You'll have to aggressively go after your doctor to get you back up to your baseline cognition rather than accepting the tyranny of low expectations your doctor is trying to get you to accept. Don't settle for anything less than 100% recovery. Screaming may be required, your doctor should feel embarrassed that they KNOW NOTHING on how to get you back to 100%.
When I was given the orientation portion(date, month, year, day, place, and city.) after spending 3 days in the ER and step down units, I failed completely.Early Cognitive Scores May Predict Long-Term Outcomes After Stroke
Low MoCA scores post-stroke tied to cognitive and functional impairment 3 years later
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Early
post-stroke test scores on the Montreal Cognitive Assessment (MoCA)
predicted long-term cognitive and functional outcomes, a pooled analysis
of two European studies found.
Patients assessed with a MoCA score of <26 within 7 days of stroke were five times more likely to have cognitive impairment in at least one cognitive domain and functional impairment 3 years later, reported Martin Dichgans, MD, of Ludwig-Maximilians University in Munich, Germany, and co-authors, writing online in Neurology.
"This test should be used to screen people with stroke and to counsel them and their families about long-term prognosis and also to identify those who would most benefit from interventions that could improve their outcomes," Dichgans said in a statement.(Fucking tyranny of low expectations here.)
While MoCA has been used to evaluate cognitive function in different stroke settings, this study set out to investigate whether administering the test within 7 days after stroke predicted long-term outcomes independently from pre-morbid cognitive status, demographic characteristics, or stroke severity.
The analysis leveraged data from two prospective hospital-based studies that were planned in parallel. In total, researchers studied 274 stroke patients: 125 patients from the DEDEMAS (Determinants of Dementia After Stroke) study in Germany and 149 patients from STROKDEM (Study of Factors Influencing Post Stroke Dementia) in France. Patients were enrolled from 2010 to 2014, and over 95% had ischemic strokes. The median admission NIH Stroke Scale (NIHSS) score in the cohorts was 2, indicating a large proportion of patients with minor stroke (only 75 patients had NIHSS scores >3).
MoCA was administered within 7 days after stroke symptom onset, with cognitive impairment defined by a MoCA score <26. All patients had a comprehensive evaluation of cognitive and functional outcome in face-to-face interviews during follow-up visits at 6, 12, and 36 months after stroke. Analyses were adjusted for age, sex, education, history of hypertension and diabetes mellitus, baseline Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) score, and NIHSS score at admission.
About 43% of patients in DEDEMAS and 44% in STROKDEM had a MoCA score <26. Pooled analyses showed that a baseline MoCA score <26 was associated with cognitive impairment at 3-year follow-up, defined by neuropsychological testing (OR 5.30, 95% CI 2.75–10.22) and by a Clinical Dementia Rating (CDR) score ≥0.5 (OR 2.53, 95% CI 1.53–4.18).
Baseline MoCA score <26 also was linked to functional impairment at 3 years, defined by modified Rankin Scale score >2 (OR 5.03, 95% CI 2.20–11.51) and by Instrumental Activities of Daily Living score <8 (OR 2.48, 95% CI 1.40–4.38). Baseline MoCA score <26 was also tied to mortality (HR 7.24, 95% CI 1.99–26.35) across the follow-up period.
MoCA increased the area under the curve for predicting cognitive impairment (defined by neuropsychological testing; 0.81 versus 0.72, P=0.01) and functional impairment (defined by modified Rankin score >2; 0.88 versus 0.84, P=0.047).
Applicability to Other Populations?
While these results are promising, it's not clear they can be applied to other patient populations, observed Elisabeth Marsh, MD, of Johns Hopkins University School of Medicine, and Franz Fazekas, MD, of Medical University of Graz, Austria, writing in an accompanying editorial.
"The mean admission NIHSS score, a measure of stroke severity, was low for the cohort: only 2," they wrote. "The authors attempt to address this by stratifying their analysis (by NIHSS score <3 versus greater) without finding significant differences; however, given that the majority of their population had low scores, results may be different for a patient presenting initially with a more severe stroke."
Applying and interpreting MoCA also will be more difficult in patients with severe strokes, the editorial added.
The analysis also excluded patients with a known history of dementia before infarction and did not take into account possible consequences of post-stroke rehabilitation or cognitive therapy. "Therefore, despite the temptation to use the MoCA to identify patients for aggressive rehabilitation paradigms meant to reduce long-term morbidity, it remains unknown whether such interventions will be effective in modifying outcome or whether in these cases the MoCA is merely a tool for stratification of poor prognosis," Marsh and Fazekas noted.
Dichgans and co-authors also listed other study limitations, including attrition bias -- i.e., that people not examined by face-to-face follow-up visits may be more likely to have dementia. In addition, pre-stroke cognitive function was assessed only by the IQCODE questionnaire and residual confounding is possible.
Despite these limitations, "our sample is representative of patients who are most likely to benefit from targeted prevention," the researchers wrote. "Given the brevity of the test and its feasibility in the setting of acute stroke, our findings support the use of the MoCA as a routine clinical tool to identify high-risk patients who might benefit from close monitoring."
Patients assessed with a MoCA score of <26 within 7 days of stroke were five times more likely to have cognitive impairment in at least one cognitive domain and functional impairment 3 years later, reported Martin Dichgans, MD, of Ludwig-Maximilians University in Munich, Germany, and co-authors, writing online in Neurology.
