How to be a better OT

How to do a functional cognitive assessment

• Season 1 • Episode 6

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Do you rely solely on pen-and-paper screening tools like the MoCA to assess your clients' cognition? Discover why observing real-life activities is crucial, and learn a step-by-step process for conducting effective non-standardised functional cognitive assessments.

Episode Summary: In this episode of the How to Be a Better OT podcast, host Clare Batkin dives into non-standardised functional cognitive assessments. Clare explains why observing a client completing a functional task, like making a cup of tea or going to the hospital newsagent with a specific goal in mind, often provides better insights into their real-world safety and independence than standard screening tools. She walks you through a step-by-step process covering how to choose the "just right" activity, set up the environment, run the assessment using the pause, prompt, praise framework, and effectively document your findings to support clear and safe recommendations.

 

Key Takeaways:

  • The "Why" Over Pen-and-Paper: Learn why functional assessments reveal the true interaction of cognitive, physical, and sensory deficits that screening tools might miss.
  • Choosing the "Just Right" Task: How to select an activity that is relevant, safe, and challenging enough to reveal difficulties without overwhelming the client, complete with case studies (like Mrs. Smith's showering assessment and Jon's meal prep).
  • Strategic Preparation: Discover how to modify tasks for physical limitations, manage environment logistics, and even embed memory tests into your pre-assessment setup.
  • The Pause, Prompt, Praise Framework: A breakdown of how to run the assessment by holding back to allow problem-solving, delivering graded prompts (from general to explicit), and offering the right kind of praise to keep clients engaged.
  • Documentation and Recommendations: Tips for using data collection templates, choosing between step-by-step or subheading documentation styles, and translating your clinical findings into actionable recommendations for NDIS planners and hospital discharge teams.

 

Links & Resources Mentioned:

  • Deep Dive: Watch the in-depth on-demand webinar on functional cognitive assessments, plus get documentation examples and tutorials on self-care and standardised cognitive assessments by joining the Connector Membership.
  • Advanced Learning: Access specific recordings on how to conduct and write recommendations for meal preparation assessments, including how to overlap assessments with capacity-building therapy, by joining the Alliance Membership.

 

If you found this step-by-step guide to functional cognitive assessments helpful, please subscribe, leave a review, and share this episode with a fellow OT! Be sure to tune in next time when we will be talking about how to effectively address pressure injury risks, from identifying risks to making practical recommendations.  

