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Mini-Mental State Examination, Cognitive FIM Instrument, and the Loewenstein Occupational Therapy Cognitive Assessment: Relation to Functional Outcome of Stroke Patients
Manuel Zwecker, MD, Shalom Levenkrohn, MD, Yudit Fleisig, MD, Gabi Zeilig, MD, Avi Ohry, MD, Abraham Adunsky, MD
ABSTRACT. Zwecker M, Levenkrohn S, Fleisig Y, Zeilig G, Ohry A, Adunsky A. Mini-Mental State Examination, cognitive FIM instrument, and the Loewenstein Occupational Therapy Cognitive Assessment: relation to functional outcome of stroke patients. Arch Phys Med Rehabil 2002;83:342-5. Objectives: To compare 3 cognitive tests, used on admission, for predicting discharge functional outcome and to assess the efcacy of these tests in predicting functional outcome at discharge in stroke patients undergoing rehabilitation. Design: Cohort study. Setting: Geriatric rehabilitation department of a tertiary care hospital in Israel. Patients: Sixty-six patients undergoing acute inpatient comprehensive rehabilitation after rst clinical stroke. Interventions: Not applicable. Main Outcome Measurements: Cognitive status was assessed with the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), the Mini-Mental State Examination (MMSE), and the cognitive subscale of the FIM instrument. The FIM motor subscale was used to assess functional outcome status. Functional gain was determined by the motor FIM gain (efcacy), and the relative (to potential) functional gain was determined by the Montebello Rehabilitation Factor Score. Efciency was calculated by efcacy divided by the length of hospital stay. Results: A signicant increase in total FIM scores (34.8 points) occurred during rehabilitation mainly because of improvement in motor functioning (31.5 points). Signicant improvement in global cognitive status was documented by all 3 tests. Intertest correlation coefcients ranged between .47 and .67. The LOTCA showed somewhat higher correlation coefcients with most of the parameters of functional motor outcomes. Correlation between the MMSE and FIM cognitive subscale and these outcome parameters were nearly identical. Conclusion: The LOTCA is slightly better than the MMSE and the FIM cognitive subscale in predicting functional status change after stroke rehabilitation but it is a time-consuming and exhausting instrument to use. The FIM cognitive subscale requires a better overall understanding of the patients situation at time of administration and therefore is less convenient for the initial assessment. The similar correlation of all 3 tests with functional outcomes and the simplicity of administration of the MMSE suggests its use in the initial assessment of stroke patients. Key Words: Cerebrovascular accident; Cognition; Neuropsychological tests; Rehabilitation; Treatment outcome. 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation TROKE IS THE THIRD leading cause of death and the leading cause of neurologic disability in the United States S and Europe. Stroke survivors may have physical, cognitive,
1,2

From the Departments of Neurological Rehabilitation (Zwecker, Zeilig, Ohry) and Geriatric Rehabilitation (Levenkrohn, Fleisig, Adunsky), Sheba Medical Center, Tel-Hashomer, Israel. Accepted in revised form April 12, 2001. No commercial party having a direct nancial interest in the results of the research supporting this article has or will confer a benet upon the authors(s) or upon any organization with which the author(s) is/are associated. Correspondence to Manuel Zwecker, MD, Dept of Neurological Rehabilitation, Sheba Medical Center, Tel-Hashomer 52621, Israel, e-mail: mzwecker@hotmail.com. Reprints are not available. 0003-9993/02/8303-6374$35.00/0 doi:10.1053/apmr.2002.29641

