Stroke's Impact: Understanding Cognitive Function Changes

A stroke can affect the way your brain understands, organises and stores information, which is also known as cognition. This can lead to cognitive problems, which are very common after a stroke. Cognitive impairment is the second most common cause of dementia, and about a third of stroke patients develop dementia within a year of their stroke. Cognitive problems are usually worst during the first few months after a stroke, but they can and often do get better. Treatments for cognitive problems focus on ways to cope with the problems, rather than 'fix' them.

Problems with planning and problem-solving (executive function)

A stroke can affect your executive function, which is your ability to plan and problem-solve. If your executive function is affected by a stroke, you may experience difficulties in the following areas:

• Working out how to perform certain tasks: This could range from simple tasks like changing the TV channel to more complex tasks like cooking a meal.
• Planning the steps needed to complete a task: You may struggle to think of all the necessary steps to perform a task, such as making a cup of tea, or to put them in the correct order.
• Initiating or completing a task independently: You may need prompting or reminders to start or finish a task, such as getting dressed.
• Solving problems without assistance: You may find it challenging to determine what to do when something unexpected happens or goes wrong.
• Multitasking: Switching between tasks or remembering where you left off may be difficult.

These difficulties can impact various aspects of your life, including daily activities, work, and social interactions. However, it's important to note that these problems can be improved through practice and rehabilitation. Occupational therapists, clinical psychologists, or clinical neuropsychologists can provide support and help you develop strategies to cope with these challenges.

• Practice: Focus on mastering one task at a time, gradually moving from simpler tasks like making a sandwich to more complex ones like cooking a meal.
• Routine and prompts: Develop a daily or weekly routine to help structure your activities. Use prompts and reminders, such as written instructions, checklists, or notes around the house, to guide you through tasks.
• Break tasks into smaller steps: Simplify tasks by breaking them down into smaller, manageable steps.
• Talk through tasks: Discuss tasks with someone before attempting them to better understand the steps involved.
• Anticipate potential issues: Consider what could go wrong during a task and plan how you would handle those situations.

Problems with memory and thinking

A stroke can affect the way your brain understands, organises and stores information. This is also known as cognition. Different parts of your brain work together to produce cognitive skills like thinking and memory. If one of those parts of your brain is damaged by a stroke, this can lead to cognitive problems.

There are different types of cognitive problems which can affect people in different ways. When you’re in hospital, you should be assessed to find out if you have any cognitive problems. However, some cognitive problems are not easy to identify, and some might only be noticeable after you return home. You should be assessed again at regular intervals after you leave the hospital.

Diagnosing Cognitive Problems After a Stroke

It’s likely that you’ll need to complete a cognitive assessment. This will tell you more about the problems you’re having and why they’re happening. The assessment is usually done by a doctor, occupational therapist or sometimes a psychologist. It involves a lot of questions, which can make you feel like you’re taking an exam, even though you are not. The results of the assessment will help your stroke team decide the best way to help you. The findings should be explained to you.

Types of Cognitive Problems After Stroke

There are several different types of cognitive problems.

• Problems with planning and problem-solving (executive function)
• Problems noticing things on one side (spatial neglect)
• Problems moving or controlling your body (apraxia)
• Controlling movement and finding your way around (visual perception)
• Confusion and denial (anosognosia)
• Problems recognising things (agnosia)

Having cognitive problems does not mean that you have dementia. Many people worry about this, but dementia gets worse over time, whereas cognitive problems after a stroke often get better.

Treatments for Cognitive Problems After Stroke

Cognitive problems are usually worst during the first few months after a stroke, but they can and do get better. Problems are likely to improve most quickly over the first three months, as this is when your brain is at its most active, trying to repair itself. It’s still possible for problems to improve after this, but you may find that it takes longer. Recovery can continue at a slower pace for months or years.

Treatments for cognitive problems focus on ways to cope with the problems, rather than ‘fix’ them. An occupational therapist can assess you and help you learn coping strategies. This may involve using aids to help you manage, such as writing in a diary or using labels and reminders. Or it may involve learning other techniques that can help you.

If your problems are quite specific or severe, you may be referred to a clinical neuropsychologist or clinical psychologist. These healthcare professionals specialise in the way the brain works.

If you think you may be experiencing some of the problems described, the first thing to do is to speak to your GP. They will check if there is anything else that could be causing the problems, such as an infection or side effects of medication.

Depression, anxiety and sleep problems are common after a stroke, and can make you perform less well on cognitive tasks. So if you feel depressed, anxious, or have difficulty sleeping, then let your GP or occupational therapist know.

It’s easy for people, including doctors, to forget that there are effects of stroke you cannot see. So do not wait to be asked about them. If you’re finding it hard, tell someone. Make it clear how your problems are affecting you and ask what support you can get.

Do not be too hard on yourself. Having cognitive problems after a stroke is not something you can control. Be patient with yourself. You’re not stupid, even though you may feel that way. Allow yourself more time to get things done and do not expect too much of yourself. Brain injury is a serious condition that needs diagnosis and rehabilitation, in the same way you need rehabilitation after another type of physical injury, like a broken leg.

