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Classic tower of Hanoi, planning skills, and the Indian elderly

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East Asian Arch Psychiatry 2015;25:108-14 Original Article

Classic Tower of Hanoi, Planning Skills, and the

Indian Elderly
R Balachandar, R Tripathi, S Bharath, K Kumar

Abstract
Objective: Elderly populations are vulnerable to age-related cognitive decline. Planning, a frontal lobe
function, is reported to be affected in the elderly population. There is a paucity of studies which assessed
planning skills in the elderly Indian population. The present study aimed to examine the utility of the
classic Tower of Hanoi in the assessment of planning skills of elderly Indian subjects.
Methods: A total of 215 (60 of whom were females, all aged 55-80 years) cognitively normal elders and
24 patients with mild Alzheimer’s disease were recruited. All subjects provided informed consent and their
planning skills were assessed using the classic Tower of Hanoi. Performance at each level was measured
by the total time taken to solve, number of moves to solve, and the number of rule violations. Receiver
operating characteristic curve analysis was exploratively performed to test the utility of the Tower of
Hanoi in differentiating patients with mild Alzheimer’s disease from those who were cognitively normal.
Results: Performance measures of cognitively normal group steeply worsened with increasing complexity.
With receiver operating characteristic curve analysis, patients with mild Alzheimer’s disease were poorly
differentiated from cognitively normal group according to their Tower of Hanoi performance.
Conclusion: The Tower of Hanoi test is of limited value for the assessment of planning skills in the
Indian elderly population. There is a need to modify and develop a suitable neuropsychology tool to
assess the planning skills of elderly Indian subjects and further validate it.

Key words: Aged; Intelligence tests; Mild cognitive impairment

Dr Rakesh Balachandar, PhD, Department of Clinical Neurosciences , National
Institute of Mental Health and Neurosciences, Bangalore, India.
Dr Ravikesh Tripathi, MPhil, PhD, Consultant Clinical Psychologist, Narayana
Hrudayalaya, Bangalore, India.
Prof. Srikala Bharath, MD, FRCPsych, Department of Psychiatry, National
Institute of Mental Health and Neurosciences, Bangalore, India.
Prof. Keshav Kumar, PhD Department of Clinical Psychology, National
Institute of Mental Health and Neurosciences, Bangalore, India.
Address for correspondence: Prof. Srikala Bharath, Department of Psychiatry,
National Institute of Mental Health and Neurosciences, Bangalore 560029,
India.
Tel: (91-80) 2699 5271; Fax: (91-80) 2656 4830;
Email: srikala.bharath@gmail.com
Submitted: 23 December 2014; Accepted: 3 March 2015
Introduction
Executive functions act at the highest level of cognition
to enable optimal performance of the activities of daily
living. Studies of ageing have demonstrated predominant
age-related decline in executive functions compared
with other cognitive domains.1-4 Executive functions are
presumably mediated by the frontal and temporal lobe
neuronal system.1,5 One of the important subcomponents of
executive functions, planning, is also mediated via neuronal
circuits involving the frontal lobe. Neuroimaging studies
have reported predominant frontal lobe atrophy in healthy
ageing.6 Planning is defined as a process of formulating a
sequence of operations intended to achieve a final goal.7 It
involves a 2-stage process: initially to formulate a logical
strategy to determine the sequence of actions required to
achieve the specific goal and later the ability to monitor and
guide towards its successful completion.3,8 The Tower of
Hanoi (TOH), a neuropsychological tool, is often used to
assess planning skills.9,10
Planning along with working memory, verbal and
visual organisation, judgement and reasoning are crucial
for performing instrumental activities of daily living.
They are tested during successful completion of a TOH
task. Due to age-related cognitive decline, planning skills
among the elderly fade compared with young adults and
hence performance of tasks in the TOH also worsens with
advancing age.10
The importance of planning skills is seen among
patients with mild cognitive impairment (MCI) and
Alzheimer’s disease (AD). Executive skills compensate
for the memory impairment in amnestic MCI. Dysfunction
in these cognitive domains has a higher prediction for the
conversion of amnestic MCI to frank AD.11 Further, patients
with AD develop deficits in planning ability during the
course of their illness.12
Previous studies among the elderly Indian
population have documented a lack of cognitive tests that
include planning skills.13-15 As an important cognitive
domain, planning needs to be assessed among the elderly

