Cognitive Dysfunction In Patients with a Primary Brain Tumor: Exploring and Navigating Uncharted Waters

1
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

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Objectives

• 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.

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Case 1 Janet

• 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

4
Case 2 Bernie

• 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

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Factors Contributing to Neurobehavioral Changes
Associated with Brain Tumors

• Location of the tumor
• Pathologic type
• Patient characteristics

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• 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)

• 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

• OCCIPITAL
• Alexia (disorders of reading)
• Homonymous hemianopsia
• Impaired extraocular muscle movements
• Color anomia
• Achromatopsia (impairment in color perception)

• TEMPORAL
• Auditory and perceptual changes
• Memory and learning impairments
• Aphasia and other language disorders

• 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)

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Factors Contributing to the Neurobehavioral
Changes Associated with Brain Tumors

• Pathologic type
• Low grade histology
• High grade histology
• Patient characteristics
• Age
• Physical co-morbidities
• Psychological co-morbidities
• Symptom experience
• Fatigue
• Pain

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Factors Contributing to the Neurobehavioral
Changes Associated with Brain Tumors

• Adverse effects of treatment
• surgery
• radiation therapy
• chemotherapy
• Side effects of adjunctive medications
• corticosteroids,
• anticonvulsants
• psychoactive medications
• Medical complications
• endocrine dysfunction
• seizures
• infection
• anemia
• sleep disorders

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Effects of Cognitive Dysfunction on Patient,
Family and Health Care Team

• Physical, psychological, social and vocational
  functioning
• Level of distress
• Quality of individual and family life
• Insight and self-appraisal
• Self care abilities, decision-making and
  treatment adherence

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Cognitive Function

• Cognitive function encompasses the processes by
  which sensory input is elaborated, transformed,
  reduced, stored, recovered and used.

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Domains of Cognitive Function

• 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

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Attention- Capacity to Detect and Orient to
Stimuli

• Prioritize signals from one spatial location
• spatial attention
• Prioritize some forms of information and to
  suppress others on the basis of a functional goal
  
• selective or focused attention
• Self maintain an alert and ready-to-respond state
• arousal/sustained attention

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Concentration-Directing Thoughts and Actions
Toward a Stimulus

• Capacity- refers to the amount of information
  processing a person can do in a given time
• Control refers to an individuals ability to
  direct concentration capacities.
• Concentration exists in three forms
• sustained concentration
• focused concentration(selective)
• divided (alternating)
• Distractions
• environmental external
• self internal

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Visuospatial and Contructional Skills -Apraxia

• Difficulty performing a planned motor activity in
  the absence of paralysis of the muscles normally
  used in the performance of that act.
• Can also be considered a disorder of language as
  many procedural tasks are verbally mediated.

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Visuospatial and Contructional Skills -Apraxia

• Ideational apraxia
• Basic sequence of events and logical plan
  underlying a chain of simple actions is disrupted
• Ideomotor apraxia
• Dissociation between the areas of the brain that
  contain the ideas for movements and the motor
  areas that actually execute the movements.
• Constructional apraxia
• Inability to produce properly organized
  constructions such as drawings or simple building
  tasks
• Motor apraxia
• Not generally reported by patient, but family
  will often describe difficulty with using common
  objects (toothbrush, eating utensils).

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Visuospatial and Constructional Skills

• Loss of topographical memory
• Inability to find the way and tendency to become
  lost in familiar and unfamiliar environments

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Visuospatial and Constructional Skills

• Apraxic agraphia-
• poor letter formation
• spatial distortions
• patient/family report illegible handwriting

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Visuospatial and Constructional Skills

• Alexia (difficulty reading)
• 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

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Visuospatial and Constructional Skills

• Acalculia (difficulty with calculation)
• may result from misplacement of digits,
  misalignment of columns, or aphasia for number
  symbols

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Sensory-Perceptual Function

• Distinction between sensation and perception
• The senses capture information from the
  environment
• Subsequent elaborations and interpretations in
  different parts of the brain enable one to
  perceive or become aware of external stimulation
• The most common perceptual deficits are
• auditory
• tactile
• visual

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Factors Influencing Evaluation of
Sensory-Perceptual Function

• Underlying primary sensory deficit (eg. color
  blind at baseline, hypoacusis at baseline
  secondary to age-related hearing loss)
• Advancing age may diminish senses and dull
  perception
• The state of the perceiver(e.g. anxiety, physical
  discomfort) may influence the perception of a
  stimulus
• Severe language problems can impair a patients
  ability to respond appropriately to tests of
  sensory function

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Common Sensory-Perceptual Deficits in Patients
with a Primary Brain Tumor

• 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.

