The Validity of Using the CanadianOccupational Performance Measure with

Older Adults with and withoutDepressive Symptoms

Martina C. McNulty, PhD, OTR/LAngela L. Beplat, MS, OTR/L

ABSTRACT. No studies could be found that investigated the use of theCanadian Occupational Performance Measure (COPM) with older adultswith clinically significant depressive symptoms. This retrospective studyutilized a sample of community-living older adults, ten with a clinicallysignificant number of depressive symptoms (CDS) and a matched sampleof persons who did not have a CDS. Older adults with CDS identifiedsignificantly more occupational performance concerns on the COPM.The top five concerns identified for participants with CDS were walkingand/or transfers, travel, house cleaning tasks, self-care, and shopping.The results of this pilot study support the use of COPM with older adultswith CDS.

KEYWORDS. Depression, mood disorders

Martina C.McNulty is Assistant Professor, Division of Occupational Therapy atCollege of Health in the University of Utah, Salt Lake City, UT.

Angela L. Beplat is affiliated with Programs for Infants and Children in Anchorage,Alaska.

Address correspondence to: Martina C. McNulty, PhD, OTR/L, Division of Oc-cupational Therapy University of Utah, 520, Wakara Way, Salt Lake City, UT(E-mail: tina.mcnulty@hsc.utah.edu).

The authors thank Rebecca Good, MOTS, for her editorial assistance with thismanuscript.

Physical & Occupational Therapy in Geriatrics, Vol. 27(1), 2008Available online at http://potg.haworthpress.com

C© 2008 by Informa Healthcare USA, Inc. All rights reserved.doi: 10.1080/02703180802206231 1

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2 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

INTRODUCTION

Occupational therapists have become interested in clients’ self-perceived occupational performance concerns due to the increasingrecognition of the importance of client-centered care (Law, Baptiste, &Mills, 1995). One can argue that the method most used for assessmentof self-perceived occupational performance limitations is the CanadianOccupational Performance Measure (COPM). This tool has been usedextensively with older adults with varying diagnoses and has yielded clin-ically useful results (Atwal & Owen, 2003; Chan & Lee, 1997; Ward,Jagger, & Harper, 1996.) However, no studies were found that inves-tigated the use of the COPM with older adults with clinically signifi-cant depressive symptoms. This is despite the evidence that older adultswith depressive disorders are more likely to experience activity limita-tions in the future than their nondepressed cohorts (Cronin-Stubbs et al.,2000; Penninx, Leveille, Ferrucci, Van Eijk, & Guralnik, 1999). Theaim of this study was to investigate the validity of using the COPMwith older adults with a clinically significant number of depressivesymptoms.

Depression is the most prevalent psychiatric diagnosis in adults over theage of 65 (Dalton & Busch, 1995). To meet the criteria for the diagnosis ofmajor depression, a person must report or display a low mood or a loss ofinterest in previously enjoyed activities that lasts at least two weeks and isaccompanied by three other signs or symptoms of depression (AmericanPsychiatric Association, 2000). These signs and symptoms include sleepdisturbances, weight loss or gain, thoughts of harming oneself, problemswith concentration or memory, low energy, fatigue, and psychomotor agi-tation or retardation.

Minor depression, also known as mild or subclinical depression in theliterature, is a recognized diagnosis that is based on the presence of asignificant number of depressive symptoms that fall short of meeting thecriteria of major depression but still negatively impact older adults’ qual-ity of life and participation in daily activities (Badger, 1998). Similar tomajor depression, minor depression is associated with an increased riskof physical disability, medical illness, major depression, and high levelsof accessing health services in older adults (Cronin-Stubbs et al., 2000;Hybels, Blazer, & Pieper, 2001; Lyness, King, Cox, Yoediono, & Caine,1999).

