The effectiveness of cognitive rehabilitation for attention deficits in focal seizures: a randomized controlled study

Enhancing Executive Functions in Pediatric Epilepsy: Feasibility and Efficacy of a Computerized Cognitive Training Program

Epilepsy, a prevalent neurological disorder characterized by recurrent seizures, significantly impacts individuals' neurobiological, cognitive, and social lives. This report presents a feasibility study investigating the effects of a computerized cognitive training program on enhancing executive functions, particularly inhibitory control, in children and adolescents with epilepsy. Employing a pre-test-intervention-post-test design, the study involved 26 participants with diverse epileptic syndromes, focusing on those without severe intellectual disabilities. The intervention, based on the CogniFit Inc. platform, consisted of personalized tasks aiming to improve participants' inhibitory skills over 16 weeks, with an average of 40 sessions completed per participant. Results indicated significant improvements in reaction times and error rates in an anti-saccade task, demonstrating enhanced inhibitory control and general performance post-intervention. These findings suggest that targeted cognitive training is a feasible approach to bolster executive functions in young individuals with epilepsy, potentially improving their academic performance, employability, and social interactions. The study underscores the importance of early cognitive interventions in epilepsy management, highlighting the potential for computerized programs to aid in mitigating cognitive deficits associated with the condition.

Neuropsychological Rehabilitation for Epilepsy in India: Looking Beyond the Basics

BACKGROUND

Neuropsychological Rehabilitation (NR) helps manage cognitive deficits in epilepsy. As internationally developed programs have limited applicability to resource-limited countries, we developed a program to bridge this gap. This 6-week caregiver-assisted, culturally suitable program has components of (1) psychoeducation, (2) compensatory training, and, (3) cognitive retraining and is called EMPOWER (Indigenized Home Based Attention and Memory Rehabilitation Program for Adult Patients with Drug Refractory Epilepsy). Its efficacy needs to be determined.

METHODS

We carried out an open-label parallel randomized controlled trial. Adults aged 18-45 years with Drug Refractory Epilepsy (DRE), fluency in Hindi and or English, with impaired attention or memory (n = 28) were randomized to Intervention Group (IG) and Control Group (CG). The primary outcomes were objective memory (Auditory Verbal Learning Test), patient and caregiver reported everyday memory difficulties (Everyday Memory Questionnaire-Revised), number of memory aids in use, depression (Hamilton Depression Rating Scale), anxiety (Hamilton Anxiety Rating Scale) and quality of life (Quality of Life in Epilepsy-31). Intention to treat was carried out for group analysis. In the absence of norms necessary for computing Reliable Change Indices (RCIs), a cut-off of +1.0 Standard Deviation (SD) was utilized to identify clinically meaningful changes in the individual analysis of objective memory. A cut-off of 11.8 points was used for quality of life. Feedback and program evaluation responses were noted.

RESULTS

The majority of the sample comprised DRE patients with temporal lobe epilepsy who had undergone epilepsy surgery. Group analysis indicated improved learning (p = 0.013), immediate recall (p = 0.001), delayed recall (p < 0.001), long-term retention (p = 0.031), patient-reported everyday memory (p < 0.001), caregiver-reported everyday memory (p < 0.001), anxiety (p = 0.039) and total quality of life (p < 0.001). Individual analysis showed improvement in 50 %, 64 %, 71 %, 57 %, and 64 % of patients on learning, immediate recall, delayed recall, long-term retention, and total quality of life respectively. Despite improvements, themes indicative of a lack of awareness and understanding of cognitive deficits were identified. Overall, the program was rated favorably by patients and caregivers alike.

CONCLUSION

NR shows promise for patients with DRE, however larger studies are warranted. The role of cognition in epilepsy needs to be introduced at the time of diagnosis to help lay the foundation for education and acceptance.

Validation of a Nonverbal Version of the Questionnaire of Experienced Attention Deficits (FEDA)

Abstract: Although objective attention deficits have been well established in aphasia patients, there is little evidence of subjective attention deficits since these are mostly assessed with rating scales and questionnaires that are often confounded by the language deficits of aphasic patients. To overcome this limitation, we developed a nonverbal version of the Questionnaire of Experienced Attention Deficits (FEDA) and assessed its preliminary reliability and validity in 70 healthy controls and 18 aphasia patients. An exploratory factor analysis revealed a two-factorial structure with good model fit in confirmatory factor analysis as well as good internal consistency (ω = .89) and discriminant validity. We consider the NFEDA to be a valuable diagnostic tool to assess subjective attention deficits in patients with language impairments such as aphasia.

American Speech-Language-Hearing Association Clinical Practice Guideline: Cognitive Rehabilitation for the Management of Cognitive Dysfunction Associated With Acquired Brain Injury

BACKGROUND

Cognitive-communication impairments following acquired brain injury (ABI) can have devastating effects on a person's ability to participate in community, social, vocational, and academic preinjury roles and responsibilities. Guidelines for evidence-based practices are needed to assist speech-language pathologists (SLPs) and other rehabilitation specialists in the delivery of cognitive rehabilitation for the adult population.

