Mental capacity required for the Canadian Occupational Performance Measure and the Self- Identified Goals Assessment

Transcription

1 The University of Toledo The University of Toledo Digital Repository Master s and Doctoral Projects Mental capacity required for the Canadian Occupational Performance Measure and the Self- Identified Goals Assessment Cari A. Eason Medical University of Ohio Follow this and additional works at: This Scholarly Project is brought to you for free and open access by The University of Toledo Digital Repository. It has been accepted for inclusion in Master s and Doctoral Projects by an authorized administrator of The University of Toledo Digital Repository. For more information, please see the repository's About page.

2 FINAL APPROVAL OF SCHOLARLY PROJECT Master of Occupational Therapy Mental Capacity Required for the Canadian Occupational Performance Measure and the Self-identified Goals Assessment Submitted by Cari Eason In partial fulfillment of the requirements for the degree of Master of Science in Biomedical Sciences Date of Presentation: December 15, 2005 Academic Advisory Committee Major Advisor David L. Nelson, Ph.D., OTR/L, FAOTA Department Chairperson Julie Jepsen Thomas, Ph.D., OTR/L, FAOTA Dean, College of Health Sciences Christopher E. Bork, Ph.D., P.T. Dean, College of Graduate Studies Keith K. Schlender, Ph.D.

3 Mental Capacity 1 Mental Capacity Required for the Canadian Occupational Performance Measure and the Self- Identified Goals Assessment Cari A. Eason Department of Occupational Therapy Medical College of Ohio at Toledo

4 Mental Capacity 2 Abstract What is the association between inpatient rehabilitation patients' cognitive status and their ability to identify and rate goals quantitatively? This study, a replication and extension of Irwin (2003), investigated the correlations between the Mini-Mental State Examination (MMSE) and the number of goals identified and rated on the Canadian Occupational Performance Measure (COPM) and the Self-Identified Goals Assessment (SIGA). Twelve males and eighteen females, with a mean age of 67.7 (SD = 10.4), participated. Within 24 hours of MMSE administration, the COPM and the SIGA were administered in a randomized counterbalanced order and in a masked way. Moderate positive Spearman correlations were found between the MMSE and the number of COPM goals identified (r =.40, p =.03); the number of COPM goals rated (r =.51, p =.004); the number of SIGA goals identified (r =.48, p =.02); and the number of SIGA goals rated (r =.48, p =.02). Unlike Irwin (2003), some participants with MMSE scores <23 were able to identify and rate at least one goal. Therapists should expect that patients with cognitive deficits will have difficulty identifying and rating goals, but it should not be assumed that a relatively low MMSE score (<23) means that self-directed goals will be impossible.

5 Mental Capacity 3 Mental Capacity Required for the Canadian Occupational Performance Measure and the Self-Identified Goals Assessment A key component in occupational therapy is the active engagement of people in the chosen occupations of their daily lives. Increasingly, a client-centered approach to occupational therapy has been advocated. According to Law and Mills (1998), clientcentered occupational therapy involves a partnership of respect between the therapist and the client. It is extremely important that the client be involved in every aspect of the therapy process, including goal-setting. Emphasis is placed on respecting the individual s past, current, and future choices, as clients have the responsibility for the decisions about their daily occupations and the therapy they receive. According to the American Occupational Therapy Association, the client-centered approach demonstrates respect and value for the client s needs, wants, and priorities (Kanny et al., 1995, p. 1040). Within the Conceptual Framework for Therapeutic Occupation (CFTO), Nelson (1994) also describes the importance of involving the client in the therapy process. According to CFTO, there are two ways to judge a person s occupational performance: objective success and subjective success. Objective success occurs when a person s occupational performance or impact match the norms of society. Subjective success occurs when a person s occupational performance or impact matches his or her personal purposes. The individual s changing meanings and purposes determine subjective success. Occupational therapists using a client-centered approach should evaluate not only a client s objective success or failure in occupational performance, but also the

6 Mental Capacity 4 client s subjective views. Therefore, the occupational therapist must listen to and appreciate the viewpoints of the client. Kielhofner (1997) agrees that in order to maintain a productive client-therapist relationship, as well as the therapy process in general, the client s needs, desires, and perspectives must be understood and respected. In order to help facilitate productive client-centered occupational therapy, individual client goal-setting must be considered. According to the American Occupational Therapy Association Code of Ethics, occupational therapists should collaborate with service recipients or their surrogate(s) in setting goals and priorities throughout the intervention process (Kornblau et al., 2000, p. 615). The active involvement of clients in setting goals and planning interventions is also valued by accrediting and regulatory agencies. In order for a rehabilitation facility to be accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), it must demonstrate a service design and delivery that focus on the needs of the persons served and a partnership with the persons served in decision making and the development of goals (Commission on Accreditation of Rehabilitation Facilities, Service Providers, 2004). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that the patient s needs be met according to the plan laid out by a rehabilitation team that must incorporate the patient s personal goals for rehabilitation as well as describe long-term rehabilitation goals and short-term skill development objectives in functional terms and developed in collaboration with the patient and the family (Joint Commission on Accreditation of Healthcare Organizations, 2000, p. TX-44a).

