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Functional Cog Intervention Cheat Sheet by

Assessment of Strategy Use and Metacognition: Choosing an Appropriate Intervention Approach

OT role in Cog Assessment

Occupa­tional therapists focus on functional cognition, or cognition that is necessary within the scope of performing his/her roles, daily occupa­tions within the contexts performed.
OTs may then only need to focus on assessing metaco­gnition and strategy use in occupa­tional perfor­mance.
You may not need to assess cognitive skills unless you need to differ­entiate an underlying skill (e.g., sustained vs. divided attention)

Different cognitive rehab interv­ention methods…

Adapta­tio­ns/­Mod­ifi­cation of tasks and enviro­nment
Technology to support cognitive perfor­mance
Task-S­pecific Training (vanishing cues, errorless learning, spaced retrieval)
Retrai­nin­g/R­eme­dia­ti-on of Impair­ments
Cognitive Strategy Training & Training in Self-a­war­eness (metac­ogn­itive training)

The Functional Approach

ADAPTATION by others
METACO­GNITIVE (person led compen­sation)
No awareness
No awareness
Awareness required
No learning
Low-level task-s­pecific learning
Learning and genera­liz­ation
No genera­liz­ation
Emphasis on changing task perfor­mance or enviro­nment rather than underlying skill

Task specific Training

Strategy Use
Task Specific Training (e.g STOMP)
Mild-Max Cues
Mild-Mod dementia, Mod-Severe CVA, Mod-Severe TBI, Parkin­son's w/cog imp, Cancer

Enviro­nmental Modifi­cation

Alter properties of the enviro­nment
Rice cooker stays plugged in--
Remove distra­cters (TV, clutter, people, use IPOD with headph­ones)
Grab bars, ramps
Re-arrange work areas (pots lower)
Add light for improved vision
Pictures to locate rooms (toilet)
**Imbed all of the enviro­nmental mods into sequencing for task-o­riented training.

Planning the Interv­ention: Supportive strategies

Based on the perfor­mance we see and individual consid­eration of HOW they wanted to do tasks, we determine if they needed any of the following ECT strategies to support task-o­riented training:
1. Environ­mental modifi­cations
2. Cognitive strategies
3. Task modifi­cation

Planning the Interv­ention: Natural tools

Rice cooker
Rice, butter and salt
Wooden spoon
** this is examples from the following video: https:­//w­ww.y­ou­tub­e.c­om/­wat­ch?­v=9­iXP­Hhfk_7E

Planning the Interv­ention: Task Steps

Where do people get dressed?
Who is in the room when they do?
What time of day?
Is the TV or radio on?
What goes on first?
*Develop a list of steps for doing the task in a way that supports the habits and routines of the occupation as well as the social, temporal and physical context in which the occupation is performed.

EVALUA­TION: Caregi­ver­-Rated Perfor­mance

Perfor­mance Score
Satisf­action with Perfor­mance
1. Operate Rice cooker
2. Put of shirt
3. Take bus to and from market
**Canadian Occupa­tional Perfor­mance Measure (COPM): semi-s­tru­ctured interview tool for priori­tizing goal areas of functional perfor­mance; caregiver reports perfor­mance on each task on a scale of 1-10 (1=worst, 10=best). (Law et al, 1990)

Evalua­tion: Choosing Fam & Client­-ce­ntered Goals

Choose goals that matter the most and potent­ially change the quality of someone’s life if better at this skill.
Make-up vs. cooking?
If client unable to identify goals, caregivers assisted.
Goals must be tasks that they did previously (proce­dural memory) and must have an obvious start and end point.

Mainte­nance of therap­eutic relati­onship

Indivi­dua­lized goal planning:
Real-life tasks broke down into practi­ce-able steps.
Training is structured through motor learning princi­ples: repeti­tive, blocked practice frequent verbal praise errorless learning contex­tua­lly­-ap­pro­priate enviro­nment with real life tools.
Examiner and caregiver rating of perfor­mance
Compen­satory modifi­cations built into practice sequences: enviro­nmental modifi­cation, cognitive strate­gies, task modifi­cation
(Ciro et al, 2014)

Spaced Retrieval

Recalling info repeti­tively over gradually longer time intervals (30 sec, 1 min, 2 min, 4, min, 8 min, etc.)
Often used for recall of specific facts, small chunks of info
If retrieval is succes­sful, length is increased
Can be used to learn small amounts of inform­ation, facts, used external aids or recall inform­ation
Can be combined with errorless learning

Implem­ent­ation of Training

Training is structured through motor learning princi­ples:
Repeti­tive, blocked practice
High dose
Errorless learning
Frequent verbal praise
Within a contex­tua­lly­-ap­pro­priate enviro­nment with real-life tools

Revise the Sequencing List with ECT Built-In

Deficits in rememb­ering steps of task
Plug in rice cooker (or it stays plugged in)
Measure and fill with rice, water, ingred­ients (if measuring is an issue, you can have pre-poured amounts of rice and ingred­ients in a baggy in refrig­erator)
Push “on” button.
Alarms sounds when ready to eat. (If not alarm, set kitchen timer as one of the steps).

Revise the Sequencing List with ECT Built-In

Deficits in rememb­ering steps of task
Plug in rice cooker (or it stays plugged in)
Measure and fill with rice, water, ingred­ients (if measuring is an issue, you can have pre-poured amounts of rice and ingred­ients in a baggy in refrig­erator)
Push “on” button.
Alarms sounds when ready to eat. (If not alarm, set kitchen timer as one of the steps).

Revise the Sequencing List with ECT Built-In

Deficits in rememb­ering steps of task
Plug in rice cooker (or it stays plugged in)
Measure and fill with rice, water, ingred­ients (if measuring is an issue, you can have pre-poured amounts of rice and ingred­ients in a baggy in refrig­erator)
Push “on” button.
Alarms sounds when ready to eat. (If not alarm, set kitchen timer as one of the steps).

Task Modifi­cation

Alter properties of the task
1. Sit down to take a bath
4. Simplify activity (rice, water in the pot—she turns on)
3. Use assistive technology for a task (pill reminder system)
5. Use pre-set microwave settings
3. Shower in the morning vs. evening

Cognitive Strategies

External: external aids to cue to task
Internal: conscious mental strategies to improve perfor­mance
Sequencing lists (how to cook rice
Search for inform­ation from left to right.
Check work against a list.
Day planner (mild)
**Imbed all of these strategies into sequencing for task-o­riented training

Vanishing Cues

The goal is to reduce cues over time as the person learns the task-s­pecific methods unique to them


Strategy Use
Adaptions: Enviro­nmental Modifi­cation to Support OP
Total Cues
Severe dementia, chronic severe stroke, TBI not responsive to training; late stages of Parkin­son's
By the time we are done with this section, you will be able to choose an occupa­tio­n-based Interv­ention based on Metaco­gnition and Strategy use

Types of Adapta­tions

Change how the task is performed
Change task goals or expect­ations
Modify task demands
Modify physical enviro­nment
Modify social enviro­nment or the cues/i­nte­rac­tions with others

Adaptation Consid­era­tions

Who is doing the adapting?
Are the adapta­tions fixed or do they require ongoing implem­ent­ation?
Are they confined to a particular enviro­nment (people)?
How does it minimize demand on the impair­ment?
Are they generic or specific to deficits or symptoms?- Task or task-s­pecific problems
Not specif­ically on test

Adaptation requires care partner collab­ora­tion…

Produces quick results
Simplifies task
May be compen­satory if the client (not care partner) implements the adapta­tions once it is presented to them
Determine who is doing the adaptation
Does not require awareness (of the client), requires consis­tency

Coaching Care Partners to Support FC

RECAPS Memory Strategies in Dementia
Tailored Activity Program (TAPs)
Care of Older Persons in their Enviro­nment (COPE)
*FC= functional cognition


Strategy Use
Metaco­gnition (e.g. MultiC­ontext Approach)
Good- Minimal (goal is good strategy use)
Any Diagnosis
Metaco­gnitive (e.g. CO-OP)
None- Mild Cues
MCI, MS, Mild-mod CVA, mild TBI/co­ncu­ssion, Cancer­Mil­d-Mod dementia Mod-Severe CVA

Metaco­gnitive Strategy Training: Key Elements

1. Focus on structured methods and/or strategies for managing multiple steps activities
2. Self-m­oni­toring, self regula­tion, awareness or self-m­ana­gement, and problem solving

Variation in Strategies

Task-s­pecific vs. General strategies
Goal management vs. Self-a­war­eness
Guidance and prompts vs. Explicit strategy instru­ction


Relati­onship between ability and perfor­mance can be modified by strate­gies.
Two types of strate­gies: Global & Domain Specific


Client­-ce­ntered, perfor­man­ce-­based, proble­m-s­olving approach that enables skill acquis­ition through a process of strategy use and guided discovery.
1. Client­-chosen goals
2. Dynamic Perfor­mance Analysis
(Observe motiva­tion, task knowledge, and capabi­lity)
3. Cognitive Strategy Use
4. Guided Discovery
5. Interv­ention
Phase 1: Prep; Phase 2: Acquis­ition; Phase 3: Verify

Strategies that improve perfor­mance

Global Strategy (Metac­ogn­itive)
Domain Specific Strategy
1. Goal
Look to the left
2. Plan
Large handled spoon
3. Do
Use a calendar or alarm
4. Check
Task sequence list

Interv­ention Process

Phase 1: Prep (Goal)
Phase 2: Acquis­ition (Plan/Do)
Plan 3: Verifi­cation
Orient client­/family to CO-OP process
- Start practice or teach perfor­mance; Patient problem solves strategies or is coached to strategy; Ask person to consider strategy effect­iveness
Verify that the goal has been met
Identify Goals-COPM Observe baseline perfor­mance
Review Goal-P­lan­-Do­-Check
Re-adm­inister COPM
Encourage others to help with transf­er/­gen­era­liz­ation of strategies to other activities
Probe for genera­liz­ation

Focus is NOT on the task itself but on...

1. Recogn­izing cognitive errors across functional tasks
2. Enhancing self-a­war­eness of task methods and self-m­oni­toring skills
3. Increasing strategy generation and effect­iveness to manage cognitive error across functional activities

MC Approach Helps Clients Learn...

The same error patterns are interf­ering with success across different activities and situations
How similar methods can controls errors across situations

MC Approach: Key Elements

1. Focus on cognitive strategies
2. Activities structured to promote transfer and genera­liz­ation
3. Metaco­gnitive Framework
4. Functional Treatment Activities
5. Therap­eutic support focused on building self-e­fficacy
6. Goal setting and revision

What if we change to a similar activity?

Some error pattern likely to emerge
Same strategy would likely be effective
Must be an activity with similar charac­ter­istic (grocery list, following recipe) (all require working memory)

Strategy Use Across Situation

Requires Variab­ility
Consistent practice
Metaco­gnitive skills (e.g. executive function)

Cognitive Perfor­mance Error Patterns

Must be observed across activities of situat­ion...
- Misses important details
- Loses track within an activity
- Performs task steps in wrong order
- Omits steps, inform­ation, or items
- Gets side-t­racked
- Repeat actions, steps, or thoughts
- Incomplete steps or inform­ation
- Jumps into an activity without pre-pl­anning

Strategy Types:

External Strategies
Internal Strategies
Structured Activity Framework or Goal Management Strategies
Emotional Self regulation strategies
- Use a list to simplify directions or to ensure all items for a task have been gathered
- Verbal or visual rehearsal
- Stop, Plan, Review
-Use of cue signs/­labels
- verbal self talk- talking through each step
- Keep it simple, split, and remove (KISSR)
- Talking aloud during task perfor­mance
- Mental practice
- Goal, plan, predict, do and review
- Implem­ent­ation intentions (if-then)
- Goal, plan, do, check (CO-OP)

Mental­/Verbal Rehearsal is Most Useful for..

- small bits of info
- facts
- temporary storage
- focusing and concen­trating

Interp­rof­ess­ional Strategy

Find a common goal
Major limiting component is working memory


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