Australia
a) All patients should be screened for cognitive and perceptual deficits using validated and reliable screening tools.
b) Patients identified during screening as having cognitive deficits should be referred for comprehensive clinical neuropsychological investigations.
UKa
A. Interventions or patient management should be organised so that people with cognitive difficulties can participate in the treatments and regularly reviewed and evaluated.
B. Every patient seen after a stroke should be considered to have at least some cognitive losses in the early phase. Routine screening should be undertaken to identify the patient’s broad level of functioning, using simple standardised measures (e.g. Montreal Cognitive Assessment MOCA).
C. Any patient not progressing as expected in rehabilitation should have a more detailed cognitive assessment to determine whether cognitive losses are causing specific problems or hindering progress.
D. Care should be taken when assessing patients who have a communication impairment. The advice from a speech and language therapist should be sought where there is any uncertainty about these individuals…
E. The patient’s cognitive status should be taken into account by all members of the multidisciplinary team when planning and delivering treatment.
F. Planning for discharge from hospital should include an assessment of any safety risks from persisting cognitive impairments.
G. People returning to cognitively demanding activities (e.g. some work, driving) should have their cognition assessed formally beforehand.
Scotland
A full understanding of the patient’s cognitive strengths and weaknesses should be an integral part of the rehabilitation plan.
Screening
Short, standardised cognitive screening measures can be used by a health professional with knowledge and experience of the presentations of cognitive functioning and factors influencing it. They can be used as a broad screen to reduce the possibility that problems will be missed and as a measure of progress. It is important for staff to understand that these screening measures will miss some of the cognitive problems which can be most important for rehabilitation and eventual functioning. These are varied but can include such issues as poor awareness of deficits or their implications, slowing of information processing, and the ability to cope with distraction. Care needs to be taken in selecting measures for use with people who have communication difficulties and, ideally, the selection should be made in collaboration with a speech and language therapist.
Assessment
Screening measures do not provide information about the depth and nature of the patient’s problems or strengths and therefore do not constitute an assessment sufficient for rehabilitation planning or for establishing suitability for a particular work role (e.g. operating machinery). Administering and interpreting full assessment results requires specialist training and should be carried out in the context of clinical interviews with access to background information.
Stroke patients should have a full assessment of their cognitive strengths and weaknesses when undergoing rehabilitation or when returning to cognitively demanding activities such as driving or work.
Cognitive assessment may be carried out by occupational therapists with expertise in neurological care, although some patients with more complex needs will require access to specialist neuropsychological expertise.
Canada
1. All high-risk patients should be screened for cognitive impairment using a validated screening tool.
2. Screening to investigate a person’s cognitive status should address arousal, alertness, attention, orientation, memory, language, agnosia, visuospatial/perceptual function, praxis and executive functions such as insight, judgment, social cognition, problem solving, abstract reasoning, initiation, planning and organization.
3. The Montreal Cognitive Assessment is considered more sensitive to cognitive impairment than the Mini Mental Status Exam in patients with vascular cognitive impairment. Its use is recommended when vascular cognitive impairment is suspected. Additional validation is needed for the Montreal Cognitive Assessment as well as other potential screening instruments such as the 5-min protocol from the Vascular Cognitive Impairment Harmonization recommendations.
4. Post-stroke patients should also be screened for depression, since depression has been found to contribute to cognitive impairment in stroke patients. A validated screening tool for depression should be used.
5. Post-stroke patients who have cognitive impairment detected on a screening test should receive additional cognitive and/or neuropsychologic assessments as appropriate to further guide management.
