Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)

Purpose of the measure :

To measure basic cognitive skills required for everyday function including orientation, visual
perceptual and psychomotor abilities, problem-solving skills and thinking operations.
The LOTCA is typically used in the initial phase of patient assessment but can also be used to
establish therapeutic goals and to review cognitive status over time

Available versions :
The original LOTCA
for use with individuals below the age of 70 years with neurological dysfunction
consisted of a total of 20 items within 4 areas: Orientation (2 items); Perception (6 items);
Visuomotor Organization (7 items); and Thinking Operations (5 items).

The LOTCA-II
was modified by separating the Perceptual area into three separate areas (Visual
Perception, Spatial Perception and Motor Praxis), revising items and including an
additional Thinking Operations subtest.
consists of a total of 26 subtests within 6 areas: Orientation (2 items); Visual Perception
(4 items); Spatial Perception (3 items); Motor Praxis (3 items); Visuomotor Organization
(7 items); and Thinking Operations (7 items).
The LOTCA-II includes multi-choice questions in the Orientation area to accommodate
language difficulties.

The LOTCA Geriatric version (LOTCA-G) is a modified version of the original LOTCA that
was designed for use with individuals aged 70 - 91 years. The LOTCA-G was developed in
response to difficulties that elderly patients experienced using the LOTCA (e.g. difficulty seeing
and using small materials, and duration of assessment). Accordingly, it contains modifications to
allow for age-related cognitive decline and sensorimotor difficulties including larger materials to
compensate for visual and motor deficits, less visual detail, shorter subtests, multiple-choice
questions, and additional memory tests not included in the original LOTCA.

Features of the measure
The original LOTCA contains 20 subtests in 4 areas. The LOTCA-II contains 26 subtests in 6
areas:
Orientation (2 subtests): Assesses the individual's orientation to place and time.
Visual Perception (4 subtests): Assesses the individual's ability to identify pictures of
everyday objects, objects photographed from unusual angles, distinguish between
overlapping figures, and recognize spatial relations between objects.
Spatial Perception (3 subtests): Assesses the individual's ability to differentiate between
right and left to determine spatial relationships between objects and self.
Motor Praxis (3 subtests): Asesses the individual's ability to imitate motor actions, use
objects and perform symbolic actions.
Visuomotor Organization (7 subtests): Assesses the individual's ability to copy geometric
figures, reproduce a 2D model, copy a coloured block design and a plain block design,
reproduce a puzzle and complete a pegboard task, and draw a clock.
Thinking Operations (7 subtests): Assesses the individual's ability to complete tasks
including sorting, categorization, and picture and geometric sequences (Annes et al.,
1996).
Most subtests of the LOTCA are scored from 1 to 4, where:
1 = patient fails to perform the task
2 = patient is able to perform part of the task
3 = patient is able to perform most of the task
4 = patient demonstrates good performance of the task
However, three Thinking Operations subtests (Categorisation, ROC Unstructured, ROC
Structured subtests) are scored on a scale from 1 to 5 (Josman, Abdallah & Engel-Yegar, 2010;
Zwecker et al., 2002).
Most subtests of the LOTCA-II are also scored from 1 to 4 using the scale above. However,
Orientation subtests are scored on a scale from 1 to 8 and three Thinking Operations subtests
(Categorization, ROC Unstructured, ROC Structured) are scored on a scale from 1 to 5.
Accordingly, the overall LOTCA-II score ranges from 26 to 115 points. Task completion
through trial-and-error is penalized in three subtests. Performance elements such as the number
of prompts provided to the individual to assist him/her in completing the task, the individual's
attention/concentration and length of time taken to complete the assessment are also recorded.
Results are provided as a profile for each subtest, where higher scores indicate less cognitive
impairment
Time:
The LOTCA and LOTCA-II take approximately 45 minutes to administer, with a reported range
from 30 to 90 minutes
Equipment:
The LOTCA kit contains testing materials (card decks, coloured blocks, pegboard set and other
materials) and a manual that includes definitions of the cognitive domains assessed, instructions
for administration and specific scoring guidelines.

The LOTCA-G includes 23 subtests in 7 cognitive areas:
Orientation (2 subtests): Orientation to place; and orientation to time
Visual Perception (4 subtests): Object identification; shape identification; overlapping
figures; and object consistency
Spatial Perception (3 subtests): On self; on examiner; and self and surroundings
Praxis (3 subtests): Motor imitation; utilization of objects; and symbolic actions
Visuomotor Organization (6 subtests): Copy geometric forms; two-dimension model
pegboard construction; block design (colour); reproducation of a puzzle; and drawing a
clock
Thinking Operations (2 subtests): Categorization; and pictorial sequencing
Memory (3 subtests): Famous personality; personal possession; and everyday objects
The Orientation subtests are scored from 1 - 8 while all other subtests of the LOTCA-G are
scored on an ordinal scale from 1 to 4, where 1 indicates severe deficit and 4 indicates average
performance. The LOTCA-G takes approximately 30-45 minutes to administe

