Cognition, mood, and purpose in life in neuromyelitis optica spectrum disorder

Cognitive performance in patients with neuromyelitis optica: clinical and imaging characteristics

This study aimed to identify the prevalence, clinical and radiographic characteristics, and risk factors for cognitive dysfunction in patients with Neuromyelitis optica spectrum disorder (NMOSD). Eighty-three participants who were diagnosed with NMOSD were recruited. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) and Frontal Assessment Battery (FAB). The mean age of the patients was 47.78 ± 13.14 years, with an average of 12.05 ± 4.62 years of formal education. The majority (54%) exhibited cognitive impairment, defined by a MoCA score < 25 (mean: 22.96 ± 3.82). Disease severity (evaluated by the Expanded Disability Status Scale) and lower formal education levels were associated with cognitive impairment (p = 0.011 and < 0.001, respectively). The annualized relapse rate, disease duration, and AQP4 antibody status were not associated with cognitive impairment. Interestingly, informant-reported cognitive decline was associated with poorer cognitive performance (p = 0.027). Radiographic findings of lesion location and severity were associated with MoCA-assessed cognitive performance, particularly for lesions in the right parietal lobes (p = 0.023). Hippocampal atrophy was negatively correlated with FAB scores. In conclusion, approximately half of the Thai patients with NMOSD exhibited cognitive impairment, which was associated with age, formal education level, disease severity, relative perception, and specific radiological findings. Further studies incorporating comprehensive neuropsychological tests and subjective cognitive complaints are warranted.

Abnormal functional connectivity of white-matter networks and gray-white matter functional networks in patients with NMOSD

Cognitive impairment (CI) has been reported in 29-70% of patients with neuromyelitis optica spectrum disorder (NMOSD). Abnormal white matter (WM) functional networks that correlate with cognitive functions have not been studied well in patients with NMOSD. The aim of the current study was to investigate functional connectivity (FC), spontaneous activity, and functional covariance connectivity (FCC) abnormalities of WM functional networks in patients with NMOSD and their correlation with cognitive performance. Twenty-four patients with NMOSD and 24 healthy controls (HCs) were included in the study. Participants underwent brain resting-state functional magnetic resonance imaging (fMRI) and the Montreal Cognitive Assessment (MoCA). Eight WM networks and nine gray matter (GM) networks were created. In patients, WM networks, including WM1-4, WM1-8, WM2-6, WM2-7, WM2-8, WM4-8, WM5-8 showed reduced FC (P < 0.05). All WM networks except WM1 showed decreased spontaneous activity (P < 0.05). The major GM networks demonstrated increased/decreased FC (P < 0.05), whereas GM7-WM7, GM8-WM4, GM8-WM6 and GM8-WM8 displayed decreased FC (P < 0.05). The MoCA results showed that two-thirds (16/24) of the patients had CI. FC and FCC in WM networks were correlated negatively with the MoCA scores (P < 0.05). WM functional networks are multi-layered. Abnormal FC of WM functional networks and GM functional networks may be responsible for CI.

Cognitive and psychopathological features of neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease: A narrative review

Clinicians are becoming increasingly aware of the cognitive and psychopathological consequences of neurological diseases, which were once thought to manifest with motor and sensory impairments only. The cognitive profile of multiple sclerosis, in particular, is now well-characterised. Similar efforts are being made to better characterise the cognitive profile of other central nervous system inflammatory demyelinating autoimmune disorders. This review discusses the current understanding of the cognitive and psychological features of neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). Detailed analysis of the cognitive sequelae of the above conditions can not only assist with understanding disease pathogenesis but also can guide appropriate management of the symptoms and consequently, improve the quality of life and long-term outcomes for these patients. This narrative review will also identify research gaps and provide recommendations for future directions in the field.

The psychological burden of NMOSD - a mixed method study of patients and caregivers

