Prospective cognitive assessment of stroke patients before inpatient rehabilitation. The relationship of the Neurobehavioral Cognitive Status Examination to functional improvement

Measurement properties of performance-based instruments for assessing mental function during activity and participation in persons with stroke: A systematic review

BACKGROUND

Various performance-based instruments exist to assess mental function after stroke and users have to select one for research or clinical practice.

OBJECTIVES

To evaluate the measurement properties of performance-based instruments to assess (any aspect of) mental function during activity and participation in persons after stroke.

MATERIAL AND METHODS

We searched in five electronic databases. COSMIN methodology was used to conduct the review. The strength of evidence was assessed using a modified GRADE approach.

RESULTS

Fifty articles were included reporting on 20 instruments assessing (1) multiple mental functions including ≥ four subdomains (2) attention, memory and executive functions, or single subdomains (3) executive functions, (4) perception, and (5) mental function of language. Highest quality evidence for sufficient results was found for some measurement properties in seven instruments. These instruments included: FIM + FAM, MPAI-4 and EFPT, MET, CBS/KF-NAP, BIT and the Scenario Test.

CONCLUSIONS

Further studies of high methodological quality are needed that evaluate the measurement properties of instruments to allow clinicians and researchers to select the most suitable performance-based measures for purpose.

SIGNIFICANCE

Results may be used to select the most suitable performance-based instrument to measure mental function during activity and participation in persons with stroke.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42018086744.

Functional status and its related factors among stroke survivors in rehabilitation departments of hospitals in Shenzhen, China: a cross-sectional study

Background

Many stroke survivors have multiple chronic diseases and complications coupled with various other factors which may affect their functional status. We aimed to investigate the factors associated with poor functional status in hospitalized patients with stroke in Shenzhen, China.

Methods

In this cross-sectional study, four urban hospitals were selected using convenient sampling, and all stroke patients in these four hospitals were included using cluster sampling. The functional status of stroke survivors was evaluated using Longshi Scale. Explanatory variables (factors affecting functional status comprising age, sex, body mass index, smoking, alcohol consumption, complications, and chronic conditions) were collected. Ordinal logistic regression was used to examine which factors were associated with poor functional status.

Results

Stroke survivors with poor functional status accounted for 72.14% and were categorised as the bedridden group based on Longshi scale, 21.67% of patients with moderate functional limitation were categorised as the domestic group, and 6.19% of the patients with mild functional restriction were categorised as the community group. The highest dependence scores were noted for feeding (73.39%), bowel and bladder management (69.74%) and entertainment (69.53%) among the bedridden group, and housework (74.29%) among the domestic group. In the adjusted model, the odds of poor functional status were higher among stroke patients with older age (odds ratio [OR] = 2.39, 95% CI: 1.55–3.80), female sex (OR = 1.73, 95% CI: 1.08–2.77), duration of stroke more than 12 months (OR = 1.94, 95% CI: 1.28–2.95), with pulmonary infection (OR = 10.91, 95% CI: 5.81–20.50), and with deep venous thrombosis (OR = 3.00, 95% CI: 1.28–7.04).

Conclusions

Older adults (age ≥ 60 years) and women were more likely to exhibit poor functional status post-stroke. Pulmonary infection and deep venous thrombosis were related to an increased risk of being dependent on activities of daily living. Therefore, clinical and rehabilitation interventions aimed at preventing or treating these common complications should be addressed to deal with subsequent dysfunction post-stroke. Since all data were obtained in metropolitan areas where the economy is well developed, future studies should be conducted in rural areas and economically less developed cities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02696-0.

Multiple Chronic Conditions Explain Ethnic Differences in Functional Outcome Among Patients With Ischemic Stroke

BACKGROUND AND PURPOSE

Mexican Americans (MAs) have worse stroke outcomes and a different profile of multiple chronic conditions (MCC) compared with non-Hispanic White people. MCC has implications for stroke treatment, complications, and poststroke care, which impact poststroke functional outcome (FO). We sought to assess the contribution of MCC to the ethnic difference in FO at 90 days between MAs and non-Hispanic White people.

METHODS

In a prospective cohort of ischemic stroke patients (2008-2016) from Nueces County, Texas, data were collected from patient interviews, medical records, and hospital discharge data. MCC was assessed using a stroke-specific and function-relevant index (range, 0-35; higher scores greater MCC burden). Poststroke FO was measured by an average score of 22 activities of daily living (ADLs) and instrumental ADLs at 90 days (range, 1-4; higher scores worse FO). The contribution of MCC to the ethnic difference in FO was assessed using Tobit regression. Effect modification by ethnicity was examined.

RESULTS

Among the 896 patients, 70% were MA and 51% were women. Mean age was 68±12.2 years; 33% of patients were dependent in ADL/instrumental ADLs (FO score >3, representing a lot of difficulty with ADL/instrumental ADLs) at 90 days. MAs had significantly higher age-adjusted MCC burden compared with non-Hispanic White people. Patients with high MCC score (at the 75th percentile) on average scored 0.70 points higher in the FO score (indicating worse FO) compared with those with low MCC score (at the 25th percentile) after adjusting for age, initial National Institutes of Health Stroke Scale, and sociodemographic factors. MCC explained 19% of the ethnic difference in FO, while effect modification by ethnicity was not statistically significant.

CONCLUSIONS

MAs had a higher age-adjusted MCC burden, which partially explained the ethnic difference in FO. The prevention and treatment of MCC could potentially mitigate poststroke functional impairment and lessen ethnic disparities in stroke outcomes.

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.

Burn Injuries and Their Impact on Cognitive-Communication Skills in the Inpatient Rehabilitation Setting

The prevalence and extent of cognitive-communication disorders and factors that have impact on outcomes are examined in the burn population within an inpatient rehabilitation facility. A retrospective data analysis was conducted on adults diagnosed with burn injury (n = 144). Descriptive statistics were used to identify the prevalence of cognitive-communication deficits on admission and discharge. The main outcomes were cognitive-communication ratings on discharge from inpatient rehabilitation as measured by the memory and problem-solving domains of the Functional Independence Measure (FIM) and composite score of the Functional Communication Measure (FCM). Medical, demographic and rehabilitation predictors of the main outcomes were assessed using regression analyses. On admission to inpatient rehabilitation, 79% of the total population presented with cognitive-communication impairments, and of them, 27% presented with persistent deficits on discharge. Admission FIM memory score, marital status, and age were significant predictors of discharge FIM memory score. Admission FIM problem-solving score, age, marital status, and prehospital living-with were significant predictors of discharge FIM problem-solving score. Admission FCM score and age were significant predictors of discharge FCM cognitive score. Persons with burn injuries are at risk for cognitive-communication impairments, which may persist after inpatient rehabilitation. FIM data obtained on admission can be used as a screening tool to identify these at-risk patients. Future work is needed to assess the efficacy of speech-language pathologist intervention for cognitive-communication deficits within the burn injury population.

