Occupational Therapy Standardized Assessment

Allen’s Cognitive Level Screen (ACLS)

- The screen consists of learning three visual-motor tasks
(leather-lacing stitches) with increasingly complex activity
demands.
- Completion of the three tasks requires that the person
attend to, understand, and use sensory and motor cues
from the material objects (leather, lace, and needles), the
administrator’s verbal and demonstrated instructions and
cues, and feedback from motor actions while making the
stitches.
- The scores obtained are interpreted using the Allen
Cognitive Scale of levels and modes of performance.

- The screen is available in two forms: the standard Allen
Cognitive Level Screen (ACLS) and a larger form
(LACLS) for persons with vision or hand function
problems.
- Purpose: The screen is used to obtain a quick measure of
global cognitive processing capacities, learning potential,
and performance abilities and to detect unrecognized or
suspected problems related to functional cognition.

Westmead Post Traumatic Amnesia (PTA) Ax
- Mild Traumatic Brain Injury (MTBI) accounts for 70-90%
of all head injured patients, 2 and the ED is the primary
point of medical contact for these patients.
- Post traumatic amnesia (PTA) ‘is the period of time during
which a person is disorientated or confused and unable to
recall new information following a head injury’.
- It is recommended that patients presenting to the ED,
following a mild closed head injury, complete an
abbreviated version of the PTA scale entitled the A-WPTAS

- Evidence based guidelines for the testing of patients with a
closed head injury which is common in the physical
trauma population.
- Post traumatic amnesia (PTA) represents a stage of
recovery post head injury during which a persons ability to
make new memories for daily events is impaired.
- PTA testing is an essential form of monitoring the patient’s
mental state and behavioral disturbances.
- The duration of PTA is also used as an index of severity
for prognosis, referral to rehabilitation services and
medico-legal and scientific purposes.

The Westmead Post-traumatic Amnesia Scale (WPTAS) is a
brief bedside standardized test that measures length of post-
traumatic amnesia (PTA) in people with traumatic brain
injury.
- It consists of twelve questions that assess orientation to
person, place and time, and ability to consistently retain
new information from one day to another.
- It is administered once a day, each and every day, until the
patient achieves a perfect score across three consecutive
days, after which the individual is deemed to have emerged
from post-traumatic amnesia.

The Westmead Post-traumatic Amnesia Scale (WPTAS)
Importance of PTA testing
- PTA testing allows for monitoring of the patient’s mental
state and behavioral disturbances common when in PTA.
This also assists to increase staff awareness and
understanding of PTA
- The duration of PTA is used as an index of severity for
prognosis, medico-legal and scientific purposes

The Westmead Post-traumatic Amnesia Scale (WPTAS)
Inclusion Criteria:
Following the initial stabilization of blunt head injury patients
who require admission.
Patients must meet one or more of the following criteria:
- Reported amnesia or patchy recall of the events
- Loss of consciousness at the scene
- Glasgow Coma Scale <15 at the scene
- Evidence of a head injury on a cerebral CT

Criteria for A-WPTAS testing:
Eligible patients are those with a history of a blunt head
injury and must meet the following criteria:
- Closed head injury within 24hrs of presentation
- Glasgow Coma Scale (GCS) of 13-15
- Opening eyes spontaneously (GCS eyes score 4)
- Obeying commands (GCS motor score 6)

Cognistat
- The Cognistat formally known as the neurobehavioral
cognitive status examination is a cognitive screening tool,
screening five major ability areas, which are language,
spatial skills, memory, calculations and reasoning
- It is a standardized assessment for adolescent, adults and
seniors. The assessment takes 15-20 minutes to administer
with the examiner asking and recording the patients
answers.
- The patient only interacts with the examiner not requiring
to interact with a computer, however may be asked
reproduce a line drawing on paper to test memory.

Cognistat
- Once the Cognistat is completed the examiner converts
recorded answers to a graphic profile, and the presents and
discuss this with the patient.

