Utilizing occupation based assessments of executive function; from acute care to the community. Connecticut Occupational Therapy Association Annual Conference 2015 Christopher Delenick, OTR/L Alpha One

Learning Objectives Participants will demonstrate the ability to describe the clinical and psychometric properties of assessments reviewed during the presentation. Participants will demonstrate the ability to identify patient populations that would benefit from the utilization of occupation based assessments. Participants will demonstrate the ability to outline methods for implementing the use of occupation based assessments in their current practice setting.

The Cognitive Puzzle –Rehab (PT/OT/SLP) –Nursing –Physician –Physician’s Assistant/Nurse Practitioner –Social Work

AOTA Commission on Practice: Statement on Cognition “Occupational Therapy comes to cognitive rehab from the standpoint of occupation, observation of functioning, and performance based assessment.”

Evaluating Cognition What level are we evaluating? In what context are we evaluating? Does the assessment consider cognitive-motor interference?

Acute HospitalSNF Community Programs Acute Rehab COGNITION

Approaches to Assessment Bottom up –Impairment focused –Lack of connection between impairment and meaningful activity/role –Deficits of components –Focus on prerequisites to function

Approaches to Assessment Top down –Role competence –Meaningfulness –Discrepancy in performance –Determine tasks that define roles –Reasons for inability to perform tasks

The “perfect” test? Has been and can be administered by many clinicians Addresses multiple cognitive domains Stable tool (research supported) Sensibility Reliability Validity –Criterion –Predictive –Ecological

Ecological validity The degree to which the cognitive demands of the test theoretically resemble the cognitive demands in the everyday environment. Chaytor & Schmitter-Edgecomb, 2003

Ecological Validity “Real-world performance tests are ecologically valid because they use naturalistic environments, do not provide artificial structure, require multitasking and reflect the press of everyday task performances.” Baum, 2009

Executive Function Initiation Planning Decision making Judgment Attention Self-monitoring Incorporating feedback Cognitive flexibility LIFE!!

Executive Function “traditional tests of executive function were not developed to measure clinically significant deficits” “…performance on these test is so unlike that of everyday performance that the assessment is of uncertain value in relation to predicting how people will manage in their everyday lives.” Dawson et al, 2009 I spelled world backwards, now I can go home!!

Occupation based assessments Arnadottir OT-ADL Neurobehavioral Evaluation (A-ONE) Assessment of Motor and Processing Skills (AMPS) Kettle Test Executive Function Performance Test (EFPT) Multiple Errands Test (MET)

The Kettle Test Developed 2005 “Brief performance measure…based on a complex everyday task...designed to tap into basic and higher level cognitive processes.” Katz, 2009

The Kettle Test Scripted instructions Prepare two hot beverages; –One for client –One for clinician Increased complexity; –Beverage for clinician differs in 2 ingredients –Electric kettle emptied and disassembled –Additional utensils and ingredients placed on tray

The Kettle Test Scored on 13 steps Guidelines for cuing Each step scored according to degree of cuing/assistance necessary for completion Total score: 0-52

The Kettle Test 0 - Intact performance 1 - Slow and/or trial & error, and/or questionable performance, but completes independently 2 - Received general cues 3 - a. Received specific cueing b. incomplete or deficient performance or c. did not perform 4 - Received physical demonstration or assistance.

The Kettle Test Follow Up: –Examiner description of process –Client recall of instructions –Client description of process –Client rating of performance –Client rating of difficulty of task

The Kettle Test When do I intervene? –Unsafe performance (client or environment) –No progress (inactivity for one minute) –Repeated failure or request for assistance

Multiple Errands Test Originally developed in Great Britain in 1991, assessments completed at a community shopping center. Adapted in 2002 for use in a hospital setting. Multiple studies of adapted hospital and community version. Measures impact of executive dysfunction. Everyday situations that require planning and multi-tasking over longer periods of time.

Multiple Errands Test 18 years of age or older No gross perceptual impairment Intact functional language skills Independent functional mobility for 30 minutes or more.

Multiple Errands Test Collect something Make a phone call Mail something Make three purchases within a budget Meet the examiner for an appointment Find out 4 pieces of information

Multiple Errands Test Collect map from the main reception desk. Buy 4 pieces of individually wrapped candy. Buy a greeting card. Buy a 12oz. can of soda. Call the time and temperature building and write down the results. Address an envelope and return the map to; Dave Smith, PT Maine Medical Center Rehabilitation Medicine Department 22 Bramhall Street Portland, ME Meet your examiner in the main lobby 20 minutes after you have started the test for an appointment. Tell the examiner when you have finished the test. Find out the following information and write it down. 1.What time did you call the “Time and Temperature Building” and what was the temperature? 2.What is the closing time of the Coffee Shop/Pavilion Grill? 3.What is the price of a snickers bar? 4.Where is public parking located?

