How to incorporate cognitive screening into routine MS patient visits
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The way Frederick W. Foley, PhD, sees it, screening for cognitive problems in patients with multiple sclerosis has been taking a back seat to other routine clinical assessments largely because the deficits aren’t obvious in a typical clinical examination.
Neurologists face pressure to squeeze all they can into a short office visit to address MS symptoms that can range from spasticity and neurogenic bladder to depression and fatigue, said Dr. Foley, director of clinical psychology at the Holy Name Medical Center Multiple Sclerosis Center in Teaneck, N.J. “They have to decide: Do I have to change the disease-modifying therapy for this patient? Do I have to order an MRI? Is the patient stable or is their MS advancing? Are they in an exacerbation? Do I have to treat their spasticity? Do I have to treat their fatigue? Do I have to treat their pain syndrome? Do I need to give them a medicine to improve their walking speed?”
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“Cognitive problems in MS are not like the problems in Alzheimer’s, where language gets dramatically affected,” said Dr. Foley, who is also professor of psychology at Yeshiva University in New York. “In MS, language functioning most of the time stays OK … The deficits are more subtle and are largely related to declines in the speed of information processing.”
Cognitive impairment can be seen irrespective of the duration of MS and is only mildly associated with physical disability. “Progressive MS generally results in more severe cognitive impairment than does relapsing-remitting MS; however, in these data the course of the disease was confounded with duration of disease,” John DeLuca, PhD, and his colleagues wrote in a review article (Lancet Neurol 2008;7:1139-51).
Further, these subtle cognitive deficits can progress and take their toll, he said. “Numerous studies have shown that cognitive status in MS is strongly related to employment status.” Job loss as a result of cognitive decline can have a major impact on patients’ financial situations.
In an effort to spotlight the importance of cognitive screening in MS care, a multidisciplinary group of clinicians, researchers and people with MS chosen by the National Multiple Sclerosis Society’s National Medical Advisory Committee developed recommendations for cognitive screening and management as a way to “promote understanding of cognitive impairment in MS, recommend optimal screening, monitoring, and treatment strategies, and address barriers to optimal management.” Published last year in Multiple Sclerosis Journal, the recommendations state that the estimated prevalence of cognitive changes in MS ranges from 34-65% in adults and is 33% in patients under 18 years of age, and that the hallmark cognitive deficit is a reduction in information processing speed (Mult Scler. 2018 Nov; 24:1665-80). At a minimum, baseline cognitive screening should be conducted with the Symbol Digit Modalities Test (SDMT) or another validated screening measure.
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Rosalind Kalb, PhD, a psychologist and lead author of the recommendations, views the effort as one way to make MS care more comprehensive. “I’m hoping that, by bringing this to the forefront, care providers will rethink their definitions of ‘benign MS’ or ‘no evidence of disease activity,’ for example, where in the past they have not generally considered cognitive progression,” said Dr. Kalb, who is the former vice president of professional information and resources at the National Multiple Sclerosis Society. “When ‘no evidence of disease activity,’ was first defined, it didn’t include cognitive change. That’s been proposed as an added element.”
At the same time, none of the recommendations “are cost free in terms of time and in terms of dollars,” Dr. Kalb acknowledged. “For the busy neurologist, the obvious objection is, ‘I don’t have time to do this.’ The answer is, ‘We can’t afford to consider cognitive screening to be a choice any more than one would consider it a choice to evaluate how a person walks, or how their bladder is functioning, or the results of their MRI.’ Cognitive deficits are such a prevalent problem in people with MS that screening has to be done.”
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With some creativity, screening can be built into the clinic setting, she said. “I think it’s more about the culture shift in care. If it seems important, people find creative ways.”
In some clinics, cognitive screening is being done routinely at every visit. In Dr. Foley’s clinic, nurses and PhD students in clinical psychology administer the SDMT in the exam room during most office visits. “Nurses go in to talk to the patient before the neurologist does anyway, so it’s relative easy for them to administer this test in two or three minutes,” Dr. Foley said. “Another thing we screen patients for is depression, because many times when patients are depressed, either they’re unaware of it or they don’t complain about it. The Beck Depression Inventory-Fast Screen is commonly used; it’s only a few items. We use the Hospital Anxiety and Depression Scale for the adults who come into our clinic. You can use either one. Both have been validated in MS.”
Screening for cognitive changes and depression “will alert you to problems before they ruin the patient’s life through job loss or economic change,” said Dr. Foley, who was president of the Consortium of Multiple Sclerosis Centers for 2002. “When cognitive impairments occur, many times there are personality changes and the family is wondering, ‘What’s going on with this person? Why are they being mean? Why are they acting this way?’ Cognitive impairment causes a lot of family problems if it’s not recognized and treated.”
In 2015, Dr. Foley and his colleagues received a grant from the not-for-profit group Women United in Philanthropy to see if it was possible to prevent unemployment in women with MS by screening them for three common symptoms that cause unemployment: cognitive problems, fatigue, and depression, “because those three things interact with each other,” he explained. “Screening can lead to treatment, which can lead to prevention of job loss and prevention of many life problems that come with cognitive problems.”
If the SDMT results reviewed during an office visit indicate a deficit in cognition, Dr. Foley informs patients that their score on this test was below a threshold and that further evaluation is required to determine if they actually have cognitive changes. “I tell them there are treatments that can help them to improve their cognitive functioning,” he said. “We want to let them know that even if they do have deficits, there is something we can do about it.”
Dr. Foley predicted increased use of such paperless technology in the future of MS care. He also predicted that telemedicine will play an increasing role in helping to improve access to care, especially for those who live in rural areas or hours away from a comprehensive MS care center. “Licensing laws are now in the process of being changed in many states around the country to allow for telehealth services, including evaluations,” Dr. Foley said. “The VA [Veterans Affairs] health system does it. [Telehealth services are] going to be the wave of the future in medicine.”
As a follow-up to their recommendations on cognitive screening, Dr. Kalb and her colleagues have formed teams of experts who are working on solutions to screening barriers. One such strategy included in the recommendations is to enhance education “via the development and dissemination of ‘toolkits’ for everyone affected by MS (patients, family members, and health care providers) about the impact of MS on cognition and available screening and treatment options.”
“I want people talking about these recommendations so people can incorporate them into MS care and use this opportunity to make comprehensive care a reality, rather than just a phrase,” Dr. Kalb said.
Dr. Foley reported having no financial disclosures. Dr. Kalb is consultant for the National Multiple Sclerosis Society as well as for Can Do Multiple Sclerosis.