Symtom Awareness

Cognitive Impairment
Individuals with MS may experience changes in cognitive function as a result of lesions in the brain (areas of inflammation in early disease) as well as brain atrophy (shrinking due to nerve cell death in more advanced disease). Similar to fatigue, pain, and numbness, cognitive impairment is an invisible symptom that can sometimes be questioned by others. Recognizing the signs of cognitive changes and finding out about treatment options, along with talking to someone who understands, is important for maintaining a high quality of life.

Cognitive difficulties may be present in as many as 65 percent of those with MS, but only about 20 percent exhibit outward symptoms. Some people may only experience cognitive symptoms, which are unrelated to one’s degree of physical impairment. A physician may also diagnose MS from isolated cognitive symptoms plus MRI or other tests.

Cognitive problems may include difficulty with attention, problem solving, multi-tasking, memory, reasoning, and use of language. Initial symptoms are usually mild, and an individual may simply be more forgetful and require more time for problem solving. Similar to other MS symptoms, cognitive problems may worsen and improve according to other factors, such as heat, stress, exacerbation, infection, and fatigue.

Until a few years ago, little research was available on cognitive impairment and MS. Recent studies are now addressing this issue and the findings are helpful in the design of treatment interventions.

For instance, research has shown that an individual’s own perception of his or her problems with memory (“metamemory”) is fairly accurate – more so than a battery of brief screenings with a physician – and therefore short tests to evaluate cognitive function are not recommended. Cognitive fatigue has been proven to be an issue with MS, which further supports the idea that brief screenings are not an accurate measure of cognitive impairment in MS. One study found that individuals with MS and matched controls (study participants without MS) had similar baseline (beginning) scores for visual memory, verbal memory, and verbal fluency. After four hours of testing, those with MS performed far worse in these same areas, while the controls’ performance improved over time.

Researchers have found, with the aid of functional MRI scanning, that individuals with early MS who are experiencing cognitive difficulties use a different “activation pattern” than healthy controls when successfully performing a sustained attention task. In other words, a different section of the brain was used by the participants with MS versus that used by healthy controls to accomplish the same task. This is thought to be a compensatory mechanism, where nerves alter their function (neuronal plasticity) to enable unaffected areas of the brain to take over for areas not functioning to their fullest extent.

Additionally, long-term memory may be affected by MS. When memories are stored in the brain, they are encoded with “cue-target” associations, so that certain words or thoughts may retrieve the stored information when needed. With MS, binding contextual information and generating new cue-target associations becomes more difficult, so retrieving long-term memory may be impaired. These memories, however, may still be recalled through pre-existing cue-target associations.

Cognitive function may reduce one’s quality of life in relation to employment, social activities, sexuality, and emotional stability. According to a booklet entitled Clear Thoughts on Cognitive Problems in Multiple Sclerosis, published by the International Organization of MS Nurses, common cognitive problems may include:

This booklet also gives tips for individuals with MS who are experiencing cognitive problems. Among others, these include: keeping the mind stimulated; getting emotional support; using organizational aids; using a kitchen timer or wristwatch alarm; concentrating on one task at a time; avoiding hot temperatures; and resting when tired, fatigued, or hot.

Advice is also given in this booklet for the care partner and families of those with cognitive problems. Ideally, the individual with cognitive problems should be accompanied when going to a doctor’s appointment, reminding him or her to bring along medications; a care partner may help organize and administer medications; recognition and praise should be offered for any accomplishments; independent activity should be encouraged, without overwhelming; and unrealistic expectations must be avoided while planning attainable goals. Care partners and families of those with cognitive problems need to be understanding and seek out support groups and counseling resources.

If possible, the first step toward avoiding or minimizing cognitive deficits is to begin treatment early with one of the approved long-term treatments for MS (these include Avonex®, Betaseron®, Copaxone®, Rebif®, and Novantrone®). This will help to minimize inflammation and eventual nerve damage. Interferon therapy has been shown to lessen cognitive dysfunction. Drugs specifically aimed at maintaining or improving cognitive function are presently under investigation for individuals with MS.

Individuals may also take advantage of cognitive retraining programs, rehabilitation programs, and computer programs with memory exercises. These programs may be offered by local medical centers, neuro-psychologists, speech pathologists, and occupational therapists. Medications, programs, and helpful tips (such as those listed previously) can greatly assist someone who is experiencing cognitive changes, enabling them to better cope and to improve their daily quality of life.

To order a copy of the Clear Thoughts booklet, please contact the International Organization of MS Nurses via phone at (201) 837-9241 or via email at info@IOMSN.org. A list of other references used for this article is available upon request through MSAA’s Helpline. For references or for more information regarding cognitive symptoms, please call MSAA’s Helpline at (800) 532-7667.