Operating Characteristics of the neurobehavioral cognitive Status Exam Using Neuropsychological Assessment as the Criterion

This study examined the performance characteristics of the Neurobehavioral Cognitive Status Exam (NCSE) using comprehensive neuropsychological assessment as the criterion. Sensitivity and specificity were assessed for the NCSE as a whole and for the individual subtests as measures of discrete cognitive abilities. The sample consisted of 50 consecutive outpatient referrals to the neuropsychological assessment service of a general medical hospital. Most of the patients in the sample had mild or moderate cognitive dysfunction.

The sensitivity and specificity of the NCSE as a whole were .74 and .86, respectively. The sensitivity of the individual NCSE subtests was lower, ranging from .20 to .48. Specificity of subtests was high (.64 to .97). The results suggest that the operating characteristics of the NCSE depend significantly on the severity and nature of the sample assessed and the criterion used. They also indicate the need for caution in using NCSE subtest performance as a basis for concluding that specific cognitive abilities are normal.

Emotional Distress Following Stroke: Interpretive Limitations of the SCL-90-R

Evaluation of affective status in medical patients is frequently hampered by the uncertain validity, questionable relevance, or both, of certain items on measures used for this purpose. In this study, we examined the validity of the Symptom Checklist-90-Revised (SCL-90-R) as a measure of psychological distress in stroke patients. Those SCL-90-R symptoms (N = 19) that were designated by at least 8 of 10 expert raters as "usual consequences of stroke" were labeled "stroke symptoms." These items loaded primarily on the Somatization, Obsessive-Compulsive, and Depression scales. Among a sample of 30 patients hospitalized for acute rehabilitation following unilateral stroke, average scores fell at or above the 70th percentile (relative to normative data given in the manual) on five of the nine symptom dimensions and on all three summary indices of distress. Significantly elevated rates of endorsement were found in the stroke group on 12 of the 19 "stroke symptoms" and on 20 of the remaining symptoms as well. Participants with right-hemisphere lesions generally reported higher levels of distress than did the smaller group of patients with left hemisphere involvement. Our study suggests that at least some portion of SCL-90-R elevations is likely to be attributable to endorsement of phenomena that comprise part of the "natural history" of stroke. Our findings underscore the need for clinicians to examine individual responses of neurological patients on such self-report measures, as simple interpretation of summary scale scores can be highly misleading.

Screening Patients with Stroke for Rehabilitation Needs: Validation of the Post-Stroke Rehabilitation Guidelines

Background. The authors assessed patients with acute stroke to determine whether the systematic use of brief screening measures would more efficiently detect cognitive and sensory impairment than standard clinical practice. Methods. Fifty-three patients admitted to an acute stroke unit were assessed within 10 days of stroke onset. Performance on the screening measures was compared to information obtained from review of the patient’s chart at discharge. Cognition, language, visual acuity, visual-spatial neglect, hearing, and depression were evaluated. Results. Formal screening detected significantly more impairments than were noted in patient charts in every domain. Only 3 patients had no impairments identified on screening; all remaining patients had at least 1 impairment detected by screening that was not documented in the chart. Thirty-five percent had 3 or more undetected impairments. Memory impairment was most likely to be noted in the chart; for all other domains tested, undocumented impairment ranged from 61% (neglect) to 97% (anomia). Conclusion. Many acute stroke patients had cognitive and perceptual deficits that were not documented in their charts. These data support the Post-Stroke Rehabilitation Guidelines for systematic assessment even when deficits are not immediately apparent. Systematic screening may improve discharge planning, rehabilitation treatment, and long-term outcome of persons with stroke.

Relationships between Cognitive Abilities and the Process Scale and Skills of the Assessment of Motor and Process Skills (AMPS) in Patients with Stroke

The purpose of this study was: 1) to determine the strength of the relationships between cognitive components at the body function/impairment level to the assessment of motor and process skills (AMPS) at the occupational performance/activities level in persons following stroke; and 2) to examine which cognitive components best explain the variance of the AMPS score. Stroke is a major cause of disability in older age that can result in motor and/or cognitive impairments leading to functional disability. The assessment of AMPS is an activity of daily living (ADL) and instrument activity of daily living (IADL) evaluation that measures two aspects enabling occupational performance and motor and process skills. Subjects included 30 hospitalized patients 4 to 5 weeks following stroke. Among them were 17 men and 13 women with a mean age of 71.33 (SD = 8.39) who had been independent in ADL prior to the event. Instruments included the AMPS IADL tasks, Thinking Operations from the LOTCA, Contextual Memory Test, Rey Complex Figure-copy, Star cancellation from the BIT, and COGNISTAT. The study supports the existence of moderate relationships between cognitive components and the AMPS' process scale and skills, and the results add information about relationships between cognitive impairments and occupational performance that can help in treatment planning.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Brief Cognitive Assessment and Prediction of Functional Outcome in Stroke

To evaluate the ability to predict outcome with a brief measure of cognitive ability, we tested consecutive admissions who received inpatient rehabilitation for stroke with the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS). Six months later, 34 discharged patients were contacted by telephone and were interviewed using a battery of functional outcome and quality of life measures. Multiple regression analysis showed that inpatient RBANS indexes predicted cognitive disability 6 months later. The present findings support the use of cognitive evaluations of patients with acute stroke to assist with prediction of outcome to be used in treatment planning.

The application of SHERPA (Systematic Human Error Reduction and Prediction Approach) in the development of compensatory cognitive rehabilitation strategies for stroke patients with left and right brain damage

Approximately 33% of stroke patients have difficulty performing activities of daily living, often committing errors during the planning and execution of such activities. The objective of this study was to evaluate the ability of the human error identification (HEI) technique SHERPA (Systematic Human Error Reduction and Prediction Approach) to predict errors during the performance of daily activities in stroke patients with left and right hemisphere lesions. Using SHERPA we successfully predicted 36 of the 38 observed errors, with analysis indicating that the proportion of predicted and observed errors was similar for all sub-tasks and severity levels. HEI results were used to develop compensatory cognitive strategies that clinicians could employ to reduce or prevent errors from occurring. This study provides evidence for the reliability and validity of SHERPA in the design of cognitive rehabilitation strategies in stroke populations.

