Award Title: Improving the post-stroke cognitive care pathway
Funder: Department of Health and Social Care

Abstract: BACKGROUNDThere is a clear need to improve continuity of care post-stroke, particularly for psychological consequences. Post Stroke Cognitive Impairment (PSCI) is highly prevalent and complex. The prognosis of cognitive recovery or decline remains unclear. Managing cognitive changes post stroke is the most frequently reported unmet need with no support pathway in place. Better diagnosis and monitoring is key to targeting interventions and undertaking high quality research of interventions to improve outcomes for stroke survivors. AIMS & OBJECTIVESThe aims of the fellowship are	to predict the likelihood of PSCI at 6-months and long-term post stroke from acute Oxford Cognitive Screen (OCS) 	to describe the experience and unmet needs of living with cognitive changes post stroke, 	to use this information to co-design a cognitive care pathway for stroke including clinician training, a cognitive trajectory guide based on acute OCS, enhanced discharge summaries and 3 points of follow up once home. 	to test the feasibility of the cognitive care pathway intervention.METHODSFirst, a risk prediction model using acute OCS scores will be evaluated. The key initial outcome will be presence of PSCI at 6-months. The model will be developed in OX-CHROINIC cohort data and validated in independent harmonized Individual Patient Data from 3 longitudinal studies from across the UK.Second, qualitative interviews will provide in-depth insight into the patient and carer perspective. This, together with the prediction model will inform the cognitive pathway development. A group of 6 (patients, carers, clinicians, service stakeholders) will follow an iterative, implementation-based co-design approach to develop the pathway and constituting pragmatic elements: (i) training for clinicians, (ii) a cognition trajectory guide, (iii) enhanced transfer of information to primary care and (iv) the cognition reviews once home (1-,3-,6-month) as the core intervention. Finally, two different stroke services will implement the proposed care pathway to determine feasibility and acceptability. Both service-level and patient-level outcome data will be collected pre and post intervention to inform a potential stepped wedge trial design. TIMELINES Year1: Risk prediction model1 + harmonising data + semi structured interviews on PSCI experiences and needsYear2: Continued Interviews + validation of risk prediction in independent harmonised cohortYear3: Working groups iterative co-design of care pathway elementsYear4+5: Feasibility study in 2 different stroke services Anticipated impact and disseminationThe immediate impact for clinical practice lies in delivering an improved post-stroke cognitive pathway including an OCS-based cognitive trajectory guide for discussion. The implementation-based co-design approach will include early conversations with the Integrated Stroke Delivery Networks to ensure it is aligned to the ongoing developments in stroke services. A definitive trial will determine the benefits of the cognitive pathway with additional check-in support for those discharged home with cognitive problems. This would ultimately result in a changed national approach to cognitive care post stroke. There will be multiple routes to dissemination of the research (e.g. publication, conferences, press, training, videos) to academics, clinicians, patients and carers, the stroke community and wider public.

Lay Abstract: AIMS:1. Improved understanding of changes in peoples' thinking abilities after stroke.2. Improved understanding of peoples' needs and wishes for dealing with their changes in thinking after stroke.3. Design a roadmap which outlines support for people whose thinking is affected by stroke.4. Prepare for a large study to test whether the new roadmap is helpful and practical.BACKGROUNDFor a long time, research and therapy for people affected by stroke have focussed on obvious changes like arm or leg strength and speech. However, more subtle changes of stroke can have a major impact. Commonly after a stroke, people have changes in specific thinking abilities (cognition) related to damage in the brain. These may include difficulties with understanding, reading, writing, remembering, spatial awareness and planning activities. Stroke care aims to repair damaged areas of the brain as soon as possible. However, hospitals focus on urgent medical treatment and must follow this with relatively short amounts of therapy before sending people home. As a result, many stroke patients feel abandoned after hospital because stroke is actually a long-term condition. Instead of being the same as before a stroke, people must adjust to a new life with variable types of brain damage.Sometimes peoples' thinking abilities recover well but for others, changes remain or become worse.The Oxford Cognitive Screen (OCS) was made to quickly test for changes in different aspects of thinking commonly affected by stroke. What is less clear is how this information can help stroke patients understand their condition and clinical teams make decisions about the kind of support people require, both whilst in hospital, and long-term for life after stroke.METHODS (*visual summary in Figure 1)	I will combine studies that have assessed (over longer periods) thinking abilities of large groups of people who have had strokes. I will use this to establish whether OCS cognitive profiles can help to give stroke survivors some idea of their futures. 	I will interview stroke survivors and their families or friends about: 	 	 		 What it means to live with post-stroke cognitive changes? 	 	 	 	 		Whether and how they want to know about future predictions? 	 	 	 	 		What their wants and needs are for long-term support? 	 	 	With a group of stroke survivors, carers and clinicians, we will develop simple tools to discuss changes in thinking, what extra follow up reviews should be like and how information is passed on to GPs. 	I will test the new pathway in 2 different places in the UK to find out if this approach could work and if there any downsides. I also want to know what the most important things are to measure for a larger studyPEOPLE WITH LIVED EXPERIENCEThis research proposal has been developed with people from the Stroke Voices in Research panel from the Stroke Association. Stroke survivors and their close family have suggested key aspects and reviewed materials. More stroke survivors will be involved in the research itself, in the pathway development, in reviewing study materials, in management of the research and in making the results known.MAKING THE FINDINGS KNOWNTo make findings from this research known, I will:	Write academic papers as well as plain language news articles. 	Support the people who were involved to talk about their experience and the findings of this research. 	Present our findings to people who have had strokes, the wider public, clinicians and academics. 	Work closely with the Stroke Association news teams.This plain language summary has been produced in partnership with Bloo Anderson (stroke survivor)

Research Activity Codes: 7.1 INDIVIDUAL CARE NEEDS
Health Categories: STROKE