Australian Occupational Therapy Journal (2015) 62, 187–196

doi: 10.1111/1440-1630.12201

Research Article

Identification and assessment of functional performance in mild cognitive impairment: A survey of occupational therapy practices Patr
ıcia Belchior,1 Nicol Korner-Bitensky,1 Melanie Holmes2 and Alexandra Robert1 1 2

Faculty of Medicine, School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada and MAB-Mackay Rehabilitaiton Center, Montreal, Quebec, Canada

Background/aim: Despite the amount of research evidence pointing to functional changes experienced by individuals with mild cognitive impairment (MCI), we still do not understand how occupational therapists are currently addressing these concerns. Thus, we designed a national study to investigate Canadian occupational therapists practices with this clientele. Methods: We conducted a Canada-wide online survey to investigate occupational therapists’ practices with clients with potential MCI. Clinicians were prompted by a case vignette that described two clients: one vignette included cues associated with amnestic MCI (aMCI), the other nonamnestic MCI (naMCI). Specifically, clinicians were asked to identify potential concerns and to indicate the screening and assessment tools they would use in clinical practice. Results: Two hundred and eighty-five participants met the inclusion criteria and were included in the final analysis. The average clinician age was 38.6 (SD = 10.3), 92% were female and 71.2% worked full-time. Almost all clinicians identified a concern in both vignettes, with cognitive concerns being identified more frequently than functional concerns [i.e. Instrumental Activities of Daily Living (IADL) concerns]. In terms of assessment practices, 18 standardised IADL assessments and 10 standardised cognitive assessments have been reported.

Patr
ıcia Belchior PhD; Assistant Professor. Nicol KornerBitensky PhD, OT; Professor. Melanie Holmes MSc; Occupational Therapist. Alexandra Robert MSc; Occupational Therapist. Correspondence: Patr
ıcia Belchior, School of Physical and Occupational Therapy, McGill University, 3654 PromenadeSir-William Osler, Montreal, QC, H3G 1Y5, Canada. E-mail: [email protected] Conflict of Interest: None. Accepted for publication 11 March 2015. © 2015 Occupational Therapy Australia

Conclusion: Encouragingly, almost all clinicians identified a concern. However, some are still missing the IADL cues. Moreover, the lack of consensus in terms of which assessment practices to employ indicates that clinicians might benefit from guidelines in this area of practice. KEY WORDS ageing, assessment, cognition, instrumental activities of daily living, mild cognitive impairment, occupational therapy.

Introduction Despite progress in the diagnosis and early detection of mild cognitive impairment (MCI), clinical practice related to the accurate screening and assessment of this population is not well understood. It is now recognised that individuals with MCI typically experience difficulties with Instrumental Activities of Daily Living (IADL): although they are still independent in performing everyday activities, they make more errors, take more time and are less efficient in their performance (Albert et al., 2011; Petersen et al., 2014). In fact, a number of studies have investigated the impact of MCI on IADL. Such studies have revealed three important findings: (i) individuals with MCI are more likely to be restricted in IADLs than normal controls but less so than those with dementia; (ii) even mild IADL restriction is associated with a much higher risk of progression to dementia and (iii) individuals classified as normal on neuropsychological tests – but with IADL restrictions – are at higher risk for dementia than those classified as having MCI without IADL restrictions (Jefferson et al., 2008; Nyg ard & Starkhammar, 2007; P
eres et al., 2006; Purser, Fillenbaum, Pieper & Wallace, 2005; Reppermund et al., 2011). Some typical activities found to be restricted include: financial management, medica-

188 tion management, shopping, walking, travelling and managing everyday technology (Dodge, Mattek, Austin, Hayes & Kaye, 2012; Hughes, Chang, Bilt, Snitz & Ganguli, 2012; Nyg ard, Pantzar, Uppgard & Kottorp, 2012). Moreover, preliminary evidence suggests that each of the four subgroups of MCI (i.e. amnestic MCI (aMCI), non-amnestic MCI (naMCI) and single- or multipledomain MCI) affects IADLs differently (Bangen et al., 2010; Kim et al., 2009). For instance, compared with healthy older adults, Bangen et al. (2010) found that those with aMCI demonstrated significant impairment in specific financial management tasks (e.g. counting money and taking precautions with finances), whereas those with naMCI demonstrated poor performance on abilities related to health and safety (e.g. awareness of one’s own health status and dealing with medical emergencies). Kim et al. (2009) found that individuals with aMCI multiple domains reported more difficulties using transportation and managing finances, while individuals with naMCI single domain reported problems using the telephone and household appliances. In addition, the presence of naMCI has been found to factor importantly in predicting risk for falls (Delbaere et al., 2012). Whereas the research evidence points to IADL performance difficulties experienced by individuals with MCI, these changes can be subtle. In practice, the type of assessments used by clinicians in this area of practice usually include two approaches: the “bottom up” approach, which is used when the aim is to identify an underlying impairment (e.g. using a neuropsychological assessment to test memory problems) or the “top down” approach, which is used to identify problems that individuals are experiencing in real life (e.g. observing an individual balancing a cheque book or counting money) (Poulin, Korner-Bitensky & Dawson, 2013). Given the importance and growing emphasis on early detection of mild cognitive impairment, we deemed it important to understand how occupational therapists are currently screening and assessing clients with subtle cognitive changes that potentially represent MCI. Our literature review revealed little to help inform the clinical community about current identification and assessment practices specific to this clientele and specific to occupational therapy, a discipline for which IADL is a domain of concern. Thus, we designed a national study to investigate Canadian occupational therapists practices relative to problem identification (clinicians expressed concerns given specific cues) and assessments (i.e. prevalence, timing and type of assessment measures used) with the MCI clientele specifically. Last, we were interested in exploring the clinicians’ reasons for choosing the screening tools/ assessments they currently use and their perceptions regarding their knowledge about MCI. © 2015 Occupational Therapy Australia

