Archives of Gerontology and Geriatrics 50 (2010) 332337

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Archives of Gerontology and Geriatrics

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Decline of physical and cognitive conditions in the elderly measured through the
functional reach test and the mini-mental state examination
Marianna Costarella a, Lucilla Monteleone b, Roberto Steindler b,*, Stefano Maria Zuccaro a
a
b

Israelitic Hospital, via Fulda, 14, I-00148 Roma, Italy

Universita di Roma La Sapienza, Department of Mechanics and Aeronautics, Via Eudossiana, 18, I-00184 Roma, Italy

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 3 December 2008
Received in revised form 18 May 2009
Accepted 22 May 2009
Available online 9 July 2009

There are several tests used to evaluate the psychophysical characteristics of the elderly and, of these, the
most suitable are the functional reach (FR) test, an index of the aptitude to maintain balance in an upright
position, and the mini-mental state examination (MMSE), a global index of cognitive abilities. The
sample of elderly people we analyzed involved 50 healthy subjects divided into three age-groups (15
subjects from 55 to 64 years, 19 from 65 to 74 years, and 16 over 75 years of age); they underwent an FR
test, which consists rst in the measurement of the anthropometric characteristics, then in the execution
of the test itself, and nally in the study of the upright posture by the analysis of the center of pressure
(COP) trend; they underwent an MMSE as well to evaluate the main areas of the cognitive function
concerning space-time orientation, short-term memory, attention ability, calculation ability and
constructive praxis. The results of these tests show, according to the age of the subject, a loss of physical
performance (FR, FR related to height, and COP displacement), as well as a loss of cognitive abilities;
however, in all cases the only signicant changes are those between the rst and the other two agegroups. Finally, a comparison between FR and MMSE shows a more rapid decline of physical
performance compared to cognitive performance.
2009 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Functional reach test
Mini-mental state examination
Space-time orientation
Short-term memory
Attention ability

1. Introduction
1.1. Aging of the cognitive and of the physical-motor abilities
Several transversal and longitudinal studies have clearly shown
that, during aging, even when neurological disease is not present,
there is a progressive and gradual loss of some intellectual
functions that becomes evident starting from the seventh or eighth
decade of life and increasingly evident after the ninth decade
(Rabbit, 1977).
The biological basis of this decline, quite modest in a healthy
older subject, can be identied as changes of the senile brain from a
macroscopic point of view (loss of brain volume), from a
microscopic point of view (reduction of neuron number and of
dendritic arborizations), and from a metabolic point of view (loss of
the main neuronal transmitter levels).
The older subject, moreover, has a decit of balance as well as
psycho-motor slowdown; psycho-motor speed is the speed by
which a subject is able to carry out an activity that requires a motor
response related to an external stimulus; therefore, the move-

* Corresponding author. Tel.: +39 06 4458 5785; fax: +39 06 4881 759.
E-mail address: roberto.steindler@uniroma1.it (R. Steindler).
0167-4943/$ see front matter 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.archger.2009.05.013

ments are slower, divided into several phases, and less uid than
those of younger subjects (Folstein et al., 1975).
This alteration of the psycho-motor seems to be partially due to
a decit of peripheral sensitive stimulus transmission (Spirduso,
1980) and has several implications in the life of the elderly: the
reduced speed of movement execution may increase the risk of
working accidents in still active subjects, may interfere in normal
daily activities and may increase the risk of accidental falls
(Salthouse, 1985; Birren and Fisher, 1995).
A technique usually used to evaluate psycho-motor speed is the
length of reaction; it consists in giving a sensorial stimulus (a
sound or a light, for example) and measuring the period of time
that the subject takes to perform an activity in response to the
stimulus (pushing a button, for example). Other tests have been
carried out to evaluate the psychometric characteristics (upright
posture, balance, etc.). In this paper we focus on the FR test which
concerns physical functions, particularly the aptitude of maintaining balance in an upright position.
FR is dened (Stelmach and Worringham, 1985) as the
maximum forward displacement that a subject can achieve,
starting from an upright position with the dominant arm extended
forward and with the st closed so as to form a right angle with the
torso, while simultaneously maintaining a xed support, and the
st always at the same level throughout the movement; the torso

