Interpreting patient/informant discrepancies of reported cognitive symptoms in MS

Neuropsychological Manifestations of Multiple Sclerosis

This review article summarizes the literature on the cognitive impairment seen amongst people with multiple sclerosis (MS) and how that impairment can impact not only their lives but also how their care needs to be managed. Recommendations regarding screening and monitoring of cognitive issues are reviewed, as well as how common comorbidities can further impact cognition. The current literature with respect to treatment options is also summarized. Finally, the article reviews the literature on some special populations living with MS.

French consensus procedure for neuropsychological assessment in multiple sclerosis

Cognitive impairment is one of the invisible symptoms of Multiple sclerosis (MS), which could be associated with depression, unemployment, reduced social interaction, inability to drive, and compromised quality of life. Moreover, the presence of cognitive impairment can be considered as a long-term prognostic factor and in the follow-up of disability. So, cognitive assessment is a crucial element in clinical follow-up of patients with MS (pwMS). International recommendations mention the use of the Brief International Cognitive Assessment in MS (BICAMS). The BICAMS, that has been recently validated in French is a brief non-exhaustive assessment, developed as a short screening battery, hence needing other supplemented tests. The present paper aims to propose a consensus, approved by expert French consensus from the Cognition group of the SF-SEP (http://sfsep.org [Société Francophone de la Sclérose en Plaques]), for cognitive assessment of pwMS suggesting the tools that should be used in order to apprehend the other cognitive impairments that could appear in MS.

Self-reported cognitive function mediates the relationship between employment status and cognitive functioning in persons with multiple sclerosis

BACKGROUND

Cognitive impairment (CI) is common in people with MS (PwMS). Evidence is lacking for the self-reported CI's mediation effect on employment status and objective cognitive performance. Self-reported CI was found to be unreliable and seemed to be more associated with depression rather than formal cognitive performance. We hypothesized that the link between subjective and objective assessments of cognitive functions, mood, and employment status may be more complex in PwMS than previously reported.

OBJECTIVE

The aims of this study are the following: (Romero-Pinel et al., 2022) to determine whether employment status could affect performance in cognitive function testing and (Rao et al., 1991) whether their relationship may be mediated by self-reported CI; and (Deluca et al., 2013) to determine whether self-reported depression interacts with self-reported CI in influencing performance in various cognitive domains in PwMS.

METHODOLOGY

A retrospective study was performed involving PwMS who completed the self-report Multiple Sclerosis Neuropsychological Questionnaire (MSNQ), Hospital Anxiety and Depression Scale-depression scale (HADS-D), Minimal Assessment of Cognitive Function in MS (MACFIMS) and had data regarding employment status. Included PwMS were classified as employed or unemployed. A structural equation modeling (SEM) approach was taken due to the advantage of examining multiple cognitive outcomes simultaneously while accounting for shared associations. First, a latent factor of memory and executive functioning modeled the error-free associations between both factors and a processing speed task (SDMT). Next, the model tested for the indirect effect of self-reported cognition (MSNQ) on employment status differences in each outcome (memory, speed, and executive functioning). Finally, we tested interactions between MSNQ and HADS-D on each of the outcomes.

RESULTS

We included 590 PwMS: 72.5% female, mean age 44.2 years (SD = 10.5), mean disease duration 8.6 years (SD 9.0). The majority (n = 455, 77.1%) had relapsing MS; 357 (60.5%) were employed. About half (n = 301, 51%) did not report CI on the MSNQ; of those, 213 (70.8%) were employed. The mean MSNQ for employed PwMS was 24.5 (SD = 10.7) and 29.8 (SD = 11.2) for unemployed PwMS. Employed PwMS had significantly better memory (β = .16, p < .05), executive functioning (β = .25, p < .05), and processing speed (β = .22, p < .05). MSNQ partially indirectly mediated the effect of employment status on memory (Δβ = .03, p < .05) and executive functioning (Δβ = .03, p < .05) and processing speed (Δβ = .04, p < .05), indicating that self-report CI partially explains the influence of employment status on these cognitive domains. The association between MSNQ with both memory and executive functioning was moderated by depression, meaning that in PwMS with high HADS-D scores, MSNQ was more strongly related to worse memory and executive functioning. The final model was an acceptable fit to the data (χ2(87) = 465.07, p < .05; CFI = .90, RMSEA = .08, 90% CI [.06, .09], SRMR = .05) explaining 41.20%, 38.50% and 33.40% of the variability in memory, executive functioning, and processing speed, respectively.

