ARTICLE Review of Cognitive Assessments for Older

ARTICLE

Review of Cognitive Assessments for Older Adults Alison Douglas, MSc Lori Letts, PhD Lili Liu, PhD

ABSTRACT. Occupational therapists who work with older adults commonly assess cognition, including capacities such as memory and attention, to evaluate daily living function. The occupational therapy literature Alison Douglas is a Doctoral Student, School of Rehabilitation Science, McMaster University, Hamilton, Canada. Lori Letts is an Associate Professor, School of Rehabilitation Science, McMaster University, Hamilton, Canada. Lili Liu is an Associate Professor, Acting Chair, Department of Occupational Therapy, University of Alberta, Edmonton, Canada. Address correspondence to: Alison Douglas, School of Rehabilitation Science, IAHS Rm. 402, McMaster University, 1400 Main St. W. Hamilton ON, L8S 1C7 (E-mail: [email protected]). The authors would like to acknowledge the assistance of Tammy Hopper, PhD, in review of the first draft of the paper. The first author was supported by: the Province of Alberta Graduate Scholarship, Canadian Occupational Therapy Foundation Thelma Cardwell Scholarship, and the Alberta Association on Gerontology Student Bursary. The first draft of this paper was presented in May 2004 at the Canadian Association of Occupational Therapists’ Annual Conference, Vancouver BC. Physical & Occupational Therapy in Geriatrics, Vol. 26(4), 2008 Available online at http://potg.haworthpress.com C 2008 by Informa Healthcare USA, Inc. All rights reserved. doi: 10.1080/02703180801963758

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PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

describes cognitive assessments; however, those standardized with older adults are not critically reviewed. The objectives of this review were to identify which standardized cognitive assessments for older adults are documented in the occupational therapy literature, to compare their psychometric properties, and to provide practice recommendations. Thirtytwo assessments met the inclusion criteria. They were grouped into three categories, and the evidence regarding their psychometric properties was summarized. The assessments that demonstrated the greatest rigor were, in the “brief screening” category, the Mini-Mental State Examination (MMSE) and Modified Mini Mental State Exam (3MS); in the “testing” category, the Cognitive Assessment Scale for the Elderly (CASE/Pecpa2r) and the Cognistat; and in the “activity/participation” category, the Assessment of Motor and Process Skills (AMPS). Limitations of each assessment are discussed. KEYWORDS. Assessment, outcome measures, review, cognition

INTRODUCTION Therapists who work with older adults routinely assess cognitive abilities and are faced with numerous cognitive assessments from which to choose. Occupational therapists assess cognition with respect to the client’s ability to function in the tasks, activities, and roles that define the person as an individual (Law, Baum, & Dunn, 2005; Townsend, 2002). Cognition is one component that affects one’s ability to engage in self-care, leisure, and productive activities (American Occupational Therapy Association [AOTA], 2002). There is a lack of consensus about which tools demonstrate the best evidence for use with older adults, and a recent survey of Canadian clinicians working with older adults (Douglas, Liu, Warren, & Hopper, 2007) found 65 standardized assessments in use, many of which were used only in certain regions. LITERATURE REVIEW Previous Reviews of Cognitive Assessments in Occupational Therapy Several texts describe cognitive assessments used in occupational therapy (see, e.g., Gelinas & Auer, 1996; Goslisz & Toglia, 2003; Hasse, 1997; Vining Radomski, 2002). However, each text provides a different list of

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assessments; the criteria for inclusion of instruments are not specified; and critiques of the psychometric properties of these assessments are not provided. Information about the criteria and consideration of psychometrics are important for evidence-based practice. The cognitive assessments described are often those designed and standardized for an adult population with brain injury, and the norms cannot be used with older adults. Texts dedicated to occupational therapy measurement tools do not include many of the tests therapists are currently using (e.g., see Asher, 1996), or focus on functional measures for this population rather than on performance components such as cognition (e.g., see Law, Baum, & Dunn, 2005). A review by Kirkpatrick and Jamieson (1993) examined tools for use in a cardiac unit and reviewed 12 neuropsychological tests, which most occupational therapists are not qualified to use, and 5 tests developed for rehabilitation professionals including occupational therapists. Criteria for inclusion were not clear, but they found that the neuropsychological tools had superior validity and reliability compared to the rehabilitation tools. The authors gave guarded endorsement to several rehabilitation tools including the Stroke Unit Mental Status Exam (SUMSE; Hajek, Rutman & Scher, 1989), Allen Cognitive Levels (ACL; Allen, Earhart, & Blue, 1992), and Early Assessment Self Inventory (EASI; Horn, Cohen, & Teresi, 1989). Reviews of cognitive tests for dementia in the medical literature focus on brief screening instruments because they assist physicians in screening and staging the progress of dementia (Cullen, O’Niell, Evans, Coen, & Lawlor, 2007; Hachinski, Iadecola, Petersen, Breteler, Nyenhuis, Black et al., 2006; Lorentz, Scanlan, & Borson, 2002). Recommended tests for dementia in these reviews include: the MMSE (Palmer, 1999; Morgan, 1997; Wells et al., 2003; Lorentz et al., 2002), the 3MS (Cullen, O’Niell, Evans, Coen, & Lawlor, 2007; Morgan, 1997), The Clock Drawing Test (Palmer, 1999; Wells, Seabrook, Stolee, Borrie, & Knoefel, 2003), the Montreal Cognitive Assessment (Hachinski et al., 2006), the Global Deterioration Scale (Wells, Seabrook, Stolee, Borrie, & Knoefel, 2003), and several ADL measures (Wells, Seabrook, Stolee, Borrie, & Knoefel, 2003). Theoretical Framework The World Health Organization International Classification of Functioning Disability and Health (ICF; World Health Organization, 2005) aims to form a standardized language and framework to understand and measure health outcomes. For this review, we chose to categorize the assessments according to the ICF model in order to provide an interdisciplinary language

