Checklist for cognitive and emotional consequences following stroke (CLCE-24): Development, usability and quality of the self-report version

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Abstract

Objective

In this paper a new checklist (CLCE-24) for identification of cognitive and emotional problems after stroke is presented. The CLCE-24 is intended to support a clinical interview by health care professionals other than the trained (neuro)psychologist.

Methods

Patients were interviewed with the CLCE-24, 6 months post stroke. Usability was determined by interviews. Quality of the self-report version was determined using reference instruments (MMSE, CAMCOG).

Results

Sixty-nine patients participated in the study (37 men; mean age 66 years). Both patients and assessors were positive about the use of the CLCE-24. Eighty percent of the patients had cognitive and/or emotional problems (73% cognitive; 51% emotional problems). Patients with complaints on the CLCE-24 also showed problems on the MMSE and the CAMCOG (p < 0.05). The CLCE-24 was a predictor of the MMSE and CAMCOG (Adj. R2 = 0.13 and 0.16, respectively) at 12 months post stroke. Internal consistency of the CLCE-24 was good (alpha of 0.81).

Conclusions

The CLCE-24 is a usable and valid instrument for cognitive screening by health care professionals in the stroke service in the chronic phase after stroke.

Introduction

The last two decennia it has become increasingly clear that the non-physical (i.e. cognitive and emotional) consequences following stroke are not some rare or exotic phenomenon affecting only a few survivors. Quite the reverse is true: the study of Tatemichi et al. [1] revealed that 78% of 227 stroke patients were left with cognitive problems. Others found that more than 50% of the patients suffered from mental slowness, whereas 20–40% of the stroke patients had memory, visuospatial and constructional, language, and arithmetic problems [2]. Aben et al. [3] studied post stroke depression and found a cumulative 1 year incidence of major and minor depression of 38% in a group of 190 first ever stroke patients.

Cognitive and emotional dysfunction will result in considerable functional problems and may hinder the outcome of rehabilitation even up to 4 or 6 years after stroke [1], [4], [5]. Because of this huge negative impact on daily life, it is essential to assess stroke patients for these less visible problems. During rehabilitation, attention is given to factors hindering functioning in daily life, and assessment of cognitive and emotional functioning is often standard procedure. Assessment of cognitive and emotional deficits should also be performed in the chronic phase after stroke when patients are discharged from rehabilitation and return home. Earlier assessment is less relevant in the acute phase due to the dramatic changes in functioning in the first few weeks after stroke [6], [7]. Identifying psychological problems in the chronic phase mostly needs to be conducted by healthcare professionals, such as the general practitioner, community nurse or physiotherapist. In many instances there is no neurologist or neuropsyhcologist involved in this stage. Suitable instruments for identification of subtle cognitive or emotional disturbances after stroke are however not available. Moreover, general practitioners, community nurses or physiotherapists often have a lack of knowledge about how to assess these psychological consequences. It has been shown earlier that general practitioners for instance have problems identifying cognitive problems associated with dementia [8]. The purpose of the present study therefore was to develop a checklist for identifying cognitive and emotional consequences in the chronic phase after stroke, which can be used by professionals other than the trained psychologist or neurologist. The new checklist is explicitely not intended to diagnose the presence and severity of cognitive and emotional impairments, which can ideally be done by neuropsychological testing; rather, it is intended to be a first step in the assessment process most probably leading to referral to a neuropsychologist or neurologist for further, more detailed assessment of the underlying pathology. In this paper the development and aspects of the quality of the new instrument are described.

Section snippets

Patients

The present study was part of the CODAS study (cognitive disorders after stroke).

Patients recruited for the CODAS study were asked to participate in the present study. The CODAS project was a prospective, longitudinal, observational study in which 196 consecutive stroke patients with a first cerebral stroke admitted to the University Hospital Maastricht, were followed neuropsychologically at 1, 6, 12, and 24 months after stroke, investigating the course of cognitive functioning and risk factors

Patients

In total 69 patients were included in the period between April 2001 and January 2002. The characteristics of the patients are shown in Table 1.

The scores of the patients on the reference instruments (MMSE and CAMCOG) at 1, 6 and 12 months post stroke are shown in Table 2.

Usability of the CLCE-24

On average it took 11.1 min (S.D. 4.5; range 5–35 min) to interview the patient using the CLCE-24. Seventy-eight percent of the interviews was done in less than 10 min. The assessors asked the patients their opinion about the

Conclusions

Examining a group of 69 patients, the usability and initial aspects of the validity of a new checklist (CLCE-24) for psychological problems after stroke were determined. The CLCE-24 is suitable for clinical practice, because the instrument was easy to use and could be used to screen the psychological problems from a patients’ perspective adequately.

The CLCE-24 was developed on the basis of a set of criteria, of which the following were met: short and simple, focussing on the problems of the

Acknowledgements

This study was funded by the Netherlands Brain Foundation and the Adriana van Rinsum-Ponsen foundation.

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