Assessment tools for attention deficits in patients with stroke: a scoping review across components and recovery phases

Study design, sample size, age, and phase of stroke

The study designs included observational studies 80% (28 out of 35 articles) and RCTs 20% (seven out of 35 articles). The total sample size was 2,987 participants, ranging 12–606 participants per study. The age range was 40.0 ± 7.7 to 83.6 ± 9.7 years. Regarding the stroke phase, 14.3% (five out of 35 articles), 22.9% (8 out of 35 articles), and 40% (14 out of 35 articles) included the acute phase (<1 month), the subacute and chronic phase (>6 months), respectively, with time frames ranging from 8.3 days to 8.5 years. Of the other eight studies, seven and one studies did not state the time after onset and were in the subacute to chronic phase, respectively.

Assessments

Studies were charted using 24 assessment tools (Table 3), including the TMT Part A (40%, 14 out of 35 articles), TEA (11.4%, four out of 35 articles), Integrated Visual Auditory (IVA)-CPT, d2 Test of Attention, PASAT, TAP (5.7%, two out of 35 articles), and others (62.9%, 22 out of 35 articles).

Components of attention functions

Table 4 and Fig. 2 show the attention assessments by component and exhibit the percentages of the assessment components, respectively.

Focused attention assessments included the following six tools: the d2 Test of Attention (5.7%), TAP (5.7%), Clinical Assessment for Attention (CAT, 2.9%), Color Trail Test Part A, Conner’s Continuous Performance Test (CCPT, 2.9%), and Wechsler Adult Intelligence Scale (WAIS) Digit Symbol Subtest (2.9%).

Sustained attention assessments comprised 10 tools: TEA (11.4%), d2 Test of Attention (5.7%), Attentive Matrices (2.9%), CAT, CCPT (2.9%), Conner’s CPT (2.9%), Digit Vigilance Test (DVT, 2.9%), Psychomotor Vigilance Task (2.9%), Computerized DVT (2.9%), and WAIS Digit Symbol Subtest (2.9%).

Selective attention assessments encompassed 10 tools: TMT Part A (40%), TEA (11.4%), d2 Test of Attention (5.7%), TAP (5.7%), Attentive Matrices (2.9%), CAT (2.9%), Color Trail Test Part A (2.9%), Digit Span (2.9%), Spatial Span (2.9%), and Visual Cancelation Task (VCT, 2.9%).

Divided attention assessments included six tools: TEA (11.4%), TAP (5.7%), CAT (2.9%), Color Trail Test Part B (2.9%), Divided Attention Test (2.9%), and Hierarchical Visual Processing (2.9%).

Spatial attention assessment included only one tool which was, CAT (2.9%).

Auditory attention assessments comprised five tools (14.3%): IVA + Plus, IVA-CPT, PASAT, Verbal Series Attention Test, and TEA.

Visual attention assessments included four tools: IVT + Plus, IVT-CPT, Partial and Whole Report TVA Paradigm, and neuropsychological tests. The most used assessment for visual and auditory attention was the IVA-CPT and PASAT (5.7 and 8.6%, respectively).

Stroke phase specific attention assessments

Table 5 exhibits the assessments according to the phase of stroke. The assessments used regardless of stage were TMT Part A and PASAT.

The acute phase (<1 month) included four tools: TMT Part A, PASAT, IVA-CPT, and the WAIS Digit Symbol Subtest.

The subacute phase comprised 11 tools: TMT Part A, PASAT, TAP, TEA, WAIS Digit Symbol Subtest, Computerized Neuropsychological Test, d2 Test of Attention, VCT, Digit Forward, Computerized DVT, and Hierarchical Visual Processing.

The chronic phase (>6 months) encompassed 18 tools: TMT Part A, PASAT, Psychomotor Vigilance Task, Conner’s CPT, CCPT, Digit Forward, Digit Vigilance Test, IVA-CPT, Attentional Matrices Test, TEA, d2 Test of Attention, Color Trail Test, IVA + Plus, Digit Span, Spatial Span, Partial and Whole Report TVA Paradigm, TAP, and d2 Test of Attention.

Assessments

In this study, we charted 24 types of attention function assessments, which exceeds those reported in prior studies. For example, Loetscher et al. (2019) reviewed only RCTs and identified 17 tools. Therefore, this study could chart additional studies that were missed in prior research by including both observational studies and RCTs. Among the 35 selected articles, TMT Part A was the most frequently utilized assessment tool, seen in 14 articles (40%). Furthermore, TMT Part A measures the motor speed and selective attention and is used in efficacy validation reviews of cognitive rehabilitation (Loetscher et al., 2019; Tsiakiri et al., 2024). TMT Part A is popular owing to its simplicity and short assessment time despite its limited scope in assessing functions. This may contribute to its frequent utilization in studies. Notably, TMT part A contains assessment factors other than those mentioned above (Tsiakiri et al., 2024). TEA was used in 11.4% of the articles, and it was not charted in previous studies (Loetscher et al., 2019; Tsiakiri et al., 2024). This is the first time TEA was charted in a study. TEA comprises eight tests that simulate ADL, each capable of assessing sustained, selective, and visual and auditory attention (Chen et al., 2013). Attention deficits in patients with strokes have been linked to difficulties in ADL (Hyndman & Ashburn, 2003; Hyndman, Pickering & Ashburn, 2008). Therefore, assessing the ADL capabilities of patients with stroke with attention deficits is crucial. This necessity probably explains why TEA was the second most commonly used tool, following the TMT Part A. Consequently, the inclusion of cross-sectional studies and RCTs in this study have resulted in the presentation of new results in the review that were not included in previous reviews (Loetscher et al., 2019).

