sensors
Article
Assessing the Global Cognition of Community-Dwelling Older
Adults Using Motor and Sensory Factors: A Cross-Sectional
Feasibility Study
Emilija Kostic 1,† , Kiyoung Kwak 2,†
Citation: Kostic, E.; Kwak, K.; Kim,
D. Assessing the Global Cognition of
Community-Dwelling Older Adults
Using Motor and Sensory Factors: A
Cross-Sectional Feasibility Study.
Sensors 2023, 23, 7384. https://
doi.org/10.3390/s23177384
Academic Editors: Wen-Hsiang
Hsieh, Jia-Shing Sheu and Minvydas
Ragulskis
Received: 24 July 2023
Revised: 22 August 2023
Accepted: 23 August 2023
Published: 24 August 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Sensors 2023, 23, 7384. https://doi.org/10.3390/s23177384
and Dongwook Kim 2,3, *
1 Department of Healthcare Engineering, The Graduate School, Jeonbuk National University, 567 Baekje-daero,
Deokjin-gu, Jeonju 54896, Republic of Korea; emilija.kostic@jbnu.ac.kr
2 Division of Biomedical Engineering, College of Engineering, Jeonbuk National University, 567 Baekje-daero,
Deokjin-gu, Jeonju 54896, Republic of Korea; kykwak@jbnu.ac.kr
3 Research Center for Healthcare and Welfare Instrument for the Elderly, Jeonbuk National University,
567 Baekje-daero, Deokjin-gu, Jeonju 54896, Republic of Korea
* Correspondence: biomed@jbnu.ac.kr
† These authors contributed equally to this work.
Abstract: Impairments in gait, postural stability, and sensory functions were proved to be strongly
associated with severe cognitive impairment such as in dementia. However, to prevent dementia,
it is necessary to detect cognitive deterioration early, which requires a deeper understanding of the
connections between the aforementioned functions and global cognition. Therefore, the current study
measured gait, postural, auditory, and visual functions and, using principal component analysis,
explored their individual and cumulative association with global cognition. The global cognitive
function of 82 older Korean males was determined using the Montreal Cognitive Assessment. The
motor and sensory functions were summarized into seven independent factors using factor analysis,
followed by age and education-level-adjusted linear regression model analysis. The seven factors
obtained using factor analysis were gait speed, gait stability, midstance, general auditory ability,
auditory recognition, overall visual ability, and postural stability. The linear regression model
included years of education, gait stability, postural stability, and auditory recognition, and was able
to explain more than half of the variability in cognitive score. This shows that motor and sensory
parameters, which are obtainable through wearable sensors and mobile applications, could be utilized
in detecting cognitive fluctuations even in the early stages of cognitive deterioration.
Keywords: cognitive function; dementia; PCA; gait; sensory functions
1. Introduction
Performing even the simplest of daily tasks requires locomotion, balance, hearing, and
vision in most cases, and the central nervous system (CNS) is responsible for regulating all
of these functions. As we age and as our brain ages, these abilities deteriorate as well [1].
However, in the case of neurodegenerative diseases such as Alzheimer’s dementia (AD),
the deterioration in locomotion, balance, hearing, and vision can indicate issues with
cognitive function that are not related to the natural aging process, because AD has an
effect on the sensory and motor regions of the CNS [2]. Emerging studies have reported a
strong relationship of gait, balance, hearing, and vision parameters with global cognitive
function. Reduced gait function and gait variability were reported as being related to the
incidence of dementia [3,4] and future cognitive decline [5]. In addition, it was shown that
among older adults with moderate hearing loss, those with a slow gait had worse global
cognitive assessment scores [6]. In the case of postural control, postural instability was
found to be correlated with brain atrophy and pathological cognitive impairment in older
individuals [7]. Visual and hearing impairments have also been reported to be associated
https://www.mdpi.com/journal/sensors
Sensors 2023, 23, 7384 2 of 10

