Cognitive Problems Persist Post-Stroke Even After Physical Recovery
By Marilynn Larkin
NEW YORK—More than half of stroke patients who have the best possible functional recovery are hampered by cognitive impairment and depression for up to three years after the event, researchers say.
Functional outcome after stroke is often only evaluated using the modified Rankin Scale (mRS), which mainly assesses the ability to do activities of daily living. Yet patients may experience mental, emotional and social problems that result in poor quality of life even after a complete physical recovery, according to a report in Stroke, online April 24.
Dr. Richard Swartz of Sunnybrook Health Sciences Centre in Toronto, Canada and colleagues studied 142 individuals who sustained a stroke, about half of whom were men, with an average age of 68 at follow-up. Most (89%) had an ischemic stroke. The average time from stroke to follow-up assessment was two and a half years.
The team conducted phone interviews to evaluate multiple levels of outcomes, as measured by the Montreal Cognitive Assessment, the Patient Health Questionnaire-2, the mRS and the Reintegration into Normal Living Index.
Ninety-six patients (68%) had an excellent recovery (0 to 1) based on the mRS. Of these, 79 completed the body function assessment, 91 completed the reintegration assessment, and 93 completed the patient health questionnaire.
More than half (54%) of those with a good outcome on the mRS were cognitively impaired, more than half (52%) had restrictions in reintegration, and about a third (32%) had symptoms of depression.
There was no difference in cognitive assessment or patient health questionnaire scores between those who had activity limitations as assessed by the mRS and those who did not.
Dr Swartz told Reuters Health, “The surprise here is that this study looked at survivors with the best possible motor/self-care functioning and found that mood and cognitive symptoms were just as common in this group as in survivors with more severe functional impairments.”
“They continue to have limits in how they’ve gotten back to their lives, and symptoms of mood or cognitive impairment even after years of therapy/recovery/time,” he said by email.
“The mRS is an excellent general assessment of global functioning . . . but it is a simple scale covering outcomes from ‘normal’ to mild impairment to full dependence to death in seven points (0-6),” he continued.
“There are many other symptoms - e.g., mood, thinking, memory, fatigue/sleep - that impact people’s quality of life, ability to work, and degree of independence, that aren’t captured and don’t seem to correlate well with the global measure.”
“Ideally,” Dr. Swartz said, “future trials will use the mRS in combination with other outcomes scales . . . to assess multiple domains of function.”
He added, “The burden and quality of life of caregivers of stroke patients could also be assessed in stroke trials."
Dr. Scott Hirsch, a neurologist at NYU Langone Medical Center in New York City, told Reuters Health the results are not surprising, as “stroke may affect areas of the brain dedicated to non-motor functioning and the mRS is focused primarily on physical disability.”
“After a stroke, patients participate in intensive rehabilitation to address the more obvious effects of stroke, such as weakness,” he said by email. “The results gleaned from the simple screening tools used in this study suggest that the quality of life of post-stroke patients might benefit by routinely screening and offering treatment for depressive mood symptoms.”
Dr. Brian S. Im, director of the traumatic brain injury program at Rusk Rehabilitation at NYU Langone, said that beyond the limitations of the mRS, “the effect of these impairments must also be viewed in the specific context of the individual and their role among their family, friends and society to fully appreciate the impact of the stroke.”
“For example,” he told Reuters Health by email, “categorizing someone as having mild, moderate or severe disability does not fully appreciate psychological barriers such as depression which may prevent an individual from carrying out activities even though they are capable of doing so.”
“It also does not provide much insight into how these disabilities affect an individual’s quality of life,” he continued. “Someone with a moderate disability who has significant family support and is content with a fairly limited range of activities may be impacted differently than another individual who has limited support and strives to do much more in the community.”
“A comprehensive approach to neuro-rehabilitation often requires multiple therapy disciplines including physical therapy, occupational therapy, psychology, neuropsychology, speech therapy, swallow therapy, social work support, and vocational counseling,” Dr. Im said. “Pharmacological management also may include equally wide ranging treatments to address cognitive functioning, mental health, physical and medical issues.”
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