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Stroke and transient ischaemic attack - Management
Cognitive impairments

  • General:
    • Almost all people with cerebrovascular disease have some degree of cognitive loss.
    • Everyone who has had a stroke or transient ischaemic attack (TIA) should be considered to have at least some cognitive losses initially, and should be screened to identify the range of cognitive impairments (e.g. with the Mini-Mental State Examination or short Orientation-Memory-Concentration Test):
      • The Mini-Mental State Examination tests orientation, registration, attention, calculation, recall, and language [Folstein et al, 1975].
      • The short Orientation-Memory-Concentration Test discriminates among mild, moderate, and severe cognitive deficits [Katzman et al, 1983].
    • People who have had a stroke should be assessed before returning to cognitively demanding activities (e.g. driving, some work activities).
    • People with cognitive impairment should be formally assessed by a specialist.
    • The approach to management should include:
      • Identification and, if possible, removal of any causative or aggravating factors (e.g. drugs, hypothyroidism).
      • Information and advice for the person and their family and carers.
      • Teaching of strategies to compensate for the impairment (e.g. using notebooks, diaries, audiotapes, electronic organizers, and audio alarms).
  • Attention and concentration:
    • Disturbed alertness is common after stroke, especially in the initial period of recovery, and with right cerebral hemisphere strokes, when it can be asymmetrical with the left side more severely affected.
  • Memory:
    • Almost all people who have had a stroke experience memory difficulties. About 20% of people who survive for 6 months after a stroke have dementia.
  • Disturbances of spatial awareness — neglect:
    • Disturbances of spacial awareness are more common in people with right cerebral hemisphere brain damage and hemianopia. The person acts as if they have reduced awareness of some part of their environment, usually the left side.
  • Disturbance of perception — visual agnosia:
    • After a stroke, some people have a specific difficulty in recognizing objects (agnosia). Agnosia is usually visual.
    • Behaviours due to visual agnosia can be mistakenly attributed to impaired memory, language, or deliberate pretence.
  • Apraxia — loss of the conceptual ability to organize activities to achieve a goal:
    • People with motor apraxia have difficulty in carrying out tasks, such as making a hot drink, despite adequate sensation and muscle strength.
    • Apraxia is usually associated with damage to the left cerebral hemisphere.
  • Disturbances of executive functioning:
    • 'Executive functioning' refers to the ability to plan and execute a series of tasks and to the ability to foresee the consequences of actions.
    • The dysexecutive syndrome encompasses several impairments including difficulties with planning, organizing, initiating, and monitoring behaviour and adapting it as circumstances change.
    • Any person who appears to have adequate skills to perform complex activities but who fails to organize the tasks needed should be formally assessed.

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