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for discussing the types of standardized cognitive assessments found in the occupational therapy literature. The ICF describes the following components of health: body structures and body-functions, activities and participation, and environmental and personal factors. The assessments found in the current literature review fell into two categories: body-functions and activities/participation. For example, assessment at the body-function level included assessment of cognitive capacities such as short-term memory or attention, and assessment at the activity or participation level included doing leather lacing or making pudding. The occupational therapy literature differentiates the assessment of capacities from the assessment of performance or function. Assessment of capacities, such as memory or attention is described in the occupational therapy literature as the “bottom-up” approach (Duchek & Abreu, 1997; Grieve, 2000; Vining Radomski, 2002). In this approach, the data on cognitive capacities are used to infer potential function in daily life. The bottom-up approach can also be described as “assessment of capacity” (Vining Radomski, 2002). Assessment of cognitive capacities corresponds to assessment at the body-function level of the ICF model (World Health Organization, 2005). The “top-down” approach (Duchek, & Abreu, 1997; Grieve, 2000), or the “assessment of function” (Vining Radomski, 2002) relies on a therapist’s observation and interpretation of performance on everyday tasks to ascertain cognitive abilities. This corresponds to assessment at the activity or participation level of the ICF model (World Health Organization, 2005). Purpose The purpose of this paper is to review the occupational therapy literature for standardized assessments which can be used for cognitive assessment with older adults, and to compare the rigor of the psychometric properties for each. Because the choice of assessment is not based solely on psychometric properties, the review is intended as a resource to assist readers in understanding the limitations and strengths of the assessments, rather than as a practice guideline. METHODS The review encompassed both assessments that measure cognitive capacities and those that examine functional skills related to cognition. The assessments were identified by the following process: all possible assessments were searched by a search of the CINAHL database using the

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following search terms: occupational therapy, assessment OR outcomes OR outcome measures, dementia OR delirium, OR cognition disorders OR cognition. The search covered 1982 to December 2005 and was limited by age to 65 and over. A manual search of textbooks with “occupational therapy” (OT) as a subject heading in the University of Alberta library system was also undertaken. Relevant OT assessments were identified using the following inclusion criteria: (a) documented in OT literature, which was defined as OT textbooks or OT journals (25 international journals listed in OT DBase (Canadian Association of Occupational Therapists, 2007); (b) have documented psychometric properties including, at the minimum, reliability and validity data; (c) could be administered by occupational therapists; (d) involve direct examiner observation of the client; and (e) be standardized with persons age 70 and over. The rationale for this set of criteria was based on the need to compare assessments that would have supporting data and clinical utility to an occupational therapist. As more occupational therapists become trained at the master’s level, they may be qualified to administer a greater range of tests. This review, however, focuses on those for which bachelor level therapists are qualified to purchase, administer, and interpret. The criteria included tests with direct observation and excluded numerous measures involving self- and caregiver-report questionnaires. The age cutoff of 70 and over for standardization data was determined in order to exclude those tests that were standardized only up to age 70, which was deemed insufficient to support use with older adults, who may be age 80 and over. For each assessment that met the inclusion criteria, a broad search of the literature was conducted across rehabilitation, medical, and psychological literature using the title of the assessment as a keyword and text word. The data was extracted by the first author and reviewed by the second author for accuracy of the ratings. The protocol for review of each assessment followed the guideline described by Law, Baum, and Dunn (2005). Because there is no current gold standard protocol for review of health measurement instruments (Mokkink et al., 2006), this protocol was chosen because of the focus on psychometric analysis. The protocol was developed for use in rehabilitation, and has been used in occupational therapy peer reviewed literature (Law, Baum, & Dunn, 2005; Letts et al., 1994) and included examination of the following attributes for each assessment: focus of assessment, clinical utility, scale construction, standardization, reliability, and validity (content, construct, criterion, and responsiveness). For further information on the definitions of each type of reliability and validity, the reader is referred to textbooks in the health sciences (e.g., Law, Baum, & Dunn, 2005; Streiner & Norman, 2003). Studies on validity

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TABLE 1. Description of Ratings for Psychometric Properties Psychometric Property

Excellent

Reliability

More than two well-designed studies completed with adequate to excellent reliability values

Validity

More than two well-designed studies supporting validity (content, construct, criterion, responsiveness)

Adequate

Poor

Reliability studies One to two poorly completed, well-designed or reliability studies reliability studies showing poor levels completed with of reliability adequate to excellent reliability values Studies poorly One to two completed or well-designed studies that did not studies supporting support the each type of validity measure’s validity

Note: Ratings taken from Law, M.C., Baum, C. & Dunn, W. (Eds.). (2005). Measuring occupational performance: Supporting best-practice in occupational therapy, Appendix E (pp. 396–405). Thorofare, NJ: Slack Inc. Used with permission.

are often not easily classified under one specific type of validity, and what is most important is the determination of whether the studies were well designed to support validity (Streiner & Norman, 2003). For this reason, an overall rating for validity was assigned rather than ratings for each type of validity. Because it was not possible to summarize each validity study in the tables, the number of validity studies and brief information about relevant studies were organized under headings. The criteria for ratings of reliability and validity are shown in Table 1. Finally, an overall rating for each assessment was given based on the rigor of the psychometric properties. Comparing the assessment to others within the same category, in terms of their psychometric properties and clinical usefulness, generated this rating. A rating of excellent was given if rigor was high for reliability and validity and the measure was clinically useful, whereas lower ratings were given for those with lower rigor or posing difficulties with clinical applicability to occupational therapy. This rating was generated as an overall summary or judgment within this study only with the goal of providing a summary for clinicians of the previous items in the table. To review each of the assessments, the data were gathered and tables completed by the first author and subsequently confirmed by the second. Where there was disagreement the raters used consensus to decide on a rating. Relevant details about the validity studies that contributed to the rating