with cognitive decline in older people [8–11]. By utilizing these motor and sensory function
parameters, cognitive deterioration could be detected in the early stages. Such an approach
yields more opportunities for slowing or inhibiting the progression of the disease, which
would not be available in the case of already progressed dementia.
Most existing studies have used very general methods in obtaining the functional
parameters, such as a timed up-and-go test, visual acuity charts, pure tone audiometry, and
a one-leg standing test. While these tests are quick and usually used in clinical settings to
determine functional impairment, they cannot be considered sensitive enough to observe
small quantifiable differences between each participant. So far, many researchers have
used functional impairment as a predictor or marker of progressed dementia or a large
drop in global cognition. In the case of the beginning stages of cognitive deterioration,
however, these binomial parameters are not enough. When it comes to early cognitive
impairment, detecting small functional differences may be necessary for the development
of diagnostic and prognostic processes. In recent years, the development of wearable
sensors and mobile applications has made it easier to obtain various biometric data without
the use of expensive or complicated equipment. This allows for more thorough testing
even in settings where a quick assessment is needed. For this reason, we opted for more
thorough testing methods and obtained a higher number of parameters than what has so
far been used to represent gait, postural stability, hearing, and vision in studies related to
cognitive deterioration.
Additionally, the aforementioned function parameters are highly correlated with one
another within the function they represent, and it may be difficult to determine their inde-
pendent relationships with the cognitive function. For this reason, an assessment of the
correlation between cognition and independent features of gait, postural and sensory func-
tions was performed with the help of linear regression to further investigate the underlying
mechanisms that link global cognition to mechanic and sensory functions. By uncovering
the correlation between independent mechanics and sensory components and global cogni-
tion, we can determine which functional deterioration corresponds to a drop in cognitive
ability and hopefully track cognitive deterioration in its early stages. The independent fea-
tures were extracted using principal component analysis (PCA) because machine learning
algorithms converge faster if principal components are used, and dimension reduction
provided by PCA prevents overfitting.
To uncover the components that can be used in detecting early cognitive deterioration,
the present study examined the functional associations between motor and sensory factors
and global cognition, which was achieved by (1) measuring the participants’ cognitive, gait,
postural stability, hearing, and visual functions, (2) utilizing PCA to identify independent
features, and assessing their correlation to global cognition, and (3) assessing the cumulative
association of these features and cognitive function using linear regression.

2. Materials and Methods

2.1. Demographics and Cognitive Testing
The participants in this study (n = 82) were all over the age of sixty-five, male, had
no history of dementia diagnosis and could complete daily activities without assistance.
They all underwent cognitive, gait, visual, auditory, and postural stability testing. The
participants’ heights and weights were measured at the time of testing, and they provided
their ages and years of education.
Global cognitive function was examined using the Montreal Cognitive Assessment in
Korean (K-MoCA). The K-MoCA is a 30-point test with higher scores representing better
cognitive function. The total evaluation time is around 15–20 min, making this test a quick
assessment of global cognitive function [12]. Ethical approval to report this study was
obtained from the Jeonbuk National University institutional review board (JBNU IRB File
No. 2019-09-015-001) and written informed consent was obtained from the participants
for their anonymized information to be published in this article. The present study was
conducted according to the guidelines of the Declaration of Helsinki.
Sensors 2023, 23, 7384 3 of 10

2.2. Gait Assessment

Participants’ gait was recorded using software for capturing human motion (First
Principle, Northern Digital Inc., Waterloo, ON, Canada) and motion sensors (Optotrak
Certus, Northern Digital Inc., Waterloo, ON, Canada), which captured the position of
17 lower-limb markers. The gait parameters of the participants were obtained as an
ensemble average of 3 trials of level walking across a walkway (10 m in length) and
were processed using Software for Interactive Musculoskeletal Modeling (SIMM, Motion
Analysis Corp., Rohnert Park, CA, USA). Spatiotemporal variables and subdivisions of the
gait cycle were used to represent the gait function.

2.3. Visual Ability

The Korean standard vision chart, and Lea Numbers chart for contrast sensitivity
testing (Lea test intl. LLC, Helsinki, Finland) were used to assess the visual ability of the
participants. The best-corrected visual acuity (VA) and corrected contrast sensitivity scores
from 1.5 m (CS15M) and 3 m (CS3M) distances were used to represent visual functioning.

2.4. Auditory Function

To measure the participants’ auditory function, an audiometer (GSI-61, Grason-Stadler,
Copenhagen, Denmark) and the Korean speech audiometry test with pre-recorded samples
were used and the participants were seated in a soundproof room, wearing well-adjusted
headphones. The variables derived from the data were (1) PTA: an average pure tone
audiometry score of the better ear at 0.5, 1, and 2 kHz; (2) SRT: The speech recognition
threshold of the better ear; (3) WRS: The word recognition score average; (4) WRSm:
Mistake count during word recognition; (5) SRS: The sentence recognition score average;
and (6) SRSm: Mistake count during sentence recognition.

2.5. Postural Stability

For measuring participants’ postural stability, the Postural Stability Testing mode of the
Biodex SD (Biodex Medical System. Inc., Shirley, NY, USA) was utilized. The examination
was performed as instructed in the product manual [13]. The obtained variables were three
stability indexes, the anteroposterior (APSI), mediolateral (MLSI), and the overall postural
stability index (PSI). These indexes represent the amount of swaying of the center of mass
while standing and are a reliable measure of postural stability [14].

