Prepare, don't scare: Rethinking cognitive readiness before epilepsy surgery

Abstract

Epilepsy surgery is an effective but underutilized treatment for drug‐resistant epilepsy, and concerns about postsurgical cognitive change are a prominent barrier. Refinements in surgical technique can reduce cognitive impact, but cognitive change cannot always be avoided, and approaches carrying lower cognitive risk are often less effective for seizure control. Cognitive change therefore needs to be addressed directly rather than minimized through surgical strategy alone. This article proposes cognitive prehabilitation, a structured presurgical intervention combining individualized risk–benefit education, compensatory strategy training, and recovery planning, as a potential advancement in presurgical care. A central conceptual shift is reframing potential postsurgical cognitive decline from an outcome to be feared to a cost that patients can prepare for, adapt to, and weigh against the benefits of seizure freedom. The literature specific to cognitive prehabilitation in epilepsy surgery is too limited to support systematic review; thus, we draw on adjacent evidence bases, including cognitive rehabilitation in epilepsy, prehabilitation in other surgical populations, and literatures on shared decision‐making and risk communication, to outline complementary frameworks. We detail theoretical components of cognitive prehabilitation, including risk communication and expectation setting, cognitive compensatory training, attention to mental and physical wellbeing, planning for postsurgical recovery, and peer support. Clinical and structural barriers to implementation are discussed, including patient engagement challenges and healthcare constraints. Priorities for future research include standardization of prehabilitation protocols, identification of patient‐level moderators of benefit, and scalable delivery formats. Cognitive prehabilitation represents an opportunity to move toward empowerment‐based presurgical care and to expand access to epilepsy surgery.

Plain Language Summary

Many people with drug‐resistant epilepsy avoid surgery because of the risks associated with declines in memory and thinking. This article describes the concept of cognitive prehabilitation, which is a presurgical program that gives patients personalized information about what may change with surgery, teaches practical strategies for managing memory and thinking difficulties should they arise, and helps them plan for recovery. The aim is for patients to prepare for possible memory and thinking changes rather than simply fear them. Research is still early, and studies are needed to test whether prehabilitation improves outcomes.

Key points.

• Concerns about postsurgical cognitive decline deter surgery, yet cognitive cost cannot be eliminated by surgical technique alone.

• Cognitive prehabilitation combines individualized risk–benefit education, compensatory strategy training, and recovery planning.

• Reframing cognitive change from a risk to be feared to a cost to be weighed supports informed, value‐aligned surgical decisions.

• Presurgical nomograms make epilepsy surgery uniquely suited to prehabilitation tailored to a patient's anticipated cognitive profile.

• Direct evidence is limited to small feasibility studies; standardized protocols and controlled trials are research priorities.

1. INTRODUCTION

Epilepsy surgery is an effective treatment for many patients with drug‐resistant epilepsy, yet concerns about surgical risk often deter patients, and sometimes providers, from considering it a reasonable option. ¹ Among these concerns, the potential for postsurgical cognitive decline is a prominent barrier. Approximately 40% of patients undergoing dominant temporal lobectomy experience cognitive decline, ² although the risk for an individual may be considerably higher or lower than this group‐based average. Because cognitive impairment contributes to poorer quality of life (QOL), lower educational and occupational attainment, social limitations, and financial strain, reducing cognitive morbidity is a clinical priority. ³ , ⁴ , ⁵ To date, most efforts to mitigate cognitive risk have focused on refining surgical approaches (e.g., limiting resection extent or using laser ablation). However, when functionally important networks are removed, damaged, or disconnected, meaningful cognitive risk may persist, and surgical techniques associated with lower cognitive risk are also less effective for seizure control. Furthermore, some patients with uncontrolled seizures can experience cognitive decline comparable to their surgical counterparts over time. ⁶ Thus, cognitive risk cannot be avoided entirely and therefore must be addressed more directly.

Indeed, in framing these outcomes, it is useful to distinguish cognitive cost from cognitive risk. Whereas the language of risk implies an uncertain, unwanted event that one hopes to avoid, costs are anticipated consequences that patients knowingly accept in exchange for the potential benefit of seizure freedom. ⁷ However, costs, like risks, may be probabilistic. Reframing these changes as costs rather than risks does not diminish their significance; it repositions them as something patients can anticipate, prepare for, and adapt to.

Cognitive prehabilitation, which refers to structured, presurgical intervention that combines individualized risk–benefit education, compensatory strategy training, and recovery planning, offers a means of mitigating these cognitive costs. Across surgical specialties, informational uncertainty rather than informational content has been shown to drive presurgical distress, ⁸ and structured presurgical education is associated with reduced postsurgical anxiety. ⁹ The evidence base specific to cognitive prehabilitation in epilepsy surgery, however, is at an early stage. No randomized trial has evaluated a prehabilitation protocol against a postsurgical or no‐intervention comparator, and the available studies are small, heterogeneous in design, and limited in postsurgical follow‐up.

The goal of this article is to provide the conceptual foundation for cognitive prehabilitation in epilepsy surgery, including frameworks, components, and strategies, to support research and program development in this area. The rationale we develop draws primarily on adjacent literatures, and the frameworks and components we describe should be understood as a structured proposal for clinical development and evaluation rather than as validated practice. Given that concerns about cognitive risk deter patients from pursuing surgery, ¹ we believe this represents a potential advance in the standard of care in epilepsy surgery, one that prepares patients rather than scares them.

