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Examination of a cut-off score to express the meaningful activity of people

with dementia using iPad application (ADOC)

Article in Disability and rehabilitation. Assistive technology · December 2013

DOI: 10.3109/17483107.2013.871074 · Source: PubMed

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Disabil Rehabil Assist Technol, Early Online: 1–6

! 2013 Informa UK Ltd. DOI: 10.3109/17483107.2013.871074

RESEARCH PAPER

Examination of a cut-off score to express the meaningful activity of

people with dementia using iPad application (ADOC)
Kounosuke Tomori1, Hirofumi Nagayama2, Yuki Saito3, Kanta Ohno4, Ryutaro Nagatani1, and Toshio Higashi5
1
Department of Occupational Therapy, Kanagawa University of Human Services, Yokosuka, Kanagawa, Japan, 2Department of Occupational
Therapy, Kitasato University, Sagamihara, Kanagawa, Japan, 3Ohta General Hospital Foundation, University Ohta Atami Hospital, Koriyama,
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Fukushima, Japan, 4Graduate Course of Health and Social, Kanagawa University of Human Services, Yokosuka, Kanagawa, Japan, and
5
Department of Community-based Rehabilitation Sciences, Unit of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical
Sciences, Sakamoto, Nagasaki, Japan

Abstract Keywords
Purpose: To determine a quantifiable measure to identify patients with dementia who can ADOC, cut-off, dementia, meaningful activity,
choose an illustration of meaningful activity using an iPad application, Aid for Decision-making occupational therapy
in Occupation Choice (ADOC). Method: We recruited 116 patients from 5 institutions in Japan.
Occupational therapists interviewed patients with dementia to determine meaningful activities History
Disabil Rehabil Assist Technol

using ADOC. The most meaningful activity was confirmed by their primary caregivers.
The cut-off was estimated from Mini-Mental State Examination (MMSE). Results: Receiver Received 13 June 2013
operating characteristic analysis indicated that an MMSE score of 8 was the cut-off for choosing Revised 14 November 2013
meaningful activities using ADOC. Sensitivity and specificity was 91.0% and 74.1%, respectively, Accepted 27 November 2013
and the area under the curve value was 0.89. Conclusion: ADOC can provide individualized Published online 24 December 2013
information regarding meaningful activities for patients with moderate dementia.

ä Implications for Rehabilitation

 As dementia progresses, difficulty in expressing needs or desires regarding meaningful
activity may increase.
 The iPad application (Aid for Decision-making in Occupation Choice; ADOC) can be useful
to promote shared decision-making through a systematic goal-setting process involving
a choice of 95 illustrations describing daily activities.
 Mini-Mental State Examination (MMSE) score greater than 8 points is required to use the
ADOC to choose most meaningful activities.
 ADOC provides individual information regarding meaningful activities for patients with
moderate dementia.

