problem solving assessment occupational therapy

5 Free Cognitive Assessments for Occupational Therapists

Finding free cognitive assessments that are applicable for occupational therapists can be a challenge when you’re in a time crunch or new to the field.

As you may have found, rehab settings don’t always have these easily on hand when you’re in need of assessing a patient’s cognition during an evaluation or treatment.

Because of this, we did the research for you and found these easy to access cognitive assessments that can be quickly printed off when you’re in a pinch. 

These cognitive assessments can be used in pretty much any adult-based occupational therapy setting , from acute care, to inpatient rehab, sub-acute rehab or outpatient, depending on what aspect of cognition you’re looking to assess. You can use the results from any of these assessments to guide your treatments, share with your rehab team for discharge planning and/or determine if your patient will benefit from further follow-up from their physician or neuropsychologist.

So without further ado, here are 5 free* cognitive assessments, along with how-to instructions if you’re new to using them. 

1. The Saint Louis University Mental Status (SLUMS) Examination

The SLUMS examination is a popular and quick cognitive assessment, and is my go-to free assessment (especially since the MoCA cognitive assessment is no longer free). The SLUMS incorporates a clock drawing task, animal naming, figure differentiation and size differentiation, assessing orientation, memory, attention, and executive function. It’s purpose is used to detect mild cognitive impairment and dementia.

If you aren’t familiar with how to use the SLUMS, be sure to check out their training video here .

2. Confusion Assessment Method for the ICU (CAM-ICU)

The CAM-ICU  is a great assessment for OTs working in the intensive care unit (ICU) to assess and monitor delirium. This is different from the other tests which looking for dementia, whereas this assessment looks for an acute onset of delirium.

This is defined by the CAM-ICU as “a disturbance of consciousness characterized by acute onset and fluctuating course of inattention accompanied by either a change in cognition or a perceptual disturbance, so that a patient’s ability to receive, process, store, and recall information is impaired.”

Delirium in the hospital develops quickly, over a short period of time and, unlike some forms of dementia, is usually reversible.

This test is an important one to use as ICU delirium often results in increased risks of: mortality, length of stay, healthcare costs, time on ventilator and re-intubation, long-term cognitive impairment, and discharge to long-term care facility. 

Here is the full training manual for how to use the CAM-ICU .

3. The Short-Blessed Test

The Short-Blessed Test (with instructions included in the link) is a quick cognitive screen designed to help detect early cognitive changes associated with Alzheimer’s disease or other dementias for OTs working with older adults. The scores range from normal cognition, questionable impairment, or impairment consistent with dementia.

4. The Kettle Test

The Kettle Test is a functional cognitive screening test that involves the client preparing two cups of a hot beverage; one for the individual being assessment and one for the examiner. The examiner asks the client to prepare a hot drink that differs in two ingredients from the one he/she chose for the examiner.

The test does require a few ingredients but your facility may already have them on hand. These include a kettle, instant coffee, tea, sugar/sweetener, milk, salt, pepper and oil (as distraction items). Other items include 3 cups, a milk pitcher, a bowl, 2 plates, 3 small spoons, a large spoon, 2 forks, a knife, and a can opener (again with distraction items).

The test with directions has a scoring guide, included in the link above. The scores range from 0-52, with higher scores reflecting more severe problems in performance. The average assessment administration time is 10-30 minutes.

5. The Mini-Mental State Examination (MMSE)*

The Mini-Mental State Examination (MMSE) is a very quick 5-10 minute screening that looks for cognitive impairment and possible dementia. The domains it assesses include orientation, registration, attention, calculation, and language and praxis. The scores range from no cognitive impairment to severe cognitive impairment.

Here are the full instructions on how to use the Mini-Mental Status Exam .

*Update: While the Mini-Mental State Exam is available widely for free access via multiple internet sources, it is copywritten by Psychological Assessment Resources (PAR), so you’ll want to check that your workplace has purchased a license before you use it. If you would like to purchase your own MMSE license, you (or your workplace) can do so here .

_______________

If you’re interested in the specific statistics of each individual cognitive assessment, simply enter the name into the Rehabilitation Measures Database here .

Do you have any other favorite free cognitive assessments that you use in your practice? Please feel free to share them in the comments below!

This post was originally published on June 18, 2017 and last updated on May 23, 2023.

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Thank you for sharing such an important aspect of cognitive assessments

For assessing cognition in people who have had a stroke there is the Oxford Cognitive Screen. It’s free to get a license.

Thank you so much for sharing this valuable information.

You’re very welcome!

Hi,im an occupational therapist in the philippines but im here in israel working as a caregiver,can you please send me the cognitive test for ots?thanks a lot.

Hi Gladys, you can access these assessments through the links in the article. Hope this helps!

Which CPT code should we be billing these under if they occur outside of evaluation day?

Hi there, these are awesome – thank you for sharing. Do you maybe have any simple assessments that can be used for cva client’s who have expressive aphasia (therefore verbal part of assessments not possible) and dominant UL affected (therefore drawing activities limited)? Thank you for your time.

I will definitely take a look and see what I can find! If anyone else knows of any now please share them to the comments 🙂

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The assessment has two main purposes. First, it provides a baseline measure for intervention of children referred for OT treatment due to cognitive and learning difficulties. Second, it identifies potential areas of cognitive strength where children may benefit from mediated learning. Its dynamic testing properties can also be used to identify areas of cognitive strength (Katz et al., 2007).

Link to Instrument

Instrument Details

Area of Assessment

Assessment type, administration mode, actual cost, diagnosis/conditions.

• Brain Injury Recovery
• Pediatric + Adolescent Rehabilitation

Populations

Key descriptions.

• For minimum and maximum scores, see the administration manual; all subtests are scored differently: 1) Orientation score range 1-16 2) Spatial Perception score range 1-12 3) Praxis score range 1-44 4) Visuomotor Construction (VC) score range 7-35 5) VC Memory (immediate) score range 5-25 6) VS Memory (delayed) score range 5-25 7) VC Time (in seconds sum over 7 subtests) 8) Thinking Operations (TO) score range 7-35 9) TO Time (in seconds sum over 7 subtests)
• Each initial incorrect response is scored using a systematic dynamic approach to modify the task through prompting and other forms of mediation; see manual for administration instructions (Katz, Parush, & Traub Bar-Ilan, 2005).

Number of Items

Equipment required.

• Table and 2 chairs (appropriately sized to ensure child's comfort)
• Adequate lighting and ventilation
• Sharpened pencil with eraser
• Several photocopies of pages 11, 13, and 14 of Test Booklet
• DOTCA-Ch Test Kit
• Examiner's manual
• Response/scoring sheets
• Present box
• Finger bead toy
• 3-D wooden maze with marble
• 5 geometric form cards
• 4 plastic geometric form pieces
• Extra set of 4 plastic geometric forms
• 100-holed plastic pegboard and 15 pegs
• Extra set of peg board and pegs
• Simplified pegboard and 9 pegs
• 10 colored 1-inch cubes
• Extra set of colored cubes
• Simplified card
• 9 plan (uncolored) 1-inch cubes
• Extra set of plain cubes
• 9-piece butterfly puzzle
• Simplified 9-piece butterfly puzzle
• Clock parts
• 14 categorization cards
• 5 sequencing picture cards
• 6 sequencing picture cards
• 3 geometric forms: circle, square, triangle
• 9 wooden sticks
• 18 plastic color an shape pieces

Time to Administer

90  minutes

Required Training

Instrument reviewers.

Initially reviewed by University of Illinois at Chicago Master of Science in Occupational Therapy students Jacob Abell, Emilie Berman, and Melissa Umansky.

Measurement Domain

Professional association recommendation.

The DOTCA-Ch was designed to be administered by occupational therapists (Katz, Parush, & Traub Bar-Ilan, 2005).

Considerations

Test data comes from an Israeli sample with research to determine standardization data for American children in progress at time of publication.

Inferences regarding child’s intellectual status resulting from poor scores cannot be made; formal diagnosis of cognitive status requires additional in-depth testing in other disciplines.

Utilize caution to avoid misinterpretation when using the DOTCA-Ch on populations not included in the psychometric samples (Katz, Parush, & Traub Bar-Ilan, 2005).

Pediatric Disorders

Test/retest reliability.

Children with Intellectual Impairments and Learning Disabilities: (Suchitporn et al., 2014; n = 38)

Excellent test-retest reliability of Orientation Subtest (ICC = 0.84)

Excellent test-retest reliability Spatial Perception Subtest (ICC = 0.86)

Excellent test-retest reliability Thinking Operations Subtest (ICC = 0.85)

Interrater/Intrarater Reliability

Children with Intellectual Impairments and Learning Disabilities: (Suchitporn et al., 2014)

Excellent interrater reliability Orientation Subtest (ICC = 0.83)

Excellent interrater reliability Spatial Perception Subtest (ICC = 0.84)

• Adequate interrater reliability Thinking Operation Subtest (ICC = 0.74)

Internal Consistency

Children with Intellectual Impairments and Learning Disabilities: (Suchitporn et al., 2014)

Excellent internal consistency Orientation Subtest (Cronbach's α = 0.83)

Excellent internal consistency Spatial Perception Subtest (Cronbach's α = 0.82)

• Excellent internal consistency Thinking operations subtest (Cronbach's α = 0.82)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity:

Children with Attention Deficit Hyperactivity Disorder: (Coster, Deeney, Haltiwanger & Haley, 1998; Katz, Parush, & Traub Bar-Ilan, 2005)

No ICC reported, per author report there are significant correlations (DOTCA-Ch: Orientation, Visuomotor Construction, Thinking Operations and School Function Assessment (SFA): Cognitive/Behavioral functional tasks)

• No ICC reported, per author report there are significant correlations (DOTCA-Ch: Spatial Perception, Praxis and SFA physical functional tasks)

Construct Validity

Discriminant Validity:

Children with Learning Disabilities, Traumatic Brain Injuries, and Typically Developing Children: (Katz, Parush, & Traub Bar-Ilan, 2005)

Significant differentiation between each group of children with learning disabillites and children with traumatic brain injuries compared with typically developing children ( p < [.001, 0001]). No ICC reported.

Children with Learning Disabilities, Traumatic Brain Injuries, and Typically Developing Children: (Katz et al., 2007)

Children with traumatic brain injuries were matched by age and gender to typically developing children.

2nd and 3rd graders with learning disabilities were age-matched to typically developing 2nd and 3rd graders.

Non-Specific Patient Population

Cut-off scores.

Typically developing children: (Katz, Bar-Ilan, & Parush, 2007; n = 381)

Scoring in the bottom 10% (or less) signifies deficient cognitive abilities

Scoring in the bottom 25% (or less) signifies a risk for cognitive dysfunction

Cut-off scores are different for each age group; see manual for details

Normative Data

Typically developing children: (Katz et al., 2007)

Results of One-way ANOVA for Total Cognitive Domain Scores of the DOTCA-Ch Between Four Age Groups

Typically Developing Children: (Ziviani et al., 2004)

Notes: * = unable to calculate Kappa due to asymmetrical cross-tabulation tables; bef = before mediation; mem = from memory; del = delayed.

Undefined Population of Children: (Katz, Parush, & Traub Bar-Ilan, 2005)

Excellent interrater reliability in Orientation Subtest (ICC = 0.93)

Excellent interrater reliability in Spatial Perception Subtest (ICC = 0.95)

Excellent interrater reliability in Praxis Subtest (ICC = 0.91)

Excellent interrater reliability in Visuomotor Construction Subtest (ICC = 0.99)

Excellent interrater reliability in Memory Subtest (ICC = 0.99)

Excellent interrater reliability in Thinking Operations Subtest (ICC = 0.87)

Typically Developing Children: (Katz et al., 2007)

Excellent interrater reliability Spatial Perception Subtest (ICC = 0.95)

Excellent interrater reliability Praxis Subtest (ICC = 0.91)

Excellent interrater reliability Visuomotor Construction Subtest (ICC = 0.99)

Excellent interrater reliability Immediate Memory Subtest (ICC = 0.99)

Excellent interrater reliability Thinking Operations Subtest (ICC = 0.87)

Poor internal consistency in Orientation Subtest (Cronbach's α = 0.61)

Adequate internal consistency reliability in Spatial Perception Subtest (Cronbach's α = 0.74)

Adequate internal consistency reliability in Praxis Subtest (Cronbach's α = 0.70)

Poor internal consistency reliability in Visuomotor Construction Subtest (Cronbach's α = 0.61)

Poor internal consistency reliability in Immediate Memory Subtest (Cronbach's α = 0.64)

Adequate internal consistency reliability in Thinking Operations Subtest (Cronbach's α = 0.77)

Undefined Sample of Children: (Katz, Parush, & Traub Bar-Ilan, 2005)

Poor internal consistency reliability in Orientation Subtest (Cronbach's α = 0.61)

Poor internal consistency reliability in Memory Subtest (Cronbach's α = 0.64)

Children with Learning Disabilities, Traumatic Brain Injuries, and Typically Developing Children (Katz, Parush, & Traub Bar-Ilan, 2005)

Significant differentiation between each group of Children with LD and TBI to typical children p < [.001, 0001]. No ICC reported.

Children with Learning Disabilities, Traumatic Brain Injuries, and Typically Developing Children (Katz et al., 2007)

Children with TBI were matched by age and gender to typically developing children.

2nd and 3rd graders with LDs were age-matched to typically developing 2nd and 3rd graders.

Multivariate Analyses of Variance Comparing DOTCA-Ch Domain Scores Among Children with Learning Disabilities, Children with Traumatic Brain Injuries, and Typically Developing Children

Notes: DOTCA-Ch = Dynamic Occupational Therapy Cognitive Assessment for Children; TBI = Traumatic Brain Injury; TD = Typically Developing; LD = Learning Disabilities; - = Not Administered; * = only 2 domains were tested; the original brief version of the Praxis Subtest was used in this study.

Bibliography

Coster, W., Deeney, T., Haltiwanger, J., & Haley, S. (1998). School Function Assessment: User’s Manual . San Antonio, TX: Therapy Skill Builders .

DOTCA-Ch Battery. (n.d.). Retrieved from http://www.maddak.com/dotcach-battery-p-27813.html

Katz, N., Golstand, S., Bar-Ilan, R.T., & Parush, S. (2007). The Dynamic Occupational Therapy Cognitive Assessment for Children (DOTCA–Ch): A new instrument for assessing learning potential. American Journal of Occupational Therapy , 61 (1), 41–52. https://doi.org/10.5014/ajot.61.1.41

Katz, N., Parush, S., & Traub Bar-Ilan, R. (2005). Dynamic Occupational Therapy Cognitive Assessment for Children (DOTCA–Ch) manual . Pequannock, NJ: Maddak.

