Performance-Based Assessments of Functional Cognition in Adults,Part 1—Assessment Characteristics: A Systematic Review

Abstract

Importance: Although the construct of functional cognition is central to the practice of occupational therapy, there is no consensus regarding the core characteristics of functional cognitive assessments. Thus, it is necessary to review existing performance-based assessments of functional cognition and describe their characteristics to understand how functional cognition is measured and has been conceptualized.

Objective: To identify performance-based assessments of functional cognition in adults and describe their characteristics.

Data Sources: A literature search was conducted in the MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus databases from inception to February 2022.

Study Selection and Data Collection: We searched for performance-based assessments that involve direct observation of the performance of everyday activities to assess integrated cognitive skills, referred to as functional cognition, in adults. We used a standardized spreadsheet to extract the characteristics of the included assessments (e.g., construct originally targeted, activities and scoring metrics used).

Findings: We identified 25 assessments; most were originally designed for measuring executive functioning. Common instrumental activities of daily living included were cooking and meal preparation, managing finances, using the telephone, and managing medication. Performance time (time taken to complete the task) was frequently used as a scoring metric. Most assessments incorporated observable indicators of functional cognitive abilities (e.g., the task is accurately performed, the task is completed, the task is performed in an efficient and safe way).

Conclusions and Relevance: The findings of this review can guide occupational therapy professionals in better understanding functional cognition by illustrating how it is conceptualized in existing assessments.

Plain-Language Summary: The objective of this review was to identify and examine the characteristics of performance-based assessments that involve direct observation of the performance of everyday activities to assess integrated cognitive skills, referred to as functional cognition, in adults. We identified 25 assessments. Actual or simulated daily activities used as part of the assessments included cooking and meal preparation, managing finances, using the telephone, and managing medications. These activities are all known to be key to independent community living. Performance time and number and types of errors were frequently used as scoring metrics. Most assessments incorporated indicators of functional cognitive abilities, such as the number of completed or failed tasks or whether the tasks were efficiently performed (i.e., the use of effective strategies). These performance-based assessments provide a standardized way to measure the dynamic integration of cognitive abilities during the performance of everyday activities (i.e., functional cognition).

The authors reviewed and describe the characteristics of existing performance-based assessments of functional cognition in adults to understand how functional cognition is conceptualized and measured.

Cognitive ability is a key determinant of healthy aging (Behr et al., 2023; Sánchez-Izquierdo & Fernández-Ballesteros, 2021) because it plays a major role in the performance of everyday activities (Gracia-García et al., 2021). Occupational therapy professionals have recognized the importance of using performance-based assessments to understand the dynamic integration of cognitive and performance skills in real-life-like contexts (American Occupational Therapy Association, 2019; Giles et al., 2017, 2020; Skidmore, 2017). To emphasize this dynamic integration of cognitive and performance skills, occupational therapy professionals have introduced the concept of functional cognition. The American Occupational Therapy Association (AOTA; 2019) defines functional cognition as “how people use and integrate their thinking and processing skills to accomplish everyday activities in clinical and community living settings” (p. 2). Similarly, Wesson et al. (2016) define functional cognition as “the observable performance of everyday activities resulting from a dynamic interaction between motor abilities, activity demands, and the task environment, guided by cognitive abilities” (p. 336). Although a consensus definition of functional cognition has not yet been reached, existing definitions emphasize that assessments of functional cognition aim to measure an individual’s integrated cognitive skills in performing everyday activities, considering the interplay among the demands of the activity and personal and environmental factors (Giles et al., 2024; Wesson & Giles, 2019). Performance-based assessments enable the observation and evaluation of integrated cognitive skills during the execution of everyday activities in naturalistic or real-life contexts and therefore serve as the most effective means of measuring functional cognition (Skidmore, 2017).

Neuropsychological tests are a traditional method for measuring cognitive ability and are designed to characterize discrete cognitive skills—such as attention, memory, and executive function—typically using pen-and-paper or computerized tasks in controlled environments (Burgess et al., 2006). Neuropsychological tests, combined with neuroimaging techniques, have been used to identify associations between cognitive skills and specific brain regions (Burgess et al., 2006; Nowrangi et al., 2014). In addition, comparisons with normative scores derived from healthy individuals’ neuropsychological test results can be used to indicate whether an individual’s discrete cognitive skills are impaired (Agelink van Rentergem et al., 2018). However, neuropsychological tests have long been criticized for their lack of ecological validity (Brunswik, 1955; Chaytor & Schmitter-Edgecombe, 2003; Manchester et al., 2004; Neisser, 1976; Sbordone, 1996).

Ecological validity consists of two primary aspects: representativeness and generalizability (Burgess et al., 2006; Kvavilashvili & Ellis, 2004). Representativeness refers to the extent to which an assessment corresponds to real-world situations encountered outside the laboratory (Burgess et al., 2006; Kvavilashvili & Ellis, 2004). Generalizability indicates the extent to which performance on an assessment can predict everyday functioning in real-world environments outside the laboratory (Kvavilashvili & Ellis, 2004; Morrison et al., 2015). In other words, ecological validity represents functional and predictive relationships between performance on assessments and behavior in real-world environments (Sbordone & Purisch, 1996). Previous meta-analyses have demonstrated weak to moderate correlations between neuropsychological tests of discrete cognitive skills and basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs) across diagnoses including Alzheimer’s disease (Martyr & Clare, 2012) and mild cognitive impairment (Berezuk et al., 2021; McAlister et al., 2016). The findings of these meta-analyses indicate that neuropsychological tests may not fully represent real-world functioning, including ADLs and IADLs (i.e., the tests exhibit limited ecological validity). As a result, scientists, including occupational therapy professionals, have recognized the importance of observing the performance of everyday activities in real-world situations to overcome neuropsychological tests’ lack of ecological validity (Sbordone & Purisch, 1996; Silverberg & Millis, 2009; Wilson, 1993).

Performance-based assessments better reflect real-world functions that are influenced by dynamic interactions among cognitive ability, activity demands, and environmental factors (Parsons, 2015; Skidmore, 2017). In other words, neuropsychological tests and performance-based assessments of functional cognition may play different roles in evaluating cognitive ability. On the one hand, neuropsychological tests can provide information at the impairment level (Chan et al., 2008), which refers to the disorder within the person (World Health Organization [WHO], 1980). On the other hand, performance-based assessments of functional cognition may be better suited to detecting functional cognitive difficulties experienced in real-life situations (Chan et al., 2008), aligning with the concepts of activity and participation in the International Classification of Functioning, Disability and Health (WHO, 2001).

However, despite the importance of functional cognition in occupational therapy, recent international surveys of occupational therapy practitioners have reported that available, standardized performance-based assessments of functional cognition are not widely implemented in practice (Goodchild et al., 2023; Manee et al., 2020; Stigen et al., 2018; Ward et al., 2024). Instead, nonstandardized observations of daily activities are the most common method of evaluating functional cognition (Goodchild et al., 2023; Manee et al., 2020; Stigen et al., 2018; Ward et al., 2024). To demonstrate the centrality of functional cognition to the ability to perform occupations, it is incumbent on occupational therapy professionals to document functional cognitive skills with the best-available standardized performance-based assessments. Previous reviews have attempted to investigate existing performance-based assessments of functional cognition (Belchior et al., 2015; Lewis et al., 2011; Poncet et al., 2017; Poulin et al., 2013; Romero-Ayuso et al., 2021; Wesson et al., 2016). However, most of these studies do not include relevant recent literature (Belchior et al., 2015; Chan et al., 2008; Lewis et al., 2011; Poulin et al., 2013). Although a recent review published in 2021 did include literature up to May 2019 (Romero-Ayuso et al., 2021), its primary focus was on exploring types of activities and technologies, such as virtual reality–based instruments, rather than on understanding how functional cognition is conceptualized in the existing assessments (Romero-Ayuso et al., 2021).

Because there are no agreed-upon criteria or component processes for measuring functional cognition, it is essential to understand how functional cognition is conceptualized in the existing assessments. Therefore, our objective was to identify and describe the characteristics of performance-based assessments of functional cognition designed for and used with adults in order to better understand how functional cognition is conceptualized. These characteristics include everyday activities used in the assessments, scoring metrics, and observable indicators of functional cognitive abilities. The findings of this systematic review will provide an enhanced conceptualization of functional cognition, enriching the identification of gaps in science of functional cognition to inform areas in which more research is needed. Moreover, improved knowledge in this area will prepare occupational therapy practitioners to apply standardized functional cognitive assessments in their practice.

Method

This review adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the protocol was preregistered in PROSPERO (CRD42022321918).

Search Strategy

We collaborated with a medical librarian to develop search terms for our study, using a combination of keywords and standardized terms. We focused on four key filters: cognition, assessment, activities of daily living and performance, and adult. These filters were selected on the basis of a previous review (Wesson et al., 2016). We used the modified search terms in each database to ensure optimal search results. We did not include the search term functional cognition because this conceptualization has often been applied retrospectively to previously existing assessments. In other words, it is possible that, for some assessments, application of the term functional cognition may represent a reconceptualization of the purpose of an assessment originally designed to measure other cognitive constructs (e.g., executive functions). With this in mind, we constructed broad search filters with combinations of the four key search terms, excluding functional cognition, for a comprehensive search. Additionally, functional cognition is not a controlled vocabulary term used in the databases. Thus, in the four key search filters, we included cognition, which is a controlled vocabulary term used across databases, to ensure our search covered any articles that explicitly mentioned functional cognition, because the term functional cognition itself includes cognition. Our systematic literature search was conducted from the inception of each respective database until February 2022. We searched the following databases: MEDLINE (n = 8,840), Embase (n = 10,376), CINAHL (n = 3,704), PsycINFO (n = 1,798), Web of Science (n = 295), and Scopus (n = 8,325). We also included 13 additional articles retrieved via manual searching. We exported a total of 33,351 results to EndNote and removed 13,620 duplicates, yielding 19,731 unique citations. To ensure comprehensive coverage, we conducted forward and backward manual searches of relevant previous reviews and examined the reference lists of all included studies (Figure 1).

Figure 1.

Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram for the identification of performance-based assessments of functional cognition for adults.

Eligibility Criteria and Selection of Assessments

To refine our definition of performance-based assessments of functional cognition, we revised the definitions used in previous reviews (Robertson & Schmitter-Edgecombe, 2017; Wesson et al., 2016). We defined performance-based assessments of functional cognition as those that involve direct observation of an individual’s performance in everyday activities using simulated items (e.g., a calendar in the Weekly Calendar Planning Activity [WCPA]) or naturalistic items within simulated (e.g., a simulated kitchen in the Executive Functional Performance Test [EFPT]) or real-world environmental settings. We included studies that met the following criteria: (1) used standardized performance-based assessments of functional cognition, (2) included participants ages 18 yr or older, (3) involved original research, and (4) were published in peer-reviewed journals and written in English. We excluded assessments that met any of the following criteria:

▪ assessments that involved direct observation of everyday activity but were not specifically designed to measure cognitive ability because they lack a standardized scoring system for functional cognition; rather, they are focused on evaluating occupational performance (e.g., Performance Assessment of Self-Care Skills; Holm & Rogers, 2024)

▪ self-report or informant-report assessments

▪ assessments that use virtual reality, computer-based assessment tools (apart from everyday activities that use the internet, such as online purchases), simulators, or hypothetical situations or real-life scenarios that lack actual performance of everyday activities

▪ assessments that focus only on isolated cognitive tasks that are not embedded in everyday activities, such as calculations or memory recall tasks.

Additionally, we excluded the following: book chapters, case studies, review articles, editorials, and gray literature, including dissertations, conference and poster proceedings, and unpublished literature. We excluded the Assessment of Motor and Process Skills (Fisher, 1995) because its scoring software was discontinued in March 2023.

To ensure consistency and accuracy, two reviewers (Moon Young Kim and Samantha B. Randolph) independently screened all titles and abstracts and conducted full-text screening to identify eligible assessments. Any discrepancies between the two reviewers were resolved through discussions involving a third reviewer (Yejin Lee) and the other coauthors.

Data Extraction

We developed a spreadsheet to extract the data relevant to the characteristics of the included assessments (e.g., discipline, population, originally targeted constructs, activities used, scoring metrics, and functional cognitive indicators). These characteristics were extracted to understand how functional cognition is conceptualized in each assessment. For the originally targeted constructs, we extracted the exact terminologies that developers used to show the varied constructs that the assessment was originally targeted to measure. In addition, for the theories and tools, we extracted any theories, models, and assessment tools used to develop each assessment. In particular, we extracted functional cognitive indicators, which refer to observable behaviors classified in each assessment’s scoring system, to understand how they have been incorporated into each assessment to measure functional cognition. Data from eligible assessments were extracted by two reviewers (Kim and Randolph), and discrepancies were resolved via discussions with the other coauthors.

Results

Identification of the Assessments

After screening, 109 studies met the inclusion and exclusion criteria. From these 109 studies, we identified 25 unique assessments (Figure 1; see the Supplemental Material, available online with this article at https://research.aota.org/ajot).

Characteristics of the Included Assessments

The characteristics of the assessments evaluated in the included studies are presented in Table A.1 in the Supplemental Material.

Originally Targeted Constructs of the Included Assessments

Of the 25 assessments, 12 were developed to assess a single cognitive construct (e.g., executive functioning); in contrast, 13 were designed to assess multifaceted cognitive processes (e.g., multitasking). The most commonly reported targeted constructs were executive functioning (n = 17) and multitasking (n = 7). In addition, assessments were developed to measure functional cognition (n = 3), cognitive performance (n = 2), basic and higher-level cognitive processes (n = 1), everyday action (n = 1), and everyday functional abilities (n = 1).

Disciplines That Developed the Included Assessments

Of the 25 assessments included, 8 were developed through interdisciplinary collaborations. The disciplines most frequently involved were occupational therapy (n = 11) and psychology (n = 10).

Theories, Models, and Other Assessments Used in Development

Some of the included assessments were designed with specific cognitive constructs in mind; however, others were designed with varied classification systems for measuring errors committed during activity performance.

Theories and models used in the development of the assessments were therefore grouped into two categories: (1) theoretical rationales for defining the constructs, such as multitasking (Burgess, 2000; Shallice & Burgess, 1991), problem-solving (Levin et al., 1991), executive function (Lezak et al., 2012), and everyday competence (Diehl, 1998; Willis, 1991) and (2) theoretical rationales for classifying errors (Chevignard et al., 2000; De Renzi & Lucchelli, 1988; Roll et al., 2019; Schwartz et al., 1998).

Of the 25 assessments, 12 were based on the characteristics of multitasking outlined by Shallice and Burgess (Burgess, 2000; Shallice & Burgess, 1991). These 12 assessments are specifically designed to enable test takers to create their own plans for task performance and goal achievement, effectively interleave tasks, and adhere to predetermined rules. Four assessments used individual theoretical rationales in defining their originally targeted constructs: identified theoretical foundations included problem-solving and learning theories (Levin et al., 1991), executive function conceptual domains (Lezak et al., 2012), the model of everyday competence (Diehl, 1998), and the dynamic interaction model of cognition (Toglia, 1991, 2011; Toglia & Kirk, 2000).

Three classification systems were used in the development of assessments that determined scores on the basis of errors. These included (1) omission, misuse, mislocation, and sequence errors, as proposed by De Renzi and Lucchelli (1988); (2) the omission and commission model suggested by Roll et al. (2019); and (3) the error classification proposed by Chevignard et al. (2000) and Schwartz et al. (1998). Table A.2 in the Supplemental Material provides detailed explanations of a combined classification of errors derived from previous studies (Baum et al., 2008; Chevignard et al., 2008; Glonnegger et al., 2016; Goverover & Deluca, 2018; Lamberts et al., 2010; Schwartz et al., 1998; Scott et al., 2011; Semkovska et al., 2002).