Purpose occupational being. Some reports and guidelines recommend

using a tailored or patient-centered occupational therapy plan
Dementia is typically characterized by memory impairments and
to manage dementia [3–5]. The goal of occupational therapy
includes impairments of other cognitive domains (such as aphasia,
for patients with dementia is to maximize their quality of life
apraxia, agnosia, or executive function) [1]. Prevalence estimates
by optimally engaging them in meaningful daily activities [3].
for dementia among those aged 85 years ranges from 18% to
However, patient’s interactions as well as the context and
38%, with the most common types including Alzheimer’s
variables related to the performance of a given task can either
dementia, vascular dementia, and mixed dementia from multiple
facilitate or impede the patient’s performance [1]. In particular,
etiologies [2].
patients with dementia often demonstrate slow deterioration in
Rehabilitation plays a vital role in the non-pharmacologic
speech and language functions. Therefore, patients with dementia
management of dementia [1]. In general, occupational therapy
are likely to encounter increasing difficulty in expressing their
primarily focuses on improving a patient’s ability to independ-
needs or desires regarding meaningful activities.
ently perform daily activities and participate in social activities
Useful semi-structured assessment tools have been used to
[1]. Therefore, providing occupational therapy to patients with
identify meaningful activities in occupational therapy. These tools
dementia requires a complete understanding of the patients as an
include the Canadian Occupational Performance Measure
(COPM) [6], Goal Attainment Scaling (GAS) [7], and Activity
Address for correspondence: Kounosuke Tomori, Department of
Card Sort (ACS) [8]. However, COPM and GAS are difficult to
Occupational Therapy, Kanagawa University of Human Services, 1-10- apply in patients with moderate-to-severe dementia because these
1 Heisseicho, Yokosuka, Kanagawa, 238-8522, Japan. Tel/Fax: (+81)46 rely mostly on linguistic communication [9,10]. The ACS, which
828 2725. E-mail: adoc.project@gmail.com uses references to 89 photographs, was designed to help assess the
 2 K. Tomori et al.
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Figure 1. Interview using the Aid for Decision making in Occupation Choice (ADOC).
occupational performance of individuals with cognitive impair-
Disabil Rehabil Assist Technol
ment. However, the cognitive coverage of this measure remains
unclear, and ample space is required for placing the photographs.
To address these problems, we developed the Aid for Decision-
Making in Occupation Choice (ADOC) application for the iPad
(Figure 1; Apple, Cupertino, CA) [11–13]. In ADOC, patient can
select activities from 95 illustrations of daily activities derived
from the activities and participation domains of the International
Classification of Human Functioning, Disability, and Health
chapters [14]. Through this process, the patient and therapist can
cooperatively determine the goals for therapy and prioritize
activities. Thus, ADOC promotes shared decision-making
between the patient and therapist through a systematic goal-
setting process in which patients select activities that they
consider meaningful.
A previous study on ADOC examined patients with moderate
dementia who participated in the goal-setting process [15].
However, there are no criteria that indicate patients with dementia
who can effectively participate in the ADOC process. This study
aimed to determine a quantifiable measure that can identify
patients with dementia who can choose an illustration of
meaningful activity using the iPad application ADOC.
Methods
The goal-setting process of ADOC
ADOC involves the following 3 steps: (1) patient’s information
inputs by therapist, (2) activities are chosen and prioritized, and
(3) patient and therapist satisfaction is measured and documented
(Figure 2) [11]. The ADOC goal-setting process is achieved in
several steps. First, the therapist logs into the ADOC system with
a user name and password and uploads patients’ personal
information. Further the patient selects up to 20 activities and
rates them according to their importance. Therapists also select
activities that are important activities related to the patient’s
goals. Referring to the selected illustrations, both patient and
therapist select up to five urgent or important activities, and each
activity is assigned a priority on the basis of the importance/
urgency matrix. Subsequently, the patient rates their satisfaction
Disabil Rehabil Assist Technol, Early Online: 1–6
with each chosen activity. Therapy plans formulated by the
therapist and patient are uploaded, saved in a PDF file, and
printed. Therapy plans are then discussed as required and signed
by the patient and therapist. During each step of the ADOC
process, instructions are presented as short captions on the iPad
screen.
Patients
This multicenter cross-sectional study included a convenience
sample of patients with and without dementia undergoing
occupational therapy. To determine a cut-off, we recruited
patients on the basis of their Mini-Mental State Examination
(MMSE) scores so that all scores were equally distributed across
the full range of possible scores (0–30 points). The exclusion
criteria were age 518 years and marked delirium.
Procedure
Figure 3 presents an outline of the study procedure. The patients
and their primary caregivers were briefed about the aims
and testing procedures of the study prior to their participation.
Written informed consent was obtained from each primary
caregiver and/or patient. This study was performed in accord-
ance with the Declaration of Helsinki, and was approved by the
ethics committee of Kanagawa University of Human Services
(No. 22-011).
MMSE was administered in each patient to assess the extent of
cognitive dysfunction. MMSE is widely used to assess cognitive
mental status in both clinical practice and research [16]. MMSE
scores range from 0 to 30; a score 25 points indicates normal or
intact cognitive function, whereas scores of 9 points indicate
severe, 10–20 points indicates moderate, and 21–24 points
indicate mild cognitive impairment [17].
In this study, we examined the minimum MMSE score at
which patients were able to choose what they considered to be the
most meaningful activity using ADOC. First, an occupational
therapist interviewed each patient using the Japanese version of
ADOC. The occupational therapist did not know the patient’s
choice of meaningful activity. ADOC was displayed to the patient,
 DOI: 10.3109/17483107.2013.871074 A cut-off score using ADOC 3
1) Patients’ information

logged on to the ADOC. Input patients’

information (name, age,
sex, main diagnosis).

2) Activity choice and prioritize

Select of importance With display of Using an importance-

activities by patient and
therapist up to 20, and
rating important degree
by patient.
illustrations selected urgency matrix, the
patient and therapist, patientandtherapist
make decision client decide on the priority
and therapist select of of activity.
activities within five.

3) Satisfaction measurement and documentation

Rating satisfaction
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Input of therapy plans by Printout of the PDF

degree each activities therapist and patient, and file and explanation
by patient. save the PDF file. to patient.

