Neuros are Monkeys when it comes to assessing cognitive problems

Romero K, Shammi P, Feinstein A. Neurologists׳ accuracy in predicting cognitive impairment in multiple sclerosis. Mult Scler Relat Disord. 2015; 4:291-5.

Cognitive impairment affects approximately 40-70% of MS patients. As management of MS typically begins with, and is co-ordinated by neurologists, they are often the first to raise concerns about a patient׳s cognitive functioning. However, it is not known how accurate the neurological examination is in identifying cognitive impairment. To this end, we conducted a retrospective chart review of 97 MS patients referred by neurologists for neuropsychological assessment based on suspected cognitive impairment. Patients were classified as globally-impaired or intact according to failure on 2 or more of 11 cognitive indices comprising the MACFIMS, a recommended neuropsychological battery for MS. 

. Cognitively intact patients when compared to those who were impaired had higher levels of education and were less likely to have mood disturbances. These findings indicate the clinical interview and standard neurological examination are not sufficiently sensitive to detect cognitive impairment in MS, and suggest the need for a brief, accurate cognitive screen to complement routine clinical evaluation.

ProfG and NDG have not commented on this one, so they are clearly expecting some teasing about the ability of Neuros to spot cognitive problems. 

When you are a researcher you are told that MS is a just movement disorder and that it is a white matter disease. However, since attending “MS life” it has struck me how easy it was to spot cognitive/behavioural problems in some people with MS and made me think, how can MS just be considered to be a movement problem? Likewise a few minutes of looking properly and you can easily find grey matter problems, so how to neuros and pathologists get it so wrong. 
In this paper they look at who was sent for cognitive testing and neuros got it wrong about half the time. So maybe they need to listen rather than flip a coin to see who gets MACFIMS Minimal Assessment of Cognitive Function in MS. A 50:50% chance of getting it right or wrong is sometimes called a monkey score as this is what a monkey would get. 

Maybe it is time to have simple tests on computers or smart phones so we can remove the monkey from the neuro.

Would MS specialists get it wrong so many times?

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  • 'Cognitively intact patients when compared to those who were impaired had higher levels of education and were less likely to have mood disturbances. These findings indicate the clinical interview and standard neurological examination are not sufficiently sensitive to detect cognitive impairment in MS, '

    Ah yes, I'm very aware of this as I'm very well educated and was contemplating starting a doctorate before the cognitive deficits and mood problems struck. The problem is I'm relatively articulate so no one (neurologists included) understands and even worse I'm told I'm still well above average so don't worry. But I do, my brain is very important to me and it is painful to observe its decline.

    From my own monitoring, I see that cognitive problems in MS are quite different from other types. Plus fatigue and anxiety has to be factored in, both certainly affect how well my brain performs on any given day. Yesterday I put imac on my toothbrush, lost my phone and forgot my cashpoint number, the day before I was helping a friend's son understand and calculate PI. Tis complicated!

    • Before MD2 chips in here, yes I can be a bit forgetful sometimes "Now you see it now you don't". Hunting for the passport in airports is often a bit or fun or light trauma dependning on how close to passport control before we find it.

    • It's not about your education, it's about how you organise your life and brain. Why would you keep Immac near your toothpaste?

    • I wish it was just forgetfulness due to age or I'd always been a bit forgetful (no offence MD) but up until last year I had a near eidetic memory. So I'm very aware of the loss.

      The irony is I was looking at a doctorate in cognitive anthropology (sadly I can't have a field of just me:)), this isn't the same, by any means, as clinical psychology but does mean, I'm relatively aware of where the holes are with cognitive assessments for MS.

    • 'Why would you keep Immac near your toothpaste?'

      Err, both in my bathroom cabinet above my sink! I should move my toothpaste to my fridge, perhaps 🙂

      And it is more than education, my comment was in relation to what this report found (I'm quite well organised, thank you very much).

    • I didn't mean to rude. I would do the same, if the immac was near the toothpaste. I've heard of people spraying hairspray under their arms instead of deodorant and they haven't got MS.. The research always mentions educational achievement, but I think a lot of tests are flawed. Apologies for any offence caused.

  • I'm 65 and have had MS for 12 years. I don't consider myself cognitively impaired generally but while I was in a wash-out period as I changed drugs I certainly noticed changes. I had difficulty finishing some sentences and at times was anxious about whether I should open my mouth, plus I frequently forgot words. It's fine now. I do compare myself with non-MS friends of my age, though – it's reassuring to see that they too forget things -the classic one seems to be going upstairs to get something then forgetting why you went.

  • I did ask the lady in the shop for a certain shade of "Dulex" paint the other day. But I'm putting that down as a classic Freudian slip.

    • Hahaha, thank you, I thought that myself when I noticed what I was doing. To poster 1.39pm, no, you are not rude and I understand what you are saying, but it is more the totality of events that is beyond 'one off' absent mindedness. Unfortunately I have mild cognitive deficits, far from the worst and most people would never notice but I do. My point about education was to illustrate how flawed the tests can be for MS. Clinical psychologists who know about MS do a lot more tests than listed in this study.

  • Do the neuros take the menopause into account? My surgical menopause meant cognitive impairment overnight. Nothing to do with my MS, I'm more or less back to normal now.

  • In reply to MD, it's not an easy thing to pick up. Diagnostic accuracy by experts of pre-senile dementia – in most cases AD, is poor with about a third being thrown out at post-mortem (this gives you an idea of the complexity of dementia). To improve diagnosis you need to look back by several years – which is the primary reason why all neurology clinics have an annual follow up. Almost certainly the individual experiencing it is more accurate in these things than a clinician, finding out a cause, however, is another matter.

  • Some off us know the results we got on IQ tests from before we got MS. Could this be used to measure cognitive decline?

  • I have a PhD. In fact, I am doing research in Neuroscience (fundamental work on AD (fucking irony) not clinical). I was diagnosed last December but my first symptoms might have started two/three years ago (during my PhD that I obtained cum laude). I have had mood swings and I am an absent minded person. Now will my cognitive abilities decline? I hope not more than the average folk. Honestly I care little to no be able to walk or pee correctly. I am, however, horribly scared of not being able to think properly. Being a researcher I had the chance (sic) to access old publications about cognitive decline and MS written by psychologists. Scientists like any human being are capable of writing stupid things and I reassure myself thinking that at the time of these papers publication psychologists were thinking that being gay was a psychological serious disease.

    BTW: IQ is a very vague and non-objective evaluation of someone cognitive abilities but no hard feelings I am very happy to have found your compelling blog MD.

    • Don't be scared, it's a waste of energy. I've had MS for four decades and my non MS friends call me for things they've forgotten. I believe my job helped that involved a lot of use of my memory. However, I write lists and don't fret too much if I forget something. I put it down to natural ageing. Don't think IQ comes into it you will always be clever, just brainy with MS. Psychologist papers? Enough said.

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