“When people are diagnosed with MS, doctors may focus on the physical symptoms and how to treat them, but what is often ignored are the cognitive problems people with MS experience: memory issues, thinking more slowly, and mental fatigue,” says Helen Genova, PhD, assistant director of the Kessler Foundation’s Center for Neuropsychology and Neuroscience Research in New Jersey. “All of these symptoms can have a negative impact on the person, and can affect their daily lives in a significant way,” Dr. Genova says. In particular, cognitive function is a major predictor of employment status among people with MS. But leaving the workforce doesn’t have to be an automatic consequence of developing MS. In at least some cases, cognitive rehabilitation and learning ways to compensate for cognitive deficits can keep a person functioning at the job, at home, and socially. This is where cognitive function testing comes in, to discern which cognitive functions are affected and what forms of rehabilitation might help.
What Are the Signs of Cognitive Impairment?
Cognitive problems can be subtle at first, notes the Multiple Sclerosis Association of America. Individuals may have difficulty finding the right words, making decisions, following conversations, and performing tasks. Memory, problem-solving, abstract reasoning, and visual-spatial abilities can all be affected. “In individuals with MS, the white matter tracts [fibers] become compromised, and therefore connections throughout the brain are not as efficient,” says Brittany LeMonda, PhD, a clinical neuropsychologist at Lenox Hill Hospital in New York City. “We often see that these types of brain changes result in slower processing speed and issues with attention and concentration. We also sometimes see issues with retrieval — like coming up with words or remembering events spontaneously,” says Dr. LeMonda. Adults and children ages 8 and up who have clinical or MRI evidence of neurologic damage consistent with MS are advised to get an early baseline screening. “If we have a baseline measure when they are first diagnosed, when we see them later we can tell if there’s a change,” says Meghan Beier, PhD, a neuropsychologist and assistant professor in the department of physical medicine and rehabilitation at Johns Hopkins University in Baltimore. Dr. Beier helped develop the National MS Society guidelines on cognitive testing. “Starting in our twenties, every human being loses speed in their thinking skills, so testing helps us know if the experiences they are having are normal or due to MS,” Beier says. Some doctors do not do baseline testing but wait until a problem becomes apparent. James Stankiewicz, MD, the clinical director at Partners Multiple Sclerosis Center in Boston, conducts a mental evaluation only when a person complains about memory or thinking function or is having work-related issues. “If there is a work-related issue, accommodations can be made in the workplace, or it may support a case for disability benefits,” Dr. Stankiewicz says.
What Cognitive Function Test Is Right for Me?
Validated tests to evaluate cognitive function are relatively new, with the first systemized exam not being developed until 2001, according to the article in Cerebrum. Screenings can be as quick as 90 seconds, although a more extensive assessment can take up to an hour and a half. The amount of cognitive testing you need can depend on whether you’ve been tested before and the severity of your symptoms. Here are three tools commonly used to assess people with MS:
Symbol Digit Modalities Test
This quick screening tool, detailed in an article published in April 2017 in Multiple Sclerosis Journal, asks the user to match given numbers with specific symbols within a minute and a half. The National MS Society recommends this as an effective way to get a minimum, rapid initial evaluation. “The point [of the test is measuring] processing speed, to see how fast somebody’s brain is working,” says Beier. “Processing speed in MS is really important, because it’s the number one system that is impacted, and it impacts everything else. You might feel like you have a memory disorder because your brain is not working as quickly as it used to.” If the exam indicates a problem, the clinician can turn to longer assessments to get a deeper understanding of the person’s cognitive status.
