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Cognitive assessments for older adults: Which ones are used by

Canadian therapists and why


doi:10.2182/cjot.07.010 This paper was published in the CJOT Early Electronic Edition, Fall 2007.

Alison Douglas ■ Lili Liu ■ Sharon Warren ■ Tammy Hopper

Key words
■ Cognition ■ Assessment ■ Older adults

Mots clés
■ Fonctions cognitives ■ Évaluation ■ Personnes âgées

Abstract
Background. Occupational therapists routinely evaluate cognition in older adults, yet little is known about which assessments
they use and for what purposes. Purpose. To examine the standardised and non-standardised assessments used by
occupational therapists to evaluate cognition. Method. A random sample of 1042 Canadian occupational therapists completed
the questionnaire by e-mail, post, or Internet website (n=247, response rate: 24.5%). Results. Respondents reported using 75
standardised and non-standardised measures. The assessments were grouped according to theoretical approach: bottom-up
(assessment of cognitive components), top-down (assessment of function) and combined (either of above, plus interview).
Theoretical approaches were used similarly across regions, despite differences in reporting of particular assessments. Therapists
used more bottom-up assessments that were standardised, identified deficits, and easy to administer. They used more top-down
assessments that were non-standardised, predicted function, and fit with their theoretical approach. Conclusion. It is
recommended that standardised top-down assessments be developed to support evidence-based occupational therapy.

Résumé
Description. Même si les ergothérapeutes évaluent régulièrement les fonctions cognitives des personnes âgées, on en connaît
relativement peu sur les évaluations qu'ils utilisent et sur les raisons pour lesquelles ils utilisent ces évaluations. But. Examiner les
évaluations standardisées et non standardisées utilisées par les ergothérapeutes pour évaluer les fonctions cognitives.
Méthodologie. Un échantillon aléatoire de 1 042 ergothérapeutes canadiens ont rempli un questionnaire par courriel, par la
poste ou par l'intermédiaire d'un site web situé sur Internet (n = 247; taux de réponse : 24,5 %). Résultats. D'après les réponses au
questionnaire, 75 mesures standardisées et non standardisées sont utilisées par les répondants. Les évaluations ont été
regroupées en fonction de l'approche théorique correspondante, soient une approche spécifique (évaluation des composantes
cognitives), une approche globale (évaluation des capacités fonctionnelles) et une approche combinée (les deux approches
susmentionnées, de même qu'une entrevue). Les approches théoriques ont été utilisées de la même manière d'une région à
l'autre, malgré des différences dans la façon de décrire certaines évaluations. Les ergothérapeutes ont utilisé davantage les
évaluations spécifiques standardisées, permettant de cibler les déficits et plus faciles à administrer. Ils ont utilisé davantage les
évaluations globales non standardisées, permettant de prédire les capacités fonctionnelles et correspondant à leur approche
théorique. Conclusion. Les auteurs recommandent l'élaboration d'évaluations globales standardisées pour appuyer
l'ergothérapie fondée sur les faits scientifiques.

ognition is one of the outcomes most frequently mea- therapy practice in the use of cognitive assessments with

C sured in health care (Miller & Weissart, 2003). The


majority (60%) of occupational therapists work with
seniors aged 65 and over (Canadian Association of
older adults.
Cognition is defined as processes in the mind that pro-
duce thought- and goal-directed action (Vining Radomski,
Occupational Therapists [CAOT], 2004a) and therapists rou- 2002). Occupational therapists assess cognition with respect
tinely assess cognition in older adults (Grieve, 2000; Strub & to occupational performance (CAOT, 1997), which is the abil-
Black, 1993). Although the literature contains descriptions ity to function in the tasks, activities, and roles that define the
and recommendations for cognitive assessment in occupa- person as an individual (Law, Baum, & Dunn, 2005). The
tional therapy, little is known about current practice and the client's cognition is assessed as a component that affects
therapists' reasons for choosing certain assessments. The pur- occupational performance in the areas of self-care, produc-
pose of the study was to describe the current occupational tivity, and leisure (CAOT, 1997). Thus, the cognitive assess-

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DOUGLAS ET AL.

