Regaining Cognitive Abilities Post-Stroke: A Comprehensive Guide

A stroke can affect the way your brain understands, organises and stores information, which is known as cognition. This can lead to a range of cognitive problems, including difficulties with memory, attention, planning, problem-solving, judgement, language and perception. The good news is that cognitive problems are usually worst during the first few months after a stroke and can get better. Treatments for cognitive problems focus on ways to cope with the issues, rather than 'fix' them. Here are some strategies to help with cognitive recovery after a stroke.

Memory loss and retrieval

• Stimulate your brain: Engage in games and activities that challenge your brain, such as checkers, chess, or brain-training apps. These activities help create new neural connections and improve memory and cognitive function.
• Speech and language therapy: Work with a speech-language therapist to improve your communication skills and stimulate your brain to form new neural connections. Include yourself in conversations with family and friends, as this can also aid in memory recovery.
• Create reminders and routines: Leave notes and reminders in visible areas to help you remember daily tasks and establish a routine. Use alarms, calendars, and planners to stay organized and form consistent habits.
• Make up mnemonic devices: Create creative ways to remember things, such as acronyms or rhymes that associate names with objects.
• Get organized: Keep the items you need for daily activities in easily accessible places. For example, lay out your clothes for the next day before going to bed and always keep your keys and phone in the same place.
• Repeat and rehearse: When given new information, repeat it to yourself several times to help it sink in. Don't be afraid to repeat information back in your own words to ensure you understand it correctly.
• Stay active: Engage in physical exercise, particularly aerobic exercise, which has been shown to improve memory, cognitive function, and overall stroke recovery.
• Eat a brain-healthy diet: Consume a diet rich in fresh fruits and vegetables, fish with omega-3 fatty acids, and plant-based foods. Avoid sweets, fried foods, butter, cheese, and red meat.
• Cognitive rehabilitation: Work with a therapist to repetitively practice tasks that enhance cognitive functions. This can include memory games, visual scanning practice, music-based therapies, or functional activity simulations.
• Use memory aids: Utilize notebooks, diaries, alarms, and notes around the house to help you remember important information and appointments.
• Rest and relax: Take regular rest breaks and plan your day to include downtime. Stress and fatigue can worsen cognitive difficulties.
• Pace yourself: Limit multitasking and slow down activities. Focus on completing one step at a time and take breaks in between tasks.
• Keep instructions simple: When receiving instructions or information, ask for clear and concise explanations. Break tasks down into smaller, more manageable steps.

Cognitive assessments

• Mini-Mental State Examination (MMSE): This is a widely used brief test that assesses orientation, registration, attention, calculation, recall, language, and visuospatial abilities. It has a total score of 30 points and is often used in combination with other assessments to detect cognitive impairment.
• Montreal Cognitive Assessment (MoCA): The MoCA evaluates similar cognitive domains as the MMSE, including orientation, registration, attention, concentration, recall, language, and visuospatial abilities. It has good sensitivity for detecting early stages of dementia and executive function impairments.
• Addenbrooke's Cognitive Examination Revised (ACE-R): The ACE-R is sensitive to dementia and includes additional assessments for anterograde and retrograde memory, letter fluency, category fluency, reading, and visuoperceptual abilities. It has a total score of 100 points.
• Trail Making Test (TMT) and Clock Drawing Test (CDT): These short tests specifically evaluate attention and executive functions, which are often affected after a stroke.
• Rey Osterrieth Figure Copy: This test assesses construction praxis, which is the ability to draw and copy shapes and figures.
• Phonological and Semantic Fluency Token Test: This language test evaluates an individual's ability to generate words based on specific criteria, such as starting with a particular letter or belonging to a specific category.
• Frontal Assessment Battery (FAB): The FAB is a quick and easy battery test used to identify frontal temporal lobe dysfunction, which can impact a range of cognitive functions.

These assessments help healthcare professionals understand the specific cognitive challenges faced by stroke survivors and tailor rehabilitation programs accordingly. The assessments can also be used to track progress and improvements over time, providing valuable insights into the effectiveness of different treatment approaches.

Brain-boosting diet and exercise

Diet

A brain-healthy diet is one that includes a lot of fresh fruits and vegetables, legumes, whole grains, and fish rich in omega-3 fatty acids.

