Cognitive impairment in patients suffering from relapsing-remitting multiple sclerosis with EDSS < or = 3.5

Cognition in acute relapses: A psychometric evaluation and its correlation with event-related potential, P300 in multiple sclerosis

OBJECTIVE

During acute relapses of multiple sclerosis (MS), physical symptoms attract utmost care. However, cognitive impairment may constitute an substantial part of a new relapse. In this study, we evaluated the cognitive status of MS patients during acute relapses.

MATERIALS AND METHODS

We enrolled 35 definite MS patients and 21 healthy subjects. Neuropsychometric tests and the event-related potential, P300 were administered to the MS patients before corticosteroid treatment, and 3 months later. The control subjects were tested only once.

RESULTS

The differences between the scores of the Timed 25-Foot Walk test, the Brief Repeatable Battery subtests (10/36 SPART, SDMT, SRT, SRT-LTM) in the relapse and remission phases were statistically significant (p = .005, p = .007, p = .05, p = .029, p = .001, respectively). The latencies of P300 waves during the relapses were significantly prolonged than the ones in the remission and the controls' (p = .004, p < .001, respectively).

CONCLUSIONS

In this study, we observed a significant involvement of visual-spatial perception, remote memory, and recall, as well as P300 latencies in acute relapses. The inclusion of cognitive assessment during a relapse can provide accurate information on cognitive status for future treatment modalities.

Clinical features and physical performance in multiple sclerosis patients with and without cognitive impairment: a cross-sectional study

The factors associated with cognitive functions in patients with multiple sclerosis (PwMS) are not yet clear. The aims of this study were (1) to compare clinical features and physical performance in healthy controls, and PwMS with and without cognitive impairment, and (2) to determine the relationship between cognitive domains and demographics characteristics, clinical features and physical performance in PwMS. A total of 112 PwMS and 25 healthy controls participated in this study. Cognitive functions were evaluated by Brief Repeatable Battery of Neuropsychological Tests (BRB-N). Based on cognitive performances by BRB-N, PwMS were divided into two groups as MS patients with impaired (MS-I, n: 57) and with normal (MS-N, n: 55) cognitive functions. For clinical features, fatigue, mood and sleep quality were evaluated by the Fatigue Impact Scale, Beck's Depression Inventory, Pittsburgh Sleep Quality Index, respectively. For physical performances, balance and walking capacity were evaluated by posturography and Six-Minute Walking Test, respectively. The results showed that the education years, postural stability and walking capacity in MS-N and healthy controls were higher than in MS-I (P < 0.05). In addition, visuospatial memory was correlated with both postural stability under all sensory conditions and walking capacity; verbal memory was correlated with education years, postural stability on eyes closed-foam surface and walking capacity; verbal fluency was correlated with only walking capacity; information processing speed was correlated with education years, postural stability under all sensory conditions and walking capacity (P < 0.001). This study suggests that the interventions that aim to improve physical performance might protect and even improve cognitive functions in PwMS.

Cognitive-Postural Interference in Multiple Sclerosis

Multiple Sclerosis (MS) is a neurodegenerative disease associated with cognition and balance impairments, which can lead to accidental falls. Postural control requires cognitive resources. This interaction is quantifiable by using the dual-task paradigm. The cognitive-postural interference (CPI) is commonly evaluated through an assessment of the dual-task cost (DTC). The aim of this review was to summarize literature related to process, results and effects of CPI in MS patients. The Prisma statement was used to guide this systematic review. Eligible articles had to include participants with MS for whom CPI was assessed using the DTC. A total of 14 articles meeting inclusion criteria were retained. All studies used the double stance with eyes open for the postural task component. Three types of cognitive tasks were used: Stroop Color–Word Test (SCWT), Word List Generation and Backward Counting. However, cognitive task scores in single or dual task were unavailable in 11 studies, which prevented calculating the DTC for that task. Prioritization instructions were provided in seven studies. Mutual interference was shown in three studies, postural interference in nine and postural facilitation in two. This review highlights the presence of CPI among MS patients. Postural interference usually occurred during dual task while cognitive performance during dual task was rarely reported. Postural task performance does not appear to vary based on EDSS level. We advise authors of future studies to use the SCWT in combination with postural task measure (sway area and postural sway) for DT assessment, with explicit prioritization instructions. Further, the cognitive and postural tasks should be performed in ST and DT and all results should be presented.

Earnings among people with multiple sclerosis compared to references, in total and by educational level and type of occupation: a population-based cohort study at different points in time

OBJECTIVES

To investigate earnings among people with multiple sclerosis (PwMS) before and after MS diagnosis compared with people without MS, and if identified differences were associated with educational levels and types of occupations. Furthermore, to assess the proportions on sickness absence (SA) and disability pension (DP) in both groups.

DESIGN

Population-based longitudinal cohort study, 10 years before until 5 years after MS diagnosis.

SETTING

Working-age population using microdata linked from nationwide Swedish registers.

PARTICIPANTS

Residents in Sweden in 2004 aged 30-54 years with MS diagnosed in 2003-2006 (n=2553), and references without MS (n=7584) randomly selected by stratified matching.

