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Analysis of cognitive status and its relationship with activities of daily living dependency: A cross-sectional study in stroke patients
Análisis del estado cognitivo y su relación con la dependencia en las actividades de la vida diaria: un estudio transversal en pacientes con accidente cerebrovascular
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Víctor Sanchez Silverioa,
Corresponding author
victorss34@hotmail.com

Corresponding author.
, Vanesa Abuín Porrasb, Isabel Rodríguez Costac
a Escuela de Ciencias Aplicadas a la Salud, Pontificia Universidad Católica Madre y Maestra, Santiago de los Caballeros, Dominican Republic
b Departamento de Fisioterapia, Universidad Europea de Madrid, Madrid, Spain
c Departamento de Enfermería y Fisioterapia, Universidad de Alcalá de Henares, Madrid, Spain
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Tables (3)
Table 1. Characteristics of the study population (n = 62).
Table 2. Description of cognitive status based on the MMSE and MoCA and on carrying out ADLs according to the Barthel Index (n = 62).
Table 3. Correlations between cognitive status based on the MMSE and the MoCA and carrying out ADLs according to the Barthel Index (n = 62).
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Abstract
Objective

To analyse cognitive status in relation to activities of daily living (ADL) dependency in stroke patients.

Methods

A cross-sectional study was carried out. The Mini Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) and the Barthel index were used to assess cognitive status and ADL, respectively. A Pearson and Spearman correlation was used considering the normality of the data in cognitive status.

Results

62 patients were evaluated. The most impaired domains were associated with writing and drawing in the MMSE (mean = 24.9 ± 4.1) and language, visuospatial/executive function, and memory in the MoCA (mean = 18.3 ± 5.6). The ADLs with most dependency on the Barthel index (mean = 78.1 ± 14.0) were eating, dressing/undressing, bathing, and going up and down stairs. On the other hand, the ADL dependency showed a correlation with the MMSE (Rho = 0.3) and the MoCA (r = 0.2). In addition, MMSE was correlated with activities including dressing/undressing (Rho = 0.3) and bathing (Rho = 0.3) and MoCA with transfer from chair to bed (r = 0.2).

Conclusions

The domains with the highest cognitive impairment were related to memory and visuospatial/executive function. The correlations reflect that stroke survivors with greater cognitive impairment show greater ADL dependency.

Keywords:
Stroke
Activities of daily living
Cognition
Barthel index
Mini Mental State Examination
Montreal Cognitive Assessment
Resumen
Objetivo

Analizar el estado cognitivo con relación a la dependencia en las actividades de la vida diaria (AVD) en pacientes con accidente cerebrovascular (ACV).

Métodos

Se realizó un estudio transversal. Se utilizó el Mini Mental State Examination (MMSE), el Montreal Cognitive Assessment (MoCA) y el índice de Barthel para valorar, respectivamente, el estado cognitivo y las AVD. Se utilizó una correlación de Pearson y Spearman, considerando la normalidad de los datos en el estado cognitivo.

Resultados

Se valoraron 62 pacientes. Los dominios de mayor deterioro se asociaron a la escritura y el dibujo en el MMSE (media = 24,9 ± 4,1) y al lenguaje, la función visuoespacial/ejecutiva y la memoria en el MoCA (media = 18,3 ± 5,6). Las AVD de mayor dependencia en el índice de Barthel (media = 78,1 ± 14,0) fueron comer, vestirse/desvestirse, bañarse y subir y bajar escaleras. Por otro lado, la dependencia en las AVD mostró correlación con el MMSE (Rho = 0,3) y el MoCA (r = 0,2). Además, el MMSE estuvo correlacionado con actividades que implican vestirse/desvestirse (Rho = 0,3) y bañarse (Rho = 0,3) y el MoCA con el traslado del sillón a la cama (r = 0,2).

Conclusiones

Los dominios con mayor deterioro cognitivo se relacionaron a la memoria y la función visuoespacial/ejecutiva. Las correlaciones reflejan que los sobrevivientes de ACV con un mayor estado cognitivo deteriorado muestran una mayor dependencia en las AVD.

Palabras clave:
Accidente cerebrovascular
Actividades de la vida diaria
Estado cognitivo
Índice de Barthel
Mini Mental State Examination
Montreal Cognitive Assessment
Full Text
Introduction

Stroke, or cerebrovascular accident (CVA), is a neurological condition of high prevalence and incidence in various countries.1 After a stroke, one of the main consequences that patients suffer is cognitive impairment.2 Studies have estimated that more than 50% of the patients with stroke may develop cognitive impairment.3 In addition, it has been suggested that the cognitive domains most frequently affected in this population are linked to attention, memory, language, visuospatial capacity and executive functions.2,4

Activities of daily living (ADLs) are a set of basic skills that a person should have in order to take care of her- or himself independently.5 These activities are divided into basic and instrumental ADLs. Basic ADLs are primary activities focused on self-care and the individual’s independent mobility (eating, using the toilet, bathing, getting dressed and walking); in contrast, instrumental ADLs are more complex activities that make an individual’s independence possible in a specific setting (household tasks, doing the shopping or handling finances).6,7 The capacity to carry out ADLs may be affected after a stroke.5 It has been estimated that from 25% to 74% of survivors of stroke require help with or are totally dependent when it comes to ADLs.8 Some studies have reported that the ADLs that are most difficult to recover after a stroke are linked to getting dressed, going up stairs and bathing.5 The evidence has also revealed that ADLs have a strong functional impact on patients with stroke.9

The cognitive status of patients with stroke may have a significant impact on their functional mobility and their functional results.10 The cognitive functions in these patients may even play an essential role in activities that contribute to human development, such as walking.11 Understanding that carrying out any activity may involve cognitive resources, it could be considered that the development in ADLs, following a stroke, could be related with cognitive status. Because of the functional framework that ADLs represent and the high prevalence of cognitive deterioration described in stroke, studying these relationships might offer help with the clinical approach to the patient with stroke. For that reason, the objective of this study was to analyse cognitive status in relation with dependence in ADLs shown by patients with stroke.

Methods

This is an analytical, cross-sectional study from a primary source. Patients with stroke that attended a rehabilitation centre (Dominican Republic) were recruited. A convenience, non-probabilistic sampling was used to select all the patients that fulfilled the following inclusion criteria during the January–September 2018 period: (a) a diagnosis of stroke, (b) age between 20 and 80 years, (c) attending the Adult Central Neurological Disorder unit at the centre selected, (d) ability to stand with or without technical help, and (e) understand and speak Spanish. The exclusion criteria were as follows: (a) presence of uncontrolled systemic disease unrelated to the stroke, (b) visual and auditory alterations, (c) history of peripheral nerve lesions, (d) antecedents of fractures and orthopaedic surgeries, and (e) being illiterate.

The processes of this research followed the Declaration of Helsinki and were approved by the Bioethics Committee of the Faculty of Health Sciences, belonging to the Mater y Magistra (Mother and Teacher) Pontifical Catholic University (Pontificia Universidad Católica Madre y Maestra in Spanish), with the identification of COBE-FACS-EXT-001-3-2016-2017. The patients interested in participating signed an informed consent approved by the previously-mentioned Ethics Committee. If the patient had any difficulties in taking autonomous decisions, the closest relative established his or her participation in our study. All data on the patients included were handled under conditions of confidentiality using numeric codes.

The main variables analysed were cognitive status, assessed by means of the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA), and ADL dependence, assessed using the Barthel Index.

The MMSE, created in 1975 to assess cognitive functions in patients with psychiatric disorders, was the first brief standardised test used as a global assessment of cognitive status.12 This test has 11 items that assess cognitive domains related to orientation in time and space (0−10 points), word registry and memory (0−3 points), attention and calculation (0−5 points), memory (0−3 points), naming objects (0−2 points), repeating phrases (0−1 point), understanding orders (0−3 points), reading phrases (0−1 point), writing phrases (0−1 point) and visuoconstructive drawing skills (0−1 point). The MMSE score ranges from 0 to 30 points; the lower scores would indicate worse cognitive status.13,14 Given that the scores on this assessment instrument are influenced by age and education, an established regulation that adds or subtracts a point in the final score depending on age and education of the individual evaluated was considered.14 It is worth mentioning that this test has been suggested for assessing cognitive status in patients with stroke.15