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were provided. The information was placed under headings (e.g., construct, criterion [concurrent], criterion [predictive]) according to the description of the type of validity being addressed by the authors of each validity study. The assessments were divided into three categories using the ICF model: (a) body-function level: under 30 minutes, (b) body-function level: over 30 minutes, and (c) activity or participation level. Because some of the bodyfunction assessments are quite lengthy, we thought it was clinically relevant to make a distinction between those that could be completed quickly and those that require more time for the client and therapist. RESULTS The literature search identified 32 standardized assessments that met the inclusion criteria. The data obtained were evaluated for each assessment and compared with other assessments in the same category. Ratings for psychometric properties (Table 1) and overall comments are shown according to each category (see Tables 2, 3, and 4). Recommendations for assessments in each category were based on the rigor of the evidence available. For the first category (body-function: under 30 minutes) the Modified Mini Mental State Exam (3MS) showed rigorous evidence with higher sensitivity and specificity compared to the Mini Mental State Exam (MMSE). Scores on both assessments have been shown to be affected by age and education levels; however, only the MMSE has normative data for age and education level. For clients with a lower cognitive status who cannot complete the MMSE, the Severe Impairment Battery may be indicated. The Clock Drawing Test is recommended if used in conjunction with another brief screening test for increased sensitivity (e.g., MMSE or 3MS) (Brodaty, & Moore, 1997; Esteban-Santillon et al., 1998; Juby, Tench, & Baker, 2002; Shulman, & Feinstein, 2003; Suhr, & Grace, 1999). It is also recommended for “multiethnic, multilingual” clients who cannot answer items on the MMSE or 3MS because of language barrier (Borson et al., 1999). For the second category (body-function: over 30 minutes): the Cognistat and CASE/Pecpa-2r showed the most rigorous psychometric properties. For the third category (activity or participation): the Assessment of Motor and Process Skills (AMPS) showed the most rigourous evidence. Significant training time and cost makes the AMPS less accessible to clinicians; however the training contributes to increased reliability of the assessment and cost has allowed the development of the AMPS computerized database which supported studies demonstrating its reliability and validity. In the second and third categories, the assessments that are associated with greater

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Construction/ Administration Time

Scoring/ Standardization Reliability

Validity

Test–retest: Clock Drawing Client asked to mark the Different scoring excellent methods hours around a circle Test Interrater: emphasize to represent a clock (Goodglass excellent visuospatial and and indicate a & Kaplan, executive functions specified time. Several 1983) to differing degrees authors recommend (Shulman, 2000). “ten past eleven” (Esteban-Santillon, et Recommend score of pass/fail al., 1998; Shulman & (Esteban-Santillon, Feinstein, 2003). et al., 1998). Time: 5 minutes or less Norm: numerous studies with n > 1,000

Overall: Adequate. Criterion (concurrent): Significant correlation with 5 other measures. Mean sensitivity and specificity 85% (Shulman & Feinstein, 2003). Age effects noted by some (Freedman et al., 1994; Kozora & McCullum, 1994; Marcopulos et. al., 1997; Tuokko et al., 1995), but not by others (Cahn & Kaplan, 1995). Categories: orientation to Cutoff score indicates Test–retest: Adequate. Criterion Early (concurrent): adequate impairment. person, place, and Assessment Significant correlation Interrater: Norm: Control: n = time; recent and Selfwith at least 4 other not 146 remote memory, Inventory measures. Sensitivity reported Experimental: n = language, visual (EASI; Horn, 93%, specificity 86% Internal con19, memory construction, Cohen, & (n = 165) sistency: impairment, calculation, and Teresi, 1989) adequate age 60–95. attention. Self-administered pencil-and-paper test. Time: 15–30 minutes

Measure

Overall Comments Good. Noted to be a screening test that is non-threatening. Note moderate sensitivity: better at identification of clients without impairment (Connor et al., 2005; Ravaglia et al., 2005). Recommended for use in conjunction with other screening tests for increased sensitivity (e.g., MMSE; Brodaty & Moore, 1997; Esteban-Santillon et al., 1998; Juby, Tench, & Baker, 2002; Shulman & Feinstein, 2003; e.g., 3MS; Suhr & Grace, 1999) Fair. Authors note that some subtests require refinement, and other tools demonstrate better standardization.

TABLE 2. Assessments of Cognition for Older Adults (Body-Function Level): Under 30 Minutes

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Cutoff score indicates Categories include: Middlesex need for further orientation, name Elderly assessment learning,verbal Assessment Norm: n = 120 comprehension, of Mental age 65–93 arithmetic, and motor State perseveration. (MEAMS; Purchase required. Golding, Time: 10–15 minutes 1989) Categories: registration Cutoff score indicates Mini Mental impairment Norm: and recall, temporal State Exam Numerous studies and spatial orientation, (MMSE; with n > 1,000 mental reversal, Folstein, language, Folstein, & constructional or McHugh, drawing skill, and 1975) following a three-stage command. Modified version (SMMSE) developed to increase consistency of administration and scoring (Molloy & Standish, 1997). Time: 10–15 minutes Test–retest: excellent Interrater: adequate but excellent for SMMSE

Test–retest: excellent Interrater: excellent

Fair. Designed to decrease Overall: Adequate. effects of education but data Criterion (concurrent): 3 lacking. Authors note it has studies (n = 30–60) similar problems to MMSE, showing moderate e.g., requires visual acuity, sensitivity and and affected by age and IQ. specificity. Norms tables for age and Construct: 2 studies education not available. Excellent. Has norms tables Overall: Excellent. for age and education. Criterion (concurrent): Designed for interpretation Numerous studies to be based only on the total supporting sensitivity score. Limitations are & specificity. 4 studies documented, yet it has show lower sensitivity shown value as a brief and specificity than screening tool (Brayne, 3MS Criterion 1998; Shulman & Feinstein, (predictive): Although 2003). not designed as a predictive tool, modest correlation with measures of decreased functional independence, increased length of rehabilitation, & decreased likelihood of independent living (Continued on next page)

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Reliability

Categories: attention, Severe orientation, language, Impairment memory, visuospatial Battery (SIB; ability, construction, Saxton praxis, ability to et al.,1990) respond to name, and social interaction. Time: 20–30 minutes. Short form takes 10 minutes

Scoring/ Standardization Cutoff score indicates Test–retest: excellent impairment. Interrater: Norm: n = 1,977 excellent over age 65.


