Hindawi

Occupational erapy International

Volume 2020, Article ID 8914372, 8 pages
https://doi.org/10.1155/2020/8914372

Research Article
Cognitive Assessments Used in Occupational Therapy Practice:
A Global Perspective

Fahad S. Manee , Mohammed Shaban Nadar , Naser M. Alotaibi , and Mehdi Rassafiani
Occupational Therapy Department, Faculty of Allied Health Sciences, Kuwait University, Kuwait

Correspondence should be addressed to Fahad S. Manee; ot_manee@hsc.edu.kw

Received 10 April 2020; Revised 22 June 2020; Accepted 21 July 2020; Published 26 August 2020

Academic Editor: Marco Tofani

Copyright © 2020 Fahad S. Manee et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This exploratory study was aimed at evaluating the current status of global occupational therapy practice on the use of assessments for
clients with cognitive impairments and providing recommendations for ongoing evidence. We targeted international occupational
therapy clinicians working with clients experiencing neurocognitive impairments. 323 occupational therapists from a wide range
of clinical practice areas participated in the study. A large number of therapists used noncognitive specific assessments with a
focus on functional approaches. The most commonly used standardized assessments were the COPM (56.7%), followed by MMSE
(54.2%) and MoCA (45.5%), while the nonstandardized assessments were clinical observation (38.4%) and generic ADL
assessment (34.1%). The use of main assessments was significantly different across world regions (p < 0:05), as were the reasons
for choosing them (p < 0:05). The occupational therapists’ use of assessment tools with clients suffering from neurocognitive
impairments is inconsistent across the globe. The identification of international best practices for selecting and implementing
proper outcome measures is warranted. It is essential to promote the development of an occupational therapy initiative to support
the use of appropriate assessments at the international levels to facilitate consistent best practice.

1. Introduction assessments appears prevalent around the globe. In Brazil,

for example, the majority of outcome measures have not been
Cognition refers to the conscious and unconscious information validated for use in clinical practice [8], and only a few cog-
processing functions that are carried out by the brain [1]. Cog- nitive assessments have been cross-culturally adapted for
nitive abilities include elementary skills such as arousal, alert- use in the Brazilian culture and language.
ness, and orientation, as well as higher cognitive skills such as In accordance with the International Classification of
insight, judgment, and problem solving. The evaluation of the Functioning, Disability and Health [9], occupational thera-
cognitive abilities of individuals with cognitive deficits is vital pists working in cognitive rehabilitation can evaluate an
to the therapeutic process [2]. A proper assessment will deter- individual’s cognitive performance at two main levels. The
mine the individual’s ability to live independently, resume first level, “body structure and function,” considers cogni-
productive life roles, and form new habits and routines [3]. tion in terms of the performance of cognitive components
Occupational therapists are constantly urged to imple- such as memory, attention, information processing, and
ment standardized outcome measures in practice [4, 5]. executive functions. This is also known as the “bottom-up”
Nonetheless, some therapists remain reliant on nonstandard- approach [10]. Some examples of assessment tools at this
ized assessments, such as informal subjective observations level include the general cognitive measures of the Mini-
[6]. Burns and Neville (2016) reported that 96% of occupa- Mental Status Examination (MMSE) and the Montreal Cog-
tional therapists working in home healthcare treating adult nitive Assessment (MoCA). Moreover, there are assessment
stroke clients used nonstandardized assessments. Therapists tools for specific cognitive domains such as memory (e.g.,
working in pediatric settings reported the use of standardized Rivermead Behavioral Memory), processing speed (e.g.,
assessments more frequently than practitioners working in Trail Making Test), and executive functioning (e.g., Wiscon-
adult settings [7]. This inconsistent use of standardized sin Card Sorting Test).
2 Occupational Therapy International

The second level, “activity and participation,” considers 2. Materials and Methods
how cognition enables an individual to successfully engage
in daily occupations such as basic and instrumental activi- 2.1. Study Design. To examine the aim of the study, we utilized
ties of daily living (ADL/IADL). This is known as the an exploratory, cross-sectional methodology containing
“top-down” approach [10] and refers to the therapist’s checklists and close-ended questions to gather therapists’ per-
observation of a client’s performance of everyday tasks to spectives regarding outcome measures. A descriptive survey
ascertain cognitive abilities. This level includes assessment methodology allows gathering data on respondents’ opinions
tools such as interviews with the client and relevant others, and detailed information pertaining to demographic profiles,
as well as occupational performance-based assessments while ensuring consistency of questions across all respondents
(e.g., Functional Independence Measure (FIM), Kitchen [16]. Ethical approval was obtained from the local university
Task Assessment, Performance Assessment of Self-Care Institutional Review Board and Human Ethics Committee
Skills (PASS), and Canadian Occupational Performance (approval # 160518).
Measure (COPM)).
2.2. Participants. The study participants were occupational
Occupational performance-based assessments are defined
therapists from around the globe attending the World Feder-
as those standardized or nonstandardized methods that
ation of Occupational Therapists (WFOT) Congress in Cape
involve a therapist observing an individual’s performance at
Town, South Africa, in 2018. The inclusion criterion was that
daily activities (e.g., FIM and PASS) [11] or a client’s self-
the occupational therapists must be regularly working with
perception of his/her occupational performance over time
clients experiencing neurocognitive impairments for at least
(e.g., COPM). Skilled observations are generally a nonstan-
two years. We excluded students and novice therapists from
dardized method of evaluating real-world performance in a
participation as the study focus was on experienced clinicians.
naturalistic context [4]. A client’s active participation is
becoming a key component in healthcare systems because it 2.3. Instrument Development and Validation. We compiled a
aligns with the client’s preferences, needs, and values. comprehensive list of cognitive assessments used in occupa-
To identify the current cognitive assessment tools used in tional therapy practice around the world by conducting a
occupational therapy practice, several researchers surveyed thorough search of health-related databases, occupational
clinicians working in various clinical settings in developed therapy books, and occupational therapy journals. We
countries, including Canada [11], USA [12], Australia [13], searched the PubMed and CINAHL electronic bibliographic
Sweden, and Japan [14]. Many respondents reported the databases from the years 1995 to 2018. The search strategies
use of standardized assessment approaches because they included variations and a combination of the terms “cogni-
consider them to be more “formal” assessments of cognition tion, occupational therapy, assessment and outcome mea-
to help identify the client’s deficits. Some of the most com- sures”. Additionally, we scanned the reference lists of
monly used measures were MMSE, FIM, and the Barthel identified studies and reviews. Since nonstandardized assess-
Index (BI). While occupational therapists play an important ments are frequently used by occupational therapists [11], we
role in cognitive rehabilitation by completing occupational included both standardized and nonstandardized choices in
performance-based assessments, the results indicate that our list of assessments.
therapists utilized assessments focused on the “body struc- To validate our list, we presented it to a group of experts
ture and function” more than using assessments focused on with different occupational therapy backgrounds, who were
“activity and participation” level [13]. Occupational thera- instructed to review and modify the list according to the
pists often find it challenging to integrate occupational- objective of the study. The expert panel consisted of four
based assessments in daily practice. This has been noted Ph.D. holders and experienced occupational therapists from
specifically by occupational therapists in Sweden and Japan Iran, USA, India, and Kuwait, with an average of 23.7 years
who found it difficult to use occupational therapy-specific of working experience (SD = 4:2) in diverse clinical back-
assessments in daily practice [14]. The challenges commonly grounds including neurocognitive rehabilitation, mental
cited included the scarcity of time in relation to the volume of health, and pediatrics. After several meetings, the expert panel
work needed to be done, the effort required to administer and agreed on a final list of 98 assessments to be included in the
score the assessment, and sometimes the physical spaces and study. To maximize utility, the assessments were listed in
home environment simulation required to implement alphabetical order and the main questions were formulated
occupational-based assessments [7, 14, 15]. These challenges to be close ended.
suggest that the selection of assessments by the occupational
therapist might be influenced by the ease of incorporation of 2.4. Structure and Format. The final version of the survey con-
the tool in practice rather than the appropriateness of the sisted of three main sections. Section 1 targeted the demo-
assessment to the client’s individualized case or the sound- graphics of the study participants, including the age, gender,
ness of its psychometric properties. country of residence, professional degree, years of clinical
The currently available research that compares the use of experience, areas of practice, and settings of practice.
cognitive assessments among occupational therapists at a Section 2 included an alphabetical list of 98 assessments
global level is somewhat limited. The aim of this study was (both occupation-based and skill-based) that can be used
to evaluate the current status of global occupational therapy with clients experiencing neurocognitive impairments. The
practice on the use of assessments when working with client participants were instructed to choose all the ones they rou-
populations with neurocognitive impairments. tinely used (Table 1). Due to the wide variety of professional
Occupational Therapy International 3

Table 1: The list of cognitive assessments used in the study.

Name of Assessment Name of Assessment

Ability to navigate (non-standardized) □ Dementia Rating Scale (DRS) □
Affective Test of Prosody (ATP) □ Digit Backward Test □
Allen Cognitive Levels (ACL) □ Digit Forward Test □
Assessment of Communication and Interaction Skills □ Disability Assessment for Dementia (DAD) □
Empirical Behavioral Pathology in Alzheimer’s
Assessment of Living Skills □ □
Disease Rating Scale (E-Behave-AD)
Assessment of Living Skills and Resources (ALSAR) □ Executive Interview (EXIT) □
Assessment of Motor and Process Skills (AMPS) □ Frontal Assessment Battery (FAB) □
A Quick Test □ Functional Autonomy Measurement System (SMAF) □
Barthel ADL Assessment (modified) □ Functional Independence Measure (FIM) □
Barthel Index □ Functional Performance Measure □
Bay Area Functional Performance Evaluation (BAFPE) □ General ADL (non-standardized) □
Bedford Alzheimer Nursing Severity Scale; for the severe demented
□ Glasgow Coma Scale (GCS) □
(BANS)
Canadian Occupational Performance Measure (COPM) □ Hierarchic Dementia Scale □
Chessington OT Neurological Assessment Battery (COTNAB) □ Home (non-standardized) □
Client-Oriented Role Evaluation □ Home Environment Assessment Protocol □
Clinical Observation (non-standardized) □ Home Falls and Accidents Screening Tool □
Clock Drawing Test & Clock Test □ Hopkins Verbal Learning Test (HVLT) □
Cognitive Adaptive Skills Evaluation □ Kitchen task (non-standardized) □
Cognitive Assessment of the Elderly (CASE/Pecpa-2r) □ Kitchen Task Assessment (KTA) □
Cognitive Assessment of Minnesota (CAM) □ Klein-Bell ADL Test □
Cognitive Assessment Screening Test (CAST) □ Kohlman Evaluation of Living Skills (KELS) □
Cognitive Performance Test (CPT) □ Leisure Satisfactory Questionnaire □
Cognitive Competency Test (CCT) □ Leisure Diagnostic Battery □
Cognitive Mode Questionnaire (CMQ) □ Limiting Long Standing Illness screen (LLSI) □
Colored ball sort (non-standardized) □ Line Bisection Test □
Comprehensive OT Evaluation (COTE) □ Loewenstein O.T. Cognitive Assessment (LOTCA) □
Contextual Memory Test (CMT) □ Loewenstein O.T. Cognitive Geriatric Assessment (LOTCA-G) □
D2 test of Attention □ Middlesex Elderly Assessment of Mental Status (MEAMS) □
Mini Mental Status Exam (MMSE)/Folstein □ Trail Making Test (TMT) □
Model of Human Occupation Screening (MOHOST) □ Test of Visual Perceptual Skills (Non-Motor)-Revised (TVPS(n-m)R) □
Montreal Cognitive Assessment (MoCA) □ Toglia Category Assessment □
Motor-Free Visual Perceptual Test (MVPT) □ Visual Field Tests: Bell's Scanning Test, Useful Field of Vision Test □
Modified Mini Mental Status Exam (3MS) □ Volitional Questionnaire □
Neurobehavioral Cognitive Status Examination (NCSE/Cognistat) □ Weschler Adult Intelligence Scale-III (WAIS-III) □
Occupational History □ Wisconsin Card Sorting Test version 4 (WCST-CV4) □
Occupational Role History □ Woodcock Johnson Test of Cognitive Ability □
Occupational Self-Assessment □ Word list (non-standardized) □
Ontario Society of O.T. Perceptual Assessment □ Work Environment Impact Scale □
Occupational Questionnaire □ Worker Role Inventory Worker Role Inventory □
Orientation Test for Aphasics □ Severe Impairment Battery (SIB) □
Other IADL tasks (e.g. medication mgmt., financial tasks)
□ Sorting shapes (non-standardized) □
(non-standardized)
Perceive Recall Plan Perform (PRPP) □ Stroke Unit Mental Status Exam (SUMSE) □
Performance Assessment of Self-Care Skills (PASS) □ Stroop test Stroop test Stroop test Stroop test □
Rancho Los Amigos (RLA) □ Structured Observational Test of Function (SOTOF) □
Rivermead Behavioral Memory Test (RMBT) □ Tests designed for acquired brain injury (SCATBI,NRS) □
Role Check List □ Test of Everyday Attention (TEA) □
Ross Information Processing Assessment – Geriatric (RIPA-G) □ Test for Severe Impairment (TSI) □
Routine Task Inventory Routine Task Inventory □ Test of Visual Motor Skills – Revised (TVMS-R) □
Safety Assessment of Function and the OTHERS: Please list below)
□ □
Environment for Rehabilitation (SAFER) ……………………………………………………..
Safety and Functional ADL Evaluation (SAFE) □ …………………………………………………… □
4 Occupational Therapy International

backgrounds among the potential respondents, we also pro- Table 2: Demographic characteristics of the participants.
vided an additional space where nonlisted assessments could
be added if needed. Participants’ characteristics Frequency Percent
Section 3 was related to the factors affecting assessment Age (year)
choices. The participants were allowed to select multiple 21-30 102 31.6
factors that contributed to their assessment choices. The list 31-40 88 27.2
of reasons provided in the survey was based on the occupa- >40 130 40.2
tional therapy literature [11, 12] as well as the authors and
Years of experience
expert panel feedback. The reasons were meant to reflect
the main rationale for choosing the assessment method in Up to 5 98 30.3
all practice areas. They included availability in the work 5-10 61 18.9
setting, established psychometric properties, client centered- More than 10 150 46.4
ness, ease of administration, and pertinence to a specific Region of residence
frame of reference. N. & S. America 78 24.1
Europe 75 23.2
2.5. Statistical Analyses. We used descriptive statistics to
Asia and Pacific 52 16.1
calculate the means, standard deviations, frequencies, and
percentages. Nonparametric chi-square tests were used to Africa 116 35.9
compare the demographic data with assessment preferences Area of practice
and the prevalent rationales for choosing them, as well as to Pediatrics 105 32.5
test for geographical differences in the use of an assessment Neurorehabilitation 134 41.5
tool. We employed Kruskal-Wallis ANOVA tests to compare Community-based 60 18.6
between two or more independent categories. p values < 0.05 Geriatrics 60 18.6
(2-tailed) were considered significant. Statistical analyses
Mental health 71 22.0
were performed using the SPSS software (version 25.0; SPSS
School-based 36 11.1
Inc., Chicago, IL) for Windows.
Note: numbers may not add up to the total due to missing responses.

3. Results
more experienced therapists selected these assessments less
3.1. Demographic Characteristics of Participants. A total of frequently.
323 participants completed the survey. The demographic Therapists with higher education degrees (i.e., above a
characteristics of the respondents (Table 2) showed that the bachelor’s degree) employed the MMSE (p = 0:049) and non-
majority were female (86.4%), and the largest age group standardized ADL assessments (p ≤ 0:001) less often, and the
was 40+ years (40.2%). Almost half of the respondents had FIM more often (p = 0:031), than therapists with BSc degrees.
more than 10 years of working experience (46.4%). The other assessment tools did not show any statistically
significant difference regarding the therapist’s educational
3.2. Common Assessments Used by Participants. The study degree. We also did not find any significant differences with
listed 98 standardized and nonstandardized assessment tools. respect to the therapist’s gender.
The participants indicated which assessment(s) they typically
used in their clinical practice. Table 3 shows the ten most 3.4. Reasons for Using an Assessment. The most common rea-
popular tools as selected by the therapists. The COPM was sons for using an assessment was “Available where I work”
the most popular choice (56.7%) followed by MMSE (79.6%) and “I am familiar with the assessment” (65.9%).
(54.2%) and MoCA (45.5%). There were also two nonstan- The full list of reasons is shown in Table 4. Chi-square anal-
dardized assessment tools among the ten most popular, yses showed significant differences in reasons for using the
namely, clinical observation (38.4%) and general ADL assessment based on the geographical regions of the world.
assessment (34.1%). There were very few responses in Table 5 shows more details on the reasons for selecting an
the extra space provided to allow additional assessments, assessment tool based on geographical regions.
and the qualitative data did not significantly add to the When comparing reasons for using an assessment based
findings of the study. We will therefore not report the on years of experience, the Kruskal-Wallis ANOVA found
qualitative findings. a statistically significant difference between therapists with
more than 10 years of experience and those with less than
3.3. Geographical Differences in Assessment Tool Choice. Chi- 10 years of experience. More specifically, experienced thera-
square analyses revealed that the use of COPM, MoCA, FIM, pists (10+ years) relied more on assessments that follow a
and the Glasgow Coma Scale varied significantly (p < 0:05) specific occupational therapy frame of reference (p = 0:021),
across the world regions. Furthermore, the frequency of did not rely on colleagues’ preferences (p ≤ 0:001), preferred
choosing MMSE (p = 0:039), MoCA (p = 0:017), clinical valid and reliable assessments (p = 0:007), were not biased
observation (nonstandardized) (p = 0:011), and the Clock towards assessments addressed in their OT curricula
Drawing Test (p = 0:045) varied significantly with the level (p ≤ 0:001), and did not rely on assessments they had learned
of the therapist’s years of professional experience, where postuniversity training (p = 0:007).
Occupational Therapy International 5

Table 3: Top ten assessments used by the participants.

Tool/assessment Frequency Percent

1 Canadian Occupational Performance Measure (COPM) 183 56.7
2 Mini-Mental Status Exam (MMSE) 175 54.2
3 Montreal Cognitive Assessment (MoCA) 147 45.5
4 Clinical observation (nonstandardized) 124 38.4
5 Barthel ADL assessment (modified) 121 37.5
6 Functional Independence Measure (FIM) 110 34.1
7 General ADL assessment (nonstandardized) 110 34.1
8 Barthel Index (BI) 102 31.6
9 Clock Drawing Test 98 30.3
10 Glasgow Coma Scale 91 28.2
Note: some participants used more than one tool/assessment in their practice.

Table 4: The reasons for using assessments (ordered from the top to the lowest reason).

Reasons for choosing assessment Frequency Percent

1 Available where I work 257 79.6
2 I am familiar with the assessment 213 65.9
3 Client-centered 197 61.0
4 Has known reliability and validity 184 57.0
5 Quick to administer 175 54.2
6 Easy to interpret 155 48.0
7 I learned it during my professional training 138 42.7
8 Follows a specific OT frame of reference (FOR) 122 37.8
9 Colleagues recommend its use in practice 110 34.1
10 Taught in the OT educational curriculum 105 32.5
11 Found it through a literature search 104 32.2
12 Developed by an occupational therapist 103 31.9
13 Described in a professional textbook/journal 56 17.3
14 I heard about it at a conference/seminar 40 12.4
15 Satisfies insurance company 29 9.0
16 Follows a specific FOR outside OT profession 26 8.0
17 Newly developed 16 5.0
Note: the participants may indicate more than one reason.

Table 5: The reasons for using the assessment tool by the geographical region.

N. & S. Asia and

Europe Africa
Rationale for using assessment America Pacific p value
No Yes No Yes No Yes No Yes
Frequency 16 61 24 51 8 44 16 100
Available where I work 0.016∗
Percent 20.8% 79.2% 32.0% 68.0% 15.4% 84.6% 13.8% 86.2%
Frequency 31 46 19 56 17 35 57 59
Client-centered 0.008∗
Percent 40.3% 59.7% 25.3% 74.7% 32.7% 67.3% 49.1% 50.9%
Frequency 28 49 26 49 22 30 62 54
Has established reliability and validity 0.034∗
Percent 36.4% 63.6% 34.7% 65.3% 42.3% 57.7% 53.4% 46.6%
Frequency 29 48 54 21 17 35 46 70
Quick and easy to administer and interpret ≤0.001∗
Percent 37.7% 62.3% 72.0% 28.0% 32.7% 67.3% 39.7% 60.3%
∗
The distribution is significantly different between the world geographical regions.
6 Occupational Therapy International

4. Discussion alence of MMSE in Australia, and a different study reported it

to be the most frequently mentioned assessment among clini-
The main aim of this study was to evaluate the current status cians in Canada [11]. A high prevalence of MMSE and
of global occupational therapy practice on the use of assess- MoCA assessments was also found in other studies [11, 21].
ments with clients experiencing neurocognitive impairments. The aims of the MMSE and MoCA approaches are compara-
The Canadian Occupational Performance Measure (COPM) ble as both are routine cognitive screening tests rated on a 30-
was the most widely used assessment, where 56.7% of our point scale that attempt to detect mild cognitive impairment.
respondents reported using the COPM. The wide use of this However, given the documented advantages of the MoCA,
measure is consistent with earlier studies specific to cognitive the abundant use of the MMSE by global healthcare profes-
impairments [11] as well as other general occupational ther- sionals is somewhat surprising. Of note, the MoCA has been
apy assessments [12]. The COPM is not a dedicated cognitive found to have higher sensitivity than the MMSE in detecting
assessment, but rather a generic client-centered measure that cognitive deficits, especially in the domains of visuospatia-
applies to most diagnoses. This high usability of the COPM l/executive function, attention, and recall, in addition to its
with cognitive impairment diagnoses emphasizes the impor- superiority in detecting cognitive deficits in patients with
tance of active participation of clients in formulating their transient ischemic attack and stroke [22]. The MoCA is also
own goals to international occupational therapy practice. A reported to be a better measure of cognitive status for some
scoping review concluded that the use of the COPM can diagnoses as it lacks ceiling and floor effects [23]. One reason
enhance client-centered practice by improving awareness of for the abundant use of the MMSE may be related to the
the client’s goals for the future, thereby reinforcing a partner- dominance of the medical model in many service settings.
ship with a collaborative goal setting [17]. Another factor may be due to the potential gap between the
Despite its overall prevalence, therapists working in the Afri- research-based scientific evidence and actual clinical practice.
can continent used the COPM significantly less than their col- The results of this study showed that therapists with
leagues from other regions of the world (38.8% vs. 67.1%, higher education degrees (i.e., above a bachelor’s degree)
respectively). Overall, occupational therapists in Africa tended employed the MMSE and nonstandardized ADL assessments
to rely more on skill-based rather than occupation-based assess- less often, and the FIM more often, than therapists with BSc
ments. In a study that explored the challenges faced by occupa- degrees. There are no differences between these groups in
tional therapists in South Africa when planning to implement other assessment tools. Therapists with higher education
occupation-based assessments and interventions, the barriers degrees might have higher knowledge and skills about
identified included lack of availability of assessments, unfa- research and evidence-based practice compared to under-
miliarity with the occupation-based assessment approach, graduate therapists. This may be a reason that therapists with
reimbursement problems, and therapist preferences [18]. higher degrees choose FIM, which is more valid and reliable.
Given the wide adoption of COPM, the question arises of However, more research is required to target educational
whether this standardized assessment can be sufficient to pro- backgrounds and find if there are differences between these
vide a comprehensive understanding of a client’s condition. two groups in using other types of assessment tools.
Findings from randomized control trials revealed that most The most cited reason by our respondents for using an
occupational therapists used other standardized assessments assessment was its “availability at work” (79.6%), which was
in conjunction with COPM to obtain a more comprehensive consistent across all world regions. A previous study of occu-
overview of their clients’ needs [19]. This result is further pational therapists in the United States found the same dom-
supported by a systematic review that reported the COPM to inant reason for choosing an assessment [12]. Such practice,
be more effective when used in conjunction with other assess- which is based on availability rather than applicability, can
ments such as the Barthel Index (BI) and the Functional Inde- directly affect the occupational therapy intervention process.
pendence Measure (FIM) [20]. Our study found that many of For this reason, a particular focus should be placed on man-
our respondents used the FIM (34.1%) and the BI (31.6%), agers and decision makers to ensure the availability of a wide
which is correspondingly consistent with previous observa- range of suitable assessment tools in their clinics.
tions [12, 13]. The FIM and BI provide measures for the level The occupational therapy literature emphasizes the need
of assistance required by an individual to perform basic daily to incorporate standardized assessments with psychometri-
life activities and are not dedicated measures of cognitive skills cally sound properties in clinical practice [24]. Accordingly,
and abilities. Occupational therapists working with cogni- the majority of respondents in this study acknowledged
tively impaired clients may find the FIM to be particularly psychometric properties to be a main factor for selecting an
valuable because it includes a cognitive subscale in addition assessment. Nevertheless, two of the ten most used assess-
to the self-care information it provides. Of note, occupational ments identified in this study were not standardized. Non-
therapists from the Asia and Pacific regions used the FIM standardized assessments can be useful, but they may also
(53.8%) and BI (44.2%) more frequently than therapists from be compromised as their results may not be reliable or valid
the remaining regions (31.9% and 29.6%, respectively). in the first place. Furthermore, the use of nonstandardized
With regard to skill-based cognitive assessments, our assessments in certain professions also carries the risk of
respondents used the MMSE (54.2%), MoCA (45.5%), Clock not being properly interpreted by the wider healthcare com-
Drawing Test (30.3%), and Glasgow Coma Scale (28.2%) munity. Occupational therapists should be continuously
more frequently than any other cognitive assessment tools. encouraged to use standardized assessments to minimize bias
A survey by Koh et al. (2008) found a particularly high prev- and interpretation errors.
Occupational Therapy International 7

The time-consuming nature of some standardized out- fore, it is important to promote the development of an inter-
come measures has been previously identified as an obstacle national occupational therapy initiative that supports the use
in clinical settings [25]. This was also evident in this study of assessments at both national and international levels. Such
where respondents identified time (“quickly administered”) an initiative should mainly be geared towards recommending
and clinical utility of the assessment (“easily interpreted”) the use of the most appropriate assessments that adequately
as major factors for selecting an assessment. Only therapists reflect the philosophy and values of occupational therapy to
from Europe did not widely consider the criterion of clinical facilitate the best possible client outcomes. Due to the global-
utility as an important reason for selecting an assessment ization of occupational therapy practice, it is important to
(28% in Europe vs. 63.3% in the rest of the world). While indicate the essence of using assessments that are culturally
assessments that are faster to administer may be more effi- sensitive and reflective of the targeted population’s own
cient and practical in a clinical setting and therefore more culture and beliefs. This will ensure the use of culturally valid
readily used, assessments that are selected based on the time and competent assessments.
factor alone may lack the necessary comprehensiveness or
sensitivity to capture the desired outcomes. 6. Implications for Occupational
A limitation of this study is the relatively small sample
size from which a conclusion about geographical variations Therapy Practice
in the use of assessment tools can be drawn. Another limita- Occupational therapists should entertain the opportunity of
tion is the convenient sampling methods we implemented in periodic professional development on emerging standardized
this study. This makes the sample nonrepresentative and outcome measures pertaining to their clinical settings. Given
may limit the generalizability of the findings in terms of accu- our findings, we propose the following:
rately reflecting the prevalence of use in different countries.
Given the nature of the WFOT World Congress event, it is (i) Skill-based cognitive assessments need to be imple-
likely that the attendees were academicians and more mented in conjunction with occupation-based assess-
resourced therapists, which may make our sample biased. ments to reflect the core principles of occupational
Nevertheless, this study provides an initial consensus over therapy practice
the prevalence of different types of assessment tools used in
cognitive clinical practices across the globe. The findings (ii) Managers and decision makers should ensure the
can be useful to occupational therapy clinicians, educators, availability of a wide range of suitable assessment
researchers, and managers. tools in their clinics
In order to support best practice, entry-level education (iii) International “assessments in occupational therapy
curricula for occupational therapy should emphasize the initiative” that is guided by a well-established emi-
importance of using occupation-based and standardized nent organization should be developed to
assessments to maintain the philosophical underpinning of
the profession. The integration of standardized assessments (a) foster international collaborations between
supports the accurate evaluation process and, by extension, professional global occupational therapy entities
emphasizes desired clinical reasoning, planning, and inter- to provide systematic recommendations and
ventions. Since not all assessments, and particularly cognitive guidelines for the use of assessments
assessments, are relevant or practical when used in countries (b) critically appraise potential international mea-
and contexts other than the ones in which they were originally sures and explore ecological validity
developed [8, 26], international use of assessments developed
in other cultures requires careful consideration of the cross- (c) establish an international occupational therapy
cultural adaptation process to ensure the appropriate use of assessment database for different areas of practice
these assessments, while incorporating linguistic, cultural,
and contextual factors. Therefore, in addition to standardiza-
tion, cultural consideration and awareness should be an inte- Data Availability
gral part of international occupational therapy curricula [27].
International educators are encouraged to teach students the The data used to support the findings of this study are avail-
assessments that are not only standardized but also culturally able from the corresponding author upon reasonable request.
relevant and applicable in their own context.
Conflicts of Interest
5. Conclusions
The authors declare that there is no conflict of interest
The use of valid standardized assessments that match the regarding the publication of this paper.
need of the client is essential for successful and competent
therapeutic intervention. In this study, we identified the most Acknowledgments
commonly used cognitive assessment tools for different geo-
graphical regions of the world and the dominant reasons for We are grateful for the support received by the WFOT. We
their use. There is no global consensus on the best assessment also thank the occupational therapists who gave their time
tools to use for patients with cognitive impairments. There- to participate in this study.
8 Occupational Therapy International

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