SUBJECT:

NEUROPSYCHOLOGY

TITLE:
MEASURING COGNITIVE IMPAIRMENT AFTER STROKE USING OCS IN
PATIENTS VERSUS HEALTHY CONTROL A MINI CRITICAL REVIEW WITH CASE
STUDY.

LECTURER:
DR PONNUSAMY SUBRAMANIAM.

PREPARED BY:
SAIDATUL SARIYAH BINTI SANAWAN (P108543)
MASTER CLINICAL PSYCHOLOGY
SEM 2, 2020/2021
 MEASURING COGNITIVE IMPAIRMENT AFTER USING OXFORD COGNITIVE
SCREENING IN PATIENT VERSUS HEALTHY CONTROL.

ABSTRACT

Stoke is considered to be one of the most non-communicable diseases that cause death in
Malaysia. The present study compared the OCS with the MMSE and MoCA with regards to their
ability to detect cognitive impairments post-stroke. In this study, 2 stroke patients and 3 healthy
control people that fit the inclusion criteria were randomized to receive the OCS, MoCA, MMSE
and BDI assessment. The relationship between the OCS, MoCA, MMSE and BDI were also
explored.Result showed that OCS interpret a client's profile specifically compared to MMSE and
MoCa that use overall marks to give impression for stroke patients. It is concluded that OCS is a
sensitive screen tool for cognitive deficits after stroke. In particular, the OCS detects high
incidences of stroke-specific cognitive impairments, not detected by the MMSE, demonstrating
the importance of cognitive profiling.

INTRODUCTION

Stroke has emerged as a public concern health issue in Malaysia. Stroke is one of the top
leading causes of death and one of the top 10 causes for hospitalization in Malaysia. Stroke is
also in the top five diseases with the greatest burden of disease, based on disability-adjusted life
years. However, prospective studies on stroke in Malaysia are limited. To date, neither the
prevalence of stroke nor its incidence nationally has been recorded. Hypertension is the major
risk factor for stroke. The mean age of stroke patients in Malaysia is between 54·5 and 62·6
years (Loo & Gan, 2012).

Study done by Ganasegaran et al., (2020), the top five Malaysian states with high search
flux volumes of ‘stroke’ were Kelantan ,Perlis Terengganu,, Negeri Sembilan and Pahang and
the top five Malaysian cities or towns with high search flux volumes were Kota Bharu , Batu
Pahat ,Ampang Jaya , Kuala Terengganu and Sungai Petani.
 Empirical study done by Hwong et al., (2021) on revealed that in Malaysia, there has
been an alarming increase in the incidence of stroke among the younger population below 65
years old, with the largest increase in men aged between 35–39 years and in women of similar
age group. The trend for 28-day all-cause mortality showed a decline for men at –13.1% and
women, –10.6%. Women had higher mortality from stroke than men. Despite a downward trend,
death rates, particularly among women, remained somewhat high. Stroke prevention and
management must be strengthened through comprehensive initiatives.

The Montreal Cognitive Assessment (MoCA) is a quick and easy to use assessment tool.
MoCA is a one-page, 30-point test that takes about 10 minutes to complete. MoCA is a
pencil-paper test that assesses nine cognitive abilities while limiting the language and
grapho-motor impact: visuospatial abilities (clock-drawing task and cube copy), executive
functioning (simplified alternating trail making, phonemic fluency), and visual-spatial abilities
(clock-drawing task and cube copy) (Demeyere et al., 2019).

Cognitive impairment emerging after stroke is an increasingly recognized factor for

long-term disability. The prevalence of cognitive impairment varies across studies, depending on
assessment methods, definitions, or sample characteristics. Frequently, screening instruments
like the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCa)
are applied even though they seem unsuitable to identify subtle or specific cognitive deficits
(Demeyere et al., 2019)

The Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment
(MoCA) are widely used to assess cognition post-stroke although these instruments have low
sensitivity for evaluating the most commonly affected cognitive domains after stroke, such as
executive function and processing speed. The MoCA and MMSE are both reliable assessments
for the diagnosis of cognitive impairment after stroke (Shen, 2016). However, It is also important
to highlight the shortcomings of MoCA originally designed for dementia in populations with
stroke (Mancuso et al., 2018).

Moreover, poststroke cognitive impairment is usually accompanied by additional

cognitive deficits. Considering this context, Demeyere et al. developed The Oxford Cognitive
Screen (OCS) which is a screening tool for the assessment of poststroke deficits in attention,
memory, praxis, language, and number processing (Shendyapina et al., 2019).The OCS allows
detailed screening of the cognitive deficits after stroke, through the separate assessment of
number cognition, praxis, executive functions, memory, language and attention.

The Oxford Cognitive Screen (OCS) is a quick cognitive test designed for stroke patients
that can be completed in 15-20 minutes. The exam is aphasia- and neglect-friendly, and it covers
cognitive domains where deficits are common after stroke, such as apraxia and unilateral neglect,
as well as memory, language, executive function, and number abilities (Demeyere, 2015).

The instrument can be used at the bedside and just requires one hand to use. Another
benefit of the tool is that it produces a summary of the cognitive profile, which may be used to
help health-care providers, patients, and caregivers communicate results more effectively. The
OCS's content validity was demonstrated in the initial British validation research, and the test
had a high reliability and validity (Demeyere et al., 2015).

