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Cognitive Functional Evaluation (CFE) Process for Individuals with Suspected

Cognitive Disabilities
Adina Hartman-Maeir a; Noomi Katz bc; Carolyn M. Baum d
a
School of Occupational Therapy, Hebrew University and Hadassah, Mount Scopus, Jerusalem, Israel b
School of Occupational Therapy, Hebrew University and Hadassah, Jerusalem, Israel c Ono Academic
College, Director Research Institute for Health and Medical Professions, Kiryat Ono, Israel d Occupational
Therapy, Washington University at St Louis, Missouri, USA

Online Publication Date: 01 January 2009

To cite this Article Hartman-Maeir, Adina, Katz, Noomi and Baum, Carolyn M.(2009)'Cognitive Functional Evaluation (CFE) Process for
Individuals with Suspected Cognitive Disabilities',Occupational Therapy In Health Care,23:1,1 — 23
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 Cognitive Functional Evaluation (CFE)
Process for Individuals with Suspected
Cognitive Disabilities
Adina Hartman-Maeir, PhD, OTR
Noomi Katz, PhD, OTR
Carolyn M. Baum, PhD, OTR/L, FAOTA

ABSTRACT. The purpose of this paper is to conceptualize the evalu-

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ation process for individuals with suspected cognitive disabilities. The

Cognitive Functional Evaluation (CFE) process yields a comprehensive
profile of the clients’ cognitive strengths and weaknesses in occupational
performance. The components of the CFE are outlined in six stages as a
decision tree with examples of standardized instruments from which to
choose the assessments for each client evaluated: (1) interview and back-
ground information; (2) cognitive screening and baseline status tests; (3)
general measures of cognition and executive functions in occupation; (4)
cognitive tests for specific domains; (5) measures of specific cognitive
domains in occupations; and (6) environmental assessment. The first
three stages are required to ascertain basic cognitive abilities underlying
occupational performance. Tests for each stage can be chosen from the

Adina Hartman-Maeir, PhD, OTR, is Lecturer, School of Occupational Therapy,

Hebrew University and Hadassah, Mount Scopus, Jerusalem, Israel.
Noomi Katz, PhD, OTR, is Professor, School of Occupational Therapy, Hebrew
University and Hadassah, Jerusalem, Israel and Director Research Institute for Health
and Medical Professions, Ono Academic College, Kiryat Ono, Israel.
Carolyn M. Baum, PhD, OTR/L, FAOTA, Professor and Director Program in Oc-
cupational Therapy, Washington University at St Louis, Missouri, USA.
Address correspondence to: Adina Hartman-Maeir, School of Occupational
Therapy, PO BOX 24026, Mount Scopus, Jerusalem 91240, Israel (E-mail:
amaeir@mscc.huji.ac.il).
Occupational Therapy in Health Care, Vol. 23(1), 2009
Available online at http://www.haworthpress.com/web/OTHC


C 2009 by Informa Healthcare USA, Inc. All rights reserved.
doi: 10.1080/07380570802455516 1
 2 OCCUPATIONAL THERAPY IN HEALTH CARE

ones listed according to the client characteristics and the theory utilized,
there is no need to use all of them. Once this data is available a further
decision is made whether a more in-depth assessment is needed (stages
(4) and (5)). The environmental component is evaluated in all instances
with at least one of the assessments. The CFE process for individuals
with suspected cognitive disabilities is recommended to be used by occu-
pational therapists as a common ground for evaluation, documentation,
and communicating information.

KEYWORDS. Occupational therapy, evaluation process, cognitive

deficits

INTRODUCTION
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Many people with chronic health conditions and disabilities have cog-
nitive problems that limit their performance in daily life activities. Besides
neurological conditions (stroke, traumatic brain injuries, Alzheimer’s)
people with Parkinson’s, multiple sclerosis, heart disease, depression,
schizophrenia, autism spectrum disorder, and attention deficit hyperac-
tivity disorder (ADHD) may suffer from cognitive disabilities. Cognition
is embedded in many aspects of daily life where the individual is required to
perform complex activities, formulate goals, conceptualize a plan designed
to achieve the goals, and carry them out effectively (Lezak, Howieson, &
Loring, 2004).
Occupational therapists have a distinctive role in assessing key cogni-
tive constructs in the performance of daily life (Baum & Edwards, 1993;
Katz & Hartman-Maeir, 2005). They assess cognition to determine the
person’s capacity to be safe, live alone, work, or do any task that is impor-
tant and meaningful for them in their daily life. By assessing a person’s
cognitive capacity in the performance of daily tasks, it is possible to deter-
mine strengths, limitations, and challenges in performance as an individual
learns skills and environmental strategies that support him or her in daily
life. As Burgess et al. (2006) emphasize, it is important to determine an
individual’s higher-level cognitive capacities in ecological activities which
tap into the complex processing that characterizes the demands of real-
world occupational living. This information enables the therapists to work
with individuals and their families to facilitate optimal participation in
those with cognitive loss. The last decade has fostered the development
of occupational therapy intervention models for persons with cognitive
 Hartman-Maeir et al. 3