CONCLUSION

Self-reported CI partially explains the associations between employment status and objective cognitive assessment in PwMS. Depression may moderate the relationship between self-reported cognitive assessment and objective cognitive performance. Thus, employment status and mood may guide the interpretation of self-reported CI.

Premorbid cognitive functioning influences differences between self-reported cognitive difficulties and cognitive assessment in multiple sclerosis

Cognitive difficulties are reported in up to 60% of people with MS (pwMS). There is often a discrepancy between self-reported cognitive difficulties and performance on cognitive assessments. Some of this discrepancy can be explained by depression and fatigue. Pre-MS cognitive abilities may be another important variable in explaining differences between self-reported and assessed cognitive abilities. PwMS with high estimated premorbid cognitive functioning (ePCF) may notice cognitive difficulties in daily life whilst performing within the average range on cognitive assessments. We hypothesised that, taking into account depression and fatigue, ePCF would predict (1) differences between self-reported and assessed cognitive abilities and (2) performance on cognitive assessments. We explored whether ePCF predicted (3) self-reported cognitive difficulties. Eighty-seven pwMS completed the Test of Premorbid Functioning (TOPF), the Brief International Cognitive Assessment for MS (BICAMS), self-report measures of cognitive difficulty (MS Neuropsychological Questionnaire; MSNQ), fatigue (MS Fatigue Impact Scale; MFIS) and depression (Hospital Anxiety and Depression Scale; HADS). Results revealed that, taking into account covariates, ePCF predicted (1) differences between self-reported and assessed cognitive abilities, p < .001 (model explained 29.35% of variance), and (2) performance on cognitive assessments, p < .001 (model explained 46.00% of variance), but not (3) self-reported cognitive difficulties, p = .545 (model explained 35.10% of variance). These results provide new and unique insights into predictors of the frequently observed discrepancy between self-reported and assessed cognitive abilities for pwMS. These findings have important implications for clinical practice, including the importance of exploring premorbid factors in self-reported experience of cognitive difficulties.

Multiple sclerosis

Multiple sclerosis remains one of the most common causes of neurological disability in the young adult population (aged 18-40 years). Novel pathophysiological findings underline the importance of the interaction between genetics and environment. Improvements in diagnostic criteria, harmonised guidelines for MRI, and globalised treatment recommendations have led to more accurate diagnosis and an earlier start of effective immunomodulatory treatment than previously. Understanding and capturing the long prodromal multiple sclerosis period would further improve diagnostic abilities and thus treatment initiation, eventually improving long-term disease outcomes. The large portfolio of currently available medications paved the way for personalised therapeutic strategies that will balance safety and effectiveness. Incorporation of cognitive interventions, lifestyle recommendations, and management of non-neurological comorbidities could further improve quality of life and outcomes. Future challenges include the development of medications that successfully target the neurodegenerative aspect of the disease and creation of sensitive imaging and fluid biomarkers that can effectively predict and monitor disease changes.

The relation between the symbol digit modalities test, fatigue, depression, and anxiety symptoms in a Belgian MS cohort

BACKGROUND

Multiple sclerosis (MS) is associated with high prevalence of cognitive impairment, ranging from 40 to 80%. The purpose of this single-center retrospective study was to examine the relation between cognitive function, as measured by Symbol Digit Modalities Test (SDMT), with fatigue, anxiety, and depression symptoms in a Belgian cohort of patients with MS.

METHODS

Sociodemographic and clinical data were analyzed in 66 (F:40, M:26) Belgian patients with a diagnosis of MS. The cognitive function was assessed with the oral version of SDMT, depression and anxiety symptoms with the Hospital Anxiety and Depression scale (HAD), fatigue symptoms with the French valid version of the Fatigue Impact Scale in MS (EMIF-SEP), which is a scale composed of four dimensions (cognitive, physical, social, and psychological) allowing a multidimensional evaluation of fatigue.

RESULTS

The multivariate linear regression analysis demonstrated that lower SDMT scores were associated with higher EDSS score and psychological dimension of fatigue symptoms. No association were found between SDMT and anxiety or depression symptoms. Conversely, higher depression and anxiety symptoms were associated with higher total fatigue symptoms, but lower physical dimension of fatigue symptoms. Higher anxiety symptoms were also independently associated with higher social dimension of fatigue symptoms.

