Occupational Therapy in Mental Health

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/womh20

Evaluating Cognitive Impairment and Its Relation

to Function in a Population of Individuals Who Are
Homeless

Caitlin E. Synovec

To cite this article: Caitlin E. Synovec (2020) Evaluating Cognitive Impairment and Its Relation to
Function in a Population of Individuals Who Are Homeless, Occupational Therapy in Mental Health,
36:4, 330-352, DOI: 10.1080/0164212X.2020.1838400

To link to this article: https://doi.org/10.1080/0164212X.2020.1838400

Published online: 04 Nov 2020.

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OCCUPATIONAL THERAPY IN MENTAL HEALTH
2020, VOL. 36, NO. 4, 330–352
https://doi.org/10.1080/0164212X.2020.1838400

Evaluating Cognitive Impairment and Its Relation to

Function in a Population of Individuals Who
Are Homeless
Caitlin E. Synovec
National Institute for Medical Respite Care, National Health Care for the Homeless Council,
Nashville, TN, USA

ABSTRACT KEYWORDS
Individuals experiencing homelessness are at risk for cognitive Functional cognition;
impairment and decreased functional skills due to complex functional performance;
comorbidities and restricted contexts. A retrospective analysis homelessness; cogni-
tive screening
of occupational therapy evaluations within an integrated,
interprofessional primary care clinic serving adults experienc-
ing homelessness was completed. Evaluations included a
standardized cognitive screening assessment and a standar-
dized functional assessment. Assessment results were analyzed
to determine the prevalence of cognitive impairment, differen-
ces between cognitive and functional assessment perform-
ance, and the relationship between cognitive impairment and
functional performance. Although most participants’ perform-
ance indicated cognitive impairment, functional performance
was varied demonstrating the need for individualized evalu-
ation and care planning in the transition from homelessness
to housing.

Introduction
Previous research has suggested that adults who are homeless often have a
cognitive impairment and multiple medical co-morbidities impacting their
ability to complete functional tasks, such as self-care or managing health
care (Andersen et al., 2014; Depp et al., 2015; Spence et al., 2004). These
studies, however, are scarce and do not use a consistent methodology for
assessing cognitive impairment (Depp et al., 2015; Stone et al., 2019). Even
fewer studies are available regarding the functional skills of individuals
experiencing homelessness and the relationship of these skills to cognition
(Helfrich & Fogg, 2007; Raphael-Greenfield, 2012). Although these studies
identified a high level of cognitive impairment, they also showed this popu-
lation demonstrated the ability to develop independent living skills and
maintain housing with appropriate supports (Helfrich & Fogg, 2007;

CONTACT Caitlin E. Synovec CESynovec@gmail.com National Institute for Medical Respite Care, National
Health Care for the Homeless Council, Nashville, TN 37206, USA.
ß 2020 Taylor & Francis Group, LLC
 OCCUPATIONAL THERAPY IN MENTAL HEALTH 331

Raphael-Greenfield, 2012). Recent research within occupational therapy

practice has emphasized the importance of using functional assessments to
identify the impact of cognitive impairments; these assessments have been
found to be more sensitive in identifying difficulties with functional
cognition than traditional screening tools (American Occupational Therapy
Association, 2019; Giles et al., 2017). Therefore, it is beneficial to further
investigate the prevalence the relationship of cognitive and functional
performance in adults experiencing homelessness to build the body of
evidence and inform practices for this population.

Homelessness
Homelessness remains a significant social and health inequity problem in
the United States, with over 560,000 individuals experiencing homelessness
on a single night in 2019 (Henry et al., 2020). There are many factors that
contribute to a person becoming homeless, including poverty, health, and a
lack of affordable housing (National Health Care for the Homeless Council
[NHCHC], 2019; National Low Income Housing Coalition, 2017; To et al.,
2016; Topolovec-Vranic et al., 2017). Studies have reported a high preva-
lence of mental health and substance use diagnoses, brain injury, and
chronic conditions among those experiencing homelessness (Fazel et al.,
2014; Stubbs et al., 2020; Topolovec-Vranic et al., 2017; Zlotnick & Zerger,
2009). In response, specific models of supportive housing and integrated
health care have been developed to address the specific and complex health
needs of this population. Models such as Housing First and Health Care
for the Homeless (HCH) have increased access to permanent housing,
mental health and primary care, and case management services (Aubry
et al., 2015; Rabiner & Weiner, 2012). Integration of occupational therapy
services in these models of care has been inconsistent, despite research in
occupational therapy has demonstrated effectiveness in addressing func-
tional needs of this population through evaluation and intervention
(Gutman & Raphael-Greenfield, 2017; Helfrich & Fogg, 2007; Helfrich &
Synovec, 2019; Marshall et al., 2020; Roy et al., 2017; Synovec et al., 2020;
Thomas et al., 2011, 2017).

Cognition
Cognition can be defined as “information-processing functions carried out
by the brain that include attention, memory, executive functions (i.e., plan-
ning, problem solving, self-monitoring, self-awareness), comprehension and
formation of speech, calculation ability, visual perception, and praxis skills”
(AOTA, 2019, p. 2). Cognitive impairment, or cognitive dysfunction, has
332 C. E. SYNOVEC

been defined as “functioning below expected normative levels or loss of

ability in any area of cognitive functioning” (Evans, 2010). Cognitive
impairment may occur as the result of a variety of diagnoses, such as trau-
matic or acquired brain injury, mental health disorders, long-term sub-
stance or alcohol use, trauma, neurological disorders, and chronic
conditions, and can affect individuals across the life span (AOTA, 2019;
Depp et al., 2015; Hayes et al., 2012; Wei et al., 2019). Individuals experi-
encing homelessness often are managing many conditions impacting cogni-
tion simultaneously. Further, contextual factors such as poor sleep, chronic
stress, and limited access to nutritious foods and overall food insecurity
can exacerbate any underlying cognitive impairment from diagnosed condi-
tions (AOTA, 2019; Deck & Platt, 2015; Hopper et al., 2010; Lachaud et al.,
2020). Previous studies examining the presence of cognitive impairment in
adults experiencing homelessness have found an overall 25% rate of cogni-
tive impairment; however, studies specifically examining older adults have
found rates up to 78% (Depp et al., 2015; Fazel et al., 2014; Stone
et al., 2019).

Cognition and function

There may be multiple assumptions regarding individuals’ ability to care
for themselves when experiencing homelessness, especially in the presence
of cognitive impairment (Tsemberis & Asmussen, 1999; Helfrich &
Synovec, 2019; Lemsky et al., 2018). These individuals, however, are living
in restricted environments such as shelters or street dwellings, effectively
precluding the practice, demonstration, or use of functional skills that they
may have learned at various points in their lives. Although assessing cogni-
tion is important, especially for populations with complex comorbidities, it
is equally important to assess functional skills to support independ-
ent living.
Literature within neuropsychiatry has previously used cognitive perform-
ance to indicate functional performance. Although cognition and function
are related, the traditional paper-pencil based cognitive assessments are
what have often been used to evaluate functional skills (Jekel et al., 2015;
Raphael-Greenfield, 2012; Seidman et al., 2003; Wesson et al., 2016).
Different from cognition, function is “the act of doing and accomplishing a
selected action (performance skill), activity, or occupation that results from
the dynamic transaction among the client, the context, and the activity”
(AOTA, 2020). The term functional cognition captures the relationship of
cognition and function, defined as “the ability to use and integrate thinking
and performance skills to accomplish complex everyday activities” (Giles
et al., 2017). The scope of occupational therapy practice includes the
 OCCUPATIONAL THERAPY IN MENTAL HEALTH 333

evaluation and assessment of functional cognition through practice-based

assessments (PBE). These require observation and analysis of an individual
completing a functional occupation or activity in order to assess independ-
ence in everyday tasks, providing a more comprehensive and accurate view
of a person’s independent living skills (AOTA, 2019; Giles et al., 2017). For
individuals experiencing homelessness, whose restricted contexts limit occu-
pational performance, functional evaluations provide an opportunity to
demonstrate skills. Additionally, the occupational therapy practitioner can
assess environmental factors and individual factors impacting performance,
such as cognition, health conditions, and life experience.
Services for individuals experiencing homelessness are most effective
when they are comprehensive (Bonin et al., 2010). Many existing shelter
and health care-based programs focus on addressing the health and eco-
nomic needs of these individuals (Aubry et al., 2015; Stergiopoulos
et al., 2019). In the majority of these programs, although there has been
an increased understanding of the impact of cognitive impairment on
this population, an unmet need to consistently assess cognition and
address functional skills to transition into independent living remains
(Burra et al., 2009; Depp et al., 2015; Helfrich et al., 2011; Helfrich &
Fogg, 2007; Marshall et al., 2020; Raphael-Greenfield, 2012; Spence
et al., 2004; Stone et al., 2019; Wolf et al., 2019). Due to the high preva-
lence of multiple factors that might impact cognition, assessment of cog-
nitive skills is important to address specific needs for those experiencing
homelessness. Since traditional cognitive assessments may not be able to
accurately reflect functional performance, it is important to also evaluate
the impact of an individual’s cognitive skills on functional abilities, so
that client-centered care and appropriate support to transition from
homelessness may be provided. Understanding patterns and prevalence
of cognitive impairment or functional difficulties provides a framework
which health care and housing programs may use to improve and tailor
their services more effectively.
Due to the dearth of evidence on cognition and function in this popula-
tion, the author sought to address the question “What is the prevalence of
cognitive impairment, differences between cognitive and functional
assessment performance and the relationship of cognitive impairment to
functional performance within a population of adults experiencing home-
lessness receiving care in an integrated primary care setting?” Through a
retrospective, descriptive study client performance on standardized cogni-
tive screening measures and PBE (referred to as functional assessments for
the remainder of this paper) was gathered and analyzed to inform current
practice for those working with individuals experiencing homelessness.
334 C. E. SYNOVEC

Method
Research design
A retrospective, descriptive study was undertaken to examine the cognitive
status and functional performance of a homeless population receiving med-
ical and mental health services at a health care agency specifically for this
population. Further analyses were completed to determine the relationship
of performance on cognitive screening tools to functional performance, as
measured by functional assessments. Retrospective data were obtained
using the agency’s electronic medical record (EMR) system. Functional
assessments included the Executive Function Performance Test (EFPT)
and/or the Assessment of Motor and Process Skills (AMPS); cognitive
screenings included the Allen Cognitive Level Screen Version 5 (ACLS-5)
and/or the Montreal Cognitive Assessment (MoCA) (Allen et al., 2007;
Baum & Wolf, 2013; Fisher & Bray Jones, 2010a; Nasreddine et al., 2005).
Use of participant data through a retrospective study was approved by the
Boston University Institutional Review Board and did not require
signed consent.

Study population
Agency records for 172 individuals for whom occupational therapy evalua-
tions were completed over a 2-year period were selected for analysis.
Selection was based on the following criteria: (1) the evaluations in the
record included at minimum of one standardized functional assessment
(EFPT, AMPS) and one standardized cognitive screening (ACLS-5,
MoCA); (2) the individual was over the age of 18; (3) the individual was
able to independently consent for services; and (4) was referred by a pro-
vider at the agency for an occupational therapy evaluation. Participation
in ongoing occupational therapy services was not required for inclusion.
At the time of evaluation, the individual may have been considered home-
less (living on the street or in a shelter) or unstably housed (e.g.,
“doubling up” or living with others but without their own room or name
on the lease). All were receiving medical and/or mental health services at
the agency prior to referral to occupational therapy. Individuals may have
been referred to the occupational therapist for evaluation for several rea-
sons, inclusive of concerns for cognitive impairment or decline; concern
regarding functional skills and ability to live independently; desire to have
a greater understanding of the individual’s cognition or functional
abilities; and to determine supports needed once qualified for housing
opportunities (e.g., permanent supportive housing, apartment within
the community).
 OCCUPATIONAL THERAPY IN MENTAL HEALTH 335

Measures
The selected measures, described below, are used routinely in the study set-
ting due to the relevance for the clinic’s population. Clinical reasoning was
used to select one cognitive assessment (ACLS or MoCA) and one func-
tional assessment (EFPT or the AMPS) based on: reason for referral, client
report, and analysis of the client by the practitioner during the interview.

Allen Cognitive Level Screen (ACLS-5)

The Allen Cognitive Level Screen Version 5 (ACLS-5) is designed to obtain
a quick measure of global cognitive processing abilities, learning potential,
and performance abilities and to detect unrecognized or suspected prob-
lems related to functional cognition (Allen et al., 2007). The ACLS-5 is
administered by an occupational therapy practitioner and is a leather-lacing
task requiring the individual to attend, understand, and use sensory cues
from material objects, the administrator’s verbal and demonstrated instruc-
tions and cues, and feedback from the person’s motor actions while making
the stitches (Allen et al., 2007). Previous versions of the ACLS have found
the screening tool to be a valid and reliable screening measure of functional
cognition across diagnostic populations and preliminary studies have found
high inter-rater reliability for the ACLS-5 (Allen Cognitive Group & ACLS/
LACLS Committee, 2016). The ACLS-5 has minor differences in adminis-
tration from its predecessor, the ACLS 90, indicating that the ACLS-5
maintains validity for use across populations (Allen et al., 2007; Allen
Cognitive Group & ACLS/LACLS Committee, 2016).
The individual’s performance on the ACLS-5 is scored on a scale of
3.0–6.0, with 0.2 intervals (Allen, 1991; Allen et al., 2007). Based on the
ACLS-5 manual, the following was used as delineations for cognitive per-
formance categories for this study: a score of 6.0 was considered “normal
cognitive performance,” 5–5.8 was considered “mild cognitive impairment,”
4.0–4.8 was considered “moderate cognitive impairment,” and 3.0-3.8 as
“severe cognitive impairment,” (Allen, 1991; Allen et al., 2007). The authors
emphasize the importance of pairing the ACLS-5 with an appropriate func-
tional observation or assessment to confirm the findings regarding func-
tional performance indicated by the ACLS-5 score (Allen et al., 2007).

Montreal Cognitive Assessment (MoCA)

The Montreal Cognitive Assessment (MoCA) is a brief measurement tool
intended to screen for mild cognitive impairment (Nasreddine et al., 2005).
The MoCA is a 30-point test that assesses cognitive domains of visuospatial
and executive functioning, naming, delayed recall, attention, language,
abstraction, and orientation (Nasreddine et al., 2005). The test is
336 C. E. SYNOVEC

administered via pencil and paper by a qualified professional and can be

completed within 10–30 min. The MoCA has been validated for use in
adults ages 55–85 and for multiple diagnoses and was found to have good
test-re-test reliability (Hobson, 2015; Nasreddine et al., 2005). Although the
MoCA has been validated for primarily older adults, additional research
has shown individuals who are or have experienced homelessness present
with age-related decline at rates 20 years prior to the general population,
indicating use of this assessment for this population (Fazel et al., 2014;
Hurstak et al., 2017).
The MoCA is scored on a scale of 0–30, with a score of 30 indicating no
errors were made during the assessment. The original cutoff scores to indi-
cate cognitive impairment, as determined by Nasreddine and colleagues
(2005), were as follows: a score of 26 or greater indicates normal cognitive
performance, a score between 17 and 25 mild cognitive impairment, and a
score of 16 or lower severe cognitive impairment. However, in follow-up
studies Carson et al. (2018) and Rossetti et al. (2011) both determined that
a using a cutoff score of 26 for normal cognitive performance may result in
false positives of mild cognitive impairment especially for those with lower
education levels. Carson and colleagues (2018) specifically recommend
applying a cutoff score of 23 for normal cognitive performance, based on
an extensive review of published data on heterogeneous populations. In
this study, based on population characteristics and following the recom-
mendations of the literature, a score of 23–30 was considered “normal cog-
nitive performance,” a score of 17–22 was considered “mild cognitive
impairment,” and a score of 16 or lower considered “significant cognitive
impairment” (Carson et al., 2018; Nasreddine et al., 2005).

Executive Function Performance Test (EFPT)

The EFPT was developed as a measure of executive performance and
records what an individual can do and the level of support needed to suc-
cessfully perform a task (Baum et al., 2008; Baum & Wolf, 2013). In the
EFPT, the practitioner observes the individual completing four functional
tasks of cooking, using the telephone, managing medications, and bill pay-
ment (Baum et al., 2008). In all four tasks, the person’s ability to use five
executive functions of a task is assessed. These executive functions include:
initiation of a task (beginning the task), organization (retrieval and arrange-
ment of tools), sequencing (execution of steps in a correct order), safety
and judgment (avoids a dangerous situation), and completion (deciding
and acknowledging when a task is complete) (Baum et al., 2008; Baum &
Wolf, 2013). The EFPT has been found to be a reliable and valid measure
for assessing executive function in a population of adults with varying
 OCCUPATIONAL THERAPY IN MENTAL HEALTH 337

diagnoses impacting cognitive function such as stroke, multiple sclerosis,

and schizophrenia (Baum et al., 2008; Cederfeldt et al., 2011; Katz
et al., 2007).
Differing from other assessments, the scoring is based on the level of
cueing required by the practitioner for the individual to complete each of
the tasks. Tasks are scored on a range of 0 to 5 as follows: 0 ¼ independent,
1 ¼ verbal guidance, 2 ¼ gestural guidance, 3 ¼ verbal direct instruction,
4 ¼ physical assistance, 5 ¼ do for participant (Baum & Wolf, 2013). A
higher score, therefore, reflects a need for more cueing and indicates more
severe executive functioning deficits.
According to the authors of the EFPT, interpretation of the numerical
score and functional performance relies on the analysis of the clinician
administering the assessment (Baum & Wolf, 2013). The EFPT is scored on
a numerical scale scores ranging from 0 to 100, where 0 indicates no execu-
tive functioning deficits and/or need for assistance to complete functional
tasks. Higher numerical scores indicate increased executive function deficits
and/or need for assistance. Previous studies examining the performance of
specific diagnostic groups on the EFPT may be used to compare a popula-
tions’ performance across means (Baum et al., 2008; Katz et al., 2007;
Raphael-Greenfield, 2012).

Assessment of Motor and Process Skills (AMPS)

The Assessment of Motor and Process Skills (AMPS) was designed to be
administered by occupational therapy practitioners to evaluate overall ADL
ability and the quality, efficiency, and safety of an individual’s motor and
process actions during functional performance (McNulty & Fisher, 2001).
The occupational therapy practitioner administers the AMPS by observing
the individual perform two familiar and relevant ADL tasks in a natural,
task-relevant environment (Fisher & Bray Jones, 2010a). The practitioner
then scores the quality of 36 performance skills enacted during the task
performance, divided between motor and process skills. Within the AMPS,
motor skills are defined as “the observable, goal-directed actions a person
performs in order to move him- or herself or task objects while interacting
with the task objects and environment” (Fisher & Bray Jones, 2010a, p.
2–5); Process skills are defined as the “observable goal-directed actions a
person performs as he or she (a) selects, interacts with, and uses task tools
and materials; (b) logically carries out individual actions and steps of an
ADL task; and c) modifies his or her performance when problems occur”
(Fisher & Bray Jones, 2010a, p. 2–5). The AMPS has established reliability
and validity across age groups, gender, and diagnoses (Ayres & John, 2015;
Fisher & Bray Jones, 2010a; Merritt, 2011).
338 C. E. SYNOVEC

To score the AMPS, the occupational therapy practitioner scores each of

the 36 tasks on a scale of 1–4, where a score of 4 ¼ competent perform-
ance, 3 ¼ questionable performance, 2 ¼ ineffective performance, or
1 ¼ inefficient performance (Fisher & Bray Jones, 2010a). The scores are
entered into the computerized AMPS scoring system, which uses multi-
faceted Rasch analyses to determine a logit score for both the motor and
process abilities resulting in linear scores (3.0 indicating lowest perform-
ance to þ4.0 highest performance) that can also be used for a criterion-ref-
erenced interpretation of the logit scores (Center for Innovative OT
Solutions, 2020; Fisher & Bray Jones, 2010a). The logit scores can indicate
“competent ADL task performance” by comparing the individual’s AMPS
logit scores to the criterion-referenced cutoff measures of 2.0 logits on the
ADL motor scale and 1.0 logit on the ADL process scale (Center for
Innovative OT Solutions, 2020). The authors of the AMPS express that
using both the motor and process skill scores is the strongest predictor of
need for assistance and that these scores should be combined with clinical
judgment to determine need for assistance to live independently in the
community (Fisher & Bray Jones, 2010b).
None of the selected measures have specific validity to adults experienc-
ing homelessness, although the EFTP and the ACLS-5 have been used in
previous studies to measure functional cognition and functional skills of
this population (Raphael-Greenfield, 2012; Helfrich et al., 2011). Each of
the measures was selected for use in this clinical setting due to their applic-
ability for diagnostic groups, feasibility of use within a primary care setting,
and ease of communicating and translating results to non-occupational
therapy practitioners.

Clinical procedures
Setting
Participants received services from an integrated primary health care
organization in an urban area that is specifically designed to meet the
complex needs of homeless individuals is a Federally Qualified Health
Center (FQHC) (Bonin et al., 2010; U. S. Department of Health & Human
Services, Health Resources & Services Administration, 2018).
Comprehensive services are delivered on-site by interdisciplinary teams of
providers including physicians, nurse practitioners, nurses, social workers,
case managers and two full-time occupational therapists providing medical
care, mental health and addiction counseling, case management, and occu-
pational therapy (Synovec et al., 2020).
Clients were referred for an occupational therapy evaluation by any of
their current providers. Upon referral for the occupational therapy
 OCCUPATIONAL THERAPY IN MENTAL HEALTH 339

evaluation, the occupational therapist completed a brief interview with the

client regarding typical routines, current perception of occupational per-
formance, and potential problem areas. Following the interview, the occu-
pational therapist administered either the ACLS-5 or the MoCA. If time
permitted, the functional assessment (EFPT or AMPS) was administered
within the same appointment. However, based on client tolerance, the time
needed for assessments, or other factors, the functional assessment was
otherwise completed in an additional appointment, typically occurring
within 1–2 weeks of the cognitive assessment. All evaluation results were
documented within the EMR; for clinical purposes, evaluations included
recommendations based on assessment results. Recommendations also con-
sidered information gained through client interview, collaboration with
referring providers, and available health history. Recommendations
included strategies to modify treatment plans due to cognitive impairment,
to support instrumental activity of daily living performance (IADL), for
community engagement, and for housing transition. The client may also
have been offered ongoing occupational therapy services and intervention,
which is described more thoroughly in Synovec et al. (2020).

Data collection
A search feature in the EMR was used to obtain cognitive and functional
evaluation records. For each record that met the inclusion criteria, the final
scores on both the cognitive and functional assessments were gathered
along with demographic data for analysis. Diagnoses for mental health and
chronic conditions were obtained from the client’s problem list within the
EMR; diagnoses were determined by a behavioral health or primary care
provider based on the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) and International Classification of
Diseases, Tenth Revision (ICD-10) categories (American Psychiatric
Association, 2013; World Health Organization, 1992). The clients’ cognitive
and functional assessment scores were entered into a de-identified data
sheet for analysis, which sorted participants by cognitive and functional
assessment completed.

Data analysis
Individuals were grouped into categories based on their performance on
the cognitive screening assessments (ACLS-5: mild, moderate, or severe;
MoCA: normal, mild, or severe). Placement into category groups was deter-
mined by using guidelines of the assessment manuals and by reviewing the
literature. The results on the EFPT or AMPS for each of the cognitive
340 C. E. SYNOVEC

screening categories were analyzed using ANOVA to determine differences

between cognitive and functional assessment performance. Additionally,
Pearson Product Moment Correlation determined the correlation for each
of the cognitive assessments in relation to each of the functional
assessments.

Results
Demographics of study population
The study population ranged in age from 23 to 73 with a mean age of 51.
Seventy-three percent identified as male, 26% identified as female, and 1%
identified gender as “other.” Table 1 depicts the distribution of mental health
and chronic conditions. Of the individuals whose records were selected, 91%
were diagnosed with a psychiatric disorder; affective (66%) and substance use
(60%) disorders were the most commonly occurring mental health diagnoses.
Half of the population experienced chronic pain (51%) and 34% had experi-
enced at least one head trauma. Twenty-three percent were identified as having
cognitive impairment prior to occupational therapy evaluation. Notably, 85%
were diagnosed with at least one mental health and one chronic health condi-
tion, with 39% experiencing at least one mental health condition and 3 or more
chronic health conditions, indicating a high prevalence of co-morbidities.

Prevalence of cognitive impairment

Overall, 93% of clients evaluated scored within a range considered cognitive
impairment. Table 2 depicts descriptive statistics for the measures that
Table 1. Mental health, chronic conditions, and co-morbidities.
Diagnosisa n %
Mental health conditions
Affective disorder 114 66
Substance abuse disorder 104 60
Psychotic disorder 40 23
Post-traumatic stress disorder 33 19
Anxiety disorder 21 12
Chronic conditions
Chronic pain 88 51
Cardiovascular 63 37
Head trauma 62 36
Diabetes 44 26
Neurological disorder 42 24
Cognitive impairment 39 23
Intellectual or developmental disability 25 15
HIV 10 6
Co-morbidities
Mental health diagnosis and one chronic condition 38 22
Mental health diagnosis and two chronic conditions 41 24
Mental health diagnosis and three or more chronic conditions 67 39
Note. N ¼ 172.
a
Categories are not exclusive.
 OCCUPATIONAL THERAPY IN MENTAL HEALTH 341

Table 2. Overall performance on cognitive and functional assessments.

n Completed n Completed
Assessments n Range Mean score SD with EFPT with AMPS
ACLS-5 97 3.4–5.8 4.65 0.56 79 18
MoCA 75 6–29 18.8 4.79 42 33
EFPT 121 0–55 12.85 9.57
AMPS-M 51 0.1–2.9 1.52 0.67
AMPS-P 51 0.3–1.5 0.66 0.4
Note. N ¼ 172.

were administered and the number of clients that completed each cognitive
assessment and functional assessment. Table 3 illustrates the distribution of
cognitive performance groups and their functional assessment performance.
Of clients who completed the ACLS-5 (n ¼ 97), none achieved a score of
6.0. Of those who completed the MoCA (n ¼ 75), only 16% achieved a
score within normal cognitive performance. These results indicate a high
prevalence of cognitive impairment within the participant group.

Overall functional performance

Analysis revealed a range of functional performance across participants
(Tables 2 and 3). One hundred twenty-one clients completed the EFPT.
Compared with previous studies, this population collectively demonstrated
decreased performance as compared to: a control group (mean score 1.51;
SD 2.27), a group of adults with mild stroke (CVA) (mean 7.87; SD 8.42),
and a group of adults with mild and moderate TBI (mean score 4.74; SD
4.65) and severe TBI (mean score 7.03; SD 4.78) (Baum et al., 2008; Baum
& Wolf, 2013). Only 14% of participants who completed the EFPT scored
within a similar range as the control group from Baum et al. (2008).
Collectively the participants performed better than another population of
adults experiencing homelessness and with a history of substance use,
adults with acute and chronic schizophrenia, and moderate CVA (Baum
et al., 2008; Katz et al., 2007; Raphael-Greenfield, 2012). Both ACLS-5 and
MoCA severe cognitive impairment groups performed similarly to these
previous study groups.
The AMPS was completed on 51 clients, and the mean scores fell below
the AMPS cutoff scores for competent ADL performance for the motor
and process scores (Table 3). Only 24% of participants scored at 1.0 or
higher on the AMPS-P, and 30% of participants scored 2.0 or higher on
the AMPS-M. None of the cognitive sub-groups performed above the
AMPS-M or AMPS-P cutoff scores. This study’s participant group per-
formed lower than a population of individuals with schizophrenia (Ayres &
John, 2015) and addiction (Rojo-Mota et al., 2014), and similarly to adults
3 weeks post-TBI (Lange et al., 2009) and with a history of CVA (Kizony &
Katz, 2002).
342 C. E. SYNOVEC

Table 3. Performance on functional assessment by cognitive group.

n Completed EFPT mean n Completed AMPS-M AMPS-P
Assessments n Mean age Age range with EFPT score with AMPS mean score mean score
ACLS-5 mild 34 50 27–67 28 8.5 6 1.4 0.8
ACLS-5 moderate 52 52 23–68 43 11.9 9 1.5 0.5
ACLS-5 severe 11 48 23–63 8 22.4 3 1.4 0.7
MoCA normal 13 50 39–64 6 9.3 7 1.0 0.7
MoCA mild 42 57 34–73 24 13.1 18 1.7 0.8
MoCA severe 20 55 28–69 12 21.3 8 1.8 0.4
Note. N ¼ 172.

Table 4. ANOVA analysis of ACLS-5 performance and functional assessment performance.

Source of variation SS df Mean square F F critical value p-Value
ACLS-5 and EFPT
Between ACLS-5 groups 1193.17 2 596.59 9.10 3.12 0.00
Within ACLS-5 groups 4981.26 76 65.54
Total 6174.43 78
ACLS-5 and AMPS-M
Between ACLS-5 groups 0.09 2 0.05 0.16 3.68 0.85
Within ACLS-5 groups 4.35 15 0.29
Total 4.44 17
ACLS-5 and AMPS-P
Between ACLS-5 groups 0.37 2 0.18 1.31 3.68 0.30
Within ACLS-5 groups 2.11 15 0.14
Total 2.48 17
p < 0.05. The values highlighted in bold reflect statistically significant findings.

Differences between and relationship of cognitive performance and

functional assessment performance
Allen Cognitive Level Screen and Executive Function Performance Test
ANOVA analysis indicated performance on the EFPT was significantly differ-
ent (p ¼ 0.00) among all cognitive groups determined by the ACLS-5 (Table 4).
Post-hoc analysis (Tukey’s HSD) found the group with severe cognitive impair-
ment scored lower on the EFPT but there was not a significant difference
between the mild and moderate cognitive impairment groups. There was a
moderate correlation between the performance on the ACLS-5 and the EFPT
for the group (Table 5).

Montreal Cognitive Assessment and Executive Function Performance Test

ANOVA analysis found a significant difference (p ¼ 0.03) among all three
MoCA cognitive groups and post hoc Fisher’s LSD identified the severe
group overall demonstrated decreased performance (Table 6). Despite this,
there was only a moderate correlation between the performance on the
MOCA and the EFPT for the group (Table 5).

Allen Cognitive Level Screen and Assessment of Motor and Process Skills
ANOVA indicated there was no significant difference on performance
among the ACLS-5 cognitive groups and the AMPS-M (p ¼ 0.85) or the
 OCCUPATIONAL THERAPY IN MENTAL HEALTH 343

Table 5. Pearson product moment correlation for cognitive and functional assessment
performance.
EFPT AMPS-M AMPS-P
ACLS-5 .472 .194 .209
MoCA .434 .287 .307
Note. Levels of correlation: 0 ¼ No correlation; 0.1–0.3/0.1–()0.3 ¼ Weak; 0.4–0.6/()0.4–().06 ¼ Moderate;
0.7–0.9/()0.7–()0.9 ¼ Strong.