PURPOSE

The American Speech-Language-Hearing Association, in conjunction with a multidisciplinary panel of subject matter experts, developed this guideline to identify best practice recommendations for the delivery of cognitive rehabilitation to adults with cognitive dysfunction associated with ABI.

METHOD

A multidisciplinary panel identified 19 critical questions to be addressed in the guideline. Literature published between 1980 and 2020 was identified based on a set of a priori inclusion/exclusion criteria, and main findings were pooled and organized into summary of findings tables. Following the principles of the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision Framework, the panel drafted recommendations, when appropriate, based on the findings, overall quality of the evidence, balance of benefits and harms, patient preferences, resource implications, and the feasibility and acceptability of cognitive rehabilitation.

RECOMMENDATIONS

This guideline includes one overarching evidence-based recommendation that addresses the management of cognitive dysfunction following ABI and 11 subsequent recommendations focusing on cognitive rehabilitation treatment approaches, methods, and manner of delivery. In addition, this guideline includes an overarching consensus-based recommendation and seven additional consensus recommendations highlighting the role of the SLP in the screening, assessment, and treatment of adults with cognitive dysfunction associated with ABI. Future research considerations are also discussed.

A Systematic Review on Serious Games in Attention Rehabilitation and Their Effects

Attention is a basic and main mental task and can play an important role in the functioning of other brain abilities such as intelligence, memory, learning, and perception, and its deficit occurs in 80% of patients with traumatic brain injury. The use of game-based tools for rehabilitation is rapidly expanding. Cognitive rehabilitation via video games is an emerging hot topic in cognitive science. Serious games serve a specific purpose in addition to entertainment. They can be more engaging than exercises since they replace reward and motivation systems with real-world motivations as a complement for rehabilitation activities. This study was aimed at identifying and categorizing serious computer games used for attention rehabilitation and evaluating their effects. Six electronic databases (Scopus, PubMed, ISI, Embase, IEEE, and Cochrane) were searched in August 2021. The search strategy consisted of three main concepts of “serious game”, “cognitive deficits”, and “cognitive rehabilitation”. The inclusion criteria were (1) journal articles, (2) English language, (3) being published in the last 10 years, (4) human participants, and (5) game-based intervention. In the 30 included studies, 22 unique games were utilized for attention rehabilitation. Lumosity (20%), Brain Age (Dr. Kawashima's Brain Training) (10%), and MoHRS (6.66%) were the most common games among the studies. There were (57%) casual, (23%) action, (10%) simulation, and (10%) multiple genres. Of the 47 tools used in the studies, 5 utilized cross-modal oddball attention tasks, 4 utilized game performance, 3 utilized the paced auditory serial additional test (PASAT), and the rest employed other tools. A total of 73 outcome measures were related to attention, 42 measures did not have significant results, 30 were significantly improved, 1 was significantly deteriorated, and 4 articles did not have any specific measures for attention evaluation. Thus, the results revealed the positive effect of serious games on attention. However, issues such as absence of scientific teams, the variety of the disorders that cause defects, the variety of criteria, differences in measurements, lack of long-term follow-up, insufficient RCT studies, and small sample sizes should be considered when designing, developing, and using game-based systems to prevent bias.

Suspend or amend? Randomized controlled trial on neuropsychological rehabilitation for epilepsy: A COVID-19 impact

COVID-19 caused devastating effects of human loss and suffering along with disruption in clinical research, forcing reconceptualization and modification of studies. This paper attempts to outline the steps followed and detail the modifications undertaken to deal with the impacts of the pandemic on the first ongoing randomized controlled trial on effectiveness of neuropsychological rehabilitation in adult patients with drug-resistant epilepsy in India. All modifications were based on evolving guidelines and circumstantial context and were planned, reviewed and approved by important stakeholders. Results obtained from the trial need to be interpreted and analysed within this context. These modifications have implications for wider outreach of neuropsychology services in India.

Applicability of Compensatory Cognitive Training in Epilepsy to Low Resource and Literacy Settings: A Focused Review

Epilepsy is one of the most prevalent neurological disorders, accounting for over 13 million disability-adjusted life years (DALYs). Nearly 80% of people with epilepsy live in low- and middle-income countries (WHO, 2019). Rehabilitation of cognitive impairments through compensatory training in such patients encompasses a wide range of techniques. However, interventional studies exploring their efficacy remain scarce despite being recommended in various reviews. Further, cultural contexts and other related factors have often been overlooked. We aimed to appraise the existing evidence on internal and external compensatory strategies in patients with epilepsy and identify the gaps and pitfalls in the existing literature for applicability to low resource and literacy settings from a neuropsychological perspective.

Methylphenidate for attention problems in epilepsy patients: Safety and efficacy

Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of seizures, and children with epilepsy have an increased prevalence of ADHD. Adults with epilepsy often have varying degrees of attentional dysfunction due to multiple factors, including anti-seizure medications, frequent seizures, interictal discharges, underlying lesions, and psychiatric comorbidities. Currently, there are no approved medications for the treatment of epilepsy-related attentional dysfunction. Methylphenidate (MPH) is a stimulant, FDA-approved for the treatment of ADHD, and often used for ADHD in the setting of pediatric epilepsy. Large database and registry studies indicate safety of MPH in children with ADHD and epilepsy, with no significant effect on seizure frequency. Small single-dose and open-label studies suggest efficacy of MPH in adults with epilepsy-related attention deficits. Methylphenidate represents a possible treatment for attentional dysfunction due to epilepsy, but large, randomized, placebo-controlled, double-blinded studies are needed.

