Cognitive Dysfunction in the Early Stages of Multiple Sclerosis-How Much and How Important?

Impact of Cognitive Impairment on Quality of Life in Multiple Sclerosis Patients-A Comprehensive Review

Multiple sclerosis (MS) is characterized by a variety of symptoms that have a major impact on quality of life (QoL) even in early stages. In addition to individual motor, sensory, visual disturbances, and brainstem and sphincter disorders, which are expressed through the widely used Expanded Disability Status Scale (EDSS), other manifestations of MS have a detrimental effect on overall functioning and quality of life, such as cognitive impairment, depression, anxiety, fatigue, and pain. However, when talking about QoL, categorical definitions cannot be used because although the concept is generally understood, it is highly nuanced. Suffering from MS can significantly reduce QoL. Numerous research studies have focused on trying to identify and assess which are the elements that most affect the loss of QoL in MS people. However, in addition to the fact that the measurement of QoL can be subjective, it is very difficult to consider these elements in isolation, as they are interrelated. One such limiting factor of QoL that has been investigated is cognitive impairment (CI). This has been shown to have an impact on the lives of MS people, although the different approaches that have been taken to assess CI have evident limitations.

Predictors of multiple sclerosis progression: A systematic review of conventional magnetic resonance imaging studies

INTRODUCTION

Multiple Sclerosis (MS) is a chronic neurodegenerative disorder that affects the central nervous system (CNS) and results in progressive clinical disability and cognitive decline. Currently, there are no specific imaging parameters available for the prediction of longitudinal disability in MS patients. Magnetic resonance imaging (MRI) has linked imaging anomalies to clinical and cognitive deficits in MS. In this study, we aimed to evaluate the effectiveness of MRI in predicting disability, clinical progression, and cognitive decline in MS.

METHODS

In this study, according to PRISMA guidelines, we comprehensively searched the Web of Science, PubMed, and Embase databases to identify pertinent articles that employed conventional MRI in the context of Relapsing-Remitting and progressive forms of MS. Following a rigorous screening process, studies that met the predefined inclusion criteria were selected for data extraction and evaluated for potential sources of bias.

RESULTS

A total of 3028 records were retrieved from database searching. After a rigorous screening, 53 records met the criteria and were included in this study. Lesions and alterations in CNS structures like white matter, gray matter, corpus callosum, thalamus, and spinal cord, may be used to anticipate disability progression. Several prognostic factors associated with the progression of MS, including presence of cortical lesions, changes in gray matter volume, whole brain atrophy, the corpus callosum index, alterations in thalamic volume, and lesions or alterations in cross-sectional area of the spinal cord. For cognitive impairment in MS patients, reliable predictors include cortical gray matter volume, brain atrophy, lesion characteristics (T2-lesion load, temporal, frontal, and cerebellar lesions), white matter lesion volume, thalamic volume, and corpus callosum density.

CONCLUSION

This study indicates that MRI can be used to predict the cognitive decline, disability progression, and disease progression in MS patients over time.

Identification and management of subclinical disease activity in early multiple sclerosis: a review

IMPORTANCE

Early treatment initiation in multiple sclerosis (MS) is crucial in preventing irreversible neurological damage and disability progression. The current assessment of disease activity relies on relapse rates and magnetic resonance imaging (MRI) lesion activity, but inclusion of other early, often "hidden," indicators of disease activity may describe a more comprehensive picture of MS.

OBSERVATIONS

Early indicators of MS disease activity other than relapses and MRI activity, such as cognitive impairment, brain atrophy, and fatigue, are not typically captured by routine disease monitoring. Furthermore, silent progression (neurological decline not clearly captured by standard methods) may occur undetected by relapse and MRI lesion activity monitoring. Consequently, patients considered to have no disease activity actually may have worsening disease, suggesting a need to revise MS management strategies with respect to timely initiation and escalation of disease-modifying therapy (DMT). Traditionally, first-line MS treatment starts with low- or moderate-efficacy therapies, before escalating to high-efficacy therapies (HETs) after evidence of breakthrough disease activity. However, multiple observational studies have shown that early initiation of HETs can prevent or reduce disability progression. Ongoing randomized clinical trials are comparing escalation and early HET approaches.

CONCLUSIONS AND RELEVANCE

There is an urgent need to reassess how MS disease activity and worsening are measured. A greater awareness of "hidden" indicators, potentially combined with biomarkers to reveal silent disease activity and neurodegeneration underlying MS, would provide a more complete picture of MS and allow for timely therapeutic intervention with HET or switching DMTs to address suboptimal treatment responses.

The presence and burden of cognitive issues: discordance between the perception of neurologists and people living with multiple sclerosis

BACKGROUND AND PURPOSE

Cognitive impairment is a common symptom of multiple sclerosis (MS) and occurs in more than 40% of people living with MS (plwMS). No real-world study has assessed the perception of neurologists and plwMS on cognitive issues.

METHODS

Using data from the 2011-2019 Adelphi MS Disease Specific Programme database, this real-world, retrospective, cross-sectional multi-cohort study included people aged ≥18 years with relapsing-remitting MS and secondary progressive MS from the United States, UK and the EU. Neurologists provided data on the patient record form for plwMS, with the same plwMS invited to voluntarily complete a patient self-completion form: a questionnaire about their experiences with MS.

RESULTS

Of 25,374 plwMS, 4817 who provided information on cognitive and mood symptoms were included in the analysis. Of the plwMS, 68% and 59% reported feeling 'mentally fatigued' and having 'difficulty concentrating', respectively. Neurologists reported only 27% of plwMS as having 'difficulty concentrating' and 15% of plwMS as having 'short-/long-term memory problems'. Neurologists reported cognitive or mood symptoms as 'not experienced' by a higher percentage of participants with relapsing-remitting MS than secondary progressive MS. Of the plwMS who experienced 'difficulty concentrating', most had a concomitant feeling of being 'mentally fatigued' (52%), followed by 'feeling anxious or tense' (49%) and 'feeling depressed' (44%). In plwMS, caregivers reported 'difficulty concentrating' (16%) as the most common cognitive issue.

