Changes in hand function in the aging adult as determined by the Jebsen test of hand function.

In the United States, the proportion of the population aged 65 years and older is increasing more rapidly than any other age group.[1] Currently, this age group represents approximately 11.6% of the population, and this figure is projected to reach over 20% by the year 2050.[2] As the number of older people increases, there will also be a greater need in the areas of acute medical, rehabilitative, and long-term care services. An understanding of the changes that occur as one ages and how these changes affect function is necessary in order to provide appropriate and effective care for the elderly. One change that may be associated with increasing age is decreasing hand function.

As one ages, many changes occur that may affect hand function. Changes in coordination, visual, touch, and auditory processes in addition to changes in the muscular, skeletal, and nervous systems occur with increasing age. A brief overview of the major changes that can influence hand function follows.

A decrease in muscle mass that is highly correlated with a decrease in muscle strength occurs with aging, especially after the age of 60 years.[3,4] Muscles that are most frequently used have less loss in strength.[5-7] Decreases in bone mass begin in the late 30s, both in men and women.[8,9] Osteoporosis, an extreme type of bone loss, affects women four times more often than it does men, with 30% of women over the age of 65 years manifesting the disorder.[10] With increasing age, declines in strength, speed of movement, and coordination occur that are related to a decline in neuromuscular function.[6] Nervous system changes include decreases in nerve conduction velocity, sensory activity, rate and magnitude of reflex responses, and arousal threshold.[11,12] Warabi et al[13] Suggested that impairment of sensory processes is a key component of decreased motor coordination and function. Visual changes that can affect hand function include decreased acuity, accommodation, color differentiation, sensitivity to light, depth perception, eye-hand coordination, and accommodation to light and dark.[9-11,14-18]

The Jebsen Test of Hand Function is a commonly used standardized test for assessing a person's functional hand use.[19] Both the dominant and nondominant hands are evaluated using a series of seven subtests related to activities of daily living. The time required to complete gross motor, fine motor, weighted, and nonweighted activities is measured with a stopwatch. The test is simple to administer; requires approximately 15 minutes to complete; and uses simple, inexpensive, and readily available test materials. Normative values for the test have been established for children in the age ranges of 6 to 7, 8 to 9, 10 to 11, 12 to 14, and 15 to 19 years.[20] Normative values for adults have been published for ages 20 to 59 and 60 to 94 years.[19] Increased time to complete the subtests is related to decreased functional hand use or disability. Published reports indicate that the test has been successfully used to evaluate patients who have hemiparesis, quadriplegia secondary to spinal injury, head trauma, and rheumatoid arthritis.[19]

The Jebsen test may be a useful means of quantifying any decline in hand function with age. In addition, it is reasonable to assume that changes in hand function could occur at varying rates between the ages of 60 and 94 years; this large age grouping therefore may be a poor representation for clinical comparison. Reference to inappropriate normative values could result in erroneous conclusions. The purposes of this study were (1) to determine whether hand function, as measured by the Jebsen test, does decline for men and women between the ages of 60 and 89 years when subjects are grouped by decade and (2) to provide normative values for those groups.

Materials and Methods

Subjects

One hundred twenty-one "normal" men and women, aged 60 to 89 years (X[Bar]=74.6, SD=7.7), volunteered to participate in the study. All subjects were living independently in the community at the time of the study. A "normal" subject was defined as a person having no report or diagnosis of a medical problem that might interfere with hand or arm function. All subjects signed a document of informed consent. Testing was performed at senior centers, churches, retirement homes, and the subjects' places of residence in the greater Los Angeles area. The number of subjects and the mean and standard deviation for age are shown for each age group by gender in Table 1. Chi-square analysis indicated no significant difference in the proportion of men and women among the three age groups.

Table l. Number of Subjects with Mean and Standard Deviation for Age for Each
Age Group by Gender
           Age Range (y)
           Men                        Women
           60-69    70-79    80-89    60-69    70-79    80-89
Age (y)
X[Bar]     65.76    74.10    84.53    65.68    74.39    84.47
SD          2.05     2.85     2.36     3.33     2.86     2.50
n          17       20       15       19       31       19

Instrumentation

The Jebsen test evaluates unilateral hand skills and provides an objective assessment of hand functions involved in activities of daily living. The test includes a series of seven subtests performed with each hand that represent a wide range of tasks involving the upper extremities. The subtests consist of the following: (1) printing a 24-letter, third-grade reading difficulty sentence; (2) turning over 7.6- x 12.7-cm (3- x 5-in) cards simulated page turning); (3) picking up small, common objects (eg, pennies, paper clips, bottle caps) and placing them in a container; (4) stacking checkers (test of eye-hand coordination); (5) simulated feeding; (6) moving large (#303), empty cans., and (7) moving large (#303), weighted (0.45-kg [1-lb]) cans. The subtests are scored by recording the number of seconds required to complete each task.

