Recognizing the Symptoms of Cancer-Related Cognitive Impairment

Jennifer Cargile, MEd, CCC-SLP

Clinicians and patients hold some misconceptions surrounding cancer-related cognitive impairment, according to Jennifer Cargile, MEd, CCC-SLP, a speech language pathologist with City of Hope Atlanta.

“A lot of times people call this ‘chemo brain’ [but], it is not just chemotherapy.” She said, noting that patients receiving immunotherapy or targeted therapies are coming to her clinic and expressing concerns over symptoms of cognitive impairment. “There are other things that cause this cognitive impairment.”

In an interview with Oncology Nursing News, Cargile discussed the reality of cancer-related cognitive impairment and the need to restructure how people think about this adverse event during cancer treatment. She urged oncology nurses to pay attention to signs of cognitive impairment in order to help improve referrals to the physician or therapist when necessary.

“We need to improve our ability to communicate about this side effect so that patients realize it is a legitimate side effect that can happen as part of treatment,” she said.

Oncology Nursing News: How real is cancer-related cognitive impairment? Is there a need to change the discourse around it?

Cargile: Cancer-related cognitive impairment is real. It is a side effect of treatment. We, as an oncology community, have done a fantastic job talking about nausea, vomiting, weight gain, weight loss, and hair loss. When someone hears the word cancer and the treatment that goes along with it, they think of those side effects. The side effects that occur cognitively happen, but we do not talk about [them] as much. Because of that, patients start experiencing these side effects, these cognitive changes, and they think: “Hold on—what's going on? What's wrong with me? Is it just because I'm not sleeping? Am I tired? Is it the stress?” Then a lot of patients start jumping to conclusions of “Oh, my gosh, am I getting dementia?”

What are some of the common symptoms that patients may experience and some of the misconceptions they might have about the symptoms they are experiencing?

The top symptoms that patients report with cancer-related cognitive impairment is, first, short-term memory impairment. This may look different for different patients. You may have a patient who says she has conversations with [her] husband, and children, and will say, “Yeah, sure, we could do that Saturday.” Then Saturday comes and they are like, “Hey, we are going to the ballgame,” and the [patient says,] “What? Did we talk about that?” They forgot details of conversations. Maybe they would do that occasionally prior to their cancer diagnosis but now they are seeing it more frequently.

I find a lot of [patients experience] short-term memory deficits in terms of forgetting where they put their belongings. I have a lot of patients report that it takes them 5 or 6 times to get out of their house. They go to their car, and they are like, “Oh, where are my keys?” They go back in, they grab the keys, they come back out, and they go, “Oh, no, I didn't get my wallet.” They go back in, they come back out and ask, “Did I lock the door?” And they go back. I had a patient yesterday tell me she has lost her debit card 3 times in the last 2 months. Those are examples of short-term memory deficits that you may see. Another one with short-term memory is forgetting to pay bills. This is a big one. I have a lot of patients show up in my office because they paid bills all their lives, and suddenly they are missing bills.

The second symptom is word-finding issues. This is [when] you are talking, you know what you want to say, you go to say the word—and it is just gone. It may be as simple as the word “pen.” Like, “Pass me the…” and you are looking at the ink pen, and you cannot come up with the word. Imagine how frustrating that is— it is not like you are trying to [find] this abstract, obscure word. You are literally just trying to get the word “pen” out. That is the kind of word-findings deficits we see.

We also see patients who cannot remember the name of loved ones. I had a patient in here 2 days ago. She was a speech therapist and she [told me,] “I know how much words mean to us as speech pathologists.” She said, “I saw one of my former coworkers walking up to me and I could not remember her name. I was like, ‘How is this happening to me, this is what I've done for my life's work, and I can't even remember this woman's name.’” She said, “I could have told you her son's name, I could tell you where they live. I could tell you how many dogs she had. But I could not think of her name in that moment.” How frustrating for her to not be able to do that.

The third symptom is multitasking issues. This rings true with my young patients. Think about your job: you have to multitask. We live in a world where emails are coming in, and you get a Teams message, you have got somebody on the phone, you have got somebody coming up behind you at your desk—you have all these stimulus inputs coming in at 1 time and you have to go through and [say] “OK, this is most important.” When people have cancer-related cognitive impairment, their ability to take all that stimuli and then determine what is most important becomes very difficult. They get overwhelmed really quickly. Multitasking becomes a problem. This can be even as for simple tasks, such as cooking, I find that a lot of my patients miss ingredients when they are cooking. Or they forget they put something in the oven.

I had a woman one time say [to herself:] “I have got time to go pick up my daughter from school and the turkey will be done. It has got an hour and a half. I'm good to go.” [The daughter goes] to school within a mile of her house. “I went to go pick her up—my daughter said, ‘Let's go to Dairy Queen.’ We went to Dairy Queen, and we ended up at Target. By the time we got home, there was smoke coming out of my oven.”

She completely forgot she left that turkey in the oven. That is an example of the difficulty with multitasking.

The misconception is those symptoms I just said are very common in normal aging, but also with dementia and Alzheimer's—patients start to jump to conclusion like “Oh, I have dementia or Alzheimer's” or, conversely, their families say “I do that too.” So, they don't feel validated that their symptoms are legitimate. But the difference is that [in] normal aging, this occasionally [happens]. With cancer-related cognitive impairment, this consistently [happens].

For patients who are experiencing these symptoms, what interventions are available?

You have to talk to your doctor. I tell my patients this. As part of our supportive care offerings, we lead a cancer-related cognitive support group here at City of Hope Atlanta. The first thing I tell everybody is: You have to talk to your doctor; this group is not a substitute for talking to your doctor, because physicians can look at treatment plans, they can look at lab levels and sometimes [this symptom is] because lab levels are out of normal ranges. They can look at things and go: ‘OK, maybe we can make some changes, and improve cognition.’ It is really important that you talk to your physician first.

The physician might also look at everything and [say] everything is looking good; we need to see if cognitive therapy would be a good resource for you.

Depending on what area of the country you are in, that [referral] be to a speech language pathologist or occupational therapist. We are both trying to really look at in-depth evaluations to look at short-term memory deficits, look at multitasking, speech very much looks at the word finding, and then determine like, what therapy is most appropriate for that patient and individualize it for what they need.

I tell patients all the time that my therapy for them may be completely different than somebody else who also has cancer-related cognitive impairment because we all lead different lives. We all have to be able to do different things in our lives, and so we tailor that therapy to what they need. Because the deal is, they need to keep their jobs, they need to keep paying bills, they need to continue to do things. Life does not stop because they have a cancer diagnosis or because they are going through cancer treatment. We have got to give them the tools they need to be successful in their daily lives.