Brett Parmenter, PhD, ABPP Kati Pagulayan, PhD VA Puget Sound Healthcare System University of Washington School of Medicine Psychiatry and Behavioral

Transcription

1 Brett Parmenter, PhD, ABPP Kati Pagulayan, PhD VA Puget Sound Healthcare System University of Washington School of Medicine Psychiatry and Behavioral Medicine

2 Brett Parmenter, PhD Has no financial interest to disclose Kati Pagulayan, PhD Grant/research support from: VA Clinical Science R&D This continuing education activity is managed and accredited by Professional Education Services Group (PESG) in cooperation with Paralyzed Veterans of American (PVA). Neither PESG, PVA, nor any accrediting organization supports or endorses any product or service mentioned in this activity. PESG and PVA staff has no financial interest to disclose. Commercial Support was not received for this activity.

3 At the conclusion of this activity, the participant will be able to: 1. Review common cognitive difficulties in individuals with MS and how these can impact daily life 2. Discuss detection of cognitive impairment in persons with MS 3. Recognize how various disciplines can help individuals with MS related cognitive impairment

4 Can lead to various clinical symptoms Motor impairments Somatosensory problems Fatigue Cognitive dysfunction High degree of variability types and severity of symptoms One of the most common disabling neurologic conditions in young adults

5 Physical Sensory, motor Visual Fatigue Affective Cognitive

6 There is marked enfeeblement of memory; conceptions are formed slowly; the intellectual and emotional faculties are blunted in their totality. (Charcot, 1877) 30 70%

7 Can occur in all stages CIS, early RRMS, SPMS, PPMS Some form seen in ~40% of patients within one month from onset of neurologic symptoms 35 45% in RRMS 50 60% with SPMS and PPMS 20% of patients with benign MS Tends to be more severe with increased disease duration, although correlation is modest Poorly correlated with physical disability Stronger correlations with MRI parameters, particularly gray matter atrophy Achiron & Barak (2003); Roy et al., (2016)

8 Highly variable: No two people are alike Changes can occur early or late or not at all; course is variable Sometimes confused with depression

9 Commonly affected Information processing Processing speed (PS) Working memory (WM) Learning and Memory Executive Functioning Less commonly affected Language

10 Information processing efficiency may be conceptualized as involving working memory capacity in addition to speed of processing. Three Factors 1) simple speed/rt 2) complex information processing speed 3) verbal/spatial working memory Archibald & Fisk (2000); Chiaravalloti et al. (2003)

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13 WM refers to a limited capacity system enabling the storage, processing, and manipulation of information Example PS is the maximum rate at which elementary cognitive operations are executed Time is finite and the faster processing can be performed, the better the resulting level of cognitive performance Baddeley & Hitch (1974); Baddeley (1992; 2003)

14 Processing speed appears to be the primary deficit Affects other areas of cognition, at least initially There is marked enfeeblement of memory; conceptions are formed slowly; the intellectual and emotional faculties are blunted in their totality. (Charcot, 1877)

15 What other cognitive abilities are affected? Memory retrieval problems Spontaneous access to information in memory; tip of the tongue Decreased concentration capacity New information not sticking ; focus on only one thing at a time; losing track Problems learning new information and solving new problems Multitasking; getting stuck

16 What happens to the MS related cognitive problems over time? Some people experience cognitive impairment early in the disease As the disease progresses, the number of people with MS who develop cognitive impairment tends to increase. In long term studies, the proportion of MS patients who were cognitively impaired at the end of 10 years was 56% Early cognitive impairment (especially PS and memory) predict disability progression and SP conversion in newly diagnosed RRMS Moccia et al. (2016)

17 Cognitive impairment can be difficult to detect during a neurological clinical examination Suspect cognitive impairment correct approximately 90% of the time Suspect no cognitive impairment correct approximately 50% of the time Benedict (2005)

18 Comprehensive neuropsychological assessment is the gold standard Thorough evaluation of cognitive and psychological functioning Evaluate functions over time Identify psychological problems Strategies to help compensate for deficits Might be needed for modified work or school program Implications for tasks such as driving, managing personal finances, making healthcare decisions, etc.

