Ieke Winkens

Cognitive Functioning after Stroke: A One-Year Follow-Up Study

Cognitive disorders after stroke are one of the main causes of disability in daily activities. The main aim of this study was to investigate the frequency of post-stroke dementia, post-stroke mild cognitive impairment (MCI) and post-stroke amnestic MCI at different times after first-ever stroke; 196 patients were included in the study. In addition, cognitive disorders and their clinical course were studied. Frequency of post-stroke dementia was about 10% at all evaluation times; most patients had post-stroke MCI. Of the cognitive functions investigated, mental speed and calculation were most frequently affected. Performance on almost all cognitive tests was improved 6 and 12 months after stroke. Thus, while the frequency of post-stroke dementia is low, the frequency of post-stroke MCI is high, but improvement of cognitive function is possible.

OCCURRENCE AND MEASUREMENT OF TRANSFER IN COGNITIVE REHABILITATION: A CRITICAL REVIEW

OBJECTIVE To investigate the occurrence of transfer of cognitive strategy training for persons with acquired brain injury, and to investigate the way in which transfer is measured. METHODS Electronic searches in PubMed, PsychINFO, EMBASE and CINAHL using combinations of search terms in the following categories: type of brain injury, transfer, type of disorder, type of intervention. A total of 39 papers was included in the review. The following aspects were judged: study design and participant characteristics, intervention characteristics and type of outcome measures used. RESULTS Transfer outcome measures could be classified into 3 groups: non-trained items, standardized daily tasks and daily life. Most studies reported at least one type of transfer; however, the methodological quality of the studies was low. Cognitive strategy training in the evaluated studies focused on 7 domains of functioning: information processing, problem solving/executive functioning, memory/attention, language, neglect, apraxia and daily activities. CONCLUSION Transfer of training effects of cognitive strategy training has been evaluated in a relatively small number of studies. Outcome measures used in these studies could be classified into 3 groups. Most studies reported the occurrence of transfer of training effects, although some serious remarks can be made concerning the methodological quality of the studies.

Vascular cognitive disorders: Memory, mental speed and cognitive flexibility after stroke

This study investigated the occurrence of cognitive disorders 1 and 6 months after stroke in a cohort of patients with a first-ever stroke. In addition, it was investigated whether age, sex and level of education are risk factors for vascular cognitive disorders. Memory, simple speed, cognitive flexibility and overall cognitive functioning were examined in 139 patients at 1 and 6 months post-stroke. Inclusion criteria on admission were first cerebral stroke, age>/=40, no other neurological or psychiatric disorders and ability to communicate. Mean age was 69.3 years (S.D.=12.3). Patients were compared with a healthy control group matched for age, sex and level of education. A large group of patients who, at 1 month after stroke, scored below the cutoff on cognitive domains, scored above the cutoff on most of these cognitive domains at 6 months. For overall cognitive functioning, 16 out of 39, for memory, 13 out of 26 and for cognitive flexibility, 15 out of 49 patients, who at 1 month scored below the cutoff, scored above the cutoff at 6 months. Simple speed did not change; 12 patients scored above the cutoff and 7 patients scored below the cutoff at 6 months after stroke. Speaking in terms of improvement or deterioration, most people remained stable on the four cognitive domains (ranging from 37.6% to 83.5%), and a substantial group improved (ranging from 12.9% to 52.1%). Older and female patients had more cognitive disturbances. Overall, the conclusion is that the prognosis of cognitive functioning after stroke is general favourable, especially in younger patients.

Efficacy of Time Pressure Management in Stroke Patients With Slowed Information Processing : A Randomized Controlled Trial

