Strategy Training During Inpatient Rehabilitation May Prevent Apathy Symptoms After Acute Stroke

Apathy mediates the association between age and cognition after stroke

PURPOSE

To examine if the association between age and post-stroke cognition is mediated by apathy.

METHODS

A cross-sectional investigation was carried out with 389 stroke survivors and informants. Data were collected through the Apathy Evaluation Scale (AES-C) and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). Bivariate analyses were conducted between the IQCODE total score and each of the demographic and clinical characteristics as well as apathy, while Baron and Kenny's 4-step approach was used to examine the mediating effect of apathy on the association between age and post-stroke cognition.

RESULTS

Participants were aged 64.3 years on average, with a mean IQCODE score of 97.6 (SD: 14.8) and a mean AES-C score of 41.3 (SD: 8.0). IQCODE scores were positively correlated with age (r = 0.32, p < 0.001) and apathy (r = 0.54, p < 0.001). Apathy contributed to 24% of the total effect of age on post-stroke cognition, exerting a significant mediating effect on the relationship between age and post-stroke cognition.

CONCLUSIONS

Apathy may have a significant impact on the cognitive health of stroke survivors. Therefore, the early identification of apathy symptoms could facilitate consideration of potential interventions, such as multisensory and cognitive stimulation, designed to improve cognitive outcomes in this population.

The neural correlates of apathy in the context of aging and brain disorders: a meta-analysis of neuroimaging studies

Introduction

Apathy is a prevalent mood disturbance that occurs in a wide range of populations, including those with normal cognitive aging, mental disorders, neurodegenerative disorders and traumatic brain injuries. Recently, neuroimaging technologies have been employed to elucidate the neural substrates underlying brain disorders accompanying apathy. However, the consistent neural correlates of apathy across normal aging and brain disorders are still unclear.

Methods

This paper first provides a brief review of the neural mechanism of apathy in healthy elderly individuals, those with mental disorders, neurodegenerative disorders, and traumatic brain injuries. Further, following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, the structural and functional neuroimaging meta-analysis using activation likelihood estimation method is performed on the apathy group with brain disorders and the healthy elderly, aiming at exploring the neural correlates of apathy.

Results

The structural neuroimaging meta-analysis showed that gray matter atrophy is associated with apathy in the bilateral precentral gyrus (BA 13/6), bilateral insula (BA 47), bilateral medial frontal gyrus (BA 11), bilateral inferior frontal gyrus, left caudate (putamen) and right anterior cingulate, while the functional neuroimaging meta-analysis suggested that the functional connectivity in putamen and lateral globus pallidus is correlated with apathy.

Discussion

Through the neuroimaging meta-analysis, this study has identified the potential neural locations of apathy in terms of brain structure and function, which may offer valuable pathophysiological insights for developing more effective therapeutic interventions for affected patients.

Motivation as a Measurable Outcome in Stroke Rehabilitation: A Systematic Review of the Literature

Motivated behaviours are thought to lead to enhanced performances. In the neurorehabilitation field, motivation has been demonstrated to be a link between cognition and motor performance, therefore playing an important role upon rehabilitation outcome determining factors. While motivation-enhancing interventions have been frequently investigated, a common and reliable motivation assessment strategy has not been established yet. This review aims to systematically explore and provide a comparison among the existing motivation assessment tools concerning stroke rehabilitation. For this purpose, a literature search (PubMed and Google Scholar) was performed, using the following Medical Subject Headings terms: "assessment" OR "scale" AND "motivation" AND "stroke" AND "rehabilitation". In all, 31 randomized clinical trials and 15 clinical trials were examined. The existing assessment tools can be grouped into two categories: the first mirroring the trade-off between patients and rehabilitation, the latter reflecting the link between patients and interventions. Furthermore, we presented assessment tools which reflect participation level or apathy, as an indirect index of motivation. In conclusion, we are left to put forth a possible common motivation assessment strategy, which might provide valuable incentive to investigate in future research.

The course of post-stroke apathy in relation to cognitive functioning: a prospective longitudinal cohort study

Apathy is common after stroke and has been associated with cognitive impairment. However, causality between post-stroke apathy and cognitive impairment remains unclear. We assessed the course of apathy in relation to changes in cognitive functioning in stroke survivors. Using the Apathy Scale (AS) and cognitive tests on memory, processing speed and executive functioning at six- and 15 months post-stroke we tested for associations between (1) AS-scores and (change in) cognitive scores; (2) apathy course (persistent/incident/resolved) and cognitive change scores. Of 117 included participants, 29% had persistent apathy, 13% apathy resolving over time and 10% apathy emerging between 6-15 months post-stroke. Higher AS-scores were cross-sectionally and longitudinally associated with lower cognitive scores. Relations between apathy and cognitive change scores were ambiguous. These inconsistent relations between apathy and changes in cognition over time suggest that post-stroke apathy does not directly impact cognitive performance. Both these sequelae of stroke require separate attention.

