Cognitive Training - Individual

Cognitive Training - Individual

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 (Sitzer, Twamley, & Jeste, 2006). Individual cognitive training is provided to patients in a one-on-one approach.

Sitzer, D., Twamley, E., & Jeste, D. (2006). Cognitive training in Alzheimer’s disease: A meta-analysis of the literature. Acta Psychiatrica Scandinavica, 114, 75–90. doi: 10.1111/j.1600-0447.2006.00789.x

Effectiveness Not Established

Systematic Review/Meta-Analysis

Chan, R.J., McCarthy, A.L., Devenish, J., Sullivan, K.A., & Chan, A. (2015). Systematic review of pharmacologic and non-pharmacologic interventions to manage cognitive alterations after chemotherapy for breast cancer. European Journal of Cancer, 51, 437–450. 

doi: 10.1016/j.ejca.2014.12.017
Print

Purpose:

STUDY PURPOSE: To review what is known about the effectiveness of pharmacologic and nonpharmacologic interventions for managing self-reported or objective cognitive impairment associated with chemotherapy for breast cancer
 
TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: MEDLINE, EBSCOhost, CINAHL, and Cochrane CENTRAL
 
KEYWORDS: Extensive list of terms, including keywords relevant to the receipt of chemotherapy, randomized controlled trials (RCTs), and cognitive impairment
 
INCLUSION CRITERIA: Prospective RCTs of pharmacologic or nonpharmacologic interventions to manage cognitive impairment during or after chemotherapy for cancer; subjective or objective measurement of cognitive function; published in English
 
EXCLUSION CRITERIA: Inclusion of patients with brain tumors or metastases; inclusion of patients not receiving chemotherapy; less than half of patients in sample diagnosed with breast cancers; unpublished RCTs; letters to the editor; retrospective chart reviews

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 29
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Retrieved references were assessed by type of cancer (13 removed), cognitive impairment as an outcome (two removed), and confirmation of RCT (one removed). The Cochrane Collaboration risk of bias criteria were used to evaluate the final set of studies on randomization, blinding, and outcome reporting. Although effect sizes or relative risk were calculated for individual studies, a meta-analysis was not done because of the heterogeneity of the interventions and outcome measures.
 

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 13
  • TOTAL PATIENTS INCLUDED IN REVIEW = 1,138
  • SAMPLE RANGE ACROSS STUDIES = 20–210 patients
  • KEY SAMPLE CHARACTERISTICS: Most studies included only women with breast cancer. All participants received chemotherapy with or without radiation therapy or hormonal therapy. Most participants were aged about 55 years. The majority of studies were conducted in the United States. Most outcomes were evaluated in the short-term (i.e., less than three months).

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship 

Results:

Risk of bias was high in 11 studies but unclear in  two studies that evaluated psychostimulants.

Pharmacologic interventions: No improvements in cognitive function were found using psychostimulants (four studies) or ginkgo biloba. Patients reported better cognitive function using epoetin alfa with doses titrated for hemoglobin levels (p < 0.05). However, a death caused by a cerebrovascular accident was noted.

Nonpharmacologic interventions: Small-group memory training improved self-reported cognitive function, and both memory and speed of processing after small-group training improved immediate and delayed recall (p < 0.05). Home-based online executive function training improved verbal function and attention (p < 0.05). Speed-feedback therapy during biking improved executive and motor function (p < 0.05). Cognitive behavioral therapy-based interventions (two studies), Tibetan sound meditation, and hatha yoga did not improve cognitive function.

Conclusions:

The pharmacologic studies reviewed did not support the use of psychostimulants or ginkgo biloba to improve cognitive function after chemotherapy for breast cancer. Epoetin alfa was not recommended for practice because of safety concerns. The nonpharmacologic studies reviewed provided some evidence that cognitive training and speed-feedback therapy might improve cognitive function for breast cancer survivors.

Limitations:

The risk of bias was high for most studies. Therefore, although positive results were found, well-designed, prospective RCTs need to be completed to confirm these findings. It is unclear how sustainable the positive results of the cognitive training and exercise interventions might be because follow-up was limited to less than three months.

