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Cognitive Changes

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Overview

“Cognitive” means of or relating to “cognition” — which refers to a range of high-level brain functions including the ability to learn and remember information, organize, plan and problem-solve, focus, maintain and shift attention, understand and use language, accurately perceive the environment, and perform calculations.

Cognitive changes are a common symptom of MS — approximately half of all people with MS will develop problems with cognition. Loss of myelin around nerve fibers can cause difficulty with transporting memories to storage areas of the brain or retrieving them from storage areas. In MS, certain functions are more likely to be affected than others:

  • Memory (acquiring, retaining and retrieving new information)
  • Attention and concentration (particularly divided attention)
  • Information processing (dealing with information gathered by the five senses)
  • Executive functions (planning and prioritizing)
  • Visuospatial functions (visual perception and constructional abilities)
  • Verbal fluency (word-finding)

A person may experience difficulties in only one or two areas of cognitive functioning or in several. Certain functions including general intellect, long-term (remote) memory, conversational skill and reading comprehension are likely to remain intact.

Only 5-10 percent of people with MS develop problems severe enough to interfere significantly with everyday activities. In very rare instances, cognitive dysfunction may become so severe that the person can no longer be cared for at home.

Relationship to other disease factors

Cognitive problems are weakly related to other disease characteristics — meaning that a person with almost no physical limitations can have significant cognitive impairment, while a person who is quite disabled physically can be unaffected cognitively.

  • Changes can occur at any time — even as a first symptom of MS — but are more common later in the disease.
  • Cognitive function correlates with number of lesions and lesion area on MRI, as well as brain atrophy.
  • Cognitive dysfunction can occur with any disease course, but is slightly more likely in progressive MS.
  • You are more likely to experience cognitive dysfunction (the first signs or new changes) during an exacerbation.
  • Cognitive changes generally progress slowly. They are unlikely to improve dramatically once they have begun.

Recognition and testing

Early recognition, assessment and treatment are important because cognitive changes — along with fatigue — can significantly affect a person’s quality of life and are the primary cause of early departure from the workforce. The first signs of cognitive dysfunction may be subtle — noticed first by the person with MS or by a family member or colleague.

  • Difficulty finding the right words
  • Trouble remembering what to do on the job or during daily routines at home
  • Difficulty making decisions or showing poor judgment
  • Difficulty keeping up with tasks or conversations
Talk to your physician if you are concerned about cognitive dysfunction. A specially trained health professional (neuropsychologist, speech/ language pathologist or occupational therapist) will administer a battery of tests and careful evaluation in order to determine the cause(s) of changes (since cognitive function can also be affected by aging or medications, as well as depression, anxiety, stress and fatigue).
 

Treatment (cognitive rehabilitation)

Based on the test findings — including cognitive deficits and strengths — the health professional can provide cognitive rehabilitation. Cognitive rehabilitation includes a combination of restorative and compensatory activities.

Restorative techniques can include learning and memory exercises:
  • Combine modes of learning: You will be more likely to remember something if you “see it, say it, hear it, write it, do it.” It’s okay to give yourself extra time.
  • Repeat & verify: Repeat what you hear and verify that it is correct to improve your attention and memory.
  • Spaced rehearsal: Repeat and practice information at intervals spread out over time to improve your ability to store information.
  • Build associations: Use memory aids! For example, to remember the name of someone you just met, associate her/his name with a friend or family member of the same name, or with a place, color or event that sounds like the new name.
Compensatory techniques — to make up for functions that are weakened — include:
  • Consolidate and centralize! Designate one place in your home as the “Grand Central” information center. Include your master calendar, mail, bills, phone messages, to-do lists, keys, wallet, shopping lists and more.
  • Plan: Post a calendar large enough to display everyone’s appointments, activities and social engagements, and reminders! Keep pens or markers hanging right beside it. Or use a computer program set up with reminders for routine tasks (synchronize it with your mobile devices so you have your appointments with you while on the go).
  • Record: Dictate your to-do list, notes or other things to remember on a digital voice recorder (available on many phones).
  • Remind: Use checklists, the alarm on your watch or phone, your kitchen timer, and more.
  • Eliminate or remove yourself from distractions. Turn off the TV, music and whatever else is “on” when speaking with someone in person or on the phone. Background visual and noise distractions can make learning or remembering more difficult. If you can’t eliminate the distraction (for example, people talking at a party) then ask, “Can we talk in a quieter place?”
  • Take a break. If you are having difficulty concentrating, take a breath and refresh.
  • Do one thing at a time. Avoid switching back and forth from one topic or task to another. Finish or find an appropriate stopping place in what you’re working on before you switch to something else.

Research on cognition

Studies are ongoing to identify ways to stabilize or improve cognitive dysfunction. Since the disease-modifying drugs have all been shown to reduce the accumulation of new demyelinating lesions, it is likely they help to stabilize cognitive changes. However, more studies are needed to determine their effectiveness in this area.

Symptomatic treatments may temporarily improve cognitive functioning without altering its long-term course. To date the most successful has been donepezil hydrochloride, showing modest improvement in verbal memory.

Studies funded by the National MS Society are investigating the natural history of cognitive changes, along with better ways of diagnosing and treating cognitive problems in MS. It is hoped that in the future, people with MS will have access to a combination of disease-modifying therapies, symptomatic treatments, and cognitive rehabilitation that will modify the course and impact of the cognitive changes in MS.

Additional resources

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