Lersilp, S., Rangson, T., Chinchai, S., & Sriphetcharawut, S. (2014). Reliability of the Dynamic Occupational Therapy Cognitive Assessment for Children (DOTCA-Ch): Thai version of orientation, spatial perception, and thinking operations subtests.  International Journal of Cognitive Research in Science,  2 (1), 69-75.

Rodger, S., Daley, E., Hughes, K., & Ziviani, J. (2005). Dynamic Occupational Therapy Cognitive Assessment for Children: Perceived utility in Australian occupational therapy practice. Australian Occupational Therapy Journal , 52 (4), 337-349. https://doi.org/10.1111/j.1440-1630.2005.00516.x

Ziviani, J., Rodger, S., Pacheco, P., Rootsey, L., Smith, A., & Katz, N. (2004). The Dynamic Occupational Therapy Cognitive Assessment for Children (DOTCA-Ch): Pilot study of inter-rater and test-retest reliability. New Zealand Journal Of Occupational Therapy , 51 (2), 17-24.

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Clinical Reasoning in Occupational Therapy: A Comprehensive Guide

Clinical reasoning is the backbone of effective decision-making and problem-solving in occupational therapy (OT). It enables therapists to analyze complex situations, gather information, and develop tailored treatment plans for their clients. In this blog post, we will delve into the intricacies of clinical reasoning in occupational therapy, exploring its importance, key components, and practical strategies. Whether you’re a seasoned occupational therapist or a student just starting your journey, this guide will empower you to enhance your clinical reasoning skills and deliver optimal outcomes for your patients.

Important of Clinical Reasoning in OT

The Significance of Clinical Reasoning in Occupational Therapy At the core of occupational therapy lies the process of clinical reasoning. This cognitive process allows therapists to integrate knowledge, clinical expertise, and patient values to make informed decisions. Here’s why clinical reasoning is paramount in occupational therapy:

• Promotes Personalized Treatment: Clinical reasoning enables occupational therapists to individualize treatment plans based on the unique needs and goals of each client. By analyzing client factors, activity demands, and environmental considerations, therapists can tailor interventions to maximize functional outcomes.
• Enhances Problem-Solving Abilities: Occupational therapists face diverse challenges and must navigate complex client situations. Clinical reasoning equips them with the skills to identify problems, explore potential solutions, and make sound judgments that optimize intervention effectiveness.
• Facilitates Evidence-Based Practice: Clinical reasoning guides therapists in critically evaluating research evidence and integrating it with their clinical expertise. This ensures that therapeutic interventions are grounded in the latest scientific knowledge and align with best practices.

Components of Clinical Reasoning in OT

Components of Clinical Reasoning in Occupational Therapy To fully grasp clinical reasoning in occupational therapy, it’s essential to understand its core components. Here are the key elements involved:

Strategy of Clinical Reasoning for OT

Strategies for Enhancing Clinical Reasoning in Occupational Therapy

• Continual Professional Development: Engage in ongoing learning and attend relevant workshops, conferences, and seminars to stay updated with the latest evidence-based practices and research.
• Reflective Practice: Regularly reflect on clinical experiences, seeking to understand the reasoning behind your decisions and analyzing the outcomes. This introspection helps refine your clinical reasoning skills over time.
• Collaborative Approach: Foster open communication and collaboration with colleagues, clients, and other healthcare professionals to gain diverse perspectives and enhance your problem-solving abilities.
• Utilize Clinical Tools: Make use of standardized assessment tools, clinical guidelines, and evidence-based resources to support your clinical reasoning process.

FAQ: Frequently Asked Questions about Clinical Reasoning in Occupational Therapy

Q1: What role does clinical reasoning play in the occupational therapy process?

A1: Clinical reasoning serves as the foundation for decision-making in occupational therapy. It guides therapists in analyzing client information, identifying problems, setting goals, planning interventions, and evaluating outcomes.

Q2: How can I improve my clinical reasoning skills?

A2: Enhancing clinical reasoning skills requires a combination of ongoing learning, reflective practice, collaboration, and utilization of clinical tools. Engaging in professional development activities and

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Cognitive Interventions In The Home: A Practical Approach For OT Professionals

Krista covell-pierson, otr/l, bcb-pmd.

• Acute Care, Community and Home Health
• Cognition and Executive Function
• Gerontology and Aging

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Editor's note: This text-based course is a transcript of the webinar,  Cognitive Interventions In The Home: A Practical Approach For OT Professionals,  presented by Krista Covell-Pierson, OTR/L, BCB-PMD.

Learning Outcomes

• Identify four ways an OT can integrate cognition into a treatment plan.
• List four assessments for cognition that are appropriate to use in the home setting.
• Recognize four types of memory impairments and distinguish between dementia and delirium.

Introduction

Today, we will delve into cognitive interventions in the home—a practical approach tailored for occupational therapy professionals. Our profession holds significant potential to profoundly impact individuals' lives, although, at times, it may seem challenging to grasp the full scope of our role. However, during our discussion, I aim to provide you with valuable insights that you can readily integrate into your practice.

I reside in Colorado and am the proprietor of Covell Care and Rehab, a private practice where we serve a diverse patient population. The majority of our patients contend with various cognitive impairments, an aspect of care that I find particularly rewarding. Our work extends to individuals coping with conditions such as dementia, brain injuries, mild cognitive impairment, and other cognitive-related issues.

In my 22-year career as an occupational therapist, I have come to believe that, as OTs, we can enhance our approach to addressing cognition. As we embark on a deeper exploration during this hour, I encourage you to consider how you can better assist patients facing cognitive challenges.

You might wonder why this topic is of utmost importance. Given your roles as OT practitioners, you likely recognize its significance and inherent value. However, I intend to equip you with the language and rationale to explain its importance to our patients, their families, our colleagues, supervisors, and third-party payers. Effective communication, both verbally and in written documentation, is crucial. Therefore, we will touch on various aspects of this skill.

Why Is This Important?

When defining cognition, it's essential to appreciate the multifaceted nature of the concept. Several skills interplay when we consider cognition. One definition I find particularly insightful is derived from the Dementias Platform in the United Kingdom, and it reads as follows: "Cognition is a term for the mental processes that take place in the brain, such as thinking, attention, language, learning, memory, and perception." The areas are listed below.

• Skill generalization and combination
• Functional cognition

We also know as OTs that these processes are not discrete abilities, like this gentleman in his raft (Figure 1).

Figure 1. Man in a raft in the water.

Cognitive processes are intricately interconnected, akin to floating on a raft. Our objective is to equip our patients with diverse skills that harmoniously converge, enabling them to become proficient, functioning individuals, regardless of age. Therefore, when we clarify our purpose, we must emphasize that we are not solely focused on enhancing learning or memory.

Instead, our aim is for these improvements to translate into a higher quality of life. Effective communication plays a pivotal role here. While we often discuss these individual facets, it is equally essential to view the bigger picture and recognize the invaluable role that occupational therapists bring to the table.

Patients may have previously undergone neuropsychological evaluations, cognitive screenings with physicians, or worked with speech-language pathologists. Nevertheless, we can step in and comprehensively assess the array of skills listed here, aligning them with our patients' life goals. Thus, our presence within the cognitive team is highly practical.

The research underscores that when patients receive occupational therapy tailored to address functional cognition, it significantly reduces their risk of hospitalization or re-hospitalization. This outcome is compelling and resonates with various stakeholders, including third-party payers, administrators, supervisors, and, most importantly, our patients and their families. Keeping our loved ones out of the hospital is a shared priority for all.

Cognition Impacts ADLs

• Home management
• Financial management
• Community involvement

Moving beyond discussing cognition, let's look at how cognition profoundly influences our daily activities, our routines, and, ultimately, our quality of life. While it's not groundbreaking for us to acknowledge that cognitive skills impact daily living, what sets us apart is our ability to effectively communicate how we can enhance these activities.

The tasks I've outlined here serve as simple examples that can be seamlessly integrated into our therapeutic goals to demonstrate tangible improvements in function through enhanced cognition.

Is it truly impactful if someone can recall five random words when prompted? Not really, because it lacks functionality. What genuinely matters is if someone can remember five essential steps in operating their washing machine, enabling them to independently and efficiently do their laundry. The real victory lies in achieving practical, meaningful outcomes where individuals no longer require constant caregiver assistance.

Our approach involves identifying these personally significant tasks, aligning them with the cognitive processes that require improvement, and then guiding our patients through the journey of mastering these tasks. This approach benefits our patients and facilitates clearer communication in our notes and collaboration with our peers, which we will delve into further.

ADLs at Home

Figure 2 shows an infographic showing how the person, task, and environment are interconnected.

Figure 2. Person-task-environment diagram.

I frequently use diagrams like the one shown here because they align with the person-environment model, which emphasizes a holistic approach to assessing occupational performance. When working with our patients, conducting a comprehensive assessment is crucial. This assessment should encompass an examination of their skills, deficits, desires, mental and physical health, and medical needs. The goal is to develop a personal profile, recognizing that all these facets significantly impact an individual's functional cognition.

Next, we focus on identifying meaningful tasks, a process in which both the patient and their family members or caregivers play a vital role. Prioritizing tasks that resonate with the patient's motivations is imperative because intrinsic motivation is pivotal, especially when dealing with cognitive challenges. If a task isn't personally meaningful, it can be challenging to rationalize its importance, particularly for those already facing cognitive difficulties.

Additionally, it's crucial to assess how the patient perceives their skillset and compare it with our observations. Often, individuals with cognitive difficulties may overestimate their abilities. Input from loved ones and caregivers is equally valuable, as their perceptions might differ from our assessments.

A particularly rewarding aspect of our work is when we can engage with patients in their homes. This intimate setting allows us to witness their daily lives, which can be both dynamic and enlightening. Unlike a static therapy gym, homes vary, offering a unique and enjoyable challenge.

Here are two real-life examples that illustrate the diversity of environments we encounter. I had a patient who was living in a mother-in-law-type apartment above the garage. She had a huge family with members coming in and out all the time. It was distracting even for me during treatment, so I knew it was distracting for her, especially living with memory loss and cognitive fatigue related to chemotherapy treatments. I also had a patient who lived two minutes away in low-income housing. She had very limited resources and no social support system in town. Her family lived out of state, and she had no friends. She was dealing with crippling anxiety, memory loss, and decreased problem-solving skills related to years of alcohol and drug abuse. These are different people in two different environments. I can start by going into the home and looking for ideas and answers based on those environments. I can see what's meaningful to them. For example, I might see that they have a smartphone or notes next to the phone. I might see that they have their own cookbooks and like to cook. I can start using those things to make the tasks more meaningful when I'm in the environment. Working in the home setting requires flexibility and adaptability, but it's where the magic truly happens. Utilizing personal items like photographs, meaningful objects, or even the layout of their home can enhance memory recall and yield better results. Whether you're considering working in a home setting or already doing so, it's a personally rewarding endeavor. You'll find ample opportunities to connect with patients and significantly impact their lives.

Lastly, the American Occupational Therapy Association (AOTA) advocates for our role in the cognitive space. They define us as experts in measuring functional cognition, encompassing everyday task performance. Recognizing subtle cognitive impairments is crucial, as they often go untreated but can significantly impact an individual's functioning. As OTs, we treat cognitive impairments because they have the potential to compromise the safety and long-term well-being of our patients. By familiarizing yourself with AOTA's resources and language, you can strengthen your documentation and advocacy efforts, ensuring that OTs continue to play a vital role in addressing cognition and improving the lives of our patients. For additional information, refer to AOTA's resources on cognitive intervention.

Integrating Cognition Into a Treatment Plan

• Starts with chart review
• Education to patients/families of brain function as it relates to ADL at home
• Identification of areas of concern at home
• Administration of cognitive assessments at home

The integration of cognition into a treatment plan is a pivotal aspect of our occupational therapy practice. It's a process that begins with a thorough chart review, a step that some therapists may sometimes overlook in the midst of their busy daily routines. However, I want to emphasize the significance of this step. Neglecting it can potentially hinder the outcomes of your treatment plan.

A strong understanding of neuroanatomy is essential when reviewing medical records, especially in cases involving cognitive challenges. While most of us studied neuroanatomy in college, refreshing your knowledge may be a good idea, especially if it's been a while. Although we won't go into an in-depth neuroanatomy lesson, I'll touch on some key points to jog your memory. This knowledge will serve as a foundation for aligning the information you gather from chart reviews with your patient assessments. It also enables you to educate your patients, their families, and caregivers about what's happening in the brain.

You don't need to become a neurologist, but having a strategic understanding of the neurological aspects can significantly benefit your approach. For example, consider a patient who exhibits inappropriate behavior, like a previous client of mine. He would go out into public and act inappropriately, especially towards some of the women working at a local coffee shop. This gentleman was quite large, standing at 6'7", and that alone could be intimidating. Some of his inappropriate behaviors required occupational therapy intervention, but I also understood that trauma in his brain might have contributed to these behaviors. It's important to approach your work with a bit of strategy and understanding about what's going on neurologically. Knowing how specific areas of the brain might be contributing to certain behaviors can be incredibly valuable. It's all about bringing this understanding back to functional cognition.

If you find yourself without access to detailed medical records or relevant neurology reports, especially when dealing with a patient diagnosed with dementia but lacking associated medical documentation, consider requesting these records or making referrals to specialists. In some areas, neurology departments may have lengthy waitlists, so it's wise to get the process started early to ensure your patients receive timely support for their cognitive challenges.

Let's briefly review the critical regions of the brain. The frontal lobe, often referred to as our "mission control," plays a central role in cognitive functioning. It influences emotional expression, problem-solving, memory, judgment, and even sexual behaviors. Understanding this region can help us connect cognitive deficits with functional challenges. The temporal lobes are responsible for visual, olfactory, and auditory processing. These processes are vital for healthy thinking, emotional responses, and communication. The occipital lobes act as our visual hub, enabling us to interpret color, shapes, and object locations. In contrast, the insular cortex facilitates sensory processing, emotional expression, and some motor functions. The parietal lobe allows us to make sense of sensory experiences in the world, ensuring we can understand our surroundings and adapt our actions accordingly. There are also subcortical structures deep within the brain, including the diencephalon, pituitary gland, limbic structures, and basal ganglia. These structures can be likened to a "switchboard" or "mission control," simplifying complex medical concepts for our patients.

When educating patients and families about brain function in relation to activities of daily living (ADLs), consider using relatable examples and analogies. For instance, you could compare the brain to an avocado. This can make complex information more accessible and engaging.

Once you've conducted a chart review and gathered relevant information, it's an excellent time to begin educating your patients and their families about brain function and its implications for daily life. This step is crucial in building a strong foundation for your treatment plan. It helps your patients and their families understand the reasoning behind your interventions, making your approach transparent and empowering.

