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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
• Cognition and ADLs
• 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
• Activities of daily leaving and MS
• Cognition and ADLs
• Problems related to ADLs measuremento Sample of behaviors,
o Tools were not designed to specific needs of MS
o Self-reports
• Development of the Actual reality
• 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
• Activities of daily leaving and MS
• Cognition and ADLs
• Problems related to measuremento Sample of behaviors, tools were not designed to specific needs of MS
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
• Activities of daily leaving and MS
• Cognition and ADLs
• 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: Money Management in MS
• Summary
Overview
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Money Management Activities in Persons with Multiple Sclerosis (Accepted)
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Comparisons between MS and HC on Money Management Survey
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Comparisons between MS and HC on Money Management performance using AR
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60
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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