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

Validity of the Short Weekly Calendar Planning Activity in patients with Parkinson disease and nonmanifesting LRRK2 and GBA carriers

BACKGROUND AND PURPOSE

Subtle executive dysfunction is common in people newly diagnosed with Parkinson disease (PD), even when general cognitive abilities are intact. This study examined the Short Weekly Calendar Planning Activity (WCPA-10)'s known-group construct validity, comparing persons with PD to healthy controls (HCs) and nonmanifesting carriers of LRRK2 and GBA gene mutations to HCs. Additionally, convergent and ecological validity was examined.

METHODS

The study included 73 participants: 22 with idiopathic PD (iPD) who do not carry any of the founder GBA mutations or LRRK2-G2019S, 29 nonmanifesting carriers of the G2019S-LRRK2 (n = 14) and GBA (n = 15) mutations, and 22 HCs. Known-group validity was determined using the WCPA-10, convergent validity by also using the Montreal Cognitive Assessment (MoCA) and Color Trails Test (CTT), and ecological validity by using the WCPA-10, Schwab and England Activities of Daily Living Scale (SE ADL), and Physical Activity Scale for the Elderly (PASE).

RESULTS

Known-group validity of the WCPA-10 was established for the iPD group only; they followed fewer rules (p = 0.020), were slower (p = 0.003) and less efficient (p = 0.001), used more strategies (p = 0.017) on the WCPA-10, and achieved significantly lower CTT scores (p < 0.001) than the HCs. The nonmanifesting carriers and HCs were similar on all cognitive tests. Convergent and ecological validity of the WCPA-10 were partially established, with few correlations between WCPA-10 outcome measures and the MoCA (r = 0.50, r = 0.41), CTT-2 (r = 0.43), SE ADL (r = 0.41), and PASE (r = 0.54, r = 0.46, r = 0.31).

CONCLUSIONS

This study affirms the known-group validity for most (four) WCPA-10 scores and partially confirms its convergent and ecological validity for PD.

What mobility factors are critical to include in a comprehensive mobility discharge assessment framework for older adults transitioning from hospital-to-home in the community? An international e-Delphi study

PURPOSE

To prioritize and achieve consensus on mobility determinant factors [cognitive, financial, environmental, personal, physical, psychological, social] considered critical to include in the COmprehensive Mobility Discharge Assessment Framework (COMDAF) for older adults transitioning from hospital-to-home.

MATERIALS AND METHODS

We conducted a three-round modified e-Delphi process with 60 international experts (seven older adults, nine family caregivers, 24 clinicians, and 20 researchers) from nine countries with universal or near-universal health coverage. Expert members rated 91 factors identified from scoping reviews using a 9-point scale: not important (1-3), important (4-6), and critical (7-9).

RESULT

A total of 41 of 91 factors (45.1%) met the a-priori consensus criterion after three rounds: five cognitive, five environmental, two personal, 19 physical, six psychological, and six social factors. No financial factors reached a consensus. The older adult steering committee member recommended the addition of two environmental factors, resulting in 43 mobility factors included in the COMDAF.

CONCLUSIONS

We advanced a comprehensive mobility framework by developing, through consensus, 43 mobility factors to be assessed as part of a COMDAF. However, its use in hospital-to-home may not be feasible. Therefore, future research will determine the core mobility factors for COMDAF and which measurement instruments best measure these factors.

RELEVANCE

An interdisciplinary discharge rehabilitation team can utilize the COMDAF during hospital-to-home transition.Implications for rehabilitationMobility assessment following a hospital discharge is a complex process requiring an interdisciplinary discharge rehabilitation team.This study provided a comprehensive list of 91 factors across all seven mobility determinants (cognitive, environmental, financial, personal, physical, psychological, and social) for clinicians in other care settings to use as a starting point to determine which mobility factor should be assessed during older adults' hospital-to-home transition.This international e-Delphi study identified 43 factors within mobility determinants (cognitive, environmental, personal, physical, psychological, and social) to be included in a Comprehensive Mobility Discharge Assessment Framework to assess older adults' mobility during the hospital to home transition.Using these 43 factors, clinicians can identify which assessment tool is best suited to assess the factors while reflecting on the logistics and feasibility; this is the next phase of this project.