Figure 2. Procedure for the Aid for Decision-making in Occupation Choice (ADOC).

Informed consent for Statistical analysis

Disabil Rehabil Assist Technol

patient and caregiver

We plotted the sensitivity and specificity of ‘‘positive’’ and
‘‘negative’’ results across a range of possible cut-off using a
Choose the meaningful Cannot choose receiver operating characteristic (ROC) analysis [18]. ROC
activity through ADOC analysis provides an estimate of the overall discriminative ability
of a scale using the area under the curve (AUC) statistic [18] and
Choose
minimum balanced error rate (BER). AUC indicates how close a
Do not agree scale is to the ideal point of 100% sensitivity and specificity; it is
Confirm caregiver not dependent on any particular cut-off [18]. BER indicates
the average positive and negative error rates (0.5  [FP/
Agree (TN þ FP) þ FN (TP þ FN)] (TP, true positives; TN, true nega-
tives; FP, false positives; and FN, false negatives; see Figure 4)).
To express the results of this analysis in a clinically relevant
Confirm attending OT Positive Negative
manner, sensitivity, specificity, positive predictive value, and
negative predictive values were calculated for MMSE scores
Know Unknown between 7 and 13. All analyses were performed using SPSS
ROC analysis
statistical software for Windows, version 15.0 (SPSS Inc.,
Figure 3. Study procedure. Chicago, IL).

and they were asked to select meaningful and familiar activities
from the illustrations. They selected the meaningful activities
by touching the relevant illustrations. After selecting an activity,
the patient provided reasons for his/her choice. To assess the
validity of determining meaningful activities and the reasons
behind the patients’ choices, the occupational therapist confirmed
their responses with the primary caregiver. The caregiver rated
the patient’s responses on a 5-point scale, with 1 indicating
they strongly disagree and 5 indicating they strongly agree.
Thus, a rating of 5 or 4 indicated agreement and was coded
as positive. Ratings between 1 and 3 were coded as negative;
3 indicated that the primary caregiver had no opinion regard-
ing the patient’s choice, 2 indicated disagreement, and 1 indicated
strong disagreement. If the patient could not select an illustra-
tion through ADOC, the case was coded as negative. If
the meaningful activity was positive, we asked the attending
occupational therapist whether the meaningful activity was
known to them.
Results
Study population
Of the 126 patients, 10 were excluded because the caregiver could
not be contacted (n ¼ 7) or MMSE could not be completed
(n ¼ 3). In total, 116 patients (49 males and 66 females) from 5
facilities were included. Table 1 presents the patients demograph-
ics. Eighty-eight (75.9%) of the 116 patients had MMSE scores
of 524 points.
Cut-off
Figure 4 shows the distribution of positive and negative responses.
MMSE scores were plotted on an ROC curve. Of the 116 patients,
89 (76.7%) were able to choose illustrations representing mean-
ingful activities, and the caregiver agreed with their selections.
Ten (8.6%) were able to identify meaningful activities, but the
caregiver either had a strong disagreement (4%) or no opinion
regarding (6%) the selection. Seventeen (14.7%) patients were
unable to identify meaningful activities.
 4 K. Tomori et al. Disabil Rehabil Assist Technol, Early Online: 1–6

TP; true positives

30 TN; true negatives
FP; false positives
FN; false negatives
1.0
25

TP=82 FN=9 0.8

20

0.6

Sensitivity
MMSE

15

0.4
Cutoff
10 7 < 8 point
Sensitivity: 92.1%
Specifically: 70.4%
0.2

5 AUC: 0.89
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FP=7 TN=19
0
0 0.2 0.4 0.6 0.8 1.0
0
TP=89
1-Specificallty

Positive Negative
n=89 n=27

Figure 4. Distribution of Mini-Mental State Examination (MMSE) scores and the receiver operating characteristic (ROC) curve.
Disabil Rehabil Assist Technol