and behavioral decits; considerable efforts have been made to identify factors that may affect functional outcomes of stroke patients admitted to rehabilitation settings. Several studies have shown that, in addition to factors such as incontinence, poor arm function, loss of sitting balance, hemianopsia, and old age,3 cognitive function and motivation are strong predictors of functional outcome in terms of activities of daily living4,5 (ADLs). Performance of ADLs requires mobility, strength, coordination, and several fundamental cognitive skills. Because cognitive impairment can limit functional gains during inpatient rehabilitation,6,7 the early assessment of cognitive skills is crucial in the evaluation of stroke patients and is a part of any routine evaluation in rehabilitation settings. Stroke can cause either specic or focal neuropsychologic decits, such as decreased attention and arousal, aphasia, perceptual, and constructional dysfunction. It may also result in calculation decit, unilateral spatial neglect, memory dysfunction, and decreased motivation or cause nonfocal changes such as intellectual impairment. General cognitive function, rather than narrow aspects of neuropsychologic functions, has a greater impact on the daily behavioral status. This means that cognitive impairments that are related to daily behavioral status and ADLs are relevant for stroke outcome prediction.6 Studies7,8 have suggested that particularly high-order cognitive abilities (eg, abstract thinking, judgment, short-term verbal memory, comprehension, orientation) are important in predicting functional status at the end of a hospital stay. These cognitive skills are fundamental to the patients awareness and understanding of his/her impairments, as well as understanding the relation between insight and the capacity to learn and perform executive control functions. Although most studies suggest that cognitive perceptual function is among the important determinants of stroke outcome, controversy exists over the best ways to assess these decits. The objectives of the present study were (1) to study the correlation between 3 commonly used cognitive tests: the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), the Mini-Mental State Examination (MMSE), and the cognitive section of the FIM instrument and (2) to investigate the efcacy of these cognitive tests in predicting

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functional outcome at discharge of stroke patients when admitted for rehabilitation. METHODS Participants We studied 66 stroke patients (49 men, 17 women) who were admitted to the stroke unit of a geriatric neurologic rehabilitation department in Israel. All patients were admitted from acute care wards after their medical conditions had stabilized, usually within 1 week after stroke onset. We admitted only patients who were presumed to benet from rehabilitation. Patients with signicant difculties in language expression or comprehension, or severe dementia were excluded. Patients were discharged when they reached either a functional level sufcient for outpatient rehabilitation or a functional plateau. Informed consent was obtained from all participants. Assessment of Functional Status Functional status was assessed with the FIM instrument,9,10 a validated instrument for documenting the severity of disability and assessing the outcome of rehabilitation treatment. The motor subscale of the FIM instrument has 4 items that assess the level of motor functions such as self-care, sphincter control, mobility, and locomotion. Scores can range from 13 to 91. Evaluation of Functional Outcomes The following parameters derived from the FIM were used to judge the rehabilitation outcome: FIM efcacy, which is the functional gain reached during rehabilitation stay (discharge FIM admission FIM) and FIM efciency, which is dened as the daily gain (efcacy length of stay [LOS] in days). Both FIM efcacy and efciency measure absolute changes. We also used the following Montebello Rehabilitation Factor Score11 (MRFS) to reect relative functional gains: MRFS efcacy (discharge FIM admission FIM maximal possible FIM admission FIM) and MRFS efciency (MRFS efcacy score LOS). These MRFS scores are measured in relation to the patients specic potential for change. We used the MRFS because it overcomes the misinterpretation caused by the ceiling effect (the fact that the gain that patients with high admission scores can achieve is limited, compared with those who start with low scores). By using this model, MRFS efcacy and efciency scores of patients who benet from rehabilitation will range from 0 to 1. The FIM was administered between 72 hours and 1 week after a patient was admitted to the stroke rehabilitation unit and again during the week in which he/she was discharged. Scoring was done by a team of rehabilitation professionals that included a physician, physiotherapist, speech pathologist, occupational therapist, social worker, and nurse. Cognitive Assessment We used 3 cognitive tests. The MMSE12 is a widely used, reliable, and validated instrument used in screening for cognitive impairment. It examines a few aspects of cognition, is easily performed, and requires 5 to 10 minutes to administer. Contents include orientation, attention, learning, calculation, abstraction, information, construction, and delayed recall. The MMSE is helpful in determining a need for further neuropsychologic assessment. A high degree of correlation has been shown between this test and standard tests of cognitive function.13 The LOTCA14 is primarily used by occupational therapists to assess cognitive function after stroke and other brain inju-

