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1 Performance-Based Cognitive Assessment Glen Gillen, EdD, OTR, FAOTA Programs in Occupational Therapy College of Physicians and Surgeons Columbia University I have no financial disclosures. Outline Approaches to cognitive & perceptual assessment Assessing and documenting the impact of cognitive & perceptual impairment on everyday living: A 2 step process Review clusters of neurobehavioral impairments observed during everyday function Review of potential standardized assessments for adoption Questions & comments.. 1

2 Two schools of thought regarding evaluating cognitive and perceptual impairments. Documenting Cognitive/Perceptual Impairment(s) Documenting the impact of cognitive and perceptual impairments on daily life. Independence and safety! 2

3 Documenting the impact of cognitive and perceptual impairments on daily life 2 steps. S T E P S T E P Level of Self Awareness 1 2 Performance Based Testing Ascertaining Level of Self Awareness (Crosson et al.) Anticipatory Awareness Emergent Awareness Intellectual Awareness 3

4 Awareness Evaluation Questionnaires (self or clinician rated) Interviews Rating scales Functional observations Comparisons of self ratings and ratings made by others such as significant others, caretakers, or rehabilitation staff Comparisons of self ratings and ratings based on objective measures of function or cognitive constructs Awareness Assessments Self Awareness of Deficits Interview (Fleming & Strong) Self Regulation Skills Interview (Ownsworth, et al.) The Patient Competency Rating Scale (Prigatano) Awareness Questionnaire (Sherer, et al.) Awareness Interview (Anderson & Tranel) Assessment of Awareness of Disability (Kottorp & Tham) Task Impairment Skewed Self Awareness 4

5 5 Series Predicted Actual Skewed Ability to Predict Everyday Function 5 Series Predicted Actual Safety! Anticipatory Compensation Situational Compensation Poor awareness compensations to improve everyday function. External Compensation Recognition Compensation 5

6 Engagement in any daily activity requires multiple cognitive and perceptual processes to support function. Impaired cognitive or perceptual processing may limit daily performance and result in an observable error during attempts to function.. 6

7 Evaluate Cognition/Perception in Context Performance Based Cognitive Assessment Tasks performed in context are ecologically valid. Require multitasking. Require access to a variety of supporting processes. More accurate indicator of performance in an unstructured situation. Fly on the wall perspective. Valid, reliable, accurate. Mechanics of Performance Based Cognitive Assessment Everyday activities that a patient wants to do, needs to do, and/or has to do. Fly on the wall : Let safe errors occur (awareness and problem solving observed). Intervene for safety concerns are breakdown in performance prevents continuation. 7

8 Mechanics of Performance Based Cognitive Assessment Error analysis based on operational definitions and descriptive terminology. Structured cuing procedures to support performance. Identifies the impact of impaired cognitive/perceptual processing that limits everyday function. Identifies cognitive and perceptual processes that support everyday function. Let safe errors occur Observe for patterns of neurobehavioral deficits. Examples 8

9 Lack of an idea of what to do Poor initiation Performance latency Incorrect tool use Mouthing objects Inability to organize and sequence Flat affect Poor awareness and judgment (safety!) Loss of the foundation of everyday performance May co exist with aphasia Ideational Apraxia: Cluster of Behaviors Does not know how to perform Clumsy movements May impact limbs and/or trunk activities Gross and fine mobility tasks impaired Static/awkward hand postures Poor manipulation Difficulty crossing midline Easily frustrated May co exist with expressive aphasia Motor Apraxia: Cluster of Behaviors Hypo attentive to the left side of the world Hyper attentive to the right side of the world Can impact any sensory system Poor awareness Decreased leftward limb and eye movements Presents with topographical disorientation Occasionally attends to left (attentional bias) Difficulty crossing midline towards left May present related to near space, far space, or both May or may not co exist with a field cut Safety concerns during mobility Unilateral Spatial Neglect: Cluster of Behaviors 9

10 Hypo attentive to the left side of the body Hyper attentive to the right side of the body Attentional bias towards the right side of the body Higher % of time managing the right side of the body Poor awareness Errors related to personal space and body management Safety Unilateral Body Neglect: Cluster of Behaviors Incorrect end point when reaching or stepping Figure ground impairment Difficulty way finding Difficulty spatially orienting objects to each other or to self Lost in space Safety concerns Perseverative errors Easily frustrated May co exist with decreased overall attention Visual Spatial Impairment: Cluster of Behaviors Difficulty multi tasking Poor decision making Poor problem solving Difficulty task switching Poor abstraction Impulsive Lack of insight Disorganization Impaired sequencing Decreased time pressure management Safety Executive Dysfunction: Cluster of Behaviors 10

11 From Non Standardized Observations to Standardized Assessment Ecological Validity is a Critical Factor to Consider ,93,86,79 11