For instance, I once worked with an aide in an assisted living facility who had been caring for residents with different diagnoses for years but was unaware of the differences between these conditions and their effects on motor planning, cognition, and progression. Educating her about these differences transformed her perspective and improved her caregiving. Incorporate this education into your treatment plans and goals, and consider including caregiver-based goals when appropriate. By fostering understanding and collaboration, you can ensure that your interventions are effective and well-received.

Identifying areas of concern in the patient's home is the next crucial step. During evaluations, patients and their families may provide a wealth of information, but it's essential to sift through this data and prioritize. Given the pervasive influence of cognitive deficits, the list of concerns can be extensive. Start by identifying safety concerns, as these should always be addressed first.

Subsequently, focus on two to three areas that are particularly important to the patient and their family. This targeted approach allows for more manageable and effective interventions. Keep in mind that cognitive improvements in one area may have a positive ripple effect on other ADLs.

Treatment Planning Within the Home Environment

• Interpretation of results/Giving results meaning
• Identification of areas to work on
• Determining Functional Cognition!

Giving meaning to assessment scores is crucial. It's not enough to provide a number; we need to translate those scores into practical implications for the individual's daily life. This helps us pinpoint areas that require intervention and tailor our treatment plans to address specific functional challenges related to cognitive deficits.

Functional Cognition

• The cognitive ability to perform daily life tasks is conceptualized as incorporating metacognition, executive function, other domains of cognitive functioning, performance skills (e.g., motor skills that support action), and performance patterns. 
• Making Functional Cognition a Professional Priority | The American Journal of Occupational Therapy | American Occupational Therapy Association (aota.org)
• Functional cognition should ONLY be evaluated in actual task performance. Home is ideal!

Functional cognition is a critical aspect of occupational therapy practice, and its definition has evolved over the years to provide a more comprehensive understanding of its role in daily life. The current definition emphasizes the integration of cognitive skills for performing activities of daily living (ADLs) and includes skills, strategies, and psychosocial elements. This updated definition acknowledges the impact of the environment, mental health, and physical health on an individual's cognitive abilities, making it a more robust framework for OTs to assess and address functional cognition in their clients.

Consideration for Functional Cognitive Treatment Planning

• Person focused
• Environment
• Emotional health
• Neurological and biological factors

In the realm of functional cognitive treatment planning, our focus naturally gravitates towards a person-centered approach. This inclination is hardly surprising, given that we, as occupational therapists, excel at catering to individual needs and aspirations. However, we may not always consider the profound impact of culture in our practice.

Culture, encompassing one's upbringing and early learning experiences, profoundly influences how individuals engage with their surroundings, perceive others, absorb and retain information, and form judgments. It's essential to recognize that these cultural nuances can vary significantly, especially when working with individuals from diverse backgrounds or those whose cultures we may not be intimately familiar with. A thoughtful exploration, whether through conversations with the patient or their family or through independent research, can unearth vital insights that should not be overlooked.

Cultural awareness aside, we must also cast our gaze upon the environmental factors that bear upon an individual's performance. Consider the case of a patient dwelling in a mother-in-law apartment, where chaos perpetually reigns. Amidst the constant juggling of pet care, from dogs to kittens and birthing cats, alongside the responsibility of caring for a boyfriend with brittle diabetes, distraction becomes a relentless companion, exhausting in its own right. Here, our task is to discern the nuances of such environments and strategize on managing their impact.

Emotional well-being is another facet deserving of our attention. A poignant quote aptly reminds us that "emotional function and cognitive function aren't unrelated to each other; they're completely intertwined." This truth is self-evident to anyone who has traversed the depths of grief, battled the shadows of depression, or grappled with the relentless grip of anxiety. When we encounter a patient navigating such emotional storms, we must acknowledge that their cognitive abilities may bear the brunt of these turbulent waters. A recently bereaved patient struggling to find equilibrium may exhibit signs of forgetfulness or cognitive struggle directly linked to their emotional state.

Lastly, we must not overlook the neurological and biological dimensions. Employing tools like brain scans and neuropsychological evaluations, we gain invaluable insights into the mind's inner workings. This knowledge becomes a cornerstone for crafting precise treatment plans and, where necessary, advocating for specialized care. Consider this parallel: just as you wouldn't prescribe the same medication for every patient with chest pain, so too should we be cautious of hastily offering psychiatric drugs without a comprehensive understanding of what's transpiring within the patient's brain. As occupational therapists, recognizing the significance of these assessments, our duty extends to educating our patients and championing their access to the expertise that can provide tailored solutions for their unique cognitive challenges.

Assessments to Use at Home

• Confusion Assessment Method: to identify patients with delirium:  The_Confusion_Assessment_Method.pdf (va.gov)
• The Brief Interview for Mental Health Status
• Performance Assessment of Self-Care Skills
• Executive Function Performance Test

Let's now delve into the assessments that can be incorporated into our practice. Although some of these assessments may initially appear unconventional for occupational therapists, they offer valuable insights and are integral to comprehensive care.

The Confusion Assessment Method (CAM) and Brief Interview for Mental Health Status (BIMS) do not inherently align with traditional OT practices, but both have gained approval from Medicare for assessing cognition. CAM, for instance, aids in identifying delirium in patients. Delirium, which can range from subtle to severe, may not always be readily apparent. By conducting CAM, we ensure that cognitive assessments are appropriate, as addressing cognition when delirium is present can be counterproductive. Even if you are confident that delirium isn't a factor, utilizing CAM demonstrates a thorough approach, which can be crucial for third-party payer compliance. The Centers for Medicare and Medicaid Services (CMS) has integrated CAM into post-acute care assessments, which might already be a part of your healthcare team's protocol.

On the other hand, BIMS, another CMS-approved assessment, serves as a valuable tool for neuropsychological screening. For example, if you encounter a patient grappling with profound grief and depression, the BIMS can shed light on their mental state. It's essential to address mental health concerns before diving into cognitive evaluations. Collaborating with your healthcare team to determine who administers these assessments can streamline the process. Alternatively, you can administer them yourself; they are efficient and quick, providing a solid foundation for cognitive assessments.

Let's explore assessments that align more closely with traditional occupational therapy practices. The Performance Assessment of Self-Care Skills is a reliable, client-centered, performance-based assessment designed to measure occupational performance in daily life tasks. It can be effectively employed with adolescents, adults, and older adults, even in home settings. Comprising 26 core tasks, including mobility, basic ADLs, IADLs with a physical focus, and crucially, 14 IADL tasks related to cognition, the PASS provides a holistic view of a patient's abilities and how they navigate various tasks.

The Executive Function Performance Test examines a patient's capabilities in tasks like cooking, phone use, medication management, and bill payment within their home environment. It offers valuable insights into a patient's functional abilities and serves as an educational tool for families. Additionally, it's accessible as a free download, providing convenient access to a useful assessment tool.

Despite their initial differences from conventional OT practices, these assessments play an indispensable role in ensuring comprehensive care and tailored interventions for our patients.

Additional Assessments to Use at Home

• Fitness to Drive Screening Measure: Web-based to identify at-risk drivers
• Loewenstein Occupational Therapy Cognitive Assessment (LOTCA): Cognitive and visual perception skills in older adults are assessed
• Mini-Mental State Examination (MMSE): Measures orientation, recall, short-term memory, calculation, language, and constructability
• Cognitive-Performance Test (CPT): Explains and predicts capacity to function in various contexts and guide intervention plans
• Cognistat: Rapid testing for delirium, MCI, and dementia (can be used with teens to adults)
• Trail Making Tests A and B

Incorporating assessments into our home-based occupational therapy practice is essential for providing comprehensive care. One critical area that demands our attention is assessing a patient's fitness to drive. If you work in the community, be it outpatient, home care, or mobile outpatient services, addressing a patient's ability to drive is paramount, especially when cognitive issues are at play. However, determining whether a patient should drive requires specific skills and training. If you lack this expertise, it's crucial to connect with a Certified Driving Rehab Specialist (CDRS), often an occupational therapist or physical therapist with extensive training in driving assessments. Collaborating with CDRSs is vital, as it directly relates to public health, safety, and community well-being. The tragic example of a wrong-way driver causing a fatal accident highlights the significance of addressing driving concerns diligently.

Here are some assessments that you can integrate into your practice. The Loewenstein Occupational Therapy Cognitive Assessment, previously known as the LOTCA, assesses cognitive and visual perception skills. It aids in identifying various levels of cognitive difficulties and provides insights into a patient's learning potential and thinking strategies. This information significantly influences our treatment planning and intervention selection. Additionally, the LOTCA offers different versions tailored to different age groups, enhancing its versatility.

Mini-Mental State Examination (MMSE) assesses orientation, recall, short-term memory, calculation, language, and constructive ability. While it's commonly administered in physician's offices, you can also use it in your home-based practice. There's a similar tool called the SLUMS (Saint Louis University Mental Screening), which is a free assessment option.

The Cognitive-Performance Test (CPT) is a performance-based assessment that explains and predicts a patient's capacity to function in various contexts. It employs the Allen Cognitive Levels for rating patients, which can be shared with their families to help them understand cognitive challenges better.

Although typically used in inpatient psychiatric facilities, the Cognistat can be adapted for home-based assessments. It's a rapid test that differentiates between delirium, mild cognitive impairment, and dementia and can be applied across various age groups.

The Trail Making Tests A and B evaluate general cognitive function, including working memory, visual processing, visual-spatial skills, selective and divided attention, processing speed, and psychomotor coordination. Trail Making Test B, in particular, has been linked to poor driving performance. If a patient performs poorly on this test and intends to drive, it's advisable to refer them to a CDRS or consider pursuing CDRS certification.

These assessments, though diverse in their applications and availability, expand our toolkit for home-based occupational therapy. Some may require purchase, while others can be downloaded. Discuss the possibility of integrating these assessments into your practice with your employer to enhance the quality of care you provide during home visits.

Clinical Observations

• Errors in math
• Frustration from the patient
• Distractibility
• Difficulty focusing
• Repeated phrases
• Requires redirection
• Unable to locate items
• Impulsivity
• Reduced reciprocity
• Reduced problem-solving skills
• Delayed or absent recall 
• Changes in perception
• Poor insight
• Changes in personality
• Irritability
• Safety concerns
• Increased fatigue
• Decreased organization

It's essential to emphasize the value of your clinical observations and activity analyses in your documentation. These observations, rooted in your skilled assessment and honed through clinical experience, provide crucial insights into a patient's cognitive abilities and challenges.

For instance, consider an activity as straightforward as making a peanut butter and jelly sandwich, reminiscent of college days. While occasional difficulties in locating items or lapses in focus are common and may not necessarily indicate a cognitive issue, persistent patterns of such challenges warrant attention. If you consistently encounter these issues or receive complaints from families, it's an indication that cognitive assessment and intervention may be necessary, even if your initial focus was on a different aspect of care. Your ability to recognize these signs and adapt your approach is a testament to your clinical expertise and dedication to comprehensive patient care.

Home Strategies

• Visual cues
• Automatic timers
• Lighting alternatives
• DME for fall prevention
• Reduced clutter
• Alarm/alert systems
• Phones and computers
• Routine modifications
• Mental health support/activities
• Paper calendars
• Timers for time modulation
• Caregiver education
• Driving alternatives
• Dementia education and training
• Emergency preparedness
• “Just right challenge” tasks
• Safety training
• Stress management

Working in a patient's home setting can be an incredibly rewarding experience for occupational therapists. It provides a unique opportunity to tap into our innate creativity and adaptability as professionals. Here are some strategies and interventions that can be seamlessly integrated into home-based care:

Utilizing visual cues can be highly effective. For example, consider a patient who frequently snacks on unhealthy foods. To address this issue, you can clear a designated place on the kitchen counter, place a placemat there, and instruct caregivers to set out specific healthier snacks on the placemat. This visual cue prompts the patient to choose healthier options, promoting improved dietary habits.

While automatic timers can be useful, it's crucial that the patient understands their purpose. Many patients may become confused when timers go off without clear instructions. Therefore, ensuring the patient comprehends the intended use of timers and how to respond when they activate is essential.

In cases where certain areas lack adequate illumination, such as bathrooms, adjusting the lighting can reduce patient distress and confusion, particularly for those with cognitive impairments. Ensuring a well-lit environment can enhance their comfort and safety.

Managing a patient's energy levels throughout the day is vital. Cognitive issues, from dementia to brain injuries, can lead to increased fatigue. Therefore, helping patients modulate their activity levels and prevent excessive exhaustion is integral to care planning.

Smartphones, computers, and phones can be valuable tools for patients, provided they have a basic understanding of how to use them. Caregiver education in this regard can empower patients to leverage technology for various aspects of daily life.

Stress can significantly worsen cognitive function. Implementing stress management techniques and strategies can be beneficial for patients. This may include relaxation exercises, mindfulness practices, or simple stress-reduction activities.

Although not listed, exercise plays a crucial role in maintaining and improving cognitive function. Incorporating physical activity, even in modified forms, can engage the cerebellum and contribute to clearer thinking and improved cognitive abilities.

In summary, home-based occupational therapy allows us to be creative and tailor interventions to suit each patient's unique environment and needs. Utilizing visual cues, appropriate technology, and effective energy management can enhance our patients' quality of life and well-being while addressing cognitive challenges.

Adding Goals to Treatment Plans

• Client-based
• Assist level

When formulating goals for cognitive interventions, it's beneficial to employ the COAST framework, emphasizing client-centered, occupation-based, specific, and time-bound goals. These objectives should align with the principles of functional cognition and measure improvements in functional outcomes. Here are a few practical examples:

Medication Management Goal

For this goal, the focus is on the patient's ability to manage their medications effectively. In the COAST framework, the goal is tailored to a specific patient, the occupation in focus is the proper administration of daily medications, the patient will employ learned strategies to achieve this goal, the specific objective is for the patient to take all five of their daily medications using the strategies they've acquired, and the patient is expected to reach this goal within a timeframe of three consecutive days within two weeks.

Phone Management Goal

This goal centers around a patient's capability to manage medical appointments through phone calls. In the COAST framework, the goal is customized to meet the specific patient's needs, the occupation in focus is the efficient management of medical appointments via telephone, the patient is encouraged to strive for independent management using their contact list and iPhone, the specific aim is for the patient to make two phone calls with a flawless accuracy rate to manage medical appointments, and the patient is expected to reach this goal within the span of four treatment sessions.

Meal Preparation Goal

In this scenario, the goal is to enhance a patient's ability to prepare a meal, leveraging visual cues. In the COAST framework, the goal is tailored to meet the specific patient's needs, the occupation in focus is the independent preparation of a meal, visual cues will be used to assist the patient in achieving this goal, the specific aim is for the patient to prepare a simple meal while relying on visual cues placed within the kitchen, and the patient is expected to reach this goal within a specified timeframe.