Cerebral small vessel disease: Recent advances and future directions

Cerebral small vessel disease (SVD) causes lacunar stroke and intracerebral hemorrhage, and is the most common pathology underlying vascular cognitive impairment. Increasingly, the importance of other clinical features of SVD is being recognized including motor impairment, (vascular) parkinsonism, impaired balance, falls, and behavioral symptoms, such as depression, apathy, and personality change. Epidemiological data show a high prevalence of the characteristic magnetic resonance imaging (MRI) features of white matter hyperintensities and lacunar infarcts in community studies, and recent data suggest that it is also a major health burden in low- and middle-income countries. In this review, we cover advances in diagnosis, imaging, clinical presentations, pathogenesis, and treatment.The two most common pathologies underlying SVD are arteriolosclerosis caused by aging, hypertension, and other conventional vascular risk factors, and cerebral amyloid angiopathy (CAA) caused by vascular deposition of β-amyloid. We discuss the revised Boston criteria of CAA based on MRI features, which have been recently validated. Imaging is providing important insights into pathogenesis, including improved detection of tissue damage using diffusion tensor imaging (DTI) leading to its use to monitor progression and surrogate endpoints in clinical trials. Advanced MRI techniques can demonstrate functional or dynamic abnormalities of the blood vessels, while the high spatial resolution provided by ultrahigh field MRI at 7 T allows imaging of individual perforating arteries for the first time, and the measurement of flow velocity and pulsatility within these arteries. DTI and structural network analysis have highlighted the importance of network disruption in mediating the effect of different SVD pathologies in causing a number of symptoms, including cognitive impairment, apathy, and gait disturbance.Despite the public health importance of SVD, there are few proven treatments. We review the evidence for primary prevention, and recent data showing how intensive blood pressure lowering reduces white matter hyperintensities (WMH) progression and delays the onset of cognitive impairment. There are few treatments for secondary prevention, but a number of trials are currently evaluating novel treatment approaches. Recent advances have implicated molecular processes related to endothelial dysfunction, nitric oxide synthesis, blood-brain barrier integrity, maintenance and repair of the extracellular matrix, and inflammation. Novel treatment approaches are being developed to a number of these targets. Finally, we highlight the importance of large International collaborative initiatives in SVD to address important research questions and cover a number which have recently been established.

Non-pharmacological intervention effects on apathy caused by central nervous system organic diseases: A network meta-analysis

BACKGROUND

To evaluate the best non-pharmacological interventions on apathy in patients with central nervous system (CNS) organic diseases.

METHODS

We searched PubMed, Web of Science, Embase, Cochrane Library electronic databases, China national knowledge infrastructure, Wanfang and Chinese biomedical literature database studies published from 2011 to May 29, 2021. A combination of subject words and free words were used for searching. Randomized controlled trials (RCTs) of non-pharmacological interventions for apathy in patients with central nervous organic disease were included. Two researchers independently identified the eligible RCTs and extracted information. The risk of bias within each individual trial was assessed using the Cocharane Collaboration's tool. Review Manager 5.4 and ADDIS 1.16.5 were used for data analysis.

RESULTS

A total of 5324 related studies were obtained in the initial screening, and final 8 RCTs including 334 patients were included, involving 4 non-pharmacological interventions of cognitive intervention, repetitive transcranial magnetic stimulation (rTMS), music therapy and occupational therapy. Direct comparison results showed that rTMS, cognitive intervention, and occupational therapy were superior to the conventional group (P < .05). Network Meta repeated rTMS, cognitive intervention was superior to the conventional group (P < .05), while the other groups did not differ from with the conventional group (P > .05). The order of superiority was rTMS, cognitive intervention, occupational therapy, music therapy, and conventional group.

CONCLUSION

Current evidence suggests that rTMS and cognitive interventions are more effective than the conventional intervention in improving apathy in patients with CNS organic diseases. It still needs more non-pharmacological intervention studies with high quality, larger sample sizes for further exploration.

Occupational therapy for cognitive impairment in stroke patients

BACKGROUND

Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. Occupational therapists use a range of interventions when working with people who have cognitive impairment poststroke. This is an update of a Cochrane Review published in 2010.

