functional use of the upper extremity is fundamental for performing movements required in 
 daily activities .
upper extremity function is divided into two categories of motor skills : 
 fine motor skills ( e.g. , feeding , dressing , and grooming ) and gross motor skills ( e.g. , 
 crawling , walking , and postural control)1 . 

it usually involves a repetitious sequence of limb motions to simultaneously move a body 
 segment and maintain its stability . in older adults , the gross motor skills ( e.g. , for 
 reaching and grasping ) as well as fine motor skills ( e.g. , for manipulation ) are slower and 
 less accurate than in normal young adults2 .
therefore , whole - arm coordination , eye - head coordination , visual 
 acuity , and muscle strength are important factors for well - coordinated upper extremity 
 function3 . visual deficits and cognitive impairment are major problems resulting in changes in reach , 
 grasp , and manipulation in community - dwelling older adults . upper extremity function , like 
 other functional activities , is affected by age - related alteration in the visual system4 .
many previous studies have indicated that 
 decreased velocity in reaching movements or in repetitive tapping tasks are associated with 
 age - related changes in visual processing4,5,6 . 

most of these studies used complex methods or equipment , such as kinematic measurement 
 systems , to evaluate the relationship between upper extremity function and visual 
 information4,5,6 .
these measurement tools 
 provide qualitative data on this relationship , but do not provide in - depth information on 
 upper extremity function or the relationships among upper extremity function , visual 
 deficits , and cognitive impairment .
these tools are able to identify the 
 scope of participants characteristics , and are appropriate for examination of the 
 relationships among visual perceptual function , upper extremity function , and cognitive 
 function .
the purpose of this study was to investigate the relationships among visual 
 perceptual function , upper extremity function , and cognitive function in community - dwelling 
 older adults .
fifty - eight community - dwelling older individuals , recruited from three senior complex 
 community centers , participated in this study . this convenience sample was recruited using a 
 leaflet that provided information regarding the purposes , procedures , rights of subjects , 
 data usages , and other aspects of this study .
the study was carried out in accordance with 
 the international ethical guidelines and declaration of helsinki and was approved by the 
 local institutional review board .
the 
 inclusion criteria were as follows : age > 60  years , absence of neurological deficits , 
 absence of severe orthopedic diseases that could impact the procedures , and absence of 
 significant cognitive impairments that would prevent understanding of verbal instructions . 

the exclusion criteria were as follows : serious visual impairment , dizziness or other 
 vestibular impairment , and a history of severe alcohol or medication abuse .
table 1table 1.clinical and demographic characteristics of the study participants ( n=58)variablesnumberpercentilegendermale2034.5female3865.5age ( yrs)616511.766701220.77175915.576801932.881851017.2 > 85712.1medical historyosteoarthritis5594.8hypertension4679.3diabetes4882.8 shows the clinical and demographic characteristics of the participants , 
 including sex , age , and medical history .
this was a cross - sectional study , in which the following four clinical tools were used : the 
 mini - mental state examination ( mmse ) , 9 hole pegboard ( 9hp ) , box and block test ( bbt ) , and 
 motor - free visual perception test , third edition ( mvpt-3 ) .
two occupational therapists with 
 clinical experience evaluated participants performance on all measurements and followed the 
 standard method for administration of each clinical measure in a small tidy therapy room . 

the mmse is a valid , reliable , and extensive test of cognitive function ; it was developed 
 as a to screening test for dementia and delirium by folstein and folstein in 1975 .
the tool 
 is a 30-point questionnaire , with scores ranging from 0 ( complete cognitive impairment ) to 
 30 ( no cognitive impairments ) and consists of 10 items grouped into five domains : 
 orientation , registration , attention - calculation , recall , and language7 .
the 9hp is a simple , reliable , and valid measurement of 
 finger dexterity .
the tool is administered by asking the individual to take pegs from a 
 container , one by one , and place them in holes on a board as quickly as possible . 

participants must then remove the pegs from the holes , one by one , and replace them back 
 into the container .
the time ( seconds ) taken to complete the test is recorded as the score . 

a stopwatch , running from the moment the participant touches the first peg until the moment 
 the last peg is placed in the container , is used to record the time8 .
the participant is asked to grasp one block at a 
 time , transport the block over a partition , and release it into the opposite compartment . 

the score is the number of blocks carried from one compartment to the other in one minute . 

