Cognitive Impairments

     Cognitive impairment has been associated with chronic disease diagnoses such as heart failure, vascular disease, diabetes, and depression (Coco, Lopez, & Corrao, 2016). And age is the biggest risk factor for a dementia or major neurocognitive disorder diagnosis. Knowing that the PACE participant is an older adult, likely with a chronic disease diagnosis, this puts them at an increased risk of having cognitive impairments. Cognitive impairment is associated with greater mortality risk, decreased quality of life, and decreased occupational participation (Murad et al., 2015). However, early detection of cognitive impairments and dementia has been shown to improve functional outcomes as individuals and caregivers access resources and treatment much sooner (Piersol & Jenson, 2017). This creates a clear role for the occupational therapist to help identify participants with cognitive deficits and provide more meaningful interventions.

 

Role of Occupational Therapy. Occupational therapists play an important role in identifying functional cognitive deficits and understanding how cognitive deficits impact each individual. Particularly when participants present with chronic diseases, occupational therapists should be assessing cognition on a regular basis and providing interventions to support occupational participation through modifications of task and environment and cognitive retraining as appropriate. The occupational therapist can also be instrumental in supporting the IDT to understand the implications of cognitive impairment for each participant and to adjust care as appropriate to better meet the needs of each individual. For example, the occupational therapist may have identified that short-term memory is impaired in a particular individual, however problem solving and language skills remain intact. For this participant, it is possible that the use of reminders such as alarms could improve medication adherence and the use of a printed summary of primary care visits may increase the participant’s understanding of the diagnoses and their plan of care. The occupational therapist could provide such recommendations to the IDT to improve the quality of care and likelihood of success for this participant.

 

Cognitive screening and assessment considerations. The occupational therapist should be assessing the cognitive and process skills of the individual as well as functional participation. The occupational therapist is skilled at breaking down activities into component parts and determining which cognitive skills and deficits support or inhibit the ability to engage in an activity.

     There are several cognitive assessments and screening tools available. The Montreal Cognitive Assessment (MoCA) is more sensitive than the Mini-Mental Status Exam (MMSE) at identifying mild cognitive impairment. A threshold of 17-19 on the MoCA has been suggested to identify those with MCI, and below 17 to help identify those with dementia (Trzepacz, Hochstetler, Wang, Walker, & Saykin, 2015). Other commonly used assessments include the St. Louis University Mental Status (SLUMS) Exam, the Allen Cognitive Levels, the Global Deterioration Scale (GDS), and the Functional Assessment Staging (FAST) Scale. Functional assessments include the Executive Function Performance Test (EFPT), the Direct Assessment of Functional Status (DAFS), and the Erlangen Test of Activities of Daily Living in Persons with Mild Dementia or Mild Cognitive Impairment (ETAM).

 

This website includes links to multiple cognitive, functional, ADL and IADL assessment and screening tools: https://multicontext.net/treatment-and-assessment-links-1

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Additional considerations. Sensory impairments can exacerbate cognitive impairments. The use of hearing aids can slow cognitive decline (Amieva, Ouvard, Giulioli, Meillon, Rullier, & Dartigues, 2015). Occupational therapists should assess the functional impact of vision and hearing impairment and advocate for appropriate referrals to specialists. Additionally, cognitive decline has been associated with depression, anxiety, and withdrawing from activities (Piersol & Jenson, 2017). The occupational therapist should also look at the psychosocial impact of cognitive impairment

 

Interventions. The type of interventions that are more effective at increasing occupational participation in clients with cognitive deficits vary depending on the severity of impairment. There is evidence to support the use of spaced retrieval and errorless learning techniques to facilitate new learning for clients with mild cognitive impairments, though this is not effective for individuals with moderate to advanced dementia (Piersol & Jenson, 2017). Aerobic and strengthening exercises may improve global cognitive function for the frail and non-frail older adults (Bherer, 2015; Zheng, Xia, Zhou, Tao, & Chen, 2016). Interventions for those with more advanced cognitive impairments should be occupation-based and contextually relevant. For example, if an individual has difficulty sequencing a task such as dressing, then a sequencing activity that isn’t dressing, such as a craft, will not generalize or be helpful. And completing this task in the person’s bedroom will be more beneficial than practicing in the therapy gym, where one does not typically get dressed. Adaptations to the task to simplify the activity and to the environment to minimize distractions and providing the right type of cues can also be helpful. And routines are integral to supporting participation for people with cognitive impairments, and the occupational therapist can support developing and integrating supportive routines (Piersol & Jenson, 2017).

     For clients with cognitive impairments and dementia, strong caregiver support is integral to successfully remaining in the community. Caregiver training programs both individually and in groups have been shown to be effective at decreasing caregiver stress and burden, improving quality of life, improving caregiver competence, and increasing independence in ADLs for the client. Caregiver training programs should include components of dementia education, skill-based learning, and psychosocial support (Piersol & Jenson, 2017). Occupational therapists should be providing robust caregiver training for this population.