Procedure

Each subject completed the Jebsen Test of Hand Function according to the published protocol.[19] Testing was performed by two investigators (MEH, SMB). Prior to testing, intertester and intratester reliability were established. Intertester reliability was determined by using the intraclass correlation coefficient (ICC[3,2]) for simultaneous timing of five subjects by the two testers.[21] For, the various subtests, this value ranged from .82 to 1.00 (Tab. 2). A test-retest study of an additional five subjects was performed by each tester in order to determine the intratester reliability. The Pearson product-moment correlation coefficients were .84 and .85 for the two investigators. Because there was no significant difference between mean values for the test and retest  correlated samples t test, P>.05), we believe the Pearson correlation coefficient is an appropriate statistic for determining intratester reliability.

Table 2. Intraclass Correlation
Coefficients for Jebsen Test of Hand
Function (n=5)
                       Dominant   Non-dominant
Subtest                Hand         Hand
Writing                1.00         1.00
Card turning            .82          .98
Small, common           .95         1.00
  objects
Simulated feeding       .99         1.00
Checkers                .99          .98
Large, light objects    .99          .99
Large, heavy            .99          .99
  objects

Data Analysis

Means and standard deviations were calculated for all subtest scores for each 10-year age group according to gender. Analyses of variance (ANOVAs) and Scheffe post boc t tests were used to determine the effects of age and gender on hand function. The Pearson product-moment correlation coefficient was also used to determine the extent of the relationship of age to the 14 subtest scores (7 scores for the dominant hand and 7 scores for the nondominant hand). The alpha level was set at .05 for all tests.

Results

Mean subtest scores and standard deviations for men and women in the various age groupings are presented in Tables 3 and 4, respectively. An increase in time on any subtest indicates decreasing hand function. There was a significant positive correlation (P<.05) between age and the time required to complete the subtests in both men and women. The Pearson correlations tended to be low to moderate, ranging from .22 to .62 for women, .21 to .62 for men, and .26 to .49 for men and women combined (Tab. 5). [TABULAR DATA 3 AND 4 OMITTED]

Table 5. Correlation (Pearson r) of
Age and Subtest Scores for Men and
Women 60 to 89 Years of Age on the
Jebsen Test of Hand Function
                              Men        Women
Subtest                       (n=52)     (n=69)
Dominant hand
  Writing                     .44        .62
  Card turning                .50        .43
  Small, common objects       .48        .28
  Simulated feeding           .52        .30
  Checkers                    .62        .36
  Large, light objects        .59        .30
  Large, heavy objects        .62        .32
Nondominant hand
  Writing                     .41        .56
  Card turning                .38        .41
  Small, common objects       .21(a)     .39
  Simulated feeding           .37        .22(a)
  Checkers                    .26(a)     .27
  Large, light objects        .56        .40
  Large, heavy objects        .53        .41
(a)Not significant, P>.05.

The effect of age grouping by decade on the time required to complete each subtest was determined by ANOVAs for men and women separately. For men, the time needed to complete all of the subtests increased as age increased. When men in their 60s were compared with those in their 70s, however, in only 1 of the 14 subtest scores ("large, light objects" with the dominant hand) was the increase significant. In contrast, the increase in 13 of the 14 subtest scores was significant when men in their 70s were compared with men in their 80s. The "small, common objects" subtest with the nondominant hand was the only subtest in which the increase was not significant. The difference between men in their 60s and men in their 80s was also significant on the same 13 subtests.

When women in their 60s were compared with those in their 70s, there was a significant increase in time needed to complete the activity by the older group in 5 of the 14 subtests: "simulated feeding" bilaterally, "large, light objects" bilaterally, and "large, heavy objects" with the nondominant hand. When women in their 70s and 80s were compared, times on 6 of the 14 subtests were significantly increased with increased age. These subtests were "writing" bilaterally, "card turning" bilaterally, "checkers" with the dominant hand, and "small, common objects" with the nondominant hand. When women in their 60s and 80s were compared, however, all except 2 of the subtests took significantly longer to complete in the older group. Time needed to complete the "small, common objects" subtest with the dominant hand and the "checkers" subtest with the nondominant hand did not increase significantly.