In your documentation, it's crucial to be explicit about the cognitive strategies being employed. This guides the treatment approach and sets clear expectations regarding when the patient is anticipated to succeed. By adhering to the COAST framework and focusing on measurable functional improvements, your cognitive goals will effectively address each patient's unique needs and challenges.

Challenges With Documentation

• EMR useability
• Limited resources online or with employers
• Cognitive goals can require extra time to ensure quality
• Medically necessary required for billing
• Third-party payer authorizations can be more difficult to obtain

Documenting cognitive interventions can pose challenges, particularly within electronic medical records (EMRs) that may not be tailored to occupational therapists. It's not uncommon for EMRs to be more user-friendly for physical therapists, so OTs often need to get creative in how they use these systems. This might involve finding workarounds or advocating for the necessary resources and support from employers to ensure efficient documentation.

Cognitive goals and interventions may also require additional time compared to traditional physical therapy interventions. Justifying this extended timeframe in your treatment recommendations for third-party payers is crucial. Instead of merely stating that you're working on a specific task, such as transfer training, provide a clear rationale for the prolonged duration. For instance, if you're implementing errorless learning techniques or addressing specific cognitive challenges, explain why this additional time is medically necessary for the patient's benefit.

Navigating third-party payment authorizations can be more complex when dealing with cognitive disabilities. Advocacy becomes essential in such cases. You may encounter denials, but don't hesitate to appeal these decisions. Back your appeal with well-structured documentation that educates the payer about the intricacies of cognitive impairments and their impact on the patient's daily life. Emphasize the medical necessity of your interventions. This advocacy can lead to successful outcomes, as exemplified by a case where an appeal secured additional therapy sessions for a patient who ultimately achieved her academic and career goals despite cognitive challenges.

In summary, documenting cognitive interventions may require creativity within EMRs, justification for extended treatment times, and advocacy to secure the necessary authorizations. Through clear and informed documentation, you can effectively convey the medical necessity of your interventions and advocate for the best outcomes for your patients.

Billing for Cognition

• Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem-solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact.
• Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem-solving and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact.

When it comes to billing for cognitive interventions in occupational therapy, there are specific Current Procedural Terminology (CPT) codes that you should use. These codes help you accurately document and bill for the services you provide. Here's a breakdown of the relevant codes:

The 97129 code is used for the initial 15 minutes of therapeutic interventions. It's important to note that this code is the same as 97130 in terms of definition. After the initial 15 minutes, you would use the 97130 code for each additional 15-minute increment of therapeutic interventions. 

It's crucial to be precise in your documentation and use the language provided in the CPT code descriptions. This helps ensure that your third-party payer understands the nature of the interventions you're providing and approves the billing accordingly. For example, if your therapy session focused on executive function tasks, make sure to explicitly mention that in your documentation. By aligning your documentation with the CPT code definitions, you provide a clear and accurate account of the services you delivered.

To stay organized and informed, consider keeping a handy reference sheet of CPT codes and their definitions, even if you're experienced in your field. This can be a valuable tool for ensuring consistency and accuracy in your billing and documentation practices.

Types of Cognitive Impairments

As we wind down, I want to talk about delirium and dementia for a second.

Delirium Vs. Dementia

Delirium is a condition that, while more commonly associated with acute care settings, can also manifest in the community or during home care visits. As occupational therapists, it's essential to be knowledgeable about delirium because of its potential severity and impact on patients. You might be the primary healthcare provider present in these situations, so identifying delirium becomes crucial.

Delirium is characterized by a sudden onset and is primarily defined by disturbances in attention and awareness. Recognizing delirium is essential because it can lead to significant complications if left unaddressed. Being vigilant and informed about delirium ensures that you can provide appropriate care and support, especially when you're working in home care or outpatient settings where immediate access to medical personnel may not be readily available.

Delirium  

• Disturbance in attention and awareness developing acutely tends to fluctuate in severity
• At least one additional disturbance in cognition
• Disturbances are not better explained by dementia
• Disturbances do not occur in the context of a coma
• Evidence of an underlying organic cause

Delirium is a condition characterized by its rapid onset and varying degrees of severity. It's marked by at least one noticeable disturbance in cognition, and it's important to note that this disturbance cannot be attributed to dementia. To help identify delirium quickly, you can utilize the delirium assessment we discussed earlier, which is a fast and efficient tool. If the assessment indicates delirium, seeking immediate medical attention is crucial. While it's rare to encounter someone in a coma during home visits, delirium can manifest in various ways and usually indicates an underlying cause.

Delirium can result from factors such as medication interactions, psychiatric issues, or infections. When you're in a home care setting and observe signs of delirium, it's essential to prioritize the person's safety and well-being by promptly getting them the necessary medical care.

• Significant cognitive decline in one or more cognitive domains.
• Cognitive impairment interferes with ADL.
• Cognitive impairment does not occur exclusively in the context of delirium.
• Cognitive decline is not better explained by other medical or psychiatric conditions.

Dementia is distinguished by significant cognitive decline in one or more cognitive domains, and this decline typically interferes with a person's ability to perform daily activities. It's important to note that delirium and dementia can coexist and are not mutually exclusive conditions. While someone with dementia can experience delirium, the two are distinct.

To diagnose dementia, a physician is required as it involves a comprehensive evaluation beyond the scope of occupational therapy. It's essential to remember that dementia is not a specific disease; rather, it is an umbrella term encompassing various conditions characterized by cognitive decline. Each type of dementia, such as Alzheimer's disease, vascular dementia, or Lewy body dementia, has its unique features and progression patterns. Thus, it's crucial to recognize that not all dementias are the same, and a proper diagnosis is necessary for appropriate management and care planning.

• Vascular dementia
• Dementia with Lewy bodies
• Frontotemporal dementia
• Alzheimer’s
• Mild cognitive impairment
• Encephalopathy

It's crucial to understand that dementia is a broad category encompassing various conditions, each with its unique characteristics and underlying causes. Dementia is not a single disease but rather a term used to describe a range of cognitive impairments. Here are some types of dementia and their distinguishing features:

Vascular dementia results from impaired blood flow to the brain, leading to problems with reasoning, planning, judgment, memory, and other cognitive functions. It is often characterized by cognitive deficits that can vary in severity, as if the brain's function has "holes" due to damage from inadequate blood flow.

Dementia with Lewy bodies is a progressive dementia characterized by a decline in thinking, reasoning, and independent function. Individuals with this type of dementia commonly experience sleep disturbances, visual hallucinations, and movement disorders, such as slow movements, tremors, and rigidity. It is closely related to Parkinson's disease.

Frontotemporal dementia refers to a group of disorders caused by nerve loss in the brain's frontal and temporal lobes. It can manifest as changes in behavior, empathy, judgment, foresight, and language abilities. The specific symptoms may vary depending on the regions of the brain most affected.

Alzheimer's disease is the most common type of dementia, accounting for 60-80% of dementia cases. It is characterized by progressive cognitive decline, including memory loss, language problems, and difficulties with daily activities. Plaques and tangles in the brain are hallmarks of Alzheimer's.

Mild Cognitive Impairment (MCI) represents cognitive impairments that are more significant than expected for an individual's age and education level but do not meet the criteria for dementia. While individuals with MCI are at increased risk of developing Alzheimer's disease, not everyone with MCI progresses to dementia.

Encephalopathy refers to a broad term for brain dysfunction. It can lead to a range of cognitive difficulties, including problems with concentration, suicidal thoughts, lethargy, vision issues, swallowing difficulties, seizures, dementia-like behaviors, and more.

Understanding the specific type of dementia is essential for appropriate care and interventions, as each type may require different management strategies and approaches. Additionally, dementia is a complex condition with various underlying causes, and research continues to uncover more about its mechanisms and risk factors.

• Stanley B. Prusiner
• Florence Clark, PhD, OTR/L, FAOTA

As we conclude this session, I'd like to share some valuable insights and practical tips for addressing cognition in occupational therapy. Remember, as occupational therapy practitioners, our role is to help people live life to the fullest, providing practical solutions for success in everyday living. We can assist individuals in maximizing their function, vitality, and productivity, regardless of their cognitive impairments.

It's crucial to advocate for our patients and for the occupational therapy profession's involvement in addressing cognition. Staying informed about neuroanatomy and emerging scientific findings allows us to develop creative and effective treatment plans tailored to each patient's needs, especially when working in a home-based setting.

One essential aspect to remember is that the brain plays a central role in all bodily functions. As Thomas Edison aptly put it, "The chief function of the body is to carry the brain around." Therefore, even when working on physical aspects with our patients, we must recognize the critical importance of cognitive function.

In documenting cognitive deficits influenced by psychosocial aspects during home visits, it's essential to provide specific examples. For instance, if a patient exhibits signs of depression that impact their daily life, you can document the patient's emotional state, any refusal to participate in activities, and your efforts to address their emotional well-being. While we cannot diagnose depression, we can highlight observable signs and symptoms and collaborate with other healthcare professionals for further evaluation and intervention.

Regarding the Allen Cognitive Levels, you can access resources and printouts online. There are books available, such as "Understanding the Allen Cognitive Levels," that can serve as valuable references. These levels can be instrumental in helping patients and their families better understand cognitive impairments and manage associated behaviors effectively.

In summary, occupational therapy practitioners play a vital role in addressing cognition, and we have the tools and knowledge to make a meaningful impact on our patients' lives. By advocating for our patients, staying informed, and using evidence-based approaches, we can help individuals with cognitive impairments lead more fulfilling and independent lives.

Thank you for joining this session.

Adamit, T., Shames, J., & Rand, D. (2021). Effectiveness of the Functional and Cognitive Occupational Therapy (FaC o T) intervention for improving daily functioning and participation of individuals with mild stroke: A randomized controlled trial.  International journal of environmental research and public health ,  18 (15), 7988. https://doi.org/10.3390/ijerph18157988

Cognition, Cognitive Rehabilitation, and Occupational Performance. (2019).  AJOT ,  73 (Supplement_2), 7312410010p1–7312410010p26. https://doi.org/10.5014/ajot.2019.73S201

Edwards, D. F., Wolf, T. J., Marks, T., Alter, S., Larkin, V., Padesky, B. L., Spiers, M., Al-Heizan, M. O., & Giles, G. M. (2019). Reliability and validity of a functional cognition screening tool to identify the need for occupational therapy.  AJOT ,  73 (2), 7302205050p1–7302205050p10. https://doi.org/10.5014/ajot.2019.028753

Manee, F. S., Nadar, M. S., Alotaibi, N. M., & Rassafiani, M. (2020). Cognitive assessments used in occupational therapy practice: A global perspective.  Occupational Therapy International ,  8914372. https://doi.org/10.1155/2020/8914372

Stigen, L., Bjørk, E., & Lund, A. (2022). Occupational therapy interventions for persons with cognitive impairments living in the community.  Occupational therapy in health care , 1–20. Advance online publication. https://doi.org/10.1080/07380577.2022.2056777

Covell-Pierson, K. (2023). Cognitive interventions in the home: A practical approach for OT professionals.  OccupationalTherapy.com , Article 5638. Available at www.occupationaltherapy.com

Occupational therapist and entrepreneur, Krista Covell-Pierson is the founder and owner of Covell Care and Rehabilitation, LLC. Krista created Covell Care and Rehabilitation to improve the quality of services available for clients of all ages living in the community through a one-of-a-kind mobile outpatient practice which aims to improve the lives of clients and clinicians alike. Krista attended Colorado State University receiving degrees in social work and occupational therapy. She has worked in various settings including hospitals, home health, rehabilitation centers and skilled nursing. Through her private practice, Krista created a model that she teaches other therapists looking to start their own business. She has extensive experience as a fieldwork educator and received the Fieldwork Educator of the Year Award from Colorado State University. Krista served as the President of the Occupational Therapy Association of Colorado for two years. She presents to groups of professionals and community members on a regular basis and has a heart to help others become the best version of themselves. 

Related Courses

Course: #5963 level: introductory 1 hour, incontinence: practical tips for the occupational therapy practitioner (part 1), course: #3609 level: intermediate 1 hour, incontinence: practical tips for the occupational therapy practitioner (part 2), course: #3610 level: intermediate 1 hour, assessing and preventing falls at home: a practical approach for the ot, course: #5413 level: intermediate 2 hours, covid-19 with older adults: an update, course: #5494 level: introductory 2.5 hours.

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Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)

The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery was developed as a measure of basic cognitive skills and visual perception in older adults with neurological impairment. The LOTCA provides an in-depth assessment of basic cognitive abilities and can also be used in treatment planning Planning ability involves anticipating future events, formulating a goal or endpoint, and devising a sequence of steps or actions that will achieve the goal or endpoint” (Anderson, 2008, p. 17) and review of progress over time.

In-Depth Review

Purpose of the measure.

The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) is a cognitive battery that measures basic cognitive skills required for everyday function including orientation, visual perceptual and psychomotor abilities, problem-solving "Goal-directed cognitive activity that arises in situations for which no response is immediately apparent or available" (Luria, 1966; as cited in (Rath et al., 2004)) skills and thinking operations. Development of the battery was based on information from clinical experience and neuropsychological and developmental theories. The LOTCA is typically used in the initial phase of patient assessment but can also be used to establish therapeutic goals and to review cognitive status over time (Annes, Katz & Cermak, 1996; Zwecker et al., 2002).

Available versions

The original LOTCA was developed by Itzkovich, Averbuch, Elazar and Katz for use with individuals below the age of 70 years with neurological dysfunction and consisted of a total of 20 items within 4 areas: Orientation (2 items); Perception (6 items); Visuomotor Organization (7 items); and Thinking Operations (5 items).

The LOTCA-II was modified by separating the Perceptual area into three separate areas (Visual Perception, Spatial Perception and Motor Praxis), revising items and including an additional Thinking Operations subtest. The LOTCA-II consists of a total of 26 subtests within 6 areas: Orientation (2 items); Visual Perception (4 items); Spatial Perception (3 items); Motor Praxis (3 items); Visuomotor Organization (7 items); and Thinking Operations (7 items).

The LOTCA-II includes multi-choice questions in the Orientation area to accommodate language difficulties. The manual has been updated to provide more accurate assessment and administration guidelines (Su, Lin, Chen-Sea & Yang, 2007).

Features of the measure

Description of tasks:.

