Sandra A. Mitchell, CRNP, MScN, AOCN National Cancer Institute, Bethesda, MD

Cognitive Dysfunction In Patients with a Primary Brain Tumor: Exploring and Navigating Uncharted Waters

Sandra A. Mitchell, CRNP, MScN, AOCN

National Cancer Institute, Bethesda, MD

Sherry W. Fox, PhD, RN, CNRN

University of Virginia School of Nursing, Charlottesville, VA

Margaret Booth-Jones, PhD

Moffitt Cancer Center and Research Institute, Tampa, FL

Objectives

Analyze the domains of cognitive function.

Identify and select tools/approaches for evaluating cognitive function in the clinic.

Explain the indications for neuropsychological evaluation.

Plan a program of support, accommodation, and rehabilitation for patients with a primary brain tumor who are experiencing cognitive dysfunction.

Case #1: Janet

37 y/o right-handed, Caucasian married female Mother of 3 (ages 5, 9, and 10) 1 month s/p 80% resection of left frontotemporal

oligodendroglioma (WHO grade 2, with elevated MIB-1 index) Considering XRT and/or chemotherapy vs. surveillance Partial motor seizures, controlled on Dilantin College educated, and working part-time at a public school No prior medical or psychiatric history Patient reporting depressed mood, increased tearfulness,

reduced energy, and word-finding difficulties Husband is concerned about her mood and ability to accomplish

daily tasks, including caring for their 3 children

Case #2: Bernie

58 y/o ambidextrous Israeli male. Married to his second wife 2 adult children from first marriage 2 weeks s/p gross total resection of a right frontal Glioblastoma

Multiforme (GBM) (WHO grade 4) Scheduled to begin treatment with XRT and concurrent

temozolomide Currently prescribed Dilantin, Decadron and Anzemet No previous psychiatric history; history of HTN Has an MBA and is working as an executive in a major

corporation – currently on sick leave Patient denies emotional distress or cognitive problems Wife and adult children are very concerned about his change in

personality and decision making abilities

Factors Contributing to Neurobehavioral Changes Associated with Brain Tumors

Location of the tumor

Pathologic type

Patient characteristics

FRONTAL•Personality changes (impulsivity, lack of inhibition, lack of concern)•Delayed initiation/apathy•Executive dysfunction•Diminished self-awareness of impaired neurologic or neuropsychological functioning (anosognosia)•Language deficits

TEMPORAL•Auditory and perceptual changes•Memory and learning impairments•Aphasia and other language disorders

PARIETAL•Somatosensory changes•Impaired spatial relations•Hemispatial neglect•Homonymous visual deficits•Agnosia (non-perceptual disorders of recognition)•Language comprehension impairments•Alexia (disorders of reading)•Agraphia (disorders of writing)•Apraxia (disorders of skilled movement)

OCCIPITAL•Alexia (disorders of reading)•Homonymous hemianopsia•Impaired extraocular muscle movements•Color anomia•Achromatopsia (impairment in color perception)

BRAINSTEM•Diplopia•Altered consciousness and attention•Cranial neuropathies (visual field loss, dysarthria, impaired extraocular muscle movements)

CEREBELLUM•Ataxia

CORPUS CALLOSUM•Transmission of visual information•Integration of sensory input•Transmission of somatosensory information

Factors Contributing to the Neurobehavioral Changes Associated with Brain Tumors

Pathologic type Low grade histology High grade histology

Patient characteristics Age Physical co-morbidities Psychological co-morbidities Symptom experience

Fatigue Pain

Factors Contributing to the Neurobehavioral Changes Associated with Brain Tumors

Adverse effects of treatment surgery radiation therapy chemotherapy

Side effects of adjunctive medications

corticosteroids, anticonvulsants psychoactive medications

Medical complications endocrine dysfunction seizures infection anemia sleep disorders

Effects of Cognitive Dysfunction on Patient, Family and Health Care Team

Physical, psychological, social and vocational functioning

Level of distress Quality of individual and

family life Insight and self-appraisal Self care abilities, decision-

making and treatment adherence

Cognitive Function

Cognitive function encompasses the processes by which sensory input is elaborated, transformed, reduced, stored, recovered and used.

