Relationship of Cognitive and Perceptual Abilities to Functional Independence in Adults Who Have Had a Stroke

Designing and validating of a questionnaire measuring perceived self-care ability (PSCA) in chronic stroke patients at home

BACKGROUND

Patients with a stroke often cannot care for themselves after hospital discharge. Assessment of their self-care ability is the first step in planning post-discharge home care. This study aimed to design and validate a measure of perceived self-care ability (PSCA) in stroke patients.

METHODS

A sequential-exploratory mixed method was conducted in Tehran, Iran, in 2020-2021. The qualitative phase involved in-depth semi-structured interviews with 12 participants. Transcripts were content analyzed. The results guided the development of 81 items. psychometric properties such as face validity (Impact Score > 1.5), content validity ratio (CVR > 0.63), content validity index (Item Content Validity Index: ICVI > 0.78, Scale Content Validity Index/Average: SCVI/Ave > 0.8) and Kappa value (Kappa > 0.7), internal consistency (Cronbach's alpha > 0.7), relative reliability (ICC: inter class correlation coefficient), absolute reliability (Standard Error of Measurement: SEM and Minimal Detectable Changes: MDC), convergent validity (Correlation Coefficient between 0.4-0.7), interpretability, responsiveness, feasibility, and ceiling and floor effects were assessed.

RESULTS

Content analysis of the qualitative interviews yielded 5 major categories and 9 subcategories that reflected "Perceptual stability", "Cognitive fluctuations", "Sensory, Motor and Physical health"," The subjective nature" and "The dynamic nature" of PSCA. Results of face and content validity reduced the number of items to 32, capturing three dimensions of PSCA in chronic stroke patients; these dimensions included perceptual ability, threatened health status, and sensory, motor, and cognitive ability. The findings supported the reliability and validity of the measure.

CONCLUSIONS

The PSCA questionnaire was developed and validated within the Iranian culture. It is useful in assessing the self-care of patients with stroke and in informing practice.

Cognitive predictors of a performance-based measure of instrumental activities of daily living following stroke

BACKGROUND

To inform cognitive interventions that target functional capacity for individuals who have survived stroke, an evaluation of predictors of daily functioning is necessary. The current literature is limited regarding identifying the associations between objective cognitive functioning and objective performance of Instrumental Activities of Daily Living (IADLs).

OBJECTIVES

To investigate the relationship between objectively measured cognitive domains/executive functions and performance on an objective measure of IADLs following a stroke.

METHODS

Cross-sectional examination of 52 participants who have survived strokes and completed assessments of immediate memory, visuospatial/constructional skills, language, attention, delayed memory, executive functions (i.e., inhibition and flexibility, concept-formation and problem-solving, abstract thinking, deductive thinking, and verbal abstraction), and a performance-based measure of IADLs (UCSD Performance-based Skills Assessment; UPSA).

RESULTS

Results indicated significant correlations between the UPSA and immediate memory, visuospatial/constructional skills, language, delayed memory, and executive functions (i.e., concept formation and problem-solving, flexibility of thinking, and verbal abstraction). A hierarchical multiple regression, controlling for age, severity of stroke, side of stroke, and depressive symptoms and including the cognitive measures individually significantly associated with the UPSA, explained approximately 62% of the variance in overall UPSA performance. This regression demonstrated that only language significantly predicted UPSA total score, in the context of multiple variables.

CONCLUSIONS

Cognitive functioning is significantly associated with IADL functioning post-stroke, and considering multiple domains of cognitive functioning together largely explains the performance of IADLs.

The role of rehabilitation psychology in stroke care described through case examples

BACKGROUND

A stroke event, sometimes referred to as a cerebrovascular accident (CVA), is a sudden and often traumatic life event that results in life-changing consequences with which affected people must cope. There are nearly 800,000 instances of stroke annually in the U.S. (American Heart Association, 2018). Stroke is the leading cause of disability in adults, and more than one-third of people who survive a stroke will have severe disability in the U.S. (Mayo, 2005). Between 35% and 75% of stroke survivors will have significant cognitive impairment (Tatemichi et al., 1994; Nys et al., 2007). An estimated one-third of people suffer depression after stroke (Hackett et al., 2005), about one-fourth experience significant anxiety (Barker-Collo, 2007), and about one-fifth suffer from insomnia (Leppavuoria et al., 2002). These and other stroke-related psychological issues negatively influence rehabilitation and outcomes through a variety of mechanisms. For example, post-stroke depression has been shown to be related to more negative functional consequences (Kneebone et al., 2000; Matsuzaki et al., 2015). Psychological disturbances may affect rehabilitation outcomes through a reduction in adherence to home exercise programs, reduced energy level, increased fatigue, reduced frustration tolerance, and potentially less motivation and hope about the future.

