Download Domains of Cognitive Functioning

Cognitive Dysfunction In Patients with
a Primary Brain Tumor: Exploring and
Navigating Uncharted Waters

Sandra A. Mitchell,
CRNP, MScN, AOCN
National Cancer Institute, Bethesda, MD

Sherry W. Fox, PhD, RN,
CNRN
University of Virginia School of
Nursing, Charlottesville, VA

Margaret Booth-Jones,
PhD
Moffitt Cancer Center and Research
Institute, Tampa, FL
Objectives
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Analyze the domains of
cognitive function.
Identify and select
tools/approaches for
evaluating cognitive function
in the clinic.
Explain the indications for
neuropsychological
evaluation.
Plan a program of support,
accommodation, and
rehabilitation for patients
with a primary brain tumor
who are experiencing
cognitive dysfunction.
Case #1: Janet
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37 y/o right-handed, Caucasian married female
Mother of 3 (ages 5, 9, and 10)
1 month s/p 80% resection of left frontotemporal
oligodendroglioma (WHO grade 2, with elevated MIB-1 index)
Considering XRT and/or chemotherapy vs. surveillance
Partial motor seizures, controlled on Dilantin
College educated, and working part-time at a public school
No prior medical or psychiatric history
Patient reporting depressed mood, increased tearfulness,
reduced energy, and word-finding difficulties
Husband is concerned about her mood and ability to accomplish
daily tasks, including caring for their 3 children
Case #2: Bernie
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58 y/o ambidextrous Israeli male. Married to his second wife
2 adult children from first marriage
2 weeks s/p gross total resection of a right frontal Glioblastoma
Multiforme (GBM) (WHO grade 4)
Scheduled to begin treatment with XRT and concurrent
temozolomide
Currently prescribed Dilantin, Decadron and Anzemet
No previous psychiatric history; history of HTN
Has an MBA and is working as an executive in a major
corporation – currently on sick leave
Patient denies emotional distress or cognitive problems
Wife and adult children are very concerned about his change in
personality and decision making abilities
Factors Contributing to
Neurobehavioral Changes
Associated with Brain Tumors

Location of the tumor
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Pathologic type
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Patient characteristics
FRONTAL
•Personality changes
(impulsivity, lack of inhibition,
lack of concern)
•Delayed initiation/apathy
•Executive dysfunction
•Diminished self-awareness of
impaired neurologic or
neuropsychological functioning
(anosognosia)
•Language deficits
TEMPORAL
•Auditory and perceptual
changes
•Memory and learning
impairments
•Aphasia and other language
disorders
PARIETAL
•Somatosensory changes
•Impaired spatial relations
•Hemispatial neglect
•Homonymous visual deficits
•Agnosia (non-perceptual
disorders of recognition)
•Language comprehension
impairments
•Alexia (disorders of reading)
•Agraphia (disorders of writing)
•Apraxia (disorders of skilled
movement)
OCCIPITAL
•Alexia (disorders of
reading)
•Homonymous
hemianopsia
•Impaired extraocular
muscle movements
•Color anomia
•Achromatopsia
(impairment in color
perception)
CEREBELLUM
•Ataxia
CORPUS CALLOSUM
•Transmission of visual
information
•Integration of sensory input
•Transmission of
somatosensory information
BRAINSTEM
•Diplopia
•Altered consciousness and attention
•Cranial neuropathies (visual field loss,
dysarthria, impaired extraocular
muscle movements)
Factors Contributing to the
Neurobehavioral Changes Associated
with Brain Tumors
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Pathologic type
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Low grade histology
High grade histology
Patient characteristics
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Age
Physical co-morbidities
Psychological co-morbidities
Symptom experience
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Fatigue
Pain
Factors Contributing to the
Neurobehavioral Changes Associated
with Brain Tumors
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Adverse effects of treatment
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Side effects of adjunctive
medications
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surgery
radiation therapy
chemotherapy
corticosteroids,
anticonvulsants
psychoactive medications
Medical complications
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endocrine dysfunction
seizures
infection
anemia
sleep disorders
Effects of Cognitive Dysfunction on
Patient, Family and Health Care Team
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Physical, psychological,
social and vocational
functioning
Level of distress
Quality of individual and
family life
Insight and self-appraisal
Self care abilities, decisionmaking and treatment
adherence
Cognitive Function
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Cognitive function
encompasses the
processes by which
sensory input is
elaborated, transformed,
reduced, stored, recovered
and used.