Components

This scoping review charted the five attention components reported by Loetscher et al. (2019), as well as visual and auditory attention, totaling seven components. CAT was extracted for the first time in this study, and it is the only tool that can comprehensively assess all seven components. CAT comprises eight different attention types, making it a versatile assessment tool (Murakami et al., 2014). Therefore, it may be advantageous to assess all components using a single tool. However, the sensitivity and specificity of each CAT item are unknown; therefore, it should be considered in conjunction with other assessments.

More assessment tools have been used to evaluating deficits in selective and sustained attention than in other components of attention. Sustained attention is the ability to maintain consistent task performance over a long period (Sohlberg & Mateer, 1987). Patients with stroke often exhibit deficits in sustained attention, which are associated with to declines in postural control, mobility, and ADL (Hyndman & Ashburn, 2003; Hyndman, Pickering & Ashburn, 2008; Lin et al., 2018; Pearce et al., 2016). In addition, deficits in sustained attention hinder motor function recovery (Robertson et al., 1997). Sustained attention is a fundamental aspect of attention; therefore, it is frequently assessed in studies considering daily life functions (Langner & Eickhoff, 2013). Selective attention disorders are prevalent and can significantly impact physical function (Barker-Collo et al., 2009; McDowd et al., 2003). Therefore, assessing both selective and sustained attention is crucial, as many assessment tools may be employed for these purposes.

Only the CAT was charted for spatial attention. Because this study excluded USN, the number of assessments charted was limited. The spatial attention test of CAT is a cancelling task, and this is a similar assessment to the Behavioural Inattention Test (BIT) (Wilson, Cockburn & Halligan, 1987). When USN is excluded, as in this study, the BIT is not charted, so it is clear that the BIT is used as an assessment specific to USN. However, the BIT is also highly useful as an assessment for attention disorders other than USN, such as extinction and drawing tests. Therefore, the assessment of spatial attention should be used not only for USN, but also for a wider range of disorders. By charting the attention function into seven components, we were able to provide a more detailed evaluation. This will lead to a more multifaceted approach to evaluating the attention function, and will be useful for diagnosis and rehabilitation.

Stroke phase

The greatest number of tools were used during the chronic phase (18 tools) of the stroke phase. In addition, TMT Part A and PASAT were frequently used regardless of the stroke phase. These results supported that of the previous review (Loetscher et al., 2019). PASAT, which involves adding numbers based on auditory information, is known for its ease of utilization (Barker-Collo et al., 2009) and PASAT is effective for evaluating divided attention (Mathias & Wheaton, 2007) and can be used in all stroke phases. The charting of common and different assessments at different stages is important for longitudinally assessing symptom changes and validating the effectiveness of rehabilitation.

The assessments used in the acute phase were TMT, PASAT, IVT-CPT, and the WAIS digit symbol subtest. These were assessments that focused (the WAIS digit symbol subtest), selective (TMT), auditory and visual attention (PASAT and IVT-CPT). All of these assessments were characterized by their short testing times and their ability to be administered quickly. We considered this a valid result. During the acute phase, the patient’s condition is unstable, and natural recovery is rapid, making it easy for physical functions to change. For this reason, it may be easier to use simple and highly sensitive assessments such as these.

Eleven different assessments were used for the subacute phase. Unlike the acute phase, various attention function assessments were used to enable evaluation of all seven attention components. In addition, the TEA, which evaluates attention function in daily life (Chen et al., 2013), was included, and we assumed that assessments that take into account the patient’s destination were being used.

Eighteen assessments were used in the chronic phase, and they covered all of the components of attention. The prevalence of assessments during the chronic phase may be a result of the stabilization of physical function recovery, enabling ease of detecting attention deficits in observational studies and excluding the impact of spontaneous recovery in intervention studies. The fact that many evaluations have been charted is thought to indicate that it is easy to incorporate any kind of attention evaluation in the chronic phase, making it possible to evaluate the patient’s condition in more detail.

Limitation of the study

This scoping review had some limitations. First, it focused exclusively on patients with stroke and, therefore, did not chart the assessment of other disease attention functions. However, given the high prevalence of attention deficits in patients with stroke, assessing these deficits is crucial for effective rehabilitation interventions. Second, this review included few spatial attention assessments and excluded patients with USN to distinguish USN from attention disorders, as USN is classified as directed attention. Previous studies did not include USN and reviewed it separately (Loetscher et al., 2019; Umeonwuka, Roos & Ntsiea, 2022). Thirdly, we did not perform a reliability test when charting. When investigating the agreement rate of the charted data, it would have been possible to create a highly reliable chart by performing a reliability test. In our next study, we will perform a reliability test. Fourthly, this study did not investigate the sensitivity, specificity, reliability, or validity of each assessment. This is because in order to create a chart of these, it was necessary to add terms associated with them. Adding terms would reduce the number of articles that took into account the components and phases, which is the purpose of this study. Therefore, in the next study, we will conduct a review focusing on sensitivity and specificity based on the results of this study. Finally, a quality assessment of the articles was not conducted owing to the differing study designs, which prevented standardized findings. This is due to the difficultly generalizing the results following the differing study designs. Future studies should include a quality assessment, particularly focusing on observational studies. In addition, this study charted the assessment tools and components of attention deficits in patients during different stroke phases. Therefore, future research should explore rehabilitation methods for specific attention components and stroke phases.