The original LOTCA contains 20 subtests in 4 areas. The LOTCA-II contains 26 subtests in 6 areas:

• Orientation (2 subtests): Assesses the individual’s orientation to place and time.
• Visual Perception (4 subtests): Assesses the individual’s ability to identify pictures of everyday objects, objects photographed from unusual angles, distinguish between overlapping figures, and recognize spatial relations between objects.
• Spatial Perception (3 subtests): Assesses the individual’s ability to differentiate between right and left to determine spatial relationships between objects and self.
• Motor Praxis (3 subtests): Asesses the individual’s ability to imitate motor actions, use objects and perform symbolic actions.
• Visuomotor Organization (7 subtests): Assesses the individual’s ability to copy geometric figures, reproduce a 2D model, copy a coloured block design and a plain block design, reproduce a puzzle and complete a pegboard task, and draw a clock.
• Thinking Operations (7 subtests): Assesses the individual’s ability to complete tasks including sorting, categorization, and picture and geometric sequences (Annes et al., 1996).

Scoring and Score Interpretation:

Most subtests of the LOTCA are scored from 1 to 4, where:

• 1 = Patient fails to perform the task
• 2 = Patient is able to perform part of the task
• 3 = Patient is able to perform most of the task
• 4 = Patient demonstrates good performance of the task

However, three Thinking Operations subtests (Categorisation, Risk Object Classification – ROC – Unstructured, ROC Structured subtests) are scored on a scale from 1 to 5 (Josman, Abdallah & Engel-Yegar, 2010; Zwecker et al., 2002).

Most subtests of the LOTCA-II are also scored from 1 to 4 using the scale above. However, Orientation subtests are scored on a scale from 1 to 8 and three Thinking Operations subtests (Categorization, ROC Unstructured, ROC Structured) are scored on a scale from 1 to 5. Accordingly, the overall LOTCA-II score ranges from 26 to 115 points. Task completion through trial-and-error is penalized in three subtests. Performance elements such as the number of prompts provided to the individual to assist him/her in completing the task, the individual’s attention/concentration and length of time taken to complete the assessment are also recorded.

Results are provided as a profile for each subtest, where higher scores indicate less cognitive impairment (Su et al., 2000). While summation of subtest scores is accepted, the authors warn that analysis of a total score impacts on the ability to identify the individual’s aptitude for each cognitive area (Katz, Itzkovich & Averbuch, 2002).

LOTCA scores were normed on an Israeli population of adults aged 20 – 70 years (Annes et al., 1996), and have since been deemed suitable for use with the US population (Annes et al., 1996; Cermak, Katz, McGuire, Greenbaum, Peralta & Maser-Flanagan, 1995; Katz et al., 1997). Age-related change in scores is not accounted for, as score norms are provided for one group of all individuals aged 20 – 70 years.

The LOTCA and LOTCA-II take approximately 45 minutes to administer, with a reported range from 30 to 90 minutes (Annes et al., 1996; Zwecker et al., 2002).

The LOTCA kit contains testing materials (card decks, coloured blocks, pegboard set and other materials) and a manual that includes definitions of the cognitive domains assessed, instructions for administration and specific scoring guidelines.

Alternative forms of the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)

The LOTCA Geriatric version (LOTCA-G) is a modified version of the original LOTCA that was designed for use with individuals aged 70 – 91 years. The LOTCA-G was developed in response to difficulties that elderly patients experienced using the LOTCA (e.g. difficulty seeing and using small materials, and duration of assessment). Accordingly, it contains modifications to allow for age-related cognitive decline and sensorimotor difficulties including larger materials to compensate for visual and motor deficits, less visual detail, shorter subtests, multiple-choice questions, and additional memory tests not included in the original LOTCA (Cooke et al., 2006a, b; Bar-Haim Erez & Katz, 2003).

The LOTCA-G includes 23 subtests in 7 cognitive areas:

• Orientation (2 subtests): Orientation to place; and orientation to time
• Visual Perception (4 subtests): Object identification; shape identification; overlapping figures; and object consistency
• Spatial Perception (3 subtests): On self; on examiner; and self and surroundings
• Praxis (3 subtests): Motor imitation; utilization of objects; and symbolic actions
• Visuomotor Organization (6 subtests): Copy geometric forms; two-dimension model pegboard construction; block design (colour); reproducation of a puzzle; and drawing a clock
• Thinking Operations (2 subtests): Categorization; and pictorial sequencing “The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
• Memory (3 subtests): Famous personality; personal possession; and everyday objects

The Orientation subtests are scored from 1 – 8 while all other subtests of the LOTCA-G are scored on an ordinal scale from 1 to 4, where 1 indicates severe deficit and 4 indicates average performance. The LOTCA-G takes approximately 30-45 minutes to administer (Bar-Haim Erez & Katz, 2003, Cermak, et al., 1995). It is available in English and Hebrew.

Client suitability

Can be used with:.

• Patients following stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (Bar-Haim Erez & Katz, 2003)
• Older individuals with dementia (Bar-Haim Erez & Katz, 2003)
• Individuals with traumatic brain injury (Annes et al., 1996)
• Individuals with CNS dysfunction (Annes et al., 1996)
• Individuals with intellectual disabilities (Jang, Chern & Lin, 2009)
• Individuals with mental illness (Jang et al., 2009; Josman & Katz, 2006)
• An adapted version has also been developed for use with children with learning difficulties (Josman et al., 2010)
• Patients with aphasia Aphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury. An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) – procedures for assessing the patient with aphasia Aphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury. An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) are included (Jang et al., 2009).

Should not be used in:

• An individual’s culture can affect the construct validity Reflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed. of the LOTCA when used with a pediatric population (Josman et al., 2010)

In what languages is the measure available?

• Chinese (Mandarin)

Psychometric Properties

A literature search was conducted to identify all relevant publications on the psychometric properties of the LOTCA. While this assessment can be used with various populations, this module addresses the psychometric properties of the measure specifically when used with patients with stroke. Eleven studies were identified.

Reliability

Internal Consistency A method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More : Katz, Itzkovich and Averbuch (1989) examined the internal consistency A method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More of the original LOTCA with patients with traumatic head injury (n=20), patients with stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (n=28) and health adults (n=55), and reported excellent internal consistency A method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More with alpha coefficients of 0.85, 0.87 and 0.95 for in the areas of Thinking Operations, Perception and Visuomotor Organization (respectively).

Test-retest: No studies have reported on the test-retest reliability A way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the LOTCA when used with patients with stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More .

Intra-rater: No studies have examined the intra-rater reliability This is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the LOTCA.

Inter-rater: Katz et al (1989) reported excellent inter-rater reliability A method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. for subtests of the LOTCA, with Spearman’s rank correlation The extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. coefficients ranging from 0.82 to 0.97.

Katz, Elazer and Itzkovich (1995) reported an agreement rate of 90% between 2 raters who used the LOTCA-G to assess 5 healthy subjects and 5 patients with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More .

Katz et al. (1995) reported that the LOTCA-G was tested on patients and healthy volunteers during its development.

Katz et al. (1995) reported that the LOTCA-G takes only 30-45 minutes (as compared to 30-90 minutes for the LOTCA), which verifies the LOTCA-G as a useful tool for use with an older population who demonstrate slower performance and sensorimotor difficulties.

Content: Katz et al. (1989) conducted a factor analysis to determine the construct validity Reflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed. of the original LOTCA, using two groups of patients with traumatic head injury or stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (n=96), and health adults (n=55). In the patient group, Visuomotor Organisation loaded on Factor 1 with 44% variance, Perception loaded on Factor 2 with 12% variance, and Thinking Operations on Factor 3 with 10% variance. In contrast, in the control group, Perception loaded on Factor 1 with 33% variance, Thinking Operations on Factor 2 with 23% variance, and Visuomotor Organisation on Factor 3 with 6% variance. Correlation The extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. coefficients within the Perception, Visuomotor Organisation and Thinking Operations subtests of the original LOTCA ranged from 0.40 to 0.80, indicating that subtests are not equivalent and the battery should be performed in full.

Su et al. (2000) examined the strength of correlations between LOTCA subtests on a sample of patients with stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (n=44), using Pearson correlation The extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. coefficients. Large correlations were found between the Visuomotor Organisation and Thinking Operations areas (r=0.66, p<0.0001); moderate correlations were found between the Orientation and Perception areas (r=0.55, p<0.0001), Thinking Operations and Orientation (r=0.47, p<0.01) and Perception (0.32 p<0.05); and small correlations were found between Visuomotor Organisation and Orientation (r=0.23) and Perception (r=0.25).

Criterion: Concurrent: Bar-Haim Erez & Katz (2003) reported adequate correlations (from r=0.55 to r=0.38) between the LOTCA-G areas and the MMSE total scores in patients with dementia (n=30), using Spearman correlation The extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. analysis.

Cooke et al. (2006a) examined the concurrent validity To validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the OT-APST in patients with stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (n=208) by comparing performance on 5 OT-APST subtests with performance on 5 corresponding LOTCA-II and LOTCA-G areas. Poor to excellent correlations were reported between OT-APST and LOTCA-II area scores (range d=0.27 to d=0.66); and poor to excellent correlations between OT-APST and LOTCA-G area scores (range d=0.25 to d=0.80), using Somers’s d concordance correlations.

Zwecker et al. (2002) reported on correlations between cognitive status and functional motor outcomes in patients with stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (n=66). Functional motor outcomes were measured according to efficacy and efficiency of FIM motor scores (isolated from total FIM scores) and Montebello Rehabilitation Factor Score (MRFS). An adequate correlation The extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. was found between LOTCA scores and MRFS efficacy (r=0.34, p<0.001) but poor correlations were reported between LOTCA scores and FIM motor efficacy (r=0.25, p<0.05), FIM efficiency (r=0.16) and MRFS efficiency (r=0.19), using Pearson correlations.

Predictive. No studies have examined the predictive validity A form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the LOTCA with patients with stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More .

Construct: Katz et al. (1989) conducted factor analysis of the original LOTCA and reported suitable construct validity Reflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed. for the Perception, Visuomotor Organization and Thinking Operations areas.

Su et al. (2000) reported that the LOTCA Orientation and Perception areas demonstrate suitable construct validity Reflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed. to measure two theoretically and statistically distinct theoretical constructs.

Convergent/Discriminant. Katz et al. (1995) reported a statistically significant difference in the time taken to complete the LOTCA and the LOTCA-G in a group of healthy adults, using two-way ANOVA (F=11.26, P<.0001), with less time taken to complete the LOTCA-G than the LOTCA.

Cooke et al. (2006b) examined the convergent validity A type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the LOTCA (2nd edition) and the LOTCA-G area means with the OT-APST subscale Many measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). means in patients with stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More , using Spearman’s rho correlations. Statistically significant correlations were found between the 5 areas of the LOTCA (2nd edition) and LOTCA-G, and the 5 corresponding subscales of the OT-APST (p<0.01). Correlations ranged from adequate (0.33 for OT-APST Apraxia subtest and LOTCA Motor Praxis area/LOTCA-G Praxis area) to excellent (0.80 for OT-APST Constructional skills subtest and LOTCA-G Visuomotor Organization area).

Zwecker et al. (2002) reported adequate correlations between the LOTCA and MMSE (r= 0.588, p<0.001) and between the LOTCA and FIM cognitive subtest (r=0.471, p<0.001) in patients with stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (n=66), using Pearson’s Correlation The extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. .

Su et al. (2000) reported significant correlations between the LOTCA, Rivermead Perceptual Assessment Battery (RPAB), and the Motor-Free Visual Perception Test (MVPT), in patients with stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (n=44). Excellent correlations were reported between LOTCA Thinking Operations and MVPT (r = 0.72, p<0.0001); LOTCA Visuomotor Organization and MVPT (r=0.79, p<0.0001); and LOCTA Visuomotor Organisation and RPAB Spatial Awareness (r=0.74, p<0.0001). Adequate correlations were reported between LOTCA Orientation and RPAB Sequencing “The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007)) (r=0.46, p<0.01) and Object Completion (r=0.38, p<0.01) subtests; LOTCA Perception and RPAB Sequencing “The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007)) (r=0.38, p<0.01); LOTCA Visuomotor Organization and RPAB Sequencing “The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007)) (r=0.52, p<0.01); and LOTCA Thinking Operations and RPAB Sequencing “The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007)) (r=0.56, p<0.0001), Object completion (r=0.36, p<0.05), Figure-ground Discrimination (r=0.51, p<0.01) and Spatial Awareness (r=0.56, p<0.0001) subtests.

Katz et al. (2000) examined correlations between cognitive performance and daily function in two subgroups of adult with right hemisphere stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (n=40 vs. patients without unilateral spatial neglect, n=21), using Spearman’s correlation The extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. analysis. Cognitive skills were measured using the LOTCA at admission to and discharge from inpatient rehabilitation, and only using the Block Design, Puzzle and Clock Drawing subtests at 6-month follow-up. Functional skills were assessed using all or some of the FIM total, motor and cognitive scores, Rabideau Kitchen Evaluation – Revised (RKE-R) (sandwich and drink preparation), and Phone Use tests at these time points. In the neglect group, adequate to excellent correlations were reported between LOTCA Visuomotor Organisation and Thinking Operations areas and functional tests at admission, discharge and follow-up (range r=0.46 to 0.80). Adequate to excellent correlations were reported between LOTCA Perception and functional tests at discharge only (range r=-0.54 to 0.75). Poor correlations were found between LOTCA Orientation and functional tasks in this subgroup. The authors reported a possible confounding effect with this sub-group, given the visual/spatial demands of the LOTCA. In the non-neglect group, poor to excellent correlations were reported between FIM Cognitive and LOTCA Orientation (r=0.05), Perception (r=0.59), Visuomotor Organisation (r=0.67) and Thinking Operations (r=0.58) areas at admission. No significant correlations were reported with FIM total or FIM motor for any LOTCA area on admission. Adequate to excellent correlations were reported between LOTCA Visuomotor Organisation and Thinking Operations subtests and functional tasks at discharge and follow up (range r=0.43 to 0.62).

Known Group: Katz et al. (1989) examined known group validity The degree to which an assessment measures what it is supposed to measure. of the original LOTCA among patients with traumatic brain injury (n=20), patients with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More (n=28), and healthy adults (n=55), using the Wilcoxon test The Wilcoxon test is a nonparametric test that compares two paired groups. This test calculates and then analyzes the differences between the pairs. The Wilcoxon Rank Sum test is used to determine whether two scores have the same continuous distribution. The Wilcoxon Signed Rank test is suitable to use as an alternative to the paired t-test when the scores are not normally distributed. . Significant differences among the three subgroups were found on initial assessment at the time of referral (p=0.0001).