7 Mental Capacity 5 There are several ways to incorporate active client goal-setting into occupational therapy. The Canadian Occupational Performance Measure (COPM) is an assessment tool used to facilitate the goal-setting process by measuring problems identified by the client (Law et al., 1998). In the Occupational Performance Process Model, the therapist and client work together to identify and prioritize occupational performance concerns. The COPM is a standard method used to do so (Fearing, Clark, & Stanton, 1998). The COPM is used to help clients identify goals for therapy, as well as measure their progress towards completing these goals. Administration consists of a four-step process: problem definition, rating of importance, scoring, and reassessment. The COPM focuses on the areas of self-care, productivity, and leisure, and takes approximately 30 to 45 minutes (Law et al., 1998). A second tool used to elicit client goals in therapy is the Self-Identified Goals Assessment (SIGA). The SIGA was developed as part of the Melville-Nelson Occupational Therapy Evaluation System for Subacute Rehabilitation (Melville & Nelson, 2001). Its main purposes are to help the client identify meaningful therapy goals and to determine progress made toward these goals (Melville, Baltic, Bettcher, & Nelson, 2002). In addition to rating each therapy goal, clients are asked to rate their overall level of functioning. Johnson (2001) reported that the SIGA was found to take an average of 5.6 minutes to complete. The COPM and SIGA can be valuable tools in assisting clients to identify their goals. However, not every client has the cognitive abilities to identify and rate therapy goals for themselves using the COPM or the SIGA. They may have cognitive deficits or lack the insight necessary for awareness of their occupational performance. The COPM

8 Mental Capacity 6 manual states that the COPM may not be appropriate for some clients with cognitive impairments (Law et al., 1998, p. 15). In addition, research has shown that clients with cognitive problems frequently have difficulty in completing the COPM (Law et al., 1998). Toomey, Nicholson, and Carswell found that use of the COPM depended on client insight, cognitive ability, emotional state and whether the client was English speaking (1995, p. 245). In an independent assessment of the COPM, Chan and Lee (1997) argued that the results of the COPM depend on the client s understanding of the administration process of the instrument and on the client's degree of insight into his or her current problems as well as those that might occur after discharge. Cassidy (2000) found that therapists had difficulty administering the SIGA to clients with cognitive impairments. Therapists found that some people did not understand the concept of goals or desired outcomes and some clients had cognitive deficits that prevented them from comprehending the instructions (Cassidy, 2000, p.16). In addition, therapists in a focus group reported that clients who lacked insight due to decreased cognitive function seemed to have difficulty completing the SIGA. Specifically, dementia or cerebral vascular accident were associated with difficulty in formulating and rating self-identified goals (Hodge, 1999). What level of cognition is necessary in order to use the COPM and the SIGA to facilitate the client-centered therapy process? Therapists need to know which clients can successfully complete the assessments. If the therapist knows in advance that a client s cognitive deficits are likely to prevent them from completing the COPM and/or the SIGA, he or she can plan alternative ways to address goal-setting. On the other hand, the

9 Mental Capacity 7 therapist needs to encourage the client whose cognitive deficit is not severe enough to prevent meaningful participation in the goal-setting process. The Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) is a widely used assessment to evaluate cognitive functioning. It is a quick, easy, and reliable screening of cognitive ability. The MMSE takes approximately 5 to 15 minutes to administer and assesses the following elements of cognition: attention, orientation, memory (including registration and recall), language, and praxis (Beers & Berkow, 2000). The brevity of the MMSE makes it especially useful in clinical settings. Therapists working in inpatient rehabilitation settings may have a limited amount of time to evaluate each client. Therefore, a quick cognitive screening may be a preferred assessment. The following study is based on a replication of a small pilot study by Irwin (2003), in which 17 inpatients from a transitional care unit completed the COPM and SIGA in a counterbalanced order. Later in the day, the MMSE was administered. Participants who had a score of 23 out of 30 or above on the MMSE were able to complete the SIGA. Participants who had a score of 24 to 26 or above were able to complete the COPM. In addition, statistically significant positive Spearman correlations were found between the MMSE and the number of SIGA goals identified, the number of SIGA goals rated, the number of COPM goals identified, and the number of COPM goals rated. Sensitivity and specificity of the SIGA and COPM were also explored. Sensitivity referred to the proportion of clients with relatively low MMSE scores (e.g., below empirically derived cut-off scores) who cannot identify and score their goals on the COPM and SIGA (p. 7). Specificity referred to the proportion of clients above the

