Association between the Cognitive-Related Behavioral Assessment Severity Stage and Activities of Daily Living Required for Discharge to Home in Patients with Stroke: A Cross-Sectional Study

1. Introduction

Poststroke cognitive impairment is present in 22–85% of patients with stroke in the subacute phase [1,2,3,4]. Previous studies have shown that poststroke cognitive impairment affects rehabilitation outcomes, independence in activities of daily living (ADLs) and walking, and functional improvement [4,5,6]. Additionally, cognitive impairment increases the risk of falls [7]. National and international rehabilitation guidelines recommend that these symptoms be considered [8,9]. The Canadian Stroke Best Practice Recommendations suggest considering the risk of poststroke cognitive impairment in all patients with stroke [8].Generally, poststroke cognitive impairment is examined using paper-based neuropsychological tests, such as the Mini-Mental State Examination (MMSE) [10], Raven’s Colored Progressive Matrices (RCPM) [11], and the Behavioral Inattention Test [12]. These tests objectively capture the severity of poststroke cognitive impairment and are useful in detecting and diagnosing poststroke cognitive impairment [13]. However, neuropsychological testing alone is limited in its ability to accurately detect disorders due to impaired consciousness and aphasia [14,15], and testing is difficult in cases of severe impairment of arousal, emotion, and communication, thereby limiting the target population. Additionally, poststroke cognitive impairment detected in ADL situations is difficult to assess by neuropsychological testing [16]. It is not sufficient to determine the risk of cognitive impairment [8] in all the aforementioned patients with stroke, and it may be difficult to measure the cognitive functions required for ADLs directly. Therefore, it could be useful to examine the effects of poststroke cognitive impairment on ADL performance by observing the behavior of patients with stroke in their daily lives [17,18]. Behavioral observation tests, such as the Catherine Bergego Scale [17] and Moss Attention Rating Scale [18], have been reported to be beneficial. However, these assessments only evaluate limited types of poststroke cognitive impairment, hemispatial neglect, and attention impairment and are not sufficient for evaluating recovering stroke patients with multiple overlapping poststroke cognitive impairments. Recently, there have been much-needed reports of comprehensive observational assessments of poststroke cognitive impairment [19].The Cognitive-related Behavioral Assessment (CBA) [20] was developed to evaluate cognitive function-related problems that occur in patients with stroke and has been found useful in clinical practice. The CBA is based on the concepts of the neuropsychological pyramid [21] and the behavioral and cognitive impairment model [22], which clearly illustrate the hierarchy of general symptoms of poststroke cognitive impairment and target the evaluation of general symptoms that are difficult to assess by neuropsychological tests. Previous studies have reported that the CBA has good to excellent inter-rater reliability and internal consistency [20,23]. Reports on the comorbid validity of the CBA show high correlations with the MMSE and the RCPM, which are used for cognitive impairment [20]. Regarding ecological validity, a strong correlation between the CBA and ADLs has also been observed [20]. We also proposed the use of the CBA to determine the stage of severity of illness and to assist patients with stroke according to the severity of illness [24]. However, it is unclear how the severity of cognitive function assessed by the CBA is characterized in terms of ADLs [25], which are necessary for discharge to home. More clarity is needed to relate the characteristics of ADL abilities to CBA severity scores. In particular, the severity of ADLs that are important for discharge to home can provide clues for setting rehabilitation goals and the rehabilitation content required by therapists.Therefore, this study aimed to clarify ADL characteristics according to severity, as judged by the CBA total score, in patients with stroke admitted to rehabilitation wards and to examine the impact of CBA severity on more important ADL items for discharge to home.

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About the Author: Tung Chi