COGNITION PART TWO HIGHER LEVEL ASSESSMENT FUNCTIONAL ASSESSMENT

Transcription

1 COGNITION PART TWO HIGHER LEVEL ASSESSMENT FUNCTIONAL ASSESSMENT

2 RECAP ON PART ONE BASIC ASSESSMENT Cognitive screening tests are one component of the cognitive assessment process and NOT equivalent to a diagnosis What were the results of the cognitive screen? Is there an indication to complete a higher level cognitive assessment? What are the implications on an individual s safety and function? Comprehensive functional assessments are required in conjunction with standardised cognitive screening/ assessment ADL assessment shower assessment, kitchen assessment, kettle test Know when to complete a re-assessment E.g. beginning and end of episode of care

3 LEARNING OBJECTIVES To have an awareness of commonly used cognitive assessments To have an understanding of the factors to consider when choosing and administering cognitive assessments Interpreting results what to look consider To have an awareness of the commonly used functional assessments

4 COGNITIVE ASSESSMENTS Consider the following when choosing a cognitive assessment: Standardisation Validity Age range Norms and percentiles Language barriers Sensitivity Cut off scores Time taken to administer *assessments used are often dependent on what is available in the OT department/team*

5 COMMONLY USED COGNITIVE ASSESSMENTS Cognitive Assessment of Minnesota (CAM) Behavioural Assessment of Dysexecutive Syndrome (BADS) Cognistat Barry Rehabilitation Inpatient Screening of Cognition (BRISC) Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) Rivermead Behavioural Memory Test (RBMT)

6 CAM Hierarchical approach to screening a range of cognitive skills to identify general areas of cognitive impairment and to guide treatment activities Can be used as a baseline to measure change 17 subtests range from simple to complex Takes 40 minutes to administer Designed for adults with neurological impairments. Items include abstract thinking, safety and judgement, concrete problem solving (simple, moderate and complex), foresight and planning, simple money and maths. The normative data is based on subjects ranging in age from 18-70, therefore not ideal for the elderly population. The scoring profile for each component indicates the level of impairment - none/mild, moderate or severe.

7 BADS Aims to assess for everyday impairment 6 subtests Includes items that are specifically sensitive to skills involved with problem solving, planning and organising behaviour. Takes 40 minutes to administer Can provide useful qualitative information about the way the person uses (or does not use) strategies for task completion Includes the DEX Dysexecutive Questionnaire Classifications include Superior, High Average, Low average, Borderline or Impaired.

8 COGNISTAT Used for acute CVA, TBI and geriatric populations 11 subtests Can take up to 45 minutes to administer Cognistat provides similar information to CAM, but is shorter to administer Standardised across a larger population than the CAM (Cognistat up to 84 years; CAM up to 70 years).

9 BRISC Reliable, short, bedside test that includes memory, communication and orientation subtests Takes 20 to 30 minutes to administer Can be used to monitor a patient s cognition even if patient is in PTA High degree of inter-rater reliability Is sensitive to change in cognition It can be administered weekly to monitor more transient cognitive deficits. Norms only established for people years of age. Age appropriate normative data is not available for comparison for the elderly population

10 LOTCA Initially designed for evaluation post brain injury (CVA, TBI) Includes 20 subtests including perception and visuomotor organisation Gives more of a profile than an overall score therefore useful to use for qualitative data to guide interventions Recommended to be used in conjunction with functional assessments and observation of patient performance in general Does not test attention, concentration or memory formally

11 RBMT Assessment of functional, everyday memory skills and used to monitor change for brain injured patients Very high inter-rater reliability Modified scoring for non-verbal or dysphasic persons or persons with perceptual deficits Four versions eliminates practice effect Does not appear to be sensitive to very mild brain damage nor to specific areas of memory dysfunction

12 INTERPRETING RESULTS Consider how you document the results/score from the assessment Document the level of impairment indicated by the assessment e.g. mild, moderate, severe Consider and document clearly how this may impact on this patients function, safety or ability to make decisions How do these results relate to the person s ability to perform functional tasks (inpatient setting or community) Make sure that other disciplines can understand your interpretation of the impairments and how that may translate to day to day functioning

13 INTERPRETING RESULTS Remember WHY you are conducting a cognitive assessment Information gained from cognitive assessments can assist the team in the decision making process regarding discharge location, the type of support services that may be required and also educates the family to the person s capabilities and needs

14 INTERPRETING RESULTS All cognitive assessments should be used in conjunction with functional assessments, clinical observations and information from staff/carers to support the results This allows you to fully understand the impact of the cognitive deficit on overall function

15 WHY IS THIS IMPORTANT? Questions often asked: Can I return home alone? What type of assistance will I need to live independently in the community?