CONCLUSION

A clear discordance was observed between neurologists and plwMS regarding the perception of the cognitive and neuropsychiatric issues. These results underline the under-perception of cognitive and emotional affective symptoms in plwMS during neurological consultations.

Effect of Tai-chi on balance, mood, cognition, and quality of life in women with multiple sclerosis: A one-year prospective study

INTRODUCTION

One of the most debilitating problems encountered by people with multiple sclerosis (MS) is the loss of balance and coordination. Our study aimed to comprehensively evaluate the effectiveness of one year of Tai-chi exercise in patients with MS using both subjective and objective methods, including posturography.

METHODS

This was a single-group longitudinal one-year study performed from the 1st of January 2019 to the 1st of January 2020. The primary outcomes of interest were the Mini-Balance Evaluation Systems Test (Mini-BESTest) and static posturography measures as objective methods to detect subtle changes associated with postural control/balance impairment. Secondary outcomes were measures of depression, anxiety, cognitive performance, and quality of life. All objective and subjective parameters were assessed four times: at baseline, and after three, six and 12 months of regular Tai-chi training. The difference was calculated as a subtraction of baseline values from every timepoint value for each measurement. If the normality test was passed, parametric one-sample t-test was used, if failed, Wilcoxon signed ranks test was used to test the difference between the baseline and each timepoint. Alpha was set to 0.017 using Bonferroni correction for multiple comparisons.

RESULTS

Out of 25 patients with MS enrolled, 15 women with MS (mean age 44.27 years) were included for statistical analyses after completing the 12-month program. After 12 months, significant improvements were found in all objective balance and gait tests: Mini-BESTest (p<0.001), static posturography measures (total area of the centre of foot pressure - TA; p = 0.015), 25 Feet Walk Test (25FWT; p = 0.001), anxiety (Beck Anxiety Inventory - BAI; p = 0.005) and cognition tests (Paced Auditory Serial Addition Test - PASAT; p = 0.003). Measures of depression (Beck Depression Inventory - BDI; p = 0.071), cognition (Symbol Digit Modalities Test - SDMT; p = 0.079), and health-related quality of life (European Quality of Life 5-Dimensions Questionnaire - EQ-5D-5L; p = 0.095) showed a trend of improvement but were not significant, which could be the result of a small sample and increased bias due the type II error.

CONCLUSION

According to these preliminary results, this study indicates the possible beneficial effects of long-term Tai-chi training on patients with MS. Although these findings need to be confirmed by further studies with a larger sample of participants of both genders and require more rigorous randomized controlled trials (RCT) design, our findings support the recommendation of regular and long-term Tai-chi exercise in patients with MS.

CLINICALTRIALS

GOV IDENTIFIER (RETROSPECTIVELY REGISTERED)

NCT05474209.

Managing cognitive impairment and its impact in multiple sclerosis: An Australian multidisciplinary perspective

Cognitive impairment in multiple sclerosis (MS) affects approximately 40-70% of patients and can have varying degrees of severity. Even mild cognitive impairment can impact on quality of life and productivity. Despite this, patients are not routinely screened or monitored for cognitive impairment in Australia due to a range of issues, with time and space being the main limiting factors. This Australian multidisciplinary perspective provides recommendations on cognition management in Australia. It gives a broad overview of cognition in MS, advice on the screening and monitoring tools available to clinicians, and strategies that can be implemented in clinics to help monitor for cognitive impairment in patients with MS. We suggest a routine baseline assessment and multidomain cognitive battery in regular intervals; a change should trigger a thorough investigation of the cause.

Correlation between cognitive impairment and metabolic imbalance of gut microbiota in patients with schizophrenia

BACKGROUND

The gut microbiome interacts with the central nervous system through the gut-brain axis, and this interaction involves neuronal, endocrine, and immune mechanisms, among others, which allow the microbiota to influence and respond to a variety of behavioral and mental conditions.

AIM

To explore the correlation between cognitive impairment and gut microbiota imbalance in patients with schizophrenia.

METHODS

A total of 498 untreated patients with schizophrenia admitted to our hospital from July 2020 to July 2022 were selected as the case group, while 498 healthy volunteers who underwent physical examinations at our hospital during the same period were selected as a control group. Fluorescence in situ hybridization was employed to determine the total number of bacteria in the feces of the two groups. The cognitive function test package was used to assess the score of cognitive function in each dimension. Then, the relationship between gut microbiota and cognitive function was analyzed.

RESULTS

There were statistically significant differences in the relative abundance of gut microbiota at both phylum and class levels between the case group and the control group. In addition, the scores of cognitive function, such as atten-tion/alertness and learning ability, were significantly lower in the case group than in the control group (all P < 0.05). The cognitive function was positively correlated with Actinomycetota, Bacteroidota, Euryarchaeota, Fusobacteria, Pseudomonadota, and Saccharibacteria, while negatively correlated with Bacillota, Tenericutes, and Verrucomicrobia at the phylum level. While at the class level, the cognitive function was positively correlated with Class Actinobacteria, Bacteroidia, Betaproteobacteria, Proteobacteria, Blastomycetes, and Gammaproteobacteria, while negatively correlated with Bacilli, Clostridia, Coriobacteriia, and Verrucomicrobiae.

CONCLUSION

There is a relationship between the metabolic results of gut microbiota and cognitive function in patients with schizophrenia. When imbalances occur in the gut microbiota of patients, it leads to more severe cognitive impairment.

Altered social cognition in early relapsing remitting multiple sclerosis

INTRODUCTION

People with multiple sclerosis (pwMS) may suffer from some degree of impaired social cognition (SC), the process that integrates the mental operations underlying social interactions. SC is still not clearly characterized in the early stages of MS, and it is not defined whether SC is independent of cognitive impairment.

METHODS

In this cross-sectional study, we aimed to compare SC measures in a population of early (≤5 years) relapsing-remitting MS (RRMS) with an age, sex, and education-matched control group. All participants performed a clinical and a comprehensive neuropsychological assessment. SC evaluation included assessment of facial emotion recognitionn by the Emotion Recognition Task, affective theory of mind (ToM) by the Reading the Mind in the eyes Test (RMET) and cognitive ToM by the Faux Pas test (FPT). Depression, anxiety, fatigue, and quality of life were also assessed. We included 38 pwMS (mean age 34.8 ± 8.7, 78.9% female sex, mean disease duration 1.9±1.3 years) and 38 healthy controls (mean age 34.9 ± 8.4, 81.6% female sex).

RESULTS

Altered social cognition was present in 34.2% of pwMS. Participants with MS performed worse than controls on measures of cognitive ToM, and affective ToM. There were no differences regarding FER. Cognitive ToM and FER correlated with cognitive functions, but no correlation was found between affective ToM and cognitive tests. The only clinical factor associated with altered SC was poor quality of life.

CONCLUSIONS

Social cognition impairment is already present in a significant percentage of early RRMS patients, namely ToM deficits. While cognitive ToM and FER appears to correlate with impaired cognitive results, affective ToM is likely independent of other cognitive functions.

The Blood Concentration of Metallic Nanoparticles Is Related to Cognitive Performance in People with Multiple Sclerosis: An Exploratory Analysis

The imbalance in the concentration of metallic nanoparticles has been demonstrated to play an important role in multiple sclerosis (MS), which may impact cognition. Biomarkers are needed to provide insights into the pathogenesis and diagnosis of MS. They can be used to gain a better understanding of cognitive decline in people with MS (pwMS). In this study, we investigated the relationship between the blood concentration of metallic nanoparticles (blood nanoparticles) and cognitive performance in pwMS. First, four mL blood samples, clinical characteristics, and cognitive performance were obtained from 21 pwMS. All participants had relapse-remitting MS, with a score of ≤4.5 points in the expanded disability status scale. They were relapse-free in the three previous months from the day of collection and had no orthopedic, muscular, cardiac, and cerebellar diseases. We quantified the following metallic nanoparticles: aluminum, chromium, copper, iron, magnesium, nickel, zinc, and total concentration. Cognitive performance was measured by mini-mental state examination (MMSE) and the symbol digit modalities test (SDMT). Pearson's and Spearman's correlation coefficients and stepwise linear regression were calculated to assess the relationship between cognitive performance and blood nanoparticles. We found that better performance in SDMT and MMSE was related to higher total blood nanoparticles (r = 0.40; p < 0.05). Also, better performance in cognitive processing speed and attention (SDMT) and mental state (MMSE) were related to higher blood iron (r = 0.44; p < 0.03) and zinc concentrations (r = 0.41; p < 0.05), respectively. The other metallic nanoparticles (aluminum, chromium, copper, magnesium, and nickel) did not show a significant relationship with the cognitive parameters (p > 0.05). Linear regression estimated a significant association between blood iron concentration and SDMT performance. In conclusion, blood nanoparticles are related to cognitive performance in pwMS. Our findings suggest that the blood concentration of metallic nanoparticles, particularly the iron concentration, is a promising biomarker for monitoring cognitive impairment in pwMS.

Cognitive impairment in multiple sclerosis: "classic" knowledge and recent acquisitions

Multiple sclerosis (MS) is a central nervous system (CNS) disease characterized by inflammation, axonal demyelination, and neurodegeneration, which can have a strong impact on all aspects of the life of the patient. Multiple sclerosis causes motor, sensory, cerebellar, and autonomic dysfunctions, as well as cognitive and psychoemotional impairment. The most frequently compromised cognitive domains are complex attention/information processing, memory, executive and visuospatial functions. Recently, alterations have also been evidenced in complex cognitive functions, such as social cognition, moral judgment, and decision-making. Cognitive impairment is characterized by high variability and can affect work skills, social interactions, coping strategies and more generally the quality of life of patients and their families. With the use of sensitive and easy-to-administer test batteries, an increasingly accurate and early diagnosis is feasible: this allows to determine the effectiveness of possible preventive measures, to predict the future progression of the disease and to improve the quality of life of patients. There is currently limited evidence regarding the efficacy, on cognitive impairment, of disease-modifying therapies. The most promising approach, which has received strong empirical support, is cognitive rehabilitation.

Effect of deep gray matter atrophy on information processing speed in early relapsing-remitting multiple sclerosis

BACKGROUND

Cognitive dysfunction, including reduced Information processing speed (IPS), is relatively common in multiple sclerosis(MS). IPS deficits have profound effects on several aspects of patients' life. Previous studies showed that deep gray matter atrophy is highly correlated with overall cognitive impairment in MS. However, the effect of deep gray matter atrophy on IPS deficits is not well understood. In this study, we evaluated the effects of deep gray matter volume changes on IPS in people with early relapse-remitting MS (RRMS) compared to healthy control.

METHODS

In this case-control study, we enrolled 63 case with RRMS and 36 healthy controls. All patients were diagnosed within 6 years. IPS was evaluated using the Integrated Cognitive Assessment (ICA) test. We also performed a 1.5T MRI to evaluate deep gray matter structures.

RESULTS

People with RRMS had lower accuracy in the ICA test (p = .01). However, the reaction time did not significantly differ between RRMS and control groups (p = .6). Thalamus volume was significantly lower in the RRMS group with impaired IPS compared to the RRMS with normal IPS and control groups (p < 10-4). Other deep gray matter structures were not significantly different between the RRMS with impaired IPS group and the RRMS with normal IPS group.

