Scholarly Agenda

Presentation
By: Alex Vinelli, OTS
Chatham University
Abstract
Stroke is one of the leading causes of disability and death in the United States (CDC, 2017). Occupational
therapists have a significant role in the recovery of patients post stroke. Occupational therapists
evaluate patients and create treatment plans to help address physical and cognitive impairments.
Physical and cognitive complications are very common after stroke. Impairments in cognition can
reduce potential functional outcomes and ones ability to return to their prior level of functioning.
Currently, there is not one assessment available that evaluates all aspects of cognition (Zucchella et al., 2014).
Formal cognitive evaluations have the ability to detect cognitive deficits, however they are not used
often in practice due to the length of time and level of expertise it takes to administer them.
Therefore, in order to effectively and efficiently detect cognitive impairments in patients post stroke,
an assessment or combination of assessments that can address all areas of cognition and monitor
changes over time is needed (Nkleby et al., 2008). An objective score can help to compare improvements in
cognition over time and help predict functional outcomes. Assessing cognition early after stroke is
important so that occupational therapists can obtain a baseline to help determine which aspects of
cognition are intact and which ones should be a focus of treatment. The purpose of this scholarly
agenda was to explore the benefits and assessments associated with early evaluation of cognition post
stroke.
Introduction

PO
What are the common benefits and assessments associated with early
evaluation of cognition post stroke?
Significance
Stroke is the 5th leading cause of death in the U.S. Each year, about 795,000 people have a
stroke (CDC, 2017).
Many patients post stroke will experience not only functional impairments, but cognitive
deficits as well. One third of patients experience cognitive deficits up to 3 years after
stroke (Patel, Coshall, Rudd, & Wolfe, 2003).
Currently in the literature, there is lack of agreement on which assessments evaluate
cognition best. There is also a lack of formal cognitive assessments that encompass all
aspects of cognition (Jaillard, Naegele, Trabucco-Miguel, LeBas, & Hommel, 2009) (K Nkleby et al., 2008).
A role of OT is to evaluate cognition and higher level thinking (OTPF, 2014).
The use of formal, standardized assessments to evaluate cognition helps to track objective
changes over time and establish a baseline for intervention (McDonnell, Bryan, Smith, & Esterman,
2011).
Neuropsychological assessments are time consuming and require an expert to administer
and interpret, therefore, a brief assessment that can address many aspects of cognition and
can be carried out by other healthcare professionals is needed (K Nkleby et al., 2008).
Search Strategy
Search engines:
AJOT, CINAHL, Google Scholar, Science Direct
Search terms:
Assessments, cognition, executive functioning, occupational therapy, stroke
Inclusion criteria:
Articles focused on cognition and stroke patients, assessments used to evaluate
cognition post stroke, and benefits of early evaluation
Exclusion criteria:
Articles that were not peer-reviewed, published before 2000, and not focused
on cognition and stroke were excluded
Evidence
(2) Level II Experimental Design Small Scale RCT
(Zucchella et al., 2014) (McDonnell, Bryan, Smith, & Esterman, 2011)

(2) Level III Quasi-Experimental Design Non-randomized without a control group

(Nkleby et al., 2008) (Dong et al., 2010)

(1) Level IV Non-Experimental Design Survey Study

(Burns & Neville, 2016)

(1) Level V Non-Experimental Design Literature Review

(Chiti & Pantoni, 2014)
 Assessing cognitive impairment following stroke
(McDonnell, Bryan, Smith, & Esterman, 2011)

Study objectives:
Determine if a brief protocol is useful for detecting cognitive impairment in patients post stroke
Determine what assessments were sensitive to change in order to create a protocol to use in a clinical setting

Methods:
17 right-handed patients post stroke ages 35-85 with no diagnosis of dementia participated in the study. 13 healthy older adults,
with no history of CVA, TIA, or other neurologic disorders were included in the control group
Subjects underwent a neuropsychological assessment using 10 cognitive tests to evaluate executive function, memory, working
memory, speed of information processing, and visuospatial function
Outcomes:
Significant differences between groups using the MoCA (Stroke mean= 21.7, control= 25.8, cutoff 24)
Significant differences between groups in the areas of executive function, memory, working memory, and speed of information
processing
At reassessment, the stroke group made significant improvements in information processing and memory, there were no
significant differences between scores for control group
The M-PASAT, IT, FCSRT, and TMT-B detected changes in cognitive functioning, which supports the use of these measures to
evaluate cognition post stroke
 Screening for cognitive deficits after
stroke: a comparison of three screening tools
(Nkleby et al., 2008)

