Cognitive Decline Presentation in Patients With Multiple Sclerosis

EP: 1.Overview of Multiple Sclerosis

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EP: 2.Cognitive Decline Presentation in Patients With Multiple Sclerosis

EP: 3.Cognitive Dysfunction Clinical Assessments for Multiple Sclerosis

EP: 4.Initiating Conversations Around Cognitive Health for Patients With MS

EP: 5.The Role of Imaging in the Assessment of Brain Health and Cognition

EP: 6.Brain Health Assessment Challenges in MS

EP: 7.Overview of Brain Atrophy Data and Cognition Research in MS

EP: 8.The Role of S1P Modulators in Multiple Sclerosis Management

EP: 9.Efficacy and Safety of S1P Receptor Modulators in Multiple Sclerosis

EP: 10.Impact of S1P Modulators on Brain Volume Measures in Multiple Sclerosis

EP: 11.Safety Considerations and Monitoring for S1P Modulators in MS

EP: 12.Using Neurofilaments as a Biomarker in MS

EP: 13.Treatment Sequencing in Patients With Multiple Sclerosis

EP: 14.Emerging Therapies and Future Directions in MS

EP: 15.Practice Pearls for the Management of Multiple Sclerosis

Stephen Krieger, MD: Do you also feel that cognitive dysfunction is a function of time and duration of illness, or is this something that you really think is there in a substantial portion of patients very early in the disease?

Heidi Crayton, MD: It's so individual. We all see those individual outliers. The data tells us that we see more cognitive dysfunction and more atrophy of central nervous system tissue over time. But we've all seen those people that are quote-unquote "newly diagnosed." They had an eloquently-placed area of inflammation that brought them to medical attention. And you look at their MRIs [magnetic resonance imaging scans] and you feel gut punched because it's a younger person whose brain looks not young at all. And they've sometimes slipped through the cracks because they had invisible MS [multiple sclerosis]—because they could walk just fine. Those are the people that are really more concerning and more worrisome, because by the time they come to medical attention, we're usually behind the 8 ball.

Stephen Krieger, MD: I've sometimes told patients that MS is an accelerated aging process of the brain—and you said it—the loss of brain parenchyma. But there are probably differences in the way MS progression affects the brain more broadly that's different from just aging. Dr Nicholas, in your practice, how do you try to tease those things out? Someone who says, Well, is it just my age, or is it the MS talking?

Jacqueline Nicholas, MD: That's always, I think, a major challenge in the MS clinic. And people ask that every day, and I think that it's not uncommon that I hear somebody come in there in their forties and fifties and tell me that they're having challenges remembering what they went in the other room for or remembering what they ate for breakfast. All jokes aside, I'm like, Well, I'm your neurologist, and I don't remember that sometimes. But I think people really are having those challenges, and we talk about the fact that overall brain health is incredibly important in MS because we know that the normal aging process does have an impact on cognition, but that with MS we're seeing it to a much greater degree. And thus, I think oftentimes when we're trying to sort that out, doing certain psychological testing to really see what is the pattern of cognitive impairment can really be helpful.

Stephen Krieger, MD: We'll get into some of the nuances of different types of cognitive impairment, I think, in a moment. But I would say even before we do that, how do we define impairment? That's kind of implicit here: the patient who says, “I forgot what I had for breakfast this morning,” and then we think, “What did I have for breakfast this morning?” And that's probably not true impairment. Dr Nelson, for you, where do you start to draw the line either officially or just intuitively with a patient—to say, I think this person is cognitively impaired?

Flavia Nelson, MD: That's a very good question. I usually ask them when they're newly-diagnosed, “Are you having any problems with your memory, like difficulty finding words or difficulty concentrating, difficulty paying attention, finishing tasks, or multitasking?” And if they say yes to any of that, then I dig a little deeper. But I think it's interesting that sometimes they're not aware of it. The family member may say, “Yes, you do,” and the patient says, “No, I don't.” And thus, that's when there's a red flag, because MS-related cognitive impairment can be so subtle that the patient may not be aware of it. Or they'll come and tell me “Well, I had a bad review at work.” And I said, “What did your boss say?” “Well, I'm not doing this or I'm not doing that.” Then, we really start that conversation. “Well, you know, MS can actually affect your ability to process information, which is very different than Alzheimer's,” et cetera.

Stephen Krieger, MD: Absolutely. I like that you mentioned the performance review at work. That's actually one of my cognitive screening questions. I'll say, “Did you get your performance review this year? How did it go?” Because almost everyone has a performance review of some sort. We certainly do. And that's when if a person endorses that they didn't do well in their performance review or their boss or their manager has some concern or problem with their work, that often opens the door to me to say “Well, how can we look at this in a little bit more detail and characterize it?”

Flavia Nelson, MD: And a lot of times they think it's stress or they think it's fatigue. You really need to tease it out and clarify it so then you can actually try to help them.

Transcript Edited for Clarity