108 © 2015 Hong Kong College of Psychiatrists


population. We observed a need for a validated and reliable
neuropsychological test to assess the planning skills of an
elderly Indian population.
In the current study, we aimed to explore the
utility of the TOH to assess planning skills in an elderly
Indian population, including patients with early AD. We
hypothesised that the classic TOH offered a means to
assess planning skills in our elderly population. We also
hypothesised that patients diagnosed with mild AD would
perform less well on the TOH than matched cognitively
healthy controls.
Methods
This study was conducted at the Geriatric Clinic & Services,
National Institute of Mental Health and Neurosciences
(NIMHANS), India after institutional ethics committee
approval. After obtaining informed consent, all subjects
underwent NIMHANS Neuropsychiatry Battery for
Elderly15 testing along with TOH assessment.
A total of 215 cognitively normal elders (CNe) were
recruited from the community (elderly forums) and elderly
caregivers of patients visiting NIMHANS. They were aged
between 55 and 80 years, and 60 of whom were females.
All cognitively healthy volunteers gave informed consent
and were screened for neuropsychiatric disorders using
Instruments for Comprehensive Evaluation of the Elderly,16
and, subsequently, the Hindi Mental State Examination
(HMSE).17 All elderly healthy volunteers were independent
and autonomous in their activities of daily living. None
reported any subjective memory complaints (relevant
indicator of cognitive decline)18 or were taking any
medication that could interfere with cognition. The CNe
were divided into 2 groups (< 60 and ≥ 60 years). Subjects
with a score of ≥ 24 in HMSE were included as CNe.19
Those with a score of < 24 were evaluated for causes of
possible cognitive deficits and appropriately managed.
Another 24 patients with AD (4 of whom were
females), with a mean (± standard deviation) age of 67.1
years, were recruited from the geriatric clinic, NIMHANS.
These patients were clinically diagnosed according to
the National Institute on Aging–Alzheimer’s Association
criteria,20 and with a Clinical Dementia Rating Scale score
of < 121 by a senior professor of psychiatry / neurology.
Classic Tower of Hanoi Task
The TOH task involves the shifting of all disks (2-5 disks)
from their primary position to a final position in a minimum
number of moves without violating certain rules. These
rules include: (a) a single disk should be moved at a time;
(b) disks should be shifted only on the pegs; and (c) a larger
disk may not be placed over a smaller disk.10
Studies that have explored planning skills of the
elderly have used 3- and 4-disk tasks of the classic TOH.3,9
In order to observe the feasibility of the test in the Indian
elderly, we included 1-step, lower (2 disks) and higher (5
disks) tasks in our planning assessment. Hence we used
East Asian Arch Psychiatry 2015, Vol 25, No.3
Tower of Hanoi and Planning Skills
the first 4 levels of the TOH task, starting from level 1
(2-disk task) to level 4 (5-disk task) with increasing levels
of complexity. At each level the disks were placed in the
primary position (extreme left peg), and shifted to the final
position (extreme right peg) while complying with the
rules. On completing the task, subjects moved to the next
higher level. Performance measures were based on 3 main
parameters: number of moves required, total time taken to
complete the task, and number of rule violations during
each task (mistakes).
Statistical Analyses
All statistical analyses were performed using R statistics.
As the data (education and performance measure scores)
followed a normal distribution (as assessed using Shapiro-
Wilk test) 2-tailed independent t test was used for group
comparisons. Univariate general linear model analysis was
also used to detect age-related changes between the groups,
adjusting for education as a covariate.
The randomly selected CNe were individually
matched for age, gender, and education with that of mild
AD patients to compare their TOH performance measures
using independent t test. We also explored the sensitivity
and specificity of the TOH in discriminating / differentiating
patients with mild AD from CNe matched for age,
gender, and education by performing receiver operating
characteristic (ROC) curve analysis.
Results
Demographic details of subjects are shown in Table 1.
Comparison of results between CNe subgroups, as well as
that between patients with mild AD and matched CNe on
TOH are presented in Tables 2 and 3, respectively..
Performance of Cognitively Normal Elders
Cognitively normal elders aged from 55 to 80 years with
a male predominance (73%). Those in the subgroup aged
≥ 60 years were significantly highly educated than those
< 60 years (p = 0.04). In this sample of CNe a steep increase
in the performance scores (time taken and total moves) was
observed as task complexity increased. The number of CNe
who could successfully complete the task also reduced as
the complexity increased. An explorative independent t
test between 2 CNe subgroups (< 60 and ≥ 60 years) did
not reveal any statistical difference in their performance
measures (Table 2). Univariate general linear model
analysis revealed that education did not significantly affect
the performance measures in the CNe group; further there
was no significant difference in the performance measures
between the 2 age-groups after controlling for education.
Performance of Patients with Mild Alzheimer’s
Disease
Subjects with mild AD experienced severe difficulty in
completing the TOH tasks. Only about 75% of patients
with mild AD could complete the level 1 (2-disk) task.
109
R Balachandar, R Tripathi, S Bharath, et al

