The relationship between depression, anxiety and cognition and its paradoxical impact on falls in multiple sclerosis patients

The influence of depression and anxiety on cognition in people with multiple sclerosis: a cross-sectional analysis

There are conflicting findings about the relationships between depression, anxiety, and cognitive dysfunction in people with multiple sclerosis (MS), and a paucity of research has examined the cumulative influence on cognition of depression plus anxiety. This study aimed to determine whether elevated symptoms of depression and anxiety alone or in combination are associated with worse cognition in people with MS. In this cross-sectional analysis, people with MS consecutively seen at a tertiary neuropsychiatry clinic completed the Hospital Anxiety and Depression Scale for symptoms of depression (HADS-D) and anxiety (HADS-A), and the Minimal Assessment of Cognitive Function in MS for cognitive indices. Accounting for covariates, regression models predicted cognitive indices from scores for HADS-D, HADS-A, and the interaction. Of 831 people with MS, 72% were female, mean age was 43.2 years, and median Expanded Disability Status Scale score was 2.0. Depressive symptoms were independently predictive of lower verbal fluency (Controlled Oral Word Association Test, p < 0.01), verbal learning (California Verbal Learning Test-II (CVLT-II) total learning, p = 0.02), verbal delayed recall (CVLT-II delayed recall, p < 0.01), and processing speed (Symbol Digit Modalities Test, p < 0.01; three-second Paced Auditory Serial Addition Test (PASAT), p = 0.05; two-second PASAT, p = 0.01). Anxiety in people with depression predicted decreased visuospatial function (Judgment of Line Orientation, p = 0.05), verbal learning (p < 0.01), verbal delayed recall (p < 0.01), visuospatial recall (Brief Visuospatial Memory Test-Revised, p = 0.02), and executive function (Delis-Kaplan Executive Function System, p < 0.01). Anxiety alone was not independently predictive of cognition. In conclusion, depression, especially with comorbid anxiety, is associated with cognitive dysfunction in people with MS.

Exploring Factors Associated with Falls in Multiple Sclerosis: Insights from a Scoping Review

Multiple sclerosis (MS) is a chronic inflammatory condition that causes demyelination of the central nervous system accompanied by a wide range of symptoms. The high prevalence of falls among patients diagnosed with MS within the initial six months highlights the importance of this issue. The objective of this study is to identify factors associated with falls in MS patients in order to increase awareness and reduce the risk of falls. This scoping review used specific Mesh terms to formulate the literature search around falls and MS using Medline, Google Scholar, Scopus, and Embase search engines. English papers published between 2012 and 2022, studies with a clear definition of falls, McDonald's diagnostic criteria for MS, and those with Expanded Disability Status Scale (EDSS) or Patient Determined Disease Steps (PDDS) scores were included. Critical data from the selected articles were extracted and classified according to the different factors associated with falls in MS patients. Eighteen articles were included in this review. The most important factors associated with falls in MS patients identified were the severity and progression of the disease, mobility and balance problems, bladder dysfunction, fear of falling, fatigue, and cognitive dysfunction. In conclusion, this scoping review yielded the most common factors associated with falls in patients with MS. Study findings can be used to develop future interventions focusing on improving mobility, proprioception, and balance to decrease fall risk and injury amongst MS patients.

Fall risk is related to cognitive functioning in ambulatory multiple sclerosis patients

BACKGROUND AND AIMS

Patients with multiple sclerosis (PwMS) may suffer severely from falling and gait disturbance. Cognitive dysfunction, a common condition in MS patients, may also increase falling rates, regardless of physical disability. We planned this study to determine the fall rate and risk factors in MS patients, follow patients for falls, and reveal the relationship between falls and cognitive dysfunction.