• Green, leafy vegetables like kale, spinach, collards, and broccoli are rich in brain-healthy nutrients like vitamin K, lutein, folate, and beta carotene.
• Fatty fish such as salmon, cod, canned light tuna, and pollack are excellent sources of omega-3 fatty acids, which are essential for learning and memory.
• Berries like strawberries, blueberries, and blackberries are packed with flavonoids—natural plant pigments that help improve memory and delay cognitive decline.
• Coffee and tea — The caffeine in these beverages can improve alertness and sharpen concentration. Coffee and tea also contain antioxidants that protect against oxidative stress and inflammation, which contribute to brain aging and neurodegenerative diseases.
• Walnuts are a type of nut that improves cognitive test scores. They are rich in omega-3 fatty acids and have been linked to lower blood pressure and cleaner arteries, which are good for both the heart and brain.
• Turmeric is a deep-yellow spice with antioxidant and anti-inflammatory properties. Its active ingredient, curcumin, may help improve memory and clear amyloid plaques associated with Alzheimer's disease.
• Pumpkin seeds are rich in antioxidants and various micronutrients such as zinc, magnesium, copper, and iron, which are all important for brain health.
• Dark chocolate with 70% or greater cocoa content contains flavonoids, caffeine, and antioxidants, which may enhance memory and slow age-related mental decline.
• Nuts are a great source of healthy fats, antioxidants, and vitamin E, which protect cells from oxidative stress.
• Citrus fruits like oranges are high in vitamin C, which helps to protect the brain from damage caused by free radicals.
• Eggs are a good source of B vitamins and choline, which are important for regulating mood and promoting brain function and development.
• Green tea contains caffeine, L-theanine, polyphenols, and antioxidants, which may boost brain function, improve alertness, protect the brain from mental decline, and reduce the risk of neurodegenerative diseases.

Exercise

Being active and engaging in regular exercise can help with cognitive problems after a stroke. Aim for aerobic exercise that gets your heart beating and makes you slightly out of breath, such as swimming, running, gardening, or brisk walking.

Remember to plan your day to balance activity with rest, as fatigue is common after a stroke. Getting good quality sleep at night will also help you stay focused and improve your cognitive function.

Medication and supplements

While medication cannot reverse memory loss after a stroke, certain drugs can help improve cognitive recovery. Doctors may recommend a combination of pharmacological and non-pharmacological strategies to aid in cognitive recovery. Some of the pharmacological approaches that may be prescribed include:

• Cognitive stimulants: These drugs are intended to boost cognitive recovery and enhance brain functions.
• Blood pressure-lowering medications: Managing hypertension has been linked to minimising cognitive decline, so these medications can be beneficial.
• Cholinesterase inhibitors: Medications like donepezil, rivastigmine, and galantamine have been studied primarily for their effects on vascular dementia, but they may have potential for treating post-stroke cognitive impairments as well.
• N-methyl-D-aspartate (NMDA) receptor antagonist memantine: Similar to cholinesterase inhibitors, this drug has been studied mostly in the context of vascular dementia.
• Citicoline, nimodipine, Ginkgo biloba, and long-chain omega-3 polyunsaturated fatty acids (O-3-FAs): These supplements may offer benefits for cognitive recovery, but more research is needed to confirm their effectiveness.

It is important to consult with doctors for more personalised information and to determine the best course of treatment for cognitive recovery after a stroke.

Compensatory techniques

• Internal self-management strategies: These strategies are taught to facilitate more efficient cognitive processing during task performance. Examples include self-talk during task completion, paraphrasing instructions, and using mental imagery or "chunking" information according to categorical relationships to aid memory.
• External strategies or environmental modification: This involves the use of physical systems to compensate for cognitive load and guide goal-directed behavior. Examples include using a diary, calendar, or checklist to support memory and organization, or using signs, alarms, or text messages to prompt goal-directed behavior.
• Errorless learning: This technique is used to compensate for learning deficits where there is difficulty distinguishing between correct performances and mistakes, even after feedback. It involves preventing the individual from experiencing errors while learning a specific task, so that only correct responses are allowed.

• Using a diary, day planner, calendar, or notepad to write down appointments and create to-do lists.
• Using photos and pictures to help trigger memory.
• Setting alarms, reminders, and memos on mobile phones to prompt throughout the day.
• Breaking down tasks into smaller, manageable steps.
• Keeping instructions clear and short.
• Using mnemonic devices: creative ways to remember things, such as acronyms or rhymes.
• Repeating and rehearsing new information to help retain it.
• Staying active and exercising to improve memory and cognitive function.
• Following a brain-healthy diet, such as the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, which includes lots of fresh fruits, vegetables, and fish rich in omega-3 fatty acids.

Frequently asked questions