Domains of Cognitive Function
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Attention and
concentration
Visuo-spatial and
constructional skills
Sensory perceptual
function
Language
Memory
Executive function
Intellectual function
Mood, thought content,
personality and behavior
Source: Halligan, Kischka & Marshall,
2003
AttentionCapacity to Detect and Orient to Stimuli
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Prioritize signals from one
spatial location
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Prioritize some forms of
information and to suppress
others on the basis of a
functional goal
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spatial attention
selective or focused attention
Self maintain an alert and
ready-to-respond state
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arousal/sustained attention
ConcentrationDirecting Thoughts and Actions
Toward a Stimulus
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Capacity- refers to the
amount of information
processing a person can do
in a given time
Control refers to an
individual’s ability to direct
concentration capacities.
Concentration exists in three
forms:
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sustained concentration
focused
concentration(selective)
divided (alternating)
Distractions
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environmental – external
self – internal
Visuospatial and Contructional Skills Apraxia
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Difficulty performing a planned motor activity in the absence of
paralysis of the muscles normally used in the performance of
that act.
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Can also be considered a disorder of language as many
procedural tasks are verbally mediated.
Visuospatial and Contructional Skills Apraxia
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Ideational apraxia
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Ideomotor apraxia
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Dissociation between the areas of the brain that contain
the ideas for movements and the motor areas that
actually execute the movements.
Constructional apraxia
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Basic sequence of events and logical plan underlying a
chain of simple actions is disrupted
Inability to produce properly organized constructions
such as drawings or simple building tasks
Motor apraxia
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Not generally reported by patient, but family will often
describe difficulty with using common objects
(toothbrush, eating utensils).
Visuospatial and Constructional Skills
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Loss of topographical memory
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Inability to find the way and
tendency to become lost in
familiar and unfamiliar
environments
Visuospatial and Constructional Skills
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Apraxic agraphia
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poor letter formation
spatial distortions
patient/family report
illegible handwriting
Visuospatial and Constructional Skills
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Alexia (difficulty reading)
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may occur as a result of an
inability to perform the
continuous and systematic
scanning eye movements
necessary for reading
may also be considered a
language deficit
Visuospatial and Constructional Skills
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Acalculia (difficulty with
calculation)
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may result from
misplacement of digits,
misalignment of columns, or
aphasia for number symbols
Sensory-Perceptual Function
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Distinction between sensation and perception:
 The senses capture information from the environment
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Subsequent elaborations and interpretations in different
parts of the brain enable one to perceive or become aware
of external stimulation
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The most common perceptual deficits are:
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auditory
tactile
visual
Factors Influencing Evaluation of
Sensory-Perceptual Function
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Underlying primary sensory deficit (eg. color blind at baseline,
hypoacusis at baseline secondary to age-related hearing loss)
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Advancing age may diminish senses and dull perception
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The state of the perceiver(e.g. anxiety, physical discomfort) may
influence the perception of a stimulus
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Severe language problems can impair a patient’s ability to
respond appropriately to tests of sensory function
Common Sensory-Perceptual Deficits
in Patients with a Primary Brain Tumor
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Agnosia- literally, without
knowledge, inability to know or
interpret sensory experiences
Tactile agnosia (inability to name
common objects placed in one
hand). Place a common object
such as coin (dime, nickel,
quarter), paper clip, pen,
randomly in either hand.
If patient is aphasic, they will
have difficulty naming objects
placed in either hand. When
they have a specific difficulty in
naming objects palpated with
only one hand, tactile agnosia or
astereoagnosis is present.
