Cognitive Changes
Cognitive changes are problems with thinking, memory and behavior. Some survivors may experience cognitive changes due to their cancers or cancer treatments. Knowing what is causing these problems can help you get the appropriate treatment.
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Cognitive Changes: Detailed Information
This information is meant to be a general introduction to this tic. The purpose is to provide a starting point for you to become more informed about important matters that may be affecting your life as a survivor and to provide ideas about steps you can take to learn more. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Suggestions and Additional Resources documents for questions to ask and for more resources
Some cancers and treatments can result in cognitive changes. These may include changes in thinking, learning, processing or remembering information. Changes in these abilities may be upsetting because they can affect many aspects of life such as the ability to work or even to do everyday tasks that were routine before.
Cancer and treatment may have different effects on different individuals. Having chemotherapy, radiation or surgical treatment does not mean that you will have cognitive changes. Yet, it is important to know whether you have an increased risk of cognitive changes.
Cognitive changes can happen suddenly (acute onset) or they can come up slowly over time (gradual onset). These types of changes may occur very differently in adults and children. This document will focus primarily on cognitive changes in adults with cancer. Talk with your health care team if you have questions related to children who experience cognitive changes. Keep in mind that there are also other reasons for cognitive changes that are not related to cancer.
Who might be at risk for cognitive changes?
Survivors who have experienced the following might be more at risk for cognitive changes:
- Tumor located in the central nervous system (CNS) which includes the brain and spinal cord
- Treatments administered directly to the CNS
- Treatments administered when extremely ill
- Chemotherapy and radiation given to the brain at the same time
- Chemotherapy given into the spinal fluid after radiation
Cancer survivors who have not had any of the above procedures may also experience some cognitive changes. These changes may occur in survivors of all ages who have received different types of chemotherapy and radiation.
The frequency and severity of cognitive changes associated with chemotherapy can vary with the dose and type of medicine used. Changes are sometimes related to higher dose treatments of chemotherapy and the use of immunotherapy treatment to boost the immune system.
Those who had surgery to remove a brain tumor may also experience cognitive changes. The frequency and severity of the changes associated with radiation and surgery to remove a brain tumor depends on the amount of damage caused to surrounding healthy tissue.
Learn what cognitive changes to watch for so you can discuss any signs or symptoms with your health care team. Some changes after cancer are very minor and are reversible, meaning the changes will go away. However, some cognitive changes may be more noticeable and may not be reversible.
What are some of the symptoms of cognitive changes?
- Acute onset cognitive changes (delirium)
Acute onset cognitive changes are those that occur suddenly and come and go with no real pattern. This can happen during treatment with chemotherapy agents. Delirium is the term used to describe these cognitive changes. Certain medications and chemotherapy treatments can cause delirium, and it may be reversible.
Symptoms of delirium may include:
- Difficulty concentrating
- Reduced level of consciousness or the person seems "out of it"
- Person does not understand what is going on around him or her
- Unusual sleep patterns, such as awake at night and asleep during the day
- Agitation
- Confusion
- Memory loss
- Loud, aggressive behavior
- Hallucinations or seeing things that are not really there
- Disorientation or the person doesn't know where s/he is
- Quiet, inactive behavior, including sedation or confusion
- Gradual onset cognitive changes (dementia)
Gradual onset cognitive changes are considered to be chronic. This means that changes come about slowly over time and are long-lasting. Dementia is the term used to describe these cognitive changes. Symptoms of dementia might not appear until you finish active treatment for cancer. Dementia symptoms can be very mild and only slightly noticeable--or they can be very noticeable.
Symptoms of dementia may include:
- Poor short-term memory
- Poor long-term memory
- Difficulty with abstract thinking (such as adding numbers together)
- Poor judgment (makes unsafe decisions)
- Changes in personality (may become moody or upset without a noticeable cause)
- Difficulty with problem solving and following directions
- Disorientation (person doesn't know where s/he is)
- Chemo-brain
Sometimes survivors experience slight changes in their ability to remember or concentrate well after they have received chemotherapy. This very mild form of dementia is sometimes called "chemo-brain." Even these mild cognitive changes can disrupt daily living and the ability work.
Symptoms of chemo brain may include:
- Difficulty concentrating
- Difficulty remembering things that occurred recently
- Difficulty completing tasks
- Confusion
- Inability to think clearly
What causes cognitive changes in cancer survivors?
A tumor or cancer cells in the brain destroy healthy cells and can cause cognitive changes. Chemotherapy, radiation and surgery are treatments that are used to remove or destroy cancer cells. However, they can also damage some of the surrounding healthy cells. Depending on how much damage occurs, there could be noticeable problems with thinking, memory and behavior.
Chemotherapy can cause fatigue and anemia. These may also lead to cognitive problems, particularly with the ability to pay attention. In addition, a survivor can experience other conditions that cause cognitive changes that may or may not be related to cancer or treatment. Some of these conditions are reversible--some are not.
Other conditions that can cause cognitive changes may include:
- Medication problems
- Stress
- Anxiety
- Depression
- Electrolyte derangements
- Hypoxemia (low oxygen levels)
- Other diseases of the brain such as Alzheimer's disease or Parkinson's disease
- Thyroid problems
- Severe nutrition problems
Discuss all of the possible causes of cognitive problems with your health care team. This will help you receive the correct diagnosis and treatment.
When do cognitive changes occur?
Cognitive changes can occur at any point during your experience with cancer. Sometimes they are the first sign of a brain tumor. These changes may also happen after completing cancer treatment or after taking certain medications.
- Chemo brain can occur during or after chemotherapy treatment.
