Cognitive Dysfunction In MS: Addressing the Emotional, Social, and Vocational Impact

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Cognitive Dysfunction In MS Addressing the
Emotional, Social, and Vocational Impact
Cognitive Dysfunction In MS Addressing the
Emotional, Social, and Vocational Impact
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Outline

• Historical perspective
• Frequency and severity of cognitive changes in MS
• Relationship to other disease characteristics
• Functions that are affected functions that are
  preserved
• Impact of cognitive dysfunction
• Emotional
• Social
• Vocational
• Medical
• How, when, and why of assessment
• Treatment options
• Strategies for clinicians

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Jean-Martin Charcot 1825-1893

Charcot with Marie Whittman and Joseph
Babinski André Brouillet - 1887
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Jean-Martin Charcot Second Lecture on Multiple
Sclerosis, 1868
There is marked enfeeblement of the memory
conceptions are formed slowly the intellectual
and emotional faculties are blunted in their
totality. The dominant feeling in the patients
appears to be a sort of almost stupid
indifference in reference to all things. It is
not rare to see them give way to foolish laughter
for no cause, and sometimes, on the contrary, to
melt into tears for no reason. Nor is it rare,
amid this state of mental depression, to find
psychic disorders arise which assume one or other
of the classic forms of mental alienation.
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Long-Standing Misconceptions about MS and
Cognition

• Cognitive impairment (CI) is rare in MS.
• CI only occurs in late stage MS or severe MS.
• MS is a white-matter disease and does not affect
  1) brain volume, 2) gray matter, 3) the cerebral
  cortex.
• If an MS patient can pass the mental status exam,
  everything is OK.
• Memory problems reported by MS patients are
  caused by stress, anxiety, and/or depression.
• Discussing CI will upset MS patients/families and
  ruin the image of MS.

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Cognition and Other Disease Characteristics

• Cognitive function correlates with number of
  lesions and lesion area on MRI, as well as brain
  atrophy.
• Cognitive dysfunction can occur at any time but
  is more common later in the disease.
• Cognitive dysfunction can occur with any disease
  course, but is slightly more likely in
  progressive MS.
• Being in an exacerbation is a risk factor for
  cognitive dysfunction.
• Depression can worsen cognition, particularly
  executive functions (Arnett et al., 1999).

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Prevalence of cognitive impairment in MS
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Cognitive Impairment over a 10-Year Period
Adapted from Amato, MP et al, Archives of
Neurology 2001581602-1606.
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Longitudinal Study of Cognitive Impairment in MS

• Percent Impaired at Baseline 26
• Percent Impaired after 10 Years 56
• Predictors of Cognitive Dysfunction after 10
  Years
• Higher EDSS
• Progressive course
• Older age

Amato, MP et al, Archives of Neurology
2001581602-1606.
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Cognitive Changes in Multiple Sclerosis
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The Impact of Cognitive Dysfunction
In Daily Functioning
Plt0.01
Plt0.05
Plt0.01
Cognitively intact (n52)
Cognitively impaired (n48)
0 1 2 3
Mean scale score
Rao et al. Neurology. 199141692.
Worsening
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Impact of Cognitive Impairment on Employment
Rao et al. Neurology. 199141692.
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Cognitive Functions Affected in MS

• Memory - acquisition and retrieval
• Attention concentration - working memory
• Speed of information processing
• Executive Functioning
• Visual/spatial organization
• Verbal fluency - word finding

DeLuca, J. What we know about cognitive changes
in multiple sclerosis. In LaRocca, N Kalb, R
(eds.) Multiple sclerosis understanding the
cognitive challenges. New York Demos Medical
Publishing, 2006.
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Cognitive Functions Unaffected in MS

• General intellect
• Long-term (remote) memory
• Recognition memory
• Conversational skill
• Reading comprehension

DeLuca, J. What we know about cognitive changes
in multiple sclerosis. In LaRocca, N Kalb, R
(eds.) Multiple sclerosis understanding the
cognitive challenges. New York Demos Medical
Publishing, 2006.
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Recognizing Memory Problems

• Difficulty learning new material or needing to
  spend longer to make it stick
• Forgetting recent conversations, TV shows, movies
• Forgetting appointments
• Losing track of medication schedules
• Neglecting to do planned tasks
• Losing or misplacing things
• Forgetting names, phone numbers, etc.