Analyses of variance were also used to compare men and women by decade. Out of 42 possible comparisons (three age groupings with 14 subtests in each group), a significant difference between men and women was found in only three subtests: "writing" with the dominant hand in subjects in their 60s and 70s and "small, common objects" with the nondominant hand in subjects in their 80s. In the three subtests with significant differences, women performed faster than men.

When the mean subtest scores for each decade in this study were compared with the normative values of Jebsen's original study in which all men and women between the ages of 60 and 94 were grouped together, the results varied (Tab. 6). In general, both men and women in their 80s took longer to complete the subtests than the reported normative values. This finding also was true for the subjects in their 70s, but to a lesser extent. For the youngest age group (subjects in their 60s), times on several subtests were faster than the reported normative values.

Table 6., Mean Publisbed Subtest Scores ([+ or -] Standard Deviation) (in Second
s) for
Men and Women 60 to 94 Years of Age on the Jebsen Test of Hand Function[19]
Subtest                       Men (n=30)           Women (n=30)
Dominant hand
  Writing                  19.5 [+ or -] 7.5   15.7 [+ or -] 4.7
  Card turning              5.3 [+ or -] 1.6    4.9 [+ or -] 1.2
  Small, common objects     6.8 [+ or -] 1.2    6.6 [+ or -] 1.3
  Simulated feeding         6.9 [+ or -] 0.9    6.8 [+ or -] 1.1
  Checkers                  3.8 [+ or -] 0.7    3.6 [+ or -] 0.6
  Large, light objects      3.6 [+ or -] 0.7    3.5 [+ or -] 0.6
  Large, heavy objects      3.5 [+ or -] 0.7    3.5 [+ or -] 0.6
Nondominant hand
  Writing                  48.2 [+ or -]19.1   38.9 [+ or -] 4.9
  Card turning              6.1 [+ or -] 2.2    5.5 [+ or -] 1.1
  Small, common objects     7.9 [+ or -] 0.9    6.6 [+ or -] 0.8
  Simulated feeding         8.6 [+ or -] 1.5    8.7 [+ or -] 2.0
  Checkers                  4.6 [+ or -] 1.0    4.4 [+ or -] 1.0
  Large, light objects      3.9 [+ or -] 0.7    3.4 [+ or -] 0.6
  Large, heavy objects      3.8 [+ or -] 0.7    3.7 [+ or -] 0.7

Discussion

The nervous, muscular, skeletal, and sensory systems all undergo age-related changes that can influence the functional abilities of the hands. The results of this study indicate that normal hand function, as measured by the Jebsen test, does decline between the ages of 60 and 89 years for both men and women. As a result, we believe the originally published normative values for the Jebsen test, in which all subjects above 60 years of age were grouped together, should not be used clinically because of the possibility of error.

Based on our results, it appears that gender has only a minor influence on the decrease in hand function. In each age group, men and women were not significantly different for the majority of tasks. Women in their 60s and 70s, however, did perform the "writing" subtest with the dominant hand significantly faster than did men in the same age groups. Interestingly, Jebsen's original study also found a decrease in the writing ability of men coupled with a much higher variability in the scores than for women. Perhaps this may be attributed to a tendency for women to perform writing tasks more frequently than men. In many instances in this study, the men reported that their wives did most of the writing.

The Jebsen Test of Hand Function is reliable and easily performed and involves tasks that are functionally related. It has been shown to be valid by successfully identifying individuals who are functionally disabled by a variety of conditions.[19] Given the results of this study, therapists may find this test useful in older patient populations for determining whether a change in function is normal or abnormal.

Conclusion

The Jebsen Test of Hand Function is a reliable means of assessing hand function. As measured by this test, hand function declines for both men and women with increasing age from the age of 60 to 89 years. The mean subtest scores established in 10-year increments in this study differ from the normative values established in Jebsen's original study. The use of narrower age ranges should enable the physical therapist to make a more accurate assessment of hand function in elderly patients. Future studies should investigate the effects of such factors as activity level, former occupation, and place of residence on the person's functional activities.

References

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