OUTCOME MEASURES

Quartiles of earnings were calculated for each study year prior to and following the MS diagnosis. Mean earnings, by educational level and type of occupation, before and after diagnosis were compared using t-tests. Tobit regressions investigated the associations of earnings with individual characteristics. The proportions on SA and/or DP, by educational level and type of occupation, for the diagnosis year and 5 years later were compared.

RESULTS

Differences in earnings between PwMS and references were observed beginning 1 year before diagnosis, and increased thereafter. PwMS had lower mean earnings for the diagnosis year (difference=SEK 28 000, p<0.05), and 5 years after diagnosis, this difference had more than doubled (p<0.05). These differences remained after including educational level and type of occupation. Overall, the earnings of PwMS with university education and/or more qualified occupations were most like their reference peers. The proportions on SA and DP were higher among PwMS than the references.

CONCLUSIONS

The results suggest that the PwMS' earnings are lower than the references' beginning shortly before MS diagnosis, with this gap increasing thereafter. Besides SA and DP, the results indicate that educational level and type of occupation are influential determinants of the large heterogeneity of PwMS' earnings.

Relationships between neuropsychological and antisaccade measures in multiple sclerosis patients

BACKGROUND

The Stroop test is frequently used to assess deficits in inhibitory control in people with multiple sclerosis (MS). This test has limitations and antisaccade eye movements, that also measure inhibitory control, may be an alternative to Stroop.

OBJECTIVES

The aim of this study was twofold: (i) to investigate if the performance in the antisaccade task is altered in patients with MS and (ii) to investigate the correlation between performances in neuropsychological tests, the Stroop test and the antisaccade task.

METHODS

We measured antisaccades (AS) parameters with an infrared eye tracker (SMIRED 250 Hz) using a standard AS paradigm. A total of 38 subjects diagnosed with MS and 38 age and gender matched controls participated in this study. Neuropsychological measures were obtained from the MS group.

RESULTS

Patients with MS have higher error rates and prolonged latency than controls in the antisaccade task. There was a consistent association between the Stroop performance and AS latency. Stroop performance but not AS latency was associated with other neuropsychological measures in which the MS group showed deficits.

CONCLUSIONS

Our findings suggest that AS may be a selective and independent measure to investigate inhibitory control in patients with MS. More studies are necessary to confirm our results and to describe brain correlates associated with impaired performance in the antisaccade task in people diagnosed with MS.

Multiple sclerosis risk perception and acceptance for Brazilian patients

The perception of multiple sclerosis (MS) severity and risk associated with therapies might influence shared decision making in different countries. We investigated the perception of MS severity and factors associated with risk acceptance in Brazil in 96 patients with relapsing-remitting MS using a standardized questionnaire and compared this with two European cohorts. Multiple sclerosis was perceived as a very severe disease and the risk of developing progressive multifocal leukoencephalopathy due to natalizumab was seen as moderate to high. Seventy-six percent considered a risk of 1:1,000, or higher, an impediment for natalizumab use. Older age was the only variable associated with higher risk acceptance and our patients showed a more conservative profile than German and Spanish patients. Our patients perceived MS severity and progressive multifocal leukoencephalopathy risk similarly to elsewhere, but their willingness to take risks was more conservative. This should be considered when discussing therapeutic options and it might have an impact on guideline adaptations.

Comparison of Brain Atrophy, Cognition and Optical Coherence Tomography Results Between Multiple Sclerosis Patients and Healthy Controls

Introduction

Cognitive impairment is also an important cause of disability in MS in addition to motor, sensory, visual, and cerebellar affections. The aim of this study is to show the relation between the cognitive disability in MS with brain atrophy and retinal nerve fiber layer (RNFL).

Methods

Forty-three multiple sclerosis (MS) patients, and 15 healthy individuals as controls were included in the study. MS patients were divided into three groups as relapsing-remitting MS (RRMS), relapsing-remitting with optic neuritis (RRMS+ON), and secondary-progressive MS (SPMS). An experienced psychologist performed modified Wechsler Memory Scale Revised form (WMS-R), Lines Orientation test, Stroop Color Word Interference test (STROOP), Standard Raven Progressive Matrices (SRPM), Benton Facial Recognition Test, verbal fluency test, and Paced Auditory Serial Addition tests in all cases. Optic coherence tomographies (OCT) were done. Cranial subcortical volumes of all subjects were measured using 3-dimensonal T1A imagines obtained by the cranial subcortical 1.5 tesla MR device (fully automatic Freesurfer program). Brain parenchymal fractions were calculated by proportioning the obtained volume measurements to the total intracranial volume.

Results

Fifty-eight subjects (65.5% female, 34.5% male) were enrolled in the study. There were significant differences among the groups in terms of parenchymal thickness, volumes of third ventricle, and white matter. There was a significant correlation between the volumes of the deep gray matter, mesial temporal structures and lateral ventricular volumes, and the test results of the WMS-R. OCT scores of all MS patients, whether or not they experienced optic neuritis, had increased, being worse especially in the SPMS group. Correlation between RNFL and the brain parenchymal fractions of the patients were statistically significant.

Conclusion

Manual methods instead of automatic segmentation method are being more commonly used in the studies with brain atrophy and MS in our country. A significant correlation between OCT scores and brain atrophy is shown with our present study, and this is followed as a reflection of decrease in cognitive tests that provides valuable and reliable knowledge for the literature.