2. COGNITIVE PREHABILITATION IN EPILEPSY SURGERY: OVERVIEW AND RATIONALE

The theoretical aims of cognitive prehabilitation are to support cognitive reserve and equip patients with skills that support functioning in anticipation of potential cognitive loss. In other surgical populations, cognitive prehabilitation has been used in older adults to reduce the risk of postsurgical delirium, and broader prehabilitation programs (e.g., nutrition, exercise, and psychological support) have improved outcomes in bariatric and cardiac surgery settings. ¹⁰ , ¹¹ , ¹² Epilepsy surgery differs from most other surgical contexts in that the nature and extent of likely cognitive cost can be estimated presurgically. For example, validated nomograms have been developed to predict the probability of postsurgical decline in verbal memory, naming, and mood following temporal lobe resection, ¹³ , ¹⁴ allowing interventions to be explicitly tailored to a patient's anticipated postsurgical cognitive profile. This creates an unusual opportunity to tailor presurgical preparation to an individual's anticipated postsurgical profile.

Outside of the surgical context, a range of cognitive interventions have been investigated in people with epilepsy. ⁴ , ¹⁵ Multiple approaches have been proposed, broadly categorized as restorative “brain training” programs, which aim to rebuild cognitive capacity through repeated practice, and compensatory, strategy‐based interventions, which emphasize skill acquisition and the use of internal and external supports to mitigate everyday cognitive difficulties. Early evidence supporting the effectiveness of cognitive interventions in epilepsy was limited by few studies with small sample sizes and lack of randomization or control groups. ⁴ However, a recent meta‐analysis of 25 studies found small to moderate effects of cognitive intervention on gains in attention, memory, and language in adults and children with epilepsy. ¹⁵ These findings are consistent with initial outcomes of the HOBSCOTCH program, the most rigorously evaluated compensatory intervention in epilepsy, which demonstrated improvements in QOL and aspects of subjective and objective cognition in a single‐site randomized trial. ¹⁶ A subsequent multisite pragmatic trial of HOBSCOTCH, including telehealth delivery, replicated short‐term gains but found that treatment effects attenuated over time and were not maintained beyond six months. ¹⁷ Compensatory approaches can therefore produce meaningful change, though durability of benefit remains unresolved. By contrast, purely restorative “brain training” programs have not shown comparable benefit. The aforementioned meta‐analysis found that “brain training” approaches were actually associated with poorer outcomes relative to controls, ¹⁵ and it has been theorized that time spent on restorative drills may displace engagement with more functionally relevant strategies.

Cognitive prehabilitation offers a natural extension of this research, leveraging established rehabilitation frameworks to prepare patients for surgery and the cognitive changes that may follow. However, because this is an emerging field, there are few empirical studies that have systematically investigated prehabilitation in epilepsy. One of the earliest preliminary studies found that both presurgical and postsurgical cognitive intervention improved memory function in those with temporal lobe epilepsy (TLE), with no significant difference by timing; data trends favored presurgical delivery, though the small sample size limits interpretation and this remains the only study to have compared the two directly. ¹⁸ A more recent initial feasibility study examining a novel standardized cognitive prehabilitation protocol, Readiness Brain Operation Optimization Training (ReBOOT), found improvements in patient‐reported surgical preparedness and presurgical compensatory strategy use. ¹⁹ Both of these studies primarily relied on education and compensatory training approaches. ¹⁸ , ¹⁹ While purely restorative approaches have not demonstrated consistent benefit in the broader epilepsy literature, the prehabilitation context introduces an interesting question of whether building cognitive reserve in advance of a known neural insult may differ mechanistically from intervening after a cognitive deficit has been incurred. Indeed, another prehabilitation program specific to speech and language training showed preliminary evidence of protective effects toward anomia for trained words after temporal lobectomy; ²⁰ however, the effect did not generalize to untrained words, and whether it confers broader preservation of postsurgical naming remains unknown.

Direct evidence for cognitive prehabilitation is therefore limited to small feasibility studies, which establish acceptability and short‐term gains in preparedness and strategy use but not efficacy for improving postsurgical cognitive outcomes. The current rationale for cognitive prehabilitation therefore draws substantially on adjacent literatures, while these early findings support continued investigation. Together, frameworks from cognitive rehabilitation in epilepsy, prehabilitation and education models in other surgical populations, and the broader literatures on shared decision‐making and risk communication offer well‐developed concepts and techniques that can be adapted to the presurgical epilepsy context. The remainder of this article draws on these adjacent evidence bases to outline practical frameworks, components, and strategies for delivering cognitive prehabilitation.

3. FRAMEWORKS FOR COGNITIVE PREHABILITATION

Two complementary frameworks help structure how cognitive prehabilitation is delivered: a multidisciplinary care pathway that determines where prehabilitation exists within the presurgical workflow (Figure 1), and a shared decision‐making model that shapes how clinicians and patients engage in preparatory conversations (Figure 2). Together, these frameworks operationalize the shift from one‐time risk disclosure to longitudinal preparation for potential cognitive changes.

FIGURE 1.

Cognitive prehabilitation integrated into the surgical workflow. Cognitive prehabilitation can be embedded within the existing epilepsy surgery pathway rather than delivered as a stand‐alone service. The arrow indicates the temporal sequence of care; the vertical line marks the timing of epilepsy surgery. Boxes list the core components at each stage: (1) presurgical work‐up, including neuropsychological evaluation; (2) preliminary cognitive risk education and referral for cognitive prehabilitation as appropriate; (3) cognitive prehabilitation, comprising ongoing cognitive/risk education, compensatory strategy training, and brain and mental health education and strategies, with referral to mental health services as appropriate; (4) postsurgical “booster” session(s) for cognitive and mood screening and referral to postoperative rehabilitation services as needed; and (5) postsurgical rehabilitation, including cognitive rehabilitation, speech therapy, and psychotherapy for adjustment.

