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Challenge of Cognitive Impairment in MS. Dr Anita Rose BA(Hons), DClinPsy Highly Specialist Clinical Psychologist, The Walton Centre NHS Foundation Trust. Facts and Figures. Problems in these areas occur to some degree in 43% - 65% of people with MS (Britell, 2000, Winklemann et al., 2007)

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Challenge of cognitive impairment in ms

Challenge of Cognitive Impairment in MS

Dr Anita Rose BA(Hons), DClinPsy

Highly Specialist Clinical Psychologist,

The Walton Centre NHS Foundation Trust

Facts and figures
Facts and Figures

Problems in these areas occur to some degree in 43% - 65% of people with MS (Britell, 2000, Winklemann et al., 2007)

NB: Not everyone with MS experiences cognitive problems

Was considered rare

Charcott (1868) noted cognitive impairment

1980’s research indicated otherwise (Bobholz & Rao, 2003)

80% are mildly affected

Relate to everyday activities and quality of life (Higginson et al., 2000)

Variability (Rao, 1986)

The most commonly affected cognitive functions in PwMS are those involving recent memory, sustained attention, speed of cognitive processing and conceptual reasoning (Schiffer, 1999)


Disconnection of large cortical areas and between cortical and subcortical structures (Filley, 1989)

“Multiple disconnection syndrome”

(Calabrese, 2006)

White matter volume & corpus callosum size correlate with cognitive dysfunction (Rao 1985, 1989)

Lesion burden (Swirsky & Sacchetti, 1992; Stoneham, 1995)

Severity of cognitive deficits associated with damage noted on MRI (Foong, 2000)

Challenge of cognitive impairment in ms

Demyelination in the sub-cortex of the brain

Thinking and behaviour


Comprehension of complex issues compromised

Gaps can appear in memory

Emotions blunted

Thoughts can become uncoordinated

Lack of insight (Longley 1995)

Subtle changes in the frontal lobe can indicate difficulties in executive function (Foong, 2000)

Cognitive deficits in ms
Cognitive Deficits in MS

Most commonly reported difficulties are:



Planning and problem solving (Executive Functions)

Information processing

Word finding


Intellectual Functions usually intact

Rare cases deficit induces subcortical dementia (Cummings and Benson, 1984)

Hidden symptom
“Hidden” Symptom

PwMS can present with relatively well-preserved language and social skills, but sometimes a marked difficulty with problem solving and insight

Having preserved language and social ability means that in ordinary conversation, cognitive problems may not be apparent

Might not be apparent on “bedside testing”

Stigma – within family and wider society

Fear – PwMS

Therefore cognition as a symptom is often ignored but it is an important correlate with quality of life



Think they are going mad, are stupid or are crazy

Causes problems in relationships, with family life

Major impact can be seen in employment

Concerns around safety, independence, ability to self-care can arise


Assessment intervention
Assessment & Intervention


Cognitive deficit might be present in early stages (Simioni et al., 2007)

Longitudinal studies suggest cognitive deficit could be used as predictive parameters of MS evolution and severity (Amato et al., 1995 & 2001; Kujala et al., 2001)

Impairment predictor of low quality of life, employment issues, carer stress

Assessment assists patient, family, healthcare professionals (Roig & Bagunya, 1997)


Cognitive rehabilitation

Aim to improve quality of life

Environmental adaptation

Increase autonomy

Memory in ms
Memory in MS

40 – 60% report memory deficits (Brassington & March, 1998)

On assessment (Beatty et al., 1996):

Mild – Moderate = 53%

Severe 22%

25% show normal performance

Core deficit in MS

Global affects can be seen

Recent memory



Working memory (? Slowed processing)

Recognition relatively unaffected

Rehabilitation of memory
Rehabilitation of Memory

Modify Environment e.g.


Colour coding

Encourage Repetition


memory aids



Helping memory
Helping Memory


Reduce clutter

Key ring by the door

Special place for wallet/purse, glasses etc

A tray for letters


Get organised

Stop and think

Be extra vigilant


Standing orders

Certain activities on certain days



Challenge of cognitive impairment in ms


Write down what people say – or use a Dictaphone

Keep a diary of important events or discussions

Write things down in an organised way

Use headings

Bullet points


Capital letters


Essential addition to anyone’s memory whether for forward planning or for remembering past event – Powell (1994)

Page a day diary

Diaries entries can act as cues or triggers

Check diary regularly

Cross out things you have done

Write in future activities/events


Prompts, Post-it notes, Dry-wipe board, Notice boards, Calendars, Notebooks, Lists, Signs, Labels, Timers, Alarms, Watch alarms, Pill boxes, Key finders, Electronic Organisers etc.


