Turning the spotlight on assessment of severe cognitive impairment: Reducing disparity and inequality in stroke care

Abstract

More than 100,000 strokes occur in the United Kingdom (UK) each year (Stroke Association, 2023). Decreasing stroke mortality rates have resulted in more people living with long-term disabilities, with approximately 50% of survivors demonstrating neurocognitive difficulties (Barbay et al., 2018). Cognitive impairment in the acute phase post stroke has been shown to impact participation in rehabilitation and increase the risk of poorer functional outcomes (D’Souza et al., 2021). Initial cognitive assessments play an important role in informing clinical reasoning for a person’s onward rehabilitation and care decisions; if an upward trajectory of improvement is demonstrated at an impairment and/or functional level, this further supports the need for referrals to inpatient specialist rehabilitation. Therefore, measuring their cognitive baseline following a stroke is pertinent to inform clinical decisions for professionals as well as advocate for patients where onward specialist rehabilitation is required to optimise their recovery. Completing cognitive assessment in the acute phase post stroke is recommended within national stroke guidelines (Intercollegiate Stroke Working Party, 2023) and these are routinely completed by occupational therapists (OTs) (Manee et al., 2020). For individuals with severe cognitive impairment following a stroke, they are highly unlikely to be able to engage in standardised assessments (Elliott et al., 2019), and functional cognitive assessments are recommended (Intercollegiate Stroke Working Party, 2023). OTs hold unique expertise in understanding occupation and the environmental impact on function. Through the utilisation of these specialist skills, we provide a vital contribution to cognitive assessments. Not only this, but we are skilled in implementing cognitive assessment results to support participation, choice and engagement in meaningful occupations. It is now time that our profession stands confident in our ability to be leaders in the field of assessment of individuals with severe cognitive impairments and drive change to improve consistency and quality of care. We completed a systematic review of OTs’ cognitive assessment practices in the acute stroke setting for individuals with severe cognitive impairment. Five academic databases (MEDLINE, CINAHL, PsychINFO, AMED and Embase) were searched and no study was found that explicitly looked at assessment practices for severe cognitive impairment post stroke. Four related studies (Geraghty et al., 2019; Koh et al., 2009; Korner-Bitensky et al., 2011; Pilegaard et al., 2014) focused on the assessment of individuals with mild cognitive impairment post stroke and participants were predominantly experienced OTs, with 5–10 years of stroke experience. These studies found that while OTs preferred using functional cognitive assessments, because they are client centred and meaningful to the patient (Koh et al., 2009), there was a wide variability in their content (Pilegaard et al., 2014). The content of functional assessments was mainly developed from their past experiences and colleague recommendations, rather than informed from research (Holmqvist et al., 2009; Koh et al., 2009).