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Recognizing Impaired Attention and Concentration

• Difficulty with focus
• Cannot stick to one task without getting
  distracted
• Problems screening out distractions
• Difficulty with divided attention tasks, e.g.,
  listening to a family member talk while cooking
  
• Running out of steam when trying to concentrate
  on reading material or other intellectual tasks
• Poor recall due to lack of attention when
  information is being learned

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Recognizing Slowed Information Processing

• Quality of work is the same but output is much
  less
• Cannot respond quickly when a lot of information
  is being presented
• Trouble dealing with tasks having a time element,
  e.g., card games, word games, deadlines
• Difficulty processing information coming from
  several different sources simultaneously

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Recognizing Problems in Executive Functioning

• Inability to perform jobs requiring analytic
  skills
• Difficulty following complex arguments or
  explanations missing the point in conversations
• Trouble following through with complicated tasks
• Being too literal or concrete
• Need for increased direction on the job because
  of difficulty in setting priorities, organizing
  time, and meeting deadlines
• Trouble with multi-tasking

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Recognizing Impaired Visual/Spatial Organization

• Gets lost when driving confused about
  right/left, north/south
• Cant do puzzles or assemble some assembly
  required items
• Trouble operating machines
• Difficulty understanding diagrams
• Problems visualizing objects without a picture
  e.g., from a description, incomplete
  picture, or disassembled picture

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A Word about Cognition and Fatigue

• Physical fatigue has less impact on cognitive
  performance than people think.
• Cognitive fatigue refers to a decline in
  cognitive performance following cognitively
  challenging tasks.
• Cognitive fatigue can occur even in the absence
  of physical fatigue.

DeLuca, J. What we know about cognitive changes
in multiple sclerosis. In LaRocca, N Kalb, R
(eds.) Multiple sclerosis understanding the
cognitive challenges. New York Demos Medical
Publishing, 2006.
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The Psychosocial Impact of Cognitive
Changes (LaRocca Kalb, 2006)

• The ability to think, remember, and reason is
  central to a persons identity. Changes in
  cognitive abilities
• Threaten the sense of self
• Damage self-esteem and self-confidence
• Cognitive abilities form the basis of our
  interactions with others.
• Cognitive impairments
• Alter communication patterns
• Impact other peoples perceptions
• Interfere with role performance
• Affect the balance in a partnership

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• I TOLD YOU THAT THIS MORNING!?! I DONT THINK
  YOURE PAYING ATTENTIONOR MAYBE YOU JUST DONT
  CARE ABOUT WHAT I HAVE TO SAY ANYMORE.

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I TOLD YOU THAT THIS MORNING

• Possible cognitive deficit(s)?
• Possible feelings?
• Wife with MS
• Husband
• Recommended strategies?

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I TOLD YOU THAT THIS MORNING

• Possible cognitive deficit(s) memory, attention,
  info processing
• Possible feelings
• Wife with MS denial, anger, anxiety, guilt,
  inadequacy
• Husband frustration, anxiety, abandonment
• Recommended strategies written note, family
  calendar, non-distracting environment for
  conversations

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HOW COULD YOU GET LOST?!? YOUVE DRIVEN THAT
ROUTE 100 TIMES!!
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HOW COULD YOU GET LOST

• Possible cognitive deficit(s)?
• Possible feelings?
• Wife
• Husband with MS
• Recommended strategies?