Positive outcome of visuospatial deficit rehabilitation in children with epilepsy using computer-based FORAMENRehab program

Children with epilepsy often show deficits in attention and visuospatial functions. Still, very few systematically controlled evidence-based pediatric neurorehabilitation methods exist. The aim was to assess the effectiveness of a computer-based rehabilitation program for visuospatial deficit remediation in children with epilepsy. Fifty-eight children aged 8-12 years participated: 17 children with epilepsy diagnosis in intervention group, 22 patients in waiting-list control group, and 19 healthy age equivalent controls. The intervention group received guided visuospatial functions rehabilitation with FORAMENRehab software twice a week for a 5-week period. Baseline assessments were carried out before and immediately after the intervention period, and as follow-up 1.31 years later. Intervention group showed positive immediate rehabilitation effect in 3 out of 4 visuospatial components: visual organization, visual attention, and visuospatial perception. A long-term rehabilitation effect in the study group was observed in all 4 of the trained components. Also, a positive generalized effect was confirmed by the parents' and children's qualitative feedback with some of the improved skills transferring to children's everyday life. One hundred percent compliance further confirmed the children's motivation to participate and the effectiveness of FORAMENRehab for pediatric neurorehabilitation.

Attention disorders in adults with epilepsy. Determinants and therapeutic strategies

Cognitive consequences in epilepsy are often described in the following domains: verbal memory, language, executive functions, and attention. Attention is involved in all cognitive activities, and attention disorders (AD) are reported in patients with various neurological diseases. This paper proposes to define the concept of AD and its assessment, to consider their determinants in epilepsy and potential therapies (drug or not). ADs are reported in new onset epilepsy, generalized epilepsy of presumed genetic origin, and in focal epilepsy. In focal epilepsy, alertness and divided attention impairment are observed and seem to improve after successful curative surgery. Additional studies are needed to assess the prevalence and nature of AD related to status epilepticus. In the field of therapeutic strategies, anti-epileptic drugs show an impact on AD. Effects of antidepressive drug therapy are not reported, as well as psychotherapy. Cognitive rehabilitation on AD is a promising therapeutic intervention but specific studies are needed to assess its efficacy.

Memory Rehabilitation in Patients with Epilepsy: a Systematic Review

Memory failure is a common clinical concern of patients with epilepsy and is associated with significant functional impairments. Thus, memory rehabilitation is of critical clinical importance. In this article, we aimed to systematically evaluate the efficacy of memory rehabilitation in patients with epilepsy. The Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) was used to guide searches, extraction and reporting of data in this review. PsycINFO, Medline and PsychBITE searches yielded 95 studies. Twelve papers met inclusion criteria, reporting outcomes of cognitive or behavioural interventions that specifically targeted the rehabilitation of memory in patients with epilepsy. Methodological rigour was rated using the Single-Case Experimental Design (SCED) scale for single-case studies and a modified version of the Downs and Black checklist for group studies. Twelve prospective studies, nine group (six pre-post design, one waitlist crossover, two randomised controlled trials) and three single-case studies were identified. Eleven of the studies included adults, eight of which involved adults with temporal lobe epilepsy (TLE). One paediatric study was identified. The quality of group studies ranged from 36% (poor) to 72% (good), using the modified Downs and Black checklist. Single-case studies were assessed using the SCED scale and assessed to range in quality from four to seven out to 11. Overall, memory rehabilitation was associated with improved memory function in all studies. Verbal memory outcomes were most commonly examined and associated with improvements. This review found that the level of evidence available to support rehabilitation of memory in patients with epilepsy was generally weak and inconsistent. Nevertheless, studies conducted to date, albeit of limited methodological quality, offer preliminary evidence that memory rehabilitation is associated with improvements in verbal memory in patients with temporal lobe epilepsy. Little is known about the efficacy of memory rehabilitation in patients with non-TLE, children, and other aspects of memory difficulties. Guidelines for future research are proposed.

Cognitive training to improve memory in individuals undergoing electroconvulsive therapy: Negative findings

Although electroconvulsive therapy (ECT) remains the most effective treatment for severe depression, some patients report persistent memory problems following ECT that impact their quality of life and their willingness to consent to further ECT. While cognitive training has been shown to improve memory performance in various conditions, this approach has never been applied to help patients regain their memory after ECT. In a double-blind study, we tested the efficacy of a new cognitive training program called Memory Training for ECT (Mem-ECT), specifically designed to target anterograde and retrograde memory that can be compromised following ECT. Fifty-nine patients with treatment-resistant depression scheduled to undergo ultra-brief right unilateral ECT were randomly assigned to either: (a) Mem-ECT, (b) active control comprised of nonspecific mental stimulation, or (c) treatment as usual. Participants were evaluated within one week prior to the start of ECT and then again within 2 weeks following the last ECT session. All three groups improved in global function, quality of life, depression, and self-reported memory abilities without significant group differences. While there was a decline in verbal delayed recall and mental status, there was no decline in general retrograde memory or autobiographical memory in any of the groups, with no significant memory or clinical benefit for the Mem-ECT or active control conditions compared to treatment as usual. While we report negative findings, these results continue to promote the much needed discussion on developing effective strategies to minimize the adverse memory side effects of ECT, in hopes it will make ECT a better and more easily tolerated treatment for patients with severe depression who need this therapeutic option.

