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Use of Cognitive Screening Tools to Detect Cognitive Impairment After an Ischaemic Stroke: a Systematic Review

  • Athula KosgallanaEmail author
  • Dennis Cordato
  • Daniel Kam Yin Chan
  • Jonathan Yong
Medicine
  • 153 Downloads
Part of the following topical collections:
  1. Topical Collection on Medicine

Abstract

There is no gold standard screening tool available to assess post-stroke cognitive impairment (PSCI). PSCI is a common and under-recognised global problem in stroke patients that may eventually lead to post-stroke dementia (PSD). Two major issues in PSCI research include the lack of a clear-cut definition and a lack of highly specific and sensitive screening tools that accurately predict PSCI. To identify the most appropriate cognitive screening tool to be used in the diagnosis of PSCI. MEDLINE and “The Cochrane Library” were searched for articles published between January 2000 and August 2016 that contained the keywords “post-stroke cognitive impairment”, “post-stroke dementia” or “cognitive tools after stroke” or “cognitive impairment after stroke”. Abstracts were selected using predetermined inclusion and exclusion criteria, and full-text reviews were performed. Publications on cognitive screening tools and PSCI or PSD were pooled separately for the review process. A total of 22 publications discussing cognitive screening tools in PSCI and PSD were identified. Only two publications discussed the use of multidomain cognitive tools. Some publications reported that domain-specific cognitive screening tools had higher sensitivity and specificity when compared to commonly use cognitive screening tools such as the Montreal Cognitive Assessment (MOCA) and Mini-Mental State Examination (MMSE). The superiority of one available tool was not evident in studies that performed a meta-analysis. The Oxford Cognitive Screen (OCS), a multidomain tool, was found to be a better predictor of PSCI/PSD than the MOCA or MMSE. To date, the literature on PSCI has primarily focused on nonspecific cognitive screening tools, although there has been a recent move towards domain-specific screening tools. Multidomain screening tools such as the OCS may be better than existing tools in the diagnosis of PSD and PSCI.

Keywords

Cognitive impairment Post-stroke dementia Post-stroke cognitive impairment Cognitive tools Domain-specific tools Dementia 

Introduction

Disability after stroke is one of the critical determinants of health burden for families and healthcare systems [1, 2, 3]. There is mounting evidence that cognitive impairment after stroke is a significant contributor to disability, and its prevalence tends to increase sharply with advancing age [3, 4, 5, 6, 7, 8, 9, 10]. One in four stroke patients will have cognitive impairment that is severe enough for them to be diagnosed with dementia [11]. Acute stroke may cause both a sudden cognitive decline and accelerated cognitive decline that is persistent over time [12].

One in three stroke survivors will have milder levels of cognitive impairment that may result in reduced participation in rehabilitation and poor adherence to treatment [13]. PSCI predicts suboptimal recovery in activities of daily living, which in turn results in a lower quality of life [14]. Early detection of cognitive dysfunction using an appropriate evidence-based tool and timely intervention may reduce the cognitive burden of post-stroke cognitive impairment (PSCI) and post-stroke dementia (PSD) [15]. One of the biggest challenge in younger cohort is stroke-related depression, leading to high suicide risk. The risk is particularly high during the first 2 years following incident stroke in younger stroke victims, male patients and those who suffer severe stroke [16, 17]. Our aim was to conduct a literature review to determine the best screening cognitive test to detect cognitive defects after incident stroke.

Search Methods and Results

Electronic databases (i.e. MEDLINE and Cochrane databases) were searched for publications between January 2000 and August 2016 containing the key search terms “post-stroke dementia”, “post-stroke cognitive impairment”, “cognitive tools after stroke” or “cognitive impairment after stroke”. Abstracts were screened for PSCI, PSD and cognitive tools. In our review, we used the preferred reporting Items for systematic reviews and meta-analysis (PRISMA) statement guidelines. Publications were then selected using inclusion and exclusion criteria (see below), and full-text reviews were performed. Publications on cognitive screening tools were pooled together for review, and those on PSD or PSCI were also selected and pooled separately. The reference section of each paper was also reviewed for additional studies.

