Surprise Findings from Tower of Hanoi Research on Executive Cognitive Function in Older Adults: Assess, Intervene, or Both?
Mildren, Whitney G.
Cazzell, Mary A.
Holland, James Daniel
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Purpose: The purpose was to determine feasibility, reliability, and item difficulty of the 22-task Tower of Hanoi (TOH), an executive cognitive function (ECF) puzzle game, in adults > 65 years. Neuroimaging research has documented prefrontal cortex (PFC) changes in aging: deficits in abstract thinking, problem solving, and loss of inhibitory control over irrelevant information. The 22-task TOH, a 4-disk transfer game across 3 vertical pegs, has never been administered to or scored on older adults nor has TOH psychometrics been established in this population. Methods: In this quantitative descriptive design, a convenience sample of 50 cognitively-intact independent-living older adults (> 65 years) completed 22 TOH tasks, 22 different start and end configurations. Eligibility included a pre-screening score of >26 score on the Montreal Cognitive Assessment. Rasch analysis was completed on: (1) item-difficulty estimation, (2) item characteristic curves, (3) item-and-person-fit statistics of predicted functioning, and (4) test information function on precision of TOH in differentiating ability levels. 22 tasks were scored for correct/incorrect, total moves, number of moves beyond minimal moves, and gender differences. Cronbach's alpha was obtained for reliability. Results: All participants completed 22 tasks. Older adults demonstrated a lower ability to solve even the easiest tasks. Most TOH items were more difficult than the demonstrated problem-solving skills needed to achieve expected number of moves. TOH reliability alpha was 0.69. Approximately 21% of all 22-items were performed correctly/participant. Females completed significantly more correct items than males (p<0.001). All incorrect moves were analyzed and number of extra moves beyond correct solution ranged from 2.8 to 11.4. Conclusion: Despite TOH's level of difficulty, participants reported increased self-confidence, improved perception of cognitive abilities, and greater motivation to further practice on TOH. This study introduces TOH as both a cognitive assessment tool and intervention. Interpretation of the results was guided by the Scaffolding Theory of Aging and Cognition.