**8. Rehabilitation**

Patients with brain tumors face the challenge of cognitive impairment due to the tumor itself or treatments. Cognitive deficits in processing speed, memory, attention, and executive functions interfere with patients' relationships, occupational activities and daily life activities.

## **8.1. Pharmacologic treatment of neurocognitive impairment**

Methylphenidate (MPH) is a CNS stimulant that increases synaptic concentration of dopa‐ mine and noradrenaline in the brain [127]. De-Long et al. [128] conducted a pilot study on children with ALL or brain tumor, they found that approximately 75% of those patients had response to treatment with MPH regarding neuropsychological dysfunction.

Meyers et al. [129] reported significant improvements in processing speed, memory, mental flexibility, and even mood, in adult patients with brain tumors and receiving MPH. Conklin et al. showed encouraging results in the use of psychostimulant medication. On 122 survi‐ vors of childhood brain tumors or ALL who were enrolled in a double-blinded, cross-over trial comparing the acute efficacy and adverse effects of MPH and placebo.

Donepezil is acetylcholinesterase inhibitor and has efficacy in the treatment of cognitive functions impairment; uses of donepezil in adult patients with brain tumors treated with RT demonstrate improvements in cognition impairment such as attention, concentration, and verbal memory [130].

However, stimulant medication is short-acting and is not expected to result in long-term improvement in academic achievement and neurocognitive functioning once it is discontin‐ ued; on the other hand, newer pscyhostimulant medications have been widely used in children with attention-deficit hyperactivity disorder (ADHD) and have proven to have fewer side effects and a longer half-life than MPH, for these reasons further studies are needed [131].

## **8.2. Cognition rehabilitation program**

Cognitive rehabilitation program has proven to be effective in in-patients with primary brain tumors. The program consists of psychoeducation, teaching of strategies to compensate for problems in attention, memory, and executive functioning in daily life.

Cognitive remediation program (CRP) highly structured and individualized regimen, included traditional massed practice rehabilitation, instruction in metacognitive strategies, and cognitive-behavioral psychotherapy focused primarily on improving resistance to distraction. Butler and Copeland tested the effectiveness of CRP. Thirty-one subjects who had been treated from CNS tumors included in the study, and they were suffering from cogni‐ tive impairment such as attention deficits documented by continuous performance test (CPT). Cognitive behavioral psychotherapy was used. Significant improvement in focused atten‐ tion and attention/concentration was observed in those who underwent the CRP, but no significant benefit was measured with regard to arithmetic computation. The authors concluded that the intervention produced improved neurocognitive functioning on meas‐ ures of attention, but that it was too early to expect a downstream effect on the desired end result of improved academic achievement [132].

A study conducted by Butler et al. all patients was offered the CRP treatment, improvement neurocognitive variables were observed but this was not statistically significant. The study results demonstrated highly significant improvement in academic achievement for those who completed the CRP, and significant gains in their child's or adolescent's attention/concentra‐ tion in activities of daily living [133].

The majority of the participants of cognitive rehabilitation program found the program to be useful. However, older participants found the program more burdensome than younger participants [134].

Richard et al. [135] conduct a study to compare two cognitive rehabilitation program, goal management training (GMT) which is a neuroscience-based integration of mindfulness and strategy training and the Brain Health Workshop (BHW) which offers supportive psychoedu‐ cation about living with a brain tumor. They found that significant improvement in execu‐ tive functions and greater attainment of pre-training functional goals in the GMT group while The BHW group showed in significant improvement in mood and behavioral regulation.
