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Learning Objectives
After studying this chapter, the reader will be able to do the
following:
1. Appreciate the role of cognition in occupational performance.
2. Describe specific cognitive capacities and abilities and analyze
their influence on occupational function.
3. Select cognitive assessment methods and tools based on indi-
vidual clients’ characteristics, properties of various measures,
and requirements of the setting or episode of care.
4. Anticipate and describe factors that should be considered in
interpreting the results of cognitive assessment.
5. Distinguish occupational therapy’s contribution to multidisci-
plinary cognitive assessment from that of other rehabilitation
disciplines.
Assessing Abilities and
Capacities: Cognition
Mary Vining Radomski and M. Tracy Morrison
6
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CONTEXT
CONTEXT
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Satisfaction with life roles
- Self-maintenance
- Self-advancement
- Self-enhancement
Sense of self-efficacy and self-esteem
Competence in tasks of life roles
Developed capacities
First-level capacities
Organic substrate
Activities and habits
Abilities and skills
122 Section II Assessment of Occupational Function
thinking, and doing is unclear, but it appears that exec- utive functions may control and coordinate the other cognitive operations in the service of goal-directed action (Salthouse, 2005). Consider the working definitions that follow and how dysfunction might be observed in every- day activities (see Table 6-1).
Primary Cognitive Operations
Primary cognitive operations such as orientation, atten- tion, and memory are thought to be prerequisite to higher level thinking abilities such as executive functions and metacognition. That is, people must have a sense of place or time and some ability to focus their attention and remember information in order to reason, problem solve, plan, and execute complex activities.
Orientation
Orientation refers to the awareness of self in relation to person, place, time, and circumstance (Sohlberg & Mateer, 1989). Orientation deficits are typically symptoms of brain dysfunction, with disorientation to time and place being most common (Lezak, 1995).
Attention
The term attention was famously defined by William James as “the taking possession by the mind, in a clear and vivid form, of one out of what seem several simul- taneously present objects or trains of thought” (James, 1890, pp. 403–404). Attentional abilities are dependent on multiple brain regions including the cingulate cortex, lim- bic system, prefrontal cortices, and sensorimotor regions (Posner, 1980). Each person is thought to have a limited capacity for consciously attending to information—a hard-wired upper limit that dictates how many inputs
C
ognition refers to the integrated functions of the human mind that together result in thought and goal-directed action. Cognition underlies being and doing and is evidenced in how people interact with others and perform both simple and complex activities of daily life. Perhaps the central role of cognition in occu- pational performance is best illustrated as one imagines what it must be like to suddenly lose the ability to con- centrate, remember, and problem solve. Survivors of trau- matic brain injury (TBI) describe how their once-familiar routines and environments become chaotic, confusing, and frightening, which devastates their sense of identity and competence (Erikson et al., 2007). Occupational therapists assess cognition because many people seeking occupational therapy services are likely to have some degree of cognitive impairment that influences their ability to participate in rehabilitation and achieve rehabilitation outcomes (Skidmore et al., 2010). Cogni- tive changes can be temporary, relatively static, or progres- sive. As above, many survivors of TBI experience deficits in information processing speed, attention, memory, and exec- utive functions that persist for months or years postinjury (Skandsen et al., 2010). A significant number of persons who sustain a spinal cord injury also have a concurrent TBI with similar implications for cognition (Macciocchi et al., 2008). Individuals with chronic conditions may also experience cognitive changes including those with multiple sclerosis (Rogers & Panegyres, 2007), Parkinson’s disease (Caviness et al., 2007), cancer (Boykoff, Moieni, & Subramanian, 2009), epilepsy (Helmstaedter et al., 2003), systemic lupus erythematosus (McLaurin et al., 2005), and human immu- nodeficiency virus/acquired immunodeficiency syndrome (Heaton et al., 2004). Even individuals with mild stroke who are independent in activities of daily living (ADL) may have executive dysfunction that impacts their ability to work, drive, and engage in recreational activities (Edwards et al., 2006; Wolf, Barbee, & White, 2011). This chapter begins with descriptions of specific cog- nitive domains and processes. We then review clinical reasoning considerations pertinent to cognitive assess- ment and describe specific methods and tools based on three complementary approaches to cognitive assessment. We conclude with considerations for interpreting the results of cognitive assessment.
DEFINING COGNITIVE CAPACITIES AND ABILITIES
The term cognition generally refers to the product of many integrated processes carried out by the brain that allow humans to be aware, think, learn, judge, plan, and execute behavior (National Institutes of Health [NIH], n.d.). These domains and processes include orientation, perception, attention, memory and learning, judgment, reasoning, language, and executive functions (NIH, n.d.). How these processes and domains precisely interact to enable being,
Table 6-1 Possible Observable
Manifestations of Cognitive
Dysfunction
Cognitive Domain
Examples of Patient Performance That Suggest Cognitive Dysfunction
Orientation Mr. K. is asked to report the correct date, time, or location. Sometimes during morning sessions he responds correctly but later in the day provides illogical or far-fetched answers.
Attention Mrs. G. sorts a basket of laundry into two piles based on color. She stops and looks around every time she hears an overhead page, requiring cues to restart the task.
Memory Mr. B. takes his medication right before breakfast. Two hours later, Mr. B. reports that he cannot recall whether or not he took his morning pills (episodic memory failure).
