Cognitive impairment common after stroke

Patients with stroke often experience cognitive impairment, especially in the first year, and up to one-third develop mild to severe dementia within five years, according to a scientific statement from the American Heart Association/American Stroke Association.

The statement, which was published May 1 by Stroke, was based on a scoping review of the available literature. The authors said that collaboration among clinicians, including primary care and specialty care physicians, and other therapists and health professionals is crucial after a stroke to identify and manage cognitive problems after stroke. They recommended a tailored neuropsychological evaluation to identify cognitive strengths and weaknesses and individualize care.

Physical activity such as tai chi, boxing, and resistance exercises may improve cognitive function after stroke, with a possible advantage for aerobic exercise over nonaerobic, the statement said. Secondary stroke prevention, including antihypertensive therapy, statins, diabetes control, and anticoagulation for atrial fibrillation, is important to prevent the risk for or worsening of poststroke cognitive impairment, since this condition becomes more likely with subsequent strokes, according to the statement. Hypertension treatment and lifestyle programs to reach target blood pressure after stroke have not been shown to themselves positively affect cognitive function, the statement said.

There is limited evidence about cognitive outcomes after stroke because randomized trials have not recorded it as an outcome measure, the authors noted. “The few studies that evaluated cognitive outcomes after acute stroke treatments suggest that intravenous thrombolysis and mechanical thrombectomy improve cognitive outcomes (compared with no treatment) but that these benefits are strongly associated with functional outcome,” they wrote.

Other considerations include safety issues in the home, return to work (if applicable), and driving, as well as assessing for caregiver fatigue and connecting patients and caregivers with available community resources. Patients should also consider advance care planning, including personal medical directives and identifying an enduring power of attorney, the statement said.

“Future research might inform best practices for cognitive screening after stroke. Perhaps the most pressing need, however, is the development of effective and culturally relevant treatments for PSCI [poststroke cognitive impairment] through the conduct of adequately powered clinical trials of cognitive rehabilitative techniques, pharmaceutical agents, and lifestyle modifications in diverse groups of patients,” the authors wrote. “Along with this, studies are required to evaluate whether multidisciplinary clinics or other models of care improve outcomes for patients with PSCI. Given the significant contribution of PSCI to the growing burden of dementia, focusing on these unanswered questions should be considered a priority.”