Date Presented 3/31/2017
Functional cognition assessed by occupational therapy should complement neuropsychological testing of fluid and crystallized cognition if our goal is to optimize participation in work activities. Evidence suggests functional and fluid cognition as potential targets for intervention.
Primary Author and Speaker: Alex Wong
Contributing Authors: Cynthia Chen, Sheryl H. X. Ng, Alexis Young, Allen Heinemann, Bob Heaton, Carolyn Baum
PURPOSE: Gainful employment, or paid employment, is well recognized as part of full participation and a key recovery milestone (Hackett, Glozier, Jan, & Lindley, 2012). However, existing work programs have primarily focused on remediation of motor function and psychosocial adjustment but have neglected to develop strategies to help clients with neurocognitive limitations secure a job (Dodson, 2010). This study aimed to investigate if cognition would contribute to increased chances of gainful employment and, if so, what aspects of cognition would play a significant role for targeting future interventions.
DESIGN: This study was part of a multisite, 5-yr project in which participants were recruited from three rehabilitation facilities to complete a 2-day assessment. Participants were at least 1 yr postinjury, age 18 yr and older, able to comprehend and speak English at a fifth grade level, and able to return for follow-up testing. We recruited 480 working-age adults with stroke (n = 149, 31%), traumatic brain injury (TBI; n = 155, 32%), and spinal cord injury (SCI; n = 176, 37%); 25% had either full-time or part-time employment. Those who were more likely to return to work tended to be White (33%), to be married (39%), to have a college degree (42%), to have TBI (33%), not to be wheelchair bound (30%), to have greater upper-limb function (M = 37), and to have better performance in all cognitive domains (all p < .05).
METHOD: Participants underwent the NIH Toolbox cognitive battery (for measuring fluid and crystalized cognition) and emotional battery (depression and anxiety), the Executive Function Performance Test (functional cognition), and the Neurology Quality of Life Measurement System (upper-extremity function) as part of the assessment battery. Gainful employment was measured by an occupational outcome survey. A multivariate logistic regression model with forward stepwise procedure was conducted to predict gainful employment. We adjusted for sociodemographic variables in all models and added domains sequentially. The domain entered into the model first was motor, followed by emotion, functional cognition, fluid cognition, and crystallized cognition. We further described their work characteristics such as earning, perceived work ability, and work satisfaction.
RESULTS: Participants had higher odds of gainful employment if they were married or had a partner (OR = 2.38, p = .007), held a college degree (OR = 2.26, p = .043), and had better upper-limb motor function (OR = 1.04, p = .043). Emotion had no significant association with gainful employment, whereas cognition remained significant even after adjustment. Participants requiring fewer prompts on sequencing tasks (OR = 0.86, p = .046) and better inhibition control and attention (OR = 1.10, p < .001) were more likely to return to gainful employment, whereas crystallized cognition was not significant. The overall R
2 was 34%. Of the employed participants, 70% had at least 75% abilities compared with before injury, 56% were satisfied with their job performance, 42% had present earnings better than before and 19% the same as before, 57% perceived the same ability to work, and 61% had the same pace of work as before.
CONCLUSION: Cognition was related to gainful employment even after adjustment for demographic, motor, and emotional factors, and functional and fluid cognition both played a significant role in securing gainful employment. Our results suggest that a multimodal assessment of cognition is needed to support work participation. Current care has involved neuropsychologists to assess fluid and crystallized cognition. Occupational therapists offer a unique opportunity to assess functional cognition that is not usually assessed by neuropsychologists and provide clinically meaningful information.
References
Dodson, M. B. (2010). A model to guide the rehabilitation of high-functioning employees after mild brain injury. Work, 36, 449–457. https://doi.org/10.3233/WOR-2010-1044
Hackett, M. L., Glozier, N., Jan, S., & Lindley, R. (2012). Returning to paid employment after stroke: The Psychosocial Outcomes In StrokE (POISE) cohort study. PloS ONE, 7(7), e41795. https://doi.org/10.1371/journal.pone.0041795
