Mind Over Matter: Cognitive Impairment Can Complicate Treatment for Older Patients

Of the various ailments that can complicate cancer treatment for the elderly, one of the trickiest is cognitive impairment. Ranging from just a little memory loss to full dementia, cognitive impairment can complicate treatment, but is not an outright barrier.

The complications begin at the outset. “Sometimes it’s very difficult to know if someone is cognitively impaired,” says Ilene Browner, a geriatric oncologist at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University. “Well-educated or well-adapted older adults who might have some cognitive impairment compensate exceptionally well.”

Browner has learned over time that she has to use tests that can’t be learned. And while it’s not generally a popular topic of family conversation, unmasking cognitive impairment is often accomplished through a combination of screening questions and corroborating family members.

If cognitive impairment is established, Brown- er recommends that a geriatrician or a neurologist be a part of the patient’s medical team.

The stress and complexity of cancer and treatment choices can make almost anyone feel cognitively impaired. But Browner is after a specific kind of awareness: “Do they understand, even if it’s only for a freeze-frame of time, what’s happening?”

Once she’s achieved that, there is the challenge of designing appropriate treatment that matches with a patient’s goals of care. All of the major vectors of treatment present cognitive challenges.

Chemotherapy sometimes causes a side effect known as chemo brain — what even much younger patients can describe as intellectually crippling. For patients with cognitive issues, it’s important to watch to make sure treatment doesn’t worsen their impairment and affect their day-to-day function.

Anesthesia can also pose a threat, so if surgery is called for, alternatives such as a nerve block should be considered.

And if radiation is called for, it’s critical to find out if the patient can understand the need to stay still, accomplish that and also understand the daily routine — the back and forth of the treatment that frustrates many patients.

The ultimate question is always whether or not the treatment makes the patient more vulnerable, and what can be done about that.

“It’s really understanding the context of their illness, what their treatments are and how they can be delivered, and whether or not the patient understands and has support,” says Browner.

Family plays a big role. If a patient is alone, it might mean a different treatment, moving to a more supportive treatment environment or possibly not treating at all.

“I’ve had patients with moderate dementia who are still functioning, still have good quality of life, have meaningful interactions with family, but have bad cancer,” she says. Treatment wasn’t easy, but was accomplished through cooperation and communication.

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“They had years to live, and mostly good quality years,” she says. “It took a bit of a village to make it work.”