Managing cognitive impairment following stroke: protocol for a systematic review of non-randomised controlled studies of psychological interventions

Rehabilitation interventions for cognitive deficits in stroke survivors: A systematic review of randomized controlled trials

Cognitive deficits are one of the most common impairments after stroke. It negatively affects physical and social functioning. Rehabilitation interventions for cognitive deficits post-stroke have taken less consideration. The present study aimed to provide an overview of the effects of various rehabilitation interventions on cognitive functions in patients with stroke. PUBMED, SCOPUS, PEDro, EMBASE, MEDLINE, and REHABDATA were searched for randomized controlled trials (RCTs) investigating the effects of rehabilitation interventions on cognitive domains poststroke until August 2021. The methodological quality of the selected studies was evaluated using the Cochrane Collaboration tool, and the effect sizes were calculated. Forty-four studies met the inclusion criteria. A total of 3561 individuals with stroke, 57.60% of whom were males. The mean age for all participants was 65.48 years. Eighteen RCTs were high, moderate (n = 17), and low methodological quality (n = 9). The results showed evidence for the beneficial effects of many rehabilitation interventions on cognition in individuals with stroke. Rehabilitation plays a crucial role in improving cognitive functions in stroke patients with mild cognitive deficits. Virtual reality (VR), computer-based cognitive rehabilitation (CBCR), and non-aerobic exercises may promote cognitive functions in patients with stroke.

Association between zinc deficiency and cognitive decline in community-dwelling older adults

This is a cross-sectional study evaluating the association between zinc deficiency and cognitive decline in 591 community-dwelling older adults living in the cities of Campinas, Limeira, and Piracicaba-SP. Cognitive status was evaluated using the Cognitive Abilities Screening Instrument-CASI-S, considering a decline for scores <23 for those aged 60-69 and <20 for those aged ≥70 years. Among the evaluated cognitive domains, older adults with zinc deficiency had significantly lower mean scores on the memory test (p=0.018). For zinc deficiency, values below 70 µg/dL were considered for women and 74 µg/dL for men. The prevalence of zinc deficiency was 3.9%, and cognitive deficit was 9.4%, being significantly higher in those with zinc deficiency compared with those with normal serum zinc concentrations. In adjusted multiple logistic regression analysis, the factors that remained associated with cognitive decline were zinc deficiency (OR=3.80; 95%CI=1.30-11.12), low schooling level (OR=3.12; 95%CI=1.49-6.50), lack of a partner (OR=1.88; 95%CI=1.04-3.42), risk of malnutrition (OR=3.98; 95%CI=2.36-6.71), and a history of encephalic vascular accident (OR=2.70; 95%CI=1.04-6.98). Zinc deficiency was associated with the presence of cognitive decline in older adults. Actions in primary health care are necessary to prevent the deficiency of this nutrient.

Association between zinc deficiency and cognitive decline in community-dwelling older adults

Abstract This is a cross-sectional study evaluating the association between zinc deficiency and cognitive decline in 591 community-dwelling older adults living in the cities of Campinas, Limeira, and Piracicaba-SP. Cognitive status was evaluated using the Cognitive Abilities Screening Instrument-CASI-S, considering a decline for scores <23 for those aged 60-69 and <20 for those aged ≥70 years. Among the evaluated cognitive domains, older adults with zinc deficiency had significantly lower mean scores on the memory test (p=0.018). For zinc deficiency, values below 70 µg/dL were considered for women and 74 µg/dL for men. The prevalence of zinc deficiency was 3.9%, and cognitive deficit was 9.4%, being significantly higher in those with zinc deficiency compared with those with normal serum zinc concentrations. In adjusted multiple logistic regression analysis, the factors that remained associated with cognitive decline were zinc deficiency (OR=3.80; 95%CI=1.30-11.12), low schooling level (OR=3.12; 95%CI=1.49-6.50), lack of a partner (OR=1.88; 95%CI=1.04-3.42), risk of malnutrition (OR=3.98; 95%CI=2.36-6.71), and a history of encephalic vascular accident (OR=2.70; 95%CI=1.04-6.98). Zinc deficiency was associated with the presence of cognitive decline in older adults. Actions in primary health care are necessary to prevent the deficiency of this nutrient.

The efficacy and safety of agomelatine, sertraline, and escitalopram for senile post-stroke depression: A randomized double-blind placebo-controlled trial

OBJECTIVES

This study aims to investigate the efficacy and safety of agomelatine, sertraline, and escitalopram for patients with senile post-stroke depression (SPSD, aged over 65 years).

PATIENTS AND METHODS

A total of 165 patients (aged over 65 years) with post-stroke depression (PSD) were recruited. These patients were randomly assigned to one of four groups and given an anti-depressant or a placebo as follows: group A (agomelatine in combination with conventional cerebrovascular disease medication) 48 patients; group B (sertraline in combination with conventional cerebrovascular disease medication) 47 patients; group C (escitalopram in combination with conventional cerebrovascular disease medication) 50 patients; and, a control group (conventional treatment alone) 20 patients. The efficacy of the different treatments was evaluated using the Hamilton Depression Scale (HAMD), the National Institute of Health Stroke Scale (NIHSS), and the Activities of Daily Living (ADL) Barthel index (BI) at one, two, four, and six weeks after treatment began.

RESULTS

According to the HAMD, NIHSS score, and BI index, the patients who received one of the three antidepressant treatments showed significant improvement compared with the control group (p < 0.05), but there was no significant difference between the three groups receiving anti-depressant medication (p > 0.05). Laboratory tests showed that the general adverse effects of the treatments were mild in all three groups, and patients generally tolerated the treatments.