Nursing Implications:

This systematic review provided limited support for cognitive training and structured exercise to improve cognitive function after chemotherapy for breast cancer. Cognitive training is currently categorized as likely to be effective for cognitive impairment.

Morean, D.F., O'Dwyer, L., & Cherney, L.R. (2015). Therapies for cognitive deficits associated with chemotherapy for breast cancer: A systematic review of objective outcomes. Archives of Physical Medicine and Rehabilitation, 96, 1880–1897. 

doi: 10.1016/j.apmr.2015.05.012
Print

Purpose:

STUDY PURPOSE: To evaluate the effectiveness of interventions for objectively measured cognitive impairments in women with breast cancer who received chemotherapy
 
TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: CINAHL, Cochrane, EMBASE, PsycINFO, and PubMed
 
KEYWORDS: Breast cancer, chemobrain, chemofog, chemotherapy, and several terms related to cognition and language deficits; appendix 1 described an extensive list of search terms and strategies that were used for PubMed and EMBASE
 
INCLUSION CRITERIA: Objective measurement of cognitive function; sample consisted of women with breast cancer who received or were receiving chemotherapy; experimental design (cross-sectional, longitudinal, or randomized clinical trials) 
 
EXCLUSION CRITERIA: Case studies or series, commentaries, editorials, dissertations not published in a peer-reviewed journal, systematic reviews, and meta-analyses

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 1,745
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Abstracts were screened, and 30 duplicates were eliminated (plus 14 titles without abstracts). Abstracts were reviewed to validate that the studies involved women with breast cancer who were undergoing or received chemotherapy and that they had an objective neuropsychological assessment (1,556 articles excluded). The remaining articles (n = 145) were reviewed to ensure an that an intervention was administered for cognitive impairment (131 articles excluded) and that the studies met specific quality criteria as defined by the Physiotherapy Evidence Database rating scale criteria as well as criteria for treatment fidelity (two articles excluded).  

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 12
  • TOTAL PATIENTS INCLUDED IN REVIEW = 442
  • SAMPLE RANGE ACROSS STUDIES = 12–107 patients
  • KEY SAMPLE CHARACTERISTICS: Although education status may influence neuropsychological test results, only half of the studies provided this information. Likewise, menopausal status may affect cognition, and this was only reported by two thirds of the studies.

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship

Results:

Studies of pharmacologic interventions were not found to be effective in improving cognitive function. Medications reviewed included d-methylphenidate (n = 1), epoetin alfa (n = 2), and ginkgo biloba (n = 1). Evidence for nonpharmacologic interventions was mixed. No improvements in cognitive function were found with Tibetan sound meditation (n = 1). Natural restorative therapy (n = 1) improved attention only when comparing the baseline with the final 90-day evaluation (p = 0.01). Exercise (n = 1) improved attention (p = 0.019) and verbal memory (p = 0.048) but not working memory. Cognitive rehabilitation (n = 1) improved four out of six measures of information processing speed (p < 0.05) but not attention, verbal memory, or executive function. Cognitive behavioral training (n = 2) improved verbal memory (p < 0.05) in both studies and was effective in improving in information processing speed when compared to baseline scores in one study (p ≤ 0.01) but not the other. Computerized cognitive training was effective in one study in improving processing speed (p = 0.009), executive function (p = 0.008), and a measure of executive function and language (p = 0.003) but not verbal memory. However, in another study, there was no difference in verbal memory or information processing speed between the intervention and control groups.

Conclusions:

Nonpharmacologic interventions, especially cognitive training, may have a role for improving attention, information processing speed, and verbal memory. Exercise and computerized cognitive training may be effective for improving executive function. However, additional research validating these findings with larger sample sizes and evaluating other cognitive domains is needed. In addition, studies determining the dose or duration of interventions is required for a durable response.

Limitations:

  • A small number of studies (n = 12) were included in the review for multiple types of interventions.
  • Only one study had a sample size greater than 100 (range = 12–107).
  • Studies of low quality were included. 

