Performance of Medication Tasks: Relationship Among Patient-Reported Outcomes, Performance-Based Assessments, and Objective Assessments.

IMPORTANCE: Occupational therapy practitioners use standardized assessments to guide their clinical decision-making, but it is unclear how well performance on standardized assessments translates to performance at home. OBJECTIVE: To understand the concurrent and predictive validity of patient-reported outcomes and performance-based assessments for monitoring performance at home within the context of medication management and adherence. DESIGN: Exploratory study. SETTING: Participants completed standardized assessments in a lab or at home, which were followed by home-based electronic monitoring of medication adherence. PARTICIPANTS: Sixty community-dwelling adults with hypertension or stroke who independently took antihypertensive medications. OUTCOMES AND MEASURES: Participants completed the Hill-Bone Medication Adherence Scale, the Hill-Bone Medication Adherence Reasons Scale, the Performance Assessment of Self-Care Skills Medication Management subtask, and the Executive Function Performance Test-Enhanced Medication Management subtest. Then, they used an electronic pill cap to monitor medication adherence at home for 1 month. RESULTS: Patient-reported outcomes and performance-based assessments in the context of medication management and adherence demonstrated poor concurrent and predictive validity to medication adherence at home. CONCLUSIONS AND RELEVANCE: There is a gap between what people think they will do, what they can do on a standardized assessment, and what they actually do at home. Future research is needed to strengthen concurrent and predictive validity to clinically meaningful outcomes. Plain-Language Summary: Occupational therapy practitioners should use caution when using standardized assessments to try to predict client performance at home. They should also continue to use a battery of assessments, clinical reasoning, and client preferences to guide their decision-making for monitoring performance at home within the context of medication management and adherence.

Development and Validity of Norms for Cognitive Dispersion on the Uniform Data Set 3.0 Neuropsychological Battery.

OBJECTIVE: Cognitive dispersion indexes intraindividual variability in performance across a battery of neuropsychological tests. Measures of dispersion show promise as markers of cognitive dyscontrol and everyday functioning difficulties; however, they have limited practical applicability due to a lack of normative data. This study aimed to develop and evaluate normed scores for cognitive dispersion among older adults. METHOD: We analyzed data from 4,283 cognitively normal participants aged ≥50 years from the Uniform Data Set (UDS) 3.0. We describe methods for calculating intraindividual standard deviation (ISD) and coefficient of variation (CoV), as well as associated unadjusted scaled scores and demographically adjusted z-scores. We also examined the ability of ISD and CoV scores to differentiate between cognitively normal individuals (n = 4,283) and those with cognitive impairment due to Lewy body disease (n = 282). RESULTS: We generated normative tables to map raw ISD and CoV scores onto a normal distribution of scaled scores. Cognitive dispersion indices were associated with age, education, and race/ethnicity but not sex. Regression equations were used to develop a freely accessible Excel calculator for deriving demographically adjusted normed scores for ISD and CoV. All measures of dispersion demonstrated excellent diagnostic utility when evaluated by the area under the curve produced from receiver operating characteristic curves. CONCLUSIONS: Results of this study provide evidence for the clinical utility of sample-based and demographically adjusted normative standards for cognitive dispersion on the UDS 3.0. These standards can be used to guide interpretation of intraindividual variability among older adults in clinical and research settings.

Feasibility of Augmenting Cognitive Strategy Training With Non-Invasive Brain Stimulation.

Many individuals post-stroke have difficulty identifying if or how they can continue performing meaningful daily life tasks. The objective of this study was to evaluate the feasibility of metacognitive strategy training (MCST) and transcranial direct current stimulation (tDCS) in chronic stroke. A case series design was used. Participants completed 12 intervention sessions over 4 weeks consisting of 20 min of tDCS and 45 min of MCST to address occupational performance goals. Feasibility outcomes of acceptability and safety/tolerability were evaluated and measures of occupational performance were administered pre- and post-intervention. Participants perceived the intervention to be highly acceptable and relevant to their needs. Large improvements were observed for performance and satisfaction with goals trained (Hedge's g = 2.07 and 2.11, respectively) and untrained (Hedge's g = 1.25 and 1.43, respectively) within the intervention. An intervention combining MCST with tDCS was feasible to administer and positively received by stakeholders; further research is warranted.