124 Section II Assessment of Occupational Function
be the subject of deliberate concentration in working mem- ory for approximately 30 seconds (Lezak, 1995). Without this focused attention, the memory trace decays, and the memory is not retained (Lezak, 1995). Unlike long-term memory, which is thought to have an infinite capacity, working memory has a restricted holding capacity of seven plus or minus two chunks of information (Miller, 1956). In addition to its role in information processing, working memory is the foundation of concentration and problem solving (Baddeley, 1990). Based on electrochemical activity in the brain, working memory reflects the contribution of attention to the memory process (Lezak, 1995).
Long-Term Memory. Whereas data in working memory have a short shelf life, information in long-term memory can be stored for minutes to a lifetime (Lezak, 1995). When we remember information (an event that occurred an hour ago or a year ago), we have located and retrieved data from long-term memory and are holding it for conscious atten- tion and thought in limited-capacity working memory. Storage in long-term memory is based on relatively per- manent changes in brain cell structure (Glover, Ronning, & Bruning, 1990), although there does not appear to be a single local storage site for stored memories (Lezak, 1995). Long-term memory is thought to consist of two sub- systems, explicit (or declarative) memory and implicit (or nondeclarative) memory (Fig. 6-2). Declarative mem- ory pertains to factual information and includes epi- sodic memory (knowledge of personal information and events such as what you ate for breakfast) and semantic memory (knowledge of facts about the world such as that horses are big and ants are small) (Eysenck & Keane, 1990). Prospective memory is another form of declarative
memory-related concepts, acknowledging the continued debate regarding precise terms and their meanings in this realm. (Also see Dubuc [2011] and Levy [2011] for more in-depth information on the following discussion.)
Sensory Registers. Information from the environment is briefl y (milliseconds) held in registers (or stores) specific to the human senses (Lezak, 1995). This registration stage has been called the intake valve for determining what data from the environment are ultimately stored. This phase is influenced by acuity of the senses (such as hearing and vision), affective set, and perception.
Short-Term Memory/Working Memory. The short-term phase of information processing reflects “faculties of the human mind that can hold a limited amount of informa- tion in a very accessible state temporarily” (Cowan, 2008, p. 324). It has many labels: primary memory, immediate memory, short-term memory, and working memory. The term primary memory pertains to a pattern of neural firing associated with a given idea, about which the person may or may not be aware (Cowan, 2008). This includes data just transferred from the sensory registers related to one’s focus of attention (Levy, 2011). The term working memory per- tains to the attention-related processes that are involved in managing incoming information and manipulating stored information for planning and problem solving (Cowan, 2008). It can be thought of as the seat of conscious thought; it connotes the effortful deployment of cognitive resources during this stage as well as the manipulation of information involved in active thinking (Sohlberg & Turkstra, 2011). Many experts believe that for input from sensory registers to proceed to storage in long-term memory, the input must
Facts Events Procedural memory: skills and habits (Striatum)
Skeletal musculature (Cerebellum)
Emotional responses (Amygdala)
Declarative memory (Medial temporal lobe; diencephalon) (^) Nondeclarative memory
Classical conditioning
Figure 6-2 Two subsystems of long-term memory.
Chapter 6 Assessing Abilities and Capacities: Cognition 125
Retrograde Loss of ability to recall events that
occurred before the trauma
Anterograde Decreased memory of events
occurring after trauma
Posttraumatic
amnesia
(PTA)
Period following trauma during
which the patient is confused and
disoriented and seems to lack the
ability to store and retrieve new
information
Types of Amnesia
Definition 6-
Table 6-2 Possible Observable Manifestations of Problems with Executive Processing
From Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation. New York: Guilford Press.
Domain Examples of Performance That Suggest Executive Dysfunction
Initiation Mrs. M. wants to create a photo album for her son. She has an empty photo album and a large bag of photographs on a table and a free afternoon but cannot get herself to begin.
Inhibition Mr. G. fi nds himself lost while driving in a new city. Two hours later he notices a shopping center he continually passes by and realizes he has circled the same one-half mile block the entire time.
Task persistence
Mr. J. selects a 60-piece model of an antique car to assemble for his nephew. He dumps the pieces on the table top and tries to fi t together the two pieces that are within easiest reach. When that does not work, he quits the task.
Organization Ms. C. has missed her therapy session again. The occupational therapist notices that Ms. C. showed up 4 hours late for her last therapy session and arrived on the wrong day for preceding session. When telephoned, Ms. C. exclaims, “I thought the appointment was tomorrow! I am so upset. I need this therapy to help me get my life back together!”
Generative thinking
Mr. F. is a member of a support group for individuals with brain injury. An occupational therapist leads the group and makes a suggestion to move a future meeting time to a new day because of upcoming holidays. Mr. F. rarely participates in group dialogue, but becomes very agitated by the change and states, “I cannot have any changes in my schedule! I want us to keep the meeting time the same!” As assigned, Ms. D. brings ingredients to her outpatient therapy session so that she can prepare a familiar, favorite recipe. The recipe involves making a graham cracker crust, to be prepared during the session. Ms. D. puts large graham crackers in a bowl and starts the electric mixer. After giving Ms. D. suffi cient time to self-correct, the therapist stops the task as cracker pieces fl y out of the bowl and around the kitchen.
Awareness When Ms. S. arrives to her outpatient therapy, the therapist observes her disheveled appearance. She is wearing fl ip-fl ops despite the cold winter conditions, and she smells of body odor. When asked her about her plans for the day, she reports that she is going to a job interview immediately after the therapy session.
memory, having to do with remembering to do tasks that
one intends (Fish, Wilson, & Manly, 2010). Implicit or
nondeclarative memory differs from explicit memory be-
cause it does not involve conscious awareness of learning
(Sohlberg & Turkstra, 2011). This includes procedural
memory, which pertains to knowing how to do things;
it allows us to learn and perform skilled motor actions
(Eysenck & Keane, 1990).