Cognistat Pros:
- Broader profile than SMMSE or MoCA, more sensitive than MMSE
- Has been found to identify presence of cognitive impairment in TBI
(reliably classifies individuals in acute & post-acute settings into the
Cognistat impairment categories)
- Is predictive of function (BI or FIM) for persons with stroke
- When used with the Rivermead Behavioral Memory Test can detect
MCI and mild dementia
- The new MCI Index might be helpful for Occupational therapist
working in programs/clinics involving clients with MCI and
dementia

Cognistat Cons:
- Individuals with frontal lobe lesions may not perform in the impaired
range on this test
- Significant difficulties in reading, writing and spelling will not be
detected
- Poor performance may reflect a long-term learning disability (rather
than new, acquired cognitive impairment)
- Although may help to determine specific cognitive impairments,
evidence varies to support concurrent/predictive validity of function
- Scoring is a profile (not a single numerical score) – although some
researchers create a composite score for purposes of their research,
e.g. Drane et al., 2003; and there is now the new MCI Index score

Cognistat Cons:
- “Screening” score (of original version) produces high false positive
(so it is recommended to use total score)
- Cautions in interpreting results if presence of frontal lobe lesion,
pain, medications, sleep deprivation, sensory deficits, language
deficits
- May not be sensitive to mild impairment. For example, the Cognistat
detected only 60-80% of cognitive deficits diagnosed by a skilled
neuropsychologist (Nokleby et al., 2008) (stroke).
- It may be too simple for post-acute, high functioning TBI.
- Not recommended by researchers to use with TBI for planning rehab
& community reintegration (because not sensitive enough to residual
cognitive deficits across different stages of recovery

Westmead Head Injury Matrix (WHIM)

The Wessex Head Injury Matrix (WHIM)
- Accurately assesses: clients in and emerging from coma clients in
vegetative and minimally conscious states
- With the WHIM clients can be assessed and goals for rehabilitation
set from the outset of coma. The WHIM bridges the gap between tests
available for the very acute stages after head injury and those helpful
in later stages of recovery.
- Improvements from the initial state of coma may be gradual and,
unless accurate assessment takes place, small gains may be missed or
misinterpreted.
- The WHIM will pick up minute indices demonstrating recovery,
providing objective evidence for realistic prediction. It is easy and
quick to administer by any qualified member of a multidisciplinary
team.

The Wessex Head Injury Matrix (WHIM)
- The Wessex Head Injury Matrix (WHIM) provides accurate
assessment of patients in and emerging from coma and in the
vegetative and minimally conscious states.
- The 62-item observational matrix can be used to assess the patient
and set goals for rehabilitation from the outset of coma.
- Designed to pick up minute indices demonstrating recovery and
provide objective evidence, the WHIM provides a sequential
framework of tightly defined categories of observation covering:
Communication ability
Cognitive skills
Social interaction

Lowenstein Occupational Therapy Cognitive
Assessment (LOTCA-G)

Assessment (LOTCA-G)
- The LOTCA battery is used to assess adult persons with neurological
deficits and mental health.
- It includes 25 subtests in 6 cognitive areas, orientation, visual and
spatial perception, praxis, visuomotor organization and thinking
operations.
- Scoring is on an ordinal scale of 1-4 (1-severe deficit and 4-average
performance), except for orientation scores that range from 1-8, and
categorization where the range is 1-5.
- Reliability, validity and standards of performance, for the LOTCA,
are available for brain injured adult patients, patients following
stroke, schizophrenic patients, healthy adults and healthy children

Assessment (LOTCA-G) Pros:
- A performance test with minimal verbal requirements
- Procedures are included for use of LOTCA with clients with
aphasia
- Can be used to evaluate change over time (i.e., to re-test
clients).
- There is also a version available for geriatric population
(LOTCA-G)
- Provides a more detailed cognitive profile than the MMSE,
and may be stronger than MMSE in predicting function (as
measured by FIM).

Assessment (LOTCA-G) Cons:
- No memory subtests in the LOTCA (but present in the
LOTCA-G)
- Can be long and difficult to administer.
- One study found a substantial ceiling effect for a sample of
adults with schizophrenia – therefore, may not be useful
with this population (and perhaps also may not be useful
with adults with mild cognitive impairment).

Assessment of Motor and Process Skills (AMPS)

- The Assessment of Motor and Process Skills (AMPS) is an innovative
observational assessment that is used to measure the quality of a
person's performance of domestic (instrumental) or personal activities
of daily living (ADL).
- The quality of ADL performance is assessed by rating the effort,
efficiency, safety, and independence of 16 ADL motor and 20 ADL
process skill items.
- The ADL motor and ADL process skill items represent universal, goal
directed actions that are observed during ADL task performances.
- ADL motor skills are the observable, goal directed actions of
performance that the person enacts during the performance of ADL
tasks to move oneself or the task objects (e.g., walk across the floor,
transport objects, reach for and manipulate objects, position the body).

