Sandra A. Mitchell, CRNP, MScN, AOCN National Cancer Institute, Bethesda, MD
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Transcript of Sandra A. Mitchell, CRNP, MScN, AOCN National Cancer Institute, Bethesda, MD
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
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
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
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
Pathologic type
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)
BRAINSTEM•Diplopia•Altered consciousness and attention•Cranial neuropathies (visual field loss, dysarthria, impaired extraocular muscle movements)
CEREBELLUM•Ataxia
CORPUS CALLOSUM•Transmission of visual information•Integration of sensory input•Transmission of somatosensory information
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
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
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
Cognitive Function
Cognitive function encompasses the processes by which sensory input is elaborated, transformed, reduced, stored, recovered and used.
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
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
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 individual’s ability to direct concentration capacities.
Concentration exists in three forms:
sustained concentration focused
concentration(selective) divided (alternating)
Distractions environmental – external self – internal
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.
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).
Visuospatial and Constructional Skills
Loss of topographical memory Inability to find the way and
tendency to become lost in familiar and unfamiliar environments
Visuospatial and Constructional Skills
Apraxic agraphia- poor letter formation spatial distortions patient/family report
illegible handwriting
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
Visuospatial and Constructional Skills
Acalculia (difficulty with calculation)
may result from misplacement of digits, misalignment of columns, or aphasia for number symbols
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
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 patient’s ability to respond appropriately to tests of sensory function
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.
Anosognosia
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
Diplopia (double vision)
Visual field deficits (hemianopia, quadrantanopia)
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
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
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)
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
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)
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
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?
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
Language Production Difficulties
Repetitive speech Automatisms
Perseveration
Stereotypy
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 withstress and fatigue
May lead to conflict and frustration in families
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
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
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?
Executive Function
Adaptive abilities that enable us to:
analyze what we want develop and carry out a plan
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)
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)
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
Mood,Thought, Personality, Behavior
Mood Thought content and
processes Baseline personality and
coping style Behavior
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
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 planningOverwhelmed by complexities of busy household
Diminished mental concentration
Overlay of: Fatigue Depression Side effects of anticonvulsants
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.
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
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
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)
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
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
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
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
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
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
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
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)
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)
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
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)
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
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 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 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
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 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 visual field cuts or diplopia hearing loss from aging or chemotherapy, peripheral neuropathy
Determine patient’s language ability 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: 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 LearningImmediate Memory Domain
RBANS Story MemoryImmediate Memory
RBANS Figure CopyVisuospatial/Construction Domain
RBANS Figure RecallDelayed Memory Domain
RBANS Line OrientationVisuospatial/Construction Domain
RBANS Picture NamingLanguage Domain
RBANS Semantic FluencyLanguage Domain
RBANS Digit SpanAttention Domain
RBANS List RecallDelayed Memory Domain
RBANS List RecognitionDelayed Memory Domain
RBANS CodingAttention Domain
Trailmaking Test – Trails AExecutive Function
Trailmaking Test – Trails BExecutive Function
Janet’s 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
Bernie’s 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
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
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
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)
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
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 limitationsSherwood et al,
(2004)
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
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
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
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
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
Research Agenda
Evaluate the effects of complementary and mind-body therapies (relaxation, exercise, music, humor, nutrition, rest/sleep) on cognitive function