Multiple Sclerosis and Related Disorders 23 (2018) 69–73

Contents lists available at ScienceDirect

Multiple Sclerosis and Related Disorders

journal homepage: www.elsevier.com/locate/msard

Timed instrumental activities of daily living in multiple sclerosis: The test of T

everyday cognitive ability (TECA)
⁎
Leigh E. Charvet , Michael T. Shaw, Kathleen Sherman, Shannon Haas, Lauren B. Krupp
Department of Neurology, NYU School of Medicine, 222 East 41st Street, 10th Floor, New York, NY 10017, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: Cognitive impairment is a common symptom of multiple sclerosis (MS) that can lead to declines in
Multiple sclerosis daily functioning. Timed instrumental activities of daily living (TIADLs) have been useful to bridge between
Activities of daily living cognitive testing and real-world functioning in disorders such as Alzheimer's disease and other dementias.
Cognitive impairment However, these have not been standardized for general use, and the tasks that are typically employed have not
Assessment
been sensitive to the detection of milder forms of cognitive deficits. We developed a test of ten TIADLs tasks to
Outcomes
measure a broader range of functioning, entitled the “Test of Everyday Cognitive Ability” or TECA, and tested its
utility in a diverse sample of participants with MS.
Method: TECA performance was characterized in n = 177 participants with MS and compared to healthy con-
trols (n = 49). A subset from each group received repeated administration. In addition, all participants com-
pleted a standard battery of neuropsychological measures.
Results: TECA performances were significantly different between MS and control participants. Further, MS
participants with cognitive impairment performed significantly slower relative to those MS participants without
impairment.
Conclusions: The TECA is a TIADLs assessment appropriate for use in those with MS as it includes a broad range
of task difficulties, requires minimum motor involvement, and is sensitive to MS-related cognitive impairment.
The TECA is a brief and repeatable test of TIADLs and its ease of administration makes it suitable for both clinical
practice and research settings.

1. Introduction day responsibilities. Educational attainment is typically obtained before

Multiple sclerosis (MS) is the most common inflammatory, neuro-
degenerative disease affecting young adults (Feinstein, 2007) with a
prevalence rate of 110/100,000 worldwide (Mostert and
Kesselring, 2002). Cognitive impairment affects up to 70% of all pa-
tients (Bobholz and Rao, 2003; Jonsson et al., 2006; Smerbeck et al.,
2011). The most common deficits are in the areas of working memory,
information processing, attention, and new learning (Achiron et al.,
2013; Glanz et al., 2012; Hankomaki et al., 2014). Impairment can
occur independently from other disease features (Smerbeck et al., 2011)
and is linked to cerebral atrophy, particularly to regional grey matter
volume loss (Chiaravalloti and DeLuca, 2008; Rocca MA, 2015).
As many with MS are young to middle aged, cognitive impairment
represents a major cause of disability leading to unemployment, social
isolation, and increased dependence on caregivers (Figved et al., 2007;
Strober et al., 2012). It is critical to have clinical measures that
meaningfully reflect the influence of cognitive impairment on day to
the onset of MS and, as it is fixed, it is not an ideal representation of
cognitive functioning. In contrast, employment status has emerged as
an ongoing indicator of the influence of cognitive impairment on
function in MS (Incerti et al., 2017; Schiavolin et al., 2013), however it
is not standardized across patients (e.g., patients differ in whether they
are employed and complexity of their occupations) and does not pro-
vide an objective measurement. A measure of the completion of
common internet-based search and purchase activities has also been
linked to cognitive impairment in MS (Goverover et al., 2016, 2010).
One approach to meaningful assessment in other disorders asso-
ciated with cognitive dysfunction such as Alzheimer's disease and other
dementias has been with the measurement of timed instrumental ac-
tivities of daily living (TIADLs) (Owsley et al., 2002). However, in MS,
there is a broad range of impairments and often the TIADLs tasks have
not been sensitive for use in this population. For example, a small
sample of MS participants (n = 18) were compared to healthy controls
using a set of standard aging and dementia TIADLs tasks that were

⁎
Corresponding author.
E-mail address: leigh.charvet@nyumc.org (L.E. Charvet).

