Barts-MS rose-tinted-odometer: ★★
Last Wednesday I chaired a debate about the following case scenario, who many of you may identify as being very close to home. Professor Dawn Langdon, a neuropsychologist, made the case for testing cognition against Professor Nikos Evangelou, a neurologist, who said no we should not assess this patient’s cognition.
What would you want if this patient was you?
A 48-year commercial solicitor with early secondary progressive MS is having increasing problems coping at work due to cognitive issues. He is worried that he may have to stop working. He has had MS for 16 years and was originally treated with interferon-beta and was subsequently switched to DMF 5 years ago because of local tolerance issues around injection site reactions and severe lipoatrophy. Although his last MS relapse was more than 10 years ago, his neurological functioning has deteriorated over the last three to four years with reduced mobility, bladder and bowel problems and sexual dysfunction. He has also been depressed. He is currently on oxybutynin, sildenafil and citalopram in addition to DMF. His most recent MRI showed three new T2 lesions and increased brain volume loss compared to his last MRI done 18 months ago.
Would it help in the management of this patient if you knew he was cognitively impaired; i.e. would you refer this patient for a formal neuropsychological assessment?
Although Professor Evangelou won the debate, i.e. he swung the vote from 13% to 28% in his favour, the majority of attendees wanted this patient to have a formal cognitive assessment. Do you agree?
The cognitive assessment should simply be an extension of the neurological examination, i.e. another functional system. In other words just as we like to know if our patients have weakness in a limb we need to know if they have cognitive impairment in one of their cognitive domains. This can help in so many ways.
- Prognostically, poor cognition predicts a poorer outcome. Knowing someone has a poor prognosis may nudge both the neurologist and/or patient to a higher efficacy therapy, i.e. to flip the pyramid.
- Assessing disease activity, i.e. worsening disability or cognitive relapse. This could trigger a treatment switch, for example in the patient above Prof. Evangelou suggested switching this patient onto siponimod.
- Helping in diagnosis, i.e. dissemination in space. Cognition is another anatomical space and it may provide the neurologist with additional information.
- Diagnosing MS in patients with RIS (radiologically isolated syndrome); cognitive impairment demonstrates they have involvement of at least one functional system and if the MRI shows dissemination in time diagnosis could change from RIS to MS and the patient could be then started on treatment.
- Risk assessment; patients with cognitive impairment are at higher risk of having accidents, in particular, motor vehicle accidents, poor adherence to medication, missing medical and other appointments and not being able to cope with their own self-care. It is well known that MS patients with cognitive impairment often need help with their financial affairs.
- Targeted treatment; for example, referral for cognitive rehabilitation and the use of cognition aids.
- Review of medication; i.e. stopping or switching medications that may exacerbate cognitive impairment. For example, this patient needed his oxybutynin stopped or changed to a non-CNS penetrant anticholinergic (trospium) or to a new class of treatment (mirabegron). Many of the symptomatic medications we use exacerbates or worsen cognition.
- Screening for depression and anxiety; patients with MS who are cognitively impaired may have comorbid depression and anxiety that may be exacerbating their poor cognition.
- Medical retirement; knowing someone with MS has cognitive impairment may help make the case for medical retirement. Prof Langdon pointed out that cognitive impairment is a common cause for pwMS for underperforming at work. Instead of them being let go, or fired, knowing they have cognitive impairment may protect them under employment law.
- Social services; knowing someone with MS is cognitive impaired can help make the case for extra or specific social services and support.
These are just a few examples of why it is important to assess cognitive impairment in routine MS practice. If you can come up with any more reasons please let me know.