stroke, behavior, and cognition - uk healthcare cecentral - han_fmr stroke talk 2016.pdf · •...

11/2/2016

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An Equal Opportunity University

Stroke, Behavior, and Cognition

Dong (Dan) Y. Han, PsyD

Chief, UK Neuropsychology Service – Clinical Section

Associate Professor of Neurology, Neurosurgery,

and Physical Medicine & Rehabilitation

University of Kentucky College of Medicine


Financial Relationship Disclosure:

None

Objectives:

1. Review updates in stroke.2. Identify details involving Vascular Cognitive Impairments. 3. Discuss the data regarding the clinical utility of evaluating

cognition.

AHA 2016 Stroke Quick Review


• Prevalence: 795,000/yr in US; 3 in 4 = 1st stroke.

• Occurs every 40 seconds; every 4 minutes someone dies of stroke.

• The fifth leading cause of death, killing 130,000/yr (1/20 deaths).

• Women > men in stroke prevalence, partly due to living longer.

• AA are most impacted by stroke than any other racial group.

American Heart Association (2016). Heart disease and stroke statistics-2016 update. Circulation, 133(4): 447-454.

AHA 2016 Stroke Quick Review


• Stroke in US children are 6.4 per 100,000 children (0 to 15 years) per year, w/ half being hemorrhagic strokes.

• 87% of strokes are ischemic.

• Leading cause of long term disability/leading preventable cause of disability in US.

• Cost: $73.7 billion in 2010 for stroke‐related medical costs and disability. Costs to treat stroke may increase from $71.55 billion in 2010 to $183.13 billion by 2030.

American Heart Association (2016). Heart disease and stroke statistics-2016 update. Circulation, 133(4): 447-454.

Vascular Cognitive Impairment

An Equal Opportunity UniversityWorld J Psychiatry. 2016 Jun 22; 6(2): 199–207.

Brain at risk

cardiovascular risk factors with/without imaging features of subclinical brain insult

no obvious cognitive impairment in ADL

cardiovascular risk factors, e.g., hypertension, WM hyperintensity on MRI,

cognitive functioning remains WNL following cognitive assessment



VCI, no dementia

Impairment in at least one cognitive domain without affectation of ADL in a patient with cardiovascular risk factors

neuroimaging features of subclinical brain insult

follows the brain at risk but with cognitive impairment

cognitive impairment not severe enough to affect ADLs

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Vascular dementia

Impairment in two or more areas of cognitive domain

severe enough to impair ADL

presence of cardiovascular risk factors

neuroimaging findings of cerebral insults (WM hyperintensities)

Mixed neurodegenerative/vascular dementia

Presence of a neurodegenerative dementia, e.g, ADwith superimposed VD


An Equal Opportunity UniversityStroke 2006;37;2220-2241



• Vascular Cognitive Impairment (VCI) = cognitive impairment caused by or associated with vascular factors.

• 64% of stroke victims have cognitive impairment.

• 1/3 of stroke victims develop frank dementia.



• Postmortem studies show 34% of dementia cases show significant vascular pathology.

• Dementia Dx criteria more sensitive for AD than VCI as VCI often can present without significant memory decline.

NINDS‐CSN


NINDS & CSN creates a workshop comprised

of the following groups:

• Clinical/Epidemiology

• Neuropsychology

• Imaging

• Neuropathology

• Experimental Models

• Biomarkers

• Genetics

• Clinical Trials



• Since VCI encompasses a large range of cog deficits, test batteries need to cover all neurocognitive domains.

• Primary emphasis of VCI detection is given to executive dysfunction.

• Three separate protocols created: 60’, 30’, & 5’ test batteries.

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Vascular Neuropsychology Screen

(modified 30’ NINDS‐CSN VCI Assessment Protocol):• Clinical assessment & interview• Wide Range Achievement Test – 4th Edition (WRAT‐4) Reading• Semantic Fluency (Animals) • Phonemic Fluency (FAS)• Hopkins Verbal Learning Test‐Revised (HVLT‐R)• Rey Osterrieth Complex Figure (ROCF) Copy subtest• Trail Making Tests (TMT) A and B• Wechsler Adult Intelligence Scale‐III (WAIS‐III) Digit Symbol‐Coding• Geriatric Depression Scale‐short form (GDS‐15) or Center for Epidemiological Studies‐Depression Scale (CESD)


Utility of VCI Neuropsychological Screen


Provide the stroke team with an efficient but thorough screen of the patient’s current cognitive capacity by domain:

• Memory• Attention/focus/concentration• Executive function/problem solving• Processing speed• Language• Visuospatial• Mood (major depression in 1/3 of stroke patients)• Each domain can be more thoroughly assessed beyond the screen




• Memory

STM < LTM: Today’s breakfast < Childhood memories

Verbal memory: names, stories, conversations, etc.

