Stroke, Behavior, and Cognition - UK HealthCare CECentral - Han_FMR stroke talk 2016.pdf · •...
Transcript of 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
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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
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• 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
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• 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
Vascular Cognitive Impairment
An Equal Opportunity UniversityWorld J Psychiatry. 2016 Jun 22; 6(2): 199–207.
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 Cognitive Impairment
An Equal Opportunity UniversityWorld J Psychiatry. 2016 Jun 22; 6(2): 199–207.
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
Vascular Cognitive Impairment
An Equal Opportunity UniversityStroke 2006;37;2220-2241
Vascular Cognitive Impairment
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.
Vascular Cognitive Impairment
An Equal Opportunity UniversityStroke 2006;37;2220-2241
• 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
An Equal Opportunity UniversityStroke 2006;37;2220-2241
NINDS & CSN creates a workshop comprised
of the following groups:
• Clinical/Epidemiology
• Neuropsychology
• Imaging
• Neuropathology
• Experimental Models
• Biomarkers
• Genetics
• Clinical Trials
Vascular Cognitive Impairment
An Equal Opportunity UniversityStroke 2006;37;2220-2241
• 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)
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Utility of VCI Neuropsychological Screen
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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
Utility of VCI Neuropsychological Screen
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Provide the stroke team with an efficient but thorough screen of the patient’s current cognitive capacity by domain:
• Memory
STM < LTM: Today’s breakfast < Childhood memories
Verbal memory: names, stories, conversations, etc.
Visual memory: locations, item descriptions, faces, etc.
Utility of VCI Neuropsychological Screen
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Provide the stroke team with an efficient but thorough screen of the patient’s current cognitive capacity by domain:
• Attention/focus/concentration• Executive function/problem solving• Processing speed
Important for assessing capacity for:‐work‐driving‐managing finances‐important life decisions, etc.
Utility of VCI Neuropsychological Screen
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Utility of VCI Neuropsychological Screen
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Provide the stroke team with an efficient but thorough screen of the patient’s current cognitive capacity by domain:
• 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
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https://www.youtube.com/watch?v=gocIUW3E-go
AnatomyLeft (or dominant) posterior inferior frontal gyrusVascularMiddle cerebral artery superficial division
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https://www.youtube.com/watch?v=b_sHZRoXs6A
AnatomyLeft (or dominant) occipital region plus splenium of corpus callosumVascularPosterior cerebral artery callosal branches
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https://www.youtube.com/watch?v=LWAUmsgk8eg
AnatomyLeft (or dominant) arcuate fasciculusVascularMiddle cerebral artery
Utility of VCI Neuropsychological Screen
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Provide the stroke team with an efficient but thorough screen of the patient’s current cognitive capacity by domain:
• Visuospatial
Poor interpretation of visual inputPoor directionsReach deficitsSense of space impaired
At times, Cortical Blindness (Anton’s)
Utility of VCI Neuropsychological Screen
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Provide the stroke team with an efficient but thorough screen of the patient’s current cognitive capacity by domain:
• Mood (clinical depression in 1/3 of stroke patients)
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Post‐stroke Affect
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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
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• 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
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• 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.
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Test examples
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Utility of VCI Neuropsychological Screen
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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.
Utility of VCI Neuropsychological Screen
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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
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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
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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
Outpatient Neuropsych appt.
(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
End Patient In System PCP
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
Impact on Outcomes/Performance (CHECK/STUDY)
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
Impact on Outcomes/Performance (CHECK/STUDY)
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.
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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
WAIS-III Coding 85 16 Low Average
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
WAIS-III Coding 85 16 Low Average
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
160Performance in Standard Scores (Mean = 100 SD = 15)
Cognitive Domains
‐ Neurocognitive Performance by Domain ‐
TIME 1
TIME 2
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
160Performance in Standard Scores (Mean = 100 SD = 15)
Cognitive Domains
‐ Neurocognitive Performance by Domain ‐
TIME 1
TIME 2
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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
160Performance in Standard Scores (Mean = 100 SD = 15)
Cognitive Domains
‐ Neurocognitive Performance by Domain ‐
TIME 1
TIME 2
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
160Performance in Standard Scores (Mean = 100 SD = 15)
Cognitive Domains
‐ Neurocognitive Performance by Domain ‐
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
‐ Neurocognitive Performance by Domain ‐
TIME 1
TIME 2
TIME 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.”
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
TIME 2
TIME 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.”
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
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
160Performance in Standard
Scores (Mean = 100 SD = 15)
Cognitive Domains
‐ Neurocognitive Performance by Domain ‐
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
160Performance in Standard
Scores (Mean = 100 SD = 15)
Cognitive Domains
‐ Neurocognitive Performance by Domain ‐
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 .
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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
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NINDS‐CSN VCI Protocol Bottom Line
• Incorporation of international standards: care model
• Streamlining and increased coverage of neuropsychological evaluation
• Increased contribution to stroke treatment planning
• Facilitation of appropriate referrals
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• 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
NINDS‐CSN VCI Protocol Bottom Line
Pt Discharged from Inpatient
Care
Outpatient Neurology FU
Scheduled
Outpatient Neurology FU (6-12 weeks)
Outpatient Neuropsych appt.
Scheduled
Neuropsych Assessment
Outpatient Neuropsych appt.
(3-6 months)
Results and Interpretation
(2+ weeks)
Schedule Follow-up with Physician
(additional weeks)
Referral to Neuropsych?
End Patient In System PCP
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
End Patient In System PCP
w/ sig increased pt & prov
satisfaction
Preliminary Results and Interpretation
(e.g. 1:45 pm)
Refer for further NP evaluation if
necessary
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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
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