CONCLUSION

Some people with MS are impaired in IPS even in the early stages of the disease. Thalamic atrophy affected IPS in these patients, however atrophy in other deep gray matter structures, including caudate, putamen, globus pallidus, hippocampus, amygdala, accumbens, and cerebellum, were not significantly correlated with IPS impairment in early RRMS.

Advances in Neurodegenerative Diseases

Neurological disorders are the leading cause of physical and cognitive disability across the globe, currently affecting approximately 15% of the worldwide population [...].

Huperzine-A Improved Animal Behavior in Cuprizone-Induced Mouse Model by Alleviating Demyelination and Neuroinflammation

Huperzine A (HupA) is a natural acetylcholinesterase inhibitor (AChEI) with the advantages of high efficiency, selectivity as well as reversibility and can exhibit significant therapeutic effects against certain neurodegenerative diseases. It is also beneficial in reducing the neurological impairment and neuroinflammation of experimental autoimmune encephalomyelitis (EAE), a classic model for multiple sclerosis (MS). However, whether HupA can directly regulate oligodendrocyte differentiation and maturation and promote remyelination has not been investigated previously. In this study, we have analyzed the potential protective effects of HupA on the demylination model of MS induced by cuprizone (CPZ). It was found that HupA significantly attenuated anxiety-like behavior, as well as augmented motor and cognitive functions in CPZ mice. It also decreased demyelination and axonal injury in CPZ mice. Moreover, in CPZ mice, HupA increased mRNA levels of the various anti-inflammatory cytokines (Arg1, CD206) while reducing the levels of different pro-inflammatory cytokines (iNOS, IL-1β, IL-18, CD16, and TNF-α). Mecamylamine, a nicotinic acetylcholinergic receptor antagonist, could effectively reverse the effects of HupA. Therefore, we concluded that HupA primarily exerts its therapeutic effects on multiple sclerosis through alleviating demyelination and neuroinflammation.

Evaluation of the determinants of cognitive dysfunction in patients with multiple sclerosis

Background

Cognitive dysfunction is common among patients with multiple sclerosis (MS); however, the determinants of cognitive dysfunction are still unknown. This study aimed to investigate the determinants of cognitive dysfunction in a relatively large sample of patients with MS for rapid screening.

Results

Fifty-three patients (33.6%) had cognitive dysfunction. According to the Wechsler Memory Scale, patients with relapsing-remitting MS (RRMS) and patients with progressive MS (PMS) had significantly lower scores than the control group. Patients with RRMS compared to the control group were 76.73 ± 8.50 versus 105.58 ± 8.71 (P < 0.01), and patients with PMS compared to the control group were 72.56 ± 6.44 versus 105.58 ± 8.71 (P < 0.01). In patients with RRMS, the factors affecting the emergence of cognitive dysfunction included disability, fatigue, depression, and duration of illness, whereas in patients with PMS, just the disability variable was related to the presence or absence of cognitive dysfunction.

Conclusions

Our findings showed that disability, fatigue, depression, and duration of illness were factors associated with cognitive dysfunction in patients with RRMS. Proper identification of these factors can be helpful in the screening of cognitive dysfunction in this population.

The TRACK-MS Test Battery: A Very Brief Tool to Track Multiple Sclerosis-Related Cognitive Impairment

Tracking cognition in patients with multiple sclerosis (MS) is important for detection of disease progression but it is often not performed in routine settings due to time constraints. This exploratory cohort study aims to develop a very brief repeatable tracking tool with comparable test quality criteria to the current gold standard, the Brief International Cognitive Assessment for MS (BICAMS). The study included 88 participants (22 healthy controls, 66 MS patients) who were examined at baseline and at one-year follow-up. As a validity criterion for the six administered cognitive tests, we assessed the difference between MS patients and HC, and the correlation with MS-related disability. Combining the two tests with the highest validity-the Controlled Oral Word Association Test and Symbol Digit Modalities Test-yielded an administration time of 5 min. Comparing this new TRACK-MS test battery with the 15 min BICAMS indicated that TRACK-MS showed larger differences between MS patients and healthy controls, a higher correlation with MS-related disability, smaller practice effects, and a good test-retest reliability. We provide evidence that TRACK-MS, although faster to administer, showed at least comparable quality criteria as the BICAMS. As the study was exploratory, replication of these results is necessary.

Evaluation of cognitive dysfunction by the clock drawing test in multiple sclerosis and clinically isolated syndrome patients: Correlation with other neuropsychological tests

OBJECTIVES

To evaluate the cognitive status with a simple practical test, clock drawing test (CDT), in a larger multiple sclerosis (MS) patient group and in comparison, with controls.

METHODS

We included 171 patients (17-65 years) with MS and clinically isolated syndrome (CIS) and 98 healthy controls who applied between date 2018-2020 years in Neurology Department of Pamukkale University. The CDTs were applied to all subjects. In addition, the cognitive functions of the patient group were evaluated with the neuropsychological test battery.

RESULTS

The CDT scores were significantly lower in relapsing-remitting MS (RRMS) group than the control group (p<0.005). Progressive MS patients' CDT scores were significantly lower than RRMS and CIS (p<0.0001). According to our results, the CDT showed progressive deterioration in MS better than another practical and free tests. Additionally, the CDT scores were statistically better in patients whose disease began with sensory symptoms than whose disease started with motor and brainstem symptoms (p<0.0001).

CONCLUSION

The CDT cognitive impairment prediction performance is 60%, CDT is a useful, easy-to-administer, practical test that can be used in cognitive assessment in MS and CIS.