ries. It has a standardized battery of perceptual tests with which to assess persons with brain injuries (head injury, stroke). The test is derived from clinical experience, neuropsychologic theories, developmental theories (ie, those of Piaget), and evaluation procedures. It assesses the basic cognitive skills, dened as those intellectual functions thought to be prerequisites for managing everyday encounters with the environment. The LOTCA consists of 4 major areas that comprise 20 subsets. The subsets are specically related to the patients rehabilitation potential. The items investigated are orientation, perception, visuomotor organization, and thinking operation. Each subset is scored, and the total score can range from 22 to 91. The test provides information about the patients abilities and deciencies and about his/her capacity to cope with everyday and occupational tasks. The test, when administered by a skilled occupational therapist, takes about 45 minutes to complete. The FIM cognitive subscale is a part of the global FIM assessment and is comprised of 2 items (communication, social cognition) that relate to cognitive functions such as comprehension, expression, social interaction, problem solving, and memory. A score of 35 points represents optimal performance. This test is somewhat difcult to administer in facilities other than rehabilitation facilities and requires a better knowledge of the patient. A signicant positive correlation has been found15 between the FIM cognitive subscale and MMSE, which provides further evidence of the construct validity of both measures. All cognitive tests were administered within the rst week of admission by occupational therapists. On discharge, a second and nal cognitive assessment with the LOTCA and FIM cognitive subscale was performed. Not all tests were administered to all patients. Some patients left the hospital before another LOTCA was administered; however, because of the exploratory nature of this study, we decided to keep all patients in the study even if some of their data were missing. Only admission scores of cognitive status were correlated to motor functional outcome parameters. Statistical Analyses All data were analyzed by using BMDP software.a Changes in functional and cognitive scores were analyzed by analysis of variance with repeated measures. The Pearson correlation coefcient was used to calculate the correlation between the cognitive tests. Logistic regression analysis was used to identify variables associated with success in rehabilitation. RESULTS Mean age of the patients was 72 8.9 years (range, 47 87y). Median delay from admission to the acute hospital and transfer to rehabilitation was 4.0 days (range, 156d), and median LOS in the rehabilitation ward was 60 days (range, 9 129d). We excluded 15 patients from the study. Some were too demented to cooperate, and the others presented with communication decits (dysphasia, aphasia) that interfered with the tests. Other characteristics of the study population are presented in table 1. Functional Outcome In the total study group, a statistically signicant increase in FIM scores (34.8, P .001) occurred during rehabilitation (table 2), similar to the increase in FIM motor scores (31.5, P .001). This suggests that the change in total FIM resulted mostly from FIM motor scores. Both MRFS efcacy and efciency parameters showed a signicant improvement, yet
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COMPARATIVE COGNITIVE ASSESSMENT IN STROKE, Zwecker Table 1: Clinical and Demographic Data of Patients
N % MMSE LOTCA FIM Cognitive

Table 3: Pearson Correlation Matrix of Scores of Cognitive Tests at Admission (n 61)

Patients Gender (male/female) Previous stroke Clinical presentation Left hemisphere Right hemisphere Other Origin of stroke Thrombotic Hemorrhagic Cardioembolic stroke Other

66 49/17 10 34 26 6 38 15 3 10

74/26 15 52 39 9 58 22 5 15

MMSE LOTCA FIM cognitive * P .001.

1.000 .588* .666*

1.000 .471*

1.000

the values of these parameters varied greatly among patients. This indicates a large intersubject variability concerning the patients potential for rehabilitation and ability to achieve their potential. Cognitive Status Admission MMSE scores were available for 61 patients; their mean score was 22.8 points. Fifty-one percent of the patients showed cognitive decline (cutoff score 24). The changes observed in the scores of both FIM cognitive and LOTCA, from admission to discharge, were small (3.4 and 6.4, respectively, 0.5 standard deviations [SDs]) yet statistically signicant. Results are summarized in table 2. Correlation Between Cognitive Tests Analyses of the correlation coefcients (Pearson correlation) of the 3 cognitive tests resulted in values ranging from .47 to .67 (table 3), which were all statistically signicant. Admission scores of FIM cognitive subscale correlated better with MMSE than with LOTCA scores. The Pearson correlations of admission LOTCA were higher with the MMSE and lower with the FIM cognitive subscale, yet both were signicant (P .001). Relation Between Cognitive Status and Functional Outcome Relation to total FIM scores. We found signicant positive associations between cognitive status at admission and some of the functional gain parameters. As a cognitive status measure, the LOTCA correlation coefcients were higher than the MMSE and FIM cognitive subscale, with regard to total FIM efcacy and efciency and MRFS efcacy, but slightly lower for MRFS efciency. Correlation between the MMSE or FIM cognitive subscale and these outcome parameters were practically identical.