2.6. Statistical Analysis

All of the multiple sensory and gait parameters were standardized and for each
function, PCA was performed to derive a small number of uncorrelated independent
predictors. Parallel analysis was then performed to determine the significant components of
each function. The correlation between the cognitive score and the demographic parameters
was assessed using Spearman and Kendall’s tau-b correlation analyses, and the individual
components’ correlation with the K-MoCA score was assessed using partial correlation to
account for the influence of age and education. Subsequently, a linear regression model
containing all of the correlated factors was designed to determine the cumulative association
of said factors and the global cognitive function.
Statistical Package for the Social Sciences (SPSS) version 26.0.0 (IBM Corp, New York,
NY, USA) was used for all the statistical analyses.

3. Results
3.1. Demographics and Cognitive Assessment
The cognitive scores and demographic data of the participants (n = 82) are presented
in Table 1. A significant correlation with the MoCA score was found for age and years of
education. Age was found to be negatively correlated (r = −0.226, p = 0.005) and education
was found to be positively correlated to the MoCA score (r = 0.389, p < 0.001). These
Sensors 2023, 23, 7384 4 of 10

variables were, therefore, included in the linear regression model when observing the
combined motor and sensory function correlations to global cognition.

Table 1. Characteristics of the participants.

Variable MEAN SD MIN MAX

Age (years) 73.9 4.4 65.0 85.0
Height (cm) 167.2 5.7 153.0 180.0
Weight (kg) 67.0 8.3 46.5 88.8
Years of education 13.6 3.3 6.0 23.0
K-MoCA score 22.0 3.8 12.0 29.0
SD, Standard Deviation.

3.2. Gait Assessment

The spatiotemporal variables representing the participants’ gait function are presented
in Table 2.

Table 2. Gait function parameters of the participants.

Variable MEAN SD MIN MAX

Step length (cm) 65.0 5.8 51.8 82.7
Stride length (cm) 125.9 9.8 99.5 149.8
Cadence (steps/min) 110.0 7.7 86.9 128.2
Gait velocity (cm/s) 115.7 14.5 77.5 153.0
SLSP (%) 39.3 1.3 35.5 42.2
DLSP (%) 22.1 2.2 17.7 28.6
LR (%) 10.8 1.4 7.7 15.8
MS (%) 20.7 2.4 12.7 26.5
TS (%) 18.6 2.6 11.7 27.8
PS (%) 11.2 1.1 9.0 13.4
SW (%) 38.6 1.3 35.8 41.2
SD, Standard Deviation; SLSP, Single-Limb-Support Portion; DLSP, Double-Limb-Support Portion; LR, Loading
Response; MS, Mid-Stance; TS, Terminal Stance; PS, Pre-Swing; SW, Swing.

These variables were standardized and PCA was performed, resulting in a total of
eleven components. The first three components were able to explain 86.2% of the gait-
function variance and parallel analysis revealed that the remaining eight variables did not
need to be retained for further analysis. The rotated component matrix, which shows the
main variables of each gait-function component (in bold font), is presented in Table 3.

Table 3. Component matrix of the gait function.

Component
Variable
PC1 PC2 PC3
DLSP (%) −0.990 −0.100 −0.008
LR (%) −0.916 −0.064 −0.153
SLSP (%) 0.872 −0.105 −0.159
PS (%) −0.862 −0.120 −0.179
SW (%) 0.797 0.274 0.170
Cadence (steps/min) 0.660 0.379 0.102
Step length (cm) 0.339 0.890 −0.027
Stride length (cm) 0.372 0.884 −0.019
Gait velocity (cm/s) 0.601 0.758 0.038
TS (%) 0.181 −0.027 −0.979
MS (%) 0.282 −0.030 0.934
DLSP, Double-Limb-Support Portion; LR, Loading Response; SLSP, Single-Limb-Support Portion; PS, Pre-Swing;
SW, Swing; TS, Terminal Stance; MS, Mid-Stance; PC, Principal Component.
 TS (%) 0.181 −0.027 −0.979
MS (%) 0.282 −0.030 0.934
DLSP, Double-Limb-Support Portion; LR, Loading Response; SLSP, Single-Limb-Support Portion;
PS, Pre-Swing; SW, Swing; TS, Terminal Stance; MS, Mid-Stance; PC, Principal Component.

