Cognitive Training - Group

Cognitive Training - Group

PEP Topic 
Cognitive Impairment
Description 

Cognitive training is any intervention aimed at improving, maintaining, or restoring mental function through the repeated and structured practice of tasks which pose an inherent problem or mental challenge. Group cognitive training is provided to individuals in a group setting.

Likely to Be Effective

Research Evidence Summaries

Ercoli, L.M., Castellon, S.A., Hunter, A.M., Kwan, L., Kahn-Mills, B.A., Cernin, P.A., . . . Ganz, P.A. (2013). Assessment of the feasibility of a rehabilitation intervention program for breast cancer survivors with cognitive complaints. Brain Imaging and Behavior, 7, 543–553.

doi: 10.1007/s11682-013-9237-0
Print

Study Purpose:

To evaluate the feasibility of a cognitive rehabilitation intervention for persistent post-treatment cognitive issues in survivors of breast cancer and to conduct a substudy to garner preliminary data related to the use of quantitative electroencephalography (qEEG) to assess changes in cognitive function

Intervention Characteristics/Basic Study Process:

Five weekly, manualized, two-hour sessions were provided to five cohorts of four to nine participants. The last cohort participated in the qEEG substudy. Two difficulty levels of in-class cognitive training and three levels of homework exercises were designed to build skills in the targeted areas of attention, executive function, and memory. Participants were encouraged to do four 20-minute sessions of homework exercises per week and log their time. Participants received a training manual workbook, CDs for auditory exercises, answer keys, and a stopwatch. In-class education focused on a specified targeted area and instructions on coping strategies to minimize anxiety (such as deep breathing, relaxation, pacing, and countering negative thoughts). Goal attainment was discussed during the group sessions to facilitate setting individual short-term and long-term goals. Neurocognitive testing, self-report instruments, and the qEEG (substudy) were administered at baseline (T0), within one week (T1), and at two (T2), and four (T3) months after completing the intervention.

Sample Characteristics:

  • N = 27 (8 in substudy)  
  • MEDIAN AGE = 54.1 years (SD = 6.3 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer survivors within 18 months to five years after initial treatment completion who reported persistent cognitive issues that interfered with daily activities. Ongoing endocrine therapy and HER2-targeted adjuvant therapy were allowed. Inclusion requirements: 18–75 years old and stages 0–III breast cancer.
  • OTHER KEY SAMPLE CHARACTERISTICS: Participants primarily were Caucasian, married, and well-educated (mean 16.4 years of education). The majority received chemotherapy (89%), radiation (63%), or endocrine therapy (67%). Exclusion criteria included untreated depression, psychiatric disorders, and disorders of the central nervous system (CNS) (i.e., CNS cancer, CNS treatment with intrathecal chemotherapy, surgery, radiotherapy, traumatic brain injury, seizures, intellectual disabilities, substance abuse disorder).

Setting:

  • SITE: Single-site    
  • SETTING TYPE: Outpatient    
  • LOCATION: University of California, Los Angeles, United States

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship

Study Design:

Prospective trial

Measurement Instruments/Methods:

  • CNS Vital Signs Computerized Testing Platform
    • Finger tapping dominant, finger tapping nondominant
    • Shifting attention test
    • Stroop reaction time
    • Continuous performance test
    • Symbol digit test
  • Hopkins Verbal Learning Test, Revised (HVLT-R) (total recall, delayed recall)
  • Brief Visuospatial Memory Test, Revised (BVMT-R)
  • Trail Making Tests (TMT) A and B
  • Paced Auditory Serial Addition Test (PASAT) Trial 1
  • Judgment of Line Orientation (JLO) test
  • Patient’s Assessment of Own Functioning Inventory (PAOFI)
  • Beck Depression Inventory, Second Edition (BDI-II)
  • Spielberger State-Trait Anxiety Inventory (STAI)
  • Resting quantitative electroencephalography (qEEG)

Results:

PAOFI totals and memory complaint scores decreased between T0 and T1 (p = .031 and p = .009, respectively) and were maintained at T3 (p < .0001 in both). Decreases in high-level cognitive functions (PAOFI scale) were demonstrated at T3 (p = .005). Significant short- and long-term improvements were observed for the symbol digit, Stroop reaction time, and trail A tests (p < .05). Meaningful improvement by a reliable change index (RCI) occurred for 19% of patients (n = 5) between T0 and T1, and 30% of patients (n = 8) by T3. RCI improvement (in ≥ 2 of 16 tests) predominantly occurred for verbal learning and memory (HVLT-R), processing speed (symbol digit), and divided attention (shifting attention test). Absolute alpha power increase (qEEG) was associated with PAOFI improvements at T1 (p = .014). Change in alpha power correlated with change in PAOFI memory subscale at T1 (p = .021) and T2 (p = .004). Correlation also was noted with the PAOFI HLC subscale at T2 (p = .030) and T3 (p = .048).

Conclusions:

This study's results demonstrated the feasibility of this cognitive rehabilitation intervention and preliminary evidence for the improvement of subjective and objective cognitive function. Larger randomized, controlled trials are necessary to further determine efficacy. Preliminary results supported the potential use of qEEG as a measure of change in cognitive function. An additional randomized, controlled trial is underway.

Limitations:

  • Small sample (< 30)
  • Risk of bias (no control group)
  • Findings not generalizable
  • Other limitations/explanation: Sample primarily was Caucasian, married, and well-educated. Results may not be generalizable to other demographics.

Nursing Implications:

Cognitive rehabilitation interventions appear to be promising. Nurses should maintain an awareness of research results in this area and consider suggesting appropriate clinical trials to eligible survivors.

Hassler, M.R., Elandt, K., Preusser, M., Lehrner, J., Binder, P., Dieckmann, K., . . . Marosi, C. (2010). Neurocognitive training in patients with high-grade glioma: A pilot study. Journal of Neuro-Oncology, 97, 109–115.

10.1007/s11060-009-0006-2
Print

Study Purpose:

To evaluate the effectiveness of small group neurocognitive training to improve cognitive impairment in patients with brain tumors

Intervention Characteristics/Basic Study Process:

Pre- and post-intervention cognitive testing was performed. The 10-week-long intervention consisted of 90-minute weekly group sessions of holistic mnemonic training, which included exercises to train perception, concentration, attention, memory, retentiveness, verbal memory, and creativity.

Sample Characteristics:

  • A total of 11 patients were enrolled in the study.
  • Participants' ages ranged from 23–73 years (median = 50 years).
  • The sample was 64% male and 36% female.
  • Patients had been diagnosed with glioblastoma multiforme (n = 6) or anaplastic gliomas (n = 5).
  • Time since initial diagnosis ranged from 10–42 months (median = 15 months).
  • Every participant had received treatment that included surgery, radiation therapy, and adjuvant chemotherapy with temozolomide. One subject also received hydroxyurea and imatinib in addition to temozolomide.
  • Three subjects had tumor recurrence 3–28 months prior to study participation; none underwent additional surgery, and further treatment with radiation or chemotherapy was not provided. 
  • All subjects were taking antiepileptic medications; however a variety of drugs were used. 
  • Subjects varied in professional and educational background, but actual information was not provided.

Setting:

  • Single site
  • Outpatient setting
  • Vienna, Austria

Phase of Care and Clinical Applications:

  • Patients were undergoing long-term follow-up.
  • The study has applicability for late effects and survivorship.

Study Design:

Pilot study with pre-/post-test design

Measurement Instruments/Methods:

  • Trail Making Test–A (TMT-A)    
  • Trail Making Test–B (TMT-B)
  • Hopkins Verbal Learning Test (HVLT)
  • Controlled Oral Word Association Test (COWAT)

Results:

Although comparison of mean group differences found improvement in all neuropsychological tests, separate dependent t-tests revealed statistically significant improvement only in verbal memory total learning (p < 0.05) as measured by the HVLT. Significant improvement was not seen in verbal memory delayed recall (p = 0.11) as measured by the HVLT, psychomotor speed (p = 0.22) as measured by the TMT-A, sustained attention (p = 0.17) as measured by the TMT-B, or verbal fluency (p = 0.29) as measured by the COWAT.