FIGURE 2.

Shared decision‐making model as applied to epilepsy surgery. Five sequential, interlocking stages of shared decision‐making between the clinician and the patient (and, where applicable, family or caregivers) when considering epilepsy surgery. Curved arrows indicate progression from one stage to the next; callouts to the right summarize considerations of each stage. (1) Preparation: Establish trust, define roles, and create an open environment. (2) Information exchange: Clinical evidence, including treatment options, risks, benefits, and probabilities, is shared alongside the patient's values, including lifestyle, preferences, and goals. (3) Deliberation: Discuss alternatives, address concerns, and compare the advantages and disadvantages of each choice, weighing the overlapping risks and benefits of surgery. (4) Decision‐making: Choose the best option together and agree on a mutually acceptable plan, confirming understanding, to arrive at a joint decision. (5) Implementation and follow‐up: Execute the plan, monitor outcomes, and review and adjust as needed.

3.1. The multidisciplinary care pathway

Embedding prehabilitation within the presurgical evaluation timeline allows the intervention to be coordinated with routine encounters in epilepsy, neurosurgery, and neuropsychology, and to be tailored to the patient's seizure history, surgical plan, and neuropsychological risk profile. Initiating prehabilitation after surgical candidacy is established, but with sufficient lead time before the planned procedure, is essential. Ideally, patients have time to adopt new skills and begin habitual formation of utilizing cognitive compensatory strategies and supporting cognitive reserve prior to surgery. Operationally, this model also depends on multidisciplinary communication, including shared interpretation of cognitive cost, alignment on which domains are most vulnerable, and agreement on how anticipated cognitive changes should be discussed with patients.

A multidisciplinary model can improve the precision and relevance of prehabilitation targets, promote coherent messaging across providers, and integrate cognitive preparation into surgical decision‐making. Multidisciplinary presurgical care has strong precedent in bariatric ²¹ and oncologic surgery, ²² where psychosocial assessment and multimodal prehabilitation have evolved from gatekeeping into outcome‐enhancing interventions. These models demonstrate that multidisciplinary coordination during the presurgical window is both feasible and beneficial and provide a framework that epilepsy surgery programs can adapt.

3.2. Shared decision‐making model

Shared decision‐making (SDM) is an evidence‐based framework for helping patients navigate complex medical choices ²³ and can be a useful model in cognitive prehabilitation. Key components of SDM include systematically defining a problem, presenting balanced information, discussing risks and benefits, and supporting decisions grounded in patient values, making it a well‐fitting framework for presurgical counseling and prehabilitation in epilepsy. Importantly, preliminary research has shown that SDM increases decision readiness and perceived preparedness and reduces decisional conflict and uncertainty with epilepsy surgery. ²⁴

SDM depends on longitudinal education and deliberate expectation setting, rather than a single presurgical “risk discussion,” making cognitive prehabilitation a natural vehicle for this process given its built‐in structure of repeated patient contact. Research has highlighted that patients often feel undereducated about epilepsy surgery and this can lead to decision inertia. ¹ This pattern is not unique to epilepsy: across surgical populations, limited illness knowledge predicts greater fear, while structured preoperative education has been associated with reduced postoperative anxiety, ⁹ reinforcing that education reduces rather than amplifies fear.

4. COMPONENTS OF COGNITIVE PREHABILITATION

We propose five components to cognitive prehabilitation: individualized communication of anticipated cognitive cost, training in compensatory strategies, attention to mental and physical wellbeing, planning for the postsurgical recovery period, and, where feasible, peer support. Each is described below, with practical considerations for delivery. Structured education underpins several of these components, as it does in prehabilitation models across surgical specialties, but the approach differs from routine presurgical counseling in ways that shape how each component is delivered. Cognitive risk is individualized using validated outcome prediction rather than conveyed generically, strategies are practiced to habituation rather than described, and content is delivered longitudinally rather than concentrated at the point of consent. Although elements of this content are addressed at many surgical centers, no standardized guidelines exist for presurgical cognitive counseling in epilepsy, ²⁵ and patients continue to report feeling undereducated about surgery in ways that contribute to decisional inertia. ¹

4.1. Risk communication and expectation setting

The first component of cognitive prehabilitation is to educate patients about their anticipated cognitive cost. These conversations should begin early and before patients feel overwhelmed by scheduling logistics and procedural concerns, which allows adequate time for patients to work through practical considerations related to work or school planning, support needs, and value‐based tradeoffs. This kind of structured expectation setting has precedent in other elective procedures (e.g., bariatric surgery, joint replacement, cardiac interventions) ⁹ , ²⁶ where presurgical evaluation aligns patient expectations with achievable outcomes and the clinician functions as assessor, educator, and therapist, ²¹ , ²⁷ a model that maps well onto cognitive prehabilitation in epilepsy surgery.

When available, evidence‐based predictions of cognitive outcome, including both potential decline (e.g., verbal memory decline after dominant temporal resections) and potential stability or improvement (e.g., cognitive improvement secondary to better seizure control and reduced medication burden), should be communicated in a balanced, individualized manner that distinguishes preparing patients from merely warning them. This distinction matters: tone that feels alarmist can heighten threat perception and avoidance, whereas a preparatory frame (what might change, what can be done, and what supports will be in place) can preserve autonomy and engagement.

