Occupational Therapy Cognitive Functional Evaluation

1. Cognitive Functional Evaluation

2. Cognition is a complex and dynamic system of
interrelated parts which allows us to organize
and use knowledge in order to function in the
environment in which we live
Perception is making sense of the senses; or the
ability to process and interpret information from
the environment to make a meaningful whole
Cognition refers to the “information-processing
functions carried out by the brain that include attention,
memory, executive functions, comprehension and formation
of speech ,calculation ability, visual perception and
praxis skills

10. “Cognitive Functional Evaluation (CFE) process”
Multifaceted approach that is customized to client needs
1. Interview
2. Cognitive Screening
3. Measures of specific cognitive functions (Domain-specific)
4. Performance-based (occupation-embedded) assessments
5. Specific measures of cognitive impairment in the context of
specific occupations (occupation-embedded & domain specific)
6. Environmental assessment

11. INCOG Recommendations
Neuropsychologist: to conduct a formal cognitive
assessment using validated neuropsychological tests,
including the presence of emotional and behavioral
problems as well as effort.
Occupational therapist: to assess the impact of cognitive
impairments on performance of meaningful activities and
participation
Speech-language pathologist: to assess the impact of
cognitive impairments on communication (listening,
speaking, reading, writing).

12. Practice Solution
Framing practice in line with core constructs of
occupational therapy
- Thinking
- Reasoning
- Assessing
- Intervening
- Reporting
- Describing
‘Through our lens’

14. Cognition and Occupational Therapy
1. Functional approach
Foundation: OT focus on improved ADL
Assessment: Identify ADL performance difficulties
Intervention: Train ADLs
Outcome: Independent in ADLs

16. Testing of Cognitive Functions.
Cognition involves mental processes of knowing, thinking,
remembering, perceiving, awareness, learning, judging, and
understanding of ideas.
Skills specifically assessed in the CPM battery include levels
of attention, short-term visual memory, short-term linguistic
memory, encoding and decoding of information, incidental
and intentional learning, logical and mathematical
reasoning, problem solving, decision-making, organization,
and planning.

17. Testing of Motor Functions.
The individual’s upper extremities are examined for muscle
tone, joint range of motion, and muscular strength and
endurance.
The therapist evaluates areas such as motor planning, motor
control, gross motor coordination, fine motor coordination,
hand/eye coordination, bilateral coordination, motor
sequencing, and motor speed.
Balance and equilibrium functions are assessed due to the
requirement for balance during activities of daily living.

18. CPM Domains Standardized Tests
Visual-Spatial Perception
Figure Ground Perception Test (SCSIT*)
Cancellation of “H” (Kulkarni, 1993)
Alternating Dot-to-Dot (Kulkarni, 1993)
Minnesota Spatial Relations Test (Dawis, 1979)

19. CPM Domains Standardized Tests
Tactile-Kinesthetic Perception
Graphesthesia Test (SCSIT*)
Manual Form Perception (SCSIT*)

20. CPM Domains Standardized Tests
Motor Skills
Slosson Visual Motor Performance Test (Slosson, 1996)
Purdue Pegboard (Tiffin, 1948)
Grip and Pinch Strength (Mathiowetz, 1985)
Standing Balance Eyes Open/Eyes Closed (SCSIT*) Imitation of
Posture (SCSIT*)

21. CPM Domains Standardized Tests
Cognitive-Perceptual
Symbol Digit Modalities Test (Smith, 1991)
Detroit Tests of Learning Aptitude-2 (Hammil, 1985)
Subtest: Object Sequences
Subtest: Letter Sequences
Useful Field of View (Ball & Roenker, 1988)

22. Clinical observation could also yield assessments of:
orientation, problem solving, organization, planning,
initiation/termination, judgment, sequencing,
concrete/abstract reasoning, following directions, and
procedural memory.

