To examine the relationship between post-stroke cognitive impairment and return-to-work outcomes in working-aged stroke survivors and evaluate cognitive assessment methods used in included studies.
Data sources
MEDLINE, EMBASE, CINAHL, and APA PsycINFO databases were searched from 2003 to October 2025 according to PRISMA guidelines.
Review methods
Two reviewers independently screened titles and abstracts for inclusion. Data extraction and quality appraisal was completed by two reviewers. Narrative synthesis was completed due to substantial heterogeneity across studies.
Results
Thirty-nine studies met inclusion criteria (observational studies (n = 33), qualitative (n = 5) and randomised control trial (n = 1)). Stroke severity was predominantly mild. Post-stroke cognitive impairment prevalence across study cohorts ranged from 17.5% at 28 days to 89% at 7 years with considerable variance in assessments and timing (range 2 days to 7 years). Concentration, memory and processing speed impairments were most frequently reported. Return-to-work rates ranged from 7.5% to 100%, with no clear trends for time post-stroke or stroke sub-type. Cognition was the most commonly associated variable influencing return-to-work outcomes followed by stroke severity, mood and functional status. The invisible nature of post-stroke cognitive impairment and limited awareness among employers and clinicians was highlighted.
Conclusion
Post-stroke cognitive impairment is commonly associated with poorer return-to-work outcomes even following milder stroke. Despite high detection, post-stroke cognitive impairment often remains hidden. This review highlights the substantial variation in post-stroke cognitive assessment practices and lack of intervention studies. Findings emphasise the need for consistent assessment and management of post-stroke cognitive impairment and increased awareness of its considerable negative impact on employment outcomes.
LindsayMPNorrvingBSaccoRL, et al.World Stroke Organization (WSO): global stroke fact sheet 2019. Int J Stroke2019; 14: 806–817.
2.
StevensEEmmettEWangY, et al.The burden of stroke in Europe. King's College London for the Stroke Alliance for Europe (SAFE). 2017.
3.
ScottCALiLRothwellPM. Diverging temporal trends in stroke incidence in younger vs older people: a systematic review and meta-analysis. JAMA Neurol2022; 79: 1036–1048.
4.
ZhangMLongZLiuP, et al.Global burden and risk factors of stroke in young adults, 1990 to 2021: a systematic analysis of the global burden of disease study 2021. J Am Heart Assoc2025; 14: e039387.
5.
Audit NOoC. Irish National Auit of Stroke National Report 2023. In: Audit NOoC, editor. Dublin, 2023.
6.
DanielKWolfeCDBuschMA, et al.What are the social consequences of stroke for working-aged adults? A systematic review. Stroke2009; 40: e431–e440.
7.
TanEGaoLCollierJM, et al.The economic and health burden of stroke among younger adults in Australia from a societal perspective. BMC Public Health2022; 22: 218.
8.
SeminogOOScarboroughPWrightFL, et al.Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults. Br Med J2019; 365: l1778.
9.
TellierMRochetteA. Falling through the cracks: a literature review to understand the reality of mild stroke survivors. Top Stroke Rehabil2009; 16: 454–462.
10.
QuinnTJRichardETeuschlY, et al.European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur J Neurol2021; 28: 3883–3920.
11.
CaoMFerrariMPatellaR, et al.Neuropsychological findings in young-adult stroke patients. Arch Clin Neuropsychol2007; 22: 133–142.
12.
CrichtonSLBrayBDMcKevittC, et al.Patient outcomes up to 15 years after stroke: survival, disability, quality of life, cognition and mental health. J Neurol Neurosurg Psychiatry2016; 87: 1091–1098.
13.
AamSEinstadMSMunthe-KaasR, et al.Post-stroke cognitive impairment—impact of follow-up time and stroke subtype on severity and cognitive profile: the Nor-COAST study. Front Neurol2020; 11. DOI: 10.3389/fneur.2020.00699.
14.
EdwardsDFHahnMBaumC, et al.The impact of mild stroke on meaningful activity and life satisfaction. J Stroke Cerebrovasc Dis2006; 15: 151–157.
15.
FinchECFosterMMFlemingJ, et al.Undetected and underserved: the untold story of patients who had a minor stroke. Med J Aust2017; 206: 337–338.
16.
MoranGMFletcherBFelthamMG, et al.Fatigue, psychological and cognitive impairment following transient ischaemic attack and minor stroke: a systematic review. Eur J Neurol2014; 21: 1258–1267.
17.
PinterDEnzingerCGattringerT, et al.Prevalence and short-term changes of cognitive dysfunction in young ischaemic stroke patients. Eur J Neurol2019; 26: 727–732.
18.
