Australian Occupational Therapy Journal (2013) 60, 334–342
doi: 10.1111/1440-1630.12069
Research Article
Cognitive assessment across the continuum of care: The
importance of occupational performance-based assessment
for individuals post-stroke and traumatic brain injury
Danielle Sansonetti1,2 and Tammy Hoffmann3,4
1
Occupational Therapy Department, St Vincent’s Hospital, Melbourne, Victoria, 2Eastern Health, Melbourne, Victoria,
Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast,
Queensland, and 4Division of Occupational Therapy, School of Health and Rehabilitation Sciences, University of
Queensland, Brisbane, Queensland, Australia
3
Background/aim: When working with individuals following stroke or traumatic brain injury, an important role of
the occupational therapist is to assess the impact of cognitive impairment on their ability to engage in occupations
and resume important life roles. The aim of this study was
to survey therapists’ reasons for selection of and challenges
with using various cognitive assessment approaches, across
the continuum of care, when working with individuals following stroke and traumatic brain injury.
Methods: A cross-sectional survey, completed via post or
online, with responses from 209 Australian occupational
therapists was conducted. Participants included clinicians
working in acute, inpatient rehabilitation and community
settings.
Results: Occupational performance-based assessments
were ranked as the most important assessment method,
with 69% of participants reporting using these assessments for more than 75% of their clients with cognitive
impairment. Participants identified the lack of quantitative
data provided by these assessments as a frequent challenge.
The identification of cognitive deficits was the highest
ranked reason for using cognitive screens and batteries.
Challenges identified with using cognitive screens and batteries included difficulty linking assessment results to
occupational performance, and difficulty using results to
generate intervention strategies. The majority of partici-
Danielle Sansonetti MHSc (OT), BOccThy; Occupational
Therapist. Tammy Hoffmann PhD, BOccThy (Hons 1);
Associate Professor.
Correspondence: Danielle Sansonetti, Occupational Therapy
Department, St Vincent’s Hospital, Melbourne, St George’s
Hospital campus, 283 Cotham Road, Kew, Melbourne, Vic.
3101, Australia. Email: Danielle.Sansonetti@easternhealth.
org.au
Accepted for publication 11 June 2013.
© 2013 Occupational Therapy Australia
pants reported using a combined approach to assessment,
and used screens and batteries to support findings of occupational performance-based assessments.
Conclusions: Targeted efforts to further incorporate standardised occupational performance-based methods into
clinical practice, research, and ongoing professional development is required to enhance occupational therapy services when working with individuals with cognitive
impairment.
KEY WORDS assessment outcomes, brain injury, cognition.
Introduction
Cognitive impairment is a common consequence associated with stroke and traumatic brain injury (TBI) and
often impacts an individual’s ability to participate in
everyday activities and associated quality of life (Gauggel, Peleska & Bode, 2000; Ozdemir, Birtane, Tabatabaei,
Ekuklu & Kokino, 2001). There are up to 60,000 strokes
reported in Australia each year, with up to 45% of individuals admitted with acute stroke presenting with cognitive deficits (National Stroke Foundation, 2009). It is
estimated that the 2004–2005 cost of Australian hospital
admissions for individuals with TBI exceeded $184 million, with many individuals requiring ongoing support
for living in the community due to changes in both
physical and cognitive capacities (AIHW (Australian
Institute of Health & Welfare), 2007). When working
with individuals following stroke and TBI, occupational
therapists’ assessment of cognition is important in
determining an individual’s ability to live at home
safely and independently, resume important life roles
and activities, and re-establish old, or form new, habits
and routines (Fry & O’Brien, 2002; Hartman-Maeir, Katz
& Baum, 2009b; Poole, Dunn, Schell, Tiernan & Barnhart, 1991). With approximately 88% of stroke survivors
returning home following discharge from hospital
335
COGNITIVE ASSESSMENT IN OCCUPATIONAL THERAPY
(AIHW, 2006), many of whom have cognitive impairment, completion of thorough assessment of these individuals’ cognitive abilities is essential in order to inform
development of an effective client-centred cognitive
rehabilitation program that facilitates community reintegration.