Relation to FIM motor scores. After isolating the pure FIM motor from total FIM, the LOTCA correlated slightly better only with efcacy. Efciency of the FIM motor could not be shown with any of the cognitive tests (table 4). However, all 3 cognitive tests showed signicant correlation with the MRFS efcacy and FIM motor efcacy, with the highest score for the LOTCA and FIM cognitive subscale. The MRFS efciency and FIM motor efciency correlated poorly with all 3 tests, especially with the LOTCA (table 4). No additional effects of age, gender, or side of neurologic decit were shown on parameters associated with better rehabilitation outcomes. DISCUSSION Early evaluation of the cognitive aspects in stroke patients allows clinicians to identify the patients potential for rehabilitation and to set realistic plans for treatment. The design of this comparative study helps to assess the specic role of each of the 3 cognitive tests commonly used by stroke rehabilitation specialists and their ability to predict functional outcome at discharge after rehabilitation. Both physical and cognitive functional improvement was shown by the majority of the patients, as reected in total FIM, FIM motor, and all 3 cognitive test scores. Moreover, correlation coefcients of these cognitive tests ranged between .47 and .67, which means that they share a reasonable degree of resemblance and accounts for their construct validity. Results of the correlation among the cognitive tests are not surprising given the differences in the nature of the tests. The evaluation of the cognitive abilities needed for optimal functioning in ADLs is quite complex.13 There is a controversy among clinicians about which category is the most important and which cognitive decit has the greatest impact on maximal functioning. It is assumed that more global cognitive function, rather than narrow aspects of neuropsychologic function, predominantly affects daily behavioral status.16 Each test used assesses general cognitive function, yet differs from the others. In fact, the LOTCA was originally designed to assess basic cognitive abilities, which are dened as those intellectual functions thought to be prerequisites for managing every day encounters with the environment.14 In contrast, both the MMSE and FIM cognitive subscale are less comprehensive than the LOTCA with regard to the detection of cognitive abilities associated with the performances of ADLs.

Table 2: Functional and Cognitive Test Scores During Inpatient Rehabilitation

Test Cases (N) Admission (mean SD) Discharge (mean SD) Change (mean SD)

P*

Total FIM FIM motor FIM cognitive LOTCA MMSE

66 66 66 44 61

61.5 19.9 37.6 14.9 23.9 8.4 66.3 13.5 22.8 5.2

96.3 24.1 69.1 19.1 27.2 7.1 72.7 13.7

34.8 20.3 31.5 17.9 3.4 4.7 6.4 11.1

.001 .001 .001 .001

* Analysis of variance with repeated measures.

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COMPARATIVE COGNITIVE ASSESSMENT IN STROKE, Zwecker Table 4: Pearson Correlation Between LOTCA, MMSE, FIM Cognitive (at admission) and Outcome Parameters
Outcome parameters LOTCA (n 44) MMSE (n 61) FIM Cognitive (N 66)

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FIM FIM FIM FIM

motor motor motor motor

efcacy efciency MRFS efcacy MRFS efciency

.25* .16 .34 .19

.12 .16 .30* .26*

.14 .23 .34 .28*

* P .05. P .01.

The correlation among the tests at admission, as well as the correlation with functional outcome parameters, provides further evidence of the construct validity of these tests. This means that, on practical grounds, none of the tests is better than the other in predicting functional outcomes. This, therefore, favors the use of the MMSE, because it is brief and is the least difcult to administer. The sensitivity of the MMSE may be further enhanced by the addition of a clock drawing task in the screening.17 CONCLUSION We have shown that the LOTCA examination is only slightly superior to the MMSE and FIM cognitive subscale in its relation to the functional outcome parameters (total FIM efcacy, efciency, MRFS efcacy). Similar to the FIM cognitive subscale, the LOTCA is not a bedside-applicable procedure and has no signicant additional benet compared with the MMSE examination. We conclude that the MMSE is equal to the LOTCA and FIM cognitive subscale, is much easier to administer, and requires less time and expertise. MMSE remains useful in the initial assessment of stroke patients admitted to a rehabilitation setting, and is effective in predicting functional outcomes.
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