disabilities, including evaluation instruments and treatment methods (Katz,

2005). The choice of the appropriate treatment model for a client with cog-
nitive disabilities relies on a thorough evaluation process which provides
information pertaining to cognitive strengths and weaknesses, as well as
occupational performance and environmental factors.
The challenges presented by individuals with compromised cognition
warrants special consideration for the occupational therapy evaluation pro-
cess. The client-centered approach to practice needs to be expanded to ac-
count for the difficulties these individuals typically have in identifying and
conveying their occupational concerns, as well as the goals and barriers
to achieving them. Many individuals are often unaware of their cognitive
problems or the implications in daily life (Fleming, Strong, & Ashton,
1996; Katz & Hartman-Maeir, 2005; Prigatano, 1986, 2005). Therefore,
in order to fully and reliably understand their occupational performance,
it is necessary to systematically incorporate into the evaluation process:
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(1) methods of direct observation of performance, (2) specific question-

ing pertaining to the manifestations of cognitive deficits in daily life, (3)
obtaining information from proxies, and (4) the assessment of the environ-
ment. This paper proposes an evaluation process, the Cognitive Functional
Evaluation (CFE), which takes into account the unique characteristics of
individuals with suspected cognitive disabilities. The CFE systematically
incorporates evaluation methods, along with recommended assessments,
that can guide the occupational therapy intervention process for individuals
with suspected cognitive disabilities.

EVALUATION PROCESS FOR INDIVIDUALS WITH SUSPECTED

COGNITIVE DISABILITIES

The CFE is a systematic method comprised of several stages, from ini-

tial screening tests to in-depth examination of individual cognitive areas,
using various methods of interviews, performance based assessments, and
observations. The six recommended stages of the evaluation are listed in
Table 1 and the process is depicted in Figure 1 as a decision tree. The
following sections outline detailed information regarding the process and
recommended instruments for each stage. The focus of the process is on
occupational therapy assessment, with the vast majority of assessments
addressing cognition in a functional or simulated functional context (ex-
cept for cognitive screening tests and baseline status). The specific range
of instruments was elected based on content domain and availability to
occupational therapists, with preference given to instruments that were
 4 OCCUPATIONAL THERAPY IN HEALTH CARE

TABLE 1. Stages in the Process of the Cognitive/Functional

Evaluation (CFE)

1. Interview and background information including an occupational history

2. Cognitive screening and baseline status tests
3. General measures of cognition in occupations
4. Cognitive tests for specific domains
5. Measures of specific cognitive domains in occupations
6. Environmental assessment

developed by occupational therapists to answer questions about factors

that influence performance in everyday life. The minimal requirements for
an adequate CFE comprise the first three stages and the final stage of the
environmental assessment. Stages (4) and (5) should be carried out when an
in-depth assessment is needed. Within each stage, the therapist can choose
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from assessments that will provide the necessary information for each stage
of the CFE. The length of the evaluation process will vary, depending on
the severity and complexity of the clients’ cognitive disabilities.

Stage (1): Interview and Background Information

The purpose of the first stage is to construct the clients occupational

profile (occupational history, current occupational status, and future

FIGURE 1. CFE process.

 Hartman-Maeir et al. 5

occupational goals) along with his/her self-awareness of deficits and dis-

abilities. The first step is to determine the client’s level of awareness, since
it cannot be assumed that persons with suspected cognitive deficits have
a realistic view of their condition. Methods to evaluate awareness include
interviews with questionnaires, comparison between the answers of the
individual and a proxy, comparison to test performance, and prediction be-
fore an evaluation and after task performance (Fleming et al., 1996; Katz
& Hartman-Maeir, 2005; Lezak et al., 2004; Prigatano, 1986; Toglia, 1993,
2005).
The Self-Awareness of Deficit Interview (SADI) (Fleming et al., 1996)
is recommended for use as an initial measure of awareness. The SADI
includes three awareness parameters: awareness of deficits, awareness of
disabilities, and ability to set realistic goals. The final score is based on
comparing clients’ responses to reliable sources of information such as
the report of a proxy, medical chart, or observation of performance. Fol-
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lowing the evaluation of self-awareness, information about occupational

history and activities performed in daily functioning is obtained from the
client and/or the caregiver (if unawareness was detected) to determine
the person’s interests and experience with activities that can be used to
build daily routines. Daily routines may be obtained with an Occupational
Questionnaire (OQ) that lists activities during a 24-hr typical day (Smith,
Kielhofner, & Watts, 1986; can be downloaded from the MOHO Clearing-
house). It is further obtained with the Activity Card Sort (ACS) for adults
(Baum & Edwards, 2001) or the Pediatric Activity Card Sort (PACS) for
children ages 6–14 (Mandich, Polatajko, Miller, & Baum, 2004) and the
Preschool Activity Card Sort (PreACS) for children ages 3–6 (Berg &
LaVesser, 2006). To complete the initial interview the Canadian Occupa-
tional Performance Measure (COPM) (Law et al., 1998) is administered to
gain understanding of the client’s occupational goals and the activities of
their choice (see Table 2).

Stage (2): Cognitive Screening and Baseline Status Tests

The purpose of this stage is to portray a preliminary profile of the clients’

cognitive abilities and deficits using standardized instruments (see Table 2)
that have had their psychometric properties determined. In order to estab-
lish a basic knowledge of the cognitive abilities and deficits of the client,
the occupational therapist can choose the appropriate tests depending on
the client’s age, diagnosis, stage of illness, setting, etc.
 6 OCCUPATIONAL THERAPY IN HEALTH CARE

TABLE 2. Examples of Instruments Used at Stages (1)–(3) of the Cognitive

Functional Evaluation (CFE)

(3) General Measures of

(2) Cognitive Screening and/or Cognition and Executive
(1) Initial Interview Baseline Status Tests Functions in Occupation

Self-Awareness of Deficits Mini Mental Status Examination Routine Task Inventory

Interview (SADI)
(Fleming et al., 1996)
Brief occupational history Short Blessed test (Katzman et
and Occupational
Questionnaire (OQ)
(Smith et al., 1986;
MOHO Clearinghouse
related resources
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(MMSE) (Folstein & Folstein, Extended (RTI-E) (Katz,
1975) 2006) www.allen-
cognitive-network.org
Cognitive Performance
al., 1983) Test (CPT) (Burns,
2006)
www.Maddak.com

www.moho.uic.edu)

Activity Card Sort (ACS) Clock drawing tests (Freedman Assessment of Motor and
(Baum & Edwards, et al., 1994) Process Scale (AMPS)
2001), (Fisher, 2006a, 2006b),
Pediatric Activity Card The School AMPS (Fisher
Sort for children (PACS) et al, 2005)
(Mandich et al., 2004), www.ampsintl.com
Preschool Activity Card
Sort (PreACS) (Berg &
LaVesser, 2006)
Allen Cognitive Levels Screen Executive Function
(ACLS-5; LACLS-5) (Allen et Performance Test
al., 2007) www.allen- (EFPT) (Baum et al.,
cognitive-network.org 2003)
http://crrg.wustl.edu/
outcome
assessment.html.

Cognistat (Mueller et al., 2007) Kettle Test

Canadian Occupational
Performance Measure
(COPM) (Law et
al.,1998)
www.cognistat.com
Loewenstein Occupational
Therapy Cognitive
Assessment (LOTCA)
(Izkovich et al., 2000)
www.Maddak.com
(Hartman-Maeir et al.
2007) The test can be
acquired from the first
author.
Revised Observed Tasks
of Daily Living
(OTDL-R) (Diehl et al.,
2005)
(Continued on next page)
 Hartman-Maeir et al. 7

TABLE 2. Examples of Instruments Used at Stages (1)–(3) of the Cognitive

Functional Evaluation (CFE) (Continued)

(3) General Measures of

(2) Cognitive Screening and/or Cognition and Executive
(1) Initial Interview Baseline Status Tests Functions in Occupation

Loewenstein Occupational
Therapy Cognitive Assessment
Geriatric (LOTCA-G) (Elazar et
al., 1996) www.Maddak.com
Dynamic Occupational Therapy
Cognitive Assessment for
children (DOTCA-Ch) (Katz et
al., 2005) www.Maddak.com
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The Mini Mental Status Examination (MMSE) (Folstein & Folstein,

1975) and the Short Blessed test (Katzman, Brown, Fuld, et al., 1983) are
used extensively as screening tools for dementia by health professionals.
Clock drawing tests are used in a variety of ways to assess visual-spatial
neglect, spatial organization, memory, and executive functions (Freedman
et al., 1994). The only cognitive screen test developed in occupational
therapy is the Allen Cognitive Level (ACL), currently version ACL-5
(LACL-5 for geriatric), that has a new revised manual (Allen et al., 2007).
Extensive research on its psychometric properties exists in psychiatric
and dementia populations (Allen et al., 2007; Allen & Blue, 1998; Allen,
Earhart, & Blue, 1992).
An additional subcategory of cognitive screening tests include baseline
status batteries that provide a profile of cognitive components (instead of
global scores). For example, the Cognistat (Mueller, Kierman, & Langston,
2007) was developed by neurologists for bedside testing and is used with
permission by health professionals. It includes attention, language (naming
and comprehension), and calculations and reasoning (similarities and judg-
ment). The subtests also provide a profile of the deficits and their severity.
Studies in a variety of client populations in which brain dysfunction is
suspected show that the Cognistat is sensitive in detecting cognitive im-
pairments, differentiating between groups, as well as measuring changes
over time (Katz, Elazar, & Itzkovich, 1996; Katz, Hartman-Maeir, Weiss,
& Armon, 1997; Lezak et al., 2004; Mueller et al., 2007, see extensive
reference list at www.cognistat.com).
 8 OCCUPATIONAL THERAPY IN HEALTH CARE

The Loewenstein Occupational Therapy Cognitive Assessment

(LOTCA), LOTCA Geriatric version (LOTCA-G), and the Dynamic Oc-
cupational Therapy Cognitive Assessment for children (DOTCA-Ch) are
standardized instruments that have been studied in various populations
with suspected cognitive deficits (Bar-Haim Erez & Katz, 2003; Cermak
et al., 1995; Elazar, Izkovitch, & Katz, 1996; Katz, Parush, & Traub Bar-
Ilan, 2005; Itzkovich, Averbuch, Elazar, & Katz, 2000). These assessments
were developed by occupational therapists to assess cognitive skills that
underlie everyday functioning in the areas of orientation, visual and spa-
tial perception, praxis, visuomotor construction, thinking operations, and
memory. The aim of these assessments is to provide a profile to understand
the cognitive skills necessary for occupational performance. The specific
deficit areas can clarify clients’ difficulties in task performance and inform
about strategies that can be incorporated into treatment planning. In the
new version for children, a dynamic graded cueing system is included that
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provides learning potential, enabling treatment guidelines beyond static

assessment of here and now (Katz, Goldstand, Traub Bar-Ilan, & Parush,
2007). An application of the dynamic system to the LOTCA for adults and
elderly is underway.
At this stage of the process the occupational therapist should have a
good idea about the clients’ level of self-awareness, their previous and cur-
rent occupational performance and participation, as well as their cognitive
strengths and limitations.

Stage (3): General Measures of Cognition and Executive Functions

in Occupation

Based on the previous stage, the assessments conducted during the

third stage are designed to examine the functional impact of cognitive
deficits, as well as to discover potential deficits in higher-order cognition
(i.e., executive functioning) that may not have been yet identified. The
instruments that are listed as examples in this category represent global
measures of cognition in performance, as well as assessment designed to
specifically target executive functioning in occupational performance.
The Cognitive Performance Test (CPT) and Routine Task Inventory
Extended (RTI-E) are assessments that stem from the Cognitive Disabilities
model (Allen et al., 1992). Each is a standardized test of cognition in
function which is administered while the individual is performing a task.
The CPT comprises a battery of six basic and instrumental activities of
daily living (ADL and IADL) simulated tasks (Burns, 2006), and the RTI-E
 Hartman-Maeir et al. 9

(Katz, 2006) is a rating scale based on the observation of 30 tasks in four

occupational areas (ADL, IADL, communication, and work readiness).
The scores of both the CPT and RTI-E follow the hierarchy of cognitive
levels developed by Allen et al. (1992). Research about their psychometric
properties exists in psychiatric and dementia populations (Allen et al.,
1992; Allen & Blue, 1998; Bar-Yosef, Weinblatt, & Katz, 1999; Burns,
2006; Katz, 2006; Levy & Burns, 2005).
The Assessment of Motor and Process Scale (AMPS) (Fisher, 2006a,
2006b) derived from the Model of Human Occupation (Kielhofner, 2002),
was developed to assess the performance subsystem supporting the per-
formance capacity of the individual. The Process scale of the instrument
represents observable, integrated cognitive functions. The AMPS currently
includes a large number of ADL and IADL tasks from which the client
and therapist choose two to three tasks that are familiar to the person. The
scoring yields both a motor and a process scale score and it also describes
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levels of independence. The AMPS is the most studied measure in occu-