Table 1. Demographic details of subjects.*

Cognitively normal elders Patients with mild p Value
(n = 215) Alzheimer’s disease (n = 24)
Age (years) 63.8 ± 6.4 67.1 ± 8.4 0.07
Gender (female / male) 58 / 157 4 / 20 0.27
Duration of education (years) 12.7 ± 5 13.0 ± 4.9 0.9
*
Data are shown as mean ± standard deviation, unless otherwise specified.

Table 2. Performance measures of subgroups at various levels of Tower of Hanoi.*

Cognitively normal elders Cognitively normal elders Patients with mild

(< 60 years; n = 102) (≥ 60 years; n = 112) Alzheimer’s disease (n = 24)
Duration of education (years) 11.9 ± 5 13.3 ± 4.9 12.7 ± 5
Gender (female / male) 36 / 67 22 / 90 4 / 24
Two-disk task
Total moves 3.1 ± 0.5 3 ± 0.2 3.7 ± 2.2
Mean extra moves 0.1 0 0.7
Total time (sec) 5.7 ± 1.8 5.8 ± 1.7 12.7 ± 10
Rule violations / mistakes 0.02 ± 0.1 0.01 ± 0.1 0.3 ± 0.7
% of Patients completed 100% 100% 75%
Three-disk task
Total moves 11.8 ± 5.6 11.5 ± 5 10.4 ± 7.2
Mean extra moves 4.8 4.5 5.4
Total time (sec) 69.9 ± 57.2 62 ± 40 70.2 ± 49.6
Rule violations / mistakes 0.6 ± 0.8 0.3 ± 0.7 1.5 ± 1.2
% of Patients completed 83.4% 89.2% 50%
Four-disk task
Total moves 27.9 ± 12.3 27.2 ± 11.5 30 ± 26
Mean extra moves 12.9 12.2 15
Total time (sec) 145.5 ± 84.4 138.4 ± 73.5 158.4 ± 87.4
Rule violations / mistakes 0.4 ± 0.7 0.5 ± 0.8 2.8 ± 4.4
% of Patients completed 72.8% 79.4% 33.3%
Five-disk task
Total moves 69.3 ± 20.2 69.6 ± 28.9 -
Average extra moves 38.3 38.6 -
Total time (sec) 278.1 ± 136.4 272 ± 141.1 -
Rule violations / mistakes 0.5 ± 0.7 0.5 ± 0.7 -
% of Patients completed 27.1% 34.8% -
*
Data are shown as mean ± standard deviation, unless otherwise specified.