M. Costarella et al. / Archives of Gerontology and Geriatrics 50 (2010) 332337

Fig. 1. FR test.

must not rotate during the test (Fig. 1). An increase of FR has been
observed with the reduction of the numbers of falls of the subjects
(Duncan et al., 1990, 1992), a decrease of FR has also been observed
in people with Parkinsons disease (Riolo, 2003), on the other hand,
there is an increase of FR using the Alexander-technique (Brusse
et al., 2005), a technique of rehabilitation of movements and
upright posture; nally, a decline of FR has been observed with the
increase of age in healthy people (Cavanaugh et al., 1999; Dennis,
1999).
Several recent studies have correlated the physical performance
and the cognitive abilities in older subjects: it has been noted, for
example, that people with a handicap have an FR and a TUG
(timed up and go, a test to evaluate functional activities (Fioretti
et al., 2000) lower than subjects without a handicap). Moreover,
the FR score is higher in subjects with higher activities of daily
living (ADL) scores (Podsiadio and Richardson, 2000; Rockwood
et al., 2000).
The measurement of FR is very simple: a measuring tape is
usually sufcient for an observer to quantify the closed-st
position acquired (Stelmach and Worringham, 1985; Duncan et al.,
1990), even if in some cases sophisticated optical-electrical devices
are used together with markers applied to the tested subjects
(Cavanaugh et al., 1999; Dennis, 1999). During the test, the
position of the COP is usually also measured, as well as its forward
displacement; this displacement must be small, because the center
of mass (COM) is linked to it, and its projection must always remain
inside the support basis (Stelmach and Worringham, 1985). As
reported in the literature, a force platform has been widely used to
measure the COP (Duncan et al., 1990; Cavanaugh et al., 1999;
Dennis, 1999).
The MMSE is a means, with international validation, of global
estimation of the cognitive function of older subjects. The test is
easily given and executed; it consists of 11 items, each
corresponding to a cognitive functional area, such as time-space
orientation, attention and calculation abilities, short-term memory, recall ability, constructive praxis and mental ability; the total
score is 30/30 for normal cognitive performance. An MMSE
score > 24/30 indicates cognitive abilities within normal values for
subjects older than 65 years of age (Takahashi et al., 2006).

333

average age of 70 (15 subjects 5564 years, 19 subjects 6574

years, and 16 over 75 years of age), each subject with a low level of
co-mobidity and complexity. The criteria of exclusion were: severe
osteo-articular pathologies with functional limitations, vertebral
stenosis and primitive and minor neuro-radicular diseases,
invalidating neurological diseases (motor neuronal disease, lateral
amyotrophic sclerosis, multiple sclerosis), former acute cerebral
vascular events, cognitive decit, diabetic neuropathy, Parkinsons
disease and minor Parkinsonisms, vertigo syndromes (labyrinthine
disease, dizziness).
2. Subjects and methods
2.1. The study sample
We investigated 50 healthy subjects coming, mostly, from the
attenders of the Institutes for older people associated with the
Israelitic Hospital of Rome. They underwent the FR test and the
MMSE; before performing the tests they gave their informed
consent.
Table 1 shows the personal data (age) and the anthropometric
features (height) of the tested subjects; the subjects were divided
according to age, and, next, according to gender; the data are
presented as mean  SD. The division in groups is well-balanced
with regard to both age and gender. The height of the males is largely
greater than that of the females in all age-groups: this fact must be
considered when comparing the physical performance of the two
genders.
2.2. Methods
Following the exclusion criteria, the subjects were rst given a
short anamnesis interview to verify their health conditions: the
subjects were selected focusing on two important criteria: ability
to maintain an upright position for at least 10 min, and cognitive
function within the normal range according to their age
(MMSE > 24/30). Then anthropometric data (height, body mass,
etc.) were measured.
After the MMSE each subjects was invited to stand barefoot on
the pressure map sensor (see Section 2.3) and to maintain an
upright position with one arm at a right angle to the torso with the
st closed (Fig. 2A). The subject remained for about 5 s in this
position and then performed the FR test extending forward as far
as possible, compatibly with his conditions (Fig. 2B); then the
subject went back to the starting position, standing upright some
seconds more. The total time required for the test is 15 s and
during this period the heels must not lift from the ground. The test
must be repeated three times and each time FR and DCOP are
measured.

