Association Between 2 Measures of Cognitive Instrumental Activities of Daily Living and Their Relation to the Montreal Cognitive Assessment in Persons With Stroke.

OBJECTIVES: To explore the relation between a computer adaptive functional cognitive questionnaire and a performance-based measure of cognitive instrumental activities of daily living (C-IADL) and to determine whether the Montreal Cognitive Assessment (MoCA) at admission can identify those with C-IADL difficulties at discharge. DESIGN: Prospective cohort study. SETTING: Acute inpatient rehabilitation unit of an academic medical center. PARTICIPANTS: Inpatients (N=148) with a diagnosis of stroke (mean age, 68y; median, 13d poststroke) who had mild cognitive and neurological deficits. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Admission cognitive status was assessed by the MoCA. C-IADL at discharge was assessed by the Executive Function Performance Test (EFPT) bill paying task and Activity Measure of Post-Acute Care (AM-PAC) Applied Cognition scale. RESULTS: Greater cognitive impairment on the MoCA was associated with more assistance on the EFPT bill paying task (ρ=-.63; P<.01) and AM-PAC Applied Cognition scale (ρ=-.43; P<.01). This relation was nonsignificant for higher MoCA scores and EFPT bill paying task scores. The AM-PAC Applied Cognition scale and the EFPT bill paying task had low agreement in classifying functional performance (Cohen's κ=.20). A receiver operating characteristic curve identified optimal MoCA cutoff scores of 20 and 21 for classifying EFPT bill paying task status and AM-PAC Applied Cognition scale status, respectively. For values above 20 and 21, sensitivity increased whereas specificity decreased for classifying functional deficits. Approximately one third of the participants demonstrated C-IADL deficits on at least 1 C-IADL measure at discharge despite having a MoCA score of ≥26 at admission. CONCLUSIONS: Questionnaire and performance-based methods of assessment appear to yield different estimates of C-IADL. Low MoCA scores (<20) are more likely to identify those with C-IADL deficits on the EFPT bill paying task. The results suggest that C-IADL should be assessed in those who have mild or no cognitive difficulties at admission.

The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute stroke: relationship to functional outcome.

OBJECTIVES: To compare Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) global and subscores in classifying cognitive impairment in persons with mild stroke and to explore the relationship between admission and discharge functional status and improvement. DESIGN: Retrospective analysis of data. SETTING: Acute rehabilitation unit of a large urban university-affiliated hospital. PARTICIPANTS: Inpatients with stroke (N=72; mean age, 70y; median time poststroke, 8.5d) and mild neurologic (median National Institutes of Health Stroke Scale score, 4) and cognitive deficits (median MMSE score, 25). INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Admission cognitive status was assessed by using the MMSE and MoCA. The motor subscale of the FIM instrument (mFIM) and motor relative functional efficiency was used to assess discharge functional status and improvement. RESULTS: The MoCA classified more persons as cognitively impaired than the MMSE (89% vs 63%, respectively; using a cutoff score of 27 on the MMSE and 26 on the MoCA). The MoCA also showed less of a ceiling effect than the MMSE, higher internal reliability (Cronbach α=.78 compared with α=.60), and marginally stronger associations with discharge functional status (r=.40; P<.001) than the MMSE (r=0.30; P<.05). The MoCA visuoexecutive subscore was the strongest predictor of functional status (P=.01) and improvement (P=.02) in global and subscores for both tests. CONCLUSIONS: The MoCA may be an important cognitive screening tool for persons with stroke and mild cognitive dysfunction on an acute rehabilitation unit. Lower visuoexecutive subscores may assist in identifying persons at risk for decreased functional gains in self-care and mobility (mFIM) during inpatient rehabilitation. The findings justify further validation studies of the MoCA in persons with subacute stroke.