According to Mansuco et al., (2018) it may have a greater potential to be informative on

stroke cognitive deficits of widely used instruments, such as the Mini-Mental State Examination
(MMSE) or the Montreal Cognitive Assessment, which were originally devised for demented
patients.

The Oxford Cognitive Screen is a tool that has been designed specifically for this purpose
and therefore overcomes many of the limitations of the dementia screening tools described
above. However, OCS needs to be used with caution due to its availability of resources such as
video tutorial training and more thorough test materials (Milosevich, Pendlebury & Demeyere,
2019).
MINI CRITICAL REVIEW & STUDY

Method

The patients and healthy controls were prospectively recruited at the Department of
Physiotherapy at the Hospital Canselor Tunku Mukhriz, HUKM Kuala Lumpur . Stroke patients
coming to the unit in the relevant period were considered for inclusion, and all patients who were
considered relevant were invited in person to participate .

Inclusion criteria comprised that patients were an adults aged between 18 to 90 years old,
occurance of stroke as confirmed by CT or MRI, having first stroke in the past 12 week or 4
months, able to concentrate and engage for at least 30 minutes as determined by healthcare in the
hospital, literate and able to complete at least the orientation task and able to five informed
consent themselves. Meanwhile, the exclusion criteria comprised that the premorbid history of
neurological, neurocognitive, or psychiatric conditions, transient ischemic attack (TIA) patients,
unable to follow verbal commands, have pre - existing severe visual impairments unrelated to
stroke, and uncorrectable vision and those stroke patients who are severely ill (e.g. immobile,
cannot appreciate verbal commands.)

Healthy controls that came to the unit as a caregiver were considered for inclusions and
invited to participate in the study. The inclusion criteria included that the adults aged between
18-90 years old and had no history of neurological and psychiatric disorders, literate, no signs of
cognitive impairments as determined by MMSE (>26).

The exclusion criteria comprised that having current or past history of neurological or
psychiatric conditions, unable to complete session due to uncorrectable hearing and vision or
physical limitations

In this study, 2 stroke patients and 3 healthy control people that fit the inclusion criteria
were randomized to receive the OCS, MoCA, MMSE and BDI assessment. The relationship
between the OCS, MoCA, MMSE and BDI were also explored.
RESULTS

Participants Characteristics MMSE MoCA OCS BDI

P1 Male/63 27 19 Impairment at 8
right visual
attention

P2 Male/- 20 16 Impairment in all 50

cognitive domain
except for
perception

H1 Male/37 26 24 Mild impairment 10

in reading and
calculation
domain

H2 Male/57 29 23 No impairment in 10
all domains

H3 Female/60 28 26 No impairment in 15
all domains

DISCUSSION

Neuropsychological assessment reveals that deficits in executive functioning, attention,

mental processing speed, visual perception, and construction ability in stroke patients. Cognitive
impairment in chronic stroke patients occurs frequently and persistently within the first year after
stroke. In addition to screening measures, it is critical to perform a more full neuropsychological
assessment to detect cognitive abnormalities and their interactions with depression
symptoms.(Nakling et al., 2017).
Despite doing neuropsychological assessment, self-rating instruments such as the BDI are
useful in screening depression in patients with stroke and their caregivers. The BDI needs no
psychiatric professionals or specially trained personnel and is satisfactory in its sensitivity. Little
attention has been paid to the emotional impact and despair of stroke survivors' carers (Berg et
al., 2009).
OCS ADVANTAGES
As we can see here, cognitive assessments are usually short form tests created for dementia that
produce pass/fail ratings (e.g. the MoCA). For stroke survivors, the Oxford Cognitive Screen
(OCS) provides a domain-specific cognitive profile (Demeyere et al., 2015).

Study done by Demeyere et al., (2015), revealed that Acute cognitive impairment was common:
76 percent of patients had a low MoCA score, and 86 percent had a low score on at least one of
the OCS cognitive categories. Overall, OCS was more sensitive than MoCA (87%) and provided
domain-specific information on common post-stroke cognitive deficits (neglect, apraxia, and
reading/writing ability).

Moreover, study done by Chan et al., (2014), suggest that, while the MoCA may be a useful
screening tool for detecting gross impairments following a stroke, neuropsychological evaluation
is still required for a comprehensive and reliable detection of domain-specific cognitive deficits,
which can better inform us for realistic goal setting and vocational advice, both of which are
critical for effective rehabilitation.

The OCS instruments were already translated into several languages available which includes
English, Danish, Italian, Chinese, Mandarin, Polish and Spanish (Oxford University Innovation,
n.d.). The OSC scale was created in order to measure commonly occurring problems after stroke
and minimize confounding with aphasia and neglect (Ramos et al., 2018).

CONCLUSION
To conclude, it is important to accurately detect cognitive impairments in stroke patients.
OCS was appropriate for use as a cognitive screening tool for post stroke patients in Malaysia.
Based on this study, the results revealed that these patients on the evaluation of sub-items of the
OCS compared to the MoCA and there is also evidence of greater sensitivity of the MoCA over
the MMSE. Future research could review the five-dimension domains to further improve the
validity and internal consistency of the instruments as the OCS instrument would be more useful
for informing the management of patients with acute severe stroke who will require extensive
rehabilitation (Sodring, 1998).
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