Also called: cognitive retraining
Cognition is our mental skill or ability and includes functions such as thought, reason, perception, judgment, learning, attention and memory. When a person has problems with cognitive function that result in difficulties with these mental skills, they may be suffering from what is called cognition impairment or cognitive dysfunction. People may experience some type of cognitive problems because of their cancer, its progression or side effects of treatments like chemotherapy or radiation therapy. Cognitive rehabilitation may help a person regain or cope with changes in cognitive functioning.
Causes
There are many reasons why people with cancer may experience cognitive problems. Some of these are due to:
- cancer
- Central nervous system (CNS) tumours, such as brain tumours, or cancer that has spread (metastasized) to the brain, can cause problems in cognitive functioning.
- cancer treatments
- Chemotherapy may cause problems with memory or thinking. This is sometimes called "chemo-brain." Higher doses of chemotherapy are more likely to cause cognitive impairment.
- Radiation therapy to the brain can cause changes in cognitive functioning, because of damage to brain cells or brain swelling. This may lessen with the help of medications or with time.
- Some biological therapies (such as interleukin-2 ) can also cause cognitive impairment, especially when taken for a long period of time.
- Hormonal therapies such as anti-estrogen have been linked to cognitive impairments, but this is less severe and direct than with other therapies.
- medications
- Many drugs used to manage medical problems may cause side effects of cognitive impairment.
- These can include immune-suppressing drugs used in stem cell transplants, antibiotics, corticosteroids, pain-relievers, or medications used to manage nausea or vomiting and other cancer-related symptoms.
- infection or anemia
- Infections and low red blood cell counts (anemia) can cause fatigue in people with cancer and may result in trouble with memory or thinking.
- People having some cancer treatments can be at risk for developing an infection or anemia.
- metabolic problems
- Some cancers (such as small cell lung cancer) can produce hormones or neurochemicals that affect the brain's function.
- When the thyroid gland does not make enough of the thyroid hormones, it can reduce the person's ability to think clearly and can affect mood.
- When the liver or kidneys are not working properly, it can affect a person's mental functioning because of the buildup of toxins in the blood that are normally removed by these organs.
- nutrition problems
- Too little iron, vitamin B and folic acid can cause a decrease in attention and perception and affect movement, memory and the ability to speak clearly.
- psychosocial reactions
- Psychological reactions to cancer and cancer treatment can cause psychological symptoms that also create cognitive problems. Depression and anxiety can reduce a person's ability to concentrate or cause fatigue, irritability and problems with memory.
Often problems with cognitive function are caused by more than one factor.
Symptoms
Cognitive changes can be very mild or subtle and may not be noticed by the person affected or family members. Cognitive changes may also include a collection of symptoms that cause significant changes in a person's mental skills. These effects are often temporary, but depending on the cause they may be more long-lasting. Cognitive changes vary widely and may include:
- problems with language or speech
- trouble expressing oneself in words
- trouble recalling words or naming objects
- trouble understanding words or conversations
- trouble writing
- trouble with arithmetic
- having a hard time following directions
- trouble problem solving
- trouble remembering or memory loss
- difficulty learning new things
trouble focusing attention or easily distracted
trouble switching between tasks
difficulty concentrating or organizing thoughts
slowed speed of thinking
mood swings
irritability
confusion
personality changes
Cognitive problems can affect a person's psychosocial well-being and may interfere with their ability to understand or make decisions about their illness or treatment. Cognitive problems can also interfere with a person's ability to work or affect their ability to perform daily activities and their overall quality of life.
Diagnosis
Often the early signs of cognitive impairment may be subtle and are easy to miss and some of the changes associated with it can be confused with or made worse by depression or fatigue.
Problems with mental functioning may be assessed by:
- doing a neurological examination
- A neurological examination is part of a physical examination that checks how well a person's nervous system is working and tests speech, vision, sensation, balance, coordination, reflexes, muscle strength and muscle function including the ability to walk or move around (mobility).
- It includes a mental status examination. A mental status examination assesses a person's emotional, mental and behavioural abilities and helps find areas that are causing problems.
- A neuropsychological assessment is also done to assess cognitive function. A neuropsychosocial assessment is a special kind of psychological testing used to assess cognitive strengths and areas of weakness or impairment.
- The person is often asked to recall recently learned information or focus on a topic or task. People can "learn" the right answers to questions, so it is important that the questions be varied when assessing the person over time.
- checking for cognitive changes
- Nurses or family members may be asked about changes in a person's normal behaviour or functioning. Family members are often the first people to notice a change in a loved one's cognitive function or personality.
- The effect of cognitive impairment on the person's ability to function and quality of life is also assessed.
- doing diagnostic tests
Management
In many people with cancer, cognitive problems are reversible. Mild cognitive problems tend to respond well to focused rehabilitation efforts. Besides treating the underlying cause, such as cancer or a metabolic problem, managing cognitive changes can include education, cognitive retraining techniques and exercises or medications.
Education
The person with cancer should be given information and educated about the areas of cognitive impairment and cognitive strengths. They are better able to focus on rehabilitation of cognitive weaknesses when they are made aware of their specific deficits.
Cognitive rehabilitation
Trained healthcare professionals use a variety of techniques to help people cope with lost skills or learn new skills that make up for those that are lost.
- restorative techniques
- Restorative methods use simple relaxation techniques to help restore the person's ability to focus and maintain attention. Relaxation can also help decrease stress, which can also cause problems with cognitive function.
- compensation techniques
- Compensation techniques can help people learn new skills to make up for some of those that are lost. Sometimes this involves having the person avoid doing too many tasks at once (multitasking), decreasing their workload or increasing the amount of sleep they get. It may also include tips to help them remember, such as making lists, keeping a calendar, writing in a journal or using small, hand-held recording devices.
- vocational rehabilitation
- Vocational rehabilitation may be needed when cognitive impairment seriously interferes with the person's ability to work, go to school or do volunteer work.
Mental and physical exercises
Mental and physical exercises can help maintain memory and other mental functions.
- Mental activities like reading, doing puzzles, writing or doing some computer games can strengthen the connections between the brain cells and keep them active.
- Physical activity, including light exercise like walking, gardening or stretching can also help protect the brain.
Medications
Medications are sometimes used to manage cognitive impairments.
- Antidepressants may be used to treat depression, if cognitive problems are due to depression or made worse by it.
- Drugs called psychostimulants may be used to improve concentration and memory. An example is methylphenidate (Ritalin), a drug that stimulates the central nervous system and is used to treat attention deficit disorder because it has a focusing effect, which helps people pay attention and follow instructions better.
- Drugs that work against opioids may also be used to decrease drowsiness (somnolence) caused by the opioid pain-relieving drugs.
- Recent research has reported some evidence that erythropoietin may also improve cognitive performance, decrease fatigue and improve quality of life in people who have had chemotherapy. Erythropoietin is a natural hormone made by the kidneys that stimulates the bone marrow to make red blood cells. Epoetin (Eprex) or darbepoetin (Aranesp) are drug forms of erythropoietin that are used to treat anemia.
Counselling
Caregivers and family members close to the person with cancer may have trouble coping with personality or other cognitive changes and feel they have "lost" the person they once knew. Psychosocial counselling and support may help both the person with cancer and their family cope with these changes. A counsellor who is trained in neuropsychology can help support the person as well as tailor the rehabilitation efforts to the person on an ongoing basis as the needs change over time.