In accordance with the World Health Organisation’s
International Classification of Functioning, Disability,
and Health (2001), occupational therapists evaluate an
individual’s cognitive performance at two main levels
throughout the cognitive rehabilitation process. The first
level, ‘body structure and function’, considers cognition
in terms of performance of cognitive components such
as attention, memory, perception and executive functions. This is also known as the ‘bottom-up’ approach,
and includes assessment tools such as cognitive screens
(e.g., Mini-Mental Status Examination), standardised
assessment batteries for specific cognitive domains (e.g.,
Rivermead Behavioural Memory Test), and some components of occupational performance-based (OP-based)
assessments (e.g., Perceive, Recall, Plan, and Perform
(PRPP) system of task analysis) (Hartman-Maeir et al.,
2009b). Cognitive screens are defined as those tools that
provide a brief snapshot of cognitive functions, typically
take less than 15 minutes to administer, and include
both standardised and non-standardised tools (Hartman-Maeir et al.). Standardised assessment batteries are
defined as those tests that follow a specified protocol
for administration and scoring, have determined psychometric properties, and provide a profile of the
underlying cognitive domains necessary for occupational performance (Hartman-Maeir et al.). The second
level, ‘activity and participation’, considers cognition as
it relates to the individual’s ability to successfully
engage in daily occupations, such as basic and instrumental activities of daily living (ADL). This is also
known as the ‘top-down’ approach and includes assessment tools such as interviews with the client and relevant others, questionnaires and OP-based assessments
(Arthanat, Nochajski & Stone, 2004; Douglas, Liu, Warren & Hopper, 2007; Hartman-Maeir et al.). OP-based
assessments are defined as those standardised or nonstandardised methods that involve therapist observation
of an individual’s performance of daily activities (Douglas et al., 2007).
Previous research investigating cognitive assessment
in occupational therapy has largely focussed on three
main areas: (i) frameworks that guide cognitive assessment practices; (ii) identification of cognitive assessment tools used in occupational therapy practice;
and (iii) comparison of standardised assessment batteries and screens and their associated psychometric
properties.
Frameworks guiding cognitive assessment
Frameworks that aim to guide clinical reasoning
throughout the cognitive assessment process highlight
the complexity and multifaceted nature of selecting
appropriate assessment tools for clients. Hartman-Maeir
et al. (2009b) developed a comprehensive ‘Cognitive
functional evaluation’ process that conceptualises cognitive assessment into six stages, providing recommendations regarding specific assessments for use throughout
each stage. Furthermore, Groves, Coggles, Hinrichs,
Berndt and Bright (2010) developed an algorithm to
facilitate clinicians’ identification of an individual’s need
for cognitive assessment. In addition, Lee, Powell and
Esdaile (2001) developed the ‘Functional Model of Cognitive Rehabilitation’ that proposes a framework outlining the various personal, temporal and environmental
factors for consideration when selecting and administering cognitive assessments for individuals with cognitive
impairment. Whereas these frameworks provide a theoretical basis behind cognitive assessment, they are yet to
be empirically tested. There is also a lack of research
which has investigated the actual, opposed to theoretical, clinical reasoning processes of clinicians throughout
the cognitive assessment process.
Assessment methods used in practice
To identify the current cognitive assessment approaches
and tools used in occupational therapy practice, researchers have surveyed clinicians working in various clinical
settings across USA, Canada, and Australia (Alotaibi,
Reed & Nadar, 2009; Douglas et al., 2007; Koh, Hoffmann,
Bennett & McKenna, 2009; Korner-Bitensky, Barrett-Bernstein, Bibas & Poulin, 2011; Wheatley, 1994). Many of the
tools reported to be used by occupational therapists were
focussed towards assessment at the ‘body structure and
function’ level rather than ‘activity and participation’
(Alotaibi et al.; Douglas et al.; Koh et al.; Korner-Bitensky
et al.). Whereas it is well documented throughout the literature that one of the unique roles of occupational therapists within the practice of cognitive assessment is to
complete OP-based assessment, previous surveys indicate that only a small proportion of therapists reported
using this method of assessment as part of their daily
practice (Baum & Katz, 2010; Douglas et al.; Koh et al.). A
limitation of previous studies is the potential for selfreport bias, with survey respondents potentially placing
greater emphasis on reporting use of those standardised
assessment approaches considered to be more ‘formal’
assessments of cognition such as screens and batteries
(Douglas et al.).
