RELATIONSHIP BETWEEN COGNITIVE DEFICITS AND THE ABILITY TO PERFORM THE ACTIVITIES OF DAILY LIVING IN STROKE PATIENTS

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1 The Indian Journal of Occupational Therapy : Vol. XXXVII : No. 1 (April'05 - July 05) RELATIONSHIP BETWEEN COGNITIVE DEFICITS AND THE ABILITY TO PERFORM THE ACTIVITIES OF DAILY LIVING IN STROKE PATIENTS SP Mokashi, MOT Swami Vivekanand National Institute of Rehabilitation Training & Research, Cuttack Abstract : Although a stroke patient frequently displays congnitive impairment and decreased functional independence, the relative impact of impaired cognition on functional independence is un clear. Objective of the study was to determine whether cognitive impairments are related to functional independence in stroke patients. Subjects were screened initially with "MINI MENTAL STATUS EXAMINATION" (MMSE) to find out if there existed any cognitive deficit among them. Out of 23 subjects, 17 subjects, with 12 males and 5 females, were found to have cognitive deficits. Each subject was then interviewed regarding the activities of daily living using a FUNCTIONAL INDEPENDENCE MEASURE AND FUNCTIONAL ASSESSMENT MEASURE (FIM + FAM) UK version They were scored accordingly. To find out which cognitive component influences the performance of ADL, 5 subjects were assessed using LOEWEINSTEIN OCCUPATIONAL THERAPY COGNITIVE ASSESSMENT (LOTCA) and scored accordingly. All scores were then statistically analyzed to find out the relationship. It was found that the scores of motor FIM depend on the scores of cognitive FAM, LOTCA and MMSE. It can be concluded that the performance of ADL (activities of daily living) depends on the cognitive skill in stroke patients. INTRODUCTION Stroke is the leading cause of death and most common cause of chronic disability. The primary cognitive capacities of orientation, attention and memory largely reflect the neuroanatomical and physiological integrity of brain (Radomski, 1998) 8. They are thought to be prerequisite to higher level of thinking abilities and to influence metaprocessing. Changes in primary cognitive capacities are seen in many recipients of occupational therapy services. Stroke and traumatic brain injury (TBI) often results in problem with attention, memory and language (Capruso & Levin 1992; Hochstenbach et al 1998) 1. The presence of cognitive impairment in patients with stroke has important functional consequences, independent of the effect of physical impairment (Tatemichi et al, 1994) 16. Cognitive functions and motivation are strong predictors of functional Place of Study : SVNIRTAR, Cuttack Period of Study : Correspondence : Dr. S.P. Mokashi Asstt. Prof. & Head Department of Occupational Therapy Swami Vivekanand National Institute of Rehabilitation Training & Research, Olatpur, P.O.: Bairoi, Dist: Cuttack, Orissa Tel. : (0671) (O), (0674) (R) sunilmokashi@yahoo.com The recipient of Kamla V. Nimbkar Trophy for the Best Scientific Paper presented in 42nd Annual National Conference of AIOTA at Hyderabad, in March outcome in terms of activities of daily living (Sinyor 1986 & Grotto, 1998) 4. Kathleen et al 1998) 8 found that cognitive impairment can result in significant disability in all aspects of client life: self-care; independent living skills; work; leisure; social and interpersonal skills. The cognitive impairment was a major reason for dressing difficulties in stroke patients (Walker et al, & Walker et al, 2004) 19. The level of orientation influences Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) and social activities in acute as well as chronic stroke patients (Pedersen et al, 1996) 14. Recent studies (Maeshima et al & Pedersen et al ) state that there is no direct relationship between cognitive skills and performance of activities of daily living. Hence the relative impact of impaired cognition on functional independence is unclear. This lack of clarity is partly a result of the perception that major cognitive impairments experienced by the individuals with stroke may not be represented in the various scales of functional independence and that measures of cognitive impairments may not actually act as indicators of functional disability. The current study was designed to help determine whether cognitive impairments are related to functional independence in stroke patients. It is an early response to the perceived need to determine whether measures of cognitive impairments actually reflect disturbances in functional status in a specific patient population. 3