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So we do that setup to ensure that the task will not only be safe but the right level of challenge. It's not to say that we have everything set up perfectly every time. So sometimes we need to unplug the kettle or hide the sugar when doing a simple tea and toast assessment so that our client will have something to problem solve. But the keys to understand why you're setting things up the way that you are. Welcome to the How to Be a Better OT podcast. I'm Claire Batkin, an OT and clinical educator who is on a mission to make professional development simple, practical, and worth it for OTs. If you're ready to step back from the overworld and bring core frameworks to life, join me for step-by-step guides and practical solutions that will build your confidence and confidence so you can deliver the best outcomes for your clients and truly love what you do. Hi and welcome back to another episode of the How to Be a Better OT podcast. In this episode, we're talking about non-standardized functional cognitive assessments. This is basically where we observe a client completing a functional task, like making a cup of tea or going to the news agent in a hospital, so we can assess the impact of any cognitive impairments on their safety, independence, or efficiency. I'll talk you through a step-by-step process with some case study examples so you can learn how to choose the right task to assess and how to set up the expectations and environment for the just right challenge. Then we'll go through how to run the assessment, including the pause, prompt, praise approach and some tips for interpreting and using the results. Now, this will be a short, high-level overview of the process, but if you'd like some more details and some clinical reasoning guides to help you improve your functional cognitive assessment skills, you'll find a more in-depth on-demand webinar is available for my Connector members. There are also many other related topics included in the membership, such as self-care assessments and standardized cognitive assessments. So do go and have a look and see if that might be right for you. I'll drop the link in the show notes. Before we jump into the step-by-step process, let's talk about the why. Why should we do a non-standardized functional cognitive assessment instead of relying on a pen and paper screening tool like a mocker or a miniment tool? The main reason is because someone's performance on a screening tool is not always a reliable indicator of how they'll perform in real life. A functional assessment of the person doing real activities will give us better information about this. So for example, they could score terribly on a mocker, but then perform familiar self-care and basic meal prep tasks needed to live alone independently perfectly safely when they're in their own home environment. Or vice versa, they could do really well on a pen and paper task, but when we throw in the added complexity of multitasking and managing physical and sensory impairments too, more difficulties become apparent. So a functional assessment allows us to see the interaction of cognitive and physical and sensory deficits. In this way, functional cognitive assessments allow us to better judge what support somebody might need to be discharged from hospital or to remain living safely within their own home. And for those who've experienced a new cognitive impairment, such as after a stroke or brain injury, it can help us to judge what the best setting might be for them to continue their rehab and what remediation strategies could be helpful to work on. In terms of who might benefit from a functional cognitive assessment, there are a few potential clues. If people who know them well suggest that their thinking or personality has changed or that something isn't quite right with how they're paying attention, follow instructions or performing their daily activities, then that's worth exploring. Likewise, if someone has a diagnosis where you know cognition is commonly affected, whether it's obvious things like multiple sclerosis or a stroke, or less obvious things like someone experiencing brain fog as a result of a cancer treatment, then it should be part of your reasoning process to rule out that a non-standardized cognitive assessment isn't required, rather than only taking action when someone reports a concern. The key is to know what the goal of performing a functional cognitive assessment would be. Don't just do it for the sake of it to tick a box because they have MS as a diagnosis. Is it necessary to ensure their safety for discharge from hospital because they'll be going home alone? Or is it because you're a community-based OT working within the NDIS and you need to understand why your client has difficulty when performing tasks like meal preparation so you can suggest the right support in your functional capacity assessment report. So once you've decided that doing a functional cognitive assessment will be worth it, how do you know what activity to actually assess? You can't look at every activity that they'll need to do in their day. Nobody has endless time or funding for that. So you've got to come up with an option that will not only help you judge whether they can safely perform that particular activity, but also allow you to make some assumptions and judgments about whether other tasks are likely to be difficult too. The activity we choose to observe as the basis of a functional cognitive assessment can really vary. So it can be something as simple as can they actually follow the sequence of a few familiar steps to put hand cream on their hands? Maybe for someone that's really having low levels of arousal or alertness because they've had a significant stroke, we could start with something as basic as that. And that can tell us things like, can they recognise objects? Can they actually sequence the steps appropriately? If we're giving them a prompt and instruction, are they responding to that? Are they indicating yes or no if we're asking questions as part of the assessment? It can also be something more complex, such as performing their morning self-care routine, including grooming and showering, or completing a basic meal preparation task like a cup of tea and toast, or something more complex like planning out and going on a trip to the shops to purchase some items. The key is to think about which tasks are they currently having difficulty with, and choose something where you'd expect to see that they would still have some difficulty, but not so difficult that they won't be able to do much of the task without significant help or guidance. Now sometimes though we may start at that level for someone in a rehab setting, but for the purposes of a one-off assessment to start with, to explore possible cognitive impairments, we try to get the just right challenge. So here's some examples to try to illustrate that for you. So say you're working with Mrs. Smith, who is an 83-year-old lady admitted to your aged care hospital ward with confusion and deconditioning following a UTI. Normally she lives alone and has a good baseline of function where she's independent with her self-care and basic domestic tasks. But currently on the ward, she's needing prompting to get through her morning routine. Something too basic like putting on hand cream may not actually reveal many issues, while taking her on a shopping trip down to the hospital news agent might be too confusing and even frustrating or distressing for her. So we go with something in the middle and start with a task that she's currently needing some help with, which is having a shower. And we can come back to Mrs. Smith a little later when we talk through what the functional assessment might look like. Another example is that you are a community OT working with John who has Parkinson's disease. You know from the referral that his main areas of difficulty are with his domestic tasks and that he's actually still independent with his self-care tasks like showering, other than a bit of setup help from his partner to put a shower chair in place due to his decreased mobility. Now we may need to assess showering or a simulation of showering at some later stage from a more physical functioning point of view, but it's not likely to tell us lots of helpful information about his functional cognition or about what type of supports he's likely to need from his funder, the NDIS. So for John we might start with a basic meal prep task, such as making a cup of coffee and a sandwich. Once we've got an activity in mind that seems like it'll be the right level of difficulty, also think about how relevant it'll be for your client. Is it something they routinely do and that they'll need to continue to do? If Mrs. Smith normally climbs into a bath rather than having a shower, we may need to rethink our plan and ensure the task itself will be relevant. It's not just relevance but potential safety concerns too. If John never makes his own coffee because that's something his wife does due to the worsening of his tremors and dyskinesia associated with his Parkinson's, and he's worried about burning himself, it's not going to be a relevant or potentially even a safe option to try as our first option. Sometimes we find it tricky to choose a task because the person has physical impairments that will make their performance difficult, even if the task itself will be the right cognitive challenge for them. So in these circumstances, we may be able to modify the task slightly when we're setting it up to accommodate these physical impairments so that they don't overshadow our ability to test the person's cognition. An example could be if we were a hospital OT wanting to take our client on a small shopping trip to the hospital news agency to test their cognition after a motorbike crash, but the patient also happens to have a broken leg that would make mobilizing the 200 meters to the news agency and back a physically challenging experience, we could modify that task. So instead of making him hop that far on crutches, we could get a wheelchair and do the propelling for him, but make sure that he knows that he's in charge of using the signage to problem solve and navigate his way to the news agency. Okay, so now we've chosen the activity and we've thought about how it may need to be modified. What do we need to do in terms of preparation? Well, this will depend on which setting you're working within, but something to consider is whether good preparation could also provide you with an opportunity to do a little bit more cultitive testing. And I'll explain what I mean with an example using Mrs. Smith. We decide we're going to be doing a self-care showering assessment with her on the ward tomorrow morning. Part of the prep will involve the logistics and team communication, like making sure that the nurses know not to help her to have a shower before we get there in the morning. But we could also see Mrs. Smith today and give her some instructions to see how much she can remember tomorrow. We could explain the purpose of the assessment tomorrow, which is something we should be doing regardless, but we can also ask her to remember a few key things for us. It could be that you want her to remember your name and your face and what you'll be doing when you come and see her tomorrow. And we could also make it a little bit more challenging and ask her to remember something specific, such as remembering that she'll need to wear her red shirt tomorrow. Once assessment day comes, you can ask her whether she remembers those things. Then there's a little bit more preparation to do from a practical point of view. So hospital bathrooms can easily become dumping grounds for excess equipment, or the floor could be slippery and wet from the last patient's shower, or towers could require a full search party to be able to find. Expecting the client to clear the bathroom, dry the floor, or hunt for a towel may be setting the bar too high and could wear her out before she even gets to the task of showering. So we do that setup to ensure that the task will not only be safe but the right level of challenge. It's not to say that we have everything set up perfectly every time. So sometimes we need to unplug the kettle or hide the sugar when doing a simple tea and toast assessment so that our client will have something to problem solve. But the key is to understand why you're setting things up the way that you are. So let's recap what we've done so far before moving on to the next part of the process. We've identified why a functional cognitive assessment may be helpful for our understanding of the client's functional needs, and we've chosen an appropriate activity to observe. We've thought about whether we need to modify the task in any way to make it safe and achievable from a physical point of view. And we've done some strategic task or environment setup to help us maximize the type of information that we'll be able to gather about our client's abilities. Now it's time to actually run the assessment. Now there's a particular framework that will be helpful to remember here, the pause prompt praise framework. Say that five times fast. We need to pause and not jump in prematurely when the client first experiences difficulty. We need to give a prompt at the right level when required to ensure that the activity can keep progressing, and we need to praise the client in an affirming and reassuring rather than a patronizing way when they get through the steps of the task. So let's go through each of these elements in a little bit more detail. Let's start with a pause part. If the person is doing an activity and they're about to make a mistake, you don't want to jump in so early that they don't actually get a chance to recognize that mistake, to problem solve their way out of it, and to come up with their own solution. Unless the person is going to do something that's really unsafe, such as put a knife in a working toaster. But when it's safe for them to make mistakes, think can I just pause, hold myself back and see what they do? This is particularly important if the person will be living at home alone and won't have somebody there to ask. You want to be able to judge whether they can problem solve enough to get through the task in a safe way. When you decide that you do need to step in because they've been stuck on a task step for a while, only give them enough information so that they can actually move on to the next step. Don't give them the direct answer straight away. So think, can I give them a bit more of a general prompt? So the prompt could start really nonspecific, such as, where would you normally look for milk if John was having trouble finding the milk in the kitchen? Or does it sound like the kettle's boiling? If these general prompts aren't helpful for John, we need to get more explicit and potentially provide the answer so he doesn't get frustrated and give up on the task completely. We can say the milk will be in the door of the fridge, John, or the kettle isn't boiling, John, why is that? And then finally, the praise part. So if they find a mistake and they fix it, you want to acknowledge that. But it's not about overdoing it with an oh wow, fantastic, you're so clever. It can be something really subtle like, great, let's keep going. You know your client, so think about what sort of praise from you is most likely to keep them engaged with the assessment and something that doesn't become too patronizing. Now the one disclaimer to this type of approach is that it's not how you conduct functional retraining session if you're using something like an errorless learning approach, where you do need to jump in before they make a mistake to help the person learn the correct method. This is different though. What we're talking about here is assessing someone's capability, not retraining their cognitive abilities or ADL skills. So just make sure that you're clear on your purpose before you start. The other thing to think about in terms of running the assessment is how are you going to keep track of the errors or safety concerns you're observing so that you can write about them accurately when it comes time to do your documentation. The more you do this type of assessment, the better your brain will be at holding all that information that you're observing while also being able to make the right call about what prompts to give, but don't expect as a new grad that you'll be able to do this easily. A helpful strategy when you're first getting started is to use a template or data collection form of some description. It may be that your workplace has some templates for doing meal preparation assessments that breaks down the task into a step-by-step process, and at each step there's boxes to either tick, tally, or comment on what type of errors were observed. Or if you don't have something like this available, there are many freely available on the internet that you can find with a bit of a Google search, or you could even use some AI programs to develop your own step-by-step list of task steps that will be highly relevant to the way that the client would normally do that task. Depending on the setting, you may not be able to have this checklist with you, such as, for example, it'd be quite difficult to find somewhere dry to put it while also trying to dodge the spray of a handheld shower hose doing that self-care assessment with Mrs. Smith. So rather than completing it and filling it in as you go, you need to have it available to quickly fill in and to record your observations immediately once you finish the assessment. Whereas when you're observing John's meal prep skills, it might be fine to have the checklist out of the way on the kitchen bench somewhere and just add notes as you go. Just make sure it doesn't become distracting for John or an obvious reminder that he's being assessed because this can impact a person's performance through creating some performance anxiety. Okay, now we're up to analyzing what it was that we observed, what it means for our client's functional capacity, and what recommendations we're going to go on and make. The starting point is to have some clear examples of all the errors or difficulties that you notice your client have during the activity, but also what their strengths were too. While our focus is on cognition, we should still be thinking about what their physical and sensory abilities or limitations were, because when those type of impairments are there, it influences the complexity of the task demands. So for example, if your client now has a hand splint on that restricts their ability to use one hand, or they're getting used to moving around with a four-wheeled walker for the first time, they'll need to be consciously thinking about that during the task and likely problem-solving things like how can I now do this one-handed, or where should I be putting this walking frame when I'm trying to get something out of the fridge? So make sure you think about the physical function like mobility or sensory function like vision when processing what it was that you saw from a cognitive point of view. But like I said, the focus should be on cognition. If you do have a template available in your workplace, or you find one on the internet, you may find that it gives you some great prompts to think about what it was that you observed. It could prompt you to think about what errors occurred at each step of the task, or instead it could break down the task into cognitive skills with examples of what good performance or impairment might look like. So this could be, for example, that for someone like John, you're considering his short-term recalls, such as can he recall how you like to have your coffee if he's making one for you as part of the activity. It could be monitoring how well he can maintain his attention and whether things become more difficult when you test his multitasking abilities by asking him about an unrelated topic while he's working his way through the taste. For Mrs. Smith and her showering assessment, it could be thinking about her planning and organization, such as does she remember to bring her clothes, toiletries, and a towel with her to the bathroom? Or can she problem solve how to use those darn lever style taps in the bathroom that always seem impossible to set to the perfect temperature? You could be either recording all of these observations directly onto a data collection sheet that either goes straight into the medical file as part of your documentation, or you could purely be using it for your own information, so it doesn't need to be tidy. When it comes to the documentation of your assessment in terms of writing up progress notes, I've seen a couple of different approaches. One is to talk about the difficulties or assistance required at each step of the task, or you could document your observations in groups of similar errors or strengths. So, for example, the body of your documentation has a subheading of recall or memory, and underneath are some dot point examples of when difficulties or strengths related to memory were observed. And then you do the same for the next subheading of problem solving. And to be fair, I've also seen examples that combine both these approaches, where it's a bit of a step-by-step analysis while also summarising the key difficulties observed with a few examples noted. There's no set right or wrong way to do it, so I'd always encourage you to start by looking at how most people in your workplace document their functional cognitive assessments, as this is a type of documentation that will likely be expected. But as I always say, we should be questioning is this the best way to be doing this? And if you do have some other ideas for how to write it up, this is something that you could discuss with whoever oversees that decision in your workplace. That's how we might write it for our progress notes, where the audience is other health professionals, so we can use proper cognition terminology and jargon like difficulty modulating