Modified Mini Categories: orientation, attention/ Mental State concentration, Exam (3MS; immediate and Teng & Chui, delayed recall, listing 1987) animals, similarities, copying pentagons Time: 15–20 min

Measure

Overall Comments

Excellent. Note that age and Overall: Excellent. education affect score, but Criterion (concurrent): norm tables are not numerous studies available. Designed for supporting sensitivity interpretation to be based & specificity only on the total score. Sensitivity: 88% Recommended over MMSE Specificity: 90% by Cullen et al. (2007), and (Bland & Newman, the Research Committee of 2001; McDowell et al., American Neuropsychiatric 1997). Association (Malloy Predictive: Not designed et al., 1997). as a predictive instrument Good. Useful for measuring Overall: Excellent. progression of dementia, Criterion (concurrent): especially when other tests correlated with 5 other show a floor effect. tests. Recommended for clients Responsiveness: may with MMSE score below 10 be more sensitive to (Schmitt et al., 1997). change than MMSE especially for moderate to severe (but not end-stage) dementia, 2 studies.

Validity

TABLE 2. Assessments of Cognition for Older Adults (Body-Function Level): Under 30 Minutes (Continued)

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Good. Does not examine Short Portable Categories: orientation to Impairment classified Test–retest: Overall: Excellent. language or perceptual Criterion (concurrent): excellent into levels, also date and place, Mental motor tasks and has not Good to adequate cutoff score. Score Interrater: birthday, age, phone Status been as widely standardized correlation with at adequate scaled according to number, current and Questionand validated as the MMSE least 6 other education and race Internal conlast president, serial naire or 3MS. Sensitivity and measures. sistency: (black or white). math. (SPMSQ; specificity values are not At cutoff score of 4 excellent Norm: Control: n = Time: 5–10 minutes Pfeiffer, superior to MMSE and 3MS. errors: Sensitivity 997 1975) 73%–100%, specificity Experimental: n = 72%–91% 141 outpatients, At cutoff score of 3 n = 102 residents errors: Sensitivity: of institutions, 86%, specificity 100%. age 65 and over. Fair. Sensitivity and specificity Cutoff score indicates Test–retest: Overall: Adequate. Categories: orientation, Stroke Unit data lacking. Designed to adequate Construct: 1 study impairment immediate recent and Mental avoid reliance on language Interrater: differentiated between Norm: Control: n = remote memory, Status Exam and motor skills but data adequate CVA and non-CVA 10, mean age 71.7 concentration, general (SUMSE lacking. Intelligence score groups information, reasoning Experimental: n = Hajek, correlates with performance Criterion (concurrent): 29, CVA, mean and judgment, praxis, Rutman, & on test. correlation with 3 other age 71.6 and language. Scher, 1989) measures (statistic not Includes MMSE tasks. reported) and 4 others Time: 10–15 minutes

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CASE/Pecpa-2r Categories: temporal orientation, spatial (Cognitive orientation, attenAssessment tion/concentration, Scale for the immediate recall, Elderly— language, remote English memory, judgment version and and abstraction, Protocole agnosia, apraxia, d’Examen recent memory. Cognitif de la Purchase required. Personne Time: Approximately Agee) 45 minutes. (Geneau & Taillefer, 1994) Categories: visual Chessington perception, Occupational constructional ability, Therapy sensorimotor ability, Neurological and ability to follow Assessment instructions. Battery Purchase required. (COTNAB) Minimum of 1 hour (Tyerman, and may be spread Tyerman, over 2–3 days. Howard, & Guidelines for Hadfield, eliminating portions 1986) of the test.

Measure

Reliability

Validity

Overall Comments

Fair. Authors note that Overall: Adequate. Test–retest: Score compared to age mild impairments Construct: not reported norms and correlated may not be identified. discriminated Interrater: to level of The long between controls and adequate independence. Norm: administration time head injury/CVA rigor: Control n = 150 age may hinder use with sample. Criterion (reported to 16–65, n = 17, age 66 older adults. Small (concurrent): 1 study, be excellent, and over, n = 47 age sample sizes for correlated with 1 but data not 65–87 Experimental: n norms tables for measure. included in = 150, head injury and older adults. manual) CVA, age 16–65

Good. Lacks Overall: Adequate. Test-retest: Cutoff score indicates information on Criterion: 1 study, cutoff adequate impairment. Score predictive validity and scores according to Interrater: not compared to norms tables for age age and education, reported standardization data. and education. total score Norm: Control: n = 359 Internal Includes MMSE score, discriminated Consistency: Experimental: n = 69, which may be between controls and excellent cognitive impairment. efficient, or repetitive. impaired subjects. age 59–96

Scoring/ Standardization

TABLE 3. Assessments of Cognition for Older Adults (Body-Function Level): Over 30 Minutes

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Test–retest & Overall: Excellent. Criterion Categories: Attention, Cutoff score indicates (concurrent): 8 studies, Interrater: impairment. Modified level of Sensitivity: 36% Specificity: not version eliminates consciousness, 86% Greater sensitivity but reported. screens, and orientation, lower specificity than the Mean and generates a total language, MMSE. Criterion standard score with cut-off construction, (predictive): predictive of deviation (Drane et al., 2003). memory, ADL performance and from stanNorm: Control: n = calculations, and behaviors. dardization 139, age 20–84 (n = reasoning. sample 112 age 65–84) Purchase required. reported Experimental: n = Time: Approx 45 for each 30, neurologically minutes subtest. impaired, age 25–88 Overall: Poor. Criterion: 1 Recommended level of Test–retest: Categories: Cognitive study For Average Total adequate assistance orientation, Competency Score: Sensitivity: in CVA Interrater: determined from attention, recall, Test (CCT) sample (n = 10): 70% not Average Total Score. sequencing (Wang & scored impaired, in reported Norm: Control: pictures, financial Ennis, 1986) dementia sample (n = 16): n = 50, task, picture 93.75% scored impaired. Experimental: n = 10 interpretation, CVA, and n = 16 practical reading, dementia, age 50–93 and memory for route on paper. Purchase required. Time: 25–35 minutes.

CogniStat (Neuro behavioral Cognitive Status Examination) (Mueller, Kiernan, & Langston, 2001)

(Continued on next page)

Fair. Test items designed to relate to everyday tasks, but small older adult sample, and little information regarding reliability and validity.

Good. Good data for discriminant & predictive validity and has norms tables for older adults. Note: screening tests produce a high false-positive rate: recommended to obtain total score.

