What Functional Cognition Actually Is (And Why It Applies To You Too)

Tell me one physical movement you do that you do not have to think through. There is not one. Every occupation you assess in a client, and every occupation you engage in yourself, runs on cognition and yet most occupational therapists got one lecture on it in their entire degree.

This episode is back to basics. A more clinical conversation than usual, walking through what functional cognition actually is, where it sits in the cognitive hierarchy, and why so much of what gets delivered in community practice — the whiteboard, the visual schedule, the calendar reminder — is the output, not the strategy.

Inside this episode:

• The cognitive hierarchy: attention, information processing, memory, and executive function — and why the breakdown almost always sits lower than where you are intervening
• The difference between a neuropsychological assessment and a functional cognition assessment, and why context changes everything
• The dementia client who could make tea at home for twenty years but not in supported accommodation
• The cerebral palsy gait analogy — and why functional does not mean perfect
• Two clinical examples: the missed appointments client with reduced processing speed, and the meal preparation client with information processing demands
• The turn inward — why the same lens you bring to your clients is the one missing from how you run yourself, with practical examples from referral workflows, notifications, and the Woolies saved grocery list

This is the framework that sits underneath every other episode of Cognitive Capacity Chat. If you have ever reached for a whiteboard and wondered why it did not stick, start here.

If you want to go deeper, the Cognitive Capacity 5 Day Reset is a private podcast designed for the busy community therapist — twenty minutes a day for five days to start working with your cognition instead of against it. Available on demand at imogenot.com.au for $48.

For 1:1 mentoring and coaching enquiries, DM @imogen_occupationaltherapist on Instagram or email imogen@onot.com.au 

Sign up to my newsletter.

Follow me on Instagram.
Connect on LinkedIn.

Transcript

SPEAKER_00 0:00

Welcome to Cognitive Capacity Chat. This is the podcast for the therapist ready to think beyond the therapy room. I talk about our cognition as our foundation, not just for our clients, but for ourselves. Because the way we think, organize, and live directly shapes our clinical work, our capacity, and longevity in this profession. I'm Imogen, an OT, here to bring you practical conversations that fit into real life. This podcast is for the therapist who wants more depth, more clarity, and more life. Welcome. Hello, today I wanted to get a little bit more clinical, I suppose, in a way, and really talk about cognition and functional cognition. Because I think as therapists, we respect the clinical practice and our clinical scope. And cognition is really the forefront of my teachings and how I coach. And I really think everyone should be across how functional cognition works as occupational therapists. And it's also actually a sidebar, something that I teach from a clinical perspective as well. But this podcast is really all about how our cognition, our functional cognition truly impacts how we work. So my perspective on cognition and what I know to be true is that it's in everything. Tell me one physical movement that you do that you don't have to think through. Sure, some physical movements are now subconscious, but you have to use your brain in order to operate your body. Every single thing you do, from picking up your coffee to reversing out of your driveway to opening the front door of your client's house, your brain is telling you what to do. You have to use your brain. That is how our body works. Our brain is amazing. And yet, particularly in my degree, I know that cognition got one lecture in the neurological module of my university. One. Something that is in every single occupation that we ever assess, ever recommend, ever write. Every client we assess will have a cognitive presentation that is their functional presentation, and it could be a barrier, or it could be not be a barrier, or it could just be general overwhelm, which is often the story when we're working with people with disabilities. It could be the parent of the person with the disability that's sitting in the overwhelm. And cognition plays a really integral part when it comes to how we can operate in a way that works for everyone, and everyone is achieving what they want to achieve. So today I thought I would talk about my clinical scope around cognition and functional cognition itself, what it actually is, why it actually matters, and why I think it's really integral for us all to know and how it interplays with our us at work. So functional cognition, what is it? I think a lot of us immediately think memory or attention, but it's not just that. If you don't know the cognitive hierarchy, I have a on-demand course on my website, but effectively uh the cognitive hierarchy is a pyramid where attention is at the bottom, information processing it comes next, memory sits on top of that, and then at the very top we have executive function. Now, when we think about that pyramid, if we have reduced attention, it's going to be really tricky to then have good information processing, so on, so forth. So when we think about functional cognition, we think about where is the breakdown of their capacity to be involved in things in the uh cognitive processes, um, and how can we support them in a functional way. But there is also the difference between neuropsychologists and occupational therapists, and some neuro, you know, there's there's bend and flex in this, but neuropsychologists are typically doing a assessment that involves standardization and it involves paper-based, um, some are really good at viewing function in the home. Um, most of the time we're receiving a report from a neuropsych that's completed that assessment in their clinic on paper and doesn't really understand the the functional. Now, when I think about when I say functional, I often think about the example of a person with a demet with dementia. And typically we believe that they have poor memory and they're not able to engage, and we get them to a point of they need to go into assisted living. But at home, they were able to make a cup of tea and they were able to make their toast and they were able to do this every day. But when we put them in the assisted living environment, we often find that they deteriorate quite quickly and their presentation seems to be worse. Now that's because in their own home environment, in their where they are familiar with, they've been doing something for 20 odd years, they are able to remember that. So that's a functional cognition process. They're able to actually be functional within their ordinary daily life. I suppose when we think about a physical presentation that is functional. So think about someone who maybe has CP, cerebral palsy, um, with a left-side hemioporesis, and and when you on paper, you know, it looks like they're not able to ambulate very well. It's likely that they're, you know, if you were to picture them in your mind, your the biomechanics are not quite there, it's likely that they have a really atypical movement, um, and potentially not efficient. But when you see them in the clinic, when you see them moving about, ambulating, it's really functional. Take bum shuffling. I mean, it's not the typical mobility, and people who work out beside work beyond the disability scope, they don't think that's normal. They think that bum shuffling is not appropriate. But when it helps get a kitty around, we think, wow, that's amazing. That is so functional. And we don't look at a client and say, Oh gosh, you aren't doing that perfectly, so therefore your gate is not there. You you can't ambulate because you don't have the perfect gate. No. We assess that as functional. We add compensation where it's needed, we complete rehab where it's needed, and we make their environment work with them and not against them. And so this is exactly the same lens that we need to bring to cognition. So functional cognition is not necessarily about how well someone performs on a test or what they look like on paper, but it's about how their cognition supports them to do their occupations and potentially what we need to do as therapists to mitigate that challenge. So we might, just like our physical presentation, what aids might assist them, what conversation strategies might assist them, what rehab might assist them. Uh, and maybe we need to change the environment around them to enable them to engage in that um occupation. And it might not be perfect, but at least it's promoting that engagement. At least it is functional. I want to talk to another clinical example where I think it often gets missed in community practice. And I think it's, and something else I'm really passionate about the lack of digestible and practical learnings and theory around cognition and how tricky it is as an occupational therapist to actually learn what we are supposed to do when it comes to cognition and assessing that and making it functional. But I'm here to tell you, you already know what you need to do because you're an occupational therapist, you