You can immediately tell this is going to be useless from one word in the title: 'care'!
NOT RESULTS OR RECOVERY!
The second tell is 'assessment', assessments do absolutely nothing to get survivors recovered!
Turning the spotlight on assessment of severe cognitive impairment: Reducing disparity and inequality in stroke care
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).
Implications for Occupational Therapy practice
Research
to date, has focused predominantly on detecting the presence of mild to
moderate cognitive impairment using standardised measures. This has
placed individuals with severe cognitive impairment at a disadvantage.
These individuals are being assessed and clinical decisions are being
made, without OTs having access to a strong evidence base to guide their
practice.
Due to the heterogeneity of
available functional assessments and the individual nature in which some
may be conducted, this poses a risk to the establishment of a true
cognitive baseline and thus the measurement of change over time. Without
an evidence base guiding practice the content of functional cognitive
assessments are likely to be reliant on the OT’s clinical experience and
clinical reasoning. The application of outcomes of these functional
assessments may also be reliant on the OT’s ability to interpret and
articulate findings to individuals, families and the wider
multidisciplinary team. Not capturing an extensive baseline of their
impairments and abilities, could hold implications for subtle changes in
these cognitive areas being missed, which could impact their
opportunity for rehabilitation.
Therefore,
more needs to be explored around the content and structure of functional
cognitive assessments for this stroke population to improve consistency
within these assessments. Also, more research needs to be completed to
help understand OTs’ confidence when assessing those with severe
cognitive impairment, as it is likely that the more complex and
widespread the impairments, the more challenging functional cognitive
assessments will be to complete, particularly for less experienced
therapists.
Conclusion
The
spotlight should now be turned to focus on understanding the content of
functional cognitive assessments for those with severe cognitive
impairment following a stroke. As more is understood, this will lead the
way in supporting OTs in delivering evidence-based functional cognitive
assessments for this population as well as promoting greater equity for
this patient population in accessing specialist rehabilitation to
optimise their quality of life.
Key messages
•
There
is no research to date that has explored the cognitive assessment
practices of OTs for individuals with severe cognitive impairment
following a stroke.
•
This
is a key area for future research to improve consistency in OT practice
as well as to support OTs delivering evidence-based functional
cognitive assessments. This can ultimately improve standards of care and
patient outcomes.
•
OTs
are equipped with the specialist skills to be clinical and academic
leaders in the field of cognitive assessment and drive much needed
change for this stroke population.
Acknowledgments
Dr
Catherine Hurt, City University London. CH was an academic supervisor
for JS and supported protocol development for the systematic review.
Declaration of conflicting interests
The
author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) declared no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Jennifer Stadden https://orcid.org/0009-0004-4463-3261
No comments:
Post a Comment