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Latest MS research update - The effect of multiple medications on fatigue and cognition in MS - 22 April 2014

The MS Trust runs a weekly search for interesting and relevant research articles relating to multiple sclerosis using Medline, a specialised search engine for medical journals. The original abstracts to each of the articles can be accessed via the links provided.

For further information on any topic please contact the information team at info@mstrust.org.uk.


This week's highlighted research...

The effect of multiple medications on fatigue and cognition in MS

Research by topic areas...

Assessment tools
Carers
Causes of MS
Disease modifying treatments
Hormones and MS
Pregnancy and childbirth
Psychological aspects
Rehabilitation
Symptoms and symptom management


The effect of multiple medications on fatigue and cognition in MS

Summary

Polypharmacy is the taking of multiple medications by an individual, usually defined as five or more a day. It has been shown that it can have detrimental effects in other groups, such as the elderly, but the effect of taking five or more medications a day in people with MS has not been studied before.

85 people with MS were recruited via an American university medical centre clinic. All participants provided a list of the medications they were currently taking and completed a number of questionnaires and tests. It was found that a third (33%) of the study participants were taking five or more medications a day. These participants also reported more memory problems, more fatigue, difficulties in processing information and prospective memory (remembering to perform a planned action at the appropriate time), than those participants on fewer medications.

The results of this study suggest that polypharmacy may play a role in fatigue and cognitive difficulties seen in people with MS. Although fatigue and cognitive difficulties are common in people with MS, this study suggests that taking many medications could be making these difficulties worse. The study authors do note that their study was the first to look at polypharmacy in MS and so is a starting point and not a complete or definitive answer.


Background

Polypharmacy the taking multiple medications by an individual, usually defined as five or more a day. Most studies of the effects of polypharmacy have been in the elderly, as older adults are more likely to have multiple conditions that they require medications for. These studies have shown that taking five more medications every day in the elderly is associated with trouble with doing practical tasks or daily activities, increased falls and increased cognitive impairment, such as problems with memory or problem solving. The effect of polypharmacy on people with MS has not been studied before, so this study aimed to examine the effect of polypharmacy on fatigue and cognitive function (memory, concentration and problem solving) in people with MS.


How this study was carried out

85 people with MS were recruited to the study via a clinic held at a university medical centre in the USA. All participants had been using disease modifying drugs for at least the preceding 60 days but anyone who had taken steroids or had a relapse within four weeks of assessment was excluded from the study. All participants provided a list of the medications they were currently taking and completed a number of questionnaires and tests. These included, the Expanded Disability Status Scale (EDSS), a commonly used measure of disability in MS, the Beck Depression Inventory, a measure of depressive symptoms, the Modified Fatigue Impact Scale (MFIS) and several tests that assessed cognition, attention and different types of memory.

For the analysis the participants were divided into two groups based on how many different medications they were taking. Those taking five or more medications were "with polypharmacy" and those who were taking four or less were "without polypharmacy".


What was found

It was found that a third (33%) of participants were with polypharmacy and so were taking five or more medications a day. These participants were also older than those who took four medications or less, they had been diagnosed with MS for a longer time and also had more health conditions in addition to MS, such as asthma, high blood pressure and high cholesterol.

Those participants who were with polypharmacy reported more memory problems, more fatigue, difficulties in processing information and prospective memory (remembering to perform a planned action at the appropriate time), than those participants on fewer medications.


What does it mean?

The results of this study suggest that polypharmacy may play a role in fatigue and cognitive difficulties seen in people with MS. The authors found that the association between fatigue and cognitive impairments and the number of medications was still significant after taking into account age, duration of MS diagnosis, level of disability and other health conditions.

Although fatigue and cognitive difficulties are common in people with MS, this study suggests that taking many medications could be making these difficulties worse. The study authors do note that their study was the first to look at polypharmacy in MS and so is a starting point and not a complete or definitive answer.

The authors list several limitations and suggestions for future work. One limitation of the study is that it did not take into account the size of dose of each medication being taken. For example, the effect on fatigue could be due to a high dose of a particular medication, not the total number of medications being taken. Another is the fact that the study cannot directly address the question of whether polypharmacy is the cause of the effects seen. It is not ethically possible to perform a blinded study or randomly assign the participants to take multiple drugs. Each participant had their own individual combination of health conditions and so it is possible that the effects seen were as a result of something not measured by the study. One suggestion for future research made by the authors is a study that randomly assigns people to medication reviews that are aimed at reducing polypharmacy. They suggest that if, after medication is reduced, fatigue and memory improves, it may be possible to develop guidelines that will help clinicians and people with MS weigh up the costs and benefits of multiple medications.