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Anosognosia

• Lack of awareness of impaired neurologic or
  neuropsychological function which is obvious to
  the clinician and other reasonably attentive
  individuals.

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Common Sensory-Perceptual Deficits in Patients
with a Primary Brain Tumor

• Diplopia (double vision)
• Visual field deficits (hemianopia,
  quadrantanopia)

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Common Sensory-Perceptual Deficits in Patients
with a Primary Brain Tumor

• Achromatopsia - impairments in color perception
• Color anomia - inability to name colors or to
  select a color from an array of colors when
  requested

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Common Sensory-Perceptual Deficits in Patients
with a Primary Brain Tumor

• Visual hallucinations (photopsia)
• stars, dots, lines, fog, wavy lines
• Illusions (metamorphopsia)
• distorted objects, faces, scenes

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Common Sensory-Perceptual Deficits in Patients
with a Primary Brain Tumor

• Alexia (reading difficulties)
• words or syllables missing
• change of lines, or reduced reading span
  (hemianopic alexia)

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Common Sensory-Perceptual Deficits in Patients
with a Primary Brain Tumor

• 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 (hemispatial-neglect,
  hemianopia)
• Difficulty detecting the movements of targets in
  space - visual scenes may appear as a series of
  static snapshots

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Language

• Aphasia/dysphasia
• 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)

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Language

• Dysarthria
• 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
• interruption of speech inflections and rhythm
  (i.e. speech melody)
• resultant monotone or halting speech

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Evaluation of Spontaneous Speech

• 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?

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Language Production Difficulties

• Pauses, hesitancy
• Restricted range of vocabulary
• Use of circumlocutions
• Discontinuation of a phrase
• Substitution of a presumably-intended word by
  another word (verbal paraphasia)
• Substitution of a presumably-intended word by a
  meaning related word (semantic paraphasia)
• Difficulty with grammatical construction
• Telegraphic speech style

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Language Production Difficulties

• Repetitive speech
• Automatisms
• Perseveration
• Stereotypy

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Language Comprehension Difficulties

• 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

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Memory

• Remote memory (memories from childhood and early
  adulthood)
• usually preserved
• Recent memory
• 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

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Memory Loss Symptoms

• Examples of memory loss symptoms
• 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

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Memory Loss Symptoms

• Assess
• 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?

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Executive Function

• Adaptive abilities that enable us to
• analyze what we want
• develop and carry out a plan

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Executive Function

• Establish new behavior patterns and ways of
  thinking about and reflecting upon our behavior
• Understanding of complex social behavior such as
  understanding how others see us, being tactful or
  deceitful.
• Burgess et al (2000)

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Executive Dysfunction

• Difficulties with abstract thinking, planning,
  decision-making
• 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)

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Executive Dysfunction

• Lack of insight
• Distractibility
• Marked reduction in spontaneous purposeful
  activity
• Confabulation
• Perseveration
• Lack of concern
• Shallow affect, impulsiveness, disinhibition,
  aggression, unconcern for social rules

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Mood,Thought, Personality, Behavior

• Mood
• Thought content and processes
• Baseline personality and coping style
• Behavior

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Case 1 Janet

• 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
• 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

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Case 1 Janet- Clinical Issues

• Cognitive function
• 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
• Fatigue
• Depression
• Side effects of anticonvulsants

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Case 2 Bernie

• 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
• Currently prescribed Dilantin, Decadron and
  Anzemet
• Family concerned about personality changes and
  decision-making capacities. Patient denies any
  current concerns.

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Case 2 Bernie- Clinical Issues

• Clinical Issues
• 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
• Cultural factors
• Side effects of steroids (patient is not
  sleeping)
• Situational anxiety

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Cognitive Screening Clinical Context

• 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

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Cognitive Screening Clinical Context

• 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)

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Nursing Implications for Cognitive Screening in
the Clinic

• 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

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Evidence Supporting Cognitive Screening

• 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

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Linking Nursing and Neurocognitive Assessments

• 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

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Global AssessmentsDuring Interview and History

• Orientation - alertness and awareness of time,
  place, person and situation at all times
• Communication - ability to speak, understand, and
  respond appropriately, speech patterns
• Judgment - insight into self and situation direct
  decision making

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Global AssessmentsDuring Interview and History

• Appearance and Behavior
• attire, grooming, appearance
• General intelligence
• level of education, fund of knowledge
• Mood
• reactions to the topic being discussed
• general perspective about situation, i.e. sad?
  angry?
• Visuospatial ability
• attention given to visual cues
• attends to both right and left sides

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Factors Effecting Patterns of Cognitive Impairment