pational therapy and has been standardized on over 100,000 individuals
worldwide (Fisher, 2006a; and see www.ampsintl.com for updated refer-
ence list). Recently, The School AMPS (Fisher, Bryze, Hume, & Grswold,
2005) was developed for measuring school-related tasks. The use of the
AMPS requires a 5-day training course, with a following calibration pro-
cess. This training process contributes to the reliability of the measure but
limits it’s accessibility to practitioners.
The Executive Function Performance Test (EFPT) is a performance-
based standardized assessment of cognition and executive function (Baum,
Morrison, Hahn, & Edwards, 2003). The Kitchen Task Assessment (KTA),
an earlier functional assessment test designed by Baum and Edwards
(1993), was used as the prototype in developing the EFPT. The EFPT
includes four standardized IADL tasks (cooking, telephone use, medica-
tion management, and bill paying) that the client performs with graded
cues provided by the therapist as needed. The EFPT serves three purposes:
to determine which executive function components are deficient (initia-
tion, organization, sequencing, judgment and safety, and completion); to
determine an individual’s capacity for independent functioning; and to de-
termine the type of assistance necessary for task completion. The EFPT has
been validated in studies with individuals with stroke, multiple sclerosis,
and schizophrenia (Baum et al., 2003, in press; Goverover et al., 2005;
Katz, Felzen, Tadmor, & Hartman-Maeir, 2007).
The Kettle Test (Hartman-Maeir, Armon, & Katz, 2005, 2007) is a
newly developed, brief performance-based test that comprises a task of
assembling an electric kettle and preparing two different hot beverages.
 10 OCCUPATIONAL THERAPY IN HEALTH CARE

Following completion of the task the therapist engages the client in a

debriefing that focuses on the client’s evaluation of the performance. Task
selection was designed to require basic cognitive abilities like attention,
perception, praxis, and memory, as well as requiring higher-order executive
functions by providing unusual and complex conditions (the kettle is empty
and disconnected; target ingredients are situated within distracters). Recent
studies provide support for high interrater reliability and concurrent and
ecological validity in elderly samples with stroke and suspected dementia
(Harel, Mizrachi, & Hartman-Maeir, 2007; Hartman-Maeir, Harel, & Katz,
in press).
The revised Observed Tasks of Daily Living (OTDL-R) is a
performance-based test that requires problem solving in IADL tasks (Diehl
et al., 2005). It includes nine tasks in three areas: medication use, telephone
use, and financial management. The test is able to discriminate between
groups with cognitive impairments and associated categorization and de-
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ductive reasoning measures (Goverover & Hinojosa, 2002; Goverover &

Josman, 2004).
In general, after stage (3) of the evaluation process it is determined
if more in-depth cognitive testing is necessary. When severe deficits are
detected in the screening/baseline process, the cognitive testing can be
stopped at this point, unless specific deficits such as unilateral spatial
neglect, attention, memory, executive functions, or unawareness require
more in-depth understanding. The environmental assessment should be
done at this point if stages (4) and (5) are not necessary.

Stage (4): Cognitive Tests for Specific Domains

The purpose of this stage is to provide an in-depth understanding of

specific cognitive domains, such as attention, memory, and executive func-
tioning. The tests recommended for use at this stage target these domains
through tasks designed to simulate functional real-world requirements (see
Table 3). The Behavioral Inattention Test (BIT) (Wilson, Cockburn, &
Halligan, 1987) assesses visual-spatial attention and unilateral neglect;
the Test of Everyday Attention (TEA) (Robertson, Ward, Ridgeway, &
Nimmo-Smith, 1994) assesses sustained, selective, and divided attention
in visual and auditory modalities; the Rivermead Behavioral Memory Test
(RBMT) (Wilson, Cockburn, & Baddeley, 1985) assesses recall, recog-
nition, and prospective memory in visual and auditory modalities; and
the Behavioral Assessment of Dysexecutive Syndrome (BADS) (Wilson,
Alderman, Burgess, Emslie, & Evans, 1996) assesses executive functions
 Hartman-Maeir et al. 11