the 
 mvpt-3 , developed by chalfant and scheffelin is a representative measurement of visual 
 perception and cognitive skill , the mvpt-3 includes five different areas : spatial 
 relationships , visual discrimination , figure - ground , visual closure , and visual memory . 
 individuals older than age 10 start with the example for item 14 .
reliability of mvpt-3 
 scores was assessed with internal consistency and test - retest stability estimates .
internal 
 consistency estimates for the standardization sample ranged from 0.86 to 0.90 for ages 11 to 
 > 85 years10 .
the means and standard deviations of the dependent measures were analyzed using descriptive 
 statistics .
pearson correlations were used to determine the relationships between manual 
 dexterity , static and dynamic balance , and visual perception .
the collected data were 
 analyzed using the pasw version 18.0 for windows ( spss inc . , chicago , il , usa ) , and the 
 significance level was set at p < 0.05 .
table 2table 2.mean and standard deviation of clinical outcome measures in this study 
 ( n=58)variablesmeanstandard deviationmini - mental state examination ( scores)25.62.79 hole pegboard ( seconds)right 14.24.0left15.34.3box and block test ( scores)right63.110.6left59.311.8motor - free visual perception test - third edition 
 ( scores)44.38.3 shows the means and standard deviations for the four clinical measures .
the 
 mmse correlated significantly and positively with the bbt on the dominant and non - dominant 
 sides , with bbt on the non - dominant side , and with mvpt-3 .
the mmse correlated significantly 
 and negatively with 9hp on the dominant and non - dominant sides .
the 9hp on the dominant side 
 demonstrated a significantly positive correlation with 9hp on the non - dominant side as well 
 as a significantly negative correlation with mmse and bbt on both the dominant and 
 non - dominant sides .
the 9hp on the non - dominant side had a significantly positive 
 correlation with the 9hp on the dominant side and a significantly negative correlation with 
 mmse and bbt on the dominant and non - dominant sides .
the bbt on the dominant side had a 
 significantly positive correlation with mmse , bbt on the non - dominant side , as well as with 
 mvpt-3 , and had showed significantly negative correlation with 9hp .
the bbt on the 
 non - dominant side had a significantly positive correlation with mmse , with bbt on the 
 dominant side , and with mvpt-3 , and a significantly negative correlation with 9hp , the 
 mvpt-3 correlated significantly with mmse and bbt .
however , the mvpt-3 did not correlate 
 significantly with 9hp on either the dominant or non - dominant side ( table 3table 3.relationship among the clinical outcome measures in this study ( n=58)variablesmmse9hp - rt9hp - ltbbt - rtbbt - ltmvpt-3mmse0.4580.4190.4200.4230.7779hp - rt0.4580.9280.3570.4170.1719hp - lt0.4190.9280.3170.4320.148bbt - rt0.4200.3570.3170.9320.341bbt - lt0.4230.4170.4320.9320.322mvpt-30.7770.1710.1480.3410.322p<0.05 ; p<0.01 ; mmse : mini - mental state examination ; 
 9hp - rt : 9 hole pegboard - right ; 9hp - lt : 9 hole pegboard - left ; bbt - rt : box and block 
 test - right ; bbt - lt : box and block test - left ; mvpt-3 : motor - free visual perception 
 test - third edition ) .
p<0.05 ; p<0.01 ; mmse : mini - mental state examination ; 
 9hp - rt : 9 hole pegboard - right ; 9hp - lt : 9 hole pegboard - left ; bbt - rt : box and block 
 test - right ; bbt - lt : box and block test - left ; mvpt-3 : motor - free visual perception 
 test - third edition
this study examined the correlations among visual perception , manual dexterity , and 
 cognitive impairment for community - dwelling older adults .
the most important findings are as 
 follows : ( 1 ) visual perceptual function had a negative correlation with the 9hp performance 
 and a positive correlation with the bbt performance ; ( 2 ) visual perceptual function had a 
 positive correlation with cognitive function had ; and ( 3 ) cognitive function showed a 
 negative correlation with the 9hp score and a positive correlation with the bbt score .
visual perception is necessary for basic and instrumental activities of daily living ( adls ) 
 as well as for functional activities .
previous studies have reported that age - related visual 
 dysfunctions include generally decreased visual acuity and adaptability , reduction of depth 
 perception , and reduction in peripheral vision11 , 
 12 . because of the close relationship 
 between vision and perception , age - related visual changes influence perceptual abilities in 
 older adults .
older individuals demonstrate decreased visual discrimination , impaired 
 figure - ground discrimination , decreased visual memory , decreased spatial relations , 
 decreased pattern recognition , and poor attentional processing13 .
visuo - perceptual dysfunction influences functional 
 activities such as basic - adls , instrumental - adls , as well as work and recreational 
 activities14 , 15 .
brown et al . reported that the impairment of visual - motor 
 integration in older adults leads to poor balance skills and to a higher incidence of falls 
 and accidents16 .
zheng et al . also 
 reported that older adults with visual acuity impairment demonstrated instrumental - adls 
 functional state decline and an increased risk of mortality17 .
the results of this study suggest that improved visual perceptual 
 function in older adults is associated with improved manual dexterity .
this study also measured cognitive impairment in order to investigate the relationships 
 among visual perception , cognitive function , and manual dexterity .
although there is no 
 universal effect of aging on learning , age - related changes in memory , processing ability , 
 attention , and executive functions such as problem solving , mental flexibility , or 
 abstraction are well documented18 .
this 
 study demonstrated that cognitive performance can affect manual dexterity in older adults . 

therefore , visual perceptual impairment and cognitive dysfunction can lead to decline in 
 upper extremity function in older adults .
age - related visual perceptual impairment and 
 cognitive dysfunction should be considered in light of their effect on manual dexterity in 
 older adults .
the results of this study also suggest that there may be benefits to 
 approaches that involve rehabilitation of upper extremity function , concurrent with visual 
 perception and cognitive training for older adults .
future studies are therefore needed to 
 evaluate the therapeutic effects of visual perception and cognitive training programs on 
 upper extremity function in older adults .
 [ purpose ] the purpose of the present study was to examine the relationship between visual 
 perceptual function and manual dexterity in community - dwelling older adults . 
 [ subjects and 
 methods ] fifty - eight participants were recruited by convenience sampling from local 
 rehabilitation centers . 
 this was a cross - sectional study that used the following four 
 clinical tools : the mini - mental state examination , 9 hole pegboard , box and block test , 
 and motor - free visual perception test , third edition . 
 [ results ] the motor - free visual 
 perception test , third edition and mini - mental state examination correlated significantly 
 and positively with box and block test , and did correlate significantly and negatively 
 with 9 hole pegboard . 
 [ conclusion ] the results of this study suggest that visual 
 perceptual impairment and cognitive dysfunction may influence manual dexterity in older 
 adults , and rehabilitation of upper extremity function , along with visual perception and 
 cognitive training , may be beneficial for this population . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION