Over 70% of patients experience post-stroke cognitive impairment (PSCI) but outpatient stroke clinics often lack a consistent cognitive assessment protocol for follow-ups. PSCI is frequently determined based on the subjective assessment of cognitive functioning by patients or caregivers. Our goal was to assess the practice of unstructured PSCI screening at our stroke clinic and test if a cognitive screening protocol would improve PSCI detection. 

We led a quality improvement project to identify the problem's root causes and introduce a feasible cognitive screening protocol. We performed a baseline chart review on 79 stroke patients seen at the clinic to assess documentation of discussion of cognitive symptoms during visits. We developed a pre-screening survey to assess educational level, post-stroke rehabilitation participation, and vascular risk factors. We enrolled 30 follow-up patients with either an ischemic or hemorrhagic stroke. An examiner conducted a short-form MoCA (MoCA-sf) test and a CLCE-24 questionnaire for subjective cognitive complaints (SCC) on each patient. We collected discharge mRS and NIHSS scores from the electronic record.

In baseline chart review, 65% of 79 patients did not have any discussion of cognitive symptoms documented during their visit prior to our intervention. In our screening results, 53% of patients screened positive for cognitive impairment (<=12 MoCA-sf score). There was a moderately negative correlation between MoCA-sf scores and history of hypertension (-0.48, p 0.007) and hyperlipidemia (-0.38, p 0.044). There was no statistically significant correlation between subjective cognitive complaints (CLCE-24 score) and MoCA-sf scores (-0.09, p 0.626) or between MoCA-sf and discharge NIHSS (-0.26, p 0.251) and mRS (-0.29, p 0.207) scores.

Relying on patient-initiated discussions, subjective cognitive complaints, or discharge status may lead to missed PSCI diagnoses. High PSCI prevalence in follow-up patients highlights the need for objective screening, like MoCA-sf, in stroke clinics, especially for those with hypertension and hyperlipidemia.