of shifting, planning, and multitasking. Data from these tests provide thera-
pists with a more in-depth understanding of the cognitive-based difficulties
a client might have in performing daily routine tasks, as well as in per-
forming more complicated and novel occupations. All four instruments
mentioned are standardized and have been studied extensively with vari-
ous populations; three of them now also have children versions (TEA-Ch,
Manly et al., 2001; RBMT-C, Wilson, Ivani-Chalian, & Aldrich, 2005;
BADS-C, Emslie, Wilson, Burden, Nimmo-Smith, & Wilson, 2003).
An additional facet to assessing specific cognitive domains in occu-
pational therapy is provided by dynamic cognitive assessment, adding
learning potential and metacognition to the assessment (Toglia, 2005).
Two instruments listed in this category are the Contextual Memory Test
(CMT) (Toglia, 1993) and the Toglia Categorization Assessment (TCA),
with a Deductive Reasoning (DR) part (Toglia, 1994). The unique fea-
ture of both tests is the dynamic component consisting of a graded cueing
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system, which provides a measure of both current level of ability in mem-

ory or categorization, as well as the learning potential when mediation
is provided. In addition, incorporated in these tests is the evaluation of
intellectual and task-specific online awareness that enables the therapist
to see whether the client’s level of awareness changed during the perfor-
mance of the task (Toglia & Kirk, 2000). Both tests were developed for
clients following traumatic brain injuries but were further studied in clients
with schizophrenia, as well as in children with traumatic brain injuries and
ADHD (Goverover & Hinojosa, 2004; Josman, 2005; Josman, Berney, &
Jarus, 2000a, 2000b).
If further cognitive testing is required, particularly for mild cases, or
when functional problems are reported but no deficits were found on initial
measures, referral for extensive neuropsychological assessment is recom-
mended. Stage (5) is necessary to determine the impact of the cognitive
deficits on daily life.

Stage (5): Specific Cognitive Measures in Occupations

The purpose of this stage is to determine the manifestations of the spe-

cific cognitive deficits in occupational performance. The measures listed
under this category in Table 3 address the areas of unilateral-spatial ne-
glect, attention, memory, executive functions, and awareness in functional
contexts.
The ADL Checklist for Neglect (Hartman-Maeir & Katz, 1995) and
the Catherine Bergero Scale (CBS) (Azouvi et al., 2003) are based on
 12 OCCUPATIONAL THERAPY IN HEALTH CARE
TABLE 3. Examples of Instruments Used at the Stages (4)–(6) of the
Cognitive Functional Evaluation (CFE)
(4) Cognitive Tests for Specific
Domains
Behavioral Inattention Test (BIT)
(Wilson et al., 1987)
Test of Everyday Attention (TEA)
(Robertson et al., 1994)
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For children: TEA-Ch (Manly et
al., 2001)
Rivermead Behavioral Memory
Test (RBMT) (Wilson et al.,
1985); For children: RBMT-C
(Wilson et al., 2005)
Behavioral Assessment of the
Dysexecutive Syndrome
(BADS) (Wilson et al., 1996)
For children (BADS-C) (Emslie et
al., 2003)
(5) Measures of Specific (6) Environmental
Cognitive Domains in Assessments
Occupations
Unilateral Neglect in ADL Home Occupational
or Catherine Bergego Environmental
Scale (Azouvi et al., Assessment (HOEA)
2003; Hartman-Maeir & (Baum & Edwards,
Katz, 1995) 1998)
Attention Questionnaire Safety Assessment of
(APT-II) (Sohlberg & Function and the
Mateer, 2001) Environment for
Rehabilitation
(SAFER Tool) (Chui
et al., 2006).
Everyday Memory Home Environmental
Questionnaire (EMQ) Assessment Protocol
(Sunderland et al., 1983; (HEAP) (Gitlin et al.,
Wade, 19921 ) 2002)
Executive Functions:
Multiple Errands Test
(MET) hospital and
simplified versions
(Alderman et al., 2003;
Knight et al., 2002)
Dysexecutive
Questionnaire (DEX)
(Wilson et al., 1996)
ProEx: Profile of Executive
Control System
(Braswell et al., 1993)
Behavioral Rating
Inventory of Executive
Functions (BRIEF)
(Gioia et al., 2000)
versions for children and
adults
(Continued to next page.)
 Hartman-Maeir et al. 13

TABLE 3. Examples of Instruments Used at the Stages (4)–(6) of the

Cognitive Functional Evaluation (CFE) (Continued.)

