Feasibility of Cognitive Functions Screened With the Montreal Cognitive Assessment in Determining ADL Dependence Early After Stroke

Screening for post-stroke neurocognitive disorders in diverse populations: A systematic review

Objective: Although neurocognitive disorders (NCD) are common post-stroke, many populations do not have adapted cognitive screens and cut-offs. We therefore reviewed the appropriateness of the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and Oxford Cognitive Screen (OCS) for diagnosing NCD in culturally diverse stroke populations. Method: Using an extensive search string, diagnostic accuracy studies for MMSE, MoCA and OCS in the stroke population were retrieved from four databases. We compared translations and adaptations, adjustments in scores and cut-offs, and their diagnostic accuracy. Results: The search resulted in 28 MMSE, 39 MoCA and 5 OCS-studies in 13 western, educated, industrialized, rich and democratic (WEIRD) and 4 other countries. There was a lack of studies on South-American, African, and non-Chinese-Asian populations. All three tests needed adaptation for less WEIRD populations and populations with languages with non-Latin features. Optimal MMSE and OCS subtest cut-offs were similar across WEIRD and less WEIRD populations, whereas optimal MoCA cut-offs appeared lower for less WEIRD populations. The use of adjusted scores resulted in different optimal cut-offs or similar cut-offs with better accuracy. Conclusions: MoCA, MMSE and OCS are promising tools for diagnosing post-stroke-NCD. For culturally diverse populations, translation, adaptation and adjusted scores or cut-offs are necessary for diagnostic accuracy. Available studies report scarcely about their sample's cultural background and there is a lack of diagnostic accuracy studies in less WEIRD or culturally diverse populations. Future studies should report more cultural characteristics of their sample to provide better insight into the tests' accuracy in culturally diverse populations.

Digital computerised cognitive training for preventing cognitive decline among hypertensive patients: a study protocol for a multicentre randomised controlled trial (DELIGHT trial)

INTRODUCTION

Mild cognitive impairment (MCI) is an important intervenable stage for the prevention of dementia. Hypertension is associated with impaired cognition, and when combined with MCI, it may lead to a poor prognosis. Digital computerised cognitive training (CCT) has recently become a potential instrument for improving cognition, but evidence for its efficacy remains limited. This study aims to evaluate the efficacy of a digital adaptive CCT intervention in older patients with hypertension and MCI.

METHODS AND ANALYSIS

The multicentre, double-blinded, randomised, actively -controlled clinical trial will recruit 200 older (≥60 years) patients with hypertension and MCI from 11 hospitals across China. Participants will be randomly assigned in a 1:1 ratio to the intervention group (multidomain adaptative CCT) and active control group (non-adaptive cognitive training) for 12-week cognitive training for 30 min/day and 5 days/week. Those who have completed their 12-week training in the intervention group will be rerandomised into the continuation and discontinuation training groups. All participants will be followed up to 24 weeks. Neuropsychological assessments and structural and functional 7.0 T MRI will be obtained at baseline and at 12-week and 24-week follow-up. The primary outcome is the possible improvement of global cognitive function at 12 weeks, as measured by the Basic Cognitive Aptitude Tests. Secondary and exploratory endpoints include the major cognitive domain function improvement, self-efficacy, mental health, quality of life and MRI measurements of the brain.

ETHICS AND DISSEMINATION

The trial has been approved by the institutional review board of Beijing Anzhen Hospital and thereafter by all other participating centres. Trial findings will be disseminated in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05704270.

A register-based study on associations between pre-stroke physical activity and cognition early after stroke (part of PAPSIGOT)

The objective was to investigate if pre-stroke physical activity is associated with intact cognition early after stroke. The study design was a cross-sectional, register-based study. The study sample included 1111 adults with first stroke (mild or moderate severity) admitted to three Swedish stroke units. The main outcome was cognition. The associations of pre-stroke physical activity, age, sex, smoking, diabetes, atrial fibrillation, previous TIA, statin treatment, hypertension treatment, reperfusion therapies, stroke severity, and education on the outcome cognition were analyzed using binary logistic regression. Physical activity was assessed within 48 h of admittance, and cognition was screened during stroke unit care. The results were: mean age 70 years, 40% women, 61% pre-stroke physically active, and 53% with post-stroke cognitive impairment. Patients with pre-stroke light or moderate physical activity have higher odds for intact cognition compared to inactive: odds ratio (95% confidence interval) 1.32 (0.97-1.80) and 2.04 (1.18-3.53), respectively. In addition to pre-stroke physical activity, people with younger age, a higher level of education, less severe stroke (more mild than moderate), being non-diabetic, and non-smoking have higher odds for intact cognition. In conclusion physical activity before stroke is associated with intact cognition in patients with mild and moderate stroke.