MahonSFaulknerJBarker-ColloS, et al.Slowed information processing speed at four years poststroke: evidence and predictors from a population-based follow-up study. J Stroke Cerebrovasc Dis2020; 29: 104513.
19.
CramerSCRichardsLGBernhardtJ, et al.Cognitive deficits after stroke. Stroke2023; 54: 5–9.
20.
StolwykRJMihaljcicTWongDK, et al.Poststroke cognitive impairment negatively impacts activity and participation outcomes: a systematic review and meta-analysis. Stroke2021; 52: 748–760.
21.
EdwardsJDKapoorALinkewichE, et al.Return to work after young stroke: a systematic review. Int J Stroke2018; 13: 243–256.
22.
SynhaeveNESchaapsmeerdersPArntzRM, et al.Cognitive performance and poor long-term functional outcome after young stroke. Neurology2015; 85: 776–782.
23.
StolwykRJMihaljcicTWongDK, et al.Post-stroke cognition is associated with stroke survivor quality of life and caregiver outcomes: a systematic review and meta-analysis. Neuropsychol Rev2024; 34: 1235–1264.
24.
BaldwinCBruscoNK. The effect of vocational rehabilitation on return-to-work rates post stroke: a systematic review. Top Stroke Rehabil2011; 18: 562–572.
25.
KnoflachMMatosevicBRückerM, et al.Functional recovery after ischemic stroke–a matter of age: data from the Austrian Stroke Unit Registry. Neurology2012; 78: 279–285.
26.
FinchEFosterMFlemingJ. Disrupted biographies: making sense of minor stroke after hospital discharge. Disabil Rehabil2021; 43: 2632–2639.
27.
BranniganCGalvinRWalshME, et al.Barriers and facilitators associated with return to work after stroke: a qualitative meta-synthesis. Disabil Rehabil2017; 39: 211–222.
28.
KitakamiMYaedaJ. A systematic review and meta-analysis of cognitive functions predicting employment of individuals with acquired brain injury. Asian J Occup Ther2020; 16: 45–53.
29.
Party ISW. National Clinical Guideline for Stroke for the UK and Ireland. 2023.
30.
HolguinJAMargetisJLNarayanA, et al.Vascular cognitive impairment after mild stroke: connectomic insights, neuroimaging, and knowledge translation. Front Neurosci2022; 16: 905979.
31.
HillG. Corrigendum to: World Stroke Organization (WSO): global stroke fact sheet 2022. Int J Stroke2022; 17: 478.
32.
PollockASt GeorgeBFentonM, et al.Top ten research priorities relating to life after stroke. Lancet Neurol2012; 11: 209.
33.
StaniszewskaSBrettJSimeraI, et al.GRIPP2 Reporting checklists: tools to improve reporting of patient and public involvement in research. Br Med J2017; 358: j3453.
34.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J2021; 372: n71.
35.
PopayJRobertsHSowdenA, et al.Guidance on the conduct of narrative synthesis in systematic reviews: a product from the ESRC Methods Programme. Version 1. Lancaster. 2006.
36.
AbdinEChongSAPehCX, et al.The mediational role of physical activity, social contact and stroke on the association between age, education, employment and dementia in an Asian older adult population. BMC Psychiatry2017; 17. DOI: 10.1186/s12888-017-1272-8.
37.
BugnicourtJMGuegan-MassardierERousselM, et al.Cognitive impairment after cerebral venous thrombosis: a two-center study. J Neurol2013; 260: 1324–1331.
38.
KoopmanKUyttenboogaartMVroomenPC, et al.Long-term sequelae after cerebral venous thrombosis in functionally independent patients. J Stroke Cerebrovasc Dis2009; 18: 198–202.
39.
AlfieriAGazzeriRPircherM, et al.A prospective long-term study of return to work after nontraumatic nonaneurysmal subarachnoid hemorrhage. J Clin Neurosci2011; 18: 1478–1480.
40.
HofgrenCSamuelssonHKlassonS, et al.Cognitive screen and employment long-term after infratentorial stroke. Acta Neurol Scand2022; 145: 610–618.
41.
HommelMMiguelSTNaegeleB, et al.Cognitive determinants of social functioning after a first ever mild to moderate stroke at vocational age. J Neurol Neurosurg Psychiatry2009; 80: 876–880.
42.
NtsieaMVVan AswegenHLordS, et al.The effect of a workplace intervention programme on return to work after stroke: a randomised controlled trial. Clin Rehabil2015; 29: 663–673.
43.
OwnsworthTShumD. Relationship between executive functions and productivity outcomes following stroke. Disabil Rehabil2008; 30: 531–540.
44.
PowellJKitchenNHeslinJ, et al.Psychosocial outcomes at 18 months after good neurological recovery from aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry2004; 75: 1119–1124.