Activities Used

Table A.3 in the Supplemental Material provides details on the activities performed in each assessment. The activities used in the included assessments can be categorized into three groups: (1) ADLs or IADLs; (2) special occupations, encompassing Charge of Quarters duty tasks, work-related tasks, secretarial tasks, and hotel front desk duties; and (3) scenario-based tasks involving actual performance of multiple subactivities in hypothetical situations, such as planning a day or night out and purchasing items.

Twelve assessments include multiple activities, whereas 13 include a single activity. The most commonly used activity was cooking or meal preparation (n = 12), followed by managing finances (n = 10), using the telephone and communication (n = 7), and managing medication (n = 6). Additionally, 3 assessments incorporated ADLs, and another 3 assessments used planning activities.

The assessments that used cooking and meal preparation tasks involved various recipes. The assessments involving medication can be divided into two categories: taking medication and managing medication. Three assessments involving taking medication require test takers to take medications at the correct dosage, at a specific time, or both, whereas other assessments of managing medication included tasks such as pill dispensing using a pillbox.

Of the 10 assessments including finance-related tasks, 6 incorporated shopping activities such as purchasing items, 3 involved paying bills and balancing a checkbook, and 1 focused on calculating current fines and replacement costs for overdue books and videos. Among the 7 assessments with telephone use tasks, 6 evaluated communication abilities, such as asking for needed information, whereas 1 solely involved looking for telephone numbers.

Of the 25 assessments, most were developed with a physical set-up that mimicked real-world environments but were conducted in clinical or laboratory settings. However, 4 assessments were specifically designed for performance in real-world environments, including participants’ home kitchen (n = 2), a campus apartment (n = 1), and a shopping center, hospital, or facility (n = 1).

Scoring Metrics

Table A.1 provides details on the scoring metrics used in the included assessments. Among the included assessments, 19 used multiple scoring metrics, and 6 used a single scoring metric. The most frequently used scoring metric was performance time (time taken to complete the task; n = 14), followed by accuracy in performing tasks (n = 10); number and type of errors (n = 9; refer to Table A.2), number of tasks completed, failed, or attempted (n = 9); efficiency of task performance (how efficiently tasks were performed, e.g., better efficiency indicates higher accuracy in less time in the WCPA; n = 8); failure to comply with predetermined rules (n = 5); and level of assistance or cues required, such as verbal cues or physical help (n = 4). Other scoring metrics were also used in specific assessments, including the Allen Cognitive Level assigned (n = 1), the Cognitive Performance Test profile (n = 1), and the failure to correctly interpret instructions (n = 2).

Observable Indicators of Functional Cognitive Abilities

The majority of assessments (n = 22) included functional cognitive indicators as part of their scoring metrics that reflected observable behaviors caused by cognitive dysfunction during the performance of everyday activities. The most frequent functional cognitive indicators were judgment, problem-solving, and efficiency, followed by accuracy and completion. Table A.4 provides more details on observable functional cognitive indicators incorporated into the included assessments.

Discussion

This systematic review reports the characteristics of performance-based assessments of functional cognition. We identified a total of 25 assessments that varied in their originally targeted constructs, activity demands, scoring metrics, and measurement of observable functional cognitive indicators.

Originally Targeted Constructs of Assessments

The assessments included in this review were originally developed to measure various targeted constructs, such as executive function, multitasking, cognitive performance, basic and higher-level cognitive processes, everyday action, and everyday functional abilities. Although not explicitly described by their authors, the common goal of these assessments is to measure the successful integration of cognitive abilities during the performance of everyday activities. Therefore, we propose that the term functional cognition may better reflect the construct measured by the performance-based assessments included in this study. Although there is no gold-standard definition of functional cognition, most existing definitions consistently refer to the ability to dynamically integrate cognitive abilities to perform everyday activities (AOTA, 2019; Baum et al., 2023; Giles et al., 2017, 2024; Wesson et al., 2016; Wesson & Giles, 2019). Using factor analysis and a large sample size (N = 493), Baum et al. (2023) have supported the unique contribution of functional cognition by proposing that it is a construct distinct from fluid and crystallized cognition. To further develop this concept, we encourage future work to include conceptual analyses to better define the spectrum of functional cognitive tasks and strengthen the evidence regarding the construct of functional cognition.

