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Performance-Based
Cognitive Assessment
Glen Gillen, EdD, OTR, FAOTA
Programs in Occupational Therapy
College of Physicians and Surgeons
Columbia University I have no financial disclosures.
Outline 
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Approaches to cognitive & perceptual assessment
Assessing and documenting the impact of cognitive & perceptual impairment on everyday living: A 2 step process
Review clusters of neurobehavioral impairments observed during everyday function
Review of potential standardized assessments for adoption
Questions & comments…..
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Two schools of thought regarding evaluating cognitive and perceptual impairments. Documenting Cognitive/Perceptual Impairment(s) Documenting the impact of cognitive and perceptual impairments on daily life. Independence and safety!
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Documenting the impact of cognitive and perceptual impairments on daily life… 2 steps. S
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Level of Self‐Awareness 2
Performance Based Testing Ascertaining Level of Self‐
Awareness (Crosson et al.)
Anticipatory Awareness Emergent Awareness Intellectual Awareness 3
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Awareness Evaluation
Questionnaires (self or clinician rated)
Interviews
 Rating scales
 Functional observations
 Comparisons of self‐ratings and ratings made by others such as significant others, caretakers, or rehabilitation staff
 Comparisons of self‐ratings and ratings based on objective measures of function or cognitive constructs
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Awareness Assessments
Self‐Awareness of Deficits Interview (Fleming & Strong)  Self‐Regulation Skills Interview (Ownsworth, et al.)
 The Patient Competency Rating Scale (Prigatano)  Awareness Questionnaire (Sherer, et al.)
 Awareness Interview (Anderson & Tranel)  Assessment of Awareness of Disability (Kottorp & Tham) 
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Task
Impairment
Skewed Self‐Awareness 4
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Series 1
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Predicted
Actual
Skewed Ability to Predict Everyday Function Series 1
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Predicted
Actual
Safety!
Anticipatory Compensation Situational Compensation Poor awareness compensations to improve everyday function.
External Compensation
Recognition Compensation
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Engagement in any daily activity requires multiple cognitive and perceptual processes to support function….
Impaired cognitive or perceptual processing may limit daily performance and result in an observable error during attempts to function..
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Evaluate Cognition/Perception in Context
Performance Based Cognitive Assessment
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Tasks performed in context are ecologically valid.
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Require multitasking.
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Require access to a variety of supporting processes.
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More accurate indicator of performance in an unstructured situation. “Fly on the wall” perspective.
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Valid, reliable, accurate.
Mechanics of Performance Based Cognitive Assessment
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Everyday activities that a patient wants to do, needs to do, and/or has to do.
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“Fly on the wall”: Let safe errors occur (awareness and problem solving observed).
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Intervene for safety concerns are breakdown in performance prevents continuation.
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Mechanics of Performance Based Cognitive Assessment
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Error analysis based on operational definitions and descriptive terminology.
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Structured cuing procedures to support performance. 
Identifies the impact of impaired cognitive/perceptual processing that limits everyday function. 
Identifies cognitive and perceptual processes that support everyday function.
Let safe errors occur…
Observe for patterns of neurobehavioral deficits.
Examples……
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Lack of an idea of what to do
Poor initiation
Performance latency
Incorrect tool use
Mouthing objects
Inability to organize and sequence
Flat affect
Poor awareness and judgment (safety!)
Loss of the foundation of everyday performance
May co‐exist with aphasia Ideational Apraxia: Cluster of Behaviors
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Does not know how to perform
Clumsy movements
May impact limbs and/or trunk activities
Gross and fine mobility tasks impaired
Static/awkward hand postures
Poor manipulation
Difficulty crossing midline Easily frustrated May co‐exist with expressive aphasia Motor Apraxia: Cluster of Behaviors
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Hypo‐attentive to the left side of the world
Hyper‐attentive to the right side of the world Can impact any sensory system Poor awareness Decreased leftward limb and eye movements
Presents with topographical disorientation
Occasionally attends to left (attentional bias)
Difficulty crossing midline towards left
May present related to near space, far space, or both
May or may not co‐exist with a field cut Safety concerns during mobility
Unilateral Spatial Neglect: Cluster of Behaviors
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Hypo‐attentive to the left side of the body
Hyper‐attentive to the right side of the body
 Attentional bias towards the right side of the body
 Higher % of time managing the right side of the body
 Poor awareness  Errors related to personal space and body management
 Safety 
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Unilateral Body Neglect: Cluster of Behaviors
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Incorrect end point when reaching or stepping
Figure‐ground impairment Difficulty way finding
Difficulty spatially orienting objects to each other or to self
“Lost in space”
Safety concerns
Perseverative errors Easily frustrated May co‐exist with decreased overall attention
Visual‐Spatial Impairment: Cluster of Behaviors
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Difficulty multi‐tasking
Poor decision making
Poor problem solving
Difficulty task switching
Poor abstraction
Impulsive
Lack of insight
Disorganization
Impaired sequencing
Decreased time pressure management Safety Executive Dysfunction: Cluster of Behaviors
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From Non‐Standardized Observations to Standardized Assessment
Ecological Validity is a Critical Factor to Consider....
100,93,86,79…
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A‐ONE (Arnadottir, 1990, 1999, 2015)
Analysis of everyday performance
Dressing
 Grooming and Hygiene
 Transfers and Mobility
 Feeding
 Communication
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Cognitive processes that support/limit performance Organization
Sequencing
 Neglect
 Spatial Dysfunction
 Initiation
 Alertness
 Attention
 Memory
 Ideation
 Etc. 
