Academic journal article British Journal of Occupational Therapy

Concurrent Validity of the Executive Function Performance Test in People with Mild Stroke

Academic journal article British Journal of Occupational Therapy

Concurrent Validity of the Executive Function Performance Test in People with Mild Stroke

Article excerpt


Occupational therapists working in acute care assess the performance of activities of daily living (ADL). Studies have shown that executive dysfunction is common in adults after stroke (Nys et al 2005, Zinn et al 2007). Executive functions enable people to engage successfully in self-directed activities and have been defined (Lezak et al 2004) as consisting of four components: volition (awareness, initiative and motivation); planning (attention, impulse control, working memory and flexibility); goal-directed activity (starting, maintaining, switching and stopping); and effective performance (monitoring, self-correcting and regulating the tempo). Even mild executive dysfunction, such as deficit in attention, has been shown to cause problems in ADL (Stephens et al 2004).

To help such patients with an appropriate intervention, it is important to be aware of the underlying causes of the limitations of the patients' performance in their ADL, both at home and in the community. Assessing executive functions is, therefore, an important issue in the acute stroke care of adults, particularly since the length of stay on acute wards for adults who have had a stroke has been steadily reduced (Johansson and Malmberg 2004) and it is not obvious that all patients will be offered the opportunity to participate in rehabilitation. However, most of the instruments used by occupational therapists in acute care focus on assessing personal ADL (P-ADL) (Van der Putten et al 1999). An assessment of more complex activities, such as instrumental activities of daily living (I-ADL) (Cahn-Weiner et al 2002), has been shown to be more appropriate for detecting executive dysfunction (Hanks et al 1999, Pohjasvaara et al 2002, Mok et al 2004, Nys et al 2005), and there is evidence that people have problems with I-ADL in the acute phase after stroke (Hofgren et al 2007).

Patients in acute care who have salient executive impairments most probably will be recruited to a rehabilitation team. However, there may be a risk that patients with hidden mild executive dysfunctions will be discharged to their homes without any follow-up as to how they manage and compensate for the limitations in everyday life, unless the occupational therapists are provided with a clinically more relevant instrument for assessing activity limitations before discharge. The Mini Mental State Examination (MMSE) screening instrument is sometimes used to measure the cognitive status of the patient in acute care, but the problem with MMSE is that it fails to detect executive dysfunctions such as abstract thinking, judgement and problem solving (Patel etal 2003, 2007).

Occupational therapists, therefore, need an instrument that is easy to administer and appropriate for assessing I-ADL during the acute care of patients with mild stroke. There are currently few neuropsychological assessments in the acute care situation for patients with mild stroke. If activity problems could be detected by an instrument, the occupational therapist at the acute ward may be able to teach patients and their families strategies to compensate for their problems. It has been emphasised that it is important to assess executive function in naturalistic activities, however, because even if people do not show cognitive impairment in cognitive tests after having had a stroke, they may still have problems in executive functions (Alderman et al 2003, Gioia and Isquith 2004, Burgess et al 2006). It is, therefore, important to find a valid and reliable instrument that is easy to use in the acute care setting to assess executive skills in relation to I-ADL. The EFPT may be such an instrument.

The EFPT is a standardised test (Baum et al 2003) whose primary purpose is to measure executive function through I-ADL and to determine the level of support needed for the patient to engage in the I-ADL task as much as possible. It could be said that the instrument EFPT uses both a bottom-up and a top-down approach in assessing patients (Brown and Chien 2010). …

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