CONCLUSION

A decrease of HAMD and NIHSS scores and an increase in the BI index could be observed in the patients receiving agomelatine, sertraline, or escitalopram treatment. Thus, it would appear that the condition of SPSD in older patients can be improved with the use of either agomelatine, sertraline, or escitalopram.

Effect of aerobic exercise on post-stroke cognitive function: a systematic review

Background/Aims

Literature suggests that aerobic exercise improves cognitive impairments post stroke. This systematic review was conducted to analyse evidence on the effectiveness of aerobic exercise in improving post-stroke cognitive impairments.

Methods

Online databases (PubMed, EMBASE and Web of Science) were systematically searched from inception until 13 July 2017 using the keywords stroke/exercise/cognition. Clinical trials that met the inclusion criteria were assessed for methodological quality using the PEDro scale. Extracted data were synthesised for evidence.

Results

A total of seven studies met the inclusion criteria. Participants in most of the studies were aged over 60 years and the majority had ischaemic stroke. The most commonly used measure for assessing cognition was the Mini Mental State Examination. The majority of studies included moderate to high intensity exercise (50–70% of VO2max) for 30–60 minutes three to five times per week. There is moderate evidence that aerobic exercise enhances global cognitive function, attention and working memory. Evidence that aerobic exercise improves memory, levels of brain-derived neurotrophic factor and executive function is conflicting and limited.

Conclusions

Aerobic exercise is moderately effective in improving post-stroke cognitive impairments. More clinical trials are needed in view of the methodological limitations and paucity of existing studies.

Improving Cerebrovascular Function to Increase Neuronal Recovery in Neurodegeneration Associated to Cardiovascular Disease

Mounting evidence indicates that the presence of cardiovascular disease (CVD) and risk factors elevates the incidence of cognitive impairment (CI) and dementia. CVD and associated decline in cardiovascular function can impair cerebral blood flow (CBF) regulation, leading to the disruption of oxygen and nutrient supply in the brain where limited intracellular energy storage capacity critically depends on CBF to sustain proper neuronal functioning. During hypertension and acute as well as chronic CVD, cerebral hypoperfusion and impaired cerebrovascular function are often associated with neurodegeneration and can lead to CI and dementia. Currently, all forms of neurodegeneration associated to CVD lack effective treatments, which highlights the need to better understand specific mechanisms linking cerebrovascular dysfunction and CBF deficits to neurodegeneration. In this review, we discuss vascular targets that have already shown attenuation of neurodegeneration or CI associated to hypertension, heart failure (HF) and stroke by improving cerebrovascular function or CBF deficits.

Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke, 6th edition update 2019

The 2019 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Mood, Cognition and Fatigue following Stroke is a comprehensive set of evidence-based guidelines addressing three important issues that can negatively impact the lives of people who have had a stroke. These include post-stroke depression and anxiety, vascular cognitive impairment, and post-stroke fatigue. Following stroke, approximately 20% to 50% of all persons may be affected by at least one of these conditions. There may also be overlap between conditions, particularly fatigue and depression. If not recognized and treated in a timely matter, these conditions can lead to worse long-term outcomes. The theme of this edition of the CSBPR is Partnerships and Collaborations, which stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care to optimize recovery and outcomes. Accordingly, these recommendations place strong emphasis on the importance of timely screening and assessments, and timely and adequate initiation of treatment across care settings. Ideally, when screening is suggestive of a mood or cognition issue, patients and families should be referred for in-depth assessment by healthcare providers with expertise in these areas. As the complexity of patients treated for stroke increases, continuity of care and strong communication among healthcare professionals, and between members of the healthcare team and the patient and their family is an even bigger imperative, as stressed throughout the recommendations, as they are critical elements to ensure smooth transitions from acute care to active rehabilitation and reintegration into their community.

Addressing cognitive impairment following stroke: systematic review and meta-analysis of non-randomised controlled studies of psychological interventions

OBJECTIVE

Cognitive impairment is a pervasive outcome of stroke, reported in over half of patients 6 months post-stroke and is associated with increased disability and a poorer quality of life. Despite the prevalence of post-stroke cognitive impairment, the efficacy of existing psychological interventions for the rehabilitation of cognitive impairment following stroke has yet to be established. The aim of this study is to identify psychological interventions from non-randomised studies that intended to improve post-stroke cognitive function and establish their efficacy.

DESIGN

Systematic review and meta-analysis of non-randomised studies of psychological interventions addressing post-stroke cognitive impairment.

DATA SOURCES

Electronic searches were performed in the Pubmed, EMBASE and PsycINFO databases, the search dating from inception to February 2017.

ELIGIBILITY CRITERIA

All non-randomised controlled studies and quasi-randomised controlled trials examining psychological interventions to improve cognitive function following stroke were included, such as feasibility studies, pilot studies, experimental studies, and quasi-experimental studies. The primary outcome was cognitive function. The prespecified secondary outcomes were functional abilities in daily life and quality of life.

METHODS

The current meta-analyses combined the findings of seven controlled studies, examining the efficacy of psychological interventions compared with treatment-as-usual controls or active controls, and 13 one-group pre-post studies.

RESULTS

Results indicated an overall small effect on cognition across the controlled studies (Hedges' g=0.38, 95% CI=0.06 to 0.7) and a moderate effect on cognition across the one-group pre-post studies (Hedges' g=0.51, 95% CI=0.3 to 0.73). Specific cognitive domains, such as memory and attention also demonstrated a benefit of psychological interventions.

CONCLUSIONS

This review provides support for the potential of psychological interventions to improve overall cognitive function post-stroke. Limitations of the study, in terms of risk of bias and quality of included studies, and future research directions are explored.

PROSPERO REGISTRATION NUMBER

CRD42017069714.