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder of the central nervous system with common symptoms of rapid onset of eye pain, loss of vision, neck/back pain, paralysis, bowel and bladder dysfunction and heat sensitivity. The rare, unpredictable, and debilitating nature of NMOSD constitutes a unique psychological burden for patients and their caregivers, the specific nature and extent of which is not yet known. This mixed methods study, informed by both quantitative and qualitative data collected via self-report measures, focus groups, and in-depth interviews, aims to investigate and understand the psychological burden of patients with NMOSD and their caregiver/loved ones, so as to inform a specialized intervention. 31 adults living with NMOSD and 22 caregivers of people with NMOSD in the United States and Canada, recruited from NMOSD patient advocacy groups, social media groups, and through word of mouth from other participants, completed a battery of standardized self-report measures of anxiety, depression, trauma, cognitive fusion, valued living, and coping styles. Semi-structured focus group sessions were conducted via HIPAA-compliant Zoom with 31 patients, and separate focus groups were conducted with 22 caregivers. A subset of these samples, comprised of 16 patients and 11 caregivers, participated in individual semi-structured interviews, prioritizing inclusion of diverse perspectives. Descriptive statistics and bivariate correlations were run on quantitative self-report data using SPSS [Version 28.0.1]; data were stored in REDCap. Reflexive thematic analysis was employed regarding qualitative individual interview data. The majority of patients reported experiencing anxiety, depression, cognitive fusion, over-controlled coping, and lack of values-based living. Caregivers also reported heightened anxiety, cognitive fusion, and over-controlled coping, although they did not endorse clinically significant depression. Patient and caregiver degree of anxiety and of overcontrolled coping were both strongly positively correlated, likely affecting how both parties manage NMOSD-related stressors, both individually and as a dyad. Patients reported more anxiety, depression, psychological inflexibility, and lack of values-based living, compared with caregivers. Patient and caregiver narrative themes included mistrust of medical professionals, lack of support immediately following diagnosis, changes in relationships, deviation from values-based living, internalization of feelings, and avoidant coping strategies to manage the psychological burden of NMOSD. A novel mental health intervention targeting the specific psychological burden of life with NMOSD is proposed.

The prevalence of depression, anxiety, and sleep disturbances in patients with neuromyelitis optica spectrum disorders (NMOSD): A systematic review and meta-analysis

OBJECTIVE

To estimate pooled prevalence of depression, anxiety, and sleep disturbances in neuromyelitis optica spectrum disorders (NMOSD) cases.

METHODS

Electronic database of PubMed (MEDLINE), the Cochrane Central Register of Controlled Trials (CENTRAL), Embase and Web of Science ware systematically searched to identify relevant studies published not later than June 10, 2022. Specifically, original articles that reported the prevalence of depression, anxiety and sleep disturbances were selected. All pooled prevalence and 95 % confidence intervals (CIs) were calculated using a random-effects model. Publication bias was examined using funnel plots, and sensitivity analysis was used to explore the stability of the pooled results.

RESULTS

A total of 31 studies involving 4213 participants were included in this review. The pooled prevalence of depression was 40 % (95 % CI: 32-49 %), the pooled prevalence of anxiety was 45 % (95 % CI: 24-66 %), and the pooled prevalence of sleeping disturbances was 55 % (95 % CI: 46-64 %). The depression and anxiety prevalence estimates varied based on different screening tools.

CONCLUSIONS

There is a high prevalence of depression, anxiety, and sleep disturbances among NMOSD. These findings underscore the importance of regular monitoring of psychological status in NMOSD as well as the need for preventive approaches, early diagnosis, and intervention to improve medical and psychosocial outcomes.

Paths to hippocampal damage in neuromyelitis optica spectrum disorders

AIMS

Many patients with neuromyelitis optica spectrum disorders (NMOSD) suffer from cognitive impairment affecting memory, processing speed and attention and suffer from depressive symptoms. Because some of these manifestations could trace back to the hippocampus, several magnetic resonance imaging (MRI) studies have been performed in the past, with a number of groups describing volume loss of the hippocampus in NMOSD patients, whereas others did not observe such changes. Here, we addressed these discrepancies.

METHODS

We performed pathological and MRI studies on the hippocampi of NMOSD patients, combined with detailed immunohistochemical analysis of hippocampi from experimental models of NMOSD.

RESULTS

We identified different pathological scenarios for hippocampal damage in NMOSD and its experimental models. In the first case, the hippocampus was compromised by the initiation of astrocyte injury in this brain region and subsequent local effects of microglial activation and neuronal damage. In the second case, loss of hippocampal volume was seen by MRI in patients with large tissue-destructive lesions in the optic nerves or the spinal cord, and the pathological work-up of tissue derived from a patient with such lesions revealed subsequent retrograde neuronal degeneration affecting different axonal tracts and neuronal networks. It remains to be seen whether remote lesions and associated retrograde neuronal degeneration on their own are sufficient to cause extensive volume loss of the hippocampus, or whether they act in concert with small astrocyte-destructive, microglia-activating lesions in the hippocampus that escape detection by MRI, either due to their small size or due to the chosen time window for examination.

CONCLUSIONS

Different pathological scenarios can culminate in hippocampal volume loss in NMOSD patients.