OBJECTIVES

This manuscript aims to identify and describe the role of rehabilitation psychology in treating these common post-stroke complaints and, ultimately, optimizing post-stroke outcomes via two case examples.

METHODOLOGY

This manuscript describes two cases of individuals in post-acute rehabilitation who had psychological issues which were negatively affecting outcomes.

CONCLUSION

Given the abrupt and significant life-changing nature of stroke, it is often necessary to manage a diverse array of psychological issues that often cannot be simply managed via psychotropic medications. Moreover, an understanding of the patients' emotional adjustment and issues can help them maximize their rehabilitation, recovery, and community integration. For the cases discussed, psychology consultations were central in helping optimize their rehabilitation and functional outcomes.

The determinants of motorized mobility scooter driving ability after a stroke

Purpose: To investigate the determinants related to the ability to drive a motorized mobility scooter after a stroke.Method: The study was a cross-sectional study. The ability to drive a motorized mobility scooter was measured with the Power Mobility Clinical Driving Assessment. The independent variables included cognitive functions measured by the Color Trails Test and reaction time test, visual functions measured by a visual acuity test and visual field test, and motor functions measured with a dynamometer, the Box and Block Test, and the Functional Independence Measure.Results: The correlation analyses revealed that the Power Mobility Clinical Driving Assessment scores had significant correlations with reaction time (ρ = -.65, p < 0.01), binocular visual field (r = .64, p < 0.01), binocular visual acuity (r = .40, p = 0.03), and the grip strength of the unaffected hand (r = .47, p = 0.01). The multiple regression analysis indicated that reaction time, binocular visual field, and the grip strength of the unaffected hand were the most significant determinants of the ability to drive a motorized mobility scooter (R² = .76).Conclusions: The reaction time, binocular visual field, and grip strength of the unaffected hand were the most significant determinants related to the ability to drive a motorized mobility scooter after a stroke. IMPLICATIONS FOR REHABILITATIONMotorized mobility scooter driving ability for stroke patients is correlated with demographics (age, mobility scooter driving experience, time since last drive) and cognitive, visual and motor functions (reaction time, binocular visual field, visual acuity, and the grip strength of unaffected hand).Primary determinants of motorized mobility scooter driving ability for stroke patients include reaction time, binocular visual field, and grip strength of the unaffected hand.Comprehensive assessments incorporating cognitive, visual and motor functions are needed to evaluate the ability to drive a motorized mobility scooter after a stroke.

Telehealth Delivery of Memory Rehabilitation Following Stroke

OBJECTIVE

Rehabilitation of memory after stroke remains an unmet need. Telehealth delivery may overcome barriers to accessing rehabilitation services.

METHOD

We conducted a non-randomized intervention trial to investigate feasibility and effectiveness of individual telehealth (internet videoconferencing) and face-to-face delivery methods for a six-week compensatory memory rehabilitation program. Supplementary analyses investigated non-inferiority to an existing group-based intervention, and the role of booster sessions in maintaining functional gains. The primary outcome measure was functional attainment of participants' goals. Secondary measures included subjective reports of lapses in everyday memory and prospective memory, reported use of internal and external memory strategies, and objective measures of memory functioning.

RESULTS

Forty-six stroke survivors were allocated to telehealth and face-to-face intervention delivery conditions. Feasibility of delivery methods was supported, and participants in both conditions demonstrated treatment-related improvements in goal attainment, and key subjective outcomes of everyday memory, and prospective memory. Gains on these measures were maintained at six-week follow-up. Short-term gains in use of internal strategies were also seen. Non-inferiority to group-based delivery was established only on the primary measure for the telehealth delivery condition. Booster sessions were associated with greater maintenance of gains on subjective measures of everyday memory and prospective memory.