Occupational Therapy Practitioners' Perceptions on Addressing Cognition in Acute Care: A National Survey

This study aimed to identify commonly used standardized cognitive screens and functional performance assessments among occupational therapy practitioners at level 1 trauma centers in the USA. A survey completed by 269 occupational therapy practitioners revealed the most common cognitive screens and the association between cognitive tool training and standardized cognitive tool implementation. Implications for practice are discussed with suggestions for improving occupational therapy practice.

When stroke survivors' self-ratings are inconsistent with the ratings of others: a cohort study examining biopsychosocial factors associated with impaired self-awareness of functional abilities

Background Stroke survivors' self-ratings of functional abilities are often inconsistent with ratings assigned by others (e.g. clinicians), a phenomenon referred to as 'impaired self-awareness' (ISA). There is limited knowledge of the biopsychosocial contributors and consequences of post-stroke ISA measured across the rehabilitation journey. This multi-site cohort study explored biopsychosocial correlates of ISA during subacute rehabilitation (inpatient) and at 4 months post-discharge (community-dwelling). Methods Forty-five subacute stroke survivors participated (Age M (s.d.) =  71.5 (15.6), 56% female), and 38 were successfully followed-up. Self-assessments were compared to those of an independent rater (occupational therapist, close other) to calculate ISA at both time points. Survivors and raters completed additional cognitive, psychological and functional measures. Results Multivariate regression (multiple outcomes) identified associations between ISA during inpatient admission and poorer outcomes at follow-up, including poorer functional cognition, participation restriction, caregiver burden, and close other depression and anxiety. Regression models applied cross-sectionally, including one intended for correlated predictors, indicated associations between ISA during inpatient admission and younger age, male sex, poorer functional cognition, poorer rehabilitation engagement and less frequent use of non-productive coping (adjusted R 2  = 0.60). ISA at community follow-up was associated with poorer functional cognition and close other anxiety (adjusted R 2  = 0.66). Conclusions Associations between ISA and poorer outcomes across the rehabilitation journey highlight the clinical importance of ISA and the value of assessment and management approaches that consider the potential influence of numerous biological and psychosocial factors on ISA. Future studies should use larger sample sizes to confirm these results and determine the causal mechanisms of these relationships.

Examining Real-World Therapy Practice of Cognitive Screening and Assessment in Post-Acute Care

OBJECTIVES

Routine implementation of cognitive screening and assessment by therapy providers in post-acute settings may promote improved care coordination. This study examined the frequency of cognitive screening and assessment documentation across post-acute settings, as well as its relationship with contextual factors and outcomes.

DESIGN

Cross-sectional observational study using Medicare claims and electronic health record data from 1 large health system.

SETTING AND PARTICIPANTS

Older adults admitted to post-acute care after an acute hospitalization.

METHODS

Descriptive analysis examined documentation of cognitive screening and assessment. Logistic and hierarchical linear regression evaluated the relationship among patient factors, cognitive screening and assessment, and patient outcomes.

RESULTS

The most common admission diagnoses for the final sample (n=2535) were total hip or knee joint replacement (41.7%) and stroke (15.3%). Following acute hospitalization, patients were discharged to inpatient rehabilitation (22.6%), skilled nursing (9.3%), or home health (68.1%). During the post-acute care stay, 38% of patients had documentation of cognitive screening by any therapy discipline. Patterns of documentation varied across disciplines and post-acute settings. Documentation of standardized cognitive assessments was limited, occurring for less than 2% of patients. Admission for stroke was associated with significantly higher odds of cognitive screening or assessment [odds ratio (OR) 2.07, 95% CI 1.13, 3.82] compared to patients with other diagnoses. There was no significant relationship between documentation of cognitive screening or assessment and 30-day readmissions (OR 0.81, 95% CI 0.53, 1.28).

CONCLUSION AND IMPLICATIONS

The key finding was inconsistent documentation of cognitive screening and assessment across disciplines and post-acute settings, which could be in part due to variation in electronic health record platforms. Future work can expand on these results to understand the degree to which contextual factors facilitate or inhibit routine delivery and documentation of cognitive screening and assessment. Findings can support implementation of standardized data elements to lead to improved care coordination and outcomes.