Memory impairments are typically characterized as
mild, moderate, or severe based on the results of cognitive
assessment. The term neurologic amnesia is reserved to de-
scribe losses of broad categories or segments of memory
resulting from brain trauma, stroke, or tumor (Dubuc,
- (see Definition 6-2).
Executive Abilities
The term executive abilities (also called executive functions)
refers to a group of higher order thinking processes that
enable individuals to achieve self-determined goals and
engage independently and purposefully in complex every-
day tasks, such as work and academic life (Lezak, 1995).
As outlined in Table 6-2, the domains and functions that
comprise executive processing underlie the personalized
methods through which individuals begin, accomplish,
and complete tasks. As such, executive abilities are critical
to occupational performance.
Executive Functions in Everyday Life
Executive abilities determine our ability to problem solve, plan, establish goals, monitor our work, and initiate and terminate tasks. Individuals with executive deficits com- monly experience significant disability when they encoun- ter novelty and complexity such as when discharged from clinical environments to return home (Baum et al., 2008).
Chapter 6 Assessing Abilities and Capacities: Cognition 127
status; (2) to understand the patient’s cognitive strengths, weaknesses, and capacity for strategy use in order to plan intervention; and (3) to estimate the patient’s abil- ity to safely perform every day activities (Baum & Katz, 2010). The purpose and methods will vary by patient, setting, competence of the therapist, roles of neuro- psychology and/or speech language pathology person- nel, and the point in the continuum of care at which the patient is assessed. However, one aspect of occupational therapy cognitive assessment is consistent: the focus on occupational performance. Occupational therapists have the potential to contribute a critical and unique perspec- tive to the cognitive assessment process by combining their understanding of cognitive domains and operations and task analysis with keen observation and interpreta- tion skills. Procedures for Practice 6-1 describes the general pro- cess for assessing cognition, which represents a segment of a comprehensive occupational therapy evaluation. A cognitive assessment should incorporate patient/ family self- report, measures of specific cognitive domains or processes, and observations of functional perfor- mance; occupational therapists may conduct part or all of the assessments, depending on setting. Examples of these assessment approaches are included in Assess- ment Table 6-1. In-depth and more extensive analyses of cognitive assessments can be found in the work of Katz (2011) and Gillen (2009).
understand these constructs in order to assess cognition.
For clarity and convenience, in this section we have de-
scribed various cognitive domains and processes as separate
and discrete entities. However, doing so belies the reality of
their inseparability, as evidenced in the concept of dual-task
performance. Based on an experimental dual-task paradigm
from cognitive psychology, older adults and clinical popu-
lations demonstrate greater decrements in performance
of a relatively simple primary task (such as walking) when
a secondary (cognitive) task is added (McCulloch, 2007;
McDowell, Whyte, & D’Esposito, 1997; Sosnoff et al., 2011)
than do healthy controls. These dual-task conditions appear
to be sensitive to frontal brain damage (McDowell, Whyte, &
D’Esposito, 1997) and illustrate how attention, memory,
and executive functions intersect in function. Dual-task
performance involves divided attention, challenges the re-
source limitations of working memory, and requires flexi-
ble allocation of attention, which is thought to represent
an executive ability (McCulloch, 2007; McDowell, Whyte, &
D’Esposito, 1997). Although dual-task assessment methods
have not yet been formalized in occupational therapy prac-
tice, dual-task performance is clearly relevant to the com-
plexities of real-world occupational performance.
THE PROCESS OF COGNITIVE ASSESSMENT
Occupational therapists assess cognition for many rea-
sons: (1) to measure baseline, progress, and/or outcome
Procedures for Practice 6-
Procedures for Assessing Cognition
Prepare Review the patient’s medical record to learn about diagnosis, background, results of procedures and other
diagnostics, other disciplines involved in care. Look for information about possible language-communication
problems, literacy, or medical issues (e.g., pain or fatigue) that may confound cognitive assessment.
Obtain information from patient and/or family about perceptions of current status and priorities. Informally
observe functional performance to establish hypotheses regarding possible areas of cognitive dysfunction.
If information is not available in the medical record, perform a vision screen to assure that the patient
has adequate visual skills to participate in a valid cognitive assessment.
Coordinate with members of the interdisciplinary team so that elements of cognitive assessment are
complementary and not duplicative.
Select Decide what approach and/or measure(s) to use to assess cognition. Consider factors described above
(e.g., diagnosis, patient priorities, and contributions of other team members), purpose of cognitive
assessment, and psychometric properties of assessment options relative to patient characteristics.
Administer If using standardized measures or methods, follow published setup and administration procedures.
Observe and note behaviors during assessment; record assessment scores.
Interpret Use scoring guidelines, if available, to interpret score. Consider the extent to which other variables (such
as pain, fatigue, and stress) may have influenced performance.
Report Document results in medical record; discuss results with patient, family, and/or team members.
128 Section II Assessment of Occupational Function
Instrumentand Reference
Description
Time toAdminister
Validity
Reliability
Sensitivity
Strengths andWeaknesses
Selected Measures Involving Self-Report Self-Awarenessof DeficitsInterview (SADI)(Fleming,Strong, &Ashton, 1996)
Tool designed to obtain bothqualitative and quantitative data onstatus of self-awareness. The patientis asked about self-awarenessof deficits, self-awareness offunctional limitations because ofdeficits, and ability to set realisticgoals. A therapist familiar with thepatient’s level of functioning assignsa score in each realm (0–3, with 0representing full awareness).
