Cognitive Impairment in MS— What is it and What Can the MS Nurse Do? Patricia Pagnotta, MSN,ARNP, CNRN, MSCN The MS Center of Greater Orlando Maitland, FL July 2011

Myth or Truth Related to Cognition in MS Myth: Only present in 3% of persons with MS Truth: Studies estimate between 43% to 70% of persons with MS have some degree of cognitive impairment

Myth or Truth Related to Cognition in MS Myth: Only present in individuals with severe disability Truth: Cognitive function is not correlated with physical function. AND As opposed to age-related cognitive changes, the cognitive changes in MS occur much earlier and have disabling affects on many aspects of persons lives

Myth or Truth Related to Cognition in MS Myth: Only present in progressive forms of MS Truth: Cognitive impairment can be present at or before the diagnosis of MS or CIS is made. Myth: Cognitive function is not related to MRI activity Truth: MRI T2 lesion load, third ventricle width, and thalamic atrophy are recognized as the most predictive conventional MRI markers. Increased Grey Matter lesions are highly correlated with cognitive dysfunction.

Myth or Truth Related to Cognition in MS Myth: Cognitive decline in persons with MS is related to severity of depression Truth: Symptoms of apathy, indifference and euphoria are more typically associated with CIMS than depression

What is CIMS Commonly Not Affected Procedural Learning- performing activities General Intelligence- standardized IQ testing Basic Attention- can wait their turn in line Semantic Memory- general information and facts- recognizing objects/items not tied to specific time or place of learning, i.e. vocabulary words

What is CIMS Commonly Affected Processing Speed- primary impairment, causes dysfunction in other cognitive domains Complex Attention- multi-tasking Executive Function- decision making process Word Finding- fluency of speech

What is CIMS Commonly Affected Episodic Memory- events, facts experiences that have occurred Working Memory-brief storage and manipulation of information Encoding into Long Term Memory

What is CIMS Common complaints “Tip of the Tongue” phenomenon Wrong word came out “Blanking out” in a familiar area Difficulty following directions or conversations Withdraw from social activities Personality changes (defensive) Require assistance with ADL

What is CIMS Common Problems Preservative Errors: difficulty shifting principles or direction, can cause problems for individuals whose objectives shift frequently Immediate memory fairly normal Recent memory more dramatically affected Perform better on recognition than free recall

The Prevalence of CIMS Studies estimate between 43% to 70% of persons with MS have some degree of cognitive impairment Usually progresses very slowly Often under-recognized or misdiagnosed as depression, stress, or personality disorder

How is CIMS Identified When there is evidence of dysfunction? Patient complaint Support person complaint History/Assessment Invisible symptom Denial Some studies show persons with higher educational reserve have slower decline in brain atrophy

How is CIMS Identified Neuropsychological testing is the gold standard Disadvantage: Not readily available in all areas Can take 3-5 hours to complete Advantages: Differential diagnosis Vocational assessment Disability evaluation

How is CIMS Identified PASAT- Paced Auditory Serial Addition Test*+ California Verbal Learning Test II* Symbol Digit Modalities Test* + Brief Visuospatial Memory Test Revised, Learning*+ Brief Visuospatial Memory Test Revised, Delayed Recall*+ Delis-Kaplan Executive Function System* Judgment of Line Orientation Test* Controlled Oral Word Association Test* Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNSQ) MMSE- not very sensitive to this population * Minimal acceptable for Neuropsychological testing + most predictive in greater than 50% of persons

Importance of Treatment of Cognitive Impairment Significantly correlated with HRQL Primary factor in patient decisions to leave workforce Contributes significantly to accidents, impairment of daily function, and loss of social contacts

Treating CIMS Treating CIMS Processing Speed and Working Memory Episodic Memory Pharmacotherapy I amphetamine Adderall Amantadine Provigil Nuvigil Aricept Retraining or Remediation Computer Training Tasks RIS Method Behavioral Compensation Speech Therapy Occupational Therapy General Cognitive Rehabilitation Self-Generation Effect

Treating CIMS The Role of Nurse: Helping acknowledgement of changes Helping develop coping strategies Guiding patient to take control- cognitive rehabilitation, planning for the future Educating patient and support persons and helping patient educate support persons Providing medical advice Advocating for DMD and adherence strategies Advocating for routine health screens

Specific Strategies for Treating CIMS Stay Active Physically Mentally Use of Reminders, PDA, Notes, To Do Lists Make associations Use of routines Smoking Cessation Limit Alcohol Diet Proper Sleep Plan Organization Appointment reminders Repeat new names when you meet people Limit Stress Expand social support networks Rest Breaks Accept Help Treat symptoms

Strategies for Treating CIMS Consider using a tool even if not most sensitive as screening for other memory problems, i.e. MMSE Ask direct probing questions of patients, more detailed than “How is you memory” dig into their routines and work life Suggest computer assisted cognitive rehabilitation Consider how cognition may be placing person at risk, i.e. driving and have a plan for acting Consider screening early, possibly with assessment tools available commercially Encourage support persons to actively engage in cognitive rehabilitation with patient. Consider game nights. Seek input from members of the healthcare team who interact with patient, i.e. home health nurses, injection training nurses

Brain Teasers Websites http://www.positscience.com/games-teasers http://www.lumosity.com * http://www.minddabble.com http://hartfordauto.thehartford.com http://playwithyourmind.com http://www.msactivesource.com/multiple-sclerosis-memory-resources.xml http://www.multiplesclerosis.com/us/index.php?WT.mc_id=MSL120639 http://www.happy-neuron.com/ * http://www.fitbrains.com/ http://games.aarp.org/ *fee required

Questions about Disability: Getting Help http://www.nationalmssociety.org/government-affairs-and-advocacy/government-programs/social-security-disability/index.aspx http://www.allsup.com/