Assessing Functional Cognition and Health During COVID-19 Pandemic: Gender Differences Among Community-Dwelling Adults

INTRODUCTION/OBJECTIVES

The COVID-19 pandemic has long-term implications for adult health and function, whether or not people were infected with the disease. Although cognitive disruptions are among the major symptoms of COVID-19, most research focused on managing medical symptoms, such as respiratory symptoms or pain. Thus, less is known about the pandemic's long-term implications for assessing functional cognition. This study aimed to examine COVID-19's effects on community-dwelling adults' functional cognition and health, comparing gender differences.

METHODS

This cross-sectional study divided 118 community-dwelling adults (25 previously infected with COVID-19) into gender groups. Primary outcome measures included the Daily Living Questionnaire (DLQ) and short form health status survey, SF-12.

RESULTS

No significant differences were found in functional cognition or health between participants who had contracted COVID-19 and those who remained healthy, but men had better functional cognition and health measures in comparison with women.

CONCLUSIONS

Gender differences in functional cognition and health state may relate to gender-based family roles. It is essential to assess functional cognition of young adults who were exposed to a pandemic, such as COVID-19, because it may significantly affect their health and functional status. The DLQ is a reliable, valid assessment of functional cognition that may suit individuals who previously contracted COVID-19.

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.

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.

Weekly Calendar Planning Activity (WCPA): Validating a Measure of Functional Cognition for Adolescents With Attention Deficit Hyperactivity Disorder

IMPORTANCE

Adolescents with attention deficit hyperactivity disorder (ADHD) often experience difficulties with executive function and participation in life roles. Ecologically valid performance-based tests (PBTs) are needed to assess functional cognition in this population.

OBJECTIVE

To examine the known-groups, concurrent, and ecological validity of a functional cognition PBT, the Hebrew version of the Weekly Calendar Planning Activity (WCPA) Middle/High School Version, among adolescents with and without ADHD.

DESIGN

Cross-sectional between-groups design.

SETTING

Community.

PARTICIPANTS

One hundred two adolescents (ages 12-18 yr), with (n = 52) and without (n = 50) ADHD.

OUTCOMES AND MEASURES

The Hebrew version of the WCPA Middle/High School Version, MOXO™-Continuous Performance Test (MOXO-CPT), Behavior Rating Inventory of Executive Function (BRIEF) parent form, and Child and Adolescent Scale of Participation (CASP).

RESULTS

The results showed significant between-groups differences with medium to large effect sizes for scores on most WCPA measures, with the ADHD group receiving significantly lower scores. Significant correlations in the expected direction were found between scores on the MOXO-CPT Attention and Hyperactivity indices and WCPA measures. Significant correlations were also found between most WCPA measures and the BRIEF Global Executive Composite (GEC) and the CASP. Multiple linear regression on the CASP indicated that the WCPA strategy score and the BRIEF GEC were significant predictors in the model.

CONCLUSIONS AND RELEVANCE

Results support the known-groups validity of the WCPA Middle/High School Version between adolescents with and without ADHD. Concurrent and ecological validity were supported by significant associations with measures of cognition and participation. What This Article Adds: These results reinforce the premise that the WCPA Middle/High School Version can be implemented as a valid measure of functional cognition among adolescents with ADHD.

The contribution of functional cognition screening during acute illness hospitalization of older adults in predicting participation in daily life after discharge

Background

Cognitive assessment in acutely hospitalized older adults is mainly limited to neuropsychological screening measures of global cognition. Performance-based assessments of functional cognition better indicate functioning in real-life situations. However, their predictive validity has been less studied in acute hospital settings. The aim of this study was to explore the unique contribution of functional cognition screening during acute illness hospitalization in predicting participation of older adults one and three months after discharge beyond traditional neuropsychological measures.

Methods

This prospective longitudinal study included 84 older adults ≥ 65 years hospitalized in internal medicine wards due to acute illness, followed by home visits at one month and telephone interviews at three months (n = 77). Participation in instrumental activities of daily living, social and leisure activities was measured by the Activity Card Sort. In-hospital factors included cognitive status (telephone version of the Mini-Mental State Examination, Color Trails Test), functional cognition screening (medication sorting task from the alternative Executive Function Performance Test), emotional status (Hospital Anxiety and Depression scale), functional decline during hospitalization (modified Barthel index), length of hospital stay, the severity of the acute illness, symptoms severity and comorbidities.