CONCLUSION

A complex relationship exists between cognitive performance, fatigue, and neuropsychiatric symptoms in Belgian people with MS. The level of disability and fatigue adversely affects the cognitive function in MS, whereas depression and anxiety seem to not have a significant effect. A more complex relationship exists between fatigue and neuropsychiatric symptoms, with a divergent interplay between the different dimensions of fatigue that supports the multidimensional approach to assessing fatigue in MS.

Self- and observer ratings of capacity limitations in patients with neurological conditions

OBJECTIVE

The purpose of this study was to compare the self- and observer ratings of capacity limitations in patients with neurological conditions. Research on this topic is relevant for assessing the patients' ability to participate in work and social life and improving collaborative patient-clinician relationships.

METHOD

The self- and observer ratings of capacity limitations in a sample of N = 245 patients with neurological conditions from a rehabilitation facility were compared and assessed using the short rating of activity limitations and participation restrictions in mental disorders according to the International Classification of Functioning, Disability and Health (Mini-ICF-APP) and the equivalent self-rating questionnaire (Mini-ICF-APP-S).

RESULTS

Paired-samples t-tests revealed significant differences between the self- and observer ratings for six out of 13 capacity dimensions. On average, the patients rated the capacity dimensions adherence to regulations, planning and structuring of tasks, professional competency and endurance as significantly less limited, in comparison to the observers (small to medium effect sizes). The self-ratings for limitation of contact with others and self-care were only marginally higher than the observer ratings.

CONCLUSIONS

The findings show that psychological capacity limitations occur in patients with neurological conditions. In clinical practice, limitations in each capacity dimension and discrepancies in patient- and clinician-ratings should be thoroughly assessed. This is especially relevant in patients with neurological conditions who have a potential tendency to underestimate or deny their disability.

Differences in metacognition between multiple sclerosis phenotypes: cognitive impairment and fatigue are key factors

Background

Cognitive impairment is present in 40-65% of patients with multiple sclerosis (pwMS). Objectively measured cognitive performance often does not match patients' subjective perception of their own performance.

Objective

We aimed to compare cognitive performance and subjective perception of cognitive deficits between pwMS and healthy controls (HCs), as well as the accuracy of subjective perception.

Methods

In total, 54 HC and 112 pwMS (relapsing-remitting, RRMS, and progressive PMS) underwent neuropsychological evaluation and completed perceived deficit, fatigue, and anxiety-depression scales. Participants were classified according to their consistency between subjective self-evaluation of cognitive abilities and objective cognitive performance to assess accuracy. Regression models were used to compare cognitive performance between groups and explore factors explaining inaccuracy in the estimation of cognitive performance.

Results

PMS showed greater and more widespread cognitive differences with HC than RRMS. No differences were found between pwMS and HC in the perception of deficit. PMS had higher ratios of overestimators. In explaining inaccuracy, fatigue and cognitive preservation were found to be risk factors for underestimation, whereas physical disability and cognitive impairment were risk factors for overestimation.

Conclusion

PwMS have metacognitive knowledge impairments. This study provides new information about metacognition, data on the prevalence of impairments over a relatively large sample of PwMS, and new insights into factors explaining it. Anosognosia, related to cognitive impairment, may be present in pwMS. Fatigue is a key factor in underestimating cognition.

Cognitive deficits in multiple sclerosis: Auditory and visual attention and inhibitory control

BACKGROUND

A growing body of evidence has been paid to the cognitive impairment in patients with multiple sclerosis (MS). However, studies concerning cognitive functions in MS have also yielded conflicting results. This study investigates the attention and inhibitory control functions in patients with MS and their relationship with other clinical features, such as depression and fatigue in these patients.

METHODS

Participants included 80 patients with MS and 60 healthy controls. The attention and inhibitory control, fatigue, and psychiatric screening in all subjects were studied, respectively with the Integrated Visual and Auditory Continuous Performance Test (IVA-CPT), Fatigue Severity Scale (FSS), and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Patients with MS performed the IVA-CPT task more poorly than the healthy control group (p < 0.001). However, multiple regression analysis did not show any significant relationship between disease duration, FSS, and HADS on attention and inhibitory control.

CONCLUSION

Inhibitory control and attention are significantly impaired in patients with MS. Finding the basics of cognitive deficits in MS have potentially important clinical implications for developing better cognitive rehabilitation strategies.