Thelen JM, Lynch SG, Bruce AS, et al.
Polypharmacy in multiple sclerosis: Relationship with fatigue, perceived cognition, and objective cognitive performance..
J Psychosom Res. 2014 May;76(5):400-4.
abstract

More about fatigue and cognition

Often the treatment of MS falls into the category of polypharmacy as taking several drugs at once to control several different symptoms may be required. Many of these drugs act on the central nervous system and so can have other effects as well as those that were originally intended, these are known as side effects. Many drugs that act in the central nervous system can have side effects, due to the way they work, these can include drowsiness, fatigue and cognitive difficulties. As fatigue and cognitive dysfunction can be common symptoms in MS, medications that make these symptoms worse can be very unwelcome. If you are affected by these symptoms, you could see your doctor for a medication review. It may be possible for you to be switched onto another treatment that does not have the same effect on the central nervous system. This could be another medication that works a different way or perhaps trying alternative methods of managing symptoms, that does not involve taking a medication, such as changes to routine, diet or activity.

Fatigue is believed to be the most common symptom in MS, but there are a number of ways that it can be managed. These include planning, prioritising the most important tasks and putting aside or delegating those tasks that are less important and pacing yourself. You can read more in Living with Fatigue.

Periods of fatigue may also cause other MS symptoms to worsen temporarily. This is particularly true of cognitive symptoms such as problems with memory, concentration and attention span. People report that it is harder to 'think straight' when they are fatigued. StayingSmart was developed by the MS Trust in partnership with Dr Dawn Langdon, a neuropsychologist at Royal Holloway University of London. It is a web-based resource designed for people who want to know, or know more, about how MS can affect thinking. The Tips and Tricks section, which includes ideas shared by people living with cognitive symptoms, and Gadgets and Gizmos features readily available items of equipment that may be helpful.

Keep up to date

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You can also sign up for our News alerts which cover reports about MS on our news page and in the media.

Open Door, the MS Trust's free quarterly newsletter is available both by post and by email. It contains information on all the publications and support that the MS Trust provides, articles on a wide range of topics written by health professionals and people with MS as well as news about MS and recent research. Sign up for Open Door here or call us on 0800 032 38 39 or 01462 476700

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Assessment tools

Carpinella I, Cattaneo D, Ferrarin M.
Quantitative assessment of upper limb motor function in multiple sclerosis using an instrumented action research arm test.
J Neuroeng Rehabil. 2014 Apr 18;11(1):67. [Epub ahead of print]
abstract

Phillips GA, Wyrwich KW, Guo S, et al.
Responder definition of the multiple sclerosis impact scale physical impact subscale for patients with physical worsening.
Mult Scler. 2014 Apr 16. [Epub ahead of print]
abstract

Sandroff BM, Motl RW, Pilutti LA, et al.
Accuracy of StepWatch™ and ActiGraph Accelerometers for measuring steps taken among persons with multiple sclerosis.
PLoS One. 2014;9(4):e93511.
abstract

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Sonder JM, Balk LJ, Bosma LV, et al.
Do patient and proxy agree? Long-term changes in multiple sclerosis physical impact and walking ability on patient-reported outcome scales.
Mult Scler. 2014 Apr 7. [Epub ahead of print]
abstract

Baumstarck K, Boucekine M, Boyer L, et al.
Quantification of relevance of quality of life assessment for patients with cognitive impairment: the suitability indices.
BMC Neurol. 2014 Apr 8;14(1):78. [Epub ahead of print]
abstract

Read the full text of this paper

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Carers

Bambara JK, Turner AP, Williams RM, et al.
Social support and depressive symptoms among caregivers of veterans with multiple sclerosis.
Rehabil Psychol. 2014 Apr 14. [Epub ahead of print]
abstract

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Causes of MS

Tsai CP, Lin FC, Lee CT.
Beta2-adrenergic agonist use and the risk of multiple sclerosis: a total population-based case-control study.
Mult Scler. 2014 Apr 14. [Epub ahead of print]
abstract

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Disease modifying treatments

Kaufman M, Pardo G, Rossman H, et al.
Natalizumab treatment shows no clinically meaningful effects on immunization responses in patients with relapsing-remitting multiple sclerosis.
J Neurol Sci. 2014 Mar 26. [Epub ahead of print]
abstract

Hanson KA, Agashivala N, Wyrwich KW, et al.
Treatment selection and experience in multiple sclerosis: survey of neurologists.
Patient Prefer Adherence. 2014;8:415-22.
abstract

