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Cognition and MS

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Cognition and MS

This presentation by Dr Anita Rose, Consultant Neuropsychologist, looks at cognition and MS. It explores assessment, managing cognitive deficits and factors assessing cognition including pain, emotions and fatigue.

It was presented at the MS Trust Annual Conference in November 2013.

This presentation by Dr Anita Rose, Consultant Neuropsychologist, looks at cognition and MS. It explores assessment, managing cognitive deficits and factors assessing cognition including pain, emotions and fatigue.

It was presented at the MS Trust Annual Conference in November 2013.

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Cognition and MS

  1. 1. COGNITION AND MS Dr Anita Rose Consultant Neuropsychologist
  2. 2. Aims/Learning Objectives • Cognition and MS • Is it really an issue? • Assessment • Is assessment worth it? • I am not a neuropsychologist so what can I do? • Assessments • Cognitive domains • Neuropsychological/Cognitive profile of MS • Managing cognitive deficits • Specific strategies • Factors affecting cognition including: • • • Emotions Fatigue Pain
  3. 3. Facts and Figures! • Prevalence • Not everyone with MS experiences cognitive problems • As early as the 1800‟s, Jean-Martin Charcot described the cognitive changes that can occur in MS. • “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” • Yet took clinicians until 2001 to codify a standard test to measure cognitive function
  4. 4. • 1980s research indicated otherwise (Bobholz &Rao 2003) • 40% - 60% have cognitive deficits • 80% are mildly affected • Relate to everyday activities and quality of life (Higginson et al. 2000) • Variability (Rao, 1986) • 50% - 75% unemployed within 10 years of diagnosis – cognitive issues being reported as leading predictor (Julian et al., 2008) compared to age, physical disability & education (15%)
  5. 5. Dementia? • Overt dementia in MS is rare • Most cases of cognitive impairment in MS are relatively less severe than those observed in classically dementing neurological disorders, such as Alzheimer‟s disease • However, cognitive impairment in MS can be extremely debilitating, with substantial negative impacts on daily living
  6. 6. Pathology • Disconnection of large cortical areas and between cortical • • • • and subcortical structures (Filley, 1989) “Multiple disconnection syndrome” (Calabrese, 2006) White matter volume & corpus callosum size correlate with cognitive dysfunction (Rao 1985, 1989, Hulst et al., 2013) Lesion burden (Swirsky & Sacchetti, 1992) Biological in basis (Hurst, 2013)
  7. 7. “Hidden” Symptom • PwMS can present with relatively well-preserved language and social skills, but sometimes a marked difficulty with problem solving and insight • Having preserved language and social ability means that in ordinary conversation, cognitive problems may not be apparent • Might not be apparent on “bedside testing” • Stigma – within family and wider society • Fear – PwMS • Therefore cognition as a symptom is often ignored
  8. 8. Impact • Frightening • Think they are going mad, are stupid or are crazy • Causes problems in relationships, with family life • Major impact can be seen in employment • Later stages concerns around safety, independence, ability to self-care • Insight
  9. 9. ASSESSMENT – IN OTHER WORDS WHAT ISN‟T WORKING?
  10. 10. Clinical Questions • Who needs to be assessed • What cognitive domains need to be covered • With what frequency should the assessments take place • Strategies for assessment related to purpose • Comprehensive: Assessment for rehabilitation, benefits, vocational planning • Detection: Identification of individuals showing deficits • Monitoring: Assessing cognitive changes as a treatment outcome
  11. 11. Assessment & Intervention • Assessment at Point of diagnosis and Beyond • Cognitive deficit might be present in early stages (Simioni et al., 2007) • Longitudinal studies suggest cognitive deficit could be used as predictive parameters of MS evolution and severity (Amato et al., 1995 & 2001; Kujala et al., 2001) • Impairment predictor of low quality of life, employment issues, carer stress • Assessment assists patient, family, healthcare professionals (Roig & Bagunya, 1997) • Treatment • Cognitive rehabilitation • Aim to improve quality of life • Environmental adaptation • Increase autonomy
  12. 12. Help I am not a neuropsychologist • But you are a trained healthcare professional! • Clinical interview • Ask questions • Screening tools: • Brief • Inexpensive (or free!)
  13. 13. Screening Approaches • Number of cognitive screens: • MSNQ (MS Neuropsychological Screening Questionnaire) • MMSE (Mini Mental Status Examination) • BRB-N (Brief Repeatable Battery-Neuropsychological • BNPB (Brief Neuropsychological Battery) • SEFCI (Screening Examination for Cognitive Impairment) • RBANS (Repeatable Battery for the Assessment of Neuropsychological Status) • BSB (Basso Screening Battery) • MACFIMS (Minimal Assessment of Cognitive Function in MS) • ANAM (Automated Neuropsychological Assessment Metrics) • Expensive • Need to be trained i.e. Neuropsychologist • American