Potential role of a cognitive rehabilitation program following left temporal lobe epilepsy surgery

ABSTRACT Research into memory and epilepsy has focused on measuring problems and exploring causes with limited attention directed at the role of neuropsychological rehabilitation in alleviating post-operative memory difficulties. Objectives To assess the effects of a memory rehabilitation program in patients with left temporal lobe epilepsy following surgery. Methods Twenty-four patients agreed to participate and 18 completed the study; nine received memory rehabilitation while nine had no input and were designated as controls. Verbal learning efficiency, naming abilities, memory subjective ratings, ecological activity measures and a language fMRI paradigm were used as outcome measures. Results Improved verbal learning and naming test performance, increase in memory strategy use and improved self-perception were observed following the rehabilitation. Changes in fMRI activation patterns were seen in the rehabilitation group over the long term. Conclusion The findings support the potential role of a cognitive rehabilitation program following left temporal lobe surgery.

Neurorehabilitation with FORAMENRehab for attention impairment in children with epilepsy

Epilepsy is a frequent neurological disorder in children and often accompanied with attention impairment. Still, few systematically controlled rehabilitation techniques for children exist. The aim of this study was to design and measure the impact of the FORAMENRehab computer-based intervention method for attention impairment rehabilitation in children with epilepsy. We chose the FORAMENRehab program because it allows separate training for different attention components based on individual needs. Forty-eight children participated in the study. At baseline, all patients underwent neuropsychological examination of attention with the NEPSY test battery. The study group consisted of 17 8- to 12-year-old children with partial epilepsy and attention impairment who received neurorehabilitation over 5weeks (10 sessions) with FORAMENRehab Attention module accompanied by a therapist. Two control groups were included: the first control group of 12 children with partial epilepsy and attention impairment (waiting-list) participated in assessments with baseline tasks before and after the five-week period and received no active training. Additionally, all patients participated in the follow-up assessment 1.31years later. The second control group consisted of 19 typically developing children who only participated in the first assessment. After the intervention, study group patients showed significant improvement in complex attention and tracking (P<0.025). To achieve the effect of intervention in children with partial epilepsy, 10 sessions tailored to individual levels of ability were the minimum. Three attention components - sustained, complex, and tracking - need selective and longer training for more effective remediation. Follow-up assessment revealed a long-term positive effect of intervention. After 1.31years, the study group had significantly improved in three out of the four attention components (P<0.025), whereas the waiting-list group showed improvement in only two aspects of one complex attention component. In conclusion, attention impairment rehabilitation with FORAMENRehab is effective for children with epilepsy. Rehabilitation should focus on training specific components of attention and follow an individual-based rehabilitation process.

The relevance of neuropsychiatric symptoms and cognitive problems in new-onset epilepsy - Current knowledge and understanding

Neurobehavioral and cognition problems are highly prevalent in epilepsy, but most research studies to date have not adequately addressed the precise nature of the relationship between these comorbidities and seizures. To address this complex issue and to facilitate collaborative, innovative research in the rising field of neurobehavioral comorbidities and cognition disturbances in new-onset epilepsy, international epilepsy experts met at the 3rd Halifax International Epilepsy Conference & Retreat at White Point, South Shore, Nova Scotia, Canada from September 18 to 20, 2014. This Conference Proceedings provides a summary of the conference proceedings. Specifically, the following topics are discussed: (i) role of comorbidities in epilepsy diagnosis and management, (ii) role of antiepileptic medications in understanding the relationship between epilepsy and neurobehavioral and cognition problems, and (iii) animal data and diagnostic approaches. Evidence to date, though limited, strongly suggests a bidirectional relationship between epilepsy and cognitive and psychiatric comorbidities. In fact, it is likely that seizures and neurobehavioral problems represent different symptoms of a common etiology or network-wide disturbance. As a reflection of this shared network, psychiatric comorbidities and/or cognition problems may actually precede the seizure occurrence and likely get often missed if not screened.

Non-pharmacological interventions for people with epilepsy and intellectual disabilities

BACKGROUND

Approximately 30% of patients with epilepsy remain refractory to drug treatment and continue to experience seizures whilst taking one or more antiepileptic drugs (AEDs). Several non-pharmacological interventions that may be used in conjunction with or as an alternative to AEDs are available for refractory patients. In view of the fact that seizures in people with intellectual disabilities are often complex and refractory to pharmacological interventions, it is evident that good quality randomised controlled trials (RCTs) are needed to assess the efficacy of alternatives or adjuncts to pharmacological interventions.This is an updated version of the original Cochrane review (Beavis 2007) published in The Cochrane Library (2007, Issue 4).

