1. 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

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Brain Teasers Websites * *
*fee required

21. Questions about Disability: Getting Help