Needs Assessment of Self-Management for Individuals With Chronic Spinal Cord Injury/Disease.

Since the 1980s, survivorship for persons with spinal cord injury/disease (SCI/D) has significantly improved; however, life expectancy remains lower than the general population due to secondary health conditions (SHCs) that lead to decreased function and death. This study explored (1) facilitators and barriers to engaging in self-management (SM) for persons with SCI/D and (2) stakeholder perspectives on potential SM program components and content for intervention development. Around 38 participants with SCI/D responded to this cross-sectional study and needs assessment conducted at the University of Missouri, Columbia. Responses were analyzed to determine descriptive statistics. Participants indicated barriers to SM include transportation/distance, presence of SHCs, and a lack of local resources. Participants noted that virtual SM programs with strong psychological health/coping components were preferred. These findings should guide the development of an SM program tailored to SCI/D to reduce the prevalence and impact of SHC on the SCI/D population.

Persons with Spinal Cord Injury/Disease (SCI/D) experience secondary health conditions to a higher degree than the general population which impacts their function, quality of life, and lifespan. The factors that limit or support participation in self-management behaviors and programs were explored and we asked people with SCI/D what they would want out of a self-management program tailored to their needs. Results showed that virtual programs with a both group and individual sessions with a strong mental health component were preferred.

American Speech-Language-Hearing Association Clinical Practice Guideline: Cognitive Rehabilitation for the Management of Cognitive Dysfunction Associated With Acquired Brain Injury.

BACKGROUND: Cognitive-communication impairments following acquired brain injury (ABI) can have devastating effects on a person's ability to participate in community, social, vocational, and academic preinjury roles and responsibilities. Guidelines for evidence-based practices are needed to assist speech-language pathologists (SLPs) and other rehabilitation specialists in the delivery of cognitive rehabilitation for the adult population. PURPOSE: The American Speech-Language-Hearing Association, in conjunction with a multidisciplinary panel of subject matter experts, developed this guideline to identify best practice recommendations for the delivery of cognitive rehabilitation to adults with cognitive dysfunction associated with ABI. METHOD: A multidisciplinary panel identified 19 critical questions to be addressed in the guideline. Literature published between 1980 and 2020 was identified based on a set of a priori inclusion/exclusion criteria, and main findings were pooled and organized into summary of findings tables. Following the principles of the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision Framework, the panel drafted recommendations, when appropriate, based on the findings, overall quality of the evidence, balance of benefits and harms, patient preferences, resource implications, and the feasibility and acceptability of cognitive rehabilitation. RECOMMENDATIONS: This guideline includes one overarching evidence-based recommendation that addresses the management of cognitive dysfunction following ABI and 11 subsequent recommendations focusing on cognitive rehabilitation treatment approaches, methods, and manner of delivery. In addition, this guideline includes an overarching consensus-based recommendation and seven additional consensus recommendations highlighting the role of the SLP in the screening, assessment, and treatment of adults with cognitive dysfunction associated with ABI. Future research considerations are also discussed.

Interventions to Improve Social Participation, Work, and Leisure Among Adults Poststroke: A Systematic Review.

