it is a complex clinical syndrome that involves memory impairment , behavioral 
 disorders , and personality changes1 .
the 
 main features of dementia are reduced cognitive ability , neurological and psychiatric 
 symptoms , and functional disability2 .
alzheimer s disease ( ad ) has a similar clinical presentation to vascular dementia , but they 
 differ because the onset of ad typically occurs in old age .
in addition , ad symptoms are irregular and 
 fluctuating3 , which includes frontal 
 lobe symptoms such as impairments in executive cognitive functions such as attention , 
 planning , and cognitive processing speed4 . 
 as a result ,
people with ad experience severe behavioral changes such as depression , 
 behavioral delay , psychomotor slowness , and anxiety5 .
ad is associated with damage to the hippocampus and entorhinal 
 cortex6 , which progresses to the 
 prefrontal , right parietal posterior , occipital , and temporal lobes of the cerebral cortex , 
 as well as to the nigrostriatal cells7 . as elderly patients with dementia age ,
they show reductions in abilities such as sight , 
 balance control , vestibular function , and proprioceptive sensation .
these reductions 
 contribute to physical inactivity , cognitive impairment8 , increased muscle stiffness , and functional limitations , which 
 result in reduced activities of daily living , weight gain , and muscle loss . physical 
 weakness
the 
 emotional disorders that occur in 4050% of elderly patients with dementia decrease quality 
 of life , negatively impact other health conditions , and impair cognitive function10 , 11 .
the complicated characteristics of elderly patients with dementia 
 are interrelated and contribute to progressive impairment .
therefore , an integrated approach 
 is necessary in order to improve health and preserve functional ability and quality of life 
 and for elderly patients with dementia12 .
the present study investigated the effects of combined cognitive and fine motor activity 
 therapies on the degree of dementia , depression , and activities of daily living in elderly 
 patients with the ad .
participants were 26 patients with ad who were at least 65  years old , and who attended the 
 gyeonggi s senior center .
inclusion criteria were as follows : no exercise habits , cdr 0.55 
 points , a diagnosis of ad , no regular cognitive rehabilitation treatment after onset of 
 dementia , and ability to understand simple verbal instructions .
participants were excluded 
 if they had vascular dementia by stroke , diagnosis of other dementia , fracture or 
 musculoskeletal disorder13 , or brain 
 surgery .
the present study was approved by sahmyook university institutional review board 
 ( syuirb2014 - 027 ) and each subject was able to follow instructions and gave informed consent 
 by signing an approved consent form ; thus , the rights of human subjects were protected .
characteristics of the combined fine motor skill and cognitive therapy group were : 3 males 
 and 10 females , mean age of 80.15  5.21  years , mean height of 156.15  10.38  cm , mean 
 weight of 54.08  9.32  kg , and duration after ad onset of 5.46  3.71  years .
characteristics 
 of participants in the control group were : 2 men and 11 women , mean age of 80.00  
 6.90  years , mean height of 151.46  6.94  cm , mean weight of 53.46  12.24  kg , and duration 
 after ad onset of 5.77  3.41  years .
thirty - nine participants were divided into either the cognitive intervention group with 
 fine motor activities ( n = 20 ) or the control group ( n = 19 ) .
four of 29 participants in the 
 experimental group had limited participation , and 3 participants in the experimental group 
 abandoned the study . in the control group ,
both groups were treated with 5  mg donepezil just prior to sleep , once 
 daily for 12 weeks .
participants in the experimental group engaged in fine motor activities 
 for 60  min , thrice a week for 12 weeks . cognitive therapy with fine motor activities
consisted of coloring , singing14 , matching picture cards , playing 
 instruments , physically interactive games ( ball toss , bowling , and ring toss ) , doing 
 puzzles15 , chopsticks games , janggial 
 football , and a fishing game .
therapy was conducted using a chair or a wheelchair with 
 armrests and back , a desk , and small tools .
first , a physical therapy program occurred for 
 5  min in order to release shoulder and neck tension by stretching and clapping .
dementia was assessed using the korean convenience mental state examination ( korean - mini 
 mental state examination , k - mmse ) .
k - mmse primarily assesses cognitive ability , is highly 
 reliable ( cronbach s  = 0.98 ) , and consists of scales to assess disorientation , memory , 
 visual ability , concentration , calculation , verbal language , writing , reading , and 
 configuration abilities16 .
the degree of dementia in elderly patients with ad was assessed using the clinical dementia 
 scale ( clinical dementia rating , cdr ) .
the cdr assesses both alzheimer s dementia and the 
 severity of different types of dementia .
it consists of 6 subscales , including memory , 
 orientation , judgment and problem - solving , social activities , family life and hobbies , and 
 personal hygiene .