Cognition in patients with neuromyelitis optica spectrum disorders: A prospective multicentre study of 217 patients (CogniNMO-Study)

BACKGROUND

There is limited and inconsistent information on the prevalence of cognitive impairment in neuromyelitis optica spectrum disorders (NMOSD).

OBJECTIVE

To assess cognitive performance and changes over time in NMOSD.

METHODS

This study included data from 217 aquaporin-4-IgG-seropositive (80%) and double-seronegative NMOSD patients. Cognitive functions measured by Symbol Digit Modalities Test (SDMT), Paced Auditory Serial-Addition Task (PASAT), and/or Multiple Sclerosis Inventory Cognition (MuSIC) were standardized against normative data (N = 157). Intraindividual cognitive performance at 1- and 2-year follow-up was analyzed. Cognitive test scores were correlated with demographic and clinical variables and assessed with a multiple linear regression model.

RESULTS

NMOSD patients were impaired in SDMT (p = 0.007), MuSIC semantic fluency (p < 0.001), and MuSIC congruent speed (p < 0.001). No significant cognitive deterioration was found at follow-up. SDMT scores were related to motor and visual disability (p_Bon < 0.05). No differences were found between aquaporin-4-IgG-seropositive and double-seronegative NMOSD.

CONCLUSIONS

A subset of NMOSD patients shows impairment in visual processing speed and in semantic fluency regardless of serostatus, without noticeable changes during a 2-year observation period. Neuropsychological measurements should be adapted to physical and visual disabilities.

The prevalence of cognitive impairment in patients with neuromyelitis optica spectrum disorders (NMOSD): A systematic review and meta-analysis

OBJECTIVE

To estimate pooled prevalence of cognitive impairment in neuromyelitis opticaspectrum disorders (NMOSD) cases.

METHODS

We searched PubMed, Scopus, EMBASE, Web of Science, and google scholar. We also searched the gray literature including references of the included studies, and conference abstracts which were published up to 20th October 2020. The search strategy included the MeSH and text words as (((Cognitive Dysfunctions) OR Cognitive Impairment) OR Cognitive Declines) OR Mild Cognitive Impairment) OR Mental Deterioration) AND (Neuromyelitis Optica spectrum disorder OR NMOSD OR Devic syndrome OR Neuromyelitis Optica spectrum disorders).

RESULTS

The literature search revealed 1830 articles, after deleting duplicates 1434 remained. For the meta-analysis, 25 studies were included. Totally, 761 NMOSD patients were evaluated and 329 patients had cognitive impairment. Mean age ranged from 34-53 years. The prevalence of cognitive impairment ranged from 3% to 75%.The pooled prevalence of cognitive impairment was 44%, 95%CI(35%-54%), (I²=89.1%, P<0.001) which shows a high statistical heterogeneity . By excluding the abstract of Jung et al which was published in 2009, we found that the pooled prevalence was 34% (95% CI:31-37%) (I²=0) CONCLUSION: Cognitive impairment should be considered in NMOSD patients as its pooled prevalence is estimated as 44%.

Cognitive impairment in NMOSD-More questions than answers

INTRODUCTION

Neuromyelitis optica spectrum disorder (NMOSD) is a type of central nervous system antibody-mediated disease which affects mainly optic nerves and spinal cord, but may also present with acute brainstem syndrome, acute diencephalic syndrome, and cerebral syndrome with typical brain lesions. One of the most disabling symptoms, diagnosed in 29%-67% of cases, is cognitive dysfunction, with such processes as memory, processing speed, executive function, attention, and verbal fluency being predominantly affected. However, description of cognition in NMOSD patients is still a relatively new area of research.

METHODS

A systematic MEDLINE search was performed to retrieve all studies that investigated cognitive impairment and its clinical correlates in patients with NMOSD.

RESULTS

We summarize the current knowledge on cognitive impairment profile, neuropsychological tests used to examine NMOSD patients, clinical and demographical variables affecting cognition, and magnetic resonance imaging correlates. We provide a comparison of cognitive profile of patients with multiple sclerosis and NMOSD.

CONCLUSION

Patients with NMOSD are at significant risk of cognitive deficits. However, the knowledge of cognitive symptoms in NMOSD and potential modifying interventions is still scarce. Further accumulation of clinical data may facilitate effective therapeutic interventions.

Scrambler therapy improves pain in neuromyelitis optica: A randomized controlled trial

OBJECTIVE

To determine whether Scrambler therapy is an effective, acceptable, and feasible treatment of persistent central neuropathic pain in patients with neuromyelitis optica spectrum disorder (NMOSD) and to explore the effect of Scrambler therapy on co-occurring symptoms.

