Abstract
The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, through the use of occupations and activities, facilitate clients’ cognitive functioning to enhance occupational performance, self-efficacy, participation, and perceived quality of life. Cognitive processes are integral to effective performance across the broad range of daily occupations such as work, educational pursuits, home management, and play and leisure. Cognition plays an integral role in human development and in the ability to learn, retain, and use new information to enable occupational performance across the lifespan.
This statement defines the role of occupational therapy in evaluating and addressing cognitive functioning to help clients maintain and improve occupational performance. The intended primary audience is practitioners 1 within the profession of occupational therapy. The statement also may be used to inform recipients of occupational therapy services, practitioners in other disciplines, and the wider community regarding occupational therapy theory and methods and to articulate the expertise of occupational therapy practitioners in addressing cognition and challenges in adapting to cognitive dysfunction.
Occupational therapy theory and research support the principle that cognition is essential to the performance of everyday tasks (Toglia & Kirk, 2000). Occupational therapy education is grounded in an understanding of the relationship between cognitive processes and performance of daily life occupations and prepares practitioners to focus on occupational performance. This understanding of the relationship between cognition and performance is in keeping with the disciplinary perspective of occupational therapy that emphasizes engagement in the client’s desired occupations to promote cognitive functioning and occupational performance (Baum & Katz, 2010). Occupation is understood as both the means and the end of occupational therapy intervention; participation in occupations enhances clients’ ability to adapt to cognitive dysfunction, which leads to enhanced participation in desired daily activities.
Occupational therapy practitioners administer assessments and interventions that focus on cognition as it relates to participation and occupational performance. Furthermore, practitioners assert that cognitive functioning can be fully understood and facilitated only within the context of occupational performance. This understanding of the relationship among the client’s sense of self, roles, daily occupations, and context make occupational therapy a profession that is distinctly qualified to address cognitive deficits that negatively affect the daily life experience of clients.
Occupational therapy practitioners may choose from a range of interventions that use engagement in clients’ desired occupations and activities to enhance function-based outcomes, often in collaboration with care partners. Considerable progress has been made over the past two decades in advancing the knowledge of cognition and in identifying effective rehabilitative strategies, and these advances are reflected in occupational therapy practice that addresses cognitive dysfunction (D’Amico et al., 2018; Gillen et al., 2015; Jensen & Padilla, 2017).
Definitions
Occupations are everyday activities that are important to the person, that help define the person to self and others, and that support a person’s life roles (AOTA, 2014b). Occupations help structure everyday life and contribute to health and well-being. Engagement in occupations as the focus of occupational therapy intervention involves addressing both neurologically mediated occupational performance deficits and the client’s psychological responses to those deficits (AOTA, 2014b).
Activities of daily living (ADLs) are an array of activities pertaining to care of the self, including basic self-care such as bathing, dressing, toileting, and transferring between surfaces and locations (AOTA, 2014b). Instrumental activities of daily living (IADLs) are those required for independent living in the community. Essential IADLs include health management and maintenance (e.g., obtaining appropriate nutrition, managing medications), financial management, home management, and community mobility skills (e.g., driving, using public transit; AOTA, 2014b). IADLs involve routine components but additionally require (to a greater or lesser degree) planning, problem solving, and decision making. IADLs are more diverse, more likely to involve a social component, and more likely to involve the need to adjust responses to changing task and environmental demands than are ADLs.
Cognition refers to information-processing functions carried out by the brain that include attention, memory, executive functions (EFs; i.e., planning, problem-solving, self-monitoring, self-awareness; Evans, 2010), comprehension and formation of speech (Sohlberg & Turkstra, 2011), calculation ability (Roux et al., 2003), visual perception (Warren, 1993), and praxis skills (Donkervoort et al., 2001). Cognitive processes can be conscious or unconscious (Reber, 2013) and often are divided into basic-level skills (e.g., attention and memory processes), EFs (Schutz & Wanlass, 2009), and metacognition, which encompasses awareness and appraisal of one’s own cognitive abilities (Ownsworth, 2018).
Cognitive dysfunction can be defined as functioning that is below expected normative levels or loss of ability in any area of cognitive functioning (Evans, 2010). The term cognitive rehabilitation has been widely discussed and used in a variety of contexts. However, there is no singular, consensus-based definition. In general, it refers to a broad category of “therapeutic services designed to improve cognitive functioning and participation in activities that may be affected by difficulties in one or more cognitive domains” (Katz et al., 2006, p. 2). Many factors affect occupational performance, so in addition to providing intervention to improve cognitive functioning directly (i.e., cognitive rehabilitation), occupational therapy practitioners may also address other factors that influence clients’ occupational performance outcomes. Such factors include the nature of the demands imposed on the person by the activity itself (i.e., activity demand) and the facilitations or obstacles provided by the social or physical environment (i.e., performance context).
