Estimating functional cognition in older adults using observational assessments of task performance in complex everyday activities: A systematic review and evaluation of measurement properties

From Hospital to Home: Validating a Cognitive-Functional Evaluation of Elders (COFEE-HD)

Background. Increase in hospitalizations of older adults emphasizes the need for efficient hospital discharge planning to enable optimal reentry upon returning home. Yet few assessments offer an extensive picture of the older adult's functional-cognitive state. A comprehensive assessment for discharge planning together with a written summary can be beneficial to the older adult and family. Purpose. This quantitative study compared a modified version of a previously validated tool COFEE (cognitive OT functional evaluation of elders), for use in the hospital, HD (hospital discharge) with standard hospitals assessments. Methods. Of the 77 participants recruited in hospital, home assessments were conducted 4 months later on 64 participants. Findings. The COFEE-HD scores (physical functioning, personal and environmental safety and meta cognitive functioning) were significantly correlated with standard hospital measures and with the home assessment. Implications. The COFEE-HD was found to have a high level of validity in a hospital setting, and the resulting evaluation can provide important insights into function, safety and cognitive function for post-discharge behaviors.

Amyloid and tau burden relate to longitudinal changes in the performance of complex everyday activities among cognitively unimpaired older adults: results from the performance-based Harvard Automated Phone Task

Background

Changes in everyday functioning constitute a clinically meaningful outcome, even in the early stages of Alzheimer's disease. Performance-based assessments of everyday functioning might help uncover these early changes. We aimed to investigate how changes over time in everyday functioning relate to tau and amyloid in cognitively unimpaired older adults.

Methods

Seventy-six cognitively unimpaired participants (72 ± 6 years old, 61% female) completed multiple Harvard Automated Phone Task (APT) assessments over 2.0 ± 0.9 years. The Harvard APT consists of three tasks, performed through an automated phone system, in which participants refill a prescription (APT-Script), select a new primary care physician (APT-PCP), and transfer money to pay a bill (APT-Bank). Participants underwent Pittsburgh compound-B and flortaucipir positron emission tomography scans at baseline. We computed distribution volume ratios for a cortical amyloid aggregate and standardized uptake volume ratios for medial temporal and neocortical tau regions. In separate linear mixed models, baseline amyloid by time and tau by time interactions were used to predict longitudinal changes in performance on the Harvard APT tasks. Three-way amyloid by tau by time interactions were also investigated. Lastly, we examined associations between tau and change in Harvard APT scores in exploratory voxel-wise whole-brain analyses. All models were adjusted for age, sex, and education.

Results

Amyloid [unstandardized partial regression coefficient estimate (β) = -0.007, 95% confidence interval (95% CI) = (-0.013, -0.001)], and medial temporal tau [β = -0.013, 95% CI = (-0.022, -0.004)] were associated with change over time in years on APT-PCP only, i.e., higher baseline amyloid and higher baseline tau were associated with steeper rate of decline of APT-PCP. Voxel-wise analyses showed widespread associations between tau and change in APT-PCP scores over time.

Conclusion

Even among cognitively unimpaired older adults, changes over time in the performance of cognitively complex everyday activities relate to cortical amyloid and widespread cerebral tau burden at baseline. These findings support the link between Alzheimer's disease pathology and function and highlight the importance of measuring everyday functioning in preclinical disease stages.

Patient-report and caregiver-report measures of rehabilitation service use following acquired brain injury: a systematic review

OBJECTIVE

To review patient-report/caregiver-report measures of rehabilitation service use following acquired brain injury (ABI).

DATA SOURCES

Medline, APA PsycINFO, Embase and CINAHL were searched on November 2021 and November 2022. Authors were contacted if measures were not included in manuscripts/appendices.

STUDY SELECTION

Included articles were empirical research or a research protocol, available in English and described measures of patient report/caregiver report of rehabilitation service use post-ABI via quantitative or qualitative methods. Two reviewers independently screened 5290 records using DistillerSR. Discrepancies were resolved by team adjudication.

DATA EXTRACTION

Data extraction was piloted with high levels of agreement (k=.94). Data were extracted by a single member with team meetings to seek guidance as needed. Data included administration characteristics (reporter, mode of administration, recall period), psychometric evidence and dimensions assessed (types of services, setting, frequency, duration, intensity, qualitative aspects).

DATA SYNTHESIS

One hundred and fifty-two measures were identified from 85 quantitative, 56 qualitative and 3 psychometric studies. Psychometric properties were reported for four measures, all of which focused on satisfaction. Most measures inquired about the type of rehabilitation services used, with more than half assessing functional (eg, physical therapy) and behavioural health rehabilitation services, but fewer than half assessing community and academic reintegration (eg, special education, vocational rehabilitation) or cognitive (eg, neuropsychology) services. Fewer than half assessed qualitative aspects (eg, satisfaction). Recall periods ranged from 1 month to 'since the ABI event' or focused on current use. Of measures that could be accessed (n=71), many included a limited checklist of types of services used. Very few measures assessed setting, frequency, intensity or duration.

CONCLUSIONS

Despite widespread interest, the vast majority of measures have not been validated and are limited in scope. Use of gold-standard psychometric methods to develop and validate a comprehensive patient-report/caregiver-report measure of rehabilitation service use would have wide-ranging implications for improving rehabilitation research in ABI.

Addressing ADL ability in people with poststroke cognitive impairments: A Danish survey of clinical practice

BACKGROUND

In Denmark, stroke represents a leading disability cause. While people with difficulties in performing activities of daily living (ADL) due to poststroke cognitive impairments are often referred to occupational therapy, limited knowledge is available on the nature of these services.

AIM/OBJECTIVE

To explore how Danish occupational therapists describe their practice when addressing decreased ADL ability in people with poststroke cognitive impairments in hospital and municipality settings.

MATERIAL AND METHODS

National, cross-sectorial, web-based public survey.

RESULTS

244 occupational therapists accessed the survey; 172 were included in the analysis. Most respondents could indicate the theory guiding their reasoning; half used standardised assessments. Regarding intervention, restorative and acquisitional models were preferred; specific strategies were identified. Intensity: 30-45 min 3-4 times/week in hospitals; 30-60 min 1-2 times/week in municipalities.

CONCLUSIONS

Therapists report to be guided by theory in their reasoning. Standardised assessments are used to a higher extend than previously reported. Still, the results invite critical reflections on correct use of assessment instruments, content and intensity of interventions, and how therapists keep themselves updated.

SIGNIFICANCE

The results document the need for practice improvements and may inform the definition of standard care in future trials.

Cognitive Function and Participation of Stroke Survivors Living With Companion Animals: A Cross-Sectional Study

INTRODUCTION/OBJECTIVES

Companion animals (CAs) may benefit human health, but few studies have examined their impact on stroke survivors. This study examines participation, quality of life (QoL), attachment, cognition, and executive function differences between stroke survivors living with and without CAs.

METHODS

In this cross-sectional, community-setting study, 25 stroke survivors with a CA and a matched group of 27 without a CA completed standard tools.

RESULTS

Stroke survivors with a CA scored significantly higher in participation and 1 cognitive performance test. No significant differences were found in other cognitive measures or QoL, and attachment to a CA was not correlated with participation or QoL within the research group. However, lower attachment avoidance correlated with better participation in survivors living with dogs.

CONCLUSION

Living with CAs, especially dogs, might be associated with some cognitive function and participation benefits among stroke survivors. The link between CAs and cognitive function is unclear: Survivors with higher cognitive functioning might be more capable of caring for a CA, or having and caring for a CA might promote better cognitive function. Attachment patterns also might explain stroke survivors' participation levels. Further study is warranted.

Loss-of-Set and Strategy Application on the Menu Task: An Exploratory Study

Background. The Menu Task (MT) is an occupational therapy screening measure designed to identify people in need of functional cognitive (FC) assessment. Purpose. To explore whether test-taker strategy selection on the MT is clinically informative. Methods. Using a cross-sectional design we administered assessments of FC including the MT and the After MT interview, cognitive screening measures, and self-report instrumental activities of daily living assessment to a convenience sample of 55 community-dwelling adults. After MT interviews responses were qualitatively characterized as (a) loss of set (e.g., not recognizing that food preferences are irrelevant to task performance), (b) calorie counting, or (c) planning. Findings. Loss of set was associated with poorer performance on most study measures, calorie counting was associated with superior performance on most study measures, and no differences were observed relating to planning. Implications. Determining the test-takers approach to the MT adds information to that provided by the MT itself.

Using a digital tool to detect early changes in everyday functioning in older adults: A pilot study of the Assessment of Smartphone Everyday Tasks (ASSET)

INTRODUCTION

To investigate the utility of a new digital tool for measuring everyday functioning in preclinical Alzheimer's disease, we piloted the Assessment of Smartphone Everyday Tasks (ASSET) application.

METHODS

Forty-six participants (50.3 ± 27.1 years; 67% female; 20 young unimpaired, 17 old unimpaired, 9 mildly cognitively impaired) completed ASSET 7 times. ASSET comprises two main tasks, simulating a Patient Portal and a Calendar. We assessed ASSET's internal consistency, test-retest reliability, and user experience.

RESULTS

ASSET main tasks correlated with each other (r = 0.75, 95% confidence interval [CI] = [0.58, 0.86]). Performance on ASSET's Patient Portal related to cognition (r = 0.64, 95% CI = [0.42, 0.79]) and observer ratings of everyday functioning (r = 0.57, 95% CI = [0.24, 0.79]). Test-retest reliability was good (intraclass correlation coefficient = 0.87, 95% CI = [0.77, 0.93]). Most participants rated their experience with ASSET neutrally or positively.

DISCUSSION

ASSET is a promising smartphone-based digital assessment of everyday functioning. Future studies may investigate its utility for early diagnosis and evaluation of treatment of Alzheimer's disease.

Using machine learning to modify and enhance the daily living questionnaire

The Daily Living Questionnaire (DLQ) constitutes one of a number of functional cognitive measures, commonly employed in a range of medical and rehabilitation settings. One of the drawbacks of the DLQ is its length which poses an obstacle to conducting efficient and widespread screening of the public and which incurs inaccuracies due to the length and fatigue of the subjects.

Objective

This study aims to use Machine Learning (ML) to modify and abridge the DLQ without compromising its fidelity and accuracy.

Method

Participants were interviewed in two separate research studies conducted in the United States of America and Israel, and one unified file was created for ML analysis. An ML-based Computerized Adaptive Testing (ML-CAT) algorithm was applied to the DLQ database to create an adaptive testing instrument-with a shortened test form adapted to individual test scores.

Results

The ML-CAT approach was shown to reduce the number of tests required on average by 25% per individual when predicting each of the seven DLQ output scores independently and reduce by over 50% when predicting all seven scores concurrently using a single model. These results maintained an accuracy of 95% (5% error) across subject scores. The study pinpoints which DLQ items are more informative in predicting DLQ scores.

Conclusions

Applying the ML-CAT model can thus serve to modify, refine and even abridge the current DLQ, thereby enabling wider community screening while also enhancing clinical and research utility.

Assessments of Functional Cognition Used with Patients following Traumatic Brain Injury in Acute Care: A Survey of Australian Occupational Therapists

This study aimed to describe how occupational therapists working in acute care settings in Australia assess cognitive function in patients with TBI, the influences on assessment choice, and clinician perceptions of performance-based assessment. An online survey was completed by 81 occupational therapists. The most common method of cognitive assessment was reported as non-standardized observation of functional tasks (94.7%), followed by carer-report / self-report (93%). Despite their being positive perceptions of performance-based assessment there was limited use in practice. Assessment use was impacted by practical and organizational constraints including access to assessment resources, time and the built environment in acute care.

The aging mind: A complex challenge for research and practice

Cognitive decline as part of mental ageing is typically assessed with standardized tests; below-average performance in such tests is used as an indicator for pathological cognitive aging. In addition, morphological and functional changes in the brain are used as parameters for age-related pathological decline in cognitive abilities. However, there is no simple link between the trajectories of changes in cognition and morphological or functional changes in the brain. Furthermore, below-average test performance does not necessarily mean a significant impairment in everyday activities. It therefore appears crucial to record individual everyday tasks and their cognitive (and other) requirements in functional terms. This would also allow reliable assessment of the ecological validity of existing and insufficient cognitive skills. Understanding and dealing with the phenomena and consequences of mental aging does of course not only depend on cognition. Motivation and emotions as well personal meaning of life and life satisfaction play an equally important role. This means, however, that cognition represents only one, albeit important, aspect of mental aging. Furthermore, creating and development of proper assessment tools for functional cognition is important. In this contribution we would like to discuss some aspects that we consider relevant for a holistic view of the aging mind and promote a strengthening of a multidisciplinary approach with close cooperation between all basic and applied sciences involved in aging research, a quick translation of the research results into practice, and a close cooperation between all disciplines and professions who advise and support older people.

The Weekly Calendar Planning Activity to Assess Functional Cognition in Parkinson Disease

The Weekly Calendar Planning Activity (WCPA) may improve understanding of functional cognition in people with Parkinson disease (PwPD) without dementia. We aimed to determine if WCPA performance (a) discriminates between PwPD with and without cognitive impairment and healthy controls and (b) correlates with other indicators of cognition and daily function. This was a cross-sectional study. Parkinson disease (PD) participants without dementia were divided into normal cognition (PD-NC, n = 25) and possible mild cognitive impairment (PD-MCI, n = 21) groups. Their WCPA performance was compared with that of a normative sample (n = 196) and correlated with neuropsychological test performance and self-reported cognition and participation. Both the PD-MCI and PD-NC groups had impaired WCPA performance. WCPA performance correlated with executive function, processing speed, and self-reported cognition and participation. The WCPA can detect functional cognitive deficits in PwPD without dementia and can inform occupational therapy interventions to support functional cognition, occupational performance, and participation in this population.

Methodological Issues in Advancing the Status of Functional Cognitive Assessment

Many individuals in acute hospital and post-acute care settings experience changes in their capacity to perform complex activities of daily living associated with deficits in functional cognition. Occupational therapists regularly assess and treat these occupational performance deficits. The construct of functional cognition offers oportunities for occupational therapists to define an approach to cognition that is both distinct from that of other disciplines and that supports evidence-based interventions. This article provides a rationale for performance-based assessment of functional cognition and an overview of the methodological issues associated with the development and implementation of reliable and valid screening and comprehensive asseements of functional.

Further Validation of the Menu Task: Functional Cognition Screening for Older Adults

Occupational therapists need a brief tool to identify the potential for functional cognitive deficits leading to impaired occupational performance. The objective is to establish the sensitivity and specificity, concurrent and known-group validity of the Menu Task by comparison with performance on the Weekly Calendar Planning Activity (WCPA). Using a cross-sectional design, we administered the Menu Task and the WCPA to a community-dwelling convenience sample of 287 adults aged from 55 to 93 years. The receiver operating characteristic (ROC) analysis estimated sensitivity and specificity. Concurrent and known-group construct validity was examined by comparing scores on the Menu Task with the WCPA scores. As a result, a new cutoff score of 9 was established for the Menu Task (area under the curve [AUC] = 0.80, sensitivity = 0.89, 95% confidence interval [CI] = [0.73, 0.97]; specificity = 0.58, 95% CI = [0.52, 0.64]). Both concurrent and construct validity were supported. The Menu Task demonstrates sensitivity to functional cognitive impairments in a community sample.

A Systematic Review of Tools Assessing the Perspective of Caregivers of Residents With Dementia

In collaboration with stakeholders, we conducted a systematic review of psychometric evidence for self-report tools measuring the perspective of family caregivers of nursing home residents with dementia. Our rationale for this review was based on evidence that nonpharmacological interventions can ameliorate dementia symptoms in nursing home residents. Such interventions require caregiver participation, which is influenced by perspectives. Yet, no existing tool measures the multidomain caregiver perspective. Our review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. The final sample included 42 articles describing 33 tools measuring domains of nursing home dementia care such as behavioral and psychological symptoms of dementia, resident quality of life, dementia-specific knowledge, communication, and medication use. We uncovered evidence gaps for tools measuring dementia-specific knowledge, communication, and medication use, all of which were important to our stakeholders. Future research should focus on development of psychometrically sound tools in alignment with the multidomain caregiver perspective.

Cognitive Correlates of Instrumental Activities of Daily Living Performance in Parkinson Disease Without Dementia

OBJECTIVE

To investigate cognitive correlates of instrumental activities of daily living (IADL) performance among people with Parkinson disease (PD) without dementia.

DESIGN

Cross-sectional.

SETTING

Academic medical center.

PARTICIPANTS

Volunteer sample (N=161) comprising participants with PD without dementia (n=102) and healthy comparison (HC) participants (n=59).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Performance-based assessment of cognitively-demanding IADL (meal preparation, bill paying, shopping, medication management, small home repair), neuropsychological tests (attentional control/flexibility, planning, working memory, memory, crystallized intelligence), and measures of motor function and other characteristics (eg, depressive symptoms).

RESULTS

There were no group differences in neuropsychological test performance (P>.06). The PD group performed more poorly than the HC group on a number of cognitive IADL tasks (P<.04). After accounting for the effects of motor impairment and other disease-related characteristics, neuropsychological test performance accounted for a small but unique portion of the variance in performance of all cognitive IADL combined, meal preparation, shopping, and medication management in the PD group (R 2=4%-13%; P≤.01).

CONCLUSIONS

The PD group had cognitive IADL performance limitations despite being unimpaired on neuropsychological tests. Within PD, neuropsychological test performance accounted for a small but significant portion of the variance in cognitive IADL performance over and above the effects of motor and other impairments. These results support the added value of using performance-based IADL assessments in functional evaluations of individuals with early and mild PD without dementia.

Cognitive Recovery After Stroke: A Meta-analysis and Metaregression of Intervention and Cohort Studies

BACKGROUND

Cognition affects poststroke recovery, but meta-analyses of cognition have not yet provided a comparison of observational and intervention evidence.

OBJECTIVE

To describe the trajectory of poststroke cognition and the factors that moderate it across intervention and observational cohorts.

METHODS

Six databases were searched up to January 2020. Studies describing quantitative changes in cognition in adults poststroke were included. Interventions were classified into pharmacological, therapist-led, nonroutine/alternative, and usual care. Summary estimates were compared via hierarchical mixed-effects models. Age, recovery stage, stroke etiology, cognitive domain targeted in studies, and intervention types were investigated as moderators of cognition. Recovery stage and intervention were further analyzed in a multiplicative metaregression model.

RESULTS

A total of 43 intervention trials and 79 observation cohorts involving 28 222 stroke participants were included. Heterogeneity was significant (τ² = 0.09; CI = 0.01-0.21, P < .001) with no evidence of publication bias. Cognitive recovery was greater in intervention trials (g = 0.47; CI = 0.37-0.58) than observational cohorts (g = 0.28; CI = 0.20-0.36) across all moderators analyzed. Nonroutine/alternative and pharmacological trials achieved the best overall results (g = 0.57, CI = 0.42-0.73, and g = 0.52, CI = 0.30-0.74, respectively), followed by therapist-led (g = 0.46; CI = 0.17-0.74), and usual care (g = 0.28; CI = 0.11-0.45) interventions. Medium recovery effects (ie, g ≥ 0.5) were observed in examining first-ever stroke, executive function, visuo-perceptual, consciousness, and psychomotor skills, 61 to 180 days poststroke, in participants aged 65 to 70 years.

CONCLUSION

Cognitive recovery is possible using different controlled interventions in all recovery stages, with smaller benefits ≥2 years poststroke. Longer-term studies are needed to determine the role of nonroutine/alternative therapies and the association between cognitive recovery and performance in everyday activities.

The Clinical Utility and Ecological Validity of the Medication Management Ability Assessment in Older Adults with and without Dementia

OBJECTIVE

Older adults are susceptible to medication nonadherence, which may signify functional decline. Thus, performance-based proxies of medication-taking behavior may help diagnose dementia. We assessed the Medication Management Ability Assessment's (MMAA) clinical utility and ecological validity.

METHOD

This was a retrospective chart review of 180 outpatients (age = 72 ± 8 years) who completed the MMAA during clinical evaluations. Forty-seven were cognitively normal (CN), 103 had mild cognitive impairment (MCI), and 30 had dementia. Most (136) were independent in medication management, whereas 28 were assisted and 16 were dependent. Kruskal-Wallis tests assessed whether MMAA scores differed by diagnosis and independence. Receiver operating characteristic (ROC) analyses identified diagnostic cut-offs. Classification accuracy estimates were derived.

RESULTS

MMAA performance differed across diagnosis as expected (p's < .001). Those who were independent in medication management outperformed assisted and dependent counterparts (p's < .001). Assisted and dependent cases were no different. At a cut-off = 23, the MMAA was good-to-strong in distinguishing dementia from CN cases (Sn = 0.96, Sp = 0.83), dementia from MCI (Sn = 0.70, Sp = 0.83), and dementia from functionally unimpaired cases (Sn = 0.78, Sp = 0.83). At a cut-off = 27, it had good sensitivity but weaker specificity when distinguishing both MCI and all cognitively impaired patients (MCI and dementia) from CN cases (Sn = 0.81, Sp = 0.66 and Sn = 0.81, Sp = 0.72, respectively).

CONCLUSIONS

The MMAA has ecological validity and clinical utility in identifying dementia. Its inclusion in neuropsychological practice may be especially useful when medication mismanagement is suspected.

Assessment of Cognitive-Motor Performance Costs, Task Prioritization, and Adaptation to Dishwashing Under Increased Demand in Older Women With Arthritis

Background and Objectives

Hand arthritis can limit upper-limb instrumental activities of daily living (IADLs) and require the recruitment of additional cognitive and motor resources to support performance. We devised a dual-task protocol for dishwashing to examine cognitive-motor performance costs and prioritizations under increased demands, processes of adaptation, and individual differences in performance costs.

Research Design and Methods

Sixty women with hand arthritis (aged 60–91) completed a standardized dishwashing protocol. Motor demand was increased via the properties of the soap dispenser. Cognitive demand was increased using audial attention and response inhibition tasks. The protocol was completed twice per lab visit on 3 occasions. Response time and dishwashing time provided measures of cognitive and motor task performance. Prioritization was determined by comparing the magnitude of dual-task cost (DTC) across tasks. Adaptation to the dishwashing protocol and novel dispenser was assessed by change in DTC across lab visits. Individual differences in cognitive and physical ability were assessed with the trail making B test and gait speed.

Results

Estimates from linear mixed-effects models revealed that response time increased, whereas dishwashing time decreased, during the dual-task study stages. Cognitive-motor prioritization effects were most pronounced among women with lower cognitive and physical ability. Evidence of prioritization and individual differences in DTC diminished across lab visits.

Discussion and Implications

The pattern of results suggests that older women with arthritis prioritize the motor over cognitive components of dishwashing, a common IADL. Adaptation across lab visits resulted in improved performance, reduced evidence of prioritization, and attenuated differences in DTC across physical and cognitive abilities.

Promising observational instruments of parent-child (0-12 years) interaction within the child protection system: A systematic review

BACKGROUND

Parent-child interaction (PCI) is considered a critical environmental factor that affects child development. In the field of child and family intervention, assessment of caregiver-child interaction has great relevance for decision-making.

OBJECTIVE

The aim of this study is to report the results of a systematic review of the best observational instruments to assess the quality of PCI, taking into account the most advanced protocols.

METHODS

Firstly, one search was conducted to identify eligible observational instruments, and a second search was conducted to identify studies reporting on the psychometric properties of the instruments previously identified. To assess and rate the quality of the psychometric properties of the tools, the COSMIN (Consensus-based Standards for the Selection of Health Measurement Instruments) checklist was applied.

RESULTS

The nine PCI observational tools selected (with category B - promising) are widely used by researchers and clinicians across different stages of childhood. The Keys to Interactive Parenting Scale (2-71 months) obtained the highest rating.

CONCLUSIONS

The most reported and robust psychometric property was inter-rater reliability, but validity evidence is understudied. This systematic review can help clinicians keep up-to-date, provide evidence for policymakers to judge risks and benefits of health care behaviors, as well as assess the evaluation programs in child abuse and neglect context.

Structural validity and internal consistency of an ecological observation-based assessment, the Activities of Daily Living Profile

INTRODUCTION

Direct observation of everyday task performance is considered the most accurate measure of independence for individuals with executive function impairments. However, few observation-based measures have been shown to have sound psychometric qualities and be clinically applicable. The objective of this study was to investigate the Activities of Daily Living (ADL) Profile's structural validity using exploratory factor analyses and internal consistency in order to identify the minimum set of tasks required to achieve reliable scores in each of three ADL environments (personal, home and community).

METHODS

Ninety-one persons with a severe traumatic brain injury aged 16-40 years (convenience sample) were recruited from a university affiliated level 1 trauma hospital. The 17 observation-based tasks of the ADL Profile were administered by one of five occupational therapists, either in the hospital or in the subjects' home and community environments. This measure of independence considers goal formulation, planning, carrying out and verifying goal attainment.

RESULTS

Exploratory factor analysis indicated the unidimensionality of the 17 tasks of the ADL Profile. A single factor explained more than 80% of the common variation, which in this case is the concept of independence. Internal consistency of task scores is very high (0.955), suggesting redundancy of the tasks. Approaches used to reduce the number of items, and to optimise the clinical applicability of the tool, showed that a minimum of two tasks per each of three environments (personal, home, community) is required to obtain reliable results that respect the tool's internal structure. Each assessment should contain both simple and familiar and more novel and complex tasks.

CONCLUSIONS

Findings show that the ADL Profile is a valid and clinically applicable observation-based measure of independence that considers four important task-related components: goal formulation, planning, carrying out and verifying goal attainment.

Independent Older Adult's IADL and Executive Function According to Cognitive Performance

Participation in Instrumental Activities of Daily Living (IADL) is essential in occupational therapy aiming to improve the life situation of elderly. Effective executive function (EF) is important to successful functioning in IADL. The purpose of this study was to examine EF and IADL performance differences according to cognitive levels as measured by the Montreal Cognitive Assessment (MoCA), age, and gender. In all, 80 elderly (49% female; age M = 73.4) were assessed at home, with Weekly Calendar Planning Activity (WCPA-10), IADL scale, and MoCA as a cognitive screening tool for dividing into normal cognitive (NC) level and mild cognitive impairment (MCI). The comparison between the MoCA groups on the WCPA-10 and IADL shows significant differences between the groups; gender and age differed only in IADL. IADL and WCPA-10 performance among independent elderly relates to their cognitive level. We suggest that intervention that will focus on EF may assist in improving performance and maintaining participation in occupation.

Can Brief Cognitive or Medication Management Tasks Identify the Potential for Dependence in Instrumental Activities of Daily Living?

Background and Objectives: The identification of functional performance deficits is critical to the community independence of older adults. We examined whether a combined cognitive and performance-based medication management measure would be able to better classify an individual’s functional cognitive status and potential for instrumental activities of daily living (IADL) impairment than either measure alone.

Research Design and Methods: Community-dwelling adults age 55 and older (n = 185) were administered the Mini-Cog, the Medication Transfer Screen-Revised (MTS-R), a combination measure the Medi-Cog-Revised (Medi-Cog-R), the Performance Assessment of Self-Care Skills (PASS) Checkbook Balancing and Shopping tasks (PCST), additional cognitive screening measures, and a self-report daily living scale. Receiver operating characteristic (ROC) curve analyses were computed for the Mini-Cog, MTS-R and the Medi-Cog-R using the PCST performance as the criterion measure. The area under the curve (AUC), sensitivity, and specificity were computed for each measure.

Results: The Medi-Cog-R most accurately identified individuals as impaired on the PCST. An AUC statistic of 0.82 for the Medi-Cog-R was greater than either the Mini-Cog (0.75) or the MTS-R (0.73). The Medi-Cog-R demonstrated a sensitivity of 0.71 and a specificity of 0.78 in classifying individuals with impaired IADL as measured by the PCST.

Discussion and Implications: The Mini-Cog, the MTS-R, and the Medi-Cog-R all show discriminant validity, but the combined measure demonstrates greater sensitivity and specificity than either component measure alone in identifying IADL impairment. The Medi-Cog-R appears to be a useful screening measure for functional cognition and can be used to prompt further assessment and intervention to promote community independence.

Cognitive Function in Cardiac Patients: Exploring the Occupational Therapy Role in Lifestyle Medicine

Patients with cardiac dysfunction are at increased risk of mild cognitive impairment, which can affect their ability to successfully engage in daily activities important for home and community safety and in maintaining health and well-being. This risk increases in accordance with the number of cardiac conditions and cardiovascular risk factors or comorbidities. Occupational therapy has a role in chronic disease management in assessing and improving functional abilities affected by physical, emotional, and cognitive domains. With a holistic and client-centered approach, occupational therapy can complement lifestyle medicine principles through promotion and enablement of engagement in purposeful activity and self-management practices. It is suggested that the clinical management of patients with cardiac dysfunction expands beyond the traditional physical aspects of care to encompass cognitive considerations and incorporate occupational therapy in practice.

Measurement properties of performance-based instruments to assess mental function during activity and participation in traumatic brain injury: A systematic review

Background: Performance-based measures that focus primarily on the ability to engage in ADL are routinely used by occupational therapists to assess a client's cognitive abilities.Objective: To perform a systematic review to investigate measurement properties of performance-based instruments to assess mental function during activity and participation in individuals with traumatic brain injury.Material and methods: Pubmed, EMBASE, CINAHL, PsycINFO and OTseeker were searched. The Consensus-based Standards for the selection of health measurement instruments checklist was used to evaluate methodological quality of each included study. The quality criteria adapted by Terwee were applied to extract the results of each measurement property followed by a best evidence synthesis.Results: Twenty-eight articles, including 40 ratings of measurement properties, were included. The combination of the Functional Independence Measure and the Functional Assessment Measure showed moderate evidence of good internal consistency (Cronbach's alpha 0.99), but conflicting evidence of reliability (ICC 0.83) and poor evidence of construct validity. All other instruments showed limited or unknown evidence.Conclusions: This review provides an overview of measurement properties of performance-based instruments and contributes to such methodological considerations before choosing an instrument. Though, the results reveal a lack of high-quality evidence for any of the measurement properties, it is recommended to use tools with the highest possible evidence for positive ratings.Significance: This review contributes with psychometric evidence on instruments to use in occupational therapy practice and research.

Assessment of cognitive instrumental activities of daily living: a systematic review

PURPOSE

Cognitive instrumental activities of daily living are particularly related to executive functions, such as scheduling appointments, monthly payments, managing the household economy, shopping or taking the bus. The aim of this systematic review was to determine the available tests for the assessment of executive functions with ecological validity to predict individuals' functioning.

MATERIALS AND METHODS

An electronic search was conducted in MEDLINE, Cochrane Central, PsyCInfo and IEEE Xplore until May 2019, in addition to a manual search. The PRISMA criteria and the Covidence platform were used to select articles and extract data.

RESULTS

After applying the search selection criteria, 76 studies were identified. They referred to 110 tools to assess instrumental activities of daily living. Those that have received most attention are related to menu preparation and shopping. Performance-based measures are the most widely used traditional methods. Most tests were aimed at the adult population with acquired brain damage, cognitive impairment or dementia. There was a predominance of tests based on the Multiple Errands Test paradigm.

CONCLUSIONS

In recent years, it has increased the number of tools that assess the instrumental activities of daily living based on technologies such as personal or environmental sensors and serious games.IMPLICATIONS FOR REHABILITATIONAssessment of Instrumental Activities of Daily Living through performance-based measures is especially useful for the early detection of dysfunctions or preclinical disability.Difficulties in performing instrumental activities of daily living are closely associated with deficits in executive functions and prospective memory.Activities of Daily Living can be understood as multitasks.The use of virtual reality-based tests was shown to be sensitive to the detection of cognitive deficits in Activities of Daily Living.An advantage of using virtual reality in assessments is that it can help to predict the level of personal autonomy in patients who are in an institutional environment and could be a first approximation to the real environment.

Longitudinal evaluation of cognition after stroke - A systematic scoping review

BACKGROUND

Cognitive impairment affects up to 80 percent of the stroke population, however, both the available evidence about post-stroke cognition and the measures used to evaluate it longitudinally have not been well described. The aims of this systematic scoping review were: to identify and characterize studies evaluating cognition longitudinally after stroke; to summarize the cognitive instruments used and the domains they target; and to organize cognitive domains assessed using the International Classification of Functioning, Disability and Health (ICF).

METHODS

We used a systematic scoping approach to search for peer-reviewed articles involving adults with stroke that evaluated cognition longitudinally. Screening of titles, abstracts, and full reports was completed independently by two reviewers, across six electronic databases (PubMed, PsycInfo, Medline, Cinahl Plus, Embase, and Web of Science). Cognitive domains were mapped to an ICF function independently by the same two reviewers, using a previously tested, standardized approach.

RESULTS

A total of 5,540 records were found; 257 were included, representing a total pooled sample of 120,860 stroke survivors. Of these studies, 200 (78%) provided specific cognitive outcomes from the longitudinal evaluations, 57 (22%) reported model predictions, and 77 (30%) included interventions. Cognition was evaluated with 356 unique instruments, targeting 95 distinct cognitive domains, and 17 mental functions from the ICF. The Mini-Mental State Examination was the most frequently used instrument (117 reports, 46%). Other tools used longitudinally were the Trail Making Test (17% of reports), tests of verbal fluency (14%), the Functional Independence Measure (14%), the Montreal Cognitive Assessment (13%), the Digit Span (11%), and the Stroop test (10%). Global cognition was evaluated in 170 reports (66%), followed by higher-level cognitive functioning (29%), memory (28%), language (21%), attention (21%), and perceptual skills (14%). Studies using functional (or performance-based) cognitive assessments over time were scarce (< 1%).

CONCLUSION

Our findings indicate that whilst there is a substantial number of studies available that report longitudinal evaluations of cognition after stroke, there is large variability in the measures used and the cognitive domains they target. Nonetheless, the available data for evaluation of cognition over time after stroke can be organized and described systematically.

Reliability and Validity of a Functional Cognition Screening Tool to Identify the Need for Occupational Therapy

IMPORTANCE

The Centers for Medicare & Medicaid Services (CMS) has identified the need to assess functional cognition as part of the postacute care planning process.

OBJECTIVE

We examined the reliability, validity, and clinical utility of the Menu Task (MT) as a screening measure of functional cognition to assess the need for occupational therapy services.

DESIGN

Cross-sectional study testing a convenience sample of community-dwelling older adults (n = 130) and adults hospitalized for elective orthopedic surgery (n = 60). The MT and four neuropsychological screening tests-the Brief Interview of Mental Status, the Montreal Cognitive Assessment, Trail Making Tests A and B, and an instrumental activities of daily living (IADL) scale-were administered.

SETTING

Community-dwelling participants were tested at the University of Wisconsin occupational therapy program and in community settings. Hospitalized participants were tested at the University of Missouri Orthopedic Institute.

PARTICIPANTS

We recruited healthy community-dwelling adults in Madison, WI (community sample; n = 130) and patients hospitalized for elective orthopedic surgery in Columbia, MO (hospital sample; n = 60). Inclusion criteria were age 55 yr or older, living in the community, and willingness to be tested in English; for the hospital sample, participants had to be referred for elective orthopedic surgery requiring a hospital stay and be independent in activities of daily living before being admitted for surgery.

RESULTS

We found significant differences between groups classified as impaired or not impaired on the basis of MT scores. Participants classified as impaired on the MT performed significantly less well than those classified as not impaired on the neurocognitive and IADL measures.

CONCLUSION

The reliability and validity of the MT were supported.

WHAT THIS ARTICLE ADDS

The American Occupational Therapy Association and the occupational therapy experts advising CMS have stressed the importance of a brief performance-based screening tool to identify people who need more comprehensive occupational therapy evaluation. The implementation of a functional cognition screening tool as part of the required CMS assessment protocol should greatly increase the number of patients referred for occupational therapy evaluation and treatment. The MT has the capacity to address the gap in the proposed CMS assessment of Medicare recipients across postacute care settings.

Medication Management Performance and Associated Cognitive Correlates in Healthy Older Adults and Older Adults with aMCI

OBJECTIVE

Difficulties managing medications, particularly among older adults experiencing cognitive deficits, is an important contributing factor to medication nonadherence that may have significant negative financial and health outcomes. The current study examined the performance of healthy older adults' (HOA) and individuals with amnestic mild cognitive impairment (aMCI) on the medication management abilities assessment's (MMAA, a performance-based measure of medication management) original scoring criteria and derived error process measures, assessing medication overtaking and undertaking magnitude. Exploratory correlations between performances on the MMAA and self-reported confidence in medication management skills and cognitive abilities were also examined.

METHOD

A sample of 25 HOAs with aMCI and 25 age- and education-matched HOAs completed the MMAA, a self-reported medication management confidence rating and a battery of neuropsychological tests.

RESULTS

HOAs performed significantly better on the MMAA score and committed significantly less process errors than individuals with aMCI. Despite these differences in MMAA performance, the HOA and aMCI groups rated similar high levels of confidence in their ability to manage a new medication routine. Notably, while the HOA group's performance on all of the MMAA measures did not relate to cognitive measures, the aMCI group's performance on the MMAA score was significantly related to memory and executive functioning and a new process error score for overtaking was related to processing speed.

CONCLUSIONS

Although these results present promising potential for the MMAA as a measure of medication management in a clinical setting, further studies need to examine the validity of the MMAA against real-world adherence measures.

Neurocognitive Rehabilitation: Skills or Strategies?

The author describes personal and professional milestones in becoming an occupational therapist and his early experience in the first behavior disorder program for neurologically based aggression in the world. A real clinical example is used to bring these early lessons into vivid focus. New evidence underlines occupational therapists' unique role in skill-habit training in clients with severe neurological impairment. For clients with milder impairments, irrespective of diagnosis, strategy training may maximize community independence and reduce hospital recidivism. The concept of functional cognition is described as an important development for the profession. Even in an environment of rapid innovation, occupational therapists need to recognize that it is the commonplace activities that have meaning for the individual that really matter. This is both the art and science of occupational therapy, and it will never be superseded by technological innovation because true creativity and genuine empathy cannot be mechanized.

Overview of reviews of standardised occupation-based instruments for use in occupational therapy practice

INTRODUCTION

Using standardised instruments is one approach to support evidence-based practice. Referring to systematic reviews is an option to identify suitable instruments. However, with an abundance of systematic reviews available, therapists are challenged to identify an appropriate instrument to use. Therefore, this overview of reviews aimed to summarise relevant systematic review findings about standardised occupation-based instruments relevant for occupational therapy practice.

METHODS

An overview of reviews was conducted. A systematic search was performed on four databases up to March 2018. Included systematic reviews were analysed for quality using A MeaSurement Tool to Assess systematic Reviews (AMSTAR).

RESULTS

A total of 2187 articles were identified after removing duplicates. Ultimately, 58 systematic reviews were identified that yielded 641 instruments. From those, 45 instruments were selected for appraisal as they met the inclusion criteria of being developed mainly by occupational therapists and were recommended in the summarised findings from the systematic reviews. The instruments were classified according to the following occupation domains: (i) multidimensional, (ii) activities of daily living, (iii) productivity, (iv) social, (v) sleep/rest, (vi) sexuality and (vii) spirituality. No systematic review was identified that specifically focussed on occupations related to school/education, leisure and play.

DISCUSSION

Certain occupation domains such as activities of daily living, social and sleep/rest received high attention amongst researchers. There is a need for systematic reviews of instruments to measure education/school, play and leisure. Limited numbers of instruments were developed by occupational therapists outside the occupation domain of activities of daily living, and in areas of practice other than children and older people. Nevertheless, this overview can give some guidance for occupational therapists in selecting a suitable occupational therapy instrument for practice.

Contribution of executive functioning to instrumental activities of daily living in older adults

The Texas Functional Living Scale (TFLS) is a performance-based measure of instrumental activities of daily living (IADLs). Executive dysfunction has been linked to impairment on other IADL measures but has not been thoroughly investigated with the TFLS. This study examined the contribution of executive functioning to IADLs on the TFLS among 228 older adults (M age =76.0 +/- 6.5 years; 59% females) who completed the TFLS as part of comprehensive assessment at an outpatient neuropsychology clinic. Executive functioning measures included the Trail Making Test (TMT) Part B, the Controlled Oral Word Association Test, and the Wechsler Abbreviated Scale of Intelligence-II (WASI-II) Matrix Reasoning and Similarities subtests. Results from a hierarchical regression model revealed that only TMT Part B (β = -.23, p = .023) and WASI-II Similarities (β = .32, p = .002) scores significantly predicted TFLS Total scores after controlling for the contributions of demographics (i.e., age, education, and gender), and intellectual functioning and capabilities in other neurocognitive domains (i.e., WASI-II Vocabulary and Block Design subtests, TMT Part A, and Repeatable Battery for the Assessment of Neuropsychological Status Coding subtest, and the Immediate Memory, Delayed Memory, and Visuospatial/Construction Indices).

Measuring instrumental activities of daily living in non-demented elderly: a comparison of the new performance-based Harvard Automated Phone Task with other functional assessments

BACKGROUND

Impairment in instrumental activities of daily living (IADL) may occur in the earliest stages of mild cognitive impairment (MCI). However, there are few reliable measures of IADL in MCI or that have a sufficient range of scores in clinically normal (CN) elderly. The objective of this pilot study was to examine the convergent validity of a phone performance-based IADL instrument, the Harvard Automated Phone Task (APT), designed to measure the earliest IADL changes in Alzheimer's disease (AD), with other sensitive performance-based and subjective measures of everyday functional capacity among CN and MCI participants.

METHODS

Twenty-nine CN and 17 MCI participants were administered the Harvard APT, the computer performance-based Czaja Functional Assessment Battery (CFAB), and the AD Cooperative Study ADL prevention instrument (ADCS ADL-PI) participant and study partner versions; in addition, 52 different CN and 7 MCI participants were administered the Harvard APT and the Subjective Study Partner and Participant-reported (SSPP) IADL scale. The Harvard APT was compared with the three other IADL assessments.

RESULTS

In both CN and MCI, better performance on the Harvard APT was associated with better performance on the CFAB. In CN, better performance on the Harvard APT was associated with better ADCS ADL-PI participant-reported IADL, while in MCI better performance on the Harvard APT was associated with better ADCS ADL-PI study partner-reported IADL. Furthermore, in CN better performance on the Harvard APT was associated with better SSPP-IADL participant and study partner-reported IADL.

CONCLUSIONS

In this small pilot study, the Harvard APT, a brief, self-administered, objective measure of IADL performance, appears to correlate well with other sensitive measures of everyday functioning, providing good preliminary convergent validity for this new measure. Moreover, it appears to perform well across both CN and MCI participants, which suggests that it is a promising measure of early, clinically meaningful functional change. This may not be the case as suggested in our small sample for subjective IADL scales that may perform differentially depending on the reporter (self vs. study partner) across the clinical spectrum possibly due to diminishing awareness of IADL difficulties in individuals who become cognitively impaired. Secondary prevention trials in AD have a great need for such ecologically valid and reliable measures of early IADL changes.

Convergent and concurrent validity of a report- versus performance-based evaluation of everyday functioning in the diagnosis of cognitive disorders in a geriatric population

ABSTRACTBackground:Several methods have been developed to evaluate activities of daily living (ADLs) in mild cognitive impairment (MCI) and mild dementia. This study evaluated the convergent and concurrent validity between (1) two report-based methods (the advanced (a)- and instrumental (i)-ADL tools) and (2) a performance-based method (the Naturalistic Action Test (NAT)) to check if their ability to differentiate between cognitively healthy comparisons (HCs), persons with MCI, and persons with mild Alzheimer's disease (AD) are comparable to each other.

METHOD

This was a cross-sectional study, undertaken in a geriatric day hospital. The participants comprised community-dwelling HCs (n = 21, median age 78.0 years, 61.9% female), MCI (n = 20, median age 79.5 years, 55.0% female), and AD (n = 20, median age 80.0 years, 85.0% female) adults. A diagnostic procedure for neurocognitive disorders was employed. In addition, the a- and i-ADL tools and the NAT were administered separately by blinded raters.

RESULTS

The NAT and both the a- and i-ADL tools showed significant differences between HCs, MCI, and AD participants. Convergent validity showed moderate to strong significant correlations between the NAT, and a- and i-ADL tools (range -0.583 to -0.663; p &lt; 0.01). Concurrent validity showed that the NAT (AUC 0.809-1.000) and the a- and i-ADL tools (AUC 0.739-0.964) presented comparable discriminatory accuracy (p = 0.0588).

CONCLUSIONS

In contrast to prior studies comparing report-based and performance-based methods of assessing ADL, this study indicates that the NAT and the a- and i-ADL tools have strong convergent and concurrent validity, and appear to have similar discriminatory power in differentiating between HCs, MCI, and AD.

Kettle test efficacy in predicting cognitive and functional outcomes in geriatric rehabilitation

BACKGROUND/AIM

Limited research has been available to support the use of the Kettle Test in a subacute rehabilitation setting with patients diagnosed with a variety of medical conditions. The Kettle Test is an occupation based performance measure designed to detect cognitive processes and function. The aim of this research was to measure the correlation between three cognitive tests, the Mini-Mental State Examination (MMSE), Cognitive Functional Independence Measure (Cognitive FIM) and the Kettle Test. Secondly, to assess the efficacy of these tests in predicting functional outcomes via the motor subscale of the Functional Independence Measure (mFIM).

METHODS

A prospective single-centre cohort study in a subacute rehabilitation setting of 97 patients.

RESULTS

Correlation coefficients between the tests were statistically significant and moderately strong, with values ranging from 0.593 to -0.589. Significant positive correlations were seen between admission MMSE, Cognitive FIM and the mFIM and significant negative correlations between Kettle Test scores and the mFIM. The Kettle Test score had a stronger relationship with mFIM (r = -0.40; P < 0.01) compared to the Cognitive FIM (r = 0.33; P < 0.01) and MMSE (r = 0.26; P < 0.05). The Kettle Test variance is significantly associated with the MMSE and Cognitive FIM at admission and discharge measures. Modelling identified that age and gender significantly contribute to this relationship. When adjusted for age and gender the MMSE and Cognitive FIM both explained the 47% of the variance at discharge.

CONCLUSION

There were statistically significant inter-test correlations between the MMSE, Cognitive FIM and Kettle Test. The Kettle Test had the strongest relationship to patient functional outcomes.

Screening for Functional Cognition in Postacute Care and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014

Occupational therapists have a long history of assessing functional cognition, defined as the ability to use and integrate thinking and performance skills to accomplish complex everyday activities. In response to passage of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 (Pub. L. 113-185), the American Occupational Therapy Association has been advocating that the Centers for Medicare and Medicaid Services consider functional cognition for inclusion in routine patient assessment in postacute care settings, with important implications for occupational therapy. These efforts have the potential to increase referrals to occupational therapy, emphasize the importance of addressing functional cognition in occupational therapy practice, and support the value of occupational therapy in achieving optimal postacute care outcomes.

The tailored activity program (TAP) to address behavioral disturbances in frontotemporal dementia: a feasibility and pilot study

PURPOSE

To explore the feasibility of implementing the Tailored Activity Program with a cohort of people with frontotemporal dementia and their carers (dyads).

METHODS

The Tailored Activity Program is an occupational therapy based intervention that involves working collaboratively with family carers and prescribes personalized activities for behavioral management in people with dementia. Twenty dyads randomized into the study (Tailored Activity Program: n = 9; Control: n = 11) were assessed at baseline and 4-months. Qualitative analyzes evaluated feasibility and acceptability of the program for the frontotemporal dementia cohort, and quantitative analyzes (linear mixed model analyzes, Spearman's rho correlations) measured the impact of the program on the dyads.

RESULTS

The Tailored Activity Program was an acceptable intervention for the frontotemporal dementia dyads. Qualitative analyses identified five themes: "carer perceived benefits", "carer readiness to change", "strategies used by carer to engage person with dementia", "barriers to the Tailored Activity Program uptake/implementation", and "person with dementia engagement". Quantitative outcomes showed an overall reduction of behavioral symptoms (F_18.34 = 8.073, p = 0.011) and maintenance of functional performance in the person with dementia (F_18.03 = 0.375, p = 0.548).

CONCLUSIONS

This study demonstrates the potential for using an activity-based intervention such as the Tailored Activity Program in frontotemporal dementia. Service providers should recognize that while people with frontotemporal dementia present with challenging issues, tailored therapies may support their function and reduce their behavioral symptoms. Implications for rehabilitation The Tailored Activity Program is an occupational therapy based intervention that involves prescribing personalized activities for behavioral management in dementia. The Tailored Activity Program is an acceptable and feasible intervention approach to address some of the unique behavioral and functional impairments inherent in frontotemporal dementia.

The course and prognostic factors of cognitive status after central nervous system trauma: a systematic review protocol

INTRODUCTION

Traumatic brain injury (TBI) is among the most disabling injuries, resulting in a range of cognitive impairments. Traumatic spinal cord injury (SCI) often occurs in conjunction with TBI; the two are best considered together in the context of trauma to the central nervous system (CNS). Despite strong indications of cognitive dysfunction in CNS trauma, little is known about its natural history or relationship with other factors. The current protocol outlines a strategy for a systematic review of the current evidence examining CNS trauma as a prognostic factor of cognitive decline in the adult population.

METHODS AND ANALYSIS

The review will be conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All peer-reviewed English language publications with a longitudinal design that focus on cognition in adults (ages 18 and older) with either TBI or SCI, or both from inception to December 2016 found through Medline, Central, Embase, Scopus, PsycINFO, supplemental PubMed and bibliographies of identified articles will be considered eligible. Quality will be evaluated using published guidelines. Results will be grouped by: (1) prognostic factors of cognitive deficits; and (2) development of, or time until development of, cognitive deficit in patients with CNS trauma. Close attention will be paid to the evaluative properties of the measurements used to assess cognition.

ETHICS AND DISSEMINATION

The authors will publish findings from this review in a peer-reviewed scientific journal(s) and present the results at national and international conferences. This work will advance scientific certainty regarding natural history and prognostic factors of cognitive status in males and females with CNS trauma, informing clinicians, policymakers and future researchers on the topic.

PROSPERO REGISTRATION NUMBER

CRD42017055309.

Association Between 2 Measures of Cognitive Instrumental Activities of Daily Living and Their Relation to the Montreal Cognitive Assessment in Persons With Stroke

OBJECTIVES

To explore the relation between a computer adaptive functional cognitive questionnaire and a performance-based measure of cognitive instrumental activities of daily living (C-IADL) and to determine whether the Montreal Cognitive Assessment (MoCA) at admission can identify those with C-IADL difficulties at discharge.

DESIGN

Prospective cohort study.

SETTING

Acute inpatient rehabilitation unit of an academic medical center.

PARTICIPANTS

Inpatients (N=148) with a diagnosis of stroke (mean age, 68y; median, 13d poststroke) who had mild cognitive and neurological deficits.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Admission cognitive status was assessed by the MoCA. C-IADL at discharge was assessed by the Executive Function Performance Test (EFPT) bill paying task and Activity Measure of Post-Acute Care (AM-PAC) Applied Cognition scale.

RESULTS

Greater cognitive impairment on the MoCA was associated with more assistance on the EFPT bill paying task (ρ=-.63; P<.01) and AM-PAC Applied Cognition scale (ρ=-.43; P<.01). This relation was nonsignificant for higher MoCA scores and EFPT bill paying task scores. The AM-PAC Applied Cognition scale and the EFPT bill paying task had low agreement in classifying functional performance (Cohen's κ=.20). A receiver operating characteristic curve identified optimal MoCA cutoff scores of 20 and 21 for classifying EFPT bill paying task status and AM-PAC Applied Cognition scale status, respectively. For values above 20 and 21, sensitivity increased whereas specificity decreased for classifying functional deficits. Approximately one third of the participants demonstrated C-IADL deficits on at least 1 C-IADL measure at discharge despite having a MoCA score of ≥26 at admission.

CONCLUSIONS

Questionnaire and performance-based methods of assessment appear to yield different estimates of C-IADL. Low MoCA scores (<20) are more likely to identify those with C-IADL deficits on the EFPT bill paying task. The results suggest that C-IADL should be assessed in those who have mild or no cognitive difficulties at admission.

Measurement of Functional Cognition and Complex Everyday Activities in Older Adults with Mild Cognitive Impairment and Mild Dementia: Validity of the Large Allen's Cognitive Level Screen

OBJECTIVE

To explore the validity of the Large Allen's Cognitive Level Screen-5 (LACLS-5) as a performance-based measure of functional cognition, representing an ability to perform complex everyday activities in older adults with mild cognitive impairment (MCI) and mild dementia living in the community.

METHODS

Using cross-sectional data from the Sydney Memory and Ageing Study, 160 community-dwelling older adults with normal cognition (CN; N = 87), MCI (N = 43), or dementia (N = 30) were studied. Functional cognition (LACLS-5), complex everyday activities (Disability Assessment for Dementia [DAD]), Assessment of Motor and Process Skills [AMPS]), and neuropsychological measures were used.

RESULTS

Participants with dementia performed worse than CN on all clinical measures, and MCI participants were intermediate. Correlational analyses showed that LACLS-5 was most strongly related to AMPS Process scores, DAD instrumental activities of daily living subscale, Mini-Mental State Exam, Block Design, Logical Memory, and Trail Making Test B. Multiple regression analysis indicated that both cognitive (Block Design) and functional measures (AMPS Process score) and sex predicted LACLS-5 performance. Finally, LACLS-5 was able to adequately discriminate between CN and dementia and between MCI and dementia but was unable to reliably distinguish between CN and MCI.

CONCLUSION

Construct validity, including convergent and discriminative validity, was supported. LACLS-5 is a valid performance-based measure for evaluating functional cognition. Discriminativevalidity is acceptable for identifying mild dementia but requires further refinement for detecting MCI.

Early diagnosis of mild cognitive impairment and mild dementia through basic and instrumental activities of daily living: Development of a new evaluation tool

BACKGROUND

Assessment of activities of daily living (ADL) is paramount to determine impairment in everyday functioning and to ensure accurate early diagnosis of neurocognitive disorders. Unfortunately, most common ADL tools are limited in their use in a diagnostic process. This study developed a new evaluation by adopting the items of the Katz Index (basic [b-] ADL) and Lawton Scale (instrumental [i-] ADL), defining them with the terminology of the International Classification of Human Functioning, Disability and Health (ICF), adding the scoring system of the ICF, and adding the possibility to identify underlying causes of limitations in ADL.

METHODS AND FINDINGS

The construct validity, interrater reliability, and discriminative validity of this new evaluation were determined. From 2015 until 2016, older persons (65-93 y) with normal cognitive ageing (healthy comparison [HC]) (n = 79), mild cognitive impairment (MCI) (n = 73), and Alzheimer disease (AD) (n = 71) underwent a diagnostic procedure for neurocognitive disorders at the geriatric day hospital of the Universitair Ziekenhuis Brussel (Brussels, Belgium). Additionally, the ICF-based evaluation for b- and i-ADL was carried out. A global disability index (DI), a cognitive DI (CDI), and a physical DI (PDI) were calculated. The i-ADL-CDI showed high accuracy and higher discriminative power than the Lawton Scale in differentiating HC and MCI (area under the curve [AUC] = 0.895, 95% CI .840-.950, p = .002), MCI and AD (AUC = 0.805, 95% CI .805-.734, p = .010), and HC and AD (AUC = 0.990, 95% CI .978-1.000, p < .001). The b-ADL-DI showed significantly better discriminative accuracy than the Katz Index in differentiating HC and AD (AUC = 0.828, 95% CI .759-.897, p = .039). This study was conducted in a clinically relevant sample. However, heterogeneity between HC, MCI, and AD and the use of different methods of reporting ADL might limit this study.

CONCLUSIONS

This evaluation of b- and i-ADL can contribute to the diagnostic differentiation between cognitively healthy ageing and neurocognitive disorders in older age. This evaluation provides more clarity and nuance in assessing everyday functioning by using an ICF-based terminology and scoring system. Also, the possibility to take underlying causes of limitations into account seems to be valuable since it is crucial to determine the extent to which cognitive decline is responsible for functional impairment in diagnosing neurocognitive disorders. Though further prospective validation is still required, the i-ADL-CDI might be useful in clinical practice since it identifies impairment in i-ADL exclusively because of cognitive limitations.