ment is part of the process of assessing the client's roles and approaches with other client groups. For example, a prefer-
performance of occupations. ence for non-standardised over standardised tests was found
The occupational therapy literature provides descrip- among occupational therapists whose clients had rheuma-
tions of various assessment approaches including: 1) the toid arthritis (Blenkiron, 2005). In addition, therapists
bottom-up approach, 2) the top-down approach, and 3) the working with children with autism reported using non-
combined approach. Using the bottom-up approach (Duchek standardised assessments more frequently than standardised
& Abreu, 1997; Grieve, 2000; Vining Radomski, 2002), the ones (Watling, Deitz, Kanny, & McLaughlin, 1999). A recent
therapist focuses on cognitive capacities, such as memory or decline in the reporting of bottom-up, standardised assess-
attention, and uses performance to infer potential function in ments in pediatrics has been hypothesized to be linked to an
daily life. The top-down approach (Duchek & Abreu; Grieve; increase in the use of functional standardised assessments
Vining Radomski) refers to the therapist's observation of a and observation of functional skills compared to previous
client's performance of everyday tasks to ascertain cognitive surveys (Burtner, McMain, & Crowe, 2002).
abilities. The combined approach (Vining Radomski) pro-
vides information not obtainable from the previous Purposes and reasons for
approaches. Information may include data obtained from cognitive assessment
client self-report and caregiver report on standardised ques- The three purposes for assessment have been described by
tionnaires or from interviews. Kirshner and Guyatt (1985). These are to (1) identify deficits,
either by screening or more detailed assessment, (2) predict
Standardised and non-standardised function, such as safety or need for services, and (3) measure
methods for assessment change, which includes obtaining baseline and measuring
Standardised assessments are those ones which use a docu- outcomes.
mented protocol, are scored, and are administered under uni- Therapists must select amongst a wide array of mea-
form conditions (Mandich, Miller, & Law, 2002; Vining sures. A review of the occupational therapy journals
Radmoski, 2002; Wheatley, 2001; Wilkins, Law, & Letts, 2001). (CINAHL database) and textbooks (Asher, 1996; Duchek &
They have the advantage of providing objective, quantifiable Abreu, 1997; Goslisz & Toglia, 2003; Grieve, 2000; Law et al.,
data and a common terminology to communicate with other 2005; Vining Radomski, 2002) identified at least 26 cognitive,
professionals on the health-care team (Wheatley, 2001). They standardised assessments that were recommended for cogni-
also form a foundation for evidence-based practice in that tive assessment with older adults (Douglas & Liu, 2005).
they can be used to compare clients to a normative group, and Choices of assessments are based on psychometric prop-
scores cumulated across clients can be used to evaluate inter- erties and other factors, such as clinical utility and theoretical
vention (Mandich et al.). construction (Law et al., 2005). Several textbooks offered pri-
Informal or non-standardised assessments do not follow marily descriptive information about cognitive assessments
a standard protocol and include such measures as interviews in occupational therapy without providing a critique of the
and observation (Pedretti & Early, 2001). For example, a clin- rigor of their psychometric properties, such as reliability and
ician may observe clients in the kitchen to determine their validity (Gélinas & Auer, 1996; Goslisz & Toglia, 2003; Vining
ability to organise and plan (Vining Radomski, 2002). Radomski, 2002). Furthermore, each textbook provided a
Non-standardised assessments have the disadvantage of different list of assessments, and the criteria for inclusion of
being highly subjective. Results from these assessments are instruments were unclear. Textbooks dedicated to reviewing
influenced by the therapist's opinion of what constitutes psychometric properties for occupational therapy outcome
impaired performance, and by the therapist's ability to deter- measures did not include a comprehensive list of direct mea-
mine the relationship between specific behaviours and cogni- sures of performance components, such as cognition (Asher,
tive processes (Vining Radomski, 2002). However, 1996; Law et al.; Letts, Baum, & Perlmutter, 2003).
non-standardised assessments also have advantages: they Few critical reviews were available that pertained to the
provide important functional information and may be used psychometric characteristics of cognitive assessments for
to assess clients who cannot tolerate a full standardised test or older adults. Kirkpatrick and Jamieson (1993) examined
for whom communication is difficult (Vining Radomski, standardised cognitive measures for use in a cardiac unit.
Wheatley, 2001). They can also be individualised to a client's They reviewed 12 brief neuropsychological screening tests
particular goals and environment, which may change over and five tests from the rehabilitation literature. They found
the course of therapy (Mandich et al., 2002). that the data they reviewed supported superior validity and
The frequency of use of standardised and non-standard- reliability of the brief neuropsychological screening tools.
ised assessments by occupational therapists working with Again, the inclusion criteria were not specified. Medical lit-
older adults is unknown; however, some evidence exists to erature reviews of cognitive tests for dementia have focused
support increased frequency of use of non-standardised on brief screening instruments favoured by physicians

© CAOT PUBLICATIONS ACE VOLUME 74 ■ NUMBER 5 ■ CANADIAN JOURNAL OF OCCUPATIONAL THERAPY ■ DECEMBER 2007 371
DOUGLAS ET AL.

(Lorentz, Scanlan, & Borson, 2002), and excluded assess- that were found in the literature review. It was piloted by five
ments described in the literature for occupational therapists. occupational therapists who gave feedback about clarity,
Aside from psychometric properties, clinical utility and completion time, and face validity of the instrument
theoretical construction are also considered by occupational (Portney & Watkins, 2000; Streiner & Norman, 1995). The
therapists when choosing an assessment tool (Law et al., questionnaire contained three sections: Part A: Theoretical
2005). Clinical utility refers to the usefulness of the results, approaches to assessment: respondents indicated frequency of
time required for training, ease of scoring, administration, use of each approach. Part B: Specific assessment instruments
and interpretation, fit with clinical setting, and the purpose used: respondents listed up to five assessments they used
of the assessment. Theoretical construction of the tool refers (either standardised or non-standardised), and rated fre-
to the fit between the assessment tool and the clinician's the- quency, purpose, and reasons for their choice. The purposes
oretical approach to occupational therapy. For example, listed were: (1) identify deficits (includes screening or more
when assessing the performance of daily activities (top-down detailed assessment), (2) predict (safety, compensation or
approach) a therapist may be more likely to favour assess- need for service in the community), and (3) measure change
ments that allow direct observation of daily activities. (includes obtaining baseline, measures outcomes). The rea-
sons for choice were listed for ranking by the participants,
Study objectives and can be seen in Table 7. Part C: demographics: respondents
The four objectives of the study were to describe (1) the fre- indicated their primary practice setting, geographic region,
quency of theoretical approaches used and whether frequen- age category, and gender (Douglas, 2005).
cies varied by geographic region; (2) which assessments the
respondents were using (e.g., bottom-up or top-down, stan- Participant recruitment
dardised or non-standardised); (3) the purposes for which The sample size calculation was based on an estimated
the assessments were used (identification of deficits, predic- response rate of 35% and indicated that 364 respondents
tion, and measurement of change); and (4) the importance of were needed. The expected response rate of 35% was based
their reasons for choosing their assessments. on previous surveys of Canadian occupational therapists;
however, survey response rates generally are much lower. For
Method postal surveys, response rates have been noted to be between
Design and development of survey tool 30 and 60% (Portney & Watkins, 2000), but as low as 5 to
A combined or multimodal design (Schaefer & Dillman, 10% for some questionnaires (Edwards et al., 2003). For
1998) for the postal and Internet survey was chosen for this electronic surveys, response rates have been reported to vary
study, because it is associated with increased speed, and between 19 and 43% (Yun & Trumbo, 2000). There is no
reduced costs and respondent burden compared to telephone standard for an acceptable survey response rate (Cummings,
interviews and postal-only surveys (Schaefer & Dillman). Savitz, & Konrad, 2001); however, lower response rates
The combined design addresses potential sampling bias by increase the likelihood of response bias (Edwards et al.;
ensuring that those individuals without access to the Internet Portney & Watkins).
have equal ability to respond. Individuals were eligible for the study if they were occu-
Although there is debate over whether response rates are pational therapists who had consented for their contact
greater for postal, e-mail, or web-based surveys (Klein, 2002), information to be released, worked in Canada, and had direct
e-mail and postal surveys have been shown to be equally effec- client contact with older adults. The OT Networker database
tive (Schaefer & Dillman, 1998). In this study, e-mail requests from the CAOT (CAOT, 2004b) provided contact informa-
were sent to all those with e-mail addresses, as the response tion for those that met the criteria. The sample was stratified
rates were not expected to be significantly different between by province of residence according to the national distribu-
e-mail and postal response rates, and e-mail notices are asso- tion of occupational therapists (CAOT, 2001). Ethics
ciated with reduced cost. The e-mail requests directed the approval was obtained from the University of Alberta Health
respondents to a web-based survey. Web-based surveys have Research Ethics Board. The study adhered to ethical princi-
numerous access advantages over e-mail surveys, which ples of confidentiality, informed consent, voluntary partici-
include reduced risk of file corruption and reduced deletion pation, and explanation of risks and benefits. The
due to "spam" filtering and fear of viruses (Dillman & Bowker, questionnaires were mailed or e-mailed to 1042 randomly
2001). The researcher used published information to develop selected occupational therapists on October 1, 2004.
both the e-mail notices (Schaefer & Dillman) and the design A follow-up letter or e-mail was sent to the therapists
of the web-based survey (Dillman & Bowker; Dillman, three weeks later, and an incentive was available in the form
Tortora, & Bowker, 1998; Klein). of a certificate of participation that could be printed from the
A questionnaire was developed based on theoretical website and used for a professional portfolio.
approaches and reasons for choosing specific assessments