OBJECTIVES

To assess the impact of occupational therapy on activities of daily living (ADL), both basic and instrumental, global cognitive function, and specific cognitive abilities in people who have cognitive impairment following a stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases (all last searched September 2020), trial registries, and reference lists.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that evaluated an intervention for adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or considered within the scope of occupational therapy practice as defined in the review. We excluded studies focusing on apraxia or perceptual impairments or virtual reality interventions as these are covered by other Cochrane Reviews. The primary outcome was basic activities of daily living (BADL) such as dressing, feeding, and bathing. Secondary outcomes were instrumental ADL (IADL) (e.g. shopping and meal preparation), community integration and participation, global cognitive function and specific cognitive abilities (including attention, memory, executive function, or a combination of these), and subdomains of these abilities. We included both observed and self-reported outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies that met the inclusion criteria, extracted data, and assessed the certainty of the evidence. A third review author moderated disagreements if consensus was not reached. We contacted trial authors for additional information and data, where available. We assessed the certainty of key outcomes using GRADE.  MAIN RESULTS: We included 24 trials from 11 countries involving 1142 (analysed) participants (two weeks to eight years since stroke onset). This update includes 23 new trials in addition to the one study included in the previous version. Most were parallel randomised controlled trials except for one cross-over trial and one with a two-by-two factorial design. Most studies had sample sizes under 50 participants. Twenty studies involved a remediation approach to cognitive rehabilitation, particularly using computer-based interventions. The other four involved a compensatory and adaptive approach. The length of interventions ranged from 10 days to 18 weeks, with a mean total length of 19 hours. Control groups mostly received usual rehabilitation or occupational therapy care, with a few receiving an attention control that was comparable to usual care; two had no intervention (i.e. a waiting list). Apart from high risk of performance bias for all but one of the studies, the risk of bias for other aspects was mostly low or unclear.  For the primary outcome of BADL, meta-analysis found a small effect on completion of the intervention with a mean difference (MD) of 2.26 on the Functional Independence Measure (FIM) (95% confidence interval (CI) 0.17 to 4.22; P = 0.03, I2 = 0%; 6 studies, 336 participants; low-certainty evidence). Therefore, on average, BADL improved by 2.26 points on the FIM that ranges from 18 (total assist) to 126 (complete independence). On follow-up, there was insufficient evidence of an effect at three months (MD 10.00, 95% CI -0.54 to 20.55; P = 0.06, I2 = 53%; 2 studies, 73 participants; low-certainty evidence), but evidence of an effect at six months (MD 11.38, 95% CI 1.62 to 21.14, I2 = 12%; 2 studies, 73 participants; low-certainty evidence). These differences are below 22 points which is the established minimal clinically important difference (MCID) for the FIM for people with stroke. For IADL, the evidence is very uncertain about an effect (standardised mean difference (SMD) 0.94, 95% CI 0.41 to 1.47; P = 0.0005, I2 = 98%; 2 studies, 88 participants). For community integration, we found insufficient evidence of an effect (SMD 0.09, 95% CI -0.35 to 0.54; P = 0.68, I2 = 0%; 2 studies, 78 participants). There was an improvement of clinical importance in global cognitive functional performance after the intervention (SMD 0.35, 95% CI 0.16 to 0.54; P = 0.0004, I2 = 0%; 9 studies, 432 participants; low-certainty evidence), equating to 1.63 points on the Montreal Cognitive Assessment (MoCA) (95% CI 0.75 to 2.52), which exceeds the anchor-based MCID of the MoCA for stroke rehabilitation patients of 1.22. We found some effect for attention overall (SMD -0.31, 95% CI -0.47 to -0.15; P = 0.0002, I2 = 20%; 13 studies, 620 participants; low-certainty evidence), equating to a difference of 17.31 seconds (95% CI 8.38 to 26.24), and for executive functional performance overall (SMD 0.49, 95% CI 0.31 to 0.66; P < 0.00001, I2 = 74%; 11 studies, 550 participants; very low-certainty evidence), equating to 1.41 points on the Frontal Assessment Battery (range: 0-18). Of the cognitive subdomains, we found evidence of effect of possible clinical importance, immediately after intervention, for sustained visual attention (moderate certainty) equating to 15.63 seconds, for working memory (low certainty) equating to 59.9 seconds, and thinking flexibly (low certainty), compared to control.

AUTHORS' CONCLUSIONS

The effectiveness of occupational therapy for cognitive impairment poststroke remains unclear. Occupational therapy may result in little to no clinical difference in BADL immediately after intervention and at three and six months' follow-up. Occupational therapy may slightly improve global cognitive performance of a clinically important difference immediately after intervention, likely improves sustained visual attention slightly, and may slightly increase working memory and flexible thinking after intervention. There is evidence of low or very low certainty or insufficient evidence for effect on other cognitive domains, IADL, and community integration and participation.  Given the low certainty of much of the evidence in our review, more research is needed to support or refute the effectiveness of occupational therapy for cognitive impairment after stroke. Future trials need improved methodology to address issues including risk of bias and to better report the outcome measures and interventions used.

Lesion location may attenuate response to strategy training in acute stroke

BACKGROUND

Strategy training, a rehabilitation intervention, reduces disability and improves functional skills associated with goal-directed behavior. Stroke lesions impacting selected ventromedial regions of interest associated with initiation of goal-directed behavior may attenuate intervention response. If so, strategy training may not be optimal for people with stroke lesions in these regions.