Activity Demands Used in Assessments

The assessments included in this review used a wide range of cognitively demanding everyday activities with varied levels of complexity. Previous work suggested using performance-based assessments of functional cognition in an ordered manner on the basis of the cognitive demand of their activities: ADL measures (e.g., the FIM^®), IADL measures (e.g., the EFPT), and then novel tasks performed in real-world environments that require higher-order executive functioning (e.g., the Multiple Errands Test; Morrison et al., 2015). This order reflects a general increase in complexity of activities on the basis of their characteristics, with IADLs and novel tasks demanding more cognitive effort than ADL tasks (Morrison et al., 2015). We noted that the included assessments used multiple activity domains, such as ADLs, cooking and meal preparation, managing medication, managing finances, using the telephone and communication, and planning travel or appointments. Indeed, these different domains of activity are likely to involve varying levels of complexity and cognitive effort, because more novel tasks generally require greater cognitive effort. However, it is crucial to note that, although the assessments incorporate similar types of activities within the same domain, the demands of these activities can still vary across assessments because of different characteristics of the activities. For example, although 12 assessments use cooking and meal preparation activities, their activities are heterogeneous, ranging from simple cooking (e.g., making coffee) to more complex cooking (e.g., baking a cake and cooking an omelet). Thus, the complexity of activities should be carefully considered when selecting appropriate assessments for occupational therapy clients or research purposes.

In addition, to more effectively determine and order the complexity of activities used in performance-based assessments of functional cognition, it is essential to understand other factors that influence the cognitive demands of these activities, beyond activity characteristics. These other factors include personal factors (e.g., a person’s functional ability, previous experiences, habits, routines) and environmental factors (e.g., familiarity with the environment). As an example of an environmental factor, we identified four assessments that are designed to be administered in real-world environments (i.e., outside of clinical laboratory settings). The assessments conducted in familiar real-world environments (e.g., clients’ homes) can potentially enhance test-takers’ comfort and the assessments’ generalizability. However, it is also important for test administrators to be aware of potential distractions that can arise in these environments, such as interruptions from family members or multiple conversations in background noise. Therefore, when selecting the appropriate assessment to evaluate clients’ abilities or for research purposes, occupational therapy practitioners and scientists should consider personal and environmental factors in addition to activity characteristics to determine the most suitable assessment for their use.

Role of Scoring Metrics

The assessments included in this review used multiple scoring metrics, including performance time, errors, accuracy, task completion and failures, efficiency, rule breaks, level of assistance or cues required, number of tasks attempted, and goal maintenance. The most frequently used scoring metric was performance time. Although a few assessments had a time restriction to complete the activities, for others, the time taken to perform the activities is recorded without penalizing slow performance. Performance time may serve as an indicator of the influence of processing speed on performance of activities (Wesson & Giles, 2019). However, delayed performance time may also be caused by other multiple cognitive issues, such as the inappropriate use of strategies (e.g., using a one-quarter-cup measuring cup four times for 1 cup of water instead of using a 1-cup measuring cup), not solely processing speed. In addition, how diagnosis, aging, education, and other factors influence performance time is not currently understood. Therefore, with each assessment, the interpretation of performance time should be approached with caution to best understand how time taken should be interpreted and whether cutoff scores are indicated.