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HOW COULD YOU GET LOST

• Possible cognitive deficit(s) memory, attention,
  visual-spatial, sequencing
• Possible feelings
• Wife anxiety, loss of respect/confidence, anger
• Husband with MS anxiety, anger, embarrassment,
  loss of confidence
• Recommended strategies pre-planning of route
  maps in memory book minimal distractions in car

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• YOU REALLY MESSED UP THE
• CHECKBOOK THIS TIME!!

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YOU REALLY MESSED UP THE CHECKBOOK

• Possible cognitive deficit(s) attention/concentra
  tion, organization, planning/sequencing,
  problem-solving
• Possible feelings
• Wife with MS embarrassment, guilt, anxiety
• Husband anger, anxiety, loss of partnership
• Recommended strategies template,
  distraction-free environment

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• WHERE ARE YOU?!?
• OUR MEETING WITH THE CLIENT
  STARTED AN HOUR AGO?

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WHERE ARE YOU?!?....

• Possible cognitive deficit(s) memory, planning
  organization, attention, visual/spatial skills
• Possible feelings
• Boss anger, frustration, confusion, anxiety
• Employee with MS embarrassment, frustration,
  fear
• Recommended strategies calendar, tickler system,
  pre-route planning

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MOMI TOLD YOU YESTERDAY THAT I WAS GOING TO
SARAS HOUSE AFTER SCHOOL!
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MOMI TOLD YOU YESTERDAY

• Possible cognitive deficit(s)
• attention/concentration, organization
• Possible feelings
• Mom with MS embarrassment, guilt, anxiety
• anger, suspiciousness (if not true)
• Child anxiety, loss of confidence, guilt (if not
  being truthful)
• Recommended strategies family calendar,
  distraction-free environment

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When Cognitive Evaluation is Appropriate

• To establish a baseline
• There are reported changes in ability
• There is a potentially treatable condition
• Person is being started on a new treatment
• When considering an application for SSDI or
  vocational rehabilitation
• When there is a need to know
• Note The standard mental status examination will
  miss 50 of cognitively impaired patients
  (Peyser, 1980)

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Cognitive Evaluation

• Battery of tests designed to assess areas of
  reported difficulties, as well as pre-existing
  and current strengths
• Clinical neuropsychologist, occupational
  therapist, speech-language pathologist
• Full test battery 6-8 hours over two days
• Expensive/often without insurance coverage
• Various screening batteries available, including
  a 5-minute self-report instrument (MS
  Neuropsychological Screening Questionnaire
  Benedict et al., 2003 2004)

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Treatment of Cognitive Dysfunction

• Symptomatic treatments
• Disease modifying agents
• Cognitive rehabilitation

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Symptomatic Treatments as of 2012, none shown
to be effective in controlled clinical trials
Acetylcholinesterase inhibitors donepezil
Anti-fatigue agents Stimulants amantadine modafinil methylphenidate attention
Potassium channel blockers 4-aminopyridine 3,4-diaminopyridine
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Disease Modifying Agents

• fingolimod
• interferon beta 1a (Cohen et al., 2002)
• interferon beta 1b (Flechter et al., 2007)
• glatiramer acetate (Schwid et al., 2007)
• natalizumab (Iaffaldano et al., 2012 Portaccio
  et al., 2012 Mattioli et
  al., 2011)
• mitoxantrone (Zéphir et al., 2008)
• teriflunomide

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Cognitive Rehabilitation

• Direct retraining of impaired functions
• Memory exercises
• Attention training
• Compensatory strategies
• Notebooks, lists, organizers
• Time and energy management
• Substitution strategies

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Guidelines for Treatment (for now)

• Symptomatic Treatments slow progress
• Not much of real value has emerged all clinical
  trials have had negative results
• Disease Modifying Agents may be most important
• Modest results so far, but if they can slow or
  halt accumulation of cerebral lesions . . .
• Cognitive Rehabilitation common-sense help
• Disappointing thus far but common-sense points
  to compensatory measures as best strategy
• Address affective and social issues related to MS

