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To describe the process of developing a cognitive rehabilitation intervention for patients with post-stroke cognitive impairment (PSCI) and to describe the intervention prior to evaluation in a pilot randomised controlled trial (RCT).

The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research. ispartof: European Stroke Journal vol:6 issue:3 pages:1-177 ispartof: location:England status: Published online

Background and Purpose: Cognitive impairment no dementia (CIND) and dementia are common stroke outcomes, with significant health and societal implications for aging populations. These outcomes are not included in current epidemiological models. We aimed to develop an epidemiological model to project incidence and prevalence of stroke, poststroke CIND and dementia, and life expectancy, in Ireland to 2035, informing policy and service planning. Methods: We developed a probabilistic Markov model (the StrokeCog model) applied to the Irish population aged 40 to 89 years to 2035. Data sources included official population and hospital-episode statistics, longitudinal cohort studies, and published estimates. Key assumptions were varied in sensitivity analysis. Results were externally validated against independent sources. The model tracks poststroke progression into health states characterized by no cognitive impairment, CIND, dementia, disability, stroke recurrence, and death. Results: We projected 69 051 people with prevalent stroke in Ireland in 2035 (22.0 per 1000 population [95% CI, 20.8–23.1]), with 25 274 (8.0 per 1000 population [95% CI, 7.1–9.0]) of those projected to have poststroke CIND, and 12 442 having poststroke dementia (4.0 per 1000 population [95% CI, 3.2–4.8]). We projected 8725 annual incident strokes in 2035 (2.8 per 1000 population [95% CI, 2.7–2.9]), with 3832 of these having CIND (1.2 per 1000 population [95% CI, 1.1–1.3]), and 1715 with dementia (0.5 per 1000 population [95% CI, 0.5–0.6]). Life expectancy for stroke survivors at age 50 was 23.4 years (95% CI, 22.3–24.5) for women and 20.7 (95% CI, 19.5–21.9) for men. Conclusions: This novel epidemiological model of stroke, poststroke CIND, and dementia draws on the best available evidence. Sensitivity analysis indicated that findings were robust to assumptions, and where there was uncertainty a conservative approach was taken. The StrokeCog model is a useful tool for service planning and cost-effectiveness analysis and is available for adaptation to other national contexts.

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.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.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).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 REHABILITATIONThe 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.

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. 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. 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. 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 rehabilitationThe 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. 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.

Post&ndash, stroke cognitive impairment (PSCI) is a common consequence of stroke. Epidemiological evidence indicates that, with an ageing population, stroke and PSCI are likely to increase in the coming decades. This may have considerable implications for the demand for nursing home placement. As prevalence estimates of both cognitive impairment and dementia on admission to nursing home among residents with and without stroke have not yet been compared, they were estimated and compared in this study. We performed a cross&ndash, sectional survey to establish the admission characteristics of 643 residents in 13 randomly selected nursing homes in Ireland. The survey collected data on resident&rsquo, s stroke and cognitive status at the time of nursing home admission. The survey found, among nursing home residents that experienced stroke prior to admission, prevalence estimates for cognitive impairment (83.8%, 95% CI = 76.9&ndash, 90.6%) and dementia (66.7%, 95% CI = 57.9&ndash, 75.4%) were significantly higher compared to residents that had not experienced stroke prior to admission (cognitive impairment: 56.6%, 95% CI = 52.4&ndash, 60.8%, X2 (1) = 28.64, p &lt, 0.001, dementia: 49.8%, 95% CI = 45.6&ndash, 54.1%, X2 (1) = 10.47, 0.01). Since the prevalence of PSCI is likely to increase in the coming decades, the findings highlight an urgent need for health service planning for this increased demand for nursing home care to meet the care needs of these stroke survivors.

Purpose: Exploring the views of those impacted by stroke is key to the design of an effective and appropriate cognitive rehabilitation intervention for post-stroke cognitive impairment. This qualit...

Recent evidence suggests that familiarity with an environment may protect against spatial memory decline for familiar objects in older adults. We investigated whether a familiar context also reduces age-related decline in spatial memory for novel objects. Twenty-four younger and 23 older participants viewed a virtual rendering of a local environment along two different routes, each through a well-known (West) or lesser-known (East) area within the environment. Older and younger participants reported being more familiar with one (i.e. West) area than the other. In each trial, participants were presented with one route and were instructed to learn ten novel objects and their locations along the route. Following learning, participants immediately completed five test blocks: an object recognition task, an egocentric spatial processing (direction judgement) task, an allocentric spatial processing (proximity judgement) task and two pen-and-paper tests to measure cognitive mapping abilities. First we found an age effect with worse performance by older than younger adults in all spatial tasks, particularly in allocentric spatial processing. However, our results suggested better memory for objects and directions, but not proximity judgements, when the task was associated with more familiar than unfamiliar contexts, in both age groups. There was no benefit of context when a separate young adult group (N = 24) was tested, who reported being equally familiar with both areas. These results suggest an important facilitatory role of context familiarity on object recognition, and in particular egocentric spatial memory, and have implications for enhancing spatial memory in older adults.

IntroductionStroke 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 analysisA 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 disseminationThis 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.PROSPERO registration numberCRD42017069714.