24. Sensory Motor Dysfunction
Selected Clinical Manifestation Selected Therapeutic Approaches
Muscle Tone Therapeutic Exercise
Postural Control Positioning
Selectivity of Movement Strengthening
Coordination Reflex Inhibition
Range of Motion Sensory Stimulation
Sensory Facilitation of Adaptive
Visual, Auditory, Tactile, Response through Meaningful
Proprioceptive, Vestibular Activity: Graded, Progressive,
Bilateral, and Reciprocal

25. Cognitive Dysfunction
Selected Clinical Manifestation Selected Therapeutic Approaches
Problem Solving Computer Based Cognitive Retraining
Decision Making Problem Solving, Logical Thinking &
Planning Decision Making
Organizing Exercises in Reading, Writing &
Mathematical Concepts
Divergent/Convergent/
Abstract Reasoning
Cognitive Behavioral Job Related Cognitive Retraining
Self-Regulation, Behavior Modification
Self-Correction Individual & Group Counseling
Education of Client and Significant others

27. OCCUPATION ANALYSIS
PREPARATION / SET UP TIME REQUIRED
‘STEPS’ TIME REQUIRED
1:
2
3
4
5
6
7
CLEAN UP / PUT AWAY TIME REQUIRED
TOTAL TIME:

28. ‘Steps – Tasks - Routines’ Errors
1. X
2. X
3. X
4. X
5.
6.
7.
8.
PERFORMANCE ANALYSIS
4/8 error free = 50% Mastery

29. Performance-based assessments
PURPOSE
Identify functional performance concerns to address –
occupation-embedded
EXAMPLES
•Assessment of Motor and Process Skills (AMPS)**
•Routine Task Inventory (RTI)
•PRPP Stage One

30. Assessment of Motor & Process Skills (AMPS)
Origin: USA
Purpose: To identify occupational performance skill
conceptualized as ability to complete the motor and process
elements of everyday tasks
Client group: Anyone who has the capacity to attempt
standardized task test items but has difficulty doing so

31. Occupation Focus: IADL selected from the list
of those that have been standardized
Performance Assessed:
Motor skill units of the task
Process skill units of the task

71. Cognition & OT
2. Remedial – Cognitive Retraining Approach
Foundation: Emergence of neuropsychology
Assessment: Detect dimensions of disordered cognition
Intervention: Cognitive retraining
Outcome: Generalization to ADL

72. Cognitive Screening Tools
PURPOSE
Create a preliminary overview of a person’s cognitive
impairments & strengths
EXAMPLES
•Rowland Universal Dementia Assessment Scale
•Montreal Cognitive Assessment
•Cognistat
•Kimberley Indigenous Cognitive Assessment
•Mini Mental Status Exam

73. Specific Cognitive Domains Tests
PURPOSE
Develop a detailed understanding of specific cognitive
impairments & inform design of intervention
EXAMPLES
•Rivermead Behavioral Memory Test (RBMT)
•Contextual Memory Test (CMT)
•Test of Everyday Attention (TEA)
•Post Traumatic Amnesia Scale (PTA Scale)
•Wessex Head Injury Scale
•Line Bisection Test

74. Wessex Head Injury Matrix (WHIM)
A 62-item hierarchical scale designed to
measure (predict) recovery from coma.
Observe behaviors covering an individual's
level responsiveness and interaction with their
Environment
Sub-sets: Communication, Attention, Social Behaviour,
Concentration, Visual Awareness, and Cognition

75. Westmead Post Traumatic Amnesia
Scales (PTA Scales)
A set of 12 questions designed to measure the
length of post-traumatic amnesia (PTA) in TBI
patients – able to participate in standardized testing.
Questions cover orientation to person, place, time & the
consistent ability to retain new information from one day to
the next.
Requires perfect score for 3 consecutive days

76. Rowland Universal Dementia
Assessment Scale (RUDAS)
Series of questions designed to screen for dementia –
applicable to people from diverse cultural and linguistic
backgrounds
Domains assessed: Memory, Visuospatial Orientation,
Praxis, Visuoconstructional Drawing, Judgement,
Memory/Recall, Language

77. Montreal Cognitive Assessment
(MoCA)
A one-page, 30-point rapid screening instrument for mild
cognitive dysfunction.
Domains assessed: Attention & Concentration, Executive
functions, Memory, Language, Visuoconstructional skills,
Conceptual thinking, Calculations and Orientation.

