Top Things to Know: Cognitive Impairment After Ischemic and Hemorrhagic Stroke
Published: May 01, 2023
Prepared by Anne Leonard MPH, BSN, RN National Senior Director Science and Medicine
- Post-stroke cognitive impairment (PSCI) ranges in severity from mild to severe and occurs in up to 60% of stroke survivors in the first year after stroke with a higher rate seen acutely after stroke and often occurs in the presence of a variety of stroke-related deficits and other comorbid conditions (depression, hyponatremia, or delirium) which adds to the complexity of diagnosis and treatment. The risk of developing future dementia is increased after stroke in those with transient cognitive impairment.
- This statement defines vascular cognitive impairment (VCI), vascular dementia (VaD), post-stroke cognitive impairment (PSCI) and post stroke dementia (PSD); and differentiates vascular cognitive impairment and dementia from post-stroke cognitive impairment (PSCI) and dementia.
- The natural history of post-stroke dementia is based on clinical observation. What might be seen are five different scenarios: 1) post-stroke dementia develops at the onset of stroke and stabilizes, 2) starts at the onset of stroke and progresses, 3) develops after recurrent strokes, 4) develops at the onset of stroke in the presence of pre-existing cognitive impairment or 5) develops more than 3-6 months after stroke (delayed onset).
- This scientific statement presents a conceptual framework for factors contributing to the pathophysiology of PSCI.
- Risk factors for PSCI generally reflect pre-stroke cognitive decline, pre-existing cerebral vulnerability/reduced reserve, and stroke impact; for example, a minor stroke may precipitate dementia in an older person with a vulnerable brain.
- Key vulnerable factors for the development of PSCI include age, cerebral small vessel disease and neurodegeneration.
- PSCI is associated with other adverse outcomes, including physical disability, sleep disorders, depression, personality and behavioral changes and other neuropsychological changes that all contribute to overall quality of life.
- Regarding differential diagnosis, the following areas are considered; pre-stroke cognitive decline, co-existing age-related neuropathologies (example Alzheimer’s Disease) and the effects of medical conditions and complications, such as metabolic abnormalities, medication side effects, infections, delirium, sleep disorders, hearing and vision impairments and depression.
- Screening and diagnostic modalities in the clinic are tailored neuropsychological evaluations to improve diagnostic accuracy for cognitive impairment post-stroke and provide a thorough characterization of the patient’s cognitive strengths and weaknesses.
- Management of PSCI includes interdisciplinary collaboration, cognitive rehabilitation, physical activity, medical and pharmacological treatments, and may include emerging complementary and integrative treatments.
- Anticipatory guidance is given in this statement for patients and caregivers. Included in this discussion is a comprehensive cognitive evaluation with considerations for pharmacological and non-pharmacological treatments, management of stroke risk factors to prevent stroke recurrence, targeting of high-risk populations, evaluation for comorbid complications and assessing for home safety, driving and return to work (if applicable) are warranted.