well’’ Fis also a concept in the mind of the people. Older adults’ views of aging well is an important avenue of inquiry, because it is helpful in testing to what extent a scientific concept has been disseminated through different continents, countries, and cultures and because this familiarity is required for engaging elderly people (in different part of the world) in practices or programs that promote aging well. Trying to make cross-cultural comparisons of elderly people’s views, the same 20-item questionnaire (plus a rank order for selecting the five most-important aspects) used by Phelan et al.2 and Matsubayashi et al.3 was administered to elderly adults in seven Latin American (Brazil, Chile, Colombia, Cuba, Ecuador, Mexico, and Uruguay) and three European (Greece, Portugal, and Spain) countries. A sample of 1,189 elderly adults (495 men and 694 women; mean age 68.2) participated in this study (unpublished data). The reliability coefficient of the questionnaire used was high (a 5 0.89). To identify differences between countries, item-by-item and country-by-country comparisons were made; minor significant differences were found (o10% of the total comparisons). Therefore, to make comparisons between the results of the current study and those reported by Phelan et al. (Japanese-American and white American participants), and Matsubayashi et al. (Japanese participants), the results from the current study from LatinAmerican and European countries are reported. Table 1 shows the percentage of respondents who rated each item as important in successful aging. Following Phelan et al. and Matsubayashi et al., a cutoff of 75% or more respondents estimated as important differs from 7 items in the Japanese sample to 19 in the Latin American sample, whereas Japanese Americans, white Americans, and European samples, respectively, rated 13, 14, and 16 of the 20 attributes as important. There was a major consensus in all samples or individuals assessed in a given country regarding items 2 (good health), 3 (satisfaction with life), 5 (having friends and family), 10 (adjusting to changes), 11 (taking care of oneself), and 18 (being free of chronic diseases). In other words, multidimensionality is a characteristic of the lay concept of aging well involving: physical (2 and 18), psychological (3, 10, 11), and social (5) conditions. These multidimensional items are central to the concept of aging well in all countries. Some problematic methodological issues can be emphasized. First of all, our sample was not representative of the elderly population in our 10 surveyed countries. Second, although our participants come from two continents, all of them belonged to a similar culture, which makes similarities with the existing data from Japan, the country that is culturally the most different from the others, more important. Finally, from an educational point of view, all of our participants were literate, whereas in all surveyed countries, a high percentage of elderly people are illiterate in this cohort, and therefore, it is difficult to generalize our results. In conclusion, according to Matsubayashi et al., there is a gradient of consensus from Japanese in Japan, Japanese in the United States, and white people in the United States, Europeans, and Latin Americans. Also, our results are also coincident with those of Phelan et al. and Matsubayashi et al.; the lay concept of aging well is multidimensional in the mind of elderly adults, supporting those authors who claim against