The online version of this article can be found at:
2008 22: 1095Clin Rehabil
Torgeir Bruun Wyller
Kjersti Nøkleby, Erik Boland, Hilde Bergersen, Anne-Kristine Schanke, Lasse Farner, Jørgen Wagle and
Screening for cognitive deficits after stroke: a comparison of three screening tools
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Clinical Rehabilitation 2008; 22: 1095–1104
Screening for cognitive deficits after
stroke: a comparison of three screening tools
Kjersti Nøkleby Department of Geriatric Medicine, Ullevaal University Hospital, Erik Boland Department of Neuropsychology,
Ullevaal University Hospital, Oslo, Hilde Bergersen Department of Brain Injury, Sunnaas Rehabilitation Hospital,
Anne-Kristine Schanke Department of Research, Sunnaas Rehabilitation Hospital, Nesoddtangen, Lasse Farner,
Jørgen Wagle and Torgeir Bruun Wyller Faculty of Medicine, University of Oslo and Department of Geriatric Medicine, Ullevaal
University Hospital, Oslo, Norway
Received 18th February 2008; returned for revisions 20th April 2008; revised manuscript accepted 25th May 2008.
Objective: To assess the concurrent validity of three screening tests for focal
cognitive impairments after stroke.
Design: Comparison of results from the screening tests with those from a more
comprehensive neuropsychological battery.
Setting: Stroke rehabilitation wards of a general hospital and a rehabilitation hospital.
Subjects: Forty-nine stroke patients (25–91 years, 35% women).
Measures: Screening tests were the Cognistat, the Screening Instrument for
Neuropsychological Impairments in Stroke (SINS) and the Clock Drawing Test. Health
professionals, blind to the results of the reference method, did the screening.
Reference method was a neuropsychological assessment based on the Norwegian
Basic Neuropsychological Assessment, classifying the patients as ‘impaired’ or ‘not
impaired’ within the following cognitive domains: language, visuospatial function,
attention and neglect, apraxia, speed in unaffected arm, and memory.
Results: The best sensitivity (95% confidence interval) was achieved for language
problems by Cognistat, naming (80%, 44–98); for visuospatial dysfunction, attention
deficits and reduced speed, all by SINS visuocognitive (82%, 60–95, 72%, 39–94,
and 78%, 56–93, respectively); and for memory problems by Cognistat memory
(69%, 52–87). The data were insufficient to assess any subtest for apraxia.
Sensitivity in detecting deficits in any domain was 82% (71–94) for the Cognistat
composite score, 71% (57–85) for the SINS composite score, and 63% (49–78)
for the most sensitive score of the Clock Drawing Test.
Conclusion: The Cognistat and the SINS may be used as screening instruments for
cognitive deficits after stroke, but cannot replace a neuropsychological assessment.
The Clock Drawing Test added little to the detection of cognitive deficits.
Cognitive deficits after a stroke influence the out-
come negatively1–3and increase the level of burden
on the carers.4Assessment of cognitive functions is
important for the patient and the proxies in their
Hospital, NO-0407 Oslo, Norway.
? SAGE Publications 2008
Los Angeles, London, New Delhi and Singapore10.1177/0269215508094711
process of understanding and adapting to the
new situation, and will also give useful directions
in rehabilitation planning. Cognitive deficits are
common, and may constitute the only form of
clinical neurological impairment.5The prevalence
varies with different populations, test batteries
and the timing of the assessments. In five studies,
35–82% of stroke patients were found to have
impairments in at least one domain.5–9The most
common impairments were reduced mental speed,
neglect, attention deficits, aphasia, apraxia and
Standard clinical practice often fails to discover
screening has been found to detect significantly
more symptoms than have been documented in
the charts.10A neuropsychological assessment is
the best way to assess cognitive function, but it
is time-consuming and requires special expertise
to administer and interpret. Thus, there is a need
for simpler screening tests that can be carried out
by other health professionals. Screening tests
should be easy and quick to administer, and be
able to differentiate between different cognitive
deficits. Sensitivity should be prioritized before
specificity, as a false-negative result may remain
unchecked, whereas a false-positive result is
likely to be disclosed by further testing.