Domains of Cognitive Function Attention and concentration Visuo-spatial and

constructional skills Sensory perceptual function Language Memory Executive function Intellectual function Mood, thought content,

personality and behavior

Source: Halligan, Kischka & Marshall, 2003

Attention- Capacity to Detect and Orient to Stimuli

Prioritize signals from one spatial location

spatial attention Prioritize some forms of

information and to suppress others on the basis of a functional goal

selective or focused attention Self maintain an alert and

ready-to-respond state arousal/sustained attention

Concentration-Directing Thoughts and Actions Toward a Stimulus Capacity- refers to the amount

of information processing a person can do in a given time

Control refers to an individual’s ability to direct concentration capacities.

Concentration exists in three forms:

sustained concentration focused

concentration(selective) divided (alternating)

Distractions environmental – external self – internal

Visuospatial and Contructional Skills -Apraxia

Difficulty performing a planned motor activity in the absence of paralysis of the muscles normally used in the performance of that act.

Can also be considered a disorder of language as many procedural tasks are verbally mediated.

Visuospatial and Contructional Skills -Apraxia

Ideational apraxia Basic sequence of events and logical plan underlying a

chain of simple actions is disrupted Ideomotor apraxia

Dissociation between the areas of the brain that contain the ideas for movements and the motor areas that actually execute the movements.

Constructional apraxia Inability to produce properly organized constructions

such as drawings or simple building tasks Motor apraxia

Not generally reported by patient, but family will often describe difficulty with using common objects (toothbrush, eating utensils).

Visuospatial and Constructional Skills

Loss of topographical memory Inability to find the way and

tendency to become lost in familiar and unfamiliar environments


Apraxic agraphia- poor letter formation spatial distortions patient/family report

illegible handwriting


Alexia (difficulty reading) may occur as a result of an

inability to perform the continuous and systematic scanning eye movements necessary for reading

may also be considered a language deficit


Acalculia (difficulty with calculation)

may result from misplacement of digits, misalignment of columns, or aphasia for number symbols

Sensory-Perceptual Function

Distinction between sensation and perception: The senses capture information from the environment

Subsequent elaborations and interpretations in different parts of the brain enable one to perceive or become aware of external stimulation

The most common perceptual deficits are: auditory tactile visual

Factors Influencing Evaluation of Sensory-Perceptual Function

Underlying primary sensory deficit (eg. color blind at baseline, hypoacusis at baseline secondary to age-related hearing loss)

Advancing age may diminish senses and dull perception

The state of the perceiver(e.g. anxiety, physical discomfort) may influence the perception of a stimulus

Severe language problems can impair a patient’s ability to respond appropriately to tests of sensory function

Common Sensory-Perceptual Deficits in Patients with a Primary Brain Tumor

Agnosia- literally, without knowledge, inability to know or interpret sensory experiences

Tactile agnosia (inability to name common objects placed in one hand). Place a common object such as coin (dime, nickel, quarter), paper clip, pen, randomly in either hand.

If patient is aphasic, they will have difficulty naming objects placed in either hand. When they have a specific difficulty in naming objects palpated with only one hand, tactile agnosia or astereoagnosis is present.

Anosognosia

Lack of awareness of impaired neurologic or neuropsychological function which is obvious to the clinician and other reasonably attentive individuals.


Diplopia (double vision)

Visual field deficits (hemianopia, quadrantanopia)


Achromatopsia - impairments in color perception

Color anomia - inability to name colors or to select a color from an array of colors when requested


Visual hallucinations (photopsia)

stars, dots, lines, fog, wavy lines

Illusions (metamorphopsia) distorted objects, faces,

scenes


Alexia (reading difficulties) words or syllables missing

change of lines, or

reduced reading span (hemianopic alexia)


Problems with figure-ground discrimination

Problems in estimating depth on a staircase or reaching for a cup/door handle

Bumping into obstacles or failure to notice persons on one side (hemispatial-neglect, hemianopia)

Difficulty detecting the movements of targets in space - visual scenes may appear as a series of static snapshots

Language

Aphasia/dysphasia language production

(expressive aphasia/dysphasia)

language comprehension (receptive aphasia/dysphasia)

May be accompanied by alexia (loss or impairment

of the ability to read) and/or agraphia (loss or

impairment of the ability to produce written language)

Language

Dysarthria sensorimotor disorder

affecting the respiratory and articulatory functions involved in speech sound production

speech may be garbled, slurred or muffled, while grammar, comprehension, and word choice are intact

Dysprosody interruption of speech

inflections and rhythm (i.e. speech melody)

resultant monotone or halting speech

Evaluation of Spontaneous Speech Can communication be

established? Does the patient produce

speech at all? Is the patient's speech

comprehensible (if not, is it because of semantic errors or because of dysarthria)?