attention. But sometimes we'll be needing to outline our findings for a non-clinical audience, such as when writing a functional capacity assessment report. An example could be that John wants to have some support for meal preparation included in his NGIS plan, so we need to assess what his current ability is and also what his priorities and goals are so that we can first come to the right conclusion about what support he might need from a clinical perspective, and then ensure that we're presenting the NGIA planner with enough clear examples so that they can understand why we're making that recommendation. Is it that we'll be recommending John has support worker hours allocated for someone to come in and do the cooking or preparation for him when his wife isn't available to assist? Is it that he has the ability to do some aspects safely, such as to reheat a meal in a microwave? So instead we just want to have some pre-prepared meals funded so that he can maintain his independence on the days when his wife is home late from work? Or is it that he needs some extra OT hours for meal preparation capacity building because he actually loves cooking and wants to explore some compensatory strategies and aids that might allow him to keep doing this? To make the right recommendation, we first need to know what is he currently capable of and what will be an effective support that ensures that he is safe and able to prepare his meals, but we also need to consider John's wishes and priorities. Even if technically he may be able to increase his capacity with some OT help, if he's got many other activities that he wants to prioritize first, such as optimizing his home environment to minimize falls risk, or maybe he wants to work harder with the physios for now, the more realistic option may be the support worker hours, at least in the short term. Once we know the recommendation, we can ensure that our FCA report includes some specific examples of why John is not able to safely prepare a full meal and how we know that what we've proposed will be safe and effective. It doesn't need to be that step-by-step outline of how the assessment went, although if they did come back and ask for some more information, you might need to do it this way. But the starting point is a summary of your observations and the assistance that he required. Now, if you are in a caseload where assessing meal prep skills and making recommendations around this comes up a lot, within my Alliance membership I do have an on-demand recording where we talk through how to do this, including how sometimes our assessments overlap with therapy when we're also trialling strategies and aids. So I'll drop the link to the Alliance membership in the show notes if that sounds like it could be helpful for you. In terms of making recommendations for someone in a hospital setting, often it's centered around whether they'll be safe for discharge. And this shouldn't just be based on their abilities to complete the task that you observed, but what it told you about their cognition and function overall, whether there are likely to be other challenges that they'll experience in other activities too. For example, if we found Mrs. Smith had difficulty with planning and organization and problem solving during her self-care assessment, we may suggest that she has some supervision. Or assistance with this upon discharge, but that she would also benefit from supervision for some other more complex tasks that require the same planning and problem solving too, such as preparing her own meals. Now, chances are she'll do better in her own home environment, but we don't usually have the luxury of being able to complete functional cognitive assessments within someone's home environment. So this is where sometimes erring on the side of caution is common. If she does have family who could move in for the short term to provide some assistance and supervision and to check that she does in fact do better once she's home, that would be ideal. Or we may be recommending that she receive some help from community services instead. The other final consideration I'll mention when you're considering your recommendations is rehab potential. So for people in hospital, do you feel there will be some improvement if they had some more time and opportunity to practice in a rehab ward before going home? Well, for someone like John in the community, it's not rehab as such, but rather is there an opportunity for him to improve his skills from a capacity building perspective? Once you're clear on what you're recommending, make sure that the rest of the involved stakeholders know too. So in a hospital ward, your progress note should make it pretty clear if someone is safe for discharge or whether they need some more time or some extra support prior to discharge. And you should be discussing your reasoning in team meetings too. For someone in a community setting, it may involve giving a handover to the person's family or a support coordinator so they can assist with requesting the supports that will be required. But it's not just the team and others that you're discussing your recommendations with. Make sure you also are having discussions with your client and sharing your thoughts in a way that's appropriate for their level of understanding and where they are in their overall client journey. Okay, that is it. We have reached the end of the how to do a functional cognitive assessment process. Just to recap, remember to always be clear on the purpose of why you're completing a functional cognitive assessment. Think carefully about what activity you should observe and how you should set it up, be mindful of the prompts that you give throughout the assessment, and be observant of non-cognitive factors that may be impacting performance too, and ensure your documentation and recommendations are clear and shared with whoever needs to hear them. If you would like a deeper dive into this topic, there are some relevant webinar recordings within both My Connector and Alliance memberships, including one on completing a self-care assessment that includes some documentation examples showing either the step-by-step approach versus a subheading based on type of difficulty approach. And remember the Alliance membership comes with all the connector content, but in this case it also has an extra recording related specifically to meal preparation, assessment, and recommendations. Thanks for sticking around to the end. I hope you found this episode helpful. If you did, come back for the next episode where we'll be talking about how to effectively address pressure injury risks. So we'll cover everything from identifying the risks to making practical recommendations that will improve your client's safety and comfort. I'll talk to you then. The information shared on this podcast is for general educational use only, so please always use your own clinical reasoning and seek appropriate professional supervision for any individual client situations. If you'd like to learn more with your OT tutor so that you can be a better OT who loves what you do, check out the EuroT Tutor website. The links will be in the show notes. There are free resources in the Learning Library, paid CPD memberships, online courses, supervision and mentoring opportunities, and options for your team to all learn together with me.