Stroke Outcomes in Thai Elderly Patients Treated with and without Intravenous Thrombolysis

Higher mortality was found in very old patients with acute ischemic stroke treated with intravenous recombinant tissue-plasminogen activator (rtPA) as compared to younger patients. The benefit of thrombolytic treatment in this particular subgroup is still a subject of debate. The purpose of this study was to compare stroke outcomes in Thai patients aged over 70 years treated with and without intravenous rtPA. This was a retrospective review of sequential cases and was not a randomized controlled study. One-hundred and five patients with acute ischemic stroke aged over 70 years who were treated with intravenous rtPA and 105 patients without rtPA treatment (control group) were included in the study. Patients’ base-line characteristics and study outcomes of interest were compared. There were significant differences in the base-line characteristics of the two groups. However, for the subgroup of patients aged over 80 years, these characteristics were similar. Those who were treated with intravenous rtPA had a higher rate of favorable outcomes (40% vs 16%; P=0.137) and a lower rate of mortality (22% vs 44%; P=0.128) than patients who did not receive rtPA treatment. In well-matched subgroups of patients aged over 80 years, our retrospective review revealed there was a trend of a higher rate of favorable outcome and lower mortality in patients receiving rtPA treatment. More study is needed to further confirm the suggested benefit of thrombolysis in Asian octogenarian acute stroke patients.

Concurrent neuromechanical and functional gains following upper-extremity power training post-stroke

BACKGROUND

Repetitive task practice is argued to drive neural plasticity following stroke. However, current evidence reveals that hemiparetic weakness impairs the capacity to perform, and practice, movements appropriately. Here we investigated how power training (i.e., high-intensity, dynamic resistance training) affects recovery of upper-extremity motor function post-stroke. We hypothesized that power training, as a component of upper-extremity rehabilitation, would promote greater functional gains than functional task practice without deleterious consequences.

METHOD

Nineteen chronic hemiparetic individuals were studied using a crossover design. All participants received both functional task practice (FTP) and HYBRID (combined FTP and power training) in random order. Blinded evaluations performed at baseline, following each intervention block and 6-months post-intervention included: Wolf Motor Function Test (WMFT-FAS, Primary Outcome), upper-extremity Fugl-Meyer Motor Assessment, Ashworth Scale, and Functional Independence Measure. Neuromechanical function was evaluated using isometric and dynamic joint torques and concurrent agonist EMG. Biceps stretch reflex responses were evaluated using passive elbow stretches ranging from 60 to 180º/s and determining: EMG onset position threshold, burst duration, burst intensity and passive torque at each speed.

RESULTS

PRIMARY OUTCOME

Improvements in WMFT-FAS were significantly greater following HYBRID vs. FTP (p = .049), regardless of treatment order. These functional improvements were retained 6-months post-intervention (p = .03).

SECONDARY OUTCOMES

A greater proportion of participants achieved minimally important differences (MID) following HYBRID vs. FTP (p = .03). MIDs were retained 6-months post-intervention. Ashworth scores were unchanged (p > .05). Increased maximal isometric joint torque, agonist EMG and peak power were significantly greater following HYBRID vs. FTP (p < .05) and effects were retained 6-months post-intervention (p's < .05). EMG position threshold and burst duration were significantly reduced at fast speeds (≥120º/s) (p's < 0.05) and passive torque was reduced post-washout (p < .05) following HYBRID.

CONCLUSIONS

Functional and neuromechanical gains were greater following HYBRID vs. FPT. Improved stretch reflex modulation and increased neuromuscular activation indicate potent neural adaptations. Importantly, no deleterious consequences, including exacerbation of spasticity or musculoskeletal complaints, were associated with HYBRID. These results contribute to an evolving body of contemporary evidence regarding the efficacy of high-intensity training in neurorehabilitation and the physiological mechanisms that mediate neural recovery.

Validity and reliability of The Johns Hopkins Adapted Cognitive Exam for critically ill patients

OBJECTIVE

To validate The Johns Hopkins Adapted Cognitive Exam designed to assess and quantify cognition in critically ill patients.

DESIGN

Prospective cohort study.

SETTING

Neurosciences, surgical, and medical intensive care units at The Johns Hopkins Hospital.

PATIENTS

One hundred six adult critically ill patients.

INTERVENTIONS

One expert neurologic assessment and four measurements of the Adapted Cognitive Exam (all patients). Four measurements of the Folstein Mini-Mental State Examination in nonintubated patients only. Adapted Cognitive Exam and Mini-Mental State Examination were performed by 76 different raters.

MEASUREMENTS AND MAIN RESULTS

One hundred six patients were assessed, 46 intubated and 60 nonintubated, resulting in 424 Adapted Cognitive Exam and 240 Mini-Mental State Examination measurements. Criterion validity was assessed by comparing Adapted Cognitive Exam with a neurointensivist's assessment of cognitive status (ρ = 0.83, p < .001). Ordinal logistic regression established optimal predicted cut points for cognitive status classification (≤ 28 = severely impaired, 29-55 = moderately impaired, ≥ 56 = mildly impaired or normal). Using these cut points, the Adapted Cognitive Exam appropriately classified cognitive status 90% of the time. Construct validity was assessed by comparing Adapted Cognitive Exam with Mini-Mental State Examination in nonintubated patients (ρ = 0.81, p < .001). Face validity was assessed by surveying raters who used both the Adapted Cognitive Exam and Mini-Mental State Examination and indicated the Adapted Cognitive Exam was an accurate reflection of the patient's cognitive status, more sensitive a marker of cognition than the Mini-Mental State Examination, and easy to use. The Adapted Cognitive Exam demonstrated excellent interrater reliability (intraclass correlation coefficient = 0.997; 95% confidence interval 0.997-0.998) and interitem reliability of each of the five subscales of the Adapted Cognitive Exam and Mini-Mental State Examination (Cronbach's α: range for Adapted Cognitive Exam = 0.83-0.88; range for Mini-Mental State Examination = 0.72-0.81).

CONCLUSION

The Adapted Cognitive Exam is the first valid and reliable examination for the assessment and quantification of cognition in critically ill patients. It provides a useful, objective tool that can be used by any member of the interdisciplinary critical care team to support clinical assessment and research efforts.

Cerebrovascular disease and cognition in older adults

The well-established association between advanced age, cerebrovascular pathology, and cognitive decline is receiving greater attention as the population attains new levels of longevity. This chapter will provide an overview of vascular anatomy and age-related cerebrovascular disorders and diseases, including stroke and degenerative dementia. The cognitive and functional sequellae of these cerebrovascular disorders will also be described in detail. Throughout this review, we will emphasize topics that have been relatively underrepresented in the literature, including age-related diseases of the cerebral small vessels, nuanced characterization of cognitive impairment associated with insidious small-vessel vascular dementia, and the real-life functional consequences of cerebrovascular changes in older adults.

Convergent Validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST) with Two other Cognitive-Perceptual Tests

Background:

It is common for individuals with a neurological impairment, such as a stroke, to present with cognitive-perceptual impairments. The early identification of such problems can assist with rehabilitation efforts. Standardised cognitive and perception tests are often used by practitioners to make such identifications; therefore, it is important to examine the measurement properties of these tests.

Objective:

This study investigated the convergent validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST) with two other cognitive-perceptual tests: the Neurobehavioural Cognitive Status Examination (Cognistat) and the Developmental Test of Visual Perception — Adolescent and Adult (DTVP-A). The Cognistat is primarily a test of cognition but has some subscales that evaluate perceptual skills. The convergent validity between the Cognistat and the DTVP-A was also investigated. It is imperative that tests used by therapists have documented validity to ensure that the results obtained actually measure the skills and abilities that the tests claim they measure.

Method:

Thirty-two adult patients, ranging in age between 46 and 91 years (mean = 73, SD = 4.6) with a primary diagnosis of stroke, completed the OT-APST, the Cognistat and the DTVP-A. Spearman's rho was used to analyse the correlations between the tests' subscales.

Results:

Three of the Cognistat subscales were significantly correlated with OT-APST subscales: Cognistat Constructional Ability and OT-APST Body Scheme; Cognistat Memory and OT-APST Functional Skills; and Cognistat Calculations and OT-APST Body Scheme. Only one of the OT-APST subscales, Body Scheme, had statistically significant correlations with the DTVP-A's Figure-Ground, Visual-Motor Search and Visual Closure subscales. There were significant correlations between the Cognistat's Constructional Ability and Judgment subscales and five of the six DTVP-A's subscales.

Conclusion:

Given that only a few of the subscales from the Cognistat and DTVP-A were significantly correlated with those of the OT-APST, this indicates that many of the constructs assessed by the three tests are not associated; hence, limited convergent validity evidence for the OT-APST was present. Further inquiry is required because it is important that such instruments are assessing what they purport to test, particularly when they are used to determine clients' strengths and weaknesses in clinical practice.

Cognitive impairment in acquired brain injury: a predictor of rehabilitation outcomes and an opportunity for novel interventions

Cognitive impairment is a common sequela in acquired brain injury and one that predicts rehabilitation outcomes. There is emerging evidence that impairments in cognitive functions can be manipulated by both pharmacologic and nonpharmacologic interventions to improve rehabilitation outcomes. By using stroke as a model for acquired brain injury, we review the evidence that links cognitive impairment to poor rehabilitation outcomes and discuss possible mechanisms to explain this association. Furthermore, we examine nascent promising research that suggests that interventions that target cognitive impairments can lead to better rehabilitation outcomes.

Caring for stroke survivors: baseline and 1-year determinants of caregiver burden

BACKGROUND

Caregiver burden following stroke can have significant adverse health consequences for caregivers and threatens the recovery and successful rehabilitation of patients. Our objective was to identify patient factors that contribute to higher levels of caregiver burden.

METHODS

We prospectively studied patients admitted to our stroke unit over a 2-year period (2001-2002). Data were collected at baseline and at 1 year. Caregiver burden was measured at 1 year using the Relatives Stress Scale (completed by 155 caregivers) and the Bakas Caregiver Outcomes Scale (143 caregivers). Explanatory patient factors at baseline included sociodemographic status, stroke severity, stroke sub-type, functional disability (Barthel Index), functional handicap (Oxford Handicap Scale and Modified Rankin Scale), and cognitive status (orientation, clock drawing). At 1 year, mental health and health-related quality of life were assessed using the Fatigue Impact Scale, Geriatric Depression Scale, Global Deterioration Scale, and 36-item Short Form Health Survey.

RESULTS

The baseline patient factors predictive of caregiver burden by multiple regression analysis were older patient age (P<0.01), male gender (P<0.05), ischemic stroke (P<0.05), urinary incontinence (P<0.0001), and impaired clock drawing (P<0.05). At 1 year, significant correlates of caregiver burden were older patient age (P<0.05), male gender (P<0.01), poor mental health (P<0.05), functional handicap (P<0.05), and functional disability (P<0.001).

CONCLUSIONS

The functional status of patients can be used to identify caregivers at risk of caregiver burden. Patient demographic variables, cognitive function, and mental health status may further expose vulnerable caregivers. These factors should be considered in the development of strategies to offset caregiver burden.

Prediction of functional rehabilitation outcomes in clients with stroke

OBJECTIVES

To evaluate the validity of the Neurobehavioral Cognitive Status Examination (NCSE or Cognistat) and to determine its effects in order to estimate the functional outcomes of survivors with stroke.

METHODS

The present study first studied the factor structure NCSE in 148 Chinese survivors with stroke (aged 45-91 years). They were admitted to hospital consecutively and recruited prospectively. The relationship of NCSE with Functional Independence Measures (FIM), a set of measures commonly adopted as an indicator of the outcome of rehabilitation, was studied.

RESULTS

One hundred and forty-eight patients with stroke (49.3% male, 50.7% female), with a mean age of 70.38 and an average number of years of education of 3.50 years joined the study. A two-factor NCSE structure was obtained, namely verbal-spatial and integrated cognition, accounting for 62.77% of the variance. A significant relationship between NCSE factors and the functional status of clients with stroke on admission and upon discharge, as well as age, years of education and length of hospital stay were indicated.

CONCLUSIONS

This study supports a systematic relationship between cognitive factors and functional outcome in Chinese patients with stroke. Similarities and differences in the NCSE factor structure between the population with stroke and general neurological populations were discussed and the utility of NCSE in stroke rehabilitation, such as its predictive validity in functional independence is suggested.