Client suitability:
Can be used with:
Patients following stroke (Bar-Haim Erez & Katz, 2003)
Older individuals with dementia (Bar-Haim Erez & Katz, 2003)
Individuals with traumatic brain injury (Annes et al., 1996)
Individuals with CNS dysfunction (Annes et al., 1996)
Individuals with intellectual disabilities (Jang, Chern & Lin, 2009)
Individuals with mental illness (Jang et al., 2009; Josman & Katz, 2006)
An adapted version has also been developed for use with children with learning
difficulties (Josman et al., 2010)
Patients with aphasia - procedures for assessing the patient with aphasia are included
(Jang et al., 2009).
Should not be used in:
An individual's culture can affect the construct validity of the LOTCA when used with a
pediatric population (Josman et al., 2010)

Purpose of the measure
The CDT is used to quickly assess visuospatial and praxis abilities, and may determine the
presence of both attention and executive dysfunctions (Adunsky, Fleissig, Levenkrohn, Arad, &
Nov, 2002; Suhr, Grace, Allen, Nadler, & McKenna, 1998; McDowell & Newell, 1996).
The CDT may be used in addition to other quick screening tests such as the Mini-Mental State
Examination (MMSE), and the Cognitive Functional Independence Measure.

Available versions
The CDT is a simple task completion test in its most basic form. There are several variations to
the CDT:
Verbal command:
Free drawn clock: the individual is given a blank sheet of paper and asked first to draw
the face of a clock, place the numbers on the clock, and then draw the hands to indicate a
given time. To successfully complete this task, the patient must first draw the contour of
the clock, then place the numbers 1 through 12 inside, and finally indicate the correct
time by drawing in the hands of the clock.
Pre-drawn clock: alternatively, some clinicians prefer to provide the individual with a
pre-drawn circle and the patient is only required to place the numbers and the hands on
the face of the clock. They argue that the patient's ability to fill in the numbers may be
adversely affected if the contour is poorly drawn. In this task, if an individual draws a
completely normal clock, it is a fast indication that a number of functions are intact.
However, a markedly abnormal clock is an important indication that the individual may
have a cognitive deficit, warranting further investigation.
Pictures courtesy of Mary Ganguli MD MPH, University of Pittsburgh,
Regardless of which type is used (free drawn or pre-drawn), the verbal command CDT can
simultaneously assess a patient's language function (verbal comprehension); memory function
(recall of a visual engram, short-term storage, and recall of time setting instructions); and
executive function. The verbal command variation of the CDT is highly sensitive for temporal
lobe dysfunction (due to its heavy involvement in both memory and language processes) and
frontal lobe dysfunction (due to its mediation of executive planning) (Shah, 2002).
Copy command:
the individual is given a fully drawn clock with a certain time pre-marked and is asked to
replicate the drawing as closely as possible. The successful completion of the copy
command requires less use of language and memory functions but requires greater
reliance on visuospatial and perceptual processes.

Clock reading test: a modified version of the copy command CDT simply asks the
patient to read aloud the indicated time on a clock drawn by the examiner.

The copy command clock-drawing and clock reading tests are good for assessing parietal lobe
lesions such as those that may result in hemineglect. It is important to do both the verbal
command and the copy command tests for every patient as a patient with a temporal lobe lesion
may copy a pre-drawn clock adequately, whereas their clock drawn to verbal command may
show poor number spacing and incorrect time setting. Conversely, a patient with a parietal lobe
lesion may draw an adequate clock to verbal command, while their clock drawing with the copy
command may show obvious signs of neglect.
Time-Setting Instructions:
The most common setting chosen by clinicians is "3 O'clock" (Freedman, Leach, Kaplan,
Winocur, Shulman, & Delis, 1994). Although this setting adequately assesses comprehension
and motor execution, it does not indicate the presence of any left neglect the patient may have
because it does not require the left half of the clock to be used at all. The time setting "10 after
11" is an ideal setting (Kaplan, 1988). It forces the patient to attend to the whole clock and
requires the recoding of the command "10" to the number "2" on the clock. It also has the added
advantage of uncovering any stimulus-bound errors that the patient may make. For example, the
presence of the number "10" on the clock may trap some patients and prevent the recoding of the
command "10" into the number "2." Instead of drawing the minute hand towards the number "2"
on the clock to indicate "10 after," patients prone to stimulus-bound errors will fixate and draw
the minute hand toward the number "10" on the clock.