2 There are several reasons why this study has a clinical relevance. First, as many as two-thirds of all patients with severe brain injury experience cognitive losses. Second, because the expressed goal of rehabilitation is to increase patient s independence and document progress in rehabilitation as measured by different functional status scales e.g. Functional Independence Measure (FIM), it seems reasonable to investigate the relationship between impaired cognition and functional status. Third, if cognition has a significant relation to motoric functional independence, then perhaps this awareness would lead to more precise clinical intervention that uses the each patients s relative cognitive strengths to remediate specific functional deficits. Fourth, if cognition has a significant relationship with functional independence, then future research can investigate whether any specific variable has particular relevance in predicting eventual functional independence. Fifth, knowledge regarding the relationship between cognitive impairment as measured by Loweinstein Occupational Therapy Cognitive Assessment (LOTCA) and functional abilities (as measured by FIM) can contribute to our knowledge of both these clinical scales that are used in rehabilitation settings to rate the patients competence in behavioral tasks. METHODS The study was conducted in the Department of Occupational Therapy, at National Institute of Rehabilitation Training and Research to find out the relationship between cognitive deficits and ability to perform activities of daily living. Subjects were selected randomly for the study. The concerned Physician/Surgeon referred all the subjects to Occupational Therapy Department. Inclusion Criteria: Subjects with : Cerebro-Vascular Accident (CVA) both due to hemorrhage & infarction. the age group of 20 and above. both sexes (males & females). involvement of either hemisphere. sub-acute and chronic stage. aphasia were also included. homonymous hemianopsia were also included. Exclusion Criteria: Subjects with : CVA due to traumatic brain injury. brain tumors associated with CVA. infectious brain diseases like malaria & meningitis etc. identified orthopedic problem (e.g. osteoporosis, OA, RA, fracture and shoulder subluxation/dislocation) double stroke. acute TIA. Procedure: The subjects gave their consent before they participated in the study. They were screened initially with MINI MENTAL STATUS EXAMINATION (MMSE) to find out if there existed any cognitive deficit among them. Out of 23 subjects, 17 subjects, with 12 males and 5 females, were found to have cognitive deficits (mean age group ± 43 years for males and ± 57 years for females). Each subject was then interviewed regarding the activities of daily living using a FUNTIONAL INDEPENDENCE MEASURE AND FUNTIONAL ASSESSMENT MEASURE (FIM+FAM) UK version 1.1. They were scored accordingly. Since the investigator had a keen interest to find out which cognitive component influences the performance of ADL, 5 subjects were assessed using LOEWEINSTEIN OCCUPATIONAL THERAPY COGNITIVE ASSESSMENT (LOTCA) and scored accordingly. All scores were then statistically analyzed to find out their relationship. All the assessments were done within 2 days of reporting to the Department of Occupational Therapy. Instruments used: Functional Independence Measure and Assessment Measure (FIM+FAM), UK Version 1.1, (Fig.1), Mini Mental Status Examination (MMSE), (Fig.2) and Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), 2nd edition, (Fig.3(a) & (b)). Fig. 1 4

3 Fig. 2 Fig. 3(a) Fig. 3(b) RESULTS & DISCUSSION Data of 17 subjects, which include 12 males with the mean age group of ± 43 years and 5 females with the mean age group of ± 57 years was analyzed using SPSS 11 Chicago inc, can be seen in Table 1. There was no significant difference in motor and cognitive score between younger age group and older age group. This contrast with the finding reported by Kaplan & Hier (1982) 3 and Patel et al (2002) 12, but compatible with the findings of Van Ravensberg et al (1984) 3 & Katz et al (1999) 7. Comparison between right and left hemisphere (male subjects) can be seen in Table 2. There was no significant difference in motor scores between right and left hemisphere male subjects, except for locomotion, which is significant at p<0.05. Whereas the cognitive score of FAM and MMSE showed significant difference at p<0 & p<0.05. The comparison between right and left hemisphere female subjects can be seen in Table 3 there was no significant difference between motor scores of FIM and cognitive score of FAM but there was significant difference between MMSE scores of right and left hemisphere female subjects with p<0.05. Table 4 shows the comparison between male and female subjects. There was a significant difference in mobility among male and female subjects with