UNLABELLED Winkens I, Van Heugten CM, Wade DT, Habets EJ, Fasotti L. Efficacy of Time Pressure Management in stroke patients with slowed information processing: a randomized controlled trial. OBJECTIVE To examine the effects of a Time Pressure Management (TPM) strategy taught to stroke patients with mental slowness, compared with the effects of care as usual. DESIGN Randomized controlled trial with outcome assessments conducted at baseline, at the end of treatment (at 5-10wk), and at 3 months. SETTING Eight Dutch rehabilitation centers. PARTICIPANTS Stroke patients (N=37; mean age +/- SD, 51.5+/-9.7y) in rehabilitation programs who had a mean Barthel score +/- SD at baseline of 19.6+/-1.1. INTERVENTION Ten hours of treatment teaching patients a TPM strategy to compensate for mental slowness in real-life tasks. MAIN OUTCOME MEASURES Mental Slowness Observation Test and Mental Slowness Questionnaire. RESULTS Patients were randomly assigned to the experimental treatment (n=20) and to care as usual (n=17). After 10 hours of treatment, both groups showed a significant decline in number of complaints on the Mental Slowness Questionnaire. This decline was still present at 3 months. At 3 months, the Mental Slowness Observation Test revealed significantly higher increases in speed of performance of the TPM group in comparison with the care-as-usual group (t=-2.7, P=.01). CONCLUSIONS Although the TPM group and the care-as-usual group both showed fewer complaints after a 3-month follow-up period, only the TPM group showed improved speed of performance on everyday tasks. Use of TPM treatment therefore is recommended when treating stroke patients with mental slowness.

Checklist for cognitive and emotional consequences following stroke (CLCE-24): Development, usability and quality of the self-report version

OBJECTIVE In this paper a new checklist (CLCE-24) for identification of cognitive and emotional problems after stroke is presented. The CLCE-24 is intended to support a clinical interview by health care professionals other than the trained (neuro)psychologist. METHODS Patients were interviewed with the CLCE-24, 6 months post stroke. Usability was determined by interviews. Quality of the self-report version was determined using reference instruments (MMSE, CAMCOG). RESULTS Sixty-nine patients participated in the study (37 men; mean age 66 years). Both patients and assessors were positive about the use of the CLCE-24. Eighty percent of the patients had cognitive and/or emotional problems (73% cognitive; 51% emotional problems). Patients with complaints on the CLCE-24 also showed problems on the MMSE and the CAMCOG (p<0.05). The CLCE-24 was a predictor of the MMSE and CAMCOG (Adj. R(2)=0.13 and 0.16, respectively) at 12 months post stroke. Internal consistency of the CLCE-24 was good (alpha of 0.81). CONCLUSIONS The CLCE-24 is a usable and valid instrument for cognitive screening by health care professionals in the stroke service in the chronic phase after stroke.

Training patients in Time Pressure Management, a cognitive strategy for mental slowness

Purpose: To provide clinical practitioners with a framework for teaching patients Time Pressure Management, a cognitive strategy that aims to reduce disabilities arising from mental slowness due to acquired brain injury. Time Pressure Management provides patients with compensatory strategies to deal with time pressure in daily life. Application of the training in clinical practice is illustrated using two case examples from a randomized controlled trial on the effectiveness of Time Pressure Management for patients with stroke. Rationale: The Time Pressure Management approach is based on Michons task analysis, describing levels of decision-making in complex cognitive tasks. Decisions with little or no time pressure are not impaired by mental slowness. Therefore, patients should try to transfer actions from situations with high time pressure to situations where the preserved decision levels with little or no time pressure can work. Theory into practice: Several factors are required to teach patients to use Time Pressure Management. First, sufficient awareness is needed to recognize that there is a deficit and behavioural change is necessary. Sufficient awareness is also required to recognize and anticipate time pressure situations and to realize that the strategy is helpful and might also be useful in new and more difficult circumstances. Second, adequate motivation is needed to learn the strategy. And finally, the training should be adjusted to the patients individual learning abilities and cognitive skills.

Effectiveness of a low intensity outpatient cognitive rehabilitation programme for patients in the chronic phase after acquired brain injury

The aim of this prospective cohort study was to examine the effectiveness of a low intensity outpatient cognitive rehabilitation programme for patients with acquired brain injury in the chronic phase. Twenty-seven patients with acquired brain injury (i.e., stroke, traumatic brain injury, subarachnoid haemorrhage; 52% male) with a mean age of 49.5 (SD 9.2) years and 25 relatives with a mean age of 48.8 (SD 8.8) years were recruited to the study. Mean time since injury in the patient group was 1.9 years (SD 2.0). The group programme consisted of 15 weekly sessions of 2.5 hours and included cognitive strategy training, social skills training, and psycho-education. Patients also received homework. Relatives were invited to attend twice. Repeated measurements were taken: prior to treatment (baseline, T0); directly after treatment (T1, 21 weeks); and at follow-up (T2, 45 weeks). Primary outcome measures were individualised goals (GAS), cognitive failures (CFQ), and quality of life (SA-SIP). Patients did improve significantly on individual goals (p < .05) between T0 and T1 and the level of attainment remained stable between T1 and T2. Goals were mostly set in the cognitive and behavioural domains. There were no significant differences between the measurements (T0–T1–T2) on the CFQ and the SA-SIP. The programme had a positive effect on the individual goals set by the patients. However, this did not result in a higher participation level or a better quality of life. This may be due to the low intensity and short duration of the programme.

