Prognostic rules for predicting cognitive syndromes following stroke: A systematic review

Abstract

Purpose Stroke survivors are at high risk of developing cognitive syndromes, such as delirium and dementia. Accurate prediction of future cognitive outcomes may aid timely diagnosis, intervention planning, and stratification in clinical trials. We aimed to identify, describe and appraise existing multivariable prognostic rules for prediction of post-stroke cognitive status. Method We systematically searched four electronic databases from inception to November 2019 for publications describing a method to estimate individual probability of developing a cognitive syndrome following stroke. We extracted data from selected studies using a pre-specified proforma and applied the Prediction model Risk Of Bias Assessment Tool (PROBAST) for critical appraisal. Findings Of 17,390 titles, we included 10 studies (3143 participants), presenting the development of 11 prognostic rules – 7 for post-stroke cognitive impairment and 4 for delirium. Most commonly incorporated predictors were: demographics, imaging findings, stroke type and symptom severity. Among studies assessing predictive discrimination, the area under the receiver operating characteristic (AUROC) in apparent validation ranged from 0.80 to 0.91. The overall risk of bias for each study was high. Only one prognostic rule had been externally validated. Discussion/conclusion: Research into the prognosis of cognitive outcomes following stroke is an expanding field, still at its early stages. Recommending use of specific prognostic rules is limited by the high risk of bias in all identified studies, and lack of supporting evidence from external validation. To ensure the quality of future research, investigators should adhere to current, endorsed best practice guidelines for conduct of prediction model studies.

European Stroke Organisation and European Academy of Neurology joint guidelines on post‐stroke cognitive impairment

“…Our literature review was based on a recent systematic review [150] and found seven prognostic tools [151][152][153][154][155][156][157] that had been applied in an acute stroke population and were designed to predict a variety of future cognitive outcomes. Eligible studies were from Europe and Asia and included a variety of stroke types.…”

Informing Patients with Acute Stroke About their Risk of Dementia: A Survey of UK Healthcare Professionals

“… 22 Prognostic models, specific to the stroke population are being developed, however, international guidelines on post-stroke cognitive impairment recognise that there are currently no tools suitable for use in clinical practice. 7 , 27 Should a risk prediction tool be suitable for use in clinical practice, it is important that the ethics of discussing risk of dementia are carefully considered. A previous study explored the feasibility of using a prediction tool for dementia as part of follow-up care for people who have a stroke.…”

“…There are currently no robust prognostic tools that accurately predict which stroke patients are at risk of developing post-stroke dementia. 7 A qualitative study used semi-structured interviews to assess the acceptability to patients, carers, and clinicians of using dementia risk prediction tools as part of post-stroke follow-up care. 8 This study interviewed 15 stroke patients and their carers (at six and twelve months post-stroke) and 17 clinicians, in the North East of England.…”

“…Previous research has focused on predicting and preventing dementia following a stroke, yet no studies have explored whether it would be acceptable to discuss risk of dementia at the time of stroke. 1 , 7 , 22 Discussing risk of dementia at the time of stroke, while the patient is receiving medical help, may be an ideal time to educate patients about the symptoms of dementia, inform patients about how to modify lifestyle risk factors for dementia, and highlight the support that is available. However, informing people who have just had a stroke that they also have an increased risk of developing dementia, a condition that is not currently curable, may cause emotional distress and potentially, interfere with optimal cognitive and physical recovery.…”

Neurodegeneration Over 3 Years Following Ischaemic Stroke: Findings From the Cognition and Neocortical Volume After Stroke Study

“…However, stroke clinicians are now shifting their focus to improvements in rehabilitation and post-acute care (63)(64)(65)(66). Post-stroke cognitive impairment is identified as a key priority area for research and support by stroke survivors, but predictive models for individualised risk factors for cognitive decline are sorely needed (67). In other neurodegenerative diseases causing dementia, there is a strong association between brain atrophy and cognitive decline: neurodegeneration precedes and predicts the onset of cognitive impairment (68)(69)(70)(71).…”