The MoCA was developed in 2005 to identify mild cognitive impairment and Alzheimer’s disease in older adults.16 This test (available at: www.mocatest.org) examines the following cognitive skills: visuospatial and executive functions (0−5 points), animal names (0−3 points), memory using words remembered (0−5 points), attention (0−6 points), language (0−3 points), abstraction (0−2 points) and orientation in time and space (0−6 points). The MoCA score ranges from 0 to 30 points; lower scores indicate a more unfavourable cognitive status. This test may be influenced by educational level; however, its pre-established rules offset this limitation by including 1 point in the final score for individuals that have 12 or more years of formal education.17 Using the MoCA in patients with stroke has been suggested; in addition, it has been catalogued as superior compared to the MMSE, given that it assesses the cognitive domains affected following a stroke in a more balanced manner.15

The Barthel Index was designed in 1965 to measure the evolution of subjects with neuromuscular processes in a hospital for chronic patients in Maryland (USA).18 Its principal objective is to assess ADLs in patients with disability. The popularity of this questionnaire for assessing basic ADLs in patients with stroke has been confirmed.19 The Barthel Index consists of 10 items that establish the individual’s dependence or independence in the following ADLs: eating (0−10 points), dressing and undressing (0−10 points), personal grooming (0−5 points), bathing (0−5 points), stool control (0−10 points), urine control (0−10 points), using the toilet (0−10 points), transfer to/from the bed/armchair (0−15 points), walking (0−15 points) and going up and down stairs (0−10 points). The total score lies in a range of 0−100 points; lower scores would indicate greater dependence in ADLs.20

We performed a descriptive analysis of each cognitive domain in the MMSE and MoCA and of each ADL in the Barthel Index. In the MMSE and MoCA cognitive domains, the mean score in percentages was extrapolated, with domains showing percentages lower than 50% of the maximum score being considered as high levels of cognitive impairment; this strategy has been used in previous studies.21 A Pearson correlation was established between cognitive status in the MMSE and MoCA and performance of ADLs according to the Barthel Index. Before this, a Kolmogorov-Smirnov test was performed to verify the normality of the MMSE and MoCA data. If these data distributions were not normal, the non-parametric equivalent related to the Spearman correlation was used. These tests were applied using the SPSS Version 23 statistical package, with the statistical significance of the P value established as P < 0.05.

ResultsCharacteristics of the population

During the recruitment period, 195 patients with neurological problems came to the centre. Of these, 134 corresponded to patients with stroke; 62 of this population were finally included in this study. Of the 72 patients with stroke excluded, 48 were incapable of standing, 11 were over 80 years old, 7 had another pathological condition parallel to the stroke, 4 presented visual problems, hearing problems or both, and 2 patients did not understand Spanish. The majority of patients included were male (53.2%), with a basic education (59.7%), stroke chronicity between 0 and 6 months (56.5%) and had the right side of the body affected (53.2%). These characteristics can be seen in Table 1.

Table 1.

Characteristics of the study population (n = 62).

Variable  Mean  Minimum and maximum  Standard deviation 
Sex
Male  33  53.2       
Female  29  46.8       
Age
≤55 years  31  50.0  56.6  20–80  12.6 
>55 years  31  50.0       
Education
Basic (1−8 years)  37  59.7       
Medium (9−12 years)  12  19.4       
Superior (≥13 years)  13  21.0       
Stroke chronicity
0−6 months  35  56.5  12.6  1–84  17.1 
> 6 months  27  43.5       
Body side affected
Left  29  46.8       
Right  33  53.2       

%: percentage; n: number of cases.

Description of cognitive status and ADLs

Table 2 shows the description of cognitive status based on the MMSE and MoCA, as well as the dependence in ADLs evaluated according to the Barthel Index. In the MMSE (mean = 24.9 / CI = 23.8–25.9), high levels of cognitive impairment were found in writing (47%) and drawing (42%). Other domains such as reading, as well as attention and calculation, were impaired, but less severely. In the MoCA (mean = 18.3/CI = 16.9–19.8), high levels of cognitive impairment were found in language (48.3%), visuospatial and executive functions (38.4%) and memory (37%). Although other domains such as abstraction and attention revealed impairment, it was less severe. In the Barthel Index (mean = 78.1/CI = 74.5–81.7), the activities with the greatest dependence were eating, dressing, bathing, and going up and down stairs.