Using personalized prognosis in the treatment of relapsing multiple sclerosis: A practical guide

The clinical course of multiple sclerosis (MS) is highly variable among patients, thus creating important challenges for the neurologist to appropriately treat and monitor patient progress. Despite some patients having apparently similar symptom severity at MS disease onset, their prognoses may differ greatly. To this end, we believe that a proactive disposition on the part of the neurologist to identify prognostic “red flags” early in the disease course can lead to much better long-term outcomes for the patient in terms of reduced disability and improved quality of life. Here, we present a prognosis tool in the form of a checklist of clinical, imaging and biomarker parameters which, based on consensus in the literature and on our own clinical experiences, we have established to be associated with poorer or improved clinical outcomes. The neurologist is encouraged to use this tool to identify the presence or absence of specific variables in individual patients at disease onset and thereby implement sufficiently effective treatment strategies that appropriately address the likely prognosis for each patient.

Association of cognitive impairment and quality of life in patients with multiple sclerosis: A cross-sectional study

Background: Cognitive impairments in patients with multiple sclerosis (MS) are suggested as a prognostic factor for disease development, and consequently higher disability and more deficits in daily and social activities. In this regard, we aimed to investigate the association between quality of life (QOL) and cognitive function in patients with MS. Methods: We conducted a cross-sectional study on patients with relapsing-remitting MS (RRMS). General characteristic variables were carried out, and then all patients underwent assessments such as Multiple Sclerosis Quality of Life-54 (MSQOL-54), Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS), Expanded Disability Status Scale (EDSS), Beck Depression Inventory-II (BDI-II), and North American Adult Reading Test (NAART). Results: In the present study, a total of 92 patients, including 76 women with a mean disease duration of 6.82 ± 4.80 years were involved. Results of simple Pearson correlation revealed a significant positive relation between California Verbal Learning Test (CVLT) total learning with MSQOL mental health (r = 0.267, P = 0.017) and physical health (r = 0.299, P = 0.007). After adjusting for potential confounders, there was a negative correlation between MSQOL mental health with Delis-Kaplan Executive Function System (D-KEFS) (r = -0.303, P = 0.015) and Judgment of Line Orientation (JLO) (r = -0.310, P = 0.013). Besides, MSQOL physical health was negatively associated with Brief Visuospatial Memory Test-Revised (BVMT-R) in the adjusted model (r = -0.270, P = 0.031). Conclusion: There is a statistically significant association between specific aspects of cognitive decline and QOL. Therefore, more attention should be paid to cognitive impairment in patients with MS as based on our findings, it is significantly associated with QOL.

Predominant domains and associated demographic and clinical characteristics in multiple sclerosis-related cognitive impairment in mildly disabled patients

Background

Cognitive impairment (CI) is a common finding in multiple sclerosis (MS); however, there is a limited information about its prevalence in mildly disabled cases. We aimed to determine the most affected domains, and also the relation between the demographic factors and cognitive outcomes in mildly disabled relapsing–remitting MS (RRMS).

Results

Ninety-one mildly disabled RRMS patients with expanded disability status scale (EDSS) < 4 and literacy level above 9 years, were recruited. Based on Minimal Assessment of Cognitive Function in MS (MACFIMS) battery, CI was observed in 19.8% of the patients while 40.60% of the patients had at least one failure in cognitive tests. The most common impaired cognitive domain was information processing speed and working memory (27.5%). There was no significant difference between men and women in terms of CI in our sample (p-values > 0.05). Disease duration (p = 0.01), EDSS (p = 0.01), and education (p < 0.01) were significantly different between CI and non-CI patients, while age (p = 0.72), sex (p = 0.50), diagnostic gap (p = 0.89), and frequency of relapses (p = 0.22), did not differ considerably.

Conclusions

RRMS patients experience some degrees of CI that may present even before the onset of remarkable physical disability; nevertheless, a higher EDSS score and longer disease duration increases the risk of CI. These findings suggest routine cognitive assessment of MS patients.

Brain atrophy patterns in multiple sclerosis patients treated with natalizumab and its clinical correlates

BACKGROUND

Multiple sclerosis (MS) is defined as a demyelinating disorder of the central nervous system, witnessing over the past years a remarkable progress in the therapeutic approaches of the inflammatory process. Yet, the ongoing neurodegenerative process is still ambiguous, under-assessed, and probably under-treated. Atrophy and cognitive dysfunction represent the radiological and clinical correlates of such process. In this study, we evaluated the effect of one specific MS treatment, which is natalizumab (NTZ), on brain atrophy evolution in different anatomical regions and its correlation with the cognitive profile and the physical disability.

METHODS

We recruited 20 patients diagnosed with relapsing-remitting MS (RR-MS) and treated with NTZ. We tracked brain atrophy in different anatomical structures using MRI scans processed with an automated image segmentation technique. We also assessed the progression of physical disability and the cognitive function and its link with the progression of atrophy.

RESULTS

During the first 2 years of treatment, a significant volume loss was noted within the corpus callosum and the cerebellum gray matter (GM). The annual atrophy rate of the cortical GM, the cerebellum GM, the thalamus, the amygdala, the globus pallidus, and the hippocampus correlated with greater memory impairment. As for the third and fourth years of treatment, a significant atrophy revolved around the gray matter, mainly the cortical one. We also noted an increase of the thalamus volume.

CONCLUSION

Atrophy in RR-MS patients treated with NTZ is regional and targeting highly cognitive regions mainly of the subcortical gray matter and the cerebellum. The cerebellum atrophy was a marker of physical disability progression. NTZ did not accelerate the atrophy process in MS and may play a neuroprotective role by increasing the thalamus volume.

The Relationship between Cognitive Dysfunction and Postural Stability in Multiple Sclerosis

Background and Objectives: Multiple Sclerosis (MS) is a demyelinating disease of the central nervous system (CNS), most commonly characterized by balance dysfunction, fatigue syndrome and cognitive impairment. The goal of our study was to determine the association between cognitive functions and static posture control. Materials and Methods: The research group consisted of 76 randomized MS patients (ICDG 35.0) hospitalized at the Neurological Rehabilitation Clinic of the Medical University of Lodz. This group was divided into three subgroups according to the cognitive assessment based on the Mini Mental State Examination (MMSE) for patients over 65 years of age and the Montreal Cognitive Assessment (MoCA) under the age of 65. Fatigue syndrome was assessed using the Fatigue Severity Scale (FSS), and postural stability using a stabilometric platform. Results: The men demonstrated poorer stabilometric platform measurements than the women. Statistically significant differences were observed between patients without dysfunction and severe cognitive impairment. The results of the stabilometric platform were found to correlate with body mass index in all three groups of patients (Spearman’s test). Conclusions: Body mass index and cognition have impact on postural stability in MS patients with moderate disability and fatigue syndrome.