Correlates of patient-reported cognitive performance with regard to disability

The patient-reported form of the Multiple Sclerosis Neuropsychological Questionnaire (MSNQ) assesses perceived problems attributable to cognitive and neuropsychiatric symptoms. It is inconsistently related to objective cognitive performance in multiple sclerosis (MS), while strongly correlated with depression. We assessed whether the relationship between subjective and objective cognitive screening tools is moderated by disability. Furthermore, we investigated the MSNQ as a screening tool for both cognitive impairment and depression. 275 MS patients completed the patient-reported MSNQ, two‐question screening tool for depression and Symbol Digit Modalities Test (SDMT) and were divided into Expanded Disability Status Scale (EDSS) subgroups: Low 0.0–3.0, Medium 3.5–6.0, High 6.5–9.0. MSNQ scores correlated significantly with depression but not SDMT in all subgroups. After correcting for age, sex, education, EDSS and depression, MSNQ significantly predicted SDMT in the total group, but not the subgroups. MSNQ significantly predicted a positive depression and/or cognitive impairment screen in the total group and all subgroups. The relationship between subjective and objective cognitive screening tools is not influenced by physical disability. MSNQ scores are substantially influenced by depression, and reflect cognitive function to some degree. Patient-reported cognitive measures can be useful to identify patients requiring further (neuro)psychological assessment.

Investigating the association of mood and fatigue with objective and subjective cognitive impairment in multiple sclerosis

Discrepancies between subjective cognitive difficulties and objective measures of cognitive function in people with MS have been identified and may be related to mood and fatigue. The aim of the present study was to examine associations of depression and fatigue with discrepancies between subjective and objective cognitive functioning in pwMS. 177 participants with MS attending a University Hospital Department of Neurology MS Outpatient clinic completed the Brief International Cognitive Assessment for MS (BICAMS), MS Neuropsychological Questionnaire (MSNQ), Hospital Anxiety and Depression Scale (HADS) and Modified Fatigue Impact Scale (MFIS). To quantify the discrepancy between objective (BICAMS) and subjective (MSNQ) cognitive functioning, discrepancy scores were calculated by subtracting MSNQ z-score from composite BICAMS z-score. Based on their discrepancy score, participants were grouped as 'Underestimated', 'Overestimated' and 'Non-discrepant'. 39% of the total sample demonstrated poorer subjective cognitive functioning than their objective cognitive performance suggested ('Underestimated'). 23% of the total sample indicated lower objective scores than their subjective report suggests ('Overestimated'). 38% participants indicated relatively no discrepancy between objective and subjective cognitive measures ('Non-discrepant'). Significant differences were observed between the discrepancy groups in terms of depression and fatigue, with the 'Underestimated' group demonstrating greater levels of depression and fatigue (ps < .01). Regression analysis indicated that cognitive fatigue and depression significantly contributed to variance in subjective cognitive functioning. Our findings suggest that subjective reports of cognitive function may be influenced by depression and fatigue, emphasising the importance of cognitive, mood and fatigue screening as part of routine clinical care.

Subjective Cognition Reported by Caregivers Is Correlated With Objective Cognition in Liver Transplant Recipients

Objective cognitive assessments, a gold standard diagnostic tool for cognitive impairment, may not be feasible in busy liver transplantation (LT) practice because they are often time consuming. This study determined whether subjective cognition, patients' self-ratings and/or caregivers' ratings of patients' cognition, reflects objective cognition in LT recipients. A convenience sample of 60 adult LT recipients and their caregivers, recruited at a single transplant center, participated in this cross-sectional descriptive study. Subjective cognition (ie, recipient self-rated and caregiver rated) was measured using the Everyday Cognition (ECog; global and 6 domain scores). Objective global and domain-specific cognition of recipients was measured using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Trail Making Test parts A and B, Digit Span Backward, and Rey-Osterrieth Complex Figure. Agreement between LT recipients' ECog scores and those of their caregivers was fair to moderate (intraclass correlation coefficient = 0.48 for global score, 0.35-0.56 for domain scores). Significant, albeit rather weak, correlations were found between subjective and objective scores. Recipients' ECog visuospatial abilities scores were correlated with Rey-Osterrieth Complex Figure scores (r_s  = -0.39; P = 0.007), whereas caregivers' ECog global, attention, visuospatial abilities, and organization scores were, respectively, correlated with the scores of RBANS global (r_s  = -0.33; P = 0.04) and attention (r_s  = -0.46; P = 0.005), Rey-Osterrieth Complex Figure (Copy; r_s  = -0.34; P = 0.03), and Trail Making Test part A (r_s  = 0.31; P = 0.049). The findings suggest that caregivers may estimate LT recipients' cognition better than recipients themselves. Caregivers may provide supplemental information that could be useful for clinicians when considering the cognitive functioning of LT recipients.