METHODS

We conducted a randomized single-blind, sham-controlled trial in patients with NMOSD who have central neuropathic pain using Scrambler therapy for 10 consecutive weekdays. Pain severity, pain interference, anxiety, depression, and sleep disturbance were assessed at baseline, at the end of treatment, and at the 30- and 60-day follow-up.

RESULTS

Twenty-two patients (11 per arm) were enrolled in and completed this trial. The median baseline numeric rating scale (NRS) pain score decreased from 5.0 to 1.5 after 10 days of treatment with Scrambler therapy, whereas the median NRS score did not significantly decrease in the sham arm. Depression was also reduced in the treatment arm, and anxiety was decreased in a subset of patients who responded to treatment. These symptoms were not affected in the sham arm. The safety profiles were similar between groups.

CONCLUSIONS

Scrambler therapy is an effective, feasible, and safe intervention for central neuropathic pain in patients with NMOSD. Decreasing pain with Scrambler therapy may additionally improve depression and anxiety.

CLINICALTRIALSGOV IDENTIFIER

NCT03452176.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that Scrambler therapy significantly reduces pain in patients with NMOSD and persistent central neuropathic pain.

Review of Treatment for Central Spinal Neuropathic Pain and Its Effect on Quality of Life: Implications for Neuromyelitis Optica Spectrum Disorder

OBJECTIVES

Neuromyelitis optica spectrum disorder (NMOSD) causes disabling and persistent central neuropathic pain (NP). Because the pain syndrome in NMOSD is severe and often intractable to analgesic treatment, it interferes with quality of life in patients. No interventional trials have been published looking at response to interventions for pain in NMOSD. This is a synthesis of the literature surveying the impact on quality of life of interventions in all mechanisms of central spinal NP. This review has important implications for management of pain in NMOSD.

METHODS AND DATA SOURCES

A systematic database search was conducted using PubMed, Embase, and CINAHL Plus with keywords including "spinal cord," "quality of life," and "neuropathic pain" in an attempt to identify original research that targeted spinal NP treatment and used quality of life as an outcome measure. Both pharmacologic and nonpharmacologic treatments were sought out.

RESULTS

Twenty-one studies meeting our eligibility criteria were identified and evaluated, 13 using pharmacologic treatments and 8 using nonpharmacologic interventions. Overall, sample sizes were modest, and effects on decreasing pain and/or improving quality of life were suboptimal.

CONCLUSIONS

This review provides researchers with a foundation from which to start a more thorough and thoughtful investigation into the management of NP in NMOSD and underscores the importance of including quality of life as a clinically meaningful outcome measure.

Case Report: Scrambler Therapy for Treatment-Resistant Central Neuropathic Pain in a Patient with Transverse Myelitis

Central neuropathic pain is a severely disabling consequence of conditions that cause tissue damage in the central nervous system. It is often refractory to treatments commonly used for peripheral neuropathy. Scrambler therapy is an emerging noninvasive pain-modifying technique that uses transcutaneous electrical stimulation of nociceptive fibers with the intent of reorganizing maladaptive signaling pathways. It has been examined for the treatment of peripheral neuropathy with favorable safety and efficacy outcomes, but its application to central neuropathic pain has not been reported in transverse myelitis. We describe the use of Scrambler therapy in a patient with persistent central neuropathic pain due to transverse myelitis. The patient had tried multiple drugs for treatment of the pain, but they were not effective or caused adverse effects. After a course of Scrambler therapy, pain scores improved considerably more than what was reported with previous pharmacologic and nonpharmacologic interventions. This case supports further investigation of Scrambler therapy in multiple sclerosis, neuromyelitis optica spectrum disorder, and other immune-mediated disorders that damage the central nervous system.

Positive Psychosocial Factors and Cognition in Ethnically Diverse Older Adults

OBJECTIVES

Cross-sectional and longitudinal evidence from largely non-Hispanic White cohorts suggests that positive psychosocial factors, particularly self-efficacy and social support, may protect against late-life cognitive decline. Identifying potentially protective factors in racial/ethnic minority elders is of high importance due to their increased risk of Alzheimer's disease. The overall goal of this study was to characterize cross-sectional associations between positive psychosocial factors and cognitive domains among Black, Hispanic, and White older adults.

METHODS

A total of 548 older adults (41% Black, 28% Hispanic, 31% White) in the Washington Heights-Inwood Columbia Aging Project completed cognitive and psychosocial measures from the NIH Toolbox and standard neuropsychological tests. Multiple-group regressions were used to compare cross-sectional associations between positive psychosocial factors and cognition across racial/ethnic groups, independent of demographics, depressive symptoms, and physical health.