Features of the measure
Scoring:
There are a number of different ways to score the CDT. In general, the scores are used to
evaluate any errors or distortions such as neglecting to include numbers, putting numbers in the
wrong place, or having incorrect spacing (McDowell & Newell, 1996). Scoring systems may be
simple or complex, quantitative or qualitative in nature. As a quick preliminary screening tool to
simply detect the presence or absence of cognitive impairment, you may wish to use a simple
quantitative method (Lorentz et al., 2002). However, if a more complex assessment is required, a
qualitative scoring system would be more telling.
Different scoring methods have been found to be better suited for different subject groups
(Richardson & Glass, 2002; Heinrik, Solomesh, & Berkman, 2004). In patients with stroke, no
single standardized method of scoring exists. Suhr, Grace, Allen, Nadler, and McKenna (1998)
examined the utility of the CDT in localizing lesions in 76 patients with stroke and 71 controls.
Six scoring systems were used to assess clock drawings (Freedman et al., 1994; Ishiai, Sugishita,
Ichikawa, Gono, & Watabiki, 1993; Mendez, Ala, & Underwood, 1992; Rouleau, Salmon,
Butters, Kennedy, & McGuire, 1992; Sunderland et al., 1989; Tuokko, Hadjistavropoulos,
Miller, & Beattie, 1992; Watson, Arfken, & Birge, 1993; Wolf-Klein et al., 1989). Significant
differences were found between controls and patients with stroke on all scoring systems for both
quantitative and qualitative features of the CDT. However, quantitative indices were not helpful
in differentiating between various stroke groups (left versus right versus bilateral stroke; cortical
versus subcortical stroke; anterior versus posterior stroke). Qualitative features were helpful in
lateralizing lesion site and differentiating subcortical from cortical groups.
A psychometric study in patients with stroke by South, Greve, Bianchini, and Adams (2001)
compared three scoring systems: the Rouleau rating scale (1992); the Freedman scoring system
(1994), and the Libon revised system (1993). These scoring systems were found to be reliable in
patients with stroke (please see for the details of this study).
Subscales:
None typically reported.
Equipment:
Only a paper and pencil is required. Depending on the method chosen, you may
need to prepare a circle (about 10 cm in diameter) on the paper for the patient.
Training:
The CDT can be administered by individuals with little or no training in cognitive assessment.
Scanlan, Brush, Quijano, & Borson (2002) found that a simple binary rating of clock drawings
(normal or abnormal) by untrained raters was surprisingly effective in classifying subjects as
having dementia or not. In this study, a common mistake of untrained scorers was failure to
recognize incorrect spacing of numbers on the clock face as abnormal. By directing at this type
of error, concordance between untrained and expert raters should improve.
Time:
All variations of the CDT should take approximately 1-2 minutes to complete (Ruchinskas &
Curyto, 2003).

Alternative forms of the CDT
The Clock Drawing Test-Modified and Integrated Approach (CDT-MIA) is a 4-step, 20-item
instrument, with a maximum score of 33. The CDT-MIA emphasizes differential scoring of
contour, numbers, hands, and center. It integrates 3 existing CDT's:
Freedman et al's free-drawn clock (1994) on some item definitions
Scoring techniques adapted from Paganini-Hill, Clark, Henderson, & Birge (2001)
Some items borrowed from Royall, Cordes, & Polk (1998) executive CLOX
The CDT-MIA was found to be reliable and valid in individuals with dementia, however this
measure has not been validated in the stroke population (Heinik et al., 2004).

Client suitability
Can be used as a screening instrument with:
Virtually any patient population (Wagner, Nayak, & Fink, 1995). The test appears to be
differentially sensitive to some types of disease processes. Particularly, it has proven to be
clinically useful in differentiating among normal elderly, patients with neurodegenerative or
vascular diseases, and those with psychiatric disorders, such as depression and schizophrenia
(Dastoor, Schwartz, & Kurzman, 1991; Heinik, Vainer-Benaiah, Lahav, & Drummer, 1997; Lee
& Lawlor, 1995; Shulman, Gold, & Cohen, 1993; Spreen & Strauss, 1991; Tracy, De Leon,
Doonan, Musciente, Ballas, & Josiassen, 1996; Wagner et al., 1995; Wolf-Klein, Silverstone,
Levy, & Brod, 1989).
Can be used with: patients with stroke. Because the CDT requires a nonverbal response, it may
be administered to those with speech difficulties but who have sufficient comprehension to
understand the requirement of the task.
Should not be used in:
Patients who cannot understand spoken or written instructions
Patients who cannot write
As with many other neuropsychological screening measures, the CDT is
affected by age, education, conditions such as visual neglect and hemiparesis, and other factors
such as the presence of depression (Ruchinskas & Curyto, 2003; Lorentz, Scanlan, & Borson,
2002). The degree to which these factors affect ones score depends much on the scoring method
applied (McDowell & Newell, 1996). Moreover, the CDT focuses on right hemisphere function,
so it is important to use this test in conjunction with other neuropsychological tests (McDowell
& Newell, 1996).


Score
Ashworth Scale (Ashworth,
1964)
Modified Ashworth Scale (Bohannon & Smith, 1987)
0 No increase in tone No increase in muscle tone
1
Slight increase in tone giving a
catch when the limb was moved
in flexion or extension
Slight increase in muscle tone, manifested by a catch and
release or by minimal resistance at the end of the range of
motion (ROM) when the affected part is moved in
flexion or extension
1+ N/A
Slight increase in muscle tone, manifested by a catch,
followed by minimal resistance throughout the remainder
(less than half) of the ROM
2
More marked increase in tone
but limb easily flexed
More marked increase in muscle tone through most of the
ROM, but affected parts easily moved
3
Considerable increase in tone,
passive movement difficult
Considerable increase in muscle tone, passive movement
difficult
4
Limb rigid in flexion or
extension
Affected part rigid in flexion or extension