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Simple test predicts stroke recovery over three years

StrokeA simple test, the Montreal Cognitive Assessment, taken within a week of a stroke may help predict how well people will have recovered up to three years later, according to a German study.

"We found that this test, which takes less than 10 minutes, can help predict whether people will have impaired thinking skills, problems that keep them from performing daily tasks such as bathing and dressing and even whether they will be more likely to die," said study author Dr Martin Dichgans, of Ludwig-Maximilians University in Munich, Germany. "This test should be used to screen people with stroke and to counsel them and their families about long-term prognosis and also to identify those who would most benefit from interventions that could improve their outcomes."

For the study, 274 people in Germany and France who had a stroke were given the test, called the Montreal Cognitive Assessment, within a week of the stroke. They were then divided into two groups: those with no problems with thinking and memory skills and those with cognitive impairment. The participants were tested for their thinking and memory skills, motor functioning and ability to complete daily living tasks six months later and then at one and three years after the stroke.

The study found that those who had thinking problems within one week of the stroke were seven times more likely to die during the three years of the study than those who did not have thinking problems. The survival rate for those with thinking problems after three years was 83%, while the rate was 97% for those with no thinking problems early on.

Those with thinking problems on the first test were also five times more likely to have problems with their motor skills than those who did not have thinking problems early on. By three years after the stroke, 29% of those with thinking problems on the first test had problems with their motor skills, compared to 5% of those who did not have thinking problems early on.

Those with cognitive impairment were more than twice as likely to have problems completing their daily activities such as bathing and dressing, with 42% having problems compared to 13% three years after the stroke. Those with cognitive impairment were five times more likely to continue having thinking problems three years after the stroke than the other group.

Dichgans noted that the test helped predict outcomes even when other factors such as the severity of the stroke were taken into account.

A limitation of the study was that most of the people involved had relatively mild strokes, so more research is needed to determine whether the results apply to people with more severe strokes.

Abstract
Objective: To examine whether the Montreal Cognitive Assessment (MoCA) administered within 7 days after stroke predicts long-term cognitive impairment, functional impairment, and mortality.
Methods: MoCA was administered to 274 patients from 2 prospective hospital-based cohort studies in Germany (n = 125) and France (n = 149). Cognitive and functional outcomes were assessed at 6, 12, and 36 months after stroke by comprehensive neuropsychological testing, the Clinical Dementia Rating (CDR) scale, the modified Rankin Scale (mRS), and Instrumental Activities of Daily Living (IADL) and analyzed with generalized estimating equations. All-cause mortality was investigated by Cox proportional hazard models. Analyses were adjusted for demographic variables, education, vascular risk factors, premorbid cognitive status, and NIH Stroke Scale scores. The additive predictive value of MoCA was examined with receiver operating characteristic curves.
Results: In pooled analyses, a baseline MoCA score <26 was associated with cognitive impairment, defined by neuropsychological testing (odds ratio [OR] 5.30, 95% confidence interval [CI] 2.75–10.22) and by CDR score ≥0.5 (OR 2.53, 95% CI 1.53–4.18); functional impairment, defined by mRS score >2 (OR 5.03, 95% CI 2.20–11.51) and by IADL score <8 (OR 2.48, 95% CI 1.40–4.38); and mortality (hazard ratio 7.24, 95% CI 1.99–26.35) across the 3-year follow-up. Patients with MoCA score <26 performed worse across all prespecified cognitive domains (executive function/attention, memory, language, visuospatial ability). MoCA increased the area under the curve for predicting cognitive impairment (neuropsychological testing 0.81 vs 0.72, p = 0.01) and functional impairment (mRS score >2, 0.88 vs 0.84, p = 0.047).
Conclusion: Early cognitive testing by MoCA predicts long-term cognitive outcome, functional outcome, and mortality after stroke. Our results support routine use of the MoCA in stroke patients.

Authors
Vera Zietemann, Marios K. Georgakis, Thibaut Dondaine, Claudia Müller, Anne-Marie Mendyk, Anna Kopczak, Hilde Hénon, Stéphanie Bombois, Frank Arne Wollenweber, Régis Bordet

[link url="https://www.aan.com/PressRoom/Home/PressRelease/2674"]American Academy of Neurology material[/link]
[link url="http://n.neurology.org/content/early/2018/10/17/WNL.0000000000006506"]Neurology abstract[/link]

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