assessing cognitive and functional skills in older adults
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Assessment of Cognitive and Functional Skills of Older Adult PPT presentationTRANSCRIPT
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C. Munro Cullum, PhD, ABPPKathleen Saine, PhD
The University of Texas Southwestern Medical Center at Dallas
Pearson Webinar 5-8-2012
ADLs = basic self care tasks (eg, dressing, feeding, transfers, mobility, toileting)
IADLs = Higher-level tasks that require coordination of skills (eg, housework, managing finances, shopping, using communication devices, transportation, care of pets/others, health management, meal preparation)IADLs are necessary for independent living and a breakdown in IADLs may be first sign of dementia
• Enhanced understanding of impact of cognitive impairment on daily fx
• Literature suggests relationships between IADL measures and behavior/ability
• IADL dysfunction may predict:• Dementia• Institutionalization• Death
• How best to measure IADLs?
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How to assessWhat to assessNeuropsych & practical relevanceHow to select / construct itemsScoring & psychometric issuesBreadth vs depth vs time to administerwithin the context of neuropsych eval
Rating scale vs performance-basedTarget populationPurpose of examination (dx, rx, placement, feedback; clinical / research)Psychometric properties (norms, etc)Ease of administration/scoringPortabilityAdministration time
Lawton & Brody IADL Scale (1969)Functional Activities Questionnaire (FAQ; 1982)Disability Assessment for Dementia (1999)Alzheimer Disease Cooperative Study (ADCS) Activities of Daily Living Inventory (1997)Everyday Cognition (Ecog; 2008)
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• Ratings vs performance-based tasks• Potential Issues with rating scales
• Raters (self or other) may be unaware• Lack of familiarity with pt’s abilities• Potential rating bias ( + or - ) • Potential influence of mood/situational effects• How to validly measure without adding much
time to evaluations?
• Ratings may lack objectivity
Direct observation/rating of behaviors (e.g. see Schmitter-Edgecombe et al, 2011)
Questions involving everyday problemsEveryday Problems Test (Willis & Marsiske, 1993)
Behavioral simulation tasks
Direct Assessment of Functional Status (DAFS; Loewenstein et al, 1989)
Independent Living Scales (ILS; Loeb, 1996)
UCSD Performance-based Skills Assessment(UPSA; Patterson et al, 2001; Gomar et al, 2011)
Texas Functional Living Scale (TFLS; Cullum, Saine & Weiner, 2009) [formerly the Test of Everyday Functional Abilities (TEFA)]
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Independent Living Scales (ILS; Loeb, 1986)• Widely used; 68 items, Five domains:
• Memory/Orientation• Managing Money• Managing Home and Transportation• Health and Safety• Social Adjustment
Administration time: 45 minutes (+ 10 min. scoring)
UPSA (Patterson et al., 2001)• Developed in psychiatric populations• Five Domains:
• Household Chores• Communication• Finance• Transportation• Planning Recreational Activities
Administration time: 45 minutes* (+ 10 to 15 min. scoring)
TFLS (Cullum, Saine & Weiner, 2009)• Developed for use in dementia• Four domains:
• Time• Money / Calculation• Communication• Memory
Administration time: 15-20 minutes (+ 5 min. scoring)
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ILS – Long history, widely used UPSA – More recent, developed in psychiatric populations but recently applied to MCI and dementiaTFLS – Designed for dementia, with brevity and cognitive loading in mind
Reviewed literature on performance-based and other-rated IADL measuresIdentified types of tasks that met TFLS development criteriaSought simple items with face validity while avoiding ceiling effectsPiloted various tasks in pts with dementia
Performance-basedCognitively-orientedUseful in dementiaGood psychometric propertiesPortableEasy to administerBRIEF
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Adjunct with neuropsych evaluationSupplement dx information, clarify NP
Treatment planningProviding feedback to pts & familiesCharting disease progressionResponse to treatment
Selected by Pearson as a brief IADL measure for WAIS4/WMS4 standardization
N = 800 stratified based on U.S. census
Clinical sample of 212 mixed SsAssisted living, Caregiver-supported, AD, Intellectual disability (mild & moderate), TBI, Schiz, Depression, Autism
Cumulative percentages for subscalesSkewed due to nature of items, so could not use scaled scores
Overall total T-score • 50 total raw score points possible
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Pearson, 2009
TimeCalendar use:
Identifying day of weekFinding dates
Clock drawing Time reading
Subtotal = 9 point maximum
Money & CalculationAdding money (2q, 2d, 3n; 4q, 2n, 3p)Figuring money (take $1.73 out of bag)Making change
Subtotal = 8 point maximum
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CommunicationWater bill / check writing / envelope addressPhone book lookup #, drug store, dial #, 911Sandwich making stepsRecipe reading / microwave setting
Subtotal = 28 point maximum
MemoryTaking candy out of bottle when timer rings
Without or with promptsRecall of check written (to whom)Recall amount of check
Subtotal = 5 point maximum
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TFLS Microwave setting / meal preparation subtest
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Discriminated AD (MM=20) from controlUnrelated to age, but r = .5 with educGood test-retest reliability @ 1mo., r = .93Subscales r with total, most > .9Corr. with BDRS = .4Corr. with CERAD Beh Rtg Scale = .05Total score correlated with MMSE
Cullum et al. (2001). Neuropsychiatry, Neuropsychology & Behavioral Neurology, 14, 103-108.