Moreover, developers of the Multiple Object Test proposed categorizing the scoring metrics as quantitative indicators (e.g., total number of errors and time) and qualitative indicators (error types) of cognitive ability (Glonnegger et al., 2016). On the one hand, scoring metrics may provide quantitative information, such as task performance time, number of task completions and failures, and task accuracy (e.g., number of tasks correctly performed), that may be more appropriate for screening purposes, because these indicators may provide quick quantitative data that offer diagnostic utility for highlighting potential functional cognitive deficits (Glonnegger et al., 2016). On the other hand, qualitative metrics, such as error type, efficiency, rule breaks, and types of cues needed to perform successfully, may provide a deeper understanding of how cognitive dysfunction influences task performance (Belchior et al., 2015). Thus, measures of performance quality can be effectively used in designing and planning interventions by revealing the underlying functional cognitive processes that either facilitate or compromise task performance. In particular, assessments that use the level of support required as a scoring metric (e.g., EFPT, Kettle Test, Kitchen Task Assessment), mostly developed by occupational therapy professionals, can assist in clinical decision-making by determining the amount and type of assistance individuals need to perform everyday activities (Hartman-Maeir et al., 2009; Wesson & Giles, 2019), which is known as the dynamic–interactive assessment approach (Wesson & Giles, 2019). It is distinguished from the categorical approach, which counts the number of correctly performed activities or the number of errors occurring during the performance of everyday activities (Wesson & Giles, 2019). The dynamic– interactive assessment approach could be a unique contribution of the assessments developed by occupational therapy professionals to measure what individuals can do to perform everyday activities and maximize their independence in everyday life.

Observable Indicators of Functional Cognitive Abilities

In addition to scoring metrics, 25 assessments incorporated functional cognitive indicators that can be observed via behaviors and “doing” during the performance of everyday activities. These indicators include self-awareness and monitoring; initiation, accuracy and completion; organization; planning; judgment, problem-solving, and efficiency (e.g., strategy use); sequencing; rule breaks; and more (Table A.4). These observable indicators are supported by the dynamic integration of cognitive processes, executive functions, cognitive skills, and metacognition (Toglia & Foster, 2021; Wesson & Giles, 2019). In other words, these indicators may demonstrate functional cognitive abilities that support or limit the performance of everyday activities. Thus, occupational therapy practitioners can observe these indicators to evaluate functional cognitive abilities during the performance of everyday activities.

Existing studies have shown that functional cognitive indicators may have insignificant or significant relationships with discrete cognitive skills measured with neuropsychological tests (Baum et al., 2017; Baum & Edwards, 1993; Fazeli et al., 2017; Hendry et al., 2016; Jarry et al., 2021; Kim et al., 2017; Radomski et al., 2018; Rojo-Mota et al., 2021; Scott et al., 2011; Semkovska et al., 2002). When they are related, the correlations are only in the weak to moderate range (Hendry et al., 2016; Rojo-Mota et al., 2021; Scott et al., 2011). For instance, previous studies found that poorer attention, memory, and executive functions had weak to moderate correlations with omission errors, whereas there were no significant relationships with addition or repetition errors (Hendry et al., 2016; Scott et al., 2011). Similarly, executive functions measured using the Five Digit Test showed significant moderate relationships with the EFPT’s sequencing domain but not with its initiation, organization, judgment and safety, and completion subdomains (Rojo-Mota et al., 2021). These findings support those of previous studies that show that discrete cognitive skills measured using neuropsychological tests may not directly relate to integrated use of cognitive skills in the performance of everyday activities (Berezuk et al., 2021; Martyr & Clare, 2012). Therefore, it is important to use performance-based assessments of functional cognition, which incorporate functional cognitive indicators, to assess how cognitive functions are dynamically integrated during the performance of everyday activities. However, although these previous findings support the need for functional cognition to understand the integrated cognitive skills to perform everyday activities, further studies are needed to effectively use these indicators in occupational therapy practice. For example, future research is required to determine whether all these indicators are necessary, whether a hierarchical approach to these indicators is appropriate, or whether some indicators may be more effective than others in distinguishing functional cognitive deficits in adults.