Is the patient's speech fluent or nonfluent?

Are there semantic errors?

Language Production Difficulties

Pauses, hesitancy Restricted range of vocabulary Use of circumlocutions Discontinuation of a phrase Substitution of a presumably-

intended word by another word (verbal paraphasia)

Substitution of a presumably-intended word by a meaning related word (semantic paraphasia)

Difficulty with grammatical construction

Telegraphic speech style

Language Production Difficulties

Repetitive speech Automatisms

Perseveration

Stereotypy

Language Comprehension Difficulties

Difficulty following multistep commands Problems comprehending television or

movies, difficulties reading, working on the computer or participating in conversation

May be difficult to differentiate from problems with attention, and can overlap withstress and fatigue

May lead to conflict and frustration in families

Memory

Remote memory (memories from childhood and early adulthood)

usually preserved

Recent memory Recall is uncued information

retrieval Recognition is cued information

retrieval in which the individual “remembers” by selecting from a number of pieces of information, including the target information

Memory Loss Symptoms

Examples of memory loss symptoms:

Forgetting a message Losing track of a

conversation Forgetting to do things Forgetting what has been

read or events in movies/TV programs

Inability to navigate in familiar places

Memory Loss Symptoms

Assess: Severity? Onset gradual or sudden? Memory impaired

consistently or only on occasions?

Fluctuation in severity? Is it an isolated symptom or

are there other cognitive impairments?

How is it affecting work or pastimes?

Executive Function

Adaptive abilities that enable us to:

analyze what we want develop and carry out a plan

Executive Function

Establish new behavior patterns and ways of thinking about and reflecting upon our behavior

Understanding of complex social behavior such as understanding how others see us, being tactful or deceitful.

Burgess et al (2000)

Executive Dysfunction Difficulties with abstract

thinking, planning, decision-making

Difficulty with goal formulation

Difficulty with complex, multistage tasks

Poor temporal sequencing Problems with reasoning

and problem-solving Difficulty with carrying out

everyday routine activities (eg. making a cup of tea, brushing teeth, dressing)

Executive Dysfunction Lack of insight Distractibility Marked reduction in

spontaneous purposeful activity

Confabulation Perseveration Lack of concern Shallow affect, impulsiveness,

disinhibition, aggression, unconcern for social rules

Mood,Thought, Personality, Behavior

Mood Thought content and

processes Baseline personality and

coping style Behavior

Case #1: Janet

37 y/o right-handed female, status post 80% resection of left frontotemporal oligodendroglioma (WHO grade 2, with elevated MIB-1 index). Considering XRT and/or chemotherapy vs. surveillance. Partial motor seizures, controlled on Dilantin

Patient reporting depressed mood, increased tearfulness, reduced energy, and word-finding difficulties.

Husband is concerned about her mood and ability to accomplish daily tasks, including caring for their 3 children

Case #1: Janet- Clinical Issues

Cognitive function Short-term memory problems Frustrated by problems with expressive dysphasia Diminished initiative, feels somewhat apathetic Executive dysfunction:

Problems with planningOverwhelmed by complexities of busy household

Diminished mental concentration

Overlay of: Fatigue Depression Side effects of anticonvulsants

Case #2: Bernie

58 y/o ambidextrous male, status post gross total resection of a right frontal Glioblastoma (WHO grade 4). Scheduled to begin treatment with XRT and concurrent temozolomide

Currently prescribed Dilantin, Decadron and Anzemet

Family concerned about personality changes and decision-making capacities. Patient denies any current concerns.