P. BELCHIOR ET AL.

Methods Overview of research design In 2013, we conducted a Canada-wide online survey to investigate occupational therapists’ practices with clients with MCI. Clinicians were prompted by a case vignette that described two clients: one vignette included cues associated with aMCI, the other naMCI. Clinicians were asked to identify potential concerns they might have (if any) and to indicate the screening and assessment tools they would use (if any) for each client as per their current practice. The aMCI and naMCI subtypes were chosen, because they are representative of a large portion of the MCI population (Busse, Hensel, G€ uhne, Angermeyer & Riedell-Heller, 2006). In addition, the use of vignettes has been shown to be a valid method to measure actual clinical practices (Jones, Gerrity & Earp, 1990; Peabody et al., 2004). This research protocol was approved by the Institutional Review Board of the Faculty of Medicine, McGill University, Montreal, Canada.

Sample size considerations Sample size was based on the primary outcome of interest – the proportion of clinicians using standardised functional assessments – with a high degree of precision and narrow confidence intervals. Using the assumption that 20% of clinicians used a standardised functional assessment (Cochran, 1977), and with a desired 2-sided confidence interval of 95% along with a desired precision of 7–10% in estimating actual use of various assessments, a range of 120–200 clinicians were needed – 60–100 per case vignette (aMCI and naMCI). On the basis of previous studies in this domain (Korner-Bitensky, Barrett-Bernstein, Bibas & Poulin, 2011), we anticipated a participation rate of 80% and, accordingly, the recruitment goal was set at 250 or more participants.

Study population Clinicians were identified by lists provided through the provincial licensing body or by the Canadian Association of Occupational Therapists (CAOT). In Canada, clinicians must be registered to work as occupational therapists. Therefore, these are representative lists. To meet inclusion criteria, clinicians had to: (i) have been working with a geriatric clientele for at least six months in the past year; (ii) perform screenings and/or assessments in their practice and, (iii) currently see clients similar to those described in the vignettes.

Development of the case vignettes The two case vignettes, respectively, representing a client with aMCI and naMCI, were created using focus group methodology. Four occupational therapists and two researchers, who have treated older adults experiencing cognitive impairment, worked together to create

189

IDENTIFICATION AND ASSESSMENT OF MCI

these “typical” clients. Below are some excerpts from each vignette. Vignette 1 – aMCI “Mrs. B is a 68-year-old married high school teacher. The couple often cooks together and have always enjoyed having friends over for dinner but lately she finds it overwhelming; the meals are getting simpler and she entertains less and less. She states that she is having trouble recalling recent conversations with colleagues and, a couple of months ago, she drew a blank during a class she was giving when trying to summarise its content. Last month she mistakenly transferred money from her stock folder to her regular account.” Vignette 2 – naMCI “Mr. J is a 72-year-old man who recently retired from work as an accountant. Mr. J. and his companion are avid bridge players and they organise mini tournaments at home. Lately though, Mr. J is having trouble keeping up with the game. He is also having trouble paying attention to group conversations during social events and difficulty understanding ironies or jokes within the social gatherings. His planning skills have also deteriorated in that he cannot plan trips to new destinations anymore.” The types of functional problems described represent those typically experienced by individuals with MCI. Whereas the individual can still perform daily tasks independently, they begin to experience subtle difficulties in their performance (De Vriendt et al., 2012). The cues used to demonstrate these mild IADL problems in the aMCI vignette were: meals becoming simpler; entertaining less and less; trouble recalling recent conversations with colleagues; drawing a blank during a lecture when trying to summarise class content; and, difficulties with financial management. In the naMCI vignette, the cues were: trouble keeping up with the game; trouble paying attention to group conversation and understanding ironies or jokes within social gatherings; and, problems planning new trips.

to the next vignette (Mr. J) and the same questions would ensue. After reading each vignette, clinicians were asked to “state each potential problem [they] identified based on the information in the vignette” and, subsequently, to “indicate the screening/assessments [they] would typically use for the client and when [they] would use each”. Both questions were open-ended and the format permitted documenting up to 10 problems and 10 assessments. Finally, clinicians were asked to: (i) identify three reasons that best explained their choice of assessments; and, (ii) indicate the extent of their knowledge about MCI. To answer the former question, clinicians were provided with a list containing the following reasons as options: (i) available at work; (ii) heard about it at a conference/seminar/meeting; (iii) found it through a literature search; (iv) saw it described in a textbook/journal that I usually read; (v) colleagues using it said good things about it; (vi) it is required at work; (vii) it has known reliability and validity in assessments with the geriatric clientele; (viii) it is quick and easy to administer; (ix) I learned it during my professional training and, (x) If there is any other reason, please specify. They were not asked to rank the reasons in the order of preference. To answer the latter question, participants were asked to choose one answer among the following: (i) very comfortable; (ii) somewhat comfortable or, (iii) not confortable.

Data collection Clinician recruitment and survey completion were performed through e-mail. Specifically, clinicians were contacted via their provincial licensing body or through the e-mails listed on the CAOT website. The e-mail contained an introductory letter describing the study and requesting their participation if they were eligible. Online consent was obtained from those who were eligible and agreed to participate. Completion of the survey took approximately 15–20 minutes and varied depending on whether clinicians responded to questions for either vignettes or not.