Accuracy of self-assessment of real-life functioning in schizophrenia

A consensus has not yet been reached regarding the accuracy of people with schizophrenia in self-reporting their real-life functioning. In a large (n = 618) cohort of stable, community-dwelling schizophrenia patients we sought to: (1) examine the concordance of patients' reports of their real-life functioning with the reports of their key caregiver; (2) identify which patient characteristics are associated to the differences between patients and informants. Patient-caregiver concordance of the ratings in three Specific Level of Functioning Scale (SLOF) domains (interpersonal relationships, everyday life skills, work skills) was evaluated with matched-pair t tests, the Lin's concordance correlation, Somers' D, and Bland-Altman plots with limits of agreement (LOA). Predictors of the patient-caregiver differences in SLOF ratings were assessed with a linear regression with multivariable fractional polynomials. Patients' self-evaluation of functioning was higher than caregivers' in all the evaluated domains of the SLOF and 17.6% of the patients exceeded the LOA, thus providing a self-evaluation discordant from their key caregivers. The strongest predictors of patient-caregiver discrepancies were caregivers' ratings in each SLOF domain. In clinically stable outpatients with a moderate degree of functional impairment, self-evaluation with the SLOF scale can become a useful, informative and reliable clinical tool to design a tailored rehabilitation program.

A Multidimensional Assessment of Metacognition Across Domains in Multiple Sclerosis

OBJECTIVE

In neurological diseases, metacognitive judgements have been widely used in order to assess the degree of disease awareness. However, as yet little research of this type has focused on multiple sclerosis (MS).

METHOD

We here focused on an investigation of item-by-item metacognitive predictions (using feeling-of-knowing judgements) in episodic and semantic memory and global metacognitive predictions in standard neuropsychological tests pertinent to MS (processing speed and verbal fluency). Twenty-seven relapsing-remitting MS (RR-MS) patients and 27 comparison participants took part.

RESULTS

We found that RR-MS patients were as accurate as the group of comparison participants on our episodic and semantic item-by-item judgements. However, for the global predictions, we found that the MS group initially overestimated their performance (ds = .64), but only on a task on which performance was also impaired (ds = .89; processing speed). We suggest that MS patients, under certain conditions, show inaccurate metacognitive knowledge. However, postdictions and item-by-item predictions indicate that online metacognitive processes are no different from participants without MS.

CONCLUSION

We conclude that there is no monitoring deficit in RR-MS and as such these patients should benefit from adaptive strategies and symptom education.

Self-awareness and underestimation of cognitive abilities in patients with adult temporal lobe epilepsy after surgical treatment

INTRODUCTION

Self-awareness of cognitive, emotional, functional, and social performance is critical for compliance with treatment. However, few studies have investigated self-awareness and the associated effects on other cognitive variables in patients with temporal lobe epilepsy (TLE) after surgical treatment.

AIM

This study was designed to investigate the prevalence of impaired self-awareness (ISA) in patients with TLE who have undergone surgical treatment. Associated correlations with clinical variables (frequency of seizures before surgery, time elapsed since the epilepsy diagnosis, depression, and anxiety) and verbal and visual episodic memory function and differences between patients with right and left TLE were also investigated.

METHOD

Twenty-three adults with TLE after surgical treatment were assessed with the Patient Competency Rating Scale (PCRS-R-BR), the Rey Auditory Verbal Learning Task (RAVLT), and the Modified Ruche Visuospatial Learning Test (RUCHE-M). Patients were considered to have memory dysfunction if delayed recall as assessed with the RUCHE-M or RAVLT was at or below the 25th percentile. Patients were considered to have ISA if PCRS-R-BR discrepancy scores were at or above the 75th percentile. Underestimated cognitive ability (UCA) was defined as a PCRS-R-BR discrepancy percentile score ≤25. Results were analyzed using frequency, Spearman correlation, regression analyses, and the Mann-Whitney test.

RESULTS

Frequency analysis of the total sample indicated ISA in 39.13% of patients (n = 9), UCA in 39.13% of patients (n = 9), and impaired verbal and/or visual memory performance in 69.56% of patients (n = 16). Moderate positive correlations were found between the frequency of seizures before surgical treatment and relatives' reports, as well as between the duration of time that had elapsed since the epilepsy diagnosis and patient reports. Negative and moderate correlations were found between the frequency of seizures and the discrepancy score, as well as between depression and patient reports. No differences in PCRS-R-BR were found between patients with right vs. left TLE. No clinical variables significantly predicted self-report or self-awareness.

