#5. Don’t provide cognitive-based interventions (e.g.

, paper-and-pencil
tasks, table-top tasks, cognitive training software) without direct
application to occupational performance.
To improve occupational performance, cognitive-based interventions should be embedded in an occupation
relevant to the patient. Examples of cognitive-based interventions include awareness approaches, strategy training,
task training, environmental modifications, and assistive technology. The use of cognitive-based interventions not
based on occupational performance will result in suboptimal patient outcomes.

4 Elements to Include in a Functional Cognition Toolkit

Practical community access materials Kitchen and household items
• Maps of your facility, neighborhood, and city • Cookbooks
• Information on support groups and • Cooking utensils, pots, pans, bowls, timer
community centers • Cleaning supplies
• Schedules for facility or local community activities • Food items

Supplies for personal organization and work
• Templates for lists and planning
• Calendars and planners
• Office supplies such as pencils, pens, sticky notes,
poster board
• White boards and dry erase markers
A handbook for accessing useful computer programs,
apps, and websites
• Transit schedule and ridesharing apps
• Online menus and meal planning resources
• Budgeting and money management tools
• Instructions for smartphone calendar, alarm, and
app management

This work was developed by Vanessa Jewell, PhD, OTR/L; Rebecca Jessen, OTD, OTR/L; and Hillary Richardson, MOT,
OTR/L. Gordon Muir Giles, PhD, Dip COT, OTR/L, FAOTA, provided a valuable review of this content.

Copyright © 2019 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all
other uses, contact copyright@aota.org.
 Facilitate success while providing the
If your client’s And barriers to the
And their strengths are . . . Try . . . Instead of . . . “just-right” challenge with supports
goal is . . . goal are . . .
as needed . . .
An intervention in which the client
To cook a simple Very motivated, has functional Cognitive impairments in Cancelling specified Grade environment by increasing or
crosses off items needed for a recipe
meal after a use of BUE, no visual selective attention, sustained letters or numbers decreasing the amount of non-recipe
while searching through and finding the
stroke impairments attention, problem-solving presented in a worksheet ingredients in the kitchen
items in the kitchen
Cognitive impairments in An intervention in which the client Grade difficulty of task (e.g., number of
To participate in Completing
No visual impairments, has processing speed, problem prepares lunches for children, choosing lunch items, number of non-related items
parenting duties organizational
functional use of BUE solving, planning, and from a number of ingredients in the in kitchen); grade cueing and level of
after a TBI worksheets
organization kitchen distraction
Grade difficulty of task (e.g., provide a
An intervention-focused on grocery Completing pencil- list, ask/assist client to prepare their
To complete Impairments in short-term
No impairments in mobility, shopping: guide the client to create and/ and-paper worksheets; own list based on items needed; add
grocery shopping memory, selective attention,
range of motion, or balance or follow a list, shop while using the list computer-based memory a budget component; grade cueing;
after a mild TBI and problem solving
(real, simulated, or online shopping) games grade environment [activity level, noise,
familiarity])
An intervention in which the client Completing pa-
Grade difficulty of activity (e.g., number
No impairments in mobility or Impairments in short-term performs simulated work tasks per-and-pencil work-
To return to work or complexity of tasks, session length);
range of motion, client identifies memory, selective attention, incorporating planning, prioritization, sheets; board games or
following a mild grade cueing; grade environment (noise
work as “satisfying and and sustained attention; and time management skills; OT and other table top games;
TBI and activity level); act as a liaison between
important,” supportive employer limited activity tolerance client identify necessary workplace cognitive training
client and employer as needed
accommodations software
Asking client to identify
To return to
An intervention introducing safety issues safety risks in detailed
home living Supportive family in the home; Demonstrates impulsivity and Grade cueing; grade level of safety threat
that need to be corrected or avoided pictures of various
environment client is motivated poor safety awareness presented
during completion of a project scenes and ways to
following a stroke
avoid/correct risks
To complete ADLs
with minimal Supportive family and Utilizing an errorless learning approach Sequence cards
Grade cues provided; HOH assistance as
assistance after caregivers; intact procedural Impaired short-term memory with client; complete ADLs in the same depicting an ADL or
needed to prevent errors
a diagnosis of memory place and in the same way daily IADL; board games
dementia
Note: it is important to remember that the categories outlined on the chart are not mutually exclusive, and the skills can have a transactional influence (e.g., discrimination skills can influence motor skills, motor skills can influence
modulation, etc.).

Choosing Wisely Recommendation References

1. American Occupational Therapy Association. (2013). Cognition, cognitive rehabilitation, and occupational performance. American Journal of Occupational Therapy, 67(Suppl.), S9–S31.
http://doi.org/10.5014/ajot.2013.67S9
2. Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M.,…Ashman, T. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008.
Archives of Physical Medicine and Rehabilitation, 92, 519–530. http://doi.org/10.1016/j.apmr.2010.11.015
3. Gillen, G., Nilsen, D. M., Attridge, J., Banakos, E., Morgan, M., Winterbottom, L., & York, W. (2015). Effectiveness of interventions to improve occupational performance of people with cognitive impairments
after stroke: An evidence-based review. American Journal of Occupational Therapy, 69, 6901180040. http://doi.org/10.5014/ajot.2015.012138
4. Smallfield, S., & Heckenlaible, C. (2017). Effectiveness of occupational therapy interventions to enhance occupational performance for adults with Alzheimer’s disease and related major neurocognitive
disorders: A systematic review. American Journal of Occupational Therapy, 71, 7105180010. http://doi.org/10.5014/ajot.2017.024752