Visual memory: locations, item descriptions, faces, etc.




• Attention/focus/concentration• Executive function/problem solving• Processing speed

Important for assessing capacity for:‐work‐driving‐managing finances‐important life decisions, etc.






• Language

1M in US with:‐Wernicke’s aphasia (Comprehension difficulty w/ nonsensical output,

e.g., knife= gleeble, cooking when hospital shoes gleeble mo ay ni)‐Broca’s aphasia (Output difficulty)‐Global aphasia (Both difficult w/ poor reading and writing)

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https://www.youtube.com/watch?v=dKTdMV6cOZw

AnatomyLeft (or dominant) posterior section of the superior temporal gyrusVascularMiddle cerebral artery superficial division


https://www.youtube.com/watch?v=gocIUW3E-go

AnatomyLeft (or dominant) posterior inferior frontal gyrusVascularMiddle cerebral artery superficial division


https://www.youtube.com/watch?v=b_sHZRoXs6A

AnatomyLeft (or dominant) occipital region plus splenium of corpus callosumVascularPosterior cerebral artery callosal branches


https://www.youtube.com/watch?v=LWAUmsgk8eg

AnatomyLeft (or dominant) arcuate fasciculusVascularMiddle cerebral artery




• Visuospatial

Poor interpretation of visual inputPoor directionsReach deficitsSense of space impaired

At times, Cortical Blindness (Anton’s)




• Mood (clinical depression in 1/3 of stroke patients)

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Post‐stroke Affect


Hacket, et al., 2005Robinson, 2003

Morris et al., 1993

• 1/3 will experience clinical depression at some point following a stroke (by definition, beyond situationally appropriate).

• 19.3% and 18.5% of stroke survivors have major depression or minor depression, respectively.

• No significant difference of post‐stroke depression between hemorrhagic and ischemic strokes.

• Poor functional outcomes: recovery delayed by up to 2 years; reduced QoL & rehab efficacy; increased mortality.

Vascular Dementia


• Caused by a series of small strokes.

• Affects memory, thinking, language, judgment, and behavior:

Difficulty performing tasks that used to come easily, such as:

balancing a checkbook

playing games (such as bridge)

learning new information or routines

getting lost on familiar routes

trouble finding the name of familiar objects

losing interest in things you previously enjoyed

flat moodmisplacing itemsPersonality changes and loss of social skills

Vascular Dementia


• Third most common type of dementia

• As the dementia becomes worse, symptoms are more obvious and interfere with ADL’s:

Change in sleep patterns, often waking up at nightDifficulty doing basic tasks, such as preparing meals, choosing proper clothing, or drivingForgetting details about current eventsForgetting events in your own life historyHaving delusions, depression, or agitationHaving hallucinations, arguments, striking out, or violent behaviorHaving more difficulty reading or writingHaving poor judgment and loss of ability to recognize dangerUsing the wrong word, not pronouncing words correctly, or speaking in confusing sentencesWithdrawing from social contact

Any of the neurologic problems that occur with a stroke may also be present.


Test examples

An Equal Opportunity University An Equal Opportunity University

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• Track the patient’s cognitive and affective recovery over time.– Especially important in f/u care, rehab, and community reintegration.

– Assessment tools in the screen are evidence‐based.

• Assist in differential diagnosis, e.g., pre‐existing dementia.

• Provide input as a part of an interdisciplinary team.



Evidence‐based assessment of cognitive capacity related to:

• Medical decisional capacity/activate POA

• Driving

• Financial management

• Medication management

• Cooking

• Shopping

• Returning to work

• Level of required supervision

• Any other cognitively related ADL’s

Sample Data DisplayTEST DATA SET: TIME 1 (actual table from screen)Measure SS %ile Interpretation

WRAT-IV Reading 84 14 Low Average

Phonemic Fluency 75 5 Borderline Impairment

Semantic Fluency 88 21 Low Average

HVLT-R total 65 1.1 Mild Impairment

HVLT-R Delayed Memory <51 <0.1 Severe Impairment

HVLT-R Discriminability <51 <0.1 Severe Impairment

ROCF Copy 65 1.1 Mild Impairment

Trail Making Test A 82 12 Low Average

Trail Making Test B 83 13 Low Average

WAIS-III Coding 85 16 Low Average

CESD N/A N/A Unremarkable Mood

Sample: 55 yo RH AA F 12 yrs ed, w/ Hx of LBG hem after IP DC, tried to resume normal ADL’s including work and driving(left food on the burner; almost burned down the house)

