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35 (2002) 153160
www.elsevier.com/locate/archger
Department of Geriatric Rehabilitation, Sheba Medical Center, Tel Hashomer 52621, Israel
b
Sackler School of Medicine, Tel A6i6 Uni6ersity, Ramat A6i6, Tel A6i6, Israel
c
Department of Geriatric Medicine, Sheba Medical Center, Tel Hashomer 52621, Israel
Received 3 August 2001; received in revised form 14 January 2002; accepted 15 January 2002
Abstract
The use of reliable and valid brief cognitive screening instrument for selecting the
appropriate candidates for stroke rehabilitation is crucial. Clinicians often face the question
which test should be preferred, that will best correlate with functional outcome. The
objective of this study was to compare the clock drawing task with other cognitive tests used
for the evaluation of discharge functional outcome in elderly stroke patients. We conducted
a retrospective chart study including 151 consecutive patients, admitted for inpatient
comprehensive rehabilitation following acute stroke. The clock drawing task (CDT), minimental state examination (MMSE) and the cognitive-functional independence measure
(cognFIM) were used to assess the cognitive status. Functional status outcome was evaluated
by the functional independence measure (FIM), using absolute and relative parameters of
efficacy and efficiency. Correlation coefficients (Pearson correlation) between the three
cognitive tests resulted in r-values ranging from 0.51 to 0.59 (PB 0.001). All three tests
correlated significantly with motor outcomes. MMSE did not confer additive value to CDT.
It is concluded that CDT is similar to mini-mental and both are somewhat better than
cognFIM with respect to the evaluation of functional status outcome following stroke. The
correlations between the tests as well as the simplicity of administration favor the use of
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either CDT or MMSE in the initial assessment of elderly stroke patients. 2002 Elsevier
Science Ireland Ltd. All rights reserved.
Keywords: Elderly; Stroke; Cognition; Functional outcome
1. Introduction
In the United States and Europe stroke is the third leading cause of death and
the leading cause of neurological disability (Murray and Lopaz, 1997). Stroke
survivors may remain with physical, cognitive and behavioral changes. Those who
survive the acute crisis are referred to rehabilitation facilities whose main goals are
the improvement of physical impairments and functional outcomes. The economic
burden associated with stroke is heavy and, since financial sources for rehabilitation
programs are limited, prediction of the effectiveness of rehabilitation process is of
major concern (Kaste et al., 1992).
Most of the elderly stroke patients display some cognitive and perceptual decline
on admission, which may be associated with limited functional gains and poor
rehabilitation outcomes. The commonly used mini-mental state examination
(MMSE) have been evaluated with regards to functional outcome of stroke patients
(Mysiw et al., 1989; Diamond et al., 1996; Hajek et al., 1997). More recently, the
clock drawing task (CDT) has been used to identify elderly with cognitive decline
(Shulman et al., 1986; Libon et al., 1993), yet data regarding its use in the cognitive
evaluation of elderly stroke patients are limited (Friedman, 1991; Lieberman et al.,
1999) and a possible association with motor functional outcome has not been
studied in large series.
The objective of the present study was double: the first, to study the correlation
between three commonly used cognitive tests; the CDT, the MMSE and the
cognitive-functional independence measure (cognFIM). The second, to investigate
the use of these cognitive tests in evaluating the functional outcome at discharge of
stroke patients.
2. Patients and methods
2.1. General
This is a retrospective chart review study designed to evaluate whether cognitive
assessment by the CDT, as compared with MMSE and cognFIM, is associated with
functional outcome of elderly stroke patients. The study took place in the Geriatric
rehabilitation ward, which is a 30-bed unit utilizing an interdisciplinary team
approach. Team members meet twice a week to evaluate the status of each patient.
During these meetings, a treatment plan is established and monitored with the
purpose of coordinating and integrating staff activities, and promoting effective
rehabilitation. These patients usually undergo, in average, 5 h per week of physical
and occupational therapy.
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2.2. Patients
We have included in the study consecutive patients admitted to our ward for
rehabilitation following acute stroke. All patients were admitted from the acute care
hospital after their medical condition had stabilized, usually within 1 week after
stroke onset. We admitted only those patients judged to benefit from rehabilitation,
after considering their deficits and their potential of rehabilitation. Patients with
significant difficulties in language expression or comprehension or severe dementia
were excluded from the study, as well as patients with documented psychiatric
disorders such as depression and schizophrenia. The existence of spatial and
perceptual problems did not exclude patients from the study.
Patients were discharged once they had reached a functional level sufficient for
outpatient rehabilitation or had reached a functional plateau.
We collected data concerning age, gender, delay between stroke onset and
admission to rehabilitation, length of rehabilitation stay (LOS). Patients were
classified as suffering left or right hemiparesis or hemiplegia, or other (e.g. ataxic
stroke).
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3. Results
3.1. General
We have studied 236 patients, 85 of who were excluded due to various reasons.