CONCLUSIONS

This exploratory study supports the feasibility and potential effectiveness of telehealth options for remote delivery of compensatory memory skills training after a stroke. These results are also encouraging of a role for booster sessions in prolonging functional gains over time.

Kettle test efficacy in predicting cognitive and functional outcomes in geriatric rehabilitation

BACKGROUND/AIM

Limited research has been available to support the use of the Kettle Test in a subacute rehabilitation setting with patients diagnosed with a variety of medical conditions. The Kettle Test is an occupation based performance measure designed to detect cognitive processes and function. The aim of this research was to measure the correlation between three cognitive tests, the Mini-Mental State Examination (MMSE), Cognitive Functional Independence Measure (Cognitive FIM) and the Kettle Test. Secondly, to assess the efficacy of these tests in predicting functional outcomes via the motor subscale of the Functional Independence Measure (mFIM).

METHODS

A prospective single-centre cohort study in a subacute rehabilitation setting of 97 patients.

RESULTS

Correlation coefficients between the tests were statistically significant and moderately strong, with values ranging from 0.593 to -0.589. Significant positive correlations were seen between admission MMSE, Cognitive FIM and the mFIM and significant negative correlations between Kettle Test scores and the mFIM. The Kettle Test score had a stronger relationship with mFIM (r = -0.40; P < 0.01) compared to the Cognitive FIM (r = 0.33; P < 0.01) and MMSE (r = 0.26; P < 0.05). The Kettle Test variance is significantly associated with the MMSE and Cognitive FIM at admission and discharge measures. Modelling identified that age and gender significantly contribute to this relationship. When adjusted for age and gender the MMSE and Cognitive FIM both explained the 47% of the variance at discharge.

CONCLUSION

There were statistically significant inter-test correlations between the MMSE, Cognitive FIM and Kettle Test. The Kettle Test had the strongest relationship to patient functional outcomes.

Determining client cognitive status following mild traumatic brain injury

BACKGROUND

People with mild traumatic brain injury (mTBI) commonly experience cognitive impairments. Occupational therapists working in acute general hospitals in Australia routinely access client Glasgow Coma Scale (GCS) scores, and assess cognitive status using standardized tools and by observing basic activity of daily living (ADL) performance. However, limited evidence exists to identify the best assessment(s) to determine client cognitive status.

AIM/OBJECTIVES

To determine whether cognitive status assessed by GCS score and the Cognistat are predictive of basic ADL performance among clients with mTBI in an acute general hospital and make inferences concerning the clinical utility of these assessment tools.

MATERIAL AND METHODS

Retrospective analysis of medical record data on demographics, Cognistat, GCS, and modified Barthel Index (MBI) using descriptive statistics, chi-square tests and linear regression.

RESULTS

Data analysis of 166 participants demonstrated that no associations exist between GCS and Cognistat scores, or Cognistat scores and MBI dependency level. The presence of co-morbid multi-trauma injuries and length of stay were the only variables that significantly predicted MBI dependency level.

CONCLUSION AND SIGNIFICANCE

While the MBI scores are of value in identifying clients with difficulty in basic ADLs, Cognistat and GCS scores are of limited use in differentiating client levels of cognitive impairment and the authors caution against the routine administration of the Cognistat following mTBI. Further research is required to identify more suitable assessments for use with a mTBI population.

Spatial cognitive rehabilitation and motor recovery after stroke

PURPOSE OF REVIEW

Stroke rehabilitation needs to take major steps forward to reduce functional disability for survivors. In this article, we suggest that spatial retraining might greatly increase the efficiency and efficacy of motor rehabilitation, directly addressing the burden and cost of paralysis after stroke.

RECENT FINDINGS

Combining motor and cognitive treatment may be practical, as well as addressing the needs after moderate-to-severe stroke. Spatial neglect could suppress motor recovery and reduce motor learning, even when patients receive appropriate rehabilitation to build strength, dexterity, and endurance. Spatial neglect rehabilitation acts to promote motor as well as visual-perceptual recovery. These findings, and the previous underemphasized studies, make a strong case for combining spatial neglect treatment with traditional exercise training. Spatial neglect therapies might also provide motor stimulation if people cannot participate in intensive movement therapies because of limited strength and endurance after stroke.