19 Mini mental State Examination (MMSE) Poor sensitivity with MS patients Nearly 70% rate of false negatives Screen Symbol Digit Modalities Test (SDMT) oral version Can be administered and scored in less than 5 minutes <55 accurately classified 72% of cognitively impaired patients Multiple Sclerosis Neuropsychological Questionnaire (MSNQ) 15 item questionnaire; informant report correctly classified up to 94% of cognitively impaired patients Beatty & Goodkin (1990); Benedict et al. (2004); Parmenter et al. (2007)

20 Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) Recommended for smaller centers with only one or two staff, little NP training Constructed to maximize international use 5 min: SDMT (processing speed) 15 min: SDMT (processing speed) T1 T5 CVLT II (verbal list learning) T1 T3 BVMT R (visuospatial learning)

21 Does it really matter? Is this something worth investigating in people with this disease?

22 Greater risk for employment problems Difficulties with activities of daily living May need personal assistance Dependent on others for shopping, home repairs, household chores, driving More likely to be in MVA Affects interpersonal relationships Reduces quality of life May reduced ability to understand and adhere to treatment regimens see Messinis et al. (2010)

23 How specific cognitive deficits can affect daily functioning Memory retrieval problems May affect medication management, work, cooking Decreased concentration capacity May lose track of conversations; may affect reading a book, watching TV

24 Problems learning new information and solving new problems Getting stuck, can t figure things out; may affect balancing the checkbook and driving Problems with working memory May affect ability to track conversations, be easily sidetracked Problems with processing speed May affect ability to understand what is going on especially if things are happening quickly, may affect driving

25 Home, social, educational, vocational Poorer performance on an objective measure reliant on attention, processing speed, inhibitory control was associated with reduced social participation Increased subjective cognitive difficulties associated with reduced participation in the home Hughes et al. (2015)

26 Positive association with: Advanced age Low IQ Low education Depression Not significantly associated with: Neurological symptoms Duration of disease Medication usage see Messinis et al. (2010)

27 Depression Can affect working memory MS patients with depression perform more poorly on cognitive tasks compared to MS patients without depression Depression causing cognitive impairments? Are they both manifestations of underlying neurologic disease? Cognitive impairment and depression appears to be mediated by slowed PS at least in younger patients (<39 years) with less disability and less disease duration Blair et al., (2016); Feinstein (2007) see Messinis et al. (2010)

28 Cognitive Rehabilitation Intervention for cognitive/behavioral deficits resulting from neurological illness or injury Two fundamental principles: 1. Plasticity: the brain can recover from damage that causes cognitive impairment (restorative) 2. Behavioral Adjustment: Individuals can change behavior or environment to adapt to circumstances as a result of illness or injury (compensatory)

29 Literature supports multidisciplinary rehabilitation for neurological disorders, but few studies have been done specifically looking at MS patients Can involve both group and individual treatments focused on both physical and cognitive functioning

30 Studies have looked at specific techniques and only NP data Most have focused on RRMS Duration of treatment range from 1 day to 6 months with a frequency ranging from 5 times per week to 2 times per month Studies varied greatly, sometimes comparing highintensity versus low intensity treatment, specific versus non specific cognitive tasks, specific treatment compared to other types of treatment See Mitolo, M. et al. (2015).

31 Some studies have found benefits that appear specific to the intervention However, studies vary greatly about type of intervention domains targeted, which make it difficult to draw conclusions In general, it seems that interventions that target executive functioning, attention, and processing speed have good preliminary results Not clear how specific interventions need to be and how well these generalize to everyday life Equivocal findings regarding affect on mood, QoL, fatigue, and subjective cognitive problems See Mitolo, M. et al. (2015).

