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The Neuro Center's physician newsletter. Click here to go to Neurogram's home page. Beyond Physical Disability in Multiple SclerosisAcross studies, the prevalence of cognitive dysfunction in individuals with MS is 30-70 percent with the degree of impairment ranging from mild to severe. Much of this dysfunction is subtle and, in fact, people with mild dysfunction are often lead to believe that they aren't trying hard enough to organize themselves or remember things. The extent to which cognitive dysfunction creates impairment in occupational functioning and lifestyle varies a great deal. Mild movement difficulties and fatigue can be devastating to a parent responsible for caring for small children, whereas a mild reduction in speed of cognitive processing can severely hamper an individual's ability to compete in the workplace. There is not a direct correspondence between the number of lesions apparent on MRI scans and the degree or type of cognitive dysfunction. Further, individuals with MS are challenged by living with the uncertainty of when the next relapse might occur, its possible severity and duration, and the degree of recovery that can be expected. Research has shown that there is a correlation between depressive symptoms in individuals with MS, the level of the disability, and the patient's lack of social support. There is likely a reactive component to these symptoms--the emotional response to having a chronic progressive illness--as well as a direct, organic component that is the result of structural changes in the brain. Depression alone, however, can account for some cognitive changes people with MS may experience. The Role of Neuropsychology in Multiple Sclerosis CareNeuropsychologists are clinical psychologists who focus on the relationship between brain functioning, cognitive abilities and behavior. Like neurologists, neuropsychologists often have specialty training and experience in specific disease processes. Neuropsychologists assess patients using standardized paper and pencil tests that allow a comparison of a patient's performance with that of neurologically intact individuals of a comparable age and educational level. In this way, a judgment can be made as to the level of a patient's impairment. Additionally, a neuropsychologist investigates the pattern of performance within an individual to identify relative strengths and weaknesses or to determine whether a pattern of performance is consistent with specific focal or diffuse brain dysfunction. A neuropsychologist also assesses an individual's mood state and personality structure to determine what role psychological factors may play in a person's ability to utilize his or her cognitive abilities. When individuals with MS present for a neuropsychological evaluation, their most common complaint is poor memory functioning. Memory is a complex process made up of many steps--including attention to the information to be remembered, learning (also called rehearsing or encoding), retention (also called consolidation) and remembering (or retrieval). Thus, a memory problem could be more accurately labeled as an attention problem, inefficient learning, forgetting or retrieval failure. By looking at the pattern of a person's performance on different tests of attention, learning and retrieval, a neuropsychologist can better characterize an individual's problem and suggest appropriate compensation strategies. For example, an individual with retrieval failure may be instructed in the use of cues to facilitate recognition and recall of information. An individual who shows poor learning may be encouraged to minimize distractions in the environment, write information down and review the information frequently. A more subtle deficit in cognitive functioning that is often seen in individuals with MS is called executive dysfunction. This refers to an impairment in higher order thinking or the ability to apprehend a problem and then plan, organize and adjust an appropriate response in the setting of intact or even excellent general intellectual abilities. Sometimes impairments in this domain become obvious only when there is a time pressure to complete a task or a lack of structure to guide a step by step plan. This type of dysfunction can create significant problems in the workplace. However, results from a neuropsychological evaluation can be used to suggest adjustments in work duties or methods of task completion so that individuals with MS can best utilize their intact abilities to compensate for this weakness. While studies have demonstrated that most individuals with MS have intact immediate attention and language skills, many have deficits in speed of processing. Individuals complain of not being sharp, of having difficulties keeping up with conversations, and of being slow to learn information. As our society values the quick wit and the fast solution, it's easy to see how individuals with slowed processing speed are easily made to feel inferior or stupid. Again a neuropsychological evaluation can be used to help an individual better understand the changes that have taken place as a result of MS and the degree to which some intact abilities may be masked by these changes. It's estimated that 40 percent of those with MS also suffer from depression, and individuals with MS are not immune to developing other physical or psychiatric disorders. Thus, assessment of emotional functioning and personality/coping style is an integral part of a neuropsychological evaluation. Cognitive difficulties can combine with physical changes, disability and endogenous causes of depression to deflate an individual's sense of self-esteem, optimism and sense of autonomy. While cognitive difficulties can contribute to symptoms of depression, depression in and of itself can create cognitive dysfunction. This can perpetuate a cycle that is difficult to break. Many individuals experience relief from symptoms of depression with appropriate pharmacological intervention. Individual and family psychotherapy can also help a person combat symptoms of depression, develop self-esteem and learn stress management skills. These services can be provided by a neuropsychologist, clinical psychologist, counselor or social worker who has experience in and understanding of the MS disease process. Additionally, the National Multiple Sclerosis Society sponsors peer support groups. These groups provide people with MS the opportunity to discuss their concerns and fears, share their triumphs, and hear how others have learned to live with the disease. At the James Q. Miller Multiple Sclerosis Consultative Clinic, we are proud to offer comprehensive neuropsychological assessment and counseling referrals to the MS community. Our goal is to provide assistance to practitioners in the management and care of their MS patients, and to develop clinical research projects studying cognitive changes in MS.
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