Table 2.

Description of cognitive status based on the MMSE and MoCA and on carrying out ADLs according to the Barthel Index (n = 62).

Variable (score range)  Mean  CI 95%  SD  Minimum–maximum 
MMSE Global (0−30)  24.9  23.8–25.9  4.1    12–30 
Orientation in time and space (0−10)  8.4  8.0–8.8  1.6  84.4  0–10 
Registry of words (0−3)  2.9  2.8–3.0  0.4  98  0–3 
Attention and calculating (0−5)  3.6  3.2–4.0  1.6  73  0–5 
Memory (0−3)  2.4  2.2–2.7  0.8  82.6  0–3 
Naming (0−2)  2.0  2.0–2.0  0.0  100  2–2 
Repetition (0−1)  0.9  0.8–0.9  0.2  90  0–1 
Comprehension (0−3)  2.6  2.4–2.7  0.6  87  0–3 
Reading (0−1)  0.7  0.6–0.8  0.4  74  0–1 
Writing (0−1)  0.4  0.3–0.6  0.5  47*  0–1 
Drawing (0−1)  0.4  0.2–0.5  0.4  42*  0–1 
Global MoCA (0−30)  18.3  16.9–19.8  5.6    5–28 
Visuospatial and executive functions (0−5)  1.9  1.6–2.2  1.2  38.4*  0–5 
Naming (0−3)  2.6  2.4–2.7  0.6  87.6  0–3 
Attention (0−6)  3.0  2.5–3.5  1.8  51  0–6 
Language (0−3)  1.4  1.1–1.7  1.0  48.3*  0–3 
Abstraction (0−2)  1.4  1.2–1.6  0.7  73.5  0–2 
Memory (0−5)  1.8  1.4–2.3  1.7  37*  0–5 
Orientation in time and space (0−6)  5.1  4.9–5.4  1.0  86.5  0–6 
Global Barthel Index (0−100)  78.1  74.5–81.7  14.0    15–100 
Eating (0−10)  6.9  6.3–7.5  2.4    5–10 
Dressing and undressing (0−10)  6.5  5.8–7.2  2.8    0–10 
Personal grooming (0−5)  4.1  3.7–4.6  1.8    0–5 
Bathing (0−5)  2.9  2.3–3.6  2.4    0–5 
Stool control (0−10)  9.1  8.6–9.7  2.0    0–10 
Urine control (0−10)  9.5  9.0–10.0  1.9    0–10 
Using the toilet (0−10)  8.9  8.3–9.5  2.2    0–10 
Armchair/bed transfer (0−15)  12.3  11.6–13.0  2.8    5–15 
Walking (0−15)  12.0  11.2–12.7  2.9    0–15 
Going up and down stairs (0−10)  5.4  4.7–6.2  3.0    0–10 

%: percentage of the mean in reference to the maximum score for the cognitive domain; CI: confidence interval; MMSE: Mini-Mental State Examination; MoCA: Montreal Cognitive Assessment; SD: standard deviation.

*

A score lower than 50% indicates high levels of cognitive impairment.

Correlations between cognitive status and ADLs

Table 3 shows the correlations between cognitive status on the MoCA and MMSE and dependence in ADLs according to the Barthel Index. We found a direct correlation between the dependence in ADLs shown in the Barthel Index and the cognitive status revealed in the MMSE (Rho = 0.3) and MoCA (r = 0.2); lower scores in the MMSE and MoCA were correlated with lower scores in the Barthel Index. For ADLs in the Barthel Index, we found a direct correlation in the MMSE with the activities of dressing and undressing (Rho = 0.3) and bathing (Rho = 0.3). In the MoCA, we found a direct correlation with transferring to and from the bed/an armchair (r = 0.2).

Table 3.

Correlations between cognitive status based on the MMSE and the MoCA and carrying out ADLs according to the Barthel Index (n = 62).

