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

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

Surveying the Landscape of Persistent Concussive Symptoms in Adults Through an Occupational Lens.

IMPORTANCE: Little is known about how and to what extent persistent concussive symptoms affect occupational performance in adults. OBJECTIVE: To evaluate the impact of persistent postconcussive symptoms on occupational performance. DESIGN: A cross-sectional study design was used in which the occupational performance needs of adults with persistent concussion symptoms were identified by a trained occupational therapist via semistructured interview. SETTING: University research space. PARTICIPANTS: Adults ages 18 to 60 yr experiencing persistent concussion symptoms. OUTCOMES AND MEASURES: Occupational performance was evaluated using the Canadian Occupational Performance Measure. Data were then categorized by two researchers using the Occupational Therapy Practice Framework: Domain and Process (4th ed.). RESULTS: The most commonly affected occupational performance areas included education and work, social participation, and performance of instrumental activities of daily living. CONCLUSIONS AND RELEVANCE: Aligning with prior knowledge of the impact of psychosocial difficulties and higher order cognitive deficits on daily life, performance of complex occupations is heavily affected in adults with persistent concussive symptoms. Plain-Language Summary: The functional impact of symptoms that adults experience postconcussion becomes apparent as they return to their life occupations. The results of this study showed that adults with persistent concussive symptoms more commonly experienced occupational challenges with participation in education, social activities, and the performance of instrumental activities of daily living, with subtle, important variations in symptoms across adults. Detailed, client-centered evaluation of occupational performance changes postconcussion is an area of potential growth for occupational therapy practice and research.

Addressing Participation in Adults With Postconcussive Symptoms Using Cognitive Strategy Training: A Feasibility Trial.

IMPORTANCE: Some people experience persistent symptoms after a concussion that greatly affect occupational performance. OBJECTIVE: To evaluate the feasibility and preliminary effect of metacognitive strategy training in a sample of adults with postconcussive symptoms. DESIGN: Single-group, prospective design. SETTING: University research laboratory. PARTICIPANTS: Adults with persistent concussive symptoms affecting function (N = 14). INTERVENTION: Ten 45-min sessions of a metacognitive strategy training intervention, Cognitive Orientation to daily Occupational Performance (CO-OP). OUTCOMES AND MEASURES: Assessed feasibility outcomes included recruitment, retention, and adherence rates, and intervention acceptability was evaluated with the Client Satisfaction Questionnaire-8. The preliminary effect was measured on occupational performance (Canadian Occupational Performance Measure), concussive symptoms (Neurobehavioral Symptom Inventory), sleep (Pittsburgh Sleep Quality Inventory), vision (College of Optometrists in Vision Development-Quality of Life Outcomes Assessment), and cognition outcomes (Dysexecutive Questionnaire, Weekly Calendar Planning Activity, and National Institutes of Health Toolbox Cognition Battery). RESULTS: Acceptable recruitment (32%), retention (93%), and adherence rates (100%) were observed, along with a high level of acceptability to participants. Large intervention effects were present for occupational performance, general concussive symptoms, and cognitive functioning. CONCLUSIONS AND RELEVANCE: Findings suggest that the CO-OP is feasible to administer for adults with postconcussive symptoms and perceived as suitable for the needs of this population. Feasibility findings, coupled with improvements in occupational performance outcomes, provide the foundation for a future larger scale trial. Plain-Language Summary: The Cognitive Orientation to daily Occupational Performance intervention is practical to use to address the functional impact of persistent concussive symptoms in adults. Further research is needed to evaluate the efficacy of the CO-OP intervention with this population.

The Technology in Caring Questionnaire: Development and Psychometric Properties.

OBJECTIVE: We developed the Technology in Caring Questionnaire (TCQ) to assess the use of technology-based strategies by dementia caregivers. METHODS: One hundred caregivers completed a survey that included TCQ items along with measures of technology proficiency and patient and caregiver-centered outcomes. RESULTS: The final 34-item TCQ scale had adequate to excellent internal consistency (raw Cronbach alpha = 0.75; standardized Cronbach alpha = 0.95; Guttman lambda-6 = 0.97). TCQ scores demonstrated modest convergent associations with scores from measures of smartphone ( r = 0.265, P < 0.01) and computer proficiency ( r = 0.230, P < 0.05) but a strong association with overall technology experience scores ( r = 0.578, P < 0.001). Elevated TCQ scores were associated with reduced informant-reported cognitive symptoms ( B = -0.003, P < 0.05), increased ability of caregivers to find support and information ( B = 0.03, P < 0.001), and increased direct care strain ( B = 0.03, P < 0.05), after controlling for dementia severity and demographics. CONCLUSION: The TCQ has good psychometric properties for the assessment of technology-based care strategies among dementia caregivers. Findings imply that the use of technologies may aid in symptom management and finding support and information but may also increase caregiver strain.

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

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

Characteristics of Hospitalized Adults 55 and Older With Clostridioides difficile Infection.

