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Stroke cognitive deficits and rehabilitation dr venugopal kochiyil

Cognitive deficit in stroke & rehabilitation
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Stroke cognitive deficits and rehabilitation dr venugopal kochiyil

  1. 1. Cognitive rehabilitation in stroke Venugopal Kochiyil Medical Head of the Unit - Northern Adelaide Rehabilitation Service Modbury Hospital South Australia, Australia
  2. 2. Post stroke cognitive impairment • Common but underdiagnosed • Poor prognosis • 40 – 70% of stroke patients • Inadequately assessed, not diagnosed and not treated www.ebsr.com Shigaki CL, Frey SH. Semin Neurol 2014;34(5):496-503
  3. 3. Cognitive domains • Attention – focusing, shifting, dividing, sustaining • Executive fns – planning, organising, inhibition, control • Visuospatial abilities and praxis - visual search, drawing, construction, apraxia, agnosia, neglect • Memory – Visual/ Auditory, recall, recognition • Language
  4. 4. Cognition • Not a unitary concept • Domains are not independent • Affect of different states of physiology and mood • Only 50% of vascular cognitive impairments shows amnestic signs • What is the gold standard in assessment
  5. 5. Cognitive problems after stroke • Not being aware of one’s surroundings • Poor attention and concentration to tasks • Memory difficulties especially short term memory • Poor problem solving and reasoning • Poor executive functioning • Slower processing of new information
  6. 6. Profile of cognitive deficits and stroke • Most frequent after cerebral artery stroke than vertebrobasilar strokes • Cortical strokes (74 % v/s 50%) • Cardioembolic stroke vs vessel disease • Haemorrhagic strokes (larger) • Left hemispheric strokes (language issues) • Stroke recurrence • Lesion location and volume
  7. 7. Profile of cognitive impairments after stroke • Does this affect all domains? • Probably greater effect in attention and executive functions • Marked deficits in attention, abstract thinking and processing speed • Higher risk of non amnestic cognitive impairments associated with history of stroke (especially lacunar strokes)
  8. 8. Focal v/s diffuse damage • Focal v/s diffuse problems • Genu of IC • Underlying subclinical cerebrovascular disease • Higher white matter hyper intensities and dementia • Slowed processing, attentional and executive deficits – Internal capsule, caudate and thalamic lesions – disrupt fronto-striato-thalamic circuits Cumming TB, Marshal RS. Int Journal of Stroke2013;8:38-45
  9. 9. Characteristics Vascular dementia Alzheimer’s dementia Onset Sudden or gradual Gradual Progression Slow and stepwise Constant insidious decline Neurological findings Focal deficits Subtle Memory Mildly affected Early and severe Executive functions Early and severe Late Neuroimaging Infarct or white matter lesions Hippocampal atrophy Gait Affected early Normal Cardiovascular history TIA, stroke, CCF Nil
  10. 10. Speed of processing • Cognitive slowing is a main issue with stroke • It is an independent contributor of functional outcome and dependency • Effect on cognitive performance (time sensitive tasks)
  11. 11. Memory
  12. 12. Functional memory • Information storage, retrieval • Related to attention and executive functions • Related to speech • Integration of contextual information with memory content • Intrusions • Overestimating performance accuracy • Barrier for independence Shigaki CL, Frey SH. Semin Neurol 2014;34(5):496-503
  13. 13. Memory function • Vascular dementia – superior long term memory but significant frontal executive function deficits • Memory deficits present over time • Subcortical infarcts – lower memory performances (episodic, semantic and working memory) • ? More executive than memory Cumming TB, Marshal RS. Int Journal of Stroke2013;8:38-45
  14. 14. Aphasia • Broca’s aphasia/Wernicke’s aphasia
  15. 15. Perceptual issues - Neglect • Three components for hemispatial neglect visuospatial – right inf parietal lobule visuomotor component – right dorsolateral prefrontal object centred component – deep temporal gyrus • Egocentric neglect and allocentric neglect (peripersonal and extrapersonal) • Visual and or sensory • Network of areas/focal areas
  16. 16. www.ebsr.com
  17. 17. Neglect • Seen in approx 30 % strokes • Significant functional deficits • Predictor of functional recovery and returning home • Sometimes seen only with high levels of activity • Tend to recover during first six months. • Variable at times