1.2. Aim of the work

Table 1
Characteristics of the examined subjects: (mean  SD).

The aim of this work was to study the inuence of age and of
anthropometric features (gender, height, body mass) on the
psycho-physical characteristics and, especially, the correlation
between physical performance and cognitive abilities. On the
analogy of a former work in which the performance of students and
professors of the Department of Mechanics and Aeronautics of the
University of Rome, La Sapienza, were compared (Monteleone
et al., 2007), we used a pressure map sensor to monitor the exact
execution of the FR test, particularly that the heels did not lift from
ground during the test. In this way it was also possible to measure
the displacement of the COP (DCOP) and to correlate it to the FR.
In this way we examined at the same time the physical
performance and the cognitive abilities of 50 subjects with an

Age-groups

No of subjects

Years

Height (cm)

All subjects
5564
6574
>75

15
19
16

60.4  2.5
69.2  3.3
78.9  3.2

165.7  6.6
159.3  9.2
163.0  8.5

Males
5564
6574
>75

9
8
11

59.9  2.8
70.0  3.5
79.5  3.4

170.1  4.2
167.4  6.6
166.1  8.0

Females
5564
6574
>75

6
11
5

61.2  1.7
68.6  3.2
77.6  2.3

159.2  4.0
153.5  5.5
156.2  5.3

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M. Costarella et al. / Archives of Gerontology and Geriatrics 50 (2010) 332337

Fig. 3. Adopted instrumentation: measuring tape (top, at left); pressure p map

(bottom, at right).

acquired pressure map it is possible to calculate COP coordinates

and therefore to determine its trends in the anteriorposterior and
in the mediallateral directions. The difference between the
anteriorposterior at the beginning of the test and at the maximum
extension gives the displacement of the DCOP. It must be pointed
out that only the anteriorposterior component of the displacement is considered signicant for the test (as explained below).
2.4. Data analysis

Fig. 2. (A) A subject in the initial position. (B) A subject at the maximum extension.

2.3. Instrumentation
The measurement of FR is performed by means of a simple
measuring tape, which is extended between two stands; its height
can be adjusted so as to be aligned with the extended arm of the
subject (Fig. 3, left). An observer follows the displacement of the
arm, moving along with the st, reading its initial and nal
positions; if the subject does not keep his arm horizontal the test is
not valid and must be repeated. The value of the FR is the difference
between the two readings; the accuracy is 1 cm.
The correct execution of the test is veried thanks to the
pressure map sensor. The sensor (Fig. 3, bottom), is 40 cm  40 cm,
has 6400 sensitive elements resulting from the crossing of
horizontal and vertical conductive strips applied to two Kapton1
sheets, and between which a piezoresistive material, VelostatTM, is
placed. The sensor works thanks to the variation of the contact
resistance between the conductive strips and the piezoresistive
material as a result of the applied pressure (Del Prete et al., 2001);
the sensor has a spatial resolution of 0.5 cm, a range of 400
500 kPa, a sensitive threshold of 1 kPa, a negligible response time,
and is therefore apt to detect dynamic phenomena such as posture
which is characterized by oscillations of the body (Levin and
Mizrahi, 1996). Maps are acquired at a frequency of 20 Hz; so,
during the whole test, 300 pressure maps are acquired.
As the subject stands barefoot on the sensor, it is possible to
conrm that the heels do not lift during the test. Fig. 4A and B
shows plantar pressure maps at the beginning of the test and at the
maximum extension; if the impression of one of the heels
disappears, the test is not valid and must be repeated. From each

