Cognitive Remediation After Treatment for Glioblastoma Multiforme

Many patients recovering from treatment for glioblastoma multiforme, be it radiation, chemotherapy, or surgery, experience some degree of emotional difficulties and/or cognitive changes.

Cognitive dysfunction is a frequent complication in long-term survivors of brain tumors and can be related to both the brain tumor and its treatment. GBM treatment can also lead to behavioral changes, creating even more stress for the individual and the family. A therapy called cognitive remediation — also known as cognitive rehab or cognitive rehabilitation — can help.

Brain tumors and their treatments cause physical changes to brain tissue and can lead to diffuse cognitive deficits, including problems with attention, memory, executive functioning, and information processing.  

Executive functioning problems include difficulty with executing “everyday actions,” such as carrying out a sequence of actions, planning a task, beginning a task, knowing when one has completed a task, or even becoming “lost” while in the middle of a task.  Executive functioning problems are highly related to problems carrying out everyday activities.

A glioblastoma may also affect mood and emotions, and this is not simply a reaction to being diagnosed with a life-threatening brain tumor. The area of the brain where a tumor is located determines what functions are affected, which could be speech, motor control, cognition, or even emotions. For example, a space-occupying lesion in the left temporal lobe is associated with low mood, but on the right side can produce manic reactions. A tumor in the frontal lobe will often modify emotional processing and behavior. 

Cognitive remediation combined with cognitive behavioral therapy is a valuable treatment to help a patient overcome all of these difficulties. Cognitive remediation treatment can teach long-lasting skills that help restore everyday functioning and optimize quality of life.  Research has demonstrated that cognitive remediation interventions that incorporated elements of memory, information processing, and attention led to significant improvements in a number of cognitive areas.

The good news is that everyone, even after brain tumor treatment, has intact cognitive abilities and strengths. Cognitive remediation therapy teaches a patient to use those existing abilities to compensate for deficits in other areas. Cognitive remediation in combination with cognitive behavioral therapy incorporates all domains of functioning: emotional, behavioral, and cognitive.

Cognitive rehabilitation is based on the principle of experience-dependent neuroplasticity, meaning that the human brain is not a static organ but can be physically changed when exposed to challenges or exercises. These changes can occur within neural pathways and synapses after exposure to enriched environments. Cognitive remediation provides such an enriched environment.

What is cognitive remediation/cognitive rehabilitation?

• Cognitive remediation teaches compensatory strategies, such as using a memory notebook or daily planner, as well as using task analysis (the process of breaking down tasks into logically sequenced steps in order to better carry out important activities of daily living.  The central goal is to  apply these strategies to everyday life after brain tumor surgery. 
• Cognitive remediation incorporates attention-enhancing exercises that require a variety of neural networks. These attention exercises engage both visual and auditory skills, both of which are essential to many everyday tasks.  Attention and information-processing exercises are designed to enhance information retention and recall, contributing to improvements in memory. 
•  Attention, memory, and executive functions are interdependent, and impairments in these areas profoundly impact daily functioning.  Therefore, exercises that increase capacity for attention, working memory, and short-term memory will increase overall mental capacity.  Such exercises also increase an individual’s awareness of the mental effort required to process information. 
• Cognitive remediation in integrated with components of cognitive behavioral psychotherapy to help patients process and understand the emotional effects of a brain tumor. The neuropsychologist will help the patient identify negative thought patterns and teach the elements of thought modification and relaxation techniques.
• Cognitive remediation is a collaborative treatment in which the individual and provider set goals and then customize treatment in order to reach these goals.

Much of a patient’s distress over post-operative cognitive changes can be reduced by pre-surgical counseling and testing. Psychometric testing before surgery can help establish the patient’s abilities and strengths and set the stage for remediation after surgery. Individuals will also learn how to self-report their cognitive difficulties to help themselves and their treatment provider develop a rehabilitation plan.

Behavioral, emotional, and cognitive changes after brain tumor surgery can be stressful, but with preparation before and quality rehabilitation after surgery, a patient can achieve excellent results and a good quality of life.

The Weill Cornell Medicine neuropsychology service within Neurological Surgery is pleased to offer several services to assist patients after brain tumor surgery, including a comprehensive Cognitive Remediation Program that focuses on improving working memory, attention, and focus. The five-week program includes personal consultation, telephone sessions, and online components designed to improve performance in a wide range of cognitive tasks. Find out more about the Cognitive Remediation Program.