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Implications for patient care

• Even mild cognitive dysfunction can impact
  treatment
• Your patients may not
• Show up on time for appointments
• Follow complex explanations
• Remember what theyve been told
• Follow through on treatment plans
• You may want to
• Provide informational brochures
• Provide appointment reminders
• Write down specific instructions
• Remind patients to write down their questions
• Invite patients to bring a family member or
  friend to appointments

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Recommended Strategies for Your Patients

• Get someone to work with you.
• Make up your mind that its OK to do things a
  little differently than in the past.
• Although abilities may not improve, function can
  be enhanced.
• Compensation is keye.g., many memory problems
  can be solved with better organization.
• Consistency is essential. Stick with your
  program and follow through with your new
  strategies.
• Keep the mind active and stimulated.

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Summary

• More that 60 of people with MS experience
  cognitive changes.
• Cognitive dysfunction is more related to MRI
  changes than to other disease characteristics.
• While many functions can be affected, some are
  more likely to be affected than others.
• The impact on individuals and families is
  significant.
• Disease-modifying therapies are the best
  protection symptomatic medications have been
  shown to be of no benefit in large-scale clinical
  trials.
• Compensatory strategies are essential.
• Adequately treating depression may improve
  cognitive functioning.

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National MS Society Resources for Your Patients

• Booklets
• Available from the National Multiple Sclerosis
  Society (by calling 1-800-344-4867 or online at
  www.nationalmssociety.org/Brochures)
• MS and the Mind
• Solving Cognitive Problems
• Fatigue What You Should Know
• Hold that Thought
• Webcast Hold that Thought Cognition and MS
  (http//www.nationalmssociety.org/multimedia-libra
  ry/webcasts--podcasts/ms-hold-that-thought/index.a
  spx)
• Website (http//www.nationalmssociety.org/about-mu
  ltiple-sclerosis/symptoms/cognitive-function/index
  .aspx)

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National MS Society Resources for Clinicians

• MS Clinical Care Network
  Website
  www.nationalMSsociety.org/MSClinicalCare
  E-mail healthprof_info_at_nmss.org
• Clinical consultations with MS specialists
• Literature search services
• Professional publications (Clinical Bulletins
  Expert Opinion Papers Talking with Your MS
  Patients about Difficult Topics Pamela Cavallo
  Education Series for nurses, rehab professionals,
  mental health professionals, and pharmacists
• Professional Education Programs (Nursing, Rehab,
  Mental Health)
• Consultation on insurance and long-term care
  issues
• Quarterly professional e-newsletter

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Recommended Readings

• Books
• Feinstein A. The Clinical Neuropsychiatry of
  Multiple Sclerosis (2nd ed.). Cambridge
  Cambridge University Press, 2007.
• Gingold J. Facing the Cognitive Challenges of
  Multiple Sclerosis. New York Demos Medical
  Publishing, 2006.
• Kalb R, Holland N, Giesser B. Multiple Sclerosis
  for Dummies. Hoboken NJ Wiley Publishing, 2007.
• LaRocca N. Cognitive Challenges Assessment and
  Management. In R. Kalb (ed.) Multiple Sclerosis
  The Questions You Have The Answers You Need (4th
  ed.) New York Demos Medical Publishing, 2007.

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Recommended Readings, contd

• LaRocca N Kalb R. Multiple Sclerosis
  Understanding the Cognitive Challenges. New York
  Demos Medical Publishing, 2006.
• Society Publications
• Expert Opinion Paper Assessment and Management
  of Cognitive Impairment in Multiple Sclerosis,
  2008 (www.nationalMSsociety.org/ExpertOpinionPaper
  s).
• LaRocca N. Talking with Your MS Patient about
  Cognitive Dysfunction, 2009 (www.nationalMSsociety
  .org/PRCPublications).