Sample Data Display


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Sample Data Display

Recommendations:• Discontinue driving at least until V/S skills improve (repeat testing)• Discontinue autonomous financial & medication management• Discontinue cooking (memory decline: burner, oven)• Pt retired from work

Sample Data Display


TEST DATA SET: Time 1 & 2 (Hypothetical for illustration)Measure TIME 1

SSTIME 1 %ile

TIME 2 SS

TIME 2 %ile

WRAT-IV Reading 84 14 84 14

Phonemic Fluency 75 5 86 17

Semantic Fluency 88 21 90 26

HVLT-R total 65 1.1 87 19

HVLT-R Delayed Memory <51 <0.1 85 16

HVLT-R Discriminability <51 <0.1 85 16

ROCF Copy 65 1.1 92 29

Trail Making Test A 82 12 85 16

Trail Making Test B 83 13 84 14

WAIS-III Coding 85 16 85 16

Sample Data Display

An Equal Opportunity University An Equal Opportunity University

Ambulatory Care Innovation Grant (UWMF & PP)

Round 7: Multidisciplinary Stroke Clinic (MSC)

• Flow reduction

• MSC: months to hours

• Press‐Ganey

• “STAR performer” status post‐MSC: patient satisfaction

• Provider satisfaction

• Reversed Shared Medical Appointment (SMA) Concept

• Pilot study at the University of Wisconsin, Madison

VCI Neuropsychological Screen in Action

Multidisciplinary Stroke Clinic (MSC)

Change Leaders: Dong (Dan) Han, PsyD

Bruce Hermann, PhD

Jana Jones, PhD

Justin Sattin, MD

Amelia Anderson, PhD

Team Members: UWHC Department of Neurology

Stroke Service and Neuropsychology Service

Project Start Date: 9/09

Project Status: Finalized

Key Outcomes: Needs Assessment Completed

Structural Changes Implemented

Quality Improvement Data Collected and Analyzed

1 2 3 4 5

Project Aim/Goal and Measures

• The MSC will achieve improvement in

patient appointment wait time

• by decreasing

the wait gap between stroke neurology and neuropsychology outpatient appointments

• by 50+%

• within the first quarter of 2009-2010

• focusing on merging the follow up appointmentprocesses into one protocol, using the resources of the two services

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Pt Discharged from Inpatient

Care

Outpatient Neurology FU

Scheduled

Outpatient Neurology FU (6-12 weeks)

Outpatient Neuropsych appt.

Scheduled

Neuropsych Assessment


(3-6 months)

Results and Interpretation

(2+ weeks)

Schedule Follow-up with Physician

(additional weeks)

Referral to NP?

End Patient In System PCP

Y

Cognitive Data

Forwarded to Referring Physician

PRE‐MSCIMPLEMENTATION

4‐9 months after 1st F/U:

Total = 5‐10 months after IP Discharge

RICH DATA butBUSY & LONGfor stroke!

End Pt in System PCP

1 2 3 4 5Problem/Needs Assessment (PLAN)

Pt Sees Physician to Discuss Overall

Results

Pt Sees NP for Feedback

N

POST‐MSC IMPLEMENTATION

Only hours during 1st F/U:

Total = 1‐3 months after IP Discharge

(anticipated wait for post‐stroke recovery & F/U)

Pt Discharged from Inpatient Care

Schedule MSC Appt (for 6-12 weeks)

Pt Arrives for MSCNeuropsych Appt

(e.g. 1:00 pm)

Neurology FU Appt (e.g. 2:00 pm)

Cognitive Data incorporated

into FU and filed


Preliminary Results and Interpretation

(e.g. 1:45 pm)

Refer for further NP OP

evaluation if necessary

1 2 3 4 5

Changes Implemented (DO)

1 2 3 4 5

Impact on Outcomes/Performance (CHECK/STUDY)

Value Added Time = Use of wasted ‘in between tasks” time

1 2 3 4 5


Provider Satisfaction SurveyKey: lower # = negative; higher # = positive

2

4.5

0

1

2

3

4

5

Turn. of data return before MSC Turn. of data return after MSC

2.75

4.75

0

1

2

3

4

5

Effect. of scheduling before MSC Effect. of scheduling after MSC

44.25

4.5

4

4.75

0

1

2

3

4

5

Perceived levelof value topatients

Perceivedpatient

satisfaction

Providersatisfaction

Value added toclinic practice

Impact ofmultidiscp. onstroke service

1 2 3 4 5


Patient Satisfaction Survey (38% survey response rate)Key: lower # = negative; higher # = positive

