Session number: 1096
Abstract title: Effects of Cognitive Impairment on Quality of Rehabilitative Care and Functional Outcomes in Stroke
Author(s):
S Zinn - HSR&D, VAMC, Durham, NC
HB Bosworth - HSR&D, VAMC, Durham, NC
TK Dudley - HSR&D, VAMC, Durham, NC
PW Duncan - Medical Research Service, VAMC, Kansas City, MO
RD Horner - HSR&D, VAMC, Durham, NC
Objectives: Cognitive impairment is associated with reduced functional recovery in patients post-stroke. Differences in access to, provision of, or reduced ability to benefit from, rehabilitation services due to cognitive impairment may account for part of its impact. We examined the role of cognitive impairment on access, content, process, and functional outcome of rehabilitation in stroke patients.
Methods: This is a secondary analysis of a nation-wide, prospective cohort of 288 Department of Veterans Affairs stroke patients followed for six months post-stroke. Rehabilitation process variables, including percentage of compliance with AHCPR recommendations for post-stroke rehabilitation, were examined for patients assessed as cognitively impaired or unimpaired according to education-adjusted MMSE score. Multivariable linear regression models assessed the unique effect of cognitive status on performance of activities of daily living (ADLs) and instrumental ADLs at six-month follow-up, adjusting for rehabilitation content and process and case mix.
Results: Cognitively impaired and unimpaired stroke patients were similar in receipt of and interval to initiation of post-acute rehabilitation, and in the level of compliance with guidelines for care received. Although provision of most cognition-related treatment elements, including occupational and speech therapy, were similar for both groups, cognitive goals were more frequently charted when impairment was present. Controlling for baseline function and rehabilitation process, cognitively impaired patients had worse IADL performance at 6 months than unimpaired patients; there was no difference between impairment groups for ADL performance.
Conclusions: Despite similar access to, and quality of, stroke rehabilitation, cognitively impaired stroke patients have restricted recovery. The presence of cognitive impairment was related to greater dependency in complex instrumental ADLs at follow-up, suggesting that even the mild to moderate levels of severity characteristic of this sample contributed to longer-term disability. Further research is needed to determine whether rehabilitation candidates with cognitive impairment will benefit from a more cognitively-focused rehabilitation process.
Impact statement: The worse functional recovery experienced by cognitively impaired stroke patients is not attributable to either access to or quality of rehabilitative care. Improved outcomes may be achieved by modifying the content to be more appropriate to the cognitively impaired patients’ needs and abilities.