godok.id

Why I still like the verbal reasoning subtest of theCognitive Competency Test (and am even liking thepicture interpretation subtest, too)(Paper-based versus functional assessments)or(Can the verbal reasoning subtest tell yousomeone is safe to go home?)Lilli Ju Lin, OTReg(NB)Health & Aging Program, Horizon Health NetworkSt. Joseph’s Hospital, Saint John, New Brunswick

Outline Introduction (and why this interests me) Objectives Super duper fast background About the test What others have said about the test Test administration/scoring – a few tips and common errorsQuantitative vs. qualitative interpretationPicture interpretation really?A couple of casesQuestions to answer

Introduction (and why this interests me) Much discussion and debate about the merits of the Cognitive Competency Test and its utility as anassessment of cognition and its ability (or inability) toinform a client’s level of functional independence.Lots of CAOT webinars on cognition over the past fewyears; 2-day course in HalifaxRecent research (masters and doctoral level) by OTsMy background – psychology, psychology lab, workedfor a neuropsychologist as psychometrist in a healthyaging programReally want to talk about this with other OTs!!!

Disclaimer Even though I’m doing a presentation about a paper-based test I am still all about FUNCTION. Nothing is as informative as seeing someone dosomething!

Why? Verbal reasoning subtest often used alone Easy-to-administer with cutoff score But functional? But how do you rationalize when there are differencesin “score” and “function”

Objectives To provide a very brief background on the CCT. To discuss the value in analyzing the quality of the client’sperformance with the actual verbal reasoning score, andhow this can provide meaningful information. To provide case examples of how the picture interpretationsubtest can relate to the verbal reasoning subtest, andwhat this could mean functionally. To pose other questions around the verbal reasoningsubtest (e.g., how it compares to the Independent LivingScales subtest on Managing Health and Safety).

Ultimately To spark interesting discussion andcontribute to our confidence inhow we select and use screeningand assessment tools, in concertwith actual functional assessments.

“Occupational therapists commonly assess cognitivecapacities such as memory, attention, and problemsolving when working with older adults. Results ofcognitive assessments provide critical informationused to determine safety for independent living,driving ability and eligibility for a variety of services.OTs commonly use standardized screening measuressuch as the Mini Mental Status Exam or the MontrealCognitive Assessment. Interpretation of scoresbeyond the limits of the data to support them canresult in unethical health care, including incorrectidentification of dementias and incorrect decisionsabout driver’s licenses or placement.”Alison Douglas, PhD, OT Reg(Ont)Summit on Aging, OSOT, 31 October 2009

Super duper fast background Cognitive Competency Test Familiar Used across Canada (Alison Douglas et al., 2007) “Standardized” for older adults, with “norms” Has some construct validity, correlations with otherclinical measures (e.g., MMSE) (Briana Zur, 2011)

About the CCT Described by its developers as an assessment tool thatattempts to measure cognition in relation to everydayliving, and was designed to close a gap betweenpsychological assessment and everyday functioning (Wang,1990; Wang & Ennis, 1986). “an ability to know and to make use of knowledge” (Wang,Ennis, & Copland, 1987. p. 1) “incorporates the concept of multidimensionality ofcognitive skill and adopts a practical approach bysimulating daily living skills” (Wang & Ennis, 1986, p. 120) Face validity

What others have said about the test Douglas et al., 2007 – Critical review of cognitiveassessments for older adults Zur, 2011 – Assessment of occupational competence indementia: Identifying key components of cognitivecompetence and examining the validity of the CognitiveCompetency Test Debbie McQuillen 19 June 2012 - Assessment of cognition in seniors: Are youassessing what you think you are? Choosing assessment tools Functional assessments of cognition (CCT, ILS, AMPS) “Bad” vs. “good” score Can they do what they say they’d do?Ask the question, follow it with functional activity Medication, money, safety (calling superintendent, etc.)