cdr data are analyzed with a complex algorithm and yield scores from 05 
 points , with higher numbers indicating more severe dementia ( cronbach s  = 0.90)17 .
overall degeneration associated with dementia was assessed with the global deterioration 
 scale ( gds ) .
the gds is most widely used as the basis for determining drug therapy for 
 patients with dementia .
it evaluates declining cognition and social functioning , and 
 consists of subscales for memory , orientation , judgment and problem - solving skills , social 
 activities , family life and hobbies , and hygiene or grooming ( cronbach s  = 0.93)18 .
the korean form of the geriatric 
 depression scale ( kgds ) was used to assess depression .
the kgds is useful for administration 
 to elderly people who are healthy , ill , or have impaired cognition , and consists of 30 scale 
 items .
depression is classified as mild ( 1418 points ) , moderate ( 1921 points ) , or severe 
 ( 22 points or more ) ( cronbach s  = 0.94)19 .
the mbi consists 
 of the following 10 subcategories : personal hygiene , bathing , eating , toileting , climbing 
 stairs , dressing , adjustable stool use , urine control , walking or wheelchair use , and 
 transferring to chair or bed , which are scored to a maximum total of 100 points ( cronbach s 
  = 0.90)20 .
descriptive statistics were used to describe participant characteristics , and 
 independent sample t - tests and  tests assessed homogeneity between groups . 

paired t - tests were used to evaluate changes before and after the k - mmse , cdr , gds , kgds , 
 and mbi .
independent t - tests were used to test differences in demographic characteristics 
 between groups .
k - mmse , cdr , gds , kgds , and mbi scores improved in the experimental group but only kgds 
 scores improved for participants in the control group .
however , there were no significant 
 differences between the groups for any of the variables ( p<0.05 ) ( table 1table 1.comparison of outcome measures with groups and between groups ( n=26)parametersvalueschange valuescognitive therapy group ( n=13)control group ( n=13)cognitive therapy group ( n=13)control group ( n=13)prepostprepostpost - prepost - precognitive parametersk - mmse ( score)18.62 ( 2.46)22.08 ( 2.62)***15.08 ( 3.54)14.54 ( 4.40)3.46 ( 1.85)0.54 ( 4.87)degree of dementiacdr ( score)2.38 ( 0.87)1.73 ( 0.78)**2.23 ( 0.83)2.50 ( 1.38)0.65 ( 0.62)0.26 ( 0.78)gds ( score)5.15 ( 0.89)4.46 ( 1.12)**4.85 ( 1.46)5.08 ( 1.32)0.69 ( 0.63)0.23 ( 0.92)depression parameterskgds ( score)15.08 ( 6.47)11.46 ( 6.03)*10.38 ( 9.96)9.38 ( 10.27)3.62 ( 3.66)0.92 ( 3.37)adl parametersmbi ( score)55.54 ( 15.30)60.92 ( 12.95)*56.77 ( 19.55)55.23 ( 21.73)5.38 ( 6.19)1.38 ( 8.48) values are mean ( sd ) , k - mmse : korea - mini mental state examination , cdr : clinical 
 dementia rating , gds : global deterioration scale , kgds : korea geriatric depression 
 scale , mbi : modified barthel index .
 values are mean ( sd ) , k - mmse : korea - mini mental state examination , cdr : clinical 
 dementia rating , gds : global deterioration scale , kgds : korea geriatric depression 
 scale , mbi : modified barthel index .
the purpose of this study was to investigate the effects of cognitive therapy with fine 
 motor activities on cognition , degree of dementia , depression , and activities of daily 
 living in elderly patients with ad .
cdr scores and gds scores were significantly decreased in the experimental group compared to 
 the control group ( p<0.05 ) . in a previous study
, spector22 administered a cognitive stimulation program that included using 
 money , a ball game , and a word game , which was realistic training for patients with 
 dementia .
patients were 
 assigned to either the experimental group ( n = 115 ) or the control group ( n = 86 ) .
the 
 experimental group participated in the cognitive stimulation program and the control group 
 received only general medical intervention .
there were significant increases in the 
 experimental group mmse scores compared to the control group ( p<0.05 ) .
yamanaka15 assessed a cognitive 
 stimulation program for patients with dementia , which also occurred for 45  min twice per a 
 week for 7 weeks .
the experimental group ( n=26 ) participated in a cognitive stimulation 
 program that included word puzzles , word games , physically interactive games , puzzles , using 
 tools , number card games , and using money .
mmse 
 scores were significantly increased in the experimental group compared to the control group 
 ( p<0.05 ) .
eleven participants in the experimental group 
 were participated in face - name associated training with errorless learning and spaced 
 retrieval training , as well as memory training .
eleven participants in the control group 
 participated in face - name associated training with errorless learning , as well as memory 
 training .
this study showed increased cognition , similarly to the 
 findings of spector22 and yamanaka15 .