45.
SamuelssonHVikenJRedforsP, et al.Cognitive function is an important determinant of employment amongst young ischaemic stroke survivors with good physical recovery. Eur J Neurol2021; 28: 3692–3701.
46.
Balasooriya-SmeekensCBatemanAMantJ, et al.Barriers and facilitators to staying in work after stroke: insight from an online forum. BMJ Open2016; 6: e009974.
47.
SchellekensMMBootEMVerhoevenJI, et al.Cognitive performance is associated with return to work after ischemic stroke in young adults: the ODYSSEY study. Eur Stroke J2025; 10: 784–795.
48.
DemersMCharalambousMKwahLK, et al.Unique needs and challenges experienced by young people with stroke: an international qualitative analysis. Neurol Clin Pract2025; 15: e200406.
49.
AdamitTMaeirABen AssayagE, et al.Impact of first-ever mild stroke on participation at 3 and 6 month post-event: the TABASCO study. Disabil Rehabil2015; 37: 667–673.
50.
BlomgrenCSamuelssonHBlomstrandC, et al.Long-term performance of instrumental activities of daily living in young and middle-aged stroke survivors-impact of cognitive dysfunction, emotional problems and fatigue. PLoS One2019; 14: e0216822.
51.
BuunkAMGroenRJMVeenstraWS, et al.Leisure and social participation in patients 4–10 years after aneurysmal subarachnoid haemorrhage. Brain Inj2015; 29: 1589–1596.
52.
CragoEAPriceTJBenderCM, et al.Impaired work productivity after aneurysmal subarachnoid hemorrhage. J Neurosci Nurs2016; 48: 260–268.
53.
FrideYAdamitTMaeirA, et al.What are the correlates of cognition and participation to return to work after first ever mild stroke?Top Stroke Rehabil2015; 22: 317–325.
54.
GaastraBEwbankFTapperW, et al.Long-term cognitive outcome following aneurysmal subarachnoid haemorrhage. J Stroke Cerebrovasc Dis2022; 31: 106184.
55.
GabrieleWRenateS. Work loss following stroke. Disabil Rehabil2009; 31: 1487–1493.
56.
HackettMLGlozierNJanS, et al.Returning to paid employment after stroke: the Psychosocial Outcomes in StrokE (POISE) cohort study. PLoS One2012; 7: e41795.
57.
HofgrenCBjörkdahlAEsbjörnssonE, et al.Recovery after stroke: cognition, ADL function and return to work. Acta Neurol Scand2007; 115: 73–80.
58.
KauranenTTurunenKLaariS, et al.The severity of cognitive deficits predicts return to work after a first-ever ischaemic stroke. J Neurol Neurosurg Psychiatry2013; 84: 316–321.
59.
KjorkEBlomstrandCCarlssonG, et al.Daily life consequences, cognitive impairment, and fatigue after transient ischemic attack. Acta Neurol Scand2016; 133: 103–110.
60.
KrajewskiKDombekSMartensT, et al.Neuropsychological assessments in patients with aneurysmal subarachnoid hemorrhage, perimesencephalic SAH, and incidental aneurysms. Neurosurg Rev2014; 37: 55–62.
61.
KruisheerEMHuenges WajerIMCVisser-MeilyJMA, et al.Course of participation after subarachnoid hemorrhage. J Stroke Cerebrovasc Dis2017; 26: 1000–1006.
62.
MorsundÅHEllekjærHGramstadA, et al.Factors influencing employment after minor stroke and NSTEMI. J Stroke Cerebrovasc Dis2020; 29: 105036.
63.
NorlanderALindgrenIPessah-RasmussenH, et al.Fatigue in men and women who have returned to work after stroke: assessed with the fatigue severity scale and mental fatigue scale. J Rehabil Med2021; 53: 1–8.
64.
SaarKTolvanenAPoutiainenE, et al.Returning to work after stroke: associations with cognitive performance, motivation, perceived working ability and barriers. J Rehabil Med2023; 55: jrm00365.
65.
SchulzCHGodwinKMHerschGI, et al.Return to work predictors of stroke survivors and their spousal caregivers. Work2017; 57: 111–124.
66.
SlavinSJMcCune-RichardsonLMooreJ, et al.Cognitive testing during mild acute ischemic stroke predicts long-term return to work. J Stroke Cerebrovasc Dis2022; 31: 106132.
67.
TurunenKEALaariSPKKauranenTV, et al.Domain-specific cognitive recovery after first-ever stroke: a 2-year follow-up. J Int Neuropsychol Soc2018; 24: 117–127.
68.