While literature regarding risk communication with epilepsy surgery is limited, research in other medical settings ²⁸ , ²⁹ has highlighted evidence‐based strategies for risk communication that can be integrated as part of the SDM framework in cognitive prehabilitation. For example, clinicians should opt for numerical risk estimates (e.g., “your risk of memory decline is __%”) rather than relying on qualitative descriptors (e.g., “moderate risk”), which are more vulnerable to subjective interpretation. ³⁰ , ³¹ Emphasizing absolute as opposed to relative risks has also been shown to improve comprehension. For instance, saying “your risk of memory decline would be reduced from __% to __% if we avoid resecting the hippocampus” tends to be more tangible than “your chance of memory decline will be decreased by __% if we avoid resecting the hippocampus.” ²⁹ Clinicians should also be explicit that measured cognitive decline maps imperfectly onto everyday functioning, and that little is known about how objective decline on neuropsychological testing translates to functional impact for an individual patient.

Because predictions carry uncertainty, clinicians should explicitly frame uncertainty in a way that is honest but actionable (e.g., best‐case, most‐likely, worst‐case ranges, and the factors that increase or decrease risk), and revisit understanding over time as additional presurgical data and treatment refine the clinical picture. The best‐case/worst‐case scenario framework, developed for high‐risk surgical decision‐making, has been associated with improved shared decision‐making in conversations with elderly oncology patients and acutely ill surgical patients, ³² and offers a useful template for structuring cognitive outcome discussions in epilepsy surgery. Additional strategies to promote patients' understanding of complex medical information are summarized in Table 1 and are important skills to consider in the context of risk communication.

TABLE 1.

Communication strategies for complex decision‐making.

Teach‐back method	The teach‐back method is a technique used to verify a patient's understanding of information. It requires patients to explain concepts in their own words. This allows practitioners to clarify or provide additional information if the patient's responses contain errors or omissions. Research has shown that this method enhances patient knowledge and health outcomes for all patient populations. 33 Asking a patient to describe their understanding of their proposed surgical procedure, risks, and benefits allows providers to determine their level of fear associated with the procedure (potentially based upon a biased or misinformed view).
Plain language communication	Communication between patient and provider is crucial to help patients maintain active participation in their care. Use of plain language communication has been recommended across multiple medical disciplines. 34 In use of this strategy, providers communicate in such a way that can be understood the first time a concept is being explained, using more informal tone and common terms when possible. For instance, instead of saying, “Undergoing a temporal lobectomy can result in memory declines, but without treatment, your memory is at risk for decline as well” providers can instead say, “The surgery we are considering will remove a part of the temporal lobe, which is the area of brain near your ear. It is the area responsible for memory, and removing this part may cause your memory to get worse. This might sound scary, but seizures are not harmless to your memory. Every time a seizure happens, it is like an “electrical storm” in the brain. Over time, these repeated storms can cause long‐term damage to the same area responsible for memory”. As this example demonstrates, it may take more time to break down information in plain language.
Use of visual aids	Research has suggested better and faster visual processing as opposed to text/auditory information, particularly in stressful environments. 35 , 36 Tools such as risk grids and infographics on cognitive functions can break down information in a more manageable way. Instead of saying “there is a 20% risk of verbal memory decline”, providers can use a probability icon array showing 100 “people” and shading 20 of them. Use of visual aids works through dual encoding, in which the brain can store information in two different ways, making it easier to remember later, and can be particularly important in patients with epilepsy who may have material‐specific memory impairment.
Written materials	Providing patients with written material can help them process information at their own pace, review the material at any time, and to help share with family and caregivers.
Involving family or support people	Involving family members or other designated support people can bolster comprehension by providing a “second set of ears” to capture information that patients can miss due to cognitive difficulties or overload. Support people can ask clarifying questions, take notes, and help to reinforce key concepts at a later time. Patients' retention and understanding of complex surgical information has been shown to improve when they have a support network rather than going through the process alone. 37

Another important application of SDM entails structuring prehabilitation around the patient's values. This can lead to more effective discussions, as it individualizes counseling to ensure that the choice of epilepsy surgery aligns with the patient's personal goals. Specifically, it is important for clinicians to explore whether the tradeoff between seizure freedom/reduction and potential neuropsychological changes is acceptable within the context of the patient's lifestyle. For instance, patients pursuing further education or in cognitively demanding professions may be less willing to accept the cost of cognitive decline. Value‐clarification exercises can be particularly effective at eliciting patient preferences, ³⁸ and may involve asking the patient to rate the importance of a list of key values (e.g., education, specific recreational activities, safety) and discuss how epilepsy surgery may impact each area.

Finally, ethical risk counseling should include reassessment of the patient's attitudes toward surgery after detailed disclosure of risks and benefits. As emphasized by bioethics literature, informed consent is an ongoing process rather than an event, and patients may revise their initial decisions after obtaining more detailed information about a medical procedure. ³⁹ Importantly, while patients retain the right to revise their initial decisions, the structured preparation provided through cognitive prehabilitation is theoretically more likely to increase engagement with surgery, as patients feel more informed and in control of the decision.

4.1.1. Culturally and linguistically responsive counseling

Studies in the US have found no significant differences in rates of epilepsy by race or ethnicity. ⁴⁰ Presurgical counseling needs, however, are not equally distributed. In many cultures, misconceptions continue to exist in the diagnosis of epilepsy, which may be viewed through a spiritual or social lens. The specific beliefs, sources of stigma, and health‐system expectations that patients bring to a surgical discussion vary substantially across regions and communities, so culturally responsive counseling requires attention to the local context rather than application of a fixed protocol.

