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Neurocognitive Manifestations in ME/CFS

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Title: Neurocognitive Manifestations in ME/CFS


1
Neurocognitive Manifestations in ME/CFS
  • Gudrun Lange, PhD
  • Professor
  • Department of Physical Medicine and
    Rehabilitation, Rutgers-NJMS

2
Outline
  • Why is it important to talk about cognitive
    function in ME/CFS?
  • What is the clinical presentation?
  • How can cognitive dysfunction in ME/CFS be
    understood?
  • What is an effective neuropsychological battery?
  • What is the research evidence?
  • Final thoughts

3
Brainfog Common and Disabling
  • Experienced as difficulties with attention,
    concentration and multi-tasking
  • Recognized as important Listed as symptom in all
    ME/CFS case definitions
  • Serves as objective criterion for disability
    lack of validated physiological markers

4
Clinical Presentations
  • I feel like Im loosing my mind
  • I feel like having the brain of an 80-year old
    in the body of a 36-year old
  • I feel stupid

5
Conceptualization of Cognitive Dysfunction
  • Possible etiology of cognitive dysfunction
  • Genetic
  • Acquired
  • Severity of cognitive dysfunction
  • Severe
  • Moderate
  • Mild

6
Determination of Severity of Cognitive Dysfunction
  • Subjective
  • Patient and family report
  • Perception of degree of loss of cognitive
    function
  • Objective
  • Neuropsychological evaluation
  • Statistical determination of degree of loss of
    cognitive function
  • Behavioral observations during testing should be
    taken into consideration

7
An effective neuropsychological battery for
ME/CFS patients
  • Has to include standardized and normed measures
    that
  • Sufficiently and repeatedly challenge complex
    information processing and multi-tasking
  • reliably demonstrate areas of cognitive
    resilience
  • assess mood and anxiety
  • ascertain adequate effort

8
Intellectual profiles in ME/CFS
  • WAIS-IV profile Scores discrepant from expected
    levels
  • Case 1 Case 2

9
Case 1
10
Case 2
11
  • Wisconsin Card Sorting Test (WCST)
  • ? California Verbal Learning Test II (CVLT-II)
  • ? Wechsler Memory Scale - Fourth Edition (WMS-IV)
  • ? Boston Naming Test (BNT)
  • ?Rey Osterrieth Complex Figure (ROCF)
  • ? Judgment of Line Orientation Test (JOL)
  • ? Hooper Visual Organization Test
  • ? Hand Dynamometer
  • ? Grooved Pegboard
  • ? Finger Tapping Test (FTT)
  • ? Validity Indicator Profile (VIP)
  • Clinical Interview
  • ? Wechsler Adult Intelligence Scale - Fourth
    Edition (WAIS-IV)
  • ?Test of Premorbid Functioning (TOPF)
  • Beck Depression Inventory II (BDI II)
  • ? Spielberger State Trait Anxiety Questionnaire
    (STAI)
  • ? Gordon Diagnostic Test
  • ? Stroop Test
  • ? DKEFS
  • Trails
  • Verbal Fluency Test
  • Paced Auditory Serial Attention Test (PASAT)
  • ?

12
Findings on neuropsychological exam
  • Decreased attention, concentration and slowed
    processing speed
  • Problems sequencing pieces of information and
    prioritizing their use for quick decision making
  • Limited working memory,
  • less information available online
  • Learning difficulties
  • Changes in learning strategy
  • Poor absorption and recall

13
Neuropsychological Profile in ME/CFS
  • Profile suggests mild, subtle deficits
  • Evaluation of impairment relative to expected
    level of intellectual function necessary to
    uncover true deficiencies
  • Profile not consistent with dementia
  • Generally no frank memory problem
  • Profile can be differentiated from conditions of
    a more focal nature

14
Brain Abnormalities in ME/CFS
  • Lange et al., 2005
  • Used verbal working memory task to
  • probe brain function using fMRI
  • simultaneously assessing efficient information
    processing behaviorally
  • Statistically controlled for age, mood, anxiety,
    self-reported mental fatigue score
  • Equated on prior behavioral test performance on
    same task

15
Brain Abnormalities in ME/CFS
  • Controls versus ME/CFS
  • No differences in brain activity during simple
    condition
  • When task demands get more complex, ME/CFS
    increased involvement of
  • Anterior Cingulate BA 24/32
  • Left DLF BA 10/44/45/47
  • Bilateral supplemental and premotor BA6/8
  • Parietal regions BA 7/40

16
Brain Abnormalities in ME/CFS
17
Brain Abnormalities in ME/CFS
  • Increased signal change was significantly
    accounted for by ME/CFS report of mental fatigue
  • Perceived mental fatigue is reflected by
    increased functional recruitment of
  • Left superior parietal region (BA7)
  • Responsible for shifts in attention
  • Bilateral supplementary and premotor regions
    (BA6/8)
  • Associated with automatic information processing
  • maintenance of temporal order

18
Brain Abnormalities in ME/CFS
  • No lack of effort accounted for the differences
    in signal change
  • To achieve behavioral performance similar to
    Controls
  • Brains of ME/CFS work harder when tasks are
    complex
  • Require efficient and quick information
    processing
  • Require effective online sequencing and
    prioritization

19
Consequences of cognitive dysfunction in ME/CFS
  • Automaticity of cognitive function is often lost
  • Mundane tasks become effortful
  • Multi-tasking often impossible
  • Considered by patients as affecting every aspect
    of their lives
  • Mental exertion can last for a long time

20
Is there an effective cognitive screen for ME/CFS
patients?
  • Dementia screens and typical brief bedside memory
    tests are not appropriate
  • i.e. MMSE, Mini-Cog
  • Suggestions
  • Serial 7s, Digit Span Sequencing
  • May work if done for at least a few minutes
  • Quickly give a 6-or-7 step set of complex driving
    directions and request repetition

21
Final thoughts
  • If evaluation of cognitive function is needed
  • Refer to Clinical Neuropsychologist knowledgeable
    about ME/CFS
  • Much more work is needed to familiarize
    Neuropsychologists with ME/CFS to provide valid
    and reliable neuropsychological assessments.

22
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