OBJECTIVE

To examine whether ventromedial regions of interest attenuate changes in disability status attributed to strategy training.

DESIGN

Secondary analysis of data from two randomized controlled clinical trials.

SETTING

Inpatient stroke rehabilitation.

PARTICIPANTS

People with acute stroke diagnosis and available diagnostic studies enrolled in inpatient rehabilitation randomized controlled studies between 2009 and 2017.

INTERVENTION

Participants were randomized to strategy training or a control condition in addition to the usual care during inpatient rehabilitation.

MAIN OUTCOME MEASURES

Diagnostic magnetic resonance imaging studies were retrieved from electronic medical records, and stroke lesion location was characterized by a neuroradiologist. Intervention response was defined by Functional Independence Measure change scores of 22 points or greater.

RESULTS

Only 186 of 275 participants had diagnostic studies available; 13 patients showed no apparent lesion on their diagnostic study. Among 173 cases, 156 had complete data at discharge (strategy training n = 71, control n = 85). Twenty-five cases had a lesion within a region of interest (strategy training n = 14, control n = 11). Intervention response was attenuated in the strategy training group for those with lesions in regions of interest [χ² (1, n = 71) = 4.60, P = .03], but not for those in the control group [Fisher exact test, n = 85, P = .19).

CONCLUSIONS

Lesions in the ventromedial regions of interest may attenuate response to strategy training.

Setting priorities for ageing research in Africa: A systematic mapping review of 512 studies from sub-Saharan Africa

Background

In 2040, the older population's growth rate in sub-Saharan Africa (SSA) will be faster than those experienced by developed nations since 1950. In preparation for this growth, the National Institute on Aging commissioned the National Academies' Committee on Population to organize a workshop on advancing aging research in Africa. This meeting provided a platform for discussing some areas requiring improvement in aging research in SSA regions. We believed that conducting a systematic review of peer-reviewed articles to set priorities for aging research in SSA is warranted. Therefore, this article is the first in a Four-Part series that summaries the types and trends of peer-reviewed studies in SSA.

Methods

This systematic mapping review followed the Search-Appraisal-Synthesis-Analysis Framework. We systematically searched multiple databases from inception till February 2021 and included peer-reviewed articles conducted with/for older adults residing in SSA. Conventional content analysis was employed to categorize studies into subject-related areas.

Results

We included 512 studies (quantitative = 426, qualitative = 71 and mixed-method = 15). Studies were conducted in 32 countries. Quantitative studies included were observational studies: cross-sectional (n = 250, 59%), longitudinal (n = 126, 30%), and case-control (n = 12, 3%); and experimental studies: pre-post design (n = 4, 1%), randomized control trial (RCT, n = 12, 3%); and not reported (n = 21, 5%). Fifteen qualitative studies did not state their study design; where stated, study design ranged from descriptive (n = 14, 20%), ethnography (n = 12, 17%), grounded theory (n = 7, 10%), narrative (n = 5, 7%), phenomenology (n = 10, 14%), interpretative exploratory (n = 4, 6%), case studies (n = 4, 6%). Of the 15 mixed-method studies, seven did not state their mixed-method design. Where stated, design includes concurrent (n = 1), convergent (n = 1), cross-sectional (n = 3), informative (n = 1), sequential exploratory (n = 1) and retrospective (n = 2). Studies were classified into 30 (for quantitative studies) and seven (for qualitative and mixed-method) subject-related areas. HIV/AIDs-related and non-communicable diseases-related studies were the most predominant subject-related areas. No studies explored the transdisciplinary co-production of interventions.

Conclusions

There are glaring gaps in ageing research in SSA, especially mixed-methods and RCTs. A large number of studies focused on HIV/AIDs and non-communicable disease-related studies. National and international funding agencies should set up priority funding competitions for transdisciplinary collaborations in ageing research.

Setting priorities for ageing research in Africa: A systematic mapping review of 512 studies from sub-Saharan Africa

BACKGROUND

In 2040, the older population's growth rate in sub-Saharan Africa (SSA) will be faster than those experienced by developed nations since 1950. In preparation for this growth, the National Institute on Aging commissioned the National Academies' Committee on Population to organize a workshop on advancing aging research in Africa. This meeting provided a platform for discussing some areas requiring improvement in aging research in SSA regions. We believed that conducting a systematic review of peer-reviewed articles to set priorities for aging research in SSA is warranted. Therefore, this article is the first in a Four-Part series that summaries the types and trends of peer-reviewed studies in SSA.

METHODS

This systematic mapping review followed the Search-Appraisal-Synthesis-Analysis Framework. We systematically searched multiple databases from inception till February 2021 and included peer-reviewed articles conducted with/for older adults residing in SSA. Conventional content analysis was employed to categorize studies into subject-related areas.

