Cognitive Behavioral Issues and Their Nursing Management
What are Cognitive Interventions
Cognitive interventions have been defined as mechanisms designed to change cognitive function, such as attention, concentration, or memory ( Baltes & Danish, 1980).
An intervention may be defined as a programmatic attempt at altering the course of life-span developmental phenomenon. Interventions may be classified as concrete technologies involving such parameters as the goal (enrichment, prevention, or alleviation).
The target behavior (attention, cognition, memory,
or perception), the setting (family, classroom, community, or hospital), and
the mechanism (training, practice, or health delivery).
Nurse scientists
have broadened the scope of their research in health and illness by including
multivariate models of affective, cognitive, and behavioral interventions. This
review describes the research of nurse scientists in two areas:
(1) The integrative reviews of
nonpharmacological interventions
(2) Programs of research in chronic illness, medication adherence, and pain.
These programs are examples,
and are not presented as a comprehensive review of cognitive intervention
research from nurse scientists.
Cognitive Behavioral Techniques for Symptom Management
Eller (1999) reviewed the research on guided imagery, visualization, cognitive-behavioral techniques for symptom management of stress, anxiety, depression, and for reducing blood pressure, pain, and the side effects of chemotherapy.
McDougall (1999) reviewed cognitive-behavioral interventions designed to improve cognitive function in older adults without cognitive impairment. Snyder and Chlan (1999) reviewed the research on music therapy designed to manage pain, decrease anxiety and aggressive behaviors, and improve performance and well-being.
Even though the three integrative reviews were framed within the paradigm of complementary and alternative therapies, they illuminated the vast differences between and among the interventions.
Three major differences in the interventions emerged from these comprehensive reviews:
(1) Dose (number of sessions and length of exposure)
(2)Tthe target populations
(3) The methodologies.
Cognitive Behavioral Techniques for Symptom Management Chronic Illness
Chronic illness, such as cancer, HIV, and fibromyalgia, do not have cure as their primary goal for treatment. Therefore, palliation, symptom management, and health promotion become important day-to-day activities to maintain function and live with the illness.
A number of intervention studies to ameliorate symptoms from chemotherapy treatment are published. Since chemotherapy often causes individuals to experience cognitive difficulties and physical fatigue, which last over time, the programs of two researchers are illustrated.
Elderly cancer survivors reported difficulty with attention, concentration, and memory.Women undergoing treatment for breast cancer have difficulty with attention fatigue, and cancer survivors may suffer cognitive losses.
McDougall (2001) tested the effectiveness of an efficacy-based intervention designed to improve memory performance, memory self-efficacy, and metamemory in older adult cancer survivors and those with other chronic conditions.
A total of 78 older adults (58 Fs, 20 Ms ) with an average age of 82 years participated in the eight-session program. Individuals were grouped by chronic condition: cancer = 11, arthritis 16, heart disease = 32, and other =19. The cancer group was older, M=84.82, reported greater memory decline, and had lower self-reported instrumental activities of daily living scores.
The cancer group made significant gains in short-term memory of immediate and delayed story recall, memory-efficacy ( M,= 48.22, M. 58.00), and meta-memory (subjective memory evaluation) change (M, 2.18, M -2.50). The responses of a group of elderly to training varied depending on their health status.
Efficacy of a Natural Environment Intervention,
Cimprich and Ronis (2003) tested the efficacy of a natural environment intervention, delivered 120 minutes per week of exposure, in the home of the individual. Capacity to direct attention was assessed with objective measures at two time points: 2 weeks before surgery and 2 weeks after surgery.
Compared with the control group, the intervention group showed greater
ability to direct attention. These two studies are examples of research
programs in which aspects of cognitive function have been used as outcomes of
health promotion interventions.
Cognitive Behavioral Health Promotion Interventions
A unique program of research is the work of Stuifbergen , Becker, Blozis , Timmerman, & Kullberg (2003).
Over more than 10 years of
systematic inquiry, she has demonstrated that cognitive behavioral
health-promotion interventions reduce the burden of illness and improve the
health of women with multiple sclerosis (MS).
Older adults and Medication Errors
Older adults are particularly vulnerable to medication errors, whether intentional or unintentional. With older adults, age, cognitive function, and presence of depression are known to influence compliance and adherence behaviors.
Two programs of research, emphasizing technology, are relevant to this review. Fulmer and her team (1999) tested two experimental interventions: video telephone and standard telephone against a control group receiving usual care.
Compliance was determined as the percentage of therapeutic coverage as recorded by Medication Event. Monitoring System (MEMS) chaps. The experimental groups, while not significantly different from each other, showed greater medication compliance than the control group, which worsened at 8 weeks.
Insel and Cole (2004) also incorporated the MEMS as a mechanism to enhance the availability of environmental cues to not only remember to take medications, but also to remember if the medications were taken as intended.
The primary outcome measure, the percentage of days in which the correct number of doses was taken, significantly increased. The intervention focused on providing external memory questions to older adults responsible for self-management of medications.
The cues assist in both remembering to perform the intended action (prospective memory) and remembering if the action was performed as intended (source monitoring).
Therefore, the cues used both visual placement in salient places surrounding the time of day medicines need to be taken and also provided a way for older people to check if they have taken the medicines as desired.
The interventions were tailored to the unique needs/lifestyle of the individual and embedded in the context of their living situation.
These two studies provide examples in which the use of a commercially available technology produces significant health outcomes to assist older adults to maintain their independence.
Nurse researchers are making progress in developing cognitive interventions to manage pain. Two research programs are described here. Wells- Federman and her team (Wells- Federman , Arnstein , & Caudill, 2002) provided a cognitive-behavioral treatment pain-management intervention to chronic pain patients.
Physicians who determined that these individuals did not receive relief from pain and suffering after they had undergone multiple evaluations and treatments referred all individuals to the research project.
The intervention was a group pain- management program that met once per week for 10 consecutive weeks. Topics explored during these weekly sessions were the role of lifestyle factors such as diet, activity, and physical and emotional tension.
As a result of the
intervention, pain intensity lowered by 18% and depression scores were reduced
by 29%. In addition self-efficacy for pain management increased 36%. This
intervention demonstrated that cognitive behavioral treatment reduced suffering
and improved the well-being of persons with chronic pain.
Delivery of Nonpharmacological Interventions
Good, Anderson, Stanton-Hicks, Grass, and Makii (2002) evaluated the results of three nonpharmacological interventions delivered to 311 patients following gynecological surgery: jaw relaxation, music, combination of relaxation and music and a control group. Participants in the intervention groups practiced the technique for 2 minutes preoperatively and received coaching.
The investigators evaluated sensation and distress of pain, opioid intake, or patient-controlled analgesia (PCA), and sleep. The intervention groups experienced less pain than the control group only receiving PCA.
When combined
with PCA, the three interventions had the same effects, that is a 9% to 29%
reduction in pain. Those individuals who slept well had less pain on the
following day.
The future holds great promise for the ability of science to assist older adults in maintaining cognitive function necessary for quality of life.
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