• Age
• Medical History
• Tumor progression and location
• Fatigue
• Depression
• Treatments, particularly radiation
• Drug therapy such as steroids, anticonvulsants,
  complementary therapies

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Goals of Clinical Cognitive Screening

• 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

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Ideal Screening Instrument Characteristics

• 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)

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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)

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Mini-Mental State Exam (MMSE)

• 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

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Issues with the MMSE

• 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

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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)

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Neurobehavioral Cognitive Status Examination
(NCSE)(Cognistat)

• 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

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When to Refer for a Formal Neuropsychological
Examination

• 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

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Patient or Family Request

• 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

64
Health Care Provider Request

• 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

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Other Referrals for Testing

• 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

66
How to Present the Idea of a Neuropsychological
Exam

• 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

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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

68
Testing Considerations

• Determine patients sensory limitations
• visual field cuts or diplopia
• hearing loss from aging or chemotherapy,
• peripheral neuropathy
• Determine patients language ability
• expressive providing answers
• receptive understanding the demands of the
  tasks
• Limit testing to 1-2 hours to minimize fatigue

69
Neuropsychological Testing

• Brief well-validated measures
• 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

70
RBANS List Learning Immediate Memory Domain
71
RBANS Story Memory Immediate Memory
72
RBANS Figure Copy Visuospatial/Construction Domain
73
RBANS Figure Recall Delayed Memory Domain
74
RBANS Line Orientation Visuospatial/Construction
Domain
75
RBANS Picture Naming Language Domain
76
RBANS Semantic Fluency Language Domain
77
RBANS Digit Span Attention Domain
78
RBANS List Recall Delayed Memory Domain
79
RBANS List Recognition Delayed Memory Domain
80
RBANS Coding Attention Domain
81
Trailmaking Test Trails A Executive Function
82
Trailmaking Test Trails B Executive Function
83
Janets Test Profile

• 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

84
Bernies Test Profile

• 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

85
Providing Feedback

• 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

86
Neuropsychiatric Referral

• Neuropsychological evaluation may identify
  emotional
• and behavioral symptoms requiring medication
• 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

87
Principles of Cognitive Rehabilitation and
Accommodation

• Systematically evaluate cognitive function at
  regular intervals (Meyers et al, 2000)
• Set specific goals for restoration, substitution
  or restructuring of environment (Lazar, 1998)
• Include rehabilitative disciplines (Lazar, 1998)
• Consider role for pharmacologic agents (Barton
  Loprinzi, 2002 Chan et al, 2003 Meyers et al,
  1998)
• Evaluate for and remediate co-morbidities,
  including fatigue, depression, anxiety, insomnia,
  and physiologic discomfort (Litofsky et al, 2004)

88
Principles of Rehabilitation

• Three types of rehabilitative approaches are
  typically included
• Restoration cognitive training and exercises
  directed towards strengthening and restoration of
  function
• Substitution compensatory devices and
  strategies directed towards substitution of lost
  functions and promoting conservation of affected
  brain functions
• Restructuring environmental restructuring and
  planning to promote improved functioning by
  changing the demands placed on the individual by
  themselves and others

89
Anticipatory Guidance

• 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)

90
Psychological Support

• 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

91
Future Directions

• Practice
• More refined evaluation and description of the
  nature of cognitive dysfunction
• Deliberative intervention/remediation/support
• Timely referral to multidisciplinary experts
• Program Planning
• Advocate for improved access to
  neuropsychological evaluation, and cognitive
  rehabilitation
• Systematically evaluate patients at regularly
  scheduled intervals to document progress and
  adjust the plan
• Education
• Develop skills in assessing, describing aspects
  of cognitive functioning
• Expand the knowledge base of intervention
  techniques and approaches

92
Research Agenda

• Instrument Refinement and Psychometric
  Evaluation- brief, clinically useful, valid and
  reliable measures of cognitive function
• Prevalence, incidence, correlates, and sequelae
  of cognitive dysfunction
• Evaluate the relative contributions of mood
  disturbance, insomnia, fatigue, and physiologic
  discomfort

93
Research Agenda

• Develop, test and refine intervention approaches
  targeted to
• remediate or substitute specific aspects of
  cognitive dysfunction (eg. language, memory)
• global aspects of cognitive dysfunction
• programs of patient and family support and
  adjustment

94
Research Agenda

• Evaluate the effects of pharmacologic therapies
  for disorders of mood (anxiety, depression),
  attention, wakefulness, and memory on cognitive
  function and quality of life

95
Research Agenda

• Evaluate the effects of complementary and
  mind-body therapies (relaxation, exercise, music,
  humor, nutrition, rest/sleep) on cognitive
  function