A number of assessment methods that differ-
entiate between different cognitive domains have
been tested in stroke populations. CAMCOG11
and the shorter Rotterdam-CAMCOG have been
validated only for screening for post-stroke
dementia,12not for domain-specific cognitive def-
icits. The Middlesex Elderly Assessment of Mental
State (MEAMS) was found to be too insensitive in
a stroke population,13whereas the Repeatable
Battery for the Assessment of Neuropsychological
Status (RBANS) may be promising.14
We identified three short tests, different in scope
and ambition, which had some potential to serve
as screening tests for stroke patients. Cognistat
Cognitive Status Examination)15is widely used
and has been utilized with diverse populations. A
high inter-rater reliability has been found,16while
normative data are slightly conflicting regarding
Instrument for Neuropsychological Impairment
in Stroke (SINS),19which is considerably shorter,
has been validated to some extent,19but there is
a need for validation against a better ‘gold stan-
dard’. The Clock Drawing Test is brief, well
known and popular with clinicians.20As a screen-
ing instrument for stroke patients, the Clock
Drawing Test has not been fully evaluated.
The aim of this study was to assess the concur-
rent validity of Cognistat, SINS and three differ-
ent scoring protocols of the Clock Drawing Test
used with stroke patients, comparing them with a
standardized neuropsychological assessment as the
gold standard. We also wanted to measure time
spent on each of the tests, and to explore the valid-
ity of Cognistat’s clinimetrical structure.
Material and methods
Patients were included from the stroke rehabili-
tation units of Sunnaas Rehabilitation Hospital
and Ulleva ˚ l University Hospital in Norway. The
inclusion criteria were stroke according to the
World Health Organization (WHO) definition, a
stable medical condition, age above 18, and ability
to give informed consent. We aimed for a hetero-
geneous patient group with respect to age, lateral-
ity, severity and time after stroke, in order to
evaluate the validity of the screening tests over
a spectrum of clinical settings. A sample size of
50 was planned, based on pretest simulations of
confidence intervals under different conditions.
The protocol was approved by the Regional
Committee for Ethics in Medical Research and
the Norwegian Data Inspectorate.
The three screening tests were administrated by
physicians, psychology students or psychologists
without a speciality in neuropsychology. All were
given a brief training session in the use of the test
methods. The order of the three screening tests
was randomized (by simple drawing of lots) for
each patient. For each patient, all three tests
were administered by the same tester and during
one session. The time spent in each test was noted.
1096 K Nøkleby et al.
Cognistat is designed to give an independent
assessment of ten central cognitive domains, and
ten corresponding subtests are scored: orientation,
attention, understanding of simple commands,
repetition of sentences, naming, visuoconstruction,
verbal memory, calculation, similarities/verbal
abstraction, and every-day/concrete judgement.
Correct responses in each subtest are added, and
the test result is presented as a differentiated
cognitive profile. There is a certain age-correction
in that a more lenient cutpoint is applied for sub-
jects over 65 years.
Most domains begin with a relatively difficult
screening task. If the patient passes the screening
test, he or she is presumed to function normally in
that domain, and the tester continues to the next
domain. When the patient fails the screening test,
it continues with a metric portion that explores a
possible deficit further. Due to doubts about the
consistency of this ‘screen and metric’ system,21we
administered the test by giving all patients the
screening as well as the metric items. The fluency
subtest was not included in the analysis since no
scoring method had been provided for it.
To summarize the Cognistat result, we used a
Cognistat Total Score22and a Cognistat Compo-
site Score.23By adding up the domains in which
from 0 to 10, reflected how many cognitive
functions were intact. A score of 0 thus indicated
an extensive cognitive impairment. A Cognistat
Composite Score was generated by adding up all
the subtest scores, with a maximum score of 82.
The Screening Instrument for Neuropsychological
impairment in Stroke (SINS)
SINS aims to detect neuropsychological impair-
ments that are important for the basic physical
functioning of the patient. Cognitive domains
like concentration, learning and memory are not
assessed. It has 18 items on three subscales. It tests
for aphasia (four items: pick out objects on com-
mand, point at named objects, name objects, and
reading); visuocognitive dysfunction (six items:
pick objects from a drawer, fold a piece of paper
and put it in an envelope, put on a jacket, draw a
person, letter cancellation, and draw a daisy); and
apraxia (eight items replying to commands and
also by imitation: wave goodbye, pretend to use
a comb, light a candle, purse lips, smile and stick
out the tongue, move sideways (the latter three test
for oral apraxia)). The test gives a score on each
subscale but not a global score. For analytical
purposes, however, total and composite scores of
SINS were constructed in the same way as the
ranges of 0–3 and 18–54, respectively.