Neuroimaging predictors of longitudinal disability and cognition outcomes in multiple sclerosis patients: A systematic review and meta-analysis

BACKGROUND

Cross-sectional magnetic resonance imaging (MRI) studies have generated substantial evidence relating neuroimaging abnormalities to clinical and cognitive decline in multiple sclerosis (MS). Longitudinal neuroimaging studies may have additional value for predicting future cognitive deficits or clinical impairment, potentially leading to earlier interventions and better disease management. We conducted a meta-analysis of longitudinal studies using neuroimaging to predict cognitive decline (i.e. the Symbol Digits Modalities Test, SDMT) and disability outcomes (i.e. the Expanded Disability Status Scale, EDSS) in MS.

METHODS

Our systematic literature search yielded 64 relevant publications encompassing 105 distinct sub-analyses. We performed a multilevel random-effects meta-analysis to estimate overall effect size for neuroimaging's ability to predict longitudinal cognitive and clinical decline, and a meta-regression to investigate the impact of distinct study factors on pooled effect size.

RESULTS

In the EDSS analyses, the meta-analysis yielded a medium overall pooled effect size (Pearson's correlation coefficient r = 0.42, 95% CI [0.37; 0.46]). The meta-regression further indicated that analyses exclusively evaluating gray matter tissue had significantly stronger effect sizes than analyses of white matter tissue or whole brain analyses (p < 0.05). No other study factors significantly influenced the pooled effect size (all p > 0.05). In the SDMT analyses, the meta-analysis yielded a medium overall pooled effect size (r = 0.47, 95% CI [0.32; 0.60]). The meta-regression found no significant study factors influencing the pooled effect size.

CONCLUSION

The present findings indicate that brain imaging is a medium predictor of longitudinal change in both disability progression (EDSS) and cognitive decline (SDMT). These findings reinforce the need for further longitudinal studies standardizing methods, using multimodal approaches, creating data consortiums, and publishing more complete datasets investigating MRI modalities to predict longitudinal disability and cognitive decline.

Cognitive function and oral health in relapsing-remitting multiple sclerosis

OBJECTIVES

Multiple sclerosis (MS) is often associated with reduced cognitive function, and there is also emerging evidence of a heightened vulnerability to oral health problems. However, although links between cognitive function and oral health have been identified in other special populations, it remains to be established whether this relationship is also evident for people with MS. The aim of this study was to provide the first empirical test of whether there is a relationship between cognitive function and oral health in people diagnosed with relapsing-remitting multiple sclerosis (RRMS).

METHODS

One hundred and eleven individuals were evaluated: 56 people diagnosed with RRMS and 55 demographically matched healthy controls. All participants completed an objective oral health assessment as well as a standardized battery that assessed six distinct neurocognitive domains.

RESULTS

Relative to controls, people with RRMS presented with higher rates of decayed teeth and mild gingivitis, and also performed more poorly in three of the six neurocognitive domains assessed (language, complex attention, and executive function). However, for the RRMS group, no associations emerged between oral health with performance on any of the six neurocognitive domains.

CONCLUSIONS

These data cross-validate previous research which shows people with RRMS are more likely to present with both reduced cognitive function and poorer oral health, but also extends this literature in a meaningful way by additionally showing for the first time that these clinical features are unrelated in RRMS.

CLINICAL RELEVANCE

The findings emphasize the need for early assessment of both oral health and cognitive function in people with RRMS so that appropriate interventions and support can be put in place for each of these clinical symptoms.

Significance of the Diagnosis of Executive Functions in Patients with Relapsing-Remitting Multiple Sclerosis

Multiple sclerosis (MS) is a progressive chronic disease of the Central Nervous System (CNS). Cognitive decline occurs rather rarely in relapsing–remitting multiple sclerosis (RRMS) compared to other types. The present study aimed to assess executive functions (EF) in relation to clinical and demographic variables in patients with RRMS. The study involved 22 individuals with RRMS (aged 23 to 49 years) and 22 matching controls. All the individuals with RRMS were in the remission phase. The assessments were carried out using MoCA, BDI-II, Halstead Category Test, Porteus Maze Test, verbal fluency tasks and Stroop Colour-Word Interference Test. The findings show that the two groups differed significantly in all the tests. All patients with RRMS in the remission phase presented at least one cognitive deficit, observed in general cognitive functioning, abstract reasoning or other executive functions, i.e., fluency, interference suppression, planning, or ability to modify activity in response to feedback. The deficits in most cases (except for those measured with the MoCA, Category Tests and phonemic fluency), are not related to intensity of depression and duration of the disease. Findings suggest that the diagnostic process in the case of patients with RRMS may include psychological assessment focusing on potentially existing cognitive, mainly executive, deficits and their severity.