  18. 18. How to test
  19. 19. http://1.bp.blogspot.com/- ArnmNmP4UOs/TyIq5ljBzXI/AAAAAAAAAqI/S3Z9TUQ4eYM/s1600/cns.jpeg
  20. 20. Pusher syndrome • Seen in about 10% of stroke patients • Impaired control in vertical and horizontal body postures • Leaning towards weaker side
  21. 21. Apraxia • Inability to execute a purposeful activity despite presence of adequate strength, sensation, coordination • Related to parietal or frontal premotor involvement • Ideomotor • Ideational • Constructional • Dressing • Single step/mutlistep • Conceptual
  22. 22. Assessment of Praxis • Tasks like gesturing • Mimicking an object use • Motor sequencing (Luria sequence) • Actual use of an object
  23. 23. Praxis • Affect ability to use objects • Affect grooming • Affect motor training • Only limited information on natural recovery • Severe ideomotor apraxia is associated with incomplete recovery
  24. 24. Hypoperfusion • Ischemia and hypoperfusion • Aphasia and neglect are more closely associated with hypoperfusion • Reduction in brain volume (esp gray matter) • CCF and cognitive issues
  25. 25. Subcortical strokes • Cerebellum has a role in cognition • Multiple cognitive issues – visuospatial, verbal working memory, executive functions • Basal ganglia/thalamus – multiple cognitive issues
  26. 26. Assessing cognitive impairments post stroke • Mini Mental screening evaluation (MMSE) – unable to identify milder cognitive impairments and fronto - temporal impairments • Clock drawing test (CDT) – visuospatial, praxis, attention and executive areas • Montreal cognitive assessment – screening for mild cognitive impairments, score of less than 26/30 is significant, available in multiple languages
  27. 27. Cognitive assessment • Addenbrooke’s cognitive assessment • Instrumental activities of daily living – ability to travel, manage finances, medication management, independent use of telephone
  28. 28. Cognitive rehabilitation • Retraining • Correcting deficits • Enhances the capacity/improve ability • We can use all kind of technologies – low tech to high tech
  29. 29. Rehab and cognitive deficits post stroke • Issues with cognitive impairments – discharge/recovery/participation • Capacity of the person to make decisions • Good at identifying but not so good at providing solutions • Generic treatments
  30. 30. Compensatory v/s restorative strategies • Compensatory or restorative (cognitive skill training) rehab • KPI pressures • Restorative rehab is resource intense • Externally generated or internally generated compensatory strategies
  31. 31. Interventions for generalised cognitive impairments • Managing hypertension reduced risk but consider downside • Escitalopram • Rivastigmine • Increasing physical activity
  32. 32. Interventions for functional memory • Reduce distractions • Memory tools • External structure • Internalised mnemonic strategies • Routines • Repeated practice – unfortunately do not generalise • What do we do when patient has limited insight? • Errorless learning for implicit memory
  33. 33. Interventions for apraxia • Very difficult to treat • Compensatory training like strategy training – verbal cueing during action initiation and execution • Restorative training like sensory stimulation and perceptuo-motor control
  34. 34. Therapy for neglect • Visual scanning for “where” neglect • Prism adaptation for “aiming” defects – do visual- manual exercises while wearing a prism lenses Shigaki CL, Frey SH. Semin Neurol 2014;34(5):496-503
  35. 35. Assistive technology in cognitive rehab • External aids can improve independence • Cognitive orthoses, cognitive prosthesis • Mainly compensatory • Patient factors to consider • Evidence is still limited
  36. 36. Recovery • In many, cognitive decline continue post stroke • Recovery in about 20% patients • Most improvements in first three months but recovery can continue for an year • Deficits in language and memory improves more than that of attention Marin AG, Berteanu M. Int J Pharm Med Biol Sci 2015;4(2):146-150
  37. 37. Summary • Common problem after stroke • Impact functional recovery and independence • Needs detailed assessment • Gap between diagnosis and treatment approaches • Limited evidence for therapeutic approaches

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