Anosognosia
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Lack of awareness of
impaired neurologic or
neuropsychological function
which is obvious to the
clinician and other
reasonably attentive
individuals.
Common Sensory-Perceptual Deficits
in Patients with a Primary Brain Tumor
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Diplopia (double vision)
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Visual field deficits
(hemianopia, quadrantanopia)
Common Sensory-Perceptual Deficits
in Patients with a Primary Brain Tumor
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Achromatopsia - impairments
in color perception
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Color anomia - inability to
name colors or to select a
color from an array of colors
when requested
Common Sensory-Perceptual Deficits
in Patients with a Primary Brain Tumor
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Visual hallucinations
(photopsia)
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stars, dots, lines, fog, wavy
lines
Illusions (metamorphopsia)
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distorted objects, faces,
scenes
Common Sensory-Perceptual Deficits
in Patients with a Primary Brain Tumor
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Alexia (reading difficulties)
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words or syllables missing
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change of lines, or
reduced reading span
(hemianopic alexia)
Common Sensory-Perceptual Deficits
in Patients with a Primary Brain Tumor
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Problems with figure-ground
discrimination
Problems in estimating depth
on a staircase or reaching
for a cup/door handle
Bumping into obstacles or
failure to notice persons on
one side (hemispatialneglect, hemianopia)
Difficulty detecting the
movements of targets in
space - visual scenes may
appear as a series of static
snapshots
Language
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Aphasia/dysphasia
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language production
(expressive
aphasia/dysphasia)
language comprehension
(receptive
aphasia/dysphasia)
May be accompanied by
 alexia (loss or impairment
of the ability to read) and/or
 agraphia (loss or
impairment of the ability to
produce written language)
Language
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Dysarthria
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sensorimotor disorder
affecting the respiratory and
articulatory functions
involved in speech sound
production
speech may be garbled,
slurred or muffled, while
grammar, comprehension,
and word choice are intact
Dysprosody
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interruption of speech
inflections and rhythm (i.e.
speech melody)
resultant monotone or
halting speech
Evaluation of Spontaneous Speech
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Can communication be
established?
Does the patient produce
speech at all?
Is the patient's speech
comprehensible (if not, is it
because of semantic errors
or because of dysarthria)?
Is the patient's speech fluent
or nonfluent?
Are there semantic errors?
Language Production Difficulties
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Pauses, hesitancy
Restricted range of
vocabulary
Use of circumlocutions
Discontinuation of a phrase
Substitution of a presumablyintended word by another
word (verbal paraphasia)
Substitution of a presumablyintended word by a meaning
related word (semantic
paraphasia)
Difficulty with grammatical
construction
Telegraphic speech style
Language Production Difficulties
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Repetitive speech
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Automatisms
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Perseveration
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Stereotypy
Language Comprehension Difficulties
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Difficulty following multistep commands
Problems comprehending television or
movies, difficulties reading, working on the
computer or participating in conversation
May be difficult to differentiate from problems
with attention, and can overlap with
stress and fatigue
May lead to conflict and frustration in families
Memory
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Remote memory (memories from
childhood and early adulthood)
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usually preserved
Recent memory
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Recall is uncued information
retrieval
Recognition is cued information
retrieval in which the individual
“remembers” by selecting from a
number of pieces of information,
including the target information
Memory Loss Symptoms
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Examples of memory loss
symptoms:
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Forgetting a message
Losing track of a
conversation
Forgetting to do things
Forgetting what has been
read or events in movies/TV
programs
Inability to navigate in
familiar places
Memory Loss Symptoms
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Assess:
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Severity?
Onset gradual or sudden?
Memory impaired
consistently or only on
occasions?
Fluctuation in severity?
Is it an isolated symptom or
are there other cognitive
impairments?
How is it affecting work or
pastimes?
Executive Function
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Adaptive abilities that enable
us to:
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analyze what we want
develop and carry out a plan
Executive Function
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Establish new behavior
patterns and ways of thinking
about and reflecting upon our
behavior
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Understanding of complex
social behavior such as
understanding how others see
us, being tactful or deceitful.