Sensors 2023, 23, 7384 The first component was highly correlated to all the subdivisions of the gait cycle 5 of 10

apart from MS and TS, and moderately correlated with cadence, while the third compo-
nent was highly correlated only to MS and TS. The first component was positively corre-
lated toThe first component
cadence, SLSP, and was SW, highly correlated
and negatively to all thewith
correlated subdivisions
DLSP, LR,of and thePS,
gait cycle
mean-
apart
ing thatfrom MS and
the first TS, and moderately
component correlated
has higher values with cadence,
for faster whilesingle
pace, longer the third
limbcomponent
support,
wasshorter
and highlydouble
correlated
limbonly to MSThis
support. and component
TS. The firstwascomponent was positively
termed “gait correlated
stability” because theto
cadence,of
duration SLSP,
the and SW,limb
single andsupport
negatively correlated
phase has been with DLSP, LR,
referred and
to as thePS,best
meaning
index that the
of the
first component has higher values for faster pace, longer single limb
limb’s support capability [15]. The second component was highly positively correlated to support, and shorter
double
step limbstride
length, support. This
length, component
and was was
velocity, and termed “gait stability”
therefore because
termed “gait the duration of
speed”.
the The
single limbcomponent
third support phase was has been referred
positively correlatedto aswith
the best
MS index of the limb’s
and negatively support
correlated
capability
with TS. In [15].
other The second
words, within component was highly
the single-limb positively
support, correlated
the moment to step
at which thelength,
mid-
stridephase
stance length,endsandaffects
velocity,theand was
third therefore termed
component “gait speed”.
(the relations between the subdivisions of
the gaitThe thirdcan
cycle component
be seen inwas thepositively
illustrationcorrelated
presented withinMS and 1).
Figure negatively
The third correlated
component with
TS. In other words, within
was termed “midstance” for this reason. the single-limb support, the moment at which the midstance
phase ends affects
Among the components,
the three third component gait (the relations
stability wasbetween the subdivisions
significantly of the gait
positively correlated
with the K-MoCA score (r = 0.273, p = 0.014) after adjusting for age and education. termed
cycle can be seen in the illustration presented in Figure 1). The third component was
“midstance” for this reason.

Figure 1. Subdivisions of the gait cycle.

Figure 1. Subdivisions of the gait cycle.

Among the three components, gait stability was significantly positively correlated
with the K-MoCA score (r = 0.273, p = 0.014) after adjusting for age and education.

3.3. Visual Ability

The visual ability examination results are presented in Table 4.

Table 4. Visual ability of the participants.

Variable MEAN SD MIN MAX PC1

CS3M 16.1 5.6 0.0 25.0 0.892
CS15M 22.2 4.1 5.0 25.0 0.944
VA 0.8 0.3 0.2 2.0 0.870
SD, Standard Deviation; CS3M, Contrast Sensitivity at 3 m distance; CS15M, Contrast Sensitivity at 1.5 m distance;
VA, Visual Acuity; PC, Principal Component.

After performing PCA, the parallel analysis revealed only one significant component
to represent the visual function. This component explained 81.4% of the variance in the
data and was highly positively correlated to VA, C3M, and C15M, meaning that the higher
value of the visual component represents higher corrected visual ability. The component
was found not to be significantly correlated to global cognition. The coefficients of the
variables included in the component matrix are presented in Table 4.
Sensors 2023, 23, 7384 6 of 10

3.4. Auditory Function

The results of the pure tone audiometry and the speech, word, and sentence recognition
tests are shown in Table 5.

Table 5. The auditory function of the participants.

Variable MEAN SD MIN MAX PC1 PC2

PTA (dB HL) 26.3 11.8 9.2 61.7 0.305 0.901
SRT (dB HL) 22.6 11.8 5.0 57.5 0.088 0.884
WRS 75.7 13.2 32.0 96.0 −0.731 −0.463
WRSm 12.2 6.5 2.0 34.0 0.744 0.449
SRS 97.3 3.3 81.2 100.0 −0.930 0.018
SRSm 2.1 2.7 0.0 15.0 0.920 −0.039
SD, Standard Deviation; PTA, Pure Tone Audiometry better ear 0.5, 1, and 2 kHz average; SRT, Speech Recognition
Threshold; WRS, Word Recognition Score; WRSm, Word Recognition mistakes; SRS, Sentence Recognition Score;
SRSm, Sentence Recognition mistakes; PC, Principal Component.

PCA and parallel analysis showed that two significant components explained 81.8% of
the data variance. Table 5 shows the individual parameters’ effect on the two components.
The first component was highly positively correlated with the WRSm and SRSm and
highly negatively correlated with the WRS and SRS scores, meaning that a higher value
of the first auditory component is representative of a lower ability for recognizing words
and sentences. The second component was highly positively correlated with the PTA and
SRT values, meaning that a higher value of the second auditory component is an indicator
of lower general auditory ability. After adjusting for age and education, the component
representing the inability to recognize words and sentences was negatively correlated
with the K-MoCA score (r = −0.375, p = 0.001) while the component representing general
auditory ability had no significant correlation with cognition.

3.5. Postural Stability

The postural stability index scores are presented in Table 6.

Table 6. Postural stability of the participants.