Functional cognition is defined as how people use and integrate their thinking and processing skills to accomplish everyday activities in clinical and community living settings (AOTA, 2017b). Rather than trying to isolate specific cognitive functions (e.g., attention, memory), occupational therapists assess the client’s ability to apply the totality of their metacognitive (i.e., self-awareness of cognitive ability), cognitive, and performance-based capacities or skills to achieve occupational performance goals (Giles et al., 2017).
Cognitive Dysfunction
Cognitive dysfunction may occur at any time across the lifespan and may be associated with a wide range of clinical conditions. This type of dysfunction can be transient or permanent, static or progressive, general or specific, and of different levels of severity affecting people in different domains of their lives. Problems in occupational performance depend on the person’s internal resources and the demands of the activity and of the environment to which the person is required to respond. Even subtle cognitive impairments consistently influence social participation; subjective well-being; and academic, employment, and functional performance across different ages and populations (Foster et al., 2011; Frittelli et al., 2009; Wadley et al., 2008). Most often, cognitive impairments are categorized by severity (e.g., mild or major neurocognitive disorder [NCD]; American Psychiatric Association, 2013) or by the clinical conditions that cause the dysfunction (i.e., diagnostic group).
A substantive body of literature supports interventions that advance occupational performance in people with cognitive impairments from stroke and traumatic brain injury (TBI) and client and caregiver training for major NCDs (Cicerone et al., 2011; Gillen et al., 2015; Radomski et al., 2016; Rohling et al., 2009). People with these conditions are among the most frequently seen by occupational therapy practitioners. Additionally, occupational therapy practitioners address cognitive barriers to functioning resulting from developmental disorders, environmental factors, or disease. Specifically, these client populations include people experiencing cognitive dysfunction related to the following:
Neurological disease, events, injuries, and disorders—for example, stroke, TBI, Parkinson’s and Huntington’s diseases, HIV/AIDS, Alzheimer’s disease and related NCDs, rheumatoid arthritis, diabetes, lupus, Lyme disease, multiple sclerosis, chronic fatigue syndrome, chronic obstructive pulmonary disease, and cardiac and circulatory conditions (Aucott, 2015; Dodd et al., 2015; Fenu et al., 2018; Foster et al., 2011; Gorman et al., 2009; Jellinger, 2012; Jensen & Padilla, 2017; Leslie & Crowe, 2018; Medina et al., 2018; Pelimanni & Jehkonen, 2018; Reilly & Hynes, 2018; Teodoro et al., 2018; Wheeler & Acord-Vira, 2016; Wolf & Nilsen, 2015)
Mental health conditions—for example, schizophrenia, major depressive disorder, bipolar disorder, and substance use disorders (Bowie et al., 2012; Brown et al., 2009; Lam et al., 2014; Medalia et al., 2009)
Human genetics and development—for example, environmental deprivation, fetal alcohol syndrome, learning disabilities, and pervasive developmental disorders (Green et al., 2009; Malarbi et al., 2017; Vogan et al., 2018)
Transient or continuing life stresses or changes—for example, stress-related disorders, pain syndromes, anxiety disorders, and grief and loss (Bar-Haim Erez & Katz, 2018)
Other medical conditions—for example, burns (Bajorek et al., 2017; Purohit et al., 2014)—or medical interventions—for example, chemotherapy (Cerulla et al., 2018; Jim et al., 2012)—that affect cognitive functioning
Delirium or time in an intensive care unit (Tobar et al., 2017; Weinreich et al., 2017).
In addition to rehabilitative approaches, occupational therapy practitioners recognize that habilitative approaches to cognitive functioning can be appropriate for populations with normative neurological development (e.g., to enhance self-management skills in the school-age population; see Appendix A, Case Example 1) and the well elderly population (e.g., to promote best ability to function and prevent disability and occupational performance problems; Clark et al., 1997, 2012). Occupational therapy practitioners are at the forefront of using novel approaches to assess and enhance function among these diverse populations (Chui et al., 2018; Peralta et al., 2017; Rand et al., 2009).
Occupational Therapy Service Delivery
The occupational therapy service delivery process broadly comprises evaluation and intervention leading to the outcome of enhanced participation in areas of occupation. Occupational therapy practitioners are often an integral part of interprofessional teams, in which their knowledge of cognition, participation, and context complements the expertise of other clinicians on the team, including, but not limited to, neuropsychologists and speech-language pathologists.