32 Substitution, remediation, accommodation, assimilation, or reorganization as a means of closing a gap in a skill area, expectation, or demand This can be behavioral or strategic

33 Compensatory strategy includes someone who has difficulty planning activities creating a schedule the night beforehand. Substitution is an example of an internal strategy and usually involves using an intact cognitive ability to replace one that is impaired, such as using visual memory to aid failing verbal memory.

34 Examples of Compensatory Techniques Use of external memory aides Study participants reported improved mood with effective use Cognitive management strategies Use of flow charts Talking self through activities that are difficult Example of Substitution Technique Use of Visual Cues Emphasizing visual memory if verbal memory is reduced Langill & Parmenter, 2009; Messinis et al., 2010; Shevil & Finlayson, 2010

35 Grocery List: 1.Apples 2.Oranges 3.Flour 4.Sugar 5.Milk 6.Eggs 7.Butter 8.Cheese

36 Repetition: Reading the list or hearing the list many times makes it more likely that we can recall the information Use of Cues: relatedness between the list items (semantic) may help us to chunk it into smaller components Fruit, Dairy, and Bakery

37 Write down the grocery list Cross items off when placed in the cart

38 Timers for turning lights/appliances on and off Watch or cell phone alarms and reminders Voice messages or recordings Basket or designated places to put items

39 Take breaks If limited attention span is an issue, it might be difficult to follow long conversations or stay on an extended task. Step by step Limit doing more than one thing at a time. Multiple step instructions or procedures can lead to confusion. Allow for extra time Veterans with MS often take longer to process information

40 VA Puget Sound Healthcare System Neuropsychologists can help develop strategies focused on impairments identified on neuropsychological evaluation Speech Therapists Can offer technological assistive devices such as ipads Occupational Therapists Develop individualized compensatory techniques If the Veteran is a student, working with their school s Office of Disability Resources If the Veteran is employed, working with their place of employment about reasonable accommodations National MS Society

41 Cognitive impairment affects approximately 50% of patients with MS Areas affected: information processing, memory, executive functioning Cognitive impairment associated with functional impairment Can be difficult to detect in routine clinical care: neuropsychological testing is gold standard Cognitive rehabilitation and compensatory techniques might be helpful

42 Thank you!

43 Archibald, C.J. & Fisk, J.D. (2000). Information processing efficiency in patients with multiple sclerosis. Journal of Clinical and Experimental Neuropsychology, 22, Anderson, C.R. & Parmenter, B.A. (2010). Processing Speed and Working Memory in Multiple Sclerosis (MS): Comparison of the Relative and Independent Consequence Models. Archives of Clinical Neuropsychology, 25(6), 537. Baddeley, A.D. (1992). Working memory. Science, 255, Baddeley, A. (2003). Working memory: looking back and looking forward. Nature Reviews Neuroscience, 4, Baddeley, A.D. & Hitch, G.J. (1974). Working memory. In G. Bower (Ed.). The Psychology of Learning and Motivation (pp ). San Diego, CA: Academic Press. Beatty, W.W. & Goodkin, D.E. (1990). Screening for cognitive impairment in multiple sclerosis: an evaluation of the Mini Mental State Examination. Archives of Neurology,47, Benedict, R.H.B. (2005). Integrating cognitive function screening and assessment into the routine care of multiple sclerosis patients. CNS Spectrum, 10, Benedict, R.H.B., et al. (2002) Minimal neuropsychological assessment of MS patients: a consensus approach. Clinical Neuropsychologist, 16, Benedict, R.H.B., et al., (2004). Reliable screening for neuropsychological impairment in multiple sclerosis. Multiple Sclerosis, 10, Benedict, R.H.B., et al. (2006). Neocortical atrophy, third ventricular width, and cognitive dysfunction in multiple sclerosis. Archives of Neurology, 63, Blair, M. et., (2016). The mediating role of processing speed in the relationship between depressive symptoms and cognitive function in multiple sclerosis. Journal of Clinical and Experimental Neuropsychology, 38(7), DOI: / Bruce, J., et al. (2012). Impact of armodafinil on cognition in multiple sclerosis: a randomized, double blind crossover pilot study. Cognitive Behavioral Neurology, 25(3), Chiaravalloti, N.D., Christodoulou, C., Demaree, H.A., & DeLuca, J. (2003). Differentiating simple versus complex processing speed: influence on new learning and memory performance. Journal of Clinical and Experimental Neuropsychology, 25,