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DOUGLAS ET AL.

Data analysis The regional representation of the respondents was com-


Descriptive statistics regarding frequencies and percentages pared to the membership in CAOT (n=5,090) and all occupa-
were obtained using SPSS software (SPSS Inc., 2004). Open- tional therapists in the country (n=9,485). Some of the
ended questions with the names of the assessments were provinces had expected numbers of less than five practicing
grouped according to whether the assessment was standard- occupational therapists; therefore, the provinces were grouped
ised or non-standardised. The non-standardised assessments into regions to allow the use of a chi-square calculation. The
were categorised according to similarities in the type of task following regions were used: British Columbia, Prairie
performed, such as being interviewed or participating in Provinces (Alberta, Saskatchewan, and Manitoba), Ontario,
kitchen tasks. Subsequently, the assessments were categorised Quebec, and Atlantic Provinces and Territories (New
according to theoretical approach (i.e., bottom-up or top- Brunswick, Nova Scotia, Prince Edward Island,
down). The first author assigned the assessments to each Newfoundland, Nunavut, Yukon Territories, and Northwest
group based on the literature review or by checking the test Territories). The groupings were based solely on numbers of
manuals regarding the assessment description, purpose, and respondents rather than any perceived similarity in culture,
theoretical approach. The categories were checked by the sec- working conditions, or geographic proximity. There was a sig-
ond author. If the assessment was not given a standardised nificant difference between distributions in region of residence
name, the assessment was assumed to be non-standardised; when comparing the respondents to the membership in CAOT
for example, “word list” as a possible response was catego- (x2=46.19, df =4, p<.001), and to all occupational therapists in
rized as a non-standardised assessment because it was from a the country (x2=63.30, df=4, p<.001). Compared to the CAOT
list generated by the therapist, and, therefore, could not be membership, there was also a proportionally higher represen-
identified as a particular standardised assessment. tation of respondents from the Prairie Provinces.
Chi-square analyses were used to determine how to In Part A of the questionnaire, the respondents were
compare the composition of the sample to practicing asked about the theoretical approaches they used for cogni-
Canadian occupational therapists (n=9,485), and to the tive assessment. The combined approach was the most
membership of the CAOT (n=5,090) (CAOT, 2001). Chi
square analyses were also used to examine the variability in TABLE 1
the use of each theoretical approach to cognitive assessment Demographic description of respondents
across geographic regions. Post-hoc analysis using Yates
Characteristic Frequency among respondents
Correlation Coefficient was used to determine specific differ-
Number (n) Percent (%)
ences in the use of theoretical approach by geographic region.
Gender (n= 214)
Results Male 11 5.1
There were 1042 surveys sent by e-mail and post, of which 35 Female 203 94.9
were returned undeliverable (34 by e-mail, 1 by post). From
Age Group (n=219)
the 1008 deliverable surveys, 251 were returned (24.9%), and 65 and over 1 0.5
247 of them were deemed valid, indicating a valid response 55-64 10 4.5
rate of 24.5%. 45-54 47 21.4
Among the 247 valid questionnaires, 167 (67.6%) were 35-44 73 33.6
25-34 82 37.3
completed through the web-based survey, 43 (17.4%) were
24 and under 6 2.7
completed electronically and returned via e-mail, and 37
(15.0%) were paper versions returned to the researcher by Place of Residence (n=216)
post. The respondents were asked to indicate how they British Columbia 21 8.5
received the invitation to participate in the study. There were Atlantic Provinces & Territories 11 5.1
Ontario 76 30.8
140 responses from direct e-mail requests (17.3% e-mail Quebec 30 12.1
response rate), and 45 responses from direct postal requests Prairie Provinces 78 36.1
(22.3% postal response rate). The number of respondents
indicating that they had received requests from indirect Primary Work Setting (n=216)
sources such as advertising, forwarded e-mails, and by word General hospital 78 36.7
Client's home 54 24.8
of mouth was 36 (14.6% of respondents). Rehabilitation centre 34 15.6
The demographic characteristics of the respondents are Community clinic 7 3.2
shown in Table 1. There was no significant difference Private health business 4 1.8
between the observed and expected gender distribution (x2= Mental health centre 8 3.7
.93, df=1, p= .335) or age distribution (x2= 1.93, df=5, p= Post secondary 1 0.5
Chronic care/LTC 30 13.8
.858) compared to membership statistics for CAOT.

