Cognitive Health and Sphinogine-1-Phospate Receptor Modulators in Multiple Sclerosis - Episode 3
Heidi Crayton, MD; Jacqueline Nicholas, MD; and Flavia Nelson, MD, share their practices and diagnostic assessments for cognitive decline in their patients with multiple sclerosis.
Stephen Krieger, MD: That's a perfect segue. Dr Nicholas, you mentioned neuropsychology testing. Talk a little bit about what you do in your practice. I'll ask each of you this. What do you do in your practice to pursue and characterize cognitive dysfunction?
Jacqueline Nicholas, MD: We do a couple of things. I think of the regular assessments when patients are coming into clinic, we do a Symbol Digit Modalities Test, which I think is just a really rough screening cognitive test that we can assess for changes over time. But I often find that those conversations that we're having together, and really, as both of you have mentioned, asking about their daily function and particularly employment being key. One of the things that we've been doing more and more over time is as a newly-diagnosed patient comes in, is to try to get a baseline neuropsychological evaluation. And then that serves as a benchmark, so that down the road, if problems do arise, we can actually go back for a repeat evaluation to see if there have been changes.
Stephen Krieger, MD: That's great.
Jacqueline Nicholas, MD: —and to potentially provide some recommendations on how we can best maintain how they're doing now.
Stephen Krieger, MD: Getting a sense of that baseline is really crucial because obviously not everyone is coming from the same baseline. Dr Crayton, you heard Symbol Digit Modalities Test and neuropsychology testing. Are these the things you're using? Do you use some other way of assessing cognitive function?
Heidi Crayton, MD: I actually don't use those outside of a clinical research environment. I'm really fortunate that I have a wonderful neuropsychology group that I can refer to, and I utilize them quite a bit. I think it is important to have a nice baseline. Baseline imaging, baseline neuropsychology testing is great. I spend a lot of time just—I always say “coffee chat”—just chatting with the patient, because that really tells you a lot. And I feel the people that are very anxious about not remembering where their keys are, what they went in that other room for—those people, I tell them, “I'm not as concerned about you. I'm more concerned with people that lack insight and judgment.” And oftentimes we pick that up. They have absolutely no idea. Or it's a caregiver that is nodding behind the scenes; those are the people to be more concerned about. But that's a very nice, simple, easy way to know that we're already a little bit behind the 8 ball, and we really need to aggressively jump on their brain preservation.
Stephen Krieger, MD: No, I think you're quite right. Something like the Symbol Digit Modalities Test is a test of processing speed. It's a good screening test, but how someone's cognitive function is actually behaving in their lives I think ends up being often more meaningful. Both of you made allusions to the fact that sometimes people don't realize the extent of their cognitive troubles. And it's interesting. We've long talked about cognitive function in MS [multiple sclerosis] as being a problem with processing speed. But nobody ever comes in and says, “My processing speed is slower.”
Heidi Crayton, MD: They can't multitask.
Stephen Krieger, MD: Right. They can't multitask. And this is a point that my neuropsychology colleague Jim Sumowski, PhD, professor of neurology at Mount Sinai in New York, New York, has pointed out, and some of his work is looking at what the real phenomena are in cognitive dysfunction. Word finding has come up in our conversation, and that he has borne that out in some of his work looking at cognitive dysfunction. You mentioned word finding also. Are there specific things that you do now to assess cognitive dysfunction that you didn't do 5 years ago?
Flavia Nelson, MD: Yes. Actually, in an ideal world, every patient will have a baseline neuropsychological evaluation. But those are expensive. They're not always covered by insurance, and not everyone has a neuropsychologist available, right?
Stephen Krieger, MD: Sure.
Flavia Nelson, MD: Also, in an ideal world, a neurologist or an MS specialist will have time to do the Single Digit Modalities Test [SDMT], which doesn't take very long, and it measures information processing speed which is the main domain affected by MS. But there's not always time for that, especially in a busy private practice, which is where most of our patients are being seen. What I did, I think, is something that was very helpful in my practice, and that is assess patients over a period of an hour, but in a separate visit. And the nurse practitioner was the one administrating the SDMT, the CVLT-II [California Verbal Learning Test-II] which is for verbal memory, and the BVMT-R [Brief Visuospatial Memory Test-R] which is for visuospatial issues. And that's actually the official screening. The BICAMS [Brief International Cognitive Assessment for Multiple Sclerosis] is the official screening recommended if you have time to do it, which takes actually more time than they say, but it is a very good screening for all 3 problems. You do those, and then you do your other assessments in terms of disability, like EDSS [Expanded Disability Status Scale], Timed 25-Foot Walk, and the Six-Minute Walk Test. All of these things that you don't really have time to do when you're seeing the patient for their six-month visit or their annual visit. We do these once a year in a separate visit. It lasts about an hour, and then we enter all that data in a database and try to have not necessarily a baseline for everyone, but because we just started that program in 2019 and then put it on hold during the pandemic as you can imagine. But it's a very good way of following patients longitudinally over time and see if they're stable based on metrics, rather than just a conversation which can vary significantly on a visit-by-visit basis. I thought that was very useful, and I'm thinking about reproducing that in Miami because I started that in Minnesota.
Stephen Krieger, MD: That's wonderful. What I love about this quick conversation about it is you've heard comprehensive, thorough neuropsychology testing. You've heard Symbol Digit Modalities Test quick-testing, and then coffee chat, the more sort of real lived experience of cognitive dysfunction. And there's no 1 way to do it. And thus, I like this. And I think all of these techniques are ways of pulling out different ways that cognitive dysfunction can affect somebody with MS, be that the classical slow processing speed, the failures of multitasking and executive function, the word-finding problems which I think are probably more prevalent than we used to realize, and other ways.And as I struggle with my words.
Transcript Edited for Clarity