"This test should be used to screen people with stroke and to counsel them and their families about long-term prognosis and also to identify those who would most benefit from interventions that could improve their outcomes," Dichgans said in a statement.(Fucking tyranny of low expectations here.)
While MoCA has been used to evaluate cognitive function in different stroke settings, this study set out to investigate whether administering the test within 7 days after stroke predicted long-term outcomes independently from pre-morbid cognitive status, demographic characteristics, or stroke severity.
The analysis leveraged data from two prospective hospital-based studies that were planned in parallel. In total, researchers studied 274 stroke patients: 125 patients from the DEDEMAS (Determinants of Dementia After Stroke) study in Germany and 149 patients from STROKDEM (Study of Factors Influencing Post Stroke Dementia) in France. Patients were enrolled from 2010 to 2014, and over 95% had ischemic strokes. The median admission NIH Stroke Scale (NIHSS) score in the cohorts was 2, indicating a large proportion of patients with minor stroke (only 75 patients had NIHSS scores >3).
MoCA was administered within 7 days after stroke symptom onset, with cognitive impairment defined by a MoCA score <26. All patients had a comprehensive evaluation of cognitive and functional outcome in face-to-face interviews during follow-up visits at 6, 12, and 36 months after stroke. Analyses were adjusted for age, sex, education, history of hypertension and diabetes mellitus, baseline Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) score, and NIHSS score at admission.
About 43% of patients in DEDEMAS and 44% in STROKDEM had a MoCA score <26. Pooled analyses showed that a baseline MoCA score <26 was associated with cognitive impairment at 3-year follow-up, defined by neuropsychological testing (OR 5.30, 95% CI 2.75–10.22) and by a Clinical Dementia Rating (CDR) score ≥0.5 (OR 2.53, 95% CI 1.53–4.18).
Baseline MoCA score <26 also was linked to functional impairment at 3 years, defined by modified Rankin Scale score >2 (OR 5.03, 95% CI 2.20–11.51) and by Instrumental Activities of Daily Living score <8 (OR 2.48, 95% CI 1.40–4.38). Baseline MoCA score <26 was also tied to mortality (HR 7.24, 95% CI 1.99–26.35) across the follow-up period.
MoCA increased the area under the curve for predicting cognitive impairment (defined by neuropsychological testing; 0.81 versus 0.72, P=0.01) and functional impairment (defined by modified Rankin score >2; 0.88 versus 0.84, P=0.047).
Applicability to Other Populations?
While these results are promising, it's not clear they can be applied to other patient populations, observed Elisabeth Marsh, MD, of Johns Hopkins University School of Medicine, and Franz Fazekas, MD, of Medical University of Graz, Austria, writing in an accompanying editorial.
"The mean admission NIHSS score, a measure of stroke severity, was low for the cohort: only 2," they wrote. "The authors attempt to address this by stratifying their analysis (by NIHSS score <3 versus greater) without finding significant differences; however, given that the majority of their population had low scores, results may be different for a patient presenting initially with a more severe stroke."
Applying and interpreting MoCA also will be more difficult in patients with severe strokes, the editorial added.
The analysis also excluded patients with a known history of dementia before infarction and did not take into account possible consequences of post-stroke rehabilitation or cognitive therapy. "Therefore, despite the temptation to use the MoCA to identify patients for aggressive rehabilitation paradigms meant to reduce long-term morbidity, it remains unknown whether such interventions will be effective in modifying outcome or whether in these cases the MoCA is merely a tool for stratification of poor prognosis," Marsh and Fazekas noted.
Dichgans and co-authors also listed other study limitations, including attrition bias -- i.e., that people not examined by face-to-face follow-up visits may be more likely to have dementia. In addition, pre-stroke cognitive function was assessed only by the IQCODE questionnaire and residual confounding is possible.
Despite these limitations, "our sample is representative of patients who are most likely to benefit from targeted prevention," the researchers wrote. "Given the brevity of the test and its feasibility in the setting of acute stroke, our findings support the use of the MoCA as a routine clinical tool to identify high-risk patients who might benefit from close monitoring."
The German
portion of the study was funded by the German Research Foundation,
German Center for Neurodegenerative Diseases, European Union, and
Vascular Dementia Research Foundation. The French portion of the study
was funded by the French Health Ministry and French Foundation for the
Head and Arteries.
Dichgans and co-authors reported having no disclosures relevant to the manuscript.
Marsh and Fazekas reported financial relationships with Biogen Idec, Genzyme, Merck, Novartis, Perceptive Informatics, Roche, Teva-Ratiopharm, and Actelion.
Dichgans and co-authors reported having no disclosures relevant to the manuscript.
Marsh and Fazekas reported financial relationships with Biogen Idec, Genzyme, Merck, Novartis, Perceptive Informatics, Roche, Teva-Ratiopharm, and Actelion.
last updated
Primary Source
Neurology
Source Reference: Zietemann V, et al “Early MoCA predicts long-term cognitive and functional outcome and mortality after stroke” Neurology 2018; DOI:10.1212/WNL.0000000000006506.Secondary Source
Neurology
Source Reference: Marsh E, Fazekas F “Independence after stroke: Mind over matter” Neurology 2018; DOI:10.1212/WNL.0000000000006494.
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