Case #2: Bernie- Clinical Issues Clinical Issues:

Cognitive dysfunction:

Mild short term memory problems

Markedly diminished mental concentration Personality changes (impulsive, lacking tact, easily

frustrated) Anosognosia (diminished awareness of impaired

functioning)

Overlay of: Cultural factors Side effects of steroids (patient is not sleeping) Situational anxiety

Cognitive Screening: Clinical Context

Evaluation of brain function Occurs with each verbal and non-verbal interaction with a patient Screening may be formal or informal Screening may also be conscious or unconscious Screening may be part of a professional or a social

interaction

Cognitive Screening: Clinical Context

Cognitive impairment is common in persons with primary brain tumors (Fox, et al., 2004; Tucha et al., 2000)

Cognitive impairment may have different patterns according to tumor types and treatment

Caregivers or informant descriptions of cognitive decline, should be taken seriously and cognitive assessment and follow-up initiated (Guideline, 2001; Patterson & Glass, 2001)

Nursing Implications for Cognitive Screening in the Clinic

To identify issues in decision-making To identify ways to improve quality of life To identify best methods to assist caregivers To identify a changing illness trajectory To promote safety for the patient To improve the patient/nurse relationship To facilitate effective advocacy

Evidence Supporting Cognitive Screening

Patients with mild cognitive impairment should be recognized and monitored for decline due to their increased risk for subsequent dementia (guideline).

General cognitive screening instruments should be considered for the detection of dementia (guideline).

Interview based techniques may be considered in identifying patients with dementia, particularly in an at-risk population (option).

American Academy of Neurology Guidelines on Early Detection of Dementia and Mild Cognitive Impairment, (2001)Patterson & Glass (2001) Screening for Cognitive Impairment and Dementia in the Elderly

Linking Nursing and Neurocognitive Assessments

Interview with client and observations of client during the interview are essential

Identification of fund of knowledge based on age, culture, and education provide a basis for accurate evaluation and screening

Obtaining a history of the person provides invaluable clues to future assessment of cognition

Global AssessmentsDuring Interview and History

Orientation - alertness and awareness of time, place, person and situation at all times

Communication - ability to speak, understand, and respond appropriately, speech patterns

Judgment - insight into self and situation direct decision making

Global AssessmentsDuring Interview and History

Appearance and Behavior attire, grooming, appearance

General intelligence level of education, fund of knowledge

Mood reactions to the topic being discussed general perspective about situation, i.e. sad? angry?

Visuospatial ability attention given to visual cues attends to both right and left sides

Factors Effecting Patterns of Cognitive Impairment

Age Medical History Tumor progression and location Fatigue Depression Treatments, particularly radiation Drug therapy such as steroids, anticonvulsants,

complementary therapies

Goals of Clinical Cognitive Screening

To assess multiple areas of cognitive function quickly To identify areas of cognitive dysfunction To screen in such a way that the results are reliable,

valid and clinically relevant for patient care, safety and self-esteem

To be practical about what is possible in the setting and the patient population

Ideal Screening Instrument Characteristics

Can be administered by clinicians at all levels and requires 5-15 minutes to administer to most patients

Orientation, attention/concentration, executive, language, spatial, and memory functions included

Acceptable sensitivity with disorders commonly encountered by neuroscience clinicians

Mallory, et al., (1997)

Evidence-Based Cognitive Screening Instrument Recommendation #1

Mini-Mental State Exam (MMSE)(Folstein, Folstein & McHugh, 1975)

or Modified Mini-Mental State Exam

American Academy of Neurology Guidelines on Early Detection

of Dementia and Mild Cognitive Impairment (2001)


Mini-Mental State Exam (MMSE)

Tests orientation, registration, attention and calculations, recall and language

Takes approximately 12-15 minutes to administer Scores added for a single number score Deals with communication Answers to individual questions may have more value

than the single score Score of 23/24 out of 30 possible points suggests

significant cognitive dysfunction or possible dementia

Issues with the MMSE

May be insensitive to mild cognitive impairments May be insensitive to impairments from lesions in the

right hemisphere No measure of visual perceptual deficits False positives are reported in those of advanced age

and low educational levels

Evidence-Based Cognitive Screening Instrument Recommendation #2

Neurobehavioral Cognitive Status Examination (NCSE)(Cognistat)(Kiernam, et al., 1987; Mueller, 1984)

Abdulwadud, (2002)


Neurobehavioral Cognitive Status Examination (NCSE)(Cognistat)

Provides data in ten areas including LOC, orientation, attention, communication, memory, constructional ability, calculations, reasoning, abstracting and similarities.