One hundred and fifty one patients met the above criteria and were included in the
final analysis. Mean age of patients was 73.79 9.9 (range 5995). Median delay
from admission to the hospital and transfer to rehabilitation was 7.9 days (range
and median LOS in the rehabilitation ward was 39 days (range 12 87). Other
characteristics of the study population are presented in Table 1.
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Table 1
General characteristics of study population and cognitive assessment on admission
Total number
Females/males
Age (mean 9 SD)
Rehabilitation LOS (median)
151
58/93
73.7 99.9
39
Stroke type
Hemiparesis
Hemiplegia
Other
69
60
22
5.5 9 3.3
22.0 95.5
25.5 97.6
Table 2
Mean changes in functional scores and functional outcome parameters (mean 9SD)
Test
Functional scores
Total FIM
Motor FIM
Cognitive FIM
Functional outcome parameters
Absolute motor efficacy
Absolute motor efficiency
Relative motor efficacy
Relative motor efficiency
*ANOVA with repeated measures.
Admission
Discharge
Change
P*
70.5 9 22.2
45.1 9 17.5
25.5 9 7.6
94.5 9 22.7
66.4 9 8.7
28.0 9 6.3
24.0 915.0
21.3 913.2
2.5 93.6
B0.001
B0.001
B0.001
21.3 9 13.2
0.59 9 0.43
0.50 9 0.30
1.63 9 1.72
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Table 3
Pearson correlation matrix (r) of scores of cognitive tests at admission (n =151)
CognFIM
MMSE
CDT
CognFIM
MMSE
CDT
1.000
0.57*
0.51*
1.000
0.59*
1.000
*PB0.001.
4. Discussion
It has previously been shown that cognitive status at admission and success of
rehabilitation are associated, with a better rehabilitation outcome and shorter LOS
in the cognitively intact elderly stroke patients (Luxenberg and Feigenbaum, 1986;
Warren et al., 1989; Galski et al., 1993). However, the question which cognitive test
should be used is often questioned.. The design of this comparative study serves to
Table 4
Pearson correlation (r) between CDT, MMSE, CognFIM (at admission) and outcome parameters
(n = 151)
Outcome parameters
CDT
MMSE
CognFIM
Motor FIM
Absolute efficacy
Absolute efficiency
Relative efficacy
Relative efficiency
0.24
0.16
0.37
0.21
0.22 (P =0.005)
0.13 (NS)
037 (PB0.001)
0.18 (P =0.03)
0.04
0.02
0.32
0.22
(P= 0.003)
(P= 0.05)
(PB0.001)
(P= 0.01)
(NS)
(NS)
(PB0.001)
(PB0.001)
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assess both the inter-tests correlation, and the possible association of each of these
cognitive tests with functional outcome parameters.
Functional improvement was encountered in the majority of the patients and
reflected by total and motor FIM gains, as well as in other efficacy and efficiency
parameters. However, only the relative outcome parameters, which take into
account the rehabilitation potential, proved statistically significant. This means that
interpretation of absolute efficacy and efficiency parameters should be made with
caution. These findings are consistent and are in accordance with previous findings
in hip fractured elderly (Heruti et al., 1999).
The similar results obtained for correlation coefficients in all three tests and
ranging between 0.51 and 0.59 probably mean that they share a reasonable degree
of resemblance to each other, accounting for construct validity of these tests. This
is not surprising, considering the nature of the tests that had been applied. The
relative high correlation between clock task and cognFIM is somewhat surprising,
yet, it may result from bias during testing due to the fact that it has been usually
performed last. Overall, there is a controversy about which cognitive category is the
most important one and which cognitive deficit has the greatest impact on maximal
functioning. It is assumed that more global cognitive function, rather than narrow
aspects of neuropsychological function, predominantly affects daily behavioral and
functional status (Carter et al., 1988). Each of the tests we have used assesses
general cognitive function, yet they differ from each other. However, a significant
correlation was observed between the tests, as well as with functional outcome
parameters, providing further evidence of the construct validity of these tests. This
means that on practical grounds, these tests are comparable in evaluating future
functional outcomes. Since cognFIM is not an easy bedside-applicable procedure,
the use of MMSE or CDT is favored, with the last being briefer, easier to
administer and psychologically non-threatening.
We conclude that there is a statistically significant inter-test correlation between
CDT, MMSE and cognFIM. All three tests correlate with the change of functional
status during rehabilitation. CDT and MMSE are somewhat better than cognFIM
with regards to motor outcome and should also be preferred as they are shorter,
and may substitute each other.
Acknowledgements
Special thanks to the rehabilitation team at the Geriatric Division, Sheba
Medical Center, for assistance in treating the patients and in data collection.
Appendix A
Absolute functional gain parameters:
FIM efficacy (EFC)= FIM discharge FIM admission.
FIM efficiency (EFCN) = FIM efficacy/length of stay.
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