METHODS

The study was conducted on 124 patients who have RRMS diagnoses. Patients' gait speed, simultaneous gait speed during other tasks, functions of the upper extremity, balance rating, and fear of falling were evaluated with dual-task Timed-Up-and-Go-3 versions (TUG, TUG-C, TUG-M), Timed 25 Foot Walk (T25WFT), Nine Hole Peg Test (9HPT), Berg Balance Scale (BBS) and Falls Efficacy Scale-International (FES-I) tests. Cognitive functions, fatigue levels, and quality of life were measured with the Symbol Digit Modalities Test (SDMT), Fatigue Severity Scale (FSS), and Multiple Sclerosis Quality of Life (MSQoL) test. Two groups were formed as "fallers" and "non-faller patients". We monitored the patients in six months period.

RESULTS

Forty-six patients fell at least once in the last one year before the study began. Fallers were older, less educated, had lower SDMT scores and higher disability scores. Non-faller patients scored lower in FES-I, TUG, and FSS tests. SDMT scores showed statistically significant, linear, positive, and moderate correlation with BBS and 9HPT scores (r = 0.307, p = 0.038, and r = 0.320, p = 0.030, respectively).

CONCLUSION

We determined that advanced age, lower education level, and cognitive dysfunction adversely affect gait speed and balance. Among the fallers, those with lower SDMT and MoCA scores had higher falling rates. We determined that EDSS and BBS scores are predictive factors for falls in patients with MS. In conclusion, patients with cognitive impairment should be closely monitored for the risk of falling. Consideration of falls during follow-up examinations might be predictive of cognitive deterioration in patients with MS.

Depressive symptoms and falls among Chinese older adults: A bidirectional relationship

BACKGROUND

Falls and depressive symptoms are prevalent and costly. Although they are frequently interrelated, the nature of interrelationships between them was not well understood. Therefore, using longitudinal data, we aimed to explore whether there is a longitudinal bidirectional relationship between falls and depressive symptoms among older Chinese and whether this is different for men and women.

METHODS

Older adults aged 60 years+ who completed all 2011, 2013, 2015 waves of data from the China Health and Retirement Longitudinal Study on falls and depressive symptoms were included (N=2,203). Random intercept multilevel models were used to analyze data.

RESULTS

Significant bidirectional associations at between-person (b=0.09, SE=0.01, p<0.001) and within-person levels (b=0.05, SE=0.02, p=0.005) were observed between depressive symptoms and falls. When participants reported falls, they reported higher levels of depressive symptoms. However, no gender differs in these relationships.

CONCLUSIONS

Regardless of gender, there are significant bidirectional associations between falls and depressive symptoms.

Network alterations underlying anxiety symptoms in early multiple sclerosis

BACKGROUND

Anxiety, often seen as comorbidity in multiple sclerosis (MS), is a frequent neuropsychiatric symptom and essentially affects the overall disease burden. Here, we aimed to decipher anxiety-related networks functionally connected to atrophied areas in patients suffering from MS.

METHODS

Using 3-T MRI, anxiety-related atrophy maps were generated by correlating longitudinal cortical thinning with the severity of anxiety symptoms in MS patients. To determine brain regions functionally connected to these maps, we applied a technique termed "atrophy network mapping". Thereby, the anxiety-related atrophy maps were projected onto a large normative connectome (n = 1000) performing seed-based functional connectivity. Finally, an instructed threat paradigm was conducted with regard to neural excitability and effective connectivity, using transcranial magnetic stimulation combined with high-density electroencephalography.

RESULTS

Thinning of the left dorsal prefrontal cortex was the only region that was associated with higher anxiety levels. Atrophy network mapping identified functional involvement of bilateral prefrontal cortex as well as amygdala and hippocampus. Structural equation modeling confirmed that the volumes of these brain regions were significant determinants that influence anxiety symptoms in MS. We additionally identified reduced information flow between the prefrontal cortex and the amygdala at rest, and pathologically increased excitability in the prefrontal cortex in MS patients as compared to controls.

CONCLUSION

Anxiety-related prefrontal cortical atrophy in MS leads to a specific network alteration involving structures that resemble known neurobiological anxiety circuits. These findings elucidate the emergence of anxiety as part of the disease pathology and might ultimately enable targeted treatment approaches modulating brain networks in MS.