Takes 30-45 minutes to administer Several questions are specific to screening Relies on communication and language skills Useful for evaluating ability to complete complex

tasks Useful in identifying cognitive impairment in persons

with focal neurologic lesions

When to Refer for a Formal Neuropsychological Examination

When patient requests assessment or expresses concerns When family members express concern When a physician or other health care provider needs a baseline

or notices cognitive changes When a rehabilitation counselor or therapist needs a

comprehensive baseline When documentation of disability or accommodation is required When competency is an issue When there are issues of placement in a rehabilitation or adult

living facility

Patient or Family Request Many patients are information seekers and are concerned about

their brain function Subjective ratings of cognitive ability can be distorted and can lead

to significant distress Patients and families may want a baseline to help make decisions

regarding further treatment for their brain tumor Some brain tumor patients are unaware of their cognitive,

emotional, and personality changes (anosognosia – related to frontal lobe dysfunction)

Some family members want testing to assist with regaining a specific function: ability to drive, return to work, or live alone

Health Care Provider Request pre-surgical assessments

laterality and pre-surgical deficits language assessment prior to awake craniotomy

post-surgical assessment - rehabilitation and recovery pre-chemotherapy baseline during chemotherapy if cognitive and / or emotional changes are

observed pre-radiation therapy to obtain a baseline to address concerns

for radiation induced dementia during or after radiation if delirium or cognitive decline observed

Other Referrals for Testing

Multidisciplinary rehabilitation may require neuropsychological assessment for admission

Schools and employers may require neuropsychological testing and documentation to return to school or work and to receive necessary accommodations

Brain tumors are not automatically considered a disabling condition and insurance companies and Social Security may require neuropsychological testing and documentation

Competency to make treatment decisions may be in question and may require testing and documentation

How to Present the Idea of a

Neuropsychological Exam Some patients associate psychology or psychiatry with “being crazy”

and resist the referral Some patients are concerned that they will appear stupid or be

emotionally traumatized in some way Patients should be told that a neuropsychological evaluation is an

assessment of brain function and a determination of strengths and weaknesses that will allow for more comprehensive treatment planning

Neuropsychological testing is not painful or invasive Neuropsychological test is not an “IQ test”

The Neuropsychological Exam

Clinical interview with patient and with a family member when possible

Behavioral observation Estimate of premorbid function Brief, repeatable battery of tests assessing cognitive domains Assessment of mood and quality of life Feedback to patient, family, and referring physician Documentation Referral to appropriate services Follow-up to determine change over time

Testing Considerations

Determine patient’s sensory limitations visual field cuts or diplopia hearing loss from aging or chemotherapy, peripheral neuropathy

Determine patient’s language ability expressive – providing answers receptive – understanding the demands of the tasks

Limit testing to 1-2 hours to minimize fatigue

Neuropsychological Testing

Brief well-validated measures: attention, concentration and vigilance verbal learning and verbal memory visuospatial function language – fluency, naming, reading executive function – problem solving, reasoning,

susceptibility to interference psychomotor speed and stamina

Appropriate psychosocial measures: emotional distress quality of life

RBANS List LearningImmediate Memory Domain

RBANS Story MemoryImmediate Memory

RBANS Figure CopyVisuospatial/Construction Domain

RBANS Figure RecallDelayed Memory Domain

RBANS Line OrientationVisuospatial/Construction Domain

RBANS Picture NamingLanguage Domain

RBANS Semantic FluencyLanguage Domain

RBANS Digit SpanAttention Domain

RBANS List RecallDelayed Memory Domain

RBANS List RecognitionDelayed Memory Domain

RBANS CodingAttention Domain

Trailmaking Test – Trails AExecutive Function

Trailmaking Test – Trails BExecutive Function

Janet’s Test Profile

Verbal memory (list learning and story memory) impaired Recognition better than recall for delayed memory Visuospatial/constructional ability intact Attention impaired characterized by slow responding but free of

errors Language function significant for reduced fluency and impaired

naming Executive function characterized by slowing and reduced

effortful output Questionnaire information and clinical interview significant for

symptoms of clinical depression

Bernie’s Test Profile

Verbal memory (list learning and story memory) mildly impaired and significant for intrusion errors and perseverations

Recognition equivalent to recall for delayed memory Visuospatial/constructional ability impaired and figure is

distorted Attention impaired characterized by increased distractibility and

a high error rate Language function significant for loss of set during the fluency

task and circumlocution errors on naming Executive function characterized by poor set shifting, loss of set,

and increased susceptibility to interference Questionnaire information and clinical interview not significant

for symptoms of clinical depression or clinical anxiety

Providing Feedback

Discuss findings with patient and family members at the end of the exam in real time