Development of the questionnaire

Data coding

The questionnaire used to obtain information on the actual practices of clinicians was designed following guidelines that increase the validity of the content as well as the participant response rate (Dillman, 2000): it was adapted from a questionnaire used in a study investigating clinicians’ practices related to patients with stroke (Korner-Bitensky et al., 2011). The first section consisted of questions regarding clinicians’ intrinsic factors (i.e. age, education, work schedule, work load and level of experience with the geriatric clientele). In the following section, clinicians were asked if they see individuals like Mrs. B in their practice. If they answered yes, they were asked to answer the questions related to Mrs. B. If they answered no, they would skip

Two trained research assistants coded the open-ended responses to the online survey. The authors reviewed all the codes for accuracy and consistency. The responses were classified according to the problems identified and the assessments used for each client. First, each clinician was coded as a problem identifier (yes/no) with a yes categorisation if the clinician stated one or more concerns about the client represented in each vignette they had responded to. Thus, a clinician could have been coded as a problem identifier for one vignette but not for the other. Then, the identified problems were coded as either an (i) IADL problem (activities and participation domain) or (ii) cognitive problem (global cognition, memory, executive function and © 2015 Occupational Therapy Australia

190 attention) according to the International Classification of Functioning Disability and Health (ICF) (WHO, 2001). For example, if the clinician indicated the presence of memory problems and difficulties with IADL’s, she/he would be coded as a problem identifier (yes) as well as an IADL problem identifier and cognitive problem identifier. Specifically, a clinician was considered an IADL problem identifier if she/he: (i) expressed that the client had a potential problem with IADL performance or (ii) indicated one or more of the specific IADL cues presented in either vignette under the problem response [e.g. meals are getting simpler (Mrs.B) or deteriorated ability to plan new trips (Mr. J)]. Next, we explored clinicians’ assessment practices according to each vignette. First, all assessments mentioned by clinicians were categorised as either IADL or cognitive assessments and as standardised or not. To be considered standardised, an assessment had to be developed under standard norms with evidence of reliability and validity, and with instructions on administration under uniform condition (Law, Baum & Dunn, 2005). To accomplish this classification, each assessment was examined to understand the constructs measured and to verify the psychometric properties (for those that were standardised). An assessment was coded as an IADL assessment if it measured performance in everyday function [e.g. Independent Living Scale (ILS)]. The IADL assessments were further classified as performance-based, semi-structured interviews or self or informant report questionnaires. As for the cognitive assessments, they were classified as screening assessments [e.g. Mini-Mental State Examination (MMSE)], global cognitive assessments if they measure different cognitive domains (e.g. Cognitive Competency Test (CCT)) or domain-specific cognitive assessment if they measure specific cognitive skill [e.g. Trails Making Test (TMT)].

Data analysis Descriptive statistics and frequencies were calculated to report on the characteristics of the clinicians. In addition, frequencies were calculated to identify the prevalence of concerns reported for each vignette. The frequency of use of assessments was analysed per vignette, per construct (IADL assessments and cognitive assessments), and according to whether they were standardised or not. Last, the reasons why clinicians select the assessments they use in practice, as well as their self-perceived general knowledge of MCI, was also examined using frequency distributions.

Results Participants Six hundred and nineteen clinicians began the survey. Of these, 274 did not meet the inclusion criteria: specifically, 128 did not work with a geriatric clientele in the © 2015 Occupational Therapy Australia

P. BELCHIOR ET AL.

past 16 months and 146 reported that they did not see individuals like the ones depicted in the vignettes. Moreover, 60 had missing data and thus were also not included in the final analysis: 29 had no information recorded and 31 had only partial information recorded. As a result, we were unable to determine whether they saw the types of clients represented in the vignettes or not. Of the 285 participants included in the analysis, 168 (58.9%) indicated that they had seen patients as depicted in both vignettes, 47 (16.5%) had only seen clients like Mrs. B (aMCI) and the remaining 70 (24.6%) had only seen clients like Mr. J (naMCI). Table 1 presents the participants’ demographics information. The average clinician age was 38.6 (age range 23–70 years), 92.7% were female and 71.2% worked fulltime. This information is consistent with census data for occupational therapists (Service Canada, 2013), which suggests that our sample was representative of the general population of occupational therapists working in Canada. In addition, most hold a bachelor’s degree (72.3%) and have at least half of their workload comprised of a geriatric clientele (84.2%). Finally, about half (50.9%) have worked with this clientele for over 10 years.

Problems identified by the clinicians Table 2 shows cognitive problems and IADL problems identified by clinicians. For the aMCI case, of the 215 clinicians who reported seeing individuals like Mrs. B in their practice, only one did not indicate any concern

TABLE 1: Clinicians’ personal factors Clinicians factor

n = 285

Mean age  SD (year) (missing = 50) 38.6 (10.2) Gender % Female 92.7 Work schedule Full-time 71.2 Degree Bachelors 72.3 Masters 27.0 Doctorates 0.7 Workload – geriatric clientele (missing = 50) (%) < 25 6.4 26–50 9.4 51–75 24.2 76–100 60.0 Experience with geriatric clientele (years) 10 50.9

191

IDENTIFICATION AND ASSESSMENT OF MCI

TABLE 2: Type and number of problems identified by clinicians aMCI vignette (n = 214)

%

Functional problem identifiers (n = 186) 86.9 General functional problem 29.6 Specific functional problems (related to the cues) Unable to manage finance 86.6 Meals are getting simpler 52.2 Trouble recalling recent conversations 17.7 Entertains less and less 17.2 Drew a blank during a class 10.8 Other specific functional problems (not related to the cues) Driving 10.8 Managing medication 3.2 Shopping 0.5 Cognitive problem identifiers (n = 168) 78.5 Specific cognitive problems Memory 89.9 Executive function 22.0 Global cognition 12.5 Attention 11.9 Functional and cognitive problem identifiers 67.7 (n = 145) naMCI (n = 236)