What others have said about the test Debbie McQuillen 15 Jan 2013 - Assessing cognition in seniors: Makingsense of the numbers (beyond the cut off scores) April 2013 – 2 day CAOT workshop on cognition inHalifax Functional Subsections stand alone Cultural bias Outdated

What others have said about the test Sylvia Davidson 26 June 2012 – Occupational therapists and their rolewith older adults: The generalist as specialist? Occupational therapists have the knowledge and the skillsto be experts in the care of older adults We can build the relationships we need to be effectiveleaders in the care of older adults We can inspire others with our passion and our vision! “Function trumps numbers”

Test administration/scoring(a few tips and common errors) Client: Hearing, vision, language, fatigue, medication,position, comfort, cultural background, mental status,time of day Administrator: Tone of voice, speed of speech,position, rapport Generally encouraging, but not correcting Avoid: “That’s right!” Ok: “You’re doing just fine” Always introduce Sometimes you just have to cut them off

Test administration/scoring(a few tips and common errors) LOOK IT UP Not good enough to go by “feel” Know how many times you can cue! Appropriate cues: “Tell me more”; “Anything else” Repeating the question (as often as necessary) Inappropriate cues: “Who would you call?” Try to maintain standardized approach. But can ask supplemental questions (but note this)

Test administration/scoring(a few tips and common errors) Scoring: Specific examples are given Not cover everything Refer to general guidelines on scoring Grasps idea Safety for self or others Appropriate situational priorities Social convention/considerations

Test administration/scoring(a few tips and common errors) Some common issues/questions #2 – During a very bad winter storm, your electricpower goes out and you know it will be out for a verylong time, what will you do? Light, lamp, lantern, flashlight 1 point? #6 – What would you do if you saw thick smoke comingfrom under your neighbour’s door? Break down the door and save them 1 point? #10 – prioritizing urgent household tasks I’d throw out the cup and call the electrician.

Quantitative vs. qualitative interpretation Content What are they saying Are they even talking about the situation? Do they demonstrate understanding of thesituation? Context Where do they live? What supports do they have? What is their life experience?

Quantitative vs. qualitative interpretation CCT IS JUST A SCREEN!! Discussed with neuropsychologists Modifications to questions Note all cues

Qualitative interpretation Helpful observations to make while administering Participation – cooperative, etc. Tangentiality – “One time, the road was really slippery but I had just put on winter tires. Man, they really need to plow the streetsbetter ”Concrete – “I don’t smoke.” “We don’t use gas.” “No one wouldbreak into our home.”Perseverative – If found door open: “I’d check for smoke and fire.”Risk-taking – If there was smoke coming from my neighbour’s door:“I’d kick down the door and drag my neighbour out.”Vague – “You just always have to do the right thing and make sureyou contact someone!”Knowledge – “I don’t know. My husband takes care of all that.”Word-finding – If power out during winter storm: “Make sure I haveenough round things.”Need for cues – indicates need for prompting/supportNeed for question to be repeated – attention? memory?

Interpretation tips – reporting What I used to write: Where they lost their points Some qualitative observations Client’s score 11/20 is in the impaired range of the verbalreasoning subtest of the Cognitive Competency Test,which suggests client does not have adequate verbalreasoning/problem solving skills in safety situations.

Interpretation tips – reporting What I write now: Indicated knowledge in 8/10 safety situations presented Able to identify at least 1 appropriate action in 9/10situations presented Qualitative observations with examples Suggestive of being able to manage common/familiarsituations Impaired score suggests client may have difficulty withunfamiliar/more complex situations

Interpretation tips – discrepancies Explaining to team/families ****HELPFUL! High score, but poor performance functionally (e.g.,issues with meal prep, personal care) Verbal reasoning is strongly weighted on VERBAL skills. High score demonstrates client’s knowledge/intelligence andverbal skills, which is why they may present as seeming alright Functional assessments more telling (can’t “walk the walk” ) Impaired score, but good performance functionally Look at quality, context of the responses One lady scored 9/20 on verbal reasoning Intellectual disability; staff in apartment building and verystrong social/formal supports Safe behaviours, awareness/insight Responses were appropriate to her context/environment!

Picture interpretation really? Neuropsychologist who used it with difficult case Someone who scored “high” on everything Completed functional assessments well (ADLs and IADLs) But team and family still had questions based on hispersonal history Examples of individuals who’ve scored in normalrange of VR, but then bomb the PI what?

Picture interpretation really? Present pictures and ask them “Tell me what ishappening in this picture” Concrete/perceptual elements vs. inferential statements BE CAREFUL OF SCORING! Interpretation “Such cognitive skills are necessary prerequisites forappropriate social interaction.” (CCT) Client had difficulty interpreting cues in the social andphysical environment. This raises concerns about client’sability to appropriate interpret a social or safetysituation.

What is happening in this picture?