p=0, whereas there was no significant difference among other components of motor FIM, Cognitive FAM and MMSE. Comparison between left hemisphere and right hemisphere stroke subjects with both male and females can be seen in Table 5. Except for mobility, there was significant difference in both motor FIM, Cognitive FAM and MMSE between hemispheres with p<0.05 and p<0. This was in contrast with the findings reported by Sharon et al (1995) 1. The probable reason for this might be that the deficits in spatial and constructional abilities are more severe and more frequent in patients with Right Cerebro Vascular Accident (RCVA) than in patients with Left Cerebro Vascular Accident (LCVA) Heilman & Valenstein (1993) 5. Fordyee (1971) 3 and Sergent (1984) 2 found that the subjects with right hemisphere damage also showed loss of spatial relation in functional task. This might have accounted for the difference in this study. The cognitive FAM, MMSE and LOTCA were used to assess the cognitive functions among subjects with stroke. There were no surprising results between 3 assessment scales in assessing cognitive functions. These findings are consistent with the findings of Zwecker et al (2002) 4. The evaluation of the cognitive abilities needed for optimal functioning in ADL is quite complex (Carter et al 1988) 2. There is a controversy among clinicians about which category is the most important and which cognitive deficit has a greater impact on maximal functioning. It has been assumed that more global cognitive functions, rather than the narrow aspects of neuro-psychologic functions predominantly affect the daily behavioral status (Osmon et al 1992) 4. Correlation between cognition and ADL can be seen in (Table 6). There was a positive correlation between cognition and ADL with significance of p<0. This contrasts with the 5

4 Table 1 Descriptive Statistics Components N Range Minimum Maximum Sum Mean Std. Dev. Std. Error Self care Sphin/control Mobility Locomotion Communication Social Cognition MMSE* * Mini Mental Status Examination Table 2 Comparison between Right Hemisphere and Left Hemisphere in Male Subjects. Components Mean Mean Z te # Mini Mental Status Examination, *significance at p<0.05, **significance at p<0, *** Significance Positive at rank p< rank 0.001(2-tailed). Negative rank rank Self care 2.75 (2) 5.08 (6) Table 3 Self care 8.30 (10) (12) -1.4 Sphincter Control 4.33 (3) 6.00 (7) Comparison between right and left hemisphere Sphincter Control in female subjects (10) (13) -1.5 Mobility 1.00 (1) 2.50 (2) Mobility 2.00 (1) 3.25 (4) -1.5 Locomotion 2.00 (1) 2.67(3) Locomotion 0.00 (0) 3.50 (6) -2.2 Communication 2.00 (1) 3.80 (5) Communication 5.20 (5) 5.80 (5) -0.1 Social cognition 5.83 (3) 6.72 (9) Social cognition (9) (21) -2.5 MMSE# 4.33(3) 7.22(9) MMSE# (1) 12.46(23) -3.9 findings reported by Pedersen et al (2001) 13 & Maeshima et al (1997) 10, but compatible with the findings reported by Kaplan & Corrigan (1994) 6 and Kizony & Katz (2002) 9. # Mini Mental Status Examination, * significance at p <0.05 (2-tailed). to learn the compensatory strategies. Cognition affects learning of compensatory strategies. Walker et al (2004) 19 in the recent has supported this finding. As part of Occupational Therapy intervention for the 17 subjects, who participated in the study, compensatory strategies were taught to subjects to find out their learning skill. The subjects who had cognitive problem were unable It was not possible to correlate cognitive components of different scales with each ADL subset in detail because of the varied n size after removal of ceiling scores. Correlation between components of cognitive skills and components of 6

5 Table 4 Comparison between Male and Female Subjects. # Mini Mental Status Examination, * significance at p <0.05 (2-tailed). Table 5 Comparison between Right and Left Hemisphere in Both Male and Female Subjects. # Mini Mental Status Examination, *significance at p <0.05, **significance at p<0(2-tailed) Table 6 Correlation between Cognitive Skills and Activities of Daily Living Spearman s rho Self care N Mini Mental Status Examination N Self care ** 85 ** Correlation is significant at the p<0 (2-tailed). Mini Mental Status Examination.788** activities of daily living can be seen in (Table7). The orientation correlated positively with motor FIM among all subjects except one, with significance of p<0. This has been supported by the findings of Tatemichi et al (1994) 16. The visual perception correlated with self care with significance of p<0 and p<0.05 respectively in all subjects. Correlation between visual perception and sphincter control was seen only in two subjects with the significance of p<0.05 