  14. 14. MSNQ MS Neuropsychological Screening Questionnaire • Time • 5 min (patient and informant) • Results • Reported symptoms of cognitive and behavioral problems • Repeatability? • Utility as change measure not established • Sensitivity/Specificity (Informant)1 • Sensitivity: .83 • Specificity: .97 • So good measure? • Subjective report – no objective results but supports clinical interview • In public domain [1] Benedict R et al (2003) Mult Sclr. V9 95-101
  15. 15. MMSE Mini Mental Status Examination • Time • 5-10 minutes • Results • Global summary score • Repeatability? • Single form so practice effect • Sensitivity/Specificity1 • Sensitivity: 21-36% MS • Generally poor with specific or subcortical lesions • Specificity: 89-100% • So good measure? • Only picks up global damage • No longer free • Poor results in MS [1] Fischer JS (2001) in SD Cook (Ed) Handbook of MS 3 rd ed.
  16. 16. Montreal Cognitive Assessment (MoCa)
  17. 17. • Time • 10 mins • Results • Global Score but can consider subtests • Repeatability • Single form ?practice effects • MS? • Number of papers suggest valid for population e.g. Dagenais et al. 2013; Kumar et al. 2012; • Good measure? • Visual spatial might be a problem but can be considered when scoring • Easy to administer • Free • Norms available • No qualifications needed
  18. 18. BICAMS • BICAMS (Brief International Cognitive Assessment for MS) is an international initiative to recommend and support a cognitive assessment that is brief, practical and universal • Consists of: • The Symbol Digit Modalities Test • The California Verbal Learning Test –II, first five recall trials • The Brief Visuospatial Memory Test –Revised, first three recall trials • Takes 15 minutes to administer • All the tests comes from established tests which you have to purchase • To purchase you have to be qualified tester – Level 2 e.g. neuropsychologist • But worth watching to see what happens • http://www.bicams.net/
  19. 19. “Stupidity is not a handicap – park elsewhere” Yvette
  20. 20. NEUROPSYCHOLOGICAL PROFILE: WHAT CAN I EXPECT TO SEE?
  21. 21. Cognitive Impairment in MS • Processing speed • Attention/concentration • Sustained • Complex • Memory • Episodic/recent memory • Working memory • Executive functioning (EF) • Abstract reasoning • Problem-solving • Language • Verbal fluency • Naming • Visuospatial skills
  22. 22. Information Processing • Primary deficit (Rao et al., 1991) • Significant impact (Langdon & Thompson, 1996) • Evidence indicates that people with MS require a longer time to digest new information • Takes longer to process information and formulate the proper response • Accuracy rarely affected, just takes longer (Demaree, 1999) • Takes longer to complete tasks • Given additional time = improved accuracy • Working memory deficits due to impaired speed
  23. 23. Attention • Attention = vigilance, capacity for information, switching attention, selective attention • Research produced inconsistent findings (Higginson et al. 2000) • Definition of attention • Measuring instruments very varied • However all note Attention difficulties: • • • • Selective Divided Sustained Alternating • 20-25% of MS patients • Deficits in rapid and complex info processing • Working memory • Attentional switching • Rapid visual scanning • Intact attention span (if not distracted!)
  24. 24. Attention • People with MS report: • Becoming easily distracted • Having trouble keeping track of what is being said and done or have • • • • • • • trouble making sense of things Having trouble focusing on one person, thing or conversation in crowded environments Having trouble keeping track of more than one thing at a time Having difficulty doing more than one task at a time Having difficulty learning and remembering information Becoming easily frustrated with yourself and others Feeling confused and overwhelmed Avoiding contact with care givers, friends and family • All of the above are not helped if distracted or interrupted
  25. 25. Language • Mild confrontation naming deficits • Speech abnormalities (dysarthria, hypophonia) • Poor verbal fluency (retrieval deficit/speed) • 20-25%
  26. 26. Visual Processing • One study suggests 26% impairment • Visual processing (Warren, 1993) • • • • • (Vleugels, 2000) Visual Cognition Visual Memory Pattern Recognition Scanning Visual Attention • In people with MS impairments reported as: • difficulty in recognising objects accurately • difficulty in reading maps • difficulty in driving • problems finding way around • ability to draw or assemble things is impaired
  27. 27. Memory in MS • 40 – 60% report memory deficits (Brassington & March, 1998) • On assessment (Beatty et al., 1996): • Mild – Moderate = 53% • Severe 22% • 25% show normal performance • Core deficit in MS • Global affects can be seen • Recent memory • Retrieval • Encoding • Working memory (? Slowed processing) • Recognition and Implicit relatively unaffected