Variable MEAN SD MIN MAX PC1

PSI 0.8 0.5 0.3 3.4 0.995
APSI 0.6 0.4 0.2 2.5 0.937
MLSI 0.3 0.3 0.1 2.1 0.897
SD, Standard Deviation; PSI, Postural Stability Index; APSI, AnteroPosterior Stability Index; MLSI, MedioLateral
Stability Index; PC, Principal Component.

After performing PCA, the parallel analysis revealed only one significant component
to represent postural stability. The individual parameters’ effect on the component is
presented in Table 6. This component explained 89.1% of the data variance and is highly
positively correlated to all the postural indexes, meaning that the higher values of the
postural stability component represent more swaying during standing, and consequently
lower postural stability. This component representing postural instability was significantly
negatively correlated with global cognition (r = −0.394, p < 0.001) following age- and
education-adjusted analysis.

3.6. Global Cognition and Gait, Postural Stability, Auditory and Visual Functions
Among the obtained components, the inability to recognize auditory information,
postural instability, and gait stability were significantly linearly correlated to the MoCA
score. These components were used in training a linear regression model to determine
the cumulative association with the global cognitive function. A model that includes age
and education was designed using the stepwise method, where the parameters are added
one by one if their coefficients are significant, and removed if they lose significance after
Sensors 2023, 23, 7384 7 of 10

the addition of new parameters. The addition criterium was p ≤ 0.05 and the removal
criterium was p ≥ 0.01. The model parameters are presented in Table 7.

Table 7. Age- and education-adjusted linear model significant parameters.

Component β S.E. t p-Value R2

Auditory
Recognition −0.249 0.349 −2.684 0.009
Inability
0.527
Postural instability −0.282 0.334 −3.179 0.002
Gait stability 0.191 0.301 2.386 0.019
Years of education 0.411 0.093 5.058 <0.001
S.E., Standard Error.

The model excluded age as it was found to be non-significant in explaining the variance
in MoCA score with other variables present. Additionally, the MoCA score was observed to
be positively associated with the years of education and gait stability while it was negatively
associated with the postural instability and inability to recognize auditory information. To
summarize, global cognition was shown to be positively associated with years of education,
gait stability, postural stability, and auditory recognition. These components together
explained 52.7% of the variability in the global cognition scores.

4. Discussion
In the present study, the aim was to compare the cognitive function and the inde-
pendent components that represent gait, postural stability, hearing, and visual ability in a
cohort of older adults, and to determine how a combination of these factors is associated
with global cognition, to uncover the components that can be used in detecting early cogni-
tive deterioration. Hence, principal component analysis was utilized to extract independent
functional components, and their individual and cumulative association with cognitive
function was assessed.
The results of the demographics analysis showed that age and years of education were
highly correlated with global cognition, which is in accordance with previous reports. Years
of education were positively correlated with cognitive scores and education was found
to be positively associated with a delay in cognitive decline onset [16]. In addition, the
prevalence of dementia was found to be higher in older individuals and those with fewer
years of education [17].
Regarding the gait function, the principal component analysis resulted in three sig-
nificant components: the gait stability component, the gait speed component, and the
midstance component. The stability component was found to be significantly correlated
with global cognition after adjusting for age and education, while for the gait speed and
midstance components, that was not the case. To our knowledge, no previous research
has reported a correlation between midstance and cognition. Regarding slow gait, it has
been shown to predict future cognitive decline in older individuals [3]; however, it has
not been used as a parameter for diagnosing current cognitive impairment. Therefore,
it is likely that a decrease in gait speed precedes cognitive deterioration. Whether the
correlation between the slowing of the gait and incidence of dementia is causal or a result of
a change in a separate, independent factor, is yet to be uncovered. The positive correlation
between the stability component and cognitive score indicates that higher stability during
walking (represented by a higher percentage of the gait cycle spent relying on one rather
than both limbs [15]) is associated with higher global cognition. Similarly, the observed
correlation between postural instability and cognitive function was negative, meaning that
older individuals with better postural stability perform better on cognitive tests, which is
in accordance with previous research [7]. These results show that lower static and dynamic
stability correlates to lower cognitive function. It was previously discovered that the inci-
dence of falls was significantly higher among nursing home residents with dementia than
among those without dementia [18], suggesting a correlation between stability and severe
Sensors 2023, 23, 7384 8 of 10