Manifestations of mental slowness in the daily life of patients with stroke: a qualitative study

Objective: To explore the consequences of mental slowness in the daily life of patients with stroke. Design: In a cross-sectional survey semi-structured interviews were completed. Interviews were transcribed and coded by two independent reviewers. Qualitative analysis was done by means of the ‘constant comparison method’. Setting: Three rehabilitation centres in the Netherlands. Participants: A convenience sample of 13 patients with stroke, suffering from mental slowness, was derived from December 2003 to May 2004. Main outcome measures: Interview descriptions of the everyday consequences of mental slowness. Results: Patients experienced many problems in daily life due to mental slowness. These could be divided into two main groups: (1) problems in cognitive functioning; (2) psychological and somatic complaints. In response to these problems, some patients mentioned the use of compensation strategies in order to reduce the demands on their information processing capacity. Conclusions: Mental slowness in cognitive functioning affects a wide range of activities, causing emotional symptoms in many patients and stimulating the spontaneous use of compensation strategies in some patients.

Reliability and validity of two new instruments for measuring aspects of mental slowness in the daily lives of stroke patients.

The objective of the study was to examine psychometric characteristics of two measures related to mental slowness experienced after stroke: One measure is aimed at performance on tasks, the other is a questionnaire evaluating perceived consequences of mental slowness. A group of 37 stroke patients and 33 matched controls were studied. A subgroup of 10 patients and 22 controls was observed by two independent raters to determine inter-rater reliability, a subgroup of 18 patients completed the questionnaire twice over a two-week interval to determine test-retest stability. Results showed that internal consistency was acceptable for the Mental Slowness Observation Test (Cronbachs α = .61 and .73) and good for the Mental Slowness Questionnaire (α = .91). For the Observation Test, correlations between the results of the two raters ranged between .77 and .99 and intra-class correlation coefficients were between .86 and .99. For the Questionnaire, correlations between two test occasions ranged between .85 and .90 and intra-class correlation coefficients were between .91 and .95. Correlations of between .52 and .67 were found between the Observation Test and neuropsychological tasks for speed of information processing. The Questionnaire correlated most strongly with scores on tests for activities of daily living (ADL) functioning, and fatigue and depression (correlations ranged between .37 and .63). It was concluded that the two new instruments offer reliable and valid methods for measuring limitations in daily activities related to mental slowness and some of the consequences of mental slowness in terms of sense of time pressure, fatigue, depressive complaints and independent ADL functioning.

Impaired awareness of deficits in individuals with neuropsychiatric symptoms after acquired brain injury: associations with treatment motivation and depressive symptoms.

OBJECTIVE The purpose of this study was to investigate impaired awareness of deficits in relation to treatment motivation and depressive symptoms in patients with neuropsychiatric symptoms after acquired brain injury. METHOD The study had a Cross-sectional design with 93 outpatient brain injury patients with neuropsychiatric symptoms in the chronic phase after injury. Awareness was measured by the discrepancy in answers between patients and significant others and/or clinicians. Patients were divided into 3 awareness groups: underestimation, accurate estimation, and overestimation of competencies. Treatment motivation and depressive symptoms were measured with self-report questionnaires. RESULTS Average discrepancy scores suggested patients had accurate awareness of deficits. However, when dividing patients into 3 awareness groups, 30% underestimated, 38% accurately estimated, and 32% overestimated their competencies. Linear regression analysis with discrepancy scores showed overestimation of competencies (positive discrepancy scores) was associated with less depressive symptoms, whereas underestimation (negative discrepancy scores) was associated with more depressive symptoms (β = -.28 to -.42, p < .05). Group analysis revealed that the underestimation group reported significantly more depressive symptoms than the overestimation group (β = .43 to .44, p < .05). No significant difference between the accurate estimation and overestimation group was found (p > .05). An association between awareness and treatment motivation was not statistically confirmed. CONCLUSION This study demonstrated that when considering awareness groups, more nuanced results arise than when only considering discrepancy scores. From a clinical and scientific standpoint, it is important to distinguish awareness groups in addition to considering mean discrepancy scores.