Cognitive and Neuropsychiatric Assessment of Stroke patients

INTRODUCTION Definition of stroke: The World Health Organisation’s definition of stroke is “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer, with no apparent cause other than of vascular origin. Pathologically it occurs due to a rupture or occlusion of a cerebral vessel. OBJECTIVES OF STUDY PRIMARY OBJECTIVE: 1. To evaluate the Cognitive and Neuropsychiatric Deficits in patients after stroke. SECONDARY OBJECTIVES: 1. To assess the most common cognitive and neuropsychiatric impairments after stroke and 2. To assess the factors affecting the severity of cognitive and neuropsychiatric impairments after stroke. MATERIALS AND METHODOLOGY: TYPE OF STUDY: Cross sectional study. PLACE OF STUDY: PSG Hospitals, PSGIMS&R, Coimbatore. STUDY POPULATION: Patients aged 18-60 years diagnosed as stroke presenting to the department of General Medicine and Neurology for follow up 3 months after the diagnosis of stroke, meeting the inclusion criteria, during the study period of 1 year (March 2018 to March 2019). Patient sample size is restricted to a total number of 75. INCLUSION CRITERIA: Age between 18-60 years. Patients presenting to the General Medicine/ Neurology OPD, diagnosed as Stroke (Ischemic/ Haemorrhagic) by Brain Imaging earlier who have come for follow up 3 months after the diagnosis of stroke and Written Informed Consent. EXCLUSION CRITERIA: Age less than 18 years, Age more than 60 years, Severe aphasia (as it interferes with performance/understanding of the instructions of the neuropsychological tests), Other existing psychiatric and neurological diagnoses that are known to affect cognition. METHODOLOGY: This study is based on cross sectional collection of data of patients aged between 18-60 years diagnosed as stroke earlier who have come for review/follow up 3 months after the diagnosis of stroke in the General Medicine/ Neurology OPD of PSG Hospitals, Coimbatore. Patients presenting to the OPD with a confirmed diagnosis of stroke (by brain imaging modality) and meeting the inclusion criteria as mentioned above, during the study period of March 1st 2018 to March 1st 2019 are taken into consideration for the study. A proforma is prepared which includes personal details and detailed clinical history of the patient. After taking informed consent from the participant, the participants are made to undergo two assessment tests, both of which are validated tests world over. The first is the Montreal Cognitive Assessment (MOCA) which measures the cognitive skills of the patient such as executive skills, memory and attention. Time to administer the MOCA test is approximately 10 minutes. The total possible score is 30 points, a score of 26 or above is considered normal. The second is the Hospital Anxiety and Depression scale (HADS) which measures the presence of anxiety and depression in the participants. RESULTS: Out of the 75 patients assessed, 57 patients were males (76%) and 18 patients were females (24%). Out of the 75 patients included, 2 patients (2.7 %) were between the ages of 20 to 30. The majority of the patients were between the age groups of 51 to 60 (56 %). The 2nd highest group was between the ages of 41 to 50 years (26.6 %). The mean age of the patients who presented was 49.7 years.The total score of the Montreal Cognitive Assay in 30. A score of 26 or more is considered normal and below that is abnormal. Out of the 75 participants, 52 members had a score of less than 25 (69.3%) and 23 members had a score of 26 and above (30.7). Thus 69.3% of the participants had a cognitive impairment on assessment. Anxiety was assessed using the Hospital Anxiety and Depression scale. 57 patients had no anxiety features (76%), 9 patients had borderline symptoms (12%) and 9 patients had features of clinical anxiety (12%). Depression was assessed using the Hospital Anxiety and Depression scale. 58 participants had no symptoms of depression (77.3%), 14 members had clinical features of depression (18.7%) and 3 members had borderline symptoms (4%). To assess which type of stroke (Ischemic or Haemorrhagic) causes greater cognitive impairment Fischer’s exact test was used. There was no statistical significance on the type of stroke and cognitive impairment. (p value >0.05). Patients with Fronto-temporo-parietal region stroke have more chances of having MOCA score of less than 25 when compared with stroke occurring at other sites and the difference is statistically significant. (p-value less than 0.05).The association between the site of stroke and anxiety/ depression symptoms was assessed using Fischer’s exact test. It was found that in patients with a lesion in the Fronto-Tempero-Parietal region had a statistically significant risk of developing anxiety and depression as compared to strokes in other regions (p-value less than 0.05). There is a positive correlation between patients having MOCA score less than 25 and the tendency to develop Depression and Anxiety, means there is a high chance of development of Depression in patients having MOCA less than 25 when compared to MOCA score 26 and above and the difference is statistically significant with (P value