  28. 28. • Most people describe: • Forgetting appointments • Forgetting shopping lists or things have to do • Forgetting what someone has just said • Reading the newspaper and then forgetting what read
  29. 29. Model of Memory
  30. 30. Memory Model for the layman! Attention Attention must be paid in order to be able to learn Recording The brain needs to 'take in' and record information The 3 R’s of Memory Retain The information needs to be stored in the right spot Retrieve Information needs to be recalled when it is needed again If problems occur anywhere in these steps, then memory difficulties will occur
  31. 31. Executive Functioning • Cognitive abilities required to complete goal-directed behaviors that are not automatic, overlearned, or routine (Sohlberg & Mateer, 2001).
  32. 32. Executive Functioning • 15-20% of patients with MS exhibit executive dysfunction • Impaired goal-directed behavior • Verbal disinhibition • Poor self-monitoring (e.g., tangential speech) • Reduced insight • Deficits in planning and prioritizing • Problems with abstraction and conceptualisation
  33. 33. Executive Functioning • Initiation • Sequential processing • Inhibition • Planning • Set-switching • Self-Monitoring • Judgment/Reasoning • Perseveration • Goal identification • Prioritising • Working memory • Multi-tasking • Speed of processing • Emotional control • Cognitive • Insight/Awareness flexibility/problem-solving
  34. 34. MANAGING COGNITIVE DEFICITS I.E. INTERVENTION
  35. 35. Managing Cognitive Deficits • Neuropsychological rehabilitation • Interventions aiming to enhance or support cognitive abilities following brain injury, with an emphasis on achieving functional changes (Sohlberg & Mateer, 2001) • Target: reductions in cognitive, emotional, psychological functioning that encumber everyday functioning • Goal: increase independent functioning by means of enhanced knowledge and skill, behavior change, or implementation of compensatory strategies
  36. 36. • Foundation of cognitive intervention • Tx based on current level of function • Build on strengths to support weaknesses • Collaborative • Goal-oriented • Education
  37. 37. Processing Speed • Complete one activity at a time • Schedule more time to complete tasks • Limit distractions • Record information for later review
  38. 38. Attention • Orienting procedures • “What am I doing?” • Minimises gaps in attention • Pacing • Realistic expectations • Elongated performance times • Minimise frustration – be patient! • Vary according to time of day • Schedule adequate rest
  39. 39. • Environmental modification • Work in a quiet environment • Reduce clutter • Limit distractions • Refer to checklists to complete tasks • Set timers to prevent going overtime • Work on one task at a time • Double/triple check work to minimise errors • Have a significant other check work
  40. 40. • Top Ten tips to help manage attention difficulties: • • • • • • • • • • Practice Check in Modify the environment Pace Self care Monitor mood Double check Break tasks down Do difficult tasks at the best time of day. Use family and friends for support.
  41. 41. Language • Language • Communication skills training • Group interventions • Modeling and generalization • Building social networks • In MS, many language deficits are due to physical changes (i.e., dysphagia) and reduced speed of processing. • Allow more time for communication
  42. 42. • Speech and Language referral if required • Other forms of communication may be available • Writing, drawing, gesture • Communication book with pictures • Communication aids • Use consistently, have equipment available • Carry explanatory card
  43. 43. • Allow extra time • Ask questions in a way that requires • • • • • • • • • only short answers Speak more slowly Keep sentence short and simple Avoid non-literal speech One person talk at a time Encourage people not to provide the word Encourage self-cueing • Using the first letter of a word • Going through different categories and sub-categories Encourage use of talking around the subject • Describe it • Talk around it • Don‟t get hung up on finding the right word • Getting the message across it what is important Give them permission to use gestures Teach the strategy of asking 20 questions
  44. 44. Helping Visual spatial Difficulties • Raise awareness by providing feedback • Teach self-monitoring • Promote compensation and self management so predictions can be made • Keep walking into doors • Put tram lines of tape on the floor to walk between • Forgetting passages or missing the end of sentences when reading • Use a piece of paper to cover text and guide reading • Reading Rulers • Reduce clutter • Keep things in consistent places • Increase contrast • Scanning • Dark objects on white background or vice versa • Coloured tape on sharp corners • Use written and visual cues
  45. 45. Memory: Learning Strategies • Repetition • Repeat the information over and over and over again. • Looking at something one time is never enough. • For example, trying to learn someone‟s name, repeating it over and over can aid remembering