The MEDLINE search identified 670 papers on PSCI, 538 papers on PSD and 4996 papers on cognitive impairment after stroke. Similar results were obtained from the Cochrane Library search. Seven hundred publications were excluded because they did not comply with the inclusion criteria, and another 200 were excluded due to the duplication of data. A total of 305 papers were selected for the initial review. Furthermore, another 282 publications were excluded, as most of these were not randomised studies, did not use neuropsychiatric battery as reference cognitive test, some included transient ischaemic attacks or ischaemic stroke diagnosis was not clear (no MRI confirmation). A total of 22 (approximately 10% of all selected publications) of these papers complied with the inclusion criteria regarding the cognitive tools used in a post-stroke setting. These data were pooled to extract the sensitivity and specificity of these tools.

Inclusion Criteria

Randomised studies, retrospective studies and cohort studies were targeted for this review. Regarding cognitive tools, direct face-to-face tools were targeted, including MMSE, MOCA, the Cambridge Cognitive Assessment-Revised (R-CAMCOG), Addenbrooke’s Cognitive Examination Revised (ACE-R) and Oxford Cognitive Screen (OCS). Studies that used neuropsychological battery testing as a reference test to confirm PSCI and PSD were also included.

Exclusion Criteria

Studies that used modified cognitive tools and single-domain tools were excluded (30 publications used clock drawing test), as there is mounting evidence that stroke results in multidomain impairment. Studies that included intracranial haemorrhage (ICH) were also excluded because some patients in these studies had surgical interventions.

Study Findings

Among the 22 papers selected, only one meta-analysis, one systematic review and one randomised controlled trial were found. The remainder of the papers was either retrospective or cohort studies. The sample sizes in the studies were relatively small, ranging from 40 to 300 patients. The study populations were also heterogeneous and involved various regions across the globe. The mean age of stroke patients in these studies ranged from 53.9 to 76 years.

One of the most notable findings in this review was that time to cognitive testing following acute stroke has significant variation. This may be due to lack of uniformity in diagnosing PSD/PSCI (more than four criteria’s) or the unfamiliarity. Another most interesting finding was that even that there is an enormous amount of evidence to use domain-specific cognitive tools, still many publications using less valid cognitive tools or domain neutral tools appears in literature.

Regarding the screening tools, 12 studies used the MOCA, 10 studies used the MMSE and 1 study used brief cognitive tools, i.e. abbreviated mental test (AMT), clock-drawing test (CDT) and 4AT. MOCA had a sensitivity range of 73 to 100% and a specificity range between 42 and 82%. MMSE had a sensitivity of 36% to 86% and a specificity ranging between 71 and 92%. The R-CAMCOG and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were rarely used. Except for four studies, all studies used the detailed neuropsychological battery test as a reference.

Interestingly, Blake et al. [18], in their randomised trial, concluded that MMS should not be used as a screening tool in diagnosing PSCI. One of the issues about using MOCA is that there is no consensus cutoff value in diagnosing PSD/PSCI which can cause a diagnostic dilemma. Furthermore, only five studies had head-to-head comparison on MMSE vs MOCA. Five studies use clinical criteria to diagnose cognitive defect, however, they did not specify what clinical criteria were. It is interesting to note that all most all studies, the screening was done in acute patients which contradicts the diagnosis of PSD (should allow 6-month incident event).

Only one study used the seven domains new screening tool (OCS) and compared it to the MOCA for sensitivity. Table 1 summarises the sensitivity, specificity and comments regarding the various cognitive tools used in the abovementioned papers and Fig. 1 shows the selection process.
Table 1

Commonly use cognitive tools and its sensitivity and specificity

Author

Type

(n) Included

Mean age

Cog impairment

Tool/cutoff

Sen

Spec

Reftest NPB/clinical

Time to test

comment

Blake et al. [18]

RCT

112

70.8

31 (28%)

MMSE/24

62%

88%

NPB

28 days

MMSE not recommended as a screening tool.