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Sorensen PS, Koch-Henriksen N, Petersen T, et al.
Recurrence or rebound of clinical relapses after discontinuation of natalizumab therapy in highly active MS patients.
J Neurol. 2014 Apr 12. [Epub ahead of print]
abstract

Sorensen PS, Lisby S, Grove R, et al.
Safety and efficacy of ofatumumab in relapsing-remitting multiple sclerosis: a phase 2 study.
Neurology. 2014 Feb 18;82(7):573-81.
abstract

Fox E, Green B, Markowitz C, et al.
The effect of scheduled antibody testing on treatment patterns in interferon-treated patients with multiple sclerosis.
BMC Neurol. 2014 Apr 4;14(1):73. [Epub ahead of print]
abstract

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Turner AP, Sloan AP, Kivlahan DR, et al.
Telephone counseling and home telehealth monitoring to improve medication adherence: Results of a pilot trial among individuals with multiple sclerosis.
Rehabil Psychol. 2014 Apr 7. [Epub ahead of print]
abstract

Ruggieri S, Tortorella C, Gasperini C.
Pharmacology and clinical efficacy of dimethyl fumarate (BG-12) for treatment of relapsing-remitting multiple sclerosis.
Ther Clin Risk Manag. 2014;10:229-239. Review.
abstract

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Fine AJ, Sorbello A, Kortepeter C, et al.
Progressive multifocal leukoencephalopathy after natalizumab discontinuation.
Ann Neurol. 2014 Jan;75(1):108-15.
abstract

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Hormones and MS

Bove R, Musallam A, Healy B, et al.
Low testosterone is associated with disability in men with multiple sclerosis.
Mult Scler. 2014 Apr 7. [Epub ahead of print]
abstract

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Pregnancy and childbirth

Patti F, Messina S, D'Amico E, et al.
Pregnancy outcomes in multiple sclerosis patients previously treated with cyclophosphamide.
Acta Neurol Scand. 2014 Apr 15. [Epub ahead of print]
abstract

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Psychological aspects

Sumowski JF, Rocca MA, Leavitt VM, et al.
Brain reserve and cognitive reserve protect against cognitive decline over 4.5 years in MS.
Neurology. 2014 Apr 18. [Epub ahead of print]
abstract

Gazioglu S, Cakmak VA, Ozkorumak E, et al.
Personality traits of patients with multiple sclerosis and their relationship with clinical characteristics.
J Nerv Ment Dis. 2014 Apr 10. [Epub ahead of print]
abstract

Lafosse JM, Mitchell SM, Corboy JR, et al.
The nature of verbal memory impairment in multiple sclerosis: a list-learning and meta-analytic study.
J Int Neuropsychol Soc. 2013 Oct;19(9):995-1008.
abstract

Iaffaldano P, Viterbo RG, Goretti B, et al.
Emotional and neutral verbal memory impairment in multiple sclerosis.
J Neurol Sci. 2014 Mar 26. [Epub ahead of print]
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Neumann M, Sterr A, Claros-Salinas D, et al.
Modulation of alertness by sustained cognitive demand in MS as surrogate measure of fatigue and fatigability.
J Neurol Sci. 2014 Mar 18. [Epub ahead of print]
abstract

Hildebrandt H, Eling P.
A longitudinal study on fatigue, depression, and their relation to neurocognition in multiple sclerosis.
J Clin Exp Neuropsychol. 2014 Apr 7. [Epub ahead of print]
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Rehabilitation

Sandroff BM, Klaren RE, Pilutti LA, et al.
Oxygen cost of walking in persons with multiple sclerosis: disability matters, but why?
Mult Scler Int. 2014;2014:162765.
abstract

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Akinwuntan AE, Devos H, Baker K, et al.
Improvement of driving skills in persons with relapsing-remitting multiple sclerosis: a pilot study.
Arch Phys Med Rehabil. 2014 Mar;95(3):531-7.
abstract

Dunleavy L, Preissner KL, Finlayson ML.
Facilitating a teleconference-delivered fatigue management program: perspectives of occupational therapists.
Can J Occup Ther. 2013 Dec;80(5):304-13.
abstract

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Symptoms and symptom management

Thelen JM, Lynch SG, Bruce AS, et al.
Polypharmacy in multiple sclerosis: relationship with fatigue, perceived cognition, and objective cognitive performance.
J Psychosom Res. 2014 May;76(5):400-4.
abstract

Cameron MH, Peterson V, Boudreau EA, et al.
Fatigue is associated with poor sleep in people with multiple sclerosis and cognitive impairment.
Mult Scler Int. 2014;2014:872732.
abstract

Read the full text of this paper