Table 1. Characteristics of the study population. Table 2. Sensitivity, specificity, and BER for MMSE score
between 7 and 13.
Participant (n ¼ 116)
MMSE cut-off Sensitivity Specificity BER
Mean age (SD) 78.5 (9.8)
Sex (%) 7 0.933 0.593 0.206
Male 42% 8 0.921 0.704 0.189
Female 57% 9 0.910 0.741 0.193
Diagnosis (%) 10 0.876 0.778 0.219
Stroke 39% 11 0.854 0.778 0.218
Alzheimer’s disease 18% 12 0.843 0.815 0.217
Dementia 10% 13 0.831 0.852 0.215
Parkinson disease 11%
Arthritis/bone fracture 9% MMSE, Mini-Mental State Examination; BER, balanced
Neuromuscular disease 5% error rate.
Other 5%
Facility type (%)
Selected meaningful activities
Daycare center 59%
Nursing home 22% Table 3 presents the use of ADOC for selecting meaningful
Hospital for acute treatment 18% activities through interviews between occupational therapists
Mini-Mental State Examination
Mean total score (SD) 16.6 (8.8)
and patients. The most meaningful activities were selected from
Time (min) the ‘‘Leisure category’’ (59%). Patients narrated many stories
Mean total score (SD) 16.3 (7.6) regarding the illustrated activities during interviews. Of the
89 meaningful activities confirmed by the primary caregivers,
52 (58%) were unknown to the attending occupational therapists.
Based on the ROC curve, we determined the optimal MMSE
Discussion
cut-off score for selecting meaningful activities with ADOC as 8
points. The sensitivity and specificity was 92.1% and 70.4%, In this study, the optimal MMSE cut-off that indicated
respectively. AUC was 0.89 (95% confidence interval, 0.82–0.97), patients with dementia could use ADOC to determine meaningful
whereas the minimum BER was 0.189 (Table 2). In general, we activities was 8 points. Although we examined a score of 12
considered that a good cut-off corresponded to a point near the points, we observed that this cut-off score may exclude some
upper left corner of the ROC graph. By this method, we found that patients in whom ADOC may be applicable. Hirschman et al. [19]
the optimal cut-off was 12 points (Figure 4). This score yielded suggested that 92% patients with mild-to-moderate Alzheimer
sensitivity and specificity of 84.3% and 81.5%, respectively; the disease wanted to participate in the decision-making process
BER score had no minimum value (Table 3). Using an MMSE for treatment of dementia and that 71% caregivers are in favor
cut-off of 12 points, we observed that specificity increased, of patient participation in this decision-making process. In their
whereas sensitivity decreased. Therefore, the probability that work on ‘‘memory clubs’’, Zarit et al. [20] stated that patients
ADOC is not used in patients who are capable of identifying with dementia feel empowered by the ability to express
meaningful activities may be higher with a cut-off of 12 points. their needs and by participating in planning their own future.
 DOI: 10.3109/17483107.2013.871074 A cut-off score using ADOC 5
Table 3. All categories and items of ADOC, and number of meaningful activities selected client and agreed with caregiver.

Activities (agreed Unknown to

with caregiver) attending therapist
Categories and items n % n
Self-care
Eating/drinking, using the toilet, grooming, dressing, washing/bathing, maintaining one’s health 4 4 3
Mobility
Transferring oneself, moving around within the home, moving around outside, using an elevator, moving 2 2 1
on a stairway, using transportation, driving, getting up/standing, lifting and carrying objects, hand and
arm use
Domestic life
Shopping, cooking meals, laundry, cleaning, household maintenance, maintaining vehicles/appliances, 8 9 5
making and repairing clothes, child care, assisting old people/patients, management of property,
collecting information, using a phone, writing a letter/document, cosmetic activities/barbershop,
makeup
Work/education
Remunerative employment, non-remunerative employment, informal education, school education 0 0 0
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Interpersonal interaction
Verbal or nonverbal interaction, family relationships, friendship, formal relationships, intimate 9 10 2
relationships
Social life
Religion, political life and citizenship, use of public institutions, ceremonial functions, banquet/meeting, 5 6 5
community activities (e.g. Parent–Teacher Association), community events (e.g. festival)
Sport
Baseball/catch, softball, volleyball, basketball, football, ping-pong, tennis, badminton, martial arts, 7 8 5
bowling, croquet, swimming, hiking, cycling, jogging/marathon, walking, training at a gym, golf,
dancing
Disabil Rehabil Assist Technol

Leisure
Painting, reading, handicrafts, sightseeing, music/movies at home, board games, collecting, poetry, 52 59 31
calligraphy/flower arrangement/tea ceremony, making sweets, playing instruments, karaoke,
horticulture, do-it-yourself, gambling, pet care, diary/blog, video game, computer, photography/
videography, traveling, watching sport, theme park, eating out, driving, camping, TV/radio, fishing,
Japanese dance
(others)
Drink (alcohol), boccia 2 2 0
Total 89 100 52

