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

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