Bour et al. [19]

Prospective

194

68.3

22 (11%)

MMSE/23

96%

83%

NPB

Up to 6 months

MMSE is easy to use tool in moderate to severe PSCI/PSD.

Cummings et al. [13]

 

60

72.1

39 (65%)

MMSE/24

MOCA/

82%

92%

76%

67%

NPB

98 days

MOCA is more sensitive less specific.

Demeyere et al. [20]

Cross-sectional

208

70.5

 

MOCA/26 OCS

78%

87%

 

NPB

14 days

 

Dong et al. [21]

 

100

61.2

60 (60%)

MMSE/24 MOCA/21

86%

90%

92%

77%

NPB

14 days

MOCA is superior MMSE.

De Konig et al. [22]

 

300

69.2

55 (19%)

RCAMCO G/33

91%

90%

Clinical

3–9 months

RCAMCOG is a short and accurate test.

De Konig et al. [23]

 

121

74.9

35 (29%)

RCAMCO G/33

66%

94%

Clinical

3–9 months

RCAMCOG is useful tool to screen PSCI.

Godefroy et al. [24]

Retrospective

95

68.2

 

MMSE MOCA

66%

94%

97%

42%

NPB

Less than 3 weeks

MCA has high sensitivity but low specificity.

Lees et al. [25]

Prospective

111

74.0

 

AMT-4 AMT-10 clock drawing MOCA—24/30 4-A test

60%

60%

85%

86%

100%

100%

100%

77%

78%

82%

  

Brief cognitive tests are specific but not sensitive in stroke setting.

McGovan et al. [26]

Systematic RV

11 trials

63.9

 

IQCODE/

81%

83%

  

Can predict future dementia sen 60% spec 97%—a prognostic tool.

Moris et al. [27]

 

101

76.0

51 (84%)

MMSE/24 ACE-R/88

58%

94%

77%

0%

NPB

18 months

ACE-R not suitable to use as screening tool in PSCI.

Pendulburyetal [28]

 

91

73.4

19 (21%)

MOCA/25 MMSE/ACE-R/94

77%

36%

83%

83%

92%

73%

  

MOCA and ACER have good sensitivity for MCI.

Pendulburyet al [29]

 

91

73.4

19 (21%)

TMOCA/25 TICSm

89%

85%

52%

56%

NPB

1–5 years

T MOCA and TICS feasible and valid telephone tests in PSCI.

Salvatori et al. [30]

 

80

68.2

47 (59%)

MOCA/21

91%

76%

NPB

In acute patients

MOCA is a good predictor of mid-term PSCI.

Srikanth et al. [31]

 

67

69.0

8 (12%)

SMMSE/23

50%

63%

Clinical

 

S-MMSE/IQCODE insensitive and nonspecific in PSCI.

     

IQCODE

     

Tang et al. [32]

 

189

74.2

 

IQCODE

88%

75%

Clinical

3 months

IQCODE not useful in screening PSCI.

Tang et al. [33]

 

83

72.5

 

MMSE MDRS-IP

93%

93%

80%

94%

Clinical

3 months

MDRS-IP has similar pickup rate as MMSE.

Xu et al. [34]

 

102

68.2

 

MOCA MMSE

76%

59%

81%

71%

  

MOCA detected subcortical MCI better than MMSE.

Wong et al. [35]

 

40

69.2

 

MOCA/23

73%

75%

NPB

 

HK MOCA is useful tool in PSCI.

Wu et al. [36]

 

206

68.21

95 (46%)

MOCA/21

65%

79%

Clinical

 

MOCA is an effective screening tool.

Zuo L et al. [37]

Prospective

102

53.95

 

MOCA/22

85%

88%

NPB

Acute patients

MOCA is sensitive and specific test.