10 minutes
SADI moderately correlated with theDysexecutive Questionnaire (DEX)(r^
p
0.05). Regression
analyses indicated that SADI scoreswere significantly predicted by a setof executive functioning measures(^ p
R
0.31) (Bogod,
Mateer, & MacDonald, 2003).
Strong interraterreliability (Intraclasscorrelation coefficient[ICC]
0.82). Strong
test–retest reliability(ICC
0.94) (Simmond
& Fleming, 2003)
No information
Strength:Brief semistructured interviewwith questions that are relevantto treatment planningWeakness:Potential for bias becauseclinician judges the extent towhich patient responses reflectlevel of self-awareness disorder
BehavioralRating Inventoryof ExecutiveFunction-Adultversion (BRIEF-A)(Roth, Isquith, &Gioia, 2005)
A standardized self-report andinformant report questionnaire thatmeasures an adult’s appraisal ofhis or her executive functioningin everyday life. The BRIEF-Ameasures the following domains:inhibit, self-monitor, plan andorganize, initiate, task monitor,emotional control, working memory,and organization of materials. TheBRIEF-A is composed of 75 itemswith composite scores falling intotwo broad indexes: behavioralregulation and metacognition.An overall summary score resultsin a global executive composite.Higher values reflect greaterdifficulty experienced by theindividual.
35 minutes
Convergent validity has beenestablished through correlationswith other self-reports and informantreports of frontal dysfunction.There appears to be a significantrelationship between frontallobe volumes and self-reporteddeficits measured by the BRIEF-A(Garlinghouse et al., 2010).
Moderate to high internalconsistency (
^
0.90 for clinical scales;0.93–0.96 for index andglobal scores). Highinternal consistency forboth the self-report(
0.80–0.94 for clinical scales; 0.96–0.98for index and globalscores) and informantform (
range
0.95 for clinical scales;0.96–0.98 for index andglobal scales). Goodtest–retest reliability(r^
0.82–0.94) for self-report forms andhigh (
r^
0.91–0.94) for
informant reports (Roth,Isquith, & Gioia, 2005)
A study byRabin et al.(2006) foundthe BRIEF-A tobe sensitive tomild cognitiveimpairmentsamong agroup of28 individualswith mildcognitiveimpairmentand cognitivecomplaintswhen comparedwith controls.
Strengths:Good to excellent reliability;user-friendly; providesspecific information on patientperceptions of executivefunctioning in daily lifeWeaknesses:The majority of validity studieshave been conducted by thecreators of the BRIEF-A; morestudies are needed to furthervalidate this tool.
Assessment Table 6-
Summary of Assessments of Cognition
130 Section II Assessment of Occupational Function
Assessment Table 6-
Summary of Assessments of Cognition
(continued)
Instrumentand Reference
Description
Time toAdminister
Validity
Reliability
Sensitivity
Strengths andWeaknesses
The MultipleErrands Test(MET) (Shallice& Burgess, 1991)
A naturalistic performance-basedmeasure of executive functioningdeficits. The MET is set up much likea scavenger hunt. Participants aregiven a task list (typically 12 tasks);tasks with rules (typically 9 rules);and a map of the test environment.Participants are told to begin thetest and to complete the test as theywish. Patients are successful onlywith careful planning with test goalsand rules in mind.
60 minutes
Dawson et al. (2009) establishedecological validity with good tostrong correlations (
^
when the MET was compared tothe Dysexecutive Questionnaire,AMPS and Stroke Impact Scale.Among participants with stroke, ruleadherence and time to completetask showed the most robustcorrelations with measures of dailylife function. Among the people withTBI, robust correlations were alsoseen between rule adherence andthe process score of the AMPS, aswell as between total errors andweighted errors with the DEX.
Moderate interraterreliability based on twostudies: ICCs
(Alderman et al., 2003)and ICC
0.60 (Dawson
et. al., 2009).
The MET hasnot been testedfor sensitivity.
Strengths:Complex performance-basedtest that measures individuals’performance deficits as theynavigate dynamic real-worldenvironments, possiblysensitive to otherwiseundetectable high-levelproblemsWeaknesses:Site specific, requiring carefulpreparation prior to each testsession; questionable clinicaluse given the complexity ofthe test for both participantsduring test execution andadministrators during test setupand evaluation; does not havea standardized test manualor scoring system. The METrequires a significant amountof time for test setup and highrater skill. Morrison et al. (2005)suggested scoring focus onlyon quantifiable performancedeficits versus behaviorallapses identified during the testsession.
Chapter 6 Assessing Abilities and Capacities: Cognition 131
Selected Tools for Assessing Cognitive Capacities and Abilities GalvestonOrientation andAmnesia Test(GOAT) (Levin,O’Donnell, &Grossman,1979)
A widely used measure oforientation to person, place, time,and memory for events precedingand following injury. Ten questionswith weighted error points deductedfrom a total of 100 points.
10–15minutes
Performance on the
GOAT
strongly related to aspects of theGlasgow Coma Scale (for eyeopening,
p
for verbal responding,
2
p^
Good interrater reliability(Kendall
coeffi cient
p
Well suitedto trackfl uctuationsin confusionalperiod aftertraumatic braininjury
Strength:Brief test that evaluates PTAand RA (see Definition 6-1)Weakness:Designed for use after TBI; maybe difficult to use with otherpopulations of rehabilitationpatients
Test of EverydayAttention (TEA)(Robertsonet al., 1996)
Test of sustained, selective, anddivided attention based on eightecologically plausible subtestssuch as map and telephone search(selective attention), elevatorcounting and lottery (sustainedattention), and telephone dual task(divided attention).
