sammanchester Assessing Cognition in Emergency and Acute Medicine September 2015

Transcription

1 sammanchester September 2015 Assessing Cognition in Emergency and Acute Medicine. Dr. Austin Claffey Senior Lecturer in Occupational Therapy London South Bank University.

2 Assumptions Underlying neuropsychological processes can be inferred from tests and task performance - with sufficient therapist skill. Measuring instruments, including the therapists assessing cognitive function, are loaded with measurement error - inconsistency, bias, but this is the nature of multidimensional assessment. Focusing on latent constructs may assist. Problem formulation should not depend on one error in a task, or one score in a screening test. A thorough history and informant report is gained; relevant medical issues considered. 3-Ds considered. 2

3 Focus of session AHPs need to be able to evaluate the likely impact of cognitive impairment to inform their decisions. The referral question is not a diagnosis question. AHPs need to be able to effectively evaluate cognitive function in non-routine and multiple ways. Combined cognitive screening, domain specific assessment and functional assessment is required. This is not being pragmatic; it's about good latent variable modelling. Subjective Report as assessment of affect, efficacy and cognitive function.

4 Is Robert Ruchinskas (2002) testing what were testing? 4

5 What is the referral question? Is there a problem? Functional performance Cognitive impairment Will it matter? Ecological validity What is wrong? Will impact d/c decision Will impact occupational performance Cognitive domains? Functional evidence? What to do? What is wrong?

6 Occupational therapy cognitive assessment List List List Face validity more important than other structural factors in measurement selection by OT (Belchoir et al 2015). Atheoretical but ecologically valid, a worthwhile trade off? Both Procedural & Explicit. Lack of clarity in problem identification; careless use of language. Transactional nature of cognition and performance is the real focus

7 Giovanetti et al 2008a 7

8 Analysis by principal components. you, for example. Measurement error Name recall Latent construct. Address Memory List recall 8

9 Name recall Address Memory List recall Trails A & B Fluency Tap 1 or 2 Executive Cognition Cognition Clock Cube perception dot count 9

10 Errors, not performance orientation avoid reification fallacy. Medication Memory follow instruction anticipate difficulties money management simplifying tasks Executive Cognition orientating clothes navigating frame Perception cup->saucer 10

11 Evaluate Errors and do a principal components estimate. orientation Medication Memory follow instruction anticipate difficulties money management simplifying tasks Executive Cognition orientating clothes navigating frame Perception cup->saucer 11

12 Giovanetti et al., 2008a, 2008b Errors, not performance focus, can distinguish between unimpaired, MCI and AD. Specifically in NC and MCI, errors of commission, not omission, will distinguish. Errors of omission characterise the AD performance. Assessment should also include IADL assessment. 12

13 Giovanetti et al 2008a 13

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15 Hierarchy of Skills Executive Skills Praxis Memory Object Recognition Visual and Spatial Perception Attention Sensory Registration Ownership: Harrison Training

16 orientation Name recall Medication Memory? Memory Address follow instruction List recall anticipate difficulties Trails A & B money management Executive? Cognition Cognition Cognition Executive Fluency simplifying tasks Tap 1 or 2 orientating clothes Clock navigating frame Perceptual? perception Cube cup->saucer dot count 16

17 Age and Prospective memory effects (Phillips, Henry, & Martin 2008) episodic memory age effects are seen in both lab and natural (ecologically valid) situations medication adherence is a prospective task - remembering to take - with age non-adherence increases to 59%, in others its about 10%. The criterion might be key. If doctor prescribed meds is the basis for adherence then 59% may be correct, if intent-adherence is measure, than adherence rates drop People may be complying with their own intended regime very well. This also underlines the importance of loading assessment tasks correctly. 17

18 Subjective report General memory questions and memory questionnaires appear to tap mood disorder, not cognitive ability. Memory complaint is not diagnostic and needs further evaluation Increased specificity in questioning, or in measurement can increased validity of this method (Hertzog 2002). Along with being sensitive to mood disorder, they are sensitive to efficacy. Efficacy is relevant because it relates to deployment of effort 18

19 Summary Activity Analysis and functional task observation are inherent to good cognitive assessment. This is not a pragmatic response to being unable to complete a screen. Ecological validity can distinguish performance on tests-of-planning and planning-tasks (Phillips et al., 2006). Combined domain-focused and function focused assessment in OT is recommended for older people care (Douglas,et al 2007; Belchoir et al 2015). Functional assessment should focus on errors, combined with cognitive test performance and process observations to refine latent constructs. 19

20 References Goldstein, F. C., Strasser, D. C., Woodard, J. L., & Roberts, V. J. (1997). Functional outcome of cognitively impaired hip fracture patients on a geriatric rehabilitation unit. Journal of the American Geriatrics Society, 45(1), Ruchinskas, R. A., Singer, H. K., & Repetz, N. K. (2000). Cognitive status and ambulation in geriatric rehabilitation: walking without thinking?. Archives of physical medicine and rehabilitation, 81(9), Ruchinskas, R. (2002). Rehabilitation therapists' recognition of cognitive and mood disorders in geriatric patients. Archives of physical medicine and rehabilitation, 83(5), Riva, G. (1997). Virtual reality in neuro-psycho-physiology: Cognitive, clinical and methodological issues in assessment and rehabilitation (Vol. 44). IOS press. Árnadóttir, G., Löfgren, B., & Fisher, A. G. (2012). Neurobehavioral functions evaluated in naturalistic contexts: Rasch analysis of the A-ONE Neurobehavioral Impact Scale. Scandinavian journal of occupational therapy, 19(5), Phillips, L. H., Kliegel, M., & Martin, M. (2006). Age and planning tasks: The influence of ecological validity. The International Journal of Aging and Human Development, 62(2), Douglas, A., Liu, L., Warren, S., & Hopper, T. (2007). Cognitive assessments for older adults: Which ones are used by Canadian therapists and why. Canadian Journal of Occupational Therapy, 74(5), Belchior, P., Korner Bitensky, N., Holmes, M., & Robert, A. (2015). Identification and assessment of functional performance in mild cognitive impairment: A survey of occupational therapy practices. Australian occupational therapy journal. Giovannetti, T., Bettcher, B. M., Brennan, L., Libron, D. J., Kessler, R. K., & Duey, K. (2008a). Coffee with jelly or unbuttered toast: Commissions and omissions are dissociable aspects of everyday action impairment in Alzheimer's disease. Neuropsychology, 22(2), 235. Giovannetti, T., Bettcher, B. M., Brennan, L., Libon, D. J., Burke, M., Duey, K.,... & Wambach, D. (2008b). Characterization of everyday functioning in mild cognitive impairment: A direct assessment approach. Dementia and geriatric cognitive disorders, 25(4), L.H. Phillips, J.D. Henry, & M. Martin., Adult Ageing and prospective memory: The importance of Ecological validity. Chapter 8 in: Kliegel, M., & McDaniel, M. A. (2008). Prospective memory: Cognitive, neuroscience, developmental, and applied perspectives. Psychology Press Taylor & Francis. 20

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