%

Functional problem identifiers (n = 140) 59.3 General Functional Problem 21.4 Specific Functional Problems (related to the cues) Cannot plan new trips 53.6 Trouble keeping up with the game 40.7 Difficulties understanding ironies or jokes 34.3 Trouble paying attention to group conversations 32.1 Other specific functional problems (not related to the cues) Medication management 6.4 Cooking 3.4 Cognitive problem identifiers (n = 199) 84.3 Specific cognitive problems Executive Function 88.9 Attention 53.8 Memory 18.1 Global cognition 9.0 Functional and cognitive problem identifiers 52.5 (n = 124)

when queried upon presentation of the vignette. Of the 214 which identified concerns, 186 (86.9%) indicated an IADL concern, 168 (78.5%) a cognitive concern and 145 (67.7%) identified both. For the naMCI case, 238 clinicians reported seeing individuals like Mr.J in their practice. When asked if they identified a problem, only two did not. Of the remaining 236, 140 (59.3%) identified

an IADL concern, 199 (84.3%) a cognitive concern and 124 (52.5%) identified both. Specifically for IADL concerns, the two most identified cues in the aMCI vignette were: deterioration in finance management (86.6%) and meals getting simpler (52.2%). In the naMCI vignette, the two main identified cues comprised of: inability to plan new trips (53.6%) and trouble keeping up with the game being played (40.7%). In terms of cognitive problems identified by clinicians, memory (89.9%) was the most identified problem in the aMCI case vignette, whereas it was executive function (88.9%) in the naMCI case vignette (see Table 2). Other less commonly identified problems included: mental health issues (aMCI=12.6%/naMCI=2.1%), social isolation (aMCI=23.3%/naMCI=13.0%), vocation (aMCI=23.3%/naMCI=0), safety (aMCI=6.0%/naMCI=2.1%), feeling overwhelmed (aMCI=17.7%/naMCI=2.5%), hearing loss (aMCI = 0/naMCI = 8.8%) and neurodegenerative disease (aMCI=5.1%/naMCI=0).

Types of assessments used While 77.9% (n = 145) of the clinicians that identified an IADL problem in Mrs. B (aMCI) indicated they would perform an IADL assessment on the client, only 46.2% (n = 67) indicated they would use a standardised measure. For Mr. J (naMCI), these percentages were 70.0% (n = 98) and 35.7% (n = 35) respectively. In terms of cognitive problems identifiers, 67.2% (n = 113) of the clinicians that identified a cognitive problem in Mrs. B (aMCI) indicated they would perform one or more cognitive assessments. For Mr. J (naMCI), the number was 80.4% (n = 160). Interestingly, all the cognitive assessments reported by clinicians were standardised. Last, while 67.7% (n = 145) of clinicians reported that they would use both an IADL and cognitive assessment with Mrs. B, only 52.5% (n = 124) reported so with Mr. J. Table 3 presents the information on the standardised measures clinicians would use with each client to assess IADL. Eighteen different assessments (13 performance-based and five questionnaires/semi-structured interview) are named. Given the sparse usage of standardised IADL assessments, we will report on the assessments used by at least 5% of the clinicians. This cut-off point is chosen to help better expose what is currently used by most occupational therapy’s. With this condition, the three most common measures at the initial assessment point are: the Independent Living Scale (ILS) (aMCI = 13.4%/naMCI = 10.0%), a performancebased measure that assesses activities of daily living (ADL) (e.g. hygiene, dressing, eating), behaviour (e.g. physical aggression, property abuse) and initiation (e.g. laundry, locking door); the Assessment of Motor and Processing Skills (AMPS) (aMCI = 6.4%/naMCI = 7.8%), an observation-based instrument evaluating individual’s performance in both complex and basic activities of © 2015 Occupational Therapy Australia

192

P. BELCHIOR ET AL.

TABLE 3: Frequency and time of standardised functional assessments use by clinicians that identified a functional problem aMCI (n = 186)†

naMCI (n = 140)†

Initial % Interim‡ % Discharge % Initial % Interim‡ % Discharge % Performance-based assessments Independent living scale (ILS) 13.4 Assessment of motor and processing 6.4 skills (AMPS) Executive function performance test (EFPT) 3.7  Echelle de Montreal pour L’evaluation des Activites 3.2 Financieres (EMAF)§ The Kohlman evaluation of living skills (KELS) 2.1 Kettle test 1.0 Kitchen task assessment 1.0 Multiple errands test (MET) 1.0 Perceive, recall, plan and perform (PRPP) 0.5 The Bay area functional performance evaluation 0.5 (BaFPE) Barthel index of activities of daily living 0.5 Assessment of language-related functional – activities (ALFA) Texas functional living scale (TFLS) – Test of everyday attention (TEA) – Semi-structured interview Canadian occupational performance 2.6 measure (COPM) Self or informant report questionnaire Functional autonomy measurement 0.5 system (SMAF) Self-report questionnaires Oars multidimensional functional 0.5 assessment questionnaire Functional independence measure (FIM) –

