Date Presented 04/05/19
A retrospective analysis of OT evaluations completed by individuals experiencing homelessness identified the frequency of cognitive impairment and determined the predictive ability of cognitive ability on functional performance using standardized assessments. The study results indicate there is a high prevalence of cognitive impairment among individuals experiencing homelessness; however, that cognitive impairment was not predictive of performance on functional assessments.
Primary Author and Speaker: Caitlin Synovec
PURPOSE: There is limited evidence regarding the cognitive and functional abilities of adults experiencing homelessness. Existing evidence indicates individuals are at a higher risk of cognitive impairment, however, evidence regarding functional abilities is inconclusive and often based on neuropsychological testing (Depp, Vella, Orff, & Twamley, 2015; Raphael-Greenfield, 2012). This study examined the cognitive and functional performance of individuals experiencing homelessness who completed occupational therapy evaluations within a Federally Qualified Health Center [FQHC] to identify patterns of cognitive performance, and the predictive ability of cognitive assessments on functional performance.
METHOD: A descriptive study was used to retrospectively examine client performance on cognitive and functional assessments, using the agency’s electronic medical record system. Functional assessments include the Executive Function Performance Test [EFPT] and/or the Assessment of Motor and Process Skills [AMPS]; cognitive screenings include the Allen Cognitive Level Screen v. 5 [ACLS-5] and/or the Montreal Cognitive Assessment [MoCA] (Allen et al., 2007; Baum et al., 2008; Fisher & Bray, 2010; Nasreddine et al., 2005). This study was approved by a university Institutional Review Board.
INCLUSION CRITERIA: 1) Clients who completed occupational therapy evaluations inclusive of one standardized functional assessment [EFPT, AMPS] and one standardized cognitive screening [ACLS-5, MoCA]; 2) over the age of 18; 3) able to independently consent for services; and 4) referred by a provider at the FQHC for occupational therapy evaluation. Clients’ housing status included: homeless, unstably housed, or living in an apartment through a permanent supportive housing program.
Individuals were grouped into cognitive categories based on their performance on the MoCA or ACLS-5. Cut-off scores for level of cognitive ability were determined by guidelines of the assessment manuals and literature review. The cognitive groups’ performance on the functional assessments were compared using t-tests. ANOVA analysis was used to determine the ability of the ACLS-5 or MoCA to predict functional performance as measured by the EFPT. Chi square analysis was used to determine the predictive ability of the ACLS-5 or MoCA for functional performance as measured by the AMPS.
RESULTS: Data analysis revealed that although individuals who were grouped into “severe cognitive impairment” by either the MoCA or the ACLS-5 were more likely to perform worse on the EFPT or the AMPS, the difference on performance between the cognitive impairment groups on either of the functional assessments was not found to be statistically significant. Additionally, correlation analysis indicated the overall performance and scores of the cognitive groups were not predictive of functional performance for any of the assessments used.
CONCLUSION: The results of this study support recent findings that cognitive screening tools are not sensitive enough to predict functional performance, especially for those with mild cognitive impairment. This study also demonstrates that despite a high prevalence of cognitive impairment among individuals experiencing homelessness, there is a varied range of functional abilities. The
IMPLICATIONS: 1) The need to screen for cognitive impairment among individuals experiencing homelessness. 2) The need to complete functional assessments to determine individual functional performance and abilities. 3) The importance of integrating occupational therapy services into FQHC settings serving adults experiencing homelessness, as the ability to assess for cognitive and functional skills is a unique contribution that can enhance overall client health outcomes.
References
Allen, C. K., Austin, S. L., David, S. K., Earhart, C. A., McCraith, D. B,. & Riska-Williams, L. (2007). Manual for the Allen Cognitive Level Screen-5 (ACLS-5) and Large Allen Cognitive Level Screen-5 (LACLS-5). Camarillo, CA: ACLS and LACLS Committee.
Baum, C. M., Connor, L. T., Morrison, T., Hahn, M., Dromerick, A. W., & Edwards, D. F. (2008). Reliability, validity, and clinical utility of the Executive Function Performance Test: A measure of executive function in a sample of people with stroke. American Journal of Occupational Therapy, 62, 446-55.
Fisher, A. G., & Bray Jones, K. (2010). Assessment of Motor and Process Skills. Vol. 1: Development, standardization, and administration manual (7th ed.) Fort Collins, CO: Three Star Press.
Nasreddine Z. S., Phillips N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., … Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatric Society, 53, 695-699. DOI:10.1111/j.1532-5415.2005.53221.x
