Cancer-related cognitive impairment (CRCI) is a result of a slew of confounding variables, including cancer, its treatments, and other factors. Although the side effect is expected, it doesn’t have to be accepted. Patients have many options to manage CRCI, and nurses have an important role in education, assessment, and referral to support, according to speakers at a session on April 29, 2021, during the 46th Annual ONS Congress™.
How Does Cognitive Impairment Manifest With Cancer?
Although its colloquialism is “chemo brain,” CRCI occurs with a variety of treatments or can be altogether unrelated to the treatment itself. The term refers broadly to a collection of problems that cancer survivors experience related to thinking, memory, attention, and executive function. Patients may have decreased short-term memory, difficulty finding words, increased time to perform tasks, and an overall foggy feeling.
In addition to being frustrating, CRCI can cause problems with everyday activities and have significant psychological effects, Samantha J. Mayo, PhD, RN, from the University of Toronto, said. Studies have demonstrated patients’ emotional distress when they experience difficulties in fulfilling roles and responsibilities at home or at work, doing the activities they enjoy, or maintaining health routines.
Although CRCI appears to be more common in patients with brain and central nervous system, breast, and hematologic cancers, patients with any cancer diagnosis may be at risk. John Merriman, PhD, RN, AOCNS®, from New York University Meyers College of Nursing provided insight into the mechanisms of CRCI: cancer treatments may contribute to underlying mechanisms such as inflammation and immune dysregulation. Patient-related factors like age, years of education, genetic predisposition, sex or gender, and racial identity; comorbidities and medications to treat them; and sleep problems, anxiety, depression, and fatigue may also contribute.
Nursing Strategies to Manage CRCI
Nurses should advise patients about the potential for developing cognitive symptoms, provide suggestions for reducing risk and managing day-to-day challenges, and routinely assess for changes in cognitive function to enable referral for further assessment or interventions if needed. Deborah “Hutch” Allen, PhD, RN, CNS, FNP-BC, AOCNP®, from Duke University Health System, said that nurses can use tools to assess cognitive function, including the National Comprehensive Cancer Network’s (NCCN’s) Distress Thermometer, National Institutes of Health’s Patient-Reported Outcomes Measurement Information System (PROMIS), Functional Assessment of Cancer Therapy (FACT)-Cog, and European Organization for the Research and Treatment of Cancer’s (EORTC’s) Quality-of-Life Questionnaire (QLQ)-C30 (which is available in nearly every language).
But nurses can begin by simply asking some baseline questions, such as:
- Do you forget things more often?
- Do you get distracted easily?
- Is it difficult to concentrate or stay focused?
- Does it take you longer to do things?
- Are the changes affecting your social, work, or family interactions?
Patients may be referred for formal neuropsychological testing to assess executive function, learning, memory, and processing speed.
Pharmacologic Interventions for CRCI
Medications such as methylphenidate and dexmethylphenidate, modafinil and armodafinil, and donepezil and memantine may be used off label. Complementary and alternative medicines such as gingko biloba or vitamin E and agents to improve anemia have not been proven effective and are not recommended.
Nonpharmacologic Interventions for CRCI
Current evidence continues to grow in support of nonpharmacologic strategies to mitigate the cognitive impact of cancer and cancer therapy, according to Jamie Myers, PhD, RN, AOCNS®, from the University of Kansas School of Nursing. Cognitive rehabilitation encompasses cognitive training or computer-based training; strategy training, including behavior programs that focus on compensatory strategies, psychoeducation, stress reduction, and peer support; and cognitive behavioral therapy to reframe negative behaviors or beliefs.
Current NCCN survivorship guidelines for cognitive function recommend regular physical activity as well as forms of mindfulness such as meditation, yoga, or mindfulness-based stress reduction. An anti-inflammatory diet high in omega-3 fatty acids and low in trans fats, hydrogenated or processed oils, fried foods, and added sugars also may help improve brain function.