Long-term psychological consequences of stroke (OX-CHRONIC): A longitudinal study of cognition in relation to mood and fatigue after stroke: Protocol

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Long-term psychological consequences of stroke (OX-CHRONIC): A longitudinal study of cognition in relation to mood and fatigue after stroke: Protocol

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Nele Demeyere, Owen A Williams, Elise Milosevich, ...

First Published October 26, 2021 Research Article  https://doi.org/10.1177/23969873211046120

Article information

Abstract

Background

The long-term psychological consequences of stroke and how cognitive problems change over time after the first-year following stroke remain unclear. Particularly, trajectories of domain-specific and domain-general cognitive functions and how cognition interacts with mood, fatigue and quality of life are not well described.

Aims

To determine the prevalence, trajectories and wider impact of domain-specific cognitive impairment in long-term stroke survivors, in relation to mood, fatigue and quality of life.

Methods

Participants who previously took part in the Oxford Cognitive Screening study, completed the 6-month follow-up with cognitive, mood, fatigue and quality of life assessments and agreed to be contacted for future research will be recruited into OX-CHRONIC. The eligible cohort is between 2- and 9-years post-stroke. Cognition will be assessed with a detailed neuropsychological battery, alongside questionnaire measures of mood, fatigue, activities of daily life and quality of life measures at two timepoints, 1 year apart. Additionally, medical records will be accessed to extract further clinical information about the stroke and patients may opt-in to wear an activity monitor for 1 week to provide fine-grained measures of sleep and activity. The study protocol and study materials were approved by the national ethics committee (REC Ref: 19/SC/0520).

Planned outputs

OX-CHRONIC will provide detailed data on the evolving cognitive profiles of stroke survivors over several years post-stroke. Estimates of long-term prevalence as well as the effect of changes in cognitive profiles on mood, fatigue and quality of life will be examined. This study is funded by a Priority Programme Grant from the Stroke Association (SA PPA 18/100032).

Keywords

Cognition, mood, fatigue, long-term, quality of life

Introduction and rationale

Stroke is the second leading cause of death and the third most important cause of disability burden in the world.^1,2 There are 1.2 million stroke survivors in the UK, with 100 000 new strokes every year.³ Whilst mortality rates for stroke have decreased, principally due to better acute stroke care,⁴ this improved stroke survival has resulted in a higher prevalence of chronic stroke survivors.⁵

Whilst stroke can result in long-lasting physical⁶ and communication⁷ impairments, many of the less visible consequences are changes in affected mood,⁸ wide ranging cognitive impairments^9–12 and fatigue.¹³ Post-stroke cognitive impairment (PSCI) longer term is extremely common: in the largest ever national survey conducted with over 11,000 stroke survivors, 90% of respondents reported experiencing cognitive problems.¹⁴ Whilst observed prevalence data vary depending on the nature of the measures and the included cohort,^10,12 almost all stroke survivors suffer at least one cognitive domain deficit^9,11 in the early stages post-stroke. Prevalence of cognitive impairment 1 year post-stroke has been estimated at 34%.^15,16 Cognitive impairments post-stroke negatively affect the level of social participation,¹⁷ mood¹⁸ and quality of life,¹⁹ over and above the physical impairments and level of disability. Furthermore, a recent systematic review of quantitative studies on the unmet care needs of community-dwelling stroke survivors reported that the most frequently reported unmet needs were in the area of cognition (41.92%), followed by mood (40.13%).²⁰

Post-stroke cognitive impairment is complex. It is currently comprised under the umbrella term of vascular cognitive impairment, defined as impaired cognitive function surpassing what is considered ‘normal’ within the ageing process, occurring in the presence of underlying vascular pathology.²¹ However, in predicting the natural history of post-stroke cognition, it is important to distinguish between ‘domain specific’ and ‘domain-general’ problems.²² The NICE guidelines for post-stroke cognitive assessment,²³ explicitly state to ‘as soon as possible … assess different cognitive domains post-stroke: attention, memory, spatial awareness, apraxia, and perception’. Additionally, the RCP clinical guideline for stroke²⁴ states that each cognitive domain should not be considered in isolation. The Oxford Cognitive Screen (OCS) was designed with these distinct requirements in mind, as it is a domain-specific cognitive screen designed specifically for stroke patients.^9,25 Its reach and significance as the routine first-line cognitive screening tool in stroke has been steadily increasing. The OCS has been widely adopted for clinical use within the NHS, as well as various sites internationally, as it has been culturally and language adapted in seven other countries (e.g. 26–28) with more currently under development.

Studies concerning detailed domain-specific cognitive impairments initially post-stroke generally demonstrate some improvement over time in specific cognitive domains, such as spatial inattention/neglect,²⁹ aphasia³⁰ and apraxia.³¹ However, data from the OCS screening study measuring individual domain-specific impairments show significant proportions of lasting impairment³² and similarly, a study investigating cognitive impairment post-stroke using a global cognitive screen found an overall prevalence of 56% at 6 months.³³

Additionally, stroke patients are at an increased risk of developing dementia, as a meta-analysis reported 10% develop dementia after first-ever stroke and 33% after recurrent stroke.³⁴ However, in stroke survivors who do not progress to dementia diagnoses, prevalent yet often more subtle impairments are frequently overlooked, perhaps due to some individuals maintaining a degree of personal independence despite poor cognitive recovery. To better understand the nature and trajectories of long-term PSCI, we must delineate cognitive profiles on a fine-grained neuropsychological level and investigate their relation to long-term outcomes.

OX-CHRONIC is a prospective cohort study of stroke survivors who were initially recruited via consecutive sampling in an acute stroke ward and agreed to further assessments during long-term recovery.

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