https://doi.org/10.1016/j.msard.2018.05.001
Received 28 December 2017; Received in revised form 16 February 2018; Accepted 2 May 2018
2211-0348/ © 2018 Elsevier B.V. All rights reserved.
L.E. Charvet et al.
administered (Goverover et al., 2007). While the MS participants had
slowing compared to controls, the TIADLs tasks were otherwise not
sufficiently sensitive for use in the younger and less impaired MS
sample.
To develop a more comprehensive functional measure, we expanded
on standard TIADLs tasks (Owsley et al., 2002) to create two forms of a
10-item assessment titled the “Test of Everyday Cognitive Ability” or
TECA. Tasks were designed to be sufficiently cognitively complex while
requiring only minimal motor involvement. To define the psychometric
properties of the TECA, we administered it to a large sample of MS
individuals, with and without cognitive impairment, and included
comparison to a group of healthy controls.
2. Materials and methods
2.1. Participants
This study was conducted with the approval of the Institutional
Review Board at Stony Brook Medicine, Stony Brook, New York.
Participants (n = 177) who met criteria for MS (Polman et al., 2011)
were recruited from the outpatient practices at Stony Brook Medicine's
MS Comprehensive Care Center. Healthy controls (HC, n = 49) were
primarily recruited from the State University of New York Stony Brook
campus and the surrounding community. Participants were recruited
from August 7, 2013 through September 2, 2015. A large subset of the
MS participants (n = 135) completed the TECA in the context of a se-
parate clinical trial comparing 12 weeks of two cognitive exercise
programs (Charvet et al., 2017). The other subset (n = 42) underwent
testing as part of a baseline cognitive assessment included in other
clinical investigations. All recruitment procedures were approved by
Stony Brook University's Institutional Review Board (IRB) with written,
informed consent obtained from all study participants. All participants
were compensated for their time at a rate of $20 per 30 min of testing.
Eligibility criteria for all participants included: 18 to 70 years of age,
a scaled reading score between 85 and 115 on the reading recognition
subtest of the Wide Range Achievement Test- 3rd Edition (WRAT-3), as
a proxy of premorbid general intellectual functioning, (Stone, 1995),
not currently taking CNS stimulants, English language fluency, no pri-
mary neurologic (other than MS) or psychiatric disorder, alcohol/sub-
stance abuse, major head injury resulting in loss of consciousness, or
any uncontrolled health conditions for which ongoing treatment is re-
quired. The WRAT-3 served as a screen for visual acuity as well, as it
requires the ability to accurately decipher 14 point font.
Eligibility criteria for HC participants was similar to that of the MS
participants, but without MS or any other significant medical condition.
2.2. TECA tasks
The TECA consists of ten tasks that include the previously-estab-
lished TIADLs domains (Goverover et al., 2007; Owsley et al., 2001,
2002) of communication, finance, nutrition, shopping, and medicine.
The description of the specific items is listed in Table 1.
To standardize the items in the TECA kit (see Fig. 1), props such as
groceries items are used and modified to be free of brand labeling.
Additionally, mock pill bottles with pharmacy printed labels were also
created (e.g., prescriptions made out to a “Jane Doe”).
With the intention of administration in a busy clinical or research
trial setting, the TECA was designed to be quick and efficient. As motor
slowing is a common feature of MS, each task was structured to keep
any motor involvement to a minimum (e.g., no task requires items to be
held or moved).
For administration, participants were asked to complete each task as
quickly as possible. Each item has a time limit to prevent undue ex-
tended effort, and together the maximum amount of time allotted for
administration is 23 min. However, average administration time of the
TECA, including instruction, is approximately 15 min.
70
Multiple Sclerosis and Related Disorders 23 (2018) 69–73
An alternate form of the TECA was created by composing an alter-
nate but equivalent task for each item.
2.3. Administration
All participants completed the TECA along with a larger cognitive
testing battery. The TECA was administered by a trained psychome-
trician according to a scripted instruction sheet. The TECA items were
set up in advance of testing and covered with a cloth before the testing
began to avoid advance exposure to the items.
A subset of MS participants and HCs were administered both the
TECA and the alternate form TECA, administered on separate days,
separated by five days or less. Administration order of the original and
alternate TECA forms were counterbalanced across participants.
2.4. Scoring
Each TECA task is scored according to completion time and error(s)
made with the exception of the final item 10 (a recall question), which
is scored according to accuracy only. Each task has a specified time
limit of either 120 or 180 s, depending on degree of complexity. Any
task completed with an error is automatically assigned the full time
allotment for that task (i.e., 120 or 180 s). Self-corrections were treated
as valid and correct responses as long as within the time limit. Item 10,
a recall question, is scored for a complete, partial, or incorrect response
and is assigned a multiple of 40 s (40 s corresponding to a fully correct
response, 80 s for a partially correct response, and 120 s for a fully
incorrect response).
For each task to allow for even score weighting across the items, the
resulting time score was divided by the total time allotment to provide a
proportional time score ranging from 0.0 to 1.0 for each task. For ex-
ample, if a participant took 80 s to complete a task set with a 120 s time
limit, the score would be 80 s divided by 120 s, or 0.67. For a total
score, the proportional scores were summed across all 10 tasks, and
then averaged for one representative score from 0.0 to 1.0. Higher
scores indicated worse performance for the task.
2.5. Additional measures in the neuropsychological testing battery
The TECA was administered in the context of larger batteries across
several ongoing studies that included cognitive testing. At the time of
the TECA administration, participants completed additional measures
of attention and information processing speed, depending on their
specific study. As the majority of participants completed the Brief
International Cognitive Assessment for Multiple Sclerosis (BICAMS)
which consists of the Symbol Digit Modalities Test (SDMT)
(Smith, 1982), the Brief Visuospatial Memory Test-Revised (BVMT-R)
(Benedict, 2007), and a verbal learning task (either the SRT: Selective
Reminding Task or the RAVLT: Rey Auditory Verbal Learning Test)
(Scherl et al., 2004; Schoenberg et al., 2006), these measures were in-
cluded for analyses. Additionally, participants completed other neu-
ropsychological measures that were included in analyses such as the
Digit Span (Wechsler, 2008), Paced Auditory Serial Addition Test
(PASAT) (Fischer et al., 1999) and the Delis Kaplan Executive Func-
tioning System (DKEFS) Trail Making (Delis et al., 2001).
2.6. Analyses
Internal consistency and test-retest reliability were tested for the
group as a whole and for each MS subgroup. For validity, TECA per-
formances were compared between the MS and HC groups.
Next, as we developed the TECA to characterize MS-related cogni-
tive impairment, we compared performances between MS participants
with and without suspected cognitive impairment. We defined cogni-
tive impairment following guidelines set by the BICAMS, with any
participant that scored 1.5 standard deviations below the age-
L.E. Charvet et al. Multiple Sclerosis and Related Disorders 23 (2018) 69–73