Lees et al. [38]

Meta-analysis

35 papers

  

ACE—R < 88/100 MMSE < 27/30 MOCA < 26/30 RCAMCO G < 33/49

96%

71%

84%

57%

70%

85%

78%

92%

  

Commonly used cognitive tools have similar accuracy.

No clear superiority among them.

There is no evidence that tools with longer administrative times would perform better.

Fig. 1

Selection process

Discussion

Definition of PSCI, PSD, VaD, VaMCI and VCI

PSD has been defined as the occurrence of dementia within 3 months of an incident stroke irrespective of its aetiology and onset [19, 39]. The leading cause of PSD is vascular infarction–related dysfunction; however, it could also be degenerative (Alzheimer’s) or a combination of the two.

The term vascular cognitive impairment (VCI) or vascular cognitive disorder (VCD) is defined as impairment of minimum of four cognitive domains including executive/attention, memory, language and visuospatial function after a vascular event [39]. Vascular dementia (VaD) on the other hand defined as an impairment of more than two cognitive domains which lead to decline in activities of daily living. In order to make a certain diagnosis of VCD, one needs a neuropathological assessment to exclude coexisting alternative pathologies [39].PSCI, which is also referred to as vascular mild cognitive impairment (VaMCI), has no universally accepted definition. Broadly speaking, PSCI denotes cognitive impairment following a stroke that is not severe enough for patients to be classified as having dementia. PSCI may also progress slowly to PSD [11, 12, 15]. PSCI has four subtypes, ranging from pure amnestic to multidomain impairment with little or no effect on activities of daily living [40].

Lack of clear definition on VaD is one of the biggest hurdle which delays diagnosis and hampers further care. Currently, researchers use diagnostic criteria formalised by the four main groups. The National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche’ et l’ Enseigenementen neuroscience (NINDS-AIREN) criteria, the state of California Alzheimer’s Disease Diagnostic and Treatment Centres (ADDTC) criteria, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classification [41] and International Statistical Classification of Diseases and Related Health problems 10th revision (ICD-10) classifications [42]. There is no explicit recognition of PSCI or PSD in the current above classifications [42]. Since there are many issues noted in above classifications, two expert groups have formalised expert recommendations on VCI. For example, delirium, dementia and amnesia are all grouped under the new umbrella term of neurocognitive disorders in the new DSM-5 classification [41]. International Society for Vascular Behavioural and Cognitive Disorders (VASCOG) in their 6th symposium in France 2013 produced a statement known as VASCOG statement, outlining the diagnostic criteria [40]. Similarly, the Vascular Impairment of Cognition Classification Consensus Study and expert opinion from the 2015 International Congress on Vascular Dementia (VICCS group) recognised vascular cognitive impairment and formalised a classification that identified the need for clear definition [43]. Recently, in their review paper, Mijajlovic et al. proposed consolidating the PSCI and PSD as definite entities [11].

An acute stroke can lead to a decline in various cerebral functions as well as potentially reversible conditions such as delirium and post-stroke depression; therefore, it is recommended that the final diagnosis of PSCI or PSD should not be attempted within the first 6 months of the incident event [11, 44]. This time delay in the diagnosis of PSD and PSCI has been endorsed by the American Psychiatric Association Diagnostic and Statistical Manual [45].

Screening Tools

There is currently no gold standard screening test available to assess PSCI. The MOCA has been endorsed as a preferred cognitive tool for use in stroke secondary prevention clinics by the National Institute of Excellence and the National Institute of Neurological Disorders and Stroke–Canadian Stroke Network (NINDS-CSN) [46], although this systematic review failed to establish the superiority of the MOCA over the other commonly used cognitive screening tool, the MMSE. The prevailing notion is biased towards the advantages of the MOCA, but the meta-analysis [47] concluded that the MOCA was not superior to other cognitive tools. The current literature suggests that commonly used tools (including the MMSE, MOCA, ACE-R and R-CAMCOG) perform no better than the others [47]. Recent evidence suggests that the MOCA is a reliable screening tool with high sensitivity (85%) and specificity (88%) and has shown promising results for predicting future PSCI [48]. Another excellent meta-analysis published recently by Dan Shi et al., showed that MOCA has higher sensitivity but lower specificity when compared to MMSE, however, could not find superiority [16].