cognitive impairment. The results of the present research suggest that even in individuals
with no incidence of dementia, there is a significant correlation between cognitive ability
and static and dynamic stability.
The corrected visual ability component, consisting of visual acuity and contrast sen-
sitivity parameters, was found to be uncorrelated with global cognition. Most of the
research examining cognition and visual ability was based on the presence of visual
impairment [19–21] which was found to be a risk factor for the incidence of dementia.
One previous study used cumulative contrast sensitivity scores from five different spatial
frequencies [22] and concluded that the risk of cognitive impairment was higher for partici-
pants with lower baseline contrast sensitivity scores. Considering the results of previous
studies that assessed the visual parameters separately, additional research should be con-
ducted to reach a conclusion regarding the connection between overall visual ability and
cognitive function. Examining the contrast sensitivity at more than two spatial frequencies
and including the uncorrected vision in the analysis may be necessary to accurately assess
the correlation between cognition and visual function.
Higher cognitive scores were correlated with a higher ability to recognize auditory
information; however, there was no correlation between cognitive function and general
auditory ability. Hearing loss (determined by PTA assessment) has been reported as a
risk factor for the incidence of dementia [9,10,23], suggesting that auditory impairment
precedes cognitive deterioration, yet it is not correlated to the present cognitive ability. A
recent review of the literature concluded that it is most likely that there is a mediating factor
between hearing loss and cognition [24]. Regarding auditory recognition, previous research
has shown that patients with dementia present with lower sentence comprehension, which
makes it difficult to accurately repeat heard sentences [25], suggesting that poor auditory
processing may be connected to cognitive impairment. Further research is needed to
determine the connections and mechanisms responsible for the observed correlations.
Utilizing the PCA approach made it possible to unite the individual function pa-
rameters into independent components that represent specific aspects of each function.
Differing from individual measurements, these components are linearly uncorrelated and
are a great solution for the problem of multicollinearity, which is common when perform-
ing observational medical experiments. Additionally, using PCA to obtain continuous
variables allowed more information to be retained than if binomial variables were used.
With this method, we were able to determine that while gait speed does not vary with
variance in global cognition, stability during gait does. Similarly, although the general
auditory ability did not correlate with the cognitive score, the ability to recognize auditory
information was significantly correlated with global cognition. In other words, although
a method such as PCA is more complicated, it can provide an advantage when distin-
guishing between normal aging and mild cognitive decline compared to using binomial or
individual parameters.
When the individual components were used to design a linear regression model, years
of education, gait stability, postural stability, and auditory recognition were found to be
significant and were able to explain 52.7% of the cognitive function variability. According
to the coefficients in the linear regression model, excluding the years of education which
commonly remains constant in late adulthood, the auditory recognition inability component
presents the highest association with global cognition, which is followed by postural
instability and gait stability. Therefore, a person with high auditory recognition but low
overall gait stability may score higher than if the situation were reversed. Similarly, two
people with the same auditory recognition ability and gait stability but different postural
stability would score differently in terms of cognition. This poses the question of whether a
change in one’s auditory recognition, gait stability, or postural stability would correspond to
a change in MoCA score. Based on these findings, there is a possibility that the deterioration
of any of the aforementioned functions could indicate cognitive deterioration or predict
its future occurrence. The motor and sensory assessments at different time points could
Sensors 2023, 23, 7384 9 of 10

be used to track general cognition and pose as a warning sign before a significant drop in
cognition takes place. The causal relationships are, however, yet to be uncovered.
The main limitation of this study is the small scale. A comparison of gait, postural
stability, and sensory functions across the cognitive domains could yield definitive results in
the case of a larger-scale study. In addition, this was a cross-sectional study that determined
the existence of correlations between the examined functions and cognition but was unable
to determine causality, which requires longitudinal research.
Further research should focus on developing and testing devices or applications for
monitoring and determining cognitive status based on a combination of motor and sensory
data, which would allow the quick screening and earlier detection of older individuals at a
higher risk of developing dementia.

5. Conclusions
The current study showed that having more stability during level walking and while
standing is positively associated with cognitive function. In addition, auditory recognition
ability showed a positive correlation to global cognition.
Over half of the cognitive function variability in older adults was shown to be ex-
plained by the factors presented in this research. This result shows that motor and sensory
functional differences correspond to the variability in cognitive function and can be utilized
in detecting cognitive fluctuations, even in the early stages of cognitive impairment.

Supplementary Materials: The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/s23177384/s1, Dataset S1: manuscript-dataset.csv.
Author Contributions: Conceptualization, K.K. and D.K.; data curation, K.K.; formal analysis, E.K.
and K.K.; funding acquisition, K.K. and D.K.; investigation, E.K. and K.K.; methodology, E.K. and
K.K.; project administration, K.K. and D.K.; resources, K.K.; supervision, D.K.; visualization, E.K.;
writing—original draft, E.K.; writing—review and editing, E.K., K.K. and D.K. All authors have
read and agreed to the published version of the manuscript. E.K. and K.K. contributed equally to
this paper.
Funding: This work was supported by the National Research Foundation of Korea (NRF) grant
funded by the Korean government (MSIT) (NRF-2022R1A2C2012762), received by D.K., and by the
Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by
the Ministry of Education (NRF-2022R1I1A1A01064228), received by K.K. This paper was supported
by research funds of Jeonbuk National University in 2022. The funding bodies had no role in the study
design, data collection and analysis, the decision to publish, or the preparation of the manuscript.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Review Board of Jeonbuk National University (JBNU
IRB File No. 2019-09-015-001).
Informed Consent Statement: Informed consent was obtained from all participants involved in the
study, and written consent has been obtained from the participants to publish this paper.
Data Availability Statement: The data presented in this study are available as Supplementary Material.
Acknowledgments: The authors would like to thank all the participants for their cooperation.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or
in the decision to publish the results.