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Score correlated to In 3 parts: (1) Contextual rating for level of self-report memory Memory Test impairment. Norm: questionnaire, (2) (CMT) Control: n = 375, immediate and (Toglia, age 18–86 delayed memory 1993) for array of objects related to a theme, (3) client comment on performance in test. Time: approx 30–40 minutes Cutoff score indicates Categories: Executive impairment. Norm: perseveration, Interview n = 40, age 71–96. imitation behavior, (EXIT25) intrusions, frontal (Royall, impulse control, Mahurin & lack of spontaneity, Gray, 1992) disinhibition, utilization behavior. Time: 20–35 minutes

Measure

Validity

Test–retest: not reported Interrater: excellent Internal Consistency: adequate

Fair. Has the advantage of assessing the client’s insight but norms are not separated by age or education. Tests only visual memory component of cognition.

Overall Comments

Excellent when Overall: Excellent. focusing on executive Criterion (concurrent): 5 function. Merits studies, correlation with 5 further measures, and MRI and standardization of SPECT scans scoring and Criterion (predictive): 3 administration. studies showing score predicts level of care, behaviors, IADL and use of devices Responsiveness: 2 studies, responsive to change in IADL, more responsive than MMSE

Overall: Adequate. Test–retest: Construct: 2 studies adequate discriminated between Interrater: controls and Alzheimer’s or not brain injury samples, using reported subtest scores as specified. Internal Consistency: Criterion (concurrent): 1 study, correlated with 1 adequate measure scores affected by age and education

Reliability

TABLE 3. Assessments of Cognition for Older Adults (Body-Function Level): Over 30 Minutes (Continued)

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.

20 subscales with administration of only 5 or 10 items from most to least difficult. Time: 15–35 minutes. Examiner administers only items corresponding to client’s level of functioning.

Categories: self-care, Kohlman safety and health, Evaluation of money Living Skills management, (KELS) transportation and (Kohlmantelephone use, and Thomson, work and leisure. 1992) Consists of an interview, specific questions and tasks. Purchase required. Time: 45 min–1 hr

Hierarchic Dementia Scale (Cole, Dastoor, & Koszcki, 1983)

Score correlated to rating for ability to live independently. Norm: Not reported in manual, n = 14 (mean age = 62.8) for Hebrew translation

Test–retest: not reported Inter-rater: poor to adequate

Cut-off score indicates Test–retest: excellent impairment. Interrater: Norm: n = 50, excellent dementia and n = 50 ranging from independent in community to long term care, mean age 81.1

Overall: Adequate to excellent. Good. No floor effects for persons with Construct: 2 studies, severe dementia, but discriminated between cutoff score is controls and impaired, unclear, and data on discriminated between sensitivity and persons with severe specificity for cognitive impairment. identification of Criterion (concurrent): 3 dementia are lacking. studies, correlated with 4 measures, and moderately with EEG. Conflicting data on effect of age and education Criterion (predictive): 1 study predicted those most likely to stay at home. Fair. Standardization Overall: Adequate. data poor, and no Construct: 2 studies, age norms tables, discriminated between level despite data that of living situation, better show the test score than MMSE & FIM. is influenced by age Criterion (concurrent): 2 and education. One studies with psychiatric study completed with patients correlated with 4 older adults. measures. Criterion (predictive): 1 study, predicted discharge location of older adults with 72% accuracy (n = 20) (Continued on next page)

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Rivermead Behavioral Memory Test (RBMT; adult version) (Wilson, Cockburn, Baddeley, & Hiorns, 1991)

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) and LOTCAGeriatric (Katz, Itzkovitch, Elazaar, & Averbuch, 1989)

Measure

Categories: orientation, perception, visuomotor organization, and thinking operations. LOTCA-G: enlargement of items, reduced complexity of tasks, shortened subtests to reduce overall time required, addition of memory subtests. Purchase required. Time: LOTCA-G: 30–90 minutes. Categories: verbal recall, task recall later in test, picture and face recall, retelling a story, retracing a route around room. Purchase required. Time: Approximately 30 minutes


Fair with older adults. Assessment of memory only. Supplement 3 notes the effects of intelligence, language, and perceptual problems on testing with older adults. Overall: Adequate. Construct: 1 study discriminated between controls and impaired. Criterion (concurrent): 2 studies: correlated with 2 measures.

Test-retest: Cutoff score indicates level adequate of impairment. Interpretation for older adults Interrater: adequate in Supplement 3. Norm: Control: n = 118 Experimental: n = 176, “brain damage.” Elderly subjects n = 114 age 70–94 ranging from living at home to hospital, and n = 106 age 70–90 (Test Manual, supplement 3, 1989) living at home

Overall Comments Good. However, long completion time and lack of norms according to age and education. Authors recommend use of LOTCA-G over LOTCA for adults over age 70.

Validity Overall: Adequate to excellent. Criterion (concurrent): at least 5 studies showing correlation with 3 measures, and LOTCA-G with LOTCA. LOTCA-G takes less time for older adults. Criterion (predictive): 2 studies (n = 20, 21) predictive of ADL and IADL performance.

Reliability

Test–retest: Tester rating given to not attention/ concentration. reported Norm: Control: n = 43 Experimental: n = 33, CVA Inter-rater: adequate Mean age 77 and age range 70–91


TABLE 3. Assessments of Cognition for Older Adults (Body-Function Level): Over 30 Minutes (Continued)

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Toglia Category Assessment (TCA) (Toglia, 1994)

Subtests: sort the utensils by size, then color, then utensil type. If the client is unable to, the examiner provides standardized cues. Time: 30 minutes

Test of Everyday Tests four types of attention (sustained, Attention selective, attentional (TEA) switching, and (Robertson, divided). Three Ward, parallel versions. Ridgeway, & Purchase required. Nimmo-Smith, Time: 45 min–1 hour. 1994)

Raw scores converted to percentiles. Provide norms tables for age and education, and guide for interpretation of functional implications. Norm: Control: n = 154 Experimental: n = 80, CVA, age 18–80 Score given for level of independence on each task, summed for total score Norm: n = 18 age 60–86, schizophrenia & brain injury

Fair. Difficult to Overall: Adequate. interpret Construct: 1 study functional discriminated between implications of CVA and non-CVA score and lacks samples. Criterion studies on (concurrent): 1 study, predictive validity. moderate correlation with Score is affected 2 measures Criterion by age and (predictive): less predictive education level; of IADL score than another age and cognitive test. Affected by education norms age and education. are not provided. Test–retest: not reported Interrater: adequate Internal Consistency: adequate

Fair due to reliability and validity data.

