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Stroke is the leading cause of long-term disability in the United States and not just because many people are left with paralysis or difficulty speaking. Somewhere between 50-60% of people who have a stroke will develop cognitive impairment in the months afterwards. Many of them will make a full neurological recovery, but an estimated 20-30% will experience an accelerated cognitive decline and develop vascular dementia, a serious syndrome that interferes with memory, thinking and judgment.
To assess the level of a person¡¯s cognitive function after stroke, clinicians routinely administer a series of assessments. These typically take place in a carefully controlled, quiet environment that helps a person concentrate on the task at hand. Yet how a person functions in a silent room may be quite different from how they will respond at home or in the outside world with its competing mental demands, lights and noises.
Using digital technology, Center for Rehabilitation Outcomes Research (CROR) assistant director Alex Wong, PhD, DPhil, believes he has found a way to capture cognition levels and measure executive function among stroke survivors after they leave the hospital. ¡°My ultimate goal is to track stroke survivors so we can treat problems as early as possible. If we can identify a problem, perhaps we can slow the person¡¯s deterioration,¡± Wong says. ¡°The problem is that most people aren¡¯t flagged for early-stage cognitive problems. My mobile cognitive assessments are trying to fill that gap.¡±
Wong has developed mobile versions of four commonly used cognitive-function tests and delivered them to study participants through a smartphone app. One assessment is called the Stroop Color and Word Test. During the test, participants are shown a list of color words printed in nonmatching ink colors and are asked to name the ink color, not the word. For example, the word ¡°blue¡± may be printed in red ink, which sets up a form of cognitive dissonance.
He also has developed a mobile version of the Tower of Hanoi, a neuropsychological evaluation that measures problem solving and executive function by asking participants to move differently sized discs from one peg to another within a set of rules that require them to think several steps ahead. A third assessment, known as the Spatial Memory Test, asks people to draw a line between randomly scattered numbered circles in order from lowest to highest, while a fourth test requires participants to repeat sequences of highlighted squares in order. The sequences in the Trail Making Test become progressively longer, which tests someone¡¯s spatial memory and cognitive flexibility among other things.
In the spring of 2022, Wong and his research team recruited 20 people who had experienced mild to moderate strokes to test the mobile cognitive assessments. The participants, 60% of whom were male and who averaged 55 years of age, received traditional cognitive assessments in a lab and were then trained on how to complete the mobile surveys and tests on a smartphone, which was provided to them.
Over the next two weeks, the participants were randomly prompted to complete an assessment six times a day. Then they had a follow-up visit with a researcher and returned the devices. The subjects completed between 77-85% of the assessments, a high level of compliance, and the mobile memory test results appeared valid, showing ¡°small differences and moderate agreement¡± with the in-lab tests, the researchers wrote in a 2026 published in the Archives of Physical Medicine and Rehabilitation.
However, the researchers noted that average daily scores on the assessments increased during the study for most of the mobile tests. It¡¯s possible that the study participants were scoring higher because they knew what was coming rather than because of an improved level of cognitive functioning, the researchers concluded. The so-called ¡°learning effect¡± was to be expected given the repetitive nature of the tests, they added, and could be compensated for in future research by reducing the frequency of the assessments.
The team also concluded that parts of the mobile experiment could be improved. The assessment results weren¡¯t as stable as they had hoped, a phenomenon that could have reflected a person¡¯s fatigue level or emotional state at different times of the day.
Yet overall, the findings validated the concept that cognitive tests for stroke survivors could be administered remotely after patients leave an inpatient hospital. ¡°Mobile cognitive assessments on smartphones can assess cognitive function after stroke, aiding clinicians and researchers,¡± the researchers concluded. ¡°They could be used to monitor patients¡¯ progress, identify needs and guide tailored interventions during the transition from hospital to home.¡±
The results build on previous work by Wong and his team at CROR using smartphone technology to deliver patient-reported assessments measuring everything from mood and pain levels to social isolation and depressed mood among rehabilitation patients. The researchers also have used smartphone apps to deliver exercise regimens to patients and track patients¡¯ adherence to them. The app allows patients to report things like fatigue and pain levels to a physical therapist who can then remotely adjust the exercise treatment.
Wong is now hoping to have his mobile cognitive assessments adopted outside the research lab. He has submitted a $3 million grant application to the National Institutes of Health that would provide the funding to integrate them into patient-care plans in Shirley Ryan Ä¢¹½ÊÓƵÍøÕ¾¡¯s outpatient clinics around the Chicago area. He expects to find out whether his research project is approved by the end of 2026.
¡°People may be in therapy for one hour a day. Physical and occupational therapists are using their time to provide therapy, not time-consuming assessments,¡± Wong says. ¡°If we can detect cognitive dysfunction at an early stage, we can provide early treatment.¡±