Attention and symptom distress in women with and without breast cancer.

BACKGROUND: The cognitive capacity to direct attention (CDA) is essential for self-care and independent functioning. Older women may be more vulnerable to fatigue-related losses in CDA following surgery for breast cancer. Normal functional variations in CDA associated with aging might affect attentional responses in older women newly diagnosed with breast cancer, and factors such as extent of surgery or symptom distress might influence CDA over time. OBJECTIVES: To examine (a) differences in CDA and symptom distress in older women newly diagnosed with breast cancer as compared to a control group of older women without breast cancer; (b) the pattern of change in CDA and symptom distress from the pretreatment period to 3 months after surgery; and (c) to examine the relationship of CDA with symptom distress and extent of surgery over time. METHODS: Women, 55 to 79 years of age, newly diagnosed with breast cancer (N = 47), were assessed with measures of CDA and symptom distress: (a) before surgery, (b) at 2 weeks postsurgery, and (c) 3 months postsurgery. To account for normal variations associated with aging, 48 women of similar age without breast cancer were assessed following a routine screening mammogram and 3 months later. RESULTS: Before treatment, the breast cancer group scored significantly lower than the control group (p < .05) on measures of CDA and higher on symptom distress. Repeated measures ANOVA showed significant main effects of group, but not time, for the measures of CDA and symptom distress with the breast cancer group having worse status than the control group. For CDA only, there was a significant group by time interaction effect (p = .005) so that the breast cancer group showed a gradual gain in CDA over time. CONCLUSIONS: Reduced performance in a cognitive function was observed before treatment and found to persist over an extended interval in older women newly diagnosed with breast cancer.

Changes in directed attention and short-term memory in depression.

This study examined changes in directed attention and short-term memory in depression using a newly constructed battery of computerized measures. A repeated measures design was used with two sample groups; 25 individuals meeting DSM-IV criteria for Major Depression and a group-matched comparison sample of 27. Both groups were tested at three points in time over a 10-week period. Test-retest reliability of the measures was examined. Profile analysis demonstrated that there were differences between the depressed and comparison groups in both directed attention and short-term memory. Recommendations for specific improvements in the testing battery are discussed. The ability to detect changes in directed attention and short-term memory may have clinical utility in early detection of impending onset of depression or subtle residual symptoms of an acute episode that may impair functioning or signal a relapse.

NCCN Practice Guidelines for Cancer-Related Fatigue.

These guidelines propose a treatment algorithm in which patients are evaluated regularly for fatigue, using a brief screening instrument, and are treated as indicated by their fatigue level. The algorithm's goal is to identify and treat all patients with fatigue that causes distress or interferes with daily activities or functioning. Management of fatigue begins with primary oncology team members who perform the initial screening and either provide basic education and counseling or expand the initial screening to a more focused evaluation for moderate or higher levels of fatigue. At this point the patient is assessed for the five primary factors known to be associated with fatigue: pain, emotional distress, sleep disturbance, anemia, and hypothyroidism. If any of these conditions are present, it should be treated according to practice guidelines, and the patient's fatigue should be reevaluated regularly. If none of the primary factors is present or the fatigue is unresolved, a more comprehensive assessment is indicated--with referral to other care providers as appropriate. The comprehensive assessment should include a thorough review of systems, review of medications, assessment of comorbidities, nutritional/metabolic evaluation, and assessment of activity level. Management of fatigue is cause-specific when conditions known to cause fatigue can be identified and treated. When specific causes, such as infection, fluid and electrolyte imbalances, or cardiac dysfunction, cannot be identified and corrected, nonpharmacologic and pharmacologic treatment of the fatigue should be considered. Nonpharmacologic interventions may include a moderate exercise program to improve functional capacity and activity tolerance, restorative therapies to decrease cognitive alterations and improve mood state, and nutritional and sleep interventions for patients with disturbances in eating or sleeping. Pharmacologic therapy may include drugs such as antidepressants for depression or erythropoietin for anemia. A few clinical reports of the use of corticosteroids and psychostimulants suggest the need for further research on these agents as a potential treatment modalities in managing fatigue. Basic to these interventions, the effective management of cancer-related fatigue involves an informed and supportive oncology care team that assesses patients' fatigue levels regularly and systematically and incorporates education and counseling regarding strategies for coping with fatigue (Johnson, 1999), as well as using institutional fatigue management experts for referral of patients with unresolved fatigue.

Pretreatment symptom distress in women newly diagnosed with breast cancer.