Clock Drawing Test
In the Clock Drawing Test, the subjects were
given a blank sheet of paper and the following
instruction (in Norwegian): ‘I would like you to
draw a clock, put in all the numbers, and set the
hands for 10 past 11.’ The drawings were scored
by a panel consisting of one geriatric psychiatrist,
one geriatrician and one junior physician, working
We scored each clock using three different
models, the 7-point scale from the Seven Minute
the 10-point clock test25
Sunderland 10-point scale,26respectively.
Three skilled specialists in clinical neuropsy-
chology (AKS, HB or EB) performed a neuropsy-
chological assessment of each patient. As a basis
for their clinical assessment, they used the
Norwegian standard battery of neuropsychologi-
cal tests after stroke (Basic Neuropsychological
Assessment).27,28The battery includes measures
of general abilities (20 general questions and
Raven’s Coloured Progressive Matrices); speed
and attention (Grooved Pegboard and a Letter
Cancellation Test); language (Token test and the
Intelligence Scale); praxis (a locally developed
praxis test based on Goodglass and Kaplan29)
Greek cross and block design from Wechsler
Adult Intelligence Scale); and verbal and non-
verbal learning and memory (Verbal Paired
Associates and Visual Reproduction from the
Wechsler Memory Scale). Up to three sessions
were generally necessary to complete the testing.
Screening for cognitive deficits after stroke1097
On the basis of prior factor analyses of the Basic
Neuropsychological Assessment,30as well as other
literature, we used six domains of the neuropsy-
chological reference tests: language, visuospatial
function, attention and neglect, apraxia, speed in
unaffected arm, and memory. Based on the results
of the testing, as well as clinical judgement and
knowledge of the patients’ level of functioning
before the stroke, the patients were classified as
‘definitely impaired’ or ‘not definitely impaired’
in each of these six domains. Where norms existed,
cutpoints of 1.5–2 SD from the estimated level
before the stroke were applied. When in doubt, the
three neuropsychologists carried out a consensus-
based classification. If there was still doubt after
a discussion, the patient was classified as ‘not defi-
nitely impaired’ in order to ensure that the sensi-
tivity of the screening methods should be validated
against indisputable deficits. The conclusions from
the neuropsychologists were also dichotomized
into whether all the domains were normal or at
least one domain was impaired.
SPSS version 14.0 (SPSS Inc., Chicago, IL,
USA) was used for statistical analyses. We calcu-
lated the sensitivities and specificities for the three
scoring methods of the Clock Drawing Test and
each of the subtests of Cognistat and SINS in
relation to the domains of the reference method,
and constructed receiver operating characteristic
A total of 49 patients were included (one was
lost for administrative reasons). The demographic
data and stroke-related variables are presented
in Table 1.
Based on the reference method, 41 (84%) of the
patients were categorized as definitely impaired in
one or more of the six domains studied, and 28
(60%) in two or more domains. Memory was
impaired in 26/49 subjects (53%), speed in the
unaffected arm in 23/45 (51%), visuospatial skills
in 22/49 (45%), visual inattention or neglect was
present in 11/44 (25%), 10/49 subjects (20%) had
impaired language, and 5/45 (11%) were found
to have apraxia. (The denominators vary due to
missing data in patients that were found to be
unassessable in some of the domains.)
The median time for administration of Cognistat
was 29 minutes (interquartile range (IQR) 24–38
minutes), forSINS11 minutes(IQR 9–17minutes),
and for the Clock Drawing Test 2 minutes (IQR
2–3 minutes). The results of the screening tests,
including the screening questions of Cognistat,
are shown in Table 2. The ceiling effect of some
of the tests is obvious, and it can also be seen that
for several of the Cognistat domains, patients
to be easier.
Table 3 shows sensitivities, specificities and the
area-under-the-ROC-curve (AUC) for subtests of
the screening instruments in relation to the
domains of the reference method. Tests with a
95% confidence interval of AUC not containing
0.5 are shown, in addition to a few tests commonly
believed to be important for the particular
domain. We applied the recommended cutpoints
where such were available; otherwise, we selected
cutpoints that maximized the sensitivity of the
tests while maintaining an acceptable specificity.
The aphasia subtest of the SINS and the naming
subtests of the Cognistat both performed fairly satis-
factorily as screening tests for language pathology.
question even though
study population (n¼49)
Demographic and clinical characteristics of the
Women, n (%)
Age, median (IQR, range)
Type of stroke, n (%)
Location of stroke, n (%)
Other (brainstem, bilateral, unknown)
Time interval in days from stroke to
testing, median (IQR, range)
Regular use of psychoactive drugs at
admittance, n (%)
62 (53.5–77, 25–91)
38 (17–89, 5–3624)
IQR, interquartile range.
