Hong Kong J Psychiatry 2007;17:13-6


Emotional Reactions towards Perceived Loss of Function in Older Chinese People with Dementia
AWT Fung, DNY Luk, VWC Lui, PWC Tam, RCM Chau, VWK Poon, CHL So, HWT Lo, FSL Ko, LCW Lam

Ms Ada WT Fung, BSc, BA, Department of Psychiatry, Tai Po Hospital, The Chinese University of Hong Kong, Hong Kong, China.
Dr Daisy NY Luk, MCRCPsych, Department of Psychiatry, Tai Po Hospital, The Chinese University of Hong Kong, Hong Kong, China.
Dr Victor WC Lui, FHKCPsych, Department of Psychiatry, Tai Po Hospital, The Chinese University of Hong Kong, Hong Kong, China.
Mr Peter WC Tam, MSocSc, BSc, Occupational Therapy Department, North District Hospital, Hong Kong, China.
Ms Rachel CM Chau, BSc, Department of Psychiatry, Tai Po Hospital, The Chinese University of Hong Kong, Hong Kong, China.
Ms Vickie WK Poon, MSc, Occupational Therapy Department, North District Hospital, Hong Kong, China.
Mr Clifton HL So, BSc, Occupational Therapy Department, North District Hospital, Hong Kong, China.
Mr Henry WT Lo, BSc, Occupational Therapy Department, North District Hospital, Hong Kong, China.
Ms Flora SL Ko, MSc, Occupational Therapy Department, North District Hospital, Hong Kong, China.
Prof Linda CW Lam, MD, FHKCPsych, Department of Psychiatry, Tai Po Hospital, The Chinese University of Hong Kong, Hong Kong, China.

Address for correspondence: Ms Ada WT Fung, Department of Psychiatry, G/F, Multi-centre, Tai Po Hospital, Tai Po, Hong Kong, China.
Tel: (852) 6372 0238; Fax: (852) 2667 5464; E-mail: ada_fung@cuhk.edu.hk

Submitted: 6 February 2007; Accepted: 31 March 2007

pdf Full Paper in PDF


Objectives: To evaluate emotional response towards perceived loss of activities of daily living in Chinese elders with dementia.

Partients and Methods: Eighty one elderly people with a clinical diagnosis of dementia were recruited from residential homes and social centre for the elderly in Hong Kong. A purpose-designed questionnaire on subjective evaluation of ability and emotional reactions towards functional deterioration was derived. The association between the subjective evaluation of ability, emotional reactions, ado actual activities of daily living performance measured by the Chinese version of Disability Assessment for Dementia was evaluated.

Results: There were no significant correlations between subjective evaluation of ability and the emotional reactions towards functional impairment Subjects reported greater higher emotional distress over possible loss of basic activities of daily living than instrumental activities of daily living (t = 3.04, p = 0.003). Subjects with better basic activities of daily living abilities were likely to report greater distress if their instrumental activities of daily living were impaired (Spearman's rho = 0.30, p = 0.01).

Conclusions: Although elderly people with dementia may have compromised cognitive abilities, attention to functional training is an important means of improving their emotional well-being.

Key words: Activities of daily living; Dementia; Emotions; Frail elderly




結果:主觀能力評估和情緒反應並無顯著關係。受訪者對可能喪失基本功能所造成的心理困擾,要較喪失技術性功能的嚴重( t = 3.04; p = 0.003 )。此外,擁有較佳基本功能的長者,對技術性功能受損能導致較嚴重的心理困擾 (Spearman’s rho = 0.3; p = 0.0 1 ) 。




Dementia is associated with functional impairment in everyday tasks.1-3 As dementia progresses, the ability to function declines and the ability to evaluate the extent of that inability to carry out activities of daily living (ADL) may be impaired.1,4 Depressive symptoms are frequently reported in persons with dementia.5-8 The coexistence of depression and dementia hastens functional impairment.9 Functional impairment is greater in demented elders with depression than those without.10 Although previous findings suggested that functional impairment is associated with depression, few studies evaluated how the perception of deterioration in function relates to the emotional reactions (ERs) of older people with dementia.

