Purser et al., 2005; Raji et al., 2005; Ishizaki et al., 2006) and cognitive decline and ADL limitations associated with increased mortality (Wu et al., 2004; Schupf et al., 2005).

Current Measurement

Velozo pointed out that the following cognitive instruments are typically used in national population surveys:

  • The Mini Mental State Exam (MMSE): 11 questions covering 5 areas—(1) orientation, (2) registration, (3) attention and calculation, (4) recall, and (5) language

  • The Medical Expenditures Panel Survey instrument: questions addressing memory loss, confusion, problems making decisions, and supervision for safety

Cognitive instruments generally used in rehabilitation include

  • the Functional Independence Measure (FIM), used for inpatient rehabilitation, has five questions that address memory, comprehension, expression, social interaction, and problem solving;

  • the Minimum Data Set, used in skilled nursing facilities, has approximately 11 questions that address long-term memory, short-term memory, daily cognition, awareness, and speech and understanding; and

  • the Outcome Assessment and Information Set, used in home health, contains a subset of questions that are somewhat cognitive and somewhat leaning toward function, such as managing oral medications, using the telephone, cognitive function, and speech clarity.

Velozo said that these instruments have some limitations, both in content and in measurement. Relative to content limitation, MMSE does not address the effects of cognition in a person’s daily life. MMSE also does not generate separate cognitive domain measures that are more typical in the neuropsychological literature, such as attention, memory, and executive function. Relative to measurement limitations of cognitive assessments, although FIM is widely used and has a relatively extensive literature on its psychometrics, these psychometric studies focus on the “motoric” or ADL component of FIM, not the cognitive component.

Recent developments in the area of “applied” or “functional” cognition offer one of the potential solutions for content limitations. Coster and colleagues (2004) have defined applied or functional cognition as discrete functional activities whose performance depends most critically on the application of cognitive skills with limited movement requirements: for



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