© CAOT PUBLICATIONS ACE VOLUME 74 ■ NUMBER 5 ■ CANADIAN JOURNAL OF OCCUPATIONAL THERAPY ■ DECEMBER 2007 373
DOUGLAS ET AL.

TABLE 2
Frequencies of using cognitive assessment approaches

Less than 25% of clients 25-50% of clients 50-75% of clients More than 75% of clients
Approach
n % n % n % n %
Bottom-up 42 17.1 59 24.0 58 23.6 87 35.4
Top-down 28 11.4 49 19.9 52 21.1 117 47.6
Combined 27 11.0 34 13.8 34 13.8 149 60.6

(Valid n=247)

frequently reported, followed by the top-down and then bot- combined approach.
tom-up approaches (see Table 2). A chi-square analysis of the In Part B of the questionnaire, respondents were asked to
reported frequency of each approach according to region of list up to five assessments (either standardised or non-stan-
residence showed no significant differences in the distribu- dardised), which they used to assess cognition with older
tions of the bottom-up approach, top-down approach, or adults. A total of 65 standardised and 9 non-standardised

TABLE 3
Regional use of 15 most reported assessments of cognition

Assessment name Frequency Region of Residence


Respondents BC Prairie Provinces ON QC Maritimes/ Territories
(n=225) (n=21) (n=78) (n=76) (n=30) (n=11)

n % n % n % n % n % n %
Mini Mental 159 70.7 13 8.6 59 38.8 56 36.8 18 11.8 6 3.9
Status Exam (MMSE,SMMSE)
Cognitive 127 56.4 8 6.5 49 39.5 51 41.1 9 7.3 7 5.6
Competency Test (CCT)
Neurobehavioral 78 34.7 7 9.1 54 70.1 15 19.5 0 0.0 1 1.3
Cognitive Status Examination
(NCSE/Cognistat)
General ADL task 65 28.9 5 7.9 22 34.9 24 38.1 8 12.7 4 6.3
Kitchen task 58 25.8 4 7.0 25 43.9 20 35.1 5 8.8 3 5.3
Interview 48 21.3 9 19.6 15 32.6 13 28.3 6 13.0 3 6.5
(of client or not specified)
Cognitive Assessment 40 17.8 0 0.0 1 2.7 13 35.1 21 56.8 2 5.4
Scale for the Elderly
(CASE/Pecpa-2r)
Clinical Observation 39 17.3 4 10.3 14 35.9 8 20.5 13 33.3 0 0.0
Executive Interview 27 12.0 0 0.0 25 96.2 1 3.8 0 0.0 0 0.0
(EXIT)
Rivermead Behavioral 35 11.1 0 0.0 3 13.0 15 65.2 5 21.7 0 0.0
Memory Test (RBMT)
Clock Drawing 20 8.9 3 15.0 4 20.0 8 40.0 9 15.0 2 10.0
Test & Clox test
Motor Free Visual 19 84.5 3 16.7 3 16.7 7 38.9 3 16.7 2 11.1
Perceptual Test (MVPT)
Cognitive Assessment 17 7.5 3 17.6 9 52.9 3 17.6 0 0.0 2 11.8
of Minnesota (CAM)
Independent Living 16 7.1 5 35.7 6 42.9 2 14.3 0 0.0 1 7.1
Scales (ILS)
Modified Mini Mental 12 5.3 2 16.7 2 16.7 6 50.0 1 8.3 1 8.3
Status Exam (3MS)

Note: percentages by column cannot be calculated because respondents could report use of up to five assessments.

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DOUGLAS ET AL.

TABLE 4
Assessments included in bottom-up group
Standardised assessments
Affective Test of Prosody (ATP) (executive function skills) MMSE/Folstein
Bay Area Functional Performance Evaluation (BAFPE) Modified Mini Mental Status Exam (3MS)
Brief Cognitive Rating Scale (BCRS) Montreal Cognitive Assessment (MOCA)
Charron Test of Attention & Concentration Motor Free Visual Perceptual Test (MVPT)Version 1 or 3
Chessington OT Neurological Assessment Battery (COTNAB) Neurobehavioral Cognitive Status Exam (NCSE/Cognistat)
Clock Drawing Test & Clox test Ontario Society of Occupational Therapist Perceptual Assessment
Cognitive Assessment of Minnesota (CAM) Other perceptual tests: (biVABA), Orientation Test for Aphasics,
Cognitive Assessment Scale of the Elderly (CASE/Pecpa-2r) Dynavision
Cognitive Assessment Screening Test (CAST) Rivermead Behavioral Memory Test (RBMT)
Cognitive Competency Test (CCT) Ross Information Processing Assessment- Geriatric (RIPA-G)
Cognitive Mode Questionnaire (CMQ) Severe Impairment Battery (SIB)
Contextual Memory Test (CMT) Stroke Unit Mental Status Exam (SUMSE)
Dementia Rating Scale (DRS) Stroop test
Executive Interview (EXIT) Test for Severe Impairment (TSI)
Frontal Assessment Battery (FAB) Test of Everyday Attention (TEA)
Hierarchic Dementia Scale Test of Visual Perceptual Skills (TVPS)
Hopkins Verbal Learning Test (HVLT) Tests designed for acquired brain injury (SCATBI, NRS)
Independent Living Scale (ILS) Trail Making Tests
Kingston Standardised Cognitive Assessment Visual Field Tests: Bell's Scanning Test, Useful Field of Vision Test
Kohlman Evaluation of Everyday Living Skills (KELS) Weschler Adult Intelligence Scale (WAIS)
Loewenstein OT Cognitive Assessment (LOTCA) or LOTCA-G Woodcock Johnson Test of Cognitive Ability
Middlesex Elderly Assessment of Mental Status (MEAMS)
Non-standardised assessments
"colored ball sort (non-standardised)" "word list"
"sorting shapes"

