Cognition

Jennifer Thompson, MS, OTR/L

Cognition is how we think, learn, organize our thoughts, establish memories, understand and respond to social cues, make plans, and adjust to challenges and new situations in our environment. visuospatial awareness, planning, emotional regulation, task organization and sequencing, impulse control including safety awareness/ judgement, problem solving, and working memory.  Cognitive impairments may arise as a result of acutely acquired injuries, but also may result from chronic medical conditions.  Various diagnoses for cognitive impairments can include: encephalopathy, traumatic brain injury (TBI), dehydration, cerebrovascular accident (CVA), peripheral vascular disease (PVD), diabetes, alcohol/ substance use and overuse, end-stage renal disease (ESRD), post-traumatic stress disorder (PTSD), hearing loss, lack of sleep, and many others. A patient’s cognitive baseline may also be related to traumatic situations, such as military conflict, challenging family dynamics, childhood trauma, education level, environmental exposure and more.  The interdisciplinary team approach is crucial as the patient may require assessment from a psychologist, psychiatrist, and additional resources from a social worker.  

Areas of Cognition include:

• Attention
• Memory: short/long term, delayed recall
• Orientation
• Executive Function: planning, emotional regulation, task organization and sequencing, impulse control including safety awareness/judgment, problem solving, visuospatial awareness and construction, and working memory.
• Language

Evaluation of Cognition

1. Assess during self-care routine and with functional tasks.

• Attention: How long can the patient maintain attention? For a full conversation? Is the patient internally/ externally distractible? Does the patient require a low stim environment?
• Memory: Does the patient remember why they are in the hospital? Is the patient oriented to self, date, location? Can they recall this information within a session only or can they remember after a few days? Is the patient able to recall the directions of the task? 
• Executive Function
  • Working memory: does the patient recall what you’re asking them to do? Can he/she repeat directions back to you but not actually perform the task?
  • Planning: is the patient able to plan the task including position (seated/standing), what items they will need (comb, clothing, etc)?
  • Emotional regulation: does the patient have low frustration tolerance (does he/she get frustrated with the task easily? Do they have emotional outbursts that affect participation in therapy?)
  • Impulse Control, Safety Awareness and Judgement: Is the patient able to use own coping strategies for impulse control? Can he/she anticipate dangers in the environment prior to performing functional mobility (i.e. not walking on wet surfaces)? Does the patient understand safety recommendations (transfer with least restrictive device as prescribed by PT)? Does the patient overestimate abilities and underestimate impairments? 
  • Task Sequencing/Organization: Can the patient sequence and organize the task effectively (i.e. bathe before dressing, attempt donning belt before donning pants, load utensil with food before bringing to mouth, fill tea kettle with water before putting on the stove to boil?)
  • Problem Solving: is the patient able to identify problems and barriers before starting the task? Can he/she initiate and use trial/error approach? Can the patient identify errors in performance after the task is completed by themselves or does the patient require cues?
  • Visuospatial Awareness and construction: assesses manipulation of 2 and 3 dimensional objects. Can the patient button a shirt? Tie shoes? Make a bed? Set up an electric tea kettle?
• Language- see SLP guide for additional information.

2. Common assessments used (see Clinical Resource Library>Cognition>Evaluation for PDF files). Some assessments are paper/pencil only (blue), and some require additional materials- read through before administering (orange).

• Allen Cognitive Level Screen (ACLS): learning, problem solving during visual motor tasks. Requires purchase of assessment materials. https://www.mcssl.com/store/allencognitive/complete-screening-assessment
• Brief Interview for Mental Status (BIMS): memory, temporal orientation, attention, organization.
• Clock Drawing Test: memory, visuospatial awareness/construction, attention, organization.
• Executive Function Performance Test (EFPT)- executive fxn: bill pay, making oatmeal on stovetop, dialing phone, medication management.
• Kettle Test- executive fxn, visuospatial awareness/ construction, problem solving, recall/memory, and reflection of performance. Requires electric tea kettle and additional materials. 
• Montreal Cognitive Assessment (MoCA)- memory/ recall, visuospatial awareness/construction, attention, language/fluency.
• Mini-Mental Status Exam (MMSE)- was previously gold standard in cog assessments, but is now used less frequently. MoCA is more reliable.
• Multiple Errands Test (MET)- higher level cognitive tasks including making change/mathematics, dialing phone, and interacting with others. **Pt is required to perform functional mobility during this assessment.
• SLUMS- similar to the MoCA; memory/ recall, visuospatial awareness/construction, attention, language/fluency.