A Longitudinal Evaluation of Cognitive Fatigue on a Task of Sustained Attention in Early Relapsing-Remitting Multiple Sclerosis

Background

Cognitive fatigue can be objectively measured on tasks of sustained attention and can be defined as decreased performance as a result of sustained cognitive effort. Individuals with multiple sclerosis (MS) early in their disease are vulnerable to cognitive fatigue, although this has yet to be evaluated longitudinally. We aimed to evaluate cognitive fatigue over a 3-year interval in individuals with early-phase relapsing-remitting MS (RRMS). The sensitivity of the Paced Auditory Serial Addition Test (PASAT) at detecting cognitive fatigue was evaluated, as was the impact of scoring method.

Methods

32 people with MS and 32 controls completed the 3- and 2-second PASAT (PASAT-3″ and -2″) as a measure of sustained attention at baseline and 3-year follow-up.

Results

Performance on the PASAT remained stable across time, with improvement noted on the PASAT-2″ likely due to practice and the small sample size. Cognitive fatigue was noted at both times, although sensitivity varied based on scoring method. No evidence of worsening cognitive fatigue was noted over time. The MS group performed worse only when cognitive fatigue was the outcome variable.

Conclusions

Although individuals with MS continue to be vulnerable to cognitive fatigue at follow-up, severity does not seem to increase with time. Cognitive fatigue may be a more sensitive marker of cognitive impairment than overall task performance in those with early-phase RRMS, which has important implications given that clinically only task performance is typically assessed.

Rapid cognitive screening in multiple sclerosis accomplished by the Free Recall and Recognition Test

This study sought to investigate the feasibility of the Free Recall and Recognition Test (FRRT) as a practical screening tool for cognitive impairment in multiple sclerosis (MS). Persons with MS (n =227) were consecutively recruited and assessed with four cognitive tests; FRRT, Symbol Digit Modalities Test (SDMT), Paced Auditory Serial Addition Test (PASAT), and the Mini-Mental State Examination (MMSE). Disease severity was assessed by the Expanded Disability Status Scale (EDSS). The FRRT, which was completed by 99% of the cohort in approximately 5 minutes per assessment, correlated significantly with the other cognitive tests, as well as with the disease severity rating. A cut-off of 4 for the FRRT recall rendered 90% sensitivity and 25% specificity, and a cut-off of 4.2 for the FRRT recognition resulted in 70% sensitivity and 51% specificity. We conclude that the FRRT proved feasible as a practical screening tool for cognitive impairment in MS within a clinical setting. Multiple Sclerosis 2007; 13: 272–274. http://msj.sagepub.com

Language disorders in multiple sclerosis: A systematic review

BACKGROUND

Although cognitive impairments are common in patients with multiple sclerosis (MS), language impairments are not well defined.

OBJECTIVE

The goal of this review was to examine the presence and nature of language disorders associated with MS.

METHOD

A search of PubMed and PsycINFO databases was conducted using combinations of the following terms: language disorders, language pathology, language impairment, multiple sclerosis, communication, language and speech. Studies were chosen based on the original language of the text, year of publication, peer-review status and specificity of the results regarding language and communication disorders.

RESULTS

This review covers 30 articles from 13 countries. The studies involved patients with different types of MS. Various language impairments were reported in MS. However, since the methods used in the studies varied widely, it is difficult to draw any conclusions thus far.

CONCLUSION

Given the various cognitive deficits in MS, it is expected that higher language abilities would be affected. This aspect should be investigated in future studies.

The association between cognitive impairment and physical disability in multiple sclerosis

Background: The association between cognitive impairment and physical disability was examined in a larger, more representative sample of patients with multiple sclerosis (MS) than in previous studies. Method: Two hundred and fifty-three patients attending an MS clinic were assessed with respect to physical disability using the Expanded Disability Status Scale and cognitive impairment using a battery of neuropsychological tests. Results: Physical disability correlated with duration of disease; cognitive impairment did not. Virtually all measures derived from the cognitive battery were significantly correlated with physical disability. Three measures of speeded information processing and one involving delayed recall of verbal material were unique predictors of disability status. The relationship between cognitive impairment and physical disability was equivalent for patients with shorter (<3 years) versus longer (>10 years) disease duration. Cognitive impairment correlated with the rate of disability progression as reflected by the progression index. Conclusion: Cognitive impairment is more closely associated with physical disability than most previous studies indicate. This relationship appears to be stable throughout the duration of MS, although this conclusion is qualified by the cross-sectional design of the study. Further attention should be paid to cognitive impairment as a possible predictor of the rate of patients’ physical decline.