4.3 3.2

1.6 2.1

10.0 7.8

4.2 5.0

1.4 2.1

2.1 1.6

– 1.0

5.7 0.7

– 0.7

0.7 0.7

0.5 0.5 1.0 0.5 – –

– – – – – –

2.1 1.4 – 0.7 1.4 –

– – – 0.7 – 0.7

– – – – – –

– 0.5

– –

0.7 –

– 0.7

– –

– –

– 0.5

0.7 –

– –

– –

–

0.5

3.5

–

–

0.5

–

1.4

–

–

–

–

1.4

–

–

–

–

0.7

–

–

†Number of clinicians that identified at least one functional problem in the specific vignette. ‡At some point during the course of treatment. §At the time that the manuscript was written this tool was only available in French.

daily living; and, the Executive Function Performance Test (EFPT) (aMCI = 3.7%/naMCI = 5.7%), which examines executive function, capacity for independent functioning and amount of assistance required to complete a task. The EFPT tasks include: cooking, telephone use, medication management and finance. Moreover, only three assessments have been used at all occasions (Table 3): the ILS (Initial: aMCI = 13.4%/ naMCI =10%; Interim: aMCI = 4.3%/naMCI = 4.2%; Discharge: aMCI = 1.6%/naMCI = 1.4%), the AMPS (Initial: aMCI = 6.4%/naMCI = 7.8%; Interim: aMCI = 3.2%/ naMCI = 5%; Discharge: 2.1% for both aMCI and naMCI)  and the Echelle de Montreal pour L’evaluation des Activites Financieres (EMAF) (Initial: aMCI = 3.2%/naMCI = 0.7%; © 2015 Occupational Therapy Australia

Interim: aMCI = 1.6%/naMCI = 0.7%; Discharge: aMCI = 1%/naMCI = 0.7%). Table 4 presents the information on the standardised measures clinicians would use with these two clients to assess cognition (if reported by > 5%). At the initial assessment point, the majority reported that they would use a screening tool: the Montreal Cognitive Assessment (MOCA) (aMCI = 70.2%/naMCI = 68.8%) was the most prevalent, followed by the Mini-Mental State Examination (MMSE) (aMCI = 39.2%/naMCI = 42.2%) and the Cognitive Assessment Scale for the Elderly (CASE) (aMCI = 23.8%/naMCI = 23.6%). The Cognitive Competency Test (CCT) was the only global cognitive assessment reported (aMCI = 19.0%/naMCI = 10.5%). In

193

IDENTIFICATION AND ASSESSMENT OF MCI

TABLE 4: Frequency and time of standardised cognitive assessments use by clinicians that identified a cognitive problem aMCI (n = 168)†

Screening cognitive assessments Montreal cognitive assessment (MoCA) Mini-Mental State Examination (MMSE) Cognitive assessment scale for the elderly (CASE) Global cognitive assessments Cognitive Competency Test (CCT) Domain-specific cognitive assessments Rivermead behavioural memory test (RBMT) Clock drawing Trails making test (TMT) Executive interview (EXIT) Bells Motor-free visual perceptual test (MVPT)

na MCI (n = 199)†

Initial %

Interim‡ %

Discharge %

Initial %

Interim‡ %

Discharge %

70.2 39.2 23.8

35.1 20.2 9.5

12.5 5.9 2.3

68.8 42.2 23.6

27.1 13.5 10.5

14.5 6.0 –

19.0

2.9

1.7

10.5

4.0

3.5

10.1 7.1 5.3 3.5 3.5 2.3

1.1 1.1 2.9 1.7 0.5 0.5

1.1 – – – – –

2.0 10.5 22.6 5.5 7.5 5.5

– 4.0 9.0 1.5 4.0 5.5

0.5 1.5 5.5 1.0 0.5 0.5

†Number of clinicians that identified at least one cognitive problem in the specific vignette. ‡At some point during the course of treatment.

terms of domain-specific cognitive assessment, the most frequently reported tests for aMCI were assessing memory, attention and executive dysfunction using: The Rivermead Behavioral Memory Test (RBMT) (10.1%), the Clock drawing (7.1%) and the Trails Making Test (TMT) (5.3%). The less reported tests were the Executive Interview (EXIT) (3.5%), Bells test (3.5%) and the Motor-Free Visual Perceptual Test (MVPT) (2.3%). For naMCI, the most frequently mentioned were tests of attention and executive dysfunction using the TMT (22.6%), Clock drawing (10.5%) and Bells test (7.5%). The least reported were the EXIT (5.5%), MVPT (5.5%) and the RBMT (2.0%). Assessments occurring during the course of treatment (Interim) or at the end of treatment (Discharge) were less frequent (see table 4).

Reasons for choosing an assessment and knowledge about MCI The three most frequently reported reasons that best explained a clinician’s choice of assessments were: having good reliability and validity with the geriatric clientele (68.5%), availability of the assessment in the work environment (61.7%) and being quick and easy to administer (55.3%). When asked about their knowledge of MCI, 42% of the clinicians reported being very comfortable with the topic, 53% reported being somewhat comfortable and 5% reported not comfortable.