- ADL process skills are the observable actions of
performance the person enacts to logically sequence the
actions of the ADL task performance over time, select and
use appropriate tools and materials, and adapt his or her
performance when problems are encountered (e.g., initiate
and sequence actions, choose and gather task objects,
accommodate actions when problems occur).

Assessment of Motor and Process Skills (AMPS) Pros:
- Provides for a standardized ADL analysis
- Identifies between difficulties with process (cognitive) &
motor (physical) tasks
- Some cultural sensitivity (e.g. client plans own meal of
choice)
- Useful in mental health & physical disability settings
- Easy to convert data to a written report (a program does
this for you; also provide graphics)
- Good for variety of age groups

Assessment of Motor and Process Skills (AMPS) Pros:
- May be more appropriate than using the assessment
activities offered by other task/performance tests such as
ILS
- Based on MOHO Is recommended for assessment of
executive functions in a published inventory of tests of
executive function for stroke (Poulin et al, 2013)

Assessment of Motor and Process Skills (AMPS) Cons:
- OT needs specific training to administer
- Expensive training: 5-day course (and must follow-up training by
testing 10 people within 3 months and submitting results to become
“calibrated”).
- Not specifically designed to evaluate for presence of cognitive
impairments – but Process score can represent cognitive limitations
- Research recommends assessing client in home instead of clinic
because environmental factors may influence performance in
particular Process score (Park 1994)
- Limitations for use on its own to predict level of assistance or predict
employment (see psychometrics)

Cognitive Assessment of Minnesota (CAM)

- The CAM is a screening tool that assesses a wide range of
cognitive skills.
- It covers a variety of cognitive skills which are organized
into a hierarchy from simple to complex.
- In order to perform higher level cognitive functions, the
more basic functions must first be achieved.
The hierarchy is divided into four areas:
- Store of knowledge
- Manipulation of old knowledge
- Social awareness and judgment
- Abstract thinking.

The specific subtests are
- Attention span
- Memory /orientation
- Visual neglect
- Following directions
- Immediate memory
- Temporal awareness
- Matching
- Object identification
- Visual memory and sequencing
- Recall/recognition
- Auditory memory and sequencing
- Simple money skills
- Simple math skills
- Foresight and planning
- Safety and judgment
- Concrete problem solving
- Abstract reasoning.

The assessment was designed by OTs, so functional tasks and outcomes
are emphasized throughout the test.
Population:
- This test is designed to be used for adult clients who have cognitive
impairments due to a CVA or a TBI (Level IV through Level VII on
the Rancho Los Amigos Scale of Cognitive Functioning).
Focus of measurement:
___ Organic systems _X_ Abilities ___ Participation/life habits ___
Environmental Factors

Strengths
- Developed by occupational therapists
- Functional based activities
- Theoretical basis for the hierarchical nature of the cognitive
skills
- Assesses a vast amount of cognitive skills
- Development is backed by research
- Validity and reliability are well established
- Relatively inexpensive for the kit
- Items needed for the subtests are common items that are
also inexpensive
- Instructions for administration can be found in both the
examiner’s guide and on the subtest sheets

Weaknesses
- Requires items not included in the kit that need to be
gathered and/or purchased
- Worksheets have to be copied for each administration
- Only to be used in clients with CVA or TBI (not
psychological diagnoses)
- Standardized administration may be difficult with cognitive
clients and may seem rote.

Middlesex Elderly Assessment of Mental State (MEAMS)

- Type/Purpose of Test: This is a screening test used to detect
impairment of cognitive skills in the elderly population. It
allows practitioners to differentiate between cognitive
impairments and physical dysfunctions.

It measures the major areas of cognition using 12 subtests.
They are:
- Orientation
- Name Learning
- Naming
- Comprehension
- Remembering Pictures,
- Arithmetic
- Spatial Construction
- Fragmented Letter Perception
- Unusual Views
- Usual Views
- Verbal Fluency
- Motor Perseveration.