10 Mental Capacity 8 MMSE cut-off points who are able to identify and score their goals using the COPM and SIGA (p. 7). Perfect specificity (100%) was found for both SIGA measurements at a cut-off score of <23. However, two participants who scored less than 23 were able to identify goals using the SIGA. Overall, <23 on the MMSE was the most sensitive cut-off score for the SIGA. Maximum specificity (88%) for the COPM was at the <27 level. Sensitivity for identifying goals on the COPM was maximized (80%) at the <24 level. The participants primary diagnoses included orthopedic conditions, cardiovascular disease, general debility, and respiratory disease. There were several limitations to this study, including small sample size and lack of participants with primary cognitive diagnoses. Only a small number of participants were not able to complete the COPM and SIGA, making it difficult to determine the cut-off points. Like Irwin (2003), the current study attempted to predict successful administration of the COPM and SIGA based on scores on the MMSE. However, rather than recruiting participants from a transitional care unit as in Irwin's study, an inpatient rehabilitation unit serving patients with neurological and cognitive impairments was utilized. The primary research questions in this study are: (a) What are the correlations between the MMSE score and the goals identified and scored on the COPM? (b) What are the correlations between the MMSE score and the goals identified and scored on the SIGA? The secondary research questions are: (c) What is the optimal cut-off point on the MMSE as determined by the sensitivity and specificity of the COPM goals identified and scored? (d) What is the best cut-off point on the MMSE as determined by the sensitivity and specificity of the SIGA goals identified and scored?

11 Mental Capacity 9 Method Participants The participants included 30 inpatients from the Medical College of Ohio Rehabilitation Hospital in Toledo. The participants were recruited between September 9, 2004, and May 4, Each participant met the following inclusion criteria: 50 years of age or older, voluntary consent to participate in the study, and the basic ability to answer simple questions requiring more than yes or no responses (e.g., "With whom do you live?"). Initially, participants were recruited from patients who had their initial occupational therapy evaluations completed by one of the two primary full-time occupational therapists on Sunday through Friday. Towards the end of the recruitment period, participants were recruited after chart review by the primary student investigator. One of two research assistants must have been able to administer the informed consent and MMSE within 4 days of the beginning of the initial occupational therapy evaluation, and the student investigator must have been able to administer the COPM and SIGA within 24 hours of the visit by the research assistant. The sample consisted of 12 males and 18 females with a mean age of 66.7 (SD = 10.4). The primary diagnoses of the participants included the following: cerebral vascular accident, total knee arthroplasty, total hip arthroplasty, spinal cord injury, traumatic brain injury, multiple sclerosis, spinal fusion, myelopathy, transmetatarsal amputation, and chronic inflammatory demyelinating polyneuropathy exacerbation. Instruments The Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) is an assessment tool used to screen cognitive functioning. It is used widely by

12 Mental Capacity 10 many healthcare disciplines in assessing the mental status of clients. It includes the following sections: orientation, registration, attention and calculation, recall, language, repetition, three-stage command, reading, writing, and copying. The total maximum score is 30. Guidelines are suggested for determining the severity of cognitive impairment. Folstein, Folstein, and McHugh (1975) found test-retest reliability to be r =.89 and interrater reliability to be r =.83. In addition they confirmed validity in showing a positive correlation between scores on the MMSE and on the Wechsler Adult Intelligence Scale s verbal and performance scores. The Canadian Occupational Performance Measure (COPM) is the second instrument used in this study. Developed as an assessment tool to be used in clientcentered therapy, it provides a structure to help clients identify and rate goals for therapy. The COPM utilizes a semi-structured interview format. The therapist uses interviewing skills to assist the client in identifying problems they are experiencing in occupational performance, including occupations that they want to do, need to do, or are expected to do throughout the day. Together, the client and therapist explore the three areas of selfcare, productivity, and leisure. The therapist may offer examples of occupations in each area. After problem areas are identified, the client then rates the importance of each occupation in his or her life using a ten-point scale. The client then narrows the problem list down to five. Each problem is rated by the client on his or her current ability to do the occupation, as well as on his or her satisfaction in the way he or she currently does the occupation. Finally, a total performance score and total satisfaction score are computed by taking the mean of the scores in each category. Reassessment at a later date