78. Kimberley Indigenous Cognitive
Assessment (KiCA)
Series of questions designed to assess cognitive status in
Indigenous people of the Kimberley.
Domains assessed: Orientation, Recognition & naming,
Registration, Verbal comprehension, Verbal fluency, Recall,
Visual naming, Frontal/Executive function, Free recall,
Cued recall, Praxis

79. Lowenstein Occupational Therapy
Cognitive Assessment (LOTCA)
A standardized set of 25 subtests in 6 cognitive areas
required for everyday function. Used to assess adults with
neurological deficits and mental health disorders.
Domains assessed: Orientation, Visual and Spatial
perception, Motor praxis, Visuomotor organization and
Thinking operations

80. Cognistat
A rapid analysis of major cognitive impairments in
medical and psychiatric settings. Shortened version: rapid
screen for delirium, MCI & dementia.
Domains assessed: orientation, attention, language, spatial
skills, memory, constructions and reasoning.
Illustrated as a graphic profile of cognitive +/-

81. Cognition & OT
3. Combined Approach: Cognitive domains assessed within
the context of task performance
Foundation: Occupational Performance
Assessment: Detect dimensions of disordered cognition
during performance of pre-set tasks
Intervention: ??
Outcome: Optimum performance

82. Specific tests of cognitive impairment in context of specific
occupations
PURPOSE
Determine how specific cognitive deficits manifest
themselves in occupational performance
EXAMPLES
•ADL-focuced Occupation-based Neurobehavioral
Evaluation (A-ONE)
•Executive Function Performance Test (EFPT)
•Kettle Test
•ADL Checklist of Neglect

83. ADL-focused Occupation-based Neurobehavioral
Evaluation (A-ONE)
Formerly: Árnadóttir Occupational Therapy
Neurobehavioral Evaluation (A-ONE)
Origin: Iceland
Purpose: To diagnose neurobehavioral impairments that
directly impact occupational performance
Client Group: Adults who have had a stroke and have
difficulty with basic ADL

84. Occupation Focus:
Standardized basic personal care tasks
Performance Assessed:
Part 1: Independence
Dressing
Grooming & Hygiene
Transfers & Mobility
Feeding
Communication
Part 2:
Neurobehavioral impairments impacting performance

85. A-ONE: PART 2
APRAXIA
Motor
Ideational
Oral
AGNOSIA
Astereognosis
Visual object agnosia
Visual spatial agnosia
Associative visual agnosia
Anosognosia
BODY SCHEME DISORDERS
Unilateral body neglect
Somatoagnosia
R/L discrimination
SPATIAL RELATIONS
Unilateral spatial neglect
Spatial relations
Topographical disorientation

86. MOTORIC
Perseveration
Abnormal tone: Right side
Abnormal tone: Left side
Other:
APHASIA:
Wernicke’s aphasia
Jargon aphasia
Anomia
Paraphasia
Peservation
Broca’s aphasia
Dysarthria
Other
EMOTION:
Lability
Euphoria
Apathy
Depression
Aggressiveness
Irritability
Frustration
Restlessness

87. Executive Function Performance Test
TEST ITEMS: Tasks (Sequential order)
Hand Washing (severe cog. impairment)
Oatmeal Preparation
Telephone
Taking Medication
Paying Bills
TEST ITEMS: Executive function components
Initiation
Execution
• Organization
• Sequencing
• Judgement & Safety Completion