For better dementia care planning, it would be important to appreciate the subjective experience of functional impairment in older people with this disorder. This study aimed to examine the perceptions of own ability to carry out ADL in elderly people with dementia, and their ERs towards their perceived and actual impairment.



The participants were people recruited for a functional training programme from 6 residential homes (old-aged homes [OAHs]) and 1 community centre for elderly people in Hong Kong. The inclusion criteria were meeting the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnosis of dementia, being aged 60 years or above, and able to communicate freely verbally. A proportion of subjects with Clinical Dementia Rating (CDR) Classification of Questionable Dementia was also included to obtain a full spectrum of dementia severity. Eighty one subjects were assessed. Informed consent was obtained from the participants and / or their first-degree relatives, as well as the superintendents of the OAHs and the in-charge officer of the social centre.


Subjective Evaluation and Emotional Reactions towards Functional Deterioration

A questionnaire on ERs towards functional deterioration (ERQ) was designed to evaluate the self-perception of levels of everyday functioning. It comprised 6 items relating to self-evaluation of basic activities of daily living (BADL: self-care / grooming) and 20 items relating to own perception about instrumental activities of daily living (IADL: meal preparation, household chores, and travelling and communication). For each activity, the ERQ measured (1) subjective ability (SA) to perform such activity and (2) ER towards possible loss of ability to carry out the specific task.

Participants were asked to rate their SA to carry out both BADL and IADL on a 4-point scale (0-3), where 0 represented ‘subject feels that they can no longer perform this task’, 1 represented ‘subject feels that they can perform the task with maximal assistance’, 2 represented ‘subject feels that they can perform the task with minimal assistance’, and 3 represented ‘subject feels that they can perform the task well as before’. They were also asked to rate their ER if they were unable to carry out the activities concerned on a 4-point scale (0-3), where 0 represented ‘subject is not unhappy, if s/he is no longer able to carry out the task in concern’, 1 represented ‘slightly unhappy’, 2 represented ‘very unhappy’, and 3 represented ‘extremely unhappy’.

Functional Assessment

The objective functional performance of the participants was assessed using the Chinese version of the Disability Assessment for Dementia (DAD).11 This assessment evaluated BADL and IADL from 3 perspectives. A composite BADL and ADL score (usually expressed in

%) was derived from the 3 subscale scores of initiation, planning and organisation, and effectiveness. The severity of dementia was measured using the CDR and the Mini- Mental State Examination (MMSE).12 Mood symptoms were assessed using the Cornell Scale for Depression in Dementia (CSDD).13

Statistical Analysis

To examine the relationships between SA and objective functional performance, the subjective function scores obtained from the ERQ were compared with the ADL scores obtained from DAD using correlation analyses. The relationships between ER and DAD scores were also analysed. A non-parametric correlation was carried out to examine the correlations between variables with skewed distributions. Statistical significance was set at a level of p = 0.05. Bonferroni Corrections were performed for multiple comparisons. Data analysis was performed with the Statistical Package for the Social Sciences (SPSS) Windows version 14.0.


Demographic Characteristics

The mean age of the participants (n = 81) was 83.77 (7.08) years. There were 17 men and 64 women. The mean years of education was 2.21 (SD = 3.23) years. Eighteen (22%) subjects were diagnosed with a CDR of 0.5 (questionable dementia); 30 (37%) were mildly demented (CDR 1), 28 (35%) were moderately demented (CDR 2), 5 (6%) were suffering from severe dementia (CDR 3). The Chinese version of MMSE scores ranged from 1 to 27 (mean = 14.96, SD = 5.10). The mean CSDD score was 4.09 (3.81). The mean (SD) BADL subscale scores for initiation, planning and organisation, and effectiveness were 0.83 (0.30), 0.70 (0.34), and 0.68 (0.32) respectively. The mean (SD) IADL subscale scores on initiation, planning and organisation, and effectiveness were 0.38 (0.35), 0.20 (0.26), and 0.26 (0.27) respectively. The mean (SD) SA scores on BADL and IADL were 2.69 (0.47) and 2.08 (0.75) respectively. The mean (SD) score for ER to functional impairment in BADL and IADL were 1.11 (0.86) and 0.87 (0.77) respectively (Table 1).

