342
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 admis-
sion, for predicting discharge functional outcome and to assess
the efficacy 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 com-
prehensive rehabilitation after first clinical stroke.
Interventions: Not applicable.
Main Outcome Measurements: Cognitive status was as-
sessed 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
(efficacy), and the relative (to potential) functional gain was
determined by the Montebello Rehabilitation Factor Score.
Efficiency was calculated by efficacy divided by the length of
hospital stay.
Results: A significant increase in total FIM scores (34.8
points) occurred during rehabilitation mainly because of im-
provement in motor functioning (31.5 points). Significant im-
provement in global cognitive status was documented by all 3
tests. Intertest correlation coefficients ranged between .47 and
.67. The LOTCA showed somewhat higher correlation coeffi-
cients with most of the parameters of functional motor out-
comes. 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 patient’s situation
at time of administration and therefore is less convenient for
the initial assessment. The similar correlation of all 3 tests with
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 financial interest in the results of the research
supporting this article has or will confer a benefit 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
Arch Phys Med Rehabil Vol 83, March 2002
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; Neuro-
psychological tests; Rehabilitation; Treatment outcome.
© 2002 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
TROKE IS THE THIRD leading cause of death and the
S leading cause of neurologic disability in the United States
and Europe. Stroke survivors may have physical, cognitive,
1,2
and behavioral deficits; 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, coordina-
tion, and several fundamental cognitive skills. Because cogni-
tive 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 specific or focal neuropsychologic deficits, such as de-
creased attention and arousal, aphasia, perceptual, and con-
structional dysfunction. It may also result in calculation deficit,
unilateral spatial neglect, memory dysfunction, and decreased
motivation or cause nonfocal changes such as intellectual im-
pairment. General cognitive function, rather than narrow as-
pects of neuropsychologic functions, has a greater impact on
the daily behavioral status. This means that cognitive impair-
ments that are related to daily behavioral status and ADLs are
relevant for stroke outcome prediction.6 Studies7,8 have sug-
gested that particularly high-order cognitive abilities (eg, ab-
stract thinking, judgment, short-term verbal memory, compre-
hension, orientation) are important in predicting functional
status at the end of a hospital stay. These cognitive skills are
fundamental to the patient’s awareness and understanding of
his/her impairments, as well as understanding the relation be-
tween 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 out-
come, controversy exists over the best ways to assess these
deficits.
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 efficacy of these cognitive tests in predicting
 COMPARATIVE COGNITIVE ASSESSMENT IN STROKE, Zwecker
functional outcome at discharge of stroke patients when admit-
ted 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 sta-
bilized, usually within 1 week after stroke onset. We admitted
only patients who were presumed to benefit from rehabilitation.
Patients with significant difficulties in language expression or
comprehension, or severe dementia were excluded. Patients
were discharged when they reached either a functional level
sufficient 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 disabil-
ity 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 efficacy, which is the
functional gain reached during rehabilitation stay (discharge
FIM ⫺ admission FIM) and FIM efficiency, which is defined
as the daily gain (efficacy ⫼ length of stay [LOS] in days).
Both FIM efficacy and efficiency measure absolute changes.
We also used the following Montebello Rehabilitation Fac-
tor Score11 (MRFS) to reflect relative functional gains: MRFS
efficacy (discharge FIM ⫺ admission FIM ⫼ maximal possible
FIM ⫺ admission FIM) and MRFS efficiency (MRFS efficacy
score ⫼ LOS). These MRFS scores are measured in relation to
the patient’s specific potential for change. We used the MRFS
because it overcomes the misinterpretation caused by the “ceil-
ing 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 effi-
cacy and efficiency scores of patients who benefit from reha-
bilitation 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 cogni-
tive 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 neuropsy-
chologic assessment. A high degree of correlation has been
shown between this test and standard tests of cognitive func-
tion.13
The LOTCA14 is primarily used by occupational therapists
to assess cognitive function after stroke and other brain inju-
343
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 the-
ories, developmental theories (ie, those of Piaget), and evalu-
ation procedures. It assesses the basic cognitive skills, defined
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 specifically related to the patient’s rehabilita-
tion potential. The items investigated are orientation, percep-
tion, 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 patient’s abilities and
deficiencies 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 com-
plete.
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 compre-
hension, expression, social interaction, problem solving, and
memory. A score of 35 points represents optimal performance.
This test is somewhat difficult to administer in facilities other
than rehabilitation facilities and requires a better knowledge of
the patient. A significant positive correlation has been found15
between the FIM cognitive subscale and MMSE, which pro-
vides further evidence of the construct validity of both mea-
sures.
All cognitive tests were administered within the first week of
admission by occupational therapists. On discharge, a second
and final cognitive assessment with the LOTCA and FIM
cognitive subscale was performed. Not all tests were adminis-
tered 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 co-
efficient was used to calculate the correlation between the
cognitive tests. Logistic regression analysis was used to iden-
tify 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, 1–56d), 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 deficits (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 significant 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 efficacy and
efficiency parameters showed a significant improvement, yet
Arch Phys Med Rehabil Vol 83, March 2002
344 COMPARATIVE COGNITIVE ASSESSMENT IN STROKE, Zwecker