assessments were reported, of which 20 (30.7%) had not been (97.8%) were standardised assessments. The majority of
previously reported in the literature related to occupational responses in the bottom-up group (99%, n=643) listed a
therapy practice (Douglas & Liu, 2005). A reference list for standardised assessment. For the top-down group, a total of
the assessments can be provided on request. 29 assessments were found (see Table 5). The majority of
Respondents were asked to indicate the frequency of use responses in the top-down group (80.6%, n=294) listed a
of each assessment, and a majority of the responses (n=372, non-standardised assessment.
65.5%) indicated the assessment was used either 2 to 4 times The respondents were asked to indicate any or all of
per week or 1 to 5 times per month. The 15 most frequently three purposes that applied to each assessment. The results
reported assessments are shown in Table 3 and listed accord- for the assessments grouped by theoretical approach are
ing to the respondents' regions of residence. Each of the shown in Table 6. The most frequently indicated purpose was
remaining 74 assessments was reported by less than 5% marked with an asterisk for each group. Bottom-up assess-
(n=12) of respondents. The most frequently used standard- ments were more frequently reported to be used to "identify
ised assessments (Mini Mental Status Exam and Cognitive deficits", while top-down assessments were more frequently
Competency Test) and non-standardised assessments reported to be used to predict.
(General Activities of Daily Living, Kitchen task, and Clinical Ten possible reasons for choice of an assessment were
observation) were used across the country, but others generated from the literature review. In the questionnaire, the
(Cognitive Assessment Scale of the Elderly/Pecpa, Executive respondents were asked to rate the perceived importance of
Interview, and Rivermead Behavioral Memory Test) were each reason for each assessment they listed. Using a 5 point
preferred by occupational therapists in certain regions. scale, from 1 reflecting "not important" to 5 reflecting "very
The following tables list the names of assessments iden- important", the three reasons most frequently ranked by
tified in use by respondents and the groups to which they respondents as important or very important were tabulated
were allocated. A total of 46 assessments in the bottom-up for each assessment, as was the one reason most frequently
approach group were reported (see Table 4), of which 45 ranked not important.

© CAOT PUBLICATIONS ACE VOLUME 74 ■ NUMBER 5 ■ CANADIAN JOURNAL OF OCCUPATIONAL THERAPY ■ DECEMBER 2007 375
DOUGLAS ET AL.

TABLE 5
Assessments included in top-down group
Standardised assessments
ADL assessment for Functional Independence Measure (FIM) Empirical Behavioral Pathology in Alzheimer's Disease Rating Scale
Allen Cognitive Levels (ACL) or Large-ACL, ACL-90, ACL-2000 (E-Behave-AD)
Arnadottir OT Neurobehavioral Evaluation (A-ONE) Functional Autonomy Measurement System (SMAF)
Assessment of Living Skills and Resources (ALSAR) Functional Performance Measure
Assessment of Motor and Process Skills (AMPS) Kitchen Task Assessment (KTA)
Barthell ADL Assessment (modified) Limiting Long Standing Illness screen (LLSI)
Bedford Alzheimer Nursing Severity scale: for the severely Model of Human Occupation Screening Test (MOHOST)
demented (BANS) Perceive Recall Plan Perform (PRPP)
Canadian Occupational Performance Measure (COPM/MCRO) Safety Assessment of Function and the Environment for
Cognitive Performance Test (CPT) Rehabilitation (SAFER)
Disability Assessment for Dementia (DAD) Structured Observational test of Function (SOTOF)
Non-standardised assessments
Ability to navigate Kitchen task
Clinical Observation Home
General ADL Other IADL tasks (e.g. medication mgmt, financial tasks)

For each of the 10 possible reasons, the number of chosen, except in the cases of the Mini Mental Status Exam
assessments ranked important or very important was then and Cognitive Competency Test. Respondents for the Mini
summed. Likewise, the number of assessments for which the Mental Status Exam used this option most frequently (n=21,
reason was ranked not important was also calculated. Finally, 13.2%); with the most often described reason being that the
the reasons ranked important and very important, as well as Mini Mental Status Exam was requested by others, such as
not important for the greatest number of assessments were the physician, the team, or the program (n=19, 11.9 %). For
tabulated (see Table 7). the Cognitive Competency Test, the other reason most fre-
For the bottom-up group, the three reasons ranked quently described was that the testing tasks were related to
important or very important for the greatest number of daily function and/or appeared to have face validity (n=6,
assessments were 1) It is easily administered in my work setting 4.7%). These reasons were not reported in sufficient numbers
(e.g., resources, space, and setup), 2) It can be administered in for them to be designated as one of the three highest ranked
a reasonable amount of time, and 3) It is available. The reason reasons. The number of respondents that ranked them as
ranked not important for the greatest number of assessments important or very important was lower than for all other rea-
was It fits with my theoretical approach. sons; therefore, these responses were not included in the
For the top-down group, the three reasons ranked overall summary table.
important or very important for the greatest number of
assessments were 1) It gives me the type of information
TABLE 7
required for the team, client or family, 2) I am familiar with it, Reasons for choosing theoretical approach groups
and 3) It fits with my theoretical approach. The reason ranked
not important for the greatest number of assessments was It Reasons for choice Assessment group
is used by my colleagues. of assessment Bottom-up Top-down
The response other was also provided, with a blank for
Available ✔
the respondents to specify the reason. This option was rarely
Used by colleagues X ✔
Reported valid/reliable
TABLE 6 Easily interpreted ✔
Purpose for using theoretical approach groups Type of info needed ✔
Administration time ✔
Assessment group Purpose (columns not mutually exclusive) Easy in setting ✔
Identify deficits Predict Measure change Familiarity
Bottom-up 570* 316 242 Learning time
Top-down 195 208* 88 Fits theoretical approach X

*purpose reported by the most respondents per assessment group ✔ : 3 reasons rated "important" or "very important" for the greatest number of
Note: percentages could not be calculated because respondents could identify assessments
more than one assessment within each group X: reason rated "not important" for the greatest number of assessment

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DOUGLAS ET AL.