RESULTS

We included 512 studies (quantitative = 426, qualitative = 71 and mixed-method = 15). Studies were conducted in 32 countries. Quantitative studies included were observational studies: cross-sectional (n = 250, 59%), longitudinal (n = 126, 30%), and case-control (n = 12, 3%); and experimental studies: pre-post design (n = 4, 1%), randomized control trial (RCT, n = 12, 3%); and not reported (n = 21, 5%). Fifteen qualitative studies did not state their study design; where stated, study design ranged from descriptive (n = 14, 20%), ethnography (n = 12, 17%), grounded theory (n = 7, 10%), narrative (n = 5, 7%), phenomenology (n = 10, 14%), interpretative exploratory (n = 4, 6%), case studies (n = 4, 6%). Of the 15 mixed-method studies, seven did not state their mixed-method design. Where stated, design includes concurrent (n = 1), convergent (n = 1), cross-sectional (n = 3), informative (n = 1), sequential exploratory (n = 1) and retrospective (n = 2). Studies were classified into 30 (for quantitative studies) and seven (for qualitative and mixed-method) subject-related areas. HIV/AIDs-related and non-communicable diseases-related studies were the most predominant subject-related areas. No studies explored the transdisciplinary co-production of interventions.

CONCLUSIONS

There are glaring gaps in ageing research in SSA, especially mixed-methods and RCTs. A large number of studies focused on HIV/AIDs and non-communicable disease-related studies. National and international funding agencies should set up priority funding competitions for transdisciplinary collaborations in ageing research.

Early apathetic, but not depressive, symptoms are associated with poor outcome after stroke

BACKGROUND AND PURPOSE

Depression and apathy are frequent neuropsychiatric disturbances after stroke and may appear together. Despite the overlap in symptoms between poststroke depression and apathy, these two syndromes might be associated with different prognoses and benefit from different treatments. We aimed to disentangle the relationship between early depressive and apathetic symptoms and outcome after stroke.

METHODS

Of 698 enrolled patients with ischemic stroke, we included 443 participants (median age = 69 years, 51% female) who underwent depressive and apathetic symptom assessment on Day 8 after stroke. We divided patients into four groups: without greater depressive and apathetic symptoms (Group 1), with only apathetic symptoms (Group 2), with only depressive symptoms (Group 3), and with both depressive and apathetic symptoms (Group 4).

RESULTS

After adjusting for age and stroke severity, Group 2 and Group 4 had an increased risk of poor 3-month outcome (odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.16-3.38, p = 0.01 and OR = 1.58, 95% CI = 1.24-2.01, p < 0.01, respectively). Group 2 and Group 4 also had an increased risk of poor 12-month outcome (OR = 3.85, 95% CI = 2.19-6.78, p < 0.01 and OR = 1.54, 95% CI = 1.22-1.96, p < 0.01, respectively) and mortality (hazard ratio [HR] = 2.76, 95% CI = 1.19-6.41, p = 0.02 and HR = 1.77, 95% CI = 1.32-2.38, p < 0.01, respectively). Compared with Group 1, Group 3 did not have an increased risk of unfavorable outcomes.

CONCLUSIONS

Early apathetic, but not depressive, symptoms are related to worse outcomes after stroke. Our study underscores the importance of recognizing apathetic symptoms independently from depressive symptoms.

Apathy after stroke: Diagnosis, mechanisms, consequences, and treatment

Apathy is a reduction in goal-directed activity in the cognitive, behavioral, emotional, or social domains of a patient’s life and occurs in one out of three patients after stroke. Despite this, apathy is clinically under-recognized and poorly understood. This overview provides a contemporary introduction to apathy in stroke for researchers and practitioners, covering topics including diagnosis, neurobiological mechanisms, associated consequences, and potential treatments for apathy. Apathy is often misdiagnosed as other post-stroke conditions such as depression. Accurate differential diagnosis of apathy, which manifests as reductions in initiative, and depression, which manifests as negative emotionality, is important as it informs prognosis. Research on the neurobiology of apathy suggests that there are few consistent associations between stroke lesion location and the development of apathy. These may be resolved by adopting a network neuroscience approach, which models apathy as a pathology arising from structural or functional damage to brain networks underlying motivated behavior. Importantly, networks can be affected by physiological changes related to stroke, including the acute infarct but also diaschisis and neurodegeneration. Aside from neurobiological changes, apathy is also associated with other negative outcome measures such as functional disability, cognitive impairment, and emotional distress, suggesting that apathy is indicative of a worse prognosis following stroke. Unfortunately, high-quality trials aimed at treating apathy are scarce. Antidepressants may have limited effects on apathy. Acetylcholine and dopamine pharmacotherapy, behavioral interventions, and transcranial magnetic stimulation may be more promising avenues for treatment.

