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Dennis Lin, OTD/OTRL
Occupational Therapist
Department of Rehabilitation, City of Hope
Tips for
Managing
Chemo-Brain
CITY OF HOPE
Overview
2
"Chemo Brain" or "Chemo Fog"
 Otherwise known as:
o Chemotherapy Induced Cognitive Impairment
o Cancer Related Cognitive Impairment
 A real clinical syndrome
 Commonly reported side effect
 Effects people receiving treatment for all cancers
o Risks related to cancer treatment, surgery, and other medications
o Effect of the cancer itself
o Impacts felt before, during, and after treatment
o Growing need
CITY OF HOPE
Overview
3
Up to 40% have
impairments before any treatment
Up to 75%
experience difficulties during treatment
Up to 60% have symptoms that
persist for months or
years after treatment
Schmidt JE et al, J Cancer Surviv, 2016
Wefel, JS CA Cancer J Clin, 2015
CITY OF HOPE
Causes
4
Not completely understood
Biological effects of treatment
• Impacted brain cell and activity
• Inflammation
• Cytokine effect
• Oxygenation (Anemia, blood flow)
• Change in hormones
Factors
• Age
• Genetics
• Depression and Anxiety
• Lifestyle (sleep, diet, energy)
CITY OF HOPE
Common Complaints
5
 Comments:
o "Hard time having conversations"
o "No recollection of what I was supposed to"
o "Always feel lost at work"
o "Can't focus on more than one thing"
 Effect on Identity
o Impacted confidence
o Impacted roles
o Sense of guilt
o Anger/frustration
CITY OF HOPE
Cognitive Skills
6
Impacted Areas
• Attention/Concentration
• Verbal memory
• Visual memory
• Visual/Spatial
• Speed of processing information
NOT affected:
• Old memories generally NOT
impacted
• Syndromes of cortical dysfunction
(aphasia, agnosia, apraxia)
CITY OF HOPE
How to address chemo brain?
7
 Brain Training (Remedial approach)
o Brain Exercises targeting specific cognitive skills
o Repeated practice and enhancing challenge
 Helpful Strategies (Compensatory approach)
o Helpful tools to support performance
(e.g. calendars, alarms, reminders)
o Creating a supportive environment
 Lifestyle Management
o Healthy habits that support brain health
o Managing stress and energy related to goals
 Adapting Goals
o Learn new ways of accomplishing goals
CITY OF HOPE
Lifestyle Management
8
CITY OF HOPE
Focal areas
9
Exercise Sleep Hygiene
Fatigue
Management
Healthy
Eating Habits
Pain
management
Lifestyle
Balance
Managing
Mood
CITY OF HOPE
Healthy Habits
10
 Exercise
o Improve activity tolerance and fatigue
o Setting goals to be active 4x/week or total
of 30 minutes/day
o Setting daily step goals
 Sleep Hygiene
o Physical Recovery
o Consistent sleep routines
o Protecting sleep environment
 Mood
o Manage distractions
o Deep breathing and meditation
o Journaling and Counseling
 Lifestyle Balance & Fatigue
o Careful planning
o Ensure proper balance of all activities
o Budget energy
CITY OF HOPE
Lifestyle Management
11
CITY OF HOPE
Cognitive Awareness
12
Arousal
Attention
Memory
Executive Function
CITY OF HOPE
Cognitive Hierarchy
13
Arousal
• Fatigue
• Sleep Quality
• Medication
Side Effects
Attention
• Sustained
Attention
• Divided
Attention
• Multi-tasking
• Alternating
Attention
Memory
• Working
Memory
• Short Term
Memory
• Long Term
Memory
Executive
Functioning
• Initiation
• Motivation
• Judgement
• Planning
• Problem
Solving
-Which of these areas effect you?
-What contributes to lapses in your
memory?
CITY OF HOPE
Managing Attention Span
14
 Know your limits
o How much and how long can you focus
o Pace appropriately
o Take on what you can handle
 Control your environment
o Be aware of what you need to focus on
o Reduce or remove distractions
o Plan with others
 Prepare for how you want to focus
o Relax and manage stress
o Guided or mental imagery
o Verbalize or talk out loud
CITY OF HOPE
Time Pressure Management
15
Time Pressure Management
 Prioritize!
