Post-stroke cognitive impairment is associated with poorer return-to-work outcomes in working-aged stroke survivors: A systematic review

ObjectivesTo 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 sourcesMEDLINE, EMBASE, CINAHL, and APA PsycINFO databases were searched from 2003 to October 2025 according to PRISMA guidelines.Review methodsTwo 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.ResultsThirty-nine studies met inclusion criteria (observational studies (<i>n</i> = 33), qualitative (<i>n</i> = 5) and randomised control trial (<i>n</i> = 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.ConclusionPost-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.PROSPERO: CRD42023462322.