Due to the relationship between depressive disorders and declines inoccupational performance (Girard, Fisher, Short, & Duran, 1999; Oak-ley, Khin, Parks, Bauer, & Sunderland, 2002; Schulman, Gairola, Kuder,

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McNulty and Beplat 3

& McCulloch, 2002), self-identified occupational performance concernsalso need to be studied in-depth in older adults. Occupational therapistsneed to be aware of the profound impact symptoms associated with ma-jor and minor depression can have on functional activities of daily living(ADL) or instrumental activities of daily living (IADL) evaluation andoutcome measures (Chesworth, Duffy, Hodnett, & Knight, 2002; Lynesset al., 1999; Oakley et al., 2002). When occupational therapists assess oc-cupational performance and satisfaction with performance, they need tokeep in mind that low scores could be due to the presence of a depressivedisorder (Chesworth et al., 2002; Girard et al., 2002; Oakley et al., 2002).Satisfaction is an important aspect to assess in older adults, along withoccupational performance, because the data show that older adults withdepressive disorders present them more somatically and less ideationally(Serby & Yu, 2003).

The COPM was developed as an assessment tool for therapists to buildrelationships with clients and to assess self-perceived occupational perfor-mance concerns in the areas of self-care, leisure, and productivity (Lawet al., 2005). An earlier study using the COPM with an individual with adepressive disorder showed promising results. Waters (1995) conducted acase study of a 42-year-old woman, who was admitted to acute care sub-sequent to a suicide attempt, with a diagnosis of major depression. Watersused the COPM to focus the occupational therapy intervention on occupa-tional performance enhancement. Results showed significant increases inboth performance and satisfaction scores. Waters reported that the COPMhelped to build a partnership between the therapist and client, as well ashelping the client to take responsibility for the therapeutic change process.

The evidence shows that the presence of clinically significant depressivesymptoms, even if the equivalent of minor depression, adds significantlyto the risk of disability in older adults (Cronin-Stubbs et al., 2000; Hybelset al., 2001; Lyness et al., 1999). This data must be compelling to occu-pational therapists, given our long-standing commitment to the goals ofindependence and quality of life for older adults. In an effort to make ourpractice more sensitive to the occupational issues of older adults with aclinically significant number of depressive symptoms, the following studywas undertaken to determine if the COPM is a valid assessment tool touse with this population. Our hypothesis was that the COPM would de-tect more total occupational performance concerns for older adults withclinically significant depressive symptoms compared to their peers with-out clinically significant depressive symptoms. We also tested whether theCOPM results would be different on the three dimensions measured on theassessment, i.e., importance, occupational performance, and satisfaction

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4 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

with occupational performance, between these two groups. The researchquestions were:

1. Do older adults with CDS compared to those without CDS havea. significantly more occupational performance concerns related to

ADL, IADL, productivity, and leisure?b. significantly different mean ratings of self-perceived importance,

occupational performance, and satisfaction with performance?2. What are the top five occupational concerns, and what percentage of

participants identified each concern when comparing the two groups?

METHODS

Design

This study was a retrospective comparative study that utilized preex-isting data from a broader study of older adults living in the community(McNulty, 2003).

Participants

In the original study (McNulty, 2003), older adults were eligible toparticipate if they were (a) living in the community within 50 miles ofa Southwestern city in the United States and were either homebound ornonhomebound, (b) able to speak and read English, and (c) at least 60 yearsof age. Exclusion criteria for this study were (a) being under 60 years of ageor (b) potentially not being able to give informed consent by demonstratinga score of 19 or less on the Mini–Mental Status Exam (Folstein, Folstein,& McHugh, 1975).

Since only 10 out of the 40 participants had a clinically significant num-ber of depressive symptoms (CDS), another 10 participants were matchedbased on their age, gender, and the lowest number of depressive symptomsreported on the Geriatric Depression Scale (GDS) (Yesavage et al., 1983).

The participants with CDS were matched with 10 participants withoutCDS in this order: a) same gender, b) age plus or minus four years, andc) geriatric depression score closest to zero. The data analysis was per-formed on these 20 participants to attain balanced groups, with eachgroup representing opposite ends of the depressive symptom spectrum. Themean ages of participants with and without CDS were, respectively, 75.0(SD = 10.0) and 75.9 (SD = 8.5) years. Both groups had seven women and

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McNulty and Beplat 5

three men. There were no significant differences between the two groupsin the demographic characteristics of marital status, ethnicity, living aloneor with others, gender, and age. Chi-Square analyses showed significantdifferences between the two groups for both assistance level (X2 = 7.5,p ≤ .01) and who assists (X2 = 8.5, p ≤ .04), indicating that the groupwith a clinically significant number of depressive symptoms reported us-ing a higher amount of assistance level and more source of assistance thanwould be expected by chance.

Instruments

Geriatric Depression Scale

The number of depressive symptoms was assessed using the GeriatricDepression Scale (GDS). The GDS is an interview tool designed to screenfor the presence of depressive disorders in older adults. It is not, however,a diagnostic tool. The GDS is made up of 30 yes/no questions aboutfeelings, interests, activities, and hopes. On the GDS, scores between 0and 10 indicate normal mood; scores between 11 and 19 are associatedwith symptoms of mild depression; and scores between 20 and 30 areconsistent with major depression (Stiles & McGarrahan, 1998). The GDSis applicable for screening depression in older adults who may be physicallyhealthy or physically ill (Yesavage et al., 1983).

The Cronbach’s alpha coefficient for the GDS was calculated to be 0.94,which shows high internal consistency for the GDS (Yesavage et al., 1983).Split-half reliability was found to be 0.94, and test–retest reliability was0.85 (p < .001) for the GDS. Construct validity was supported by a studycomparing the GDS with the Hamilton Rating Scale for Depression and theZung Self-Rating Depression Scale (Austin et al., 1999). The specificityand sensitivity of the GDS were examined by Yesavage and colleagues(1983), and they found it to have an 84% sensitivity rate and, importantlyfor this study, a 95% specificity rate when a cutoff score of 11 on the GDSwas used. The latter finding indicates that the GDS correctly identifiedwhether or not older adults actually had a diagnosis of a depressive disorder95% of the time.

Mini-Mental Status Exam

The Mini–Mental Status Exam (MMSE) (Folstein et al., 1975) was usedin this study as a screening tool to determine whether potential participantswere competent to give consent. The cutoff for participation in this study

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6 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

was a score of 19 or below on the MMSE, because such a score couldsuggest an inability to give informed consent due to cognitive impairment.This cutoff point was chosen based on the studies done by Folstein et al.(2000) and Weissman et al. (1985).

Canadian Occupational Performance Measure

Importance, performance, and satisfaction with self-identified occupa-tional performance concerns were assessed using a modified version ofthe COPM (McColl, Paterson, Davies, Doubt, & Law, 2000). The COPMis a semistructured interview assessment that was designed to measureperformance and satisfaction with occupational functioning in the areasof self-care, leisure, and productivity and is based on a client-centeredapproach to practice (Law et al., 2005).

When an occupational therapist administers the COPM, it is recom-mended the therapist encourage the client to describe his or her dailyroutine of activities, from rising in the morning until going to bed. Thisstep is optional but can serve to remind participants about their daily habitsand routines and help them to focus on what they have to do on a regularbasis, which is the main emphasis of the COPM. The first formal stepof the COPM, “perceived needs,” involves the participant describing anyactivity (a) that he or she needs to do, wants to do, or is expected to doand (b) that he or she experiences challenges in performing or feels isproblematic to perform (Law et al., 2005). The therapist can then probedeeper into the activity that is problematic for the client, asking him or herto go into more detail about specific tasks and/or steps within the activitythat are perceived as difficult. The self-generated concerns are then placedinto three categories: self-care, leisure, and productivity.

After the client has identified problematic tasks, he or she is asked torate each task on a scale of importance from “not important at all” (i.e.,1) to “very important” (i.e., 10). The five most important tasks are thenrated on similar scales of performance from “not being able to performat all” (i.e., 1) to “performing very well” (i.e., 10) and satisfaction withperformance (from “not satisfied” to “very satisfied” on the same scale).The standard protocol of COPM administration was used in this study withone exception: participants rated every occupational performance concernas to importance, performance, and satisfaction with performance, insteadof only rating the top five considered the most important.

The COPM has acceptable psychometric properties. Test–retest relia-bility was found to be .63 for satisfaction and .84 for performance (Lawet al., 2005). Studies have also supported the utility of the COPM in com-munity practice (Law et al., 2005; McColl et al., 2000). McColl et al.’s

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McNulty and Beplat 7

(2000) study supported the construct validity of the COPM based on itscorrelations with the Satisfaction with Performance Scaled Questionnaire,the Reintegration to Normal Living Index, and the Life Satisfaction Scale.Criterion validity of the COPM was established by comparing the occur-rence of COPM problems with spontaneously client-identified problemsof community living (McColl et al., 2000).

Procedures

The data for this study originated in an earlier study approved by theuniversity institutional review board. Informed consent was obtained fromall of the participants who were recruited through a local senior center or aflyer sent to 300 people through the Meals on Wheels R© program. The datawere collected by two occupational therapists specializing in gerontic occu-pational therapy and a second year occupational therapy graduate student.

The data were collected over two visits. Upon the first visit to theparticipant’s home, a member of the research team described the study inits entirety and sought a signature for informed consent. If the participantchose not to participate in the study at that time, the researcher left. Ifthe participant was willing to participate in the study and gave informedconsent, then a research team member administered the MMSE. The datacollector ended the visit if the participant scored 19 or below.

For those scoring 20 and above on the MMSE, the tests administeredwere the COPM, the GDS, and the Role Checklist (Oakley, Kielhofner,Barris, & Reichler, 1986). Demographic data were also collected, includ-ing the participant’s gender, age, and the number and types of IADL andADL assistance. The first home visit required approximately 1 to 2 hours.Within 1 week, a member of the research team conducted a second homevisit and administered the Safety Assessment of Function and Environmentfor Rehabilitation (Letts, Scott, Burtney, Marshall, & McKean, 1998) andthe Assessment of Motor and Process Skills (Fisher, 2001). The partici-pants were compensated $25.00 for each home visit for a total of $50.00.The results of the Role Checklist, Safety Assessment of Function and En-vironment for Rehabilitation, and the Assessment of Motor and ProcessSkills are reported elsewhere (McNulty, 2003).

Data Analysis

The variables in this study were (a) the presence or lack of CDS, (b)total occupational performance concerns further classified into subcate-gories of ADL, IADL, productivity, and leisure, (c) importance ratings, (d)occupational performance ratings, and (e) satisfaction with occupational

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8 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

performance ratings on the COPM. Data were analyzed using the StatisticalPackage for the Social Sciences software (Statistical Analysis Software,2000). For questions comparing group differences, an ANOVA (analysisof variance) was utilized. A statistical significance level of p ≤ .05 wasused. Descriptive data (i.e., occupational concerns identified on the COPM)were coded according to these categories: a) ADL, b) IADL, c) produc-tivity, and d) leisure, based on the definitions laid out in the occupationaltherapy practice framework (American Occupational Therapy Association,2002).

RESULTS

As hypothesized, participants with a clinically significant number ofdepressive symptoms (CDS) identified more occupational performanceconcerns on the COPM, compared to those without CDS. A one-wayANOVA revealed a significant difference between the two groups for totaloccupational performance concerns, F (2, 18) = 10.07, p ≤ .05. Twoone-way ANOVAs showed significant differences between the groups forthe number of ADL and IADL concerns, respectively, F (2,18) = 8.71,p ≤ .01 and F (2,18) = 6.45, p ≤ .05. No significant differences werefound between the groups based upon number of leisure and productivityconcerns identified.

There was a significant difference between the groups for importance rat-ings of occupational performance concerns on the COPM, F(2,18) = 5.24,p ≤ .05, with a mean rating of importance for the group with CDS,M = 6.8, and without, M = 4.0. The results of two one-way ANOVAsdid not reveal significant differences between the groups for ratings of oc-cupational performance and satisfaction with performance on the COPM.

Descriptive data from the COPM, when comparisons were drawn be-tween participants with and without CDS, revealed percentages of specificoccupational performance concerns (see Table 1). Table 1 shows a com-parison of the two groups, based on the percentage that identified eachconcern. Figure 1 illustrates the mean number of concerns identified bythe two groups in the categories of ADL, IADL, leisure-socialization, pro-ductivity, and total mean number of occupational performance concerns.

DISCUSSION

In this study, older adults with CDS identified significantly more totaloccupational performance concerns, as compared with those without CDS.

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TABLE 1. Top Five Occupational Performance Concerns Identified forRespective Groups

Occupational Performance Concern Participants with CDS Participants without CDS

Activities of daily lvingWalking and/or transfers 80% 10%Self-care (bathing, dressing) 40% 20%

Instrumental activities of daily livingTravel (visiting and transportation) 60% 30%House cleaning tasks 50% 10%Shopping (grocery or other) 40% 10%

Note: CDS = Clinically significant number of depressive symptoms.

This study is consistent with Girard and colleagues’ (1999) finding thatpersons with depression were less able on the ADL motor and ADL pro-cess ability continuum. Girard et al.’s study used the Assessment of Motorand Process Skills to measure objective occupational performance ability,and this study also assessed self-perceived (subjective) occupational per-formance using the COPM. The results found in the current study supportthe strength of self-perceived occupational performance and the clinicalutility of the COPM with older adults with CDS.

Another significant aspect of the participants in this study was that only 1out of the 10 participants with CDS had a high enough number of clinicallysignificant symptoms to be consistent with major depression. The majority,nine participants, had depressive symptoms more typically associated withminor depression. This finding is consistent with other studies that havefound increased levels of limitation in activities of daily living for personswith minor depression (Badger, 1998; Cronin-Stubbs et al., 2000; Hybelset al., 2001; Katz, Streim, & Paremelee, 1994; Lyness et al., 1999).

A statistically significant difference was found in the current studybetween the two groups with regard to importance ratings on the COPM.Older adults with CDS rated their occupational concerns as being moreimportant (higher on the scale of 1 to 10), than their peers without CDS.This could indicate that the importance rating of occupational performanceis showing sensitivity to the affective differences between older adults withand without CDS.

Results of the present study did not show significant differences be-tween groups for ratings of occupational performance or satisfaction withoccupational performance on the COPM. We must cautiously interpretthese findings. If there were more participants with GDS scores indicative

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10 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

FIGURE 1. Mean number of occupational performance concern(s) identified(according to category) for participants with and without a clinically significantnumber of depressive symptoms (CDS). ∗p ≤ .05; ** p ≤ .01.

of major depression, there may have been significant differences for sat-isfaction ratings, associated with thought distortions and feelings of lowself-esteem. Until a larger study with more participants is conducted withthese tools, we cannot know if the results are accurate because of the highrisk of type II error present in this study. For example, this study may not

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McNulty and Beplat 11

have enough power (based upon a small number of participants and/or lackof persons with clinically significant depressive symptoms consistent withmajor depression) to reject the null hypothesis when it should be rejected(Portney & Watkins, 2000).

Some of the demographic differences between groups might have ac-counted for the similar performance and satisfaction ratings. Significantdifferences between older adults, with and without CDS, were found forthe demographic categories of both assistance level and who assists. Oneadult with CDS was independent in all ADL, in comparison to seven with-out CDS. Nine adults with CDS required assistance with ADL, comparedto three without CDS. Of the nine adults with CDS requiring assistance,three had family assistance, two had paid assistance, and four had bothpaid and family assistance in their homes. Older adults with CDS mayhave rated their performance and satisfaction higher (i.e., similar to thosewithout CDS) because of the higher level of assistance they received intheir home.

The top five occupational concerns identified on the COPM, with per-centages comparing older adults with and without CDS, can be seen inTable 1. One of the striking results of the current study was how closelythese occupational concerns compared with a study of a much larger samplesize. Schulman and colleagues (2002) compared 117 community-dwellingolder adults (ages 65 and older) with and without depression and foundsignificant differences between the two groups in the need for assistancewith bathing, handling finances, light housework, shopping, and traveling.The need for assistance with cooking, comparing those with and withoutdepression, respectively, was the most significant difference that Schulmanet al. found in their study (49% versus 18%). Cooking was not identifiedas one of the top five occupational concerns in the current study; however,40% of the participants were recruited through the Meals on Wheels R© pro-gram, and cooking might not have been a high priority because their mealswere being prepared and delivered to them regularly. The top five occupa-tional concerns from the current study matches four of the concerns foundin Schulman’s study, which indicates the importance and meaningfulnessof these occupational concerns for older adults.

Limitations

The use of convenience sampling and a small sample size limits theability to generalize the results of this study. Future investigations could bestrengthened by the inclusion of older adults with a broader representation

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12 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

of different ethnic groups and geographic regions of the country alongwith a much larger sample size. Another limitation of this study was thecollection of data at one point in time. Depression status may change overtime and it would be useful to collect data at two different points in time,e.g., a few months apart, to understand how self-identified occupationalperformance concerns may change or stay the same over time. Anotherpotential limitation is that researchers did not have confirmation from aqualified mental health practitioner that participants with a score of 11 orabove did indeed have a diagnosis of a depressive disorder.

Implications for Occupational Therapy Practice and Recommendationsfor Future Research

Occupational therapists have a unique opportunity to not only screen fordepression in older adults but also understand their unique occupationalperformance concerns on an individual basis. Occupational therapists canthen design an individualized intervention plan collaboratively, with anolder adult, to possibly prevent and/or mitigate depressive symptoms re-sulting from an inability to perform daily occupations. Schulman andcolleagues (2002) found a strong association between the need for IADLassistance and depression and suggested that an individual’s ability to per-form independent daily living tasks should be assessed during home visits.This could help occupational therapists to accurately determine the needsthat are not being met for community-dwelling older adults. This additionalinformation could be critical to develop an effective interdisciplinary careplan.

More studies with older adults are needed that further investigate depres-sive disorders and their impact on occupational performance, specificallystudies with larger sample sizes that measure depressive symptoms overtime. Various treatment options and/or preventative measure for depres-sive disorders are important areas to investigate. For example, a study thatcompares the number of depressive symptoms in older adults receivingweekly or biweekly occupational therapy services with a control groupcould provide strong data for analysis. Clark et al. (1997) designed a wellelderly program incorporating occupational therapy services, in which thestudy’s entire aim was to prevent further physical disability, which wasvalidated in the study’s findings. Further research which addresses the pre-vention of depressive symptoms would make it possible for occupationaltherapists to play a key role in keeping older adults mentally and physicallyhealthy.

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Summary

This study provides support for the validity of using the COPM witholder adults with a clinically significant number of depressive symp-toms. Considering that several studies have shown a link between de-pressive symptoms and declines in occupational performance (Oakley etal., 2002; Girard et al., 1999; Chesworth et al., 2002; Lyness et al., 1999;Schulman et al., 2002), it is plausible that occupational therapists, by fo-cusing their intervention on assisting older adults in performing daily livingtasks, could potentially prevent some depressive symptoms or help to pre-vent minor depression from becoming major depression. The study givespractitioners an important reminder not to assume that older adults withminor depression have a less serious threat to independence and qualityof life compared to older adults with major depression. Occupational ther-apists have the skills to assess abilities and challenges to participating indaily living tasks and to make recommendations with regard to energyconservation, environmental adjustments, adaptive equipment, and com-munity resources. The COPM allows occupational therapists to gain rap-port with an older adult during the assessment process as well as to providea client-centered intervention that focuses on self-perceived occupationalperformance.

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Atwal, A., & Owen, S.A.D.R. (2003). Struggling for occupational satisfaction: Olderpeople in care homes. British Journal of Occupational Therapy, 66(3), 118–124.

Austin, M.P., Mitchell, P., Wilhelm, K., Parker, G., Hickie, I., Brodaty, J.C., et al.(1999). Cognitive function in depression: A distinct pattern of frontal impairmentin melancholia? Psychological Medicine, 29, 73–85.

Badger, T.A. (1998). Depression, physical health impairment and service use amongolder adults. Public Health Nursing, 15, 136–145.

Chan, C.C.H., & Lee, T.M.C. (1997). Validity of the Canadian Occupational Perfor-mance Measure. Occupational Therapy International, 4(3), 229–247.

Chesworth, C., Duffy, R., Hodnett, J., & Knight, A. (2002). Measuring clinical effec-tiveness in mental health: Is the Canadian Occupational Performance an appropriateMeasure? British Journal of Occupational Therapy, 65, 30–34.

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