Disclosure Statement

Chemobrain: It’s Not All In Your Head Dr. Shah, MD, MPH 2016 DMU Memory Clinic Associate Dean, Global Health Des Moines University

Objectives • • • •

What is dementia What are the reversible causes of dementias Overview of chemobrain Chemobrain without Chemo: Post-Operative Cognitive Decline (POCD) • Difference between dementia and delirium • Assessment of memory and thinking changes • Practical tips to improve memory

I, Yogesh Shah, MD do not have any financial interests or relationships with any manufacturers of products or providers of services I might be discussing in my presentation. I have no financial relationships with any of the companies supporting this educational event. I will not discuss any pharmaceuticals, medical procedures, or devices that are investigational or unapproved for use by the FDA.

Case • Linda is a 67-year-old white female with mild hypertension. In Dec. 2015 she was diagnosed with invasive ductal carcinoma. • She finished her chemotherapy for breast cancer in January 2016. • She has problems focusing and word finding. She is unable to do multitasking. • What is this condition? How long does this last? • Does this lead into Alzheimer's disease?

Dementia-Diagnostic Criteria-DSM IV • Acquired syndrome of decline in memory and at least one: – language – judgment – executive function impairments

DEMENTIA-DIAGNOSTIC CRITERIA-DSM IV AND DSM 5

• Functional decline – social/occupational

• Not in context of delirium

1

DSM 5 Major Neurocognitive Disorder (NCD)Alzheimer’s NCD

Mild Neurocognitive Disorder Mild Cognitive Impairment (MCI)

Dementia-DSM 5 There is evidence of substantial cognitive decline from a previous level of performance in one or more of the domains The cognitive deficits are sufficient to interfere with independence

Mild NCD-MCI-DSM 5 • There is evidence of modest cognitive decline from a previous level of performance in one or more of the domains • The cognitive deficits are insufficient to interfere with independence • The cognitive deficits do not occur exclusively in the context of a delirium. • The cognitive deficits are not primarily attributable to another mental disorder (e.g., major depressive disorder, schizophrenia).

NONREVERSIBLE & REVERSIBLE

CAUSES OF NCD-DEMENTIA

NONREVERSIBLE DEMENTIAS

2

Nonreversible Causes Alzheimer’s (AD) Vascular (VaD) Frontotemporal (FTD) Mixed (AD and VaD) Lewy Body (DLB)

RISK FACTORS FOR NONREVERSIBLE DEMENTIAS

Risk Factors for AD-Possible

Risk Factors for AD-Established • Age • Family history • Down’s Syndrome

• Lack of physical activity • Lack of social interaction • Previous head trauma

• APOE-E4 (whites) • A. fibrillation

Risk Factors for AD-Possible (con.) • Smoking • Alcohol • Health conditions

Risk Factors for AD-Health Conditions • • • • • • •

Stroke Hypertension Diabetes Hyperlipidemia Obesity Depression Obstructive Sleep Apnea

3

Reversible Causes of Dementia

DEMENTIA REVERSIBLE DEMENTIAS

Reversible Causes of Dementia D E M E N T I A

drugs emotional illness-depression metabolic/endocrine disorders eye/ear/environment nutritional/neurologic tumors/trauma infection alcoholism/anemia/atherosclerosis

Drugs • Regularly review medications and supplements • Manage medications that could affect cognition • Do frequent medication reconciliation

Drugs That May Cause Memory Loss Antianxiety drugs Narcotic painkillers Sleeping aids Incontinence drugs -Anticholinergics Antihistamines Cholesterol drugs Antidepressant drugs Hypertension drugs

CHEMOBRAIN

4

Chemobrain • • • • •

What is Chemobrain How common is it What are the outcomes of chemobrain What are the causes What is POCD

How Common Is Chemobrain • 15-80% • 1/3 rd of people show cognitive impairment even before chemo • Difficulty finding words or names— the tip-of-the-tongue experiences

Chemobrain • Mild cognitive impairment following cancer treatment -common symptoms • “chemobrain” or “chemofog,” • Misleading since chemotherapy may not be its sole cause

Chemobrain Outcomes • The symptoms might last 3-9 months • Most people recover, the process may be slower than they wish • 30% don’t recover

Causes of Chemobrain • The cancer itself • Other drugs used as part of treatment, such as steroids, anti-nausea, or pain medicines • Surgery and the drugs used during surgery (anesthesia) • Sleep problems • Hormone changes or hormone treatments • Nutritional deficiencies • Depression, stress, anxiety, or other emotional pressure

CHEMOBRAIN WITHOUT CHEMO: POSTOPERATIVE COGNITIVE DYSFUNCTION

(POCD)

5

Postoperative Complications • Postoperative delirium • Postoperative cognitive dysfunction

POSTOPERATIVE DELIRIUM

What Is Delirium • Acute confusional state • Disorder of attention and cognition

Criteria to Diagnose Delirium • Disturbance of consciousness • Change in cognition or perception disturbance • Rapid onset and tendency to fluctuate • Evidence that disturbance is caused by consequences of a general medical condition