A major issue regarding the use of the MOCA is that there is no universally accepted definition for PSD and PSCI. In addition, the MOCA does not have a consensus cutoff in a stroke setting; it cannot be used in aphasic patients, and it does not assess intellectual function, information processing speed or nonverbal memory [4]. Neither the MOCA nor the MMSE evaluates specific stroke syndromes, such as aphasia, visual loss, visuospatial inattention, apraxia and problems of reading and writing, which are the important domains that limit recovery in stroke victims [10]. Conversely, compared with the other tools, the MOCA can identify subcortical type defects (including frontal executive dysfunction, visuospatial dysfunction, working memory and bradyphrenia) [49]. An International Psychogeriatric Association survey reviewed the use of short cognitive tests in a post-stroke setting to assess PSCI and PSD [46]. MMSE and the clock-drawing test (CDT) were found to be the most commonly used tools in clinical practice [46]. The Hopkins Verbal Learning Test (HVLT) had better sensitivity (96%) than the MMSE (88% with cutoff 25/26) when using a cutoff of 18/19(HVLT) in detecting mild dementia. In addition, the HVLT could detect mild cognitive impairment (MCI) when using a lower cutoff of 16/19 with a sensitivity of 80%, a specificity of 84% and a similar profile for both vascular cognitive impairment (VCI) and Alzheimer’s disease [50]. Combining the HVLT with a reading test increased the specificity and sensitivity in diagnosing VCI to 89% and 90%, respectively [51, 52]. In specialised memory clinics, different tools of varying complexity (for example, Addenbrooke’s cognitive examination (ACE), ACE-R, Face and Cued Selective Reminding Test (FCSRT), R-CAMCOG, HVLT, MOCA, the Cognitive Assessment Screening Test (CAST), Rowland Universal Dementia Assessment Scale (RUDAS) or the Addenbrooke’s Cognitive Examination-III (ACEIII) may be preferable depending on the type of dementia.

The most widely used screening tests for post-stroke cognitive assessments are the MMSE (domain neutral) and the MOCA (domain-general); however, they are not specific for detection of the multidomain cognitive dysfunction seen in PSD and PSCI. Both tests were initially developed to assess dementia in outpatient settings rather than to identify cognitive defects in stroke patients [53]. The MOCA is probably better at detecting MCI than the MMSE [10, 54]. However, no randomised studies have directly compared the MMSE and MOCA. A recent meta-analysis showed that the MOCA, MMSE, ACE-R and Rotterdam CAMCOG had similar sensitivities and specificities for detecting dementia in post-stroke settings [47]. The MOCA is the most extensively studied cognitive screening test and has been shown to have high sensitivity and specificity for diagnosing PSCI and PSD [48].

Detailed Neuropsychological Battery Tests

Detailed multidomain neuropsychological assessments using neurocognitive battery tests have been validated in research settings to analyse each cognitive domain in depth. These tools are difficult to perform in day-to-day practice due to their time-consuming nature and limited availability of staff qualified to perform such tests. Commonly used multidomain neurocognitive battery tests include the Consortium to Establish a Registry for Alzheimer’s disease (CERAD) and the National Institute of Neurological Disorders and Stroke–Canadian Stroke Network Vascular Cognitive Impairment Harmonisation Standards (NIND–CSN) tests [38, 46].

It is impractical to conduct these detailed tests in routine clinical practice, including busy hospital outpatient clinics; however, the selective use of these components may be appropriate in an inpatient setting. Current practice in many stroke centres, including our institution, is to use a brief cognitive screening test followed by a formal neuropsychological battery assessment if more detailed clarification is required.