OBJECTIVES

To assess data derived from randomised controlled trials of non-pharmacological interventions for people with epilepsy and intellectual disabilities.Non-pharmacological interventions include, but are not limited to, the following.• Surgical procedures.• Specialised diets, for example, the ketogenic diet, or vitamin and folic acid supplementation.• Psychological interventions for patients or for patients and carers/parents, for example, cognitive-behavioural therapy (CBT), electroencephalographic (EEG) biofeedback and educational intervention.• Yoga.• Acupuncture.• Relaxation therapy (e.g. music therapy).

SEARCH METHODS

For the latest update of this review, we searched the Cochrane Epilepsy Group Specialised Register (19 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) via CRSO (19 August 2014), MEDLINE (Ovid, 1946 to 19 August 2014) and PsycINFO (EBSCOhost, 1887 to 19 August 2014).

SELECTION CRITERIA

Randomised controlled trials of non-pharmacological interventions for people with epilepsy and intellectual disabilities.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria and extracted study data.

MAIN RESULTS

One study is included in this review. When two surgical procedures were compared, results indicated that corpus callosotomy with anterior temporal lobectomy was more effective than anterior temporal lobectomy alone in improving quality of life and performance on IQ tests among people with epilepsy and intellectual disabilities. No evidence was found to support superior benefit in seizure control for either intervention. This is the only study of its kind and was rated as having an overall unclear risk of bias. The previous update (December 2010) identified one RCT in progress. The study authors have confirmed that they are aiming to publish by the end of 2015; therefore this study (Bjurulf 2008) has not been included in the current review.

AUTHORS' CONCLUSIONS

This review highlights the need for well-designed randomised controlled trials conducted to assess the effects of non-pharmacological interventions on seizure and behavioural outcomes in people with intellectual disabilities and epilepsy.

Indications and expectations for neuropsychological assessment in routine epilepsy care: Report of the ILAE Neuropsychology Task Force, Diagnostic Methods Commission, 2013-2017

The International League Against Epilepsy (ILAE) Diagnostic Methods Commission charged the Neuropsychology Task Force with the job of developing a set of recommendations to address the following questions: (1) What is the role of a neuropsychological assessment? (2) Who should do a neuropsychological assessment? (3) When should people with epilepsy be referred for a neuropsychological assessment? and (4) What should be expected from a neuropsychological assessment? The recommendations have been broadly written for health care clinicians in established epilepsy settings as well as those setting up new services. They are based on a detailed survey of neuropsychological assessment practices across international epilepsy centers, and formal ranking of specific recommendations for advancing clinical epilepsy care generated by specialist epilepsy neuropsychologists from around the world. They also incorporate the latest research findings to establish minimum standards for training and practice, reflecting the many roles of neuropsychological assessment in the routine care of children and adults with epilepsy. The recommendations endorse routine screening of cognition, mood, and behavior in new-onset epilepsy, and describe the range of situations when more detailed, formal neuropsychological assessment is indicated. They identify a core set of cognitive and psychological domains that should be assessed to provide an objective account of an individual's cognitive, emotional, and psychosocial functioning, including factors likely contributing to deficits identified on qualitative and quantitative examination. The recommendations also endorse routine provision of feedback to patients, families, and clinicians about the implications of the assessment results, including specific clinical recommendations of what can be done to improve a patient's cognitive or psychosocial functioning and alleviate the distress of any difficulties identified. By canvassing the breadth and depth of scope of neuropsychological assessment, this report demonstrates the pivotal role played by this noninvasive and minimally resource intensive investigation in the care of people with epilepsy.

Multifactorial determinants of the neurocognitive effects of electroconvulsive therapy

For many patients with neuropsychiatric illnesses, standard psychiatric treatments with mono or combination pharmacotherapy, psychotherapy, and transcranial magnetic stimulation are ineffective. For these patients with treatment-resistant neuropsychiatric illnesses, a main therapeutic option is electroconvulsive therapy (ECT). Decades of research have found ECT to be highly effective; however, it can also result in adverse neurocognitive effects. Specifically, ECT results in disorientation after each session, anterograde amnesia for recently learned information, and retrograde amnesia for previously learned information. Unfortunately, the neurocognitive effects and underlying mechanisms of action of ECT remain poorly understood. The purpose of this paper was to synthesize the multiple moderating and mediating factors that are thought to underlie the neurocognitive effects of ECT into a coherent model. Such factors include demographic and neuropsychological characteristics, neuropsychiatric symptoms, ECT technical parameters, and ECT-associated neurophysiological changes. Future research is warranted to evaluate and test this model, so that these findings may support the development of more refined clinical seizure therapy delivery approaches and efficacious cognitive remediation strategies to improve the use of this important and widely used intervention tool for neuropsychiatric diseases.

