While cognitive symptoms — changes in brain function that can impair your ability to remember or learn information — are common with MS, they don’t always get the attention they deserve from doctors or people with the disease. Neither group may be aware of how cognitive symptoms can be recognized, accurately diagnosed, and treated. That’s why a neuropsychologist may be a welcome addition to your MS care team. Neuropsychologists specialize in diagnosing and treating cognitive and emotional symptoms related to neurologic conditions. For people with MS, seeing a neuropsychologist can help them get a more accurate sense of how the disease is affecting their mental and emotional health and then develop a treatment plan targeted at those issues. Not everyone with MS needs to see a neuropsychologist, but everyone with the disease can benefit from some form of cognitive screening. Here’s now neuropsychologists fit into the system of screening and treatment for cognitive symptoms and what to expect if you visit one. The most established role is to assess a person’s thinking skills. For someone with cognitive symptoms, a neurologist or other doctor “might refer that person to a neuropsychologist for cognitive testing, to see whether those symptoms are, in fact, due to MS or some other medical condition,” says Beier. Neuropsychologists are trained to assess different aspects of cognition, including memory, attention, and concentration, according to Beier. And while all neuropsychologists do assessments, some also specialize in techniques for treating cognitive or emotional difficulties. “I work in a rehab neuropsychology model,” says Beier, which often means following up with interventions, such as cognitive rehab, “which I think of as physical therapy for the brain,” she says, “exercises for the brain to improve symptoms or prevent them from getting worse.” It’s important to accurately assess what’s going on behind someone’s symptoms before deciding on a course of treatment, Beier emphasizes, because different cognitive problems may lead to similar symptoms. For example, when people with MS have trouble recalling words during a conversation, “one person might have processing speed difficulties, whereas somebody else might be having [planning and prioritizing] difficulties,” she says, “so their brain isn’t organizing things as efficiently.” Your neuropsychologist can then prescribe exercises designed to help improve the area of thought in which you’re struggling. If processing speed is your main problem, you may be given a task to do somewhat slowly and then gradually work to complete it faster. But in a rehab model of neuropsychology, the goal is to improve a person’s cognition by any practical means. This can mean addressing factors that aren’t directly related to brain damage caused by MS, such as lifestyle and other medical conditions. For example, both stress and lack of sleep can contribute to cognitive problems, as can lack of adequate fatigue management in people with MS, says Beier. Good fatigue management includes planning your activities well and paying attention to your environment, because factors like heat can contribute to both physical and mental exhaustion. Depression and anxiety can also harm cognition and are common in people with MS. Depression tends to sap a person’s motivation and slow down their thinking, while anxiety typically leads to “anxious thoughts in their working memory, which blocks other things that [they’re] trying to learn. So addressing anxiety and depression can have a positive effect on cognition,” says Beier.
Seeing a Neuropsychologist: What to Expect
Ideally, Beier says, everyone with MS would receive a baseline cognitive screening and an annual follow-up screening, which is what the National Multiple Sclerosis Society recommends. But most people with MS don’t receive this annual screening, even though it only takes 3 to 5 minutes. The lack of routine screening means that cognitive problems are usually identified by people with MS or their family members and then confirmed by a requested screening. But even if your neurologist or primary care doctor does this, “a lot of providers don’t know what to do if the screening is positive or how to change their treatment so that the symptoms are addressed,” says Beier. It’s also not a given that your doctor will refer you to a neuropsychologist in such a situation. While neuropsychologists can be found in major cities in the United States, many smaller cities and rural areas simply don’t have any. And the initial wait time for an appointment is in the ballpark of 3 to 6 months, Beiers says. All of these factors mean that you may need to proactively request a referral to a neuropsychologist if your initial screening suggests cognitive problems. When you arrive for your first appointment, your neuropsychologist will give you a more in-depth cognitive assessment that may involve answering questions or completing tasks, depending on the kind of testing your neuropsychologist believes is appropriate. Based on the results of your assessment, the neuropsychologist may schedule more appointments, where you’ll complete cognitive exercises tailored to your needs. These may be with either the neuropsychologist or another practitioner, such as a speech pathologist or occupational therapist. Beier typically doesn’t ask people to do cognitive exercises on their own unless they live somewhere remote. “I do think that the tailored programs that speech pathologists, occupational therapists, or neuropsychologists do have the most evidence behind them,” she explains. Similarly, while doing certain computer-based cognitive exercises at home may help your cognition, that doesn’t mean you’ll benefit from them as much as you would from a more personalized program, Beier says. One example of a very personalized approach is that for someone having trouble with speed on certain work-related tasks, a neuropsychologist or other provider “might have them bring in a project from work and time them to see if they can increase their efficiency,” Beier notes. But your provider can also choose by-the-book exercises for you based on what aspects of your cognition need improvement. If you think seeing a neuropsychologist might be helpful for your cognitive symptoms, Beier stresses that you should make this known. “Right now, I think what’s happening is, if patients advocate for themselves or family members advocate, then usually they’re referred to a neuropsychologist,” she says. But Beier urges all people with MS to get a cognitive screening, even if it’s not from a neuropsychologist. “Getting a neuropsychological evaluation is an opportunity to figure out what your areas of strength and weakness are,” she notes. “There are strategies to improve those areas of weakness, and the earlier we intervene, the better your outcomes are going to be.”