The Rao's Brief Repeatable Battery in the study of cognition in different multiple sclerosis phenotypes: application of normative data in a Serbian population

Cognitive impairment is prevalent in multiple sclerosis (MS) occurring in 43-72 % of patients with all MS phenotypes. The aim of our study was to assess cognitive performance in different MS subtypes in Serbian population. Rao's Brief Repeatable Battery of neuropsychological tests (BRB-N) was administered to 168 MS patients [37 patients with clinically isolated syndrome (CIS) suggestive of MS, 65 with relapsing-remitting MS (RRMS), 31 with secondary progressive MS (SPMS) and 35 patients with primary progressive MS (PPMS)]. The percentage of cognitively impaired patients in our total MS cohort was 58.9 %. Prevalence of cognitive dysfunction was 40.5 % in CIS group, 36.9 % in RRMS, 96.8 % in SPMS, and 85.7 % in PPMS group. Patients in CIS and RRMS groups performed consistently better all tests of the Rao's battery than patients in SPMS and PPMS cohort. CIS and RRMS groups performed consistently better in all tests of the Rao's battery than SPMS and PPMS cohort. Additionally, difference in the performance of any of the BRB-N tests was not found between CIS and RRMS. However, there was a significant difference between SPMS and PPMS patients in the performance on five tests of Rao's battery. Statistical significance (p < 0.05) in favor of PPMS patients was demonstrated for the following tasks: SRT_lts, SRT_cltr, SDMT, SRT_D, SPART_D. Our study demonstrates that cognitive impairment is frequent in all MS phenotypes. Furthermore, we have found that cognitive deficit is most severe and most frequent in SPMS patients, followed by PPMS subjects and then CIS and RRMS patients.

Heterogeneity of sickness absence and disability pension trajectories among individuals with MS

Background

The variability of progression of multiple sclerosis (MS) suggests that MS is a heterogeneous entity.

Objective

The objective of this article is to determine whether sickness absence (SA) and disability pension (DP) could be used to identify groups of patients with different progression courses.

Methods

We analyzed mean-annual net months of SA/DP, five years prior to MS diagnosis, until the year of diagnosis, and five years after for 3543 individuals diagnosed 2003–2006, by modeling trajectory subgroups.

Results

Five different groups were identified, revealing substantial heterogeneity among MS patients. Before diagnosis, 74% had a flat trajectory, while the remaining had a sharply increasing degree of SA/DP. After diagnosis, 95% had a flat or marginally increasing trajectory, although at various SA/disability pension (DP) levels, whereas a small group of 5% had decreasing SA/DP. A majority had few or no SA/DP months throughout the 11-year study period. Higher age and a lower educational level were associated with an unfavorable trajectory (p values <0.01).

Conclusions

There’s a considerable heterogeneity of MS progression in terms of SA/DP. Compared with other measures of disability, sickness-absence and disability pension offer a continuous variable that can be assigned to every individual for each time period without missing data. To what extent the SA/DP measure reflects classical MS outcome-measures as well as how correlated it is with co-morbidities and working-conditions needs to be investigated further.

Update on the relationships between neuropsychological dysfunction and structural MRI in multiple sclerosis

Multiple sclerosis (MS) is a chronic inflammatory disease of the CNS, characterized by demyelination and neurodegeneration. Besides the sensory and motor deficits that are the hallmark of this disease, approximately 50% of MS patients are cognitively impaired. Over the years, structural neuroimaging has been used widely in MS patients for both diagnostic and research purposes. Various conventional and nonconventional magnetic resonance imaging (MRI) measures have provided important information about the degree and mechanisms of cerebral pathology, and these measures correlate with cognitive and affective disturbances. In this article, recent contributions to the literature regarding the correlation between MRI and neuropsychological function in MS are reviewed.

Preference-based Health status in a German outpatient cohort with multiple sclerosis

Background

To prospectively determine health status and health utility and its predictors in patients with multiple sclerosis (MS).

Methods

A total of 144 MS patients (mean age: 41.0 ±11.3y) with different subtypes (patterns of progression) and severities of MS were recruited in an outpatient university clinic in Germany. Patients completed a questionnaire at baseline (n = 144), 6 months (n = 65) and 12 months (n = 55). Health utilities were assessed using the EuroQol instrument (EQ-5D, EQ VAS). Health status was assessed by several scales (Expanded Disability Severity Scale (EDSS), Modified Fatigue Impact Scale (M-FIS), Functional Assessment of MS (FAMS), Beck Depression Inventory (BDI-II) and Multiple Sclerosis Functional Composite (MSFC)). Additionally, demographic and socioeconomic parameters were assessed. Multivariate linear and logistic regressions were applied to reveal independent predictors of health status.

Results

Health status is substantially diminished in MS patients and the EQ VAS was considerably lower than that of the general German population. No significant change in health-status parameters was observed over a 12-months period. Multivariate analyses revealed M-FIS, BDI-II, MSFC, and EDSS to be significant predictors of reduced health status. Socioeconomic and socio-demographic parameters such as working status, family status, number of household inhabitants, age, and gender did not prove significant in multivariate analyses.

Conclusion

MS considerably impairs patients’ health status. Guidelines aiming to improve self-reported health status should include treatment options for depression and fatigue. Physicians should be aware of depression and fatigue as co-morbidities. Future studies should consider the minimal clinical difference when health status is a primary outcome.

The nature of verbal memory impairment in multiple sclerosis: a list-learning and meta-analytic study

The primary purpose of this study was to test the hypothesis that multiple sclerosis (MS) patients have impaired acquisition rather than a retrieval deficit. Verbal memory impairment in MS was examined in 53 relapsing-remitting MS patients and 31 healthy controls (HC), and in a meta-analysis of studies that examined memory functioning in MS with list-learning tasks. The MS group demonstrated significantly lower acquisition and delayed recall performance than the HC group, and the meta-analysis revealed that the largest effect sizes were obtained for acquisition measures relative to delayed recall and recognition. Our data argue against a retrieval deficit as the sole explanation for verbal memory impairment in MS, and make a consistent case for the position that deficient acquisition contributes to the memory dysfunction of MS patients. Deficient acquisition may result from demyelination in relevant white matter tracts that reduces encoding efficiency as a result of impaired speed of information processing.