Testing the effectiveness of group-based memory rehabilitation in chronic stroke patients

Memory complaints are common after stroke, yet there have been very few studies of the outcome of memory rehabilitation in these patients. The present study evaluated the effectiveness of a new manualised, group-based memory training programme. Forty outpatients with a single-stroke history and ongoing memory complaints were enrolled. The six-week course involved education and strategy training and was evaluated using a wait-list crossover design, with three assessments conducted 12 weeks apart. Outcome measures included: tests of anterograde memory (Rey Auditory Verbal Learning Test: RAVLT; Complex Figure Test) and prospective memory (Royal Prince Alfred Prospective Memory Test); the Comprehensive Assessment of Prospective Memory (CAPM) questionnaire and self-report of number of strategies used. Significant training-related gains were found on RAVLT learning and delayed recall and on CAPM informant report. Lower baseline scores predicted greater gains for several outcome measures. Patients with higher IQ or level of education showed more gains in number of strategies used. Shorter time since onset was related to gains in prospective memory, but no other stroke-related variables influenced outcome. Our study provides evidence that a relatively brief, group-based training intervention can improve memory functioning in chronic stroke patients and clarified some of the baseline factors that influence outcome.

Symptom distress and quality of life after stereotactic radiosurgery in patients with pituitary tumors: a questionnaire survey

Background

Stereotactic radiosurgery (SRS) is a common treatment for recurrent or residual pituitary adenomas. The persistence of symptoms and treatment related complications may impair the patient’s quality of life (QOL).

Purpose

The purpose of this study was to examine symptom distress, QOL, and the relationship between them among patients with pituitary tumors who had undergone SRS.

Methods

This study used a cross-sectional design and purposive sampling. We enrolled patients diagnosed with pituitary tumors who had undergone SRS. Data were collected at the CyberKnife Center at a medical center in Northern Taiwan in 2012. A questionnaire survey was used for data collection. Our questionnaire consisted of 3 parts the Pituitary Tumor Symptom Distress Questionnaire, the World Health Organization Quality of Life Instrument Short-Form (WHOQOL-BREF), and a demographic questionnaire.

Results

Sixty patients were enrolled in the study. The most common symptoms reported by patients after SRS were memory loss, fatigue, blurred vision, headache, sleep problems, and altered libido. The highest and lowest scores for QOL were in the environmental and psychological domains, respectively. Age was positively correlated with general health and the psychological domains. Level of symptom distress was negatively correlated with overall QOL, general health, physical health, and the psychological and social relationships domains. The scores in the psychological and environmental domains were higher in males than in females. Patients with ≤6 symptoms had better overall QOL, general health, physical health, and psychological and social relationships than those with >6 symptoms.

Conclusion

Symptom distress can affect different aspects of patient QOL. Levels of symptom distress, number of symptoms, age, and gender were variables significantly correlated with patient QOL. These results may be utilized by healthcare personnel to design educational and targeted interventional programs for symptom management to improve patient QOL.

Relationship of age to impulsivity and decision making: a baseline secondary analysis of a behavioral treatment study in stimulant use disorders

Because stimulant use disorders remain prevalent across the lifespan, cognition is an important area of clinical care and research focus among aging adults with stimulant use disorders. This secondary analysis of a National Institute on Drug Abuse Clinical Trials Network study suggests that decision making, verbal learning/memory, executive function, and set shifting are important cognitive domains to screen clinically and treat in aging adults with stimulant use disorders. Some suggestions are made on how clinical treatment providers can practically use these results. An important direction for future research is the development of cognitively remediating treatments for impaired cognitive domains in aging adults with stimulant use disorders.

What is important in rehabilitation for persons with epilepsy? Experiences from focus group interviews with patients and staff

This study aimed to identify the issues experienced as essential in rehabilitation for persons with epilepsy. Six focus group interviews were conducted, five groups with patients that had completed comprehensive rehabilitation for persons with epilepsy, in a day-care setting, at the Neurological Rehabilitation Clinic at Stora Sköndal Hospital, between 2006 and 2009 (total n=17) and one group with staff members (n=5). Using content analysis, two themes emerged: life with epilepsy and rehabilitation experiences. The result emphasizes that rehabilitation for persons with epilepsy should be designed individually, in structure and in content. Encounters between patients were important, as well as the team's attitude in meeting with the patients. Therapeutic working alliance is essential between patients and staff for creating an individual rehabilitation.

Effective group-based memory training for patients with epilepsy

Patients with epilepsy experience memory problems, but there have been few attempts to provide and evaluate the effectiveness of memory training. We designed a 6-week, group-based, psychoeducation and strategy course that was evaluated using a waitlist crossover design, with three assessments conducted 12 weeks apart. Thirty-one patients with a history of seizures participated. Significant gains were found on tests of anterograde (Rey Auditory Verbal Learning Test) and appointment memory. In addition, patients reported using more strategies and experiencing fewer prospective memory difficulties in daily life. Memory was more likely to improve in participants who were younger, less educated, and less depressed. Moreover, lower baseline memory, but better attention corresponded to better outcome. Of the clinical variables related to epilepsy, only number of anticonvulsant medications was found to be associated with outcome. Our study provides evidence that a relatively short intervention can improve memory functioning in patients with epilepsy.

