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.