5/13/2013
Assessment and Treatment of High
Level and Low Level Cognitive Deficits
Claudine Campbell, MOT, OTR/L
May 31, 2013
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
This presenter has no conflict of interest to report
regarding any commercial product/manufacturer
that mayy be referenced during
g this presentation.
p
Objectives
1. Identify the prevalence of cancer-treatment related
cognitive changes
2. Discuss additional factors contributing to cognitive
dysfunction related to cancer survivorship
3 Identify
3.
Id tif the
th occupational
ti
l therapy
th
assessmentt tools
t l
that can be used with clients who have cancerrelated cognitive dysfunction
4. Describe the various occupational therapy treatment
approaches for addressing cognitive dysfunction in
patients with cancer
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
1
5/13/2013
Prevalence of Cognitive Dysfunction
Resulting from Cancer
• Up to 75% of patients with cancer experience
cognitive impairment during or after cancer
treatment1
– Memory, executive functioning, attention deficits
• Nearly 4 million cancer survivors have some form of
cognitive difficulty1,2
• Cognitive impairments resulting from cancer related
treatment vary
– Subtle or dramatic
– Temporary or permanent
Pediatric and Adolescent
Patients with Cancer 3,4
• 1 in 570 young adults between the age of 20 - 34
years is a childhood cancer survivor
• Cranial radiation and chemotherapy are associated
with neurocognitive deficits
• Neurocognitive dysfunction is most common with:
– Acute Lymphoblastic Leukemia (ALL)
– Solid tumors involving the CNS
• Damage to cortical and sub-cortical white matter is
most commonly cited in the literature
– Results in impaired processing speed, visual spatial and
visual motor skills
Older Adults with Cancer5,6
• Approximately 60% of new cancers are diagnosed in
older adults >65 years of age in the US
• Chemotherapy-related cognitive impairment is
underdiagnosed in the older adult population
– Depression
D
i may b
be a confounding
f
di ffactor
t
• Older adults may be more vulnerable to cognitive
changes as a result of cancer treatment
– Cognitive reserve
– Cognitive capacity
– Resiliency vs. vulnerability
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5/13/2013
Patients with Brain Tumors1,7,8
• In 2010 more than 688,096 people in the U.S. were living with the
diagnosis of a primary brain or central nervous system tumor
– Approximately 70, 000 new cases of primary brain tumors will be
diagnosed this year
• Approximately 5% of patients who receive radiation therapy for a brain
tumor develop radiation necrosis
• Negative treatment effects on the CNS may lead to cognitive
dysfunction
– Focal radiation necrosis (inflammation)
– Cerebral edema
– Diffuse leukoencephalopathy
– Acute vs. late toxicities
Patients with Prolonged
Hospitalization9,10
• 60-80% of patients requiring mechanical ventilation in the ICU
experience delirium
• ICU survivors report persistent difficulty with concentration,
memory and executive function
– 1/3 or more h
have llong-term
t
cognitive
iti impairment
i
i
t
– 46% of patients with ARDS present with cognitive impairment
1 year after hospital discharge; 25% have deficits 6 years later
• There is a higher incidence (23-41%) of depression, anxiety, and
PTSD in ICU survivors which negatively impacts cognitive
function
Patients with Breast Cancer2,11
• There are currently 2.6 million breast cancer survivors in
the US
• Multimodality cancer treatment leads to cancer treatment
associated cognitive changes
– Surgery, exposure to general anesthesia, radiation therapy,
hormone therapy, chemotherapy
• Mild cognitive impairment is one of the most common
symptoms reported by breast cancer survivors
– Reported in 17 to 75% clients with breast cancer
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5/13/2013
Risk Factors Associated with
Cognitive Dysfunction
• The risk for post-treatment cognitive
problems is potentially a combination of
several factors2
–
–
–
–
–
–
Age
g
Cognitive reserve
Genetics
Lifestyle (education level, occupation)
Environmental exposures
Specific cancer treatments
Additional Contributing Factors
•
•
•
•
•
•
•
Disease process or progression of disease
Physiological effects of chemotherapy and radiation
Direct effects of cancer and/or cancer treatment on CNS
Pain
Fatigue
Depression/anxiety
Limited or ineffective:
– Strategy use
– Problem solving skills
– Understanding of the causes of cognitive impairment
Physiological Effects of Cancer
Treatment on Cognition
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5/13/2013
Effects of Chemotherapy
• Animal studies demonstrate the negative
effects of chemotherapy on brain function6
– Inhibition of hippocampal neurogenesis
– Oxidative damage
– White matter damage
– Decreased hypothalamic-pituitary-adrenal
axis activity
– Reduced brain vascularization and blood
flow
Effects of Radiation Therapy
• Animal studies demonstrate radiation-induced
neurotoxicity12
– Prolonged reduction in cell proliferation
– Depressed neurogenesis
– Vascular injury
• Toxicity from brain tumor therapy (RT) can range
from focal neurological deficits to generalized
neurological syndromes1
– Decreased cognitive function
– Fatigue, weakness, impaired balance
