Date Presented 04/02/2022

For people experiencing homelessness (PEH), cognition may be assessed as a predictor of independent living skills and housing stability, but it does not include performance-based assessment. A scoping review was completed to identify what methods have been used to evaluate functional cognition of PEH to increase knowledge of current practices and support the role of OT in supporting transitions from homelessness to housing.

Primary Author and Speaker: Caitlin E. Synovec

Additional Authors and Speakers: Lee Westover, Leonie Boland

PURPOSE: A lack of affordable housing in most communities has resulted in the use of measures to prioritize people experiencing homelessness (PEH) for housing based on medical and social vulnerabilities (Brown & Watson, 2018). The growing awareness of the prevalence of traumatic brain injury and cognitive impairment in PEH has also increased the use of measures of cognition to predict independent living skills and ability to maintain housing. However, recent research has shown assessing for functional cognition (FC) through performance and occupation-based assessments can better identify barriers and supports to performing everyday life activities. Due to the growth in knowledge regarding functional cognition as well as an increased focus on cognitive status and functional skills within homelessness services, a scoping review was initiated to identify current practices to how functional cognition is evaluated in PEH.

DESIGN: This scoping review was conducted using the Joanna Briggs Institute protocol.

METHOD: In collaboration with an academic librarian, a search strategy was developed. Search terms included population (e.g. homeless) and concept (e.g., cognition), while context remained open. We searched 5 databases: Medline, CINAHL, PsychInfo, Embase, and Social Services Abstracts. Three reviewers completed the review and extraction process. Each article was screened by two independent reviewers for inclusion in the full text review and data extraction, and any conflicts were resolved through consensus. Systematic and scoping reviews were scanned for additional references and articles. Inclusion criteria were developed using the AOTA definition of functional cognition (Giles at el., 2020). Studies were included that either 1) assessed for FC or 2) assessed a component of cognition through a standardized or non-standardized tool and related to functional performance, compared to functional performance, or compared to performance on a functional assessment.

RESULTS: Of 7,742 articles retrieved from the initial search, a total of 127 articles were included for full text review. Thirty-eight articles were determined to meet inclusion criteria for data extraction. Categories for data extraction included: functional outcome/area of function addressed, tools used for assessment of cognition and/or function (standardized or non-standardized), and how reported outcomes were interpreted. Following data extraction, articles were then divided into two categories. First, whether they met the definition of FC as defined by the literature, and if researchers assessed functional cognition according to this definition. The second category included articles that assessed components of cognition, but implied impact on function without directly assessing functional cognition or functional performance. Very few studies implemented performance-based assessment to measure functional cognition.

CONCLUSION: This scoping review indicates several other disciplines seek to assess FC through non-performance based assessments. It is critical that occupational therapy asserts its role as the profession with the distinct ability to assess functional cognition and more accurately assess a person’s functional capabilities. This will ensure that individuals who need support are able to access it, individuals who would benefit independent living are provided the opportunity, and overall support the transition from homelessness.

IMPACT STATEMENT: Occupational therapy has a distinct role in working with people experiencing homelessness to identify functional cognitive skills. Including evaluation of functional cognition in OT practice can improve housing outcomes as supports are identified, while following an evidence-and strengths-based approach.


Giles, G. M., Edwards, D. F., Baum, C., Furniss, J., Skidmore, E., Wolf, T., & Leland, N. E. (2020). Making functional cognition a professional priority. The American Journal of Occupational Therapy, 74(1), 7401090010p1–7401090010p6.

Brown, M., Cummings, M., Lyons, J., Carrión, A., & Watson, D. P. (2018). Reliability and validity of the Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT) in real-world implementation. Journal of Social Distress and Homelessness, 27(2), 110-117.