1 Running head: FUNCTIONAL COGNITION Functional Cognition in Patients with Traumatic Brain Injury Rachel L. Steffen University of Florida
2 FUNCTIONAL COGNITION Abstract Since Operations Enduring Freedom and Iraqi Freedom, brain injured Veterans have differed greatly from the general population in how they are affected by their injury (Jones, Young, & Leppma, 2010). To identify specific deficits and treatment goals, it is essential to assess function in the post deployment Veteran with mild traumatic brain injury (mTBI). Measurements of applied cognition give insight Computer Adaptive Mea sure of Functional Cognition for Traumatic Brain Injury ( CAMFC TBI ) assessment measures challenges that moderate to severe TBI patients face daily. It is hypothesized that a match between functional ability and item dif ficulty exists. This match is expecte d to only hold true for moderate to severe TBI patients. Mild TBI patients are expected to perform exceptionally well on the CAMFC TBI, indicating the items may be too easy for them. Ninety moderate to severe TBI patients participated in the initial testin g of the CAMFC TBI. Then, a Rasch one parameter rating scale model compared item difficulty to func tional ability. Resultant measures of ability were higher than expected in patients with moderate to severe TBI, and may trend similarly for those with mTBI. Therefore, it becomes necessary to develop more challenging items for the CAMFC TBI, in or der to differentiate individuals with mTBI
3 FUNCTIONAL COGNITION Introduction Brain injury is a major public health concern in the United States. Each year, approximately 1.7 million people acquire a brain injury (Centers for Disease Control and Prevention [CDC], 2010). However, this number does not include the incidences of military personnel who acquire brain injury. The severity of brain injuries ranges from mild to severe o n a continuum. Mild traumatic brain injury (mTBI) is classified as a minor change in mental status or consciousness while severe TBI is defined as an extended period of unconsciousness or amnesia post injury (CDC, 2010). Since the beginning of Operation En during Freedom (OEF) and Operation Iraqi Freedom (OIF), brain injury has shown to affect Veterans in a significantly different manner than in civilians who acquire brain injuries (Jones, Young, & Leppma, 2010) TBI resulting from blast injuries are conside red more complex than other causes of TBI, such as motor vehicle accidents or sports injuries (Defense and Veterans Brain Injury Center, 2011) According to the Defense and Veterans Brain Injury Center (DVBIC) (2011), t here are four components that make up a blast injury. T he first component to a blast injury is primary blast injury. Primary blast injury occurs as a result of exposure to a pressure wave from the blast itself (DVBIC, 2011) The environment in which the blast occurs affects the pressure wave (DVBIC, 2011) A smaller, more closed environment creates a stronger effect of the blast than in an open space (DVBIC, 2011) ry. Someone who is further from the blast is likely to be less affected than someone who is closer. Secondary blast injury results from flying debris from the blast penetrating the brain (DVBIC, 2011) The third component of a blast injury is tertiary injury. When an individual is thrown as a result of the blast it is called tertiary blast injury (DVBIC, 2011) Hitting another object, such as a wall, after being thrown by the blast is common. Tertiary injuries typically cause blunt force trauma to the brain as a result of the acceleration and deceleration forces (DVBIC, 2011) Finally, quaternary blast injury occurs as a result of severe trauma. A high volume of blood loss and inhalation of toxic gases from an explosion are examples of complications from injuries that can augment the current injury (DVBIC, 2011)
4 FUNCTIONAL COGNITION Mild TBI (mTBI) and Post Traumatic Stress Disorder (PTSD) are the two most common injuries of returning soldiers (Jones, Young, & Leppma, 2010). Blast injuries have been found to be the most common cause of traumatic brain injury in OEF/OIF military Veter ans (Elder, Mit sis, Ahlers, & Cristian, 2010). Common deficits that occur in mild TBI patients include challenges within t he cognitive areas of attention, memory, processing speed, and executive function The most affected construct is memory. Patients wit h mild traumatic brain injury tend to have difficulty with verbal memory, verbal recognition, naming, verbal fluency and processing speed (Miotto et al., 2010) Visual memory is also shown to be affected (Sosnoff, Broglio, & Ferrara, 2008) Patients may e xhibit increased distractibility in regards to attention deficits (Flynn, 2010). Flynn also claims that executive dysfunction is likely to occur (2010). A major concern that accompanies TBI is the presence of comorbidities. Patients who have been diagnosed with TBI typically also have diagnoses of PTSD, anxiety disorders, and adjustment problems (Carlson et al., 2010). These comorbidities may also coincide with substance abuse, family dynamics, and individual personality characteristics to affect treatment and recovery outcomes (French, Spector, Stiers, & Kane, 2010). TBI and its common comorbidities often negatively affect quality of life and interfere with act ivities of daily living (ADLs) (Snell & Halter, 2010). As a result, research on blast injuries and their effects has been a major focus of medical profess ionals. Snell and Halter suggest that significantly more research needs to be done on these types of injuries in order to improve treatment practices (2010). The first step in creating and implementin g more effective treatments for V eterans is to develop measures that accurately measure scales that are currently used to immediately determine the type and severity of a brain injury. The Glasgow Coma Scale computerized tomography (CT) scans and neuropsychological tests are th e current diagnostic measures that determine the level of brain injury that has been acquired. While these common measures accurately determine the severity of b rain injuries, they do not provide insight into the daily difficulties that may be faced as a result of the injury. Therefore, measures that assess the function of the Veteran post diagnosi s are necessary to identify specific deficits and to determine dist inct goals of
5 FUNCTIONAL COGNITION treatment. Assessments that measure functional or applied cognition determine how TBI affects an functional cognition would ask if the patient can pay attention to a conversation without getting distracted or if they can follow an automated telephone system. Velozo and colleagues have developed an assessment, called the Computer Adaptive Measure of Functional Cognition for Traumatic Brain Injury (CAMFC TBI), which address es the challenges faced by patients in everyday life (Velozo, Heaton, &Donovan, 2011) In order to develop this assessment, Velozo and colleagues built an item pool and field tested it. A literature review, advisory panel of experts, and focus groups provided the means for developing a pool of items for the measure. Once this process was complete, ninety patients with moderate to severe TBI were tested using this measure. The difficulty of the items within the CAMFC TBI is designed to match the ability level of the patient. Therefore, it is hypothesized that a match between functional ability and item difficulty e is expected to only hold true for moderate to severe TBI patients. Mi ld TBI patients are likely to perform exceptionally well on the CAMFC TBI, indicating the items may be too easy for them. The purpose of this study is to determine the match between the difficulty of the items on the CAMFC TBI and the functional ability of the pa tients with moderate to severe TBI. If the difficulty of the items matches the ability level of the patients, then it is hypothesized that the items may be too easy for patients with mild traumatic brain injury. This would then indicate the necessity to ex pand the measure and include more challenging items that would differentiate the functional ability levels of patients with mTBI. Methods This study is a secondary analysis of a study by Velozo an d colleagues using the CAMFC TBI to test the functional cogn ition of patients with moderate to severe TBI. A self report paper and pencil version of the CAMFC TBI and a battery of cognitive assessments were field tested on 47 patients in
6 FUNCTIONAL COGNITION outpatient rehabilitation and 43 individuals 1 year or more post injury While the CAMFC TBI has six constructs or subtests, four of those subtests are the focus of this study. They are attention, memory, processing speed, and executive functioning. There are 52 attention questions, 35 questions that assess memory function, 33 quest ions regarding processing speed, and 64 executive function questions. Each question within the measure has 5 p ossible answer choices. Participants may respond with never, sometimes, often, always, or not applicable (N/A) according to their level of functio ning. In Figure 1, a shortened list of questions used in the CAMFC TBI is provided. Once patients were recruited for the study, one on one appointments were se t up to administer the measure. After voluntarily consenting to participate, the patients answere d demographic questions. Participants were then given the CAMFC TBI to complete. Following the testing of the ninety patients, the data was compiled and put into an Access database. The tables of data within the database were then transferred to an Excel spreadsheet. Data was transferred into SPSS for demographic analysis and Winsteps for Rasch analysis Rasch analytic methodology is a one parameter item response theory (IRT) analysis that investigates assessments at the item level. By investigating the measure at the item level, it allows both person ability and item difficulty to be a nalyzed on the same linear continuum. Each construct ( memory, attention, processing speed, and executive functi oning ) was analyzed separately. The mean of the item distribution was compared to the mean of the person distribution. Conclusions regarding the ability level of the patients with moderate to severe TBI were made along with the decision to develop a pilot study for Veterans with mild TBI. Results Table 1 summarizes the demographics of the participants in the study. Overall, there were ninety partic ipants in the study. Seventy percent of the respondents were males and 30% of the respondents were females. The ages of the patients ranged from eighteen to eighty four. The mean age was 38.18 with a standard deviation of 15.76. The majority of the patient s did not currently work (80.0%) or drive (65.6%). Eighty percent of the participants were white, 11.1% were African American, 4.4% were Hispanic, 3.3% were classified as Other, and 1.1% did not respond to the question. Participants with an income of
7 FUNCTIONAL COGNITION $21,0 00 per year or higher accounted for 74.5% of the respondents. Patients with an income of over $50,000 per year were represented the most. However, 10% of the respondents were of an income of less than $5,000 per year. For education level, no college degree and up to a 12 th grade education were marked most, while an education of an 8 th grade level was marked least. The null hypothesis for this study was that there is no difference between pers on ability and item difficulty. Figure 2 presents a map comparing the distribution of patient measures to item difficulties for the attention construct in log equivalent units or logits. The s to the left of the vertical dashed line represent the distribution of person measures with the lowes t ability person at the bottom of the figure and the highest ability person at the top. To the right of the vertical line is the distribution of the items of the top of the figure. standard deviations of the patients (letters to the left of the dashed vertical line) and items (letters to the right of the vertical line). Item difficulty and person ability is determined from IRT analysis. The item response theory puts person ability measures and item difficulty measures on the same linear continuum. Both person ability measures and item difficulty measures go from low to high. There are people of low ability and high ability as well as item s of low difficulty and high difficulty. If a person can do an item of a particular difficulty level, then they have a higher probability of being able to perform the items at a lower difficulty. The 1 parameter model provides this relationship. For the attention subtest, t he person distribution is approximately normal with the mean of t he persons at approximately 1.2 logits, two standard deviations higher than the mean of the items (which is s above the mean of the person distribution. While there are no
8 FUNCTIONAL COGNITION ceiling effects, 33 individuals with moderate to sever e TBI have Attention measures that are above the average difficulty level of most difficult item. For figure 3 or the memory subtest, the mean of the persons is approximately 1.6 logits, which is more than 2 standard deviations hi gher than the mean of the items which again, is anchored at 0.0 logits. None of the items are above the mean of the person distribution. Even the most challengi below the mean of the persons. The easiest item within the memory construct is item 68 (When driving, remembers to take the key when getting out). Forty six of the participants with modera te to severe TBI have Memory measures that are above the average difficulty level of the most difficult item. The p rocessing speed map, as shown in figure 4 has a person mean of 1 logit. The mean of the persons is 2 standard deviations higher than the mea n of the items (which is once again at 0.0 logits). None of the items within the processing speed subtest are above the person mean. There are 52 patients that have measures that are above the average difficulty level of the most difficult item, which is i tem Item number 118 is the easiest item in The final subtest, executive function, is presented in figure 5 The distribution of the persons is relatively normal. The mean of the persons is 1 logit, which is 2 standard deviations above the mean of that was above the mean of the person distribution. The least challenging item is 163, The executive function subtest resulted in the overall least amount of patients that were above the average difficulty level above t he most difficult item. Only 13 patients with moderate to severe TBI were above this level. Discussion
9 FUNCTIONAL COGNITION The results show a skewing of the data tow ards the high end of the measurement scale. The person ability mean was at least 2 standard errors greater than the item difficulty mean for each construct Therefore, the nul l hypothesis was rejected. The rejection of the hypothesis indicates that the person measures for individuals with moderate to severe TBI are significantly greater than the difficulty of items These results suggest the need for more challenging questions to be included in the measure in order to further differentiate patients with moderate to severe TBI This difference between person measures and items measures is expected to be even more pr onounced in individuals with mTBI. Dr. Velozo and colleagues are presently conducting a pilot study of 30 Veterans with mTBI who are being administered the attention, memory, processing speed and executive constructs of the CAMFC TBI. The person measure d istributions for individuals with mTBI on these constructs are expected to be even higher than the person distribution for individuals with moderate severe TBI. Following administration of the CAMFC TBI, the individuals with mTBI are being interviewed abo ut the functional cognitive challenges they are experiencing in everyday life. These interviews should be useful in generating items reflecting more subtle functional cognitive deficits of this population. Incorporating these items into the CAMFC TBI sh ould be effective in further differentiating of individuals with moderate severe TBI and further differentiating individuals with mTBI. The most significant strength of this study is the ecological validity of the CAMFC TBI. The results found in this stud y reflect everyday situations. It can be expanded to real life issues regarding patients with TBI. However, there are some limitations as well. As a self report measure, t he patients may be exaggerating or trying to hide the severity of their injury depend ing on their feelings regarding their injury. Also, if this instrument were to be included in military assessments, then the self report could become an even greater issue. Veterans may under report deficits due to their desires to return home or to return to war.
10 FUNCTIONAL COGNITION The present study provides initial evidence for the need to modify the CAMFC TBI for individuals with mTBI. The results need to be verified by assessing individuals with mTBI CAMFC TBI. Furthermore, qualitative interviews of individuals with mTB I may be useful in generating more challenging items. Through this additional testing and modifications, the CAMFC TBI may become a useful assessment for Veterans dealing with the cognitive challenges of mTBI.
11 FUNCTIONAL COGNITION References Carlson, K. F., Nelson, D., Orazem, R. J., Nugent, S., Cifu, D. X., & Sayer, N. A. (2010). Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment related traumatic brain injury. Journal of Traumatic Stress 23(1), 17 24. Retr ieved from EBSCO host Centers for Disease Control and Prevention. (March 8, 2010). Injury Prevention and Control: Traumatic Brain Injury. March 19, 2011, from http://www.cdc.gov/TraumaticBr ainInjury/index.html Defense and Veterans Brain Injury Center. (2011). Blast injuries. Retrieved from http://www.dvbic.org/TBI --The Military/Blast Injuries.aspx Elder, G. A., Mitsis, E. M., Ahlers, S. T., & Cristian, A. (2010). Blast induced mild traumatic brain injury. Psychiatric Clinics of North America 33(4), 757 781. doi:10.1016/j.psc.2010.08.001 Flynn, F. G. (2010). Memory impairment after mild traumatic brain injury. CONTINUUM: Lifelong Learning In Neurology 16 (6), 79 109. French, L. M., S pector, J., Stiers, W., & Kane, R. L. (2010). Blast injury and traumatic brain injury. In C. H. Kennedy, J. L. Moore, C. H. Kennedy, J. L. Moore (Eds.) Military neuropsychology (pp. 101 125). New York, NY US: Springer Publishing Co. Retrieved from EBSCO h ost Jones, K., Young, T., & Leppma, M. (2010). Mild traumatic brain injury and posttraumatic stress disorder in returning Iraq and Afghanistan war veterans: Implications for assessment and diagnosis. Journal of Counseling & Development 88(3), 372 376. Re trieved from EBSCO host Miotto, E., Cinalli, F., Serrao, V., Benute, G., Lucia, M., & Scaff, M. (2010). Cognitive deficits in patients with mild to moderate traumatic brain injury. Arquivos De Neuro Psiquiatria 68 (6), 862 868. doi:10.1590/S0004 282X201000 0600006 Snell, F. I., & Halter, M. (2010). A signature of war: Mild traumatic brain injury. Journal of Psychosocial Nursing and Mental Health Services 48(2), 22 28. doi:10.3928/02793695 20100108 02 Sosnoff, J. J., Broglio, S. P., & Ferrara, M. S. (2008). Cognitive and motor function are associated following mild traumatic brain injury. Experimental Brain Research 187 (4), 563 571. doi:10.1007/s00221 008 1324 x
12 FUNCTIONAL COGNITION Velozo, C. A., Heaton, S. C., & Donovan, N.J. (2011). CAMFC TBI. Retrieved from http://icfmeasure.phhp.ufl.edu/tbi
13 FUNCTIONAL COGNITION Table 1 Variable Mean +/ Standard Deviation (Range) or n (%) Age 38.18 +/ 15.76 (18 84) Gender Male 63 (70) Female 27 (30) Handedness Right 79 (87.8) Left 11 (12.2) Do you currently work? No 72 (80.0) Yes 17 (18.9) Missing 1 (1.1) Do you currently drive? No 59 (65.6) Yes 27 (30.0) Missing 4 (4.4) Ethnicity White 72 (80.0) African American 10 (11.1) Hispanic American 4 (4.4) Other 3 (3.3) Missing 1 (1.1) Income Under 5,000 9 (10.0) 5,000 10,000 3 (3.3) 11,000 15,000 2 (2.2) 16,000 20,000 8 (8.9) 21,000 35,000 11 (12.2) 35,000 50,000 24 (26.7) Over 50,000 32 (35.6) Missing 1 (1.1) Education 8 th Grade 2 (2.2) 10 th Grade 7 (7.8) 11 th Grade 6 (6.7) 12 th grade 19 (21.1) GED 5 (5.6) No degree college 23 (25.6) Degree college 14 (15.6) 4 year college 7 (7.8) Graduate/Professional degree 7 (7.8)
14 FUNCTIONAL COGNITION Figure 1 Examples of items from the CAMFC TBI. Under each construct, t he easiest items are at the top of the list and the hardest items are at the bottom of the list. Attention questions 1. Correctly answer 2 Turn toward a ringing phone. 3 Complete 2 to 3 minute conversation using the phone. 4 Correctly write down message from an answering machine. 5 Select outfit from a dresser (chest of drawers) or closet 6 Participate in a 10 to 20 minute conversation, staying on topic. 7 Pick out important information from a lecture/instruction. 8 Write down a phone message while talking on the phone at the same time. 9 Look toward person after being touched lightly. 10 Make more mistakes as the length of the task increases. Memory questions 1 Know the current month. 2 Recall a simple routine (for example, doing an exercise, using memory book). 3 Recall to take medicine at the right time and right amount. 4 Recall to put food away in refrigerator when finished. 5 Recall to give someone a telephone message. 6 Recall where the car is parked in the mall/grocery store parking lot. 7 Recall birthdays, holidays or anniversaries. 8 Recall the story li ne in a book from one reading to the next. 9 Recall to do weekly chores. 10 Lose train of thought in a conversation. Processing Speed questions 1 Answer the phone within at least 3 rings. 2 Get dressed within 15 minutes. 3 Follow simple directions without asking people to repeat. 4 Put away clean dishes within 15 minutes. 5 Get money from an ATM within 5 minutes. 6 Sort daily mail within 5 minutes. 7 Pay for a fast food order within 30 seconds. 8 Read a one page letter within 5 minutes. 9 Take a long time to finish eating a meal (for example, over 20 minutes). 10 React slowly in driving situations (for example, reacting to stop lights, pedestrians, sudden stops in traf fic. Executive Functioning questions 1 Plan a common daily activity (for example, gathering items needed for dressing or grooming). 2 Fill free time with activities without being told. 3 Recognize and corrects mistakes. 4 Stay seated until a task is done. 5 Choose clothes based on the weather. 6 Seek help when needed. 7 Stop talking when a discussion becomes heated. 8 Estimate the time needed to do a series of tasks to meet a deadline.
15 FUNCTIONAL COGNITION 9 Ask q uestions to get more information about injury, 10 Gives up if first attempt to solve a problem is not successful.
16 FUNCTIONAL COGNITION Figure 2 Attention Map Applied cognitive functioning for TBI ZOU804ws.txt Feb 10 0:03 2012 INPUT: 90 PERSONS, 228 ITEMS MEASURED: 90 PERSONS, 52 ITEMS, 4 CATS 3.57.2 ---------------------------------------------------------------------------PERSONS MAP OF ITEMS | 4 X + | | X | | X | X | | 3 T+ XXX | X | X | XXX | XXX | X | X S| 2 X + XX | | XXXXXXXXX | XX | XX | XXXXX | 28) Reads 30 minutes without taking a break XX M|T 1 XXXXX + 39) Writes down message while talk on the phone XXXXXXX | XXXXXX | 33) Maintains speed accuracy when do a task in distract XXXXXXX | 18) Writes down messages from an answering machine XXXXXX |S 16) Watches TV without being distracted by other talk XXXX | 11) Stays focused on 5 10 min in a noisy environment XXX S| 07) Writes down a short phone message XX | 32) Returns to an activity after a short interruption 0 XXX +M 05) Copies daily schedule correctly XX | 14) Has a conversation with a small group XX | 22) Selects meal items from a complex menu XX | 38) Maintains safe driving while answering cell X |S 02) Go es directly from to a specific location | 03) Greets person when that person enters the room T| 36) Notices when a warning light appears on the dashboard | 48) Leaves out steps of a task (R) 1 + 01) Correctly answer questions about himself/herself |