Treatment 

• Intervention strategies/emphasis
  • Cognition is best assessed during functional tasks-  these familiar tasks are better for assessment of memory than new or novel activities. Recall of information with less meaning will be more difficult to recall.
  • Grading activities.
    • Progress from self-care routine (grooming/ feeding are a great place to start due to the repetitive nature of these tasks) and progress to multistep higher level cognitive tasks (cooking, making the bed, etc). Overhead shirts are typically easier than front button shirts due to the visuospatial organization and fine motor control required to do up buttons. Can grade cooking tasks from using a microwave to make tea, to higher level tasks such as making a cake and operating the oven.
  • Utilize items that are familiar to the patient- photographs, memory books, checklists and alarms to help with recall, memory, and organization. Pneumonics, songs, and poems can all help with memory. This is a great time to integrate neurologic music therapy into sessions if this is available!
  • Focus on safety
    • what is the phone number to call in an emergency (911, or country equivalent)? 
    • What is your address, name, allergies, etc? 
    • What do you do if your home is on fire? 
    • What do you do if you have run out of medication?
  • Start simple.
    • Can the patient gather all items they need for a task? If not- create a list with the patient using their terminology to ensure success. 
    • Does the patient understand directions? Consider written handouts and multimodal directions rather than providing the patient auditory information.
  • Reduce your amount of cues as the patient progresses. 
• Important information
  • Ensure the patient has hearing aides, glasses, alternative communication devices, etc as required.
  • Consider using wallet cards or identification bands for those who can’t remember their names, allergies, phone numbers, addresses, etc.
  • Determine best time for patient- some people do best first in the morning, and some perform tasks best after they’ve had something to eat or an afternoon nap.
  • Medication can play a role in cognition, level of alertness and arousal.
  • Integrate SLP recommendations into session. 
  • Integrate MD/ surgeon as necessary for clearance to return to driving. Some OTs have specializations in return to driving assessment (certified driver rehabilitation specialists), though patients require medical clearance to return to driving.

Additional Resources/ Helpful Websites

Allen Cognitive Level Screen (ACLS): https://allencognitive.com/ 

• Assessment materials: https://www.mcssl.com/store/allencognitive/complete-screening-assessment
• https://www.youtube.com/watch?v=SMNOAybdMAk

References

Baum CM, Connor LT, Morrison T, Hahn M, Dromerick AW, Edwards DF: Reliability, validity, and clinical utility of the Executive Function Performance Test: a measure of executive function in a sample of people with stroke. Am J Occup Ther; 2008 Jul-Aug;62(4):446-55.

Baum, CM, Wolf, TJ, Wong, AWK, Chen, CH, Walker, K, Young, AC, Carlozzi, NE, Tulsky, DS, Heaton, RK & Heinemann, AW (2016): Validation and clinical utility of the executive function performance test in persons with traumatic brain injury, Neuropsychological Rehabilitation, DOI: 10.1080/09602011.2016.1176934

Ciesielska N, Sokołowski R, Mazur E, Podhorecka M, Polak-Szabela A, Kędziora-Kornatowska K. Is the Montreal Cognitive Assessment (MoCA) test better suited than the Mini-Mental State Examination (MMSE) in mild cognitive impairment (MCI) detection among people aged over 60? Meta-analysis. Psychiatr Pol. 2016 Oct 31;50(5):1039-1052.

Grossman M, Irwin DJ. The Mental Status Examination in Patients With Suspected Dementia. Continuum (Minneap Minn). 2016 Apr;22(2 Dementia):385-403

Gonzalez Kelso I, Tadi P. Cognitive Assessment. [Updated 2020 Nov 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556049/

Mervis, C. B., Robinson, B. F., & Pani, J. R. (1999). Visuospatial Construction. The American Journal of Human Genetics, 65(5), 1222–1229. https://doi.org/10.1086/302633 

Salimi S, Irish M, Foxe D, Hodges JR, Piguet O, Burrell JR. Can visuospatial measures improve the diagnosis of Alzheimer’s disease? Alzheimers Dement (Amst). 2018;10:66-74.