the degree of dementia also decreased , 
 similarly to the findings of jean23 . in 
 order to increase cognitive functioning , aerobic exercise or strength training
however , a recent study demonstrated that the effects of exercise are 
 mediated via synaptic plasticity mechanisms or neuron generation24 , 25 .
brain areas 
 responsible for the hand function are utilized , so fine motor activity should improve 
 cognitive functioning due to stimulating both the premotor cortex and also the nerves of the 
 other cortex .
the degree of dementia in elderly patients with ad is thought to significantly 
 decrease because of increasing the cognitive function .
depression can occur at any age , and it is a mental illness with both social and personal 
 effects . cognitive impairment and dementia risk increase in elderly patients with 
 depression26 .
an experimental group 
 ( n = 11 ) was offered exercise programs with cognitive activities for 20  min thrice a week , 
 for 12 weeks . a control group ( n = 9 )
was provided only with cognitive activities for 20  min 
 thrice a week , for 12 weeks .
general physical therapy was offered to both groups for 30  min , 
 5 times a week , for 12 weeks .
both 
 groups had significantly decreased gds scores ( p < 0.05 ) but there was no difference 
 between groups . kerse26 used the otago program with 193 
 elderly people with depression , for 30  min thrice a week , for 6 months .
the experimental 
 group ( n = 97 ) participated in upper extremity exercise programs from the otago exercise 
 program and the control group ( n = 96 ) had only a social visit .
as a result , gds-15 scores 
 significantly decreased in both groups ( p < 0.001 ) , but there was no difference between 
 groups . in this study , kgds was used to assess depression in elderly patients with 
 alzheimer s dementia .
kgds scores decreased significantly in the experimental group compared 
 to the control group ( p < 0.05 ) .
the present study found decreased depression , similarly 
 to the results of yoon19 and kerse26 .
depression includes impairment in 
 cognitive functioning and decreased ability to perform activities of daily living due to 
 alzheimer s dementia . however , cognitive treatment with fine muscle activity improved not 
 only cognitive function and the ability to participate in activities of daily living , but 
 also decreased depression .
the variation in findings between studies likely results from differences in study 
 durations , participants , and treatment methods .
physical activity is necessary to the 
 elderly , who are often concerned about the possibility of declining health , including social 
 support , lack of exercise , discomfort , and falls
. decreased abilities of elderly patients 
 with dementia to perform activities of daily living contribute to difficulties with walking 
 or climbing stairs , which increase the probability of a fall , followed by entering a medical 
 institution , and incurring the associated medical costs27 .
tsolaki28 investigated gait and balance 
 in 176 elderly people with mild cognitive impairment . there were 20 sessions once a week for 
 12 weeks .
the experimental group ( n = 104 ) participated in cognitive training , including 
 naming objects and numbers backwards .
activities of daily living significantly increased in the experimental group ( p < 
 0.001 ) . in the present study , the mbi measured ability of elderly patients with ad to 
 perform daily living tasks , and found that mbi was significantly increased in the 
 experimental group compared to the control group .
our findings demonstrating increased activities of daily living are 
 similar to results reported by tsolaki28 . 

fine muscle activities with cognitive therapy improved hand manipulation for elderly 
 patients with ad , improved sensation and function of the hand , and improved performance of 
 activities of daily living . although not a replacement for a walker , a cane , or other 
 suitable balance treatments , improved hand function contributes to reducing fear to perform 
 activities of daily living for elderly patients with alzheimer s disease .
executive 
 function in elderly patients with ad was advanced due to various activities such as 
 coloring , using chopsticks , jenga and block play , mosaics , puzzles , jigsaw puzzles , playing 
 instruments , singing , and tossing a ball .
mbi 
 scores of 5074 points indicate a moderate level of independence in daily life .
therefore , 
 although the mbi scores increased from 5.38 points to 60.92 points for elderly patients with 
 ad in the present study , these patients still require assistance .
 [ purpose ] this study evaluated the effects of combined fine motor skill and cognitive 
 therapies on cognition , depression , and activities of daily living in elderly patients 
 with alzheimer s disease ( ad ) . [ subjects and methods ] twenty - six participants comprised 2 
 groups . 
 the experimental group ( n=13 ) received combined fine motor skill and cognitive 
 therapy , and the control group ( n=13 ) received only general medical care . 
 [ results ] the 
 experimental group showed improvements in cognition , degree of dementia , depression , and 
 activities of daily living compared to the control group . however , there were no 
 significant differences between the two groups . 
 [ conclusion ] these results suggest that 
 combined fine motor skill and cognitive therapy improves cognition , degree of dementia , 
 depression , and daily living in elderly patients with ad . 
 these therapies would therefore 
 be effective as general medical care strategies . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION