Cognitive Functional Evaluation (CFE) Process for Individuals with Suspected Cognitive Disabilities

Online awareness is associated with superior performance on assessments of functional cognition

Background

Intact awareness facilitates an individual's adoption of strategies to support community living skills. However, most studies have not examined awareness during ongoing complex task performance. Objective: To examine whether community-dwelling adult's Accuracy and Strategy use on the Weekly Calendar Planning Activity 17-item version (WCPA-17), Total Cues on the Performance Assessment of Self-care Skills Checkbook Balancing and Shopping Task (PCST), and scores on the self-report Alzheimer's Disease Cooperative Study - Activities of Daily Living Scale (ADCS-ADL) differ between groups who do and do not demonstrate awareness of performance difficulties on the WCPA-17.

Methods

Using data collected as part of a larger study we performed a cross-sectional analysis of 274 community-dwelling adults aged 55 to 93 years. Two methods classified participants into groups aware or unaware of their performance. Independent sample t-tests examined group differences on four dependent variables: Accuracy and Strategy use on the WCPA-17, PCST Total Cues, and score on the ADCS-ADL.

Results

Using one classification method, aware individuals showed superior Accuracy (p < 0.001), used more Strategies (p = 0.002), needed fewer PCST Total Cues (p < 0.001), and reported greater independence on the ADCS-ADL (p < 0.004), similar trends were observed with the other method in Accuracy (p < 0.001) and PCST Total Cues (p < 0.001) but Strategy use and ADCS-ADL differences failed to reach significance after Bonferroni correction.

Conclusion

Groups categorized as aware performed better on all measures. Intact awareness is critical to performance on complex everyday activities and can be evaluated with functional cognition assessments.

The Multiple Errands Test: A Guide for Site-Specific Version Development

Background. The complex and real-world nature of the Multiple Errands Test (MET) makes it a valuable and increasingly popular assessment of cognitive function. However, these same qualities make its local implementation challenging. Purpose. To produce an evidence-based guide for site-specific adaptation of the MET. Method. The CAN-IMPLEMENT© knowledge translation framework informed a structured approach to the creation of a guide to site-specific version development, informed by twenty-two published approaches to MET adaptation. Applicability of the guide was supported by a two-phase revision process, in which a site-specific hospital and community version produced from its recommendations were administered with forty-two neurologically intact participants and stakeholder feedback obtained. Findings. We offer an outline of core components which maintain the integrity of the MET, and adaptable peripheries which may be modified when required by the local setting. Implications. The proposed guide provides a systematic yet flexible guide for site-specific MET development.

Establishing the Validity of the Internet-Based Bill-Paying Task to Assess Executive Function Deficits Among Adults With Traumatic Brain Injury

IMPORTANCE

Executive function (EF) deficits are common after traumatic brain injury (TBI). During rehabilitation, it is important to identify EF deficits and understand their impact on daily function. The internet-based Bill-Paying Task, modified from the Executive Function Performance Test, has not yet been validated for use with people with TBI.

OBJECTIVE

To examine the known-groups, convergent, and ecological validity of the internet-based Bill-Paying Task for assessing EF deficits after TBI.

DESIGN

Cross-sectional study with two consecutive parts based on the study's objectives.

SETTING

Inpatient rehabilitation and community.

PARTICIPANTS

Part 1 included 42 adults with TBI and 47 healthy adults; Part 2 included 28 of the 42 adults with TBI.

MEASURES

Assessments included the Internet-based Bill-Paying Task, WebNeuro neurocognitive computerized battery, Semantic Verbal Fluency test, Behavioural Assessment of the Dysexecutive Syndrome (BADS), Dysexecutive Questionnaire (DEX), and cognitive items of the FIM® and the Functional Assessment Measure (cognitive FIM+FAM).

RESULTS

For Part 1, participants with TBI required significantly more cues and longer completion time to perform the internet-based Bill-Paying Task. For Part 2, moderate significant correlations were found between the internet-based Bill-Paying Task total score and the WebNeuro, Semantic Verbal Fluency test, BADS, DEX, and cognitive FIM+FAM.

CONCLUSIONS AND RELEVANCE

This study supports the known-groups, convergent, and ecological validity of the internet-based Bill-Paying Task for assessing EF deficits among adults with preserved basic cognitive abilities after TBI. Therefore, it can be used to assist with rehabilitation treatment planning after TBI. What This Article Adds: The internet-based Bill-Paying Task, an online payment task relevant to today's technological world, is valid to assess higher cognitive abilities of people after a traumatic brain injury. This assessment may contribute to a better understanding of patients' cognitive profiles and their potential impact on daily performance.

Clinical validation of the Allen's Cognitive Level Screen in acquired brain injury

BACKGROUND

The evaluation of functional cognition is a central concern in clinical practice. However, there are few standardized or validated tools, and many of them take too long, requiring screening tests.

AIMS

To explore the convergent validity of the ACLS-5 with other cognitive screening test and functional independence test in a sample of people with acquired brain injury. Moreover, to examine the prediction of ACLS-5 on functioning and cognitive performance outcomes.

MATERIALS AND METHODS

A cross-sectional design was applied following the guidelines of the STROBE checklist. A consecutive sample of people with acquired brain injury was recruited from rehabilitation centers. A cognitive screening test and daily living activity tests were implemented, such as ACLS-5, MoCA, Barthel, and FIM+FAM. Data were analyzed using non-parametric methods. In addition, a structural analysis and simple regression models were performed.

RESULTS

Eighty patients with chronic acquired brain injury, with a mean age of 52, were recruited. All tests are significantly related to the ACLS-5 score, a moderate effect size for MoCA (ρ = 0.36), and a strong effect size for the other two (ρ > 0.50).

CONCLUSIONS

ACLS-5 predicts functional and cognitive performance quickly and effectively, optimizing assessment time and avoiding mental fatigue or physical exhaustion.

Screening Tools: They're So Quick! What's the Issue?

Screening tools are needed in occupational therapy practice to determine which clients require formal evaluation. Because screening tools also tell us who does not require formal evaluation, they are key to improved clinical efficiency. Screening tools are brief, easy to administer, and often freely available. These qualities also lead to misuse of screening tools, including using them to measure progress over time or to serve as a confirmatory assessment on which to base treatment planning. We present additional common missteps of screening tool use, including a lack of consideration for a tool's psychometric properties, and exemplars of these common misuses in adult and pediatric practice. Finally, we offer solutions to address these concerns.

Self-reported strategy generation and implementation in the multiple errands test: A qualitative description

The Multiple Errands Test (MET) is a naturalistic assessment of executive function. Strategy use during the MET can provide useful information for the development of a cognitive profile and intervention plan in patients with brain injury. However, while observed external strategy use in the MET is well-documented, information about internal strategy use and reference data with healthy controls is limited. Contextual influences on strategy selection in this real-world assessment are also not well understood. This qualitative descriptive study explored the internal and external strategies used during MET performance by cognitively intact adults. Strategies were categorized as planning, checking, and problem solving. When planning, participants simplified and familiarized themselves with MET requirements before developing an action plan. They checked their performance by asking for help and using cues in the physical environment. When problems arose, these were solved through self-talk, comparing alternatives, applying context and modifying their plan. Results highlighted that individuals employ both visible and hidden strategies during the MET. This suggests that reflective discussions with patients following cognitive task engagement may be important, to uncover and understand strategy use, both to inform analysis of performance and guide strategy training.

Assessment tools and factors used to predict discharge from acute general medical wards: a systematic review

PURPOSE

To identify assessment tools and patient factors statistically associated with discharge destination in general medical inpatients.

MATERIALS AND METHOD

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Four electronic databases were searched. Studies were eligible if they were a quantitative study design, had adult acute general medical inpatients and published in English. Outcomes of interest were tools or factors with statistical correlations with discharge destination (home, subacute or residential care). Articles were screened by two independent assessors. Data were extracted by one reviewer and independently checked by a second reviewer. Data were analysed/described descriptively.

RESULTS

Twenty-three studies were included. Twenty-three tools and 44 factors were identified, which spanned Health Condition, Body Structure and Function, Activity, Participation, Environment and Personal concepts of the World Health Organisation International Classification of Function, Disability and Health (WHO ICF).

CONCLUSIONS

The large number of tools and factors found and their distribution across several WHO ICF concepts exemplifies the complexities of predicting discharge. No single assessment tool that best predicts discharge destination was identified, but rather there were a variety of potential tools identified. Further research is needed to determine the psychometric properties of the identified assessment tools as well as additional predictors of subacute care (including rehabilitation). This is important as it may allow for timely clinical decision making.