Correlations between hippocampal functional connectivity, structural changes, and clinical data in patients with relapsing-remitting multiple sclerosis: a case-control study using multimodal magnetic resonance imaging

Multiple sclerosis is associated with structural and functional brain alterations leading to cognitive impairments across multiple domains including attention, memory, and the speed of information processing. The hippocampus, which is a brain important structure involved in memory, undergoes microstructural changes in the early stage of multiple sclerosis. In this study, we analyzed hippocampal function and structure in patients with relapsing-remitting multiple sclerosis and explored correlations between the functional connectivity of the hippocampus to the whole brain, changes in local brain function and microstructure, and cognitive function at rest. We retrospectively analyzed data from 20 relapsing-remitting multiple sclerosis patients admitted to the Department of Neurology at the China-Japan Union Hospital of Jilin University, China, from April 2015 to November 2019. Sixteen healthy volunteers were recruited as the healthy control group. All participants were evaluated using a scale of extended disability status and the Montreal cognitive assessment within 1 week before and after head diffusion tensor imaging and functional magnetic resonance imaging. Compared with the healthy control group, the patients with relapsing-remitting multiple sclerosis had lower Montreal cognitive assessment scores and regions of simultaneously enhanced and attenuated whole-brain functional connectivity and local functional connectivity in the bilateral hippocampus. Hippocampal diffusion tensor imaging data showed that, compared with the healthy control group, patients with relapsing-remitting multiple sclerosis had lower hippocampal fractional anisotropy values and higher mean diffusivity values, suggesting abnormal hippocampal structure. The left hippocampus whole-brain functional connectivity was negatively correlated with the Montreal cognitive assessment score (r = −0.698, P = 0.025), and whole-brain functional connectivity of the right hippocampus was negatively correlated with extended disability status scale score (r = −0.649, P = 0.042). The mean diffusivity value of the left hippocampus was negatively correlated with the Montreal cognitive assessment score (r = −0.729, P = 0.017) and positively correlated with the extended disability status scale score (r = 0.653, P = 0.041). The right hippocampal mean diffusivity value was positively correlated with the extended disability status scale score (r = 0.684, P = 0.029). These data suggest that the functional connectivity and presence of structural abnormalities in the hippocampus in patients with relapse-remission multiple sclerosis are correlated with the degree of cognitive function and extent of disability. This study was approved by the Ethics Committee of China-Japan Union Hospital of Jilin University, China (approval No. 201702202) on February 22, 2017.

Assessment of cognitive functions in patients with multiple sclerosis

Background

About 40–70% of patients with multiple sclerosis (MS) develop cognitive impairment (CI) throughout their life. We aim to study the influence of MS on cognitive changes. This is a case–control study of fifty patients with MS who met the revised 2017 Mc Donald Criteria and fifty age- and sex-matched healthy subjects. The Expanded Disability Status Scale (EDSS) was used to assess the degree of disability, and the Montreal Cognitive Assessment (MoCA) scoring system was used to assess cognitive function.

Results

MS patients show low total MoCA score than the controls. Total MoCA scores were lower in patients with CI versus those with intact cognition. CI was higher in those with a longer duration of illness and a high EDSS. MoCA was positively correlated with education level but negatively with EDSS and disease duration.

Conclusion

MoCA scale has optimal psychometric properties for routine clinical use in patients with MS, even in those with mild functional disability. The longer the disease duration and the higher the EDSS, the lower the MoCA score and the higher the education level, the higher the MoCA score. As for the profile of cognitive dysfunction in patients with MS, the domains most frequently failed by the patients were memory, attention, visuospatial learning, and language.

Cognitive impairment and depression in patients with relapsing-remitting multiple sclerosis depending on age and neuroimaging findings

Background

Multiple sclerosis is an insidious, disabling, both physically and mentally, demyelinating disease of the central nervous system. This work aims to evaluate relationships between cognitive impairment in separate domains, depression and their correspondence with MRI-findings, as well as the influence on each other’s manifestations, in patients with relapsing–remitting multiple sclerosis.

Results

Visual–spatial/executive functions and memory domains suffered more frequently than others in the study subjects under 40 years; in patients over 40 years old memory, visual–spatial/executive functions and abstract thinking impairment prevailed the most. Such cognitive domains as memory, language, abstract thinking, visual–spatial and executive functions were impacted in both groups of patients even without the apparent cognitive decline according to MoCA scale. Presence of depression impacted language and attention more prominently than the rest of the domains only in participants younger 40 years. According to the MRI, frontal lobe, corpus callosum and periventricular area were affected more often compared to other brain regions in case of cognitive impairment; meanwhile, combined lesions of frontal lobe and corpus callosum, fronto-temporal region were associated with depression.

Conclusion

Cognitive impairment and depression are one of the common, yet disabling and socially disrupting manifestations of MS. Quite frequently such complaints are neglected or considered as parts of comorbidities. At the same time cognitive impairment can be amplified by depression, especially in patients under 40 years.

Neurocognitive performance in relapsing-remitting multiple sclerosis patients is associated with metabolic abnormalities of the thalamus but not the hippocampus- GABA-edited 1H MRS study

OBJECTIVES

Multiple sclerosis (MS) is an inflammatory demyelinating disease that may cause physical disabling as well as cognitive dysfunction. The presented study investigated how the neuropsychological status depends on the thalamus and hippocampus's metabolic processes, using γ-aminobutyric acid-edited magnetic resonance spectroscopy (GABA-edited ¹H MRS) in patients with early MS, and how the results differ from healthy volunteers.

METHODS

We recruited 36 relapsing-remitting (RRMS) MS patients and 22 controls (CON). In addition to common ¹H MRS metabolites, such as N-acetyl-aspartate (tNAA), myoinositol (mIns), total choline and creatine (tCr, tCho), we also evaluated GABA and glutamate/glutamine (Glx). Metabolite ratios were correlated with the results of Single-Digit Modality Test (SDMT) and Expanded Disability Status Score (EDSS).

RESULTS

In the thalamus, GABA ratios (GABA/tCr, GABA/tNAA) were significantly lower in RRMS patients than in CON. Both tCho- and mIns-ratios correlated with lower scores of SDMT but not with EDSS. Metabolic ratios in the hippocampus did not differ between RRMS and CON and did not correlate with any of performed tests.

DISCUSSION

This study is the first to provide GABA-edited ¹H MRS evidence for MS-related metabolic changes of the thalamus and hippocampus. The findings underline the importance of evaluating subcortical grey matter in MS patients to improve understanding of the clinical manifestations of MS and as a potential future target for treatment.