Subjective Evaluation and Emotional Reactions towards Loss of Functioning

There were no significant correlations between SA and ER in both BADL and IADL [SA (IADL) vs. ER (IADL), Spearman’s rho = –0.14, p = 0.21; SA (BADL) vs. ER (BADL), Spearman’s rho = 0.09, p = 0.43]. Concerning the association between subjective evaluation and objective ADL assessment, SA to carry out BADL was significantly associated with DAD scores (BADL: Spearman’s rho = 0.33, p = 0.003; IADL, Spearman’s rho = 0.36, p = 0.002). Subjective ability to carry out IADL was not associated with DAD scores on IADL (Table 2).

Subjects perceived that they performed BADL (mean = 2.69, SD = 0.47) better than IADL (mean = 2.08, SD = 0.75). There was a significant difference in ER towards impaired ability in BADL, compared with ER due to impaired IADL. Participants were more upset over possible impairment of BADL (mean = 1.11, SD = 0.86) than possible impairment of IADL (mean = 0.87, SD = 0.77) [t = 3.04, p

= 0.003]. The DAD (BADL) scores correlated significantly with ER towards the loss of IADL (Spearman’s rho = 0.30, p = 0.01). A better performance in DAD (BADL) correlated positively with ER towards IADL impairment. Subjects with better BADL ability were likely to report greater distress if their IADL were impaired. A similar but statistically non- significant trend was observed in the correlation between actual ability and ER towards perceived loss of BADL (Spearman’s rho = 0.27, p= 0.02, Bonferroni Corrections). No significant correlation between actual ability and ER towards loss of IADL was found (Table 2).


The relationships between the severity of dementia and functional impairment have been widely reported. Instrumen- tal ADL declines rapidly in the early stages of dementia, while the decline of BADL occurs at a later stage.14-19 The significant association between self-evaluation and objective measures of BADL suggested that subjects with dementia were able to evaluate their basic functioning. The lack of association between subjective and objective measures of IADL may be related to sensitivity of the scales, as IADL have already been greatly impaired in most subjects with dementia.

We were unable to identify any significant association between SA and ERs towards possible loss of functioning. While the results may be related to reduced ability to express emotions in subjects with more severe dementia, the findings may also reflect their expectations of function. While most of our participants reported their ability to perform everyday chores as less efficient, they did not report significant ERs towards that loss of functioning. It is possible that they did not have high expectations of independent functioning, so were less concerned about possible impairment. On the other hand, the analysis of the relationship between actual ability and ERs towards functional impairment showed that a better preservation of BADL was associated with higher reported emotional distress towards possible loss of ability to function. It is likely that a better performance of BADL reflected a milder stage of dementia, so the subjects were more able to appreciate the distress associated with functional impairment. With increasing severity of dementia, the ability to appreciate personal performance may be reduced.

There are a number of limitations in this preliminary study. First, perceptions of the ability to carry out daily tasks, particularly for IADL, may be distorted in moderately and severely demented people.1,4 Second, the ERQ might not be an appropriate questionnaire for examining ERs to perceived functional loss of IADL for people residing in OAHs. There are healthcare workers available to assist the residents with everyday activities in residential homes and residents are exempted from performing most instrumental chores.20 It might be difficult for the participants to accurately assess and report on their feelings towards functional loss of the activities concerned. Third, the small sample size, with few community-dwelling older people with dementia limits the generalisability of these results. Future studies should evaluate larger samples of community-dwelling older people with different levels of dementia. It would be important to evaluate and acknowledge the limitations of evaluating function in subjects with moderate-to-severe dementia. Lastly, it would be interesting to examine the responses of older people without dementia, as it is not clear how normal older people and those with dementia differ in terms of self- reported functioning and self-perception towards functional loss.

Our study highlights the difficulty of evaluating emotional distress related to functional impairment in subjects with dementia. To accurately appreciate the impact of functional disability, it is important to adopt simple measures to enhance communication and comprehension. Our findings suggest that those older people with milder levels of dementia are able to express their emotional distress over functional loss, particularly towards loss of maintenance of BADL. This reiterates the importance of the need for functional training to enhance the quality of life in this group of people.


