Category: Stroke; Clinical Practice (assessment, diagnosis, treatment, knowledge translation/EBP, implementation science, program development)
Objective : To determine whether subgroups that grade cognitive severity based on the Montreal Cognitive Assessment (MoCA) are associated with functional gain during acute inpatient stroke rehabilitation.
Design : Observational study of individuals with stroke admitted to acute inpatient rehabiliation.
Inpatient rehabilitation facility of a large, urban academic medical center.
Participants (or Animals, Specimens, Cadavers) : N=334 individuals with a diagnosis of stroke who underwent rehabilitation between 2012 and 2016, and who were identified prospectively and via retrospective chart review. N = 91 individuals were excluded because they did not complete the MoCA. The included sample had a mean age of 70.3 years, mild stroke severity (mean National Institute of Health Stroke Scale=7.0), and were 54% male. Based on the MoCA, individuals were classified as Normal (MoCA of 25-30; N=55), Mildly Impaired (20-24; N=109), or Moderately Impaired (< 20; N=170).
Interventions : Not applicable.
Main Outcome Measure(s) : The motor subscale of the Functional Independence Measure (M-FIM), administered at rehabilitation admission and discharge. We calculated the mean relative functional gain (mRFG) and the mean relative functional efficiency (mRFE, which adjusts for length of stay) on the M-FIM. We also determined the proportion of individuals in each group who met the minimal clinically important difference (MCID) on the M-FIM.
Results : The Moderately Impaired group had significantly poorer mRFG and mRFE than the Mildly Impaired group (mRFG mean difference=11.2, 95% CI: 4.2-18.2, p=.001, Cohen's d=.45; mRFE mean difference=1.0, 95% CI: 0.2-1.9, p=.013, Cohen's d=.36). The Mildly Impaired group in turn exhibited poorer mRFG and mRFE than the Normal group (mRFG mean difference=11.2, 95% CI: 4.0-18.4, p=.02, Cohen's d=.57; mRFE mean difference=1.9, 95%CI: 0.5-3.2, p=.004, Cohen's d=.55). There was a difference in M-FIM MCID by group (X2=14.3, p=.001). The Moderately Impaired group had the smallest proportion of individuals who made a clinically meaningful change on the M-FIM (45%), the Mildly Impaired group had an intermediate proportion (58%), and the Normal group had the highest proportion (73%).
Conclusions : MoCA subgroups differentiate the degree of functional gains and the likelihood of making clinically meaningful gains in acute inpatient stroke rehabilitation. Grading cognitive impairment by MoCA subgroup can assist clinicians in predicting functional gain in stroke survivors being treated in inpatient rehabilitation, and may enable a more tailored and targeted approach to care.
Abhishek Jaywant– Assistant Professor, Weill Cornell Medicine, New York, New York
Joan Toglia– Professor and Dean, Mercy College, Dobbs Ferry, New York
Faith Gunning– Associate Professor, Vice-Chair for Research and Psychology, Weill Cornell Medicine, New York, New York
Michael O'Dell– Professor, Vice-Chair of Clinical Services, Weill Cornell Medicine, New York, New York