TRIAL REGISTRATION

A priori, PROSPERO (CRD42017064209).IMPLICATIONS FOR REHABILITATIONThis systematic review identified a large number of assessment tools and patient factors associated with discharge destination (home, subacute and residential care) in general medical inpatients.All of the domains of the WHO ICF framework are associated with discharge destination and must be considered.Clinicians in the acute setting can use these findings to assist selection of assessment tools to identify patients likely to need rehabilitation or subacute care.Early identification of patients who are unable to return to their place of residence is essential as it allows for provision of early rehabilitation and subsequent discharge planning.

Cognition, Cognitive Rehabilitation, and Occupational Performance

The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, through the use of occupations and activities, facilitate clients’ cognitive functioning to enhance occupational performance, self-efficacy, participation, and perceived quality of life. Cognitive processes are integral to effective performance across the broad range of daily occupations such as work, educational pursuits, home management, and play and leisure. Cognition plays an integral role in human development and in the ability to learn, retain, and use new information to enable occupational performance across the lifespan.

This statement defines the role of occupational therapy in evaluating and addressing cognitive functioning to help clients maintain and improve occupational performance. The intended primary audience is practitioners1 within the profession of occupational therapy. The statement also may be used to inform recipients of occupational therapy services, practitioners in other disciplines, and the wider community regarding occupational therapy theory and methods and to articulate the expertise of occupational therapy practitioners in addressing cognition and challenges in adapting to cognitive dysfunction.

Predictive Value of the Cognitive Performance Test (CPT) for Staging Function and Fitness to Drive in People With Neurocognitive Disorders

The Cognitive Performance Test (CPT) is a standardized occupational therapy assessment that examines cognitive integration with functioning in an instrumental activities of daily living context. Conventional cognitive measures provide diagnostic utility but do not fully address the functional implications. Ninety-one veterans diagnosed with cognitive impairment were evaluated. We compared the predictive value of the CPT with the Large Allen Cognitive Level Screen (LACLS), Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA) for the need to retire from driving versus ability to pass an on-road exam. Measures were also analyzed by diagnostic classification. CPT correctly classified a mild versus major neurocognitive disorder, whereas MMSE, MoCA, and LACLS did not differentiate the groups. A CPT cutoff score of <4.7/5.6 showed 89% sensitivity for failing the road exam and 75% specificity for ability to pass. CPT discriminated functional level in neurocognitive disorders and had better predictive value for fitness to drive compared with conventional cognitive measures.

Cognitive Assessment Trends in Home Health Care for Adults With Mild Stroke

OBJECTIVE

This article describes current trends in cognitive assessment use for adults with mild stroke by home health practitioners in the United States.

METHOD

Participants were 56 home health occupational therapists and occupational therapy assistants. A self-administered survey about use of cognitive assessment tools in home health care and influences on their use was conducted.

RESULTS

Ninety-six percent of participants assessed cognition in adults with mild stroke. Nonstandardized assessments were the most widely used method for evaluating cognition in the home health setting. Influences such as specialized training in specific assessments, confidence, and productivity requirements may have affected the practitioners' cognitive assessment decisions in home health care.

CONCLUSION

Although cognitive assessments are widely used in home health care, occupational therapy practitioners are selecting nonstandardized assessments most frequently to assess cognition.

Allen Cognitive Level Screen for the classification of subjects treated for addiction

Introduction The Cognitive Disabilities Model (CDM) is an occupational approach that can allow the classification of the functional-cognitive abilities of persons with addictions. The objective of the study was to explore the applicability of the ACLS-5 to assess a sample of persons undergoing addiction-rehabilitation treatment. Methods A sample of 232 participants was recruited from an outpatient treatment centre in Madrid (Spain). The ACLS-5, the Montreal Cognitive Assessment (MoCA), and the Prefrontal Symptom Inventory (PSI) were administered. Sociodemographic and addiction-related data were also obtained. Results Half of the sample showed serious deficits in functional cognition, which ultimately could be related to problems in their daily performance. Scores of ACLS-5 showed significant correlations with the severity of addiction, with those obtained with the MoCA, and with attentional symptoms on the PSI scale. Conclusions The data suggest the applicability of the ACLS-5 in assessing the degree of functional cognition in subjects treated for addiction, providing evidence to support ecological validity and facilitating the development of well-targeted cognitive rehabilitation programmes from an occupational perspective. The use of occupational-based instruments to assess the functioning of those with addictions is a requirement of occupational therapy professionals working in this general area.