Table 6. ANOVA analysis of MoCA performance and functional assessment performance.

Source of variation SS df Mean square F F critical value p-Value
MoCA and EFPT
Between MoCA groups 761.79 2 380.89 3.94 3.24 0.03
Within MoCA groups 3773.83 39 96.76
Total 4535.62 41
MoCA and AMPS-M
Between MoCA groups 2.68 2 1.34 2.62 3.32 0.09
Within MoCA groups 15.35 30 0.51
Total 18.04 32
MoCA and AMPS-P
Between MoCA groups 1.02 2 0.51 3.41 3.32 0.05
Within MoCA groups 4.49 30 0.15
Total 5.51 32
p < 0.05. The values highlighted in bold reflect statistically significant findings.

AMPS-P performance (p ¼ 0.30) (Table 4). Additionally, there was a weak

correlation between the performance on the ACLS-5 and the AMPS-M or
the AMPS-P for the group (Table 5).

Montreal Cognitive Assessment and Assessment of Motor and Process Skills

ANOVA analysis did not find a statistically significant difference among
the MoCA cognitive groups and the AMPS-M groups (p ¼ 0.09) (Table 6).
ANOVA analysis revealed there was a significant difference between the
severe cognitive impairment group and both the normal and mild cognitive
impairment groups on their performance on the AMPS-P (p ¼ 0.05), con-
firmed by Fisher’s LSD post hoc analysis (Table 6). There was a weak cor-
relation between the performance on the MoCA and the AMPS-M or the
AMPS-P for the group (Table 5).

Discussion
The results of this study present several significant findings. The overall
performance of the clients on the cognitive screening tools indicates a pre-
dominance of cognitive impairment in the tested population. What may be
most notable is that though the initial EMR data has a similar percentage
of cognitive impairment to the Depp et al. (2015) study, after administering
cognitive assessments, 92% of individuals were found to have some level of
cognitive impairment. The majority of screening tools used to identify cog-
nitive impairment in this population are the Mini Mental Status Exam or
344 C. E. SYNOVEC

other similar tools, which may not be comprehensive enough to identify

groups of individuals with mild-moderate cognitive impairment as identi-
fied by the MoCA or ACLS-5 (Folstein et al., 1975; Stone et al., 2019). The
high number of those falling within a cognitive impairment category indi-
cates the need for agencies serving adults experiencing homelessness to
routinely implement cognitive measures, especially those that are more
comprehensive. Those who have experienced homelessness often develop
compensatory strategies enabling survival, where cognitive impairment may
not be visible without assessment. Cognitive abilities affect a person’s ability
to learn and remember information, think critically, and problem solve sol-
utions to situations they encounter. Ensuring that health services, case
management, and housing support services are developed to compensate
for cognitive impairment can improve client outcomes, as clients will be
better able to understand and follow through on instructions outside of the
clinic. Additionally, further research to validate cognitive screening tools
for this population is critical, as they often present with lower literacy levels
and higher presence of environmental and contextual stressors than cogni-
tive tools’ normed populations.
The outcomes of this study present two important considerations for
practice. First, the inconsistent relationships between performance on cog-
nitive screening tools and functional assessments supports previous litera-
ture indicating that cognitive screening tools are not sensitive enough to
predict functional performance (Giles et al., 2017). Although the more
severe groups tended to perform worse, only the performance-based func-
tional assessments were able to detect the differences among all the cogni-
tive impairment groups. Providers for adults experiencing homelessness
should not make assumptions on functional abilities based on cognitive
abilities. The results highlight the need for use of both cognitive and func-
tional measurement. The demonstrated variability in functional skills is
reflective of the heterogeneity of the population.
The second consideration pertains to functional performance of adults
experiencing homelessness. The performance of the study group, as a
whole, on functional assessments fell below that of the normed populations
on both the EFTP and the AMPS, indicating overall decreased functional
skills and abilities supporting the need to for occupational therapy services
to be available to this population to both assess for and develop skills
(Synovec et al., 2020). As each client presents with a set of skills and expe-
riences, use of functional assessments allows the practitioner to directly
analyze skills and determine how cognitive impairment or symptoms of
diagnoses may impact each person. An older adult who became homeless
after a significant health event, but previously lived independently for sev-
eral years, will present with very different knowledge and skills than a
 OCCUPATIONAL THERAPY IN MENTAL HEALTH 345