and p<0 respectively. The visual perception correlated with mobility with most of the subjects except one, the level of correlation was significant at p<0. The visual perception correlated with locomotion with most of the subjects except one, the level of correlation was significant at p<0. The above findings have been supported by the studies of Scherzer et al (1993) 6. This study has found the evidence to support two dissociable types of abstract cognitive abilities in performance of individuals with brain injury. These two types of abstract cognitive abilities are verbal and visual perceptual. Individuals with brain injury need visual perceptual cognitive ability for safe and independent ambulation, this is in accordant with Rapport et al (1993) 15 &Walker & Lincoln (1991) 17. There was a positive correlation between spatial perception and self-care with the significance of p<0, whereas the spatial perception had no correlation with sphincter control among most of the subjects except one who had a positive correlation with significance of p<0. The mobility and locomotion correlated well with the spatial perception among all subjects with significance of p<0. This has been strongly supported by findings of Holmen et al (1993) 5. He stated that visuo-spatial impairments are strongly related to poor functional outcome in stroke rehabilitation and recovery. Lorenze and Cancro (1962) 2 established a strong correlation between Components visuo-spatial perception Mean and U both test dressing Significance and Right Left personnel hygiene skills. Diller et al (1976) 2 have found the hemisphere hemisphere positive correlation (10) between (7) perception and feeding performance. Self care * Sphincter Control * The motor praxia correlated well with the self-care and Mobility mobility Locomotion among all subjects with 6.14 the significance of.028* p<0. Locomotion Communication had a positive correlation with motor.009** praxia among Social cognition most of the 9.80 subjects with 7.86 the significance of.415 p<0 except MMSE# one subject subjects 6.14 correlated well with.009** motor praxia in sphincter control with the significance of p<0 but 2 subjects had no correlation among them. This result contrasts with the finding reported by Pedersen (2001) 13 but resembles with the findings of Warren (1981) 20 ; Baum &Hall (1981) 1 ; Lorenze and Cancro (1962) 2 ; Neistadt (1993) 1. Visuomotor component correlated with self-care in 3 subjects of which 2 subjects had a significance of p<0.05 and one subject had a significance of p<0. Sphinter control correlated with visuomotor skills only in 3 subjects with the significance of p<0.05. Mobility and locomotion correlated well among most of the subjects with the significance of p<0 except one who had no correlation. Thinking operation correlated well with self-care in 4 7

6 Table 7 Correlation between Components of Cognitive Skills with components of Activities of Daily Living (ADL) Components P1 P 2 ñ Sig. ñ Sig. Orientation self care - - Orientation sphincter control - - Orientation - mobility - - Orientation locomotion - - Visual perception self care.008 Note: P1: patient 1, P2: patient 2, P3: patient 3, P4: patient 4, ñ: Spearman s rho correlation test, sig.:.05 denotes p<0.05& sig.: denotes p<0, Visual perception sphincter control 2.05 (-) denotes there was no significant correlation. subjects. Among them, 3 subjects had a significance of Visual perception - mobility - - the Indian population, (c) LOTCA assessment was done only p<0.05 and one subject had a significance of p<0. The Visual on five perception subjects, locomotion and (d) There was no - post hoc - analysis. sphincter control correlated with thinking operation only in Spatial perception- self care 2 subjects with the significance of p<0.05, whereas mobility RECOMMENDATIONS Spatial perception - sphincter control and locomotion correlated with thinking operation in 3 Spatial The perception further -mobility research can be done with larger sample size, subjects with significance of p<0. Spatial which perception would -locomotion permit study of potential relationship There was a significant difference among the LOTCA scores Motor among praxia - variables. self care between RCVA and LCVA. There was also difference among Motor praxia - sphincter control - - The post hoc analysis can be done to find out the impact the scores of younger stroke subjects with older stroke Motor of praxiacognition mobility on performance of activities of daily living. subjects on LOTCA assessment. These findings are Motor praxia - locomotion - - supported by Patel et al (2002) 12. Visuomotor The research self-care can also be done to.030 find out.05 which among - - The following are the limitations of the study: (a) Low sample Visuomotor the cognitive - sphincter scales control are easier, 5 require.05 less time 6 and.05 efficient in measuring cognitive function. size, (b) None of the assessment scales was standardized on Visuomotor - mobility - - Visuomotor - locomotion - - IJOT : Vol. XXXVII : No. 1 8 Thinking operation -self care April July Thinking operation sphincter control Thinking operation- mobility - - Thinking operation -locomotion - -