Validity of the Functional Loewenstein Occupational Therapy Cognitive Assessment (FLOTCA)

The Functional Loewenstein Occupational Therapy Cognitive Assessment (FLOTCA) was developed to assess integrative higher cognitive abilities in people with traumatic brain injury (TBI). The FLOTCA measures performance on three tasks: navigating on a map, organizing a toolbox, and planning a daily schedule. This study assessed the psychometric properties of the FLOTCA with a sample of 25 participants with TBI ages 18–49 and 25 matched healthy participants. The FLOTCA showed high interrater reliability (intraclass correlation = .996) and internal consistency reliability for the total score (α = .82). Construct validity was supported for the total score, t (48) = −5.48, d = 1.52, and the separate tasks. Moderate ecological validity was obtained with the combined FIM™ and Functional Assessment Measure, r (19) = .44, p &lt; .05. The results indicate that the FLOTCA can be used to assess higher cognitive abilities in functioning and can serve as the basis for intervention planning.

Factors discriminating employment status following in-patient evaluation among persons with schizophrenia

BACKGROUND

Employment is a key element in recovery from schizophrenia. Yet 60%-80% of people with schizophrenia are not involved in work occupations. Factors influencing employment were explored mostly in community settings, while the recovery process begins already during hospitalization.

OBJECTIVE

The aim of the study was to investigate parameters that can distinguish during hospitalization between people with schizophrenia who will work in competitive employment, in sheltered employment or will not work after discharge.

METHODS

The research followed 104 participants from acute hospitalization to the community, six months after discharge, to obtain employment related data. The participants' cognitive abilities, schizophrenia symptoms, and functional capacity were evaluated during hospitalization. In addition, demography and illness related factors were collected.

RESULTS

The results indicate that persons with different employment statuses varied in several parameters during hospitalization. However, the most effective discriminant model includes negative symptoms, functional capacity measure and the number of hospitalizations.

CONCLUSIONS

The study suggests that people with different employment statuses have unique characteristics already during hospitalization. In the future, appropriate rehabilitation programs may be suggested to each group based on these characteristics to promote employment among people with schizophrenia and contribute to recovery.

Putting executive performance in a theoretical context

This article provides a theoretical context to understand the role of executive functions in occupational performance. The authors provide definitions of the components of executive functions and their occupational significance. Assessment and intervention strategies for individuals with executive function deficits are discussed.

How Occupational Therapists Engage Adults with Cognitive Impairments in Assessments

Introduction:

There is little discussion in the multidisciplinary literature about how to engage adults with cognitive impairments in health-related assessments. This qualitative descriptive study used semi-structured interviews to explore how nine occupational therapists working across a range of practice settings addressed this issue.

Method:

Interviews were digitally recorded and transcribed verbatim. Inductive analysis revealed themes, which were refined through an iterative process.

Findings:

The findings showed that the participants used individually developed strategies to engage clients in assessments. The first theme, ‘Managing a complex process’, described the steps used with clients and families to obtain informed consent, prepare for the assessment, and consider the impact of having a third party present. The second theme, ‘Recruiting cooperation’, addressed how the participants used their relationship with clients to recruit them to engage in the assessment.

Conclusion:

The findings provided a snapshot of processes employed in practice to determine the needs and capabilities of clients with cognitive impairments, and the compromises therapists make in relation to eliciting informed consent and the integrity of formal assessment tools. The findings have implications for the profession and further research.

Executive functioning: a scoping review of the occupational therapy literature

BACKGROUND

Increasingly recognized as an important factor in the performance of complex, goal-directed tasks, executive functioning is understood in different ways across disciplines.

PURPOSE

The aim was to explore the ways in which executive functioning is conceptualized, discussed, described, and implied in the occupational therapy literature.

METHOD

A scoping review of the occupational therapy literature was conducted following Levac, Colquhoun, and O'Brien's (2010) recommended methodology.

RESULTS

Executive functioning is described both as a set of performance component skills or processes and as the executive occupational performance inherent in complex occupations. Executive functioning is implicit in occupational performance and engagement, and some health conditions seem to be commonly associated with impaired executive functioning. Assessing executive functioning requires dynamic occupation- and performance-based assessment. Interventions targeting executive functioning are grounded in metacognitive approaches.

CONCLUSION

Executive functioning is a complex construct that is conceptualized with considerable variance within the occupational therapy literature, creating barriers to effective service delivery.

Cognitive assessment across the continuum of care: the importance of occupational performance-based assessment for individuals post-stroke and traumatic brain injury

BACKGROUND/AIM

When working with individuals following stroke or traumatic brain injury, an important role of the occupational therapist is to assess the impact of cognitive impairment on their ability to engage in occupations and resume important life roles. The aim of this study was to survey therapists' reasons for selection of and challenges with using various cognitive assessment approaches, across the continuum of care, when working with individuals following stroke and traumatic brain injury.