Cognition in early relapsing-remitting multiple sclerosis: consequences may be relative to working memory

The Relative Consequence Model proposes multiple sclerosis (MS) patients have a fundamental deficit in processing speed that compromises other cognitive functions. The present study examined the mediating role of processing speed,as well as working memory, in the MS-related effects on other cognitive functions for early relapsing-remitting patients. Seventy relapsing-remitting MS patients with disease duration not greater than 10 years and 72 controls completed tasks assessing processing speed, working memory, learning, and executive functioning. The possible mediating roles of speed and working memory in the MS-related effects on other cognitive functions were evaluated using structural equation modeling. Processing speed was not significantly related to group membership and could not have a mediating role. Working memory was related to group membership and functioned as a mediating/intervening factor. The results do not support the Relative Consequence Model in this sample and they challenge the notion that working memory impairment only emerges at later disease stages. The results do support a mediating/intervening role of working memory. These results were obtained for early relapsing-remitting MS patients and should not be generalized to the broader MS population. Instead, future research should examine the relations that exist at other disease stages.

Cognitive functioning in multiple sclerosis

In this article, the nature and course of cognitive dysfunction in MS are reviewed, particularly in the context of recent advances in our understanding of the diffuse nature of neuropathology in MS, and in the context of specific factors that may confer risk or protection for the development of cognitive impairment. In addition, assessment and screening approaches of MS-related cognitive dysfunction are discussed. MS is a condition not only restricted to the adult population, and this article includes a brief description of cognition in pediatric-onset MS. Finally, promising intervention approaches to treat cognitive problems in MS are summarized.

Altered functional adaptation to attention and working memory tasks with increasing complexity in relapsing-remitting multiple sclerosis patients

As attention, processing speed, and working memory seem to be fundamental for a broad range of cognitive performance, the present study on patients with mild forms of relapsing-remitting multiple sclerosis (RR-MS) focused on these domains. To explore subtle neuropsychological changes in either the clinical or fMRI domain, we applied a multistep experimental design with increasing task complexity to investigate global brain activity, functional adaptation, and behavioral responses to typical cognitive processes related to attention and working memory. Fifteen patients with RR-MS (mean age 38 years, 22-49 years, 9 females, mean disease duration 5.9 years (SD = 3.6 years), mean Expanded Disability Status Scale score, 2.3 (SD = 1.3) but without reported cognitive impairment), and 15 age-matched healthy controls (HC; mean age, 34 years, 23-50 years, 6 women) participated. After a comprehensive neuropsychological assessment, participants performed different fMRI experiments testing attention and working memory. In the neuropsychological assessment, patients showed only subtle reduction in learning and memory abilities. In the fMRI experiments, both groups activated the brain areas typically involved in attention and working memory. HC showed a linear in- or decrease in activation paralleling the changing task complexity. Patients showed stronger activation change at the level of the simple tasks and a subsequent saturation effect of (de-)activation at the highest task load. These group/task interaction differences were found in the right parahippocampal cortex and in the middle and medial frontal regions. Our results indicate that, in MS, functional adaptation patterns can be found which precede clinical evidence of apparent cognitive decline.

Assessment and rehabilitation of cognitive impairment in multiple sclerosis

Patients with multiple sclerosis (MS) have a substantial risk of cognitive dysfunction, even in the earliest stages of the disease, where there is minimum physical disability. Despite the high prevalence rates and the significant impact of cognitive dysfunction on quality of life in this population, cognitive functions are not routinely assessed due to the high cost and time consumption. This article provides an overview of the current state of knowledge related to cognition in MS and on the optimal approach to neuropsychological assessment of this population. It then focuses on the pharmacological and other treatment options available for MS patients with, or at risk for developing, cognitive impairment. The available immune-modulating agents may reduce the development of new lesions and therefore prevent or minimize the progression of cognitive decline. However, there is currently insufficient evidence concerning the efficiency of symptomatic treatment in MS. There is also currently no optimal non-pharmacological treatment strategy for cognitive decline in MS, as the studies published to date report heterogeneous results. Nevertheless, non-pharmacological treatments such as cognitive rehabilitation may benefit some MS patients. As cognition is increasingly recognized as a major feature of MS, its assessment and rehabilitation will become a greater priority.

Control of visually guided saccades in multiple sclerosis: Disruption to higher-order processes

Ocular motor abnormalities are a common feature of multiple sclerosis (MS), with more salient deficits reflecting tissue damage within brainstem and cerebellar circuits. However, MS may also result in disruption to higher level or cognitive control processes governing eye movement, including attentional processes that enhance the neural processing of behaviourally relevant information. The attentional control of eye movement was investigated in 25 individuals with MS and a comparable number of neurologically healthy individuals matched for age and IQ. This entailed an evaluation of distractor-related effects on the generation of both unpredictable and predictable visually guided saccades, as well as an evaluation of the effects of presenting endogenous cues prior to target onset. For unpredictable saccades, we revealed an exaggerated distractor effect in MS, with saccade latencies prolonged and endpoints less accurate in the presence of a visual distractor. Predictable saccades tended to be hypometric for MS patients, although we found no significant distractor effects. For endogenously cued saccades, we found no group differences in latency following a valid cue, but an exaggerated increase in latency following invalid cues for MS patients. MS patients also generated a significantly greater proportion of erroneous responses to cue stimuli. These ocular motor characteristics demonstrate considerable sensitivity with respect to evaluating attentional deficits in MS, evident even in the absence of clinical signs of disease.