Cognitive Decline in Multiple Sclerosis Is Related to the Progression of Retinal Atrophy and Presence of Oligoclonal Bands: A 5-Year Follow-Up Study

Background: Brain atrophy, which is associated with cognitive impairment and retinal nerve fiber layer (RNFL) atrophy, is the main biomarker of neurodegeneration in multiple sclerosis (MS). However, data on the relationship between inflammatory markers, such as oligoclonal bands (OCBs) in the cerebrospinal fluid (CSF), and cognition, RNFL atrophy, and brain atrophy are scarce. The aim of this study was to assess the influence of RNFL thickness, brain atrophy markers, intrathecal OCBs, and the immunoglobulin G (IgG) index on cognitive decline over a 5-year period in patients with MS. Methods: This prospective, single-center, observational cohort study included 49 patients with relapsing MS followed up over 5 years. At baseline, the patients underwent brain magnetic resonance imaging (MRI). Cognitive evaluation was performed using the Brief International Cognitive Assessment for MS (BICAMS), and RNFL thickness was assessed using optical coherence tomography (OCT). OCBs and IgG levels in the CSF were evaluated at baseline. The BICAMS, OCT, and MRI findings were re-evaluated after 5 years. Results: A significant reduction in information processing speed, visual learning, temporal RNFL thickness, the Huckman index, and third ventricle mean diameter was found in all 49 patients with relapsing MS over the observation period (p < 0.05). Of the patients, 63.3% had positive OCBs and 59.2% had elevated IgG indices. The atrophy of the temporal segment and papillomacular bundle and the presence of OCBs were significantly related to a decline in information processing speed in these patients (p < 0.05). However, brain atrophy markers were not found to be significant on the general linear models. Conclusions: RNFL atrophy and the presence of OCBs were related to cognitive decline in patients with MS over a 5-year follow-up period, thereby suggesting their utility as potential biomarkers of cognitive decline in MS.

Speech Pathology-Specific Questionnaire for Persons with Multiple Sclerosis (SMS): adaptation, validation and preliminary assessment of the diagnostic potential

INTRODUCTION

Speech and voice disorders are among the least well-described clinical manifestations of Multiple Sclerosis (MS) although their estimated prevalence reaches 40-50%. The aim of the present study was adaptation and validation of the Speech Pathology-Specific Questionnaire for Persons with Multiple Sclerosis (SMS) into the Polish language to be used as part of the diagnostic procedure to quantify important speech-related changes and to improve individual tailoring of therapeutic activities.

MATERIAL AND METHODS

The study included a total number of 178 participants. The study group consisted of 107 patients diagnosed with Multiple Sclerosis, mean age 42.8±11.6 years and the Control Group were 71 healthy sex and age matched normophonic subjects, mean age 44.2±12.5 years with no neurological symptoms. Translated version of SMS was administered to all participants of the study. Voice Handicap Index (VHI) questionnaire was used for comparison purposes. Test-retest reproducibility, internal consistency, floor and ceiling effects, discriminant validity and construct validity of the Polish SMS were investigated. Preliminary assessment of diagnostic value of SMS was conducted on the basis of the results recorded in duration-related quartiles of the Study Group.

RESULTS

High value of Intraclass Correlation Coefficient (ICC= 0 .930) obtained for the test-retest indicates a good level of reproducibility of the Polish SMS. High Cronbach's alpha (α=0.94) proves the test's good internal consistency. There were no floor and ceiling effects for the SMS test score in the Study Group and they were negligible in the Control Group. A significant difference in mean SMS total scores between patients and controls (14.22 points vs. 6.06 points) shows discriminant validity of SMS. Similar differences were observed for all the subscales of the test (in t test: p<0.001). A statistically significant correlation was found for the SMS score and its all subscales, as well as between all the subscales of the test proving good construct validity of the test. Similarly, statistically significant correlations were observed for the total score of SMS and VHI (r=.817, p <0.001) as well as between the particular subscales of SMS test and the subscales of VHI. There was a statistically significant difference in the mean total score of SMS in the distinguished quartiles of the Study Group with the highest values (20 points) recorded in the group of patients suffering from MS for over 15 years.

CONCLUSION

The psychometric properties of the Polish version of Speech Pathology-Specific Questionnaire indicate that it is a valid patient-reported outcome measure suitable for the assessment of speech-language pathology aspects on the population of Multiple Sclerosis patients and can be used as an complementary diagnostic tool in clinical practice.

Visual-Attentional Load Unveils Slowed Processing Speed in Multiple Sclerosis Patients: A Pilot Study with a Tablet-Based Videogame

Slowing in information processing speed (IPS) is the key cognitive deficit in multiple sclerosis (MS). Testing IPS in different cognitive load conditions by using computerized tools might reveal initial IPS slowness underestimated by classic paper-and-pencil tests. To investigate the extent to which IPS can be affected by increased task demands, we developed three tasks based on the manipulation of the visual-attentional load, delivered with a home-made, tablet-based videogame. Fifty-one patients with MS (pwMS), classified as having no cognitive impairment in classic paper-and-pencil tests, and 20 healthy controls (HC) underwent the videogame tasks; reaction times (RTs) and accuracy were recorded. A significant reduced performance of pwMS as compared with HC was found on the videogame tasks, with pwMS being on average slower and less accurate than HC. Furthermore, pwMS showed a significantly more pronounced decrement in accuracy as a function of the visual-attentional load, suggesting a higher susceptibility to increased task demands. Significant correlations among the Symbol Digit Modalities Test (SDMT) and the videogame mean RTs and accuracy were found, providing evidence for the concurrent validity of the videogame as a valid tool to test IPS in pwMS. The high potential that might derive from the adoption of computerized assessment tools in clinical practice should be taken into consideration and investigated further.