Patients who suffer traumatic brain injury frequently report difficulty concentrating on tasks and completing routine activities in noisy and distracting environments. Such impairments can have long-term negative psychosocial consequences. A cognitive control function that may underlie this impairment is the capacity to select a goal-relevant signal for further processing while safeguarding it from irrelevant noise. A paradigmatic investigation of this problem was undertaken using a dichotic listening task (study 1) in which comprehension of a stream of speech to one ear was measured in the context of increasing interference from a second stream of irrelevant speech to the other ear. Controls showed an initial decline in performance in the presence of competing speech but thereafter showed adaptation to increasing audibility of irrelevant speech, even at the highest levels of noise. By contrast, patients showed linear decline in performance with increasing noise. Subsequently attempts were made to ameliorate this deficit (study 2) using a cognitive training procedure based on attention process training (APT) that included graded exposure to irrelevant noise over the course of training. Patients were assigned to adaptive and non-adaptive training schedules or to a no-training control group. Results showed that both types of training drove improvements in the dichotic listening and in naturalistic tasks of performance in noise. Improvements were also seen on measures of selective attention in the visual domain suggesting transfer of training. We also observed augmentation of event-related potentials (ERPs) linked to target processing (P3b) but no change in ERPs evoked by distractor stimuli (P3a) suggesting that training heightened tuning of target signals, as opposed to gating irrelevant noise. No changes in any of the above measures were observed in a no-training control group. Together these findings present an ecologically valid approach to measure selective attention difficulties after brain injury, and provide a means to ameliorate these deficits.

BACKGROUND: Falls and fall-related injuries are symptomatic of an aging population. This study aimed to design, develop, and deliver a novel method of balance training, using an interactive game-based system to promote engagement, with the inclusion of older adults at both high and low risk of experiencing a fall.STUDY DESIGN: Eighty-two older adults (65 years of age and older) were recruited from sheltered accommodation and local activity groups. Forty volunteers were randomly selected and received 5 weeks of balance game training (5 males, 35 females; mean, 77.18 ± 6.59 years), whereas the remaining control participants recorded levels of physical activity (20 males, 22 females; mean, 76.62 ± 7.28 years). The effect of balance game training was measured on levels of functional balance and balance confidence in individuals with and without quantifiable balance impairments.RESULTS: Balance game training had a significant effect on levels of functional balance and balance confidence (P CONCLUSIONS: Commercial hardware can be modified to deliver engaging methods of effective balance assessment and training for the older population.

ObjectiveCognitive 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.DesignSystematic review and meta-analysis of non-randomised studies of psychological interventions addressing post-stroke cognitive impairment.Data sourcesElectronic searches were performed in the Pubmed, EMBASE and PsycINFO databases, the search dating from inception to February 2017.Eligibility criteriaAll 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.MethodsThe 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.ResultsResults 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.ConclusionsThis 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 numberCRD42017069714.

Previous studies have reported an age-related decline in spatial abilities. However, little is known about whether the presence of other, task-irrelevant stimuli during learning further affects spatial cognition in older adults. Here we embedded virtual environments with moving crowds of virtual human pedestrians (Experiment 1) or objects (Experiment 2) whilst participants learned a route and landmarks embedded along that route. In subsequent test trials we presented clips from the learned route and measured spatial memory using three different tasks: a route direction task (i.e. whether the video clip shown was a repetition or retracing of the learned route); an intersection direction task; and a task involving identity of the next landmark encountered. In both experiments, spatial memory was tested in two separate sessions: first following learning of an empty maze environment and second using a different maze which was populated. Older adults performed worse than younger adults in all tasks. Moreover, the presence of crowds during learning resulted in a cost in performance to the spatial tasks relative to the 'no crowds' condition in older adults but not in younger adults. In contrast, crowd distractors did not affect performance on the landmark sequence task. There was no age-related cost on performance with object distractors. These results suggest that crowds of human pedestrians selectively capture older adults' attention during learning. These findings offer further insights into how spatial memory is affected by the ageing process, particularly in scenarios which are representative of real-world situations.

Background While medication adherence is essential for the secondary prevention of stroke, it is often sub-optimal, and can be compromised by cognitive impairment. This study aimed to systematically review and meta-analyse the association between cognitive impairment and medication non-adherence in stroke. Methods A systematic literature search of longitudinal and cross-sectional studies of adults with any stroke type, which reported on the association between any measure of non-adherence and cognitive impairment, was carried out according to PRISMA guidelines. Odds ratios and 95% confidence intervals were the primary measure of effect. Risk of bias was assessed using the Cochrane Bias Methods Group's Tool to Assess Risk of Bias in Cohort Studies, with evidence quality assessed according to the GRADE approach. We conducted sensitivity analyses according to measure of cognitive impairment, measure of medication adherence, population, risk of bias and adjustment for covariates. The protocol was registered with PROSPERO. Results From 1,760 titles and abstracts, we identified 9 studies for inclusion. Measures of cognitive impairment varied from dementia diagnosis to standardised cognitive assessments. Medication adherence was assessed through self-report or administrative databases. The majority of studies were of medium risk of bias (n = 6); two studies had low risk of bias. Findings were mixed; when all studies were pooled, there was no evidence of an association between cognitive impairment and medication non-adherence post-stroke [OR (95% CI): 0.85 (0.66, 1.03)]. However, heterogeneity was substantial [I2 = 90.9%, p < .001], and the overall evidence quality was low. Conclusions Few studies have explored associations between cognitive impairment and medication adherence post-stroke, with substantial heterogeneity in study populations, and definitions and assessments of non-adherence and cognitive impairment. Further research using clear, standardised and objective assessments is needed to clarify the association between cognitive impairment and medication non-adherence in stroke.