Intraindividual variability in post-stroke cognition and its relationship with activities of daily living and social functioning: an ecological momentary assessment approach

ABSTRACT

Introduction

Ecological momentary assessment (EMA) is a methodological approach to studying intraindividual variation over time. This study aimed to use EMA to determine the variability of cognition in individuals with chronic stroke, identify the latent classes of cognitive variability, and examine any differences in daily activities, social functioning, and neuropsychological performance between these latent classes.

Methods

Participants (N = 202) with mild-to-moderate stroke and over 3-month post-stroke completed a study protocol, including smartphone-based EMA and two lab visits. Participants responded to five EMA surveys daily for 14 days to assess cognition. They completed patient-reported measures and neuropsychological assessments during lab visits. Using latent class analysis, we derived four indicators to quantify cognitive variability and identified latent classes among participants. We used ANOVA and Chi-square to test differences between these latent classes in daily activities, social functioning, and neuropsychological performance.

Results

The latent class analysis converged on a three-class model. The moderate and high variability classes demonstrated significantly greater problems in daily activities and social functioning than the low class. They had significantly higher proportions of participants with problems in daily activities and social functioning than the low class. Neuropsychological performance was not statistically different between the three classes, although a trend approaching statistically significant difference was observed in working memory and executive function domains.

Discussion

EMA could capture intraindividual cognitive variability in stroke survivors. It offers a new approach to understanding the impact and mechanism of post-stroke cognitive problems in daily life and identifying individuals benefiting from self-regulation interventions.

KEYWORDS:

• Stroke
• cognitive rehabilitation
• cognition
• cognitive variability
• ecological momentary assessment
• remote assessment
• mobile health

Disclosure statement

EGSM reported research support from the American Occupational Therapy Foundation outside the submitted work. EJL reported research support outside the submitted work from the National Institutes of Health (NIH), Patient-Centered Outcomes Research Institute, and Mercatus Center Emergent Ventures. He also received grant support (loaned equipment for research) from MagStim. He has served as a consultant for Boehringer Ingelheim, Prodeo, Pritikin, Merck, and IngenioRx. JML reported research support from the NIH and Barnes-Jewish Foundation outside the submitted work. He has also served as a consultant from Biogen and Regenera outside the submitted work. DCM reported research support from the NIH outside the submitted work. He has served as a consultant for Otsuka Pharmaceuticals, Optum Behavioral Health, Centerstone Research Institute, and OneMind Foundation. He also receives royalties from Oxford Press and has an ownership interest in Adaptive Health. CLM reported research subcontracts from NIH and VA Headache Centers of Excellence. He has an ownership interest in Infinite Arms. AWKW reported research support from the NIH, National Institute on Disability, Independence, and Rehabilitation Research, and Craig H. Neilsen Foundation outside the submitted work. No other disclosures were reported.

Authors’ contributions

EGSM, EJL, JML, DCM, MWMF, CLM, and AWKW contributed to the study conception and design. Material preparation, data management, and analysis were performed by EGSM, QB, KJK, SET, BAR, VP, and AWKW. The first draft of the manuscript was written by EGSM, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Availability of data and material

The datasets generated during and analyzed during the current study are not publicly available.

Consent to participate

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Online informed consent was obtained from all individual participants for being included in the study.

Consent for publication

We confirm that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere.

Ethics approval

This study was reviewed and approved by the Institutional Review Board at Washington University and Northwestern University

List of Abbreviations

ADL	=	Activities of daily living
ANOVA	=	Analysis of variance
CV	=	Cognitive variability
EMA	=	Ecological momentary assessment
LCA	=	Latent class analysis
LMR	=	Lo-Mendell-Rubin test
mRS	=	Modified Rankin Scale
NeuroQoL	=	Quality of Life in Neurological Disorders
NIHSS	=	National Institutes of Health Stroke Scale
PROMIS	=	Patient-Reported Outcome Measurement Information System
RMSSD	=	Root mean square of successive differences
VLMR	=	Vuong-Lo-Mendell-Rubin test

Additional information

Funding

This study was funded by the National Center for Medical Rehabilitation Research (grant number: K01HD095388) and the Center for Smart Use of Technologies to Assess Real-world Outcomes (C-STAR; grant number: P2CHD101899).