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MS information for health and social care professionals Cognitive problems

There is debate about both the nature and extent of cognitive dysfunction as a symptom of multiple sclerosis. It is only relatively recently that recognition has been given to this problem. Although about 50% of people with MS show some cognitive deficits when formally evaluated[1] only 5-10% experience changes severe enough to interfere seriously with activities of daily living. In particular, cognitive difficulties can lead to withdrawal from employment and study.

Its impact can be significant on:

  • behaviour
  • socialisation
  • relationships and families
  • competence in legal and financial matters
  • adjustment to disability
  • ability to benefit from rehabilitation
  • employment and vocational retraining

Cognitive problems can arise early in the course of the disease although the greater the disease duration and severity the more likely problems are to occur. As with physical symptoms, MS may affect some cognitive functions whereas others may be left intact. This is important because it gives the person assets with which to compensate for (and sometimes mask) deficiencies. Cognitive symptoms can worsen during relapse and improve during remission but more commonly symptoms develop slowly and gradually.

Although cognitive dysfunction is a sensitive area to broach with people with MS and their families, it is now generally accepted that openly recognising the problem is considerably more helpful than pretending it does not exist. Recognition opens the door to constructive discussion and the learning of compensatory strategies[2,3].

Cognitive dysfunction can take the following forms:

  • Memory loss is probably the commonest problem. Apart from the obvious difficulties presented by forgetfulness, memory loss also has implications in terms of learning new skills.
  • Reasoning and judgment, including new learning, problem solving and behavioural regulation may also be impaired but, because of the subtle nature of reasoning, this problem is often much less obvious.
  • Speed of information processing can be affected. This is particularly noticeable when people have to deal with information coming to them from different directions.
  • Attention and concentration lapses can also cause problems, especially when attention needs to be divided between tasks.
  • Visuo-spatial perception is also sometimes impaired. Cognitive functions which are less likely to be affected by MS include: language, remote knowledge, 'old knowing', previously learned motor skills (eg riding a bicycle), long-term automatic social skills[4].

Therapy

Recently, developments have been made with regard to recognising, assessing and treating cognitive disorders by neuropsychologists, speech therapists and occupational therapists. The objectives of cognitive rehabilitation are to allow the person with MS to maintain:

  • independence
  • reliability as a community member
  • capacity to contribute to society

Coping strategies

Generally, two complementary approaches may be employed: (1) a retraining approach whereby progressively more challenging exercises are given by health professionals and used to strengthen impaired function and (2) a compensatory approach, which might involve, for example, memory prompts or the recording of information.

There are many practical compensatory strategies which can be employed and a number of publications which people with MS and their families may find useful:[5,6]

  • use of a large page-to-a-day diary and establishment of reliable, obsessive habits of consulting it
  • establishment of a fixed routine, eg always keeping things in the same place
  • doing only one thing at a time and removing distractions (background noise, TV, etc)
  • use of technology eg dictaphones, bleepers, mobile phones
  • use of white boards, post-it notes or notebooks, especially by the phone
  • avoiding jobs which need concentration when fatigued or anxious

It is worth remembering that some medications including those used to counteract pain, fatigue and depression may have an impact on cognition.

Cognitive rehabilitation in head injury is routine; perhaps it will become more widely available for people with MS.

References

  1. Fischer JS, Priore RL, Jacobs LD et al. Neuropsychological effects of interferon beta-1a in relapsing multiple sclerosis. Ann Neurol 2000;48(6):885-892.
  2. Langdon DW, Thompson AJ. Cognitive problems in multiple sclerosis. MS Management 1996;3(2):1,6-9.
  3. Halper J, Holland N. Comprehensive nursing care of multiple sclerosis. New York: Demos Vermande; 1996. p93-99.
  4. Vowels L. Compensatory strategies and cognitive training in MS. Science in MS Rehabilitation: 7th Annual meeting of RIMS (Rehabilitation in Multiple Sclerosis). Copenhagen. 16-19 May 2001.
  5. Kapur N. Managing your memory: a manual for improving everyday memory skills. Southampton: Wessex Neurological Centre; 2001.
  6. Clare L, Wilson BA. Coping with memory problems: a practical guide for people with memory impairments, their relatives, friends and carers. Bury St Edmunds: Thames Valley Test Company; 1997.

Bibliography

  • Amato MP, Zipali V. Clinical management of cognitive impairment in multiple sclerosis: a review of current evidence. Int MSJ 2003;10(3):72-83.
  • MSIF. Emotions and cognition. MS in Focus 2004;4.