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Cognitive Changes

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Overview

Cognition 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.

A change in cognitive function or cognitive dysfunction  is common in MS — more than half of all people with MS will develop problems with cognition. For some, it may even be the first symptom of MS. Certain functions are more likely to be affected than others:
  • Information processing (dealing with information gathered by the five senses)
  • Memory (acquiring, retaining and retrieving new information)
  • Attention and concentration (particularly divided attention)
  • Executive functions (planning and prioritizing)
  • Visuospatial functions (visual perception and constructional abilities)
  • Verbal fluency (word-finding)
For most people, the changes in cognitive function are mild and may involve one or two areas of cognitive functioning. For fewer people with MS the changes in cognitive function will be more challenging.

Certain functions including general intellect, long-term (remote) memory, conversational skill and reading comprehension are not likely to change due to MS.

Most people who experience changes in cognitive function can use compensatory strategies and tools to help them function effectively. However, cognitive dysfunction is one of the major causes of early departure from the workforce. In very rare instances, cognitive dysfunction may become so severe that the person can no longer function independently.

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

Early recognition, assessment and treatment are important because cognitive changes — along with fatigue — can significantly affect a person’s quality of life, relationships, activities and employment. 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
  • Difficulty 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
  • Difficulty with job performance, including informal or formal disciplinary action
  • Difficulty with school performance, including falling grades and social challenges

Evaluation

Scientific evidence supports early and ongoing cognitive evaluation for people with MS. Despite this, cognitive function is not openly discussed, routinely evaluated or optimally treated. It is one of the major unmet needs in MS care. To address this gap, the National MS Society gathered a multidisciplinary group of healthcare providers, researchers and individuals affected by MS to review the scientific literature and make management recommendations. This group concluded that the appropriate management of cognitive dysfunction in MS includes:
  • Education for people with MS and their family members
  • Early screening and ongoing monitoring throughout the disease course
  • Comprehensive evaluation for any adult or child who tests positive on screening or demonstrates a significant cognitive decline
  • Comprehensive evaluation for any individual who is applying for disability insurance due to cognitive impairment
  • Interventions to improve cognitive functioning and participation in everyday activities
Talk to your healthcare provider if you are concerned about cognitive dysfunction. He or she will likely perform a short screening test and those results may lead to a referral for a more comprehensive cognitive evaluation. A specially trained health professional (neuropsychologist, speech/ language pathologist or occupational therapist) will evaluate your cognitive function using a series of tests to carefully evaluate all of the areas of cognitive function. Testing can take several hours, but this careful evaluation is needed to determine the specific cognitive functions that are affected and to sort out other possible causes of cognitive problems, such as medications, fatigue or changes in mood, including depression, anxiety or stress.

Treatment (cognitive rehabilitation)

Based on the cognitive test results — including cognitive deficits and strengths —a cognitive rehabilitation plan may be recommended. Cognitive rehabilitation includes a combination of restorative and compensatory activities.

Restorative activities 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 activities that help make up for functions that are no longer working well may 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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