The Complex Interplay Between Trait Fatigue and Cognition in Multiple Sclerosis

Cognitive impairments are frequent in patients with Multiple Sclerosis (MS). Yet, the influence of MS-related symptoms on cognitive status is not clear. Studies investigating the impact of trait fatigue along with anxio-depressive symptoms on cognition are seldom, and even less considered fatigue as multidimensional. Moreover, these studies provided conflicting results.

Twenty-nine MS patients and 28 healthy controls, matched on age, gender and education underwent a full comprehensive neuropsychological assessment. Anxio-depressive and fatigue symptoms were assessed using the HAD scale and the MFIS, respectively. Six composite scores were derived from the neuropsychological assessment, reflecting the cognitive domains of working memory, verbal and visual learning, executive functions, attention and processing speed. Stepwise regression analyses were conducted in each group to investigate if trait cognitive and physical fatigue, depression and anxiety are relevant predictors of performance in each cognitive domain. In order to control for disease progression, patient’s EDSS score was also entered as predictor variable.

In the MS group, trait physical fatigue was the only significant predictor of working memory score. Cognitive fatigue was a predictor for executive functioning performance and for processing speed (as well as EDSS score for processing speed). In the healthy controls group, only an association between executive functioning and depression was observed.

Fatigue predicted cognition in MS patients only, beyond anxio-depressive symptoms and disease progression. Considering fatigue as a multidimensional symptom is paramount to better understand its association with cognition, as physical and cognitive fatigue are predictors of different cognitive processes.

The mixed blessing of cyberloafing on innovation performance during the COVID-19 pandemic

The COVID-19 pandemic has produced major changes in work routines. With many people now working from home, cyberloafing is increasingly widespread. The COVID-19 pandemic is also an economic downturn that is disruptive and challenging for organizations. Innovation is a vital strategy for organizations to survive and recover from the pandemic crisis. Recent research suggests that cyberloafing can produce complex workplace outcomes. Therefore, we seek to explore how and why cyberloafing affects employee innovation performance. Based on the conservation of resources theory, our study explores the potential positive and negative effects of cyberloafing on employee innovation performance by identifying job anxiety, state gratitude and perceived meaning of work as critical mediating mechanisms in the COVID-19 pandemic. Results from an online survey (N = 544) during the COVID-19 pandemic showed that COVID-19 based informational cyberloafing was positively related to employees' innovation performance by enhancing their perceived meaning of work. It simultaneously weakened and strengthened employees’ perceived meaning of work through increased job anxiety and state gratitude, and ultimately had mixed effects on innovation performance. Our findings provide both theoretical and practical insights on personal internet use as well as innovation activation in crises.

The association between bladder dysfunction, balance and falls in women with multiple sclerosis: The specific contribution of fear of falling

BACKGROUND

Bladder dysfunction is the most common autonomic disturbance in people with MS (PwMS). Only a few studies have examined the relationship between bladder dysfunction and falls in PwMS. Bladder dysfunction has been deemed only a secondary outcome measure, and classified by a gross measure providing a limited perspective of this disturbing symptom. Furthermore, no study to date has focused on the relationship between bladder dysfunction and balance performance in PwMS.

RESEARCH QUESTION

Determine the relationship between bladder dysfunction with balance, falls and fear of falling in women with MS.

METHODS

The study was observational, including 44 women with MS, mean age 46.3 (SD = 5.7), all with at least a mild bladder dysfunction. Outcome measures included the Urinary Incontinence Quality of Life Scale (I-QoL), Bladder Control Scale (BLCS), Timed Up and Go Test (TUG), Four Square Step Test (FSST), Falls Efficacy Scale International (FES-I), Falls status, and posturography.

RESULTS

Participants performed the TUG in 14.1 s (S.D. = 11.1), and the FSST in 20.5 s (S.D. = 22.4). A relatively large proportion (68.2 %) of women was classified as fallers. However, no differences were found between those classified as fallers (n = 30) or non-fallers (n = 14) in terms of the I-QoL and the BLCS, controlling for age, EDSS and number of vaginal deliveries. Significant correlations scores were found between the I-QoL, BLCS and FES-I (rho ∼0.47), while controlling for age, EDSS and number of vaginal deliveries. No associations were demonstrated between the bladder dysfunction outcome scores and either the TUG and/or FSST.