13 Mental Capacity 11 can detect changes in the client s perceptions of his or her performance and satisfaction (Law et al., 1998). The reliability and validity of the COPM have been tested. Test-retest reliability has been established by Sanford, Law, Swanson, and Guyatt (1994) for Performance (ICC =.63) and for Satisfaction (ICC=.84) (as cited in Law et al., 1998). In addition, Law and Stewart (1996) found test-retest reliability to be.79 and.75 for Performance and Satisfaction, respectively, in a sample of parents of young children with disabilities (as cited in Law et al., 1998). McColl, Paterson, Davies, Doubt, and Law (2000) established content validity and criterion validity. Content validity has been established through a multivariate analysis with the Satisfaction with Performance Scaled Questionnaire, the Reintegration to Normal Living Index, the Life Satisfaction Questionnaire, and the Perceived Problems List. In addition, criterion validity was supported when a majority of participants reported at least one of the problems identified on the COPM when asked about problems of daily living. The third instrument used in this study is the Self-Identified Goals Assessment (SIGA). The SIGA was developed to assist clients in identifying personally meaningful goals to be addressed in therapy as well as evaluate their personal perception of success in occupational performance. The occupational therapist uses interviewing skills to elicit up to five self-identified goals. Emphasis is placed on specific goals related to their prior level of functioning and daily routine. The client is then asked, with the assistance of a visual aid presented to the client, How well can you do all of the things you want to do on a scale from 0 to 10, with 0 being that you can t do them at all and with 10 being you can do them your very best? If the client is not fatigued, the therapist proceeds in the

14 Mental Capacity 12 same manner to rate the goals identified by the client. Progress can be determined by asking the client to reassess his or her goals, ratings, and overall score at later dates (Melville & Nelson, 2001). Aspects of content, construct, and criterion validity have been studied for the SIGA. Melville, Baltic, Bettcher, and Nelson (2002) found that within 48 hours of completion of the SIGA, 29 out of 30 subjects stated that they felt the SIGA gave an accurate portrayal of their goals. In a focus group of registered occupational therapists, it was concluded that the SIGA enhanced client-therapist communication and rapport, boosted client motivation, and increased feelings of empowerment in the treatment process (Hodge, 1999). Cassidy (2000) found similar results. Convergent validity has been studied between the SIGA and Occupational Self Assessment (OSA), resulting in a relatively low, but statistically significant correlation (r =.41). Due to the nature of the differences between the two assessments, a higher correlation would not be expected. Convergent validity has also been studied between the SIGA and COPM Performance score (r =.76), showing a substantial correlation. Procedure For the first seven months of recruitment, two occupational therapists screened the patients for eligibility and asked them if they would be willing to speak to a student investigator concerning participation in the research project. The therapist filled out a short research screening form recording the person s primary diagnosis, age, ability to answer the screening question, and whether he or she gave permission to have a student investigator talk with him or her. If the patient granted permission, the therapist recorded the patient s name and room number in order to give the research assistants and student

15 Mental Capacity 13 investigator the necessary information to contact the patient. The student investigator then contacted one of two research assistants about potential participants. The research assistant visited the patient within 24 hours of the initial occupational therapy assessment to describe the study, request the patient s participation, and administer the IRB-approved consent form. Due to staffing shortage and therapist turnover in the Medical College of Ohio Rehabilitation Hospital, there was a lack of follow-through in participant recruitment. Following IRB approval, the recruitment method was altered in the last two months of the recruitment period in order to reach more participants. Several times a week, the student investigator performed chart reviews of all occupational therapy patients. If the patient met the criteria, the student investigator approached the patient to request his or her permission to participate in the study. The student investigator then contacted one of two research assistants. After a potential participant signed the consent form, the research assistant administered the MMSE and contacted the student investigator upon completion. The student investigator then administered the COPM and SIGA in a random, counterbalanced order in the participant s room within 24 hours of administration of the informed consent and MMSE. Results The descriptive results are presented in Table 1. The mean score on the MMSE was 26.7 (SD = 3.2), ranging from 17 to 30. The mean number of goals identified and rated using the SIGA was 3.1 (SD = 1.5), somewhat less than the mean number of goals identified and rated using the COPM: 4.4 (SD = 1.2) and 4.3 (SD = 1.2), respectively.

16 Mental Capacity 14 To investigate the relationship between the MMSE score and measures on the COPM and SIGA, four Spearman correlations were conducted, with alpha =.05. Table 2 shows that there were significant positive correlations between the MMSE and each of the four goal scores. Cognition, as measured by the MMSE, was related to the number of goals identified on the COPM, the number of goals rated on the COPM, the number of goals identified on the SIGA, and the number of goals rated on the SIGA. It should be noted, however, that the correlations indicated imperfect associations and were far from 1.0. Cut-off points on the MMSE for the successful use of the COPM and the SIGA could not be determined because few participants were unable to identify and rate goals. To test for sensitivity and specificity, there must be substantial numbers of persons with and without an identified problem. Figure 1 describes how each participant performed on the assessment, rank-ordered by scores on the MMSE. It is clear that there were very few people who had low MMSE scores and had difficulty with the COPM and SIGA. Only one person was unable to identify any goals. One person was able to identify a few goals, but not able to rate all of them. All other persons were able to identify and rate at least one goal. As shown in Figures 2 and 3, the types of goals varied somewhat from one assessment to another. The number and types of goals differed on the COPM and SIGA, even though they were administered one after the other. Of the participants who identified goals, 44.8% (13 out of 29) listed totally different goals on each assessment; 20.6% (6 out of 29) listed one goal the same; 27.6% (8 out of 29) listed two goals the same; and 6.9% (2 out of 29) listed three goals the same. Of those participants who listed