Comparison of standardised cognitive
assessment tools
Cognitive screens and standardised assessment batteries
have an important role in identifying underlying cognitive strengths and deficits at the ‘body structure and
function’ level. Previous studies have provided comprehensive comparisons on utility and psychometric properties of these assessments, including which tools are
better able to predict an individual’s functional outcome
336
(Douglas, Letts & Liu, 2008; Lewis, Babbage & Leathem,
2011; Woodford & George, 2007; Zwecker et al., 2002).
Whereas the literature has acknowledged the lack of
ecological validity of many of these assessments, it is
unknown whether clinicians use these assessments for
the purpose of predicting functional outcomes for their
clients. In response to the need for more ecologically
valid measures of cognition at an ‘activity and participation’ level, authors have investigated the application
and utility of various standardised OP-based assessments of individuals post-stroke and TBI. These include
the PRPP system of task analysis, the Kettle Test, and
the Kitchen Task assessment (Baum & Edwards, 1993;
Fry & O’Brien, 2002; Hartman-Maeir, Harel & Katz,
2009a; Nott & Chapparo, 2008).
There is a lack of research investigating therapists’
clinical reasoning behind selection and utility of cognitive assessment approaches for clients with neurological
conditions. This study aimed to survey therapists’ reasons for selection and challenges with the use of various
cognitive assessment approaches across the continuum
of care when working with individuals post-stroke and
TBI. In addition, this study aims to further examine the
utility and perceived importance of OP-based assessments in occupational therapy practice.
Methods
Design
This was a cross-sectional survey.
Participants
Participants included occupational therapy clinicians
working within public or private acute and inpatient
rehabilitation hospital settings, home-based and community-based rehabilitation settings, and private practice settings across Australia. Clinicians had to be
working with adults with cognitive impairment poststroke or TBI to be eligible. Exclusion criteria included
occupational therapists working in generic roles (e.g.,
case management), occupational therapy students and
occupational therapy assistants.
Procedure
Ethics approval was granted from the Human Research
Ethics Committee, St Vincent’s Hospital, Melbourne. A
shortlist of health facilities was generated via website
review of each Australian public and private health
network’s services to clients with neurological conditions. Information sheets that included details about
the online survey and 755 printed copies of the survey
were mailed out to occupational therapy departments
across Australia within both hospital and community
therapy settings that provide occupational therapy
services to clients following stroke and/or TBI. Private
practitioners working with this client demographic
D. SANSONETTI AND T. HOFFMANN
were contacted via email using the online listings of
private practitioners from Occupational Therapy Australia. This email directed them to a link for the online
survey that was provided on the Occupational Therapy
Australia website. The information sheet explained that
consent to participate was implied by completion of the
survey.
Survey
The survey questions were developed following a literature review, conducted by the first author, of cognitive
assessments used in occupational therapy practice,
along with their reported benefits and limitations. The
survey consisted of four sections that comprised 17
questions in total, and used the online Survey Monkey
program (www.surveymonkey.com). Prior to commencement of data collection, the survey was piloted
with ten occupational therapy clinicians who met the
eligibility criteria to allow for feedback and minor revisions to questions. The survey took approximately
15 minutes to complete.
In the section Demographic information, participants
provided information regarding their practice setting,
region within Australia and number of years they had
been practicing.
In the section Information gathering and approaches to
evaluation of cognition, participants were asked to rank
their perceived level of importance of various methods of
information gathering in relation to a client’s cognition
using a five-point scale (i.e., where 1 = not important,
5 = very important). Information gathering methods
were: initial interviews, collaborative history from family/relevant others (e.g., carers, general practitioners),
cognitive screens, home assessments, OP-based assessments, liaison with the multidisciplinary team and standardised assessment batteries. Participants were also
asked to indicate the percentage of clients over the past
month for which they used a combination of assessment
methods (e.g., OP-based assessments combined with cognitive screens or OP-based assessments combined with
standardised assessment batteries).
In the section Screens and standardised assessment batteries, participants were asked to indicate the percentage of
clients in the last month for which they used cognitive
screens and batteries; rank their main reasons for selecting these tools from a list of 16 available options generated from the literature; and indicate the most
challenging factors associated with use of these tools
from a list of options also generated from the literature.