SUMMARY

Spatial retraining, currently used selectively after right-brain stroke, may be broadly useful after stroke to promote rapid motor recovery.

The Cognistat (neurobehavioural cognitive status exam): Administering the full test in stroke patients for optimal results

BACKGROUND

One of the most commonly administered tools occupational therapists use for stroke patients is the Cognistat, which was designed as a brief screening tool of cognitive functioning. Evaluations in samples of patients have identified a high false-negative rate if the Cognistat is administered using the 'screen metric' approach. Assessing the Cognistat based on its intended design can ensure consistency and accuracy among occupational therapists for this commonly administered tool. Thus, this study examined the accuracy of administering the entire Cognistat in comparison to the screen-metric approach and the factor analytic structure within stroke patients.

METHODS

The full Cognistat was administered to stroke patients receiving inpatient rehabilitation.

RESULTS

Seventy-five patients who experienced a recent stroke met inclusion criteria. An inconsistency between the screen and metric items was found for five of 10 subscales. Additionally, a principal component analysis (PCA) found the Cognistat to be a two factor structure with six of the subscales loading on Factor 1, while the remaining subscales loaded on Factor 2.

CONCLUSIONS

Our findings confirm that occupational therapists should administer the full Cognistat to stroke patients rather than the original screen-metric approach. A two-factor structure was also supported in our results, suggesting that occupational therapists' scoring practices should reflect this finding and use the differentiated score out of 10 rather than a global sum. However, additional research is necessary to consider the clinical and theoretical significance of the Cognistats' subscale clustering.

Effectiveness of Interventions to Improve Occupational Performance of People With Cognitive Impairments After Stroke: An Evidence-Based Review

This evidence-based review was conducted to determine which interventions are effective in improving occupational performance after stroke. Forty-six articles met the inclusion criteria and were examined. Interventions for the following impairments were reviewed: general cognitive deficits, executive dysfunction, apraxia, memory loss, attention deficits, visual field deficits (included because of their close relationship with neglect), and unilateral neglect. Evidence is available from a variety of clinical trials to guide interventions regarding general cognition, apraxia, and neglect. The evidence regarding interventions for executive dysfunction and memory loss is limited. There is insufficient evidence regarding impairments of attention and mixed evidence regarding interventions for visual field deficits. The effective interventions have some commonalities, including being performance focused, involving strategy training, and using a compensatory as opposed to a remediation approach. The implications of the findings for practice, research, and education are discussed.

Diabetes reduces the cognitive function with the decrease of the visual perception and visual motor integration in male older adults

This study investigated the influence of diabetes on cognitive decline between the diabetes and non- diabetes patients and identified the associations between diabetes and cognitive function, visual perception (VP), and visual motor integration (VMI). Sixty elderly men (67.10± 1.65 yr) with and without diabetes (n= 30 in each group) who were surveyed by interview and questionnaire in South Korea were enrolled in this study. The score of Mini-Mental State Examination of Korean version (MMSE-KC), Motor-free Visual Perception Test-Vertical Format (MVPT-V), and Visual-Motor Integration 3rd Revision (VMI-3R) were assessed in all of the participants to evaluate cognitive function, VP, and VMI in each. The score of MMSE-KC in the diabetic group was significantly lower than that of the non-diabetes group (P< 0.01). Participants in the diabetes group also had lower MVPT-V and VMI-3R scores than those in the non-diabetes group (P< 0.01, respectively). Especially, the scores of figure-ground and visual memory among the subcategories of MVPT-V were significantly lower in the diabetes group than in the non-diabetes group (P< 0.01). These findings indicate that the decline in cognitive function in individuals with diabetes may be greater than that in non-diabetics. In addition, the cognitive decline in older adults with diabetes might be associated with the decrease of VP and VMI. In conclusion, we propose that VP and VMI will be helpful to monitor the change of cognitive function in older adults with diabetes as part of the routine management of diabetes-induced cognitive declines.