Burgess et al (2000)
Executive Dysfunction
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Difficulties with abstract
thinking, planning, decisionmaking
Difficulty with goal
formulation
Difficulty with complex,
multistage tasks
Poor temporal sequencing
Problems with reasoning
and problem-solving
Difficulty with carrying out
everyday routine activities
(eg. making a cup of tea,
brushing teeth, dressing)
Executive Dysfunction
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Lack of insight
Distractibility
Marked reduction in
spontaneous purposeful
activity
Confabulation
Perseveration
Lack of concern
Shallow affect, impulsiveness,
disinhibition, aggression,
unconcern for social rules
Mood,Thought, Personality, Behavior
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Mood
Thought content and
processes
Baseline personality and
coping style
Behavior
Case #1: Janet
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37 y/o right-handed female, status post 80% resection of left
frontotemporal oligodendroglioma (WHO grade 2, with
elevated MIB-1 index). Considering XRT and/or
chemotherapy vs. surveillance. Partial motor seizures,
controlled on Dilantin
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Patient reporting depressed mood, increased tearfulness,
reduced energy, and word-finding difficulties.
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Husband is concerned about her mood and ability to
accomplish daily tasks, including caring for their 3 children
Case #1: Janet- Clinical Issues
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Cognitive function
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Short-term memory problems
Frustrated by problems with expressive dysphasia
Diminished initiative, feels somewhat apathetic
Executive dysfunction:
Problems with planning
Overwhelmed by complexities of busy household
Diminished mental concentration
Overlay of:
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Fatigue
Depression
Side effects of anticonvulsants
Case #2: Bernie
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58 y/o ambidextrous male, status post gross total resection of a
right frontal Glioblastoma (WHO grade 4). Scheduled to begin
treatment with XRT and concurrent temozolomide
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Currently prescribed Dilantin, Decadron and Anzemet
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Family concerned about personality changes and decisionmaking capacities. Patient denies any current concerns.
Case #2: Bernie- Clinical Issues
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Clinical Issues:
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Cognitive dysfunction:
Mild short term memory problems
Markedly diminished mental concentration
Personality changes (impulsive, lacking tact, easily frustrated)
Anosognosia (diminished awareness of impaired functioning)
Overlay of:
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Cultural factors
Side effects of steroids (patient is not sleeping)
Situational anxiety
Cognitive Screening: Clinical Context
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Evaluation of brain function
Occurs with each verbal and
non-verbal interaction with a patient
Screening may be formal or informal
Screening may also be conscious or unconscious
Screening may be part of a professional or a social
interaction
Cognitive Screening: Clinical Context
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Cognitive impairment is common in persons with
primary brain tumors (Fox, et al., 2004; Tucha et
al., 2000)
Cognitive impairment may have different patterns
according to tumor types and treatment
Caregivers or informant descriptions of cognitive
decline, should be taken seriously and cognitive
assessment and follow-up initiated (Guideline,
2001; Patterson & Glass, 2001)
Nursing Implications for Cognitive
Screening in the Clinic
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To identify issues in decision-making
To identify ways to improve quality of life
To identify best methods to assist caregivers
To identify a changing illness trajectory
To promote safety for the patient
To improve the patient/nurse relationship
To facilitate effective advocacy
Evidence Supporting Cognitive
Screening
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Patients with mild cognitive impairment should be
recognized and monitored for decline due to their
increased risk for subsequent dementia (guideline).
General cognitive screening instruments should be
considered for the detection of dementia (guideline).
Interview based techniques may be considered in
identifying patients with dementia, particularly in an
at-risk population (option).
American Academy of Neurology Guidelines on Early Detection of
Dementia and Mild Cognitive Impairment, (2001)
Patterson & Glass (2001) Screening for Cognitive Impairment
and Dementia in the Elderly
Linking Nursing and Neurocognitive
Assessments
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Interview with client and observations of client during
the interview are essential
Identification of fund of knowledge based on age,
culture, and education provide a basis for accurate
evaluation and screening
Obtaining a history of the person provides invaluable
clues to future assessment of cognition
Global Assessments
During Interview and History
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Orientation - alertness and awareness of time, place,
person and situation at all times
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Communication - ability to speak, understand, and
respond appropriately, speech patterns
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Judgment - insight into self and situation direct
decision making
Global Assessments
During Interview and History
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Appearance and Behavior
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General intelligence
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level of education, fund of knowledge
Mood
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attire, grooming, appearance
reactions to the topic being discussed
general perspective about situation, i.e. sad? angry?
Visuospatial ability
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attention given to visual cues
attends to both right and left sides
Factors Effecting Patterns of Cognitive
Impairment
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Age
Medical History
Tumor progression and location
Fatigue
Depression
Treatments, particularly radiation
Drug therapy such as steroids, anticonvulsants,
complementary therapies
Goals of Clinical Cognitive Screening
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To assess multiple areas of cognitive function quickly
To identify areas of cognitive dysfunction
To screen in such a way that the results are reliable,
valid and clinically relevant for patient care, safety and
self-esteem
To be practical about what is possible in the setting and
the patient population
Ideal Screening Instrument
Characteristics
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Can be administered by clinicians at all levels and
requires 5-15 minutes to administer to most patients
Orientation, attention/concentration, executive,
language, spatial, and memory functions included
Acceptable sensitivity with disorders commonly
encountered by neuroscience clinicians
Mallory, et al., (1997)
Evidence-Based Cognitive Screening
Instrument Recommendation #1
Mini-Mental State Exam (MMSE)
(Folstein, Folstein & McHugh, 1975)
or Modified Mini-Mental State Exam
American Academy of Neurology Guidelines on Early Detection
of Dementia and Mild Cognitive Impairment (2001)
Mallory, et al., (1997)
Mini-Mental State Exam (MMSE)
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Tests orientation, registration, attention and
calculations, recall and language
Takes approximately 12-15 minutes to administer
Scores added for a single number score
Deals with communication
Answers to individual questions may have more
value than the single score
Score of 23/24 out of 30 possible points suggests
significant cognitive dysfunction or possible dementia
Issues with the MMSE
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May be insensitive to mild cognitive impairments
May be insensitive to impairments from lesions in the
right hemisphere
No measure of visual perceptual deficits
False positives are reported in those of advanced age
and low educational levels
Evidence-Based Cognitive Screening
Instrument Recommendation #2
Neurobehavioral Cognitive Status Examination
(NCSE)(Cognistat)(Kiernam, et al., 1987; Mueller,
1984)
Abdulwadud, (2002)
Mallory, et al., (1997)
Neurobehavioral Cognitive Status
Examination (NCSE)(Cognistat)
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Provides data in ten areas including LOC, orientation,
attention, communication, memory, constructional
ability, calculations, reasoning, abstracting and
similarities.
Takes 30-45 minutes to administer
Several questions are specific to screening
Relies on communication and language skills
Useful for evaluating ability to complete complex
tasks
Useful in identifying cognitive impairment in persons
with focal neurologic lesions
When to Refer for a Formal
Neuropsychological Examination
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When patient requests assessment or expresses concerns
When family members express concern
When a physician or other health care provider needs a baseline
or notices cognitive changes
When a rehabilitation counselor or therapist needs a
comprehensive baseline
When documentation of disability or accommodation is required
When competency is an issue
When there are issues of placement in a rehabilitation or adult
living facility
Patient or Family Request
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Many patients are information seekers and are concerned about
their brain function
Subjective ratings of cognitive ability can be distorted and can lead
to significant distress
Patients and families may want a baseline to help make decisions
regarding further treatment for their brain tumor
Some brain tumor patients are unaware of their cognitive,
emotional, and personality changes (anosognosia – related to
frontal lobe dysfunction)
Some family members want testing to assist with
regaining a specific function: ability to drive,
return to work, or live alone
Health Care Provider Request
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pre-surgical assessments
 laterality and pre-surgical deficits
 language assessment prior to awake craniotomy
post-surgical assessment - rehabilitation and recovery
pre-chemotherapy baseline
during chemotherapy if cognitive and / or emotional changes are
observed
pre-radiation therapy to obtain a baseline to address concerns
for radiation induced dementia
during or after radiation if delirium or cognitive decline observed
Other Referrals for Testing
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Multidisciplinary rehabilitation may require neuropsychological
assessment for admission
Schools and employers may require neuropsychological testing and
documentation to return to school or work and to receive necessary
accommodations
Brain tumors are not automatically considered a disabling condition
and insurance companies and Social Security may require
neuropsychological testing and documentation