CONCLUSION

Patients with TLE exhibit various patterns of ISA and negative effects on cognitive function after surgical treatment. Emotional factors and relatives' reports must be considered when assessing these patients.

Neuropsychiatric Symptoms as a Reliable Phenomenology of Cerebellar Ataxia

While cerebellar ataxia (CA) is a neurodegenerative disease known for motor impairment, changes in mood have also been reported. A full account of neuropsychiatric symptomology in CA may guide improvements in treatment regimes, measure the presence and severity of sub-clinical neuropsychiatric disturbance symptomology in CA, and compare patient versus informant symptom recognition. Neuropsychiatric phenomena were gathered from CA patients with genetic and unknown etiologies and their informants (e.g., spouse or parent). Information was obtained from in-person interviews and the Center for Epidemiologic Studies Depression Scale. Responses were converted to the Neuropsychiatric Inventory-Questionnaire (NPI-Q) scores by consensus ratings. Patient NPI-Q scores were evaluated for symptom prevalence and severity relative to those obtained from healthy controls. Patient-informant NPI-Q score disagreements were evaluated. In this cohort, 95% of patients presented with at least one neuropsychiatric symptom and 51% of patients with three or more symptoms. The most common symptoms were anxiety, depression, nighttime behaviors (e.g., interrupted sleep), irritability, disinhibition, abnormal appetite, and agitation. The prevalence of these neuropsychiatric symptoms was uniform across patients with genetic versus unknown etiologies. Patient and informant symptom report disagreements reflected that patients noted sleep impairment and depression, while informants noted irritability and agitation. Neuropsychiatric disturbance is highly prevalent in patients with CA and contributes to the phenomenology of CA, regardless of etiology. Clinicians should monitor psychiatric health in their CA patients, considering that supplemental information from informants can help gauge the impact on family members and caregivers.

Cognitive Dysfunctions and Assessments in Multiple Sclerosis

Cognitive impairment has been reported at all phases and all subtypes of multiple sclerosis. It remains a major cause of neurological disability in young and middle-aged adults suffering from the disease. The severity and type of cognitive impairment varies considerably among individuals and can be observed both in early and in later stages. The areas which have commonly shown more deficits are: information processing speed, complex attention, memory, and executive function. Even though an alteration in both the white matter and in the gray matter has been found in patients with multiple sclerosis and cognitive impairment, the underlying process still remains unknown. Standardized neurological examinations fail to detect emerging cognitive deficits and self-reported cognitive complaints by the patients can be confounded by other subjective symptoms. This review is a comprehensive and short update of the literature on cognitive dysfunctions, the possible confounders and the impact of quality of life in patients with multiple sclerosis.

Does cognitive dysfunction correlate with neurofilament light polypeptide levels in the CSF of patients with multiple sclerosis?

Objective

To investigate whether neurofilament light polypeptide (NfL) level in cerebrospinal fluid (CSF), currently a prognostic biomarker of neurodegeneration in patients with multiple sclerosis (MS), may be a potential biomarker of cognitive dysfunction in MS.

Methods

This observational case–control study included patients with MS. CSF levels of NfL were determined using enzyme-linked immunosorbent assay. Cognitive function was measured with the Brief International Cognitive Assessment for MS (BICAMS) battery and Paced Auditory Serial Addition Test (PASAT3), standardized to the Greek population.

Results

Of 39 patients enrolled (aged 42.7 ± 13.6 years), 36% were classified as cognitively impaired according to BICAMS z-scores (–0.34 ± 1.13). Relapsing MS was significantly better than progressive forms regarding BICAMS z-score (mean difference [MD] 1.39; 95% confidence interval [CI] 0.54, 2.24), Symbol Digit Modality Test score (MD 1.73; 95% CI 0.46, 3.0) and Greek Verbal Learning Test (MD 1.77; 95% CI 0.82, 2.72). An inversely proportional association between CSF NfL levels and BICAMS z-scores was found in progressive forms of MS (r_p = –0.944).

Conclusions

This study provides preliminary evidence for an association between CSF NfL levels and cognition in progressive forms of MS, which requires validation in larger samples.

