Disorientation following stroke: frequency, course, and clinical correlates

Vascular-brain Injury Progression after Stroke (VIPS) study: concept for understanding racial and geographic determinants of cognitive decline after stroke

Cognitive impairment and dementia (CID) are major public health problems with substantial personal, social, and financial burdens. African Americans are at a heightened risk for Vascular Cognitive Impairment (VCI) compared to European Americans. Recent lines of evidence also suggest a high burden of Post-stroke VCI among indigenous Africans. A better understanding of the cause(s) of the racial disparity in CID, specifically VCI, is needed in order to develop strategies to reduce it. We propose and discuss the conceptual framework for a unique tri-population, trans-continental study titled The Vascular brain Injury Progression after Stroke (VIPS) study. The overarching objective of the VIPS Study will be to explore the interplay of multiple factors (racial, geographical, vascular, lifestyle, nutritional, psychosocial and inflammatory) influencing the level and trajectory of post-stroke cognitive outcomes and examine whether differences between indigenous Africans, African Americans and European Americans exist. We hypothesize that differences which might be due to racial factors will be observed in African Americans versus European Americans as well as Indigenous Africans versus European Americans but not in African Americans versus Indigenous Americans; differences due to geographical factors will be observed in Indigenous Americans versus African Americans and Indigenous Africans versus European Americans but not in African Americans versus European Americans. This overarching objective could be accomplished by building upon existing National Institutes of Health investments in the REasons for Geographical And Racial Differences in Stroke (REGARDS) study (based in the United States of America) and the Stroke Investigative Research and educational Network (SIREN) study (based in Sub-Saharan Africa).

A Review of the Literature on Orientation as an Indicator of Level of Consciousness

PURPOSE

To review and compare the concepts of orientation and level of consciousness.

METHODS

Literature review, including studies of orientation as an indicator of level of consciousness, in the domains of nursing, medicine, and neuropsychology.

FINDINGS

Orientation to time, place, and person as a measure of level of consciousness is poorly understood. The nursing practice of assessing orientation is common in many practice settings, yet little research has been done to validate whether it is meaningful.

CONCLUSIONS

This review lays important groundwork for future evidence-based research into the use of orientation as an indicator of level of consciousness.

Cognitive Dysfunction After Acute Lacunar Infarct

Vascular dementia and vascular cognitive impairment have attracted more attention recently due to their association with increased risk of death and institutionalization. The purpose of the present study was to detect and identify the characteristics of cognitive impairments during the early stage of lacunar stroke. The subjects consisted of 23 consecutive first-ever acute lacunar infarction patients who were admitted to the Department of Neurology, Kaohsiung Municipal Hsiao-Kang Hospital, Taiwan, from November 2001 to October 2002. The National Institutes of Health Stroke Scale and Cognitive Abilities Screening Instrument (CASI) were used to evaluate stroke severity and cognitive function, and assessments were performed by a neurologist and psychologist, within 10 days of stroke onset. Of the 23 patients, 21 (91.3%) had CASI scores below their respective cutoff values and all patients had cognitive impairment in at least one cognitive domain in CASI. There were no significant correlations between CASI abnormality (below the cutoff value) and patient age, education, or the interval from stroke onset. Recent memory impairment was the most often impaired cognitive domain on CASI (19 patients, 82.6%). There were significant correlations between recent memory and "attention or concentration"(correlation coefficient, 0.52; p < 0.05), and "abstraction and judgment" (correlation coefficient, 0.44; p < 0.05). The correlations between recent memory and other domains were not significant. It was concluded that cognitive impairment after acute lacunar infarct is quite common and recent memory is the most often impaired cognitive domain. This may have been caused by the location of the specific lesion as well as by the impairment in "attention or concentration" or "abstraction and judgment".

Influence of enriched environment on spatial learning following cerebral insult

The fact that our brain is continuously shaped by the environment and experience presents many challenges. It was noted several decades ago that exposure of a laboratory rat to a complex environment alters its brain and improves problem solving in complex tasks. Rats that are housed in an enriched environment can better compensate for brain lesion-induced deficits and resist neurodegeneration. In this article, the role of an enriched environment on brain plasticity following experimentally-induced lesions is discussed.

Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population

BACKGROUND AND PURPOSE

The goals of the present study were to estimate the prevalence of acute impairments and disability in a multiethnic population of first-ever stroke and to identify differences in impairment and early disability between pathological and Bamford subtypes. Associations between impairments and death and disability at 3 months were identified.

METHODS

Impairments that occur at the time of maximum neurological deficit were recorded, and disability according to the Barthel Index (BI) was assessed 1 week and 3 months after stroke in patients in the South London Stroke Register:

RESULTS

Of 1259 registered patients, 6% had 1 or 2, 31.1% had 3 to 5, 50.6% had 6 to 10, and 10.6% had >10 impairments. Common impairments were weakness (upper limb, 77.4%), urinary incontinence (48.2%), impaired consciousness (44.7%), dysphagia (44.7%), and impaired cognition (43.9%). Patients with total anterior circulation infarcts had the highest age-adjusted prevalence of weakness, dysphagia, urinary incontinence, cognitive impairment, and disability. Patients with subarachnoid hemorrhage had the highest rates of coma. Patients with lacunar stroke had the high prevalence of weakness but were least affected by disability, incontinence, and cognitive dysfunction. Blacks had higher age- and sex-adjusted rates of disability in ischemic stroke (BI <20, odds ratio 2.76, 95% CI 1.47 to 5.21, P=0.002; BI <15, odds ratio 1.8, 95% CI 1.45 to 2.81, P=0.01) but impairment rates similar to those of whites. On multivariable analysis, incontinence, coma, dysphagia, cognitive impairment, and gaze paresis were independently associated with severe disability (BI <10) and death at 3 months.

