Original research| Volume 98, ISSUE 11, P2280-2287, November 2017

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


      • Persons with stroke and Montreal Cognitive Assessment scores <20 at acute inpatient stroke rehabilitation admission are likely to have cognitive instrumental activities of daily living (C-IADL) deficits at discharge.
      • C-IADL should be screened in patients with stroke who have mild or no cognitive impairments on the Montreal Cognitive Assessment.
      • The Executive Function Performance Test bill paying task appears to be a good candidate for screening C-IADL in an inpatient rehabilitation setting.
      • Performance-based and questionnaire methods of assessing C-IADL provide different estimates of C-IADL.



      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.


      Prospective cohort study.


      Acute inpatient rehabilitation unit of an academic medical center.


      Inpatients (N=148) with a diagnosis of stroke (mean age, 68y; median, 13d poststroke) who had mild cognitive and neurological deficits.


      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.


      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.


      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.


      List of abbreviations:

      AM-PAC (Activity Measure for Post-Acute Care), AUC (area under the curve), C-IADL (cognitive instrumental activities of daily living), EFPT (Executive Function Performance Test), IADL (instrumental activities of daily living), MoCA (Montreal Cognitive Assessment), NIHSS (National Institutes of Health Stroke Scale), ROC (receiver operating characteristic)
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