– Altered safety awareness
Effects of Steroids and Sedatives8
• Steroids
– Function to decrease
edema in the brain
– May contribute to
cognitive
iti iimpairment,
i
t
insomnia, fatigue,
hyperglycemia and
tremors
– Delay healing and
contribute to wound
infections
• Sedatives
– Contribute to
insomnia and
drowsiness
– Alter
Alt level
l
l off arousall
– Delay healing
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5/13/2013
Cancer Associated Cognitive
Impairments6
Chemotherapy
Radiation Therapy
•
•
•
•
•
•
•
•
Inattention
Lack of concentration
Decreased working memory
Impaired executive functioning
Inattention
Decreased memory
Impaired executive functioning
Impaired visual/ perceptual skills
Steroids
Sedatives
• Behavioral changes
• Decreased verbal memory
• Inattention
• Decreased level of arousal
• Delirium
• Confusion/disorientation
Current Methods to Measure
C
Cognitive
iti F
Function
ti
• Subjective: Based on clients’ perceptions of
cognitive function deficit and the functional impact
through structured interview
– Mild cognitive impairment is one of the most common
symptoms reported by survivors after breast cancer
treatment13
• Objective: Based on objectively documented
deficits in cognitive performance on
neuropsychological tests
– Research using neuropsychological tests indicates
chemotherapy affects executive function, processing
speed, attention/concentration, and verbal/visual memory13
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5/13/2013
Subjective Assessments –
Neuropsychology13
• Self report questionnaires
– European Organization for Research and Treatment of
Cancer Quality of Life (EORTC QLQ-C30)
– Cognitive Failures Questionnaire (CFQ)
– Cognitive Function Scale and Questionnaire for Selfperceived
i dD
Deficits
fi it iin Att
Attention
ti (FEDA)
• Perceived cognitive impairment is strongly associated
with fatigue, anxiety and depression
– Clinical assessment of fatigue and sleep patterns is
necessary
– Diagnosis of anxiety vs. depression
Objective Assessments Neuropsychology
• Mini-Mental State Examination (MMSE)
• High Sensitivity Cognitive Screen (HSCS)
• Visual reproduction
– Immediate and delayed recall
• Word fluency
• Block design
• Stroop test
Barriers to Accurately Assessing
Cognitive Dysfunction
•What is the patient’s normal range of
functioning on a neuropsychology test?
•Is neurocognitive testing sensitive
enough
h to d
detect subtle
bl d
deficits?
fi i ?
•Has the patient experienced a change in
cognitive functioning prior to the cancer
diagnosis or cancer treatment?
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5/13/2013
The Role of Occupational Therapy
Occupational Therapy
Evaluation Methods
• Cognitive Evaluations
– Montreal Cognitive Assessment (MOCA)
– Test of Everyday Attention
– River-mead Behavioral Memory Test
• Performance Based Cognitive Assessments
– A-ONE
– Executive Function Performance Test
– Multiple Errands Test
• Occupation Based Assessments
– Canadian Occupational Performance Measure (COPM)
– Model of Human Occupation Screening Tool
(MOHOST)
Montreal Cognitive
Assessment (MOCA)14
http://mocatest.org/permission.asp
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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5/13/2013
Treatment Approaches for Cancer
Associated Cognitive Impairment15
• Neuro-anatomy based treatment approach
• Restorative/remedial approach
• Cognitive compensatory approach
• Self-management approach
Neuro-Anatomy Based Approach15
• Theory based approach
• Dysfunction at this level can be associated to
a very specific lesion in the brain
• Strategies (usually adaptive) can be used to
resume or improve function
– Strategies focus on activity analysis and
task/cue simplification
– Divide tasks into component parts that can
be taught/learned
Restorative/Remedial Approach15
• Remediate impairment with exercises
and strategies
• Drills, computer games
• Attention process training (ATP)
• Cognitive or task “shifting”
• Limited functional application and not
100% occupation based
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5/13/2013
Compensatory Approach15
• Compensatory/adaptive strategies are used to
facilitate improved cognitive function
• Strategies for compensation can be applied to
a specific skill or functional task
• Use a patient’s strengths to achieve successful
occupational performance
– Ensure that strategy-use is functional and
meaningful for each patient
Compensatory Approach
Strategy Training15
• Mental rehearsal
– Improves planning and self regulation
• Self instructional strategies
– Verbalizing self cues and task goals
– Improves concentration/focus
• Visual imagery and self monitoring
• Task reduction
– Activity simplification by breaking down an activity
into smaller manageable tasks
• Minimize distractions
Self Management Approach15,16
• Focus on:
– Problem solving
– Action planning/goal setting
– Facilitate
F ilit t open communication
i ti
– Minimize anxiety to enhance confidence
– Promote social learning in group format
with others who have similar experiences
or conditions
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5/13/2013
Self Management Approach15,16
• Questions to guide self reflection:
– What do I have the most difficulty with?