  Cognitive status based on the MMSEa  Cognitive status based on the MoCAb 
Global Barthel Index  0.326**  0.294* 
Eating  −0.021  −0.064 
Dressing and undressing  0.305*  0.241 
Personal grooming  0.111  0.114 
Bathing  0.313*  0.200 
Stool control  0.209  0.193 
Urine control  0.098  0.097 
Using the toilet  0.153  0.198 
Armchair/bed transfer  0.177  0.251* 
Walking  0.159  0.210 
Going up and down stairs  0.212  0.176 

MMSE: Mini-Mental State Examination; MoCA: Montreal Cognitive Assessment; n: number of cases.

a

Spearman correlations.

b

Pearson correlations.

*

Statistically-significant correlation set to the value of P < 0.05.

**

Statistically-significant correlation set to the value of P < 0.01.

Discussion

In this study we analysed cognitive status on the MMSE and MoCA compared with dependence in ADLs based on the Barthel Index. Cognitive status is important in the patient with stroke, yet it is an element that does not receive any salience in the clinical setting.22 In this study, the domains with the greatest cognitive impairment in the MMSE were related to writing and drawing, although reading, as well as attention and calculation, also showed evidence of impairment. On the MoCA, we found a high level of cognitive impairment in language, visuospatial and executive functions and memory, while abstraction and attention also revealed impairment.

Other research on patients with stroke found very similar results in attention, memory, writing and drawing on the MMSE, but high levels of impairment were also found in visuospatial and executive functions and memory on the MoCA.21 Another study on acute patients followed the tendency of our study, although with respect to the MoCA, the results were more favourable (especially in the visuospatial function and language).23 We should point out that, in agreement with our study, the previous authors observed that memory was the domain with the greatest cognitive impairment on the MoCA,23 while other studies have confirmed this tendency on this test in memory and visuospatial and executive functions.3,24

An important matter is that the MoCA scores were more unfavourable compared with MMSE results. However, this might be explained by the fact that the MoCA has items focused on the cognitive domains affected after a stroke. The evidence indicates that, thanks to the detailed approach in these domains (especially with respect to the executive and visuospatial functions and memory), the MoCA may be superior to the MMSE in describing cognitive status after a stroke.15,25 In addition, just as in our work, the studies cited previously found these differences between the 2 cognitive tests, both in their global scores and in the cognitive domains.21,23,24

Within the Barthel Index, eating, dressing, bathing and going up and down stairs were the ADLs with the greatest dependence. A study with results similar to ours found low independence percentages in activities on the Barthel Index such as eating, going up and down stairs and bathing.9 Other authors, unlike this study, analysed basic and instrumental ADLs together and found that the activities most affected were going shopping, doing household tasks, using transport, mobility and bathing.4

Cognitive status can play an important role in performing ADLs. In our study, the MMSE and MoCA correlated with the Barthel Index. This indicates correlations an unfavourable cognitive status and greater dependence in ADLs in patients with stroke. Likewise, this tendency was confirmed on the MMSE with activities involving dressing and bathing, and on the MoCA with the activity related to transferring to/from the bed/armchair. These findings are comprehensible considering that carrying out ADLs requires not only motor components, but also cognitive demands that may be involved in ADL analysis, comprehension and learning.

For bathing, spatial orientation, executive function, memory and visuospatial function are needed to respectively recognise the space of the activity, plan the sequence to be performed in the activity, remember the motor patterns demanded by the activity, and mobilise the body parts in relationship to the bathtub and bath objects. In contrast, for getting dressed and undressed, a sequence has to be carried out to put on the garment, and visual-motor coordination of body movements related to the spatial setting and the garments to handle is also necessary. It has been suggested that independence for dressing/undressing and bathing, in addition to motor demands, requires adequate cognitive functions.9 This emphasises the relevance of the correlation shown in our work between cognitive status and the ADLs mentioned.

