Assessing Cognition in Occupational Therapy: Foundations and Functional Approaches

Introduction – Why Cognition Matters in Occupational Therapy

In occupational therapy (OT), cognition is not an abstract mental ability—it’s a critical foundation that directly affects how people live, function, and heal. Whether someone has experienced a traumatic brain injury (TBI), stroke, spinal cord injury, or a chronic neurological condition like multiple sclerosis or Parkinson’s disease, some degree of cognitive change is likely. These changes can deeply impact their participation in therapy and their ability to regain independence.

Occupational therapists are uniquely equipped to understand how these cognitive changes influence “doing” in the real world. Assessing cognition is not about labeling deficits—it’s about understanding how thinking processes affect real-life activities like making breakfast, driving to work, or interacting socially.

Consider this: How would you handle your daily routine if you couldn’t concentrate, remember your medication schedule, or problem-solve how to fix a broken appliance? For many clients, these scenarios are not hypothetical. After a brain injury, familiar environments may become confusing. Tasks that once felt automatic can now feel overwhelming.

This is where OT steps in—not just to test cognition, but to explore how changes in thinking affect being, thinking, and doing.

Key Reasons Cognition Is Central to OT:

• It determines how clients engage with daily activities
• It influences rehabilitation outcomes and participation
• It underpins safety, independence, and life roles
• It guides therapists in choosing meaningful interventions

Cognitive abilities are often invisible but profoundly powerful. OT’s role is to bring them into focus, connect them to everyday function, and help clients navigate life despite cognitive challenges.

What Is Cognition and Why Does It Matter for Occupational Therapists?

Cognition refers to the wide range of mental processes that allow people to perceive, think, learn, remember, communicate, and solve problems. These processes are the invisible infrastructure behind every purposeful action, from brushing teeth to managing finances or navigating a social conversation.

In occupational therapy, cognition is not treated in isolation. Instead, it’s understood in the context of occupational performance—how cognitive abilities enable or hinder the completion of meaningful daily activities.

Core Cognitive Domains:

Cognitive functions are often categorized into several interconnected domains, each playing a specific role in human functioning. Although listed separately, they rarely operate in isolation:

• Orientation: Awareness of self, time, place, and situation
• Perception: Interpretation of sensory input
• Attention: The ability to focus on relevant stimuli and shift focus as needed
• Memory and Learning: Encoding, storing, and retrieving information
• Judgment and Reasoning: Making decisions and drawing conclusions
• Language: Understanding and expressing ideas through words
• Executive Functions: Higher-order processes like planning, problem-solving, initiating tasks, and regulating behavior

Why Occupational Therapists Assess Cognition:

Occupational therapists assess cognition because it is foundational to a person’s ability to engage in everyday life. Cognitive impairments are common in many OT populations—sometimes subtle, sometimes severe—and can affect everything from self-care to employment readiness.

These impairments may be:

• Temporary, such as confusion after surgery or medication side effects
• Stable, like lasting deficits from a stroke or head injury
• Progressive, as in Alzheimer’s or Parkinson’s disease

By understanding a client’s cognitive profile, OTs can:

• Identify strengths and challenges in thinking skills
• Recognize how these affect task performance and participation
• Determine the level of supervision or support needed for safety
• Create personalized, realistic goals and interventions
• Monitor changes over time to adjust treatment plans

OT’s Unique Role in Cognitive Assessment:

What sets OT apart is the functional perspective. While psychologists or neurologists might use standardized cognitive tests to assign diagnostic labels, occupational therapists focus on how cognition affects real-world function. For example:

• Can the person safely cook a meal?
• Do they remember appointments or when to take medications?
• Can they plan and sequence a laundry task or manage a household budget?

Instead of asking “What is the IQ?”, the OT asks, “What are the cognitive strengths and weaknesses, and how do they influence the client’s ability to participate meaningfully in life?”

Key Cognitive Capacities and How Dysfunction Appears

Cognitive functions don’t operate in a vacuum. They are integrated, dynamic, and expressed through behavior. In occupational therapy, understanding how each domain presents, both when intact and when impaired, is essential to making sense of a client’s occupational performance.

Let’s explore the key cognitive capacities.

1. Orientation

Definition: Awareness of self in relation to person, place, time, and situation.

Why it matters: Orientation is a basic but vital prerequisite for goal-directed action. Disorientation is often an early marker of brain dysfunction.

Examples of dysfunction:

• A client gives correct answers in the morning but later insists it’s 1992 or says they are at a different hospital.
• Inconsistent or illogical responses to questions about date/time/location.

2. Attention

Definition: The ability to focus cognitive resources on relevant stimuli while ignoring distractions.

Components of Attention:

• Focused Attention: Basic response to stimuli (e.g., turning toward a loud noise).
• Sustained Attention: Maintaining focus over time (e.g., reading instructions).
• Selective Attention: Filtering distractions (e.g., ignoring a TV while cooking).
• Alternating Attention: Shifting between tasks (e.g., switching from cooking to answering the phone and back again).
• Divided Attention: Managing two tasks at once (e.g., walking while talking).

Why it matters: Attention is the gateway to learning and memory. Without it, encoding and retention break down.

Examples of dysfunction:

• Difficulty following through on tasks due to distraction.
• Appears overwhelmed in noisy or fast-paced environments.
• Trouble shifting focus between steps in a multi-part activity.

3. Memory

Definition: The mental capacity to store, retain, and recall information.

Memory Systems:

• Short-term / Working Memory: Holds a small amount of information temporarily. Crucial for planning and problem-solving.
• Long-term Memory:
  • Explicit (Declarative):
    • Episodic: Personal experiences (e.g., remembering breakfast).
    • Semantic: General knowledge (e.g., knowing that Paris is in France).
    • Prospective: Remembering to do things in the future (e.g., taking medication).
  • Implicit (Non-declarative):
    • Procedural: Learned motor habits (e.g., tying shoes).

Why it matters: Memory enables routines, safety, and learning. Different types of memory breakdown affect different tasks.

Examples of dysfunction:

• Forgets whether medication was taken.
• Can’t recall names or events after an injury (anterograde amnesia).
• Can’t remember past events (retrograde amnesia).
• Relies heavily on others to track appointments or manage schedules.

4. Executive Functions

Definition: Higher-level thinking abilities that govern goal-directed behavior.

Core skills:

• Initiating tasks
• Inhibiting impulsive actions
• Planning and organizing
• Problem-solving and decision-making
• Flexible thinking
• Monitoring and correcting behavior

Why it matters: Executive functions are crucial for independence. They enable people to adapt, plan, and follow through in complex or unfamiliar situations.

Examples of dysfunction:

• Unable to get started on a task despite having all the materials.
• Misses therapy appointments due to poor planning.
• Makes unsafe decisions or forgets critical steps (e.g., leaving the stove on).
• Struggles to organize bills, groceries, or a sequence of chores.

5. Self-Awareness & Metacognition

Definition:

• Self-awareness: Insight into one’s own strengths and limitations.
• Metacognition: “Thinking about thinking” — the ability to monitor, plan, and adapt one’s cognitive strategies.

Levels of Awareness (Crosson et al.):

1. Intellectual awareness – Knowing a problem exists.
2. Emergent awareness – Recognizing a problem while it happens.
3. Anticipatory awareness – Predicting and planning for difficulties.

Why it matters: Without awareness, clients may overestimate abilities, resist therapy, or engage in unsafe behaviors.

Examples of dysfunction:

• A client insists they can live independently, despite missing medications and bills.
• Denies memory or planning problems, even when family members report daily issues.
• Wears inappropriate clothing to a job interview, unaware of appearance.

How Occupational Therapists Assess Cognition – A Stepwise Approach

Occupational therapists don’t assess cognition in a vacuum. Their approach is client-centered, context-sensitive, and deeply rooted in functional performance. Rather than relying solely on standard scores, OTs use a combination of methods to understand how cognitive abilities — or deficits — play out in everyday life.

Here’s a breakdown of the general process occupational therapists follow when assessing cognition, adapted directly from Trombly’s functional evaluation model.

Step 1: Prepare – Gather Background Information

Before interacting with the client, the OT reviews their medical chart and background to gain context. This includes:

• Medical diagnoses and history (e.g., TBI, stroke, neurodegenerative disease)
• Imaging and neurological reports
• Functional status (mobility, ADLs, language ability)
• Team members involved (e.g., SLP, neuropsychologist)
• Possible barriers to testing (e.g., vision, pain, fatigue, language barriers)

Example: In D.B.’s case, chart review revealed a severe TBI, previous coma, orthopedic injuries, and a background as a police officer — all important in shaping cognitive expectations and test planning.

Step 2: Collect Patient and Caregiver Perspectives

The therapist interviews both the client and their family (if appropriate) to understand:

• Perceived cognitive problems
• Goals and values
• Real-life challenges and safety concerns
• Emotional responses to deficits

Why this matters: Clients may under- or overestimate their abilities. Family members often provide insight into behaviors the client doesn’t recognize (e.g., missing medications, unsafe cooking).

Step 3: Observe Function Informally

The OT watches how the client handles real or simulated activities, such as:

• Taking notes during therapy
• Completing homework tasks
• Participating in conversations or structured tasks

This helps generate early hypotheses about attention, initiation, memory, or executive dysfunction before formal testing begins.

Example: D.B. failed to write down homework tasks and completed none, suggesting poor memory and/or initiation.

Step 4: Select Assessment Tools

Choosing the right tests depends on:

• The client’s diagnosis and functional questions
• The therapist’s skill level and available tools
• The setting (e.g., hospital, outpatient, home)
• Collaboration with other team members (to avoid redundancy)
• The psychometric properties of tools (validity, reliability, sensitivity)

Example: D.B.’s therapist selected multiple tools to address different layers of function:

• COPM to explore self-perceived priorities and awareness
• EFPT to assess executive function in functional tasks
• Cognistat for a broad cognitive profile
• Informal observation during therapy assignments

Step 5: Administer the Assessments

Standardized assessments are given following strict protocols to ensure reliability. The therapist also pays close attention to:

• Behavioral cues (e.g., frustration, fatigue)
• Problem-solving strategies (or lack thereof)
• Emotional regulation during tasks
• Need for cues or repetition

Scores are recorded alongside qualitative observations.

Step 6: Interpret the Findings

Interpretation goes beyond numbers. OTs consider:

• Contextual factors (pain, medication effects, stress)
• Discrepancies between client report and observed behavior
• Patterns across tools (e.g., memory, attention, self-awareness)
• Functional relevance (e.g., safety in ADLs or IADLs)

Example: In D.B.’s case, EFPT scores showed significant assistance needed for managing medication and finances. Cognistat revealed impairments in attention and memory, while observation confirmed poor task follow-through and limited awareness.

Step 7: Document and Share Results

The therapist writes up the findings in the medical record and shares results with:

• The client (in clear, compassionate language)
• Family members (as appropriate)
• The interdisciplinary team

The results guide both goal-setting and treatment planning.

Bottom Line:

The OT cognitive assessment process is not just about what someone can do on a test. It’s about synthesizing:

• Objective scores
• Observed behaviors
• Environmental context
• Patient insight
  To answer one core question: How does cognition affect this person’s ability to function safely, independently, and meaningfully in daily life?

Assessment Approaches Used by Occupational Therapists

Occupational therapists use a multi-method approach to cognitive assessment that combines structured tools with real-life performance observation. This approach ensures a functional, contextual, and person-centered evaluation, which is essential when planning practical interventions.

Below are the main types of assessments OTs use to understand cognitive strengths and challenges.

1. Dynamic Assessment

What it is:
Unlike static assessments that just record performance, dynamic assessments evaluate a client’s learning potential and response to cues, feedback, and strategy training.

Key features:

• The therapist offers graded cues or changes the task as needed.
• The focus is on “how the client learns” rather than “what the client scores.”

Example tool:

• Dynamic Interactional Assessment (DIA) — integrates guided questions, self-predictions, and verbal cueing to explore how cognition affects function in real time.

Clinical relevance:
In D.B.’s case, the therapist used dynamic strategies (e.g., cueing, task adjustments) to better understand where support improved task performance.

2. Informal Observation

What it is:
Observation of how a client performs everyday tasks without structured testing — often the first and most natural form of cognitive assessment.

What OTs look for:

• Distractions or off-task behavior
• Sequencing and planning steps
• Task persistence and self-correction
• Use of memory aids or strategies

Why it’s useful:

• Ideal for clients who struggle with instructions
• Reveals task-specific strengths and weaknesses
• Helps hypothesize which cognitive domains need formal testing

Example:
D.B. consistently failed to record homework or follow through, indicating issues with initiation and working memory.

3. Performance-Based Assessment

What it is:
These assessments simulate real-world activities — like cooking, money management, or phone use — to evaluate how cognition affects actual task performance.

Why OTs use it:

• Assesses cognition in context (not in isolation)
• Helps identify supports or compensations needed
• Bridges the gap between test performance and real-life ability

What’s measured:

• Initiation, sequencing, execution, completion
• Strategy use, cue dependency, safety, and insight

4. Standardized Functional Assessments

A. Executive Function Performance Test (EFPT)

• What it assesses: Initiation, organization, sequencing, safety, and judgment across four tasks (simple cooking, medication management, phone use, bill paying)
• Scoring: Based on the level of cueing or assistance needed (0 = independent, 5 = total assistance)
• Why it’s valued: Strong psychometric support and real-world relevance

B. Arnadottir OT-ADL Neurobehavioral Evaluation (A-ONE)

• What it assesses: Performance in ADLs while identifying specific cognitive-perceptual deficits (e.g., apraxia, neglect)
• Time: ~25 minutes
• Note: Only for clients with cortical CNS dysfunction; requires certification

C. Observed Tasks of Daily Living–Revised (OTDL-R)

• Focus: IADL-related problem solving — medication use, phone use, managing money
• Strength: Quick and bedside-friendly
• Limitation: Limited assessment of novel/unstructured situations

5. Cognitive Screens and Microbatteries

These are quicker tools to get a snapshot of cognitive status, often used to decide if more in-depth testing is needed.

A. Mini-Mental State Examination (MMSE)

• Duration: 5–10 minutes
• Pros: Widely recognized, simple to administer
• Cons: Poor sensitivity to mild deficits

Read more about MMSE.

B. Montreal Cognitive Assessment (MoCA)

• Duration: ~10 minutes
• Strengths: More sensitive to mild impairments than MMSE
• Use: Common in stroke, Parkinson’s, and MCI populations
• Caution: May overidentify impairment with some scoring thresholds

C. Loewenstein OT Cognitive Assessment (LOTCA)

• What it measures: Orientation, perception, visuomotor skills, thinking operations
• Time: 30–45 minutes
• Note: Doesn’t measure memory well; may miss subtle deficits

D. Cognistat (Neurobehavioral Cognitive Status Exam)

• Subtests: Orientation, attention, comprehension, repetition, naming, construction, memory, calculation, similarities, judgment
• Time: 20–25 minutes
• Strength: Balanced breadth and depth; gives a cognitive profile across 10 domains

6. Performance-Based Executive Function Measures

A. EFPT (covered above)

B. Multiple Errands Test (MET)

• What it is: A “real-world scavenger hunt” where clients must complete a list of tasks while following rules
• Environment: Often set up in a mall, hospital, or clinic
• Purpose: To capture executive dysfunction that may not show up on structured tests
• Challenges: Requires setup and careful scoring; not yet standardized universally

In summary, occupational therapists combine observational, functional, and standardized tools to create a multi-layered understanding of cognition in context. This allows for not just diagnosis — but intervention planning grounded in the realities of daily life.

Factors That Influence Cognitive Performance and Test Results

Cognitive performance is never static or isolated — it’s shaped by a complex interplay of biological, emotional, social, and environmental factors. Understanding these variables helps occupational therapists interpret assessment results more accurately and design interventions that truly meet the client where they are.

1. Neurobiological Influences

Changes in brain structure and function directly affect cognition. The location and extent of damage or degeneration determines the type and severity of cognitive deficits.

Examples:

• Frontal lobe injury → Executive dysfunction (poor planning, disinhibition)
• Temporal lobe damage → Memory impairments
• Right parietal lobe stroke → Spatial neglect and perception issues

Normal aging also plays a role:

• Crystallized intelligence (e.g., vocabulary, general knowledge) remains stable or improves with age.
• Fluid intelligence (e.g., problem-solving, processing speed) often declines subtly starting around age 60.