Results

Functional cognition outperformed the neuropsychological measures in predicting participation declines in a sample of relatively high-functioning older adults. According to a hierarchical multiple linear regression analysis, the overall model explained 28.4% of the variance in participation after one month and 19.5% after three months. Age and gender explained 18.6% of the variance after one month and 13.5% after three months. The medication sorting task explained an additional 5.5% of the variance of participation after one month and 5.1% after three months, beyond age and gender. Length of stay and the Color Trails Test were not significant contributors to the change in participation.

Conclusions

By incorporating functional cognition into acute settings, healthcare professionals would be able to better detect older adults with mild executive dysfunctions who are at risk for participation declines. Early identification of executive dysfunctions can improve continuity of care and planning of tailored post-discharge rehabilitation services, especially for high-functioning older adults, a mostly overlooked population in acute settings. The results support the use of functional cognition screening measure of medication management ability in acute settings.

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.

Vascular Cognitive Impairment After Mild Stroke: Connectomic Insights, Neuroimaging, and Knowledge Translation

Contemporary stroke assessment protocols have a limited ability to detect vascular cognitive impairment (VCI), especially among those with subtle deficits. This lesser-involved categorization, termed mild stroke (MiS), can manifest compromised processing speed that negatively impacts cognition. From a neurorehabilitation perspective, research spanning neuroimaging, neuroinformatics, and cognitive neuroscience supports that processing speed is a valuable proxy for complex neurocognitive operations, insofar as inefficient neural network computation significantly affects daily task performance. This impact is particularly evident when high cognitive loads compromise network efficiency by challenging task speed, complexity, and duration. Screening for VCI using processing speed metrics can be more sensitive and specific. Further, they can inform rehabilitation approaches that enhance patient recovery, clarify the construct of MiS, support clinician-researcher symbiosis, and further clarify the occupational therapy role in targeting functional cognition. To this end, we review relationships between insult-derived connectome alterations and VCI, and discuss novel clinical approaches for identifying disruptions of neural networks and white matter connectivity. Furthermore, we will frame knowledge translation efforts to leverage insights from cutting-edge structural and functional connectomics research. Lastly, we highlight how occupational therapists can provide expertise as knowledge brokers acting within their established scope of practice to drive substantive clinical innovation.

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.

From word list learning to successful shopping: The neuropsychological assessment continuum from cognitive tests to cognition in everyday life

Cognitive deficits are common after brain injury and can be measured in various ways. Many neuropsychological tests are designed to measure specific cognitive deficits, and self-report questionnaires capture cognitive complaints. Measuring cognition in daily life is important in rehabilitating the abilities required to undertake daily life activities and participate in society. However, assessment of cognition in daily life is often performed in a non-standardized manner. In this opinion paper we discuss the various types of assessment of cognitive functioning and their associated instruments. Drawing on existing literature and evidence from experts in the field, we propose a framework that includes seven dimensions of cognition measurement, reflecting a continuum ranging from controlled test situations through to measurement of cognition in daily life environments. We recommend multidimensional measurement of cognitive functioning in different categories of the continuum for the purpose of diagnostics, evaluation of cognitive rehabilitation treatment, and assessing capacity after brain injury.

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.

Stroke Rehabilitation: Recent Progress and Future Promise

Significant advancements in acute stroke medical management have changed stroke rehabilitation. In addition, an ever-changing health care ecosystem and heightened awareness of continued and new challenges requires that the occupational therapy profession consider new, innovative, and pragmatic approaches to measurement, intervention, and health services research, and clinical practice. The profession must elevate the focus and rigor of research examining occupation and participation after stroke, and their associations with health. Intervention research must progress beyond early phase pilot studies to a robust collection of meaningful large multisite studies that demonstrate the effectiveness of our interventions and the effectiveness of wide-scale implementation to ensure quality and consistent delivery of evidence-based practices in occupational therapy. These studies must address the accessibility of these practices for all people who have sustained stroke, and particularly those people who are most vulnerable to inaccessible stroke rehabilitation service delivery systems.

Occupational Therapy and the IMPACT Act: Part 2. A Systematic Review of Evidence for Functional Status, Medication Reconciliation, and Skin Integrity Interventions

IMPORTANCE

Interventions that promote function, medication reconciliation, and skin integrity assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing health care costs.