IMPORTANCE: Sustaining a stroke frequently leads to difficulties in returning to work, leisure, and social participation. These outcomes are important for occupational therapy practitioners to address. OBJECTIVE: To determine the current evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve social participation, work, and leisure among adults poststroke. DATA SOURCES: MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases. STUDY SELECTION AND DATA COLLECTION: Primary inclusion criteria were peer-reviewed journal articles published between January 1, 2009, and December 31, 2019, within the scope of occupational therapy that evaluated an intervention to address work, leisure, or social participation poststroke (levels of evidence ranged from Level 1b to Level 2b). Reviewers assessed records for inclusion, quality, and validity following Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. FINDINGS: Forty-seven articles met the inclusion criteria. Forty-four articles related to social participation were categorized as follows: occupation-based approaches, metacognitive strategy training, education and training approaches, impairment-based approaches, and enriched environment approaches. Three articles related to work and 3 articles related to leisure were not further categorized (2 articles were each included in two categories). Seventeen Level 1b and 30 Level 2b articles were included. The strength of evidence to support occupational therapy interventions for social participation, work, and leisure outcomes is predominantly low. CONCLUSIONS AND RELEVANCE: Occupational therapy interventions may improve work, leisure, and social participation outcomes poststroke, with the strongest evidence existing for client education, upper extremity training, and cognitive training for improving social participation. What This Article Adds: Occupational therapy practitioners may use the available literature along with clinical reasoning to improve work, leisure, and social participation outcomes among clients poststroke. Additional research is required to build stronger evidence to support clinical decision making in stroke rehabilitation in these areas.

Methodological Issues in Advancing the Status of Functional Cognitive Assessment.

Many individuals in acute hospital and post-acute care settings experience changes in their capacity to perform complex activities of daily living associated with deficits in functional cognition. Occupational therapists regularly assess and treat these occupational performance deficits. The construct of functional cognition offers oportunities for occupational therapists to define an approach to cognition that is both distinct from that of other disciplines and that supports evidence-based interventions. This article provides a rationale for performance-based assessment of functional cognition and an overview of the methodological issues associated with the development and implementation of reliable and valid screening and comprehensive asseements of functional.

Occupation-Based Interventions for Social Participation Outcomes for Adults Poststroke (January 1, 2009-December 31, 2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on occupation-based interventions for social participation outcomes for adults poststroke.

Interventions to Improve Work and Leisure for Adults Poststroke (January 1, 2009-December 31, 2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on interventions to improve work and leisure for adults poststroke.

Impairment-Based Interventions to Improve Social Participation Outcomes for Adults Poststroke (January 1, 2009-December 31, 2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on stroke and impairment-based interventions to improve social participation for adults poststroke.

Transdisciplinary Preliminary Evaluation of Goal Maintenance in Cancer-Related Cognitive Impairment.

Women treated for breast cancer often experience decreases in executive functioning, including goal maintenance, which interferes with daily living. The objective of this study was to conduct a preliminary comparison of cognitive neuroscience assessment performance with neuropsychological, self-report, and performance-based assessments of goal maintenance in women with breast cancer. Women treated for breast cancer in the preceding 3 years completed a battery of cognitive assessments. Relationships between assessment methods were evaluated using Spearman rho correlations. Consistent with prior literature, the AY condition of the Dot Pattern Expectancy (DPX) assessment had the highest error rate. No consistent relationships between the DPX and other methods of assessment were identified; however, some moderate correlations were identified between assessments. Women treated for breast cancer present with DPX performance patterns similar to that of healthy controls in past literature. A larger study is required to confirm relationships between measures of goal maintenance across disciplines.

Development and Initial Testing of the Electronic Activity Card Sort (ACS3) Among Community-Dwelling Adults.

IMPORTANCE: The Activity Card Sort is a valid, widely used measure of participation. There is a need for remotely delivered measures of participation to support the growing use of telehealth. OBJECTIVE: To develop and test the concurrent validity and acceptability of the electronic Activity Card Sort (ACS3). DESIGN: Cross-sectional. SETTING: Research laboratory. PARTICIPANTS: Community-dwelling adults. OUTCOMES AND MEASURES: The Activity Card Sort (ACS) and the ACS3 were administered in randomized order. Relationships between performance on the overlapping items of the ACS and ACS3 were evaluated using Spearman's ρ correlations. Additionally, acceptability of the ACS3 was evaluated using a survey with a 5-point Likert scale. RESULTS: High correlations were found between each of the four domains (rs ≥ .836) and total current activities score (rs = .863) between the ACS and ACS3. Ratings on the survey indicate high levels of acceptability and usability for the ACS3. CONCLUSIONS AND RELEVANCE: Findings suggest that performance on the ACS3 is consistent with performance on the ACS. This finding coupled with a high level of acceptability indicates that the ACS3 may be a clinically useful tool for evaluating daily life participation. What This Article Adds: The ACS3 provides an electronic, paperless option for measuring multiple domains of participation in adults.