45–60minutes
Concurrent validity: moderateto moderately strong correlationbetween TEA subtests andother measures of attention(r^
Discriminant validity: statisticallysignificant differences between olderhealthy controls and older strokepatients on all subtests (
p
and on five of eight subtests withyounger paired subjects.
Test–retest reliability(across parallel forms ofthe test) is strong acrosssubtests of the parallelversions (
r^
Strengths:Development of TEA was basedon investigations for functional-neuroanatomical specializationof attention. Subtests haveecological validity for clients.There are three parallel formsof the TEA to prevent patientsfrom learning the test withrepeated administration.Weaknesses:Not appropriate for patientswith significant visual problems;rather lengthy assessment of onedimension of cognitive function
RivermeadBehavioralMemory Test(RBMT) (Wilson,Cockburn, &Baddeley, 1985)
Assesses memory skills necessaryfor everyday life includingremembering names, faces, routes,and appointments.
30–45minutes
Discriminant validity: Wilson et al.(1989) found statistically significantdifferences between persons withbrain injury and healthy controls onall RBMT subtests (
p
Interrater reliability:100% agreementwhen 40 subjectswith brain injury werescored separately butsimultaneously by tworaters (Wilson et al.,1989)
Strengths:Subtests are similar toeveryday tasks; useful in thecharacterization of memorydisorders for a wide range ofdiagnostic groups (Lezak et al.,2004). There are four parallelforms of the RBMT to preventpatients from learning the testwith repeated administration.Weakness:Requires intact visual andverbal skills
ContextualMemory Test(Toglia, 1993)
Dynamic assessment of recall,awareness of memory capacity, andmemory strategy use, in which clienttries to remember 20 objects relatedto one of two themes (ADL routineor restaurant).
30–40minutes
Concurrent validity: stronglycorrelated with the RBMT(r^
Reliability for parallelforms of test(r^
Test–retest reliability forpersons with brain injury(r^
Not established
Strength:One assessment that providesinformation about memory andinformation about metamemoryWeakness:Potential for cultural bias–associated pictures (Josman &Hartman-Maeir, 2000)
(continued)
Chapter 6 Assessing Abilities and Capacities: Cognition 133
LoewensteinOccupationalTherapyCognitiveAssessment(LOTCA) (Katzet al., 1989)
Microbattery consisting of20 subtests in four areas:orientation, perception, visuomotoroperations, and thinking operations.
30–45minutes
Discriminant validity: All subtests,except identification of objects,differentiated between patients withcraniocerebral injury and healthycontrols and stroke patients andhealthy controls using Wilcoxontwo-sample tests (
p
Strong interraterreliability (Spearman’srank correlationcoeffi cient ranged from0.82 to 0.97 for varioussubtests)
Katz et al.(1989) observedimproved testscores betweentest scores atadmission andafter 2 monthsfor TBI andstroke patients.
Strength:Provides a snapshot of anumber of cognitive capacitiesin a relatively short amountof timeWeaknesses:Does not pick up subtlecognitive deficiencies onpersons with mild injuries; doesnot include measure of memory
Cognistat(NeurobehavioralCognitive StatusExamination)(Kiernan et al.,1987)
Microbattery comprisedof 10 subtests in the areasof orientation, attention,comprehension, repetition,naming, construction, memory,calculation, similarities, andjudgment.
20–25minutes
Discriminant analysis: Wilcoxonanalysis suggested that four ofthe subtests (see areas markedwith asterisks in column to theleft) discriminated between elderlypersons with stroke and healthyindependent elderly (Katz, Elazar, &Itzkovich, 1996); statisticallysignificant differences in meanscores for healthy controls, personswith Alzheimer’s type dementia,and neurosurgical patients on 9 of10 subtests (Katz et al., 1997).
No information
Found tobe moresensitive thanMMSE withneurosurgicalpatients(Schwammet al., 1987)
Strengths:Scores as average, mild,moderate, or severe impairmentand presented in a profile ofperformance in each domain;normative data availablefor healthy elderly persons(Eisenstein et al., 2002).Weaknesses:Some test items (constructionsubtest) may be too difficultfor both stroke patients andhealthy elderly persons (Osmonet al., 1992); not appropriate forgeriatric or psychiatric patients(Engelhart, Eisenstein, &Meininger, 1994).
134 Section II Assessment of Occupational Function
Figure 6-3 Example of informal observation of performance: the patient is
asked to organize an array of items in a storage cupboard.
time period or environment, memory for instructions, performance accuracy, and evidence of organization and planning. Of course, informal observations are highly subjective and easily influenced by the clinician’s defi- nition of “normal” and his or her acumen in using the observable (behavior) to make inferences about internal cognitive processes. Informal observations may be pref- erable for patients who cannot understand verbal or written instructions, as with communication deficits or speaking another language.
Performance-Based Assessment
In general, performance-based assessment involves patient performance of a task (or tasks) that simulate an every- day activity, “under the observation of the examiner, who utilizes behaviorally based measures to quantify different aspects of functional capacity” (Loewenstein & Acevedo, 2010, p. 98). Many disciplines and fields (e.g., occupa- tional therapy, educational psychology, and neuropsy- chology) use this approach to characterize what a person does under standardized, directed conditions (Moore et al., 2007). Performance-based assessments vary widely in their structure, complexity, and assessment objectives as
Self-Report Measures
Self-reports measures consist of standardized interviews and questionnaires in which the patient rates his or her per- formance in various aspects of cognitive functioning. Keep in mind that individuals with impaired self-awareness may minimize problems on self-reports. Discrepancies between the patient’s self-report and that of significant others may be used as indicators of inaccurate perceptions of compe- tency (O’Keeffe et al., 2007).