SIGNIFICANCE

Women afflicted with MS and suffering from bladder dysfunction tend to fall and present with more balance difficulties compared with disability-matched PwMS. Nevertheless, once bladder dysfunction is detected, the perceived severity of the condition is not associated with balance and prevalence of falling, but rather on fear of falling.

Effects of diminished positive mood and depressed mood upon verbal learning and memory among people with multiple sclerosis

Objective: Cognitive impairment affects as many as 65% of people with multiple sclerosis (PWMS), and memory impairment confers greater severity of disability and functional impairment. Depression is also common among PWMS, and lifetime prevalence rates are as high as 50%. Research has yet to clearly define the relationship between memory dysfunction and depression among PWMS, and may reflect incomplete assessment of depressive symptoms. The present study examined different aspects of depressive symptoms including anhedonia (i.e., diminished positive mood) and their relationships with verbal learning and memory among PWMS.Method: Participants were 48 healthy individuals and 96 PWMS. They were primarily Caucasian (90.3%) and female (75.0%). Participants completed the California Verbal Learning Test-2 (CVLT-2) to assess verbal learning and memory and the Chicago Multiscale Depression inventory to assess depressed mood (CMDI-Mood) and diminished positive mood (CMDI-DPM).Results: Linear regression revealed that the main effect of CMDI-DPM and the interaction of CMDI-DPM and CMDI-Mood significantly explained variance across learning, recall, and recognition CVLT-2 indices. Follow-up analyses indicated that CMDI-DPM was only significant in the absence of high CMDI-Mood scores. CMDI-Mood explained variance in only CVLT-2 Trial B.Conclusions: Depressed mood had little direct effect upon memory performance in PWMS. In the absence of severe depressed mood, higher levels of positive mood corresponded to better memory performance. However, the impact of diminished positive mood was rendered null among those endorsing high levels of depressed mood. These data may imply that anhedonia corresponds with poorer memory function among PWMS, and suggests that investigators and clinicians should assess multiple mood dimensions among PWMS.

Cognitive and motor slowing mediate the relationship between depression and falls in multiple sclerosis patients

OBJECTIVE

Given the limited research concerning the relationship between depression and falls in multiple sclerosis (MS), this study aimed to examine the direct and indirect association between fall history and depressive symptoms.

METHODS

One hundred and forty seven MS patients had completed at least one neuropsychological assessment that included detailed information regarding fall history, as well as measures of depression, motor function, and cognitive processing speed.

RESULTS

Fall history was associated with higher depressive symptoms and poorer overall motor function. Higher self-reported depressive symptoms were associated with higher odds of falls in the last year (OR = 1.64, 95% CI 1.16, 2.31) in an age adjusted model. Cognitive and motor slowing serially mediated the relationship between depressive symptoms and fall history (estimate = 0.060, 95% CI = 0.01, 0.15).

CONCLUSIONS

With the extensive research on the cognitive and motor correlates of falls in MS, our findings suggest that depressive symptoms are also associated with falls in people with MS. Moreover, this study provides preliminary support for a pathway by which depressive symptoms are related to falls in part through their relationships with cognitive and motor slowing.

Higher inflammation and cerebral white matter injury associated with cognitive deficit in asthmatic patients with depression

OBJECTIVE

Depression is a common co-morbidity in asthma, worsening asthma control and impairing quality of life. Previous studies have reported a higher risk of cognitive deficit in depression, yet little research has focused on the level of cognition in asthmatic patients with depression. Evidence shows that inflammation may play an important role in both asthma and depression. Cerebral white matter injury, possibly induced by inflammation, has been associated with depression. This study assesses cognitive function in patients with asthma and a depression comorbidity, compared to patients with asthma only or depression only.