(4) Cognitive Tests for Specific (5) Measures of Specific (6) Environmental
Domains Cognitive Domains in Assessments
Occupations

Contextual Memory Test (Toglia, Awareness:

1993); Toglia Categorization
Assessment Test (Toglia, 1994)
in both awareness of
performance is assessed
pre-and post-testing
Prigatano Competence
Rating Scale (PCRS)
(Prigatano, 1986)
Assessment of Awareness
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of Disabilities (AAD)
(Tham et al., 1999)
Self-Regulation Skills
Interview (SRSI)
(Ownsworth et al., 2000)

therapist observations that rate the extent to which neglect is manifested

in activities such as grooming, dressing, and eating, as well as reading,
writing, and mobility (Barret et al., 2006; Katz, Hartman-Maeir, Ring, &
Soroker, 1999). In a broader perspective on attention deficits (not only
visual-spatial) that are common after most acquired brain injuries, the
APT-II Attention Questionnaire (Sohlberg & Mateer, 2001) measures the
manifestation of attention deficits in daily functioning. Client and proxy
should answer this questionnaire to get a more complete picture.
Memory loss has a major impact on daily functioning and occupational
performance. The Everyday Memory Questionnaire (EMQ) (Sunderland,
Harris, & Baddeley, 1983) is an example of a measure for memory disability
in terms of the frequency of forgetting things in everyday activities. Twenty-
eight statements of memory problems are listed, and the person and his/her
proxy are asked how frequently they have encountered these problems.
Factor structure was determined by Cornish (2000) and construct validity
between groups of patients and controls was established by Olsson, Wik,
Ostling, Johansson, and Andersson (2006).
Executive functions are central to complex occupations and should
be tested in complicated, novel situations that require multitasking in
 14 OCCUPATIONAL THERAPY IN HEALTH CARE

daily activities (Burgess et al., 2006; Katz & Hartman-Maeir, 2005).

The Multiple Errands Test (MET) is an assessment of executive
functions in daily life developed originally by Shallice and Burgess
(1991), especially for high functioning patients. It is a multitasking
assignment that consists of three main assignments which need to be
performed in a mall-like setting or shopping center. The tester accom-
panies the participant, recording performance and errors of different
kinds.
The MET has been found to have ecological validity in that it was
moderately correlated with most of the items in the Dysexecutive Ques-
tionnaire (DEX), which assesses executive functions in everyday life
(Alderman, Burgess, Knight, & Henman, 2003). The MET-Hospital ver-
sion (MET-HV) and the MET-Simple version (MET-SV) were shown to
distinguish between different client groups and healthy controls (Alderman
et al., 2003; Knight, Alderman, & Burgess, 2002; Levav, Averbuch, &
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Katz, 2006; Revach & Katz, 2005). Dawson et al. (2005) found cor-
relations within a post-stroke participants group between the MET and
everyday functional ability assessed using the AMPS and self-report
measures.
The DEX is provided together with the BADS battery (Wilson et al.,
1996), however it is used as a separate measure. The DEX includes a
20-item questionnaire that samples the range of problems in four broad
areas of likely change due to executive impairment: emotional or per-
sonality changes, motivational changes, behavioral changes, and cognitive
changes. Two versions of the DEX exist: one for the client’s self-rating
and one for an independent rater. Significant correlations were found be-
tween the DEX and the BADS profile score, thus validating that both
measures can be used separately or combined and provide two different
aspects of the executive function abilities and manifestation in everyday
life.
The Pro-Ex (Braswell et al., 1993) is a rating scale for adults with
neurological deficits which the therapist scores in the areas of goal selec-
tion, planning, initiation, execution, time management, and self-monitoring
based on observations, interview with caregiver, or functional testing in
daily occupations.
The Behavioral Rating Inventory of Executive Functions (BRIEF)
(Gioia, Isquith, Guy, & Kenworthy, 2000) is a comprehensive rating scale of
executive functioning in daily life, including eight separate executive scales
(inhibit, shift, emotional control, working memory, planning, organization,
and monitoring). Three versions of the BRIEF exist, for preschoolers (ages
3–5), children (ages 5–18), and adults. Extensive studies have been done on
 Hartman-Maeir et al. 15

these measures with excellent psychometric data on reliability and validity,

especially for individuals with ADHD.
Finally, evaluation of self-awareness in daily activities is needed to
understand to what extent clients can take responsibility for their re-
habilitation/treatment process. Methods for assessing awareness include
comparisons between the client and proxy responses on various question-
naires and comparisons between clients’ response and actual performance.
The Prigatano Competence Rating Scale (PCRS) (Prigatano, 1986) is an
example of one method, comprised of thirty daily activities or social en-
counters which the client and a proxy (relative or therapist) complete. The
discrepancy between the two ratings comprises the awareness score, with
overestimation (clients rate self higher than the proxy) indicating unaware-
ness of their daily performance and social behavior. The instrument was
found to be reliable and valid in individuals with acquired brain injury
(Prigatano, 2005; Prigatano, Borgaro, Baker, & Wethe, 2005).
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The Assessment of Awareness of Disabilities (AAD) (Kottorp & Tham,