Table 1
TECA Descriptions
Task Title Description Time allotted

1 Finding a Telephone Number The participant is given a name to find in a phonebook and asked to recite the number aloud. 180
2 Making Change The participant is handed a preset amount of change and asked to count the coins totaling a specific 120
amount.
3 Reading Label The participant is handed a can of soup and asked to find and read the first three ingredients of the list 120
aloud.
4 Finding Items The participant is presented with a food items arrange on a shelf and asked to identify specific items. 180
5 Read a Medicine Bottle The participant is asked to read aloud the instructions on a medicine bottle. 120
6 Buying Grocery Items Each of the food items on the shelf have prices attached. The participant is asked to select items from the 120
shelf totaling exactly $5.00.
7 Finding a Telephone Number – Name and The participant is provided with a name and address of a person and must differentiate between the same 180
Address names.
8 Finding a Telephone Number – Following The participant is asked to find the phone number of a specific business in the yellow pages of the phone 120
Instructions book.
9 Reviewing a Shopping List The participant is handed a shopping list and are asked to compare the list to the grocery shelf to identify 180
discrepancies.
10 Recalling Medicine Bottle Info The participant is asked to recall the instructions on the medicine bottle in item 120

referenced normative mean on any of the three measures (SDMT,
BVMT, and SRT or RAVLT) reagrded as cognitively impaired (Deloire
et al., 2006; Parmenter et al., 2007). We also compared those MS
participants without cognitive impairment to the HC group.
Correlations were performed between age scaled scores from
common neuropsychological measures of attention and information
processing and the TECA to indicate its validity in measuring compo-
nents of cognition.
3. Results
Demographic and clinical characteristics of the full sample are
displayed in Table 2.
3.1. Reliability
Overall, the TECA had acceptable (Loewenthal, 2004) internal
consistency (Cronbach α = 0.63 for full sample; 0.55 and 0.61 for the
MS and HC groups, respectively). Analyses of the contribution of each
specific item did not indicate overall that the removal of any one or
more items would lead to improved values. Test-retest reliability, with
the second administration using the alternate form of the test, was
completed for the subset of the sample who received two administra-
tions and was found to be acceptable for the sample as a whole
(n = 139, r = 0.68, p < 0.001), as well as for the HCs only (n = 18,
r = 0.67, p < 0.001).
3.2. Validity
While the groups were not matched on age (with the HC group
significantly younger, Table 2), TECA scores did not correlate with age
among the MS group (r = 0.06, =0.43) and we therefore did not
control for age. As would be expected, the MS group performed sig-
nificantly worse than the HC group on the TECA total score as well as
on each individual item (all p values < 0.001). This indicates that the
TECA is sensitive to MS-related cognitive impairment.
MS participants were classified into those with and without cogni-
tive impairment. The BICAMS performance cutoff that indicated cog-
nitive impairment was set at performance below a z score of −1.5 or
less on any of the three constituting measures, n = 91/177 (51%) were
in the cognitively impaired category. As shown in Table 3, the TECA
total score and most tasks significantly distinguished those MS parti-
cipants with cognitive impairment from those without, as well as from
HCs. Further, MS participants with cognitive impairment were sig-
nificantly less accurate than those who were cognitively intact, with
respective total accuracy scores of 13.76 ± 3.67 vs. 12.09 ± 2.81,
p < 0.001.
As shown in Table 4, TECA scores in the MS group significantly