METHODS

Four groups were studied: Asthma comorbid Depression group (A + D, n = 26), Depression group (D, n = 25), Asthma group (A, n = 33) and Normal controls (N, n = 28). Cognitive function was evaluated using Montreal Cognitive Assessment (MoCA). Inflammatory cytokines were measured, including interleukin-1β (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), high-mobility group box 1(HMGB1) and Netrin-1. Cerebral white matter injury was assessed by serum myelin basic protein (MBP) and myelin oligodendrocyte glycoprotein (MOG), and their correlations with cognitive performance were calculated.

RESULTS

A + D group showed the highest incidence of cognitive deficit, with the cognitive domain particularly affected. Compared to N group, serum levels of IL-6, HMGB1, Netrin-1, MBP and MOG were significantly elevated in A + D group. MOG level negatively correlated with the MoCA score.

CONCLUSION

Patients with comorbidities presented with more severe cognitive deficits and higher levels of inflammatory cytokines. Cerebral white matter injury may account for the cognitive deficit in patients and MOG could be a potential biomarker for this process.

Preventive neurology concepts for training the next-generation and closing gaps in real-world Multiple Sclerosis Care

The field of Multiple sclerosis (MS) has entered an area of growth in the understanding of the MS immune dysregulation that has led to an impressive therapeutics expansion. However, results of surveys and proceedings of the American Academy of Neurology (AAN) support the notion that US neurology residents have fragmented exposure to MS training during residency, resulting in learning gaps in diagnosis, management and follow up of patients with MS. There are annual educational offerings by MS academic societies but limited and tailored to trainees interested in MS/neuroimmunology subespecialization. Therefore, the acquisition of MS clinical skills by all neurology residents is essential for the practice of unsupervised neurology after board certification. Here, we review the current elements and goals of care that are critical for the learning of trainees. We present these elements in a framework focused on current unmet needs to avoid progression in MS in a real-world setting, tailored to preventive and personalized care: The "Multiple Sclerosis 4-square Educational Matrix". This approach could help training neurologist and patients through the essential steps of care. The trainee side emphasizes a goal-oriented approach to satisfy the educational and management components of MS in four areas: burden of symptoms, burden of disease activity, personalized risk factors and personalized patient education. The patient side is similar but simplified for their benefit. This structured approach is based on the principles of personalized preventive neurology and could be useful to solidify trainees and patient education, promoting proactive participation of patients in vital areas of their care, in an anticipatory, and goal-oriented manner. We aim to improve the unmet needs at an individual level and the value of care of populations at risk for progression and disability in MS.

Correlates of dual-task performance in people with multiple sclerosis: A systematic review

BACKGROUND

Gait, balance, and cognitive disorders are common in people with Multiple Sclerosis (MS). In addition, people with MS have impaired ability to concurrently perform gait/balance and cognitive tasks due to cognitive-motor interference (CMI). Clinical features of MS may affect CMI; however, the relationship between CMI and clinical features of MS remains unclear.

RESEARCH QUESTION

Are clinical features of MS associated with CMI?

METHODS

A systematic review was conducted, and four databases (CINAHL, MEDLINE, ProQuest, and Web of Science Core Collections) were searched up to March 2019 using a combination of keywords related to MS and dual-tasking/CMI. Cross-sectional or longitudinal studies that reported the association between CMI and clinical features of MS were included in the review. The correlation coefficient for the relationship between CMI and clinical features of MS were extracted and the results were categorized according to the clinical feature measured.

RESULTS

13 studies were included in this review, of which nine investigated the association between CMI and disability and cognition, and four investigated the association between CMI and other clinical features of MS. While some studies reported that disability and cognition were negatively associated with CMI, the evidence was inconsistent regarding the magnitude and presence of these relationships. In addition, the relationship between CMI and other clinical features of MS (balance, falls risk, fatigue, anxiety, depression, pain, spasticity) remains unclear.

SIGNIFICANCE

This review presents evidence from a small number of studies that suggests disability and cognition are negatively associated with CMI in people with MS, indicating that greater disability and cognitive dysfunction may be associated with lower dual-task performance. These findings highlight the potential importance of disability and cognition in the measurement and rehabilitation of people with dual-task impairments. However, further research is required to confirm these findings and determine the relationship between CMI and other clinical features of MS included in this review.

