national-clinical-guidelines-for-stroke-fourth-edition

6.38.1 Recommendations
A Interventions or patient management should be organised so that people with
cognitive difficulties can participate in the treatments and are regularly reviewed and
evaluated.
B Every patient seen after a stroke should be considered to have at least some cognitive
losses in the early phase. Routine screening should be undertaken to identify the
patient’s broad level of functioning, using simple standardised measures (eg Montreal
Cognitive Assessment (MOCA)).
C Any patient not progressing as expected in rehabilitation should have a more detailed
cognitive assessment to determine whether cognitive losses are causing specific
problems or hindering progress.
D Care should be taken when assessing patients who have a communication
impairment. The advice from a speech and language therapist should be sought where
there is any uncertainty about these individuals’ cognitive test results (see section
6.20).
E The patient’s cognitive status should be taken into account by all members of the
multidisciplinary team when planning and delivering treatment.
F Planning for discharge from hospital should include an assessment of any safety risks
from persisting cognitive impairments.
G Patients returning to cognitively demanding activities (eg some work, driving) should
have their cognition assessed formally beforehand.
6.38.2 Sources
A–G Consensus
6.39 Attention and concentration
Attention is a prerequisite for almost all cognitive functions and everyday activities.
Disturbed alertness is common after stroke especially in the first few days and weeks, and
more so following right hemisphere stroke. Problems may be specific (eg focusing,
dividing or sustaining attention) or more generalised, affecting alertness and speed of
processing as characterised by poor engagement and general slowness. Attention
problems may lead to fatigue, low mood and difficulty with independent living.
Evidence to recommendations
6 Recovery phase from impairments and limited activities: rehabilitation
Recommendations have not changed greatly since the previous edition of the National
clinical guideline for stroke (2008) when they were based on consensus opinion and on two
reviews (Lincoln et al 2000; Michel and Mateer 2006) of a small number of poor-quality
studies. The only new evidence of sufficient quality is one RCT (Winkens et al 2009). This
is small and inconclusive but suggests that Time Pressure Management (TPM) shows
promise with younger, more physically independent stroke survivors and that it is feasible
to train staff to deliver it in hospital or community stroke services. Adequately powered
trials of TPM and other interventions (eg Attention Process Training) would greatly
improve the evidence base for these common, disabling impairments.
© Royal College of Physicians 2012 117