Initial Validation of the Weekly Calendar Planning Activity With Adolescents With ABI.

The purpose of this study was to assess the validity of the Weekly Calendar Planning Activity Middle/High School (WCPA) in adolescents with acquired brain injuries (ABI). We recruited neurotypical controls (n = 27) and adolescents with ABI (n = 14) to complete a 90-min battery of cognitive tests. Adolescents with ABI were further divided into mild and severe groups by Glasgow Coma Scale Score and compared with controls. Mann-Whitney U tests revealed significant differences (p = .05) on the WCPA between groups in total time to complete and rules followed. Between the controls and severe group, a significant difference (p = .05) was found for total time spent, errors, rules followed, strategies used, and accurate appointments (p = .01). Moderate correlations were found between the WCPA and neuropsychological tests (ρ = .31-.45). The WCPA is a valid performance-based assessment of functional cognition that can be used to detect deficits in adolescents with severe ABI.

Initial Development and Evaluation of the Executive Function Performance Test-Enhanced (EFPT-E) in Women With Cancer-Related Cognitive Impairment.

IMPORTANCE: Psychometrically sound instruments are needed to evaluate executive functioning in the population of people with cancer. OBJECTIVE: To develop and evaluate the reliability and validity of the Executive Function Performance Test-Enhanced (EFPT-E) in women after being treated for breast cancer. DESIGN: Cross-sectional. SETTING: University research laboratory. PARTICIPANTS: Women treated for breast cancer who had cognitive impairment (n = 12) and community control participants (n = 13). OUTCOMES AND MEASURES: Evaluators (n = 8) independently scored a recorded administration of the EFPT-E to evaluate interrater reliability. An assessment battery, including the EFPT-E, was administered to evaluate the EFPT-E's known-groups validity and concurrent validity. RESULTS: Excellent interrater reliability was observed for the EFPT-E total score and each subtask score (intraclass correlation coefficient = .90-.98). Moderate effect sizes were noted for the EFPT-E total score (Cohen's d = 0.5) and the total number of cues (d = 0.4) between the breast cancer group and the control group, with the breast cancer group demonstrating poorer performance. A limited correlation was found between the EFPT-E and the other cognitive measures. CONCLUSIONS AND RELEVANCE: The results support the EFPT-E's interrater reliability and warrant continued investigation to further establish its reliability and validity. WHAT THIS ARTICLE ADDS: Assessments are needed to quantify the impact of cognitive processes within functional tasks. The EFPT-E has been developed to assess the functional impact of mild cognitive impairment; initial testing with women with cancer showed excellent agreement between raters and promising results for validity.

Cognitive oriented strategy training augmented rehabilitation (COSTAR) for ischemic stroke: a pilot exploratory randomized controlled study.