Preserved decision making ability in early multiple sclerosis

BACKGROUND

The purpose of this study was to assess decision making in patients with multiple sclerosis (MS) at the earliest clinically detectable time point of the disease.

METHODS

Patients with definite MS (n = 109) or with clinically isolated syndrome (CIS, n = 56), a disease duration of 3 months to 5 years, and no or only minor neurological impairment (Expanded Disability Status Scale [EDSS] score 0-2.5) were compared to 50 healthy controls using the Iowa Gambling Task (IGT).

RESULTS

The performance of definite MS, CIS patients, and controls was comparable for the two main outcomes of the IGT (learning index: p = 0.7; total score: p = 0.6). The IGT learning index was influenced by the educational level and the co-occurrence of minor depression. CIS and MS patients developing a relapse during an observation period of 15 months dated from IGT testing demonstrated a lower learning index in the IGT than patients who had no exacerbation (p = 0.02). When controlling for age, gender and education, the difference between relapsing and non-relapsing patients was at the limit of significance (p = 0.06).

CONCLUSION

Decision making in a task mimicking real life decisions is generally preserved in early MS patients as compared to controls. A possible consequence of MS relapsing activity in the impairment of decision making ability is also suspected in the early phase of MS.

Cognitive impairments in relapsing-remitting multiple sclerosis: a meta-analysis

There is debate in the literature regarding the magnitude, nature, and influence of cognitive impairment in individuals with relapsing-remitting multiple sclerosis (RRMS). Therefore, we conducted a meta-analysis that quantified the overall magnitude of cognitive impairment in individuals with RRMS and identified the domains of cognition and clinical/demographic variables that were moderators of the overall effect. We included 57 studies with 3891 participants that yielded a total of 755 effect sizes. Overall, there was a moderate decline in cognitive functioning in individuals with RRMS compared with healthy controls. Larger effects were observed in cognitive domains of motor functioning, mood status and memory and learning. Regarding demographic and clinical variables, age and gender were moderators of cognitive impairment in all cognitive domains, whereas neurological disability and disease duration primarily moderated performance on tasks assessing memory and learning.

Relationship of cognitive impairment to psychiatric symptoms in multiple sclerosis

Psychiatric and cognitive changes are common in patients with multiple sclerosis (MS), but their relationship has not received much attention. We studied the relationship between psychiatric symptoms and verbal memory, working memory, and mental speed in 78 patients with MS and 40 healthy control subjects using linear regression analyses. The MS group exhibited impaired performance on all cognitive tests. Apathy was associated with intrusions and depression with impaired memory and mental speed. The association between apathy and intrusions supports the hypothesis that lesions in frontal areas or frontal connections contribute to a specific neuropsychiatric syndrome in patients with MS.

Memory decline evolves independently of disease activity in MS

Background

The natural history of cognitive impairment in multiple sclerosis (MS) and its relationship with disease activity is not well known. In this study, we evaluate a prospective cohort of 44 MS patients who were followed every 3 months for 2 years. Cognitive evaluation was done at baseline and by the end of the study using the Brief Repeatable Battery-Neuropsychology. Clinical evaluation included assessment of new relapses and changes in disability (Extended Disability Status Scale (EDSS)) confirmed at 6 months.

Results

We found that verbal memory performance deteriorates after 2 years in patients with MS. These changes were observed in stable and active patients both in terms of relapses and disability progression, even at the beginning of the disease, and in patients with or without cognitive impairment at study entry. Attention and executive functions measured with the symbol digit modality test (SDMT) declined after 2 years in patients with confirmed disability progression. Furthermore, SDMT performance correlated with the EDSS change.

Conclusions

Our findings indicate that verbal memory steadily declines in patients with MS from the beginning of the disease and independently of other parameters of disease activity.

Neuropsychological deficits but not coping strategies are related to physical disability in multiple sclerosis

Detailed neuropsychological assessment was performed in 86 women (48 patients with stable relapsing-remitting multiple sclerosis (MS) and 38 matched healthy controls (HC)). Patients were categorized into patients without (EDSS < or =1, n = 26) and with physical disability (EDSS > or =2, n = 22). Patients with EDSS > or =2 scored significantly (P < 0.05) higher in Beck's depression inventory (BDI) and depression scores (DS) compared to HC and patients with EDSS < or =1. No significant differences were found with respect to the use of specific coping strategies between the patient groups, who preferred active (EDSS < or =1) or distracting (EDSS > or =2) strategies. Cognitive deficits were significantly increased in MS with EDSS > or =2 with regard to visuo-construction and visual memory, in particular with respect to geometric figures, compared to MS with EDSS < or =1. Significant positive correlations of depression variables (BDI, DS and BL) and depressive as well as denying coping strategies were found. Our results showed increased depression scores and increased cognitive deficits in advanced physically disabled patients, without selection of specific coping strategies. This supports an individual MS-specific neuropsychological therapeutic approach in order to improve disease related deficits together with social functioning.