In subsequent higher levels the number further dropped. Discussion

Patients with mild AD exhibited a trend of reduced
performance compared with CNe (Table 3). A significant
difference (p < 0.05) was observed for performance
measures of time taken for the 2-disk task and rule
violations in 3-disk task. Explorative ROC curve analysis
of performance measures revealed poor sensitivity and
specificity in differentiating patients with mild AD from
CNe (Fig).
The present study aimed to observe the utility of the
classic TOH to assess planning skills in an elderly Indian
population. The TOH was administered to CNe and a sample
of patients with mild AD. We also attempted to explore
age-related cognitive decline by stratifying the sample of
CNe into 2 groups based on their age (< 60 years and ≥ 60
years). A steep incline in the performance scores (total time

110 East Asian Arch Psychiatry 2015, Vol 25, No.3

 Tower of Hanoi and Planning Skills

Table 3. Comparison of performance measures between patients with mild Alzheimer’s disease and matched cognitively
normal elders.
Cognitively normal elders Patients with mild p Value
(n = 215) Alzheimer’s disease (n = 24)
Two-disk task
Total moves 3.1 ± 0.5 3.7 ± 2.2 0.14
Total time (sec) 6.2 ± 2.1 12.7 ± 10 0.03
Rule violations / mistakes 0.01 ± 0.1 0.3 ± 0.7 0.19
% of Patients completed 100% 75%
Three-disk task
Total moves 9.8 ± 3.3 10.4 ± 7.2 0.74
Total time (sec) 56.9 ± 31.4 70.2 ± 49.6 0.3
Rule violations / mistakes 0.3 ± 0.5 1.5 ± 1.2 0.001
% of Patients completed 84.5% 50%
Four-disk task
Total moves 26.5 ± 10.7 30 ± 26 0.6
Total time (sec) 146.7 ± 70.2 158.4 ± 87.4 0.6
Rule violations / mistakes 0.7 ± 0.9 2.8 ± 4.4 0.06
% of Patients completed 73.6% 33.3%
Five-disk task*
Total moves 70.1 ± 28.5 - -
Total time (sec) 278.1 ± 143 - -
Rule violations / mistakes 1.1 ± 1.5 - -
% of Patients completed 34.5% - -

*
The task could not be performed in patients with mild Alzheimer’s disease, therefore p values could not be calculated.

taken, number of moves) was observed among CNe groups
with increasing task complexity. We would like to stress
that the number of additional steps taken by the elderly to
solve tasks at each level also increased. This suggests that
CNe experienced difficulties in planning, completing, and
proceeding to subsequent higher levels of the task. The
performance scores of our current study were inferior to the
age-matched scores of another study.3 Interestingly, CNe of
our study exhibited inferior performances in the classical
TOH despite having more years of formal education in
comparison with the above-mentioned study.3 We can
confer that the normative data of classic TOH performance
for Indian cognitively normal elderly subjects are different.
School-educated elderly subjects often become
functionally illiterate due to underutilisation of their reading
and writing skills, as these skills acquired during schooling
may be redundant for their lifestyle or occupation. The
inferior performance on classical TOH tasks of the Indian
elderly in this study, though more educated (13.3 ± 4.9
years) than those in another study (6.3 ± 1.7 years),3 may be
explained by functional illiteracy. Alternatively, variations
in the performance of individuals with a low education
level could be attributed to one or many other reasons such
as task familiarity, performance anxiety, attitude towards
the testing situation, and appropriateness of the test for
a given population with a low level of education. It is
therefore imperative to use ecologically valid and culturally
appropriate tests to make definitive comments about the
true cognitive status of a particular individual.
Previous studies have documented age-related decline
in fluid intelligence such as planning ability.1 Our attempt
to explore the age-related cognitive decline by stratifying
the elderly population into 2 groups (< 60 years and ≥ 60
years) could not demonstrate such changes. We propose
the following observations possibly contributing to this
finding. First, ageing studies that documented age-related
changes have predominantly compared young adults and
elderly subjects.3 The age difference between the 2 groups
in our study population was very small: group 1 CNe (< 60
years) were aged between 55 and 60 years and group 2 CNe
(≥ 60 years) comprised volunteers aged between 61 and 80
years. Age-related decline in fluid intelligence is likely a
gradual process; hence narrow age differences in our study
failed to demonstrate age-related decline in the planning
process. Second, although our CNe were randomly recruited
and stratified on the basis of age, the older group (≥ 60
years) were significantly (p = 0.04) more educated than the
younger group (< 60 years).
Education, an important factor in cognitive reserve,
may contribute to our current finding.22-24 Fewer than 12
years of formal education indicates a pre-college level
of education, whereas receiving education of ≥ 12 years