17 Mental Capacity 15 the same goals on each assessment, the majority (62.5% or 10 out of 16) tended to be fairly consistent when rating the same goals on each assessment. No statistically significant order effects for the administration of the SIGA and the COPM were found. Discussion This study found a significant relationship, demonstrated by moderate positive correlations, between cognitive status (as assessed by the Mini-Mental State Examination) and the ability to identify and rate goals using the Canadian Occupational Performance Measure and the Self-Identified Goals Assessment. Knowledge of this moderate correlation helps occupational therapists seeking occupation-oriented goals in rehabilitation patients. Consistent with the present study, Irwin found significant positive Spearman correlations between the MMSE score and number of goals identified on the COPM (r =.63), number of goals rated on the COPM (r =.58), number of goals identified on the SIGA (r =.48), and number of goals rated on the SIGA (r =.53). The correlations found by Irwin were somewhat higher than those found in this study. Irwin s study of skilled nursing patients included more participants who were unable to identify and rate goals. In addition, Irwin had more participants who were able to identify goals, but could not rate them. In the present study only one participant who was unable to identify goals could not rate goals. In the present study, the mean number of goals identified on the SIGA and COPM was higher than in the Irwin study, especially on the COPM. Irwin found more goals were identified on the SIGA (2.82, SD = 1.38) than on the COPM (2.47, SD = 1.66). The present study found more goals identified with the COPM (4.4, SD = 1.2) than on the

18 Mental Capacity 16 SIGA (3.1, SD = 1.5). The reason for generating more goals in the present study is probably that the inpatient rehabilitation patients studied were younger and less frail than the skilled nursing patients studied by Irwin (2003). Neither study found an order effect. Irwin found that the most sensitive cut-off score for the SIGA is <23 on the MMSE and the most sensitive cut-off score for the COPM is <27 on the MMSE (2003). In the current study with somewhat younger and less frail participants, cut-off scores could not be determined. Two participants with MMSE scores of <23 were able to identify and rate goals on both the SIGA and COPM. Nine participants with MMSE scores of <27 were able to identify and rate goals on both the SIGA and COPM. Occupational therapists are cautioned not to automatically exclude persons with MMSE scores <23 from using the SIGA and COPM to identify goals. Hobson (1996) advocated for the use of client-centered therapy, even when the client is cognitively impaired. It should not be assumed that a relatively low MMSE score (<23) means that self-directed goals will be impossible. However, therapists should expect that patients with cognitive deficits will have difficulty identifying and rating goals. Future research is needed to find out if even lower MMSE scores truly fall below a workable cut-off point. Previous guidelines for using the MMSE as a measure of cognitive deficit vary as to the cut-off range. Folstein et al. (1975) used a MMSE cut-off score of less than 20 to differentiate between patients with dementia or functional psychosis from the normal participants and patients with personality disorder or anxiety neurosis. Folstein et al. also reported that a sample of older adult residents assumed to be intellectually intact had a MMSE score of 24 or more. Dick et al. (1984) found optimum specificity and sensitivity at a score of <24 for neurological patients. However, 4.3% of neurologically intact

19 Mental Capacity 17 patients scored lower and 76% of neurologically impaired patients scored higher on the MMSE. Anthony, LeResche, Niaz, Von Korff, and Folstein (1982) found that when a patient who scored 23 or less was considered to be cognitively impaired, sensitivity was 87% and specificity was 82.4%. The present study found that three patients who scored less than 24 were able to identify and rate goals using the SIGA and COPM. Only one patient, who had a MMSE score of 17, was unable to identify and rate at least one goal. Two participants scored below 24 but still could identify goals. This finding suggests that occupational therapists should not be dissuaded from using the SIGA and COPM to elicit client-identified goals from inpatient rehabilitation patients who have MMSE scores below 24, the recommended cut-off score indicating cognitive impairment. A final interesting finding is the frequent changing of the number, types, and ratings of client-identified goals from one assessment to the other (refer to Figures 2 and 3). This finding is similar to the goal changing behavior found in the Irwin (2003) study. Slightly less than half of the participants listed completely different goals on each assessment. Of those participants who listed the same goals on each assessment, 62.5% tended to be fairly consistent when rating the same goals on each assessment. Others, however, listed completely different scores for the same goal. For example, participant number 20 identified visiting his or her mother on both assessments, but gave a score of two on the SIGA and a score of nine on the COPM. Participants sometimes listed goals that were somewhat consistent, but more general on one assessment, and more specific on another assessment. For example, participant number 3 identified three kinds of transfers on the COPM, but identified transfers in general on the SIGA. Participant