Awareness, knowledge, and attitudes with respect to epilepsy: an investigation in relation to health-related quality of life within a Malaysian setting

The influence of awareness, knowledge, and attitudes (AKA) on the health-related quality of life (HRQoL) of patients with epilepsy has not been widely established. The aims of this preliminary study were to (1) assess general AKA and HRQoL levels, (2) correlate AKA and HRQoL levels, and (3) compare the HRQoL of patients with epilepsy with different AKA levels. A cross-sectional sample of outpatients with epilepsy were recruited from the Neurology Clinic, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia. Data analysis was carried out using the Statistical Package for Social Sciences Version 15 employing descriptive and nonparametric statistics. On written consent, included patients completed the Malay AKA Epilepsy and the Malay Quality of Life in Epilepsy-30 (MQOLIE-30) instruments. Across all patients, both AKA levels (median: 80.0, range: 0-170) and overall HRQoL (median 51.5; range 15-97) were moderate. Awareness was significantly correlated only with Seizure Worry (r(s)=+0.29, p<0.05), whereas Knowledge was not significantly linked to any domain. However, Attitudes was significantly correlated with all domains (r(s)=+0.35 to +0.47, p<0.01) except Medication Effects and Seizure Worry. Patients with good AKA levels (Total Score ≥ median) experienced significantly better Overall Quality of Life and Cognitive Functioning (p<0.05). Findings showed that AKA may play an important role in influencing patients' HRQoL, suggesting that epilepsy treatment efforts should also focus on enhancing AKA through epilepsy awareness to improve health outcomes.

Efficacy of alertness training in a case of brainstem encephalitis: clinical and theoretical implications

Although attention functions are often impaired after stroke, traumatic brain injury or inflammatory diseases, little is known about the time course and the long-term efficacy of training-induced improvement. The present single case study evaluates the time course and longitudinal stability of attention improvement after alertness training by repeatedly testing the subject between individual training sessions as well as one and seven months after the end of the training. The outpatient (M.P.) trained developed severe alertness deficits following brainstem encephalitis in 2003 without signs of cortical damage, and since then had not achieved full recovery. In 2008, M.P. participated in 15 treatment sessions on 15 separate working days over a period of three weeks. In each session a 45-minute alertness training task was administered, using the CogniPlus ALERT computer training program. Attention performance was assessed by neuropsychological tests four years, one year, and immediately before the therapy after every third training session and three times after the termination of therapy. Furthermore, a self-report questionnaire measured subjective experience of attention in everyday life situations. In order to compare the performance between training sessions, a procedure specialised for psychometric single-case diagnosis was used to analyse the data. Surprisingly, even after three consecutive training sessions, M.P. showed immense improvement in alertness. Furthermore, after two weeks she felt more energetic and more able to concentrate. Six months after the end of the training the improvement remained stable. The unexpectedly fast time course of recovery induced by the training, as well as the stable long-term effects, probably depend on intact cortical structures. In M.P. it appeared that top-down control of the alertness network on impaired brainstem arousal structures had been re-activated by the training procedure and had remained stable across a long time period.

A description of a cognitive rehabilitation programme evaluated in brain tumour patients with mild to moderate cognitive deficits

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is cognitive rehabilitation.

BACKGROUND

There is a paucity of literature on the rationale, design, and content of successful cognitive rehabilitation programmes. In the current paper, we describe in detail a cognitive rehabilitation programme that has previously proven effective in a randomized controlled trial in patients with primary brain tumours. The programme's content may be of practical interest to those working with populations of cognitively impaired patients. Programme: The programme consists of six weekly, individual, 2-hour sessions plus homework, and incorporates both strategy training and attention retraining. The elements were taken from two of the few programmes that are evidence-based. It's design consists of psycho-education, teaching of strategies to compensate for problems in attention, memory and executive functioning in daily life. The retraining was based on the assumption that a target process can be improved by frequently practising exercises. It is focused on attention as intact attention may also be necessary for adequate functioning of other cognitive domains. The hierarchically organized exercises, embedded in a game-like computer program, were tailored to the needs of the individual patient.

EVALUATION

Mean total training time was estimated to be 35 hours in seven weeks. Adherence to the programme was high. The majority of the participants found the programme to be (very) useful. However, older participants found the programme more burdensome than younger patients.

DISCUSSION

Splitting up and spreading out sessions may increase the feasibility and usefulness of the programme for older participants. Further suggestions for improvements and future studies on this programme are also provided.

Cognitive rehabilitation in patients with gliomas: a randomized, controlled trial

PURPOSE

Patients with gliomas often experience cognitive deficits, including problems with attention and memory. This randomized, controlled trial evaluated the effects of a multifaceted cognitive rehabilitation program (CRP) on cognitive functioning and selected quality-of-life domains in patients with gliomas.

PATIENTS AND METHODS

One hundred forty adult patients with low-grade and anaplastic gliomas, favorable prognostic factors, and both subjective cognitive symptoms and objective cognitive deficits were recruited from 11 hospitals in the Netherlands. Patients were randomly assigned to an intervention group or to a waiting-list control group. The intervention incorporated both computer-based attention retraining and compensatory skills training of attention, memory, and executive functioning. Participants completed a battery of neuropsychological (NP) tests and self-report questionnaires on cognitive functioning, fatigue, mental health-related quality of life, and community integration at baseline, after completion of the CRP, and at 6-month follow-up.