OBJECTIVE

In this systematic review, we focus on three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: functional status, medication reconciliation, and skin integrity.

DATA SOURCES

We conducted a search of the literature published between 2009 and 2019 in CINAHL, Cochrane, MEDLINE, PsycINFO, OTseeker, and Scopus. We also hand searched the systematic reviews and meta-analyses in our search results for articles that met our inclusion criteria. Study Selection and Data Collection: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

FINDINGS

We found 47 articles that address the three outcome areas. Regarding functional status, low strength of evidence is available for cognition and functional mobility interventions to support functional performance, moderate strength of evidence supports interventions for vision, and moderate evidence supports task-oriented and individualized interventions to promote activities of daily living (ADL) outcomes among people with neurological conditions. Strong strength of evidence supports individualized occupational therapy interventions focusing on medication adherence. Low strength of evidence was found for occupational therapy interventions to reduce pressure ulcers and promote skin integrity. Conclusion and Relevance: The evidence supports occupational therapy interventions to improve functional status in ADLs and medication management. Additional research is needed that examines the outcomes of occupational therapy interventions for other areas of function and skin integrity. What This Article Adds: We found evidence to support occupational therapy interventions that align with value-based measures in the three outcome areas of interest. The effectiveness of these interventions highlights the viability of occupational therapy as an essential profession and the worth of occupational therapy to the public, potential clients, and payers.

How Well Does the Brief Interview for Mental Status Identify Risk for Cognition Mediated Functional Impairment in a Community Sample?

OBJECTIVE

To determine the adequacy of the Brief Interview for Mental Status (BIMS) compared with other screening tools in identifying individuals with limitations in functional cognition and instrumental activities of daily living (IADL).

DESIGN

Cross-sectional observational study.

SETTING

Midsized midwestern city.

PARTICIPANTS

We assessed a convenience sample of community dwelling individuals (N=197) aged 55 years and older who were living independently.

MAIN OUTCOME MEASURES

Participant scores on the BIMS, Mini-Cog, Menu Task, and Montreal Cognitive Assessment (MoCA) were compared with the Performance Assessment of Self-Care Skills Checkbook Balancing and Shopping tasks (PCST), which are known to predict impairment in complex IADLs associated with a diagnosis of mild cognitive impairment. Multiple logistic regression analyses controlling for participant demographics, as well as sensitivity and specificity, were computed for each screening measure using the PCST as the criterion measure.

RESULTS

The Mini-Cog, Menu Task, and MoCA identified 25.89%, 32.49%, and 47.21% more individuals, respectively, as impaired than the BIMS. In multiple logistical regression analyses, the BIMS correctly identified 58% of those impaired on the PCST. However, each of the alternate screening measures correctly identified at least 70% of individuals as impaired on the PCST.

CONCLUSIONS

In this community sample, the BIMS was insensitive to subtle impairments with the potential to compromise community living, suggesting that the BIMS may be inappropriate for use outside nursing home settings.

Reliability and Validity of the Spanish Version of the Executive Function Performance Test (EFPT) in Assessing People in Treatment for Substance Addiction

IMPORTANCE

Assessing people's executive function (EF) during addiction treatment makes it possible to design individualized occupational goals.

OBJECTIVE

To determine the reliability and validity of the Spanish version of the Executive Function Performance Test (EFPT) in the occupational assessment of people being treated for substance addiction.

DESIGN

Cross-sectional, observational study to determine the EFPT's internal consistency as well as its convergent and discriminant validity with complementary tests.

SETTING

A public, free addiction treatment center operated by Madrid Salud (Madrid City Council, Spain).

PARTICIPANTS

Fifty-two people referred to an occupational therapy department for evaluation and intervention. Inclusion was based on Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) criteria for substance abuse or dependence; the exclusion criterion consisted of any circumstances that made it difficult for a person to understand or perform the test.

OUTCOMES AND MEASURES

The EFPT, other occupational tests (Allen Cognitive Level Screen-5, Lowenstein Occupational Therapy Cognitive Assessment), and a battery of neuropsychological EF tests.

RESULTS

The EFPT had an unequivocal unifactorial structure and showed strong correlations between its components and adequate consistency with the scales and the complete test. As expected, the EFPT correlated with the neuropsychological tests with a considerable effect size (-.40 < r < -.60).