Multiple Errands Test Do all the tasks but do them in any order you choose. Don’t spend more than $5. Stay on the hospital grounds. Don’t enter any “staff only” areas or other patient’s rooms. Try to complete the tasks as quickly as possible but don’t rush. Don’t speak to the person observing you unless it is part of the exercise. Don’t purchase more than 2 items in the gift shop. Don’t go back into an area you have already been in.

Multiple Errands Test Total time to complete. Total number of locations visited Total number of tasks completed Total number of rule breaks Performance Efficiency – Number of tasks completed/total number of locations visited

Multiple Errands Test Participants escorted to starting location Participants read MET instructions and rules to examiner Examiner provides standardized responses Time cut-off Participants given; –Clipboard –Task list/instructions/rules –Money –Pen –Backpack/tote bag

Executive Function Performance Test Developed by C.M Baum at the Washington University School of Medicine in St. Louis MO. Performance based standardized assessment of cognitive functioning (Baum & Edwards, 1993) Designed to examine cognitive integration and functioning in an environmental context; specifically in the context of performing a task (Baum 2008)

EFPT Three purposes: –To determine which executive functions are impaired –To determine an individual’s capacity for independent functioning –To determine the amount of assistance necessary to task completion Baum et al 2008

EFPT 4 basic tasks (essential for independent living) –Simple cooking –Telephone use –Medication management –Bill payment Baum et al 2008

EFPT Initiation Organization Sequencing Safety and judgment Completion of task Baum et al 2008

EFPT – 0-no cues – 1-verbal guidance – 2-gestural guidance – 3-direct verbal assistance – 4-physical assistance – 5-do for the participant Baum et al 2008

EFPT Executive function component score Task score Total score

Multiple Errands Test/ Kettle Test/Executive Function Performance Test

Performance Based Assessment StrengthsChallenges High ecological validityCan’t retest without alternate forms Task in contextHave to be developed for each site (MET) In line with our philosophy (OT)No time limit Inexpensive, availableNarrow scope Identifies the impact of impairment on occupational performance Change in practice (culture)

From paper to practice:

From Paper To Practice, A Timeline.

“Cognition” Time Line Course work 1 st version of MET Staff education 2 nd Version of MET “Piecemeal” No standardized testing Committee on cognition formed

“Cognition” Time Line rd Version “voucher” version 1 st use of EFPT 4 th Version Staff education 1 st use of Kettle Test

“Cognition” Time Line current Computerized documentation Cognistat eliminated Staff survey Staff education 5 th version of MET Continued education on EFPT, Kettle Test

How do you get here?

Pick a test, any test. Educate Persevere Prepare Educate Adapt Educate

References Baum, C. Connor, L., Morrison, T., Hahn, M., Dromerick, A. and Edwards D. (2008). Reliability, Validity and Clinical Utility of the Executive Function Performance Test: A Measure of Executive Function in a Sample of People with Stroke. AJOT, 62 (4) Cicerone KD. (2002) The enigma of executive functioning. Neuropsychological interventions. New York: Guilford Pr;. Chaytor, N. & Schmitter-Edgecomb, M (2003). The Ecological Validity of neuropsychological Tests: A review of the literature on everyday cognitive skills. Neuropsychology Review, 13: Dawson et al. (2009) Further Development of the Multiple Errands Test: Standardized Scoring, Reliability, and Ecological Validity for the Baycrest Version. Arch Phys Med Rehab, 90 (2). Knight C, Alderman N, Burgess P. (2002) Development of a simplified version of the multiple errands test for use in hospital settings. Neuropsychological Rehabilitation, 12(3).

References Spordone R.J.: Ecological validity: some critical issues for the neuropsychologist. In: Ecological Validity of Neuropsychological Testing, pp New York: St Lucie Press; Wolf, T., Barbee, A., White, D. (2011) Executive Dysfunction Immediately After Mild Stroke. OTJR, 31 (1), S23-S29 Wolf, T., Stift, S., Connor, L., Baum, C. (2010). Feasibility of using the EFPT to detect executive function deficits at the acute stage of stroke. Work, 36,