In the section Assessment of activity and participation,
participants were asked to indicate the percentage of clients in the last month with whom they used OP-based
assessments; indicate the percentage of these clients with
whom they would complete these assessments in the client’s own home environment; rank their main reasons
for using OP-based assessments from a list of options
generated from the literature; and indicate the most chal-
337
COGNITIVE ASSESSMENT IN OCCUPATIONAL THERAPY
Results
lenging factors associated with using these assessments
from a list of options generated from the literature.
Questions that provided a list of fixed-choice options
also contained an ‘other’ response option so that participants had the opportunity to provide additional information.
Of the surveys posted (n = 755) and available online,
211 responses were obtained. One hundred and thirtyfive (64%) of these were received by post (giving a
17.9% postal response rate) and 76 were completed
online. As the number of therapists that had access to
the online survey is unknown (i.e., the website link to
the survey was available to all occupational therapists
across Australia), it is not possible to determine an
overall response rate. Respondents from two of the surveys received worked with paediatric rather than adult
populations and were therefore excluded from the
study, leaving a total of 209 respondents. Participants’
demographic characteristics are shown in Table 1.
Data analysis
Data were analysed using the Statistical Package for the
Social Sciences (SPSS) program, version 11.0. Data were
analysed for the group as a whole, and also the clinical
groups across the continuum of care (acute, inpatient
rehabilitation, and community settings). Community
settings included home- and community-based rehabilitation services and private practitioners.
For questions requesting participants to rank their
five most important reasons for selecting assessments
from a list of options (i.e., where 1 = most important),
each ranking was attributed a numerical value to then
allow for total scores to be calculated for each option.
The overall ordered rank was then attributed accordingly, with the percentage of respondents that contributed to each ranking also calculated for each available
option (i.e., n%).
Per cent responses for each question were calculated
using the total number of respondents for each question, not the total number of participants. For example,
where participants indicated that they did not use a
specific form of assessment in their practice, and therefore did not provide further responses to questions
regarding these assessments, the per cent response was
calculated based on the actual number of respondents
that responded to that question.
Reasons for selection of assessments
Whereas 56% of participants indicated using cognitive
screens for more than half of their clients, these tools
were ranked the least important method of assessment
from the seven available options. Table 2 shows participants’ highest ranked reasons for selection of cognitive screens, and highlights differences across the
continuum of care. Clinicians working in acute settings
ranked the established psychometric properties of
cognitive screens to be a more important reason for
selection than those in inpatient rehabilitation or
community settings. Conversely, clinicians working in
inpatient rehabilitation and community settings ranked
‘identifying strengths in cognitive functioning’ and ‘to
assist with development of intervention strategies’ to
be of higher importance than those working in acute
settings.
TABLE 1: Participant demographic information
Demographic characteristics
Geographical location
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Years of practice
0–5
6–10
11–19
20+
All participants
(n = 209)
n (%)
Acute care
(n = 77)
n (%)
Inpatient rehabilitation
(n = 81)
n (%)
Community
(n = 51)
n (%)
2
27
2
19
16
4
104
35
(1.0)
(12.9)
(1.0)
(9.1)
(7.7)
(1.9)
(49.7)
(16.7)
1
10
1
8
8
3
34
12
(1.3)
(13.0)
(1.3)
(10.4)
(10.4)
(3.9)
(44.1)
(15.6)
1
12
1
10
7
1
37
12
(1.2)
(14.9)
(1.2)
(12.3)
(8.6)
(1.2)
(45.7)
(14.9)
0
5
0
1
1
0
33
11
(0)
(9.7)
(0)
(2.0)
(2.0)
(0)
(64.7)
(21.6)
87
72
39
11
(41.6)
(33.5)
(18.2)