Although use of interpretive services can often be beneficial to fill gaps, there is a predominant need for interpreters to be trained in medical and cognitive terminology to better serve multicultural needs in the context of prehabilitation. This represents cultural brokerage, which is required given the nuances in explaining concepts of surgical risks and cognitive strategies. Having built‐in time to allow these exchanges in a prehabilitation context may decrease patients' fear and reluctance of the surgical process and help foster delivery and adoption of prehabilitation strategies. Practically, this means briefing interpreters in advance on the specific cognitive constructs to be discussed, directing teach‐back to the patient through the interpreter to verify understanding, eliciting the patient's own explanatory model of epilepsy before presenting outcome estimates, and using visual aids such as icon arrays (Table 1) where language or numeracy barriers are present. It is also important to acknowledge that structured prehabilitation programs may not equally address needs across cultural contexts and should be refined accordingly.

In addition to these cultural considerations, epilepsy has been linked to lower educational attainment and income, as well as higher rates of intellectual disability. As a result, a complex feedback loop is seen in which epilepsy itself can result in poor health literacy, but the social circumstances may also create barriers for patients to understand complex information. Addressing issues of reduced health literacy involves ensuring understanding of surgical goals and seizure risks, which may require further adaptation of communication strategies and standardized cognitive prehabilitation protocols. Addressing these barriers is a matter of equity as well as efficacy; patients with lower health literacy are less likely to be offered surgery, ⁴¹ and prehabilitation that is explicitly adapted to communication needs offers one mechanism for narrowing that gap rather than reproducing it.

4.2. Cognitive compensatory training

Providing compensatory strategies before surgery allows patients to learn and practice practical supports before potential postsurgical cognitive change. These include external memory aids (e.g., calendars, reminders, note systems), organizational routines, and environmental modifications (e.g., reducing distractions during cognitively demanding tasks, breaking multi‐step instructions into discrete components). Early training is important because compensatory approaches work best when they become automatic: strategies need repetition in real‐world contexts to shift from “things I should do” to habitual routines that reliably scaffold daily functioning. Structured goal‐setting using frameworks such as SMART goals (Specific, Measurable, Achievable, Relevant, Time‐bound) can help translate strategies into concrete, trackable behaviors and provides a built‐in mechanism for reviewing progress and adjusting course across prehabilitation sessions. In other disease populations, early cognitive intervention has proven essential. For example, in the aging literature, cognitive intervention for those with Mild Cognitive Impairment compared to early stage dementia is far more effective as it helps establish compensatory strategies early to sustain independence as cognition declines. ⁴²

Strategy selection should be guided by the patient's neuropsychological profile, anticipated surgical risks, and the functional demands of their daily roles. For example, a patient undergoing dominant temporal lobectomy is at highest risk for verbal memory and naming decline; therefore, focusing on memory and language strategies would be most prudent. Patients can also work with clinicians to anticipate which activities may become more difficult postsurgically. This kind of practical planning can reduce the uncertainty that often accompanies the postsurgical period and give patients a sense of agency over their recovery trajectory. Based on evidence from other presurgical education programs, ⁹ giving patients concrete skills and a plan may reduce anticipatory anxiety by shifting the focus from uncontrollable risk to actionable preparation, thereby enhancing perceived control and supporting confident participation in surgical decision‐making. A “cognitive toolbox” (Table 2) can be useful for organizing strategy recommendations by cognitive domain and functional context, giving patients a concrete reference they can revisit before and after surgery. Additionally, having the option of “booster sessions” postsurgically can reinforce concepts and strategies discussed as part of prehabilitation and screen for any major changes that may require more intensive follow‐up.

TABLE 2.

Common components of a cognitive toolbox.

Component	Strategies	Technology/apps	Clinical notes
Memory
External memory strategies	Centralized memory notebook; written lists and note‐taking; alarm/reminder systems; calendar; medication organizers; photo documentation; location‐based reminders	Medication alarms, calendars with reminders, and digital note‐taking applications; list‐keeping and journaling apps; voice‐to‐text and dictation tools; smartwatch and wearable reminder systems	First‐line approach for memory strategies; recommended when internal strategies are insufficient. Particularly useful postsurgically when new learning is disrupted. Example: A patient concerned about forgetting entire events and conversations adopted nightly journaling paired with a digital note‐taking system.
Internal memory strategies	Errorless learning; mnemonics; clustering (chunking items); Method of Loci; visual‐verbal associations; visual‐verbal schematics; storytelling; humor; self‐generated cueing; spaced retrieval and rehearsal	Applications for acronym generation and flashcards for rehearsal	Applicable when external aids are unavailable; may be more cognitively demanding postsurgery. Example: A patient worried about retaining names made a habit of repeating each person's name aloud upon introduction and mentally rehearsing it at least three times throughout the interaction.
Language
Word‐finding strategies	Circumlocution; gesturing; visualization; phonemic cueing; rehearsal of ‘hard to remember’ word list; semantic search tools	Vocabulary and word games; can consider word‐finding and language rehabilitation applications postsurgery	Strategies engage language networks to find a ‘detour’ to access words and/or synonyms. Example: A patient reporting word‐pronunciation difficulties created a personal “difficult‐to‐pronounce” word list and practiced weekly using a digital voice assistant.
Other language strategies	Request slower speech; ask for clarification; repeat back; request written instructions; stay socially engaged	AI writing tools, text‐to‐speech and dictation applications, reader view for webpages, voice recorder	Less commonly impacted in epilepsy/epilepsy surgery but helpful tools for enhancing communication and addressing other changes postsurgery. Example: A patient concerned about understanding important details during workplace conversations committed to repeating back key points on the spot when dialoguing with colleagues.
Attention, processing speed, and executive function
Efficiency strategies	Environmental optimization (reduce distractions; designated workspace); task batching; time‐of‐day scheduling aligned with peak alertness; mindful engagement with one task at a time	Applications for time management, planning, and to‐do lists; AI voice assistants (e.g., Siri, Alexa, Google Assistant) for hands‐free reminders and task management	Emphasis placed on limiting stress and frustration by planning for extra time and taking breaks during demanding tasks. Example: A patient pursuing higher education postsurgery established a reading schedule and built an organized digital system to centralize articles and study materials.
Attention strategies	Structured task approach (break tasks into steps); checklists; self‐monitoring cues; use of timers to stay on task; active listening skills; organizational systems (filing system, designated locations for frequently misplaced items)	Applications that block distractions, structure work intervals with timed breaks, and support task initiation and sustained engagement through goal‐setting, alarms, and/or accountability features	Strategies reduce the need for executive functions to filter information and distractions. Example: A patient who had been missing bills and important mail installed a mail organizer by the front door and committed to a fixed monthly bill‐paying routine.
Cognitive fatigue management	Energy/effort pacing; scheduled rest breaks; activity monitoring; identification of personal fatigue triggers; planning for gradual return and/or modified workload postsurgery	Wearable activity trackers (e.g., Fitbit, Apple Watch) for monitoring exertion; scheduling and pacing applications	Discussing potential of increased cognitive fatigue postsurgery helps with planning and expectation setting. Feeling overstimulated in the subacute recovery phase is also common. Example: A patient worried about managing multiple work projects upon return after surgery built a comprehensive spreadsheet tracking ongoing projects, deadlines, and key notes prior to surgery.

