Instrumented Trail-Making Task to Differentiate Persons with No Cognitive Impairment, Amnestic Mild Cognitive Impairment, and Alzheimer Disease: A Proof of Concept Study

Document Type



Background: Objective and time-effective tools are needed to identify motor-cognitive impairment and facilitate early intervention. Objective: We examined the feasibility, accuracy, and reliability of an instrumented trail-making task (iTMT) using a wearable sensor to identify motor-cognitive impairment among older adults. Methods: Thirty subjects (age = 82.2 + 6.1 years, body mass index = 25.7 + 4.8, female = 43.3%) in 3 age-matched groups, 11 healthy, 10 with amnestic mild cognitive impairment (aMCI), and 9 with Alzheimer disease (AD), were recruited. Subjects completed iTMT, using a wearable sensor attached to the leg, which translates the motion of the ankle into a human-machine interface. iTMT tests included reaching to 5 indexed circles on a computer screen by moving the ankle-joint while standing. iTMT was quantified by the time required to reach all circles in the correct sequence. Three iTMT tests were designed, including numbers (1-5) positioned in a fixed (iTMTfixed) or random (iTMTrandom) order, or numbers (1-3) and letters (A and B) positioned in random order (iTMTnumber-letter). Each test was repeated twice to examine test-retest reliability. In addition, the conventional trail-making task (TMT A and B), Montreal Cognitive Assessment (MoCA), and dual-task cost (DTC: gait-speed difference between walking alone and walking while counting backward) were used as references. Results: Good-to-excellent reliability was achieved for all iTMT tests (intraclass correlation [ICC] = 0.742-0.836). Between- group difference was more pronounced, when using iTMTnumber-letter, with average completion time of 26.3 ± 12.4, 37.8 ± 14.1, and 61.8 ± 34.1 s, respectively, for healthy, aMCI, and AD groups (p = 0.006). Pairwise comparison suggested strong effect sizes between AD and healthy (Cohen's d = 1.384, p = 0.001) and between aMCI and AD (d = 0.923, p = 0.028). Significant correlation was observed when comparing iTMT number-letter with MoCA (r = -0.598, p = 0.001), TMT A (r = 0.519, p = 0.006), TMT B (r = 0.666, p < 0.001), and DTC (r = 0.713, p < 0.001). Conclusion: This study demonstrated proof of concept of a simple, safe, and practical iTMT system with promising results to identify cognitive and dual-task ability impairment among older adults, including those with aMCI and AD. Future studies need to confirm these observations in larger samples, as well as iTMT's ability to track motor- cognitive decline over time.

Publication Date


Publication Title










First Page


Last Page


PubMed ID


Digital Object Identifier (DOI)