CONCLUSIONS AND RELEVANCE

The EFPT's psychometric properties are adequate to assess the EF of people being treated for substance addiction from an occupational perspective using real activities of daily living (ADLs).

WHAT THIS ARTICLE ADDS

The results show that the EFPT can be used to assess performance of ADLs without needing to use tests from disciplines other than occupational therapy. Further studies in different sociocultural settings are needed to generalize the results.

Occupational Therapy's Value in Provision of Quality Care to Prevent Readmissions

Health care systems are prioritizing the quality of outcomes over the quantity of services provided, and health care payers and other stakeholders are focusing on preventing hospital readmissions. This priority supports the effort to reduce the cost of health care by avoiding the most expensive care type and improving the quality of health care by promoting sustained return to the community and remaining in the community. Occupational therapy practitioners have expertise that is critically important in this effort. Occupational therapy places a unique and immediate focus on patients' functional and social needs, which can be important drivers of readmissions if they are not addressed. By addressing activities of daily living, instrumental activities of daily living, functional cognition, psychosocial needs, vision, fear of falling, and safety, occupational therapy practitioners can be a valuable addition to the effort to keep people out of the hospital and participating in their lives. This article reviews the literature supporting the role of occupational therapy in each of these key areas.

The Montreal Cognitive Assessment: Is It Suitable for Identifying Mild Cognitive Impairment in Parkinson's Disease?

BACKGROUND

Administering an abbreviated global cognitive test, such as the Montreal Cognitive Assessment (MoCA), is necessary for the recommended first-level diagnostic criteria for mild cognitive impairment (MCI) in Parkinson's disease (PD). Level II requires administering cognitive functioning neuropsychological tests. The MoCA's suitability for identifying PD-MCI is questionable and, despite the importance of cognitive deficits reflected through daily functioning in identifying PD-MCI, knowledge about it is scarce.

OBJECTIVES

To explore neuropsychological test scores of patients with PD who were categorized based on their MoCA scores and to analyze correlations between this categorization and patients' self-reports about daily functional-related cognitive abilities.

METHODS

A total of 78 patients aged 42 to 78 years participated: 46 with low MoCA scores (22-25) and 32 with high MoCA scores (26-30). Medical assessments and level II neuropsychological assessment tools were administered along with standardized self-report questionnaires about daily functioning that reflects patients' cognitive abilities.

RESULTS

A high percentage of the low MoCA group obtained neuropsychological test scores within the normal range; a notable number in the high MoCA group were identified with MCI-level scores on various neuropsychological tests. Suspected PD-MCI according to the level I criteria did not correspond well with the level II criteria. Positive correlations were found among the 3 self-report questionnaires.

CONCLUSIONS

These results support the ongoing discussion of the complexity of capturing PD-MCI. Considering the neuropsychological tests results, assessments that reflect cognitive encounters in real life daily confrontations are warranted among people diagnosed with PD who are at risk for cognitive decline.

Making Functional Cognition a Professional Priority

Functional cognition is a critical domain of concern for occupational therapy practice. As the health care system moves to assessing value through achievement of quality outcomes, the field of occupational therapy must address the inclusion of functional cognition in evaluation and treatment. Evidence indicates that impaired cognition contributes to risk of hospital readmission and poor overall health outcomes across diagnostic groups. Moreover, expenditure on occupational therapy services that address functional cognition has been shown to lower hospital readmission rates. To improve client outcomes, occupational therapists must consistently screen for and, when appropriate, evaluate and treat functional cognition impairments and consider functional cognition in the discharge planning process. Occupational therapy professionals must make a proactive, coordinated effort to establish the profession's role in evaluating and treating clients' limitations in functional cognition as a means to achieving improved quality care and client outcomes.

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.

A clinical description of strategies to address traumatic brain injury experienced by homeless patients at Baltimore's medical respite program

BACKGROUND

Medical respite programs provide a safe place for people experiencing homelessness to recover from an acute illness or injury. Many patients in respite programs have experienced a traumatic brain injury (TBI) that impedes their ability to complete the self-management tasks necessary to recover from an acute medical condition. Patients with brain injuries may also have behavioral problems that are difficult to manage in a medical respite setting.