– What is the severity of the problem?
– What strategies or modifications can I use to alter
my performance?
• Encourage self monitoring during and after
completion of a task
– “Check in” or “self check”
– Anticipate difficulties and generate alternate
strategies
Self Management Components16
• Drug and symptom management
• Management of anxiety/depression/fatigue levels
• Life style modifications
• Exercise
• Healthy diet
• Regulating sleep routine
• Social support
• Communication
• Action planning
Cognitive Behavioral
Strategies
Compensatory Skills
Training
• Coping skills/relaxation
• Sleep hygiene and education
• Self/goal management
• Strategy use for completing tasks
differently
• Modify behaviors and environment
Comprehensive Cognitive
Rehab Approach
Remediation/Restoration
•
•
•
•
Cognitive “shifting”
Computer based training
Practice, practice, practice
Relevant real-life tasks
Exercise & Activity
Participation
• To promote and maintain focus/
concentration
• Stress management
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
11
5/13/2013
Challenges in Selecting Cognitive
Treatment Interventions
• The patient needs to be capable of cognitive
learning
• Does the patient have insight into his/her
deficits?
• Is
I the
th patient
ti t willing
illi to
t take
t k ownership
hi ffor
his/her cognitive program?
– Can the patient dedicate practice time to
novel restorative and compensatory
strategies?
• Are there other confounding problems?
– Pain, anxiety, depression, etc.
Possible Solutions
• Focus on strategy training instead of
solely on task mastery (the how instead
of the what)
• Cognitive strategy training in real-life
real life
contexts
• Patient centered/focused
– INDIVIDUALIZED program
• Encourage problem solving and action
planning
Case Example – Patricia
• 55 year old female diagnosed with Acute
Myeloid Leukemia (AML)
• 7th grade science teacher (on medical leave)
• Cancer treatment:
– Induction/consolidation chemotherapy
– Admitted for a Double Cord Blood
Transplant (DCBT)
– Hospitalized for 3 months for
treatment/medical complications
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5/13/2013
Acute Care Evaluation and Discharge Status
EVALUATION (prior to transplant):
Cognition
•MOCA score 27/30
BADL performance
•Independent
Strength/coordination
•Intact
DISCHARGE STATUS:
Cognition
•MOCA score 26/30
**Impaired focus, attention, memory
BADL performance
•Supervision with dressing
•Min A with showering
Strength/coordination
•Impaired hand strength/FM coordination
Outpatient Occupational
Therapy Goals
• Short term goals (4 weeks)
– Pt. will be modified independent
with making her bed and sorting
through mail/bills to complete
IADL tasks daily.
– Pt. will demonstrate increased
FM coordination to increase
writing tolerance with sending
thank-you cards and
manipulating daily medication.
Outpatient Occupational
Therapy Goals
• Long term goals (8 weeks)
– Pt. will be independent with
summarizing a short magazine
article, and counting the number
of times a word appears in the
article to demonstrate improved
attention/focus.
– Pt. will be independent with a
HEP (hand strengthening and
cognitive activities) for increased
independence with paying bills on
time, creating lesson plans, and
medication management.
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5/13/2013
Outpatient Occupational Therapy
Interventions
• Compensatory strategies
– Energy conservation techniques; task simplification
– Equipment/environment modifications; shower chair
– Activity log; writing things down
– Minimizing distractions
• Restorative activities
– Reading and summarizing content
– Graded/increased time spent reading and writing
– Creating sample lesson plans
• Self management strategies
– Goal setting/action planning
With a Decline in Function…Acute Care
Occupational Therapy Interventions
• Compensatory strategies
– Minimizing distractions in the environment
– Following simple 1-2 step directions
– Cue simplification for self care and transfers
• Restorative activities
– Repetitive practice of simple tasks (grooming and
oral care with adequate concentration)
– Recalling sequence for safe transfer to chair –
patient verbally recites the steps
– Daily orientation and recall questions
Conclusion
• Cognitive dysfunction resulting from cancer
treatment requires a combination of intervention
approaches
– Compensatory, restorative and behavioral
modification
• A patient-focused approach is necessary for
carryover
– The patient needs to be an active participant.
– Emphasis on meaningful and real-life tasks
leads to improved occupational performance
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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5/13/2013
References
1.
2.
3.
4.
5.
6.
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9.
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Hoboken, NJ, Wiley-Blackwell.
Winick, N. Neurocognitive outcome in survivors of pediatric cancer. Curr Opin in Ped 2011;
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intensive care unit. JAMA. 2004;291 (14), 1753-1762.
11. National Cancer Institute. (2011). Surveillance epidemiology and end results fact sheets:
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© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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