Fig. 1. TECA prop grocery shelf.

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L.E. Charvet et al. Multiple Sclerosis and Related Disorders 23 (2018) 69–73

Table 2
Comparison of performance between MS participants and healthy controls.
Descriptor MS sample (n = 177) MS with cognitive impairment (n = 51) MS without cognitive impairment (n = 126) Healthy controls (n = 49)

Characteristics
Age 45.8 ± 14.2b 43.2 ± 12.3b 46.8 ± 14.76b 24.4 ± 8.48
Gender (% Female) 73 75 73 54
Years of Education 14.9 ± 2.4b 14.84 ± 2.38b 14.87 ± 2.36b 15.7 ± 1.9
WRAT-3 Scaled Score 103.6 ± 8.9b 99.4 ± 10.8a,b 105.2 ± 7.6b 109.4 ± 7.2
Median EDSS (range) 3.0 (0.0–8.0) 2.5 (0.0–8.0)a 3.5 (0.0–8.0) –
SDMT z score −0.95 ± 1.14b −2.36 ± 0.78a,b −0.38 ± 0.68 −0.45 ± 0.72

WRAT-3: Wide Range Achievement Test – 3rd Edition; EDSS: Expanded Disability Status Scale; SDMT: Symbol Digit Modalities Test.
a
Significantly different from MS without cognitive impairment.
b
Significantly different from HCs.