Patients' and professionals' perspectives on the consideration of patients' convenient therapy periods as part of personalised rehabilitation: a focus group study with patients and therapists from inpatient neurological rehabilitation

BACKGROUND

Research on the optimal period for administering health services, especially rehabilitation interventions, is scarce. The aims of this study were to explore the construct of patients' convenient therapy periods and to identify indicators based on the perspectives of patients and different health professionals from inpatient neurological rehabilitation clinics.

METHODS

This study was part of a larger project on patients' convenient therapy periods following a mixed methods approach. In the current study a grounded theory approach was employed based on the use of focus group interviews. Focus group interviews were conducted in three different inpatient neurological rehabilitation clinics. Patients and therapists from inpatient neurological rehabilitation clinics who were able to speak and to participate in conversations were included.

RESULTS

A total of 41 persons, including 23 patients and 18 therapists, such as music and occupational therapists, participated in a total of six focus group interviews. The analysis of the focus group interviews resulted in the identification of a total of 1261 codes, which could be summarised in fifteen categories. However, these categories could be divided into five indicators and ten impact factors of convenient therapy periods. Identified indicators were verbal and non-verbal communication, mental functions, physiological needs, recreational needs, and therapy initiation.

CONCLUSIONS

The results provide initial evidence that convenient therapy periods are clinically relevant for patients and therapists. Different states of patients' ability to effectively participate in a rehabilitation intervention exist. A systematic consideration of patients' convenient therapy periods could contribute to a personalised and more efficient delivery of intervention in neurological rehabilitation. To our knowledge, this study is one of the first attempts to research convenient therapy periods.

Determining readiness for a reablement approach to care in Australia: Development of a pre-employment questionnaire

Reablement is described as a goal directed intervention with a view to maintain or improve the independence of clients through "doing with, rather than doing for". As a relatively new concept in care, lack of specific skills in reablement is not uncommon, however, intrinsic values aligned with reablement are beneficial to organisations providing care and support to clients. The aim of this study is to develop a pre-employment questionnaire to assess readiness for a reablement approach to care as a step towards developing a reablement culture across organisations. A questionnaire based on activities of daily living (ADL), developed by the research team in consultation with a local community-based care organisation, was completed by 166 staff members at a community-based care organisation in Tasmania across several timepoints during and following reablement education sessions in 2018. The scores from these questionnaires were utilised to develop a questionnaire appropriate for determining readiness for reablement prior to employment within the organisation. Over a period of twelve months, a total of 407 Reablement Readiness Questionnaires were submitted by staff, indicating high levels of willingness to engage in reablement prior to and following the education sessions. Exploratory factor analyses were performed, and the construct validity and internal consistency of the emerging factors were assessed. An exploratory factor analysis indicated that ADL, in relation to reablement, consist of three dimensions-Lifestyle, My body and Connecting. The corresponding questions were subsequently built into an online questionnaire for pre-employment use. This questionnaire also has potential benefit in recruitment of staff to other community service organisations, to ascertain their readiness for reablement prior to beginning a variety of different roles within client care and support.

Dependency in Activities of Daily Living During the First Year After Stroke

Background: Dependency in personal activities of daily living (ADL) is a common short-term and long-term consequence of stroke and requires targeted rehabilitation. As the duration of hospital stay has become shorter in recent decades, early identification of patients who require rehabilitation has become vital. To our knowledge, no study has investigated whether ADL dependency in the very early stages after admission to the stroke unit can explain ADL dependency 3 and 12 months later. This knowledge would facilitate planning for very early discharge and patient-centered rehabilitation.

Objective: This study evaluated whether ADL dependency within 2 days after stroke could explain ADL dependency at 3 and 12 months after stroke.

Methods: This longitudinal cohort study included patients with stroke who were treated at a stroke unit in the Sahlgrenska University Hospital (Gothenburg, Sweden) between May 2011 and March 2016. The primary independent variable was ADL dependency at 36–48 h after admission to the stroke unit, which was assessed using a Barthel Index (BI) score of ≤90. The dependent variables were self-reported personal ADL dependency at 3 and 12 months after stroke. Binary logistic regression analyses were performed.