Nursing Implications:

These findings suggest that nonpharmacologic, not pharmacologic, interventions may be helpful in managing chemotherapy-induced cognitive impairment in patients with breast cancer. However, these findings were based on a small number of studies per intervention. Additional research validating which interventions might be useful in improving cognitive impairments in women receiving chemotherapy for breast cancer is needed. 

Research Evidence Summaries

Gehring, K., Sitskoorn, M.M., Gundy, C.M., Sikkes, S.A.M., Klein, M., Postma, T. J., . . . Aaronson, N.K. (2009). Cognitive rehabilitation in patients with gliomas: A randomized, controlled trial. Journal of Clinical Oncology, 27, 3712–3722.

doi:10.1200/JCO.2008.20.5765
Print

Study Purpose:

The study was conducted to evaluate the effectiveness of a multifaceted cognitive rehabilitation program's (CRP's) measures of cognitive functioning in patients with gliomas whose disease was in remission.

Intervention Characteristics/Basic Study Process:

An eligibility screening was conducted through

  1. Telephone interviews confirming at least one cognitive symptom from the Medical Outcomes Study Cognitive Functioning Scale among individuals who expressed an interest in CRP participation.
  2. Objective neuropsychological assessment, in which participants performed at least one standard deviation below a healthy comparison group's mean (n = 294) on at least 4 of 20 neuropsychological assessment variables.

The randomization procedure was a minimization method balancing age, sex, education, tumor grade, hemisphere, radiotherapy, neurosurgery, disease duration, and institution.

The control group received standard care without cognitive intervention, and had contact with research staff at similar intervals as the intervention group. Control participants received a telephone-based empathy session during which attention to possible cognitive problems occurred without the provision of advice. At the study's completion, control participants were offered the opportunity to receive the intervention.

The intervention group received six weekly individual sessions of two hours each, carried out by seven neuropsychologists. Two techniques were incorporated. 

  1. Cognitive retraining using a computer program (C-Car) consisting of a series of hierarchically graded tasks designed to strengthen various aspects of attention on the basis of patients needs.
  2. Compensatory training consisting of six psychoeducational sessions on attention, memory, and executive function. This training included didactic and practical elements aimed to help patients compensate for impaired cognitive function.

Sample Characteristics:

  • All participants had glioma in remission.
  • The total number of participants was 140, with 70 patients each in the treatment group and control group.
  • The average participant age was 42 ± 9.4 years for the treatment group.
  • The average participant age was 43.8 ± 10.5 years for the control group.
  • The treatment group was 58.6% male and 41.4% female.
  • The control group was 57.1% male and 42.9% female.
  • The median number of years since treatment was 2.6 years for the treatment group.
  • The median number of years since treatment was 3.1 years for the control group. 

Setting:

Patients were recruited from 11 Dutch hospitals, including 10 neurosurgical centers.

Study Design:

The study utilized a randomized, controlled trial.

Measurement Instruments/Methods:

  • Dutch Adult Reading Test (DART) and the Drie-Minuten-Toets Three Minute Test (DMT) for premorbid intelligence
  • Stroop Color-Word Test (SCWT), Digit Span (Forward and Backward), Memory Scanning Test (MST), and the Test of Everyday Attention (TEA) for attention
  • Multidimensional Fatigue Inventory (MFI) for mental fatigue, activity, and motivation
  • Community Intervention Questionnaire (CIQ) for home integration, social integration, and productivity
  • Visual Verbal Learning Test (VVLT) for memory
  • Concept Shifting Test (CST), Letter Fluency (LF), and Category Fluency (CF) for executive function
  • Medical Outcomes Study Cognitive Functioning Scale
  • Cognitive Failure Questionnaire (CFQ)
  • Behavioral Assessment of Dysexecutive Syndrome (BADS)

 

Results:

Eighty percent of CRP subjects reported that the intervention addressed their problems; 87% used compensation strategies regularly, and 79% indicated a decrease in the impact of cognitive problems on daily functioning. The intervention group had significantly better combined attention scores (in four out of seven tests) than the control group (p = 0.004) at the six-month follow-up. Verbal memory and attention were improved for the intervention group at the six-month follow-up, suggesting the intervention's success with some sustainment in learned skills.