RESULTS

At the immediate post-treatment evaluation, statistically significant intervention effects were observed for measures of subjective cognitive functioning and its perceived burden but not for the objective NP outcomes or for any of the other self-report measures. At the 6-month follow-up, the CRP group performed significantly better than the control group on NP tests of attention and verbal memory and reported less mental fatigue. Group differences in other subjective outcomes were not significant at 6 months.

CONCLUSION

The CRP has a salutary effect on short-term cognitive complaints and on longer-term cognitive performance and mental fatigue. Additional research is needed to identify which elements of the intervention are most effective.

Interventions for cognitive deficits in adults with brain tumours

Increased life expectancy in patients with brain tumours has led to a greater risk of cognitive deficits, particularly during disease-free periods. Here, we review the empirical studies that have been done to treat or to prevent cognitive impairment in patients with brain tumours. Both pharmacological interventions and cognitive rehabilitation programmes have been used. Although both types of study have reported some successes, these are often difficult to interpret owing to limitations in the methods used. Most of the studies reviewed did not use a randomised group design to control for possible confounding factors such as placebo and practice effects. Investigations of newer, targeted therapies have reported delays in cognitive deterioration, but these need to be confirmed in future studies. Neuroprotection represents another potentially promising, novel approach to prevention of cognitive impairment in this vulnerable population of patients. Finally, we describe studies in patients with cancers outside the CNS, to highlight further possibilities for the prevention and treatment of cognitive deficits.

The use of self-generation procedures facilitates verbal memory in individuals with seizure disorders

The efficacy of a self-generation encoding procedure in facilitating the encoding and retrieval of verbal memories was compared with the didactic presentation of information in individuals with seizure disorders. Through a within-subject design, 87 patients (25 left temporal seizure onset, 29 right temporal, 8 frontal, and 25 psychogenic nonepileptic seizures) received a self-generation learning condition and a didactic learning condition and were subsequently tested for verbal paired associate free recall, cued recall, and recognition memory. All patient groups benefited from the use of the self-generation condition relative to the didactic condition. Better performance occurred with the self-generation procedure for cued recall and recognition memory test performance, but not free recall. Individuals with a left temporal seizure onset (patients with the poorest memory performance on the didactic condition) benefited the most from the self-generation condition. A memory encoding strategy that actively involves patient participation enhances memory performance.

[Epilepsy: role of neuropsychological evaluation]

Cognitive deficits are frequent in epileptic patients and can be considered epileptic behavioural markers. They are assessed by neuropsychological exploration, which requires the use of standardized psychometric tests. The neuropsychological data obtained complement the information provided by other perisurgical investigations. In addition to the indications concerning lateralization and the extent of the cerebral dysfunction, neuropsychological findings can assist in anticipating the possible cognitive risks resulting from surgical treatment. Finally, these results are indispensable to implementing neuropsychological rehabilitation, which should be proposed before and/or after surgery, when necessary, to patients involved in a surgical program for epilepsy.

The effects of cognitive rehabilitation on memory outcome after temporal lobe epilepsy surgery

OBJECTIVE

Epilepsy surgery is a valuable treatment option for patients with pharmacoresistant epilepsy, but seizure freedom is often achieved at the cost of cognitive impairments caused by surgery. The aim of this study was to investigate the short-term effects of cognitive rehabilitation on memory outcome after temporal lobe epilepsy surgery.

METHODS

Two groups of patients who underwent temporal lobe resection, one followed (n=55) and one not followed (n=57) by postoperative rehabilitation, were evaluated with respect to memory and attention before and 3 months after temporal lobe surgery. The groups came from different epilepsy centers, but were largely matched with respect to age, sex, type of surgery, and seizure outcome.

RESULTS

After surgery, 78% of the patients were seizure-free. Repeated-measures MANOVA revealed a significant "side x surgery" effect on verbal recognition and a "rehabilitation x surgery" effect on verbal learning and recognition. There were no effects for loss in verbal delayed recall or figural memory. Detailed analyses indicated gains as a result of rehabilitation, particularly after right temporal lobe surgery. Attention generally improved. The risk of manifesting losses in verbal memory was about four times higher without than with rehabilitation.

CONCLUSIONS

Rehabilitation can counteract the verbal memory decline that is normally seen after temporal lobe resection. Its positive effects were evident particularly with respect to the more cortically associated aspects of verbal learning rather than to the mesial aspects of long-term consolidation/retrieval. Figural memory was not affected at all, and attention improved independent of rehabilitation. Interestingly, left temporal lobe-resected patients, who were most in need of an efficacious rehabilitation, profited less than right temporal lobe-resected patients, indicating that left-sided surgery may reduce the capacity needed for efficient training of verbal memory. Thus, rehabilitation has a positive effect on memory outcome, but its usefulness for risk groups and the question of whether training should be performed after or possibly before surgery are debatable. Further research should also address different interventions, longer-term outcome, and the carryover effects on everyday functioning.