Results: Of 366 eligible patients (58% male; median age 71 years), a majority (76%) had mild stroke and 60% were ADL dependent 36–48 h after stroke. Univariable and multivariable logistic regression analyses showed that patients who were dependent within the first 2 days after stroke had higher odds for being dependent 3 months as well as 12 months after stroke.

Conclusion: The results indicated that dependency in personal ADL during the first 2 days can explain dependency at 3- and 12-month post-stroke. Therefore, early ADL assessments post-stroke can be used for understanding rehabilitation needs after stroke.

Effect of Baduanjin exercise on cognitive function in patients with post-stroke cognitive impairment: a randomized controlled trial

OBJECTIVE

To investigate the effectiveness and safety of Baduanjin training on the cognitive function in stroke survivors with cognitive impairment.

DESIGN

A randomized, two-arm parallel controlled trial with allocation concealment and assessors blinding.

SETTING

Community centre of Fuzhou city, China.

SUBJECTS

A total of 48 participants were recruited and randomly allocated into the Baduanjin exercise intervention or control group.

INTERVENTIONS

The control group maintained original medication and rehabilitation treatment. The Baduanjin training group received 24-week Baduanjin training with a frequency of three days a week and 40 minutes a day based on original medication and rehabilitation treatment.

MAIN OUTCOME MEASURES

The primary outcome was global cognitive function. Secondary outcome measures included the specific domains of cognition (i.e. memory, processing speed, execution, attention and visuospatial ability) and activities daily living.

RESULTS

In total, 41 (Baduanjin n = 22, control n = 19) participants completed 24-week treatment and data collection. Mean differences between groups at 24-week treatment were statistically significant for global cognitive function (MoCA: 2.54 (0.91 to 4.16)), execution (TMT-A: -42.4 (-75.0 to -9.8); TMT-B: -71.3 (-130.6 to -12.1)), memory (immediate recall: 2.11 (0.49 to 3.73); short-term delayed recognition: 2.47 (0.58 to 4.35) and long-term delayed recognition: 1.68(0.18 to 3.17)), attention (response time of alertness: -245.5 (-387 to -104)) and activities of daily living (modified Barthel Index).

CONCLUSION

Regular Baduanjin training is associated with less loss of cognitive function in patients after stroke.

Association Between Early Cognitive Impairment and Midterm Functional Outcomes Among Chinese Acute Ischemic Stroke Patients: A Longitudinal Study

Background: Cognitive decline is common after stroke. The influence of early cognitive impairment on midterm functional outcomes among Chinese acute ischemic stroke (AIS) patients has not been fully studied. The aim of the study was to assess the association between early cognitive impairment and midterm functional outcomes among Chinese AIS patients.

Methods: A longitudinal survey focusing on Chinese AIS patients was conducted in three stroke centers in Shanghai, China (July to December 2016). A total of 185 eligible patients were interviewed at acute stage and at 1, 3, and 6 months after onset. Patients' functional outcomes were measured by modified Rankin Scale (mRS) and Barthel Index (BI) at each time point. Cognitive function was assessed using Montreal Cognitive Assessment, Changsha version (MoCA-CS), within 7 days after stroke onset. Covariates included patient's demographic characteristics, socioeconomic status, clinical characteristics of stroke, vascular risk factors, receiving rehabilitation after discharge from acute hospital, and recurrence. Generalized linear mixed models and general linear mixed models were applied.

Results: The prevalence of cognitive impairment at acute stage of stroke among these patients was 88.1%. The risk of disability (mRS 2–5) of all patients after stroke decreased over time (OR = 0.491, 95% CI = 0.401–0.603). The risk of disability among those with cognitive impairment increased compared with those with normal cognition (OR = 7.384, 95% CI = 1.041–52.407). The BI score of all patients increased over time after controlling for covariates (β = 1.51, p < 0.01). The BI score of those with cognitive impairment was lower than that with normal cognition over the follow-up period after controlling for other covariates (β = −8.11, p < 0.05).

Conclusions: This study showed that early cognitive impairment was associated with higher risk of disability and poor activity of daily living (ADL) among Chinese AIS patients. Further studies are needed to examine the linkage between multi-domain cognitive impairment and long-term disability and ADL among stroke survivors by using neuropsychological test batteries.

