Vascular cognitive impairment is a spectrum of cognitive deficits due to many forms of vascular disease, including overt strokes. Problems with attention, memory and executive functions (e.g., monitoring, planning, and organization) occur in 32-73% of stroke survivors and have been shown to interfere with physical recovery, independence in activities of daily living, community re-integration, and overall quality of life after stroke. In order to reduce the impact of cognitive impairment on the life of a stroke survivor, it is essential to target interventions towards improving meaningful activities. It has been shown that almost 50% of individuals at 6 months post-stroke have one or more limitations in activities that require cognitive integration such as household management, shopping, meal planning, banking, and using the telephone. Fortunately, our knowledge of how to intervene effectively for persons with cognitive impairments is expanding. Evidence from studies in stroke and traumatic brain injury suggest that either training of compensatory strategies and/or cognitive skill-based training to cope with cognitive deficits can be effective in the long term. The time-intensive nature of such cognitive rehabilitation poses considerable challenges to the patient, family and health care system, however, because of the growing trend for reduced length of hospital stays, centralization of resources for stroke survivors in urban areas, and the need for specialized training in cognitive rehabilitation for health care providers. Thus, a new approach is needed to address the problem of lack of access to cognitive rehabilitation after stroke.
The purpose of the proposed study is to provide pilot data to inform a future multi-centred randomized trial to improve cognitive performance in daily activities after stroke (also called functional cognition1). In the proposed pilot study, two interventions to achieve SMART goals (i) learning cognitive compensatory strategies using a telephone-based approach and (ii) a computerized specific cognitive -skill training intervention based on controlled attention and executive function skill training will be tested for feasibility and effect against each other and against a group receiving no specialized intervention. Here, SMART refers to goals that are Specific, Measurable, Achievable, and Realistic within a defined Time period; SMARTease indicates that the intervention will be delivered in format that stroke patients and family will find easy to access and to follow.
The aims of the proposed pilot study are to: 1) Estimate recruitment, retention, protocol adherence rates and effect sizes for both interventions; 2) Provide initial supportive data for our hypotheses that the general compensatory strategy learning intervention will have a greater impact on cognitive performance and on increasing satisfaction with goal performance and function than the more specific cognitive skill training approach, while the skill training approach will have more impact on impairment-based measures. In addition, both approaches will be better than no intervention; 3) Refine the therapeutic and measurement approach; and 4) Identify personal, stroke-related, functional, and environmental variables that alter the effect of the interventions.
The pilot study will take place in Halifax and in Montreal and the findings will be used to design a multicentred trial with the power to provide robust evidence of efficacy. The goal of this research is to develop a telehealth cognitive rehabilitation program for people with post-stroke cognitive impairment, focused on promoting functional independence, successful community re-integration, and quality of life for stroke survivors and their families. The development of an easily accessible, evidence-based intervention for post-stroke cognitive impairment has the potential to change the paradigm of stroke rehabilitation services by making them more widely available outside of the traditional face-to-face tertiary care clinical setting. The ultimate goal of this research program is to develop an evidence-based telerehabilitation approach for the full spectrum of vascular cognitive impairment, regardless of an individual’s proximity to a primary health care setting.