Overall: Adequate. Construct: 2 studies discriminated between controls and CVA or head injury samples. Criterion (concurrent): 2 studies correlated with 3 measures.

Test–retest: poor to adequate Interrater: Not reported

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Assessment of Instrumental Functioning (AIF)—-part of Occupational Therapy Assessment of Performance and Support (OTAPS) (Nadler, Richardson, Malloy, Brinson, & Marran,1993 )

Arnadottir OTADL Neuro behavioral Evaluation (A-ONE) (Arnadottir, 1990).

Measure

Categories: dressing, grooming/hygiene, transfers/mobility, feeding, communication. Checklist for impairments (e.g., apraxia, neglect). Purchase and training course required. Takes more than one ADL session Categories: safety, medication administration, meal planning and preparation, and money management. Choice of tasks given. Time: not reported, but likely at least 1 hour

Construction/ Administration Time Reliability

Scored for level of independence. Norm: completed but not reported in studies reviewed

Test–retest: adequate Interrater: adequate

Test–retest: One scale provides a adequate rating for function Interrater: and the other adequate provides a rating for Internal condeficits. sistency: Norm: Control: n = 79, adequate age 19–90.


Good. Standardized instructions for adaptations to the environment or materials are not provided, although reliability scores are higher than for the SOTOF. Norms are not separated by age.

Overall Comments

Fair. Lacking in data Overall: Adequate. about effects of Construct: accurately age, education, classified 75% of clients and culture. Motor deemed impaired on and sensory MMSE. Criterion deficits may affect (concurrent): 2 studies, score. Tasks that correlated with 4 measures are novel or not Criterion (predictive): applicable are 1study, predicted post deemphasized; hospital living situation however, with 76% accuracy eliminating a task will affect the total score.

Overall: Adequate. Construct: 1 study discriminating between CVA and controls Concurrent: 1 study showing modest agreement with neuroimaging.

Validity

TABLE 4. Assessments of Cognition for Older Adults: Activity and Participation Level

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Excellent. Can be used Test–retest: Overall: Excellent. Assessment of Motor and processing skills Scores converted to with clients of various Construct: numerous excellent relative ranking evaluated. Choice of 2 or Motor and conditions, ages, and studies discriminate Interrater: based on Rasch 3 of 56 defined IADL Process cultural groups. A between diagnostic excellent analysis. tasks. Purchase and Skills barrier to its use is groups and Internal contraining course required. Norm: n = 4391 (AMPS) the need for 1-week cross-culturally valid. sistency: persons with no Admin time varies (Fisher, training course and Criterion (concurrent): excellent known disability, depending on task 2003; trial period before its correlation with at least 5 age 5–100, + divided chosen and individual updated clinical use. other measures. Criterion by age manual). (predictive): Numerous studies predictive of ADL, level of care and independence in the home Good. Designed and Test–retest: Overall: Adequate to Scores on 6 tasks Consists of 7 tasks Cognitive validated only for the excellent. Construct: 1 adequate averaged and (Medbox, Dress, Shop, Performance Alzheimer’s disease study, discriminated correlated with Allen Interrater: Toast, Phone, Wash, Test (CPT) population. Similar to between controls and adequate Cognitive Level. and Travel). Categories: (Burns, 1992) the AMPS with the Alzheimer’s disease. Internal ConPredictive levels of level of cueing and advantage of Criterion (concurrent): 2 sistency: functioning are given demonstration required. requiring less studies, correlation with 4 excellent for each level. Time: > 1 hour—requires training, but the measures. Criterion Norm: Control: n = 15 several sessions disadvantage of (predictive): 50% risk of in United States; n = fewer tasks from institutionalization for low 30 in Israel. which to choose, and scorers after 624 days Experimental: n = 77 less research into in United States; n = reliability and validity. 60 in Israel, age 65–97. (Continued on next page)

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Categories: money The Direct management (e.g., write Assessment a check), shopping, of Functional hobbies, meal Abilities preparation (make a (DAFA) sandwich), awareness, (Karagiozis, reading, transportation. Gray, Sacco, Administered in various Shapiro, & locations (gift shop, Kawas, cafeteria, exam room) 1998) Time: 45 minutes–1.5 hours Categories: time Direct orientation, Assessment communication (e.g., of Functional dialing telephone), Status transportation (e.g., road (DAFS) signs), financial skills, (Loewenshopping, eating (e.g., stein et al., correct use of utensils), 1989). dressing/grooming (e.g., coat, brush teeth). Driving subscale is optional. Time: 30–35 minutes

Measure

Good. Motor abilities may Overall: Excellent. Test-retest: interfere with score. Has Construct: 1 study adequate not been studied for discriminated between to excellent effects of age or controls and persons Interrater: education. with Alzheimer’s disease adequate Criterion (concurrent): 2 studies, moderate to good correlation with 3 measures, and with caregiver ratings of performance at home

Poor due to lack of standardization and validity data. Tasks appear to have face validity.

Overall Comments

Composite score compared to norms. Norm: Control: n = 18, hospitalized, n = 11 with depression. Experimental: n = 30, cognitive impairment. Mean age 75–77 years (age range not reported)

Overall: Poor. Criterion (concurrent): 1 study, moderately correlated with 2 measures

Validity

Test–retest: adequate Inter-rater: not reported

Reliability

Score based on correct performance and independence. Correlated with ratings. Norm: Control: n = 15, mean age 64.0 Experimental: n = 28, dementia, mean age 77.0


TABLE 4. Assessments of Cognition for Older Adults: Activity and Participation Level (Continued)

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Assessment of task of Kitchen Task making pudding on Assessment stove. Components: (KTA) (Baum initiation, organization, & Edwards, performance of steps, 1993) sequencing, judgment/safety, and completion. Time: Approx 20-40 minutes

Categories: Independent memory/orientation, Living managing money, Scales (ILS) managing home and (Loeb, 1996) transportation, health and safety, and social adjustment. Most items require verbal answer (e.g., solving a hypothetical problem). Some require performance (e.g., use of the telephone). Purchase required. Time: 45 min, but may require two sessions.

