Solving Cognitive Problems 3 of 4

III. Consider professional evaluation

A professional evaluation may be called for if you or those closest to you notice a change for the worse in cognitive functions. For example, do you have increased trouble remembering things? Is it becoming harder to stay focused on a task?  Do you experience lapses of judgment, trouble coming up with words in conversation, slowed thinking, or difficulty organizing projects or daily activities?

An evaluation is particularly in order if any of these changes get in the way of your work or social life, or create distress for you.

Evaluation may also be of value if you are considering a career change or planning to enter school or a training program.  Many people are interested in getting an evaluation because they are starting on one of the new disease-modifying drugs and want to be able to track cognitive changes over time.

In one of Dr. Rao’s studies, 40 to 50% of people with MS believed their intellectual functions had been affected by the disease. Professional evaluation showed this statistic to be correct.  But the people who were actually affected by cognitive problems were not always the ones who had diagnosed themselves.  Some of them were instead suffering from depression.  Others who were severely impaired were unaware that any changes had taken place.

Depression can be treated with drugs and/or psychotherapy.  Severe fatigue can be alleviated.  And intellectual changes can also be treated through cognitive rehabilitation.  But the choice of appropriate treatment depends on the right diagnosis!

A formal neuropsychological evaluation may require several hours.  The decision to go ahead should be made after discussions with your physician, family, and any other professionals who might be involved in your care.  Other causes for intellectual problems should be carefully ruled out, and preliminary, less expensive testing considered initially.  Do not assume that your insurance plan covers neuropsychological evaluation, even if your physician prescribes it.  You should check with your insurance carrier so you can make a fully informed decision.

Assessment of intellectual function should be done by a qualified neuropsychologist, a specialist in the behavioural changes caused by brain disease or trauma, preferably one who has had experience with people who have MS.  A psychologist without this training may have difficulty selecting the proper tests and interpreting the results.

A psychiatrist or neurologist can perform briefer evaluations, but these generally pick up only the more severe forms of cognitive dysfunction. (Janis M. Peyser, PhD, of the University of Vermont completed a study in which she found that almost half of the patients whom neurologists considered to be without intellectual problems were found to have problems when tested by a neuropsychologist.)

IV. About cognitive rehabilitation

Today, it is routine to consider some form of cognitive rehabilitation after a head injury or stroke. I n the last few years, the use of cognitive rehabilitation in MS has increased dramatically as techniques have been developed for the more common problems.

Cognitive rehab is designed to help people compensate for loss of memory or slowed learning ability.  It is provided by neuropsychologists, occupational therapists, or speech/language pathologists.

Ordinarily, cognitive rehab involves one or more sessions per week over several weeks or months.  Each session typically lasts about an hour.  These sessions will include a variety of activities depending on individual needs.  They might include doing exercises designed to enhance memory, concentration, or spatial skills.  A good deal of time may be devoted to “compensatory strategies” such as learning how to be more organized, how to use a computer effectively, how to manage time, or process paperwork.

The goals of treatment are individualized, and progress toward those goals may be checked periodically.  In many instances, the cognitive rehab program may include meetings with family members to help them understand the nature of specific problems and how they can help. Stress management, counselling, or psychotherapy may round out the treatment plan if these seem to be warranted.

• Compensatory strategies. A systematic program of cognitive rehabilitation will train the person with MS in the consistent use of techniques that compensate for lapses. We all use some of these methods.  Common memory aids include writing things down in notebooks, posting notes on the refrigerator, or carrying a pocket calendar.

Many of us also use time management methods, filing systems, checklists for complex tasks, reading comprehension strategies, and special-purpose diaries.  We routinely employ mental tricks to make the most of our abilities.  The little poem “Thirty Days Hath September” is a compensatory strategy for remembering the length of the months.

Compensatory strategies, like their physical cousins, the cane and the walker, do not address the underlying problem.  They offer an alternative way to perform a task that has become difficult.  In other words, we may not be able to alter an underlying impairment (the weakened memory, for example) but we can still find ways to dramatically improve function.  Does it really matter whether we get the phone number we need out of our head or from a pocket data bank?

• Improving function.  It’s tempting to believe that the right exercise might strengthen memory.  Some functional improvement methods are based on popular theories concerning the “plasticity” of the brain: the ability of the brain to recover from damage, perhaps by shifting functions to undamaged areas.  With some exceptions, these appealing methods have not been as successful as originally hoped.

But some retraining exercises do help. A comprehensive program of cognitive rehabilitation is likely to use a mixture of retraining and compensatory strategies.  For example, supervised programs of graded practice can improve attention and concentration levels.  This sets the stage for more effective use of compensatory strategies in everyday situations.

• Medications. Research concerning the use of medications clearly needs to continue. At present, the pharmacy has little to offer.

A drug called Aricept is currently used to treat memory problems in Alzheimer’s disease.  There has been interest in the possible use of Aricept in MS.  A recent clinical trial in which 69 individuals with MS participated found that Aricept improved performance on memory tasks.  Larger clinical trials are needed to confirm these findings.

A few studies have also looked at the effects of three MS disease-modifying drugs on cognitive function.  One large clinical trial with Avonex showed modest benefits for a variety of cognitive functions.  Two studies employing Betaseron had mixed results.  A large clinical trial of Copaxone reported no benefits for cognitive function. Since the disease-modifying drugs reduce the number and severity of MS attacks, reduce signs of damage to brain tissue as seen on MRI, and delay the progression of disability, they may all, in the long term, have beneficial effects on cognitive function.