Competency to make treatment decisions may be in question and
may require testing and documentation
How to Present the Idea of a
Neuropsychological Exam
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Some patients associate psychology or psychiatry with “being crazy”
and resist the referral
Some patients are concerned that they will appear stupid or be
emotionally traumatized in some way
Patients should be told that a neuropsychological evaluation is an
assessment of brain function and a determination of strengths and
weaknesses that will allow for more comprehensive treatment
planning
Neuropsychological testing is not painful or invasive
Neuropsychological test is not an “IQ test”
The Neuropsychological Exam
Clinical interview with patient and with a family member
when possible
 Behavioral observation
 Estimate of premorbid function
 Brief, repeatable battery of tests
assessing cognitive domains
 Assessment of mood and quality of life
 Feedback to patient, family, and referring physician
 Documentation
 Referral to appropriate services
 Follow-up to determine change over time

Testing Considerations

Determine patient’s sensory limitations

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Determine patient’s language ability

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visual field cuts or diplopia
hearing loss from aging or chemotherapy,
peripheral neuropathy
expressive – providing answers
receptive – understanding the demands of the tasks
Limit testing to 1-2 hours to minimize fatigue
Neuropsychological Testing

Brief well-validated measures:
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attention, concentration and vigilance
verbal learning and verbal memory
visuospatial function
language – fluency, naming, reading
executive function – problem solving, reasoning,
susceptibility to interference
psychomotor speed and stamina
Appropriate psychosocial measures:


emotional distress
quality of life
RBANS List Learning
Immediate Memory Domain
RBANS Story Memory
Immediate Memory
RBANS Figure Copy
Visuospatial/Construction Domain
RBANS Figure Recall
Delayed Memory Domain
RBANS Line Orientation
Visuospatial/Construction Domain
RBANS Picture Naming
Language Domain
RBANS Semantic Fluency
Language Domain
RBANS Digit Span
Attention Domain
RBANS List Recall
Delayed Memory Domain
RBANS List Recognition
Delayed Memory Domain
RBANS Coding
Attention Domain
Trailmaking Test – Trails A
Executive Function
Trailmaking Test – Trails B
Executive Function
Janet’s Test Profile
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Verbal memory (list learning and story memory) impaired
Recognition better than recall for delayed memory
Visuospatial/constructional ability intact
Attention impaired characterized by slow responding but free of
errors
Language function significant for reduced fluency and impaired
naming
Executive function characterized by slowing and reduced
effortful output
Questionnaire information and clinical interview significant for
symptoms of clinical depression
Bernie’s Test Profile
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Verbal memory (list learning and story memory) mildly impaired
and significant for intrusion errors and perseverations
Recognition equivalent to recall for delayed memory
Visuospatial/constructional ability impaired and figure is
distorted
Attention impaired characterized by increased distractibility and
a high error rate
Language function significant for loss of set during the fluency
task and circumlocution errors on naming
Executive function characterized by poor set shifting, loss of set,
and increased susceptibility to interference
Questionnaire information and clinical interview not significant
for symptoms of clinical depression or clinical anxiety
Providing Feedback
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Discuss findings with patient and family members at the end of the
exam in real time
Provide strengths and weaknesses in an educational, supportive
manner
Explain the findings in terms of the relationship to the tumor, the
treatment and to activities of daily living
Connect neuropsychological findings directly to brain function and
brain location
Provide appropriate treatment options and referrals
Plan follow-up re-evaluation
Neuropsychiatric Referral
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Neuropsychological evaluation may identify emotional
and behavioral symptoms requiring medication
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Neurobehavioral slowing, problems with concentration,
or apathy – consider stimulant medication such
as methylphenidate (Ritalin) or modafinil (Provigil)
Depressed mood – consider antidepressant
Primary memory deficit – consider memory
enhancing medication such as Aricept or Memantine
Sleep disturbance, appetite decline, and behavioral changes
from steroids require referral
Unmodulated mood and behavioral irritability may require a
mood stabilizer such as Depakote or Gabitril
Principles of Cognitive Rehabilitation
and Accommodation
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Systematically evaluate cognitive function at regular intervals
(Meyers et al, 2000)