(6.7)
40
26
10
1
(51.9)
(33.8)
(13.0)
(1.3)
32
28
18
3
(39.5)
(34.6)
(22.2)
(3.7)
15
18
11
7
(29.4)
(35.3)
(21.6)
(13.7)
338
D. SANSONETTI AND T. HOFFMANN
TABLE 2: Participants’ rankings of reasons for selection of and challenges with using cognitive screens
Reasons for selection
Identify presence of cognitive deficits
Quick and easy to administer
Support findings of OP-based assessments‡
Assist with development of intervention strategies
I am familiar with the assessment
It has known reliability and validity
Identify strengths in cognitive functioning
Predict client’s safety for return home
N/A – do not use cognitive screens
Challenges with use
Using results to predict occupational performance
(OP) within home setting
Linking assessment results to OP
Using results to generate intervention strategies
Client’s readiness to participate in assessment
Engaging my client in the assessment
Lack of resources/access to these tools
Ability to interpret assessment results
Level of confidence administering and
interpreting assessments
Ability to articulate assessment findings
All participants
ranking (%)†
Acute care
ranking (%)
Inpatient rehabilitation
ranking (%)
Community
ranking (%)
1
2
3
4
5
6
7
12
13
(64.2)
(53.9)
(50.0)
(48.8)
(39.7)
(31.8)
(26.7)
(21.6)
1 (57.1)
3 (54.2)
2 (50.0)
6 (40.0)
5 (35.7)
4 (34.2)
14 (17.1)
7 (32.8)
1.6
1 (68.4)
2 (53.9)
3 (53.9)
4 (51.3)
5 (39.5)
6 (32.9)
7 (31.6)
10 (18.4)
5.1
1 (65.8)
2 (56.1)
5 (39.0)
3 (53.7)
4 (51.2)
16 (24.4)
6 (31.7)
16 (7.3)
14.5
1 (51.1)
1 (54.9)
1 (50.6)
1 (47.1)
2
3
4
5
6
7
8
2
3
4
5
9
6
8
2
3
4
5
6
7
9
2
5
6
4
3
7
8
(41.0)
(29.3)
(23.9)
(18.6)
(16.0)
(11.7)
(10.1)
9 (9.6)
(36.6)
(31.0)
(22.5)
(19.7)
(12.7)
(18.3)
(14.1)
7 (15.5)
(48.1)
(36.4)
(29.9)
(16.9)
(13.0)
(10.4)
(7.8)
8 (9.1)
(41.2)
(19.6)
(15.7)
(21.6)
(23.5)
(9.8)
(7.8)
10 (2.0)
†Percentage of respondents that selected this option.
‡Occupational performance-based.
Table 3 shows participants’ highest ranked reasons
for selection of standardised assessment batteries. There
was consistency among therapists across the continuum
in the use of these assessments to ‘support findings of
OP-based assessments’. The availability of standardised
assessment batteries within acute and inpatient rehabilitation settings was also identified as a factor influencing
selection of these assessments.
Table 4 shows participants’ highest ranked reasons
for selection of OP-based assessments, and reveals differences across the continuum of care. Therapists working in acute settings ranked using this method of
assessment to ‘predict safety for return home’ to be of
greater importance than those working in inpatient
rehabilitation settings. Therapists working in inpatient
rehabilitation and community settings ranked using
these assessments to ‘assist with development of intervention strategies’ and ‘simultaneously trial intervention
strategies’ to be of greater importance than those in
acute settings.
Challenges with use of assessments
Challenges identified with the use of cognitive screens
and standardised assessment batteries across the
continuum of care are shown in Tables 2 and 3. In
relation to cognitive screens, clinicians working in
acute settings more frequently reported challenges
with their ‘ability to articulate assessment findings’,
and ‘level of confidence with administering and interpreting assessments’ than those working in inpatient
rehabilitation or community settings. Whereas clinicians across all practice areas ranked using standardised assessment batteries to ‘assist with development
of intervention strategies’ as the third most important
reason for using these assessments, this same factor was also identified as one of the most frequently encountered challenges associated with their
use.
The participant group as a whole identified the ‘client’s ability to tolerate full assessment’ and ‘using
results to predict occupational performance in the home
environment’ to be the most common challenges with
use of standardised assessment batteries. Less than onequarter (21%) of all respondents reported not using
these assessments in their practice, whereas a further
18% of those who did use these tools cited a lack of
resources or access to these assessments as a barrier to
their use.