The cognitive abilities of each subject are summarized by the

MMSE score.
With regard to the physical performance, as said above, in each
of the three tests we measured the FR, then we calculated the ratio
FR/H (H = height) and, from the COP trends, we calculated the
DCOP; the physical performance of each subject are the mean
values of FR, FR/H and DCOP.
For each subject we also calculated the ratio MMSE/FR. To study
how the psycho-physical features change with age in the three
examined groups the mean MMSE values of FR, of FR/H and of
DCOP were calculated together with their SD. For the three agegroups a comparison of the values of MMSE/FR was also made: the
aim is to compare changes in cognitive abilities (MMSE) and
physical performance (FR) with age; it is then possible to know
which of the two characteristics declines more quickly.
The Fisher statistic (F-test) (Vicario and Levi, 1998) was applied
to the three groups and to the examined features (cognitive
abilities, physical performance, related ratios), in order to evaluate
the importance of the above mentioned changes. Inside the
different groups and for the examined features we compared the
performance of males and females, thus permitting the study of the
inuence of gender; these comparisons were also statistically
evaluated. Finally we applied the linear regression to DCOP and FR
values in order to evaluate the possible linear correlation between
the two trends and its reliability (Pearson).
3. Results
3.1. Typical trends
Fig. 5 shows some typical examples of COP coordinate trends.
Fig. 5A shows a slow and regular forward trend until maximum

M. Costarella et al. / Archives of Gerontology and Geriatrics 50 (2010) 332337

335

The rst four parameters in Table 2 (MMSE, FR, FR/H, DCOP)

show a predictable loss both of cognitive abilities and of physical
performance with the increase of age; in several cases there is also
an increase of the SD, being an index of a greater dispersion of data
with the increase of the age. The decline of all the psychophysical
features is age-dependent: it is greater and greater going from the
younger to the older age-groups.
Applying the Fisher test to the four examined parameters,
only the 5564-year-old group is signicantly different from
the other two (p < 0.01 for all four parameters): the difference of
the data between the other two groups is statistically not
signicant (p < 0.95 in the four cases). In short, there is a
dramatic fall of the psychophysical features in the people over
65.
The examination of the ratio cognitive abilities/physical
performance shows an increase of the ratio with age; there is
also a remarkable increase of the SD with age. It seems that the loss
of cognitive abilities with age is smaller than that of physical
performance. Also for this ratio only the 5564-year-old is
signicantly different from the other two groups.
3.3. Inuence of gender
Table 2 shows also the results of the analyzed 4 parameters of
the three age-groups for males and females. With regard to the
MMSE, the results are quite similar: the male subjects performed
slightly better in the rst two groups, while the female subjects
performed slightly better in the third group; none of these three
differences are statistically signicant.
With regard to the FR, the male subjects have superior
performance in all three groups; the differences, even if considerable, in some cases, are not statistically signicant (p > 0.05).
The ratios FR/H show very small differences; the differences are
not very signicant. The DCOP do not show remarkable differences
either; neither of the two genders is superior to the other;
statistical differences are not signicant.
The ratios MMSE/FR show that the decrease of physical
performance compared to cognitive abilities is greater in the
male subjects; however the high dispersions of data (SD) make
the differences insignicant.
Fig. 4. (A) Plantar pressure map at the beginning of the test. (B) Plantar pressure
map at the maximum extension.

extension is reached and a backward trend to the upright position

with the same features. Fig. 5B shows a forward trend until
maximum extension is reached characterized by small steps and a
fast backward trend to the upright position. Fig. 5C shows a short
initial backward displacement then a forward trend with an
intermediate stop before the maximum extension and a fast
backward trend to the upright position. Fig. 5D shows a very fast
forward trend until maximum extension is reached and an equally
fast backward trend with an intermediate stop to the upright
position.
There is no typical trend, nor are the examples shown typical of
a specic group. As said above, the focus is on the forward
backward displacements of the COP; the medianlateral displacements are not considerable, as the examples clearly show, and
therefore they are not taken into account.
3.2. Global results
Table 2 shows the results of the MMSE, the FR, the ratio FR/H,
the DCOP, and the ratio MMSE/FR of the three age-groups for all
subjects.