References
1. Paraskevoudi, N.; Balcı, F.; Vatakis, A. “Walking” through the Sensory, Cognitive, and Temporal Degradations of Healthy Aging:
Multisensory Processing in Aging. Ann. N. Y. Acad. Sci. 2018, 1426, 72–92. [CrossRef] [PubMed]
2. Albers, M.W.; Gilmore, G.C.; Kaye, J.; Murphy, C.; Wingfield, A.; Bennett, D.A.; Boxer, A.L.; Buchman, A.S.; Cruickshanks, K.J.;
Devanand, D.P.; et al. At the Interface of Sensory and Motor Dysfunctions and Alzheimer’s Disease. Alzheimers Dement. 2015, 11,
70–98. [CrossRef] [PubMed]
Sensors 2023, 23, 7384 10 of 10

3. Grande, G.; Triolo, F.; Nuara, A.; Welmer, A.-K.; Fratiglioni, L.; Vetrano, D.L. Measuring Gait Speed to Better Identify Prodromal
Dementia. Exp. Gerontol. 2019, 124, 110625. [CrossRef] [PubMed]
4. Pieruccini-Faria, F.; Black, S.E.; Masellis, M.; Smith, E.E.; Almeida, Q.J.; Li, K.Z.H.; Bherer, L.; Camicioli, R.; Montero-Odasso, M.
Gait Variability across Neurodegenerative and Cognitive Disorders: Results from the Canadian Consortium of Neurodegeneration
in Aging (CCNA) and the Gait and Brain Study. Alzheimers Dement. 2021, 17, 1317–1328. [CrossRef]
5. Mielke, M.M.; Roberts, R.O.; Savica, R.; Cha, R.; Drubach, D.I.; Christianson, T.; Pankratz, V.S.; Geda, Y.E.; Machulda, M.M.; Ivnik,
R.J.; et al. Assessing the Temporal Relationship between Cognition and Gait: Slow Gait Predicts Cognitive Decline in the Mayo
Clinic Study of Aging. J. Gerontol. A Biol. Sci. Med. Sci. 2013, 68, 929–937. [CrossRef] [PubMed]
6. Sakurai, R.; Kawai, H.; Yanai, S.; Suzuki, H.; Ogawa, S.; Hirano, H.; Ihara, K.; Takahashi, M.; Kim, H.; Obuchi, S.; et al. Gait and
Age-Related Hearing Loss Interactions on Global Cognition and Falls. Laryngoscope 2022, 132, 857–863. [CrossRef] [PubMed]
7. Kido, T.; Tabara, Y.; Igase, M.; Ochi, N.; Uetani, E.; Nagai, T.; Yamamoto, M.; Taguchi, K.; Miki, T.; Kohara, K. Postural Instability
Is Associated with Brain Atrophy and Cognitive Impairment in the Elderly: The J-SHIPP Study. Dement. Geriatr. Cogn. Disord.
2010, 29, 379–387. [CrossRef]
8. Davies, H.R.; Cadar, D.; Herbert, A.; Orrell, M.; Steptoe, A. Hearing Impairment and Incident Dementia: Findings from the
English Longitudinal Study of Ageing. J. Am. Geriatr. Soc. 2017, 65, 2074–2081. [CrossRef]
9. Deal, J.A.; Betz, J.; Yaffe, K.; Harris, T.; Purchase-Helzner, E.; Satterfield, S.; Pratt, S.; Govil, N.; Simonsick, E.M.; Lin, F.R.; et al.
Hearing Impairment and Incident Dementia and Cognitive Decline in Older Adults: The Health ABC Study. J. Gerontol. A Biol.
Sci. Med. Sci. 2016, 72, 703–709. [CrossRef]
10. Maharani, A.; Dawes, P.; Nazroo, J.; Tampubolon, G.; Pendleton, N. Sense-Cog WP1 group Visual and Hearing Impairments Are
Associated with Cognitive Decline in Older People. Age Ageing 2018, 47, 575–581. [CrossRef]
11. Marquié, M.; Castilla-Martí, M.; Valero, S.; Martínez, J.; Sánchez, D.; Hernández, I.; Rosende-Roca, M.; Vargas, L.; Mauleón, A.;
Rodríguez-Gómez, O.; et al. Visual Impairment in Aging and Cognitive Decline: Experience in a Memory Clinic. Sci. Rep. 2019,
9, 8698. [CrossRef] [PubMed]
12. Nasreddine, Z.S.; Phillips, N.A.; Bédirian, V.; Charbonneau, S.; Whitehead, V.; Collin, I.; Cummings, J.L.; Chertkow, H. The