Clostridioides difficile infection in older adults can result in severe infection, difficulty in treating, and complicated disease process, yet few studies have examined the characteristics of hospitalized older adults and recurrent Clostridioides difficile infection. A retrospective cohort study was conducted to explore the characteristics of hospitalized adults 55 years and older with initial Clostridioides difficile infection and recurrences by extracting routinely documented data in the electronic health record. A sample of 1,199 admissions on 871 patients was included, with a recurrence rate of 23.9% ( n = 208). During the first admission, there were 79 deaths (9.1%). Clostridioides difficile infection recurrence was more prevalent in patients between 55 and 64 years old, and if discharged to a skilled nursing facility or with home health services. Chronic diseases significantly more prevalent in recurrent Clostridioides difficile infection included hypertension, heart failure, and chronic kidney disease. On initial admission, no laboratory abnormalities were significantly associated with recurrent Clostridioides difficile infection. This study indicates the need for utilizing routinely captured electronic health record data during acute hospitalizations to aid in targeting care to reduce morbidity, mortality, and recurrence.

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

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

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

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

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

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

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

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

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

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

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

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

Screening Tools: They're So Quick! What's the Issue?

Screening tools are needed in occupational therapy practice to determine which clients require formal evaluation. Because screening tools also tell us who does not require formal evaluation, they are key to improved clinical efficiency. Screening tools are brief, easy to administer, and often freely available. These qualities also lead to misuse of screening tools, including using them to measure progress over time or to serve as a confirmatory assessment on which to base treatment planning. We present additional common missteps of screening tool use, including a lack of consideration for a tool's psychometric properties, and exemplars of these common misuses in adult and pediatric practice. Finally, we offer solutions to address these concerns.

Role of Occupational Therapy in Facilitating Participation Among Caregivers of People With Parkinson's Disease: A Systematic Review.

IMPORTANCE: Caregivers play a critical role in facilitating the performance of people with Parkinson's disease (PD). Knowledge on how occupational therapy practitioners can mitigate the negative effects of caregiving is needed to enable caregiver participation. OBJECTIVE: To explore the effectiveness of interventions within the scope of occupational therapy practice for caregivers of people with PD to facilitate or maintain their participation in the caregiver role. DATA SOURCES: We conducted a systematic review of the literature published in CINAHL, MEDLINE, PsycINFO, and OTseeker between 2011 and 2019. Article reference lists were also hand searched for additional articles. Study Selection and Data Collection: Articles were screened and evaluated using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. The review was conducted in accordance with steps outlined by the American Occupational Therapy Association's Evidence-Based Practice Project. FINDINGS: Six articles met the inclusion criteria. Interventions in each article were distinct, prohibiting theme development. Overall, the strength of evidence was low, and the risk of bias was high. None of the studies included in this review were obtained from the occupational therapy literature. CONCLUSIONS AND RELEVANCE: Little evidence is available to support interventions within the scope of occupational therapy practice for caregivers of people with PD. Existing evidence suggests that interventions need to be flexible (e.g., in terms of time, cost, and delivery method) and tailored to the unique needs of this population. What This Article Adds: There is a continued need to develop occupational therapy interventions that support participation in the caregiving role for caregivers of people with PD.

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

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

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

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

Use of Occupation-Based Measures in LSVT BIG Research: A Case Study.

Parkinson's disease (PD) is a neurodegenerative disorder that results in a variety of motor and nonmotor symptoms that impact occupational performance. To our knowledge, no study has investigated the effect of LSVT BIG using occupational performance outcome measures. The objective of this study was to determine the effects of LSVT BIG on occupational performance with an individual with PD. The participant, a 73-year-old retired female with mild PD, completed the LSVT BIG program. Researchers measured changes in occupational performance using the Canadian Occupational Performance Measure (COPM) and the Performance Assessment of Self-Care Skills (PASS). Results indicated improved client perceptions of occupational performance and satisfaction on the COPM and improved independence and adequacy on the PASS. Despite the positive findings of this study that support the use occupational performance measures to evaluate change within LSVT BIG literature, future research should be conducted to determine causality of identified occupational performance improvements and time course of improvements.

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

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

Development of a novel virtual reality gait intervention.

INTRODUCTION: Improving gait speed and kinematics can be a time consuming and tiresome process. We hypothesize that incorporating virtual reality videogame play into variable improvement goals will improve levels of enjoyment and motivation and lead to improved gait performance. PURPOSE: To develop a feasible, engaging, VR gait intervention for improving gait variables. METHODS: Completing this investigation involved four steps: 1) identify gait variables that could be manipulated to improve gait speed and kinematics using the Microsoft Kinect and free software, 2) identify free internet videogames that could successfully manipulate the chosen gait variables, 3) experimentally evaluate the ability of the videogames and software to manipulate the gait variables, and 4) evaluate the enjoyment and motivation from a small sample of persons without disability. RESULTS: The Kinect sensor was able to detect stride length, cadence, and joint angles. FAAST software was able to identify predetermined gait variable thresholds and use the thresholds to play free online videogames. Videogames that involved continuous pressing of a keyboard key were found to be most appropriate for manipulating the gait variables. Five participants without disability evaluated the effectiveness for modifying the gait variables and enjoyment and motivation during play. Participants were able to modify gait variables to permit successful videogame play. Motivation and enjoyment were high. SUMMARY: A clinically feasible and engaging virtual intervention for improving gait speed and kinematics has been developed and initially tested. It may provide an engaging avenue for achieving thousands of repetitions necessary for neural plastic changes and improved gait.