17 FUNCTIONAL COGNITION Figure 3 Memory Map Applied cognitive functioning for TBI ZOU767ws.txt Feb 10 0:16 2012 INPUT: 90 PERSONS, 228 ITEMS MEASURED: 89 PERSONS, 35 ITEMS, 4 CATS 3.57.2 ---------------------------------------------------------------------------PERSONS MAP OF ITEMS | 5 + XX | | X | | | 4 X T+ | | XX | XXX | XX | 3 XXXX + XX S| XXX | | X | XXXXX | 2 XXXX + XXXX | XXXXXXX | XX M| XXX |T XXXXXXXX | 71) Recalls a newly learned route without assistance 1 XX + 62) Recalls where to find thing when not put in its place XXXXX | 76) Recalls frequently used phone numbers XXXX |S 53) Recalls a meal later in the day XXXXXXXX | 59) Recalls more than one appointment in a single day XXXXXX S| 72) Recalls where the car is in the mall parking lot XX | 81) Recalls to do weekly chores 0 XXX +M 79) Recalls to go to doctor's appointments | 56) Recalls what he/she did before the injury XXX | 61) Recalls to take medicine at the right time and amount X | 55) Recalls a visit from a familiar person |S 65) Recalls to put food away in the fridge when finished X T| 67) Recalls to lock the door when leaving the house 1 + | 54) Knows the current month |T | | 68) When driving, remembers to take the key when get out | 2 + |
18 FUNCTIONAL COGNITION Figure 4 Processing Speed Map Applied cognitive functioning for TBI ZOU116ws.txt Feb 10 0:21 2012 INPUT: 90 PERSONS, 228 ITEMS MEASURED: 90 PERSONS, 33 ITEMS, 4 CATS 3.57.2 ---------------------------------------------------------------------------PERSONS MAP OF ITEMS | 4 XX + X | X | X | | | T| 3 XXXX + X | | XX | X | | XX | 2 X S+ X | XXXXX | XXXX | XXX | XXXXXXXX | XXXX | 1 XXXXX M+T XXXXXX | XX | 103) Takes a message off the answering machine without replay XXXXXX | 88) Answers the phone within a least 3 rings XXX | S 102) Takes a message without asking the caller to repeat XXXXXXX | 112) Reads a one page letter within 5 min XXX | 101) Puts away clean dishes within 15 minutes 0 XXXXX S+M 100) Unloads the washing machine within 10 minutes XXX | 104) Gets money from an ATM within 5 minutes XXX | 106) Keeps up with the story of a 30 min TV without asking X |S 105) Follows an automated phone menu XXXX | | 117) Takes a long time to get dressed (R) X | 1 T+T 120) Reacts slowly in driving situations (R) | | | | 118) Needs repeated requests to respond (R) | | 2 + |
19 FUNCTIONAL COGNITION Figure 5 Executive Functioning Map Applied cognitive functioning for TBI ZOU975ws.txt Feb 10 0:32 2012 INPUT: 90 PERSONS, 228 ITEMS MEASURED: 90 PERSONS, 64 ITEMS, 4 CATS 3.57.2 ---------------------------------------------------------------------------PERSONS MAP OF ITEMS | 5 + | | | | X | 4 + | | | | | 3 + | XXXX T| XXX | X | X | 2 + XXX S| XXXXXXX | 168) Plans a short trip using public transportation X | XXXXXXXX | XXXXXXXX | 1 XXXXXXX M+T XXXX | 133) Not ask embarrassing questions/make hurtful comments XXXXXXXXXX | 156) Adds a new topic to a conversation XXXXXXXXXXX |S 122) Complete a complex task that has several steps XXXXXXXXX | 130) Recognizes and corrects mistakes XXXX S| 124) Plans a new activity 0 XXXXXX +M 121) Complete a simple task that has several steps XX | 123) Plans a common daily activity | 132) Talks at the wrong time (R) T|S 1 65) Dresses to match social situation | 139) Chooses clothes based on the weather | 180) Bothers other people while they are working (R) 1 +T 171) Makes careless errors in daily tasks (R) | | | 163) Fills gas tank before it runs out | | 2 + |
20 FUNCTIONAL COGNITION