Post-Intensive Care Unit Care. A Qualitative Analysis of Patient Priorities and Implications for Redesign

Rationale: Although survival during critical illness is improving, little evidence exists to guide post-intensive care unit (ICU) care. Understanding patients' needs and priorities is fundamental to improving care quality.Objectives: To describe the evolution of patients' priorities for recovery across the spectrum of post-ICU care.Methods: This was a secondary analysis of 39 semistructured interviews conducted from 2005 to 2006 in participants' homes 19 days to 11 years after hospital discharge after critical illness. Adult critical illness survivors (N = 39) aged 20 years or older from multiple ICUs across the United Kingdom were purposively selected to maximize diversity with respect to time since diagnosis, disease severity, sex, age, ethnicity, socioeconomic group/status, region. age, ICU admitting diagnoses, and length of stay. We used the method of qualitative description to characterize patients' priorities for recovery and their evolution within and between individual patients across three post-ICU periods: ICU transition to wards, early period (approximately the first 2 mo) after discharge to home, and late period (>2 mo) after discharge to home.Results: The analysis revealed 12 core patient priorities during recovery: feeling safe, being comfortable, engaging in mobility, participating in self-care, asserting personhood, connecting with people, ensuring family well-being, going home, restoring psychological health, restoring physical health, resuming previous roles and routines, and seeking new life experiences. In general, priorities evolved from those pertaining to basic survival during the stay on wards to being broader and more aspirational by the late postdischarge period.Conclusions: Understanding patients' priorities for post-ICU care is critical for developing stakeholder-driven clinical guidelines. Engaging other stakeholders (e.g., family members, healthcare providers, and institutionalized and frail older adults) to inform the development of clinical guidelines for post-ICU care, together with the barriers and facilitators faced in achieving patient- and family-centered care, is an important next step.

Goal Setting Improves Cognitive Performance in a Randomized Trial of Chronic Stroke Survivors

BACKGROUND AND PURPOSE

Cognitive impairment after stroke, especially executive and attention dysfunction, is common, negatively affects daily functioning, and has limited treatment options. A single-blind, parallel-design, randomized controlled trial was used to examine the impact of goal setting on poststroke cognitive performance.

METHODS

Stroke survivors (n=72; mean age, 68.38 [SD=11.84] years; 69.4% men) in the chronic phase (≥3 months) after stroke from an academic stroke prevention clinic were randomly assigned to receive goal-setting instructions (n=36) or standard instructions (n=36) after completing baseline cognitive measures of executive function (primary outcome), attention/working memory, verbal learning, and verbal recall.

RESULTS

A one-way mixed multivariate analysis of covariance (MANCOVA) found a group by instructional manipulation interaction effect for executive function (Wilks λ=0.66; F[3,66]=11.30; P≤0.001; η²_p=0.34), after adjusting for age and years of education. After similar adjustment, attention/working memory (Wilks λ=0.86; F[5,63]=2.10; P=0.043; η²_p=0.16) and verbal learning (F[1,60]=5.81; P=0.019; η²_p=0.09) also showed improvement after instruction but not verbal recall (Wilks λ=0.95; F[1,56]=2.82; P=0.099; η²_p=0.05). There were no adverse events.

CONCLUSIONS

Goal setting improved executive function, attention/working memory, and learning in a heterogeneous sample in the chronic phase after stroke. This suggests that >3 months after stroke, vascular cognitive impairment is not a fixed deficit; there is a motivational contributor. Brief treatments targeting goal-oriented behavior and motivation may serve as a novel approach or adjunct treatment to improve cognitive outcomes after stroke. Future research should investigate the use of goal setting on functional outcomes (eg, instrumental activities of daily living and vocational function) in this population, highlighting new potential avenues for treatment for vascular cognitive impairment. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03511300.

The Application of Lexical Retrieval Training in Tablet-Based Speech-Language Intervention

In the setting of shortened hospitalization periods, periods of confinement and social isolation, limited resources, and accessibility, technology can be leveraged to enhance opportunities for rehabilitative care (1). In the current manuscript, we focus on the use of tablet-based rehabilitation for individuals with aphasia, a language disorder that frequently arises post-stroke. Aphasia treatment that targets naming through effortful and errorful instances of lexical retrieval, where corrective feedback is generated on every trial, may enhance retention and generalizability of gains (2, 3). This pilot evaluation explored how six individuals with aphasia interacted with a tablet-based therapy application that targeted lexical retrieval. Participants with aphasia either (1) autonomously engaged with the therapy tasks or (2) received systematic encouragement to effortfully retrieve words. Behaviors of response latency and cue use were examined to gain insights into the behavioral patterns of both groups, as well as analyses of task accuracy and outcomes on standardized cognitive-linguistic assessments. Despite some variability, initial observations suggest that participants who received systematic training refrained from using cues to complete tasks and spent longer on each trial, which ultimately co-occurred with increased independent engagement with therapy and improved standardized outcomes. Preliminary results present an alternative means of leveraging technology to implement best-practice recommendations in the context of aphasia telerehabilitation.