Timing and Workforce Mobilization: Cognitive Screening and Assessment
Workforce competencies for cognitive screening and assessment require careful planning as does the timing of these activities, which should influence clinical decision-making and outcomes for people with stroke, without using valuable resources to simply confirm the obvious (i.e., most acute stroke patients will have some cognitive impairment). Investigations should provide more information than a simple “cognitive impairment absent/present” tick box. Guidelines emphasize the roles of occupational therapists and psychologists. A recent document from the NHS Improvement Stroke program for England [31] suggests a pathway for assessing cognitive problems by way of the first step towards cognitive rehabilitation (Fig. 16.1). As shown, key time points in the UK model are: pre-transfer of care from hospital to community at 6 weeks and 6 months. The latter review is recommended for identifying long-term problems persisting beyond the period when much spontaneous recovery has occurred. For some people with stroke, this can also be a significant time during which they appreciate the extent of their residual cognitive difficulties and the need to adjust and accept compensatory rehabilitation strategies and aids. Canada recommends the following more frequent cognitive screening/assessment regime (and extends this to those who have had a transient ischemic attack) “at various transition points throughout the continuum of stroke care [13]”:
Fig. 16.1
Pathway for assessing cognitive problems. Reprinted with permission from Gillham S, Clark L. Psychological care after stroke—improving stroke services for people with cognitive and mood disorders. NHS Improvement—Stroke, 2011. http://www.improvement.nhs.uk/stroke/Psychologicalcareafterstroke/tabid/177/Default.aspx
1.
During presentation to emergency when cognitive, perceptual, or functional concerns are noted.
2.
Upon admission to acute care, particularly if any evidence of delirium is noted.
3.
Upon discharge home from acute care or during early rehabilitation if transferred to inpatient rehabilitation setting.
4.
Periodically during inpatient rehabilitation stage according to client progress and to assist with discharge planning.
5.
Periodically following discharge to the community by the most appropriate community healthcare provider according to client’s needs, progress, and current goals.
Beyond Assessment: General Cognitive Rehabilitation
The National guideline differ slightly in how they treat the management of cognitive problems after assessment. Rather than covering general cognitive rehabilitation most (e.g., Australia, Scotland, and UK except Scotland) go straight to domain-specific advice (e.g., interventions for memory and neglect). These often include recommendations of assessment tools specific to that impairment but the point here is that they also cover restorative and compensatory techniques. The Canadian guideline includes recommendations for the rehabilitation of cognitive problems as a single collective (see Table 16.2). This includes the broadest range of interventions including psychopharmacology (not reprinted here, see full report [13]) since this guideline covers “vascular cognitive impairment and dementia.”
Table 16.2
Canadian recommendations: interventions for general cognitive problems (extracts)
Patients who demonstrate cognitive impairments in the screening process should be referred to a healthcare professional with specific expertise in this area for additional cognitive, perceptual and/or functional assessments. • Additional assessments should be undertaken to determine the severity of impairment and impact of deficits on function and safety in activities of daily living and instrumental activities of daily living, and to implement appropriate remedial, compensatory and/or adaptive intervention strategies. • A team approach is recommended, and healthcare professionals may include an occupational therapist, neuropsychologist, psychiatrist, neurologist, geriatrician, speech–language pathologist or social worker. An individualized, patient-centered approach should be considered to facilitate resumption of desired activities such as return to work, leisure, driving, volunteer participation, financial management, home management and other instrumental activities of daily living. Intervention strategies including rehabilitation should be tailored according to the cognitive impairments and functional limitations as well as remaining cognitive abilities, as identified through in-depth assessment and developed in relation to patients’ and caregivers’ needs and goals. Strategy training provides individuals who have limitations in activities of daily living with compensatory strategies to promote independence and should be offered to patients with cognitive challenges. The evidence for the effectiveness of specific interventions for cognitive impairment in stroke is limited and requires more research. • Attention training may have a positive effect on specific, targeted outcomes and should be implemented with appropriate patients. Compensatory strategies can be used to improve memory outcomes. |
Domain-Specific Recommendations
The Australian, Scottish, and UK (except Scotland) guidelines take the approach of dividing cognition into specific impairments. Recommendations for attention, memory, neglect, and aphasia are covered by all. Apraxia and executive functions are included in the UK (except Scotland) and Australian guidelines. Agnosia is specifically covered by the Australian guideline whilst the most recent guideline (UK with the exception of Scotland) makes recommendations more broadly on perception. Space does not permit detailed coverage of all eight domains. The approach taken has been to extract the relevant information into tables to enable comparisons between guidelines. The reader is referred to the original documents for specifics on the studies on which these recommendations were made.
