Date Presented 3/30/2017
A literature review found the incidence of cognitive impairment in those with high-level SCI to be 70%–77% from brain injury and other comorbidities. These impairments are often overlooked. Cognitive screening is essential for appropriate care, but there is a shortage of appropriate assessments.
Primary Author and Speaker: Susan Doyle
Additional Authors and Speakers: Tatiana Kaminsky
Contributing Authors: Michael DeWilde, Jon-Erik Golob, Olivia Allen
PURPOSE: A systematic literature review was undertaken to answer two questions. The first considered the correlation between high-level (C1–C7) acute spinal cord injury (HLA–SCI) and cognitive impairment. The second asked which assessments are most effective for evaluating cognition in adult clients who have very limited motor and/or verbal abilities, such as people with HLA–SCI.
BACKGROUND: Concomitant brain injury in persons with acute spinal cord injury (SCI) is often overlooked or undetected (Arzaga, Shaw, & Vasile, 2003). Frequently the assumption is made that persons, even with HLA–SCI, have intact cognition unless a major brain injury is noted or the person demonstrates difficulty functioning at the expected level later in the rehabilitation process (Arzaga et al., 2003). This may lead to undiagnosed cognitive impairments that could affect a client’s rehabilitation process and outcomes. Understanding when and how to assess cognition early in recovery is an important step for best practice and for fully meeting the rehabilitation needs of this population.
DESIGN AND METHOD: A systematic review of literature was conducted using key word searches of PubMed, ERIC, CINAHL, ProQuest, and the American Journal of Occupational Therapy. We included studies that examined the incidence of cognitive impairments in persons with an acute SCI. In addition, we searched for studies that addressed the psychometric characteristics of cognitive measures that could be used with this population. Articles were compiled and grouped by study design and rigor into a table to allow for analysis and comparison. Findings were synthesized and key implications were described for consumers, practitioners, and researchers.
RESULTS: Thirteen studies were identified that reported the incidence of cognitive impairment in persons with SCI. Incidence ranged from 60%–74% overall for people with SCI, with the highest rates (70%–77%) for those with HLA–SCI. Common impairments included decreased memory, attention, processing speed, visual spatial skills, and executive functioning. Identifying people with HLA–SCI with cognitive impairment was an issue. One study estimated that traumatic brain injury (TBI) was undiagnosed in more than 50% of individuals with HLA–SCI, with TBI more likely to be undiagnosed if the injury did not occur through a motor vehicle accident (Sharma, Bradbury, Mikulis, & Green, 2014). Other comorbidities, such as hypotension, reduced cardiac reserve, and sleep apnea, were also found to be correlated with impaired cognition. No specific assessments for cognitive impairment with this population were found in this search. Some assessments, such as the Preliminary Neuropsychological Battery and the Test of Nonverbal Intelligence, rely less on motor/verbal ability and may be useful with clients with HLA–SCI. However, research has not been conducted on the validity and reliability of these tools with this population.
CONCLUSION: Undiagnosed cognitive impairments can result in negative consequences and missed opportunities for appropriate rehabilitation. Early identification of cognitive impairment may lead to improved client-centered care and outcomes for persons with HLA–SCI. Further research is needed to develop an evidence-based cognitive assessment appropriate for this population that can be administered by occupational therapy practitioners.
IMPACT STATEMENT: Occupational therapists should screen high-risk persons with HLA–SCI early for cognitive impairments, including referring to neuropsychology and/or speech–language pathology for further assessment. If clients’ cognitive status can be ascertained soon after HLA–SCI, care can be focused accordingly, potentially leading to improved outcomes.
References
Arzaga, D., Shaw, V., & Vasile, A. T. (2003). Dual diagnoses: The person with a spinal cord injury and a concomitant brain injury. SCI Nursing, 20, 86–92.
Sharma, B., Bradbury, C., Mikulis, D., & Green, R. (2014). Missed diagnosis of traumatic brain injury in patients with traumatic spinal cord injury. Journal of Rehabilitation Medicine, 46, 370–373. https://doi.org/10.2340/16501977-1261