88. SCORING:
Based on the amount of cueing provided.
Scoring grid
Executive Function Performance Test
Independent
Verbal Guidance
Gestural Guidance
Verbal Direct
Instruction
Physical Assistance
Do for Participant
5 EF components (max 20 points)
Each of 4 tasks (max 25 points per task) = Total score
INTERPRETATION:
Determine supports needed at home

89. The Kettle Test
Purpose: Evaluate ability for independent community
living of people with suspected cognitive impairment
Task:
Comprises 1 task x 13 steps
Prepare a hot drink for 2 (self & therapist).
Therapist requests a drink that differs x2 elements
Scoring:
Number of cues required

90. Specific tests of cognitive impairment in context of specific
occupations
UTILITY
Pros
Questions raised

91. Cognition & OT
4. Environmental approach
Foundation: Contextual
Assessment: Identify contextual features and their impact on
performance.
Intervention: Adapt or select optimum context
Outcome: Performance in context

92. Environmental Assessment
PURPOSE
Collect information about the environment and context in
which the person needs to function
EXAMPLES
•Safety Assessment of Function and the Environment
for Rehabilitation (SAFER)
•Home Environmental Assessment Protocol (HEAP)
•Analysis of Cognitive Environmental Support (ACES)

93. Psychology:
Human cognition operates in service of individuals as they
interact with an everchanging, naturalistic environment
Contemporary Paradigm Shift
New methods to study “the behavior of an embodied
individual interacting with his or her environment” are
required
Focus [in psychology] should be on what the active, engaged
person is doing in the environment, and what information is
available to that person to support purposeful behavior.

94. Ecological valid practice = how people function in real
world situations

95. 5. Ecological approach
Foundation: OPM(A) - Occupational Therapy
Assessment: Person-centred, Occupation-embedded,
Performance-focused, Contextually relevant
Intervention: Develop mastery by prompting application of
cognitive strategies
Outcome: Enhanced occupational performance

96. Occupational Performance
The ability to perceive, recall, plan and/or carry out
occupations for specific purposes in response to internal
or external demands or motivations to the satisfaction of
self and/or significant role partners
The Perceive, Recall, Plan & Perform (PRPP)
System of Task Analysis: Assessment & Intervention
Origin: Australia
Purpose:
To identify OP mastery
To identify the cognitive strategy application reasons for
reduced mastery
To design information to improve OP
Client Group: Anyone who has difficulty meeting
the cognitive demands of everyday life

97. Occupation Focus: Any task, step, routine, skill set or
interaction that is needed or desired by client / situation
Performance Assessed:
Stage One:
Performance Mastery
Scoring:
Calculate % correct against criterion set
Calculate error impact

98. Goal-setting: Mastery
What will the client do? (Stage One task) (Skill)
Where will performance happen? (S- context)
How skillful with performance be? (Mastery level)
What Assistance is required? (aids, prompts, help)
Realistic? Relevant?
How long will it take to achieve this? (Time frame)

99. Performance Assessed:
Stage Two: Application of cognitive (information
processing) strategies to the occupation being performed

100. What are cognitive strategies?
Internally generated mental techniques which people use in
everyday task performance when faced with the need to
Understand and attend to information
Remember and retrieve information
Manipulate and apply information
Plan and modify responses using information
Cope with internal and external distractions during
participation in every day tasks

101. How are cognitive strategies assessed using the PRPP
Assessment?
Observation and scoring of strategy behaviors used
during occupational performance.
Conceptualized as the salient thinking and acting
behaviors one uses to plan, execute and evaluate
performance.
Labelled as “Descriptors” and operationally defined

102. Scoring:
Stage Two: 3-2-1 for each strategy application
behavior (3= no impact; 1= detrimental to performance)
Interpretation:
Summarize, prioritize and plot strategy application
ability / difficulty impacting on OP

103. Goal-setting: Strategy Application
(needed for SMART Mastery Goal)
Client will recall the steps for dressing
Client will maintain attention for duration of the meal
Client will organize notes prior to writing