Katz et al. (1995) compared LOTCA scores between healthy adults (n=29) and patients with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More (n=24), using the Wilcoxon test The Wilcoxon test is a nonparametric test that compares two paired groups. This test calculates and then analyzes the differences between the pairs. The Wilcoxon Rank Sum test is used to determine whether two scores have the same continuous distribution. The Wilcoxon Signed Rank test is suitable to use as an alternative to the paired t-test when the scores are not normally distributed. . Significant between group differences (range p=0.0002 to p=0.04) were reported for Orientation, Perception, Visuomotor Organization and Thinking Operations areas (excluding the Spatial Perception, Praxis, Coloured Block Design, Plain Block Design, Puzzle, Drawing a Clock, Categorization, Risk Object Classification – ROC -Unstructured and Pictorial Sequence B subtests). The group of healthy adults scored higher on all areas of the LOTCA than the group of patients with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More .

Katz et al. (1995) reported differences (although no statistical data were provided) between healthy adults and healthy elderly adults on the Visuomotor Organization and Thinking Operation areas of the LOTCA.

Katz et al (1997) compared performance between adults aged 18 – 30 years (n=36) and adults aged 58 – 70 years (n=36) on three versions of the LOTCA puzzle reproduction task (original direct placement version; subplacement version; and LOTCA-G version). Two-way anaylsis of variance (ANOVA) showed significant differences in terms of age (p<0.0001), puzzle version (p<0.0002) and age-by-version interaction (p<0.01). Older adults took significantly longer than younger adults to complete each version of the puzzle. While the younger group of adults took significantly longer to complete the subplacement version as compared to the other two versions (original; LOTCA-G version), the older adults were able to complete the LOTCA-G version at a significantly faster rate than the other two versions (original version; subplacement version).

Katz et al (2000) compared LOTCA performance between two subgroups of adults with right hemisphere stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More (patients with unilateral spatial neglect, n=19 vs. patients without unilateral spatial neglect, n=21) on admission to and discharge from inpatient rehabilitation. Patients with neglect were reported to score significantly worse on the Overlapping Figures subtest, Perception area total score, and all Visuomotor Organisation and Thinking Operations subtests and area total scores at admission and discharge (range p=0.02 to p=0.0001; Wilcoxon Rank Sum statistic).

Annes et al. (1996) compared LOTCA maximum scores between healthy young adults aged 17-25 years (n=49) and healthy older adults aged 40-75 years (n=49), using Fisher’s Exact Test or Yate’s chi square as appropriate. No significant differences were reported for Orientation or Perception areas. Younger adults performed significantly better on the Copying Geometric Forms (p=0.01), Plain Block Design (p=0.024) and Pictorial Sequence A (p=0.002) subtests, while older adults were reported to perform significantly better on the Geometric Sequence (p=0.046) subtest. The authors concluded that separate LOTCA norms are not required for the two age groups. While a significant difference was seen for the ROC-Unstructured subtest, it is considered that this difference was due to an error in the administration of the test. Note: The maximum score was used rather than mean or standard deviations, due to a ceiling effect A ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." More produced by the consistently high performance of subjects within both groups.

Annes et al. (1996) reported a significant difference in time taken to complete the LOTCA Visuomotor Organization area between healthy young adults aged 17-25 years (n=49) and healthy older adults aged 40-75 years (n=49), with the younger age group completing 6 of 7 subtests more quickly (Copying Geometric Forms, p<0.01; Pegboard Construction, p<0.01; Coloured Block Design, p<0.01; Reproduction of a 2D Model, p<0.05; Reproduction of a Model, p<0.05; and Drawing a Clock p<0.05; but not Plain Block Design).

Cermak et al. (1995) compared LOTCA performance between American (n=25) and Israeli (n=56) patients with CVA. Using the total sample group, they also compared performance between patients with right CVA (n=45) and patients with left CVA (n=36), using t-tests. Israeli participants were found to perform significantly better than American participants on the Orientation to Time subtest (p<0.01) in both subgroups (right CVA and left CVA); the Drawing a Clock (p<0.01) and Risk Object Classification – structured (p<0.05) subtests in the right CVA subgroup; and the Object Constancy (p<0.01) subtest in the left CVA subgroup. Comparison according to side of lesion showed that patients with right CVA performed significantly better (p<0.05) than those with left CVA on the Orientation to Time, Object Constancy and Spatial Perception subtests within the American subgroup; and on the Praxis subtest within the Israeli subgroup (p<0.01). However, patients with left CVA performed significantly better (p<0.05) than patients with right CVA on the Pegboard Construction subtest amongst both American and Israeli participants. It should be noted that Israeli participants were significantly younger than American participants in both the right CVA (mean age 58.5 vs 64.3, t = 2.25, p < 0.05) and left CVA (mean age 55.0 vs. 69.0, t=3.09, p<0.01) groups. The correlation The extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between LOTCA subtests and age were low to moderate for most subtests, but was moderate for the Orientation to Time subtest, in which the Israeli group performed significantly better than the American group.

Su et al. (2000) compared the perceptual performance of patients with intracerebral hemorrhage (n=22) to patients with ischemia (n=22) early after stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More and found that patients with intracerebral hemorrhage performed significantly worse on the LOTCA Thinking Operations area (p=0.007). No significant differences were reported between subjects with right-sided lesions and subjects with left-sided lesions for any LOTCA area.

Josman and Katz (2006) examined the relationship between formal categorization-sorting tests and functional sorting tasks among individuals with schizophrenia (n=37), patients post stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More (n=18) and healthy adults (n=15), using the LOTCA Picture Sort subtest, Wisconsin Card Sorting Test, Short Category Test, Risk Object Classification and five functional daily tasks (sorting laundry, utensils, invoices, and two shopping lists). One way ANCOVA revealed a significant difference in the mean performance of the LOTCA Picture Sort subtest (F= 7.57, P=0.001). Post hoc Scheffe tests revealed that patients with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More performed worse than individuals with schizophrenia (P<0.05) and healthy adults (P<0.05).

Katz et al (1995) compared LOTCA-G scores between healthy older adults (n=43) and patients with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More (n=33), using the Wilcoxon sign test. Healthy older adults performed significantly better than patients with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More for the Orientation, Perception, Visuomotor Organization and Thinking Operations areas (range p=0.0001 to p=0.05), excluding the Praxis and Coloured Blocks Design subtests. Significant differences in the time taken to complete the LOTCA-G were also found between the 2 groups (P<0.0001), with the healthy older adults completing the assessment more quickly than patients with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More .

Bar-Haim Erez & Katz (2003) compared LOTCA-G scores between healthy adults (n=43) and individuals with dementia (n=30). Healthy adults performed significantly better than individuals with dementia on all subtests (p=0.000), except for the Object Identification and Shape Identification subtests. Health adults completed the test significantly quicker than individuals with dementia (p<0.000). Comparison of healthy adults and two subgroups of individuals with dementia (mild dementia, n=13; moderate dementia, n=17) by one way ANOVA showed significant F tests for all areas (p<0.000, except visual perception p<0.05). Post hoc Scheffe testing showed that individuals with mild dementia performed better than individuals with moderate dementia in the areas of Orientation, Visual Perception, Visuomotor Organisation, Thinking Operations and Memory. Mann-Whitney analysis of subtest mean scores from the two dementia subgroups further showed that individuals with mild dementia performed significantly better than individuals with moderate dementia on 10 subtests (Orientation to Place, Orientation to Time, Spatial Perception-Self and Surrounding, Motor Imitation, Utilisation of Objects, Copying Geometric Forms, Pegboard Construction, Block Design (Colour), Categorisation, Memory of a Famous Personality), indicating that the LOTCA-G is sensitive to degree of dementia.

Responsiveness

No studies have reported on the responsiveness The ability of an instrument to detect clinically important change over time. of the LOTCA.

• Annes, G., Katz, N., & Cermak, S. (1996). Comparison of younger and older healthy American adults on the Loewenstein Occupational Therapy Cognitive Assessment. Occupational Therapy International , 3, 157-173.
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• Cermak, S. A., Katz, N., McGuire, E., Greenbaum, S., Peralta, C., & Flanagan, V.M. (1995). Performance of Americans and Israelis with cerebrovascular accident on the Loewenstein Occupational Therapy Cognitive Assessment. American Journal of Occupational Therapy , 49, 500-506.
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• Katz, N., Itzkovich, M., & Averbuch, S. (2002). The Loewenstein Occupational Therapy Cognitive Assessment. Archives of Physical Medicine and Rehabilitation , 83, 1179.
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• Su, C-Y., Chang, J-J., Chen, H-M., Su, C-J., Chien, T-H., & Huang, M-H. (2000). Perceptual differences between stroke patients with cerebral infarction and intracerebral hemorrhage. Archives of Physical Medicine and Rehabilitation , 81, 706-714.
• Su, C-Y., Chen, W-L., Tsai, P-C., Tsai, C-Y., & Su, W-L. (2007). Psychometric properties of the Loewenstein Occupational Therapy Cognitive Assessment-Second Edition in Taiwanese persons with schizophrenia. American Journal of Occupational Therapy , 61, 108-118.
• Su, C-Y., Lin, Y-H., Chen-Sea, M-J., & Yang, M-J. (2007). A confirmatory factor analysis of the Chinese version of the Loewenstein Occupational Therapy Cognitive Assessment-second edition in a Taiwanese mixed clinical sample. Occupational Therapy Journal of Research , 27, 71-80.
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The LOTCA can be purchased online from http://store.grovergear.com/ , http://www.ot-innovations.com , or http://therapro.com .

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A Problem-Solving Version of the Allen Cognitive Level Test

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Naomi Josman , Noomi Katz; A Problem-Solving Version of the Allen Cognitive Level Test. Am J Occup Ther April 1991, Vol. 45(4), 331–338. doi: https://doi.org/10.5014/ajot.45.4.331

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The purpose of this study was to construct and validate a problem-solving version of the existing Allen Cognitive Level Test (ACL) (Allen, 1985). The new problem-solving version of the ACL (ACL–PS) follows the theoretical developments of the cognitive disability theory and the information processing approach. It was constructed to provide a more accurate assessment of the problem-solving process as well as task performance, especially at the higher cognitive levels. Both tests were administered to a psychiatric adolescent group ( n = 49) who were subdivided according to diagnosis and to a matched nondysfunctional control group ( n = 29).

The results showed that both the ACL and the ACL–PS differentiated significantly between the patients and the control subjects and among the patient groups. At Level 6 of the ACL, none of the subjects needed any demonstration, with all scores distributed between independent performance or performance following verbal instructions only, that is, problem-solving phases that were added with the ACL–PS. The scoring of the ACL–PS is provided in addition to detailed scoring of the cognitive levels. It is suggested that the ACL–PS be implemented as a clinical evaluative tool with adolescents.

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Interventions Within the Scope of Occupational Therapy Practice to Improve Performance of Daily Activities for Older Adults With Low Vision: A Systematic Review

Chiung-ju liu.

Chiung-ju Liu, PhD, OTR/L, FGSA, was Associate Professor, School of Human and Health Sciences, Indiana University, Indianapolis, at the time of the study. She is now Associate Professor, College of Public Health and Health Professions, University of Florida, Gainesville; [email protected]

Megan C. Chang

Megan C. Chang, PhD, OTR/L, is Associate Professor, College of Health and Human Sciences, San Jose State University, San Jose, CA.

Importance: The prevalence of low vision increases with age. Low vision has detrimental effects on older adults’ independence.

Objective: To identify the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance in daily activities for older adults with low vision.

Data Sources: Literature published between 2010 and 2017 was searched in CINAHL, Cochrane Databases, MEDLINE, OTseeker, and PsycINFO.

Study Selection and Data Collection: The authors screened and appraised studies following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Studies were eligible if the participants’ mean age was 55 yr or older, the level of evidence was Level III or higher, the intervention was within the scope of occupational therapy practice, and the outcome measures assessed the performance of daily activities.

Findings: Fourteen studies met the review criteria. Three intervention themes were identified: low vision rehabilitation services ( n = 6), self-management approach ( n = 6), and tango ( n = 2). Moderate evidence was found for low vision rehabilitation services. Low evidence was found for using the self-management approach or adding the self-management approach to existing low vision rehabilitation services. Low evidence was found for tango.

Conclusion and Relevance: This systematic review supports the use of low vision rehabilitation services as an effective approach. Occupational therapy practitioners are encouraged to be part of multidisciplinary teams that offer comprehensive low vision evaluations and multicomponent services.

What This Article Adds: Low vision rehabilitation that offers multidisciplinary services, including occupational therapy, is effective in promoting independence among older adults with low vision.

Vision loss caused by age-related macular degeneration, diabetic retinopathy, and glaucoma is progressive and irreversible and often leads to low vision. Low vision refers to vision loss that results in difficulty in everyday life activities even with regular glasses, contact lenses, medicine, or surgery ( National Eye Institute, 2018a ). The prevalence of low vision increases drastically with age, from 1% of people in their late 60s to 17% of people in their 80s and older ( National Eye Institute, 2018b ). The adverse effects of low vision on older adults’ independence and emotional health have been well documented ( Brown et al., 2014 ; Kempen et al., 2012 ; Popescu et al., 2011 ; Taylor et al., 2016 ; van der Aa et al., 2015 ).

The top functional complaints among people with vision loss include difficulty reading, driving, recognizing faces, and performing in-home activities ( Brown et al., 2014 ). Activities such as functional mobility, shopping, meal preparation, cleaning, and self-care are negatively affected ( Taylor et al., 2016 ). Older adults with low vision report not only poorer performance in activities in daily living (ADLs) but also higher levels of depression and anxiety compared with older adults in the general population and with chronic conditions ( Kempen et al., 2012 ). A population-based study showed that community-dwelling Medicare beneficiaries with vision impairment were more likely to be hospitalized than those without vision impairment ( Bal et al., 2017 ). Clearly, the impact of vision loss on older adults’ independence and quality of life is profound. Although the pathological process of low vision cannot be reversed by current surgical or medical procedures, the functional decline associated with low vision may be attenuated through nonsurgical intervention provided by occupational therapy practitioners.

A prior systematic review that examined the effectiveness of occupational therapy interventions in improving ADLs and instrumental activities of daily living (IADLs) in older adults with low vision identified a positive effect of using multicomponent approaches to increase knowledge and build skills to overcome the disablement process ( Liu et al., 2013 ). The review also suggested that multiple sessions of training in the use of low vision devices and eccentric viewing are necessary to have a positive effect on clients’ daily activity performance. One of the national vision health objectives in Healthy People 2020 is to increase vision rehabilitation services and comprehensive vision health services ( U.S. Department of Health and Human Services, 2018 ). The demand for occupational therapy services for older adults with low vision will increase in parallel with the increased availability of vision rehabilitation and health services.

The purpose of this systematic review was to update the prior review and provide the most current empirical evidence to support occupational therapy practice in low vision rehabilitation. The question for the updated systematic review was, What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance in ADLs and IADLs for older adults with low vision?

