Speaker Disclosure. Learning Goals. Identifying and managing cognitive and behavioral effects of CNS cancers 11/21/2016

Transcription

1 Identifying and managing cognitive and behavioral effects of CNS cancers Michael Feuerstein, PhD, MPH Miami Neuro Nursing Symposium Baptist Health Neuroscience Center December 1-3, 2016 The Biltmore Hotel Coral Gables, Florida Speaker Disclosure There are no relevant commercial relationships to disclose M. Feuerstein, PhD., MPH Learning Goals Major cognitive problems, clinical correlates and bio-behavioral mechanisms in prevalent CNS cancers Approaches used to assess cognitive problems and distress in CNS cancer survivors Interventions to manage cognitive problems in CNS cancer survivors 1

2 Long term and late effects Brain Tumors Sensory Hearing Sight Taste Fatigue Depression/Anxiety/Fear Health Behavior changes (activity, diet, weight gain, smoking) Work Financial strain Health seeking skills (health care literacy) Co-morbidity Caregiver Concerns Brain Tumors Cognitive Problems BT Survivors Cognitive processing speed Attention Cognitive control and flexibility Organization Verbal learning Working memory Planning and foresight Gerke, et al. J. Neurooncology,

3 Cog Impairment Healthy Older Adults CNS Meds N=2737 Biobehavioral Plausability Brain slower Brain works harder Clinical Assessment Cognitive Function Neuropsych testing Patient-Reported Outcomes (PROMISE) Cognitive challenges at work (CSC Work) Distress Distress Thermometer (DT) fonc pdf Unmet needs- Post Treatment Cancer Survivor Profile (CSPro) 3

4 Case: MF Male, age 52 Diagnosis: Anaplastic astrocytoma, Grade 3, rt cerebellum Resection, 59 gy fractioned targeted radiation, 12 months of Temozolomide- 5 days on 25 off 12 months Premature aging- post neurosurgery and radiation -short term memory, executive functioning, info processing Brain MRI with contrast revealed absence of tumor activity Reported cognitive complains at each visit Referred to a speech pathologist-boston Naming Test Report to neuro-oncologist- WNL Referral to PT NCI-perplexed reaction from Rehab Why? Problems Persisted Neuropsychology Consult MD Anderson yrs post tx Results Cognitive processing speed (sig problem) Mental flexibility (sig problem) Working memory (sig problem) Fine motor coordination on right (sig problem) Visual constructional skills/right hemispace neglect (difficulty) Tests that were timed or required mental manipulation (difficulty) Mild depression (secondary to suboptimal function) Impression Results consistent with dysfunction of the ascending white matter tracts from the cerebellum to the frontal-sub cortical region Management Methylphenidate, Buproprion, B6 and B12, Folic Acid, Manage Stress, Acupuncture, PDA with alarm, periodic neuropsych evaluations Follow Up Cognitive Neurologist: 2013 Memory problems Cerebellar cognitive-affective Syndrome Recommend neuropsychological testing cog rehab keep mind active aerobic exercise Mediterranean diet lots of fish, no red meat hobbies ball room dancing, book club Tai chi practice online cog exercises/games For neuroplasticity to settle in human takes several- 2 years Neuropsychologist: 2005/ FU Cognitive processing speed Mental flexibility Working memory Fine motor coordination on right Visual constructional skills/right hemi space neglect (difficulty) Tests that were timed or required mental manipulation Mild depression (secondary to suboptimal function) 2015 Comprehensive Verbal and visual memory (encoding and retrieval) Information processing speed Visual-spatial processing Verbal fluency (phonemic and semantic Mild depression 4

5 Female Marine s Story Golf-ball-sized brain tumor called an astrocytoma Brain surgery Sept. 25, Left leg was paralyzed from the surgery. Given a walker released from hospital after five days. Highly motivated to recover, used walker right away upon arriving home. Walking on her own by Thanksgiving. April 2007, started taking Temodar. Temporary Disability Retired List for five years. Was angry and devastated. Never thought this would happen. Eventually began seeing a counselor who helped her deal with her emotions. June 1, 2007, medically retired. Later in June, family moved back to Virginia her husband had been transferred there. Over the next few years, received an MRI every three months. The tumor had shrunk even more due to the radiation and chemotherapy, and while it was still there, it was at least stable. Pregnant with second child, husband walked out. Moved in with parents then into her own house. Started working part-time at a bridal shop supplement her retirement pay. Toward end of her five-year retirement, decided she wanted to come back on active duty. Her tumor was stable, feeling healthy. March 2013, re-enlisted. Assigned to Basic School so she could stay in the area where her family and support system were located. Promoted to sergeant in January Cognitive Problems BT Survivors Cognitive processing speed Attention Cognitive control and flexibility Organization Verbal learning Working memory Planning and foresight Gerke, et al. J. Neurooncology, 2013 Typical Neuropsychological Evaluation Brain Tumor Abstract Reasoning Memory Attention Language Verbal Perception Executive Functioning 5

6 Cognitive Problems at Work Ottati and Feuerstein 2013 Distress and Unmet Needs 6

7 Intervention Options Symptom Management Pharma Non Pharma Cognitive Management Cog Rehab Pharma- assess continuously Compensatory strategies Lifestyle change Cognitive Rehab Back et al 2013 Trial of Cognitive Rehab Back et al

8 Cognitive Rehab for Gliomas Interventions Neuropsych training software Virtual reality and computer assisted cog rehab Computer exercises guided by neuropsychologist Holistic mnemonic training program Cognitive training, compensatory techniques, computerized homework Cognitive rehab, problem solving therapy, use of a memory notebook Outcomes Memory, attention, visual spatial function, language, reasoning Sequential recall, verbal recall Verbal and non verbal memory Creativity Bergo et al 2016 Exercise and Cognitive Function Neuro- Plasticity K o 8

9 Transient Plasticity Draganski et al 2004 Work and Cancer Survivors Accommodations Stergiou-Kita et al semi-structured interviews cancer survivors=16 Health/voc providers=16 Employer=8 Four types accommodations recommended Gradual return to work plans/flexible schedule Modification of work duties and expectations Retraining and supports at the workplace Modification of the physical work environment and/or adaptive aids/technologies We need a new approach Conventional health care model Improve the cognitive abilities of the impaired worker- change to worker to fit the job Public Health model Engineer the problem out of the workplace- change the work to fit the person 9

10 Discrimination of Cognitive Demands in Breast Cancer and BT Survivors Mathan et al., 2010, Conf Proc IEEE Eng Med Biol Soc Detect and mitigate: Memory, Information Processing Speed, Executive Function, Attention Bottom Line: What does the research tell us? 10

11 Thank you 11