Perseveration.
- It includes two parallel versions to allow for repeated
testing.
- Unique to this screening is the fact that it assesses
perception, memory, language, and executive functions in
addition to other major cognitive skills
Population:
- The elderly population. It was tested and validated on 120
elderly patients, age 65-93 years.
- _X_ Organic systems _X_ Abilities ___ Participation/life
habits ___ Environmental Factors

Ease of Administration:
- The test is short, simple, and easy to administer.
- The directions are provided in the Description and
Validation manual while the Test Material Manual itself
has step by step directions provided on each page to follow
as the test is administered.
- The Test Material Manual is set up as a flip chart so the test
giver can read the instructions on the back while the
subject views the pictures on the front of the manual. This
makes administering the test very easy.

Strength:
- The MEAMS is a short and simple screening tool useful for
assessing gross impairment of cognitive skills.
- It provides a quick way to identify if a patient may need
further assessment and evaluation regarding their cognitive
skills.
- The test manuals and score sheets are easy to understand
and follow as well.

Weakness:
- The Description and Validation manual may be a little
confusing for some.
- It does not lay out certain specifics about validity and
scoring procedures.
- It assumes that the testing manual and score sheets will be
understood by themselves.
- Because the test manuals and score sheet are easily
understood this is not a big problem.

Middlesex Elderly Assessment of Mental State (MEAMS) Cons:
- Developed only for use with elderly
- Not suitable for those with severe receptive language
problems (i.e., unable to follow simple instructions)
- Cost (approx. $200.00) for the manual, plus extra for score
sheets
- Questionable in some research as a cognitive screen (not
very sensitive to cognitive impairment)
- Adequate but low correlations with function as measured
by FIM .

Rivermead Behavioral Memory Test (RBMT)

- Memory impairment is one of the most common cognitive
issues occupational therapists assess and treat when
working with clients who have sustained a head injury.
- Memory deficits, even when subtle, can have serious
consequences for returning to daily activities and returning
to work following an accident.

- Assessment of memory related to functional tasks. Assesses
visual, verbal, recall, recognition, immediate, delayed and
prospective memory, & ability to learn new info
- The RBMT-3 uses “real life” tests such as recalling details
of a story, recalling names and faces, and remembering
important information after time has passed.
Population:
- Designed for adults with acquired, nonprogressive brain
injury.
- Normative group: English speaking adults to age 89

- Once the test has been completed a overall “General
Memory Index” is assigned to the client but more
importantly, sub scores in areas such as facial recognition,
orientation, learning a novel task and remembering names
are also provided. This is useful as it allows the OT to
pinpoint specific areas of deficit and to then provide more
targeted treatment approaches.
- The RBMT-3 is also an essential component of most
Cognitive Assessment Reports provided by OTs at GLA. The
test enables the assessor to comment on very specific
examples of memory impairments and strengths

Rivermead Behavioral Memory Test (RBMT) Pros:
- Allows comparison to norms
- Results (strengths/weaknesses for memory) allow the OT to
provide more specific and individualized memory strategies
- Results are useful to include in an education session for
family members
- Modest ability to predict everyday memory failures
- Parallel versions (RBMT-3) allow for test-retest (thus,
evaluation of change over time)

Rivermead Behavioral Memory Test (RBMT) Pros:
- Ecological validity is supported through use of some “task
performance” elements and concurrent validity with
therapists’ and relatives’ ratings of individuals with brain
injury
- In research, the ecological validity of a study means that
the methods, materials and setting of the study must
approximate the real-world that is being examined. Unlike
internal and external validity, ecological validity is not
necessary to the overall validity of a study

Rivermead Behavioral Memory Test (RBMT) Cons:
- Client needs to have good attention to participate.
- Caution in using it with clients who have limited insight
about memory changes.
- Cost may be prohibitive ($651.00 for complete kit; $123.00
for extra forms)
- OT needs to take time to learn how to administer, and
become familiar with subtests (including spatial memory
task

Independent Living Scale (ILS)

Type/Purpose of Test:
- This assessment is used to measure competency in
instrumental activities of daily living (IADL).
- Situations relevant to independent living are targeted to
gauge individual ability to problem solve, demonstrate
knowledge, and perform tasks.
- This test can be used to guide determination of the most
appropriate living arrangements for an individual.

Population:
- Can be used with a variety of adult clinical populations who
may be experiencing cognitive deficits, such as individuals
with intellectual disabilities, traumatic brain injury, or
dementia
- This assessment is most appropriate to use when the client
has achieved a somewhat stable level of functioning,
whatever their condition may be.
- __Organic systems X Abilities ___ Participation/life habits
___Environmental Factors

Ease of Administration:
- This assessment is fairly simple and straightforward. May
be somewhat difficult to ease through the administration,
depending on the cognitive abilities of the client.