Conclusions:

Significant improvement was found in verbal memory (total learning). However, it is not possible to distinguish whether the improvement was a benefit of the intervention or resulted from practice effects associated with the repeated measures occurring 12 weeks from baseline. Additionally, any assumptions regarding effectiveness of the intervention would need to be supported by a larger sample with an appropriate comparison control group.

Limitations:

  • The sample was small, with less than 30 participants.
  • The lack of a comparison control group or randomization limited the generalizability of results and the feasibility of the intervention.

Nursing Implications:

Although neurocognitive training has been suggested as a potential intervention for cognitive impairment, further studies are needed (including feasibility). Effectiveness of this intervention cannot be established based on this pilot study.

Poppelreuter, M., Weis, J., & Bartsch, H.H. (2009). Effects of specific neuropyschological training programs for breast cancer patients after adjuvant chemotherapy. Journal of Psychosocial Oncology, 27(2), 274–296.

doi:10.1080/07347330902776044
Print

Study Purpose:

The study was conducted to evaluate the need of patients with breast cancer for neuropsychological rehabilitation after adjuvant chemotherapy. It also sought to determine the effectiveness of differentiated training programs after completion of treatment.

Intervention Characteristics/Basic Study Process:

Participants were randomly assigned to one of two intervention groups. Control participants were selected from the “time-out” phase of the study when no training was being offered.

Both intervention groups took part in four one-hour training sessions per week during their inpatient stay. Participants were randomized to one of the following outpatient interventions.

  1. Neuropsychiatric Training Group (NPT). A maximum of eight participants met with a specialized occupational therapist to work on improving attention and memory through situations specifically designed to reflect the demands of everyday life. They received practice in compensational strategies and specific techniques to improve their performance in these everyday situations, and reflected on their personal experiences.
  2. Computer-based training (PC). Participants received individualized computer-based training with continuous therapeutic supervision. The software addressed specific attention and memory dimensions in eight modules. Following the PC training, participants also received individualized coaching according to their specific impairments.

Measures were completed upon admission to the rehabilitation unit (T1), at the end of in-patient rehabilitation (T2), and six months later on an outpatient basis (T3). 

Sample Characteristics:

  • The number of participants was 90.
  • All participants were female.
  • All participants had breast cancer, with an average of 9.01 months since diagnosis and 2.06 months since the conclusion of chemotherapy.
  • There were 33 participants in the NPT intervention group, 32 in the PC intervention group, and 25 in the control group.
  • The average participant age was 49.19 ± 7.71 years.
  • 16.7% of participants had a university degree, with only 3.1% not professionally trained.
  • Participants were predominately receving chemotherapy with anthracyclines; most had postoperative localized radiation therapy and adjuvant antihormonal therapy.
  • Individuals were exclused from the study if they were older than 64 years; had psychiatric mental health disorders or other cancer, psychiatric, or neurologic problems; or were currently using psychoactive medications.

Setting:

The study took place at the Tumor Biology Center Rehabilitation Unit in Freiburg, Germany.

Study Design:

The study utilized a randomized, controlled trial.

Measurement Instruments/Methods:

  • Questionnaire of Self-Perceived Deficits in Attention (FEDA) for attention
  • Test Battery for Attentional Performance (TAP) for attention
  • Digit Span for attention
  • Wechsler Memory Scale-Revised for memory
  • Rivermead Behavoral Memory Test (RBMT) Immediate and Delayed Story Recall for memory
  • Learning and Memory Test (LGT-3) for memory
  • Multidimensional Fatigue Inventory (MFI) for mental fatigue, activity, and motivation
  • Hospital Anxiety and Depression Scale (HADS) for anxiety and depression
  • European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - 30 (EORTC QLQ-30) for global and functional quality of life. The EORTC QLQ-30 uses six subscales (global, physical, role, cognitive, emotional, social functioning). Scores range from 0–100, with higher scores indicating higher quality of life.