Van PattenRMerzZCMulhauserK, et al.Multivariable prediction of return to work at 6-month follow-up in patients with mild to moderate acute stroke. Arch Phys Med Rehabil2016; 97: 2061–2067.e1.
69.
VestlingMTufvessonBIwarssonS. Indicators for return to work after stroke and the importance of work for subjective well-being and life satisfaction. J Rehabil Med2003; 35: 127–131.
70.
WallmarkSRonne-EngströmELundströmE. Predicting return to work after subarachnoid hemorrhage using the Montreal Cognitive Assessment (MoCA). Acta Neurochir2016; 158: 233–239.
71.
WesterlindEAbzhandadzeTRafstenL, et al.Very early cognitive screening and return to work after stroke. Top Stroke Rehabil2019; 26: 602–607.
72.
TurnerGMMcMullanCAtkinsL, et al.TIA And minor stroke: a qualitative study of long-term impact and experiences of follow-up care. BMC Fam Pract2019; 20: 1–10.
73.
AlenljungMRanadaÅLLiedbergGM. Struggling with everyday life after mild stroke with cognitive impairments – the experiences of working age women. Br J Occup Ther2019; 82: 227–234.
74.
LindgrenIBrogårdhCPessah-RasmussenH, et al.Work conditions, support, and changing personal priorities are perceived important for return to work and for stay at work after stroke – a qualitative study. Disabil Rehabil2022; 44: 2500–2506.
75.
van der KempJKruithofWJNijboerTCW, et al.Return to work after mild-to-moderate stroke: work satisfaction and predictive factors. Neuropsychol Rehabil2019; 29: 638–653.
76.
NasreddineZSPhillipsNABedirianV, et al.The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc2005; 53: 695–699.
77.
HofgrenCEsbjornssonEAnianssonH, et al.Application and validation of the barrow neurological institute screen for higher cerebral functions in a control population and in patient groups commonly seen in neurorehabilitation. J Rehabil Med2007; 39: 547–553.
78.
van der HornHJSpikmanJMJacobsB, et al.Postconcussive complaints, anxiety, and depression related to vocational outcome in minor to severe traumatic brain injury. Arch Phys Med Rehabil2013; 94: 867–874.
79.
KrabbePFStouthardMEEssink-BotML, et al.The effect of adding a cognitive dimension to the EuroQol multiattribute health-status classification system. Med Decis Making1998; 18: 418–424.
80.
QuinnTJRichardETeuschlY, et al.European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur Stroke J2021; 6: I–XXXVIII.
81.
KosgallanaACordatoDChanDKY, et al.Use of cognitive screening tools to detect cognitive impairment after an ischaemic stroke: a systematic review. SN Compr Clin Med2019; 1: 255–262.
82.
GrechMWithielTKlaicM, et al.Characterisation of young stroke presentations, pathways of care, and support for ‘invisible’ difficulties: a retrospective clinical audit study. Brain Impair2024; 25. DOI: 10.1071/IB23059.
83.
HobdenGTangEYHDemeyereN. A modified Delphi survey to build expert consensus on the structure and content of an enhanced care pathway for cognitive changes after stroke in the UK. BMC Health Serv Res2024; 24: 1162.
84.
NuccioEPetrosinoFSimeoneS, et al.The needs and difficulties during the return to work after a stroke: a systematic review and meta-synthesis of qualitative studies. Disabil Rehabil2024; 46: 4901–4914.
85.
WasseniusCClaessonLBlomstrandC, et al.The centrality of work in everyday life after stroke: a qualitative study of long-term stroke survivors. Scand J Occup Ther2023; 30: 539–549.
86.
DuongPEganMMeyerM, et al.The impact of stroke on employment income: a cohort study using hospital and income tax data in Ontario, Canada. Clin Rehabil2024; 38: 1109–1117.
87.
GarlandAJeonS-HStepnerM, et al.Effects of cardiovascular and cerebrovascular health events on work and earnings: a population-based retrospective cohort study. CMAJ2019; 191: E3–E10.
88.
BrownDLBoden-AlbalaBLangaKM, et al.Projected costs of ischemic stroke in the United States. Neurology2006; 67: 1390–1395.
89.
KimSELeeHKimJY, et al.Three-month modified Rankin Scale as a determinant of 5-year cumulative costs after ischemic stroke: an analysis of 11,136 patients in Korea. Neurology2020; 94: e978–e991.
90.
CravenKKettlewellJDe Dios PerezB, et al.What do employers need when supporting stroke survivors to return to work?: a mixed-methods study. Top Stroke Rehabil2025; 32: 392–404.
91.
CravenKHolmesJKettlewellJ, et al.Development of a digital, self-guided return-to-work toolkit for stroke survivors and employers using intervention mapping. PLOS Digit Health2025; 4: e0000971.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