20 Mental Capacity 18 number 29 identified yard work, walking to the park, and playing with the dog on the SIGA, but identified outdoor mobility on the COPM. There seem to be more self-care related goals identified on the COPM than on the SIGA. For example, participant number 25 listed fixing hair, bathing, and foot care on the COPM, but no self-care goals on the SIGA. Showering or bathing was identified 11 times on the COPM, but only twice on the SIGA. In addition, participants tended to identify more goals on the COPM than on the SIGA. These goal-changing behaviors are interesting, considering that both assessments were given on the same day, with the second immediately following the first. There are several possible explanations for these discrepancies. The wording of the assessments may elicit certain types of goals. The COPM lists the specific categories of self-care (including the subcategories of personal care, functional mobility, and community management); productivity (with the subcategories of paid/unpaid work, household management, and play/school); and leisure (with the subcategories of quiet recreation, active recreation, and socialization). Examples are also given to assist the patient in identifying goals. This may cause the patient to consider goals they would not have thought of using the SIGA. A second possibility is that the additional time from the initial assessment to the second assessment allowed for more reflection. However, the COPM tended to elicit more goals, regardless of order. Thirdly, the participants may not have been reliable regarding their goals. It is possible that they did not have insight into their deficits, or how disabling they were at the time. A final possibility is that the participants may have assumed that the student investigator would not waste time by trying to get the same information in two different ways. They may have actively

21 Mental Capacity 19 thought up novel goals that were not previously stated. Further investigation to determine the causes of the frequent goal-changing behaviors is warranted. A major limitation to this study was the small number of participants with MMSE scores below 25. It is possible that recruiting participants from a rehabilitation hospital, which requires the ability to endure several hours of therapy per day, did not result in access to patients with lower cognitive abilities. Future research may consider recruiting a larger number of participants from a skilled nursing facility. It should be noted that special procedures will be necessary to attain informed consent from patients with cognitive deficits. The MMSE was used in this study because it is widely used in hospitals by other members of the healthcare team, and therefore likely to be available to therapists for use in screening cognitive ability. However, future research may wish to consider using Allen s levels of cognition (Allen & Blue, 1998) to determine cut-off scores for use of assessments that elicit client-identified goals. Acknowledgments Sincere appreciation is expressed to Peggy Lieske, Mary Wiitala, and Melanie Himmelein, the occupational therapists at the Medical College of Ohio Rehabilitation Hospital, for their assistance in participant recruitment as well as to Kristy Knight and Julie Norton for their support as research assistants. Thanks are also expressed for the School of Allied Health/ School of Nursing Research Support Award which aided the completion of this research project.

22 Mental Capacity 20 References Allen, C. K., & Blue, T. (1998). Cognitive disabilities model: How to make clinical judgments. In N. Katz (Ed.), Cognition and occupation in rehabilitation: Cognitive models for intervention in occupational therapy. Bethesda, MD: AOTA. Anthony, J. C., LeResche, L., Niaz, U., Von Korff, M. R., & Folstein, M. F. (1982). Limits of the Mini-Mental State as a screening test for dementia and delirium among hospital patients. Psychological Medicine, 12, Beers, M. H. & Berkow, R. (Eds.). (2000). The Merck manual of geriatrics. (3rd ed). Whitehouse Station, NJ: Merck Research Laboratories. Cassidy, J. L. (2000). Clinical utility of a measure of self-identified goals in occupational therapy. Unpublished manuscript, Medical College of Ohio at Toledo. Chan, C. C. H., & Lee, T. M. C. (1997). Validity of the Canadian Occupational Performance Measure. Occupational Therapy International, 4, Commission on Accreditation of Rehabilitation Facilities, Service Providers. (2004). Medical rehabilitation accreditation and standards. Retrieved February 23, 2004, from MED/AccreditationStandards.htm Dick, J. P. R., Guiloff, R. J., Stewart, A., Blackstock, J., Bielawska, C., Paul, E. A., & Marsden, C. D. (1984). Mini-mental state examination in neurological patients. Journal of Neurology, Neurosurgery, and Psychiatry, 47,