Several authors have examined the relationships between cognitive status and ADLs in patients with stroke. One study, which coincided with the results of the present work, verified the impact of cognitive impairment on ADLs when studying cognitive status in 75 patients by means of the MMSE, but assessing ADLs with the Katz Index and the Lawton Scale.4 In another study, assessing 185 patients with ischemic stroke in the acute stage and then later in a follow-up period, the authors observed that the cognitive impairment assessed using the MoCA was associated with greater difficulty in performing ADLs than that based on the Barthel Index.10 Furthermore, a study that including MMSE and MoCA results together in subacute patients indicated that good cognitive functions were very closely associated with a good functional result on a great part of the ADLs based on a modified Barthel Index, except for the activities referring to intestinal control and walking.26 These findings continue the line of our work with respect to the previously-mentioned ADLs that were among the most impacted in the Barthel Index.

The various elements that make up the structure of ADLs need, while carrying them out, the participation of specific cognitive domains in the patient with stroke. A study on 25 patients reflected in the MMSE minimum and moderate correlations, respectively, with basic and instrumental ADLs; in addition, the study revealed that memory in the MMSE cognitive test was associated with the performance of ADLs, especially instrumental activities.27 Along these lines, other authors confirmed moderate correlations among the Barthel Index, the MoCA and its domains related to visuospatial/executive functions; they also observed minimum correlations with memory and language.28

Memory and visuospatial/executive functions certainly seem to have an essential role in performing ADLs. This fact gains major relevance in our study, considering that the sample evaluated showed greater impairment in the cognitive domains mentioned earlier. Even several researchers that used more complex and reliable cognitive tests lend support to this same tendency. In their study on 166 patients, using a series of neuropsychological tests, the scientists found that the impairment to the executive functions and memory were associated to a poor functional result measured with the Barthel Index.29

You can see that a great part of the evidence follows our line of work in that correlations are reflected between cognitive status and dependence on ADLs. This tendency was seen in studies that used methodologies similar to ours, but also in studies using different scales to assess cognitive status and ADLs. The visuospatial and executive functions and memory were shown to be affected the most, although each specific MMSE and MoCA domain was not evaluated based on the ADLs. Nonetheless, the descriptive findings and the correlations found constitute a basis in the clinical context for evaluation purposes or therapy planning, as well as to continue studying ADLs, especially with the cognitive tests used in our study. In contrast to other complex tests, the MMSE and the MoCA are very feasible screening tests that can be applied reliably in short time periods by any rehabilitation professional. This finding, during routine clinical practice, could be of great interest for analysing the condition of dependence in the home of the patient with stroke by considering that patient’s cognitive status.

A limitation to this study is due to the reduced sample that underwent assessment. In future studies, the spectrum of the sample should be broadened, including patients from various centres in the evaluation. Along those lines, it is crucial for studies to include evaluations that enable us to verify the behaviour of cognitive status and ADLs in follow-up periods, using the MMSE, MoCA and Barthel Index. We also recommend analysing the cognitive domains of the MMSE and the MoCA on the basis of carrying out ADLs, as well as using regression models to visualise the predictive influence of cognitive status by means of these tests in ADL performance. We also suggest that instrumental ADLs should be added to these analyses; because instrumental ADLs are more complex, incorporating them would provide more specific information about how the patients are handling themselves in their homes.

To sum up, the cognitive domains related to the greatest impairment were associated to writing and drawing on the MMSE and to language, visuospatial and executive functions and memory on the MoCA. On the Barthel Index, the ADLs with the greatest dependence were related to eating, dressing and undressing, bathing and going up and down stairs. In addition, cognitive status assessed using the MMSE and MoCA was related to ADL dependence based on the Barthel Index. This is a clinical reflection of the fact that survivors of stroke with impaired cognitive status might show greater dependence in ADLs, especially in those linked to dressing/undressing, bathing and transferring to/from the bed/an armchair. Longitudinal follow-up studies, which include a greater sample, are need to provide more specific information to back these correlations between cognitive status and ADLs.

Funding

The authors received no specific economic backing for this study.

Conflict of interest

The authors have no conflicts of interest to declare.

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Please cite this article as: Sanchez Silverio V, Abuín Porras V, Rodríguez Costa I. Análisis del estado cognitivo y su relación con la dependencia en las actividades de la vida diaria: un estudio transversal en pacientes con accidente cerebrovascular. Rev Cient Soc Esp Enferm Neurol. 2021. https://doi.org/10.1016/j.sedene.2021.02.001

Copyright © 2021. Sociedad Española de Enfermería Neurológica
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