Limitations

We were unable to compare our findings with those of previous reviews because of the heterogeneity of the included assessments, resulting from different inclusion and exclusion criteria. Specifically, previous studies included performance-based assessments that incorporated everyday activities (e.g., IADLs), even though these assessments were not originally designed to measure cognitive ability (e.g., Performance Assessment of Self-Care Skills). Although everyday activities such as IADLs can be cognitively demanding and serve as valuable resources for understanding functional cognitive abilities, we excluded them in this review because of insufficient evidence regarding the extent of their cognitive demands. Specifically, these assessments do not provide standardized scoring metrics for measuring functional cognition, mostly relying instead on measuring independence in occupational performance as a scoring metric (i.e., occupational performance measures). Although we did not include measures of occupational performance per se in this review, this does not eliminate the possibility of using them as functional cognitive assessments. However, we recommend that future studies provide scaling or scoring systems for how functional cognition is measured and specify the observations needed to assess functional cognition with these assessments.

Moreover, the focus of this study was to describe how functional cognition is conceptualized in the existing performance-based assessments of functional cognition. Thus, we have left clinical utility—including the availability of technology and manuals—and the influence of population characteristics, such as diagnosis and gender, out of the scope of this review. We suggest future reviews address the clinical utility of performance-based assessments of functional cognition to guide occupational therapy practitioners to use appropriate assessments for their practice, specifically according to diagnoses.

Last, although we provided activities, scoring metrics, and observable indicators of functional cognition to illustrate how functional cognition is conceptualized in the included assessments, future studies should determine agreed-upon essential characteristics of functional cognitive assessments. For example, future studies may need to discuss how comprehensively functional cognitive indicators should be included in functional cognition assessments, whether these indicators have hierarchical structures, and whether there are patterns of deficits in functional cognitive indicators across diagnoses or severities of cognitive impairments.

Implications for Occupational Therapy Practice

Most assessments that occupational therapy practitioners have used to measure cognitive ability in their clinical practice—regardless of their focus on discrete cognitive skills or functional cognition—have been either nonstandardized assessments or assessments of general ADL ability (Goodchild et al., 2023; Manee et al., 2020; Stigen et al., 2018; Ward et al., 2024). Therefore, there is a need to investigate systematic ways to measure cognitive skills that occur during the performance of everyday activities. We suggest that the concept of functional cognition can be useful to address this need because it provides a framework for understanding the dynamic integration of cognitive skills during the performance of everyday activities in the real world. We have described everyday activities, scoring metrics, and observable functional cognitive indicators that have been used in the existing assessments of functional cognition. This information can be useful for occupational therapy practitioners to better understand how functional cognition is measured and conceptualized in the existing assessments, thereby enhancing the applicability of functional cognition in occupational therapy practice.

Conclusion

The core of functional cognition includes the dynamic integration of cognitive and performance skills in the context of everyday activities. Performance-based assessments using everyday activities are an effective approach to measuring functional cognition in adults. We identified cooking and meal preparation as the activity most commonly used in the performance-based assessments of functional cognition. Moreover, performance time was the scoring metric most frequently incorporated in the included assessments. Functional cognition can manifest as observable functional cognitive indicators that represent difficulties in functional cognition (e.g., errors in initiation, organization, sequencing, rule breaking, inefficiency, and delayed performance) or that support functional cognition (e.g., appropriate use of strategies or self-regulation). Occupational therapy practitioners can use these indicators to better evaluate functional cognitive abilities during the performance of everyday activities. Moreover, because functional cognition can be influenced by personal factors, activity characteristics, and environmental factors, the complexity and difficulty of the performance of everyday activities can vary across the assessments. Thus, practitioners are encouraged to understand the client’s goals and occupational profile to better measure functional cognition by using the assessments identified in this review.

Supplemental Material

Supplemental Information

Supplementary material for Performance-Based Assessments of Functional Cognition in Adults, Part 1—Assessment Characteristics: A Systematic Review

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2025.050948.pdf for Performance-Based Assessments of Functional Cognition in Adults, Part 1—Assessment Characteristics: A Systematic Review by Yejin Lee, Samantha B. Randolph, Moon Young Kim, Erin R. Foster, Jessica Kersey, Carolyn Baum and Lisa Tabor Connor in The American Journal of Occupational Therapy

Footnotes

*

Indicates studies included in the systematic review.

Acknowledgments

We appreciate the librarian who helped create search terms. We are thankful to the institution for providing technical support.

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