- Delirium may occur suddenly during treatment. Delirium usually happens after an identified cause, such as chemotherapy, and it is often reversible.
- Dementia comes on gradually over time and usually after treatment is completed. It may be harder to identify than delirium, and it may not have one identifiable cause. Dementia can develop as early as three months after radiotherapy to the brain. It may also occur 48 months or longer after completion of radiation therapy. Dementia symptoms may also occur after surgery to remove a brain tumor.
What can be done to better manage cognitive changes?
Whether cognitive changes will improve or be permanent depends on their cause. Acute cognitive changes (delirium) that occur because of certain medicines often improve when you stop taking the medicine. Chronic changes (dementia) are often not reversible, but may be improved if the cause of the problems can be corrected.
If you notice changes in your thinking, memory or behavior, keep a record of the problems that you have. Ask your family or friends to also watch for changes. Talk to your health care team about these symptoms as soon as possible. Treating the underlying condition often lessens or eliminates the cognitive problems.
The following suggestions can help you manage cognitive changes:
- Take prescribed medication as directed.
Keep a journal of medications you are taking noting any side effects of the medications. Always talk to your health care team before you stop taking any medication. Check with your health care team before using any over the counter or prescription medications, or natural products to treat your symptoms.
Cognitive changes and problems with memory may make it hard to remember to take prescribed medication. If this is true, try different methods to help, such as:
- Writing down the time and date when you take the medication
- Taking the medication at the same time every day
- Using a medication reminder or pill dispenser
- Asking someone to help you keep track, if necessary
- Avoid dangerous activities if you are alone.
If you are having severe problems with concentration and memory, you may find yourself distracted. This could be dangerous during certain activities. Examples of activities you may want to avoid when alone include:
- Cooking
- Using tools that could cause injury
- Driving
- Traveling to unfamiliar places
- Ask your family to watch for safety issues:
If you have trouble with memory or concentration, you may want to sit down with your family and share your concerns. It may put your mind at rest to discuss ways they can help you go about your daily activities.
Examples of ways your family can help include:
- Creating a checklist to keep by the door for you to review to make certain that certain things have been done such as turning off kitchen appliances
- Driving you to appointments
- Helping you with specific challenging tasks
- Setting up a system to take medications properly
- Get plenty of rest and sleep:
Rest may not get rid of the problem, but enough rest may help make it better. If you have problems sleeping at night, consider trying the following:
- Limiting naps during the day
- Developing an exercise plan with your health care team
- Using a bedtime ritual, such as meditating
- Using aromatherapy
- Reading or other relaxing activities to prepare for sleep
This document was produced in collaboration with:
Terri S. Armstrong, MS, APRN, BC
Advanced Practice Nurse, Department of Neuro-Oncology
M.D. Anderson Cancer Center
Clinical Assistant Professor and Doctoral Student
University of Texas-Houston School of Nursing
Works Cited
Cohen, M.Z., & Armstrong, T. "Cognitive dysfunction." In C. Yarbro, M. Frogge, M. Goodman (Ed.), Cancer Symptom Management 3rd Edition: 635-650. Boston: Jones and Bartlett, 2004.
Armstrong, T.S., & Gilbert, M.R. "Central nervous system toxicity." Current Opinions in Oncology.
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Cognitive Changes: Suggestions
The suggestions that follow are based on the information presented in the Detailed Information document. They are meant to help you take what you learn and apply the information to your own needs. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Additional Resources document for links to more resources.
- Use a health journal to communicate symptoms and side effects of medicine with your health care team:
- Record any cognitive changes that you notice. Keeping a health journal will help you to remember examples when you had difficulty concentrating or remembering simple things. These examples can be valuable for communicating with your health care team.
- Write down everything you want to ask your health care team between appointments.
- Keep track of your medications and bring this information to the appointment, along with all of your medication bottles. This helps the health care team be informed about all of the medications you are taking, including vitamins and over-the-counter medications.
- Take notes during your health care appointments, and write down your next appointment date and time.
- Things you can do to help you keep track of important information:
- Keep all of your important documents together in a notebook that allows you to bring it with you to your appointments.
- Provide copies of relevant documents (such as test results) to the health care team. You can also fax or mail these to the doctor before the appointment. Allowing the health care team to read your documents may be an easier way for some people to communicate.
- Store pamphlets, medication side effect inserts and important phone numbers in your binder so that everything is in one place.
- Contact your health care team by phone to let them know of your concerns. This will alert your team about the changes you are experiencing and help make sure that you talk about them at your next appointment.
- Take the medication your health care team prescribes as directed to help cognitive changes:
Keep a journal of medications you are taking noting any side effects of the medications. Always talk to your health care team before you stop taking any medication. Check with your health care team before using any over the counter or prescription medications, or natural products to treat your symptoms.
- Avoid dangerous activities if you are alone:
If you are having severe problems with concentration and memory, you may find yourself distracted. This could be dangerous during certain activities. Examples of activities you may want to avoid when alone include:
- Cooking
- Using tools that could cause injury
- Driving
- Traveling to unfamiliar places
- Ask your family to watch for safety issues:
If you have trouble with memory or concentration, you may want to sit down with your family and share your concerns. It may put your mind at rest to discuss ways they can help you go about your daily activities.
- Talk with your family and an attorney about legal documents you may need:
- If you are beginning to experience cognitive problems, it is important to make sure your medical and financial wishes are respected. Talk to your family about your wishes. Also, talk to an attorney about the legal documents that you will need to do this.
- Organize important information for your family, including medical wishes, finances and estate planning.
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