  46. 46. Multimodal learning • It helps to learn the same information in different ways. • For example, to learn a new recipe, it helps to read over the steps in the recipe, listen to someone telling you the steps (or reading it aloud yourself), and practice the recipe by doing it. • See it, hear it, do it!
  47. 47. Errorless Learning • This is a method of learning which unlike more traditional • • • • teaching ideas does not encourage guessing. If attempting to help someone remember a piece of information it is common practice to suggest that they „have a guess‟. This technique suggests that if information cannot be recalled on the first time of asking, the correct answer should be given immediately. Replacing several guesses with the correct answer may lead to the information being remembered. This information is less likely to be remembered if several incorrect guesses are made, as these could later be recalled by the person with memory problems.
  48. 48. • Example of Errorful Learning • Example of Errorless Learning Carer: „Can you remember the name of your granddaughter?‟ Tom: „Erm...I‟m not sure‟ C: „Why don‟t you have a guess?‟ T: „Is it Alice?‟ C: „No, but the first letter is right. Have another guess.‟ T: „Alex?‟ C: „No, try again‟ T: „Amy‟ C: „Yes, that‟s right‟ Carer: „Can you remember the name of your granddaughter?‟ Tom: „Erm...I‟m not sure‟ C: „Your granddaughter‟s name is Amy‟ http://www.wales.nhs.uk/sitesplus/861/home
  49. 49. Memory: External Strategies • Write it down • When something is important to remember, write it down, and keep it in a safe place • Check notes regularly. • Writing information down also allows for repeated exposure to the information • Hear, Write, Read – 3x exposure • Calendar • PDA or cell phone • Notebook
  50. 50. • DIARIES • Essential addition to anyone‟s memory whether for forward planning or for remembering past event – Powell (1994) • Page a day diary • Diaries entries can act as cues or triggers • Check diary regularly • Cross out things you have done • Write in future activities/events • MEMORY AIDS • Prompts, Post-it notes, Dry-wipe board, Notice boards, Calendars, Notebooks, Lists, Signs, Labels, Timers, Alarms, Watch alarms, Pill boxes, Key finders, Electronic Organisers etc. etc.
  51. 51. Memory: Internal strategies • Aim is to take in, retain and access information as effectively as possible • Concentrate („getting information in‟) • „Reflective listening‟; recapping what‟s been said in your own words–perceived as attentive listening • Incorporates some repetition and deeper processing • If you miss what is said, ask again • Chunking/grouping • Name/face association • Verbal/non-verbal „recoding‟ • PQRST technique • Mnemonics
  52. 52. Executive Functioning • Structure and Routine! • Do things that require the most initiation in the morning or after a • • • • • • • • rest • Set a small number of goals for each day Set up (with assistance) organisational practices Large family calendar Online bill payment Use labels Schedules Simplify activities Prioritise Checklists
  53. 53. Executive Functioning Meta-cognitive strategies • To regulate behavior and increase goal- oriented behavior • Self-talk • Tracking behaviors • Self-monitoring • Tracking errors and attention lapses • Goal Management Training
  54. 54. Goal Management Training • Maintaining intentions in goal-directed behavior is reliant on intact executive functioning • GMT based on theory of goal neglect resulting in disorganised behavior following frontal lobe injury
  55. 55. AIM OPTIONS PROS CONS COMMENCE AND MONITOR
  56. 56. Awareness/insight • Education around deficits can help. • Strategies that raise awareness of performance - videos, checklists, or giving feedback. • Feedback: • • • • non-critical feedback should be concrete (plain; able to be seen), Use specific examples and information Provide opportunities for feedback from others: • Family • Friends • Peers • Encourage the person to evaluate their own performance in different areas, particularly focusing on areas that are causing difficulty.
  57. 57. • Build self-esteem by encouraging the person to try a (non-dangerous) activity that he/she feels confident doing. • Give the person visual and verbal reminders or “hints” (e.g., a smile or the words "good job") to improve confidence in carrying out basic activities more independently. • Remember lack of insight is part of the neurological damage and not just the person being obstinate. • Be aware, however, that denial can also be a coping mechanism to conceal the fear that he/she cannot do a particular task. Therefore they may insist that the activity cannot be done or is “stupid.”
  58. 58. Influences on Cognition • Include: • Physical difficulties • Fatigue • Depression/anxiety • Engagement • Pain • Medications
  59. 59. “A new study shows that licking the sweat off a frog can cure depression. The down side is, the minute you stop licking, the frog gets depressed again!” Sonet
  60. 60. “Work used to interfere with my laziness but thanks to MS I have all the time in the world to be lazy!” Wendy Bessenyei

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