Effect sizes for the CRP ranged from 0.23 to 0.55. The intervention group had significantly better combined scores on verbal memory tests than the control group (p = 0.009). Effect sizes for the intervention group on two of three tests were 0.48 and 0.43. Mental fatigue on the MFI was improved in the intervention group at the six-month follow-up (p = 0.044), with an effect size of 0.41.

Self-reported cognitive function (CFS, CFQ, burden) was better in the intervention group on completion of the CRP (p = 0.001). Effect sizes ranged from 0.31 to 0.48. However, at the six-month follow-up this improvement was maintained, while the control group continued to improve.

There were no significant differences between groups on neuropsychiatric assessment scores at baseline. There were no statistically significant group differences in attention or verbal memory scores at completion of the CRP.

 

 

Conclusions:

CRP was useful in improving cognitive function, with sustained improvements in verbal memory and attention over time.

Limitations:

  • Mild cognitive impairment was detected by baseline cognitive function scores in the majority of subjects, which could impact the expected change from the CRP intervention (ceiling effect).
  • The study did not indicate whether hemispheric location of the tumor influenced cognitive functioning.
  • The authors did not specify whether they controlled for tumor characteristics, seizure frequency, and use of anti-epileptics in the analyses.

Kesler, S., Hadi Hosseini, S.M., Heckler, C., Janelsins, M., Palesh, O., Mustian, K., & Morrow, G. (2013). Cognitive training for improving executive function in chemotherapy-treated breast cancer survivors. Clinical Breast Cancer, 13, 299-306.

doi:10.1016/j.clbc.2013.02.004
Print

Study Purpose:

To test the feasibility and effectiveness of a computerized home-based cognitive intervention program

Intervention Characteristics/Basic Study Process:

Subjects were randomly assigned to the intervention group or a wait-list control group. The intervention was a 12-week computerized training program (Lumos Labs) using the subjects' home computers. It included 48 sessions that were 20-30 minutes long, involving combinations of 13 exercises to improve executive function. Subjects were assigned five exercises to complete four times per week. Exercises were designed for practice and training in cognitive flexibility, working memory, processing speed, and verbal fluency.  Completion, duration and performance of exercises were recorded in the computer system, providing an adherence measure. Outcome measures were collected at baseline and within three days of intervention completion; wait-list controls had pre-post measures taken 12 weeks apart.

Sample Characteristics:

  • N = 41    
  • MEAN AGE = 55.5 years (SD = 0.5 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All subjects had stage I-IIIA  breast cancer, received surgical intervention and adjuvant chemotherapy, and completed treatment at least 18 months prior to study participation.
  • OTHER KEY SAMPLE CHARACTERISTICS: Subjects had at least a high school education; 60%-70% also received radiation therapy and hormonal therapies.

Setting:

  • SITE: Single site    
  • SETTING TYPE: Home  

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship

Study Design:

Randomized controlled trial

Measurement Instruments/Methods:

  • Wisconsin Card Sorting Test (WCST)
  • Delis-Kaplan Executive Functions System, Letter Fluency Test
  • Hopkins Verbal Learning Test Revised
  • Wechsler Adult Intelligence Scale (digit span and symbol search subscales)
  • Behavioral Rating Inventory of Executive Function (Global Executive Composite score)
  • Clinical Assessment of Depression

Results:

There was 95% compliance with the training program. The intervention group had significant improvement as shown by Cohen’s d, the WCST (EF = 0.58, P = .008), the Letter Fluency Test (EF = 0.82, P = .003), and symbol search (EF = 0.87, P = .009). While there were no significant effects of age, education, radiation, or hormonal treatment, presence of depressive symptoms had a significant effect on self-reported global executive function.

Conclusions:

This approach for training and home-based exercises is feasible, and compliance was high. The program was effective for improving some components of executive function. Further study with longitudinal measures is warranted to demonstrate maintained improvements in cognitive function after program completion or if continued program use is needed to maintain any improvements.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Findings not generalizable
  • Intervention expensive, impractical, or needs training
  • The computerized training cost was covered by the research study; however, it is commercially available for individual cost, which may be an issue for some patients. The sample was a homogenous group of patients, potentially limiting generalizability to other patient groups.