The project is supported by a fund from the SK Yee Medical Foundation.


  1. Förstl H, Kurz A. Clinical features of Alzheimer’s disease. Eur Arch Psychiatry Clin Neurosci 1999;249:288-90.
  2. Tran M, Bedard M, Molloy DW, Dubois S, Lever JA. Association between psychotic symptoms and dependence in activities of daily living among older adults with Alzheimer’s disease. Int Psychogeriatr 2003;15:171-9.
  3. Yu F, Kolanowski AM, Strumpf NE, Eslinger PJ. Improving cognition and function through exercise intervention in Alzheimer’s disease. J Nurs Scholarsh 2006;38:358-65.
  4. Farias ST, Mungas D, Jagust W. Degree of discrepancy between self and other-reported everyday functioning by cognitive status: dementia, mild cognitive impairment, and healthy elders. Int J Geriatr Psychiatry 2005;20:827-34.
  5. Lyketsos CG, Steele C, Baker L, Galik E, Kopunek S, Steinberg M, et al. Major and minor depression in Alzheimer’s disease: prevalence and impact. J Neuropsychiatry Clin Neurosci 1997;9:556-61.
  6. Rubin EH, Veiel LL, Kinscherf DA, Morris JC, Storandt M. Clinically significant depressive symptoms and very mild to mild dementia of the Alzheimer type. Int J Geriatr Psychiatry 2001;16:694-701.
  7. Teri L, McKenzie G, LaFazia D. Psychosocial treatment of depression in older adults with dementia. Clinical Psychology: Science and Practice 2005;12:303-16.
  8. Starkstein SE, Jorge R, Mizrahi R, Robinson RG. The construct of minor and major depression in Alzheimer’s disease. Am J Psychiatry 2005;162:2086-93.
  9. Ritchie K, Touchon J, Ledésert B. Progressive disability in senile dementia is accelerated in the presence of depression. Int J Geriatr Psychiarty 1998;13:459-61.
  10. Hargrave R, Reed B, Mungas D. Depressive syndromes and functional disability in dementia. J Geriatr Psychiatry Neurol 2000;13:72-7.
  11. 1 Genlinas I, Gauthier L, McIntyre M, Gauthier S. Development of a functional measure for persons with Alzheimer’s disease: the disability assessment for dementia. Am J Occup Ther 1999;53:471-81.
  12. Morris JC. Clinical dementia rating: a reliable and valid diagnostic and staging measure for dementia of the Alzheimer type. Int Psychogeriatr 1997;9(Suppl 1):S173-8.
  13. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-84.
  14. Green CR, Mohs RC, Schmeidler J, Aryan M, Davis KL. Functional decline in Alzheimer’s disease: a longitudinal study. J Am Geriatr Soc 1993;41:654-61.
  15. Galasko D, Edland SD, Morris JC, Clark C, Mohs R, Koss E. The Consortium to Establish a Registry for Alzheimer’s Disease (CERAD). Part XI. Clinical milestones in patients with Alzheimer’s disease followed over 3 years. Neurology 1995;45:1451-5.
  16. Stern Y, Liu X, Albert M, Brandt J, Jacobs DM, Del Castillo-Castaneda C, et al. Application of a growth curve approach to modeling the progression of Alzheimer’s disease. J Gerontol A Bio Sci Med Sci 1996;51:M179-84.
  17. Schmeidler J, Mohs RC, Aryan M. Relationship of disease severity to decline on specific cognitive and functional measures in Alzheimer disease. Alzheimer Dis Assoc Disord 1998;12:146-51.
  18. Njegovan V, Hing MM, Mitchell SL, Molnar FJ. The hierarchy of functional loss associated with cognitive decline in older persons. J Gerontol A Bio Sci Med Sci 2001;10:M638-43.
  19. Suh GH, Ju YS, Yeon BK, Shah A. A longitudinal study of Alzheimer’s disease: rates of cognitive and functional decline. Int J Geriatr Psychiatry 2004;19:817-24.
  20. Desai AK, Grossberg GT, Sheth DN. Activities of daily living in patients with dementia: clinical relevance, methods of assessment and effects of treatment. CNS Drugs 2004;18:853-75.
View My Stats