Table 4 shows the highest ranked challenges with the
use of OP-based assessments across the continuum of
care. Almost 20% of participants across acute and
inpatient rehabilitation settings identified ‘articulating
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COGNITIVE ASSESSMENT IN OCCUPATIONAL THERAPY
TABLE 3: Participants’ rankings of reasons for selection of and challenges with using standardised assessment batteries
Reasons for selection
To identify cognitive deficits
Support findings from OP-based assessments
To assist with development of intervention strategies
Assessment is available at my facility
To identify strengths in cognitive functioning
It has known reliability and validity
I am familiar with the assessment
Results are easily linked to occupational performance (OP)
Measure change
Predict safety for client’s return home
N/A – do not use standardised assessment batteries
Challenges with use
Client’s ability to tolerate full assessment
Using results to predict OP in home environment
Using results to generate intervention strategies
Linking results to OP
Lack of resources/access to these assessments
Client’s readiness to participate in assessment
Level of confidence administering and interpreting assessments
Ability to interpret assessment results
Ability to articulate assessment findings
All participants
ranking (%)†
Acute care
ranking (%)
Inpatient
rehabilitation
ranking (%)
Community
anking (%)
1 (62.5)
2 (56.8)
3 (51.8)
4 (49.6)
5 (43.2)
6 (43.9)
7 (17.1)
8 (16.5)
9 (11.6)
10 (20.8)
21.4
1 (53.2)
3 (40.4)
5 (40.4)
2 (44.6)
7 (29.8)
4 (34.0)
8 (29.8)
9 (25.5)
10 (11.1)
6 (34.0)
31.3
2 (62.3)
1 (62.3)
4 (55.7)
3 (55.7)
5 (44.3)
6 (50.8)
8 (27.9)
7 (31.1)
10 (13.8)
9 (22.9)
18.2
1 (73.7)
2 (65.8)
3 (60.5)
5 (47.3)
4 (52.6)
6 (50.0)
7 (34.2)
8 (23.7)
9 (10.5)
12 (5.2)
8.3
1
3
2
5
6
4
7
10
7
2
1
5
3
4
7
8
8
11
1
2
3
4
5
7
8
9
9
(35.7)
(29.1)
(23.1)
(20.9)
(18.1)
(17.0)
(10.4)
(9.3)
(9.3)
1
2
3
4
4
4
8
7
9
(32.8)
(31.3)
(20.9)
(16.4)
(16.4)
(16.4)
(9.0)
(10.4)
(7.5)
(42.9)
(23.4)
(28.6)
(19.5)
(16.9)
(20.8)
(14.3)
(9.1)
(14.3)
(33.3)
(41.7)
(20.8)
(27.1)
(25.0)
(14.6)
(8.3)
(8.3)
(4.2)
†Percentage of respondents that selected this option.
assessment findings’ to be one of the highest ranked
challenges with use of OP-based assessments.
Utility and perceived importance of OPbased assessments
OP-based assessments were ranked as the most important method of information gathering by the participant
group as a whole. In descending order participants then
ranked collaborative history, initial interview, liaison
with the multidisciplinary team, standardised assessment batteries, home assessment and cognitive screens
as the most important methods of information gathering. Sixty-two per cent of participants reported using
OP-based assessments in combination with cognitive
screens, and 28% reported using OP-based assessments
in combination with standardised assessment batteries
for more than half of their clients presenting with cognitive impairment.
Overall, 69% of participants reported using OP-based
assessments for more than 75% of their clients with
cognitive impairment within the last month, making
this the most frequently used method of cognitive
assessment across the continuum of care. Clinicians in
inpatient rehabilitation settings reported the highest
use, with 80% using this method of assessment for
more than 75% of their clients, compared with clinicians in community (67%) and acute (58%) settings.
Only 5% of participants that used OP-based assessments reported using standardised measures, with the
PRPP system of task analysis and the Assessment of
Motor and Process Skills cited as the measures of
choice in these instances. Seventy-two per cent of clinicians in inpatient rehabilitation and community settings reported conducting OP-based assessments
within the client’s own home environment for more
than half of their clients presenting with cognitive
impairment, whereas only 14% of those in acute settings reported doing the same.
Discussion
This study surveyed occupational therapists’ use and
selection of cognitive assessment methods, along with
the challenges associated with their use when working
with individuals with cognitive impairment post-stroke
and TBI. The main findings of this study highlight the
importance of applying a combination of approaches
throughout the cognitive assessment process, along with
the value that clinicians place on OP-based assessment
in occupational therapy practice.
