Download Clinical Cases in Correctional Telemedicine

Ana Maria Lopez, MD, MPH, FACP
Associate Professor of Clinical Medicine and Pathology
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Define “chemo brain”/cognitive
dysfunction
Identify chemotherapy’s effects on
cognitive function
Understand potential causes
Outline patient concerns and usual care
Discuss self management strategies for
“chemo brain”
Identify symptoms that would
necessitate medical attention
 Number
of patients receiving dose-intense
chemotherapy for breast cancer has
increased
 Number of breast cancer survivors has
increased
 Number of survivors who are experiencing
long term side effects has increased
 Cognitive dysfunction is one of these late
effects
Children with cancer: at risk for
academic underachievement due to:
side effects of treatment, school
absences, and anxiety related to their
disease.
“chemo brain”
 Impairment of cognitive function
related to cancer and/or cancer
treatment
 May present as dementia or delirium
 Characterized by slower memory
retrieval, reduced information
retention, and difficulty concentrating
 Reasoning, problem solving, and
talents are not affected
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“I have chemo brain. I can’t concentrate.”
“I used to teach and lecture. Now, I have
trouble putting sentences together.”
“I’ve lost my focus. I can’t even keep track
of the characters in a movie!”
Cancer and cancer treatment can raise
the risk for both
 Greater risk of experiencing dementia
and delirium with increased age
 Delirium most often caused by specific
ailment
 Dementia often caused by more
general conditions
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Dementia:
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Definition: Loss of mental function that
affects daily living
Onset: Gradual over months and years
Causes: Brain tumor, stroke, Alzheimer’s,
Huntington’s disease, vascular dementia
Symptoms: Difficulty completing familiar
tasks, disorientation, language problems,
memory loss, disruptive/inappropriate
behavior, fragmented sleep
Delirium:
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Definition: Acute confused state
Onset: Sudden (within hours/days) with
fluctuating symptoms
Causes: Medication (such as chemotherapy),
infections, fever, anemia, malnutrition,
dehydration
Symptoms: Reduced ability to focus, sustain
or shift attention, reduced awareness,
impaired memory, agitation, apathy,
affected sleep
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Symptoms associated with dementia and
delirium
Reduction in information recalled and
absorbed at once
Things take longer to do, require more
mental effort
Similar to Attention Deficit Disorder (ADD)
Noticeable difference in carrying out tasks
when compared to pre-cancer cognitive
state
Here are a few examples of what patients
experience with chemo brain:
 Forgetting things: short-term loss
 Difficulty concentrating, focusing attention
 Trouble remembering details like names,
dates
 Trouble multi-tasking: cognitive flexibility
 Taking longer to finish things: information
processing speed
 Trouble finding the right words to say
 Feeling in a “chemo fog”
Yes, chemo brain is real, but
there is not a single cause
Postulated mechanisms of chemotherapy-associated cognitive changes
Vardy, J. et al. Ann Oncol 2007 0:mdm500v1-500; doi:10.1093/annonc/mdm500
Copyright restrictions may apply.
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Many physicians attribute pt’s
cognitive concerns to:
◦ Menopause
◦ Depression
◦ Anxiety
The cancer itself
Chemotherapy drugs
Other drugs used as part of treatment
Patient age (greater chance over age
60)
Stress
Low blood counts/anemia
Stress/depression – can impede
concentration
 Medication to aid side effects/pain meds
- can cause severe drowsiness
 Hormonal changes – can cause cognitive
changes
 Low blood counts – can cause fatigue,
which may make it difficult to concentrate
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20-30% of people undergoing
chemotherapy for any type of cancer
will experience cognitive impairment
 Often breast cancer patients are more
likely to have symptoms of chemo
brain
 One study found 35% of women with
breast cancer had memory problems
before starting chemotherapy*
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* www.chemobraininfo.org
Tx
Arm
N
Cognitive
impairment
(%)
Odds
ration
P-value
CMF
39
28%
--
--
Control
34
12%
6.4
.013
Not affected by anxiety, depression, fatigue or time
since treatment. Cancer 1999
47 cancer patients with metastatic cancer and
significant prior chemotherapy, at least 3
weeks post treatment
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34% had cognitive deficits.
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53% had memory deficits
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47% had frontal dysfunction
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33% had attention difficulties
Therefore, neurobehavioral abnormalities
should be considered when determining the
risks and benefits of cancer treatment.
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39 patients and a control group
1.9 years post treatment.