Measures of Functional Cognitive Performance
Occupational therapists’ education and expertise lend themselves especially well to this aspect of cognitive assessment. There are three themes in the realm of assess- ing cognitive functional performance: dynamic assessment, informal observations of function, and performance-based assessments.
Dynamic Assessment
Unlike static assessments, which identify and quantify impairment at a specific point in time, dynamic assess- ment refers to an approach in which the clinician uses cues and feedback to understand how to elicit the patient’s best performance (Toglia & Cermak, 2009). Dynamic Interactional Assessment (DIA) (Toglia, 1998) is an example of a dynamic assessment approach. DIA consists of awareness questioning, cueing and task grad- ing, and strategy investigation (Toglia, 1998). Patients predict their performance before beginning the assess- ment task. Graded verbal cues are offered as needed once the patient begins work, and parameters of the task are changed, if necessary, to buoy the patient’s performance. The therapist also asks questions about what strategies or approaches the patient uses. Toglia (1993) incorpo- rated DIA into a number of the standardized assessment tools she developed, including the Contextual Memory Test. In addition to these specific measures, therapists can convert any task (such as organizing the messy cup- board in Fig. 6-3) into a dynamic assessment by deliber- ately manipulating task and environment variables and offering strategies and cues to determine in what condi- tions the patient performs at his or her best (Dougherty & Radomski, 1993).
Informal Observation
Informal observation of task performance enables the therapist to make hypotheses about cognitive strengths and weaknesses and identify domains warranting further evaluation. For example, during an ADL or homemaking evaluation, occupational therapists observe attention to task by counting episodes of distraction in a specific
136 Section II Assessment of Occupational Function
a brief summary of each influence, supported with specific examples from the literature.
Neurobiological Influence on Cognition
Throughout this chapter, we have alluded to the neu- robiological influence on cognition; that is, the ways in which changes to the anatomy and physiology of the brain impact cognition. Persons with stroke have local damage to brain tissue that often results in predictable and specific cognitive deficits, such as frontal lobe damage leading to executive dysfunction and temporal lobe damage affect- ing memory. Neurobiological changes that accompany aging also seem to affect thinking abilities and memory. Crystallized intelligence (well practiced, overlearned skills and knowledge) is reportedly maintained or strengthened into the eighth decade of life, whereas fluid intelligence, which entails reasoning and problem solving for unfamil- iar challenges, begins a slow decline in the sixth decade of life (Lezak, 1995). Normal age-related cognitive changes underscore the importance of using age-normed cognitive assessments whenever possible. Changes or deterioration of other functions of the human body have secondary neurobiological influences on cognition. For example, visual-perceptual impairments alter the inputs into the memory process, limiting what a person can accurately remember. Diminished visual acu- ity in and of itself is associated with significantly reduced performance on neuropsychological evaluations (Hunt & Bassi, 2010). Dehydration and anemia may also negatively impact cognition (Denny, Kuchibhatla, & Cohen, 2006; Lieberman, 2007), as do some medications. Research- ers suggest a link between adjuvant chemotherapy for operative primary breast cancer and cognition (Schilling et al., 2005).
Affective Influences on Cognition
A person’s emotional state has a pervasive influence on cognition (Chepenik, Cornew, & Farah, 2007). For exam- ple, anxious people differ from others in several aspects of attentional functioning. Anxious people are more likely to attend to threat-related stimuli and use limited- capacity working memory for worry, self-concern, and other task-irrelevant distractions (Beaudreau & O’Hara, 2009). Persons with depression also frequently com- plain about poor memory but often do not demonstrate memory deficits on neuropsychological testing (Lezak, 1995). Depressed individuals are thought to show pas- sive disengagement with the environment in that their attentional focus is on internal concerns rather than environmental events (Eysenck & Keane, 1990). De- pressed people also demonstrate a negative recall bias (a tendency to recall more negative information about
a naturalistic measure of executive performance designed to present ongoing and dynamic challenges throughout test performance. Patients are presented with a list of 12 everyday tasks and 9 rules. Test initiation and task execution is left to the participant without interference or cueing from the examiner. The MET is site specific, which means the test tasks are dependent on the test location. To date, a standardized manual with scoring system that is site neutral does not exist. The MET does not have an easily replicated scoring system, which creates signifi- cant challenge to clinicians attempting to administer the test in clinical settings. Questions about the clinical utility of the MET remain as this test is extremely chal- lenging for patients with TBI and requires significant skill and time to administer. Since the first publication, alternative versions of the MET have been published in effort to simplify the administration and to meet site- specific needs (Alderman et al., 2003; Dawson et al., 2009; Knight, Alderman, & Burgess, 2002; Morrison et al., 2005; Rand et al., 2009).
Measures of Specific Cognitive Domains and Processes
While performance-based assessments are designed to have relevance to performance in real-world contexts (Connor & Maier, 2011), tools and methods that assess specifi c cognitive capacities and abilities are generally composed of desktop activities with standardized admin- istration and scoring procedures. Cognitive screens and microbatteries allow the clinician to assess a number of cognitive domains using a single tool. A cognitive screen takes less than 15 minutes to administer and provides the clinician with a general sense of a patient’s cognitive status but little information about what specific areas may be impaired. A microbattery may take up to 45 min- utes to administer and consists of a number of subtests, typically associated with an array of cognitive capacities and abilities. Many instruments have demonstrated reli- ability and validity and standardized scoring criteria that greatly reduce therapist bias.
