Cognitive Dysfunction in Multiple Sclerosis Stavra Romas, MD Neurologist, Cognitive Division IMSMP - PowerPoint PPT Presentation

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Cognitive Dysfunction in Multiple Sclerosis Stavra Romas, MD Neurologist, Cognitive Division IMSMP

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Cognitive Impairment in Multiple Sclerosis (MS) patients is related with the lesion burden. ... (Hildebrandt, Multiple Sclerosis, 2006) correlation between ... – PowerPoint PPT presentation

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Title: Cognitive Dysfunction in Multiple Sclerosis Stavra Romas, MD Neurologist, Cognitive Division IMSMP


1
Cognitive Dysfunction in Multiple
SclerosisStavra Romas, MDNeurologist,
Cognitive DivisionIMSMP
2
Cognitive Symptoms in MS
  • What is the person experiencing?
  • What is causing the complaints?
  • What can we do about it in terms of medical
    management?

3
Overview of Cognitive Symptoms
  • 40-50 have cognitive symptoms
  • 10 meet criteria for dementia
  • Cognitive symptoms can occur early
  • Information doesnt increase fears (Segal et al.,
    2006)
  • Screening is important

4
Assessment of Cognitive Symptoms
  • Medical History and Medication
  • Educational and Employment history
  • Psychosocial history
  • Family history
  • MRI
  • Brief Neuropsychological screen (Rao et al.,
    1990)
  • Neuropsychological Battery

5
Factors Causing Cognitive Symptoms
6
How MS lesions Affect Cognition
  • Lesion load
  • Atrophy
  • Normal appearing white matter
  • Other factors?

7
Lesion load
  • Cognitive Impairment in Multiple Sclerosis (MS)
    patients is related with the lesion burden.
  • Frontal Lobe Cognitive decline is related with
    the corresponding regional lesion load.
  • Both lesion load and lesion location can be
    important
  • (Fillipi, 2000)

8
Lesion Load
  • Three factors play a role in the
  • Pathogenesis of cognitive dysfunction
  • 1) Lesion load
  • 2) The severity of the damage within individual
    lesions
  • 3) Normal appearing white matter
  • (Filippi, 2000)

9
Brain Atrophy
  • Multiple studies with variable results
  • Methods of estimating brain atrophy vary
    considerably
  • (Hildebrandt, Multiple Sclerosis, 2006)
    correlation between memory performance and
    relative ventricular width.

10
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11
MRI Findings Never Explain the Whole Picture
  • NAWM?
  • Temporal course or age at onset?
  • Other factors?

12
Factors Causing Cognitive Symptoms
13
Disorders of Mood and Affect
  • Euphoria/lability
  • Pseudobulbar symptoms
  • Depression
  • Anxiety
  • Bipolar Symptoms
  • Psychotic Symptoms

14
Neuropsychiatric MS
  • Multiple case reports of pure neuropsychiatric
    presentation of MS
  • Lyoo at al,1996 performed brain MRI on 2,783
    inpatients referred as part of psychiatric
    evaluation
  • 53 patients (1.9) had WM pattern consistent with
    MS

15
Neuropsychiatric MS
  • Suspect MS
  • Lack of previous psychiatric history
  • Late-onset or atypical features
  • Lack of response to standard treatments
  • Cognitive changes
  • Neurological findings
  • MRI findings, particularly atrophy or lesions in
    WM of the cerebral hemispheres
  • (Asghar-Ali, 2004)

16
Factors Causing Cognitive Symptoms
17
Disorders of Sleep
18
Pathologic Fatigue
19
Factors Causing Cognitive Symptoms
20
Attention Deficit Disorder
  • Persistent pattern of inattention and
    hyperactivity-impulsivity or both.
  • Associated with volume differences in prefrontal
    cortex, and cerebellum
  • Prefrontal cortex regulates attention
  • Cerebellum connects directly to PFC

21
Attention Deficits and Multiple Sclerosis
  • Attention is affected by individual differences
    in frontal cortex and cerebellum
  • Lesions often occur in these areas in MS
  • Attention deficits are a major complaint in MS
  • The combination of these factors in an individual
    can cause significant difficulties similar to
    those seen in ADD.

22
Factors Causing Cognitive Symptoms
23
Medication and Cognition
  • PAIN
  • Self medication
  • Recent steroid use- (Uttner et al, 2005) 30
    patients with RRMS treated with standard and high
    doses of methylprednisolone for 5 days showed
    reversible impairment in declarative memory
    (CVLT)

24
Medical Management of Cognitive Symptoms
  • Treat/control disease
  • Mood/Affect
  • Sleep/Fatigue
  • Attention Deficits
  • Medication

25
Drug Studies
  • Betaseron- N30, only one of 13 cognitive
    measures was improved compared with placebo at 2
    and 4 years follow up
  • Avonex- N166, improved information processing
    and memory compared with placebo at 2 years
    follow up

26
Drug Studies
  • Copaxone- N251, improvements occurred in
    neuropsychological test scores during 2 years of
    treatment regardless of whether patients were
    receiving Copaxone or placebo
  • Copaxone 10 yr- N153, test of attention showed
    declining function for the group as a whole

27
Drug Studies
  • Copaxone-10 yr In general, cognitive worsening
    was associated with disease activity as measured
    by the relapse rate and changes in overall
    disability on the EDSS. Furthermore, ongoing
    disease activity and disability progression
    during the first 2 years predicted cognitive
    worsening during extended follow-up

28
Mood and Affect
  • Appropriate and reactive?
  • Otherwise medication and psychotherapy
  • Treatment of pathological laughter and tears

29
Antidepressants for MS
  • SSRIs
  • Buproprion
  • Effexor
  • TCAs
  • Stimulants?
  • Combination of therapy and medication is more
    effective than either alone

30
Treatment for Pathological laughter and tears
  • Amitriptyline
  • Levodopa
  • Desipramine
  • Fluoxetine
  • Fluvoxamine

31
Sleep/Fatigue
  • Review sleep hygiene
  • Sleep study
  • Medication only if necessary

32
Medications for ADD
  • Stimulants- methylphenidate, amphetamine
  • Non-stimulants- atomoxetine
  • Alpha-agonists- clonindine, guanfacine
  • Buproprion
  • TCAs
  • Modafinil

33
Factors Causing Cognitive Symptoms
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