Drs Jeffrey Dunn and Regina Berkovich review available tools and resources for the care of patients with multiple sclerosis, focusing on specific symptoms.
Jeffrey Dunn, MD: Cognitive disturbance, cognitive slowing, difficulty with multitasking and mental status processing is one of the most disabling symptoms that patients with multiple sclerosis [MS] can have. It’s one of the most difficult to assess. It can sometimes feel as if it’s one of the most difficult to treat. What issues or educational resources are there out there that pertain to or address this difficult, challenging problem of cognitive dysfunction in patients with MS?
Regina Berkovich, MD, PhD: In my clinic, I can tell you again, I have to rely on my own experience. In my clinic I do the MoCA [Montreal Cognitive Assessment] on all of my patients, definitely on those with reports or observations of the cognitive symptoms. I tend to do it at least twice a year, sometimes more frequently if it’s necessary. We see evidence of those cognitive relapses, and improvement of cognition and worsening of cognition. We also monitor the volumetric studies as well, but those are a more specialty type of monitoring. The best advice in respect to cognition is to be on adequate disease-modifying therapy, that’s No. 1. Second is to be realistic and adequately treat the emotional conditions, such as depression, anxiety, pseudobulbar affect—which is majorly undertreated in my opinion, or underrecognized perhaps—and monitor with the tests, I favor MoCA. It happens to be very telling to me. Do those regular MRIs; don’t underestimate the importance of annual MRIs.
Also, understand the limitations that we have, even with the most efficacious therapies. We have to set some expectations on a more realistic basis, but we do the best we can. Think about it critically from the standpoint of, could I have done better if I started this patient earlier on more effective therapy, perhaps looking more into the scientific data on brain volume, on gray matter, on the cortical lesions? I know there is a lot of resistance in neurology toward the brain volumes because we don’t monitor for it. Yes, but you want to know what data are out there, because then you may do better for your patient if you implement the scientific data earlier in their disease, even though you may not be routinely monitoring volumes.
Jeffrey Dunn, MD: Two other domains that can have a major impact on quality of life for the patient with MS are fatigue and pain. Same question, are there resources out there that you know of that you would advise our colleagues to use that might be especially helpful?
Regina Berkovich, MD, PhD: I would say that the pain management specialist is always among my best friends because certain procedures have to come from that specialty management. Of course, educating patients on different resources for fatigue. My experience has been that if you are careful about treating patient depression, pseudobulbar affect, improving a patient’s motivation with more adequate disease-modifying therapy, you deal with less fatigue. Now of course, if the treatment armamentarium that some of our colleagues have includes only 1 or 2 medications, that would be much more difficult. But this is why I wish we were given the chance to participate in some of the patient consultations earlier.
Jeffrey Dunn, MD: What advice would you have for MS health care providers when communicating with diverse patient populations?
Regina Berkovich, MD, PhD: Be honest and positive. I hear so many times, my patients coming and telling me, “I’m feeling better. But I was told a long time ago by the neurologist who diagnosed me that MS therapies are not designed to make me feel better.” That’s not the right type of message we want to give. Yes, it’s true that improvement of MS symptoms or improvement in the disability was never a primary outcome of the clinical trials. But do we see some of the patients doing better? Yes, we do. So we shouldn’t give that type of message that we don’t expect to see improvement. That can bemisleading, negativistic, and will not really help anyone, and will not help build trust either.
Jeffrey Dunn, MD: Yes. Dr Berkovich, you are considered preeminent in your field. You’re widely recognized and respected throughout the country for your expertise in caring for patients with MS. You’ve given your professional life to the service of this mission. We are so grateful that you could come and share your wisdom with us on these questions. I do want to give you the chance to remind everybody that you’re not speaking policy, that these are your own opinions.
Regina Berkovich, MD, PhD: Yes. This entire conversation we had, the dialogue or my monologue, you may say, was an expression of my professional opinion.
Jeffrey Dunn, MD: But sage opinion based on ample experience and wise words. Thank you so much for sharing those with us and with our audience.
Regina Berkovich, MD, PhD: Thank you. It’s a great honor for me. Thank you.
Jeffrey Dunn, MD: Thank you so much. Thank you all for watching this NeurologyLive® Peers & Perspectives® program. If you enjoyed the content, please subscribe to our e-newsletter to receive upcoming Peers & Perspectives® and other great content with the convenience of it being right in your inbox.
Transcript Edited for Clarity