CONCLUSIONS

The extent of these findings indicates that an acute assessment of impairments and disability is necessary to determine the appropriate nursing and rehabilitation needs of patients with stroke.

Medical complications after stroke: a multicenter study

BACKGROUND AND PURPOSE

This prospective, multicenter study was performed to determine the frequency of symptomatic complications up to 30 months after stroke using prespecified definitions of complications.

METHODS

We recruited 311 consecutive stroke patients admitted to hospital. Research nurses reviewed their progress on a weekly basis until hospital discharge and again at 6, 18, and 30 months after stroke.

RESULTS

Complications during hospital admission were recorded in 265 (85%) of stroke patients. Specific complications were as follows: neurological-recurrent stroke (9% of patients), epileptic seizure (3%); infections-urinary tract infection (24%), chest infection (22%), others (19%); mobility related-falls (25%), falls with serious injury (5%), pressure sores (21%); thromboembolism-deep venous thrombosis (2%), pulmonary embolism (1%); pain-shoulder pain (9%), other pain (34%); and psychological-depression (16%), anxiety (14%), emotionalism (12%), and confusion (56%). During follow-up, infections, falls, "blackouts, " pain, and symptoms of depression and anxiety remained common. Complications were observed across all 3 hospital sites, and their frequency was related to patient dependency and duration after stroke.

CONCLUSIONS

Our prospective cohort study has confirmed that poststroke complications, particularly infections and falls, are common. However, we have also identified complications relating to pain and cognitive or affective symptoms that are potentially preventable and may previously have been underestimated.

Dementia three months after stroke. Baseline frequency and effect of different definitions of dementia in the Helsinki Stroke Aging Memory Study (SAM) cohort

BACKGROUND AND PURPOSE

Vascular dementia is a common cause of dementia, and cerebrovascular disease is related to a higher risk of dementia. The frequency of dementia associated with ischemic stroke and the effects of different definitions of dementia in the diagnosis are still incompletely known. We evaluated the frequency of cognitive decline and dementia 3 months after ischemic stroke in a large stroke cohort.

METHODS

Our cohort consisted of consecutively admitted ischemic stroke patients (n = 486) aged 55 to 85 years in the Helsinki (Finland) Stroke Aging Memory Study (SAM). Subjects were assessed by structured medical, neurological, and radiological examinations and interview with a close informant, as well as by the Mini-Mental State Examination and detailed clinical mental status examination of defined cognitive domains. The criteria for dementia were those of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (DSM-III, DSM-III-R, and DSM-IV), the National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN), and the International Classification of Diseases, 10th Revision (ICD-10).

RESULTS

We found that 451 (92.8%) of the patients were testable, 239 (49.2%) of the patients were women, and the mean age was 71.2 years. Any cognitive decline was present in 61.7%. In the groups aged 55 to 64, 65 to 74, and 75 to 85 years, the frequency of any cognitive decline was 45.7%, 53.8%, and 74.1% (P = .0008), respectively. The frequency of dementia was 25.5% by DSM-III, 20.0% by DSM-III-R, 18.4% by DSM-IV, 21.1% by NINDS-AIREN, and 6.0% by ICD-10 criteria. The frequency increased with increasing age: by the DSM-III definition, frequency in the aforementioned age groups was 19.3%, 23.7%, and 25.5%, respectively (P = .014). There was an overlap in the cases diagnosed as demented according to the different guidelines. Compared with standard diagnosis, the DSM-III was the most sensitive and ICD-10 the most specific. Concordance was moderate between the DSM criteria and NINDS-AIREN criteria but was poor between ICD-10 and the other criteria.

CONCLUSIONS

Cognitive decline and dementia were frequent in the cohort of ischemic stroke patients, and the frequency increased with increasing age. Different definitions gave different frequency estimates, and overlap in the cases was observed. Our findings question the validity of current criteria for dementia in the setting of cerebrovascular disease and emphasize the need for further debate and studies to refine the categories of cognitive impairment related to cerebrovascular disease.

Complications after acute stroke

BACKGROUND AND PURPOSE

We sought to observe the type, timing, and frequency of complications occurring in hospitalized patients after an acute stroke.

METHODS

In a single hospital, we prospectively identified a consecutive cohort of patients who were either admitted after an acute stroke or who suffered a stroke while already an inpatient (n=613). We retrieved the case notes for 607 (99%) of these strokes, and a single observer, using predefined diagnostic criteria, reviewed the notes and recorded the type, timing, and frequency of complications that occurred during the inpatient period. We also measured the reliability of complication identification from case note review by comparing two observers on a sample of records.

RESULTS

Complications were recorded after 360 strokes (59%); the most common individual complications were falls (complicating 22% of all strokes), skin breaks (18%), and urinary tract (16%) or chest (12%) infections. Miscellaneous "other" complications complicated 32% of strokes. Seizures and chest infections occurred early, whereas depression and painful shoulder were later problems. Complications were more common in older patients, who were more disabled before their stroke and had suffered more severe strokes. We demonstrated moderate to good agreement between the two observers for most complications.

CONCLUSIONS

Complications after acute stroke are common, confirming that stroke rehabilitation requires active and knowledgeable medical input. Knowing the nature and timing of complications, together with the identification of high-risk patients, may be useful to those planning stroke services. The differences in our results and those previously reported, most notably for skin breaks, are probably due to the different methods used, in particular patient selection and diagnostic criteria for complications. Although complications may be useful as a measure of outcome in comparative studies (eg, therapeutic trials and audit), the methodological difficulties in accurately and reliably measuring them must be addressed.