Being as active as you can may help with cognitive problems. It can also help with emotional problems like low mood and anxiety. If you can, try to aim for aerobic exercise that gets your heart beating and makes you slightly out of breath. This could be a sport like swimming or running, or you can try gardening or brisk walking.

Fatigue is very common after a stroke. It can make it even harder to concentrate or remember things. Plan your day so that you balance being busy with taking breaks and resting. You’re not going to be able to take life at the same pace as you did before, at least not to begin with. Take breaks when you need to and make sure you get good quality sleep at night. It will help you to focus if you do.

Cognitive problems can take a long time to improve. If you go back to work too soon, you could find it more difficult than if you went back a little later. An occupational therapist can give you advice about the best time to go back to work. They can also talk to your employer about how they can support you when you do.

Look into aids and equipment that you may find helpful, especially for problems with memory. Your occupational therapist will be able to suggest some to you.

Your mind needs to rest just as much as your body. Even small things like going for a short walk, listening to music or having a quiet moment to yourself in another room can help to calm your mind. Some people find mindfulness or meditation really helpful. Relaxing can be difficult if you have a busy home life, but it’s important to find a way to rest your mind when you get tired or frustrated.

Tell people about your cognitive problems. They are nothing to be embarrassed about. Explaining how someone can help will make it easier for you both. This might include speaking slowly or writing things down. It will also stop them from getting offended if you forget something or get distracted.

Cognitive problems can affect your confidence and how you feel about yourself. Talking about it can really help. Many people find support groups useful, because you can talk about problems with people who are going through the same thing. If you prefer not to join a group, try talking to a friend or family member who you feel comfortable with.

Problems moving or controlling your body (apraxia)

Apraxia is a cognitive disorder that can occur after a stroke, causing difficulty in carrying out everyday activities. It is not due to muscle weakness or sensory loss but is instead a loss or disturbance of the ability to organise actions to achieve a goal.

Apraxia is a weakening of the top-down formulation of an action—the inability to sustain the intent to complete a movement. As a result, the nervous system is easily influenced by irrelevant input—a sort of pathologic absent-mindedness.

Apraxia is common in patients with left hemispheric strokes, especially in lesions involving the left frontal and parietal lobes. It can be spontaneous during everyday activities (difficulty with dressing, using utensils, starting the car, turning keys to open doors). In can cause difficulty when performing motor tasks and becomes evident when the patient is asked to do something and appears unable to initiate or complete the task.

There are two forms of apraxia: ideomotor and ideational. Ideomotor apraxia can affect the patient by hindering their ability to select, sequence and use objects and it is thought to affect people more in test situations than in normal activities of daily living. Patients with ideational apraxia are unable to perform a skilled activity because they have lost the conceptual ability to organise the actions required to achieve their goal. For example, they may attempt to put clothes on the wrong part of their body.

There is a lack of research investigating apraxia in acute stroke, as well as its resolution longitudinally. However, the following interventions have been used to treat apraxia:

• Strategy training in daily living activities: teaching internal or external compensatory strategies that enable a functional task to be completed.
• Sensory stimulation: stimulations including deep pressure, sharp and soft touch are applied to the patients' limbs.
• Proprioceptive stimulation: the patient leans on and puts weight through their upper and lower limbs.
• Cueing, verbal or physical prompts: given to enable each stage of the task to be completed.
• Chaining (forward or backward): the task is broken down into its component parts. Using backward chaining, the task is completed with facilitation from the therapist apart from the final component, which the patient carries out unaided.
• Normal movement approaches: the therapist facilitates the body through normal movement patterns.

Problems with communication

A stroke can affect the way your brain understands, organises and stores information, which in turn affects your memory and thinking. This is also known as cognition. Different parts of your brain work together to produce cognitive skills like thinking and memory. If one of those parts of your brain is damaged by a stroke, this can lead to cognitive problems.

Communication problems are very common after a stroke. A stroke often alters communication, with its location influencing what will be affected. In addition to communication problems like aphasia, a condition affecting the ability to understand or process language, communication deficits may include decreased attention, distractibility and the inability to inhibit inappropriate behaviour. Problem-solving ability is sometimes affected, typically in survivors of right-brain strokes.

Diagnosing Cognitive Problems

When you’re in hospital, you should be assessed to find out if you have any cognitive problems. However, some cognitive problems are not easy to identify, and some might only be noticeable after you return home. You should be assessed again at regular intervals after you leave hospital.

Cognitive Assessments

It’s likely that you’ll need to complete a cognitive assessment. This will tell you more about the problems you’re having and why they’re happening. The assessment is usually done by a doctor, occupational therapist or sometimes a psychologist. It involves a lot of questions, which can make you feel like you’re taking an exam, even though you are not. The results of the assessment will help your stroke team decide the best way to help you. The findings should be explained to you.

Types of Cognitive Problems

There are several different types of cognitive problems.