OBJECTIVE

This paper describes the experiences of one medical respite program in screening, assessing, and treating patients experiencing homelessness who have traumatic brain injuries.

METHODS

Services by clinical providers were tailored to better address needs of those with a history of TBI, as well as implementation of environmental modifications. Two retrospective case studies were completed to illustrate the importance of addressing TBIs in respite programs.

RESULTS

Modifications to programming can improve patient outcomes and assist in transitioning patients to appropriate community resources.

CONCLUSIONS

Identifying and treating patients with TBIs in respite programs can result in long-term positive benefits for patients.

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.

The Screening Utility and Ecological Validity of the Neuropsychological Assessment Battery Bill Payment Subtest in Older Adults with and without Dementia

Objective

The Neuropsychological Assessment Battery Bill Payment subtest has shown strong diagnostic accuracy in dementia due to Alzheimer’s disease (AD) versus non-AD. Its relationship to mild cognitive impairment (MCI) or all-cause dementia has not been fully examined nor has its ecological validity as a proxy of financial independence.

Method

We describe 270 women (63%) and men (age = 72 ± 8.39) who completed Bill Payment during outpatient neuropsychological evaluation. Seventy-one were cognitively normal (CN), 160 had MCI, and 39 had Dementia. Two hundred fourteen were independent in money management, 31 were assisted (had oversight/some help), and 25 were dependent (relied on others). Receiver operating characteristic (ROC) curves tested Bill Payment’s utility as a dementia screen. Kruskal–Wallis tests examined whether Bill Payment differed by levels of financial independence.

Results

At a cutoff of 17, Bill Payment had strong sensitivity (0.87) and specificity (0.80) for dementia versus CN cases. A cutoff of 15 distinguished dementia from MCI (Sn = 0.64, Sp = 0.85), whereas a cutoff of 16 distinguished dementia from functionally unimpaired cases (MCI + CN) with greater sensitivity and similar specificity (Sn = 0.74, Sp = 0.81). Sensitivity attenuated in MCI versus CN cases (Sn = 0.46, Sp = 0.83). Those who were independent in money management had higher scores than assisted and dependent cases (p ≤ 0.046). Assisted and dependent cases were no different (p &gt; 0.05).

Conclusions

Bill Payment is a valid screen of all-cause dementia. Lower Bill Payment scores may mark subtle functional decline beyond cognitive impairment alone. Specifically, results provide preliminary evidence of Bill Payment’s ecological validity as a measure related to financial independence. It may prove useful when impaired financial abilities are suspected but unreported.

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.

Using the New Postacute Care Quality Measures to Demonstrate the Value of Occupational Therapy

As the health care system continues to evolve toward one based on quality not quantity, demonstrating the value of occupational therapy has never been more important. Providing high-quality services, achieving optimal outcomes, and identifying and promoting occupational therapy's distinct value are the responsibilities of all practitioners. In relation to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, the Centers for Medicare and Medicaid Services (CMS) is implementing new functional items and related outcome performance measures across postacute care (PAC) settings. Practitioners can demonstrate the role and value of occupational therapy services through their participation in data collection and the interpretation of the resulting performance measures. In this column, we review the objectives of the IMPACT Act, introduce the new self-care and mobility items and outcome performance measures being implemented in PAC settings, and describe ways to use these new data to advocate for occupational therapy. We also discuss American Occupational Therapy Association initiatives to provide materials and guidance for occupational therapy practitioners to contribute to PAC data collection.

Justifying Rehabilitation Intensity Through Functional Performance Measures in Postacute Care

The Centers for Medicare and Medicaid Services (CMS) has scrutinized the provision of rehabilitation services in skilled nursing facilities (SNFs) for some time. Little research guidance exists on appropriate dosage or rehabilitation intensity (RI) among SNF patients or patients in other postacute care (PAC) settings. CMS developed a PAC assessment, the Continuity Assessment Record and Evaluation (CARE) Tool, in response to questions about what issues drive placement in various PAC settings under Medicare. The ability to adequately assess functional outcomes and correlate them to the RI provided by using the CARE Tool is promising. However, further research, policy advocacy, and practice analysis must be undertaken to promote and protect adequate access to occupational therapy and physical therapy in SNFs and other PAC settings. Individual practitioners must participate in data gathering to ensure that the data for analysis are fully informed by the occupational therapy perspective.