Cognitive impairment in multiple sclerosis

Cognitive dysfunctions are frequent symptoms of multiple sclerosis (MS) and occur in up to 65% of patients. Especially memory, attention, executive and visual constructive functions are impaired. These problems strongly affect patients' ability to work, social relationships, and quality of life. Symptoms of physical disabilities can arise independently. Cognitive dysfunctions are clear indicators of MS progression, because they represent highly complex functions that depend on the integrity of the neuronal networks. Once manifested after a relapse, they remain stable . Given a differentiating diagnosis, it is possible to treat these dysfunctions by cognitive training and with pharmaceutical drugs, for example by immunomodulating drugs. However, treatment options are limited at present. This report provides a detailed description of cognitive functions and performance in MS patients, their comorbidities such as fatigue and depression and therapeutic options.

Caregiver burden in multiple sclerosis: the impact of neuropsychiatric symptoms

BACKGROUND

We studied the level of distress in caregivers of patients with recently diagnosed multiple sclerosis (MS), and their relation to clinical characteristics.

METHODS

Caregivers of patients with MS and Parkinson's disease completed measures of distress and quality of life. MS patients underwent neurological, neuropsychiatric and neuropsychological examinations. Multivariate regression analyses were used to explore the relationship between patient variables and caregiver distress.

RESULTS

Caregivers of patients with MS experienced high levels of distress and reduced quality of life related to caregiving. The level of distress was similar to that reported by elderly spouses of patients with longstanding Parkinson's disease. Psychiatric symptoms and cognitive impairment in patients with MS were associated with caregiver's distress and quality of life, even after controlling for level of disability (all p values <0.01). Patients' physical impairment was associated with caregiver distress, but not with caregiver quality of life.

CONCLUSION

Caregivers of patients with MS experience high levels of distress and reduced quality of life. Psychiatric symptoms and cognitive impairment contributed significantly to caregiver distress, over and above the effect of disability due to neurological symptoms.

Cognitive impairment in multiple sclerosis: evidence-based analysis and recommendations

Cognitive impairment is common in multiple sclerosis (MS), occurring at all stages of the disease, and can be a major source of vocational disability, social impairment, and impoverished quality of life. Dysfunction in free recall from long-term memory, speed of information processing, working memory, and abstract reasoning are frequently observed in MS. Despite weak correlation with disease duration and physical disability status, the degree of cognitive impairment in MS has been related to the extent of topographically specific neuronal tissue damage and loss. Additional clinical factors including disease course, fatigue, affective disturbance, and medication can impact on the degree of MS-related cognitive impairment. We suggest that the symbol digits modalities test, paced auditory serial addition task, the clock drawing test and the MS neuropsychological screening questionnaire be considered as valid and relevant screening tests for cognitive impairment in MS.

Troubles cognitifs et sclérose en plaques rémittente : intérêt de leur détection précoce

INTRODUCTION

Cognitive impairment is frequent in relapsing remitting Multiple Sclerosis and is often diagnosed after disruption of occupational and social relations.

METHODS

We studied at baseline a homogeneous population of 32 RRMS patients, diagnosed for less than 5 years, with spontaneous memory complaints, and 20 controls. Sixteen patients were followed for 2 years, combining physical examination, neuropsychological tests, and brain MRI. Neuropsychological tests used evaluated memory capacities, attentional capacities, executive functions, language, and visuo-constructive praxis. Lesion load on brain MRI was measured with semi-automatic segmentation procedures and manual control.

RESULTS

Eighty percent of patients presented cognitive impairment, and this proportion was higher than that found in the literature. These disorders were more marked for verbal episodic memory, attention, and executive functions. Patients with brain MRI that initially fulfilled the Barkhof criteria and those with callous lesions had more memory disorders. No link between global T1 and T2 lesion loads and neuropsychological scores was found. A statistical link between posterior fossa lesions and attentional disorders was shown. In the longitudinal follow-up, patients had better performances in memory and attentional domains, and a lower number of cognitive domains with dysfunction for each patient. This improvement on neuropsychological tests, whereas EDSS levels were stable, underlined a possible test-retest effect.

CONCLUSION

During the initial phase of the disease, most of the relapsing remitting patients present a mild cognitive impairment. Early detection, therapeutic propositions, and recognition of disorders are necessary.

Cognitive impairment in patients with multiple sclerosis using the Brief Repeatable Battery-Neuropsychology test

AIMS

To assess the cognitive impairment of multiple sclerosis (MS) patients using the Brief Repeatable Battery-Neuropsychology (BRB-N) test.

METHODS

The performance of 59 patients with MS in the BRB-N test was assessed and compared with 152 matched healthy controls (HC).

RESULTS

In most tests, MS patients performed worse than controls. Age and educational level strongly influenced the performance of the subjects. The Symbol Digit Modality Test (SDMT) best correlated with the other individual tests and contributed most to the general BRB-N factor. Furthermore, a correlation between physical disability and performance in some BRB-N tests was observed. Indeed, patients with progressive MS and greater physical disability performed worse in some tests than less disabled patients with relapsing MS. By creating a global BRB-N Z score, we found that patients generally performed 0.7 standard deviation (SD) below the level of controls. We obtained cut-off values stratified by age and education to determinate cognitive impairment in MS patients.