2. Affective and Transient States

Emotions and temporary conditions, such as fatigue or illness, can significantly interfere with cognitive performance.

Key influences:

• Depression: May appear as memory problems due to reduced working memory capacity being taken up by negative thought loops.
• Anxiety: Can impair focus, attention, and mental flexibility.
• Pain and fatigue: Act like internal distractions, reducing the ability to concentrate or encode new information.
• Poor sleep, nutrition, hydration: Physiological states that reduce cognitive efficiency.

Clinical Insight:
In D.B.’s case, the therapist noted no visible distress or pain during testing, helping rule out those factors when interpreting his results. However, conflicting reports from his family and his own denial suggested potential mood-related influences (e.g., adjustment issues or reduced insight).

3. Sociocultural Influences

A person’s culture, education, and life experience deeply shape both cognitive processing and test performance.

Examples:

• Years of formal education strongly influence test scores — a client with low education may appear impaired when they’re not.
• Clients from some cultures may underreport difficulties due to norms around independence or overreport due to culturally informed humility.
• Language and literacy can skew test results if tools aren’t properly adapted.

OT Consideration:
Assess whether poor scores are due to actual cognitive impairment or due to testing bias, language barriers, or unfamiliarity with the test format.

4. Task and Environment Factors

The setting, structure, and novelty of the task can dramatically alter performance, especially for clients with executive dysfunction or attention deficits.

Key elements:

• Task familiarity: Familiar routines require less attention and cognitive effort.
• Environmental distractions: Noise, clutter, poor lighting, or social interruptions can reduce performance, particularly in those with brain injury.
• Contextual cues: Support memory and planning (e.g., visual labels in a kitchen).

Example:
A client might do well with medication management in a quiet clinic but become confused in a cluttered home where distractions are present. This doesn’t mean their cognition has changed — it means the environmental demands have increased.

Bottom Line:

Cognitive assessment is not just about test scores. It’s about understanding how multiple internal and external factors interact with cognitive ability and either support or hinder occupational performance.

OTs bring unique value by interpreting assessments through this holistic lens, ensuring that treatment plans are realistic, respectful of context, and truly person-centered.

Bringing It All Together – The OT’s Role in Cognitive Assessment

Cognitive assessment in occupational therapy is much more than checking boxes or calculating test scores. It’s about weaving together complex data — from client behavior, caregiver input, clinical tests, and contextual understanding — to paint a functional, personalized picture of how cognition affects a person’s everyday life.

The OT’s Unique Perspective

Occupational therapists don’t just ask:

“Is there a memory problem?”

They ask:

“How is this memory problem affecting their ability to remember medication times, attend therapy, cook safely, or navigate public transport?”

By approaching cognition through the lens of occupational performance, OTs create a bridge between neuropsychological insights and real-world application, turning information into intervention.

How OTs Integrate Cognitive Assessment

They synthesize multiple sources:

• Objective scores from screening or standardized tools
• Behavioral observations from real or simulated tasks
• Reports from clients and caregivers
• Contextual factors (mood, fatigue, environment, cultural background)

From this, they determine:

• Where breakdowns are occurring
• What supports or adaptations are needed
• How to approach therapy in a way that respects both the client’s goals and their cognitive capacities

Goal of Cognitive Assessment in OT

The ultimate purpose is not to diagnose, but to empower:

• Empower clients with strategies and self-awareness
• Empower caregivers with knowledge and realistic expectations
• Empower the therapy team with insights for safe, effective, meaningful care

A Living, Dynamic Process

Cognitive assessment in OT is ongoing. As clients recover, decline, or adapt, their abilities shift — and so must the therapist’s approach. What worked in inpatient rehab may not apply in a noisy home environment. What was once a weakness may become a strength with cueing or strategy training.

This dynamic, human-centered process is what makes occupational therapy’s role in cognitive assessment so vital — and so unique.

Final Thought

Occupational therapists are not just assessing cognition — they’re interpreting how people think, feel, and act in the real world, and helping them rebuild or retain the capacity to live life fully.

That’s the essence of functional cognition in OT.

Read: Cognition for Caregivers – A Simple Guide for Patients and Caregivers