Identifying risk factors for cognitive issues in multiple sclerosis

INTRODUCTION

Cognitive impairment (CI) in Multiple Sclerosis (MS) has progressively regained clinical and research interest and is currently recognized as a debilitating and burdensome problem for these patients. Studying risk and protecting factors that may influence the development and course of CI is currently an area of increasing interest, due to the potential for preventive strategies. Areas covered: In this narrative review the authors briefly addressed the physiopathologic basis, assessment and management of CI in MS and then focused on identifying modifiable and not modifiable risk factors for CI in MS, providing an overview of the current knowledge in the field and indicating avenues for future research. Expert opinion: Improving our understanding of potentially modifiable environmental and lifestyle risk factors or protective factors for CI is important in order to prompt preventive strategies and orient patient counselling and clinical management. To this aim, we need to enhance the current level of evidence linking lifestyle factors to cognition and evaluate some factors that were only preliminary addressed in research. Moreover, we need to explore the role of each factor into the subject cognitive outcome, next to the possible interactions between different environmental factors as well as between environmental and genetic factors.

Metacognition and self-awareness in Multiple Sclerosis

Although a large range of literature on awareness and metacognition focuses on different neurological populations, little attention has been paid to Multiple Sclerosis (MS). This paper gathers literatures related to studies of anosognosia and the theoretical construct of metacognition which both offer a means to operationalize and measure awareness in MS. We focused on both a clinical concern, regarding the relationship between subjective and objective evolution of cognitive performance, and the theoretical issue of metacognitive processes implicated in disease awareness. We identified 26 papers with findings related to awareness of cognitive impairment in MS using questionnaire-based or performance-based methods. We found support for the idea that the relationship between subjective evaluation and neuropsychological evaluation depends on disease duration and is strongly modulated by other variables, such as mood state. We propose that the metacognitive deficit for memory tasks in this population arises from memory impairment. Finally, we discuss methodological issues, variability in MS patients, and the domain specificity of metacognitive impairment.

Ecological impact of isolated cognitive relapses in MS

Isolated cognitive relapses (ICRs) are transient deficits in cognitive performance that are the only presentation of a multiple sclerosis (MS) relapse. Here, we evaluated the impact of ICRs on cognitive difficulties in daily activities (assessed with the Multiple Sclerosis Neuropsychological Screening Questionnaire, Informant Version (MSNQ-I)) to characterize ICRs’ clinical relevance. We used 2-year-long retrospective data to compare 15 relapsing-remitting MS (RRMS) patients with ICRs with 57 RRMS patients presenting an asymptomatic gadolinium enhancing lesion (and no-ICRs). ICRs were associated not only with neuropsychological performance decline but also with an increase in the daily cognitive difficulties. These findings support the ecological relevance of ICRs.

Estimating Everyday Neuropsychological Functioning in Multiple Sclerosis: Reliability and Validity of the Greek Multiple Sclerosis Neuropsychological Questionnaire

The Multiple Sclerosis Neuropsychological Questionnaire is a brief screening questionnaire for the assessment of everyday neuropsychological competence of patients with Multiple Sclerosis. The aim of the present study was to examine psychometric properties of the Greek version of the instrument. One hundred and three MS patients and 60 informants participated in the present study and completed the questionnaire. From the initial patient sample, 51 participants completed broadly used neuropsychological tests and measures estimating cognitive failures and depression. Moreover, after a six-month interval the MSNQ was administered to 58 patients from the initial sample in order to explore test-retest reliability. Cronbach's α was 0.92 and 0.93 for patient and informant forms, respectively. The patient form was correlated significantly with measures of cognitive failures and depression. Low correlations were found between the informant form and performance on cognitive tests. In regard to the patient form, significant correlation was observed between repeated administrations and, psychometrically, the three-factor structure was preferable than the one-factor structure. The present study confirms the already established pattern of correlations among the two MSNQ forms, neuropsychological test performance and depression measurements. Additional research is needed in order to define a cut-off score for the MSNQ-I providing further information about the diagnostic interpretability of the instrument.

Perceived cognitive deficits and depressive symptoms in patients with multiple sclerosis: Perceived stress and sleep quality as mediators

Multiple Sclerosis (MS), an autoimmune disorder marked by inflammation of the central nervous system, is associated with a myriad of symptoms. Individuals with MS are more likely to experience depressive symptoms, perhaps due to perceived cognitive impairments. Thus, we aimed to explore perceived stress and sleep deficits as potential mediators of the association between perceived cognitive deficits and depressive symptoms. We recruited a sample of 77 MS participants from an outpatient, university-based MS clinic in the United States. Participants ranged in age between 30 and 75 years old (M = 51.12; SD = 9.6), with more females than males (83% female; n = 64). Participants completed the Perceived Deficits Questionnaire, the Pittsburgh Sleep Quality Index, the Perceived Stress Scale, and the Center for Epidemiological Studies Depression Scale - Revised. Correlation analyses and mediation analyses were conducted with bootstrapping technique. Statistical analyses revealed that higher levels of perceived cognitive deficits were associated with lower quality of sleep, more perceived stress, and higher levels of depressive symptoms. Additionally, both perceived stress and sleep quality served as a significant mediator in the perceived cognitive impairments and depressive symptoms linkage. Our novel findings demonstrate the importance of underlying mechanisms (e.g., sleep quality and perceived stress) in the conceptualization of MS. Perceived stress and sleep quality are potentially modifiable factors, perhaps serving as a target for future treatment, to buffer risk of MS patients developing depression.