Discussion This study examined occupational therapists’ practices regarding problem identification and assessment with

the MCI clientele. Guided by two case vignettes depicting either a potential client with aMCI or a client with naMCI, clinicians were asked to identify any concerns they might have and their usual assessment practices for each client. Encouragingly, almost all clinicians identified at least one IADL or cognitive concern in each case vignette. Interestingly, among the problem identifiers, we found different patterns of problem identification according to MCI subtype. Specifically, clinicians were more likely to identify IADL concerns in the aMCI vignette (86.9%) than in the naMCI vignette (59.3%). It might be the case that IADL cues related to memory concerns are more easily recognised by clinicians or it could be that the cues in the aMCI vignette (e.g. unable to manage finance, meals getting simpler) were more obvious and less challenging to be identified than in the naMCI case (e.g. cannot plan new trips, trouble keeping up with the game). Although, almost all clinicians identified a problem in the vignettes, IADL cues were too often missed, especially in the naMCI case. Considering that assessment of IADL performance is the domain of concern and expertise in occupational therapy, clinicians should be aware of the subtle functional changes occurring in the population. It could be that the clinicians that missed the obvious IADL cues, considered these subtle changes in performance as part of the normal ageing process. Thus, it seems challenging for clinicians to differentiate decline in IADL performance that is part of the normal ageing process from what might be a sign of pathology. With the ageing of the population, clinicians will © 2015 Occupational Therapy Australia

194 increasingly be faced with this concern. In fact, this is a topic that deserves much attention because to date, there is a lack of studies investigating the differences between normal from pathological functional decline. In terms of assessment practices, while many clinicians reported they would assess the clients using domain-specific cognitive assessments (i.e. a “bottom up” approach), a good number of them also reported they would use a top down approach to assess IADL performances. This is encouraging since the use of “top down” tools for IADL performance assessment is recommended, because they are considered ecologically valid for they better represent performance in real world environments (Poulin et al., 2013). In addition, just over half of clinicians (aMCI = 67.7%/naMCI = 52.5%) indicated they would typically use both a cognitive measure of impairment along with a functional assessment of performance. Although specific guidelines for assessment practices with individuals with MCI are not available, a combination of “bottom up” and “top down” approaches is recommended in geriatric care (Douglas, Liu, Warren & Hopper, 2007). Finally, it was encouraging that the vast majority of clinicians chose a performance-based IADL assessment instead of an IADL questionnaire. Performance-based measures in which evaluators can observe individuals executing tests in a real world environment might be more sensitive to capture these subtle functional declines. Some clinicians also pointed out that other concerns, such as mental health issues (e.g. depression and social isolation), could be affecting cognition and functional performance. In fact, not only can depression be concomitant with cognitive impairments but it can also be the specific cause of cognitive impairment. Thus, appropriate assessments in this area should also be considered when appropriate (Potter & Steffens, 2007). In terms of standardisation, while practically all cognitive assessments reported were standardised, this was not the case for the IADL assessments. This same pattern of results has been reported in previous studies investigating occupational therapy assessment practices in stroke (Douglas et al., 2007; Korner-Bitensky et al., 2011). The issue in using non-standardised IADL assessments is that clinicians need to rely on clinical reasoning, which is subjective. Thus, the validity of such assessments can easily be put into question. In fact, the acquisition of valid outcome measures is part of evidence-based practice and, as such, clinicians, whenever possible, should make use of instruments which have had their psychometric properties studied in their target population to support their practice. Among the assessments used by clinicians, only the ILS and the TFLS have some psychometric properties studied with the MCI population (Belchior et al., 2015). This rather makes it difficult for clinicians to choose an assessment for this clientele. Interestingly, despite the lack of use of standardised IADL assessments, the most mentioned reason © 2015 Occupational Therapy Australia

P. BELCHIOR ET AL.

for choosing an assessment was having good validity and reliability. Among standardised IADL assessments reported, the ILS, a tool that assesses an adult’s competency to live independently, was the most often named. It includes 68 items from five subscales (memory/orientation, managing money, managing home and transportation, health and safely) (Loeb, 1996). While the validity of two of its subscales (managing finance and health and safety) has been investigated with the MCI population (Bangen et al., 2010), further studies are needed. Moreover, considering that individuals with MCI still live independently and that the IADL problems faced by this population are very subtle, the appropriateness of using the ILS scale with MCI should be questioned. In fact, a recent study has suggested that assessments which focus on performance errors might be more sensitive to capture the subtle functional changes in this population (Giovannetti et al., 2008). The second most used functional assessment was the AMPS (Fisher, 1995). Although further studies are needed in this area, this stands as an interesting choice of assessment since preliminary evidence suggests that motor performance, which can impact IADL performance, might be compromised in these individuals (Tam et al., 2008). Finally, the EFPT assesses five executive function constructs (initiation, organising, sequencing, judgement and safety and completion) in four tasks (cooking, telephone, medication and bills) (Baum, Morrison, Hahn & Edwards, 2003). Given that executive function is strongly correlated with IADL performance (Gold, 2012), this tool might provide the treating clinicians with very relevant information about task execution and, more importantly, the executive impairments that are impacting performances. It is important to note the lack of consensus and widespread use of IADL assessments and the use of assessments that have not been validated with the MCI population. This is likely a reflection of the inconsistencies present in the literature concerning functional assessment practices for MCI, which translates in a lack of established guidelines in this area. Indeed, it must be challenging for clinicians to draw conclusions on the best functional assessments to use from the literature in these circumstances. The idea that development of standards is needed to guide practices, as has already been pointed out by other researchers (Gold, 2012; & Nyg ard, 2003), is further demonstrated here. In terms of cognitive tools, the MOCA (Nasreddine et al., 2005), a tool specifically designed to screen for MCI and more sensitive than the MMSE for MCI detection, was used by the vast majority of clinicians. However, there are still clinicians not screening for MCI with such a tool. Nevertheless, this finding shows a change in practice as previous studies assessing occupational therapy practices found that the MMSE was the

195

IDENTIFICATION AND ASSESSMENT OF MCI

most used assessment (Douglas et al., 2007; KornerBitensky et al., 2011). One reason for the widely use of MOCA might be that it is a well-recognised tool among health-care professionals, providing a common language when working in multidisciplinary health-care settings. Moreover, cognitive assessments alike the MOCA may be easier to interpret compared with standardised functional assessments. In terms of reassessment, very few clinicians reported reassessing the clients. The MOCA and MMSE were the only two frequently reported tools for reassessment. However, these tools are not appropriate to monitor changes in cognition in individuals with MCI. The lack of reassessments might be related to workplace constraints, or it is not in the mandate of the institutions where clinicians work. Last, when clinicians were prompted to indicate the extent of their knowledge about MCI, our results demonstrate that about half of the clinicians are somewhat comfortable with this topic. With an ever-increasing ageing population, clinicians should be well prepared to manage clients with MCI.