RESULTS

Positive associations between self-efficacy and language did not significantly differ across race/ethnicity, although the bivariate association between self-efficacy and language was not significant among Hispanics. Additional positive associations were observed for Whites and Blacks, but not Hispanics. Negative associations between emotional support and purpose in life and working memory were seen only in Hispanics.

CONCLUSIONS

Results confirm and extend the link between self-efficacy and cognition in late life, particularly for White and Black older adults. Previous studies on positive psychosocial factors in cognitive aging may not be generalizable to Hispanics. Longitudinal follow-up is needed to determine whether negative relationships between certain psychosocial factors and cognition in Hispanics reflect reverse causation, threshold effects, and/or negative aspects of having a strong social network. (JINS, 2018, 24, 294-304).

Defense Automated Neurobehavioral Assessment Accurately Measures Cognition in Patients Undergoing Electroconvulsive Therapy for Major Depressive Disorder

OBJECTIVES

The Defense Automated Neurobehavioral Assessment (DANA) is an electronic cognitive test battery. The present study compares DANA to the standard Mini-Mental State Examination (MMSE) in subjects undergoing electroconvulsive therapy for the treatment of major depressive disorder.

METHODS

Seventeen inpatient subjects in the Johns Hopkins Hospital Department of Psychiatry were administered longitudinal paired DANA and MMSE tests (7.6 ± 4.1 per patient) from January 10, 2014 to September 26, 2014. Regression analyses were conducted (with or without MMSE scores of 30) to study the impact of the MMSE upper limit, and within-subject regression analyses were conducted to compare MMSE and DANA scores over time.

RESULTS

Statistically significant relationships were measured between DANA and MMSE scores. Relationships strengthened when MMSE scores of 30 were omitted from analyses, demonstrating a ceiling effect of the MMSE. Within-subject analyses revealed relationships between MMSE and DANA scores over the duration of the inpatient stay.

CONCLUSIONS

Defense Automated Neurobehavioral Assessment is an electronic, mobile, repeatable, sensitive, and valid method of measuring cognition over time in depressed patients undergoing electroconvulsive therapy treatment. Automation of the DANA allows for more frequent cognitive testing in a busy clinical setting and enhances cognitive assessment sensitivity with a timed component to each test.

Psychiatric comorbidities and suicidality among patients with neuromyelitis optica spectrum disorders in Argentina

BACKGROUND

Neuromyelitis optica is a relapsing inflammatory, secondarily demyelinating astrocytopathy that most commonly affects the optic nerves and the spinal cord.

OBJECTIVE

This study aimed to evaluate the psychopathological profile, presence of current depression, and suicidality in patients with neuromyelitis optica spectrum disorders (NMOSD) in an Argentinean cohort, and compare these parameters to those in patients with multiple sclerosis (MS) and in healthy controls (HCs).

METHODS

Twenty patients with NMOSD, 18 with MS, and 20 healthy controls were included. The presence and grade of current depression were assessed using Beck's depression inventory (BDI), while psychiatric disease and suicidality were assessed using the Mini-International Neuropsychiatric Interview.

RESULTS

The prevalence of psychiatric disease in the NMOSD group was 45%, significantly higher than in the MS group (16%, p = 0.06) and the HCs (5%, p = 0.008). Recurrent major depressive disorder was the most frequent psychiatric disease and was diagnosed in four (20%) patients in the NMOSD group and in two (11%) patients in the MS group. In the NMOSD group, two (10%) patients were diagnosed with past manic episodes, one (5%) with current dysthymic disorder, one (5%) with lifetime psychotic disorder, and one (5%) with bulimia nervosa. One patient (5.5%) in the MS group and one in the HC (5%) were diagnosed with current generalized anxiety disorder. Ten patients (50%) in the NMOSD group had current depressive symptoms versus five (28%) patients in the MS group (p = 0.16) and two (10%) in the HC group (p = 0.02). Six (30%) patients with NMOSD versus only one (5.5%) patient with MS had attempted suicide at least once, this difference was statistically significant (p = 0.05). Current suicide risk was high in patients with NMOSD (8, 40%) and moderate in patients with MS (4, 22%).

CONCLUSIONS

Our study shows that the prevalence of psychiatric comorbidities in patients with NMOSD is significantly higher than in patients with MS and healthy controls. Given the high frequency of suicidality, assessment of pertinent psychiatric disorders in such patients to optimize monitoring and comprehensive treatment is required.