Evaluation of Occupational Performance
Occupational therapy evaluation focuses on determining what the client most needs and wants to be able to do and identifying the factors that support or hinder the desired performance (AOTA, 2014b). The Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014b) identifies the underlying factors and occupations that practitioners consider during the evaluation and intervention process (i.e., client factors, performance skills, performance patterns, context and environment, activity demands).
The relationship of cognitive dysfunction to occupational performance is complex, necessitating a thorough understanding of the contributions of various client factors and the current level of client participation (Giles, 2005, 2011; Lowenstein & Acevedo, 2010). The interaction between a person’s cognitive functioning and each factor is transactional in nature, and as such, cognitive functioning as a whole is always embedded in occupational performance. As a result, cognitive functioning cannot be accurately understood in isolation from the context in which it takes place or by an analysis of individual cognitive skills. Therefore, assessment of isolated cognitive functions is insufficient to determine the impact of cognitive abilities on occupational performance.
Occupational therapy practitioners examine cognition and performance from multiple perspectives and use multiple methods during the evaluation process, including interviews of the client and others (e.g., parent, teacher, family, care partner), cognitive screening, environmental assessment, specific cognitive measures, and performance-based assessments. Rather than trying to isolate cognitive skills, practitioners seek to assess a client’s capacity to manage everyday problems. Preferred assessments are performance based and presented in the form of potentially familiar ADL or IADL tasks, such that performance can be influenced by the client’s use of strategies and previously acquired performance skills. In general, these assessment tasks have more than one route to satisfactory performance, have greater cognitive than physical emphasis, and require the integration of multiple sources of information and the sequencing of multiple action steps for goal completion.
The Cognitive Functional Evaluation–Extended (CFE–E; Bar-Haim Erez & Katz, 2018; Hartman-Maeir, Katz, & Baum, 2009) is an example of a multifaceted approach used by occupational therapy practitioners for clients with suspected cognition-related disabilities. The CFE–E process is intended to be customized to each client’s needs and can include up to six types of assessments, as outlined in Appendix B.
Models for Intervention and Cognitive Rehabilitation
Occupational therapy scholars have developed theoretical models that explain and guide intervention. These models, and the specific approaches and methods they incorporate, are used by occupational therapy practitioners to address cognition and to provide evidence-based cognitive rehabilitation to improve occupational performance. These models include, but are not limited to, the following:
Dynamic Interactional Model (Toglia, 2018)
Cognitive Rehabilitation Model (Averbach & Katz, 2011; Schwartz & Sagiv, 2018)
Cognitive Disabilities Model (McCraith & Earhart, 2018)
Cognitive Orientation to daily Occupational Performance Approach (Dawson et al., 2017)
Neurofunctional Approach (Clark-Wilson et al., 2014; Giles & Clark-Wilson, 1993; Trevena-Peters et al., 2018).
The development of occupational therapy theoretical models is ongoing, as is the refinement of the models’ applicability to particular client populations, severity of deficits, and environmental contexts. Application of these models to the occupational therapy process is highlighted in the case examples in Appendix A.
Key Features of Interventions
Many occupational therapy intervention models are multimodal and include a range of strategies that practitioners adapt to the individual client’s needs. Occupational therapy interventions may address cognition directly—for example, by teaching new thinking procedures or strategies—or indirectly—for example, by training in habits and skills, modifying environments, or educating care partners. Occupational therapy practitioners may select different approaches to address different types of occupational performance deficits in the same client. Although a variety of interventions may be used, interventions are always directed toward minimizing the negative impact that cognitive challenges have on occupational performance. Key features found within various models include metacognitive and domain-specific strategy instruction, specific task or habit training, environmental modifications, and remediation of specific cognitive deficits; knowledge of these features can assist practitioners in choosing an approach or approaches that are best suited to the client.
Metacognitive and Domain-Specific Strategy Instruction
Metacognitive strategy instruction (MSI) involves helping clients across the lifespan improve their awareness of cognitive processes and use higher order thinking procedures (e.g., self-regulatory strategies, internal problem solving, reasoning strategies) when they encounter novel problems (Barnes et al., 2008; Flook et al., 2015). MSI relies on the holistic analysis skills of the occupational therapy practitioner in understanding the whole person and in helping clients learn strategies to deconstruct their own performance and then modify the way they approach their occupational performance goals. MSI enables clients to generalize the application of these compensatory strategies to novel circumstances (Dawson et al., 2017; Toglia, 2018). Case Examples 1–3 in Appendix A illustrate these approaches.