1098 K Nøkleby et al.
Distribution of results of the screening tests (n¼49)
n (%) with
n (%) with
n (%) who
n (%) passing
but scoring below
on metric test
11, 10–12, 0–12
6, 5–7, 0–8
5, 4–6, 0–6
12, 10–12, 0–12
7, 6–8, 0–8
0–6, 2/3 if465 years,
3/4 if ?65 years
3, 2–4.5, 0–6
0–12, 7/8 if465 years,
9/10 if ?65 years
8, 5–10, 0–12
3, 2.5–4, 0–4
0–8, 3/4 if465 years,
4/5 if ?65 years
6, 4–8, 0–8
5, 4–6, 0–6
12, 11–12, 6–12
17, 14–18, 7–18
24, 23–24, 14–24
7 minutes screen
0–7, no recommended cutpoint
6, 3.5–7, 0–7
0–10, no recommended cutpoint
9, 8–10, 0–10
1–10, no recommended cutpoint
9, 4–10, 2–10
In all tests, a higher score indicates better function.
aCalculations based on a lower number of patients. One patient had missing data for SINS visuocognitive, one for the screening question for calculation in
Cognistat, and two for the screening question for visuoconstruction in Cognistat.CDT, Clock Drawing Test; IQR, interquartile range; SINS, Screening Instrument for Neuropsychological Impairment in Stroke.
Screening for cognitive deficits after stroke1099
Regarding visuospatial function, attention and
neglect, the visuocognitive part of SINS per-
formed best, as was also the case for speed in the
non-affected arm. The attention part of the
Cognistat performed markedly better than the
apraxia subtest of the SINS in detecting apraxia,
but for this domain the estimates are uncertain due
to a low number of cases. The Cognistat memory
domains of the neuropsychological assessment (reference method)
Sensitivity, specificity and areas-under-the-ROC-curve for selected subtests of the screening methods in relation to
Language Cognistat similarities
0.88 (0.78- 0.98)
0.69 (0.48- 0.91)
CDT 7 minutes screen 0.64 (0.48–0.80)
CDT 7 minutes screen
Memory Cognistat memory
0.63 (0.36–0.90)Impaired in one
or more domains
Subtests are selected on the basis of presumed relevance or statistically significant results (95% CI for area-under-the-ROC-
curve not covering 0.5).
Some of the calculations are based on a lower number of patients due to missing data (see text and Table 2).
aCalculations based upon recommended, age-dependent cutpoints, see Table 2.
AUC, area-under-the-ROC-curve; CDT, Clock Drawing Test; CI, confidence interval; ROC, receiver operating characteristics;
SINS, Screening Instrument for Neuropsychological Impairment in Stroke.
1100 K Nøkleby et al.
subtest performed best as an indicator of memory
problems. For the detection of any cognitive def-
icit, the Cognistat composite score had the best
sensitivity, while the area-under-the-ROC-curve
was best for the visuocognitive part of SINS.
The three scoring methods for the Clock
Drawing Test produced strikingly similar results,
and none gave any useful information about
visuospatial function or attention and neglect.
Even for the highest possible cutpoints, the sensi-
tivities were only 55% for detecting neglect and
attention deficits, and specificities were also poor.
For visuospatial abilities, the Clock Drawing
Test performed slightly better with a sensitivity
of 68%, but the ROC curve still did not deviate
significantly from the ‘no information’ line.
When aggregating the
domains of the reference method, the Clock
Drawing Test again failed to perform significantly
better than chance, whereas the two summarized
poor specificity. For example, with a total score
cutpoint of 8/9, the sensitivity was 81% and the
language score, comprising the dichotomized
results of the comprehension, repetition and
naming subtests. A normal result according to the
recommended cutpoints gives a score of 1 for each
of the three subtests, so that the language score has
a range of 0–3. This composite language score
performed better than the three language subtests
alone, with pairs of sensitivity and specificity
of 60%/85% and 90%/54% for the cutpoints
1/2 or 2/3, respectively, and an AUC of 0.82
(95% CI 0.66–0.98).
Adding the Clock Drawing Test to a different
subtest, like SINS aphasia or SINS visuospatial,
did not significantly improve the results.
We found modest to fair agreement between the
screening tests and the results of the neuropsycho-
logical assessment. For screening purposes, render-
ing sensitivity more important than specificity, our
results indicate that SINS represent an attractive
alternative for many purposes. This instrument is
very plain, and demonstrates a sensitivity that for
several domains is as good as that for Cognistat.