340
D. SANSONETTI AND T. HOFFMANN
TABLE 4: Participants’ rankings of reasons for selection of and challenges with using occupational performance-based assessments
Reasons for selection
Provides valuable information re: impact of
cognitive impairment on occupational performance (OP)
To identify the level of independence within OP
Results are easily linked to OP
To predict safety for client’s return home
To identify cognitive deficits
To simultaneously trial intervention strategies
Assist with development of intervention strategies
To identify strengths in cognitive functioning
Predict the need for services following discharge
Challenges with use
Lack of quantitative data provided by assessment
Generalising results to the home environment
Knowing the level of prompts to provide
No challenges
Articulating assessment findings to others
Documenting results
Interpreting results
Knowing how to set up the environment for assessment
Using results to generate intervention strategies
All participants
ranking (%)†
Acute care
ranking (%)
Inpatient
rehabilitation
ranking (%)
1 (81.4)
1 (74.6)
1 (83.5)
2
3
4
5
6
7
8
9
(60.6)
(54.3)
(52.1)
(47.3)
(38.8)
(31.4)
(30.8)
(19.5)
3
4
2
6
8
9
7
5
(54.9)
(53.5)
(67.6)
(46.5)
(25.4)
(23.9)
(32.4)
(24.5)
2
3
4
6
5
8
9
7
(68.4)
(56.9)
(51.9)
(44.3)
(46.8)
(17.7)
(22.8)
(21.5)
3
2
11
4
7
6
5
8
(60.4)
(62.5)
(22.9)
(54.2)
(41.7)
(35.4)
(39.5)
(13.5)
1
2
3
4
5
6
7
8
9
(44.4)
(43.9)
(21.2)
(15.9)
(15.3)
(14.3)
(13.2)
(12.7)
(11.6)
2
1
3
6
4
9
6
8
5
(41.4)
(50.0)
(22.9)
(14.3)
(18.6)
(10.0)
(14.3)
(11.4)
(15.7)
1
2
3
5
3
6
7
7
9
(47.5)
(33.8)
(18.8)
(17.5)
(18.8)
(16.3)
(15.0)
(15.0)
(7.5)
2
1
3
4
9
5
7
7
6
(44.0)
(46.0)
(24.0)
(18.0)
(4.0)
(16.0)
(10.0)
(10.0)
(12.0)
Community
ranking (%)
1 (83.3)
†Percentage of respondents that selected this option.
In contrast with previous research, findings indicated
that OP-based assessments were the most frequently used
and considered the most important method of cognitive
assessment by participants across the continuum of care
(Alotaibi et al., 2009; Koh et al., 2009; Wheatley, 1994).
One of the key strengths identified with these assessments was their provision of valuable information
regarding the impact of cognitive impairment on a client’s occupational performance capacity. This is of particular relevance to clinicians in hospital settings who are
often expected to make predictions and recommendations about a client’s safety, independence and efficiency
in ADL performance. In acute hospital settings, clinicians
are often required to make rapid decisions regarding a
client’s readiness for discharge home, or alternatively
advocate the need for ongoing therapy in an inpatient
rehabilitation setting (Groves et al., 2010). It is therefore
not surprising that clinicians working in acute settings
ranked using OP-based assessments for the purpose of
predicting clients’ safety for return home to be more
important in their practice than those working in inpatient rehabilitation or community settings. Clinicians’ use
of OP-based assessments for predictive purposes also
highlights the need to use ecologically valid methods of
cognitive assessment in practice that are able to identify
the real-life manifestation of the impact of the client’s cognitive impairment on their ability to engage in daily tasks
and fulfil important life roles (Aubin, Chapparo, Gelinas,
Stip & Rainville, 2009; Giles, 1998; Lewis et al., 2011).
Similar to findings of Douglas et al. (2007), results of
the present survey indicated that when using OP-based
assessments, participants tend to use non-standardised
methods. The main challenge identified by participants
when using OP-based assessments was the lack of
quantitative data provided by this method. This may
further explain some of the challenges identified by clinicians; in knowing the level of prompts to provide
throughout OP-based assessments, and articulating
assessment findings. Along with providing quantitative
data, standardised OP-based assessments, such as the
PRPP system of task analysis, hold the benefit of providing a format for structuring both the task and observations. This structure can assist with interpretation and
articulation of assessment results (Fry & O’Brien, 2002).