Potential limitations It is likely that clinicians with an interest in the area of cognition and MCI were those that responded to the survey. This could bias the results. Also, the use of case vignettes in research could be considered a limitation due to constrained generalisation. Nonetheless, its use has been shown to be a valid measure and successful in previous studies (Korner-Bitensky et al., 2011; MenonNair, Korner-Bitensky & Ogourtsova, 2007). Last, another limitation lay in the construct of the question concerning individuals’ knowledge of MCI in our survey as it was comprised of three answers (i.e. very comfortable, somewhat comfortable and not comfortable): a three points scale can be a source of bias as most people might have opted for a mid-point on the scale.

Conclusion The idea that individuals with MCI already face decline in performance of everyday tasks is not new (Nyg ard, 2003). Although, this study shows that there is room for improvement in problem identification, screening and assessment practices in this area. For instance, considering that IADL assessment is the domain of concern and expertise of occupational therapists, they should be more aware of the possible functional problems experienced by this population. In fact, occupational therapists should take a lead role in this area of practice. In addition, there is a widespread use and lack of consensus on assessment practices. This might be a reflection of the lack of guidelines in this area of practice. Future research should develop standards to guide clinicians.

Acknowledgments This study was funded by the Richard and Edith Strauss Canada Foundation.

References Albert, M. S., DeKosky, S. T., Dickson, D., Dubois, B., Feldman, H. H., Fox, N. C. et al. (2011). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s and Dementia, 7, 270–279. doi: 10.1016/j.jalz.2011.03.008. Bangen, K. J., Jak, A. J., Schiehser, D. M., Delano-Wood, L., Tuminello, E., Han, S. D. et al. (2010). Complex activities of daily living vary by mild cognitive impairment subtype. Journal of the International Neuropsychological Society, 16, 630–639. doi: 10.1017/s1355617710000330. Baum, C. M., Morrison, T., Hahn, M. & Edwards, D. F. (2003). Test manual for the executive function performance test. St. Louis, MO: Washington University. Belchior, P., Holmes, M., Bier, N., Bottari, C., Mazer, B. & Robert, A. In press. A scoping review of performancebased tools for assessing functional performance in individuals with mild cognitive impairment. The Open Journal of Occupational Therapy. Busse, A., Hensel, A., G€ uhne, U., Angermeyer, M. C. & Riedell-Heller, S.G. (2006). Mild cognitive impairment. Long-term course of four clinical subtypes. Neurology, 67, 2176–2185. doi: 10.1212/01.wnl.0000249117.23318.e1. Cochran, W. G. (1977). Sampling Techniques, 3rd ed. New York: John Wiley & Sons. De Vriendt, P., Gorus, E., Cornelis, E., Velghe, A., Petrovic, M. & Mets, T. (2012). The process of decline in advanced activities of daily living: A qualitative exploratory study in mild cognitive impairment. International Psychogeriatrics, 24, 974–986. doi: org/10.1017/S1041610211002766. Delbaere, K., Kochan, N. A., Close, J. C. T., Menant, J. C., Sturnieks, D. L., Brodaty, H. et al. (2012). Mild cognitive impairment as a predictor of falls in community-dwelling older people. American Journal of Geriatric Psychiatry, 20, 845–853. doi: 10.1097/JGP.0b013e31824afbc4. Dillman, D. (2000). Mail and internet surveys: The tailored Design Method. New York: John Wiley. Dodge, H., Mattek, N. C., Austin, D., Hayes, T. L. & Kaye, J. A. (2012). In-home walking speeds and variability trajectories associated with mild cognitive impairment. Neurology, 78, 1946–1952. doi: 10.1212/WNL.0b013e318259 e1de. Douglas, A., Liu, L., Warren, S. & Hopper, T. (2007). Cognitive assessments for older adults: Which ones are used by Canadian Occupational Therapists and why. Canadian Journal of Occupational Therapy, 74, 370–381. doi: 10.2182/ cjot.07.010. Fisher, A. (1995). The assessment of motor and processing skills (AMPS). Fort Collins, CO: Three Star Press. Giovannetti, T., Bettcher, B. M., Brennan, L., Libron, D. J., Kessler, R. K. & Duey, K. (2008). Coffee with jelly or