Visual search patterns in neglect: comparison of peripersonal and extrapersonal space

Previous studies of visual search patterns in visuospatial neglect have analyzed shifts of attention during search tasks using eye tracking technology and verbal reports. The purpose of the present study was to replicate and extend upon reported parameters of visual scanning patterns of neglect patients in peripersonal space (within arms reach) and to examine whether similar patterns of visual search are also apparent in extrapersonal space (beyond arms reach). Using a simple verbal visual search and target detection paradigm right-hemisphere stroke participants, with and without neglect, and healthy older volunteers named targets on scanning sheets placed in peripersonal and extrapersonal space. The healthy controls and right-hemisphere stroke group without neglect showed similar 'reading' type strategies, while the neglect group displayed an unsystematic search pattern, during search in both peripersonal and extrapersonal space. Group comparisons of search parameters support the presence of multiple cognitive deficits affecting the complex visual search patterns of neglect patients, including a rightward attentional bias, a reduced spatial scale of attention (local processing bias), and a deficit of working memory affecting both near and far space search. Ventral visual stream damage and neglect, however, were related to slower target report rate and more misidentification errors in extrapersonal space. The ease of administration of this verbal target detection task in both peripersonal and extrapersonal space, and the relationship of the measures produced to theorized attentional and executive deficits in neglect, provide impetus for further research on the severity and independence of individual scanning deficits in neglect.

The Impact of the Inpatient Rehabilitation Facility Prospective Payment System on Stroke Program Outcomes

OBJECTIVE

To examine the impact of the Medicare inpatient rehabilitation facility (IRF) prospective payment system (PPS) on outcomes in a stroke rehabilitation program.

DESIGN

An analysis was performed on a database including 945 stroke patients admitted to an inpatient stroke rehabilitation program 5 yrs before implementation of the IRF PPS and 3.5 yrs after implementation. Patients were classified with regard to stroke location (left vs. right), level of cognitive impairment, presence/absence of unilateral neglect, and level of depressive symptomatology. Functional status was evaluated at time of admission and discharge by functional independence measure (FIM). Other outcome measures included length of stay (LOS) and discharge destination. The impact of IRF PPS on LOS, progress in rehabilitation, and discharge destination was examined via univariate analyses of covariance and logistic regression.

RESULTS

Patients admitted after implementation of the IRF PPS had shorter LOS but made less progress, had lower functional levels at discharge, and had higher rates of institutional discharge.

CONCLUSIONS

Although associated with decreased LOS, implementation of the IRF PPS was associated with decreased functional gains, lower discharge FIM levels, and higher rates of institutional discharge. Cost savings associated with the PPS must be considered in light of these untoward outcomes.

Executive Function Deficits in Acute Stroke

OBJECTIVES

To establish the frequency of executive dysfunction during acute hospitalization for stroke and to examine the relationship of that dysfunction to stroke severity and premorbid characteristics.

DESIGN

Inception cohort study.

SETTING

Inpatient wards at a Veterans Affairs hospital.

PARTICIPANTS

Consecutive sample of inpatients with radiologically or neurologically confirmed stroke. Final sample included 47 patients screened for aphasia and capable of neuropsychologic testing. Two nonstroke inpatient control samples (n=10 each) with either transient ischemic attack (TIA) or multiple stroke risk factors were administered the same research procedure and tests.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Composite cognitive impairment ratio (CIR), calculated from 8 scores indicative of executive function on 6 neuropsychologic tests by dividing number of tests completed into the number of scores falling below cutoff point, defined as 1.5 standard deviations below normative population mean.

RESULTS

Stroke patients had a mean CIR of .61, compared with .48 for TIAs and .44 for stroke-risk-only. Analysis of variance revealed that CIRs of stroke-risk-only patients but not TIAs were lower than those of the stroke patients (P=.02). Impairment frequencies were at least 50% for stroke patients on most test scores. The Symbol Digit Modalities Test (75% impairment) and a design fluency measure distinguished stroke from nonstroke patients. CIR was not related to stroke severity in the stroke patient sample, but was related to estimated premorbid intelligence.

CONCLUSIONS

Executive function deficits are common in stroke patients. The data suggest that limitations in information processing due to these deficits may require environmental and procedural accommodations to increase rehabilitation benefit.

Reliability of Dynamic Muscle Performance in the Hemiparetic Upper Limb

We established reliability of upper-limb muscle performance in adults with post-stroke hemiparesis. Ten adults with post-stroke hemiparesis (51.5 +/- 34.5 months) performed isokinetic concentric shoulder flexion, elbow flexion, and extension at 3 criterion speeds (30 degrees/s, 75 degrees/s, and 120 degrees/s) on 3 separate occasions (Days 1, 7, and 49). As several participants were unable to reach criterion speeds, actual speed and power were also analyzed. Relative reliability (intraclass correlation coefficient-ICC) was excellent for torque and power (0.82 to 0.98) but less consistent for speed (0.63 to 0.99). Absolute reliability (standard error of measurement-%SEM) ranged between 0% to 34%. No systematic errors were observed across sessions. Smallest real differences (SRD) ranged between 4-11Nm for torque and 3-24W for power. Shoulder flexion, elbow flexion, and elbow extension torque, speed, and power can be measured reliably following stroke. Given that many of these individuals demonstrate inability to generate torque at preselected speeds, power may be a more valid indicator of muscle performance.

Functional outcome following traumatic brain injury: the Turkish experience

The objectives of this study were to describe the demographic characteristics and the nature of the functional recovery in a group of Turkish survivors of traumatic brain injury (TBI) who were referred for inpatient rehabilitation and identify variables correlated with discharge functional status as measured by the Functional Independence Measure (FIM). There were 40 patients in the study, 32 (69.6%) male and eight (17.4%) female, mean age 28+/-9.8 years. Motor vehicle accidents accounted for 62.5% of injuries, 22.5% of injuries occurred from violence and 15% resulted from falls. The mean durations of acute hospital stay, coma, and rehabilitation stay was 68, 26.7, and 78.4 days, respectively. Extracranial injuries including bone fractures were the most common associated injuries and medical complications such as spasticity and contractures were present in more than half of the patients.TBI survivors in this study made statistically significant functional improvements. Discharge FIM were significantly correlated with the admission FIM, durations of acute hospital stay and coma, and time since TBI. Multiple regression analysis of the data disclosed that FIM score obtained at the time of discharge from rehabilitation service was best predicted by two variables, time since brain injury and the FIM score at admission (multiple R=0.78, R=0.60, P<0.001). This sample of Turkish TBI survivors showed significant functional improvements after rehabilitation and admission functional status and the time since TBI had the most impact on discharge functional outcome.

The effect of poststroke cognitive impairment on rehabilitation process and functional outcome

OBJECTIVES

To determine whether cognitive impairment affects access to, or quality of, rehabilitation services, and to examine the effects of functional outcomes in stroke patients.

DESIGN

Secondary analysis of prospective cohort of stroke patients followed for 6 months after stroke.

SETTINGS

Eleven large-volume US Department of Veterans Affairs hospitals nationwide.