 Plan decisions ahead of time to improve processing
 Identify all the problems that must be solved
by creating steps
 Develop short plans to help with information overload
or mental slowness
 Create an emergency plan if the task
becomes stressful
 Carry out and monitor the plan
CITY OF HOPE
Memory Strategies
16
Internal Memory Strategies
 Mental Imagery
o Sensory cues
o Visualize and Contextualize
o Diagram or structure
 Semantic Clustering
o Organize based on importance or meaning
o Organize based on procedure
 Chunking
o Matching like things together
 Mnemonics
o Helpful for lists
o Engrained routines
CITY OF HOPE
Memory Strategies
17
Method of Loci
• Associating memories with familiar
structure
• E.g. bedroom, house, routinely used
process
• Sequential Order
• Visualizing a walk through
• Memory by associating content with
structured steps
• E.g. associating each list item with a
sequential step
CITY OF HOPE
PQRST Reading
18
PREVIEW QUESTION REVIEW SUMMARIZE TEST
CITY OF HOPE
Memory Strategies
19
External Memory Aides
Robust physical and digital calendars
Phone Reminders
Shared family calendar (Apple Calendars,
Google Calendars)
Voice or Video Memos
Creating separate group messages
Paired Memory Routines
Constant, easy access
Consistent reading and note taking
Takes time to learn and update
routines
Safety net plans
CITY OF HOPE
Examples
20
Christmas Shopping
 Goal: To avoid forgetting items on your list or items
to follow up on
 Create a physical or mental map of steps based
on priority
 Anticipate how you may get distracted (plan
to maintain focus).
 Double check the list, create the next steps and
plan for follow up
Graceful Speech in Conversation
 Relax
 Focus on goal of conversation
 Focus on quality of interaction
Doctor's Visit
• Anticipate the topics of the visit, prepare
questions ahead of time
• Focus and relax mind prior to visit
• Ask for pause in discussion or clarification
• Summarize your understanding with doctor
• Practice recall and strengthen memory
by summarizing to friend/family
• Create specific plans for follow up
CITY OF HOPE
Manage your Goals
21
Be
graceful
Focus on
appropriate
goals
Learn new
strategies to
support
ability
Practice and
build
confidence
Measure
success by
QOL
Adaptation
CITY OF HOPE
Resources and Services
22
Notify your Doctor of your symptoms
 Neurology or Neuropsychology
 Occupational Therapy/Speech Therapy
Brain Training Programs:
 BrainHQ
 NeuroNation
Resources:
 https://www.additudemag.com/
 https://intuitivecreativity.typepad.com/expressiv
eartinspirations/100-art-therapy-exercises.html
 Accommodations under the ADA:
o https://askjan.org/publications/individuals/emplo
yee-guide.cfm
o https://askjan.org/disabilities/Cancer.cfm

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Learn Tips for Managing Chemobrain or Mental Fogginess

  • 1. Dennis Lin, OTD/OTRL Occupational Therapist Department of Rehabilitation, City of Hope Tips for Managing Chemo-Brain
  • 2. CITY OF HOPE Overview 2 "Chemo Brain" or "Chemo Fog"  Otherwise known as: o Chemotherapy Induced Cognitive Impairment o Cancer Related Cognitive Impairment  A real clinical syndrome  Commonly reported side effect  Effects people receiving treatment for all cancers o Risks related to cancer treatment, surgery, and other medications o Effect of the cancer itself o Impacts felt before, during, and after treatment o Growing need
  • 3. CITY OF HOPE Overview 3 Up to 40% have impairments before any treatment Up to 75% experience difficulties during treatment Up to 60% have symptoms that persist for months or years after treatment Schmidt JE et al, J Cancer Surviv, 2016 Wefel, JS CA Cancer J Clin, 2015
  • 4. CITY OF HOPE Causes 4 Not completely understood Biological effects of treatment • Impacted brain cell and activity • Inflammation • Cytokine effect • Oxygenation (Anemia, blood flow) • Change in hormones Factors • Age • Genetics • Depression and Anxiety • Lifestyle (sleep, diet, energy)
  • 5. CITY OF HOPE Common Complaints 5  Comments: o "Hard time having conversations" o "No recollection of what I was supposed to" o "Always feel lost at work" o "Can't focus on more than one thing"  Effect on Identity o Impacted confidence o Impacted roles o Sense of guilt o Anger/frustration
  • 6. CITY OF HOPE Cognitive Skills 6 Impacted Areas • Attention/Concentration • Verbal memory • Visual memory • Visual/Spatial • Speed of processing information NOT affected: • Old memories generally NOT impacted • Syndromes of cortical dysfunction (aphasia, agnosia, apraxia)
  • 7. CITY OF HOPE How to address chemo brain? 7  Brain Training (Remedial approach) o Brain Exercises targeting specific cognitive skills o Repeated practice and enhancing challenge  Helpful Strategies (Compensatory approach) o Helpful tools to support performance (e.g. calendars, alarms, reminders) o Creating a supportive environment  Lifestyle Management o Healthy habits that support brain health o Managing stress and energy related to goals  Adapting Goals o Learn new ways of accomplishing goals
  • 8. CITY OF HOPE Lifestyle Management 8
  • 9. CITY OF HOPE Focal areas 9 Exercise Sleep Hygiene Fatigue Management Healthy Eating Habits Pain management Lifestyle Balance Managing Mood
  • 10. CITY OF HOPE Healthy Habits 10  Exercise o Improve activity tolerance and fatigue o Setting goals to be active 4x/week or total of 30 minutes/day o Setting daily step goals  Sleep Hygiene o Physical Recovery o Consistent sleep routines o Protecting sleep environment  Mood o Manage distractions o Deep breathing and meditation o Journaling and Counseling  Lifestyle Balance & Fatigue o Careful planning o Ensure proper balance of all activities o Budget energy
  • 11. CITY OF HOPE Lifestyle Management 11
  • 12. CITY OF HOPE Cognitive Awareness 12 Arousal Attention Memory Executive Function
  • 13. CITY OF HOPE Cognitive Hierarchy 13 Arousal • Fatigue • Sleep Quality • Medication Side Effects Attention • Sustained Attention • Divided Attention • Multi-tasking • Alternating Attention Memory • Working Memory • Short Term Memory • Long Term Memory Executive Functioning • Initiation • Motivation • Judgement • Planning • Problem Solving -Which of these areas effect you? -What contributes to lapses in your memory?