METHODS

A cross-sectional survey, completed via post or online, with responses from 209 Australian occupational therapists was conducted. Participants included clinicians working in acute, inpatient rehabilitation and community settings.

RESULTS

Occupational performance-based assessments were ranked as the most important assessment method, with 69% of participants reporting using these assessments for more than 75% of their clients with cognitive impairment. Participants identified the lack of quantitative data provided by these assessments as a frequent challenge. The identification of cognitive deficits was the highest ranked reason for using cognitive screens and batteries. Challenges identified with using cognitive screens and batteries included difficulty linking assessment results to occupational performance, and difficulty using results to generate intervention strategies. The majority of participants reported using a combined approach to assessment, and used screens and batteries to support findings of occupational performance-based assessments.

CONCLUSIONS

Targeted efforts to further incorporate standardised occupational performance-based methods into clinical practice, research, and ongoing professional development is required to enhance occupational therapy services when working with individuals with cognitive impairment.

BPSD following traumatic brain injury

Annually, 700,000 people are hospitalized with brain injury acquired after traumatic brain injury (TBI) in Brazil.

OBJECTIVE

We aim to review the basic concepts related to TBI, and the most common Behavioral and Psychological Symptoms of Dementia (BPSD) findings in moderate and severe TBI survivors. We also discussed our strategies used to manage such patients in the post-acute period.

METHODS

Fifteen TBI outpatients followed at the Center for Cognitive Rehabilitation Post-TBI of the Clinicas Hospital of the University of São Paulo were submitted to a neurological, neuropsychological, speech and occupational therapy evaluation, including the Mini-Mental State Examination. Rehabilitation strategies will then be developed, together with the interdisciplinary team, for each patient individually. Where necessary, the pharmacological approach will be adopted.

RESULTS

Our study will discuss options of pharmacologic treatment choices for cognitive, behavioral, or affective disorders following TBI, providing relevant information related to a structured cognitive rehabilitation service and certainly will offer an alternative for patients and families afflicted by TBI.

CONCLUSION

Traumatic brain injury can cause a variety of potentially disabling psychiatric symptoms and syndromes. Combined behavioral and pharmacological strategies, in the treatment of a set of highly challenging behavioral problems, appears to be essential for good patient recovery.

Dynamic Lowenstein Occupational Therapy Cognitive Assessment: Evaluation of Potential to Change in Cognitive Performance

OBJECTIVE. We studied the psychometric properties of the dynamic version of the Lowenstein Occupational Therapy Cognitive Assessment (DLOTCA) and examined the most frequent level of mediation used for planning for intervention.

METHOD. Participants included 83 clients hospitalized after first stroke (mean age = 57.7, standard deviation = 8.33) and 45 healthy control participants. All were assessed with the DLOTCA after providing informed consent.

RESULTS. Interrater reliability showed high correlations between all pairs of raters. Internal consistency reliability showed moderate to high αs (.602–.813) for all domains except Visual Perception. We found significant differences between the groups of participants before mediation; both benefited from mediation, showing moderate to high effect sizes. Stroke clients needed higher levels of mediation.

CONCLUSION. The DLOTCA is effective in providing insight into whether participants need mediation and the level and type of assistance they require. The DLOTCA provides guidance for planning intervention for people with cognitive disabilities.

Cognitive rehabilitation following traumatic brain injury

Annually, some 500,000 people are hospitalized with brain lesions acquired after traumatic brain injury (TBI) in Brazil. Between 75,000 and 100,000 individuals die within hours of the event and 70,000 to 90,000 evolve to irreversible loss of some neurological function. The principal causes of TBI include motor vehicle accidents (50%), falls (21%), assaults and robberies (12%) and accidents during leisure activities (10%). Within this context, cognitive rehabilitation, a clinical area encompassing interdisciplinary action aimed at recovery as well as compensation of cognitive functions altered as a result of cerebral injury, is extremely important for these individuals. Therefore, the aim of this study was to review the basic concepts related to TBI, including mechanisms of injury, severity levels of TBI, the most common findings in moderate and severe TBI survivors, and the most frequent cognitive impairments following TBI, and also to discuss the strategies used to handle patients post-TBI. The study results yielded relevant information on a structured cognitive rehabilitation service, representing an alternative for patients and families afflicted by TBI, enabling the generation of multiple research protocols.