Five subscale scores are added to obtain a full scale standard score, and combined to obtain both a problem solving, and performance score. Norm: Control: n = 590, aged 65 and over. Experimental: n = 248, variety of diagnoses, aged 17 and over. Provides score for level of support required. Norm: n = 106 persons with Senile Dementia of the Alzheimer’s type (SDAT), age 60 and over Test–retest: not reported Interrater: adequate Internal consistency: excellent

Overall: Adequate. Construct: 1 study showing significant correlation across stages of dementia. Criterion (concurrent): significant correlation with 3 measures of cognition

Test–retest: Overall: Adequate to excellent. Construct: 1 excellent study differentiated Interrater: between controls and excellent various diagnoses Internal Conincluding dementia. sistency: Concurrent: 3 studies, adequate correlated with 6 to excellent measures, not significantly affected by age or education but racial groups had significant difference in score.

Fair to good. Several executive function skills are not assessed (e.g., planning) and criteria for assessing “sequencing” need development (Josman & Birnboim, 2001).If the task is novel to the client, assesses executive skills more than functional cooking ability (Duncombe, 2004). Adaptations for motor or sensory deficits are not provided. (Continued on next page)

Good. Cognitive slowing with age may affect score (Baird et al., 2001) and test lacks age norms tables. Note that controversy exists about the use of ILS scores for determinations of capacity (Baird et al., 2001).

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Scoring/ Standardization Reliability

Validity

Overall Comments

Large Allen Cognitive Level Test (L-ACL) (Allen, 1996)

Categories: ability to learn and complete three types of leather lacing stitches. Test items adapted for decreased vision and sensation, provide suggestions if one-handed or tremors. Time: 20-30 min.

Test-retest: Score associated poor with cognitive level according to Interrater: excellent norms tables Norm: n = 110, mental illness, age 65 and over

Fair to good. Less Overall: Adequate. language based than Construct: scores other cognitive function affected by age, assessments, and quick education and to administer. Authors of socioeconomic status. 2 one study note studies discriminated self-selecting for craft between controls and activity may influence Alzheimer’s. Criterion score. (concurrent): correlation with at least 3 measures. Criterion (predictive): moderate correlation with measure of community function Poor. Authors state scoring Score for time taken Test–retest: Overall: Adequate. Categories: grooming, St. George does not account for Criterion (concurrent): 1 not and number of dressing, demeanor, Hospital physical impairments or study, correlation with 4 reported prompts. Total home management, Memory age-related variations, measures. score compared Inter-rater: telephone/transport, Disorders Clinic which may increase adequate to norms. money management, Occupational scores for time taken. Norm: n = 49, from Internal Conplanning leisure, Therapy Method of interrater sistency: a memory clinic, practical recall. All items Assessment reliability testing may not excellent a day center or are timed. Scale (OTAS) have reflected community, Time: 30–40 min (Fairbrother, administrator differences age 53–90 Burke, Fell, in providing prompts. Schwartz, & Schuld, 1997)

Measure

TABLE 4. Assessments of Cognition for Older Adults: Activity and Participation Level (Continued)

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Good to excellent. Scored by time and Test–retest: Overall: Adequate. 10 subsections including Administration time long, Criterion (concurrent): 2 excellent accuracy. Cutoff dressing, eating, motor but similar to AMPS. studies, correlation with Interrater: score indicates skills, cognition, and Warrants more validity 3 measures.Criterion excellent impairment. social interaction. data, with larger sample (predictive): poorer Choice of 3 of a possible Norm: Control: n = Internal consizes. Has advantage of predictor of discharge sistency: 18 Experimental: 50 tasks which are low correlations with status from rehabilitation varies n = 18, probable criterion referenced. At age, education, and than cognition as among Alzheimer’s least 1 hour depression. Can be measured by the Mattis subtests disease, age 65 used with mild or severe Dementia Rating Scale from poor and over dementia. (MacNeill, Gerskovich, to excellent Caron, & Lichtenberg, 1997) Good. Low cost and Test–retest: Overall: Adequate. Checklist Consists of a Screening Structured training requirements, Criterion (concurrent): 1 adequate completed: Assessment (vision, Observational but this is balanced by study showed independence in Interrater: balance etc), followed by Test of poorer findings for agreement with 5 adequate performance, 4 ADL tasks (eating, Function reliability. Can be used measures. Criterion Internal conintact skills, washing hands, pouring (SOTOF) as an initial screening (predictive) authors sistency: performance and drinking, and (Laver & test due to shorter stated predictive due to adequate problems and dressing). Purchase Powell, 1995) administration time, and higher relationship with underlying required. can be used before the measures of ADL than dysfunction (e.g., Time: impaired clients client is able to mobilize. neuropsychological agnosia). may take 5–10 minutes function Norm: Control: n = for each task 86, age 60–97

Structured Assessment of Independent Living Skills (SAILS) (Mahurin, DeBittignies, & Pirozzolo, 1991)

