Rehabilitation for Cognitive Impairment after Stroke: Exploration of Possibilities for the Delivery of Cognitive Rehabilitation

Aim: The overarching aims of this thesis are to explore the potential suitability of cardiovascular rehabilitation, an expanded version of cardiac rehabilitation, for post-stroke rehabilitation, including cognitive intervention where relevant, and to identify existing barriers and facilitators to delivery of cognitive rehabilitation for all stroke patients with cognitive impairment as part of routine post-stroke care. Methods and results: This thesis employed an explanatory sequential mixed methods design, combining quantitative and qualitative methodologies. Four interrelated studies were conducted to address the thesis aims. The first study involved a systematic review of the literature to establish whether cardiovascular/cardiac rehabilitation, with or without a cognitive rehabilitation intervention, improved post-stroke outcomes, particularly cognitive outcomes. A limited literature demonstrated that, although cardiac rehabilitation-type interventions had no significant effect on post-stroke cognitive function, improvements in anxiety, depression, and cardiovascular fitness were evident. The qualitative component of this thesis (Studies 2 and 3) involved semi-structured interviews with stroke and cardiac rehabilitation professionals, and the data were analysed using Thematic Analysis. The first qualitative study (Study 2) explored the potential for expansion of cardiac rehabilitation services to include stroke patients, thereby becoming a cardiovascular rehabilitation model. Participants recommended a hybrid model, in which shared modules are delivered to all patients and stroke-specific education and exercise are delivered to those with stroke. Cognitive impairment was described as a barrier to cardiac rehabilitation, and the inclusion of a cognitive rehabilitation intervention could address the cognitive needs of stroke and cardiac patients simultaneously. The second qualitative study (Study 3) aimed to identify barriers and facilitators to the delivery of cognitive rehabilitation in existing stroke services, for individuals with more significant impairments who may not be eligible for cardiovascular rehabilitation. Participants highlighted the importance of the multidisciplinary team approach to stroke rehabilitation, as well as barriers to delivery of cognitive rehabilitation including inadequate resourcing, the lack of defined pathways for continuing rehabilitation in the community and poor access to stroke-specific expertise. The findings suggest that improved resourcing of psychology and neuropsychology, in particular, would promote better access to comprehensive cognitive assessment and cognitive rehabilitation. The final quantitative study of this thesis (Study 4) considered the impact of stroke, cognitive impairment and post-stroke cognitive impairment on healthcare utilisation. Stroke was associated with more frequent visits to the GP, outpatient clinics and rehabilitation services. While poor cognitive function was also associated with increased GP utilisation, cognitive impairment, with or without stroke, was associated with reduced visits to outpatient services. Conclusion: The overall findings from this thesis indicate that adapted cardiovascular rehabilitation may be a suitable model through which to deliver rehabilitation post-stroke, including cognitive rehabilitation. Further research is needed also to establish the potential effectiveness of cardiovascular rehabilitation on post-stroke cognitive impairment. Inconsistent cognitive screening practices makes it difficult to specify the numbers of patients with stroke who would require cognitive rehabilitation, thus impacting on the capacity to identify resources needed for delivery of cognitive rehabilitation. Inadequate resourcing continues to be a major barrier to the effective delivery of stroke services in Europe and limited access to stroke-specific expertise in the community further impedes the delivery of cognitive rehabilitation. The overall results of this thesis indicate an urgent need for investment in stroke rehabilitation services across all healthcare settings, to improve access to cognitive rehabilitation post-stroke. Rehabilitation for cognitive impairment is a neglected aspect of stroke rehabilitation and the absence of appropriate cognitive care post-stroke is likely to have significant implications for healthcare services worldwide.</p

Inclusion of stroke patients in expanded cardiac rehabilitation services: a cross-national qualitative study with cardiac and stroke rehabilitation professionals