Domain-specific strategy instruction focuses on teaching clients particular strategies to manage specific perceptual or cognitive deficits. For example, a client may learn to use an internal routine to scan the whole environment to assist with left-sided neglect, a social skills strategy to manage interpersonal interactions, or a mental checklist to identify things to be recorded in a personal digital assistant. Domain-specific strategy instruction can involve technology-based cognitive prosthetics to assist with problems with activity initiation or memory impairment (Fish et al., 2008; Gentry et al., 2008). Case Example 4 in Appendix A illustrates these approaches.
Specific Task or Habit Training
Specific task or habit training assists clients to perform a specific functional behavior (Mastos et al., 2007; Trevena-Peters et al., 2018). In specific task or habit training, the practitioner attempts to circumvent the cognitive deficit that hampers performance by teaching an actual functional task. The intervention is designed to help the client achieve optimal occupational performance by learning a routine so that the cognitive deficits no longer interfere with occupational performance (Clark-Wilson et al., 2014; Giles & Clark-Wilson, 1993; Trevena-Peters et al., 2018). Errorless learning is often used in preference to trial-and-error learning for people with profound cognitive deficits (Haslam & Kessels, 2018). By addressing basic skills, clients may be able to improve self-awareness, mental efficiency, and organization, resulting in continued cognitive improvements (Parish & Oddy, 2007; Trevena-Peters et al., 2018). Case Examples 3–6 in Appendix A illustrate these approaches.
Environmental Modifications
Environmental modifications and simplifications may be a component of all occupational therapy intervention models (AOTA, 2015a). The approach may involve direct engagement with the client, or it may be consultative and indirect, as when the intervention relies on the presence of a care provider (e.g., a parent of a pediatric client or a family or paid care partner of an older adult). For example, occupational therapy practitioners can assist care providers with making task or environmental changes that lower the cognitive demands an activity places on the client. Care providers can be trained to use new ways of interacting with the client; the client is not expected to learn or change, but the task demands, social dynamics, and physical environment are changed to reduce the cognitive complexity of the behavior required for successful performance. This approach is often used in combination with other cognitive intervention approaches; altering demands of the task or environment is a relatively quick and easy way to optimize cognitive performance and decrease care partner burden (Gitlin et al., 2018; Piersol et al., 2017). Case Examples 5 and 6 in Appendix A illustrate these approaches.
Remediation of Specific Cognitive Deficits
Cognitive remediation approaches attempt to improve cognitive performance using paper-and-pencil or computer-based exercises of increasing difficulty that are intended to redevelop the damaged brain systems that support a specific cognitive skill (e.g., attention, memory, problem solving; Sohlberg & Mateer, 1987; Zickefoose et al., 2013). Evidence that these interventions result in improved occupational performance (i.e., that they translate into improvements in ADL or IADL competency) is largely lacking (Galetto & Sacco, 2017; Kumar et al., 2017).
Remediation through repetitive cognitive exercises has resulted in posttreatment improvements on laboratory cognitive or neuropsychological tests and changes in neuronal activity after training (Cicerone et al., 2011; Covey et al., 2018; Kim et al., 2009; Sohlberg & Mateer, 1987, 2011). However, the repetitive practice of cognitive skills, whether using paper and pencil or computer programs, appears to improve only the direct skills that are targeted and not to result in enhanced functional task performance, which is the focus of occupational therapy intervention (AOTA, 2018). Therefore, metacognitive and domain-specific strategy instruction, specific task or habit training, and environmental modifications are more consistent with occupational therapy’s core goal of improving occupational performance than are exercises to improve specific cognitive deficits.
Contributions to the Interprofessional Team
Occupational therapy practitioners are important members of interprofessional rehabilitation teams that work with people who have cognitive impairments associated with mental health and neurological conditions. Within interprofessional teams, occupational therapists can incorporate the findings of neuropsychological testing to inform occupational therapy interventions. As part of interprofessional teams, occupational therapy practitioners bring a distinct focus on occupational performance as both an intervention and an outcome (AOTA, 2014b). Interprofessional programs that address the needs of people with neurocognitive impairments are variously described as comprehensive outpatient programs, postacute rehabilitation, and holistic neurological rehabilitation (Cicerone et al., 2008, 2011; Geurtsen et al., 2010) and often emphasize the integration of cognitive, interpersonal, and functional interventions within a therapeutic milieu (Turner-Stokes et al., 2015).
