OptiCogs: The development of a multicomponent intervention to rehabilitate people post-stroke with cognitive impairment

Background

Stroke is among the leading causes of death and disability worldwide. Cognitive impairment is common post-stroke and is associated with a lower quality of life, higher rates of mortality, institutionalisation and increased healthcare costs. Despite the prevalence and associated burden of cognitive impairment for people post-stroke, there is uncertainty regarding the optimal rehabilitative approach to improve cognitive unction for people post-stroke.

Aim

This thesis aimed to identify and develop the evidence-base for an intervention to rehabilitate cognitive impairment in people post-stroke.

Methods

This research, situated within the development stage of Medical Research Council guidance for developing complex interventions, adopted a mixed-methods approach. Firstly, a systematic review and meta-analysis of 64 randomised controlled trials was completed to evaluate the totality of evidence across a breadth of rehabilitation interventions for people with cognitive impairment post-stroke. Secondly, a qualitative descriptive study design was used to examine perspectives among people with stroke, healthcare professionals and carers with regard to the optimal design and delivery of a cognitive rehabilitation intervention post-stroke. Having established both quantitative and qualitative underpinnings to intervention development, stakeholders in stroke rehabilitation were engaged to give insights into the development and refinement of the intervention. An intervention development panel of healthcare professionals and people post-stroke was formed to guide the development of OptiCogs; a complex, multicomponent intervention to rehabilitate cognitive impairment for people post-stroke. Finally, a single-arm feasibility study was conducted to evaluate the feasibility, acceptability and safety of the developed intervention.

Results 

The systematic review and meta-analysis identified that multicomponent interventions which combined cognitive training in conjunction with physical activity yielded favourable outcomes in improving cognitive function in people post-stroke. Findings from the qualitative study demonstrated that interventions with meaningful goals and a familiar context were key to engagement in cognitive rehabilitation post-stroke. The qualitative results also emphasised the point of readiness to intervene with cognitive intervention post-stroke, in particular the importance of an initial adjustment period in the acute phase wherein people post-stroke find it difficult to engage in cognitive rehabilitation interventions. Qualitative results also demonstrated that healthcare professionals were vital to intervention delivery, with the occupational therapist reported as the most suitable healthcare professional to lead intervention delivery. Finally, findings from the feasibility study suggested that OptiCogs, a six-week multicomponent intervention, delivered online, is feasible to implement, is acceptable to people post-stroke and is a safe intervention. While further modifications to OptiCogs are needed and a pilot trial needs to be conducted, preliminary findings suggest improvements in cognitive function, quality of life, fatigue, physical function and occupational performance for people post-stroke.

Conclusion

Overall, this thesis showed that, although modifications are required prior to a larger scale evaluation of the intervention, OptiCogs is feasible to implement, and may prove beneficial at improving outcomes important to people post-stroke. Future research priorities for OptiCogs include the continued engagement of stakeholders in the research process, assessment of intervention fidelity and the conduct of a process evaluation. The findings from this thesis provide implications for clinical practice, as well as future research opportunities to further develop OptiCogs and improve the rehabilitation of people post-stroke with cognitive impairment.