Discussion ments when generating their own list. Because the respon-
The purpose of the study was to delineate the assessments in dents were assured anonymity, it is expected that this desir-
current use by occupational therapists and their pattern of ability bias was minimized. The discrepancy in reporting may
use. In Part A of the questionnaire, the two most frequently have been due to a tendency to recall more standardised than
used theoretical approaches were the combined approach non-standardised assessments when asked to report about
and top-down approach, respectively. In Part B, the numer- formal assessment procedures. Alternatively, it may have been
ous listed assessments were used routinely with differences in more difficult for therapists to name or describe a non-stan-
purposes and reasons for use noted between the bottom-up dardised task (e.g., kitchen task such as making coffee), than
and top-down groups. The findings in Part A were compared naming a standardised test.
with the findings in Part B. The reported cognitive assessments were organised into
The combined approach was the most popular and standardised and non-standardised groups. Subsequently,
included both direct observation and an interview with the they were also organised according to theoretical approach
client, the family, or both. This approach was recommended (i.e., bottom-up and top-down). It was found that the
as best practice in a review of validity of cognitive assess- responses regarding assessment purpose and reasons for
ments (Wells, Seabrook, Stolee, Borrie, & Knoefel, 2003) and choice had greatest similarity amongst assessments using the
in a study demonstrating increased validity when using inter- same theoretical approach; therefore, they will be discussed
views in combination with bottom-up cognitive assessments according to theoretical approach.
(MacKinnon & Mulligan, 1998).
When examining the specific assessments reported, it is Bottom-up assessments
noted that the more frequently reported tools were used The bottom-up approach involves assessment of impair-
across regions; however, a number of tools were used region- ments in cognitive function rather than assessment of abili-
ally. The large list of assessments indicates that there is a wide ties to perform activities of daily living. In this study,
range of practice for use of cognitive measures with older bottom-up assessments were reported to be used to identify
adults. The regional use of some assessments may result from deficits, which was the primary purpose for which these
the influence of a local advocate for the assessment, univer- assessments were designed. The most popular of these assess-
sity curricula, or local networks of clinicians. In contrast, ments were screening tools, for which sensitivity and speci-
there was no significant difference found in the use of theo- ficity for identification of dementia has been studied in large
retical approaches between geographic regions of the coun- sample sizes (Lorentz, Scanlan, & Borson, 2002; Wells et al.
try. This result showed that the theoretical approach to 2003).
cognitive assessment with older adults is similar across Availability, administration time, and ease of adminis-
geographic regions of the country. It also suggests that tration were the most highly ranked reasons for choosing
respondents were seeking similar types of assessments in bottom-up assessments. These assessments generally can be
their practice and would benefit from the use of assessments administered at the bedside or in a quiet room with a table,
that employed similar approaches. and were designed with ease of administration as a main con-
In Part B of the questionnaire, more respondents listed sideration. These findings suggest that occupational thera-
standardised compared to non-standardised assessments. pists value assessments that are easily and quickly
This result may indicate that therapists used a greater variety administered and readily available. They are seen as impor-
of standardised assessments, despite using non-standardised tant factors in the clinical utility of cognitive assessments in
assessments more frequently. However, respondents may this study, and must be taken into consideration when
have under-reported the use of non-standardised assess- reviewing and developing cognitive assessments for occupa-
ments in Part B. It was noted that 60.6% of respondents tional therapy.
indicated using interviews when rating a list in Part A (theo- The reason, It was reported to have good reliability, valid-
retical approaches), whereas in Part B, only 21.3% listed ity or responsiveness for its stated purpose, was ranked lower
interviews. This discrepancy in reporting of interviews than anticipated. It must be noted that the respondents were
between Parts A and B provided evidence of a non-standard- not asked to rank items in terms of clinical practice, but rea-
ised test that was likely underreported in Part B. Many thera- sons for choice of a particular assessment. Thus, the lower
pists may have considered only standardised assessments ranking of this reason may reflect skepticism or uncertainty
when asked to list the assessments they used, despite the fact about the assessments' psychometric properties rather than a
that the questionnaire cued them to recall both standardised devaluing of these attributes in clinical practice as a whole.
and non-standardised assessments. Given the current Despite their widespread use and popularity, respon-
emphasis on evidence-based practice, many therapists may dents indicated that the bottom-up assessments did not fit
have perceived that they should be using standardised assess- with the occupational therapists' theoretical approach. The
ments and, therefore, discounted non-standardised assess- definition of theoretical approach was not specified in the

© CAOT PUBLICATIONS ACE VOLUME 74 ■ NUMBER 5 ■ CANADIAN JOURNAL OF OCCUPATIONAL THERAPY ■ DECEMBER 2007 377
DOUGLAS ET AL.