Purpose: To investigate the effect of adding cognitive strategy training to task-specific training (TST), called Cognitive Oriented Strategy Training Augmented Rehabilitation (COSTAR), compared with TST on activity and participation for chronic stroke survivors in an outpatient occupational therapy settingMaterials and methods: We conducted an exploratory, single-blind, randomized controlled trial. Participants were randomized to TST or COSTAR protocol. Our primary outcomes measured activity and participation after stroke: the Stroke Impact Scale (SIS), Canadian Occupational Performance Measure (COPM), and Performance Quality Rating Scale (PQRS).Results: Forty-four participants were randomized. The COSTAR group had an attrition rate of 50% and an average of 9.8 of 12 sessions were completed; the TST group had an attrition rate of 25% and an average of 10.7 sessions were completed. Generally both groups improved on the majority of primary and secondary outcomes. There is little evidence to support a beneficial effect of COSTAR over TST for improvement of primary measures of activity performance or secondary measures.Conclusion: Negligible findings may be attributed to an inadvertent treatment group equivalency. Further, the research design did not allow for adequate measurement of the effect of each intervention on participants' ability to generalize learned skills.Implications for rehabilitationStroke rehabilitation is largely based upon the principles of task-specific training, which is associated with improvements in upper extremity motor performance; however, TST requires a heavy dosage and lacks generalization to untrained activities.Cognitive strategy use has been associated with improved generalization of treatment to untrained activities and novel contexts however, it is often not used in TST protocols.The results of this preliminary study found no clear advantage between task-specific training and strategy-adapted task-specific training on trained and untrained activities when both interventions targeted activity performance.Task-specific training, if focused at the activity performance level rather than the impairment reduction level, may have a stronger effect on improving in individual's ability to participate in everyday life activities even without the use of cognitive-strategies.Incorporating cognitive strategy-use into TST would likely produce the greatest effect on generalization and transfer of the treatment effects to other activities and contexts rather than solely on activity performance of trained activities.

The construct validity of a new screening measure of functional cognitive ability: The menu task.

This study evaluated the construct validity of the Menu Task (MT): a new performance-based screening measure of functional cognition. We enrolled 114 community dwelling adults (55 years or older) in the study: all participants completed the MT and four other neuropsychological screening measures. Construct validity was evaluated using a three-step hierarchical regression model with the MT as the dependent variable. Demographic control variables were entered at step 1, followed by the Brief Interview of Mental Status (BIMS), and the Trail Making Test A (TMT A) at step 2, and finally TMT B and the Montreal Cognitive Assessment (MoCA) at step 3. It was hypothesised that measures sensitive to executive functioning (TMT B and MoCA) would significantly explain MT performance after controlling for demographic variables and adding measures of cognitive function to the model, providing additional evidence for construct validity of the MT. All three steps of the model were statistically significant (p < 0.01). Inclusion of measures sensitive to executive function in step 3 explained 30% of variability in MT score (adjusted R2 = 0.30). Our findings provide further empirical support for the construct validity of the MT, and offer implications for the use of the MT in acute and post-acute care settings.

Complex Task Performance Assessment (CTPA) and Functional Cognition in People With Parkinson's Disease.

OBJECTIVE: The objective of this study was to determine how Parkinson's disease (PD) affects functional cognition as assessed by the Complex Task Performance Assessment (CTPA) and to examine the associations of CTPA performance with other indicators of executive function in people with PD. METHOD: Volunteers with PD without dementia (n = 20) and community control participants (n = 19) completed neuropsychological testing, patient-reported outcome measures, and the CTPA. RESULTS: There were no group differences for CTPA performance accuracy; however, the PD group took longer to complete the CTPA than did the control group. In the PD group, inefficient CTPA performance correlated with poorer cognitive flexibility and worse reported everyday shifting and task monitoring. CONCLUSION: Decreased executive function, namely cognitive flexibility and attentional control, may impair functional cognition in people with PD. Future studies with larger, more diverse samples are warranted to determine the discriminant validity and sensitivity of the CTPA. Use of performance-based assessments such as the CTPA may increase the understanding of functional cognition in people with PD.

Combining Virtual Reality Motor Rehabilitation With Cognitive Strategy Use in Chronic Stroke.