Table 3 with poorer performance, as would be expected. Surprisingly, there

Total and individual task scores for the TECA between groups. were no significant differences in performance between those with re-
TECA score (Mean ± SD) MS with MS without Healthy lapsing (n = 135) vs. progressive (n = 42) subtypes for the TECA total
cognitive cognitive controls score or individual items (all p’s > 0.06).
impairment impairment (n = 49)
(n = 91) (n = 86)
4. Discussion
Total Score 0.39 ± 0.15a,b 0.30 ± 0.12b 0.24 ± 0.10
Task 1 0.43 ± 0.33a,b 0.26 ± 0.22 0.23 ± 0.20
Task 2 0.16 ± 0.22 0.15 ± 0.24 0.11 ± 0.15
The TECA is a brief, repeatable, and standardized measure of
Task 3 0.15 ± 0.25a,b 0.06 ± 0.04 0.05 ± 0.04 TIADLs affected by mild to moderate cognitive impairment in in-
Task 4 0.11 ± 0.24 0.04 ± 0.11 0.07 ± 0.20 dividuals with MS. The TECA addresses a major need for a measure-
Task 5 0.14 ± 0.20 0.10 ± 0.12 0.09 ± 0.14 ment tool that provides a context for interpreting clinical mean-
Task 6 0.70 ± 0.34a,b 0.48 ± 0.37 0.33 ± 0.32
ingfulness of change on other neuropsychological measures. It provides
Task 7 0.45 ± 0.33a,b 0.31 ± 0.26b 0.18 ± 0.19
Task 8 0.61 ± 0.33b 0.53 ± 0.33b 0.25 ± 0.04 correspondence between changes in standard cognitive measures to
Task 9 0.90 ± 0.24b 0.79 ± 0.32 0.65 ± 0.05 expected changes in daily functioning. Furthermore, the TECA includes
Task 10 0.56 ± 0.30 0.51 ± 0.29 0.45 ± 0.23 items that would be generalizable for the assessment of individuals with
a broad range of neurologic and medical conditions associated with
Note: Significance at p < 0.01 to correct for multiple comparisons.
a cognitive involvement including milder or more subtle deficits.
Significantly worse compared to MS subset without cognitive impairment.
b There have been few previous reports of the use of TIADLs for MS-
Significantly worse than HCs.
related cognitive impairment. Using measures developed for an aging
and dementia population, the one prior study (Goverover et al., 2007)
Table 4
in MS did not find the standard TIADLs to be sensitive in a small
Total TECA scores as predicted by standard tests of information processing and
sample, without a link between performances with the SDMT and other
attention.
measures (Goverover et al., 2007). In contrast to more typical TIADLs
Tests Raw Score (Mean ± SD) Pearson's r p value measures, the TECA incorporates a broader range of tasks and scores
SDMT Total 49.5 ± 11.8 −0.53 < 0.001
providing greater sensitivity to deficits as demonstrated in this study.
BVMT-R Total 21.4 ± 7.4 −0.32 < 0.001 Overall, the 10 item TECA had low to acceptable reliability overall,
Verbal Learning Total 48.3 ± 10.2 −0.36 < 0.001 which may be improved with the refinement of task instructions to
Digit Span Total 25.6 ± 5.1 −0.22 0.007 reduce variability of responses and the addition of new tasks. Reliability
was not compromised by any single item; instead, the range of tasks is
PASAT Trials
2 Second Trial 39.8 ± 12.1 −0.39 < 0.001 useful for detecting a range of real-world deficits. Test-retest reliability
3 Second Trial 28.5 ± 10.1 −0.41 < 0.001 using the alternate form is also low to acceptable and may be improved
with additional items as well. It is important to note that the TECA
DKEFS Trail Making Test reliability is typical of what would be expected for many of the neu-
Condition 1 27.6 ± 16.1 −0.49 < 0.001
Condition 2 46.3 ± 25.8 −0.43 < 0.001
ropsychological measures that are currently in use (Calamia et al.,
Condition 3 46.2 ± 30.5 −0.55 < 0.001 2013). Internal consistency would not be expected to be high given the
Condition 4 96.8 ± 60.0 −0.52 < 0.001 range of tasks included across the 10 test items.
Condition 5 29.0 ± 16.2 −0.38 < 0.001 The TECA meets strong criteria for validity in its distinction be-
tween groups. In addition, it links to standard measures of attention and
SDMT: Symbol Digit Modalities Test; BVMT-R: Brief Visuospatial Memory Test
processing speed that have been demonstrated to be sensitive to cog-
– Revised; Verbal Learning: Completion of either the Serial Reminding Task or
the Rey Auditory Verbal Learning Test; PASAT: Paced Auditory Serial Addition
nitive impairment in MS. Performance on the TECA differentiated MS
Test; Visual Span Corsi Blocks; DKEFS: Delis–Kaplan Executive Function participants from healthy controls as well as those MS participants who
System. do and do not meet screening criteria for cognitive impairment.
Note: Age-normative scaled scores used for all measures Therefore, the TECA may provide a bridge from standard cognitive
assessment to prediction of daily functioning difficulties in persons with
correlated with measures of attention and information processing speed MS.
as well as verbal and visual learning. In the future, tasks could be introduced to expand the TECA's scope,
TECA scores were linked to some but not all clinical features of MS. such as prospective memory tasks. More difficult tasks could also po-
Both disease duration (r = 0.21, p = 0.03) and EDSS (r = 0.24, tentially increase the TECA's sensitivity and reliability. Further research
p = 0.003) were positively associated with TECA performance, in- can link performance on the TECA with additional neuropsychological
dicating longer disease and worse neurologic disability are associated tests and also improve the overall reliability of the measure.
There are several limitations to the current study. Three of the ten

72
L.E. Charvet et al.
TECA tasks involve the use of a phonebook which is not commonly used
in the present day by the younger population. The visual scanning and
memory skills that are built into the phonebook tasks will likely need to
be replaced with a more culturally relevant prop. The younger age of
the healthy control samples prevented an adequate matching for age,
which may have also influenced performances. Finally, the cultural
appropriateness of the tasks is a future consideration for the TECA,
especially if it expands to international use. The TECA represents a
promising first step towards a reliable, valid, and straight-forward
measure of TIADLs with the potential for broad clinical and research
use in MS and other disorders.
Administered using a standardized and portable kit, the TECA is
feasible for clinical settings and across sites in clinical trials. While we
have shown the TECA to be useful in MS, the items are generalizable to
other disorders associated with a range of cognitive impairment, in-
cluding those with only mild to moderate deficits.
Funding
This study was supported by the National MS Society grant G-1508-
06000 and The Lourie Foundation, Inc.
Declaration of interest statement
The authors report no conflict of interest.
Acknowledgments
We thank Wendy Fang, Ariana Frontario, Margaret Kasschau and
Colleen Schwarz for their contributions.
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