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Catherine Bergego Scale (CBS) (Azouvi, 2003)
Analysis of everyday performance
Dressing
Grooming/hygiene  Mobility
 Feeding
 Social interactions
 10 items in total
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Cognitive processes that support/limit performance Lateralized Attention Deficit
 Awareness
 Topographical Disorientation 
Executive Function Performance Test (EFPT) (Baum et al., 2008; Katz et al., 2007; Goverover et al., 2005)
Analysis of everyday performance
Cooking Oatmeal
 Making Phone Call  Taking Medication  Paying a Bill
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Cognitive processes that support/limit performance Initiation
Organization
 Sequencing
 Safety and Judgment
 Completion
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Multiple Errands Test (Knight, Alderman, & Burgess, 2002; Shallice & Burgess, 1991 )
Analysis of everyday performance
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Multi tasking during a shopping/community experience
Purchase 3 items, pick up an envelope from reception, use telephone, post the envelope
Writing down four items re: information (ex. gift shop hours)
Meet assessor and ask the time
Inform assessor that the test was completed
Cognitive processes that support/limit performance Executive functions
Dysexecutive
syndrome
 Initiation
 Planning
 Attentional switching
 Working memory
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Assesment of Disabilities in patients with Apraxia
(Van Heugten, 1999, 2000).
Analysis of everyday performance
Cognitive processes that support/limit performance Initiation Planning
 Ideation
 Control
 Execution
 Awareness of errors
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Hygiene
Dressing
 Preparing food
 Patient chosen activity
The Kettle Test
(Hartman‐Maeir, Armon, & Katz, 2005)
Analysis of everyday performance
Cognitive processes that support/limit performance Making two hot beverages with different ingredients using an electric kettle.
 13 discrete steps in total.
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Screening for a broad range of basic and higher level cognitive processes.
 Executive functions
 Working memory
 Awareness/safety
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Weekly Calendar Planning Activity
(Toglia, 2015)
Analysis of everyday performance
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Ability to use a list, follow rules, and enter information accurately into a weekly schedule.
Cognitive processes that support/limit performance 
Executive functions: planning, working memory, organization, self‐monitoring, self‐
regulation, etc. Questions, comments, thank you!
American Occupational Therapy Association (2013). Cognition, cognitive rehabilitation, and occupational performance. American Journal of Occupational Therapy 67: S9‐S31.
Baum, C. M., Connor, L. T., Morrison, T., Hahn, M., Dromerick, A. W., & Edwards, D. F. (2008). Reliability, validity, and clinical utility of the Executive Function Performance Test: A measure of executive function in a sample of people with stroke. American Journal of Occupational Therapy, 62, 446–455.
Burgess, P. W., Alderman, N., Forbes, C., Costello, A., Coates, L. M., Dawson, D. R., . . . Channon, S. (2006). The case for the development and use of “ecologically valid” measures of executive function in experimental and clinical neuropsychology. Journal of the International Neuropsychological Society, 12, 194–209.
Bottari, C., & Dawson, D. R. (2011). Executive functions and real‐world performance: How good are we at distinguishing people with acquired brain injury from healthy controls? OTJR: Occupation, Participation and Health, 31, S61–S68
Burns, S. C., & Neville, M. (2016). Cognitive assessment trends in home health care for adults with mild stroke. American Journal of Occupational Therapy, 70, 7002290020.
Chevignard, M. P., Taillefer, C., Picq, C., Poncet, F., Noulhiane, M., & Pradat‐Diehl, P. (2008). Ecological assessment of the dysexecutive syndrome using Execution of a Cooking Task. Neuropsychological Rehabilitation, 18, 461–485.
Dickerson, A. E., Meuel, D. B., Ridenour, C. D., & Cooper, K. (2014). Assessment tools predicting fitness to drive in older
adults: A systematic review. American Journal of Occupational Therapy, 68, 670–680.
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Gillen, G. (in press). Evaluation and Treatment of Limited Occupational Performance Secondary to Cognitive Dysfunction. In Schultz‐Krohn, W. & Pendleton, H. (eds.) Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction, 8th ed., Elsevier Science/Mosby, St. Louis.
Gillen, G., Nilsen, D. M., Attridge, J., Banakos, E., Morgan, M., Winterbottom, L., & York, W. (2015). Effectiveness of interventions to improve occupational performance of people with cognitive impairments after stroke: An evidence‐based review. American Journal of Occupational Therapy, 69, 6901180040, 1‐9.
Gillen, G. & Brockmann‐Rubio, K. (2016). Treatment of cognitive‐perceptual
impairments: A function‐based approach. In Gillen, G. (ed.) Stroke Rehabilitation: A Function‐Based Approach, 4th edition, Elsevier Science/Mosby, St. Louis, pp:612‐646.
Gillen, G. (2009). Cognitive and Perceptual Rehabilitation: Optimizing Function. Elsevier/Mosby, St. Louis. Morrison, M. T., Edwards, D. F., & Giles, G. M. (2015). Performance‐based testing in mild stroke: Identification of unmet opportunity for occupational therapy. American Journal of Occupational Therapy, 69, 6901360010.
Sansonetti, D. & Hoffmann, T. (2013). Cognitive assessment across the continuum of care: The importance of occupational performance‐based assessment for individuals post‐stroke and traumatic brain injury. Australian Occupational Therapy Journal 60(5), 334‐342.
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