Although this modularized approach to cognitive rehabilitation is an oversimplification intended to aid clarity, it is also a true reflection of the design of the majority of the rehabilitation studies, which focus on a single impairment (e.g., neglect). In clinical practice, rehabilitation acknowledges that each cognitive domain, such as perception, attention, and memory, cannot be considered in isolation, as most everyday activities draw on a range and interaction of cognitive abilities.
Attention/Concentration
Each of the four guidelines mentions the pivotal role played by attention and the impact of attentional impairments. The ability to select and concentrate on relevant information or events is fundamental to everyday life. When this ability is impaired, other cognitive skills will be affected. Attention can therefore be considered a “mediator” or starting point for many aspects of cognition. Attentional deficits have an acute negative impact on functional ability [32–34].
Trials of rehabilitation of attention involve a number of different approaches. Computerized rehabilitation has been used; this allows repetition of tasks that draw on attention [35–37]. Approaches also focus on practice and development of specific strategies for time pressure management (TPM) [38, 39]. TPM is an intervention directly aimed at behavioral and cognitive change in treatment situations that are designed to mirror real-life situations. The goal is to develop alternative cognitive strategies to compensate for mental slowness. Attention process training (APT) has also been used [40, 41]. APT is “a theoretically based, hierarchical, multilevel treatment, including sustained, selective, alternating, and divided attention” [40].
A Cochrane systematic review of attention [24] concluded that there was no evidence to refute or support the use of specific rehabilitation techniques for attentional impairments that improve functional independence after stroke. An update to this review is in progress. The latest update to Cicerone’s review of cognitive rehabilitation for attention impairments [23] made practice standard recommendations for interventions for traumatic brain injury but this may well be applicable to stroke. The UK (except Scotland) guidelines, the most recently updated of all the guidelines, make recommendations based mainly on consensus opinion and a recent underpowered randomized controlled trial [39] of TPM (see Table 16.3). Although inconclusive, the latter trial suggests that TPM shows promise with younger, more physically independent stroke survivors and that it is feasible to train staff to deliver TPM in hospital or community stroke services.
Overall, there is a lack of high quality trials to inform selection of specific interventions and much of the evidence is at consensus level. Adequately powered randomized controlled trials of TPM and other interventions (e.g., APT) would greatly improve the evidence base for these commonly disabling impairments (Table 16.3).
Table 16.3
Recommendations from National Clinical Guidelines: Attention (extracts)
Australia | Cognitive rehabilitation can be used in stroke survivors with attention and concentration deficits |
Canada | The evidence for the effectiveness of specific interventions for cognitive impairment in stroke is limited and requires more research • Attention training may have a positive effect on specific, targeted outcomes and should be implemented with appropriate patients |
Scotland | There is not yet sufficient evidence to support or refute the benefits of cognitive rehabilitation for patients with problems of attention |
UKa | A. Any person after stroke who appears easily distracted or unable to concentrate should have their attentional abilities (e.g. focused, sustained and divided) formally assessed B. Any person with impaired attention should have cognitive demands reduced through: – having shorter treatment sessions – taking planned rests – reducing background distractions – avoiding work when tired. C. Any person with impaired attention should: – be offered an attentional intervention (e.g. Time Pressure Management, Attention Process Training, environmental manipulation), ideally in the context of a clinical trial – receive repeated practice of activities they are learning. |
Memory
Memory impairments (see Chap. 8) are related to a general reduction in functional ability for everyday tasks, even after factors such as age and stroke severity are taken into consideration [42]. Memory impairments also are upsetting for family members who cope with the consequences of forgetfulness; caregiver well-being correlates negatively with a patient’s memory problems [43]. The following simple three-step model has been advocated as useful for explaining and offering interventions to rehabilitate the effects of memory impairments:
1.
Encoding—organizing and processing information for later recall. Encoding may happen consciously or unconsciously.
2.
Consolidation—the process by which a piece of information becomes stored in memory in a more permanent way.
3.
Retrieval and recognition—recalling previously encoded and consolidated information in a meaningful way [44].