16 FUNCTIONAL ASSESSMENTS Conventional tabletop measures of cognition are valuable diagnostically but have limited ecological validity and do not fully address the functional implications of cognitive deficits (Hartmen- Maeir, Harel, Katz, 2009) A major focus of Occupational Therapy is to evaluate a person s performance of everyday tasks (or occupations ) through functional assessment. There are numerous standardised and non standardised functional assessment tools available

17 FUNCTIONAL ASSESSMENTS There are numerous standardised and non standardised functional assessment tools available Choosing an assessment tool depends on what you are trying to assess Some examples of standardised functional assessment tools for basic activities of daily living include Modifed Barthel Index Functional Independence Measure Katz Index of Independence in Activities of Daily Living

18 FUNCTIONAL ASSESSMENTS Instrumental activities of daily living are more complex than basic activities of daily living and require basic and higher-level cognitive functions such as executive functioning (Cahn-Weineret al., 2007) Therefore performance based or functional assessments that incorporate the cognitive complexity involved in instrumental activities of daily living are necessary

19 EXAMPLES OF FUNCTIONAL ASSESSMENTS Examples of performance-based measures which incorporate cognitive challenges in functional IADL contexts include: Cognitive Performance Test (Burns, 2006) Assessment of Motor and Process Skill (Fisher, 2006a, 2006b) Executive Function Performance Test (Baum, Morrison, Hahn, & Edwards, 2003) Kettle Test (Hartmen-Maeir, Armon & Katz 2005)

20 CASE STUDY A.R. is a 73-year-old married man who was living independently in the community before his stroke. He did not have any residual motor deficits at this stage of rehabilitation and was independent in basic activities of daily living, yet his conventional cognitive test scores revealed some mild deficits in measures of clock drawing and visual attention. A. R. s performance on the Kettle Test demonstrated a significant need for assistance on multiple steps: He was baffled by the empty kettle, had difficulty connecting the electrical cord, and only prepared one cup of beverage (instead of two), using cold water. (taken from Hartmen-Maeir, Harel & Katz 2009)

21 CASE STUDY The face validity of the Kettle Test can be useful in determining the need for assistance during activities of daily living and identifying potential safety concerns (taken from Hartmen-Maeir, Harel & Katz 2009)

22 UP NEXT IN THE SERIES Cognitive rehabilitation and retraining techniques

23 REFERENCES Barry, P. (1991). Barry rehabilitation inpatient screening of cognition. BRISC Manual. Arizona, USA. Drane, D. L., & al., e. (2003). Healthy older adult performance on a modified version of the Cognistat (NCSE): Demographic issues and preliminary normative data. Journal of Clinical & Experimental Neuropsychology, Golding, E. (1989). MEAMS Description and Validation. Edmunds, Suffolk: Thames Valley Test Company Rustad, R., DeGroot, T., Jungkunz, M., Freeberg, K., Borowick, L. & Wanttie, A. (1993). The Cognitive Assessment of Minnesota. Texas, USA: Therapy Skill Builders. Wilson, B. A., Alderman, N., Burgess, P. W., Emslie, H., & Evans, J. J. (2003). Behavioural assessment of the dysexecutive syndrome (BADS). Journal of Occupational Psychology, Employment and Disability, 5(2), Wilson, B.A., Cockburn, J., & Baddeley, A. D. (1991). The Rivermead Behavioural Memory Test: Manual. (2 nd Edition). England, UK: Titchfield Thames Valley Test Company Burns, T. (2006). Cognitive Performance Test (CPT). Pequannock, NJ: Maddak. Fisher, A. G. (2006a). Assessment of motor and process skills. Vol. 1: Development, standardization, and administration manual (6th ed.). Fort Collins, CO: Three Star Press. Fisher, A. G. (2006b). Assessment of motor and process skills. Vol. 2: User manual (6th ed.). Fort Collins, CO: Three Star Press. Baum, C., Morrison, T., Hahn, M., & Edwards, D. (2003). Executive Function Performance Test: Test protocol booklet. St. Louis, MO: Program in Occupational Therapy, Washington University School of Medicine. Hartman-Maeir, A., Armon, N., & Katz, N. (2005). Kettle Test protocol. Jerusalem: School of Occupational Therapy, Hadassah and Hebrew University of Jerusalem Hartman-Maeir A., harel, H. & Katz, N. (2009). Kettle Test A brief Measure of Cognitive Functional Performance: Reliability and Validity in Stroke Rehabilitation Cahn-Weiner, D., Tomaszewski Farias, S. T., Julian, L., Harver, D. J., Kramer, J. H., Reed, B. R.,et al. (2007). Cognitive and neuroimaging predictors of instrumental activities of daily living. Journal of the International Neuropsychological Society, 13,

24 ABOUT US The Therapy Collective was founded by Occupational Therapist Amy Vincent, who has extensive experience working in clinical and healthcare management roles in Australia and the United Kingdom. Amy Vincent //