PARTICIPANTS

Stroke patients (N=272) who were candidates for rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation process variables were examined for patients assessed as cognitively impaired or unimpaired according to education-adjusted Mini-Mental State Examination score. Functional outcomes were performance of activities of daily living (ADLs), measured by the FonFIM, and instrumental activities of daily living (IADLs), measured by Lawton, at 6-month follow-up.

RESULTS

Compliance with guidelines and receipt of and interval to postacute treatment initiation did not differ between cognitively impaired and unimpaired patients. Although most cognition-related treatment elements were similar for both groups, cognitive goals were more frequently charted in impaired patients. Controlling for baseline function and rehabilitation process, cognitively impaired patients had worse IADL performance at 6 months than did unimpaired patients; cognition did not significantly influence ADL performance.

CONCLUSIONS

Quality of, and access to, rehabilitative care was equivalent for patients with and without cognitive impairment. Despite a similar rehabilitation process, cognitively impaired stroke patients experienced worse recovery of IADLs.

Clock drawing task, mini-mental state examination and cognitive-functional independence measure: relation to functional outcome of stroke patients

The use of reliable and valid brief cognitive screening instrument for selecting the appropriate candidates for stroke rehabilitation is crucial. Clinicians often face the question which test should be preferred, that will best correlate with functional outcome. The objective of this study was to compare the clock drawing task with other cognitive tests used for the evaluation of discharge functional outcome in elderly stroke patients. We conducted a retrospective chart study including 151 consecutive patients, admitted for inpatient comprehensive rehabilitation following acute stroke. The clock drawing task (CDT), mini-mental state examination (MMSE) and the cognitive-functional independence measure (cognFIM) were used to assess the cognitive status. Functional status outcome was evaluated by the functional independence measure (FIM), using absolute and relative parameters of efficacy and efficiency. Correlation coefficients (Pearson correlation) between the three cognitive tests resulted in r-values ranging from 0.51 to 0.59 (P<0.001). All three tests correlated significantly with motor outcomes. MMSE did not confer additive value to CDT. It is concluded that CDT is similar to mini-mental and both are somewhat better than cognFIM with respect to the evaluation of functional status outcome following stroke. The correlations between the tests as well as the simplicity of administration favor the use of either CDT or MMSE in the initial assessment of elderly stroke patients.

Gradients of detection in neglect: comparison of peripersonal and extrapersonal space

Previous studies of target-cancellation performance in visuospatial neglect patients have reported lateral (left-right) and radial (near-far) gradients of attentional ability. The purpose of the present study was to replicate the reported attentional gradients in peripersonal space (within arms reach) and to examine whether lateral gradients of detection also appear in extrapersonal space (beyond arms reach), using equivalent tasks with no manual requirement. The relationship between radial gradients in peripersonal space and neglect severity (degree of lateral gradient) in extrapersonal space was also of interest. Right-hemisphere stroke subjects, with and without neglect, and healthy control subjects named visual targets on scanning sheets placed in peripersonal and extrapersonal space. The neglect group showed lateral gradients of increasing target detection from left to right in both peripersonal and extrapersonal space, which were not evident in the performance of either of the control groups. Double dissociations of neglect severity in peripersonal and extrapersonal space were also found in analyses of individual performance. Lesion analyses showed that peripersonal neglect was related to dorsal stream damage and extrapersonal neglect was related to ventral stream damage. Group analyses showed no significant radial gradients in peripersonal space in the three groups. In addition, while analyses of some individuals found significant near-far and far-near radial gradients, there was no correlation between radial gradients in peripersonal space and neglect severity in extrapersonal space. These results are discussed in terms of theorised hemispheric mechanisms of spatial attention and the relationship of neglect in the two co-ordinate spaces to the extent and location of damaged neurons in the right hemisphere.

Functional recovery following rehabilitation after hemorrhagic and ischemic stroke

OBJECTIVES

To quantify recovery after rehabilitation therapy and to identify factors that predicted functional outcome in survivors of intracerebral hemorrhage (ICH) compared with cerebral infarction.

DESIGN

Retrospective study of consecutive ICH and cerebral infarction admissions to a rehabilitation hospital over a 4-year period.

SETTING

Free-standing urban rehabilitation hospital.

PARTICIPANTS

A total of 1064 cases met the inclusion criteria (545 women, 519 men; 871 with cerebral infarction, 193 with ICH).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional status was measured using the FIM trade mark instrument, recorded at admission and discharge. Recovery was quantified by the change in FIM total score (DeltaFIM total score). Outcome measures were total discharge FIM score and DeltaFIM total score. Univariate and multivariate analyses were performed.

RESULTS

Total admission FIM score was higher in patients with cerebral infarction than in patients with ICH (59 vs 51, P=.0001). No difference in total discharge FIM score was present. Patients with ICH made a significantly greater recovery than those with cerebral infarction (DeltaFIM total score, 28 vs 23.3; P=.002). On multivariate analysis, younger age, longer length of stay, and admission FIM cognitive subscore independently predicted total discharge FIM and DeltaFIM total score. The severity of disability at admission, indicated by total admission FIM score, independently predicted total discharge FIM score, but not DeltaFIM total score. The ICH patients with the most severely disabling strokes had significantly greater recovery than cerebral infarction patients with stroke of similar severity.

CONCLUSIONS

The patients with ICH had greater functional impairment than the cerebral infarction patients at admission, but made greater gains. Patients with the most severely disabling ICH improved more than those with cerebral infarction of comparable severity. Initial severity of disability, age, and duration of therapy best predicted functional outcome after rehabilitation.

Sex differences in the clinical presentation, resource use, and 3-month outcome of acute stroke in Europe: data from a multicenter multinational hospital-based registry

BACKGROUND AND PURPOSE

The information on the existence of sex differences in management of stroke patients is scarce. We evaluated whether sex differences may influence clinical presentation, resource use, and outcome of stroke in a European multicenter study.

METHODS

In a European Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month survival, disability (Barthel Index), and handicap (Rankin Scale).

RESULTS

Overall, 2239 patients were males and 2260 females. Compared with males, female patients were significantly older (mean age 74.5+/-12.5 versus 69.2+/-12.1 years), more frequently institutionalized before stroke, and with a worse prestroke Rankin score (all values P<0.001). History of hypertension (P=0.007) and atrial fibrillation (P<0.001) were significantly more frequent in female stroke patients, as were coma (P<0.001), paralysis (P<0.001), aphasia (P=0.001), swallowing problems (P=0.005), and urinary incontinence (P<0.001) in the acute phase. Brain imaging, Doppler examination, echocardiogram, and angiography were significantly less frequently performed in female than male patients (all values P<0.001). The frequency of carotid surgery was also significantly lower in female patients (P<0.001). At the 3-month follow-up, after controlling for all baseline and clinical variables, female sex was a significant predictor of disability (odds ratio [OR], 1.41; 95% CI 1.10 to 1.81) and handicap (OR, 1.46; 95% CI 1.14 to 1.86). No significant gender effect was observed on 3-month survival.

