Research on healthcare disparities has found that racial and ethnic minority population were less likely to receive intensive and effective rehabilitation following an acquired brain injury compared to their White counterparts. Immigrant status and language barriers further perpetuate the disparities in access to rehabilitation care. In addition to institutional barriers such as absence of culturally and linguistically appropriate health materials as well as lack of cultural competency training for staff, patient factors such as dissonance in cultural value orientation to health care has been identified as a common culturally-mediated barrier accounting for lower healthcare utilization rate among immigrants. Cultural factors including health beliefs and values impact patient’s self-appraisal of illness and have been studied as significant predictors for treatment adherence. The present case study seeks to demonstrate the role of socio-cultural factors in shaping the course of a Chinese immigrant patient’s neuropsychological evaluation and cognitive rehabilitation following an aneurysm rupture and subarachnoid hemorrhage.

The patient is a 64-year-old, monolingual Mandarin-speaking female who was born and raised in mainland China, referred for neuropsychological evaluation for treatment planning following an anterior communicating artery aneurysm rupture and subarachnoid hemorrhage. Cognitive complaints included selective retrograde amnesia and difficulty with short-term episodic memory. Patient completed neuropsychological assessment, then underwent a course of time-limited cognitive remediation.

Neuropsychological assessment was administered in Mandarin Chinese, and the majority of the tests utilized available norms from Mandarin-speaking Chinese population. While the patient continued to demonstrate at or above average functioning in aspects of executive function, she exhibited a pattern of “rapid forgetting” on modality-nonspecific learning and memory in addition to reductions in attention, working memory, psychomotor speed and visuo-perceptual integration. In the absence of mood symptoms, the patient demonstrated emotional resilience and strong family support system. Given reportedly minimal benefits from prior SLP intervention, barriers to treatment were examined and considered: linguistic factor, difficulty in holding on to information due to anterograde amnesia, and the lack of family involvement in the treatment process. In the context of Chinese family system and immigration history, family-centered care is imperative for the patient’s rehabilitation process. Main treatment goals included improving awareness of cognitive deficits as well as reinforcing consistent use of external strategies to compensate for impaired orientation and memory. Flexibility in the use of evidenced-based interventions were emphasized. The patient’s family were counselled in a culturally competent manner to further understand the aspects that matter the most for the patient and incorporate multi-sensory learning to facilitate intervention.

In this case study, we utilized culturally and linguistically appropriate norms and critically examined barriers to treatment from a contextual lens. This case highlights the role of culturally competent neuropsychological evaluation and incorporating a strength-based and multi-method approach in informing treatment planning for cognitive rehabilitation with immigrant population. Given the dearth in the existing cross-cultural literature, there is a clear need to conduct high-quality research in under-studied and under-represented immigrant populations to reduce the gap in service delivery and enhance treatment effectiveness.

Post-stroke depression (PSD) and anxiety disorders are the most common psychiatric issues that occur after cerebrovascular accident (CVA), with prevalence rates of up to 50%. Less studied, post-stroke apathy and pseudobulbar affect (PBA) also occur in a subset of individuals after CVA leading to reduced quality of life. Cognitive impairments also persist, especially memory, language, and executive difficulties. Residual cognitive and emotional sequelae after CVA limit return-to-work with between 20-60% becoming disabled or retiring early. This study examined the frequency and relative contribution of cognitive, behavioral and emotional factors for not returning-to-work after CVA.

Participants included 242 stroke survivors (54% women, average age of 59.2 years) who underwent an outpatient neuropsychological evaluation approximately 13 months after unilateral focal CVA. Exclusion criteria were a diagnosis of dementia, comprehension issues identified during assessment, multifocal or bilateral CVA, and inpatients. Predictors of return-to-work included in logistic regression analyses were psychological (depressive and anxiety disorders, apathy, PBA, history of psychiatric treatment before stroke) and neuropsychological (memory, executive functioning) variables. Depression and anxiety were diagnosed using DSM-IV-TR or -5 criteria. Apathy was operationalized as diminished goal-directed behavior, reduced initiation and decreased interest that impacted daily life more than expected from physical issues after stroke (including self- and family-report using the Frontal Systems Behavior Scale [FrSBe]). PBA was defined by the Center for Neurologic Study-Lability Scale and clinical judgment based on chart review.

Post-stroke apathy persisted in 27.3% of patients 13 months after stroke, PBA persisted in 28.2% of patients (i.e., uncontrollable crying spellings not simply attributable to depression alone, uncontrollable laughing spells), anxiety disorders persisted in 18.6% of patients (mainly panic attacks), and PSD persisted in 29.8% of patients. Memory loss persisted in 67.4% of patients and executive difficulties persisted in 74.4% of patients. Thirteen months after stroke, 34.7% of individuals had returned-to-work and 47.1% had not returned-to-work. The other 18.2% were not working either at the time of their stroke or after the stroke. Logistic regression indicated that post-stroke apathy, PBA, and memory loss were significant predictors of not returning-to-work (odds ratio p < 0.001). Patients who experienced post-stroke apathy were 7.1 times more likely to not return-to-work after stroke (p=0.008), those who suffered from PBA were 4.8 times more likely to not return-to-work (p=0.028), and those with memory loss were 6.6 times more likely to not return-to-work (p=0.005). PSD, history of treatment for psychiatric issues before the stroke, presence of an anxiety disorder after stroke, and executive difficulties were not significant predictors (p’s>0.05).

Results replicate the finding that return-to-work is hindered by residual cognitive deficits after stroke and extends previous research by clarifying the multifactorial emotional and behavioral barriers to not returning-to-work. Results highlight the importance of quantifying post-stroke apathy and pseudobulbar affect in a standard neuropsychological work-up after stroke to identify candidates for services to facilitate efforts in returning to work (e.g., vocational rehabilitation services, psychotherapy, interventions for decreased initiation).