Occupational therapy practitioners bring to the rehabilitation team an understanding of the interrelatedness of the mind, body, and spirit and of the transactional relationship of client factors, the environment, and occupational performance (AOTA, 2014b). Clients in interprofessional rehabilitation programs have shown increased self-awareness, increased self-efficacy for symptom management, increased perceived quality of life, and increased community integration (Cicerone et al., 2008, 2011; Turner-Stokes et al., 2015). Additionally, occupational therapy practitioners work in other interprofessional settings in which evaluation of functional cognition can contribute to the plan of care or comprehensive evaluation. Such settings may include primary care practices or workplaces that use functional capacity evaluations.
Advancing Future Research and Directions for the Profession
Occupational therapy practitioners use existing and emerging evidence as summarized in systematic reviews (e.g., D’Amico et al., 2018; Gillen et al., 2015; Radomski et al., 2016; Turner-Stokes et al., 2015) and the AOTA Occupational Therapy Practice Guidelines series (see, e.g., Noyes & Lannigan, 2019; Wheeler & Acord-Vira, 2016; Wolf & Nilsen, 2015) to guide their approach to evaluation and intervention. All of the occupational therapy approaches recommended in this statement have (at minimum) case series and proof-of-concept designs showing effectiveness, and some have been found effective in large-scale, multicenter, randomized controlled trials (Baum et al., 2017; McEwen et al., 2015; Trevena-Peters et al., 2018; Vanderploeg et al., 2008).
A general consensus now exists among several payers, including insurance companies and Medicare contractor policy statements, that sufficient information is available to support evidence-based protocols and implementation of empirically supported treatments for disability caused by cognitive impairment after TBI and stroke (Rohling et al., 2009). In addition, there is increasing support from systematic reviews for cognitive interventions that address environmental adaptation for people with Alzheimer’s disease and related major NCDs (Jensen & Padilla, 2017), interventions for caregivers (Piersol et al., 2017), and interventions that directly address the client’s performance skills (Smallfield & Heckenlaible, 2017).
Intervention studies for schizophrenia have tended to be multimodal, potentially obscuring the active component of treatment; however, evidence is most robust when cognitive interventions are strategy based and combined with other rehabilitative interventions such as supported employment (Bowie et al., 2012; Cella et al., 2017; Wykes et al., 2011). Related to multiple sclerosis, evidence is emerging that strategy-based approaches may be effective in improving daily functioning (das Nair et al., 2016; Reilly & Hynes, 2018; Stuifbergen et al., 2012).
Occupational therapy practitioners use an evidence-based approach that relies on teaching strategies, modifying the environment, and training clients in functional activities to help clients optimize performance while accounting for client factors including impaired cognition. Practitioners direct their interventions to occupational performance deficits caused by cognitive impairment, rather than the cognitive impairment in isolation.
AOTA has responded to congressional action and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act (2014; Public Law 113-185) by engaging with the Centers for Medicare & Medicaid Services to advance the importance of screening for functional cognition in acute and postacute settings across diagnostic groups (Giles et al., 2017). Community and primary care are additional settings in which occupational therapy practitioners can use their distinct perspective to support people with cognitive deficits (Gitlin, 2003; Gitlin et al., 2018). Occupational therapy practitioners continue to work to advance the evidence base in these areas. From a more general perspective, evidence supports occupational therapy as the only health care discipline for which increases in hospital expenditure have been shown to reduce hospital recidivism, supporting the need for continued and increased screening for functional cognition (Rogers et al., 2017).
Qualifications of Occupational Therapy Practitioners
Occupational therapy practitioners are well qualified to assess and address cognitive deficits affecting daily activity performance because of their education and training in cognitive functioning, task analysis, learning, and diagnostic conditions and their holistic understanding of the wide range of factors and contexts that affect performance (Accreditation Council for Occupational Therapy Education, 2018). It is the professional and ethical responsibility of occupational therapy practitioners to provide services only within each practitioner’s level of competence and scope of practice (AOTA, 2015b). The Occupational Therapy Code of Ethics (AOTA, 2015b) establishes principles that guide safe and competent professional practice and that must be applied when providing care to clients with cognitive dysfunction. Practitioners should refer to relevant principles from the most current Code of Ethics and comply with state and federal regulatory requirements.
AOTA asserts the importance of cognition to human performance and to the superordinate goals of occupational therapy. Using theoretical models and evidence-supported methods and approaches, occupational therapy practitioners assess and address cognition so that clients may optimally perform the roles and activities that advance their productivity, wellness, and life satisfaction.
Footnotes
1
When the term occupational therapy practitioner is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2015c). Occupational therapists are responsible for all aspects of occupational therapy service delivery and are accountable for the safety and effectiveness of the occupational therapy service delivery process. Occupational therapy assistants deliver occupational therapy services under the supervision of and in partnership with an occupational therapist (AOTA, 2014a).