CONCLUSIONS

Sex-specific differences existed in a large European study of hospital admissions for acute stroke. Both medical and sociodemographic factors may significantly influence stroke outcome. Knowledge of these determinants may positively impact quality of care.

Attentional abilities and functional outcomes following stroke

Although stroke affects cognitive functioning as well as motor functioning, research on cognitive consequences has lagged behind that focused on motor function. The evidence that is accruing suggests that cognitive function is importantly related to successful rehabilitation. The present study examined two aspects of attentional functioning (divided attention and switching attention) in older adult stroke survivors and healthy older adults. In addition, the authors investigated the relation between attention and functional outcomes following stroke. Results revealed stroke-related deficits in both of the types of attention as well as significant associations between attentional functioning and both physical and social outcome measures. Poorer attentional performance was associated with a more negative impact of stroke on daily functioning. These findings suggest an important role for attention in post-stroke function and provide information that can contribute to improving outcomes following stroke.

Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome

OBJECTIVE

To assess whether, and to what extent, cognitive outcome relates to overall functional outcome among elderly stroke patients.

DESIGN

Nonconcurrent prospective study.

SETTING

Geriatric rehabilitation division at a large, urban, academic, freestanding hospital in Israel.

PARTICIPANTS

Three hundred thirty-six patients aged 60 years and older admitted consecutively for rehabilitation after first acute stroke. Inclusion criteria were met by 315 patients, who were included in the final analysis. Average age was 75.3 years. The stroke was right sided in 44.1%.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The motor subscale of the FIM instrument assessed functional status. Absolute functional gain was determined by the FIM motor gain. Relative functional gain was calculated according to the Montebello Rehabilitation Factor Score. Cognitive status was assessed with the Mini-Mental State Examination (MMSE) and the FIM cognitive subscale.

RESULTS

FIM scores increased significantly during rehabilitation, mainly due to improvement in motor functioning. A strong association was found between the cognitive scales (r=.853, P<.001). Better rehabilitation outcomes were observed in patients with higher admission cognitive status, adjusting for the effect of age, sex, onset to admission interval, length of stay, and severity of stroke (odds ratio = 2.0; 95% confidence interval, 1.5-2.5).

CONCLUSIONS

Impaired cognitive status at admission negatively affects the rehabilitation outcome of elderly stroke patients. The utility of routinely using a cognitive test for all patients before admission to rehabilitation, preferably the MMSE, is emphasized. The time, cost, and effort involved in performing such a test are negligible, and the potential benefits are considerable.

Mini-Mental State Examination, cognitive FIM instrument, and the Loewenstein Occupational Therapy Cognitive Assessment: relation to functional outcome of stroke patients

OBJECTIVES

To compare 3 cognitive tests, used on admission, for predicting discharge functional outcome and to assess the efficacy of these tests in predicting functional outcome at discharge in stroke patients undergoing rehabilitation.

DESIGN

Cohort study.

SETTING

Geriatric rehabilitation department of a tertiary care hospital in Israel.

PATIENTS

Sixty-six patients undergoing acute inpatient comprehensive rehabilitation after first clinical stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

Cognitive status was assessed with the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), the Mini-Mental State Examination (MMSE), and the cognitive subscale of the FIM instrument. The FIM motor subscale was used to assess functional outcome status. Functional gain was determined by the motor FIM gain (efficacy), and the relative (to potential) functional gain was determined by the Montebello Rehabilitation Factor Score. Efficiency was calculated by efficacy divided by the length of hospital stay.

RESULTS

A significant increase in total FIM scores (34.8 points) occurred during rehabilitation mainly because of improvement in motor functioning (31.5 points). Significant improvement in global cognitive status was documented by all 3 tests. Intertest correlation coefficients ranged between.47 and.67. The LOTCA showed somewhat higher correlation coefficients with most of the parameters of functional motor outcomes. Correlation between the MMSE and FIM cognitive subscale and these outcome parameters were nearly identical.

CONCLUSION

The LOTCA is slightly better than the MMSE and the FIM cognitive subscale in predicting functional status change after stroke rehabilitation but it is a time-consuming and exhausting instrument to use. The FIM cognitive subscale requires a better overall understanding of the patient's situation at time of administration and therefore is less convenient for the initial assessment. The similar correlation of all 3 tests with functional outcomes and the simplicity of administration of the MMSE suggests its use in the initial assessment of stroke patients.

Is there a relation between neuropsychologic variables and quality of life after stroke?

OBJECTIVES

To describe the quality of life (QOL) of stroke patients and to distill neuropsychologic predictors for poor QOL.

DESIGN

A cohort study in which patients were neuropsychologically assessed at a mean of 72.2 days after stroke, with follow-up at a mean of 9.8 months after stroke.

SETTING

Research department of a rehabilitation center.

PATIENTS

A consecutive sample of 164 stroke patients (mean age, 55.2yr) recruited from a university hospital, a regional hospital, and a rehabilitation center.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Orientation, memory, attention and concentration, visuospatial and visuoconstructive functions, language, and arithmetic skills were assessed with neuropsychologic tests. QOL was assessed with the Sickness Impact Profile (SIP).

RESULTS

An overall mean SIP score +/- standard deviation of 20 +/- 11 showed that stroke has a high impact on everyday functioning. Further analyses indicated that QOL is related in particular to tests measuring spatiotemporal and/or sequential aspects of behavior. Forward/backward stepwise regression analysis (n = 106) showed that poor QOL was more likely if patients had a poor result on the Trailmaking Test (TMT) B and/or were women.

CONCLUSION

The predictive value of the TMT is most effective and very useful because the TMT is a short and economical procedure. However, the gender-related aspects of recovery deserve more attention, as does the possible bias that can be caused by the composition of a measurement. Further research is needed to refine predictive models that are needed to facilitate the development of more adequate, individual rehabilitation programs.

Cognitive evaluation and functional outcome after stroke

OBJECTIVE

To investigate the initial overall cognitive ability and its components as a predictor of functional improvement and ambulation during rehabilitation. Initial cognitive status is widely known to be a predictive factor in functional recovery in patients with stroke although some reports have found no such relationship.