Although the initial phase of illness is recognized as important in the overall process of adjustment after a diagnosis of breast cancer, little is known about pretreatment patterns of symptom distress. Seventy-four women ages 25 to 79 years and newly diagnosed with breast cancer were studied to determine physical, cognitive, and affective distress in the pretreatment period. Severity of distress was assessed about 11 days before primary surgery using the Symptom Distress Scale (SDS), Attentional Function Index (AFI), and Profile of Mood States (POMS). Higher levels of distress (SDS) were related to a triad of symptoms, insomnia, fatigue, and loss of concentration. Also, lowered effectiveness in cognitive function (AFI) and significant disturbances in mood state (POMS) were observed. Overall, a greater number of symptoms was associated with lowered cognitive function (r = -0.47; p < 0.01) and greater mood disturbance (r = 0.65; p < 0.01). Younger women younger than 55 years of age (n = 25) reported significantly (p = 0.02) greater overall symptom distress (SDS) than older women (n = 49). Interestingly, severity of distress did not differ in groups anticipating breast-conserving surgery (n = 35) instead of mastectomy (n = 39). The findings showed a discernible pattern of symptom distress before any treatment in women newly diagnosed with breast cancer, indicating a need for early intervention to promote the initial process of adjustment.

Anxiety and directed attention in women awaiting breast cancer surgery.

PURPOSE/OBJECTIVES: To investigate the relationship between anxiety and directed attention (the ability to focus and concentrate) in women awaiting breast cancer surgery and the potential influence of age and extent of anticipated surgery (breast conservation versus mastectomy) on attentional functioning and anxiety. DESIGN: Descriptive, cross-sectional. SAMPLE AND SETTING: Convenience sample of 45 women newly diagnosed with localized breast cancer at a Midwestern university medical center. METHODS: Subjects were assessed approximately 11 days before surgery using objective measures of attention: Digit Span, the Symbol Digit Modalities Test, the Necker Cube Pattern Control Test, the Attentional Function Index (a subjective measure of effectiveness of attentional functioning), and the Tension-Anxiety subscale of the Profile of Mood States. MAIN RESEARCH VARIABLES: Capacity to direct attention, perceived attentional functioning, anxiety level, age, and extent of anticipated breast surgery. FINDINGS: Level of anxiety was related inversely (r = -0.63, p < 0.01) to perceptions of attentional functioning but not to performance on any objective measures of attention in the pretreatment period. No differences in anxiety level existed in regard to age or extent of anticipated surgery. However, older women (> or = 55 years) showed overall significantly lowered (p < 0.001) performance on the attentional measures than younger women. CONCLUSIONS: Preoperative anxiety is a clinically significant issue in women newly diagnosed with breast cancer regardless of age and extent of anticipated surgery. Higher anxiety requires use of attentional resources and initially may act to reduce perceptions of effectiveness in attentional functioning. Older women who have high anxiety combined with both subjective and objective decline in attentional functioning may be at particularly high risk for attentional fatigue. IMPLICATIONS FOR NURSING PRACTICE: Women newly diagnosed with breast cancer may experience not only increased anxiety and associated perceptions of decreased attentional functioning but also a subsequent depletion of attentional reserves as a result of the onset of attentional fatigue. Nurses can assess anxiety in women during the preoperative period and assist them in coping with the psychological and cognitive demands associated with this highly stressful period.

Age and extent of surgery affect attention in women treated for breast cancer.

Women treated for breast cancer have shown attentional fatigue manifested as a decreased capacity to concentrate or direct attention in daily life activities. This study was conducted to determine if age and extent of surgery increase the risk of early development of attentional fatigue in 74 women newly diagnosed with Stage I or II breast cancer. Measures of capacity to direct attention (CDA) were obtained at two time points, about 12 days before, and 15 days after, breast-conserving surgery or mastectomy. ANOVA showed significant age and age by time interaction effects (p < .05). Women aged 65-79 showed a significant mean decline (p < .05) in CDA over time regardless of extent of surgery. Women aged 46-64, who underwent mastectomy, showed a mean loss in CDA, whereas those having breast-conserving surgery showed a significant mean gain (p < .05). Women aged 25-45 showed no significant mean change in CDA over time. Older age and more extensive surgery increase the likelihood of loss of attention due, in part, to greater risk of attentional fatigue.

Factors influencing registered nurses teaching breast self-examination to female clients.