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Set specific goals for restoration, substitution or restructuring
of environment
(Lazar, 1998)
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Include rehabilitative disciplines (Lazar, 1998)
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Consider role for pharmacologic agents (Barton & Loprinzi, 2002; Chan
et al, 2003; Meyers et al, 1998)
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Evaluate for and remediate co-morbidities, including fatigue,
depression, anxiety, insomnia, and physiologic discomfort (Litofsky et
al, 2004)
Principles of Rehabilitation
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Three types of rehabilitative approaches are typically included:
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Restoration: cognitive training and exercises directed towards
strengthening and restoration of function
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Substitution: compensatory devices and strategies directed
towards substitution of lost functions and promoting conservation of
affected brain functions
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Restructuring: environmental restructuring and planning to promote
improved functioning by changing the demands placed on the
individual by themselves and others
Anticipatory Guidance
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Consider support group, online support, counseling resources available
through the NBTF and ABTA, individual and family counseling
Make of list of things that others can do to help the caregiver, and keep
the list by the phone to consult when friends call to ask how they can
help
Expect that mood disorder, particularly depression is present and
contributing to cognitive difficulties (Litofsky et al, 2004)
Provide explanations and information that help link emotions, and
changes in behavior and functioning to the tumor site and treatment
Help the patient and family anticipate the trajectory of the illness, and
plan for the next phases - end of life decision-making, articulate wishes,
and fulfilling desired short term goals
Help the patient maintain who they are and the roles that are important
to them by suggesting alternatives, adaptation, accommodation and
problem solving
Maintain patient involvement and dignity, despite limitations
Sherwood et al, (2004)
Psychological Support
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Psychoeducation specific to cognitive and emotional changes
associated with brain tumor and treatment
Cognitive/behavioral strategies to help with relaxation, reduce
frustration
Compensatory strategies to enhance memory and concentration
Activity pacing techniques to assist with fatigue and stamina issues
Individual and family therapy to address adjustment and role issues
Future Directions
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Practice
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More refined evaluation and description of the nature of cognitive
dysfunction
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Deliberative intervention/remediation/support
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Timely referral to multidisciplinary experts
Program Planning
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Advocate for improved access to neuropsychological evaluation,
and cognitive rehabilitation
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Systematically evaluate patients at regularly scheduled intervals to
document progress and adjust the plan
Education
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Develop skills in assessing, describing aspects of cognitive
functioning
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Expand the knowledge base of intervention techniques and
approaches
Research Agenda
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Instrument Refinement and Psychometric Evaluation- brief,
clinically useful, valid and reliable measures of cognitive function
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Prevalence, incidence, correlates, and sequelae of cognitive
dysfunction
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Evaluate the relative contributions of mood disturbance,
insomnia, fatigue, and physiologic discomfort
Research Agenda
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Develop, test and refine
intervention approaches
targeted to:
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remediate or substitute
specific aspects of cognitive
dysfunction (eg. language,
memory)
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global aspects of cognitive
dysfunction
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programs of patient and
family support and
adjustment
Research Agenda
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Evaluate the effects of
pharmacologic therapies for
disorders of mood (anxiety,
depression), attention,
wakefulness, and memory on
cognitive function and quality
of life
Research Agenda
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Evaluate the effects of
complementary and mind-body
therapies (relaxation, exercise,
music, humor, nutrition,
rest/sleep) on cognitive function