IMAGINE study protocol of a clinical trial: a multi-center, investigator-blinded, randomized, 36-month, parallel-group to compare the effectiveness of motivational interview in rehabilitation of older stroke survivors

BACKGROUND

Rehabilitation pathways are crucial to reduce stroke-related disability. Motivational Interviewing (MI), as a person-centered complex intervention, aimed to empower and motivate, and could be a resource to improve rehabilitation outcomes for older stroke survivors. The IMAGINE project aims to assess the impact of MI, as a complement to standard geriatric rehabilitation, on functional improvement at 30 days after admission, compared to standard geriatric rehabilitation alone, in persons admitted to geriatric rehabilitation after a stroke. Secondary objectives include assessing the impact of MI on physical activity and performance, self-efficacy, safety, cost-utility, participants' experiences and functional status at 3 months.

METHODS

We will conduct a multicenter randomized clinical trial in three geriatric rehabilitation hospitals in Spain. Older adults after mild-moderate stroke without previous severe cognitive impairment or disability will be randomized into the control or intervention group (136 per group, total N = 272). The intervention group will receive 4 sessions of MI by trained nurses, including the design of a personalized rehabilitation plan agreed between stroke survivors and nurses based on stroke survivors´ goals, needs, preferences and capabilities. Main outcome will be the Functional Independence Measure (FIM). In-hospital physical activity will be measured through accelerometers and secondary outcomes using validated scales. The study includes a process evaluation and cost-utility analysis.

DISCUSSION

Final results are expected by end of 2020. This study will provide relevant information on the implementation of MI as a rehabilitation reinforcement tool in older stroke survivors. A potential reduction in post-stroke disability and dependence would increase person's health-related quality of life and well-being and reduce health and social care costs. IMAGINE has the potential to inform practice and policymakers on how to move forward towards shared decision-making and shared responsibilities in the vulnerable population of older stroke survivors.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03434938 , registered on January 2018.

Feasibility and acceptability of the multicontext approach for individuals with acquired brain injury in acute inpatient rehabilitation: A single case series

The Multicontext (MC) approach, a metacognitive intervention designed to improve awareness, strategy use, and executive functioning, may be beneficial for individuals with acquired brain injury (ABI) undergoing acute inpatient rehabilitation. The goal of this study was to provide evidence of feasibility and acceptability of the MC approach and to explore clinical outcomes. A case series of eight individuals with acquired brain injury and at least mild executive functioning impairment were recruited from an acute inpatient rehabilitation unit. The MC approach - involving guided questioning and patient self-generation of strategies practiced across everyday functional cognitive tasks - was implemented within routine occupational therapy. Occupational therapists implemented the MC approach with high adherence to the treatment protocol. Therapists' perceived challenges were the time constraints of inpatient rehabilitation as well as client factors. Participants rated the MC approach as highly satisfying and engaging. They described subjective improvements in their ability to use executive functioning strategies. The MC approach was associated with improvement in awareness, strategy use, and executive functioning at the conclusion of treatment. The MC approach may be a beneficial intervention for individuals with acquired brain injury and executive dysfunction undergoing acute inpatient rehabilitation. Further evaluation with larger samples in controlled trials is warranted.Trial registration: ClinicalTrials.gov identifier: NCT04363645..

Establishing and measuring treatment fidelity of a complex cognitive rehabilitation intervention: The multicontext approach

Introduction

This article describes the process of establishing and measuring treatment fidelity of a complex cognitive rehabilitation intervention that uses a metacognitive strategy framework (the multicontext approach). We adapted treatment guidelines for use within an inpatient rehabilitation setting for people with acquired brain injury; explored training methods and therapist perspectives; developed and examined inter-rater reliability of a fidelity measure; and examined adherence to and proficiency of treatment methods.

Method

Therapist perspectives of the intervention and training were obtained from written questionnaires and reflections. Inter-rater reliability of 21 treatment components across 22 video-recorded treatment sessions was assessed by examining absolute agreement between two raters using Cohen’s kappa. The proportion of treatment components implemented in individual sessions as well as average proficiency ratings was calculated.

Results

The fidelity measure demonstrated good inter-rater agreement, ranging from 91–100% for treatment adherence and kappa of .77 to .94 for therapist proficiency. Adherence and proficiency varied between therapists but increased to nearly proficient levels with adjustments to training and procedures. Therapists highlighted the critical importance of video review as a training tool.

Conclusion

The fidelity measure provides a clinical tool for therapist self-reflection, supervision and training, as well as a tool for future research.

