New Advances for MS patients with Cognitive Issues

Kiren Kresa-Reahl

Kiren Kresa-Reahl, M.D. 
MS Neurologist

For patients with multiple sclerosis, maintaining mobility usually is the greatest concern. However, a gradual loss of cognitive function often is just as devastating and can develop insidiously. Cognitive dysfunction can have a career-ending impact on employment, and frontal lobe issues (executive dysfunction) can detract from social connectedness. Recognizing symptoms of MS-related cognitive decline and being vigilant about medications and co-morbidities are important in keeping our patients’ cognitive function as healthy as possible. 

Causes of cognitive loss

It’s common for patients with MS to experience cognitive impairment in areas such as information processing, attention and concentration, executive function, visuospatial function, memory and verbal fluency. 

Four common causes include:  

  1. “Hardware” problem: With axonal loss over time and atrophy due to brain inflammation, information processing speed can suffer. Typical symptoms include name recall, mental fatigue and difficulty learning new tasks. 
  2. Depression or anxiety: Both conditions affect up to 50 percent of MS patients and can contribute to “pseudo-dementia.” Fortunately, with routine screening and appropriate treatment with SSRIs and SNRIs, patients often see improvement in attention and concentration. 
  3. Medications: Many medications used to manage MS symptoms such as spasticity, neurogenic bladder (anticholinergics), neuropathic pain, and insomnia cause sedation and cognitive impairment. It requires a balancing act to alleviate physical symptoms without detracting from cognitive function.
  4. Sleep disorders: Many MS patients have difficulty sleeping, with conditions that include primary insomnia, restless leg syndrome, and sleep apnea – all of which are treatable.  

The good news is that, in 3 out of the 4 primary causes described above, there is much we can do to improve the MS patient’s cognition. The only thing we generally can’t fix is the “hardware” problem since we can’t reverse nerve damage. The primary solution is to prevent new MS brain lesions by using an appropriate MS disease-modifying therapy in collaboration with a neurologist. There now are 13-plus medications available to relapsing MS patients, one for primary progressive MS, and several more on the horizon.

Working together: primary care and MS specialists

Steps primary care providers can take for their MS patients with cognitive decline include: screen for depression/anxiety, review medications regularly and refer patients to a sleep specialist.  

At the Providence MS Center, we screen for MS cognitive dysfunction with a quick test known as the Symbols Digit Modalities Test, or SDMT. We also use the Beck Depression Inventory and the Epworth Sleepiness Scale.