This systematic review is one of three updated reviews supported by the American Occupational Therapy Association (AOTA) as part of the Evidence-Based Practice (EBP) Project (see also Nastasi, 2020 , and Smallfield & Kaldenberg, 2020 , in this issue). The methods for the review were specified in advance and documented in a protocol followed by the authors.

Literature Search

The search terms were the same as those used in the last review ( Liu et al., 2013 ; Table 1 ). These search terms were developed by the methodology consultant to the EBP Project and AOTA staff, in consultation with review authors and an advisory group. An experienced medical research librarian conducted the literature search in CINAHL, Cochrane Databases, MEDLINE, OTseeker, and PsycINFO. The search duration for published articles was set at January 2010 to January 2017, and the publication language was limited to English.

Search Terms for Daily Activity Performance for Older Adults With Low Vision

Suggested citation: Liu, C.-j., & Chang, M. C. (2020). Interventions within the scope of occupational therapy to improve performance of daily activities for older adults with low vision: A systematic review ( Table 1 ). American Journal of Occupational Therapy, 74, 7401185010. https://doi.org/10.5014/ajot.2019.038372

Literature Screening

The EBP Project methodology consultant reviewed the article titles and removed articles that were not relevant to the review before passing the search results to the authors. The two authors then individually screened each article title and abstract to determine eligibility. An article was included for further review if the average age of study participants was >55; the level of evidence provided was Level I (randomized controlled trials [RCTs], systematic reviews, or meta-analyses), Level II (nonrandomized studies with two or more groups), or Level III (one-group pretest–posttest studies); participants had low vision; the intervention was within the scope of occupational therapy practice; and the outcome measures assessed ADL or IADL performance. Articles were excluded if the publication format was a dissertation, thesis, or conference presentation or proceeding; the research design was not an intervention study; the intervention content was outside the scope of occupational therapy practice; or the publication language was not English. If the title and abstract did not provide sufficient information, the full text was retrieved for screening. Articles cited in the systematic reviews and meta-analyses included in the search results were also screened for eligibility.

Articles that passed the initial screening were retained for full-text screening. The two authors used the same eligibility criteria for the full-text screening. Any discord in eligibility decisions was resolved through discussion between the authors.

Risk-of-Bias Assessment, Data Extraction, and Synthesis of Intervention Themes

The two authors independently rated the risk of bias of each eligible study using the Cochrane risk-of-bias guidelines ( Higgins et al., 2011 ). The risk of selection bias, performance bias, detection bias, attrition bias, and reporting bias was rated as high, low, or unclear ( Table 2 , at the end of this article). The authors discussed any discord in bias rating until they reached a consensus.

Risk-of-Bias Table

Note . Categories for risk of bias are as follows: + = low risk of bias; ? = unclear risk of bias; – = high risk of bias. N/A = not applicable because no objective outcome measures were used. Risk-of-bias table format adapted from “Assessing Risk of Bias in Included Studies,” by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne , in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), by J. P. T. Higgins and S. Green (Eds.), 2011 , London: Cochrane Collaboration. Retrieved from http://handbook-5-1.cochrane.org . Copyright © 2011 by The Cochrane Collaboration.

Suggested citation: Liu, C.-j., & Chang, M. C. (2020). Interventions within the scope of occupational therapy to improve performance of daily activities for older adults with low vision: A systematic review ( Table 2 ). American Journal of Occupational Therapy, 74, 7401185010. https://doi.org/10.5014/ajot.2019.038372

After the risk-of-bias rating, the authors extracted and summarized study information, including level of evidence, research design, participant characteristics, intervention, outcome measures, and results, in an evidence table ( Table 3 , at the end of this article). One author extracted and entered the information, and the other checked the accuracy of the entered information.

Evidence Table for Daily Activity Performance for Older Adults With Low Vision

Note . AMD = age-related macular degeneration; IADLs = instrumental activities of daily living; M = mean; Mdn = median; NEI VFQ–25 = National Eye Institute Visual Function Questionnaire–25; NR = not reported; RCT = randomized controlled trial.

Suggested citation: Liu, C.-j., & Chang, M. C. (2020). Interventions within the scope of occupational therapy to improve performance of daily activities for older adults with low vision: A systematic review ( Table 3 ). American Journal of Occupational Therapy, 74, 7401185010. https://doi.org/10.5014/ajot.2019.038372

The authors worked together to identify intervention themes in included studies. The strength of evidence in each intervention theme was rated as high, moderate, or low according to the grade definitions by the U.S. Preventive Services Task Force (2014) . High strength of evidence indicates that the available evidence includes consistent results from well-designed, well-conducted studies and is unlikely to be strongly affected by the results of future studies. Moderate strength of evidence indicates that the available evidence is sufficient to determine the effects; however, confidence in the evidence is constrained by factors such as the number, size, or quality of individual studies; lack of coherence in the chain of evidence; or limited generalizability, and the magnitude or direction of the observed effect could change when more information becomes available. Low strength of evidence indicates that the available evidence is insufficient to assess effects because of the limited number of studies, significant flaws in study design or methods, inconsistency of findings across studies, or limited generalizability.

The database searches identified 10,549 records. After removing irrelevant articles and duplicates, the authors reviewed 469 titles and abstracts and excluded 433 articles. The authors then reviewed the full text of the remaining 36 articles. Fourteen articles met the inclusion criteria and were included in the final review. Figure 1 shows the flow of the articles through the literature screening and selection process.

Flow of articles through the selection process.

Note. Figure format from “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff, & D. G. Altman; The PRISMA Group, 2009, PLoS Medicine, 6 (7), e1000097. https://doi.org/10.1371/journal.pmed.1000097

Suggested citation: Liu, C.-j., & Chang, M. C. (2020). Interventions within the scope of occupational therapy to improve performance of daily activities for older adults with low vision: A systematic review ( Figure 1 ). American Journal of Occupational Therapy, 74, 7401185010. https://doi.org/10.5014/ajot.2019.038372

The 14 articles include 6 Level I RCTs ( Hackney et al., 2015 ; Pearce et al., 2011 ; Rees et al., 2015 ; Rovner et al., 2013 , 2014 ; Stelmack et al., 2012 ) and 8 Level III studies ( Alma et al., 2012 ; Coulmont et al., 2013 ; Goldstein et al., 2015 ; Hackney et al., 2013 ; Renieri et al., 2013 ; Ryan et al., 2013 ; Tay et al., 2014 ; Whitson et al., 2013 ). All trials included participants of both genders, and participants’ mean age was in the 80s in 8 studies ( Coulmont et al., 2013 ; Hackney et al., 2013 , 2015 ; Rees et al., 2015 ; Rovner et al., 2013 , 2014 ; Ryan et al., 2013 ; Whitson et al., 2013 ), in the 70s in 5 studies ( Alma et al., 2012 ; Goldstein et al., 2015 ; Pearce et al., 2011 ; Renieri et al., 2013 ; Stelmack et al., 2012 ), and in the 60s in 1 study ( Tay et al., 2014 ). Four studies specified a low vision condition (i.e., age-related macular degeneration) as an inclusion criterion ( Rovner et al., 2013 , 2014 ; Stelmack et al., 2012 ; Whitson et al., 2013 ). The rest of the studies did not specify a low vision condition and recruited participants who attended low vision service clinics, met a specific visual acuity criterion, or had any visual impairment.

Intervention approaches were categorized into three themes: (1) low vision rehabilitation services (6 studies, 1,130 participants), (2) self-management approach (6 studies, 603 participants), and (3) tango (2 studies, 45 participants). Outcome measures that assessed ADLs or IADLs were almost exclusively self-reported. The National Eye Institute Visual Function Questionnaire 25-item version (NEI VFQ–25; Mangione et al., 2001 ) was the most frequently used outcome measure. Key findings are presented by intervention theme in the sections that follow.

Low Vision Rehabilitation Services

Studies that evaluated outcomes of low vision rehabilitation services provided in clinics include 2 Level I studies ( Pearce et al., 2011 ; Stelmack et al., 2012 ) and 4 Level III studies ( Coulmont et al., 2013 ; Goldstein et al., 2015 ; Renieri et al., 2013 ; Ryan et al., 2013 ). All studies were high in risk of selection bias, performance bias, and detection bias.

In the Level I study by Pearce et al. (2011 ), participants who received low vision rehabilitation services completed a low vision assessment (the modified Massof Activity Inventory, on which they rated their difficulty performing daily activities) and then visited an optician to review low vision devices and discuss problems noted at home and available services. An attention control group completed the same low vision assessment, but instead of visiting the optician, they visited a nurse who measured biometrics. Although both groups showed improvement on the selected outcome, there was no difference between the groups.

In the Level I study by Stelmack et al. (2012 ), participants received five weekly low vision rehabilitation therapy sessions and a home visit from a visual therapist who taught strategies for using remaining vision and low vision devices. Participants also completed 5 hr of homework each week. Intervention participants showed significantly higher visual ability as measured by the 48-item Veterans Affairs Low-Vision Visual Functioning Questionnaire at 4 and 12 mo than did wait-list control participants.

Two Level III studies examined low vision rehabilitation services provided by a multidisciplinary team that included an occupational therapist ( Coulmont et al., 2013 ; Goldstein et al., 2015 ). Coulmont et al. (2013 ) found that the improvement on the Functional Global Profile was positively correlated with the number of direct service hours. Goldstein et al. (2015 ) found that half of participants showed a clinically meaningful difference as measured by the Activity Inventory and that the effect size of overall visual ability was large (Cohen’s d = 0.87).

Two Level III studies ( Renieri et al., 2013 ; Ryan et al., 2013 ) examined comprehensive low vision rehabilitation services that included some combination of vision assessment and education, fitting and training for magnifying devices and vision aids, advice about lighting and other methods of enhancing vision, suggestions for managing daily activities, and referral to additional services, reassessment, and follow-up. Both studies reported positive outcomes on the NEI VFQ–25.

Although 5 of the 6 studies in this theme showed positive outcomes for daily activity performance, the strength of evidence is weakened by the poor methodological quality of the studies. Thus, moderate strength of evidence supports using a multidisciplinary low vision rehabilitation team and a comprehensive low vision rehabilitation program to improve ADL or IADL performance.

Self-Management Approach

Three Level I studies ( Rees et al., 2015 ; Rovner et al., 2013 , 2014 ) and 3 Level III studies ( Alma et al., 2012 ; Tay et al., 2014 ; Whitson et al., 2013 ) examined interventions using the self-management approach. The Level I studies had low risk of bias in all categories, and the Level III studies had high risk of selection bias, performance bias, and detection bias.

Interventions in this theme shared the common feature of teaching study participants specific knowledge or a set of specific skills to manage problems related to vision loss as the problems arise. The interventions were not part of the usual low vision rehabilitation services participants received. Some interventions were multicomponent ( Alma et al., 2012 ; Rees et al., 2015 ; Rovner et al., 2014 ; Tay et al., 2014 ; Whitson et al., 2013 ), and one had a single component ( Rovner et al., 2013 ). Common intervention components across these studies included problem-solving skills ( Alma et al., 2012 ; Rees et al., 2015 ; Rovner et al., 2013 ), goal-setting or goal-planning skills ( Alma et al., 2012 ; Rees et al., 2015 ; Whitson et al., 2013 ), and encouragement of social connection ( Alma et al., 2012 ; Rovner et al., 2014 ; Tay et al., 2014 ). These components were delivered weekly in a program format ranging in duration from 6 wk ( Tay et al., 2014 ) to 20 wk ( Alma et al., 2012 ). The interventions were delivered in a group ( Alma et al., 2012 ; Rees et al., 2015 ; Rovner et al., 2013 ; Tay et al., 2014 ), individually in a one-on-one format ( Rovner et al., 2014 ), or individually with the involvement of a friend or family member ( Whitson et al., 2013 ).

Two Level I studies compared a self-management program combined with usual low vision rehabilitation services to usual low vision rehabilitation services alone ( Rees et al., 2015 ; Rovner et al., 2014 ). Rees et al. (2015 ) examined an 8-wk self-management program focused on problem-solving skills training and goal planning added to usual low vision rehabilitation services, which offered an initial assessment by a multidisciplinary team member, an optometric assessment and prescription of optical aids, and further intervention by the multidisciplinary team. Rovner et al. (2014 ) evaluated outcomes from six in-home weekly occupational therapy sessions focused on behavior activation, which emphasizes the relationships among action, mood, and mastery and promotes self-efficacy and social connection as means to improve mood and function, added to usual low vision rehabilitation services, which offered assessments of vision function, prescription of devices, and device education. The combined intervention in both studies did not show significantly greater effects on the Impact of Vision Impairment Questionnaire ( Rees et al., 2015 ) or on the Activities Inventory and the NEI VFQ–25 ( Rovner et al., 2014 ), compared with those of usual low vision rehabilitation services alone.

In the other Level I study, Rovner et al. (2013 ) compared problem-solving therapy to supportive therapy, an attention control condition. The study did not detect a difference between the intervention group and the control group on the Targeted Vision Function or the NEI VFQ–25.

In a Level III study, Alma et al. (2012 ) evaluated an intervention delivered over 20 wk by a multidisciplinary group that included two occupational therapists. The intervention focused on four components: (1) practical skills training; (2) education, social interaction, counseling, and training in problem-solving skills; (3) individual and group goal setting; and (4) a home-based exercise program. In another Level III study, by Tay et al. (2014 ), an occupational therapist delivered a 6-wk intervention focused on understanding vision loss; maximizing remaining vision and using other senses; staying in touch with others; managing personal care, medication, money, and household; participating in daily activities and hobbies; and maintaining safety and mobility. Neither study found a significant improvement in ADL-related outcomes, measured by the Utrecht Scale for Evaluation of Rehabilitation–Participation ( Alma et al., 2012 ) or the Low Vision Quality of Life Questionnaire ( Tay et al., 2014 ), after program completion.

In another Level III study, Whitson et al. (2013 ) evaluated an intervention program that was modified to enable older adults with cognitive deficits to benefit from low vision rehabilitation. The modifications included offering frequent and repetitive training sessions, simplifying the training experience, and involving a friend or family member, and the intervention was delivered by an occupational therapist over 6 wk. The study identified a positive outcome on the NEI VFQ–25—satisfaction with the ability to perform IADLS—and timed activity performance measures after intervention.

In summary, the strength of evidence to support interventions using the self-management approach is low. These studies did not show benefits of the self-management approach, alone or combined with usual low vision rehabilitation services, in improving ADLs or IADLs in older adults with low vision.