SINS could be completed in less than a quarter
of an hour in most patients, can be carried out
by physicians as well as physiotherapists and
occupational therapists, and might be feasible in
acute stroke units as well as in settings with scant
personnel, for instance in nursing homes. In con-
trast to SINS, Cognistat covers memory, but for
the other domains these two screens performed
screening question, and when used in full Cognistat
is between two and three times as time-consuming
as SINS. We found no convincing screening test
for apraxia, but our results on this domain are
uncertain due to the low number of cases.
We recommend the highest cutpoints of the
screening tests (Table 3), and a more comprehen-
sive neuropsychological assessment of patients
screening positively. For most of the tests, a
cutpoint associated with a high sensitivity was
inevitably associated with a poor specificity.
This means that the use of the tests for screening
purposes is bound to generate several false-positive
results, and ruling out cognitive deficits in these
patients may be time-consuming.
Studies with Cognistat in different populations
have found good sensitivity and poor specifi-
city,22,30but these studies have used diagnoses,
not a neuropsychological assessment, as the
criterion for validation. Two studies31,32validating
Cognistat against neuropsychological assessment
in mixed patient populations found the subtests
to be inaccurate, and the authors warn against
using Cognistat as a substitute for neuropsycholo-
gical assessment. Our results accord with this.
All versions of the Clock Drawing Test demon-
strated a surprisingly poor accuracy, as this test
has traditionally been seen as a measure of neglect
and visuospatial ability.33Our finding is, however,
consistent with that of others.34,35It has been pro-
posed that the combination of the Clock Drawing
Test with another screening test in patients with
right hemispheric stroke might improve the sensi-
tivity,36but our results do not support this.
Most studiesof cognitive
describe the tests’ psychometric properties without
relating the results to a validated ‘gold standard’.
Thus, it is a strength of our study that we use a
Screening for cognitive deficits after stroke1101
structured assessment made by a few skilled
neuropsychologists as our reference standard.
There exists, however, no classification of cogni-
tive domains that is universally agreed upon,
and the use of another test battery as the basis
for the neuropsychological assessment might
have produced different results. Another obvious
weakness of our approach is the relatively low
number of participants, rendering the confidence
intervals wide. Moreover, our population was
relatively young and to some degree selected, we
did not assess reliability, and we failed to include
patients with aphasia. It should also be acknowl-
edged that the value of a comprehensive neurop-
sychological assessment in most stroke patients
has yet to be established.
While the reference method was carried out in a
highly standardized manner, the screening tests
were administered by a relatively heterogeneous
personnel group. They underwent only a short
training session, thus increasing the risk of inter-
rater disagreement. A stronger standardization of
the way the screening tests were carried out might,
on one hand, have increased the precision and
improved the study, but would on the other
hand have made the results less realistic for a
test that is to be used as a screening tool in an
everyday clinical setting. Likewise, we aimed for
a heterogeneous patient sample with respect to the
severity of the stroke, age, localization, comorbid-
ity, and the time interval between the incident and
the test, and the screening test results were not
adjusted according to the level of the patient’s
education, whilst the results of the reference
method were. These possible weaknesses may,
however, make our results more generalizable to
a routine clinical setting.
Our study focused on the detection on focal
method nor the screening tests aimed primarily
at finding slowness of information processing or
impaired executive functioning, though these
are common general
after stroke. These questions remain open for
In conclusion, our study suggests that the very
short screening test SINS, as well as the somewhat
more time-consuming Cognistat, can be used with
a fair sensitivity for the detection of focal cognitive
Neither the reference
regarding which cognitive domains are particu-
larly affected should only be drawn very carefully
based upon these tests. Patients who screen posi-
tively may be in need of a more thorough neurop-
Thanks to Erling Bekkestad Rein, Eivind
Ystrøm and Jan Egil Nordvik for help in admin-
istering the screening tests, and to Knut Engedal
for assessing the clock-drawing tests.
University of Oslo, Ullevaal University Hospital
and Sunnaas Rehabilitation Hospital.
KN and TBW drafted the study protocol, did a
number of screening tests, and carried out the
statistical analyses. KN drafted the manuscript.
EB, HB and AKS carried out the neuropsycholo-
gical investigations. LF and JW carried out the
? Screening instruments found between 60%
diagnosed by a skilled neuropsychologist
? The Cognistat as well as the Screening
Impairment in Stroke (SINS) may be used
for screening purposes.
Clock Drawing Testadded little
1102 K Nøkleby et al.
screening tests on a number of patients. All have
contributed to the study protocol, data analyses,
initiated the study and is the guarantor.
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