• Problems with planning and problem-solving (executive function)
• Problems noticing things on one side (spatial neglect)
• Problems moving or controlling your body (apraxia)
• Controlling movement and finding your way around (visual perception)
• Confusion and denial (anosognosia)
• Problems recognising things (agnosia)

Treatments for Cognitive Problems

Treatments for cognitive problems focus on ways to cope with the problems, rather than ‘fix’ them. An occupational therapist can assess you and help you learn coping strategies. This may involve using aids to help you manage, such as writing in a diary or using labels and reminders. Or it may involve learning other techniques that can help you.

If your problems are quite specific or severe, you may be referred to a clinical neuropsychologist or clinical psychologist. These healthcare professionals specialise in the way the brain works.

• If you think you may be experiencing some of the problems described, the first thing to do is to speak to your GP.
• Depression, anxiety and sleep problems are common after stroke, and can make you perform less well on cognitive tasks. So if you feel depressed, anxious, or have difficulty sleeping, then let your GP or occupational therapist know.
• It’s easy for people, including doctors, to forget that there are effects of stroke you cannot see. So do not wait to be asked about them. If you’re finding it hard, tell someone. Make it clear how your problems are affecting you and ask what support you can get.
• Allow yourself more time to get things done and do not expect too much of yourself.
• Being as active as you can may help with cognitive problems. It can also help with emotional problems like low mood and anxiety.
• Fatigue is very common after a stroke. It can make it even harder to concentrate or remember things. Plan your day so that you balance being busy with taking breaks and resting.
• Cognitive problems can take a long time to improve. If you go back to work too soon, you could find it more difficult than if you went back a little later. An occupational therapist can give you advice about the best time to go back to work.
• There are aids and equipment that you may find helpful, especially for problems with memory. Your occupational therapist will be able to suggest some to you.
• Your mind needs to rest just as much as your body. Even small things like going for a short walk, listening to music or having a quiet moment to yourself in another room can help to calm your mind.
• Cognitive problems are nothing to be embarrassed about. Tell people about them. Explaining how someone can help will make it easier for you both. This might include speaking slowly or writing things down.
• Talking about cognitive problems can really help. Many people find support groups useful, because you can talk about problems with people who are going through the same thing.

Problems with attention

The human brain supports cognitive and integrative processes underlying complex systems, such as attention, working memory, cognitive control, and language. A stroke can interfere with any or all of these functions.

The exact frequency of attentional deficits after a stroke is a matter of debate. Within the acute phase, estimates range between 46% and 92%. At discharge from the hospital, estimates suggest a prevalence of between 24% and 51%.

Speed of information processing can also be impaired, with estimates varying between 50% and 70%. Attentional deficits may recover over time in some people, but in 20% to 50% of stroke survivors, there are persistent deficits for years.

Attentional impairments manifest themselves in a wide variety of deficits, such as:

• Diminished concentration
• Distractibility
• Reduced error control
• Difficulties doing more than one thing at a time
• Mental slowness
• Mental fatigability

Being a mediator of other processes, attentional deficits may also impair higher cognitive functions, such as language and memory.

The rehabilitation of deficits in spatial attention is covered separately from general attention.

Types of attention

There is no agreement on the typologies and taxonomies describing the range of attentional processes. For the purpose of this answer, the following attentional components are considered:

• Alertness/arousal: the ability and readiness to respond
• Selective attention: the ability to focus on a specific stimulus while ignoring irrelevant stimuli
• Sustained attention (vigilance): the ability to maintain attention over a prolonged period of time
• Divided attention: the ability to multitask and to divide attention between two or more tasks

A distinction between different attention domains is potentially important when evaluating rehabilitation. There is some evidence that attentional components need to be trained separately, as there is little generalisation of treatment from one attentional domain to another. Moreover, it has been suggested that cognitive training for certain domains, such as divided and selective attention, may be more effective than training for other domains, such as alertness and sustained attention.

Treatment

The treatment of cognitive deficits is necessary because they have a negative effect on functional abilities and quality of life. Sustained attention (concentration) is an important prerequisite for motor recovery, since sufficient sustained attention is required for learning. Deficits in attention can affect the ability to engage with physiotherapy and are associated with an increased risk of falls.

Cognitive rehabilitation involves providing therapeutic activities to reduce the severity of a cognitive deficit. This includes tasks designed to restore attention abilities, such as computerised activities and pencil-and-paper tasks requiring attention. The alternative approach is teaching people strategies to compensate for their attention impairments.

The effectiveness of cognitive rehabilitation remains unconfirmed. The results suggest there may be a short-term effect on attentional abilities, but future studies need to assess the persisting effects and measure attentional skills in daily life.

Factors influencing attention deficits

Side of the lesion

Patients with a right hemispheric lesion (RHL) were more impaired than patients with a left hemispheric lesion (LHL), especially in tonic and phasic alertness.

Site of the lesion

Patients with total anterior infarcts (TACI) presented the worst profile compared to other stroke subtypes, with a difference between total and lacunar subtypes in the Alertness test, independent of the presence of warning.

Time from stroke

Patients in the chronic phase had shorter RTs than acute patients only in the Alertness test.

Concomitant neuropsychological deficits

In patients with LHL, the presence of aphasia was associated with a greater deficit in selective attention. In patients with RHL, the presence of unilateral neglect was associated with impaired alertness and selective attention.

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