4.3. Promoting mental health and physical wellbeing

Cognitive prehabilitation is unlikely to be optimally delivered in isolation from psychological and physical health, both of which are independently related to cognition in epilepsy. Mental health symptoms are common among individuals with epilepsy, with depression and anxiety being most prevalent. ⁴³ Previous literature in epilepsy shows relationships between mood and subjective ⁴⁴ and objective ⁴⁵ cognitive functioning, along with QOL. ⁵ Therefore, incorporating mood considerations into prehabilitation may help identify psychological contributors to cognitive difficulties and allow cognitive strategies to be appropriately tailored. For instance, clinicians working with patients with elevated mood symptoms may choose to emphasize skills that can improve both everyday cognitive functioning and psychological wellbeing, such as mindfulness ⁴⁶ , ⁴⁷ and problem‐solving strategies that make tasks feel less overwhelming (e.g., breaking tasks into smaller steps).

Furthermore, evaluating mood symptoms may help clinicians identify factors that amplify fear and shape expectations related to epilepsy surgery, particularly as presurgical anxiety is related to postsurgical satisfaction in epilepsy surgery. ⁴⁸ Because epilepsy surgery can lead to exacerbation of or new onset mood symptoms, ⁴⁹ prehabilitation should include education about this risk. Discussing the “burden of normality”—including personal identity changes, heightened expectations, and shifting life goals after seizure freedom or reduction—can also help normalize the common psychosocial adjustment period following epilepsy surgery. ⁵⁰ While comprehensive mood assessment and treatment are beyond the scope of cognitive prehabilitation, brief screening can help identify patients who may benefit from more extensive presurgical psychological, psychiatric, or social work evaluation.

Finally, physical wellbeing is inherently tied to brain health and as such, can represent an important topic of discussion in cognitive prehabilitation. In individuals with epilepsy, cardiovascular risk may contribute to worse cognition ⁵¹ and worse cognitive outcomes after epilepsy surgery, ⁵² while exercise is associated with improved cognitive performance ⁵³ , ⁵⁴ and increased contralateral hippocampal volumes. ⁵⁴ Other modifiable factors, such as sleep quality, are also associated with cognition in epilepsy. ⁵⁵ Overall, many aspects of physical health represent opportunities for intervention in this population, particularly with planned surgery. Physical health goals should prioritize patient safety, particularly in light of epilepsy‐related risks, and counseling with the patient's medical providers may be appropriate in this context.

4.4. Planning for postsurgical recovery

Planning for the postsurgical recovery period represents a distinctive component of cognitive prehabilitation that sets it apart from traditional cognitive rehabilitation. While much of prehabilitation focuses on building skills and reserve in anticipation of longer‐term cognitive change, patients also benefit from anticipatory guidance about the more acute effects of surgery that may emerge in the days and weeks immediately following the procedure. These include acute language disruptions, which are among the most common sequelae of dominant temporal lobe surgery, visual field deficits, and physical effects such as transient hemiparesis or facial palsy, which, though rare, can appear in a delayed fashion days after an otherwise unremarkable surgery. ⁵⁶ A general sense of mental overstimulation or cognitive overload is also common. When these experiences arise without prior context, patients may interpret them as evidence of permanent decline or surgical failure, amplifying distress and undermining confidence in recovery. Normalizing these transient effects in advance and distinguishing them from the longer‐term cognitive changes discussed in earlier prehabilitation can help patients appraise their early recovery more accurately and reduce unnecessary alarm.

Prehabilitation also provides a natural opportunity to collaboratively develop concrete plans for the recovery period and eventual return to daily life. Return to work or school, in particular, warrants structured discussion, including realistic timelines, graduated re‐entry strategies, and identification of accommodations or communication scripts that patients can use with employers or academic institutions. Similarly, patients with significant caregiving responsibilities, social commitments, or physically demanding roles may benefit from planning around temporary modifications to those obligations. Equally important is preparing patients for the subacute recovery window itself, which is a period that is often underestimated in its psychological difficulty. As acute surgical effects resolve but functional restrictions remain, patients frequently experience boredom, restlessness, and/or low mood as they await clearance to resume meaningful activities, and this waiting period can become a source of anxiety or depressive symptoms if patients are unprepared for it. Anticipating this phase and identifying low‐demand but engaging activities that are feasible during recovery can help bridge the gap between discharge and full re‐entry. This kind of forward planning serves a dual purpose: it reduces the logistical uncertainty that can compound postsurgical stress, and it reinforces a recovery‐oriented mindset by helping patients envision a clear path back to meaningful daily functioning. ⁵⁰ Linking these plans to the compensatory strategies introduced earlier in prehabilitation, such as using organizational tools and environmental modifications during the re‐entry period, ensures continuity between the presurgical and postsurgical phases of care and positions prehabilitation as the beginning of a broader rehabilitation continuum rather than a discrete, time‐limited intervention.