One Level I study and 1 Level III study from the same research team examined the effectiveness of an adapted tango intervention in improving balance and reducing falls in older adults with visual impairments ( Hackney et al., 2013 , 2015 ). The adapted tango program consisted of 20 1.5-hr lessons over 12 wk in which participants were paired with partners without vision loss. Both studies had high risk of selection bias, performance bias, and detection bias. In the Level III study, a feasibility study, participants showed significant improvement on the NEI VFQ–25 after the program ( Hackney et al., 2013 ). The Level I study compared the adapted tango program to a standard fall prevention exercise program ( Hackney et al., 2015 ). Although participants in both programs showed a significant improvement on the NEI VFQ–25, the Level I study did not show a superior effect of the adapted tango program relative to that of the standard fall prevention exercise program.

In summary, the strength of evidence to support the use of a tango intervention to improve ADLs and IADLs in older adults with low vision is low. The strength of evidence is weakened by the limited number of studies and poor methodological quality.

The purpose of this systematic review was to identify the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve ADLs and IADLs for older adults with low vision. Fourteen studies were appraised, and three intervention themes were identified: low vision rehabilitation services, self-management approach, and tango. Moderate evidence was found in support of low vision rehabilitation services. Low evidence was found in support of the self-management approach and tango.

The themes of low vision rehabilitation services and the self-management approach overlap with the themes of multicomponent intervention, single-component intervention, and multidisciplinary intervention identified in the prior review ( Liu et al., 2013 ). Low vision rehabilitation often involves a multidisciplinary team who offer comprehensive evaluations and multicomponent services. The self-management approach can entail a single-component intervention to equip clients with one specific skill or a multicomponent intervention to provide clients with various knowledge and skills. The prior review reported robust evidence in the multicomponent intervention and single-component intervention themes, particularly for interventions delivered over multiple training sessions. The prior review also reported moderate evidence in the multidisciplinary intervention theme.

The results of the current review are consistent with those of the prior review for the multidisciplinary intervention theme and support the positive effect of low vision rehabilitation services. However, the results of the current review for the self-management approach are not as positive as those of the prior review for the multicomponent or single-component intervention themes. The discrepancy may reflect the expansion of study population age and visual impairment conditions, and lack of sensitivity of the outcome measures used in the studies included in the current review.

A wide array of low vision rehabilitation services are available, ranging from simple provision of optical and nonoptical aids to more holistic and comprehensive approaches (e.g., integrated multidisciplinary services) and from one-time service visits to multiple service visits. Prior systematic reviews have shown robust effects of low vision rehabilitation services on vision-related daily task performance regardless of service model or content ( Binns et al., 2012 ; Liu et al., 2013 ). For clients with mild visual impairments, basic low vision services, such as the prescription and provision of low vision devices, and comprehensive low vision rehabilitation services, such as low vision devices plus training in device use or eccentric viewing and environmental modifications, have been found to yield equivalent ADL outcomes ( Stelmack et al., 2017 ). For clients with more severe vision loss in the better-seeing eye, however, comprehensive low vision rehabilitation services have proved more beneficial than basic low vision services ( Stelmack et al., 2017 ). Thus, providing basic low vision services to older adults with mild vision loss is fundamental to promote ADL independence, even when the service content is simple, whereas for clients with more severe vision loss, expansion of service content and involved disciplines is necessary. One caveat of research findings on low vision rehabilitation services in general is that most studies lacked a control group, which weakens the strength of evidence.

Earlier research has shown that self-management skill training improves ADL performance in older adults with age-related vision loss, specifically vision loss caused by macular degeneration ( Eklund et al., 2004 , 2008 ; Girdler et al., 2010 ; Lee et al., 2008 ; Packer et al., 2009 ). Common components of such programs include education about age-related macular degeneration, training in the use of low vision devices, training in problem-solving skills, and provision of low vision information and resources. The self-management studies included in this review expanded the inclusion criteria from older adults with age-related macular degeneration to those with any visual impairment ( Alma et al., 2012 ; Rees et al., 2015 ; Tay et al., 2014 ). The self-management interventions thus were not tailored to participants’ low vision condition, which may have weakened the interventions’ effects ( Rees et al., 2015 ). For example, a client with central vision loss may benefit from training in face recognition, whereas a client with peripheral vision loss may not. In addition, the expansion of the visual impairment conditions addressed also resulted in samples with a wider age range. For example, in two studies ( Alma et al., 2012 ; Tay et al., 2014 ) that met the mean age inclusion criterion for this review, the lower value of the age range was in the 50s; adults in their 50s have different learning capabilities and require different self-management skills relative to adults in their 60s and older ( Tay et al., 2014 ). The effect of the self-management interventions might have been stronger if needs and learning capabilities of different age groups were taken into consideration. In short, the low evidence identified for the self-management approach might reflect the researchers’ interest in expanding the inclusion criteria to include participants with other visual impairment conditions, resulting in a heterogeneous sample who required self-management skill training tailored to each participant’s vision condition and learning capacity.

Another reason for the low strength of evidence for the self-management approach is the lack of sensitivity of the outcome measure used ( Alma et al., 2012 ; Rovner et al., 2014 ). Most studies used assessments of quality of life that include items addressing vision-related functional tasks, such as the NEI VFQ–25 ( Mangione et al., 2001 ). Strictly speaking, vision-related quality of life assessments are not functional assessments ( Ehrlich et al., 2017 ; Stelmack et al., 2002 ). Lack of sensitivity to detect change manifests through nonsignificant findings at the grand total score level but not at the item level ( Alma et al., 2012 ; Rovner et al., 2014 ; Stelmack et al., 2002 ). For example, Rovner et al. (2014) found a significant change only in NEI VFQ–25 items assessing near vision activities. Moreover, setting individualized goals and working to achieve these goals are part of the self-management programs included in the review ( Alma et al., 2012 ; Rees et al., 2015 ; Whitson et al., 2013 ), and the grand total score of a quality of life assessment might not be sufficiently sensitive to reflect improvements in these individualized goals.

Four studies that examined the self-management approach also reported high refusal rates of >40% by eligible participants ( Rees et al., 2015 ; Rovner et al., 2013 , 2014 ; Whitson et al., 2013 ). The high refusal rates are concerning because self-management is a new paradigm in health care to empower clients to be in charge of their own health. Rees et al. (2007 ) suggested that adults with low vision have low interest in participating in a self-management program because of time commitments, travel requirements, negative expectations, or perceived lack of need. The high refusal rate in Rovner et al.’s (2014) study might relate to the inclusion criterion of subthreshold depressive symptoms. Although self-management programs address emotional or psychosocial aspects of low vision and therefore may be more beneficial than low vision rehabilitation services alone ( Rovner et al., 2014 ), lack of accessibility to such programs means that low vision rehabilitation services are the frontline treatment option for older adults with vision loss. Future research should focus on increasing the accessibility and acceptability of self-management programs to older adults with low vision.

Although vision loss is a significant contributing factor to late-life disability, age-related decline in other body functions can accelerate the disablement process. Older adults with low vision also experience reduced endurance, mobility problems, and cognitive impairments ( Goldstein et al., 2015 ). Vision loss, cognitive and physical decline, and participation restrictions create a vicious circle in which relinquishing valued activities because of low vision increases the risk of cognitive decline and falls, leading to further activity limitations ( Lamoureux et al., 2010 ; Rovner et al., 2009 ). This review shows that researchers examining interventions for older adults with low vision have started to address cognitive and physical decline. Whitson et al. (2013) targeted people with low vision who also had cognitive deficits and included frequent and repetitive sessions, simplified training experience, and involvement of a companion in their self-management program. Alma et al. (2012) included home-based exercise in their self-management program, and Hackney et al. (2013 , 2015 ) examined the effect of tango on balance and mobility. Still, few studies have targeted multiple declines in older adults with low vision, and future studies are needed that focus on a multifaceted approach addressing physical and cognitive decline in addition to vision loss to reduce functional decline in older adults with low vision.

Our review findings are partially consistent with a recent scoping review that identified effective interventions to facilitate the occupational engagement of older adults with age-related vision loss ( McGrath et al., 2017 ). These interventions include self-management programs, compensatory interventions such as assistive device use, and social support. The differences in intervention themes and outcomes between the scoping review and this systematic review may be attributed to the different literature search period (2002–2015 vs. 2010–2017) and age cutoff (≥65 vs. ≥55). Our review indicates that the provision of assistive devices is often part of low vision rehabilitation services ( Pearce et al., 2011 ; Renieri et al., 2013 ; Ryan et al., 2013 ; Stelmack et al., 2012 ) and that increasing social networks is often part of self-management programs ( Alma et al., 2012 ; Rovner et al., 2014 ; Tay et al., 2014 ; Whitson et al., 2013 ).

Limitations

This systematic review has a few limitations. Given the wider age range we applied, participants in some studies may not have had age-related vision loss. In addition, although driving is an important IADL, we did not include any driving studies in this review because the samples in the located studies either were young adults or had conditions not limited to low vision.

Implications for Occupational Therapy Practice, Education, and Research

The findings of this review have the following implications for occupational therapy practice, education, and research:

• Basic low vision rehabilitation services, such as the provision of low vision devices, are effective to improve ADL performance in older adults with mild vision loss. Occupational therapy practitioners who are not low vision specialists can provide general services, such as home assessments, problem-solving training, or home exercise programs, to promote ADL performance in older adults with vision loss.
• Comprehensive low vision rehabilitation services are often provided by a multidisciplinary team. Occupational therapy education programs housed close to other vision care professional programs, such as optometry or ophthalmology, could initiate interprofessional education and practice collaboration. Such initiatives would build occupational therapy students’ capacity to work with other low vision care professionals ( Lucas Molitor & Mayou, 2018 ). Additionally, the curriculum could cover knowledge about how to apply general occupational therapy skills to better serve older adults with low vision.
• Performance-based vision-related occupational performance assessments that are sensitive to change are needed. An example is the Revised Self-Report Assessment of Functional Visual Performance ( Snow et al., 2018 ; Zemina et al., 2018 ), which includes a performance component. Performance-based assessments offer complementary information for evaluating intervention outcomes. Researchers in low vision are encouraged to include ADL and IADL measures or occupation-based performance assessments as functional outcome measures.
• Future research needs to continue examining the effectiveness of self-management programs for older adults with low vision. Specifically, the research focus could be shifted to what components to include to improve effectiveness and how to increase the accessibility and acceptability of such programs.

Low vision has detrimental effects on older adults’ independence in ADLs and IADLs. This systematic review supports the use of low vision rehabilitation services as the primary mean to promote independence in older adults with low vision. Occupational therapy services should continue to be part of low vision rehabilitation services, which provide comprehensive low vision evaluations and intervention. Although low evidence was identified for the self-management approach alone or combined with low vision rehabilitation services, increasing access to self-management programs for older adults with more severe vision loss could increase the impact of such programs. This review also shows an emerging trend of expansion of low vision intervention content by considering cognitive decline and physical decline in addition to vision loss. This expansion includes developing effective modes of intervention delivery to older adults with low vision who also experience cognitive deficits, as well as adding a physical component, such as exercise or tango, to address physical decline in older adults with low vision.

Acknowledgments

We thank Deborah Lieberman and Elizabeth Hunter for their guidance and support of this review.

* Indicates articles included in the systematic review.

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Executive Function

So, what exactly is executive function, explore popular topics.

What do all these words mean?

Executive Functioning Skills guide everything we do.  From making decisions, to staying on track with an activity, to planning and prioritizing a task .  The ability to make a decision, plan it out, and act on it without being distracted is what allows us to accomplish the most mundane of tasks to the more complicated and multi-step actions.  Children with executive functioning issues will suffer in a multitude of ways.  Some kids have many deficits in EF and others fall behind in several or all areas. Everyone needs to develop and build executive functions as they grow.  Functional adults may still be struggling with aspects of executive functioning skills.  Executive dysfunction can interfere with independence and the ability to perform activities.  The cognitive skills are an interconnected web of processing that allows for self-regulation, planning, organization, and memory.

Executive Functioning Skills

As a related resource, try these self-reflection activities for kids .

What are executive functions?

Executive functioning skills:, cognitive flexibility.

• Check for smooth changes in tasks.
• Tally number of errors.
• Record number of verbal prompts (“Are you all done?”), physical prompts (pointing, etc.)

Executive function and handwriting

How to build executive function skills:

Top executive function blog posts.

• Executive Functioning Skills , Free Resources

Tools to Stop to Think

• Attention , Executive Functioning Skills , Occupational Therapy Activities , Sensory

Self-Reflection Activities

• Executive Functioning Skills , Free Resources , Occupational Therapy

Drawing Mind Maps

• Executive Functioning Skills , Functional Skills , Occupational Therapy Activities

Executive Function Coaching

• Executive Functioning Skills , Free Resources , Mental Health , Occupational Therapy

The Power of Yet

Breaking Down Goals

• Attention , Executive Functioning Skills , Occupational Therapy

Executive Function Tests

• Attention , Development , Executive Functioning Skills , Occupational Therapy

Spring Activities for Executive Functioning

Executive function in products.

How-to Life Sequences Made Easy – Cut & Paste

Fix the Mistakes-Fun Themes Bundle

Task Completion Cards (5 Theme Bundle)

Play Dough Board Games-Full Year

Free Executive Function Resources

Coin Activities for Kids

How to Support Sensory Needs in the Cafeteria

What is Overstimulation Anxiety?

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Strengthening problem-solving skills through occupational therapy to improve older adults' occupational performance - A systematic review

Affiliations.

• 1 Department of Occupational Therapy, VIA University College, Aarhus, Denmark.
• 2 Programme for rehabilitation, Research Centre for Health and Welfare Technology, VIA University College, Aarhus, Denmark.
• PMID: 35995214
• DOI: 10.1080/11038128.2022.2112281

Background: Evidence supports the role of occupational therapy (OT) for older adults, and therapeutic use of problem solving may provide a way to improve older adult's occupational performance. Aim: To assess the effectiveness and describe the contents of OT interventions aimed at improving older adults' occupational performance by strengthening their problem-solving skills. Material and Methods: This systematic review followed the phases recommended by the Cochrane Collaboration. The following databases were searched for clinical trials on OT for populations 65+ years: CINAHL, EMBASE, MEDLINE and PsycINFO. The Cochrane risk-of-bias tool (RoB-2) and the GRADE approach were used to assess the quality of the evidence. Results were presented in tables and by narrative syntheses. Results: Five studies were included comprising a total of 685 participants. In four studies, OT with a problem-solving approach outperformed control conditions post intervention. The interventions involved problem identification, analysis, strategy development and implementation. Although no serious risk of bias was detected in the individual studies, the quality of evidence was deemed low due to inconsistent and imprecise results. Conclusions: Low-quality evidence suggests that strengthening older adults' problem-solving skills may improve their occupational performance. Significance: Further investigation is required before firm practice recommendations can be prepared.

Keywords: ADL; Activities of daily living; cognitive strategies; elderly; functioning; occupation; problem solving; rehabilitation.

Publication types

• Systematic Review
• Occupational Therapy* / methods
• Problem Solving