Issues surrounding the use of non-standardised OPbased assessments have been highlighted throughout
the literature, with the suggestion that the subjective
nature of observations made within these assessments
may be influenced by the clinician’s view of what constitutes ‘normal’ behaviour (Vining-Radomski, 2008).
The limited use of standardised OP-based assessments
may also be indicative of a lack of formal training by
therapists in the use of such tools, highlighting the need
for promotion of training in this area.
341
COGNITIVE ASSESSMENT IN OCCUPATIONAL THERAPY
The second most frequent challenge associated with
OP-based assessments was the attempt to use results
from these assessments completed in the clinical environment to predict the client’s performance in their
home environment. This is not surprising considering
the varying demands that different environmental contexts may place on the client, possibly creating differences in performance across environments (Nygard,
Bernspang, Fisher & Winblad, 1994; Toglia, Golisz &
Goverover, 2009). In order to ensure greater ecological
validity, it is recommended that OP-based assessments
are completed in conditions simulating the client’s natural environment (Giles, 1998).
The lack of ecological validity of cognitive screens
and some standardised assessment batteries was cited
by participants as the most frequent challenge in using
these tools. Difficulties were also reported when using
these assessments for linking results to occupational
performance and predicting performance in the home
environment. It is important to note that most cognitive
screens are not designed to predict an individual’s
capacity within occupational performance, with their
purpose being to highlight an individual’s strengths
and weaknesses in cognitive domains, and to measure
change at the ‘body structure and function’ level (Douglas et al., 2008; Hartman-Maeir et al., 2009b; Salter, Jutai,
Teasall, Foley & Bitensky, 2005; Sohlberg & Mateer,
2001). When considering that the second highest ranked
reason for using cognitive screens was their speed and
ease of administration, it is not surprising that despite
their limitations, these tools were reported to be regularly used across the continuum of care. The lack of
established predictive validity of cognitive screens and
some standardised assessment batteries, along with the
complexity of occupational performance activities, highlights the importance of using results from these tools
in combination with OP-based assessments when
attempting to estimate occupational performance capacity (Hartman-Maeir et al.).
Whereas this study has provided further insight into
the cognitive assessment practices of occupational therapists, there remains a gap in the literature promoting
the multifaceted utility of standardised OP-based
assessment as: an information gathering approach, a
means of generating intervention strategies, and a
method for evaluating effectiveness of interventions in
practice. With the cognitive rehabilitation literature
placing increasing emphasis on the need to measure
effectiveness of cognitive rehabilitation through investigating change at the ‘activity and participation’ level
(Wilson, Evans & Gracey, 2009), future research efforts
that focus on using OP-based assessments to demonstrate this will be important.
Limitations
Limitations of this study include the low response rate,
and that the majority of participants were from Victoria,
Western Australia, and New South Wales. The results
of this study may not be reflective of practice in all
areas of Australia. There is also potential for response
bias, with those clinicians that were more knowledgeable or with particular interest in the area of cognitive
assessment
participating.
Clinicians
may
have
responded in a way that they feel constitutes ‘best practice’ rather than actual practice. The fixed-choice format
of the survey did not allow for further exploration of
participants’ responses for some items, which may have
also resulted in omission of some information.
Conclusion
This study highlights the depth of knowledge and skill
required by occupational therapists in order to utilise a
broad range of cognitive assessment methods when
working with individuals with cognitive impairment
post-stroke and TBI. The recognition of the utility and
importance of OP-based assessments in occupational
therapy practice demonstrates the unique role of occupational therapists in cognitive rehabilitation. It is recommended that a range of assessment tools be used
throughout the cognitive rehabilitation process, in collaboration with the multidisciplinary team, to provide a
thorough cognitive evaluation that considers both the
client’s underlying cognitive capacities and occupational
performance abilities. Focussed efforts to further incorporate standardised OP-based assessments into clinical
practice, research and ongoing professional development
are required to enhance occupational therapy services
when working with individuals with cognitive impairment. Standardised OP-based assessments should also
be promoted at an undergraduate level and access to,
training in and use of them enabled by employers of
practicing clinicians. Future research efforts should also
be directed towards demonstrating the utility of standardised OP-based assessments in generating targeted cognitive rehabilitation programs that are focussed towards
affecting change in client performance at an ‘activity and
participation’ level.
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