Impaired cognitive function:
◦ 28% patients and 12% control
Cognitive impairment:
◦ Attention
◦ Mental flexibility
◦ Speed of information processing
◦ Visual memory
◦ Motor function
High risk breast cancer patients
randomized to high dose or standard
dose chemotherapy compared to
control
 Cognitive impairment:
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◦ 32% high-dose
◦ 17% standard-dose
◦ 9% control
Controlled for anxiety, depression,
fatigue
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2 years post treatment
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Certain complementary therapies can
help counter the cognitive side effects
of treatments.
 Women who exercise experience less
of the cognitive dysfunction
associated with Tamoxifen. It is
thought that the release of endorphins
help attenuate the neurotoxic effects
of some chemotherapies.
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83 breast cancer patients
 receiving chemotherapy
 Randomized to erythropoetin alfa
40,000 IU SQ weekly vs. placebo
 Evaluated:
– cognitive function (EXIT 25)
– asthenia (FACT FACT-An)
– QOL (LASA)
O’Shaughnessy O’Shaughnessy; Breast Cancer ; Res Treat, (2002)
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Patients undergoing CT and weekly
epo
◦ maintained or improved Hb levels
◦ lessened cognitive decline
◦ lessened decline in QOL, energy, and
activity
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Hb declines may correlate with
cognitive dysfunction during CT
Functional magnetic resonance images of 60-year-old identical twins during a working memory task
with incrementally increasing levels of difficulty (left to right)
Ferguson, R. J. et al. J Clin Oncol; 25:3866-3870 2007
Copyright © American Society of Clinical Oncology
Fluid attenuated inversion recovery magnetic resonance images of white matter hyperintensities
Ferguson, R. J. et al. J Clin Oncol; 25:3866-3870
2007
Copyright © American Society of Clinical Oncology
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How long does chemo brain last?
◦ Varies from person to person
◦ Once chemo treatment ends most gain
back cognitive function within a year
◦ Approximately 20% of people affected
by chemo brain say that they regain
function to a certain extent and then
plateau without full cognitive recovery
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What if I never return to my precancer cognitive function?
◦ Things can be altered in daily life to aid in
helping manage chemo brain
◦ For example, take notes and write things
down to help with remembering things
◦ Enlist the help of others to remind you of
things and help you remember things
◦ People can retain their functionality, but it
will take effort
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Use a detailed daily
planner
Exercise the brain:
take a class, do
word puzzles, or
learn a new
language
Track and
document
difficulties
Set up and follow
routines
 Write reminder
notes
 Get enough rest
and sleep
 Get physical activity
and eat a healthy
diet
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Are there tests that measure brain
changes?
◦ There have not been many pre-treatment,
post-treatment studies
◦ There is no standard measure
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Is chemo brain a brain injury?
◦ Chemo brain may be considered a type of
brain injury
◦ Carefully document all symptoms
experienced and talk with your doctor
about what you’re experiencing
◦ Doctors might recommend diagnostic
testing to see what is causing symptoms
and rule out other possibilities
Series of memory aids
 In severe cases, neuropsychologists
are recommended to assess to treat
symptoms
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◦ Neuropsychologists may recommend
cognitive rehabilitation
In general, cancer patients have fairly
mild focused cognitive problems that
respond well (Myers, 2000)
 Facilitates recovery of cognitive
function and maximizes
accommodation to current function
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If cognitive function gets severely,
noticeably worse in a short time
period
 If depression worsens or thoughts of
suicide occur seek medical attention
 If headache will not go away or head
pain feels sharp it might be a sign of
another condition
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“Can chemotherapy affect
my memory?”
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Nearly two-thirds of women treated with
chemotherapy develop some level of
cognitive problems
Most recover on their own in the weeks or
months after treatment stops
As many as 20% to 25% of patients may
develop lasting problems
Cognitive neurorehabilitation techniques
may help
American Cancer Society
www.cancer.org, search “chemo brain”
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(http://www.cancer.org/docroot/MBC/content/MBC_
2_3x_Chemobrain.asp)
Breast Cancer.org
www.breastcancer.org, search “chemo
brain”
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(http://www.breastcancer.org/treatment/planning/a
sk_expert/2008_10/)
National Cancer Institute
www.cancer.gov, search “cognitive
dysfunction”
 Chemo Brain Info
www.chemobraininfo.org
 Mayo Clinic
www.mayoclinic.com, search “chemo
brain”
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