A university hospital-based study was conducted to explore factors that influence nurses teaching breast self-examination (BSE) to female clients, using the PRECEDE (Predisposing, Reinforcing, and Enabling factors in Educational Diagnosis and Evaluation) model as an organizing framework. Female registered nurses (N = 140) from adult inpatient and outpatient units completed a questionnaire that included items about frequency of BSE, knowledge of breast cancer screening and BSE technique, health motivation, confidence and competence in performing BSE, and teaching BSE. Data analysis compared the characteristics of nurses who reported teaching BSE with nurses who did not teach. Nurses in the teaching group had more work experience in nursing and were more likely to have a friend with breast cancer than were those in the nonteaching group. The teaching group had more knowledge about breast cancer screening and BSE technique and reported more confidence and competence in performing BSE.

Symptom management: loss of concentration.

OBJECTIVE: To review the loss of the ability to concentrate in individuals with cancer, the risk factors, and nursing approaches to support and improve attentional functioning. DATA SOURCES: Published articles and books pertaining to concentration, central nervous system toxicity, attentional fatigue, and cognitive dysfunction. CONCLUSIONS: Multiple factors related to cancer, its treatment, and the demands of a life-threatening illness increase the risk for loss of concentration and attentional fatigue. IMPLICATIONS FOR NURSING PRACTICE: Nurses can assess potential loss of concentration by observation and objective and subjective measures. Attention can be conserved by reducing environmental demands and applying attention-restoring strategies.

Attentional impairment in persons with multiple sclerosis.

Multiple sclerosis (MS) entails various cognitive and psychological changes. The capacity to direct attention (CDA) is the ability to inhibit competing and distracting stimuli while processing information from the environment. A strong CDA is essential for effective functioning in daily life. The CDA may be reduced by MS lesions and by excessive attention-draining demands imposed by the disease. The purpose of this study was to assess CDA using a one-group descriptive correlational design. The sample consisted of 33 outpatients in symptom remission with relapsing-remitting MS who had virtually no physical disability. As theorized, the MS group presented with attentional deficits of varying severity, despite the presence of few physical symptoms. These deficits were unrelated to depressive symptoms. Findings indicate that nurses need to consider attentional problems even in the most early disease states. Further research is needed to better understand the impact of attentional deficits on daily life functioning and to develop nursing interventions for conservation or restoration of CDA in individuals with relapsing-remitting MS.

Development of an intervention to restore attention in cancer patients.

Developing interventions to maintain or restore attentional capacity during demanding phases of illness will help promote effective functioning in people with cancer. This study tested the effects of an experimental intervention aimed at maintaining or restoring attentional capacity in 32 women during the 3 months after surgery for localized (Stage I or II) breast cancer. The intervention was designed to minimize or prevent attentional fatigue through regular participation in activities that engage fascination and have other restorative properties. Attentional capacity was assessed using objective and subjective measures at four time points, approximately 3, 18, 60, and 90 days after breast cancer surgery. After the first observation, subjects were randomly assigned to receive the intervention (n = 16) or not to receive intervention (n = 16). Repeated measures ANOVA showed a significant interaction of experimental intervention and time on attentional capacity. Specifically, subjects in the intervention group showed significant improvement in attentional capacity over the four time points, while the nonintervention group showed a pattern of inconsistent performance over time. Findings suggest that nurses can intervene to maintain or restore attentional capacity in women after surgery for localized breast cancer. The theoretical basis for further development of attention-restoring interventions in patients with cancer is discussed.

Attentional fatigue following breast cancer surgery.

Attentional fatigue usually follows intense use of mental effort and is manifested as a decreased capacity to concentrate, that is, to direct attention. The purpose of this study was to examine the capacity to direct attention in persons with cancer during the initial phase of illness. The sample consisted of 32 women without cognitive or affective disorders who underwent surgery for localized (Stage I or II) breast cancer. Subjects manifested attentional deficits of varying intensity on a battery of tests of directed attention on the day before discharge from the hospital, which was a mean of 3 days following mastectomy or breast conservation surgery. Unexpectedly, the two surgical groups did not differ significantly in attentional capacity and functioning. Attentional test scores were not significantly correlated with narcotic pain medication interval, mood state, or self-ratings of attentional functioning. However, as number of days postsurgery increased, attentional performance decreased. The theoretical basis for further examination of attentional fatigue in people with cancer or other life-threatening illnesses is discussed.

A theoretical perspective on attention and patient education.

Understanding how people learn is critical to effective patient education. This article addresses the central role of attentional processes in supporting effective mental functioning and learning. The theoretical perspective provides a basis for examining attentional requirements associated with illness and the detrimental effects of multiple mental demands on attentional capacity and learning. Through therapeutic approaches that conserve and restore attentional capacity, patient teaching and learning can be improved.