  • 14. CITY OF HOPE Managing Attention Span 14  Know your limits o How much and how long can you focus o Pace appropriately o Take on what you can handle  Control your environment o Be aware of what you need to focus on o Reduce or remove distractions o Plan with others  Prepare for how you want to focus o Relax and manage stress o Guided or mental imagery o Verbalize or talk out loud
  • 15. CITY OF HOPE Time Pressure Management 15 Time Pressure Management  Prioritize!  Plan decisions ahead of time to improve processing  Identify all the problems that must be solved by creating steps  Develop short plans to help with information overload or mental slowness  Create an emergency plan if the task becomes stressful  Carry out and monitor the plan
  • 16. CITY OF HOPE Memory Strategies 16 Internal Memory Strategies  Mental Imagery o Sensory cues o Visualize and Contextualize o Diagram or structure  Semantic Clustering o Organize based on importance or meaning o Organize based on procedure  Chunking o Matching like things together  Mnemonics o Helpful for lists o Engrained routines
  • 17. CITY OF HOPE Memory Strategies 17 Method of Loci • Associating memories with familiar structure • E.g. bedroom, house, routinely used process • Sequential Order • Visualizing a walk through • Memory by associating content with structured steps • E.g. associating each list item with a sequential step
  • 18. CITY OF HOPE PQRST Reading 18 PREVIEW QUESTION REVIEW SUMMARIZE TEST
  • 19. CITY OF HOPE Memory Strategies 19 External Memory Aides Robust physical and digital calendars Phone Reminders Shared family calendar (Apple Calendars, Google Calendars) Voice or Video Memos Creating separate group messages Paired Memory Routines Constant, easy access Consistent reading and note taking Takes time to learn and update routines Safety net plans
  • 20. CITY OF HOPE Examples 20 Christmas Shopping  Goal: To avoid forgetting items on your list or items to follow up on  Create a physical or mental map of steps based on priority  Anticipate how you may get distracted (plan to maintain focus).  Double check the list, create the next steps and plan for follow up Graceful Speech in Conversation  Relax  Focus on goal of conversation  Focus on quality of interaction Doctor's Visit • Anticipate the topics of the visit, prepare questions ahead of time • Focus and relax mind prior to visit • Ask for pause in discussion or clarification • Summarize your understanding with doctor • Practice recall and strengthen memory by summarizing to friend/family • Create specific plans for follow up
  • 21. CITY OF HOPE Manage your Goals 21 Be graceful Focus on appropriate goals Learn new strategies to support ability Practice and build confidence Measure success by QOL Adaptation
  • 22. CITY OF HOPE Resources and Services 22 Notify your Doctor of your symptoms  Neurology or Neuropsychology  Occupational Therapy/Speech Therapy Brain Training Programs:  BrainHQ  NeuroNation Resources:  https://www.additudemag.com/  https://intuitivecreativity.typepad.com/expressiv eartinspirations/100-art-therapy-exercises.html  Accommodations under the ADA: o https://askjan.org/publications/individuals/emplo yee-guide.cfm o https://askjan.org/disabilities/Cancer.cfm

Editor's Notes

  1. Real clinical syndrome-  this is not something that is made up, it is a real syndrome that has a real impact on every day lives of cancer survivors. With more and more people being able to survive or live longer, this is an area that is becoming more prevalent. Oncologists do recognize the need to identify and address these areas. At COH, doctor's will screen and refer patients to receive treatment to address this issue.
  2. Some people get it, some people don't, just a matter of genetics Reduced Neurogenesis, reduced structure Chronic inflammation Cytokine- toxic effects on delaying or damaging brain cells
  3. Not the same as dementia or stroke
  4. Cognitive Hierarchy Understanding how memory lapses occur Adjusting and managing as necessary
  5. Examples
  6. How to process carefully in an organized manner