November 2015: Reference: Mellon L, Brewer L, Hall P, Horgan F, Williams D, Hickey A on behalf of the ASPIRE-S study group (2015) Cognitive impairment six months after ischaemic stroke: A profile from the ASPIRE-S study. BMC Neurology 15, 31; DOI 10.1186/s12883-015-0288-2. Available at: http://www.biomedcentral.com/1471-2377/15/31
Background: Cognitive impairment commonly occurs in the acute phase post-stroke, but may persist with over half of all stroke survivors experiencing some form of long-term cognitive deficit. Recent evidence suggests that optimising secondary prevention adherence is a critical factor in preventing recurrent stroke and the incidence of stroke-related cognitive impairment and dementia. The aim of this study was to profile cognitive impairment of stroke survivors at six months, and to identify factors associated with cognitive impairment post-stroke, focusing on indicators of adequate secondary prevention and psychological function.
Methods: Participants were assessed at six months following an ischaemic stroke as part of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke study (ASPIRE-S), which examined the secondary preventive and rehabilitative profile of patients in the community post-stroke. Cognitive impairment was measured using the Montreal Cognitive Assessment (MoCA).
Results: Two-hundred and fifty-six stroke patients were assessed at six months. Over half of the sample (56.6%) were found to have cognitive impairment, with significant associations between cognitive impairment and female sex (odds ratio (OR) = 1.6, 95% CI 1.01-2.57) and history of cerebrovascular disease (OR = 2.22, 95% CI 1.38-3.59). Treatment with antihypertensive medications (OR = .65, 95% CI .44-.96) and prescription of anticoagulant therapy (OR = .41, 95% CI .26-.68) were associated with reduced likelihood of cognitive impairment, however increasing number of total prescribed medications was moderately associated with poorer cognitive impairment (OR = 1.12, 95% CI 1.04-1.19).
Conclusions: Findings reveal levels of cognitive impairment at 6 months post-stroke that are concerning. Encouragingly, aspects of secondary prevention were identified that may be protective in reducing the incidence of cognitive impairment post-stroke. Neuropsychological rehabilitation post-stroke is also required as part of stroke rehabilitation models to meet the burden of post-stroke cognitive impairment.
When I read this article I was both surprised and alarmed. Mellon et al found that around half of all patients with an ischaemic stroke had cognitive impairment at 6 months post-event. As the authors state, this shouldn’t have been a surprise, as previous studies have shown ranges between 30 and 70%.
Much of 2015 I’ve reviewed evidence on poststroke complications and clinical consequences, so perhaps its right to finish this year with evidence on an issue that’s too often overlooked. Perhaps the “take home message” from this year’s Journal Club is that too many poststroke clinical consequences and complications that are too easily missed, too poorly assessed and too poorly managed. But the challenge is that for many of them, we know very little about how to effectively prevent or treat them. We’ve so often heard statements like this before, haven’t we: “The current evidence for the effectiveness of cognitive rehabilitation in stroke is sparse, with very few studies using randomised designs”?
Last night I heard a new phrase that may be something we need to take into 2016 for patients recovering from stroke: “watchful waiting”. What do we do when we have nothing to offer? What do we do when we don’t know what to do? Do we just do something, even if we know it’s ineffective? Or, do we admit to not knowing what to do and watchfully wait? In my humble opinion, there’s value in watchfully waiting. However, we can be more proactive in our watchful waiting, I’d suggest, by ensuring that we assess using a standardised, reliable and validated process. If we all do this, we’re better placed to efficiently investigate the efficacy of future interventions.
Cognitive impairment affects everything that a stroke survivor does, but what’s very interesting in this study, is the association between cognitive impairment and secondary prevention (SP) of ischaemic stroke! It seems that taking some SP medications protected survivors against cognitive impairment, but taking too many risked the opposite outcome. During 2015, the emergent “take home message” from much of the stroke recovery evidence has been, in my humble opinion, that there’s a Goldilocks Effect hanging over much of what should be happening. In stroke recovery, evidence is indicating that maximising recovery is about getting the balance right: not too much, not too little, but just right; not too early, not too late, but just right.
My exciting news is that in 2016, I’ll be offering fully online, continuing professional development (CPD) courses for health professionals using the CPDLife website, which is nearing its launch. As soon as it’s available, I’ll let you know! What’s more exciting is that any professional will be able to apply to become a CPD Educator, by submitting an expression of interest.
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