4.874.44

4.67 4.81 4.75 4.75 4.854.43 4.62 4.80 4.69 4.79 4.67 4.69

4.944.54 4.69 4.69

0.00

1.00

2.00

3.00

4.00

5.00

1 2 3 4 5

Lessons Learned (ACT)

• Merging different services into one protocol increased:

– provider satisfaction

– value added time by 78.08% on average

• Merging different services into one protocol decreased:

– unnecessary wait time between appointments by 7.26 months on average, which equates to 78.32% improvement in time saved

• Merging different services into one protocol revealed high levels of patient and provider satisfaction.

11/2/2016

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Sample Data DisplayTEST DATA SET: TIME 1 (actual table from screen)

Measure SS %ile Interpretation

WRAT-IV Reading 93 32 Average

Phonemic Fluency 82 12 Low Average

Semantic Fluency 99 47 Average

HVLT-R total 97 42 Average

HVLT-R Delayed Memory 102 55 Average

HVLT-R Discriminability 115 84 High Average

Figure Construction 100 50 Average

Trail Making Test A <45 <0.1 Severely Impaired

Trail Making Test B 60 0.4 Moderate to Severely Impaired


CESD 19 NA Mild Depression

Sample 2: 58 yo RH M w/ 18 yrs ed w/ unremarkable Med Hx5/09 moderate L hemiparesis w/ facial droop & hemisensorydisturbance. MR: multifoc R hemispheric infarcts. 70% short segment stenosis in the RICA. Complains of fatigue but upon Sx resolution, reported “feeling 100% back” to baseline by DC 3 days later.

Sample Data DisplayTEST DATA SET: TIME 1 (actual table from screen)

Measure SS %ile Interpretation

WRAT-IV Reading 93 32 Average

Phonemic Fluency 82 12 Low Average

Semantic Fluency 99 47 Average

HVLT-R total 97 42 Average

HVLT-R Delayed Memory 102 55 Average

HVLT-R Discriminability 115 84 High Average

Figure Construction 100 50 Average

Trail Making Test A <45 <0.1 Severely Impaired

Trail Making Test B 60 0.4 Moderate to Severely Impaired


CESD 19 NA Mild Depression

Sample 2: 58 yo RH M w/ 18 yrs ed w/ unremarkable Med Hx5/09 moderate L hemiparesis w/ facial droop & hemisensorydisturbance. MR: multifoc R hemispheric infarcts. 70% short segment stenosis in the RICA. Complains of fatigue but upon Sx resolution, reported “feeling 100% back” to baseline by DC 3 days later.

Sample Data Display

40

55

70

85

100

115

130

145

160Performance in Standard Scores (Mean = 100 SD = 15)

Cognitive Domains

‐ Neurocognitive Performance by Domain ‐

TIME 1

Sample 2: “I feel fine. I need to get back to work, full time, immediately.” (70 hr work weeks on ave).

Recommendation: Discourage work and driving at least until f/u (repeat testing).

Sample Data DisplayTEST DATA SET: Time 1 & 2

Measure TIME 1SS

TIME 1 %ile

TIME 2 SS

TIME 2 %ile

WRAT-IV Reading 93 32 -- --

Phonemic Fluency 82 12 91 27

Semantic Fluency 99 47 118 88

HVLT-R total 97 42 97 42

HVLT-R Delayed Memory 102 55 93 32

HVLT-R Discriminability 115 84 115 84

Figure Construction 100 50 100 50

Trail Making Test A <45 <0.1 <45 <0.1

Trail Making Test B 60 0.4 53 0.1

WAIS-III Coding 85 16 95 37

Sample 2: 10 days after DC, Pt returns to ED w/ L hemiparesis while jogging 30’. MR: R posterior parietal hemorrhagic stroke. Now acknowledges some cognitive changes, mostly reduced proc speed.

Sample Data Display

Sample 2: “Maybe I’m not doing so hot, but can I still work?”

Recommendation: No work and driving at least until f/u (TIME 3 repeat testing).

40

55

70

85

100

115

130

145


Cognitive Domains


TIME 1

TIME 2

Sample Data Display



40

55

70

85

100

115

130

145


Cognitive Domains


TIME 1

TIME 2

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Sample Data Display



40

55

70

85

100

115

130

145


Cognitive Domains


TIME 1

TIME 2

Sample Data Display



40

55

70

85

100

115

130

145


Cognitive Domains


TIME 1

TIME 2

Sample Data DisplayTEST DATA SET: Time 1, 2, & 3

Sample 2: 7/09 R Carotid Endarterectomy. 11/09 MSC F/U.Took time off work since last ED visit and now reports feeling “90-95% back to baseline.”