INTERPRETING RESULTS OF PERFORMANCE ON COGNITIVE ASSESSMENT
An individual’s cognitive performance at any point in time is determined by many interacting variables, includ- ing neurobiological, affective, cultural, task, and envi- ronmental influences. Changes in any of these domains improve or detract from a person’s cognitive status and thereby his or her occupational functioning. Therefore, to effectively assess cognition and interpret findings, occupa- tional therapists must appreciate how variables can affect performance during cognitive assessment. What follows is
Chapter 6 Assessing Abilities and Capacities: Cognition 137
education-related bias in cognitive assessments: persons with higher education may score within normal limits on cognitive tests even with decrements in their function- ing and/or persons with lower education who perform poorly on cognitive assessments may, in fact, be cogni- tively intact.
Task and Environment as Contextual Mediators of Cognition
People bring their neurobiological, emotional, and socio- cultural predispositions to all information processing, but performance at a given moment is mediated by char- acteristics of the task and environmental contexts. Here is an example of task-cognition interplay. When a task is familiar, the thinker requires relatively little attention to recognize a problem type and determine a hypothesis and plan of action (Mayer, 1992). A familiar task or prob- lem prompts the individual to retrieve a large number of interconnected units of knowledge, both related facts and previous solutions (Mayer, 1992). This suggests that patients who are expert cooks may outperform those who rarely cook on functional cognitive assessments that involve meal preparation. The environment similarly affects cognition. Contextual cues in the environment enhance recall of similar tasks or previously effective tech- niques or solutions. The stimulus-arousal properties of the environment also influence cognitive function. Light- ing and noise can focus attention or, as is often the case for persons with brain injury, provide distractions that derail thinking. In summary, cognition consists of specific but interre- lated capacities and abilities that are influenced by neuro- biological, affective, sociocultural variables, and task and environmental contexts. This discussion, although not ex- haustive, highlights the complexity, if not the mystery, of cognitive function, which is an appreciation necessary for assessing cognitive capacities and abilities in occupational therapy. This discussion also evidences the importance of knowing something about the patient (i.e., diagnosis, ed- ucation and cultural background, psychological and med- ical status, literacy, and communication abilities) before assessing his or her cognitive status. In judging the cog- nitive status of another person, teasing out performance confounders is as important as selecting and correctly ad- ministering the assessment tool. Whereas assigning and summing scores on standardized instruments requires the attentiveness of a trained technician, observing and interpreting performance during assessment requires the insight of a professional.
themselves than others do) (Baddeley, 1990). Memory
problems associated with depression seem to have a sec-
ondary effect on executive processes, possibly because of
distractions by dysfunctional negative thoughts that oc-
cupy limited-capacity working memory during problem
solving and task performance (Channon & Green, 1999).
As discussed in Chapter 3, patients who are anxious or
depressed must be referred to specialized psychological
or medical services.
Transient mental distractions can also impair cog-
nition. Pain and fatigue (especially mental fatigue)
are thought to be irrelevant inputs that interfere with
memory trace formation and diminish the function
of limited-capacity working memory by occupying at-
tention that is therefore unavailable to incoming data
(Denburg, Carbotte, & Denburg, 1997; Dick & Rashiq,
2007; Seminowicz & Davis, 2007). Therefore, clients
who are tired or in pain may be unable to demonstrate
their cognitive capabilities during assessment (Bryant,
Chiaravalloti, & DeLuca, 2004). Under such circum-
stances, the occupational therapist may defer cognitive
assessment to another time or, at a minimum, consider
the influence of these factors when interpreting the as-
sessment results.
Sociocultural Influences on Cognition
Experts suggest that basic processes of perception and
cognition are influenced by cultural and social factors,
such as education. Nisbett and Masuda (2003) sum-
marized a series of studies that illustrate information-
processing differences in East Asian and Western cultures.
They suggested that Americans tended to focus their
attention on objects and object attributes, but Japanese
subjects tended to focus on the field, background, rela-
tionship, or context of the objects. Culture may also in-
fluence displays of self-awareness. Prigatano, Ogano, and
Amakusa (1997) suggested that, because incompetence
in personal care is a sign of disgrace in Japan, Japanese
patients with TBI tended to overestimate their abilities in
this realm. On the other hand, Japanese people generally
believe it is impolite to report high estimations of social
and interpersonal skills. Therefore, Japanese patients
with TBI tended to underestimate their abilities in this
realm. Beyond cultural background, performance on cog-
nitive tests appears to be shaped by years of education.
In a study involving a random sample of age stratified
healthy older adults, younger age and higher education
were associated with better performance on cognitive
testing (Ganguli et al., 2010). This suggests a possible
Chapter 6 Assessing Abilities and Capacities: Cognition 139
Effects of Environment on Cognitive Function
During his inpatient rehabilitation, D.B. was observed to
have decreased attentional capacities, especially with com-
plex tasks. How might this problem be evident during the
occupational therapy homemaking assessment? What fac-
tors in the environment might exaggerate these problems?
What factors might minimize them?
Clinical Reasoning in Occupational Therapy Practice
Assessment Results
COPM: D.B. indicated that his ability to function independently was
limited because of lower extremity fractures. He was dissatisfied
with his inability to drive, the slowness with which he donned lower
extremity clothing, his low stamina when walking outside the home,
and lack of avocational outlets because of mobility limitations.