Research produced inconsistent findings (Higginson et al. 2000)

Definition of attention

Measuring instruments very varied

However all note Attention difficulties:






People with MS report:

difficulty in concentrating

difficulty in keeping track of what they are doing

following storylines when reading

following a conversation

All of the above are not helped if distracted or interrupted

Even mild attentional problems have significant impact(Langdon & Thompson, 1996)

Helping attention concentration
Helping Attention/Concentration

Break information into small steps

Turn off distractions like TV/radio/mobile phone


Ask person to repeat back

Write things down

Avoid over-stimulating environment

Have patience

Encourage practice – small achievable goals

Information processing
Information Processing

Primary deficit (Rao et al., 1991)

Significant impact (Langdon & Thompson, 1996)

Evidence indicates that people with MS require a longer time to digest new information

Takes longer to process information and formulate the proper response

Accuracy rarely affected, just takes longer(Demaree, 1999)

Takes longer to complete tasks

Given additional time = improved accuracy

Working memory deficits due to impaired speed

Helping information processing
Helping Information processing

Permission to take longer

Break information into small steps

Turn off distractions like TV/radio/mobile phone

Avoid over-stimulating environment

Have patience

Encourage practice – small achievable goals

e.g. use cancellation tasks

Language difficulties
Language difficulties

Verbal fluency

Some difficulty with forming words quickly in an co-ordinated fashion

Slow speech

Change in tone

Helping language difficulties
Helping Language Difficulties

Encourage people not to provide the word

Encourage self-cueing

Using the first letter of a word

Going through different categories and sub-categories

Encourage use of talking around the subject

Describe it

Talk around it

Don’t get hung up on finding the right word

Getting the message across it what is important

Give them permission to use gestures

Visual processing
Visual Processing

One study suggests 26% impairment (Vleugels, 2000)

Visual processing (Warren, 1993)

Visual Cognition

Visual Memory

Pattern Recognition


Visual Attention

In people with MS impairments reported as:

difficulty in recognising objects accurately

difficulty in reading maps

difficulty in driving

problems finding way around

ability to draw or assemble things is impaired

Helping visual spatial difficulties
Helping Visual/spatial Difficulties

Raise awareness by providing feedback

Promote compensation and self management so predictions can be made

If you keep walking into doors

Put tram lines of tape on the floor to walk between

Forgetting passages or missing the end of sentences when reading

Use a piece of paper to cover text and guide reading

Reading Rulers

Reduce clutter

Keep things in consistent places

Increase contrast


Dark objects on white background or vice versa

Coloured tape on sharp corners

Use written and visual cues

Executive functions
Executive Functions

Capacities that enable a person to engage in independent, goal directed, self-serving behaviour appropriately

In MS deficits seen in:


Problem solving


Organisation and prioritisation

Concept formation

Utilising feedback

Ways of improving executive skills
Ways of Improving Executive Skills

Base intervention/support on individuals level of:

environmental dependency

cognitive strengths and weaknesses

self awareness

Stepping Back

Take a step back – Don’t rush in

Think about it for a few moments


Set specific goal

Schedule activities

Reward f for achieving a task


Make a list of steps needed to achieve the task

Simplify the task – Break it down into small steps, and write these down

Follow the steps in the correct order

Keep these templates and use when doing tasks

Shifting or solving problems

Look at, and recognise, errors and then do the task differently

Try to be flexible

Look at the problem from a different angle

Allow longer to do the task

Contributing factors
Contributing Factors


Physical difficulties






Mood and cognition
Mood and Cognition

A vicious cycle of mood and cognitive problems can develop.

Feel embarrassed, anxious, depressed or angry because of problems.

Leads to poorer concentration, which in turn leads to more emotional distress and so the cycle continues.





Less likely

to pay

attention or

think clearly

about task


Cognitive problems are permanent….

Not necessarily. Can come and go like other MS symptoms

Cognitive problems will get worse…

Possibly. If they do it appears to be slowly progressive

Cognitive problems are only seen in Secondary Progressive MS….

Not true.

Those who experience cognitive deficits are emotionally unstable or are mentally ill….

Definitely not true

Cognitive deficits can be assessed asking a few questions e.g. MMSE….

Mental status can only detect severe problems

If patient is diagnosed with cognitive deficits it is classed as a dementia….



Cognitive impairment is common

Important to consider and assess as:


Think they are going mad, are stupid or are crazy

Causes problems in relationships, with family life

Major impact can be seen in employment

Later stages concerns around safety, independence, ability to self-care

Patient management

Intervention can have a positive impact on quality of life, mood, employment and relationships

Useful resources
Useful resources





Challenge of cognitive impairment in ms


The UKMSSNA is grateful to Dr Anita Rose for permission to use this slide presentation