Measure TIME 1 SS

TIME 1 %ile

TIME 2 SS

TIME 2 %ile

TIME 3 SS

TIME 3%ile

WRAT-IV Reading 93 32 -- -- -- --

Phonemic Fluency 82 12 91 27 91 27

Semantic Fluency 99 47 118 88 115 84

HVLT-R total 97 42 97 42 97 42

HVLT-R Delayed Memory

102 55 93 32 102 55

HVLT-R Discriminability

115 84 115 84 115 84

Figure Construction 100 50 100 50 100 50

Trail Making Test A <45 <0.1 <45 <0.1 91 27

Trail Making Test B 60 0.4 53 0.1 87 19

WAIS-III Coding 85 16 95 37 90 25

Sample Data Display

40

55

70

85

100

115

130

145

160Performance in Standard

Scores (Mean = 100 SD = 15)

Cognitive Domains


TIME 1

TIME 2

TIME 3


Sample Data Display

40

55

70

85

100

115

130

145



Cognitive Domains


TIME 1

TIME 2

TIME 3


Sample Data Display

40

55

70

85

100

115

130

145



Cognitive Domains


TIME 1

TIME 2

TIME 3

TAKE HOME MSG: Self-report, Collateral-report, & appearance of high functioning = can ALL be deceptive!!!

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Sample Data Display

40

55

70

85

100

115

130

145



Cognitive Domains


TIME 1

TIME 2

TIME 3

TAKE HOME MSG: Self-report, Collateral-report, & appearance of high functioning = can ALL be deceptive!!!Serial data = useful for appropriate treatment planning, triage, referral (PT, OT, Speech, PM&R, psych, etc.), & community reintegration .

Sample Data Display

40

55

70

85

100

115

130

145



Cognitive Domains


TIME 3

TAKE HOME MSG: Self-report, Collateral-report, & appearance of high functioning = can ALL be deceptive!!!Serial data = useful for appropriate treatment planning, triage, referral (PT, OT, Speech, PM&R, psych, etc.), & community reintegration .


NINDS‐CSN VCI Protocol Bottom Line

• A HOOK FOR THE TX TEAM TO HANG YOUR HAT ON! THE PROTOCOL ASSISTS TO VALIDATE CLINICAL JUDGMENT

OR (conversely)

• MAINTAIN SCIENTIFIC SKEPTICISM! THE PROTOCOL ASSISTS TO SHINE A LIGHT ON DECEPTIVE CLINICAL PRESENTATIONS



• Incorporation of international standards: care model

• Streamlining and increased coverage of neuropsychological evaluation

• Increased contribution to stroke treatment planning

• Facilitation of appropriate referrals


• Significantly decreased wait time for patients between services (by 4‐7 month)

• Serial data to track recovery over time

• Track functional outcomes beyond localization

• Care model, replicable to other services


Pt Discharged from Inpatient

Care

Outpatient Neurology FU

Scheduled

Outpatient Neurology FU (6-12 weeks)


Scheduled

Neuropsych Assessment


(3-6 months)

Results and Interpretation

(2+ weeks)

Schedule Follow-up with Physician

(additional weeks)

Referral to Neuropsych?


N

Y

Cognitive Data

Forwarded to Referring Physician

End Pt In System PCP

Pt Sees Physician to Discuss Overall

Results

Pt Sees NP for Feedback

NINDS‐CSN VCI Protocol Bottom Line: From This (14 values)

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NINDS‐CSN VCI Protocol Bottom Line: To This (8 values)

Pt Discharged from Inpatient Care

Schedule MSC Appt (6-12 weeks)

Pt Arrives for MSCNeuropsych Appt

(e.g. 1:00 pm)

Neurology FU Appt (e.g. 2:00 pm)

Cognitive Data incorporated into FU and

stored in HealthLink


w/ sig increased pt & prov

satisfaction

Preliminary Results and Interpretation

(e.g. 1:45 pm)

Refer for further NP evaluation if

necessary


Model (in modified form) utilized by:

UK Stroke ProgramUK TBI ServicesUK Movement Disorder ProgramUK ALS ProgramUK Memory Disorders ProgramUK Ped Hem-Oncology ServiceUK Transplant Program


stroke, behavior, and cognition - uk healthcare cecentral - han_fmr stroke talk 2016.pdf · •...

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