Strengths:
- Visual is given of the materials required for administering
the test in each section of the manual
- The test highlights the importance or establishing and
maintaining rapport
- A stimulus booklet with written directions is available for
use with adults who have a hearing impairment.
Additionally, the booklet has alternative pages with larger
print available for clients who have a visual impairment

Strengths:
- Problem solving skills and ability to perform with offered
information are two areas that have separate scores
provided for them (in addition to each subscale score) to
identify level of functioning in these areas (high, moderate,
or low)
- Graphic representation of scores is provided on the main
record form to offer a visual, including ranges of high,
moderate, and low levels of functioning in each

Independent Living Scale (ILS) Pros:
- Includes performance-based testing (with scenario-based
questions and actual tasks for the person to do, related to
function at home), thus enhancing ecological validity
- Fairly good psychometric properties for use with
individuals with schizophrenia and dementia – there is
some initial research with other populations (as per
manual, 1996), but lack of further studies with these other
groups
- Appears to reflect cognitive aspects of performance (but
may not reflect emotional influence e.g. depression;
positive & negative

Weakness:
- It may be difficult to attribute a verbal response to a
numbered score (it may not be so clear what score to give
while administering the test)
- Individuals with cognitive deficits may have a hard time
going through all 70 items on the test in one sitting (which
is what the assessment suggests doing)

Independent Living Scale (ILS) Cons:
- May not be sensitive enough to identify individuals with
mild cognitive impairment.
- Quiet room (private setting) recommended.
- Cheque-writing and phonebook tasks are not relevant to
many clients.
- Map-based way-finding task seems to be more of a memory
and attention task than measuring the person’s ability to
way-find
- Cost: about $329 for initial kit, and then $62.00 for each set
of 25 replacement forms.

Kohlman Evaluation of Living Skills (KELS)

Type/Purpose of Test:
- This assessment is used to determine a person’s ability to
function in basic living skills.
- Based on the results of this assessment, recommendations
for living situations that allow the client to function as
independently as possible can be made.
- Seventeen living skills in the following five areas are tested:
Self-Care, Safety and Health, Money Management,
Transportation and Telephone, and Work and Leisure.
- This assessment identifies areas in which the person is able
to perform and in which he or she requires assistance.

- A fairly quick and simple evaluation of an individual’s
ability to perform basic living skills to determine degree of
independence for return to community living.
- The KELS tests knowledge, not actual task performance.
- Includes 17 items in 5 categories: Self Care, Safety and
Health, Money Management, Transportation and
Telephone, and Work and Leisure.
Time to administer: 30-45 minutes

Population:
- Adolescent and beyond (no specific age range given).
- Appropriate for individuals who have cognitively disabling
conditions (Alzheimer disease, TBI), adolescents in training
programs, people in acute care units in hospitals, and the
elderly.
___ Organic systems __x_ Abilities ___ Participation/life
habits ___ Environmental Factors

Strength:
- Short administration and scoring time
- Easy to learn
- Easy to assemble equipment
- Inexpensive
- Can be transported with little effort
- Specific instructions and script are available for the
administrator of the test

Kohlman Evaluation of Living Skills (KELS) Pros:
- Helpful for many settings (inpatient, outpatient, acute
care). Research has focused on use with schizophrenia and
older adults.
- Useful for quickly obtaining information regarding the
ability of a person to perform basic living skills
- Provides information to help clinician suggest appropriate
living situations that will maximize independence –
although needs to be augmented with performance-based
assessment
- Cost: $55.00 for manual through CAOT (member price)
(also available through AOTA)

Weakness:
- Not appropriate for settings with long length of stays—
more than one month--(person’s finances, transportation,
work, and leisure have changed drastically)
- Some items not applicable in rural areas or outside of the
United States/Canada
- Does not comprehensively evaluate living skills—just a
short, basic living skills evaluation
- Many items are interview-based rather than performance-
based—may test knowledge instead of the actual
performance of the skill

Kohlman Evaluation of Living Skills (KELS) Cons:
- Not performance-based.
- Based on urban lifestyles. Some items must be scored ‘not
applicable’ in rural areas.
- Additional performance-based testing should be done to
supplement the KELS as it tests knowledge rather than the
actual performance of living skills.

Occupational Therapy Standardized Assessment

Occupational Therapy Standardized Assessment

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