Provide strengths and weaknesses in an educational, supportive manner

Explain the findings in terms of the relationship to the tumor, the treatment and to activities of daily living

Connect neuropsychological findings directly to brain function and brain location

Provide appropriate treatment options and referrals Plan follow-up re-evaluation

Neuropsychiatric Referral

Neuropsychological evaluation may identify emotional and behavioral symptoms requiring medication

Neurobehavioral slowing, problems with concentration, or apathy – consider stimulant medication such

as methylphenidate (Ritalin) or modafinil (Provigil) Depressed mood – consider antidepressant Primary memory deficit – consider memory

enhancing medication such as Aricept or Memantine Sleep disturbance, appetite decline, and behavioral changes

from steroids require referral Unmodulated mood and behavioral irritability may require a

mood stabilizer such as Depakote or Gabitril

Principles of Cognitive Rehabilitation and Accommodation

Systematically evaluate cognitive function at regular intervals (Meyers et al, 2000)

Set specific goals for restoration, substitution or restructuring

of environment (Lazar, 1998)

Include rehabilitative disciplines (Lazar, 1998)

Consider role for pharmacologic agents (Barton & Loprinzi, 2002; Chan et al, 2003; Meyers et al, 1998)

Evaluate for and remediate co-morbidities, including fatigue,

depression, anxiety, insomnia, and physiologic discomfort (Litofsky et al, 2004)

Principles of Rehabilitation

Three types of rehabilitative approaches are typically included: Restoration: cognitive training and exercises directed towards

strengthening and restoration of function

Substitution: compensatory devices and strategies directed towards substitution of lost functions and promoting conservation of affected brain functions

Restructuring: environmental restructuring and planning to promote improved functioning by changing the demands placed on the individual by themselves and others

Anticipatory Guidance

Consider support group, online support, counseling resources available through the NBTF and ABTA, individual and family counseling

Make of list of things that others can do to help the caregiver, and keep the list by the phone to consult when friends call to ask how they can help

Expect that mood disorder, particularly depression is present and contributing to cognitive difficulties (Litofsky et al, 2004)

Provide explanations and information that help link emotions, and changes in behavior and functioning to the tumor site and treatment

Help the patient and family anticipate the trajectory of the illness, and plan for the next phases - end of life decision-making, articulate wishes, and fulfilling desired short term goals

Help the patient maintain who they are and the roles that are important to them by suggesting alternatives, adaptation, accommodation and problem solving

Maintain patient involvement and dignity, despite limitationsSherwood et al,

(2004)

Psychological Support

Psychoeducation specific to cognitive and emotional changes associated with brain tumor and treatment

Cognitive/behavioral strategies to help with relaxation, reduce frustration

Compensatory strategies to enhance memory and concentration Activity pacing techniques to assist with fatigue and stamina issues Individual and family therapy to address adjustment and role issues

Future Directions Practice

More refined evaluation and description of the nature of cognitive dysfunction

Deliberative intervention/remediation/support Timely referral to multidisciplinary experts

Program Planning Advocate for improved access to neuropsychological evaluation, and

cognitive rehabilitation Systematically evaluate patients at regularly scheduled intervals to

document progress and adjust the plan Education

Develop skills in assessing, describing aspects of cognitive functioning

Expand the knowledge base of intervention techniques and approaches

Research Agenda

Instrument Refinement and Psychometric Evaluation- brief, clinically useful, valid and reliable measures of cognitive function

Prevalence, incidence, correlates, and sequelae of cognitive dysfunction

Evaluate the relative contributions of mood disturbance, insomnia, fatigue, and physiologic discomfort

Research Agenda Develop, test and refine

intervention approaches targeted to:

remediate or substitute specific aspects of cognitive dysfunction (eg. language, memory)

global aspects of cognitive dysfunction

programs of patient and family support and adjustment

Research Agenda

Evaluate the effects of pharmacologic therapies for disorders of mood (anxiety, depression), attention, wakefulness, and memory on cognitive function and quality of life

Research Agenda

Evaluate the effects of complementary and mind-body therapies (relaxation, exercise, music, humor, nutrition, rest/sleep) on cognitive function

Documents

Sandra A. Mitchell, CRNP, MScN, AOCN National Cancer Institute, Bethesda, MD