© 2015 Occupational Therapy Australia

196 unbuttered toast: Commissions and omissions are dissociable aspects of everyday action impairment in Alzheimer’s disease. Neuropsychology, 22 (2), 235–245. doi: 10.1037/0894-4105.22.2.235. Gold, D. (2012). An examination of instrumental activities of daily living assessment in older adults and mild cognitive impairment. Journal of Clinical and Experimental Neuropsychology, 34 (1), 11–34. doi: 10.1080/13803395. 2011.614598. Hughes, T. F., Chang, C.-C. H., Bilt, J. V., Snitz, B. E. & Ganguli, M. (2012). Mild Cognitive Deficits and Everyday Functioning Among Older Adults in the Community. American Journal of Geriatric Psychiatry, 20, 836–844. doi: 10.1097/JGP.0b013e3182423961. Jefferson, A. L., Byerly, L. K., Vanderhill, S., Lambe, S., Wong, S., Ozonoff, A. et al. (2008). Characterization of activities of daily living in individuals with mild cognitive impairment. American Journal of Geriatric Psychiatry, 16, 375–383. doi: 10.1097/JGP.0b013e318162f197. Jones, T. V., Gerrity, M. S. & Earp, J. (1990). Written case simulations: do they predict physicians’ behavior? Journal of Clinical Epidemiology, 48, 805–815. doi: 10.1016/08954356(90)90241-G. Kim, K. R., Lee, K. S., Cheong, H.-K., Eom, J.-S., Oh, B. H. & Hong, C. H. (2009). Characteristic profiles of instrumental activities of daily living in different subtypes of mild cognitive impairment. Dementia and Geriatric Cognitive Disorders, 27, 278–285. doi: 10.1159/000204765. Korner-Bitensky, N., Barrett-Bernstein, S., Bibas, G. & Poulin, V. (2011). National survey of Canadian occupational therapists’ assessment and treatment of cognitive impairment post-stroke. Australian Journal of Occupational Therapy, 58, 241–250. doi: 10.1111/j.1440-1630.2011.00943.x. Law, M., Baum, C. M. & Dunn, W. (2005). Measuring occupational performance: Supporting best practice in occupational therapy, 2nd ed. Thorofare, NJ: SLACK. Loeb, P. A. (1996). Independent living scales manual. San Antonio, TX: The Psychological Corporation. Menon-Nair, A., Korner-Bitensky, N. & Ogourtsova, T. (2007). Occupational therapists’ identification, assessment, and treatment of unilateral spatial neglect during stroke rehabilitation in Canada. Stroke, 38, 2556–2562. doi: 10.1161/STROKEAHA.107.484857. Nasreddine, Z. S., Phillips, N. A., Bedirian, V., Charbonneau, S., Whitehead, V., Collin, I. et al. (2005). The Montreal Cognitive Assessment, MoCA: A Brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53, 695–699. doi: 10.1111/j.15325415.2005.53221.x. Nyg ard, L. (2003). Instrumental activities of daily living: a stepping-stone towards Alzheimer’s disease diagnosis in subjects with mild cognitive impairment? Acta Neurologica Scandinavica, 107 (Suppl. 179), 42–46. doi: 10.1034/ j.1600-0404.107.s179.8.x. Nyg ard, L. & Starkhammar, S. (2007). The use of everyday technology by people with dementia living alone:

© 2015 Occupational Therapy Australia

P. BELCHIOR ET AL.

Mapping out the difficulties. Aging & Mental Health, 11, 144–155. doi: 10.1080/13607860600844168. Nyg ard, L., Pantzar, M., Uppgard, B. & Kottorp, A. (2012). Detection of activity limitations in older adults with MCI or Alzheimer’s disease through evaluation of perceived difficulty in use of everyday technology: A replication study. Aging & Mental Health, 16, 361–371. doi: 10.1080/ 13607863.2011.605055. Peabody, J. W., Luck, J., Glassman, J., Jain, S., Hansen, J., Spell, M. et al. (2004). Measuring the quality of physician practice by using clinical vignettes: A prospective validation study. Annals of Internal Medicine, 141, 813–814. doi: 10.7326/0003-4819-141-10-200411160-00008. P
eres, K., Chrysostome, V., Fabrigoule, C., Orgogozo, J. M., Dartigues, J. F. & Barberger-Gateau, P. (2006). Restriction in complex activities of daily living in MCI: Impact on outcome. Neurology, 67, 461–466. doi: 10.1212/01.wnl. 0000228228.70065.f1. Petersen, R. C., Caracciolo, B., Brayne, C., Gauthier, S., Jelic, V. & Fratiglioni, L. (2014). Mild cognitive impairment: A concept in evolution. Journal of Internal Medicine, 275, 214–228. doi: 10.1111/joim.12190. Potter, G. G. & Steffens, D. (2007). Contribution of depression to cognitive impairment and dementia in older adults. Neurologist, 13 (3), 105–117. doi: 10.1097/01.nrl. 0000252947.15389.a9. Poulin, V., Korner-Bitensky, N. & Dawson, D. (2013). Stroke-specific executive function assessment: A literature review of performance-based tools. Australian Journal of Occupational Therapy, 60, 3–19. doi: 10.1111/1440-1630. 12024. Purser, J. L., Fillenbaum, G. G., Pieper, C. F. & Wallace, R. B. (2005). Mild cognitive impairment and 10-year trajectories of disability in the Iowa Established Populations for Epidemiologic Studies of the Ederly cohort. Journal of the American Geriatric Society, 53, 1966–1972. doi: 10.1111/ j.1532-5415.2005.53566.x. Reppermund, S., Sachdev, P. S., Crawford, J., Kochan, N. A., Slavin, M. J., Kang, K. et al. (2011). The relationship of neuropsychological function to instrumental activities of daily living in mild cognitive impairment. International Journal of Geriatric Psychiatry, 26, 843–852. doi: 10.1002/ gps.2612. Service Canada (2013). Statistics Occupational Therapists. Retrieved from http://www.servicecanada.gc.ca/eng/ qc/job_futures/statistics/3143.shtml Tam, C. W., Lam, L. C., Lui, V. W., Chan, W. C., Chan, S. S., Chiu, H. F. et al. (2008). Clinical correlates of functional performance in community-dwelling Chinese older persons with mild cognitive impairment. International Psychogeriatrics, 20, 1059–1070. doi: 10.1017/S104161020 8007345. World Health Organization. (2001). International classification of functioning, disability and health. Geneva: World Health Organization.