questionnaire; however, the occupational therapy approach Mulley (1999), and they concluded that the evidence lacked
involves an emphasis on how impairments in performance rigor to support their "effectiveness."
components, such as cognition, affect daily function in self- The results of the current survey demonstrate that occu-
care, productivity, and leisure (CAOT, 1997). The therapists' pational therapists are using top-down cognitive assessments
perceived lack of fit between these assessments and occupa- to predict safety, yet the literature demonstrates a gap in the
tional therapy's theoretical approach is notable in that it indi- data upon which to base these predictions. Therapists are
cates a gap in the ability of the most common cognitive required to rely on clinical reasoning when using non-
assessments to measure function. This disparity will be standardised assessments to predict safety, and this has been
discussed further in the discussion on top-down assessments. demonstrated to vary significantly, depending on the occu-
An exception to this pattern was noted with the pational therapists' experience (Reich, Eastwood, Tilling, &
Cognitive Competency Test and the Independent Living Hopper, 1998).
Scales. These assessments were in the bottom-up group; how- For both bottom-up and top-down assessments, the
ever, they were most often reported to be used for the purpose of measurement of change was the least reported.
purpose of prediction and chosen for their ease of interpre- This may be an indication that therapists were relying on
tation and the type of information they provided. These other outcome measures besides cognitive assessments to
assessments use more functional tasks to evaluate cognitive measure change. Therapists may not expect significant
capacities, for example, the memory task requires the recall of change in cognitive scores after occupational therapy inter-
a grocery list rather than the recall of three words. The pop- vention, because the focus of intervention may be on com-
ularity of the Cognitive Competency Test may be attributable pensation for cognitive deficits. Instead, data from the client's
to the face validity of its tasks, despite its poorer psychomet- performance of treatment activities may be used to measure
ric properties compared to other assessments in this category change, as progress towards these goals is a primary outcome
(Douglas & Liu, 2005). measure in clinical practice. Alternatively, it may indicate that
therapists are not measuring change as often as identifying
Top-down assessments deficits or prediction.
The most frequently reported top-down assessments in this The occupational therapists' reasons for choosing top-
group were non-standardised assessments, such as ADL or down assessments also differed from bottom-up assessments.
kitchen tasks. Several standardised assessments exist in this Top-down assessments were chosen because they gave
category including the Kitchen Task Assessment or the needed information and fit with the therapists' theoretical
Assessment of Motor and Process Skills. However, when the approach rather than because they were easy to administer. It
occupational therapists assessed with a top-down approach, was unanticipated that therapists would rank fit with the the-
the majority of responses (80.6%) indicated that they used oretical approach as important in their choice of cognitive
non-standardised tasks. assessments. The assessments that fit the occupational thera-
The top-down assessments were used for multiple pur- pists' theoretical approach were largely non-standardised,
poses including identifying deficits (n=195) and predicting and were used for prediction of safety and the need for com-
safety or clients' need for services (n=208). The characteristic pensatory intervention. The occupational therapists in this
that these assessments had multiple purposes from the bot- study indicated that assessments that measure outcomes at
tom-up assessments, which were used most often for a single the functional level provide valuable information, and can be
purpose (identifying deficits). used to predict safety and function for older adults. However,
Milberg (1996) described the need for efficient cognitive in the survey, they also noted barriers to use these assess-
assessment tools in light of the projected increase in the ments including the availability and training required.
elderly population in North America. Efficient assessment Assessments such as the Assessment of Motor and Process
tools are those that would provide information on functional Skills require training time and cost that make these much
abilities and cognitive capacities, rather than just one or the less accessible to therapists and, therefore, limit their use.
other. The respondents identified top-down assessments to The importance of measuring outcomes that reflect daily
serve a greater range of purposes than bottom-up assess- living function has been noted in pediatric occupational
ments of cognition in older adults. therapy (Burtner et al. 2002; Watling et al., 1999). In a survey,
Because the majority of therapists reported the use of occupational therapists in hand therapy have also noted a
non-standardised assessments in this group, the results show preference for non-standardised over standardised assess-
that when the therapists were required to predict safety, most ments (Blenkiron, 2005). The hand therapists noted reasons
used non-standardised assessments. Yet, the predictive valid- for use of non-standardised assessments that included famil-
ity of non-standardised assessments with older adults has iarity and availability, but also stated the non-standardised
been called into question. Studies of non-standardised home assessments "followed a model of practice" (p. 153), and
assessments were systematically reviewed by Patterson and "[took] into account my role… i.e., assessing ADL [activities

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DOUGLAS ET AL.