2005; Tham, Bersnpang, & Fisher, 1999) is an example of another method
that assesses the discrepancy between the client’s perceived ability in re-
sponse to a structured interview and his/her observed ADL ability as scored
on the AMPS. The AAD has demonstrated acceptable reliability (between
raters and over time), internal consistency, and sensitivity to change (Tham
et al., 1999; Tham, Ginsburg, Fisher, & Tenger, 2001).
The Self-Regulation Skills Interview (SRSI) (Ownsworth, McFarland,
& Young, 2000) emphasizes emergent and anticipatory awareness in every-
day context. The SRSI is a measure of metacognition in post acute rehabili-
tation of TBI patients in an interview format including six questions applied
to a main area of difficulty experienced by the client. Significant differences
were found between groups (brain injury and healthy controls), and signifi-
cant correlations were found with the SADI (Wise, Ownsworth, & Fleming,
2005).

Stage (6): Environmental Assessment

The final stage is to provide the therapist with information about the
environment and the context in which the client with cognitive disabili-
ties has to function. Because occupational therapists understand that an
individual’s abilities can be optimized by environments that support their
ability to use their skills, it is critical to look at the natural environment of
the person, especially the physical and human environment. Many prac-
titioners visit the client’s home to determine the safety of the physical
 16 OCCUPATIONAL THERAPY IN HEALTH CARE

environment. It is critical that people with cognitive loss have the envi-
ronment assessed to determine if they have the cognitive capacity to live
alone.
Three examples of assessments that focus on home safety are presented.
The Home Occupational Environmental Assessment (HOEA) (Baum
& Edwards, 1998) is a checklist designed to identify how the home envi-
ronment supports occupational performance and the safety of the person
being assessed. It is particularly useful for clients with visual and cog-
nitive impairments. It is completed by a therapist while in the client’s
home and requires approximately 20 min. The HOEA checklist covers
issues such as accessibility within the home, sanitation, food storage,
safety issues, and lighting at the point of common tasks. The scoring
indicates the independence of the person and indicates when assistance is
need.
The second tool is the Safety Assessment of Function and the Envi-
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ronment for Rehabilitation (SAFER Tool) (Chui et al., 2006) that was
designed to help therapists assess the client’s ability to safely carry out
functional activities at home. It can be used with adults with cognitive
impairments, mental health problems, physical disabilities, and complex
needs. It includes 75 items in 12 categories of concern, including mobil-
ity, kitchen use, hazards, wandering, and communication. Level of safety
risk is rated on a 4-point scale, with higher scores indicating more se-
vere environmental problems. Internal consistency reliability and initial
support for validity is reported (Asher, 2007). Most clinicians report that
the SAFER Tool is valuable because it provides a comprehensive assess-
ment of safe function at home and provides useful ideas for environmental
interventions.
The last instrument, the Home Environmental Assessment Protocol
(HEAP) (Asher, 2007; Gitlin et al., 2002) comprises a caregiver inter-
view and direct observation designed to assess the home environment of
individuals with dementia and provide recommendations for home modi-
fications. The HEAP includes 192 items in eight areas of the house such
as bedroom, kitchen, and bathroom that are scored for presence/absence of
safety hazards, adaptations, visual cues, and comfort. High interrater agree-
ment was found and preliminary studies support content and convergent
validity (Gitlin et al., 2002) (see Table 3).

SUMMARY

The specific purpose of the CFE is to guide the evaluation of individ-

uals with suspected cognitive disabilities in a systematic decision-making
 Hartman-Maeir et al. 17

process. This evaluation process is critical to enable a comprehensive un-

derstanding of the client’s cognitive status, as well as his/her potential
in the various cognitive components as they are reflected in occupational
performance. At the end of this process the therapist should have a thor-
ough knowledge of the client’s cognitive strengths and weaknesses in
occupational performance, as well as the impact of contextual factors on
performance. It is recommended that this evaluation process will guide the
occupational therapist when a client with suspected cognitive deficits must
be evaluated and recommendations for intervention must be formulated.
As there is a range of instruments in each stage, the therapists can choose
the assessments that are most appropriate to the individual being evalu-
ated, taking into account demographic, illness, and contextual variables.
However, the decision making throughout the stages should be recorded
and explained in a final report.
The issues faced by individuals with cognitive dysfunctions demands
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interdisciplinary work to link the brain, behavior, and performance in every-

day life. Occupational therapists can lead the process with their knowledge
in cognition and its impact on occupational performance in real life and in
ecological contexts.

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Received: 31 Aug 2008
Revised: 20 Apr 2008
Accepted: 05 May 2008
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