CONCLUSIONS

Our data show that cognitive impairment is prevalent amongst MS patients, and that a single cognitive measurement might be useful for monitoring patients during the progression of this illness.

Neuropsychiatric symptoms in patients with multiple sclerosis

OBJECTIVE

To explore the range of psychiatric symptoms in patients with multiple sclerosis (MS) and their association with neurological disability.

METHOD

Patients diagnosed with MS during 1998-2000 in Rogaland and Hordaland counties, western Norway, were included. Psychiatric symptoms were assessed by the Neuropsychiatric Inventory (NPI). Patients with systemic lupus erythematosus (SLE) served as controls.

RESULTS

Eighty-six of 93 eligible MS patients were included, and 80% showed at least one psychiatric symptom. The most frequent symptoms were depression (59%), sleep disturbance (48%), irritability/emotional lability (42%), and apathy (31%). Depression was associated with higher disability score. MS patients showed significantly higher NPI irritability score (P = 0.002), appetite disturbance score (P < 0.001), and apathy score (P = 0.01) than SLE patients.

CONCLUSION

Neuropsychiatric symptoms occur frequently in patients with MS. Irritability and apathy are independent of disability and chronic disease and represent unique disease manifestations.

Attention and memory dysfunctions in mild multiple sclerosis

This study investigated the relationship between clinical symptoms and cognitive dysfunction in multiple sclerosis. Cognitive dysfunction and visual evoked potentials (VEPs) were studied in patients free of physical disability and mildly to moderately disabled patients with multiple sclerosis (MS). Disability-free patients (EDSS < or = 1.5; n = 13), mildly to moderately disabled patients (EDSS ranging from 2 to 6; n = 13) and a healthy matched control group (n = 16) were examined with respect to attention, verbal and nonverbal memory and early visual processing (VEPs). Disability-free patients showed mild impairments on phasic alertness and divided attention. Deficits were more pronounced in mildly to moderately disabled patients who were additionally impaired with respect to non-verbal memory. Despite adequate visual acuity, one half of all patients showed abnormal VEP latencies for both eyes at the same time. The findings suggest that cognitive deficits are already present in multiple sclerosis even in the absence of physical disability. Even with normal visual acuity, perceptual impairments should be considered as part of the CNS affection.

Quality of life and its assessment in multiple sclerosis: integrating physical and psychological components of wellbeing

Health-related quality of life (HRQoL) has been more intensively studied in multiple sclerosis (MS) than in any other neurological disorder. Traditional medical models of impairment and disability are an incomplete summary of disease burden. Quality of life can be thought of as the sum of all sources of satisfaction (including anticipated sources) minus all threats (including anticipated threats). Many psychosocial factors-including coping, mood, self-efficacy, and perceived support-influence the quality of life of patients with MS more than biological variables such as weakness or extent of MRI lesions. Neuropsychiatric complications such as cognitive impairment and fatigue are also important predictors, even in those patients in the early stages of the disease. We review generic and specific HRQoL measures to help clinicians choose the most appropriate therapies. Subjective (self-report) HRQoL measures may serve to alert clinicians to areas that would otherwise be overlooked. Studies of new interventions should include an assessment of HRQoL not just impairment or disability alone.

Kognitive Defizite bei Multipler Sklerose

Cognitive dysfunctions are frequent symptoms of multiple sclerosis (MS) and occur in up to 65% of patients. Especially memory, attention, executive and visual constructive functions are impaired. These problems strongly affect patients' ability to work, social relationships, and quality of life. Symptoms of physical disabilities can arise independently. Cognitive dysfunctions are clear indicators of MS progression, since they represent highly complex functions depending on the integrity of neuronal networks. Once manifested after a relapse, they remain stable. Given a differentiating diagnosis, it is possible to treat these dysfunctions by cognitive training and pharmacologically for example by immunomodulating drugs. However, treatment options are limited at present. This report provides a detailed description of cognitive functions and performance in MS patients, their comorbidities such as fatigue and depression, currently available diagnostic tools, and therapeutic options.

Exercise and Rehabilitation for Individuals with Multiple Sclerosis

It is the coexistence of physical and cognitive impairments, together with emotional and social issues in a disease with an uncertain course, that makes MS rehabilitation unique and challenging. Inpatient rehabilitation improves functional independence but has only limited success improving the level of neurologic impairment. Benefits are usually not long lasting. Severely disabled people derive equal or more benefit than those who are less disabled, but cognitive problems and ataxia tend to be refractory. There is now good evidence that exercise can improve fitness and function for those with mild MS and helps to maintain function for those with moderate to severe disability. Therapy can be performed over 6 to 15 weeks in outpatient or home-based settings or as a weekly day program lasting several months. Several different forms of exercise have been investigated. For most individuals, aerobic exercise that incorporates a degree of balance training and socialization is recommended. Time constraints, access, impairment level, personal preferences, motivations, and funding sources influence the prescription for exercise and other components of rehabilitation. Just as immunomodulatory drugs must be taken on a continual basis and be adjusted as the disease progresses, so should rehabilitation be viewed as an ongoing process to maintain and restore maximum function and QOL.