23 Mental Capacity 21 Fearing, V. A., Clark, J., & Stanton, S. (1998). The client-centered occupational therapy process. In M. Law (Ed.), Client-centered occupational therapy (pp ). Thorofare, NJ: Slack. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, Hobson, S. (1996). Being client-centred when the client is cognitively impaired. Canadian Journal of Occupational Therapy, 63, Hodge, J. R. (1999). Content validity of Self-Identified Goals Section of the Link-Nelson Occupational Therapy Evaluation for Skilled Nursing Facilities. Unpublished manuscript, Medical College of Ohio at Toledo. Irwin, B. M. (2003). Mental status required for the Canadian Occupational Performance Measure and the Self-Identified Goals Assessment. Unpublished manuscript, Medical College of Ohio at Toledo. Johnson, C. C. (2001). Convergent validity of three occupational self assessments. Unpublished manuscript, Medical College of Ohio at Toledo. Joint Commission on Accreditation of Healthcare Organizations. (2000). Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: Author. Kanny, E. M., Cada, E. A., Dufresne, G., Gurka, T., Bell, P. F., & Hertfelder, S. D. (1995). Service delivery in occupational therapy. American Journal of Occupational Therapy, 49, Kielhofner, G. (1997). Conceptual foundations of occupational therapy (2 nd ed.).

24 Mental Capacity 22 Philadelphia: F. A. Davis. Kornblau, B. L., Arnold, M., Nashiro, N., Hill, D., Slater, D. Y., Morris, J., Withers, L., Kyler, P. (1994). Occupational therapy code of ethics. American Journal of Occupational Therapy, 54, Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock, N. (1998). Canadian occupational performance measure (3 rd ed.). Ottawa, Canada: CAOT Publications ACE. Law, M., & Mills, J. (1998). Client-centered occupational therapy. In M. Law (Ed.), Client-centered occupational therapy (pp. 1-18). Thorofare, NJ: Slack. Law, M., Polatajko, H., Pollock, N., McColl, M. A., Carswell, A., & Baptiste, S. (1994). Pilot testing of the Canadian Occupational Performance Measure: Clinical and measurement issues. Canadian Journal of Occupational Therapy, 61, McColl, M. A., Paterson, M., Davies, D., Doubt, L., & Law, M. (2000). Validity and community utility of the Canadian Occupational Performance Measure. Canadian Journal of Occupational Therapy, 67, Melville, L. L., Baltic, T. A., Bettcher, T. W., & Nelson, D. L. (2002). Patient s perspectives on the Self-Identified Goals Assessment. American Journal of Occupational Therapy, 56, Melville, L. L., & Nelson, D. L. (2001). Self-Identified Goals Assessment (SIGA) protocol. Retrieved March 16, 2004, from Medical College of Ohio, Occupational Therapy Website: Nelson, D. L. (1994). Occupational form, occupational performance, and therapeutic

25 Mental Capacity 23 occupation. In C. Royeen (Ed.), AOTA Self-Study Series: The practice of the future: Putting occupation back into therapy, Lesson 2 (pp. 9-48). Rockville, MD: The American Occupational Therapy Association. Toomey, M., Nicholson, D., & Carswell, A. (1995). The clinical utility of the Canadian Occupational Performance Measure. Canadian Journal of Occupational Therapy, 62,

26 Mental Capacity 24 Table 1 Descriptive Results Variable N Mean SD Minimum Maximum MMSE COPM Goals COPM Rated SIGA Goals SIGA Rated

27 Mental Capacity 25 Table 2 Spearman Correlations Between Numbers of Goals and MMSE N Spearman Correlations with MMSE r p Number of COPM Goals Number of Rated COPM Goals Number of SIGA Goals Number of Rated SIGA Goals

28 Mental Capacity 26 Figures Figure 1. Performance on assessments, with participants rank ordered by Mini-Mental State Examination. Figure 2. Goals and rating identified by participants who were randomly assigned to do the Self-Identified Goals Assessment first, rank ordered by score on the Mini-Mental State Examination. Figure 3. Goals and rating identified by participants who were randomly assigned to do the Canadian Occupational Performance Measure first, rank ordered by score on the Mini-Mental State Examination.

29 Mental Capacity 27 Performance on assessments, with participants rank ordered by Mini-Mental State Exam MMSE SIGA COPM Score Goals Rated Goals Rated Age Gender M F F M F F M M F M F M M M M F F F F F M M F M F F F F F F Note. MMSE = participant s score on the Mini Mental State Examination. SIGA Goals = number of goals identified by participant using the Self-Identified Goals Assessment. SIGA Rated = number of goals rated by participant using the SIGA. COPM Goals = number of goals identified by participant using the Canadian Occupational Performance Measure. COPM Rated = number of goals rated by participant using the COPM.