Brief Repeatable Neuropsychological Battery
As outlined in previous research, this is a collection of five tests to evaluate cognitive dysfunction that includes the Symbol Digit Modalities Test as well as:
The Selective Reminding Test, which measures verbal learning and memory by having the test taker listen to a list of 12 words then repeat as many of the words as possibleThe 10/36 Spatial Recall Test, which has the test taker look at a checkerboard with 10 checkers on it for 10 seconds, then try to place 10 checkers on an empty board in the same patternThe Paced Auditory Serial Addition Test (PASAT), in which the test taker listens to a recording of 61 numbers and adds each number to the one immediately before itThe Word List Generation Test, in which the test taker is given a letter of the alphabet and asked to produce as many words as possible beginning with that letter in one minute
The five tests that make up the Brief Repeatable Neuropsychological Battery can be completed in 20 to 30 minutes.
Minimal Assessment of Cognitive Function in MS
Developed through other prior research, this screening tool is similar to the Brief Repeatable Neuropsychological Battery but includes seven separate tests rather than five and requires about 90 minutes. It again covers processing speed and working memory, episodic memory, executive function, visual-spatial processing, and word retrieval. Peter Arnett, PhD, director of the neuropsychology of sports concussion and MS programs at Penn State University in State College, Pennsylvania, tends to use a comprehensive battery like this. “As a neuropsychologist I want to make sure all cognitive domains are evaluated,” Dr. Arnett says.
What About Online Cognitive Evaluations?
People with MS can also go online and find several cognitive evaluations that they can take on their own, such as the Multiple Sclerosis Neuropsychological Screening Questionnaire. However, while these may give individuals some idea of their status, clinicians warn users against interpreting the results themselves. “While these tests are easy to administer,” says Arnett, “People really don’t know how to interpret results, and that may pose a danger.” Scientists are also developing sophisticated touchscreen technology to measure brain function. Investigators at the Cleveland Clinic have created a self-administered computerized tool to assess processing speed using Apple iPad technology. The intent is to have the patient complete the test on his own but discuss the test scores with a healthcare provider. “This is a very viable way of doing screening in the future,” says Arnett. Beier also sees great potential in computer testing. She is working with TestMyBrain.org to create validated, accessible, web-based cognitive assessments for people with MS. “Ideally, the best option would be if someone took a test at home like the ones at TestMyBrain, they would bring the results into their next clinic visit and discuss them with their doctor and come up with a plan for what to do with the tests,” she says. Genova recommends that individuals with MS always seek out a neuropsychologist with specific expertise in multiple sclerosis to ensure that the testing is truly beneficial.
How Can I Protect or Improve My Cognitive Function?
The National Multiple Sclerosis Society (NMSS) recommends a number of learning and memory activities that may help improve cognition. One practice to improve your attention and memory is to repeat what you hear and verify that it is correct. The NMSS also suggests a number of techniques for organizing and keeping track of information that can make up for loss of brain function, including:
Writing to-do listsJotting down appointments in calendarsUsing phone alarms as remindersCreating a center in your home to take care of important planning tasks
RELATED: How to Manage Thinking and Memory Problems in MS
Can My Employer Help Me Keep My Job?
When it comes to the workplace, the Multiple Sclerosis Association of America recommends asking employers if changes can be made to accommodate for any cognitive deficits. This might mean removing yourself from stressful decision-making or asking other employees to handle certain tasks. “I have some patients who have great employers and great bosses who are very understanding, more often than not,” says Beier. Legal protections, such as the Americans with Disabilities Act, help ensure that people with cognitive impairments can continue to work. Patients may also search online for vocational rehabilitation services. Beier recommends that people with job issues related to their illness explore the Job Accommodation Network, a source for free, expert, and confidential guidance on disability-related issues in the workplace.
What’s My Neurologist’s Role in Getting Me Cognitive Care?
Ultimately, working with your neurologist to find specialists who can work with you on the optimal cognitive rehabilitation plan may be the best solution. “You can see how important it is for people to have cognition assessed just like any other symptom that they have,” says Beier. “The main message is to advocate to get some form of cognitive screening every year, especially if you’re having functional changes.” Research is ongoing to see if medication that has been shown to reduce MS lesions may help with cognitive problems.