DELIRIUM RISK FACTORS FOR DELIRIUM

• • • • • • • •

Drugs Electrolyte Lack of drugs Infection Reduced sensory input Intracranial Urinary retention Myocardial

6

Drugs That May Cause Delirium Antianxiety drugs Narcotic painkillers Sleeping aids Incontinence drugs -Anticholinergics Antihistamines Cholesterol drugs Antidepressant drugs Hypertension drugs

Delirium / • LOC-fluctuate • Acute • Inattention, drowsiness, distractibility • Reversible

DIFFERENCE BETWEEN DELIRIUM AND DEMENTIA

Dementia • LOC-alert • Chronic • Amnesia

COGNITIVE ASSESSMENT • Irreversible-usually

Red Flags • Repetition (not normal in 7-10 min conversation) • Tangential, circumstantial responses • Losing track of conversation • Frequently deferring to family • Unexplained weight loss or “failure to thrive”

Benefits of Having NCD • You never have to watch ‘reruns’ on TV • You are always meeting ‘new’ people • You don’t have to ‘remember’ whines of your spouse • You can ‘hide’ your own Easter eggs

7

Prevention of Delirium • • • • PROTECTIVE STRATEGY FOR CHEMOBRAIN

Sleep Immobility Visual/Hearing Dehydration

Inouye SK,et al. NEJM 1999; 340(9):669-76

8

4 Pillars • • • •

Regular Exercise The Right Diet Social Interaction Manage Medications

EXERCISE - MOVING MORE

Aerobics

Exercise is the single most powerful tool you have to optimize your brain function. – Harvard psychologist John Ratey, M.D.

Neurobics

Brain Exercises: Use It or Lose It

• It is NOT about getting the right answer, it is the search that’s beneficial.

9

Neurobics

• Read regularly and keep a journal • Learn about computers and connect to the Internet

• • • •

Regular Exercise The Right Diet Social Interaction Manage Medications

• • • •

Regular Exercise The Right Diet Social Interaction Manage medications

• New England Journal of Medicine, June 19, 2003

Smart Foods • • • • • • • • •

Blueberries Walnuts Salmon Broccoli Olive oil Spinach Tomatoes Red wine/grape juice Dark chocolate/hot cocoa

Value of Connecting Your friends affect your health Surround yourself with health-conscious people

Case • Linda is a 67-year-old white female with mild hypertension and invasive ductal carcinoma. • Chemotherapy for breast cancer. • She has problems focusing and word finding. She is unable to do multitasking. Can function independently. • Mild Cognitive Impairment • 3-9 months • Follow 4 pillars of brain health

10

References • www.cancer.org • http://www.fredhutch.org/en/treatment/survivorship/survivalstrategies/chemobrain.html • http://www.cancercare.org/connect_workshops/13-chemobrain_2011-04-12 • http://www.breastcancer.org/treatment/planning/ask_expert/2008_10 • Berman MG, Askren MK, Jung M, et al. Pretreatment worry and neurocognitive responses in women with breast cancer. Health Psychol. 2014;33(3):222-231. • CancerCare. Coping with Chemobrain: Keeping Your Memory Sharp. February 10, 2016. Accessed at www.cancercare.org/publications/70coping_with_chemobrain_keeping_your_memory_sharp on May 2, 2016. • Ferguson RJ, Ahles TA, Saykin AJ, et al. Cognitive-behavioral management of chemotherapy-related cognitive change. Psychooncology.2007;16(8):772-777. • Mayo Clinic Staff. Chemo brain. January 15, 2016. Accessed at www.mayoclinic.org/diseases-conditions/chemo-brain/home/ovc-20170224 on May 2, 2016.

References • Reid-Arndt SA, Yee A, Perry MC, Hsieh C. Cognitive and psychological factors associated with early posttreatment functional outcomes in breast cancer survivors. J Psychosoc Oncol. 2009;27(4):415-434. • Schilder CM, Seynaeve C, Linn SC, et al. Cognitive functioning of postmenopausal breast cancer patients before adjuvant systemic therapy, and its association with medical and psychological factors. Crit Rev Oncol Hematol. 2010;76(2):133-141. • Schmidt JE, Beckjord E, Bovbjerg DH, et al. Prevalence of perceived cognitive dysfunction in survivors of a wide range of cancers: results from the 2010 LIVESTRONG survey. J Cancer Surviv. 2016;10(2):302-311. • Wefel JS, Saleeba AK, Buzdar AU, Meyers CA. Acute and late onset cognitive dysfunction associated with chemotherapy in women with breast cancer. Cancer. 2010;116(14):3348-3356. • Wefel JS, Vidrine DJ, Veramonti TL, et al. Cognitive impairment in men with testicular cancer prior to adjuvant therapy. Cancer. 2011;117(1):190196.

11