Montreal Cognitive Assessment, MoCA: A Brief Screening Tool for Mild Cognitive Impairment: Moca: A Brief Screening Tool for
MCI. J. Am. Geriatr. Soc. 2005, 53, 695–699. [CrossRef] [PubMed]
13. Balance SystemTM SD—Balance—Physical Medicine. Available online: https://www.biodex.com/physical-medicine/products/
balance/balance-system-sd (accessed on 12 July 2023).
14. Cachupe, W.J.C.; Shifflett, B.; Kahanov, L.; Wughalter, E.H. Reliability of biodex balance system measures. Meas. Phys. Educ. Exerc.
Sci. 2001, 5, 97–108. [CrossRef]
15. Perry, J.; Burnfield, J. Phases of Gait. In Gait Analysis: Normal and Pathological Function; Slack: New York, NY, USA, 1992; p. 9.
16. Clouston, S.A.P.; Smith, D.M.; Mukherjee, S.; Zhang, Y.; Hou, W.; Link, B.G.; Richards, M. Education and Cognitive Decline: An
Integrative Analysis of Global Longitudinal Studies of Cognitive Aging. J. Gerontol. B Psychol. Sci. Soc. Sci. 2020, 75, e151–e160.
[CrossRef] [PubMed]
17. Kim, K.W.; Park, J.H.; Kim, M.-H.; Kim, M.D.; Kim, B.-J.; Kim, S.-K.; Kim, J.L.; Moon, S.W.; Bae, J.N.; Woo, J.I.; et al. A Nationwide
Survey on the Prevalence of Dementia and Mild Cognitive Impairment in South Korea. J. Alzheimers Dis. 2011, 23, 281–291.
[CrossRef] [PubMed]
18. van Doorn, C.; Gruber-Baldini, A.L.; Zimmerman, S.; Hebel, J.R.; Port, C.L.; Baumgarten, M.; Quinn, C.C.; Taler, G.; May, C.;
Magaziner, J.; et al. Dementia as a Risk Factor for Falls and Fall Injuries among Nursing Home Residents: Falls and Dementia in
the Nursing Home. J. Am. Geriatr. Soc. 2003, 51, 1213–1218. [CrossRef]
19. Neumann, D. Neumann Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation; Mosby: Maryland Heights, MO, USA, 2009.
20. Swenor, B.K.; Wang, J.; Varadaraj, V.; Rosano, C.; Yaffe, K.; Albert, M.; Simonsick, E.M. Corrigendum: Vision Impairment and
Cognitive Outcomes in Older Adults: The Health ABC Study. J. Gerontol. A Biol. Sci. Med. Sci. 2019, 74, 1484. [CrossRef]
21. Zheng, D.D.; Swenor, B.K.; Christ, S.L.; West, S.K.; Lam, B.L.; Lee, D.J. Longitudinal Associations between Visual Impairment and
Cognitive Functioning: The Salisbury Eye Evaluation Study. JAMA Ophthalmol. 2018, 136, 989–995. [CrossRef]
22. Ward, M.E.; Gelfand, J.M.; Lui, L.-Y.; Ou, Y.; Green, A.J.; Stone, K.; Pedula, K.L.; Cummings, S.R.; Yaffe, K. Reduced Contrast
Sensitivity among Older Women Is Associated with Increased Risk of Cognitive Impairment: Reduced Contrast Sensitivity. Ann.
Neurol. 2018, 83, 730–738. [CrossRef]
23. Powell, D.S.; Brenowitz, W.D.; Yaffe, K.; Armstrong, N.M.; Reed, N.S.; Lin, F.R.; Gross, A.L.; Deal, J.A. Examining the Combined
Estimated Effects of Hearing Loss and Depressive Symptoms on Risk of Cognitive Decline and Incident Dementia. J. Gerontol. B
Psychol. Sci. Soc. Sci. 2022, 77, 839–849. [CrossRef]
24. Nadhimi, Y.; Llano, D.A. Does Hearing Loss Lead to Dementia? A Review of the Literature. Hear. Res. 2021, 402, 108038.
[CrossRef] [PubMed]
25. Liu, X.; Wang, W.; Wang, H.; Sun, Y. Sentence Comprehension in Patients with Dementia of the Alzheimer’s Type. PeerJ 2019,
7, e8181. [CrossRef] [PubMed]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.