Preventing disability in older adults with mild cognitive impairment: A Strategy Training intervention study

Non-pharmacological interventions designed to change cognitive function in older adults with Mild Cognitive Impairment have shown mixed results. Few studied interventions directly address preclinical disability. Slowing changes in disability are critical preserve independence and health related quality of life in older adults with Mild Cognitive Impairment. In this study, we discuss the design of the trial, challenges encountered, and solutions generated to guide future trials designed to prevent the onset of disability among at-risk older adults. We compared Strategy Training to enhanced-usual care in 30 older adults with Mild Cognitive Impairment. We recruited 79.7% (n = 188) of the potential participants through direct-to-consumer recruitment. We refined a three-step screening process, including a phone screen, initial in-person screening, and full in-person screening. This screening processes resulted in a high percentage of older adults completing the neuropsychological battery and adjudication of Mild Cognitive Impairment. Conducting a disability prevention among individuals without overt disability is a novel approach. Nevertheless, one of the greatest limitations to our project is the fact that follow-up is restricted to 1 year. Findings from this study can inform the design and conduct of future clinical trials that seek to slow progression of disability in older adults with Mild Cognitive Impairment.

Effectiveness of occupation-based interventions on performance's quality for hemiparetic stroke in community-dwelling: A randomized clinical trial study

BACKGROUND

Occupations define activities that people perform to occupy themselves and that people have meaning and value to them. The use of occupation-based intervention addresses activity daily of living performance.

OBJECTIVES

This study was to investigate the effects of occupation-based interventions on performance's quality for hemiparetic stroke in community-dwelling.

METHODS

Forty-three participants were enrolled in this study with a full understanding of the purpose and method of the research and had a diagnosis with hemiparetic stroke. Participants were randomized to one of two treatment groups: Experimental group (n = 23) or control groups (n = 20). The experimental group applied occupation-based intervention and control group applied action focusing intervention. All participants underwent ten treatment sessions during the study period and conducted pre- and post-assessment. Several instruments were used to measure quality of performance.

RESULTS

After the intervention training, the qualities of occupational performance were significantly higher in the experimental group applied occupation-based intervention than the control group applied action focusing intervention (p < 0.001).

CONCLUSIONS

Based on the results of this study, occupation-based intervention has positive effects on quality of performing daily activities and occupational activities independently in persons with hemiparetic stroke.

Developing a Non-Pharmacological Intervention for Individuals With Mild Cognitive Impairment

The purpose of this study is to describe one potential intervention model that is designed to slow decline to disability for individuals at-risk for dementia due to Mild Cognitive Impairment. Strategy training is a treatment model that focuses on behavioral activation through addressing barriers to daily activities. Strategy training encourages development of goals and plans to address self-identified impaired processes, and it maintains or improves individuals' ability to perform desired activities. Progression to dementia may be slowed due to the link between engagement in daily activities and production of biological factors associated with neurocognitive health. We demonstrated that an older adult with mild cognitive impairment is able to develop goals, establish effective plans, and engage in daily activities through the strategy training intervention model.

Comparison of two cognitive interventions for adults experiencing executive dysfunction post-stroke: a pilot study

Purpose This pilot partially randomised controlled trial compared the feasibility and preliminary efficacy of two promising interventions for persons with executive dysfunction post-stroke: (1) occupation-based strategy training using an adapted version of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach; and (2) Computer-based EF training (COMPUTER training). Method Participants received 16 h of either CO-OP or COMPUTER training. We assessed feasibility and acceptability of each intervention, and change in intervention outcomes at baseline, post-intervention and one-month follow-up. Performance and satisfaction with performance in self-selected everyday life goals were measured by the participant and the significant other-rated Canadian Occupational Performance Measure (COPM). Other intervention outcomes included changes in EF impairment, participation in daily life and self-efficacy. Results Six participants received CO-OP and five received COMPUTER training: one in each group discontinued the intervention for medical reasons unrelated to the intervention. The remaining nine participants completed all 16 sessions. Participants expressed high levels of satisfaction with both interventions. Both treatment groups showed large improvements in self and significant other-rated performance and satisfaction with performance on their goals immediately post-intervention and at follow-up (CO-OP: effect sizes (ES) = 1.6-3.5; COMPUTER: ES = 0.9-4.0), with statistically significant within-group differences in CO-OP (p < 0.05). The COMPUTER group also showed large improvements in some areas of EF impairment targeted by the computerised tasks (ES = 0.9-1.6); the CO-OP group demonstrated large improvements in self-efficacy for performing everyday activities (ES = 1.5). Conclusions Our findings provide preliminary evidence supporting the feasibility of using both CO-OP and COMPUTER training with patients with executive dysfunction post-stroke. Implications for Rehabilitation Computerised executive function training and occupation-based strategy training are feasible to deliver and acceptable to persons with executive dysfunction post-stroke. Preliminary evidence suggests that both interventions have a positive impact on real-world outcomes; and, that CO-OP might have a greater impact on improving self-efficacy for performing everyday activities.