Executive Functional Performance Test EFPT Executive Functional Performance Test OTR 615 Dr. Fernandez

Introduction The EFPT was developed to provide a performance based standardized assessment of cognitive function, focusing on functioning as a whole as an individual performs a task. The EFPT serves three purposes: To determine which executive functions are impaired To determine an individuals capacity for independent functioning To determine the amount of assistance necessary for task completion

Assessment The EFPT assesses an individuals ability to complete the following components of 4 basic tasks: simple cooking, telephone use, medication management and bill payment. Initiation Execution Organization Sequencing Judgment and Safety Completion

Executive Function Definition Expected Behavior Initiation The start of motor activity that begins a task. The individual moves to the materials table to collect items needed for the task. Execution The proper completion of each step (which includes: organization, sequencing and sequencing). The individual carries out the steps of the task. Organization The physical arrangement of the environment, tools and materials. The individual correctly retrieves and uses items correctly. Sequencing The coordination and proper ordering of the task. The individual correctly follows and order and can switch attention from one step to the next Judgment and Safety Application of reason and decision making to avoid dangerous situations. The individual exhibits and awareness of danger by preventing a situation. Completion The inhibition of motor performance driven by the knowledge that the task is finished. The individual indicates that he/she is finished or moves away from the area of the last step.

Assessment Unlike other executive performance assessments the EFPT does not identify what the client can’t do but rather identifies what they can do and how much assistance is needed to carry out the task. This is achieved by using a standardized cueing system relating to the degree of cognitive impairment. The EFPT is a formal cognitive test which requires adherence to testing protocol. There should be no modifications of the instructions.

Cueing System Cue Type Cue Description No cues required Subject requires no help or reassurance Indirect Verbal Guidance Verbal prompting required such as an open-ended question. Gestural Guidance Gestural prompting required Direct Verbal Assistance Required to give a one step command Physical Assistance You are physically assisting with a step Do for the subject You are required to complete the step for the sublect Cueing system scoring: 0 points for “no cues required” 5 points for “do for the subject”

How to use the cueing system Unless the participant is in danger, do not intervene until the participant shows he/she is not processing to move to the next step. If the person has difficulty with any aspect of the tasks, you must wait to give them time to process before giving the participant a cue. Don’t wait for them to make an error. Give 2 cues of each kind before progressing to the next cueing level.

How to use the cueing system Once you have determined that the subject needs direct verbal cues in one aspect of the observation (organization, sequencing, safety and judgment) go ahead and give verbal cues to finish the task without starting over at each time at a verbal and then gestural levels. You will often find yourself combining different levels of cues for the different tasks. The score of your degree of assistance must reflect the highest level of cue used to get the task done. Do not initiate conversations with the subject. Do not give negative or positive feedback.

Directions for the EFPT The tasks should be followed in the following order: simple meal preparation, telephone, taking medication, paying bills. Begin the EFPT with the script and all of the pre-test questions. Leave all of the items necessary for all tasks in the box on a table. Ask the subject to begin the task using the script. Offer assistance only after the participant has made a good attempt to process the actions necessary to carry out the step. Cueing guidelines should be used.

Directions for the EFPT Complete the cueing and behavior assessment chart for each task. Time each of the tasks and write down the time in minutes and seconds on each task sheet. Complete the score sheet with information from each task sheet.

Video of the EFPT https://www.youtube.com/watch?v=OwCogK1c9GQ

Case Study #1 PM is a 59-year old male, former truck driver who was admitted to Memorial Regional Hospital due to worsening of upper and lower extremity weakness. MRI revealed compression C4-C7 from an intradural mass/spinal cord tumor. Neurosurgeon performed a C3- C7 laminectomy with a intradural resection of the tumor. PMH: OA, Melanoma (right shoulder), Hypertension, ETOH PLOF: Patient was I with all ADL’s and IADL’s living in a single family home with significant other. No assistive device. Pt states he is on disability however does not specify why.

Case Study #1 CLOF: Patient currently at Setup-MinA for ADL’s and functional transfers. Patient noted with decreased motivation.

Results Patient requiring cues in all areas of EF for all four tasks. May pose a safety risk without direct cues.

Case Study #2 BT is a 42 year old man who was working as a Golf instructor. He has a history of alcohol use and smoking. He was admitted to Florida Medical Center with left sided weakness. Testing confirmed R CVA. Upon transfer to Healthsouth patient was changed from nectar thick liquids to NPO. PMH: ETOH, smoking, chronic low back pain PLOF: Patient was I with all ADL’s and IADL’s. He lives with his girlfriend in a home without any agricultural barriers. No assistive device prior to admission.

Case Study #2 CLOF: Pt is currently at MOD I for all ADL’s except for feeding. (Total for Peg) Patient demonstrating decreased judgment, safety awareness and at times impulsivity.

Results Patient requiring cues in all areas of EF except completion for all four tasks. May pose a safety risk without direct cues.

Case Study #3 AM is a 57-year old male admitted to Kendall Regional Hospital after being struck on his motorcycle. He suffered multiple fractures as well as a head injury. He developed respiratory failure on admission and was intubated on a ventilator for a period. PMH: Hypertension, Dyslipidemia PLOF: Patient was living in a duplex with his significant other. He is a tax attorney and does not smoke or drink. He was I with all ADL’s and IADL’s requiring no assistive device.

Case Study #3 CLOF: Patient is currently at Mod I for all ADL’s. Patient is noted with slight delays with initiation and needs redirecting as tends to become anxious during new tasks.

Results Patient requiring cues in all areas of EF except organization and completion for all four tasks. May pose a safety risk without direct cues.

Case Study #4 KM is a 57 year old female who was at Healthsouth several months ago when she was diagnosed with MS and later returned home. She presented to Westside Regional Medical Center with severe abdominal pain. CT scan revealed a bowel perforation and an ileus along with signs and symptoms of sepsis. An exploratory laparatomy was performed. PMH: Afib, anemia, chronic low back pain, COPD, hypertension, lumbar spinal stenosis, urinary incontinence, MS.

Case Study #4 PLOF: Patient was living with her husband in a single family home. Ambulating with a cane or a walker within her home environment. CLOF: Patient currently at mod assist for ADL’s. Requires minimal cues for initiation during tasks OT Barriers: Progressive nature of the disease, wound

Results Patient requiring cues in all areas of EF except sequencing and completion for three tasks. The pay bill activity was not administered as pt does not use checks to pay bills. May pose a safety risk without direct cues.

Overall Results All four patients needed some kind of cueing for every task they completed. All four patients required some cueing for the following executive functions: initiation, judgment and safety. All four patients may pose a safety risk without supervision and cueing in one or more of these tasks. Patients with MS, CVA, TBI and SCI demonstrated executive functioning deficits.

Strengths Strengths Easy to administer No formal training or certification needed to administer Observes through a top down approach of what a person is capable of doing The effects that cognitive deficits has on occupational performance can be observed and measured Real World performance test Provides the therapist empirical data for treatment planning and what kind of assistance will be needed for the patient upon discharge. Psychosocial and behavioral factors can also be observed such as: motivation, agitation, affective changes.

Weaknesses No standardized adjustments for hearing and visual impairments Equipment used to administer the EFPT has not been standardized on a wide variety of conditions and populations

Take Home Message The EFPT is a helpful tool for direct observation of how cognitive functioning can be disrupted given a variety of different conditions, and how this disruption effects occupational performance in real world tasks. I do not believe that this assessment should be used to compare severities of cognitive dysfunction based on condition, as every patient and every diagnosis is different, but it is a very helpful tool in becoming more aware of what your patients capabilities are and can help you guide your intervention planning.

Thank You Any Questions?