ILS TotalILS mem/orientationILS MoneyILS Home/transport.ILS Health/safety
.87
.78
.79
.85
.82
Weiner, Gehrmann, Hynan, Saine & Cullum (2006)
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MMSE 1 25.5 29.4MMSE 2 23.4 29.2Ann. Chg. 1.7 0.2 5.7%TFLS 1 38.2 48.3TFLS 2 34.7 49.0Ann. Chg. 3.1 -0.6 8.5%
Weiner, Fields, Hynan & Cullum, 2008
Measure AD NC Change
TFLS Total 47.17 48.77 .023Dressing 4.97 5.00 N/ATime/Orient 14.73 14.63 .661Money 11.10 11.17 .779Communic. 11.10 11.37 .269Memory 27.30 29.21 .002
Binegar, Hynan, Lacritz, Weiner & Cullum, 2009
Measure MCI NC p
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Split-half reliability- NC
Split-half – clinical
Test- retest
S.E.M.
.65* - .80 x = .75
.63* - .97 x = .92
.66 NC, .90 clin.
3.75 – 5.49 x = 4.46
Total T-scoreTimeMoney/CalculationCommunicationMemory
Time 1 Time 250.7 53.58.0 8.37.4 7.525.9 26.24.6 4.8
N=229, mean test-retest = 23 days; Cullum, Weiner & Saine, 2009
Verbal Comp. Index .74Perceptual Reasoning Index .71Working Memory Index .74Processing Speed Index .71Global Ability Index .77Full Scale IQ .79
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Auditory Memory Index .67Visual Memory Index .70Visual Working Memory .80Immediate Memory .71Delayed Memory .71
Dementia- assisted living 32.1Dementia- caregiver help 42.2Mild Intellectual Disability 28.6Mod. Intellectual Disability 22.5Schizophrenia 43.5Mild Traumatic Brain Injury 51.2
• Evidence of:• Validity• Reliability
• Clinical utility• Detects dysfunction in dementia• Distinguishes groups x level of care needed• Treatment Response• Changes over time
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• Direct/indirect requests• Diagnosis• Capacity/competence• Treatment factors• Placement issues• Support/assistance• Environmental structuring• Baseline & life planning
• No informant(s)• Patient denial/unawareness• Discrepant findings:
• Cognitive results vs. report of functional status
• Patient vs. family or other report• Facilitate access to resources
Dementia- assisted living 32.1Dementia- caregiver help 42.2Probable AD 32.0
Mild Intellectual Disability 28.6Mod. Intellectual Disability 22.5
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• 53 y/o practicing attorney• Missed recent court appearances• Urged by friends to see neurologist• Referred for assistance with diagnosis• “Is it the pot? I’m too young for AD”• Neurocognitive findings c/w AD• TFLS = 37• Correlations with daily activities• Feedback & recommendations to patient,
friends and referring neurologist
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• 67 y/o RH retired electrical engineer• 12 year history of Parkinson’s disease (PD)• R-sided tremor & stiffness w/ recent falls• Struck head in recent fall (?TBI)• Referral: PD vs TBI vs Depression?• Neurocognitive findings c/w PD• TFLS = 38• Feedback & recommendations to
patient, family & neurologist
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• 64 y/o artist homemaker on vacation• Husband fractured hip...surgery. .rehab• Patient angry, demanding at rehab• PCP diagnosed w/ AD• Additional stressors• Placed in nursing home• Son pursuing guardianship
• Friend took patient to neurologist• Referral: diagnosis, treatment, functional
needs• Initial evaluation• Follow-up evaluation with TFLS = 42• Feedback & recommendations to
referring physician, patient, advocate, son, and social worker…..
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• 50 y/o male with anoxic injury• Hx of Borderline IQ & special education• Lives with Mom in small town• Works part-time bussing tables• Recently getting lost, refusing chores….• PCP: diagnosis, treatment, placement?• NP results: IQ 65; profound memory deficits• TFLS = 25• Feedback & Recommendations to PCP,
Mom and Patient
• Utility of functional assessment
• Questions?
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Examination in various dementia types and other neurobehavioral disordersComparison with other neuropsychological measuresIdentification of most important itemsPredicting everyday behaviorsEmploying new statistical techniques & data (e.g. percentile norms for subtests)
Binegar, D.L., Hynan, L.S., Lacritz, L.H., Weiner, M.F., & Cullum, C.M. (2009). Can a Direct IADL Measure Detect Deficits in Persons with MCI? Current Alzheimer Research, 6, 48-51.
Cullum, C.M., Saine, K., Chan, L.D., Martin-Cook, K., Gray, K., & Weiner, M.F. (2001). A performance-based instrument to assess functional capacity in dementia: The Texas functional living scale. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 14, 103-108.
Cullum, C.M., Weiner, M.F., & Saine, K.C. (2009). Texas Functional Living Scale. San Antonio: Pearson.
Drozdick, L. & Cullum, C.M. (2011). Expanding the ecological validity of WAIS-IV and WMS-IV with the Texas Functional Living Scale. Assessment, 18, 141-155.
Saine, K., Cullum, C.M., Martin-Cook, K., Hynan, L., Svetlik, D.A., & Weiner, M.F. (2002). Comparison of functional and cognitive donepezil effects in Alzheimer’s disease. International Psychogeriatrics, 14, 181-185.
Weiner, M.F., Gehrmann, H.R., Hynan, L.S., Saine, K.C., & Cullum, C.M. (2006). Comparison of the Test of Everyday Functional Abilities with Direct and Caregiver-Administered Measures of Daily Function. Dementia and Geriatric Cognitive Disorders, 22, 83-86.
Weiner, M.F., Davis, B., Martin-Cook, K., Hynan, L.S., Saine, K.C., & Cullum, C.M. (2007). A direct functional measure to help ascertain optimal level of residential care. American Journal of Alzheimer’s Disease and Other Dementias, 22, 355-359.
Weiner, M., Fields, J., Hynan, L., & Cullum, C.M. (2008). Annualized functional change in Alzheimer’s disease participants and normal controls. The Clinical Neuropsychologist, 22, 801-806.