30 Mental Capacity 28 Subjects Randomly Assigned to do Self-Identified Goals Assessment First, Rank Ordered by Mini-Mental State Examination Score Participant ID # 9 25 MMSE SIGA Goals (0-10 rating) COPM Goals (1-10 rating) Community mobility (0) Traveling (0) Lose weight (8) Improve health (9) Do job adequately (5) Live out priesthood (8) Traveling (3) Being with others (6) Start parish projects (1) 4 26 Open own business (0) Community mobility (5) Up/down stairs (3) Volunteering (5) Community mobility (3) Volunteering (1) Dressing (pants) (1) Fixing hair (3) Spending time with kids (1) 1 26 Shaving (2) Writing (1) Home mobility (3) Speech (5) Socks on (6) Combing hair (6) Brushing teeth (5) Work (1) Walking (5) Hunting (deer) (5) Trap shooting (8) Traveling (5) Showering (5) Walking (5) Traveling (5) Community events (5) Arm use (2) Drink water (0) Walking (5) Bathing (4) Work (6) Yard work (0) Going to casino (6) Walking to park (5) Playing with dog (7) Driving (1) Church (1) Mobility outside (1) Going to Casinos (1) Dressing (pants) (5) Walk to corner (0) Up stairs (0) Wheelchair mobility (1) Transfers (5) Fixing hair (3) Reading (5) Cleaning (1) Shopping (2) Golfing (0) Home mobility (4) Computer use (4) Vacation (1) Out to dinner (2) Shopping (3) Gardening (1) Work (1) Driving (0) Bowling (0) Running errands (0) Visiting mother (2) Driving (1) Visiting mother (9) Shopping (5) Computer (7) Going out to eat (6) Stand (1) In/out bed (1) Walking (0) Dressing (1) Brushing teeth (10) Transfers (1) In/out car (1) Traveling (1) Visiting friends (10) Home mobility (2) Maintain active life (3) Bathing (2) Dressing (2) In/out car (1) Walking to bathroom (2) Cooking (1) Open own business (7) Community mobility (3) Work (1) Driving (5) Fixing hair (5) Bathing (8) Foot care (1) Note. The SIGA and the COPM request a maximum of five goals each. The number in parentheses after the goal is the rating of the goal, if any. SIGA scores range 0-10, COPM scores range 1-10.

31 Mental Capacity 29 Subjects Randomly Assigned to do Canadian Occupational Performance Measure First, Rank Ordered by Mini Mental State Examination Score Participant ID # MMSE COPM Goals (1-10 rating) SIGA Goals (0-10 rating) Walking (3) Walking (0) Bathing (6) Washing hair (1) In/out of tub (1) Walking to store (1) Volunteering (4) Walking on beach (1) Bathroom Dressing (4) Walking (3) Transfers (1) Gardening (0) mobility ( ) Bathing (1) Dressing (2) Driving (1) Work (2) Work (0) Dressing (1) Driving (0) Socks on (2) Ted hose on (1) Vacuuming (5) Dusting (5) Community mobility (0) Finding job (1) Bathing (4) Laundry (2) Calling others (4) Community mobility (0) Exercising (2) Traveling (3) Shopping (1) Transfer to toilet (5) Socks on (1) Work (2) Driving (1) Maintaining finances (6) In/out of shower (5) Walking with walker (1) Hygiene care (4) Transfer chair to bed (5) Washing hair (8) Dressing (8) Reading newspaper (4) Walking distances (2) Walking distances (1) Visiting family (0) Home mobility Cleaning (5) (4) Showering (1) Walking (6) Transfer into bed (2) Traveling (4) Community mobility (1) Transfers (2) Showering (2) Driving (1) Dressing (3) Hygiene care (2) Transfers (5) Showering (3) Cleaning bathrooms (1) Transfer chair to car (4) Transfer chair to toilet (1) Driving (1) Walking (3) Dressing (6) Helping wife (1) Tying shoes (1) Foot care (1) Driving (1) In/out of car (3) Volunteering (1) Driving (3) Driving (1) Work (1) Church activities (5) Hygiene care (5) Visiting friends (2) Vacuuming (5) Hygiene care (6) Visiting family and friends (6) Bathing (0) Dressing (3) Driving (0) Dressing (3) Driving (0) Painting/ ceramics (2) Walking (2) Cleaning (0) Driving (6) Fixing hair (7) Golfing (1) Bathing (3) Transfers (5) Work (2) Cooking (2) Golfing (0) Traveling (1) Cooking (10) Visiting with friends (3) Reading (7) Walking (7) Improve vision (8) Sitting during leisure (1) Work on workbench (2) Foot care (0) Cooking (4) Cleaning (0) Traveling (6) Housework (3) Housework (2) Self-care (6) Driving (4) Conference attendance (2) Shopping (1) Gardening (1) Cooking (1) Walking (2) Cooking (2) Gardening (1) Visiting friends (2) Work (1) Participating in organization (1) Note. The SIGA and the COPM request a maximum of five goals each. The number in parentheses after the goal is the rating of the goal, if any. SIGA scores range 0-10, COPM scores range 1-10.