East Asian Arch Psychiatry 2015, Vol 25, No.3 111

R Balachandar, R Tripathi, S Bharath, et al

(a)
100

80

60
Sensitivity (%)

40

20 Total time
Total moves
Rule violations
Reference line
0
100 80 60 40 20 0
Specificity (%)

(b)
100

80

60
Sensitivity (%)

40

20 Total time
Total moves
Rule violations
Reference line
0
100 80 60 40 20 0
Specificity (%)

Figure. Receiver operating characteristic curve analyses for the (a) 2-disk task and (b) 3-disk task.

112 East Asian Arch Psychiatry 2015, Vol 25, No.3


indicates a college and postgraduate level. Because our CNe
older group (≥ 60 years) received a mean education of > 12
years, the majority would have potentially been exposed to
situations that exercised their cognitive functions including
planning skills, and would thus have performed better than
the less educated CNe (< 60 years). Univariate general
linear model analysis, which was used to control the effects
of education, did not reveal significant differences between
the 2 age-groups.
Performance of Patients with Mild Alzheimer’s
Disease
Patients with early AD experienced severe difficulty in
solving TOH, as demonstrated by the proportion who could
successfully complete the 2-disk task (level 1) of TOH.
About 25% of AD patients could not complete this first
level; this percentage further increased to 50%, 66.7% and
100% for the 3-disk, 4-disk, and 5-disk tasks, respectively.
Patients with mild AD performed worse than the
matched CNe for all performance measures (Table 3). A
significant statistical difference (p < 0.05) was observed
in rule violations in the 3-disk task and time taken for the
2-disk task. An insignificant difference observed in other
performance measures could be due to fewer patients
successfully completing the levels when compared with
matched CNe (Table 3), hence the statistical analysis could
not detect significant differences. Despite the observed
differences, ROC analysis of the classic TOH performance
had poor discriminative ability to differentiate patients with
mild AD and CNe (Fig). Patients with AD predominantly
suffer from episodic memory deficit during the early
stages of illness and later develop other cognitive domain
deficits including executive functions.12 In addition, studies
that involve patients with early AD have demonstrated
the importance of executive functions in overcoming
episodic memory deficits and performing activities of daily
living.25,26 Thus we expected that explorative ROC would
not discriminate patients with mild AD and healthy controls.
Further work with a larger sample and inclusion of another
study group with moderate AD would throw more light on
this issue.
The following points should be emphasised in this
study. For reasons of long testing hours and the steep
increase in complexity of tests, our CNe experienced
cognitive fatigue.27 There is a need to develop planning
tasks that start at an easy level and gradually increase in
complexity. A task of this kind would accustom individuals
to a testing situation and encourage them to perform better
at subsequent higher levels. Further, we recommend that
tasks be designed such that they can be completed in a short
period of time.
Developing a tool that fulfils the above criteria has the
advantage of obtaining a baseline planning performance.
It is advantageous to record baseline planning deficits in
patients with AD, especially to monitor disease progression
or to evaluate the effects of intervention. A limitation of our
study is the heterogeneity in education level between the 2
East Asian Arch Psychiatry 2015, Vol 25, No.3
Tower of Hanoi and Planning Skills
CNe groups. Our sample of CNe were all educated, contrary
to our initial intention to recruit predominantly illiterate
elderly.
Conclusion
Planning skills need to be assessed regularly in cognitively
healthy elderly subjects, patients with MCI and those with
AD. In this group of elderly we have demonstrated the
need for a culturally appropriate neuropsychological tool to
assess planning ability. Finally, there is a need to developing
normative data for elderly Indian subjects after validating
the planning tool.
Acknowledgement
We thank all participants for their complete cooperation.
Declaration
The authors declared no conflict of interest in this study.
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