Results:

No intervention effects were noted in this study. Significant improvement was noted in 11 of 16 neuropsychiatric parameters for all three groups between T1 and T2. Forty participants (44.4%) maintained at least one cognitive deficit at five months; 19 (21.1%) maintained two or more deficits at T3.

Both intervention groups received similar amounts of training sessions. Eighty-four participants (87.5%) had at least one impaired neuropsychological parameter and 54 (56.2%) had two or more at baseline.

Conclusions:

No significant differences in cognitive ability between treatment groups were reported.

Limitations:

  • The study lacked a clear description of the PC intervention.
  • The use of an inpatient setting and the timing of interventions may have affected the outcome.
  • The study did not address practice effects with repeated testing over time.

Von Ah, D., Carpenter, J.S., Saykin, A., Monahan, P., Wu, J., Yu, M., . . . Unverzagt, F. (2012). Advanced cognitive training for breast cancer survivors: A randomized controlled trial. Breast Cancer Research and Treatment, 135, 799–809.

10.1007/s10549-012-2210-6
Print

Study Purpose:

To evaluate the efficacy of memory and speed of processing training for improving cognitive function in breast cancer survivors

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to one of three groups: training in speed of processing, memory training, or a wait list control group. The intervention included 10 one-hour sessions of memory and speed of processing training delivered in small groups of three to five patients over six to eight weeks. Specific intervention strategies were adapted from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trials. Follow-up was done at two months.

Sample Characteristics:

  • A total of 82 patients participated in the study.
  • Participants' mean age was 56.6 years (SD = 8.5 years).
  • The sample was 100% female.
  • All patients were diagnosed with breast cancer and had received surgery and chemotherapy. The mean time since treatment was 5.5 years.

Setting:

  • Single site
  • Outpatient setting
  • United States

Phase of Care and Clinical Applications:

Patients were in the late effects and survivorship phases of care.

Study Design:

Single-blind, three-group randomized controlled trial

Measurement Instruments/Methods:

  • Rey Auditory Verbal Learning Test
  • Rivermead Behavioral Paragraph Recall test
  • Useful Field of View for speed of processing
  • Functional Assessment of Cancer Therapy–Cognitive (FACT–Cog)
  • Squire Subjective Memory Questionnaire
  • Center for Epidemiological Studies Depression Scale
  • Spielberger State–Trait Anxiety Inventory
  • FACT–Fatigue
  • Quality of Life Cancer Survivors
  • Short Form-36

Results:

The memory training group demonstrated better immediate (d = 0.59, p = 0.036) and delayed memory performance (d = 0.70, p = 0.013) at the two-month follow-up compared to the control group. Those trained in speed of processing improved immediate memory post-intervention (d = 0.75) and at the two-month follow-up (d = 0.82) (p < 0.01). The memory and speed of processing training groups had significant improvement in perceived cognitive functioning on questionnaires. Compared to controls, speed of processing training was associated with lower symptom distress. Memory training also had a positive effect on anxiety at the two-month follow-up (p = 0.017)

Conclusions:

Memory and speed of processing training had significant positive effects on objectively measured and perceived cognitive function among female breast cancer survivors.

Limitations:

  • The sample was small at less than 100.
  • A lack of blinding and no appropriate attentional control condition introduced a risk of bias.
  • The findings not generalizable because of the highly specific sample group. The findings may not be applicable to other groups of patients or at other time points in the cancer trajectory.
  • The training needs to be delivered by individuals educated in the process.

Nursing Implications:

Cognitive training as provided here had a significant and at least a moderate positive effect on cognitive function in breast cancer survivors. Cognitive deficits with cancer treatment have substantial negative impacts on quality of life and functioning. Cognitive training is a promising intervention to address these problems.


Menu