Study objectives:
Evaluate the concurrent validity of the Cognistat, The Screening Instrument for Neuropsychological Impairment in
Stroke (SINS), and The Clock Drawing Test against a basic neurophysiological assessment to detect cognitive
impairment after stroke
Methods:
49 patients ages 25-91 were recruited from a stroke rehab unit and evaluated using a basic neuropsychological
assessment and the Cognistat, SINS, and Clock Drawing Test
Outcomes:
Modest-fair agreement between the three screens and the basic neuropsychological assessment
Results indicate the Cognistat and SINS are sensitive to cognitive changes post stroke, which supports the use of them
as screening tools
The Clock Drawing Test did not provide significant information in support of its use to detect cognitive changes
 Assessing and restoring cognitive functions early after stroke
(Zucchella et al., 2014)

Study objectives:
Determine the benefits of assessing cognition early after stroke
Evaluate the effects that implementing a cognitive training program, computer training, and metacognitive strategies have on
stroke outcomes
Methods:
Prior to beginning the study, patients were evaluated using a neuropsychological assessment to obtain information regarding
many aspects of cognition
92 patients were randomly assigned to the experimental or control group and participated in 16, one hour sessions
Patients in the experimental group received cognitive training using computer exercises while the control group received a
sham intervention
After 4 weeks of intervention, patients were reevaluated
Outcomes:
No significant differences were detected between groups for any of the tests within the neuropsychological assessment
Both groups showed improvements in cognitive performance, however only the experimental group yielded significant
improvements on all measures
Detecting cognitive impairments early after stroke and implementing cognitive training programs may improve outcomes
after stroke
Summary
There is little agreement in the literature on which assessment(s) is/are best to use to evaluate
cognition post stroke
Many common assessments used contain few items that directly measure cognition
Commonly used assessments such as the MMSE and MoCA are brief and many not detect higher level
cognitive deficits
Neuropsychological tests are lengthy and require expertise
Lack of agreement on which assessments to use and and consistency of administration makes it
difficult to track cognitive changes over time
Development of a testing protocol that assesses several cognitive domains and detects changes over
time is needed to improve functional outcomes of patients post stroke
A set protocol would help to establish a baseline and guide intervention
 References
Burns, S. C., & Neville, M. (2016). Cognitive assessment trends in home health care for adults with mild stroke. American
Journal of Occupational Therapy, 70(2), 7002290020.
Centers for Disease Control and Prevention. (2017, September). Stroke fact sheet. Retrieved from
https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_stroke.htm
Chiti, G., & Pantoni, L. (2014). Use of Montreal Cognitive Assessment in patients with stroke. Stroke, 45(10), 3135-3140.
Dong, Y., Sharma, V. K., Chan, B. P. L., Venketasubramanian, N., Teoh, H. L., Seet, R. C. S., ... & Chen, C. (2010). The
Montreal Cognitive Assessment (MoCA) is superior to the Mini-Mental State Examination (MMSE) for the detection of
vascular cognitive impairment after acute stroke. Journal of the neurological sciences, 299(1), 15-18.
McDonnell, M. N., Bryan, J., Smith, A. E., & Esterman, A. J. (2011). Assessing cognitive impairment following stroke. Journal
of clinical and experimental neuropsychology, 33(9), 945-953.
Nkleby, K., Boland, E., Bergersen, H., Schanke, A. K., Farner, L., Wagle, J., & Wyller, T. B. (2008). Screening for cognitive
deficits after stroke: A comparison of three screening tools. Clinical Rehabilitation, 22(12), 1095-1104.
Zucchella, C., Capone, A., Codella, V., Vecchione, C., Buccino, G., Sandrini, G., ... & Bartolo, M. (2014). Assessing and
restoring cognitive functions early after stroke. Functional neurology, 29(4), 255.