12 A ONE (Arnadottir, 1990, 1999, 2015) Analysis of everyday performance Dressing Grooming and Hygiene Transfers and Mobility Feeding Communication Cognitive processes that support/limit performance Organization Sequencing Neglect Spatial Dysfunction Initiation Alertness Attention Memory Ideation Etc. Catherine Bergego Scale (CBS) (Azouvi, 2003) Analysis of everyday performance Dressing Grooming/hygiene Mobility Feeding Social interactions 10 items in total Cognitive processes that support/limit performance Lateralized Attention Deficit Awareness Topographical Disorientation Executive Function Performance Test (EFPT) (Baum et al., 2008; Katz et al., 2007; Goverover et al., 2005) Analysis of everyday performance Cognitive processes that support/limit performance Cooking Oatmeal Making Phone Call Taking Medication Paying a Bill Initiation Organization Sequencing Safety and Judgment Completion 12

13 Multiple Errands Test (Knight, Alderman, & Burgess, 2002; Shallice & Burgess, 1991) Analysis of everyday performance Multi tasking during a shopping/community experience Purchase 3 items, pick up an envelope from reception, use telephone, post the envelope Writing down four items re: information (ex. gift shop hours) Meet assessor and ask the time Inform assessor that the test was completed Cognitive processes that support/limit performance Executive functions Dysexecutive syndrome Initiation Planning Attentional switching Working memory Assesment of Disabilities in patients with Apraxia (Van Heugten, 1999, 2000). Analysis of everyday performance Cognitive processes that support/limit performance Hygiene Dressing Preparing food Patient chosen activity Initiation Planning Ideation Control Execution Awareness of errors The Kettle Test (Hartman Maeir, Armon, & Katz, 2005) Analysis of everyday performance Making two hot beverages with different ingredients using an electric kettle. 13 discrete steps in total. Cognitive processes that support/limit performance Screening for a broad range of basic and higher level cognitive processes. Executive functions Working memory Awareness/safety 13

14 Weekly Calendar Planning Activity(Toglia, 2015) Analysis of everyday performance Ability to use a list, follow rules, and enter information accurately into a weekly schedule. Cognitive processes that support/limit performance Executive functions: planning, working memory, organization, self monitoring, selfregulation, etc. Questions, comments, thank you! American Occupational Therapy Association (2013). Cognition, cognitive rehabilitation, and occupational performance. American Journal of Occupational Therapy 67: S9 S31. Baum, C. M., Connor, L. T., Morrison, T., Hahn, M., Dromerick, A. W., & Edwards, D. F. (2008). Reliability, validity, and clinical utility of the Executive Function Performance Test: A measure of executive function in a sample of people with stroke. American Journal of Occupational Therapy, 62, Burgess, P. W., Alderman, N., Forbes, C., Costello, A., Coates, L. M., Dawson, D. R.,... Channon, S. (2006). The case for the development and use of ecologically valid measures of executive function in experimental and clinical neuropsychology. Journal of the International Neuropsychological Society, 12, Bottari, C., & Dawson, D. R. (2011). Executive functions and real world performance: How good are we at distinguishing people with acquired brain injury from healthy controls? OTJR: Occupation, Participation and Health, 31, S61 S68 Burns, S. C., & Neville, M. (2016). Cognitive assessment trends in home health care for adults with mild stroke. American Journal of Occupational Therapy, 70, Chevignard, M. P., Taillefer, C., Picq, C., Poncet, F., Noulhiane, M., & Pradat Diehl, P. (2008). Ecological assessment of the dysexecutive syndrome using Execution of a Cooking Task. Neuropsychological Rehabilitation, 18, Dickerson, A. E., Meuel, D. B., Ridenour, C. D., & Cooper, K. (2014). Assessment tools predicting fitness to drive in older adults: A systematic review. American Journal of Occupational Therapy, 68,

15 Gillen, G. (in press). Evaluation and Treatment of Limited Occupational Performance Secondary to Cognitive Dysfunction. In Schultz Krohn, W. & Pendleton, H. (eds.) Pedretti s Occupational Therapy: Practice Skills for Physical Dysfunction, 8th ed., Elsevier Science/Mosby, St. Louis. Gillen, G., Nilsen, D. M., Attridge, J., Banakos, E., Morgan, M., Winterbottom, L., & York, W. (2015). Effectiveness of interventions to improve occupational performance of people with cognitive impairments after stroke: An evidence based review. American Journal of Occupational Therapy, 69, , 1 9. Gillen, G. & Brockmann Rubio, K. (2016). Treatment of cognitive perceptual impairments: A function based approach. In Gillen, G. (ed.) Stroke Rehabilitation: A Function Based Approach, 4th edition, Elsevier Science/Mosby, St. Louis, pp: Gillen, G. (2009). Cognitive and Perceptual Rehabilitation: Optimizing Function. Elsevier/Mosby, St. Louis. Morrison, M. T., Edwards, D. F., & Giles, G. M. (2015). Performance based testing in mild stroke: Identification of unmet opportunity for occupational therapy. American Journal of Occupational Therapy, 69, Sansonetti, D. & Hoffmann, T. (2013). Cognitive assessment across the continuum of care: The importance of occupational performance based assessment for individuals post stroke and traumatic brain injury. Australian Occupational Therapy Journal 60(5),

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