When to Do It and Why
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Multiple sclerosis (MS) is well known for causing physical symptoms, such as numbness, spasticity, and loss of balance. But, it can also cause cognitive impairment: Between 45 and 70 percent of people who have MS develop problems with thinking, learning, and memory, according to a study. “When people are diagnosed with MS, doctors may focus on the physical symptoms and how to treat them, but what is often ignored are the cognitive problems people with MS experience — memory issues, thinking more slowly, and mental fatigue,” says Helen Genova, PhD, director of the Kessler Foundation’s Social Cognition and Neuroscience Laboratory in East Hanover, New Jersey.
“All of these symptoms can have a negative impact on the person and can affect their daily lives in a significant way,” says Dr. Genova. In particular, cognitive function is a major predictor of employment status among people with MS.
Leaving the workforce doesn’t have to be an automatic consequence of developing MS. In at least some cases, cognitive rehabilitation and learning ways to compensate for cognitive deficits can keep a person functioning at a job, at home, and socially.
This is where cognitive function testing comes in, to discern which cognitive functions are affected and what forms of rehabilitation might help.
What Are the Signs of Cognitive Impairment?
Cognitive problems can be subtle at first, according to the National Multiple Sclerosis Society (NMSS). Individuals may have difficulty finding the right words, making decisions, following conversations, and performing tasks.
Memory, problem-solving, abstract reasoning, and visual-spatial abilities can all be affected.
“In individuals with MS, the white matter tracts [fibers] become compromised, and therefore, connections throughout the brain are not as efficient,” says Brittany LeMonda, PhD, a neuropsychologist and clinical instructor in the department of psychiatry at New York University Grossman School of Medicine.
“We often see that these types of brain changes result in slower processing speed and issues with attention and concentration. We also sometimes see issues with retrieval — like coming up with words or remembering events spontaneously,” says Dr. LeMonda.
Who Should Have Their Cognitive Function Tested?
The NMSS recommends that people with MS be screened for cognitive dysfunction by an MS healthcare provider at least once a year, and more frequently if new symptoms appear or functional ability at home or work changes.
Adults and children ages 8 and up who have clinical or MRI (magnetic resonance imaging) evidence of neurological damage consistent with MS should get an early baseline screening.
“If we have a baseline measure when they are first diagnosed, when we see them later, we can tell if there’s a change,” says Meghan Beier, PhD, a neuropsychologist and assistant professor of physical medicine and rehabilitation at Johns Hopkins University School of Medicine in Baltimore. Dr. Beier helped develop the NMMS Society guidelines on cognitive testing.
“Starting in our twenties, every human being loses speed in their thinking skills, so testing helps us know if the experiences they are having are normal or due to MS,” Beier says.
What Cognitive Function Test Is Right for Me?
There are several types of tests that can be used to evaluate cognitive function in people with MS. Screenings can be as quick as a few minutes, but a more extensive assessment can take several hours, according to an article in Neurological Sciences.
The amount of cognitive testing you need depends on whether you’ve been tested before and the severity of your symptoms. Here are three commonly used tools:
Symbol Digit Modalities Test
This quick screening tool, detailed in a study, asks the user to match given numbers with specific symbols within a minute and a half. The NMSS recommends this as an effective way to get a minimum, rapid initial evaluation.
“The point [of the test is measuring] processing speed, to see how fast somebody’s brain is working,” says Beier. “Processing speed in MS is really important, because it’s the number one system that is impacted, and it impacts everything else. You might feel like you have a memory disorder, because your brain is not working as quickly as it used to.”
If the exam indicates a problem, the clinician can turn to longer assessments to get a deeper understanding of your cognitive status.