Nursing Implications:

The commercially available computerized “brain training” program studied here improved components of executive function after 12 weeks. This approach was associated with high patient compliance. Nurses can suggest that patients complaining of cognitive impairment consider trying this program.

Miotto, E.C., Savage, C.R., Evans, J.J., Wilson, B.A., Martin, M.G., Balardin, J.B., . . . & Amaro Junior, E. (2013). Semantic strategy training increases memory performance and brain activity in patients with prefrontal cortex lesions. Clinical Neurology and Neurosurgery, 115, 309-316.

doi: 10.1016/j.clineuro.2012.05.024
Print

Study Purpose:

To investigate the neural correlates of semantic strategic training in patients with distinct prefrontal cortex lesions

Intervention Characteristics/Basic Study Process:

In the 30-minute semantic organizational strategy training, subjects were taught three steps to improve memory: (1) organize words into categories, (2) memorize words, and (3) retrieve words by category. Subjects were required to undergo a minimum of five training trials and to demonstrate that they had learned how to apply the semantic organizational strategy. Pre- and post-test evaluations consisted of subjects undergoing functional magnetic resonance imaging (fMRI) scanning immediately prior to and after the semantic strategy training.

Sample Characteristics:

  • N = 21      
  • MEAN AGE = 45.7 years for bilateral orbitofrontal cortex (BOFC) patients and 39.57 years for dorsolateral prefrontal cortex (LPFC) patients
  • MALES: 57%, FEMALES: 43%
  • KEY DISEASE CHARACTERISTICS: 21 patients with confirmed primary brain tumor (PBT) located in the prefrontal cortex, specifically the LPFC or BOFC
  • OTHER KEY SAMPLE CHARACTERISTICS: At least six months post-chemotherapy and radiation therapy; time since surgical resection ranged from 6 months to 10 years (mean = 2.65 years; SD = 2.4 years); all subjects were non-aphasic, right-handed, and free of other neurological or psychiatric conditions.

Setting:

  • SITE: Not stated/unknown  
  • SETTING TYPE: Not specified    
  • LOCATION: Not stated but ethics approval was received from the University of Sao Paulo Medical School.

Study Design:

Exploratory study using a pre- and post-test design in a convenience sample

Measurement Instruments/Methods:

  • 3 word lists of 16 words each: unrelated and related non-structures, and related structure word lists for cortical activation during scanning
  • fMRI scan

Results:

Both subject groups recalled more words (p < 0.001) and organized more words together (p < 0.001) after semantic training. For the BOFC group, there were significant differences (p < 0.01) after the intervention of increased activation: (1) right cuneus and posterior cingulate gyrus, and left precuneus during the related structure word list trial and (2) left precentral gyrus, postcentral gyrus, inferior frontal gyrus, and insula during the unrelated word list trial. For the LPFC group, there were significant differences (p < 0.01) after the intervention, in multiple cortical areas: (1) increased activation in the left inferior frontal gyrus, precentral gyrus, and insula during the related non-structured word list trial (2) increased activation in the left inferior frontal gyrus, precentral gyrus, and anterior cingulate during the related structure word list trial, and (3) decreased activation in the left supramarginal gyrus, precuneus, superior temporal gyrus, and superior parietal lobe during the related structure word list.

Conclusions:

The intervention increased use of categorizing words, thereby improving memory performance in subjects with prefrontal PBT. Changes in cortical activation suggest intervention application and recruitment of compensatory brain mechanisms for memory tasks. Further study with longitudinal measures is warranted to demonstrate continued cortical activation and intervention application during memory tasks.

Limitations:

  • Small sample (< 30)
  • Risk of bias (no control group)
  • Findings not generalizable
  • Intervention expensive, impractical, or training needs
  • Other limitations/explanation: fMRI scanning for pre- and post-measures is expensive, is impractical, and requires specialized training and equipment. This study was performed in a homogenous sample.

Nursing Implications:

This study demonstrated the application of a quick single session semantic training intervention aimed at improving verbal memory performance in those with known neuropathology.