7 CONCLUSION It has been shown that the scores of motor FIM depend on the scores of cognitive FAM, LOTCA and MMSE. It is concluded that the performance of ADL depends on the cognitive skill in stroke patients. This can be an advantage in view of the ever-decreasing length of stay for patients in acute care and rehabilitation settings. ACKNOWLEDGEMENTS I would like to thank all the clients who participated in this study. I am grateful to Dr. B. M. Pradhan, Director, S.V. National Institute of Rehabilitation Training and Research (SVNIRTAR) and for his encouragement and support as well as for his kind permission to carry out this study at SVNIRTAR. I gratefully acknowledge the guidance and support I received from my guide Dr. M.G. Deo, Ex-Director, O.T. School and Centre at Nagpur. I extend my thanks to all faculty, staff and students of SVNIRTAR. REFERENCES 1. Radomski MV (2001). In Occupational Therapy for Physical Dysfunction. Trombly C. and Radomski ME (Eds). Fifth Edition: Lippincott Williams and Wilkins.2001: Carter L.T et al (1988). The Relationship of Cognitive Skills Performance to Activities of Daily Living in Stroke Patients. American Journal of Occupational Therapy.1988: 42 (7), Su CY, Chien TH, Cheng KF, Lin YT. Performance of Older Adults with and Without Cerebrovascular Accident on the Test of Visual Perceptual Skills. American Journal of Occupational Therapy.1995: 49 (6), Zwecker M et al Mini Mental State Examination, Cognitive FIM Instrument and the Loweinstein Occupational Therapy Cognitive Assessment: Relation to Functional outcome of Stroke Patients. Arch Phy Med & Rehabil.2002: 83, Suhr J, Grace J: Brief Cognitive Screening of Right Hemisphere Stroke: Relation to Funtional Outcome. Arch Phy Med Rehabil.1999: 80, Kaplan CP & Corrigan JD. Relationship between Cognition and Funtional Independence in Adults with Traumatic Brain Injury. Arch Phy Med & Rehabil. 1994:75, Katz N.et al. Funtional Disability and Rehabilitation outcome in Right Hemisphere Damaged Patients with and without Unilateral Spatial Neglect. Arch Phy Med & Rehabil.1999: 80 (4), Kathleen M., Golisz &Toglia JP. In Willard and Spackman s Occupational Therapy, 9 th edition. Neistadt ME, Elizabeth, Crepeau B (Eds). Lippincott Williams and Willkins.1998: Kizony R & Katz N. Relationships between Cognitive Abilities and the Process Scale and Skills of the Assessment of Motor And Process skills in Patients with Stroke. Occupational Participation and health. Spring.2002: 22(2) Maeshima S, et al. Funtional outcome following thalamic hemorrhage: Relationship between Motor and Cognitive Functions and ADL. Disability Rehabilitation.1997: 19 (11), Ozdemir F, et al. Cognitive Evaluation and Functional Outcome after Stroke. Am. J. Phys. Med. Rehabil.2001: 80(6), Patel MD et al. Cognitive Impairment after Stroke: Clinical Determinants and its Association with Long Term Stroke Out come. J.AM. Geriatr Soc.2002: Apr; 50(4), Pedersen PM et al. Manual and Oral Apraxia in Acute Stroke, Frequency and Influence on functional outcome: The Copenhagen Stroke Study. Am.J. Phys. Med. Rehabil.2001: 80 (9), Pedersen Pm et al. Orientation in the Acute and Chronic Stroke Patients: Impact on ADL and Social Activities. The Copenhagen Stroke Study. Arch Phy Med & Rehabil.1996: 77(4), Rapport LJ et al. Predictors of fall among Right-Hemisphere Stroke Patients in the Rehabilitation Settings. Arch Phy Med & Rehabil.1993: 74(6), Tatemichi Tk et al. Cognitive Impairment after Stroke: Frequency Pattern and Relationship to Functional Abilities. J. Neurol Neurosurgery Psychiatry.1994: 57 (2), Walker MF & Lincoln NB. Factors influencing dressing performance after stroke. J. Neurol Neurosurg psychiatry.1991; 54(8): Walker CM et al. Dressing after a Stroke: A survey of Current Occupational Therapy Practice. British Journal of Occupational Therapy.2003: 66(6) Walker Cmet al. The Impact of Cognitive Impairment on Upper Body Dressing Difficulties after Stroke: A Video Analysis of Patterns of Recovery. J. Neurol Neurosurg psychiatry. 2004:75 (1), Warren M. Relationship of Constructional Apraxia and Body Scheme Disorders in Dressing Performance in Adult CVA. American Journal of Occupational Therapy.1981: 35(7):