4.5. Peer support

When feasible, including a group component in cognitive prehabilitation might help foster a greater support network and help normalize cognitive challenges and difficult emotions related to epilepsy and the anticipation of epilepsy surgery. Epilepsy can be an isolating condition, particularly given its drastic impact on independence and the freedom to participate in common activities including travel, employment, and leisure. As such, peer support has been found to be beneficial for individuals with epilepsy across a variety of group‐treatment settings. ⁵⁷ , ⁵⁸ Group‐based cognitive prehabilitation can promote social connection among individuals with shared experiences and collaboration in the developing or refining of cognitive strategies, which may enhance patient engagement and motivation. When possible, patients may also benefit from connecting with individuals who have already undergone epilepsy surgery (e.g., through local epilepsy organizations) for additional support through the process.

5. IMPLEMENTATION BARRIERS

5.1. Unique clinical challenges in cognitive prehabilitation

Implementation of cognitive prehabilitation comes with predictable clinical challenges. In the context of presurgical counseling, some patients may experience increased anxiety when learning about cognitive costs associated with surgery. Although apprehension about postsurgical risk can delay surgical treatment, ⁵⁹ there is limited research regarding the impact of discussions specifically focused on cognitive costs. In our clinical experience, initial conversations about cognitive outcomes may increase anxiety, but education and support across multiple cognitive prehabilitation sessions ultimately bring reassurance. A tailored approach to prehabilitation may be beneficial for patients with higher presurgical anxiety, including more frequent check‐ins about feelings regarding surgery, incorporation of cognitive behavioral strategies (e.g., cognitive reframing), and direct solicitation of questions. Learning compensatory cognitive strategies can also help shift the patient's focus toward modifiable aspects of cognitive health, to foster a sense of empowerment and reduce feelings of uncertainty.

There are also challenges associated with implementing preemptive cognitive training. For instance, some patients report minimal cognitive or functional concerns at baseline and may have difficulty appreciating the relevance of strategies, particularly when surgery already feels overwhelming or when the intervention is interpreted as signaling inevitable decline. In these cases, framing strategies as performance optimization and “future‐proofing,” emphasizing flexibility (use what fits, discard what does not work well), and selecting low‐burden tools can improve engagement. For example, a patient anticipating return to a demanding job might pre‐build a comprehensive task list, document key workflows, and reorganize their workspace before surgery so that any postsurgical reduction in efficiency is buffered by structures already in place.

Other barriers to treatment include limited time or resources to adequately engage with prehabilitation. Strategy training typically requires repetition and real‐world practice to become habitual, yet patients in the presurgical window are often managing competing demands (e.g., diagnostic workups, insurance logistics, work and family planning) that can limit engagement, particularly if they have lower financial resources or limited social support. Barriers such as limited transportation, inadequate access to technology, or lack of a private environment may also restrict participation in either in‐person or virtual treatment. Motivational interviewing techniques, such as eliciting patients own reasons for engagement, exploring ambivalence, and linking strategy use to personally meaningful goals, may help enhance buy‐in and adherence, particularly when patients have many additional responsibilities or do not yet perceive a functional need for compensatory supports. ⁶⁰

5.2. Structural challenges

Additional barriers to cognitive prehabilitation relate to the broader clinical context where the treatment is conducted. Epilepsy surgical centers in lower‐resource or remote settings may lack neuropsychology capacity, and in many low‐ and middle‐income countries, neuropsychology services may not be readily available at all. Even in high‐income countries, many surgical centers operate with a single neuropsychologist, or none embedded in the surgical pathway at all, and existing staffing is typically absorbed by presurgical diagnostic assessment. Several adaptations can preserve the core of the multidisciplinary model of cognitive prehabilitation where neuropsychology resources are scarce. Structured, manualized programs can be delivered by other trained healthcare professionals, such as advanced practice providers, psychologists, or social workers, a model used by HOBSCOTCH, which has been implemented across multiple centers by non‐neuropsychologist providers. ¹⁷ Virtual delivery can extend reach further, either by allowing patients to participate remotely or by enabling a regional neuropsychologist to support several surgical centers, with local staff handling follow‐up. A stepped model can further conserve capacity by reserving full neuropsychologist‐led prehabilitation for patients at highest anticipated cognitive cost, such as dominant‐hemisphere temporal resections, while lower‐risk patients receive a single structured session and written materials. Table 3 outlines how the various components of cognitive prehabilitation map onto a minimum viable model relative to a fully resourced one. However, these adaptations have not been formally evaluated in research, and more studies are needed to understand the essential components required for improving outcomes.

TABLE 3.

Tiered framework for cognitive prehabilitation: Core components and enhanced implementation.