As suggested in Table 16.4, there are two main methods used in memory rehabilitation: (1) approaches to help encode, store, and retrieve new information (e.g., deep [semantic] encoding of material); and (2) teaching compensatory techniques to reduce disabilities (e.g., diaries, electronic organizers, and audio alarms). The Cochrane review for memory impairments post-stroke [26] concluded that there was “no evidence to support or refute the effectiveness of memory rehabilitation on functional outcomes, and objective, subjective, and observer-rated memory measures.” The more recent guidelines’ conclusions regarding the effectiveness of memory rehabilitation note there are serious limitations in the evidence base. The Australian and UK (except Scotland) recommendations are the most detailed and are very similar. There is widespread agreement between Cochrane reviewers and guideline writers that research is needed to establish both the clinical effectiveness (particularly at an activity rather than impairment level of outcome measurement) and the patient acceptability of different memory rehabilitation approaches, recruiting larger, more representative, groups of stroke patients (Table 16.4).
Table 16.4
Recommendations from National Clinical Guidelines: Memory (extracts)
Scotland | There is not yet sufficient evidence to support or refute the benefits of cognitive rehabilitation for patients with problems of attention or memory. |
Canada | The evidence for the effectiveness of specific interventions for cognitive impairment in stroke is limited and requires more research. • compensatory strategies can be used to improve memory outcomes |
Australia | Any patient found to have memory impairment causing difficulties in rehabilitation or adaptive functioning should: • be referred for a more comprehensive assessment of their memory abilities • have their nursing and therapy sessions tailored to use techniques which capitalise on preserved memory abilities • be assessed to see if compensatory techniques to reduce their disabilities, such as notebooks, diaries, audiotapes, electronic organisers and audio alarms, are useful • be taught approaches aimed at directly improving their memory • have therapy delivered in an environment as like the patient’s usual environment as possible to encourage generalisation. |
UKa | A. Patients who complain of memory impairment and those clinically considered to have difficulty in learning and remembering should have their memory assessed using a standardised measure such as the Rivermead Behavioural Memory Test (RBMT). B. Any patient found to have memory impairment causing difficulties in rehabilitation or undertaking activities should: • be assessed medically to check that there is not another treatable cause or contributing factor (e.g. hypothyroidism) • have their profile of impaired and preserved memory abilities determined (as well as the impact of any other cognitive deficits on memory performance for example, attentional impairment) • have nursing and therapy sessions altered to capitalise on preserved abilities • be taught approaches that help them to encode, store and retrieve new information for example, spaced retrieval (increasing time intervals between review of information) or deep encoding of material (emphasizing semantic features) • be taught compensatory techniques to reduce their prospective memory problems, such as using notebooks, diaries, electronic organisers, pager systems and audio alarms • have therapy delivered in an environment that is as similar to the usual environment for that patient as possible. |
Neglect
Unilateral spatial neglect was originally classified as a perceptual impairment, before being widely accepted as an attentional disorder. It tends to stand alone these days perhaps because neglect is the most frequently researched topic within cognitive rehabilitation for stroke. The disabling effects of neglect have been well documented [45] (see Chap. 4). Although severe neglect is rather easily recognized, diagnosing milder neglect can be less obvious and only become apparent when observing higher-level activities such as driving, preparing a meal, and interacting in real-world social situations [46]. These difficulties obviously impact patient function and safety on transfer of care from hospital to community.
There is a relative wealth of research evidence in this field. Twelve randomized controlled trials were included in the Cochrane review of the cognitive rehabilitation of neglect [25]. A recent update of this review (in press) has included a further 11 trials [47–57]. Providing visual scanning training remains a popular intervention in neglect trials, as is the use of prisms. The latter is sometimes prescribed as an aid to be routinely worn on glasses but recent pilot trials have succeeded in determining the feasibility (but not yet the effectiveness) of prism adaptation training, a short therapist-led intervention using prisms during a specific computerized training activity [54].
The original review [25] concluded that cognitive rehabilitation can improve performance on impairment level tests but there is insufficient evidence to support or refute its effectiveness at reducing disability, one of the main aims of rehabilitation. This gap in the evidence base is due to limitations in the quality of the research studies, especially around the reduction of bias and the choice of appropriate outcome measures. The updated review will provide a systematic determination of whether the evidence base has been strengthened recently but for now the National guideline recommendations remain mostly at the consensus level and stress the need to invite people with neglect to participate in clinical trials (Table 16.5).
Table 16.5
Recommendations from National Clinical Guidelines: Neglect (extracts)