The results of these two studies suggest that patients with
dementia should be given opportunities to express their needs
and desires to the maximum extent possible. According to the
MMSE scoring system, patients with a score of 8 points have
severe cognitive impairment [17]. Patients with more severe
dementia tend to be excluded from clinical decision-making
related to their daily lives [21,22]. Because ADOC allows patients
to choose meaningful activities, it may help therapists respect
their patients’ opinions and preferences and create opportunities
for patients to express their needs and desires, despite having
moderate-to-severe dementia.
In this study, most meaningful activities were chosen from the
‘‘Leisure category’’ (59%) instead of the ‘‘Self-care’’ category
(4%). Phinney et al. reported the following wide range of
meaningful activities for patients with dementia: leisure pastimes,
household chores, work-related endeavors, and social involve-
ment. Harmer and Orrell [23] pointed that patients with dementia,
the staff, and family caregivers had differing views about the
concepts of meaningful activity. Patients with dementia found
meaning in activities that addressed their psychological and social
needs, which related to the quality of experience of that activity
rather than to specific types of activities. In contrast, the staff and
family caregivers viewed activities that maintained physical
ability as meaningful. Rehabilitation in dementia care is likely
to emphasize the maintenance of physical or cognitive abilities,
improvement in the ability to perform activities of daily living
or instrumental activities of daily living, and risk reduction.
However, the ultimate goal of dementia care is not only to restore
or improve basic abilities but also to promote quality time spent
in meaningful and familiar activities. Previous studies have
described tailored and activity-based leisure activities for patients
with dementia that also positively affected caregiver satisfaction;
some of these activities had positive effects on patients’ well-
being and quality of life [5,24]. However, it is difficult to conduct
appropriate leisure or hobby activities without information
regarding the patient’s interests and values, because these
vary among individuals. The illustrations provided in ADOC
promote interaction and provide visual stimulation to generate
self-reflection and identification of potentially varied meaningful
activities [11]. Thus, ADOC may aid in identifying meaningful
activities for patients with dementia.
Of the 89 positive responses, 52 (58%) were unknown to their
attending occupational therapists. This result suggests that ADOC
more often elicits new information regarding meaningful
activities compared with usual conversation or existing semi-
structured assessment tools. However, one significant difference
between ADOC and other assessment tools is its process of
combined selection of activities by the patients and occupational
therapist [11]. The decision-making process regarding occupa-
tional therapy for patients with dementia can easily become
 6 K. Tomori et al.
overly complicated. For example, patients with dementia may
choose impossible or irrelevant activities. In such cases, ADOC
allows the occupational therapist to choose an alternative activity
as required, even if it is an activity the patients did not select.
ADOC was designed to facilitate shared decision-making [11,25].
The model on which ADOC was developed is closely related
to a patient-centered model, although it involves a partnership
between patients and their therapists [25]. The advantage of such
a model is that both patients and therapists bring information and
valuable suggestions into the discussion. ADOC can be applied to
various decision-making models, such as the paternalism,
informed decision, and patient-centered models [25,26], depend-
ing on the patient’s level of cognitive function or the occupational
therapy situation. ADOC may in fact be a more acceptable tool
for goal-setting for patients with dementia compared with other
available tools because it not only facilitates patients involvement
and provides the opportunity to express their needs and desires
to the maximum extent possible but also fosters a setting in which
an agreement can be reached among the patients, caregiver, and
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therapist.
Study limitations
The cut-off identified in this study was determined using the
importance/urgency matrix and a rating satisfaction score.
Patients without dementia were included because the ROC
analysis curve required recruitment of patients with equally
distributed MMSE scores across all possible scores. Although
Disabil Rehabil Assist Technol
English and Korean versions of ADOC were distributed, only
Japanese patients using the Japanese version of ADOC were
included in this study. In particular, the illustrations and items
used in ADOC are probably different among cultures,
countries, and generations. A study to determine the cross-
cultural validity of ADOC is required each time the applica-
tion is translated and the illustrations are changed for local
use.
Conclusion
The cut-off for expressing meaningful activities using ADOC
in patients with dementia was 8 points on the MMSE. ADOC
provides individual information regarding meaningful activities
for patients with moderate dementia.
Acknowledgements
The authors thank all the occupational therapists (Seshita Y,
Yamaguchi M, Ashikaga T, Akimoto T, Uezu S, Matsuo R,
and Kawano S), patients, and caregivers who volunteered to
participate in this study.
Declaration of interest
This study was supported in part by a Grant-in-Aid for Scientific
Research (C) (project no. 24531257 to K. Tomori and project
no. 23590610 to R. Nagatani) from the Japan Society for
the Promotion of Science. The authors declare no conflicts of
interests. The authors alone are responsible for the content and
writing of this article.
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