Purpose: This qualitative study explored healthcare professionals’ views in relation to the potential expansion of cardiac rehabilitation services to include stroke patients, thereby becoming a cardiovascular rehabilitation model. Design and methods: 23 semi-structured interviews were completed with hospital and community-based stroke and cardiac rehabilitation professionals in Switzerland (n = 7) and Ireland (n = 19). The sample comprised physiotherapists, occupational therapists, speech and language therapists, stroke physicians, cardiologists, psychologists, dieticians and nurses. Interviews were audio-recorded and the transcripts were analysed in NVivo using inductive Thematic Analysis. Results: Barriers and facilitators to cardiovascular rehabilitation were captured under four broad themes; (i) Cardiac rehabilitation as “low-hanging fruit,” (ii) Cognitive impairment (“the elephant in the room”), (iii) Adapted cardiac rehabilitation for mild stroke, and (iv) Resistance to change. Conclusions: Hybrid cardiac rehabilitation programmes could be tailored to deliver stroke-specific education, exercises and multidisciplinary expertise. Post-stroke cognitive impairment was identified as a key barrier to participation in cardiac rehabilitation. A cognitive rehabilitation intervention could potentially be delivered as part of cardiac rehabilitation, to address the cognitive needs of stroke and cardiac patients. Implications for rehabilitation The cardiac rehabilitation model has the potential to be expanded to include mild stroke patients given the commonality of secondary prevention needs. Up to half of stroke survivors are affected by post-stroke cognitive impairment, consequently mild stroke patients may not be such an “easy fit” for cardiac rehabilitation. A cardiovascular programme which includes common rehabilitation modules, in addition to stroke- and cardiac-specific content is recommended. A cognitive rehabilitation module could potentially be added as part of the cardiac rehabilitation programme to address the cognitive needs of stroke and cardiac patients.</div

Designing stroke services for the delivery of cognitive rehabilitation: a qualitative study with stroke rehabilitation professionals

This qualitative study explored the potential to deliver cognitive rehabilitation for post-stroke cognitive impairment (PSCI), with a specific focus on barriers and facilitators to its delivery from the perspective of Irish stroke rehabilitation professionals. Sixteen semi-structured interviews were completed with healthcare professionals in both hospital and community settings. The sample comprised physiotherapists, occupational therapists, nurses, a stroke physician, a psychologist, a neuropsychologist, a speech and language therapist, a dietician, and a public health nurse. Interviews were audio-recorded and analysed in NVivo using inductive Thematic Analysis. Barriers and facilitators to the delivery of cognitive rehabilitation were identified and described under four key themes: (i) Cognitive screening; (ii) Cognitive rehabilitation: no one size fits all; (iii) Psychology: the lost dimension of stroke rehabilitation; and (iv) Joining the dots in the community. Staffing required to deliver cognitive rehabilitation for PSCI was highlighted as under-resourced in the Republic of Ireland. Inadequate resourcing of neuropsychology and stroke-related psychological services, in particular, has had negative implications for the delivery of cognitive rehabilitation. Stroke-specific cognitive rehabilitation expertise is virtually inaccessible in the community, highlighting an urgent need for investment in specialist rehabilitation teams to deliver cognitive rehabilitation in this setting

The impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in Ireland: a cross-sectional nationally representative study

Background: Cognitive impairment after stroke is associated with poorer health outcomes and increased need for long-term care. The aim of this study was to determine the impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in older adults in Ireland. Methods: This cross-sectional study involved secondary data analysis of 8,175 community-dwelling adults (50 + years), from wave 1 of The Irish Longitudinal Study on Ageing (TILDA). Participants who had been diagnosed with stroke by a doctor were identified through self-report in wave 1. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA). The main outcome of the study was healthcare utilisation, including General Practitioner (GP) visits, emergency department visits, outpatient clinic visits, number of nights admitted to hospital, and use of rehabilitation services. The data were analysed using multivariate adjusted negative binomial regression and logistic regression. Incidence-rate ratios (IRR), odds ratios (OR) and 95% confidence intervals (CI) are presented. Results: The adjusted regression analyses were based on 5,859 participants who completed a cognitive assessment. After adjusting for demographic and clinical covariates, stroke was independently associated with an increase in GP visits [IRR (95% CI): 1.27 (1.07, 1.50)], and outpatient service utilisation [IRR: 1.49 (1.05, 2.12)]. Although participants with poor cognitive function also visited the GP more frequently than participants with normal cognitive function [IRR: 1.07 (1.04, 1.09)], utilisation of outpatient services was lower in this population [IRR: 0.92 (0.88, 0.97)]. PSCI was also associated with a significant decrease in outpatient service utilisation [IRR: 0.75 (0.57, 0.99)]. Conclusions: Stroke was associated with higher utilisation of GP and outpatient services. While poor cognitive function was also associated with more frequent GP visits, outpatient service utilisation was lower in participants with poor cognitive function, indicating that cognitive impairment may be a barrier to outpatient care. In Ireland, the lack of appropriate neurological or cognitive rehabilitation services appears to result in significant unaddressed need among individuals with cognitive impairment, regardless of stroke status.</p

A systematic review and meta-analysis of the effects of cardiac rehabilitation interventions on cognitive impairment following stroke.

Purpose: The cardiac rehabilitation model has potential as an approach to providing rehabilitation following stroke. This review aims to identify evidence for the participation of stroke patients in cardiac/cardiovascular rehabilitation programs internationally, whether or not such programs offer a cognitive intervention as part of treatment, and the impact of rehabilitation on post-stroke cognitive function. Method: Five electronic databases were searched from inception to 1 May 2019, namely: MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials, and the Web of Science. Eligible studies included both randomized and non-randomized studies of cardiac rehabilitation-type interventions which measured cognitive function in patients with transient ischemic attack (TIA) or stroke. Results: Of 14,153 records reviewed, nine studies which delivered cardiac rehabilitation-type interventions to stroke patients were finally included. Only three of these studies delivered cognitive rehabilitation as part of the intervention. Cardiac rehabilitation had no statistically significant effect on cognitive function in five randomized controlled trials (standardized mean difference= 0.28, 95% CI= -0.16 to 0.73) or in three one group pre-post studies (standardized mean difference= 0.15, 95% CI= -0.03 to 0.33). Conclusions: This review highlights that there are very few studies of delivery of cardiac rehabilitation to stroke patients and that the inclusion of cognitive interventions is even less common, despite the high prevalence of post-stroke cognitive impairment. IMPLICATIONS FOR REHABILITATION The cardiac rehabilitation model has the potential to be expanded to include patients post-stroke given the commonality of secondary prevention needs, thereby becoming a cardiovascular rehabilitation model. Up to half of patients experience cognitive impairment after stroke; suggesting that a post-stroke cardiovascular rehabilitation model should incorporate specific cognitive strategies for patients. This systematic review identified three cardiovascular rehabilitation programmes which delivered cognitive rehabilitation as part of treatment; however, evidence for efficacy is weak.</div

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.</p

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

Introduction Stroke is one of the primary causes of death and disability worldwide, leaving a considerable proportion of survivors with persistent cognitive and functional deficits. Despite the prevalence of poststroke cognitive impairment, there is no established treatment aimed at improving cognitive function following a stroke. Therefore, the aims of this systematic review are to identify psychological interventions intended to improve poststroke cognitive function and establish their efficacy. Methods and analysis A systematic review of non-randomised controlled studies that investigated the efficacy of psychological interventions aimed at improving cognitive function in stroke survivors will be conducted. Electronic searches will be performed in the PubMed, Embase and PsycINFO databases, the search dating from the beginning of the index to February 2017. Reference lists of all identified relevant articles will be reviewed to identify additional studies not previously identified by the electronic search. Potential grey literature will be reviewed using Google Scholar. Titles and abstracts will be assessed for eligibility by one reviewer, with a random sample of 50% independently double-screened by second reviewers. Any discrepancies will be resolved through discussion, with referral to a third reviewer where necessary. Risk of bias will be assessed with the Risk of Bias in Non-randomized Studies of Interventions tool. Meta-analyses will be performed if studies are sufficiently homogeneous. This review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of the evidence regarding cognitive function will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation. Ethics and dissemination This systematic review will collect secondary data only and as such ethical approval is not required. Findings will be disseminated through presentations and peer-reviewed publication. This review will provide information on the effectiveness of psychological interventions for poststroke cognitive impairment, identifying which psychological interventions are effective for improving poststroke cognitive function.</p