Domain-Specific Screening Tools

There is increasing evidence that domain-specific testing is a better tool to comprehensively screen each cognitive domain in PSCI and PSD patients. It is particularly relevant for information processing speed, visuospatial memory and executive dysfunction, which are the primary cognitive domains affected in individuals who have suffered from a stroke and are the critical factors that slow the recovery process.

A newly proposed stroke-specific screening tool with higher sensitivity and specificity, OCS, could accurately and comprehensively screen multiple domains affected by stroke in comparison to MOCA [55]. Furthermore, the OCS also assesses visual neglect, apraxia and numerical reading and writing abilities, which are known to be poorly evaluated by the MOCA [56]. In addition, other domain-specific tests, including the construction praxis test (CPT) and the construction recall test (CRT), can accurately predict post-stroke functional improvement [56].

The domains tested in the OCS are shown in Table 2. The notion of domain-specific cognitive screening has emerged due to the abovementioned limitations of the MOCA. The OCS was developed to exclusively evaluate multidomain cognitive dysfunction in stroke patients. A recent cross-sectional study [45, 47] using an acute stroke cohort showed that the seven-domain OCS had higher sensitivity than the MOCA (88% vs. 78%, respectively). In addition, other tools, including CPT (to assess visuospatial construction) and CRT (to determine memory), may predict functional recovery in stroke patients [56].
Table 2

Domains tested in OCS

Domain

Task

1. Language

Picture naming

Semantics

Sentence reading

2. Memory

Orientation

Recall and recognition

3. Number

Number writing

Calculation

4. Perception

Visual field

5. Spatial attention

Spatial neglect

Object neglect

6. Praxis

Imitation

7. Controlled attention

Executive

Limitations

The studies described are either prospective observational or small retrospective studies. Randomised studies with head-to-head comparisons of different cognitive tools have not been performed in PSCI. There is also an issue of parallel degenerative forms of dementia developing in these patients, which makes interpretation of cognitive assessments more complicated. There is currently a small amount of literature exploring domain-specific testing. The primary limitations of these studies are that they have typically used acute stroke patients with assessments performed within the first few weeks of a stroke. Furthermore, PSCI and PSD lack universally accepted definitions and have yet to be integrated into the DSM or ICD classification of dementia.

Conclusion

PSCI is a significant under-recognised problem for stroke patients across the globe. PSCI significantly hampers functional recovery and may eventually lead to PSD. Two important issues regarding PSCI research are the lack of clear definition and the lack of a highly specific and sensitive screening tool that can predict PSCI.

There is currently no globally accepted definition for PSCI/PSD

Harmonisation Standards Neuropsychological Battery after TIA and stroke. Stroke. 2012; vol. 43: 464–469 that can cast doubt on the validity of these studies, including meta-analyses. The literature has previously focused on nonspecific screening tools, with a recent emphasis on domain-specific screening tools. This study found that multidomain screening tools (such as OCS) may accurately assess cognitive defects in PSD and PSCI more so than current existing screening tests, such as the MOCA, and may be helpful in targeting therapies in the relevant post-stroke domains.

Take-home message

PSCI/PSD is an important issue. Multidomain screening tools must be used to accurately diagnose specific defects that need specific intervention which enables stroke recovery.

Notes

Authors’ Contribution

AK and CKYC involved in the design and drafting the article. DC and JY involved in proofreading editing the draft.

Compliance with Ethical Standards

Ethics Approval and Consent to Participate

We declare that this research did not require ethical and consent procedure.

Conflict of Interest

The authors declare that they have no conflict of interest.

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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Athula Kosgallana
    • 1
    Email author
  • Dennis Cordato
    • 2
  • Daniel Kam Yin Chan
    • 3
  • Jonathan Yong
    • 4
  1. 1.Hervey Bay HospitalHervey BayAustralia
  2. 2.Department of NeurologyLiverpoolAustralia
  3. 3.Department of Geriatrics, Bankstown HospitalBankstownAustralia
  4. 4.Liverpool HospitalLiverpoolAustralia

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