of daily living] function, person's social situation …" (p.153). ity. With increased emphasis on the measurement of out-
Although Blenkiron concluded that therapists lacked knowl- comes, occupational therapists may use standardised assess-
edge about standardised assessments, respondents in the ments more frequently, and begin to incorporate more of
study suggested that they were not using standardised assess- them into the assessment of activity and participation.
ments because those available in hand therapy did not fit The similar use of theoretical approaches across regions
with the theoretical model of practice, including assessment indicates that, despite regional differences in use of specific
of daily function. The respondents, therefore, noted that the assessments, all regions may benefit from assessments that
standardised assessments were not clinically useful for all employ a similar approach. Future research is warranted to
purposes. Researchers are advised to promote clinically use- determine if similar assessments can be used across regions
ful assessment instruments with evidence to support their of the country.
use for a given purpose. Assessments that measure outcomes In this study, occupational therapists stated that they
relevant to daily function have clinical utility because they used bottom-up assessments to identify deficits; important
can be used for multiple purposes, and they fit with the occu- reasons for their choice included that the assessments were
pational therapy model of practice. easy and took a reasonable time to administer. They also
noted that the bottom-up assessments did not fit with their
Study limitations theoretical approach, whereas the top-down assessments not
The sample was representative of occupational therapists only fit with their theoretical approach, but could be used for
working in Canada in terms of gender and age distribution. both identification of deficits and prediction of safety or need
The generalizability of the results is limited by the sample size for services. Furthermore, the therapists reported greater use
and the greater number of respondents from the region of of the top-down approach to assessment over the bottom-up
the country from which the survey originated. approach. The respondents identified top-down assessments
The study used a self-report questionnaire, which has as serving a greater range of purposes than bottom-up assess-
inherent limitations. Although the respondents were ensured ments of cognition in older adults.
anonymity and were requested to list assessments from mem- When researchers and clinicians develop assessment
ory rather than from a list, it was possible that they underre- tools, the reasons influencing therapists' choice of assessment
ported non-standardised assessments in Part B of the tools should be considered. The data from this study can be
questionnaire. This may have been due to a desirability bias used to identify the types of tools that occupational therapists
towards the use of standardised assessments which was not find clinically useful. They can also be used by clinicians to
overcome by the cues provided in the questionnaire. The weigh the expected advantages and disadvantages of certain
therapists' perceptions of what entailed assessment may also measures. Research into the benefits of using outcome mea-
have reduced the number of non-standardised assessments sures to enhance client care would improve client-centred
reported. practice in occupational therapy. Data regarding the predic-
The study also did not determine if the reported stan- tive properties of functional assessments for use in occupa-
dardised assessments were administered in a standardised tional therapy would increase the value of these assessments
way. The therapists' knowledge of the psychometric data and improve care for clients as well. Further research into the
(reliability, validity studies) was not challenged or assessed by therapists' perceived and actual knowledge of reliability and
the questionnaire. Instead, the questionnaire sought infor- validity would also be valuable to determine if the lower
mation about whether the reliability and validity of an importance rankings reflected a lack of knowledge or confi-
instrument were important reasons for its use. dence with these criteria.
This survey of current practice into cognitive assessment
Implications for practice with older adults demonstrated that the majority of thera-
The study describes a wide range of cognitive assessments pists who use top-down assessments were using non-stan-
used with older adults, many not previously documented in dardised assessments. This result was not unique to this area
the occupational therapy literature. The results can provide of occupational therapy practice. The top-down assessments
researchers and clinicians with the most common assess- were noted to fit with the theoretical approach, which for
ments currently used in occupational therapy and also occupational therapists emphasizes client-centredness and
inform occupational therapy educators in preparing entry- the importance of meaningful activity. Development and
level occupational therapy students for clinical practice. The promotion of top-down assessments that are standardised
list of currently used assessments can form the basis for a for use with older adults would provide efficient and clini-
critical review of the psychometric properties of assessments. cally useful measures for therapists. Moreover, their use will
The dissemination of reviews of psychometric properties for be necessary to improve evidence-based practice in occupa-
particular assessments may increase the use of assessments tional therapy.
with the best evidence to support their reliability and valid-

© CAOT PUBLICATIONS ACE VOLUME 74 ■ NUMBER 5 ■ CANADIAN JOURNAL OF OCCUPATIONAL THERAPY ■ DECEMBER 2007 379
DOUGLAS ET AL.

Acknowledgements Occupational therapy: Enabling function and wellbeing (2nd ed.)


(pp. 288-311). Thorofare, NJ: Slack.
Edwards, P., Roberts, I., Clarke, M., DiGuiseppi, C., Pratap, S.,
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Wentz, R., et al. (2003). Methods to increase response rates to
in Occupational Therapy thesis research conducted at the postal questionnaires. The Cochrane Database of Methodology
University of Alberta. The study was funded by the Society of Reviews 4, Art No.: MR000008
Alberta Occupational Therapists Research Grant. The first Gélinas, I., & Auer, S. (1996). Functional autonomy. In S. Gauthier
author received the Province of Alberta Graduate & M. Dunitz (Eds.), Clinical diagnosis and management of
Scholarship, Canadian Occupational Therapy Foundation Alzheimer's disease (pp. 191-199). Toronto, ON: Butterworth-
Heinemann.
Thelma Cardwell Scholarship, and the Alberta Association on
Grieve, J. (2000). Neuropsychology for occupational therapists.
Gerontology Student Bursary. A portion of this study was Oxford, UK: Blackwell Science Ltd.
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F. A. Davis. Hall, University of Alberta Edmonton, Alberta T6G 2G4.

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Book Marks Livres à la page


Fine Motor Skills for Children with Down Syndrome: describes what can facilitate development and recommends many
A Guide for Parents and Professionals, 2nd edition activities that are broken down into steps emphasizing activities of
(2006) daily living and play.
Maryanne Bruin The section on goal setting for the child’s Educational
Woodbine House via Monarch Books of Canada Program Plan (EPP) gives examples of clear, measurable, achiev-
5000 Dufferin Street able goals. The “Developmental Chart for Preprinting Skills” is
Downsview, Ontario, M3H 5T5 excellent in explaining the progression to printing readiness. The
241 pages; $19.95 US chapter on “Sensory Processing” is interesting and analogy is skill-
ISBN: 978-1-890627-67-6 fully used to explain modulation. Several charts cover examples of
Maryanne Bruin is an occupational therapist who is also the par- sensory processing difficulties and strategies. However I feel that
ent of a child with Down syndrome. The tone of her book is one the role of the occupational therapist in identifying areas of dys-
of theory, understanding and compassion as only one who experi- function in sensory processing and developing a program is
ences a child with Down syndrome on a daily basis could express. underplayed.
It is well organized and easy to read. This resource is valuable for parents, teachers and therapists.
She explains fine motor development in terms of building It will help every team member develop a better understanding of
blocks emphasizing the foundation blocks required to achieve fine motor skill development and therefore facilitate collaboration
control and dexterity. This analogy works well in explaining the when working with a child with Down syndrome. It offers ther-
developmental process. She describes motor milestones emphasiz- apists insight into the experiences of parents and ways to help par-
ing the progression of development and the importance of accept- ents understand the process.
ing and understanding that each child progresses individually. She Jane Henry

© CAOT PUBLICATIONS ACE VOLUME 74 ■ NUMBER 5 ■ CANADIAN JOURNAL OF OCCUPATIONAL THERAPY ■ DECEMBER 2007 381
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.