1 How do occupational therapists assess cognitive function? Linda Stigen, Phd student HIG Spesialist i somatisk og allmenhelse Kurs Ergoterapeutene 6.-7. oktober 2014
2 Background Population ageing is taking place in nearly all the countries of the world (UN, 2013; Who, 2011). Prevalence of dementia rises with age Younger recipients has doubled in the past 10 years and currently represents 4 of 10 recipients of municipal services (Romøren, 2006). The goal of the Coordination Reform is for the patient to receive the proper treatment at the right place and right time (Meld. St. 47 (2008-2009)).
3 Background Both occupational therapy theory and research support the principle that cognition is essential to performance of everyday tasks (Toglia & Kirk, 2000). Cognition is essential to effective performance across a broad range of daily occupations and plays an integral role in human development and in the ability to learn, retain and use new information in response to changes in everyday life (AOTA, 2013).
4 COGNITION AND OCCUPATIONAL THERAPY Through use of occupations and activities, occupational therapists can facilitate individuals cognitive functioning to enhance occupational performance, self-efficacy, participation and perceived quality of life (AOTA, 2013). OT`s administer assessments that focus on cognition as it relates to participation and occupational performance. OT`s examine cognition and performance from multiple perspectives and use a range of methods during the evaluation process, including interviews, cognitive screening, performance-based assessments, environmental assessments and specific cognitive measures (AOTA, 2013).
5 CANADA Douglas, Letts and Liu (2008) performed a review of cognitive assessments for older adults. They categorized their findings into three groups of assessments; - brief screening assessments (MMS, clock drawing test, Trail maiking test) - testing assessments (Cognitstat, LOTCA, Rivermead) - activity and participation assessments (AMPS, FIM, PRPP, Sunnaas kitchenobservation)
6 They found that among the brief screening tests the most commonly used and had the strongest psychometric properties, was - the Mini Mental Status Examination (MMSE) - the Modified Mini Mental Status Exam (3MS) The strongest in the testing category: - the Cognitive Assessment scale for the elderly -the Cognistat. In the activity and participation category, the AMPS had the strongest psychometric properties (Douglas, Letts & Liu, 2008).
7 CANADA CONT. A study by Douglas, Liu, Warren and Hopper (2007) investigated Canadian occupational therapists practice pattern in relation to cognitive assessment for older adults. 247 OT`s participated in the study (response rate 24,5%). Most frequently used: -The Mini Mental Status Examination (MMSE) -the Cognitive Competency Test (CCT) In addition, many of the participants also used the Neurobehavioural Cognitive Status Examination (Cognistat). Of the non-standardized tests the most frequently used were: - General Activities of Daily Living, - Kitchen task and clinical observations (Douglas, Liu, Warren and Hopper, 2007).
8 CANADA Korner-Bitensky, Barrett-Bernstein, Bibas and Poulin (2011) investigated Canadian occupational therapists` assessment and treatment of cognitive impairment post-stroke. 663 OT`s from acute care, inpatient rehabilitation care and community care participated in the study. The participants indicated using 56 different assessment and the majority mentioned standardized assessments, however many also used non-standardised assessments.
9 Standardized assessments reported were: - the Mini-Mental State Examination (MMSE), - the Neurobehavioural cognitive status examination (Cognistat) - the Cognitive Competence Test (CCT) In addition, they indicated using: - the Trail Making Test, - general assessments with a cognitive component such as the Functional Independent Measure (FIM) and the Assessment of Motor and Process Skills (AMPS). Of none-standardized assessments the most frequently used was observation of both P-ADL and I-ADL (Korner-Bitensky, Barrett-Bernstein, Bibas & Poulin, 2011).
10 AUSTRALIA Koh, Hoffmann, Bennet and McKenna (2009) investigated Australian OT`s management of patients with cognitive impairment after stroke. 102 OT`s participated in the study. The assessments most frequently used were: - the Mini Mental State Examination (MMSE), - Neurobeahvioural Cognitive Status Screening Examination (Cognistat) - brief screening tests developed by participants own centers. The participants also mentioned: - the Functional Independence Measure (FIM) - the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) (Koh, Hoffmann, Bennet & McKenna, 2009).
11 NEW ZEALAND A study by Robertson & Blaga (2013) investigated occupational therapy assessments used in acute physical care settings in New Zealand. 70 OT`s participated in the study (respons rate 47%). The study found that informal assessments such as interviews and observations were commonly used to evaluate daily living skills. Standardized assessments were used in complex situations and includes: - Cognistat - Rivermead - Loewenstain Ocupational Therapy Cognitive Assessment (LOTCA) - the Mini Mental State Evaluation (MMSE). In addition the OT`s reported that for general assessments they used: - the Canadian Occupational Performance Measure (COPM), - Functional Independence Measure (FIM) and - Assessment of Motor and Process Skills (AMPS) (Robertson & Blaga, 2013).