IMPORTANCE: Rehabilitation interventions for chronic stroke are largely impairment based, with results confined to the level of impairment instead of function. In contrast, cognitive strategy training interventions have demonstrated clinically meaningful improvements in functional outcomes. Integration of these approaches has yet to be explored. OBJECTIVE: To evaluate acceptability, recruitment, and retention rate and determine which outcome measures best capture the effect of the intervention. DESIGN: Single-group, pre-post design. SETTING: Research laboratory. PARTICIPANTS: Adults with chronic stroke and hemiparesis (N = 10). INTERVENTION: A 12-wk intervention integrating cognitive strategy training with upper extremity motor training. Two weekly sessions used Kinect-based virtual reality to encourage high numbers of upper extremity movement repetitions. The third weekly session focused on the use of cognitive strategies with practice of client-centered goals. OUTCOMES AND MEASURES: Upper extremity motor performance was measured with the Fugl-Meyer Assessment. Occupational performance on trained and untrained goals was measured via the Performance Quality Rating Scale and the Canadian Occupational Performance Measure. Outcome data were gathered preintervention, postintervention, and at 3-mo follow-up. RESULTS: The intervention was perceived as acceptable. Recruitment rate was 15%, and retention rate was 100%. Large effects were found on outcomes of upper extremity motor performance, occupational performance, and participation at follow-up. CONCLUSION AND RELEVANCE: MetacogVR is feasible for adults with chronic stroke. The effect of MetacogVR is best captured through measures of upper extremity motor performance, occupational performance, and participation. WHAT THIS ARTICLES ADDS: Traditional, impairment-based approaches to chronic stroke rehabilitation may require integration with cognitive-strategy training to affect performance on meaningful goals.

Catalyzing Research to Optimize Cancer Survivors' Participation in Work and Life Roles.

Participation refers to a state of health in which a person is able to fully engage in roles and life situations. Adults living with and beyond cancer often report persistent participation restrictions that affect their productivity and quality of life. The American Occupational Therapy Foundation convened a group of scientists from seven different disciplines in a Planning Grant Collective (PGC) to stimulate research to identify scalable ways to preserve and optimize participation among cancer survivors. Participants identified challenges, prioritized solutions, and generated novel research questions that move beyond symptom and impairment mitigation as outcomes to identify interventions that improve participation in roles and life situations. This article summarizes the PGC discussion and recommendations regarding three challenges: (a) the dynamic and multi-faceted nature of participation, (b) a need to integrate the concept of participation within the culture of oncology, and (c) identification of priority areas in which new lines of research regarding participation would be most impactful.

Reliability and Validity of a Functional Cognition Screening Tool to Identify the Need for Occupational Therapy.

IMPORTANCE: The Centers for Medicare & Medicaid Services (CMS) has identified the need to assess functional cognition as part of the postacute care planning process. OBJECTIVE: We examined the reliability, validity, and clinical utility of the Menu Task (MT) as a screening measure of functional cognition to assess the need for occupational therapy services. DESIGN: Cross-sectional study testing a convenience sample of community-dwelling older adults (n = 130) and adults hospitalized for elective orthopedic surgery (n = 60). The MT and four neuropsychological screening tests-the Brief Interview of Mental Status, the Montreal Cognitive Assessment, Trail Making Tests A and B, and an instrumental activities of daily living (IADL) scale-were administered. SETTING: Community-dwelling participants were tested at the University of Wisconsin occupational therapy program and in community settings. Hospitalized participants were tested at the University of Missouri Orthopedic Institute. PARTICIPANTS: We recruited healthy community-dwelling adults in Madison, WI (community sample; n = 130) and patients hospitalized for elective orthopedic surgery in Columbia, MO (hospital sample; n = 60). Inclusion criteria were age 55 yr or older, living in the community, and willingness to be tested in English; for the hospital sample, participants had to be referred for elective orthopedic surgery requiring a hospital stay and be independent in activities of daily living before being admitted for surgery. RESULTS: We found significant differences between groups classified as impaired or not impaired on the basis of MT scores. Participants classified as impaired on the MT performed significantly less well than those classified as not impaired on the neurocognitive and IADL measures. CONCLUSION: The reliability and validity of the MT were supported. WHAT THIS ARTICLE ADDS: The American Occupational Therapy Association and the occupational therapy experts advising CMS have stressed the importance of a brief performance-based screening tool to identify people who need more comprehensive occupational therapy evaluation. The implementation of a functional cognition screening tool as part of the required CMS assessment protocol should greatly increase the number of patients referred for occupational therapy evaluation and treatment. The MT has the capacity to address the gap in the proposed CMS assessment of Medicare recipients across postacute care settings.