Brief Repeatable Battery of Neuropsychological Tests
As outlined in an article in the journal Annals of Physical and Rehabilitation Medicine, this is a collection of five tests to evaluate cognitive dysfunction, including the Symbol Digit Modalities Test as well as:
- The Selective Reminding Test, which measures verbal learning and memory by having you listen to a list of 12 words and then repeat as many of the words as possible
- The 10/36 Spatial Recall Test, which has you look at a checkerboard with 10 checkers on it for 10 seconds and then try to place 10 checkers on an empty board in the same pattern
- The Paced Auditory Serial Addition Test (PASAT), in which you listen to a recording of 61 numbers and add each number to the one immediately before it
- The Word List Generation Test, in which you are given a letter of the alphabet and asked to produce as many words as possible beginning with that letter in one minute
These five tests can be completed in 20 to 30 minutes.
Minimal Assessment of Cognitive Function in MS
Developed through prior research, this screening tool is similar to the Brief Repeatable Battery of Neuropsychological Tests but includes seven separate tests, rather than five, and requires about 90 minutes. It again covers processing speed and working memory, episodic memory, executive function, visual-spatial processing, and word retrieval.
Peter Arnett, PhD, a neuropsychologist and professor of psychology at Pennsylvania State University in University Park, tends to use a comprehensive battery like this one. “As a neuropsychologist, I want to make sure all cognitive domains are evaluated,” says Dr. Arnett.
What About Online Cognitive Evaluations?
You can also go online and find several cognitive evaluations you can take on your own, such as the Multiple Sclerosis Neuropsychological Questionnaire. Even though these may give you some idea of your status, clinicians warn against interpreting the results yourself.
“While these tests are easy to administer, nonexperts really don’t know how to interpret results,” says Arnett. “That may pose a danger.”
There are sophisticated touch screen technologies to measure brain function, such as Qr8, which you can fill out in 15 minutes. Investigators at Cleveland Clinic have also created a self-administered computerized tool to assess processing speed using Apple iPad technology. The intent is to have you complete the test on your own but discuss the test scores with a healthcare provider.
“This is a very viable way of doing screening in the future,” says Arnett.
Beier sees great potential in computer testing. She is working with TestMyBrain.org to create validated, accessible, web-based cognitive assessments for people with MS.
“Alternatively, the MS Performance Test has been adopted by many neurology centers and MS researchers for a quick processing speed test,” she says.
Genova recommends that people with MS always seek out a neuropsychologist with expertise specifically in multiple sclerosis to ensure the testing is truly beneficial.
How Can I Protect or Improve My Cognitive Function?
The NMSS recommends a number of learning and memory activities that may help improve cognition. One practice for improving your attention and memory is to repeat what you hear and verify that it is correct.
They also suggest a number of techniques for organizing and keeping track of information that can make up for loss of brain function, including:
- Writing to-do lists
- Jotting down appointments in calendars
- Using phone alarms as reminders
- Creating a center in your home to keep items such as your to-do list, calendar, keys, and wallet
Can My Employer Help Me Keep My Job?
When it comes to the workplace, the NMSS recommends asking your employer if changes can be made to accommodate any cognitive deficits. This might mean removing yourself from stressful decision-making or asking other employees to handle certain tasks.
“I have some patients who have great employers and great bosses who are very understanding, more often than not,” says Beier.
Legal protections, such as the Americans with Disabilities Act, help ensure people with cognitive impairments can continue to work. You can also search online for vocational rehabilitation services. For anyone with job issues related to MS, Beier recommends exploring the Job Accommodation Network, a source for free and confidential expert guidance on disability-related issues in the workplace.
What’s My Neurologist’s Role in Getting Me Cognitive Care?
Ultimately, working with your neurologist to find specialists who can work with you on an optimal cognitive rehabilitation plan may be the best solution.
“You can see how important it is for people to have cognition assessed, just like any other symptom that they have,” says Beier. “The main message is to advocate to get some form of cognitive screening every year, especially if you’re having functional changes.”
Research is ongoing to see if medication that has been shown to reduce MS lesions may help with cognitive problems.
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