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rigor generally have higher costs, which is not surprising given the amount of research that is required to develop a reliable and valid measure. DISCUSSION Decisions in best-practice involve the selection of cognitive assessments that possess strong psychometric properties. In addition, decisions must incorporate clinical knowledge such as characteristics of the client and the environment (Law, 2002). For example, for a client who lacks the attentional ability for a 20-minute assessment, it would be more reasonable to use a shorter assessment that possesses acceptable psychometric properties, yet makes realistic cognitive demands on the client. Therefore, a therapist may apply best-practice by using an assessment with a lower level of evidence, because of the fit with the client or environment. It remains critical, however, to compare reliability and validity data among measures, not only when choosing a measure but also when interpreting the results. Reliability data provide information about the consistency with which a cognitive deficit can be identified. An understanding of the limitations of sensitivity and specificity would help ensure that the clinician is aware of the probability that a person who is deemed impaired is actually impaired (sensitivity), or a person who is deemed unimpaired is actually unimpaired (specificity). It is important that the clinician note, for example, when using the 3MS, that a person with impairment is identified with only 88% accuracy. The validity data can be used by the clinician to determine to what extent an assessment is measuring the intended construct or to what extent a certain score can predict or be associated with a particular function in daily life. Because clinicians are often required to interpret scores with a view to predicting constructs such as independence, safety, or the need for services, a keen awareness of the limitations of the data to support these predictions is critical. Many of the assessments in the body-function categories have been developed for the purpose of identifying deficits rather than predicting function. The use of measures such as the MMSE and 3MS for predicting function is poorly supported by evidence, and interpretation of the scores to predict, for example, driving performance or safety at home, is currently not supported in the literature. Evidence does support their use for identifying deficits, which is an important role. Occupational therapists are often required to assess cognition as a performance skill or client factor, as described in the American

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Association of Occupational Therapy practice framework (Youngstrom, 2002); therefore, the use by occupational therapists of these measures to identify deficits in body-function is supported. The purpose of this review was to focus on comparison of psychometric data in order to support and facilitate clinicians’ choices of standardized measures. Summary tables of the literature review are presented for clinicians to use as a comparative tool. After selecting a measure, a clinician’s responsibility is to understand and use the measure correctly, to consider all factors contributing to the score, and to consider the guidelines and data to support interpretation of the measure. The identification of 32 assessments in the literature indicates there is a range of choice available. This amount of choice can make evidencebased decision-making daunting for clinicians, considering the difficulty in accessing data on psychometric properties of the assessment tools. More dissemination of comparative data on psychometric properties is needed. The assessments were categorized and compared only to those in similar categories because clinicians use each type of tool for different purposes. When assessing cognitive capacities and identifying deficits, a therapist would require an assessment in the first or second categories (bodyfunction). When a clinician is required to predict if an older adult will be safe at home, or will need assistive devices or caregiver assistance, assessments at the activity or participation level may be used to directly observe performance in daily tasks. Thus, clinicians may choose measures from each category depending on the clinical requirements. It is important, in making this choice, that the clinician be aware of the validity of the assessment for the purpose. Assessments in the body-function categories were found to have criterion validity but few were studied for their predictive validity. Some assessments in the activity and participation category demonstrated evidence to support prediction of function, such as level of care or performance on ADL. Further details about the validity studies on each test are provided in many test manuals. For example, the AMPS has shown predictive validity for overall home safety (McNulty & Fisher, 2001) and increased prediction of independent living over neuropsychological tests (Lindén, Boschian, Eker, Schalén, & Nordström, 2005). In order to provide an understanding of the comparative level of evidence for each instrument, a superior instrument in each category was identified. The provision of a rating synthesizes the data for practical use. We have chosen to identify what might be considered the “best” instruments to inform therapists and to stimulate debate about the best tools to use in clinical practice and in research. The instruments were not compared between categories. For example, the CASE/Pecpa (body-function

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over 30 minutes) is not compared directly with assessments in the activity/ participation category. Because the assessments are designed for differing assessment approaches, it is important not to compare assessments with differing purposes or approaches. Assessments in the body-function (over 30 minutes) category showed the least rigor compared to the body-function (under 30 minutes) and activity and participation categories. These assessments were largely developed by and for occupational therapists and have been standardized using smaller sample sizes. Consideration may be given to the further development of these assessments, if they are found to be valuable, and used frequently by occupational therapists. The data presented in this review may be used by occupational therapists to support choice of instruments, based on most evidence and rigor, to support their use with older adults. In addition, they identify the assessments with low levels of evidence and rigor, so that therapists can be advised either to interpret these assessments with caution or avoid their use. LIMITATIONS The scope of the review was limited to the occupational therapy literature. There are assessments which are used currently by occupational therapists that were excluded because they were not found in the OT literature, but are found in the medical or neuropsychological literature. Other assessments in current use with older adults were excluded because they did not meet the inclusion criteria. For example, the Cognitive Assessment of Minnesota is not standardized on persons older than 70 years. A second limitation is related to accessing information about the psychometric testing on measures. Much of the data were found in test manuals, but for some instruments, the manuals were difficult to access. However, secondary sources were available and referenced for these assessments. Unpublished literature such as conference presentations was not included in the review, although it is possible that further psychometric data have been presented through these venues. Factors that confound the results of cognitive assessments, such as language, education, and motivation were beyond the scope of this review. The scope of the review could be expanded in subsequent research. The framework that was used for evaluation did not emphasize the assessments’ fit with a theoretical model of occupational therapy practice; however, consideration of the application of results to function was made in the “general comments” section.

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CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Comparison of psychometric properties of cognitive assessments with older adults assists in the choice of rigorous assessments and promotes the accurate interpretation of test scores. Researchers can use the data to identify needs in the development of clinically useful instruments. There is a need for therapists to have more ready access to psychometric data for cognitive assessments in occupational therapy. Much of the psychometric data are found only in test manuals, which must be purchased. It is necessary also to gather data from peer-reviewed publications. Although it is time consuming and a barrier for best-practice, a therapist must complete a comprehensive search before purchasing a test. Increased availability of psychometric data allows the comparison of assessments based on rigor of psychometric properties and allows clinicians to compare assessments they are currently using with others in the literature. It also provides a means by which researchers and test developers can determine areas of deficiency. The following assessments demonstrated the best rigor for psychometric properties for cognitive assessment with older adults: for body-function (under 30 minutes): the MMSE and 3MS; for body-function (over 30 minutes): the Cognistat and CASE/Pecpa; and for the activity and participation level: the AMPS. This review is intended to provide a resource for discussion and dissemination of evidence on the psychometric properties of cognitive assessments with older adults. It promotes the consideration of these psychometric properties as one component of evidence-based practice. It can be used as a basis for discussion about the status of cognitive assessment with older adults, and the value of psychometric properties when selecting the best cognitive assessment for the client and family.

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Received: 05/16/2007 Revised: 11/26/2007 Accepted: 12/10/2007