12 SWEDEN Recently, a study by Holmquvist, Ivarsson and Holmefur (2014) investigated Swedish OT`s practice patterns for clients with cognitive impairment following acquired brain injury. 405 OT`s from municipality care, primary care, county care and regional care participated in the study (respons rate 41%). The majority of the participants reported they most frequently used observation of daily activities and interviews to assess activity limitations and cognitive impairment.
13 In addition, many use standardized tests to assess cognitive function and the most frequently used test of cognitive function was the Mini Mental State Examination (MMSE). Other tests of cognition mentioned was the Neurobehavioural cognitive status examination (Cognistat) and the Rivermead behavioural Memory Test (RBMT). General instruments to measure occupational performance and limitations were: - the Assessment of Motor and Process Skills (AMPS), - Sunnaas ADL-index - Functional Independence Measure (FIM) (Holmquvist, Ivarsson & Holmefur, 2014).
SO, WHAT ABOUT NORWAY? 14
15 MUNICIPAL OCCUPATIONAL THERAPY Within municipal services, mediating assistive-technology is a major task of great importance to occupational therapists Implementation and use of assistive technology requires a thorough assessment in order to tailor interventions to individual needs Assessment of cognitive function can be considered as the starting point of occupational therapy interventions (Turner, Foster & Johnson, 2002).
16 RESEARCH QUESTIONS - How do municipal occupational therapists assess cognitive function? - How do municipal occupational therapists reflect on their practices regarding assessment of cognitive function?
17 National online survey distributed to members of the organisation Ergoterapiforbundet to 1380 OT`s registered with workplace in municipalities - 497 participated and completed the survey - 71 voluntary shared information on why they declined participation - 69 started but did not complete the survey = respons rate 36%
18 As the results of my study are just preliminary results, we do not want to distribute them at this moment. However, they will be published in a journal near you soon..
Summary People live longer, both with and without disabilities. Assessment of cognitive function related to occupation performance is an important task for occupational therapists although we do not know too much about how this is being done. Some research studies have focused on this issue but more needs to be done. As a profession we have to be able to go in discussions regarding our own practice and evaluate whether we are actually using the best practice. Is it enough to continue assessing cognition with brief screening tools? What do they really tell us?
REFERENCES: American Occupational Therapy Association, AOTA (2013). Cognition, Cognitive Rehabilitation, and Occupational Performance. Statement. American Journal of Occupational Therapy, 67, 6 (Supplement). Douglas, L; Letts, &Liu, L (2008). Review of Cognitive Assessments for Older Adults. Physical & Occupational Therapy in Geriatrics, Vol. 26(4), 2007. Douglas, L.; 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, p.370 381. Holmquvist, K.; Ivarsson, A B. & Holmefur, M (2014) Occupational therapist practice patterns in relation to clients with cognitive impairment following acquired brain injury. Brain Injury,Early Online, 2014. Koh, C L.; Hoffmann, T; Bennett, S. & McKenna, K. (2009). Management of patients with cognitive impairment after stroke: A survey of Australian occupational therapists. Australian Occupational Therapy Journal (2009) 56, 324 331. Korner Bitensky, N.; Barrett Bernstein, S.; Bibas, G. & Poulin, V. (2011). National survey of Canadian occupational therapists assessment and treatment of cognitive impairment post stroke. Australian Occupational Therapy Journal (2011) 58, 241 250. Meld. St. 47 (2008 2009). (2008). Samhandlingsreformen: 2008 2009. Oslo: Helse og omsorgsdepartementet. Robertson, L. & Blaga, L. (2013). Occupational therapy assessments used in acute physical care settings. Scandinavian Journal of Occupational Therapy. 2013; 20: 127 135. Romøren, T.I (2006). Yngre personer som mottar hjemmetjenester: hvem er de, hva slags hjelp får de og hvorfor øker antallet så sterkt? Rapportserie 2006:8. Gjøvik: Høgskolen i Gjøvik. Turner, A., Foster, M. & Johnson S.E (2002). Occupational therapy and physical dysfunction. Principles, skills and practice. 5th ed. Churchill Livingstone, London, UK. United Nations (2013). World population aging. Hentet 14.12.13 fra http://www.un.org/en/development/desa/population/publications/pdf/ageing/worldpopulationageingreport201 3.pdf WHO (2011). Global health and aging. Hentet 14.12.13 fra http://www.who.int/ageing/publications/global_health.pdf 20