Cognition & Everyday Functional Activity in Persons with

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Cognition & Everyday Functional Activity in Persons with Multiple Sclerosis Goverover Yael, PhD, OTR/LAssociate ProfessorDepartment of Occupational Therapy

• Activities of daily leaving (ADLs) and MS

• Cognition and ADLs

• Problems related to ADLs measuremento Sample of behaviors,

o Tools were not designed to the specific needs of MS

o Self-reports

• Development of an ADL assessment tool specific to the needs of

MS

• Summary

Overview

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Activities of Daily Living (ADL)Three areas of activities of daily living:

• Personal ADL : Self-care skills

• Instrumental ADL (IADL): tasks that require both motor and cognitive skills for successful completion.

• Advanced ADL: which also relate to participation: work, community integration.

Limitations in ADL

• Limitations in ADLs can be conceptualized as an individual's inability to participate in various activities due to a confluence of medical and psychosocialcomorbidities.

• Some people with MS are minimally affected, while others progress rapidly to total disability.o Most people falling between these two extremes

• Impairments in ADLs occur in two-thirds of people with MS

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• Activities of daily leaving and MS


• Problems related to measuremento Sample of behaviors, tools were not designed to specific needs of MS

o self-reports

• Development of the Actual reality

• More use of AR

• Summary

Overview

ADLsMotor Functioning

StrengthMuscle tone

Gross and fine motor skills

Balance and coordination

Sensory processingSensory motor

integrationVisu-spatial

Cognitive functioning

CommunicationProblem solving

Self-managementLearning

Processing speed

Psychological functioning

Emotional states, coping,

Self-concept and self-identity

Social functioning Personal and

group interactions

What are the reasons for limitations in ADLs?

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Relationship between cognitive impairments and activity limitations in MS

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Cognitive Impairments

Information processing speed/

efficiency; Executive functions; Learning

and Memory

Subjective: Self-report

Objective: BICAMS,MACFIMS

Activities of Daily Living

Cooking, money management,

paying bills, using internet, over all functional status

Subjective: Self-report

Objective: Performance based



• Problems related to ADLs measuremento Sample of behaviors,

o Tools were not designed to specific needs of MS

o Self-reports


• More use of AR

• Summary

Overview

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• Studies of everyday life activities have been significantly limited

• Most notably by a lack of reliable and sensitive measures of everyday life functioning

Problems with ADL measurement

Sample of behaviorsNot designed specifically for MS

Cooking tasks

BiasedAssociated with affective

symptomatology

Example: Use of the Executive Functions Performance Tests (designed for dementia)

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MS (n = 60) HC (n = 30) p

EFPT-Total 7.4 ± 6.1 4.5 ± 3.5 .04

Simple Cooking 2.2 ± 2.5 1.7 ± 2.0 ns

Using the Phone .79 ± 1.4 .32 ± 1.1 ns

Complex Cooking 3.0 ± 2.9 2.6 ± 2.2 ns

Taking Medication .4 ± .8 .006 ± .3 .04

Paying Bills 1.2 ± 1.9 .29 ± 1.7 .01

Executive Functions Performance Tests (EFPT): Comparison between HC and MS

Goverover, et al. (2005)

Cognitive abilities and performance of IADL in MS (EFPT)

Hand washing

Cooking oatmeal

Telephone Medication Bill payment

Cooking casserole

Executive control

.07 -.25* -.30* -.39** -.46*** -.48***

Processing speed

.19 -.21 -.18 -.50*** -.36* -.43**

New learning

.05 -.10 -.12 -.26* -.32* -.36**

Working memory

-.13 -.19 -.16 -.16 -.24* -.22

Basic attention

-.01 -.03 .02 -.27* -.13 -.20

Visuospatialfunction

.20 -.01 -.03 -.20 -.29* -.20

Kalmar, et al. (2008)

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Goverover, et al.(2005)

No correlation between objective performance and subjective ratings

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72 Participants with MS%

Gender Female 90

Male 10

Education LevelUniversity 79

High School 21

Employment statusWorking part and full-time 39Full disability pension 56Retired 4Other # 1

AidsADL mobility devise 46Do not use aid, report motor impairments 32No weakness or aid use 15

Engagement in IADL: Cooking

Participants were asked to answer 5 specific questions related to their cooking experience.

(1) Do you cook? (2) How frequent do you cook? (3) Do you have any cooking experience? (4) Describe previous specific cooking

experience (i.e. breakfast foods)(1) If you do cook breakfast foods, how often do you do so?

Score could range from 0 (not cooking at all and no previous cooking experience) to 13 (cook often in the present and past)

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Comparison between persons who cook and who do not cook

Cookers (N = 54)Mean

Non-cookers (N = 18)Mean P-value

Visual Memory-Immediate 47.4 42.7 ns

Visual Memory-Delayed 47.9 46.1 ns

Fluency 41.2 34.7 .06

Visual Perception 22.9 22.4 ns

Working Memory (PASAT) 77.1 63.4 .04

Executive Functions 34.2 31.1 ns

Processing Speed 51.9 43.9 .02

Verbal Memory 10.5 13 .02

Cooking activity with psychological functioning, and cognitive test performance

Cooking

State Trait Anxiety Inventory (State Anxiety) -.17

State Trait Anxiety Inventory (Trait Anxiety) -.09

Chicago Multiscale Depression Inventory (Depression) -.07BVMT-R (Visual Learning & Memory)

.16

CFL (Verbal Fluency) .22

JOLO (Visual Perception) .04

PASAT (Working Memory & Processing Speed) .24*

DKEFS Correct Sorts (Executive Functioning) .02SDMT (Processing Speed)

.29*SRT number of trials (Verbal Learning & Memory)

-.26*SRT 30 minutes delay (Verbal Learning & Memory)

.06

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Cognitive Impairment

Relationship between cognitive impairments and activity limitations

Actual Impairment Everyday Life

Affective Symptomatology

Subjective Everyday Life Impairment




o self-reports

• Development of the Actual reality: measurement specific to MS

needs

• More use of AR

• Summary

Overview

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Development of the Actual Reality (AR) Task

• AR is an innovative performance-based assessment approach that involves utilization of the internet to perform actual everyday life activities

AR Study Design• Three internet tasks

– Book airline ticket to Florida: united.com

– Purchasing Cookies: cookiesbydesign.com

– Ordering Pizzapizzahut.com

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AR “Ordering a pizza” Task Example

Order pizza from Pizza Hut for a party today at your friend’s house.

The guests include yourself, 4 children, and two other adults. You should order two large pizzas

Drinks should include a 2 Liter bottle of Diet Pepsi for the party.

You must pay with the credit card which is provided to you in the wallet.

Please try to complete this task as independently as possible. It is important to remember that we want you to complete all steps of the order up until the actual placement of the order. Do not place the order.

Testing Day 1 Testing Day 2

Task 1 Task 2 Task 3 Task 4 Task 5

Flights Cookies Flights Cookies Pizza

Cookies Pizza Cookies Pizza Flights

Pizza Flights Pizza Flights Cookies

Cookies Flight Cookies Flight Pizza

AR Study Design

3 weeks

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Actual Reality Scoring

Goverover et al (2010) Arch Physical Med & Rehab

4 dependent measures Name Description Cognitive skills AR Cog Cognitive skills

requiredcompetent (0)inefficient (1)severe deficit (2)

AR step errors AR ESum Type of cues to correct the errors

0 competent -96 could not perform any step of the task

# errors committed AR ENum Number of errors

0 No errors – 32 at every step

Time to complete task AR Latency Time to complete thetest

Minutes

Flight Cookies Pizza Task ME

Group ME

MS HC MS HC MS HC F FAR-Cog 7.1 3.8 5.7 4.0 7.22 2.4 .39 22.7**

AR-Enum 7.8 6.2 6.3 5.4 8.6 5 .62 5.05*

AR-Esum 17.92 13.56 13.44 11.92 18.89 9.44 .72 5.7*

AR-Latency

16.5 9.8 15.9 10.3 15.8 10.7 .26 9.3**

Comparisons among the three AR tasks between HC and MS (Means)

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Association with MS-Cog (N = 30 MS Only)

SRT SDMT BVMT-R PASAT MS-CogAR Flight: Cog -.25 -.36* -.50** -.36 -.49**

Enum -.10 -.49** -.48** -.21 -.42*ESum -.10 -.51** -.49** -.20 -.43*Latency -.08 -.52** -.34 -.13 -.36ǂ

AR cookies: Cog -.37* -.37 -.24 -.15 -.37*Enum -.17 -.37* -.31 -.46** -.44*Esum -.19 -.34 -.36ǂ -.46** -.45*Latency -.36ǂ -.59** -.37ǂ -.28 -.53**

AR Pizza: Cog -.17 -.50** -.22 -.17 -.37*Enum -.15 -.38* -.33 -.08 -.32Esum -.11 -.41* -.32 -.15 -.34latency -.12 -.56** -.46* -.12 -.43*

**p<.01; *p<.05; ǂ p<.07




o self-reports


• More use of AR: Money Management in MS

• Summary

Overview

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Money Management Activities in Persons with Multiple Sclerosis (Accepted)


Comparisons between MS and HC on Money Management Survey


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Comparisons between MS and HC on Money Management performance using AR


0

10

20

30

40

50

60

70

80

90

Over price Credit card error Choose Notice andrespond

Pace

MSHC

Money management Self-report

Money management Actual Reality

Cognitive domainsSRT-total 6 trials -.05 -.26* BVMT-R immediate recall -.008 -.43**BVMT-R Delayed recall -.03 -.41**SDMT -.10 -.38**D-KEFS-Verbal Fluency -.03 -.33**D-KEFS – color word -.10 -.38**PASAT -.12 -.32*

Affect SymptomatologyCMDI .22 .06Anxiety-State .12 .11Anxiety-Trait .22 .09

Functional StatusFunctional behavior profile -.36** -.30*IADL-self-report -.31* -.28*Actual Reality .21

Correlations between money management with cognitive abilities

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Conclusions

• Performance and self-reports of ADLs of persons with MS is significantly worse then HC

• Cognitive abilities are correlated with performance of ADLs

• It is important to address variables such as context and person characteristics that may moderate this relationship

In sum, processing speed as measured by the SDMT is the most constant and common cognitive capacity related to many of ADLs :

Health Condition (MS)

Environmental Factors

Personal Factors (Education, Fatigue)

Body function & structure

(Processing speed & memory)

Activities(Cooking, managing

finance, using computer)

Participation(Employment,

community integration)

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To end….

• To date, we have developed tools for clinicians and researchers to assess ADLs and functional cognition.

• Self-reported tools are useful to document functional status if questions are very specific and concrete

• These tools allows professionals to document functional cognitive issues and support the patients in offering recommendations to facilitate improved functional cognition in daily life

Acknowledgements:

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• John DeLuca• Nancy Chiaravalloti• Lauren Strober

• RG 2596B2/2 from the National Multiple Sclerosis Society.

• BioGen

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Cognition & Everyday Functional Activity in Persons with