DESIGN

Baseline cognitive status was scored by Minimental State Examination and its subsections with such headings as "orientation," "registration," "attention and calculation," "recall," and "language" in 43 patients with postacute stroke, aged between 51 and 68 yr. Function was evaluated in terms of motor FIM and functional ambulation as categorized in "Adapted Patient Evaluation and Conference System" functional scale at the time of admission and discharge.

RESULTS

Only total baseline Minimental State Examination score showed a significant correlation with discharge motor FIM improvement (r = 0.31, P = 0.04) and baseline orientation score correlated significantly with functional ambulation score improvement (r = 0.31, P = 0.03). In stepwise linear regression model, the same variables had an effect on similar outcome parameters.

CONCLUSIONS

Cognitiveion evaluation should be taken as a whole to predict functional outcome in patients with postacute stroke, except for the baseline orientation score that seemed more predictive for ambulation.

The relation between objective and subjective impairment in cognitive function among multiple sclerosis patients--the role of depression

OBJECTIVE

To evaluate the relations between perceived cognitive function and objective cognitive deficit and to assess variables affecting perceived cognitive function among multiple sclerosis (MS) patients.

METHODS

A cross sectional study of patients with MS. All patients were interviewed and the Expanded Disability Status Scale (EDSS) score was determined. The dependent variables were four items assessing perceived concentration and thinking, attention, memory, and whether others have noticed memory or concentration problems. The explanatory variables were age, sex, duration of disease, number of relapses in the last 2 years, EDSS score, depressive symptoms score (CES-D) and the domains of the Neurobehavioral Cognitive Status Examination (NCSE) assessing cognitive performance. Bivariate and then multivariate analysis were performed.

RESULTS

One hundred and sixty-one MS patients were included. Mean age was 44.2 years (s.d. 11.3 years), mean EDSS score was 4.86 (s.d. 1.93). Seventy-two per cent of the patients had objective cognitive impairment and 51% reported decreased perceived cognitive function. In all models assessing perceived cognitive function we could explain only a small part of the variance (R2 ranged between 18-26%). In all these models depressive symptoms explained the highest portion of the variance (partial R2 ranging between 13-26%). The only domain of the NCSE that entered some of the models was calculation (partial R2 ranging between 3-7%).

CONCLUSIONS

These findings emphasize the gap between objective and subjective assessment of cognitive function and the high correlation between perceived cognitive deficit and depressive symptoms.

Cognitive ability and functional status

Significant confusion exists in the literature about functional status. Despite its importance, little attention has focused on developing and substantiating frameworks that detail the underpinnings of functional status, which has resulted in lack of agreement about its definition and dimensions. The purpose of this literature review was to examine the development of functional status and to describe the inclusion of its cognitive dimension. Cognition is one key dimension of functional status. One must 'know how' to perform to be successful in an activity. While cognitive capacity is generally considered in relation to functional status, the nature of the cognitive dimension is poorly described and poorly understood. Three databases were selected for review: Citations in Nursing and Allied Health (CINAHL), Psychology Literature (PsychLit), and the Medical data base known as MedLine. Key word searches identified thousands of sources. This analysis includes an extensive sampling of these sources from the 1960s through to 1998. The sources sorted into four primary categories and demonstrate a growing recognition of the cognitive dimension of functional status in the literature. Despite this recognition, the lack of conceptual clarity of both the term functional status and its cognitive dimension limits communication among disciplines and limits comparisons of functional status outcomes across studies. Functional status models are needed that include cognition as a core dimension. Population specific descriptions of the cognitive dimension should be guided by knowledge in the neurosciences.

Stroke in the very old : clinical presentation and determinants of 3-month functional outcome: A European perspective. European BIOMED Study of Stroke Care Group

BACKGROUND AND PURPOSE

The oldest old represent the fastest-growing segment of the elderly population in developed countries. Knowledge of age-specific aspects of stroke is essential to establish diagnostic and therapeutic pathways and to set up prevention and rehabilitation programs. We sought to evaluate stroke features and functional outcome in patients aged >/=80 years compared with the younger age groups.

METHODS

In a European Union Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month disability (Barthel Index) and handicap (Rankin Scale).

RESULTS

Overall, 3141 patients (69.8%) were aged <80 years, and 1358 (30.2%) were aged >/=80 years. At baseline, female sex, prestroke institutionalization, and a worse prestroke Rankin score were significantly more frequent in the older patients, as were coma, paralysis, swallowing problems, and urinary incontinence in the acute phase (all P values <0.001). Brain imaging and other diagnostic tools were significantly less used in the older patients. Paralysis, swallowing problems, and incontinence during hospitalization independently predicted 3-month disability or handicap in both groups. For the older patients, prestroke institutionalization proved a further strong and independent determinant of 3-month disability (odds ratio, 2.33; 95% CI, 1.22 to 4.45) and handicap (odds ratio, 7.04; 95% CI, 1.62 to 30. 69).

CONCLUSIONS

In the very old, both medical and sociodemographic factors may significantly influence stroke outcome, showing peculiar characteristics. Knowledge of these determinants may reduce the burden on health systems, improving quality of care.

Newly developed short behavior scale for use in stroke outcome research

This study was designed to examine the scale quality of our newly developed short behavior scale and to identify its role in predicting the functional outcome of stroke patients. The short behavior scale consists of six items that assess cognitive function related to the daily behavioral status of a patient in activities of daily living and exercise. It can be scored quickly through observation of a patient's behavior. We assessed 190 stroke inpatients, who had a mean age of 61 years. The mean days and length of stay from onset were 47.3 and 138.2, respectively. We examined internal consistency with the Cronbach's alpha coefficient. Interrater reliability was tested by having two examiners evaluate 30 patients independently. We studied how the short behavior scale correlated with the admission Functional Independence Measure, Mini-Mental State Examination scores, and speech and visuospatial functions. We also studied how the short behavior scale contributed to the prediction of discharge Functional Independence Measure raw scores with stepwise multiple regression analysis. In another group of 116 patients, we cross-validated our predictive equation. The Cronbach's alpha coefficient was 0.88. The intraclass correlation coefficient was 0.84 for total score. The short behavior scale correlated significantly with cognitive Functional Independence Measure scores and Mini-Mental State Examination scores. We could explain 70.8% of the variance of discharge Functional Independence Measure scores from the Short Behavior Scale, days from onset to admission, age, speech scores, and admission Functional Independence Measure scores. Stability of the predictive equation was shown in cross-validation to a second sample of 116 patients. In conclusion, our newly developed short behavior scale proved reasonable and would be useful to enhance the precision of outcome prediction in stroke rehabilitation.