Archives of Gerontology and Geriatrics

35 (2002) 153160
www.elsevier.com/locate/archger

Clock drawing task, mini-mental state

examination and cognitive-functional
independence measure: relation to functional
outcome of stroke patients
A. Adunsky a,b,*, Y. Fleissig c, S. Levenkrohn c, M. Arad a,
S. Noy a,b
a

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

* Corresponding author. Tel./fax: + 972-3-530-3411.

E-mail address: eadunsky@hotmail.com (A. Adunsky).
0167-4943/02/$ - see front matter 2002 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 1 6 7 - 4 9 4 3 ( 0 2 ) 0 0 0 1 8 - 3

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A. Adunsky et al. / Arch. Gerontol. Geriatr. 35 (2002) 153160

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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155

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).

2.3. Assessment of cogniti6e status

Cognitive status was assessed by the MMSE, cognFIM and the CDT. The tests
were carried out by occupational therapists familiar and experienced with these
tests, between 24 and 72 h after admission. The MMSE (Folstein et al., 1975) is a
well-established reliable valid and brief cognitive screening instrument that has high
inter-rater reliability and is easy to administer. The instrument has standardized
instructions takes a mean of 10 min to administer and examines the attention
memory (orientation, recall of wards, recognition of sentences and drawings, and
initiation and maintenance of verbal and motor responses). Individual points are
assigned to the subscales with a total score of 30 points representing optimal
performance. Cognitive impairment is defined according to the standard cutoff as a
score that is either equal or below 24 points.
The cognFIM (Lincare et al., 1994) is composed of five cognitive items. Each of
these items consists of seven levels ranging from one point (total dependence) to
seven points (total independence). The range of scoring for the cognitive subscales
is five to 35 points. The test is composed of communication (comprehension and
expression) and social cognition (social interaction, problem solving and memory)
with 35 points representing optimal performance.
A third tool that we used was the CDT. This test is used not only for the
evaluation of visuospatial and praxis impairments but may also serve to detect
attention and executive dysfunction, reflecting different patterns of cognitive deficits
among demented and intact elderly. As such, it is considered as a valuable screening
tool for cognitive impairment. Subjects were presented with a pre-drawn circle and
were instructed to write in the numbers and set the time at 10 min after eleven. We
used a scoring system as suggested by Sunderland et al. (1989)

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2.4. Functional assessment

The patients were evaluated within 3 days of admission by the rehabilitation
team, according to FIM index (Granger and Hamilton, 1992), which is a standardized method of measuring the level of physical independence. FIM data were
documented at admission and upon discharge. The dependent outcome variables
that were examined included: (1). Absolute efficacy and absolute efficiency. (2).
Relative efficacy and relative efficiency (see Appendix A). The relative parameters
reflect the gain relative to the patients specific potential for change. For this
purpose we have used the Montebello score (Drubach et al., 1994) as it overcomes
the misinterpretation caused by the ceiling effect (the fact that the gain, which
patients with high admission scores can achieve, is limited compared to those with
low admission scores).

2.5. Statistical methods

The data were analyzed using BMDP statistical software (1990). Means and
standard deviations of the variables were calculated. We calculated Pearsons
correlation coefficients between the parameters. ANOVA with repeated measures
was used to evaluate the improvement between admission and discharge parameters. A P-value of 50.05 was considered as significant.

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.

3.2. Functional outcome

In the total study group, statistically significant increase in total FIM scores
(24.09 15.0, PB 0.001) occurred during rehabilitation (Table 2), similar to the
increase in motor FIM scores (21.39 13.2, PB0.001), suggesting that this change
in total FIM was contributed mostly by motor FIM scores. Overall, the results of
relative efficacy and efficiency are reasonable in terms of the daily clinical doing.
Yet, they have varied greatly among patients, indicating a large inter-subject
variability concerning the patients potential for rehabilitation.

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157

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

Cognition (mean 9 SD)

Clock drawing task
MMSE
CognFIM

5.5 9 3.3
22.0 95.5
25.5 97.6

3.3. Cogniti6e status

Results were available for all 151 patients. Mean admission MMSE was 22.1
points, with 48.7% of the patients exhibiting cognitive declines (score 24 or lower).
Mean scores of cognFIM and CDT were 25.5 and 5.5, respectively. Correlation
coefficients (Pearson correlation) between these three cognitive tests resulted in
values ranging from 0.51 to 0.59 (Table 3) which were all statistically significant.
The best inter-test correlation existed between CDT and MMSE. Admission scores
of cognFIM had a slightly higher correlation with MMSE than with clock drawing
task scores. The lowest correlation coefficient was found between drawing task
scores and cognFIM.

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.

3.4. Relationship between cogniti6e status and functional outcome

Some significant correlations were observed between cognitive status at admission and most of the functional gain parameters (Table 4). A significant correlation
exists between both CDT and MMSE to parameters of motor improvement, both
absolute and relative. CDT ad MMSE resulted similarly, none better or worse than
the other. In contrast, cognFIM correlated only with relative parameters. No effect
of age, gender or type of stroke was demonstrated on parameters associated with
better rehabilitation outcomes.
Using a stepwise logistic regression, we tried to predict success or failure in
relation to mean values of relative efficacy or efficiency (B 50% or \ 50% of mean
value of relative efficacy and efficiency), but could show no significant predictive
power of either MMSE and cognFIM or CDT. Moreover, the addition of CDT to
MMSE did not improve the predictive power for functional outcome in terms of
success or failure.

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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159

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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Relati6e functional gain parameters:

Montebello efficacy (M-EFC)= EFC/126-FIM admission).
Montebello efficiency (M-EFCN) =M-EFC/length of stay.

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