Zucchella, C., Capone, A., Codella, V., De Nunzio, A.M., Vecchione, C., Sandrini, G., . . . Bartolo, M. (2013). Cognitive rehabilitation for early post-surgery inpatients affected by primary brain tumor: A randomized, controlled trial. Journal of Neuro-Oncology, 114, 93-100. 

doi: 10.1007/s11060-013-1153-z
Print

Study Purpose:

To evaluate the effectiveness of a cognitive rehabilitation program within two weeks of surgical resection for patients with primary brain tumors

Intervention Characteristics/Basic Study Process:

Baseline neuropsychological assessments were performed within three days of admission to the inpatient rehabilitation unit and prior to treatment or control randomization. Treatment arm consisted of 16 one-hour individual sessions over a four week timeframe with content focused on time orientation, spatial orientation, visual attention, logical reasoning, memory recognition, and executive functions. Each session was therapist-guided with 45 minutes of computer-based exercises and 15 minutes of discussion about the exercises and how to apply the strategies to everyday life. In both arms of the study, patients received usual rehabilitation care with medication and physical therapies.

Sample Characteristics:

  • N = 53    
  • MEAN AGE: 58.7 years (treatment group), 52.7 years (control group)
  • MALES: 56%, 47%, FEMALES: 44%, 53%
  • KEY DISEASE CHARACTERISTICS: Two weeks post-neurosurgical primary brain tumor patients with no prior exposure to radiation or chemotherapy
  • OTHER KEY SAMPLE CHARACTERISTICS: Inclusion criteria required cognitive deficits on a minimum of three neuropsych tests.

Setting:

  • SITE: Single site    
  • SETTING TYPE: Inpatient    
  • LOCATION: Neurological Mediterranean Institute

Phase of Care and Clinical Applications:

PHASE OF CARE: Active antitumor treatment

Study Design:

Randomized double-blind control trial with pre- and post-test assessments at baseline and four weeks after randomization

Measurement Instruments/Methods:

  • Mini-Mental State Exam for global cognition
  • Digit Span and Corsi’s test for verbal and spatial immediate memory span
  • Rey auditory verbal learning test (RAVLT), immediate recall (IR) and delayed recall (DR), for verbal memory  
  • Logical memory, IR and DR, for verbal memory
  • Raven’s Coloured Progressive Matrices 47 for non-verbal reasoning
  • Frontal assessment battery for frontal functionality
  • Trials Making Test Parts A & B (TMT-A and TMT-B) for processing speed and complex attention
  • Attentive Matrices for visual selective attention
  • Rey-Osterrieth Complex Figure Copy Test for visuo-constructional abilities and verbal fluency
  • Esame Neuropsicologico per l’Afasia for expressive and receptive language abilities

Results:

Within-group analyses found significant improvements (p < 0.05) on all neuropsychological tests for the treatment arm, while the control arm showed a non-significant trend towards improvement. Significant differences between groups were observed for improvements in visual attention and verbal memory (RAVLT-DR, Logical memory-IR and DR, TMT-A, TMT-B, Attentive matrices). There was no difference between groups in the socio-demographic, clinical characteristics, or baseline neuropsychological test scores. There was no difference between groups for number of subjects withdrawing from study due to medical conditions.

Conclusions:

This inpatient cognitive rehabilitation program was developed for patients with a post-surgical primary brain tumor. Those receiving the intervention showed significant cognitive improvement in all domains, yet only visual attention and verbal memory performances were significantly different when compared to usual rehabilitation care. These results are limited by sample size, lack of additional longitudinal assessments to demonstrate sustained improvement, and program cost.

Limitations:

  • Small sample (< 100)
  • Findings not generalizable
  • Intervention expensive, impractical, and needs training
  • Subject withdrawals ≥ 10%
  • Other limitations/explanation: Only one post-test assessment immediately following completion of intervention occurred, thus lacking demonstration of sustained cognitive improvement. Findings not generalizable due to cost of inpatient rehabilitation program, which would need adapting for use in outpatient settings.

Nursing Implications:

Post-surgical cognitive interventions may be helpful in developing cognitive strategies for everyday function. Further study is warranted and intervention adaptation is necessary for outpatient settings.

Menu