understand the model that we work within, and we understand that if we assess function and we understand their occupational barriers, if we assess what those barriers actually are, and then we look at the person and we're able to actually engage in how do we implement interventions or we make some compensation or we do some rehab. What can we actually do to support this person to engage in the occupation? And it's not as scary as it may seem. It is a little bit more tricky because it's not as mathematical equation like your typical home mods or your wheelchair script, but it is it is accessible to you. You definitely can support someone's cognition, and you probably already do. So, another example of this, which often comes up where people come to us with missing appointments, and many of occupational therapists have walked in there with their whiteboard, with their whiteboard marker, but for some reason it's just not hitting. There's just this continued repetition of trying to implement the external whiteboard strategy. But unfortunately, this person just continues to miss these appointments. When it comes to cognition, we if we step back and actually assess what's happening within the function where this person is continually missing the appointment, even with reminders, even with external support, they're likely having some reduced processing speed there. And so by the time they recall to actually go and check their calendar, check the time, and then get ready, that's way too much information for them to actually initiate the ability to get ready for the appointment. So the functional cognition strategy is actually thinking about how do we reduce, mitigate the cognitive barrier that this person has with their processing speed. So a common thing that I do in this case is I actually think about well, how do I reduce the amount of steps to get to the outcome and how do I initiate that response? So here's where audible phone reminders are really good or sensor systems are really good where it's actually when the alarm comes through, we're actually hearing the sounds. So, for example, hey, it's time to get ready for your appointment at 10. And so you can see we're reducing the amount of information that they need to process themselves, and we're starting that initiation through the audible reminder. I also, you you would have heard that I also look at, well, if their appointment is at 10, then they need to start getting ready at 9. So we're not setting the reminder for 15 minutes before 10, we're setting the reminder for 9 to get to start getting ready. We might set a reminder at 9.15 to book the taxi. We might set a reminder at 9.30 that's saying, is your taxi here yet? You can see how we're reducing the amount of processing information that this the amount of information this person has to process so that they can actually start taking the steps to get there. I've used a similar situation with someone who's having difficulty with meal preparation and they're adding ingredients they've already added or missing ingredients they've already added. They haven't added, sorry. So what we do is we implemented a strategy that was putting the ingredients away as we go. Now it might seem really simple, but it meant that they're not duplicating. They meant that they knew what ingredients they hadn't put in because the strategy is now we're putting the ingredients away as we go. And so it meant that we're reducing the amount of processing information. They didn't need to stop and look at the all the ingredients on the kitchen bench. They were just able to go, I know what I need to add, I know what I haven't added, I'll check the amount on the recipe, and then I'll put it away. So you can see how we're reducing that information, but we're we're not necessarily rehabilitating the cognitive barrier, but we're actually enabling them, we're making the environment, the occupation accessible to them. The reason that I wanted to talk to this is how functional cognition, how we think about the function and the engagement really impacts us as therapists as well. So, yes, we service clients that might have reduced processing speed, but can you see yourself in that meal preparation example? If you put the ingredients away as you went, do you think it would be easier for yourself to actually complete that meal preparation? I would anticipate so. And so think about how as therapists we can optimize our cognition to actually have improved processing speed, improved memory, and then what are we going to achieve in that hierarchy of better executive function? Executive function is where we need to operate as clinicians to do a really good job, where we have to emotionally regulate so that we can talk to the pre parent that's really struggling, so that we can make decisions about complex wheelchairs, complex beds, complex home mods, so that we can step into the client that's having psychosocial difficulties and be able to regulate, grounded, calm, and be there and present for them. So we can make a plan with our supervisee of what they want to do. Think about clinical skills. So when I say functional cognition, how do we get you as a therapist to operate in a way that enables you to achieve that cognitive hierarchy? How do we help maintain your attention? Can we reduce the notifications that come through? Can we reduce how much time you're spending on your phone or being drawn across to your phone when you're trying to write a report? Can we optimize your processing speed? How do we get the information to you so you don't need to get overwhelmed? I have actually just implemented this myself with my referral process. I was taking on all the information of all the clients and all the referrals that were coming in. I've now delegated this to my admin assistant so they can review, get all the information I need to see. I say yes or no, which therapist is going to, and then delegate it back to the admin assistant to do all of the roundwork. And so it's a constant thing that comes up and down, and we're constantly working on it. But the amount of things that we can do, particularly as community therapists, who have to really think, we have to really dive into it. And it's not just our clinical work or our scope, it's also our personal life. It's that cooking of a meal. Or it's when we have to sit down and do a grocery shop and you we can't think of meals, can we use our wool Woolies app that has saved lists? So we just have to go through and tick, tick, tick. And we're reducing the amount of time that we're spending on thinking so it optimizes our capacity elsewhere. So if something like this feels really good for you and you want to learn more, there's a private podcast for the busy therapist to help increase cognitive capacity to see how I teach, to see what I do. That's available on my website for $48. And it's available all the time on demand. But if you're wanting a little bit more, I do offer one to one packages and I would love to hear from you. Best way to do that is to DM me on Instagram, which is Imogen underscore occupational therapist. Or alternatively, you can email me Imogen at O N O T.com.au. I hope to see you about.