Longitudinal Analysis of Depression and Anxiety Symptoms as Independent Predictors of Neurocognitive Function in Primary Brain Tumor Patients

PURPOSE

Primary brain tumor patients are vulnerable to depression and anxiety symptoms, which may affect their neurocognitive functioning. We performed a prospective longitudinal analysis to examine the association between depression and anxiety symptoms and domain-specific neurocognitive functioning in primary brain tumor patients receiving radiation therapy (RT).

METHODS AND MATERIALS

On a prospective trial, 54 primary brain tumor patients receiving RT underwent comprehensive neurocognitive evaluation at baseline (pre-RT), and 3, 6, and 12 months post-RT. Neurocognitive assessments measured attention/processing speed, verbal and visuospatial memory, and executive functioning, including Delis-Kaplan Executive Function System Trail-Making Test (DKEFS-TMT), DKEFS Verbal Fluency, and Brief Visuospatial Memory Test-Revised. Depression and anxiety symptoms were also assessed at each time point with Beck Depression and Anxiety Inventories (BDI-II and BAI), respectively. Higher scores reflect more numerous or severe depression or anxiety symptoms. Univariable and multivariable linear mixed-effects models assessed associations between BDI-II and BAI scores and domain-specific neurocognitive scores over time, controlling for pre-existing depression or anxiety disorders and other patient, tumor, and treatment characteristics.

RESULTS

Higher BAI scores were associated with worse attention and processing speed in univariable analyses: DKEFS-TMT visual scanning (P = .003), number sequencing (P = .011), and letter sequencing (P <.001). On multivariable analyses, these associations remained significant (all P ≤ .01). Higher BDI-II scores were also associated with poorer attention/processing speed (DKEFS-TMT Letter Sequencing) in univariable (P = .002) and multivariable (P = .013) models. Higher BAI scores were associated with worse visuospatial memory (Brief Visuospatial Memory Test-Revised Delayed Recall) on univariable (P = .012) but not multivariable analyses (P = .383). Similarly, higher BDI-II scores were associated with poorer executive functioning (DKEFS Verbal Fluency Category Switching) on univariable (P = .031) but not multivariable analyses (P = .198).

CONCLUSIONS

Among primary brain tumor patients receiving RT, increased depression and anxiety were independently associated with worsened neurocognition, particularly in attention/processing speed. Depression and anxiety symptoms should be controlled for in prospective clinical trials and managed in the clinical setting to optimize neurocognitive functioning.

Why Sex Matters: A Cognitive Study of People With Multiple Sclerosis

BACKGROUND

Cognitive dysfunction affects 40% to 70% of people with multiple sclerosis (MS). Sex may influence a person's cognition. Although a few studies have reported greater cognitive deficits in men than women, it is unclear whether specific cognitive domains are more vulnerable than others to the effects of sex or whether cognition is influenced by neurologic or psychiatric variables.

METHODS

A chart review was undertaken of 408 people with MS referred to neuropsychological services. Demographic and MS-related variables were extracted from the patients' records. We used the Minimal Assessment of Cognitive Functioning in Multiple Sclerosis for the neuropsychological assessment. Raw test scores were converted to z scores using Canadian regression-based normative means. A general linear model was conducted on the adjusted scores, controlling for age; years of education; disease course; illness duration; and disability, anxiety, and depression scores.

RESULTS

Men were more likely than women to have primary progressive MS (χ=6.415, P=0.011). There were no other sex differences with respect to demographic, neurologic, or psychiatric data. Women performed significantly better than men on the California Verbal Learning Test-Second Edition Total Learning index (F=7.846, P=0.006).

CONCLUSIONS

An analysis of a large, consecutive sample of people with MS demonstrated that sex, independent of demographic, neurologic, or psychiatric factors, is an important determinant in cognitive impairment, with men being more impaired than women on tests of verbal learning and memory.