When queried about known dependence on family members to take
medications and his lack of initiation of self-maintenance tasks, D.B.
quickly dismissed these reports as awkwardness associated with
being a guest in their home.
EFPT: When the therapist administered the EFPT, she noted D.B.
answered all pretest questions as if he experienced no difficulties
living independently, which conflicted with the information provided
by his brother. When the therapist observed D.B.’s performance, she
noted he experienced no difficulty with the hand-washing task, which
indicated he would be able to perform the rest of the EFPT tasks. D.B.
had the following scores for the rest of the EFPT tasks:
1 hand washing
0 telephone use
3 taking medication
5 paying bills
Cognistat: D.B.’s cognitive status profile indicated the following:
performance within the average range for orientation, comprehension,
naming, construction; and mild impairment in similarities, judgment,
calculations, repetition; mild to moderate impairment in attention and
memory.
Informal observation: During each of his two outpatient evaluation
sessions, the therapist gave D.B. oral instructions specific to three
homework assignments to complete at home, all of which he
agreed to do but did not make note of. He completed none of them.
He seemed motivated throughout the assessment and did not appear
distracted by pain or emotional distress during his sessions.
Interpret
observations
“D.B. seems to be quite aware of concrete changes
in his mobility but less aware of possible cognitive
changes related to initiation and memory of
medications. I wonder how much family members
are helping to prevent any errors in daily life that
might otherwise give him feedback about his
cognitive changes.”
“Based on D.B.’s performance on the EFPT tasks,
I am concerned he is having difficulty performing
tasks on his own because he is having problems
with higher order thinking abilities, like problem
solving and working memory. I noticed he had to
be cued to remember to turn off the stove after
cooking. He also needed specific verbal direction in
figuring out when to take the medications. He could
not do the mathematics required for bill paying and
did not catch the balance difference in the available
money and bill sums. If he has problems like this
on the EFPT, it is likely he is going to have problems
living alone and functioning independently without
support.”
“D.B.’s performance on the Cognistat does not
surprise me all that much given the severity of
his TBI. He seems to have a number of cognitive
strengths that I think will really help him participate
in the therapy process.”
“I’m guessing that D.B. has not had to take
responsibility for keeping track of information in
recent months; no doubt his brother has done that
for him. I bet D.B. has not had much experience
with his memory changes and does not appreciate
that he needs to compensate for these changes. He
seems to be a really good candidate for outpatient
rehabilitation at this point.”
Occupational Therapy Problem List
1. Decreased initiation of ADL and IADL
2. Decreased productivity because of poor stamina and limited
repertoire of appropriate avocational outlets
3. Memory inefficiency and inadequate repertoire of memory
compensation strategies
4. Decreased awareness of cognitive deficits interfering with
compensatory strategy use
Synthesize
results
“Overall, D.B. seems to have rather superficial
awareness of his limitations; he acknowledges
physical but not cognitive changes. His brother’s
report of D.B.’s need for supervision with medica-
tions and prompts for ADL and IADL seem consistent
with what I saw on his performance of the EFPT.
I will want to incorporate opportunities for dynamic
assessment into the treatment plan. I need to talk
a little more with D.B.’s brother about the role he
would like to play in the therapy program. Maybe he
needs a break and wants the team to take a more
dominant role for a while.”
140 Section II Assessment of Occupational Function
- Analyze bill paying and grocery shopping in terms of the specific cognitive capacities and abilities required.
- Compare the advantages and disadvantages of the three approaches to cognitive assessment described in this chapter.
- Describe each variable that influences a person’s abil- ity to think. How would you expect these variables to affect cognitive assessment of an elderly illiterate
client? How would you expect these variables to affect cognitive assessment of a college student?
- Explain the occupational therapist’s contribution to the rehabilitation team in the realm of cognitive assessment. Specifically, outline the ways in which occupational therapy complements the assessments of other professionals and the unique elements of occupational therapy.
Summary Review Questions
Glossary
Attention—The ability to deploy limited mental re- sources for purposes of concentration. Human activities have various attentional demands, including sustained attention (length of time), selective attention (compet- ing stimuli), divided attention (multiple simultaneous stimuli), and alternating attention (shifts back and forth between various stimuli).
Cognition—The general term that refl ects the mental enterprises related to absorbing information, thinking, and goal-directed action.
Dual-task performance—Conditions in which perfor- mance of a single task is compared to performance of the single task performed simultaneously with a secondary task. Dual-task cost refers to the decrement in performance of a relatively simple primary task when a secondary (cognitive) task is added (McCulloch, 2007).
Executive function—Metaprocesses that enable a per- son to initiate, plan, self-monitor, and correct his or her
approach to goal-directed tasks. Executive disorders often result from frontal lobe damage and are evidenced by problems with self-control, self-direction, and organiza- tion (Lezak, 1995).
Memory—The result of interactive cognitive systems that receive, code, store, and retrieve information.
Neuropsychological evaluation—A long battery of standardized tests for purposes of diagnosis, patient care and planning, rehabilitation evaluation, and research ( Lezak, 1995). Typically, the examiner is a doctor of psy- chology with specialized training in cognitive processes and brain–behavior relationships.
Orientation—Awareness of self in relation to person, place, time, and circumstance (Sohlberg & Mateer, 1989).
Self-awareness—The capacity to objectively perceive the self (Prigatano & Schacter, 1991) and (with a reason- able degree of accuracy) to compare that conception to a premorbid standard.
References
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