Table 1: Clinical and Demographic Data of Patients Table 3: Pearson Correlation Matrix of Scores of Cognitive Tests
at Admission (n ⴝ 61)
N %
MMSE LOTCA FIM Cognitive
Patients 66
Gender (male/female) 49/17 74/26 MMSE 1.000
Previous stroke 10 15 LOTCA .588* 1.000
Clinical presentation FIM cognitive .666* .471* 1.000
Left hemisphere 34 52
* P ⬍ .001.
Right hemisphere 26 39
Other 6 9
Origin of stroke
Relation to FIM motor scores. After isolating the pure
Thrombotic 38 58
FIM motor from total FIM, the LOTCA correlated slightly
Hemorrhagic 15 22
better only with efficacy. Efficiency of the FIM motor could
Cardioembolic stroke 3 5
not be shown with any of the cognitive tests (table 4). How-
Other 10 15
ever, all 3 cognitive tests showed significant correlation with
the MRFS efficacy and FIM motor efficacy, with the highest
score for the LOTCA and FIM cognitive subscale. The MRFS
efficiency and FIM motor efficiency correlated poorly with all
the values of these parameters varied greatly among patients. 3 tests, especially with the LOTCA (table 4). No additional
This indicates a large intersubject variability concerning the effects of age, gender, or side of neurologic deficit were shown
patients’ potential for rehabilitation and ability to achieve their on parameters associated with better rehabilitation outcomes.
potential.
DISCUSSION
Cognitive Status
Early evaluation of the cognitive aspects in stroke patients
Admission MMSE scores were available for 61 patients; allows clinicians to identify the patients’ potential for rehabil-
their mean score was 22.8 points. Fifty-one percent of the itation and to set realistic plans for treatment. The design of this
patients showed cognitive decline (cutoff score ⱕ24). The comparative study helps to assess the specific role of each of
changes observed in the scores of both FIM cognitive and the 3 cognitive tests commonly used by stroke rehabilitation
LOTCA, from admission to discharge, were small (3.4 and 6.4, specialists and their ability to predict functional outcome at
respectively, ⫾ 0.5 standard deviations [SDs]) yet statistically discharge after rehabilitation.
significant. Results are summarized in table 2. Both physical and cognitive functional improvement was
shown by the majority of the patients, as reflected in total FIM,
Correlation Between Cognitive Tests
FIM motor, and all 3 cognitive test scores. Moreover, correla-
Analyses of the correlation coefficients (Pearson correlation) tion coefficients of these cognitive tests ranged between .47
of the 3 cognitive tests resulted in values ranging from .47 to and .67, which means that they share a reasonable degree of
.67 (table 3), which were all statistically significant. Admission resemblance and accounts for their construct validity.
scores of FIM cognitive subscale correlated better with MMSE Results of the correlation among the cognitive tests are not
than with LOTCA scores. surprising given the differences in the nature of the tests. The
The Pearson correlations of admission LOTCA were higher evaluation of the cognitive abilities needed for optimal func-
with the MMSE and lower with the FIM cognitive subscale, yet tioning in ADLs is quite complex.13 There is a controversy
both were significant (P ⬍ .001). among clinicians about which category is the most important
and which cognitive deficit has the greatest impact on maximal
Relation Between Cognitive Status and Functional functioning. It is assumed that more global cognitive function,
Outcome rather than narrow aspects of neuropsychologic function, pre-
Relation to total FIM scores. We found significant posi- dominantly affects daily behavioral status.16
tive associations between cognitive status at admission and Each test used assesses general cognitive function, yet dif-
some of the functional gain parameters. As a cognitive status fers from the others. In fact, the LOTCA was originally de-
measure, the LOTCA correlation coefficients were higher than signed to assess basic cognitive abilities, which are defined as
the MMSE and FIM cognitive subscale, with regard to total those “intellectual functions thought to be prerequisites for
FIM efficacy and efficiency and MRFS efficacy, but slightly managing every day encounters with the environment.”14 In
lower for MRFS efficiency. Correlation between the MMSE or contrast, both the MMSE and FIM cognitive subscale are less
FIM cognitive subscale and these outcome parameters were comprehensive than the LOTCA with regard to the detection of
practically identical. cognitive abilities associated with the performances of ADLs.

Table 2: Functional and Cognitive Test Scores During Inpatient Rehabilitation

Cases Admission Discharge Change

Test (N) (mean ⫾ SD) (mean ⫾ SD) (mean ⫾ SD) P*

Total FIM 66 61.5 ⫾ 19.9 96.3 ⫾ 24.1 34.8 ⫾ 20.3 ⬍.001

FIM motor 66 37.6 ⫾ 14.9 69.1 ⫾ 19.1 31.5 ⫾ 17.9 ⬍.001
FIM cognitive 66 23.9 ⫾ 8.4 27.2 ⫾ 7.1 3.4 ⫾ 4.7 ⬍.001
LOTCA 44 66.3 ⫾ 13.5 72.7 ⫾ 13.7 6.4 ⫾ 11.1 ⬍.001
MMSE 61 22.8 ⫾ 5.2

* Analysis of variance with repeated measures.

Arch Phys Med Rehabil Vol 83, March 2002

 COMPARATIVE COGNITIVE ASSESSMENT IN STROKE, Zwecker 345

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