young adult who is now homeless after aging out of the foster care system
with limited access to IADL experiences.
The heterogeneity of the study population likely impacted the range of
functional performance. Different than other research groups, this study
determined a population by contextual similarities (homelessness) versus
diagnoses; however, the cognitive sub-groups demonstrate more similarities.
All of the severe cognitive impairment groups demonstrated the least func-
tional skills except for the ACLS severe cognitive group and the AMPS-P.
The lack of significance between the ACLS-5 severe cognitive group and
the AMPS-P could be attributed to the small number of participants (3)
within this subgroup. The groups with severe cognitive impairment per-
formed similarly to diagnostic groups where severe cognitive impairment is
more likely to be present, such as moderate and severe CVA, serious men-
tal illness and chronic substance use, and homelessness compounded by
substance use (AOTA, 2019; Ayres & John, 2015; Raphael-Greenfield, 2012;
Rojo-Mota et al., 2014). Overall, participants of this study performed lower
than normed control groups for both functional assessments. Both the cog-
nitive and functional performance were also likely skewed toward higher
rates of impairment, as participants were referred for assessment secondary
to demonstrating or reporting concerns regarding cognition or functional
performance. Thus, the decreased performance may not be generalizable to
the whole population of adults experiencing homelessness.
The identified decreased functional performance may be impacted by
several factors. First, most participants experienced both mental health and
chronic health condition, which compounded, may have a greater impact
on performance than more homogenous study groups. Even if other diag-
nostic groups experience comorbidities, the environmental restrictions of
homelessness in which persons are unable to routinely engage in occupa-
tions limits the opportunity to refine and develop skills. Additional context-
ual factors, such as poor sleep, inadequate nutrition, and lack of
community and social supports, may be moderating factors contributing to
decreased functional skills. These factors may impact overall skill acquisi-
tion and use and can also impact response to assessments. If a person
enters an evaluation appointment after a limited sleep from sleeping at a
bus stop and not having eaten, this can influence both the person’s ability
to respond to assessment questions and instructions. It is critical that
practitioners working with this population assess these factors prior to
assessment and consider their impact if the assessment is administered.
When working with this population, these circumstances may not
necessarily prohibit completion of the assessment (with client consent) and
point to the need to consider how these factors impact day to day
functioning.
346 C. E. SYNOVEC

The results of this study also have implications for supporting individuals
transitioning to housing. Previous studies identified that cognitive and
executive functions did not improve after participants transition from
homelessness to housing (Seidman et al., 2003); however, it has been dem-
onstrated that individuals are able to move into and maintain stable hous-
ing with appropriate supports, such as client-directed mental health care
and economic supports (Raphael-Greenfield, 2012; Stergiopoulos et al.,
2019). Addressing functional cognition through occupational therapy can
enhance the experiences of those transitioning into housing and provide
opportunity for individualized skill development within effective supportive
housing models. Performance-based assessments provide an opportunity
for the occupational therapy practitioner to identify existing skills, underly-
ing strengths, and client-specific barriers to functional performance.
Much like cognitive screening tools, further validation of functional
assessments for adults experiencing homelessness is needed. Due to the
restricted contexts, this population does not routinely have access to spe-
cific skills, which may limit applicability of certain assessments. For
example, while living a shelter, an individual may have extremely limited
experience in bill payment, limiting the use of the bill payment task within
the EFPT as it would be assessing a novel skill. There may also not be a
best or natural environment in which to complete tasks as recommended
by the AMPS, due to the instability of housing and circumstances for the
population. Assessments that allow for the practitioner to use clinical rea-
soning and client experiences to determine tasks that are appropriate and
familiar allows for psychometric properties to be upheld while providing an
accurate assessment of skills. As within many areas of practice, there is
likely not one true or best assessment, however, ensuring that assessments
are culturally relevant to diverse populations with a variety of life circum-
stances supports the applicability of tools across settings and populations.

Limitations
Due to the retrospective structure of this study based on clinical data, the
groups were not evenly distributed among the cognitive and functional
assessment groups, which could impact the strength of statistical analyses.
Additionally, due to the retrospective structure, additional moderating factors
could not be explored as data was not consistently captured in the EMR,
such as length of time spent homeless, education, or employment status.

Conclusion
Individuals experiencing homelessness present with a high rate of cognitive
impairment, but variability in functional skills. Increased cognitive impairment
 OCCUPATIONAL THERAPY IN MENTAL HEALTH 347

is likely due to the presence of multiple medical and mental health conditions,
as well as the chronic stress and trauma of homelessness. Each individual’s
independent living skills are unique, based on both cognition and life experi-
ences, thus evaluation of both is necessary. Overall, the results of this study
provide support for incorporating occupational therapy services into programs
serving adults experiencing homelessness. Occupational therapy can both
identify presence of cognitive impairment and identify a person’s functional
skills and abilities, a role typically not fulfilled by other providers (Merryman
& Synovec, 2020). By identifying cognitive and functional performance, pro-
viders can understand the client’s current skills and experiences and to tailor
their education and skill building of novel information and tasks specific to
their learning needs, resulting in appropriate accommodations and sup-
port services.

Implications
This study has two major implications. First, it supports the body of evi-
dence regarding the need for occupational therapy to administer both cog-
nitive and functional assessments. This is especially applicable to diverse
populations such as adults experiencing homelessness, where there is an
increased prevalence of cognitive impairment, yet variability in functional
skills. However, there is a need for further research to explore the use of
functional and cognitive assessments with this population to increase valid-
ity of these measures with adults experiencing homelessness.
Second, this study provides significant evidence regarding the benefit of
the availability of occupational therapy services within agencies serving
adults experiencing homelessness. Understanding of cognitive and func-
tional abilities of clients can enhance care and develop more individualized
care planning. Understanding cognitive and functional performance sup-
ports continued development of evidence-based interventions in response
to client needs and performance. Evaluation and corresponding interven-
tions can improve the effectiveness of services with the ultimate goal of
successful transitions into housing and the community.

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