Domain	Minimum viable model	Enhanced model
Timing	One structured presurgical session after surgical candidacy is established	Multi‐session pathway beginning presurgically and extending into postoperative booster sessions
Components	‐ Baseline neuropsychological assessment ‐ Individualized cognitive risk/cost education ‐ Brief compensatory strategy education ‐ Written recovery plan	‐ Full cognitive toolbox ‐ Structured goal‐setting (e.g., SMART goals) ‐ Mood/health screening ‐ Family/caregiver involvement ‐ Peer support
Delivery	Individual session: in‐person or virtual	Individual plus group components Hybrid or telehealth delivery based on patient needs
Personnel	Neuropsychologist where available; otherwise, trained epilepsy clinician using structured materials	Neuropsychologist‐led multidisciplinary team Support staff for administrative tasks
Follow‐up	Signposting to rehabilitation if difficulties emerge	Planned postoperative booster session and triage to cognitive rehabilitation, speech therapy, and/or psychological support
Outcomes	Preparedness, understanding of cognitive cost, awareness of compensatory strategies	Decision readiness, improvement in QOL, mood, and cognitive outcomes, higher rates of return to work/school, service use, cost‐effectiveness

Abbreviations: SMART goals = specific, measurable, achievable, relevant, time‐bound; QOL = quality of life.

On the other hand, epilepsy centers with more resources may be highly efficient, potentially creating challenges related to the timing of treatment. Cognitive prehabilitation in those settings has to be short and flexible to accommodate limited time frames, and multidisciplinary collaboration is essential to facilitate integration of the treatment into the presurgical pathway. Program design can help mitigate these constraints. For example, ReBOOT uses a rotating group format in which sessions can be joined in any order, allowing patients to engage flexibly around competing demands while also reducing the time burden on the lead neuropsychologist. ¹⁹

Depending on healthcare funding sources, insurance coverage may also represent a significant obstacle to implementation given the preventative nature of cognitive prehabilitation, which can be difficult to justify as a necessary treatment due to the limited outcome‐focused research in this area.

6. FUTURE DIRECTIONS AND RESEARCH NEEDS

While the conceptual case for cognitive prehabilitation is supported by adjacent literatures, the empirical base specific to epilepsy surgery remains limited, and several critical questions must be addressed before the field can move toward standardized clinical implementation. Additional research on existing or new standardized prehabilitation programs is needed to assess types and components of prehabilitation that are most beneficial to patients. Given the heterogeneity in epilepsy, future studies will also benefit from understanding factors associated with favorable outcomes in prehabilitation, including type and location of epilepsy, baseline cognitive profile and psychological status, and social determinants of health. With the appropriate validation, standardized prehabilitation programs could facilitate clinician training and expand access to care, particularly in areas with limited neuropsychological services.

The framing of postsurgical cognitive change also warrants direct study. Whether describing anticipated change as a cost to be weighed rather than a risk to be avoided affects decisional conflict, anticipatory anxiety, or willingness to proceed with surgery is an empirical question that has not been tested. Framing effects are well documented in other medical decision contexts, and the assumption that any particular formulation reduces rather than amplifies distress should be evaluated rather than presumed.

Broader implementation projects will also be important to evaluate the applicability of prehabilitation across epilepsy centers and potential barriers, particularly given the variability in presurgical workflows between institutions. Outcome‐focused research, including the effects of prehabilitation on patients' surgical decision‐making and postsurgical rehabilitation needs, as well as overall cost‐effectiveness, may help advocate for the inclusion and coverage of prehabilitation programs.

Finally, given the limited availability of neuropsychological services, future research should examine prehabilitation formats that increase patient accessibility. Previous cognitive rehabilitation treatments in epilepsy (e.g., HOBSCOTCH) ¹⁷ have successfully delivered telehealth services to patients nationwide who lack local access to cognitive rehabilitation. Additional cognitive rehabilitation formats studied in other neurological populations include self‐paced, computerized cognitive training and smartphone‐based applications. ⁶¹ Overall, there are vast opportunities to expand the currently limited research in this area, to further understand effective methods and components of prehabilitation.

7. CONCLUSION: SHIFTING TOWARD EMPOWERMENT‐BASED PRESURGICAL CARE

The integration of cognitive prehabilitation into the epilepsy surgical process offers a framework for patient‐centered, holistic care that reframes cognitive risk as something patients can prepare for rather than fear. Supporting a patient's cognitive reserve and overall readiness for surgery may optimize postsurgical recovery trajectories and replace uncertainty with informed, value‐aligned engagement in the surgical decision. As such, there is a pressing need for further research in this area, including the identification of best cognitive prehabilitation practices and pathways to clinical implementation. Ultimately, cognitive prehabilitation represents an exciting opportunity to improve surgical outcomes, support more informed decision‐making, and reduce barriers to a treatment that remains substantially underutilized.

AUTHOR CONTRIBUTIONS

Kayela Arrotta: conceptualization; writing – original draft; writing – review and editing; supervision; project administration. Sofia Lesica: conceptualization; writing – original draft; writing – review and editing. Hien Luu: conceptualization; writing – original draft; writing – review and editing. Sallie Baxendale: conceptualization; writing – review and editing; supervision.

FUNDING INFORMATION

This work was supported by the Cleveland Clinic Epilepsy Center. The corresponding author's broader work on cognitive prehabilitation has been supported by the Society of Clinical Neuropsychology Early Career Pilot Study Award and the American Epilepsy Society Junior Investigator Award in connection with the ReBOOT program; these awards supported prior research that informed the authors' perspective on cognitive prehabilitation but did not directly fund the development of this manuscript, and no findings from those projects are reported here. No specific funding was received for the preparation of this manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICAL APPROVAL

We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

SOCIAL MEDIA DESCRIPTION

A framework for cognitive prehabilitation before epilepsy surgery: risk education, strategy training, and recovery planning. #Epilepsy #EpilepsySurgery #Neuropsychology #Prehabilitation #SharedDecisionMaking #CognitiveRehabilitation.

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.