3.4. Correlation
With regard to all the subjects (with no distinction of age or
gender) and studying the correlation DCOP-FR it is possible to
consider a linear trend; in this case the linear coefcient is 0.16 and
the correlation coefcient (Pearson) is 0.60. The correlation
coefcient is not very high but the dispersion of data is wide.
Low correlation coefcients have also been observed in analogous
works (Jonsson et al., 2003).
4. Discussion
Aging gives rise to several structural and functional modications from a cerebral point of view which are the cause of decline
both of some cognitive functions (memory, visual-spatial abilities,
uid intelligence) as the MMSE scores demonstrate, and of the
psycho-motor functions, as proven by the FR test results. Besides
this remark, there is a higher and more signicant decrease of
psycho-motor and cognitive performance getting from the rst to
the other two age-groups; what above could mean a critical
threshold level of the psycho-cognitive damage of each subject.
Moreover, the results show no prevalence of males compared to
females, neither from a physical nor from a psychical point of view;
in fact even if male subjects seem to be superior to female subjects
in physical performance, in physical performance, this superiority

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M. Costarella et al. / Archives of Gerontology and Geriatrics 50 (2010) 332337

Fig. 5. (AD) Examples of COP trends: abscissa, acquisitions (total length, 30 s); ordinate, sensitive elements (1 division = 1 cm).

is valid only with regard to absolute values of the performance

(FR), not to the relative ones (ratios FR/H).
Otherwise, it could be interesting, thanks to the analysis of a
larger sample, to study what emerges from the comparison
between physical performance and cognitive abilities, that is the
faster damage of the rst compared to the second. Some data of
literature assert that physically active older people, in good
physical form, show higher cognitive and psycho-motor performance than their sedentary fellows of the same age (Connelly,
2000; Spirduso and Cronin, 2001) from this it could be assumed
that regular physical activity, that improves the psycho-physical
performance of older people through an improvement of the
physical form indexes (aerobic ability, muscular strength, balance),
could also be a protective element for older subjects in terms of
cognitive and subsequently physical functional abilities.
Finally, we would like to point out that the tests were executed
during 2 months. The authors think that it might be worth
considering, in order to estimate psycho-physical trends with age
in the one subject, to repeat the tests on the same subjects after 2 or
3 years.
Table 2
Psychophysical characteristics according to age: (mean  SD).
FR (cm)

FR/H

DCOP

MMSE/FR

All subjects
5564
28.2  1.3
6574
26.3  1.5
>75
25.3  1.3

30.7  4.3
23.5  4.8
21.4  6.0

0.185  0.023
0.147  0.028
0.130  0.033

5.5  1.3
3.9  1.2
2.8  1.2

0.933  0.122
1.162  0.250
1.307  0.457

Males
5564
6574
>75

28.7  1.2
26.4  1.4
25.3  1.3

31.5  5.0
25.7  3.9
22.8  6.2

0.185  0.027
0.153  0.023
0.137  0.033

5.5  1.6
4.3  1.1
2.7  1.2

0.931  0.152
1.048  0.170
1.213  0.429

Females
5564
6574
>75

27.5  1.1
26.2  1.7
25.8  1.3

28.3  4.7
24.0  4.4
18.5  6.0

0.178  0.032
0.156  0.026
0.119  0.037

5.5  0.8
3.7  1.3
3.1  1.2

0.936  0.069
1.246  0.273
1.513  0.497

Groups

MMSE

Conict of interest statement

None.
Acknowledgement
Presented as paper at 9th Biennal ASME Conference on
Engineering System Design and Analysis (Haifa - Il; July 7/9/2008).
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