NIHSS is not enough for cognitive screening in acute stroke: A cross-sectional, retrospective study

The aim of this study was to investigate whether the cognitive subscale of the National Institute of Health Stroke Scale (NIHSS), the Cog-4, can detect cognitive deficits in acute stroke. This was a cross-sectional, retrospective study. The study sample consisted of people with stroke enrolled in an acute stroke unit. The index test Cog-4 was calculated based on admission NIHSS score. The reference standard instrument, the Montreal Cognitive Assessment (MoCA), was performed within 36–48 h of admission. Non-parametric statistics were used for data analyses. The study included 531 participants with a mean age of 69 years. The Cog-4 failed to identify cognitive deficits in 65%, 58%, and 53% of patients when the MoCA thresholds for impaired cognition were set at ≤25 p, ≤23 p, and ≤19 p, respectively, were chosen for impaired cognition. The agreement between the Cog-4 and the MoCA was poor; Cohen’s kappa was from −0.210 to −0.109, depending on the MoCA cut-offs. The sensitivity of the Cog-4 was 35%, 42% and 48% for the MoCA thresholds for impaired cognition ≤25, ≤23 and ≤19 points, respectively. The Cog-4 has a limited ability to identify cognitive deficits in acute stroke. More structured and comprehensive tests should be employed as diagnostic tools.

Very Early MoCA Can Predict Functional Dependence at 3 Months After Stroke: A Longitudinal, Cohort Study

Introduction: After a stroke, cognitive impairment is commonly associated with poor functional outcomes. The primary aim of this study was to investigate if cognitive function, assessed with the Montreal Cognitive Assessment (MoCA) 36–48 h after stroke, could predict functional dependence 3 months later. The secondary aim was to identify an optimal threshold for the MoCA score that could predict functional dependence.

Materials and Methods: This was a longitudinal cohort study. The research database from a stroke unit at the Sahlgrenska University Hospital was linked with the Swedish Stroke Register—Riksstroke. Cognitive function and activities of daily living (ADL) were assessed with the MoCA and the Barthel Index (BI), respectively, 36–48 h after stroke. Functional outcome 3 months after stroke was studied with the modified Rankin Scale. The predictive characteristics of the MoCA were investigated using logistic regression analyses. Receiver operating characteristic curves (AUC) were used for identifying the optimal cutoff score on the MoCA for predicting functional dependence. The MoCA score that had equal sensitivity and specificity was chosen as the optimal score for predicting functional dependence.

Results: A total of 305 participants were included in the study (mean age: 68.8 years, n = 179 men). The MoCA quartiles were a significant predictor of functional dependence 3 months after stroke as an individual variable (p < 0.001, AUC = 0.72) and when adjusted for covariates such as age at stroke onset, living arrangement prior to stroke, and ADL measured with BI within 36–48 h after stroke (p = 0.01, AUC = 0.84). The MoCA score of ≤23 for impaired cognition had equal sensitivity and specificity for predicting functional dependence 3 months after stroke.

Discussion and Conclusion: Cognitive function assessed with the MoCA within 36–48 h after stroke could predict functional dependence 3 months later. The participants with MoCA scores ≤23 for impaired cognition were more likely to be functionally dependent.

Subgroups Defined by the Montreal Cognitive Assessment Differ in Functional Gain During Acute Inpatient Stroke Rehabilitation

OBJECTIVE

To validate subgroups of cognitive impairment on the Montreal Cognitive Assessment (MoCA)-defined as normal (score of 25-30), mildly impaired (score of 20-24), and moderately impaired (score less than 19)-by determining whether they differ in rehabilitation gain during inpatient stroke rehabilitation.

DESIGN

Observational study. Linear regression models were conducted and predictors included MoCA subgroups and relevant baseline demographic and clinical covariates. Separate models included the cognitive subscale of the FIM instrument as a predictor.

SETTING

Inpatient rehabilitation facility of an urban, academic medical center.

PARTICIPANTS

Inpatients (N=334) with mild-moderate strokes who were administered the MoCA on admission.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The mean relative functional gain (mRFG) and mean relative functional efficiency (mRFE, which adjusts for length of stay) on the FIM total.

RESULTS

MoCA subgroups significantly predicted mRFG and mRFE after accounting for age, sex, education, stroke severity, and recurrent vs first stroke. The normal group exhibited greater mRFG and mRFE than the mildly impaired group, while the moderately impaired group had significantly worse mRFG and mRFE than the mildly impaired group. The moderately impaired group had a significantly smaller proportion of individuals who made a clinically meaningful change on the total-FIM than the mildly impaired and normal groups. MoCA subgroups better accounted for mRFG and mRFE than a standard-of-care cognitive assessment (cognitive-FIM).

CONCLUSIONS

Use of MoCA-defined subgroups can assist providers in predicting functional gain in survivors of stroke being treated in inpatient rehabilitation.