44 Chiaravalloti, N.D., Genova, H.M., & Deluca, J. (2015). Cognitive rehabilitation in multiple sclerosis: the role of plasticity. Frontiers in Neurology, 6(67), Cook, S.D. (Ed.) (2006). Handbook of Multiple Sclerosis (4 th edition). New York: Taylor & Francis. Feinstein, A. (2007). The Clinical Neuropsychiatry of Multiple Sclerosis. Cambridge, UK: Cambridge University Press. Filippi, M., et al. (2012). Multiple sclerosis: effects of cognitive rehabilitation on structural and functional MR imaging measures an exploratory study. Radiology, 262(3), Genova, H.M. et al. (2012). Processing speed versus WM: contributions to an IP task in MS. Appl NP Adult; 19(2), Hughes, A.J. et al. (2015). Cognitive impairment and community integration outcomes in individuals living with multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 96, Kail, R. & Salthouse, T.A. (1994). Processing speed as a mental capacity. Acta Psychologica, 86(2 3), Krupp, L.B. (2004). Fatigue in multiple sclerosis: a guide to diagnosis and management. New York: Demos. Krupp, L.B. & Elkins, L.E. (2000). Fatigue and declines in cognitive functioning in multiple sclerosis. Neurology, 55, Langill, M. A., & Parmenter, B. A. (2009). Remediation Efficacy of the Memory Notebook for Patients with Memory Dysfunction in Multiple Sclerosis. Journal of the International Neuropsychological Society, 15(S1), 58. Lo, C.P., et al. (2009). Prediction of conversion from clinically isolated syndrome to clinically definite multiple sclerosis according to baseline MRI findings: comparison of revised McDonald criteria and Swanton modified criteria. Journal of Neurology, Neurosurgery, & Psychiatry, 80, McDonald et al., (2001). Recommended diagnostic criteria for multiple sclerosis: guidelines from the international panel on the diagnosis of multiple sclerosis. Annals of Neurology, 50, Messinis, L., Kosmidis, M.H., Lyros, E., & Papathanasopoulos, P. (2010). Assessment and rehabilitation of cognitive impairment in multiple sclerosis. International Review of Psychiatry, 22(1), Mitolo, M. et al. (2015). Cognitive rehabilitation in multiple sclerosis: a systematic review. Journal of the Neurological Sciences, 354, 1 9. Parmenter, B.A., Denney, D.R., & Lynch, S.G. (2003). The cognitive performance of patients with multiple sclerosis during periods of high and low fatigue. Multiple Sclerosis, 9(2), Parmenter, B.A., Weinstock Guttman, B., Garg, N, Munschauer, F, & Benedict, R.H.B. (2007). Using the Symbol Digit Modalities Test (SDMT) as a Screening Measure of Cognitive Impairment in Multiple Sclerosis. Multiple Sclerosis, 13(1), Pryse Phillips, W. & Sloka, S. (2006). Etiopathogenesis and epidemiology: clues to etiology. In S.D. Cook (Ed.) Handbook of Multiple Sclerosis (4 th edition). (pp. 1 37). New York: Taylor & Francis. Shevil, E. & Finlayson, M. (2010). Pilot study of a cognitive intervention program for persons with multiple sclerosis. Health Education Research, 25 (1), Swanton, J.K., (2006). Modification of MRI criteria for multiple sclerosis is patients with clinically isolated syndromes. Journal of Neurology, Neurosurgery, & Psychiatry, 77,

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