Everyday memory measures in multiple sclerosis: a systematic review

Everyday memory is one of the most affected cognitive functions in multiple sclerosis (MS). Assessing everyday memory problems is crucial for monitoring the impact of memory deficits on individuals' day-to-day lives and evaluating the effectiveness of interventions that aim to improve cognitive functions. The aim of this systematic review was to identify the research literature on everyday memory measures used with people with MS, describe the types of measures used, and summarise their psychometric properties. Empirical studies of cognitive function in MS using standardised everyday memory measures were included. Online databases (MEDLINE, PsycINFO, PsycARTICLES, Embase) and Google Scholar were searched. Forty-four studies met the inclusion criteria. A total of 12 measures were identified, with varied uses and administration methods. The majority of papers did not report any psychometric properties for MS populations. The few papers that did, reported that the measures have good reliability and appear to have good face, concurrent, and ecological validity, but these need to be evaluated further. This review presents researchers and clinicians with an overview of the various everyday memory measures used in studies with people with MS, to help them choose the appropriate measure for their evaluations.

Everyday memory problems in alcohol abuse and dependence: Frequency, patterns and patient-proxy agreement

Using self-report to assess everyday memory in alcoholics presents challenges given the presence of both memory and metamemory deficits. Accordingly, evaluation of the reliability and validity of proxy ratings as well as the frequency of these memory lapses are of clinical importance. In the present study, 180 patient-proxy dyads completed the Prospective and Retrospective Memory Questionnaire (PRMQ). 31.7% of proxy-rated versus 2.8% of patient-rated prospective memory scores fell in the impaired to below average range. 15% of proxy-rated retrospective memory scores were below average, whereas none of the patients reported problems in this regard. Longer delays between intention formation and action yielded better prospective memory performance, while the opposite was true for retrospective memory. Agreement between patients and proxies was generally poor to fair across severity levels and the magnitude of observed differences was large (standardized response mean > 0.8). For all PRMQ items, exact agreement occurred in 45.3% of the cases. Larger patient-proxy discrepancy was associated with older age, less education and greater disease severity. Proxy ratings were internally consistent, significantly correlated with objective memory performance, and were sensitive to differences in overall PRMQ performance between severity groups. Caution should be used in the interpretations of patients' reports.

Anti-cholinergic medications for bladder dysfunction worsen cognition in persons with multiple sclerosis

Bladder dysfunction is common in persons with MS (PwMS), often due to detrusor muscle overactivity. Anticholinergic medications are considered the first line treatment for bladder dysfunction and are known to worsen cognition in healthy older adults and in persons with dementia. Yet, it is not known if these medications have the same effect on PwMS. Thus, the Objective of this prospective matched-cohort study was to determine if anticholinergic medications affect objective measures of cognition in PwMS. We recruited PwMS starting either oxybutynin or tolterodine (cases). Cases and controls were tested with the Brief International Cognitive Assessment for MS (BiCAMS) battery prior to starting anticholinergic medications and 12weeks later. The primary outcome was change on the Symbol Digit Modalities Test (SDMT) between groups; secondary outcomes were changes on the other BiCAMS measures. Analysis of Covariance with baseline measures as covariates to assess the significance of between group differences was performed at 12weeks. Forty eight PwMS starting anticholinergic medications and 21 matched PwMS controls were recruited. There was a significant difference (p<0.001) in the change on the cognitive measures over 12weeks between groups. The controls demonstrated improvement, consistent with practice effect, while the cases remained unchanged. This study demonstrates that anticholinergic medications may have a negative effect on cognition in PwMS; further confirmatory studies are needed.

Neuropsychology of Multiple Sclerosis: Looking Back and Moving Forward

The neuropsychological aspects of multiple sclerosis (MS) have evolved over the past three decades. What was once thought to be a rare occurrence, cognitive dysfunction is now viewed as one of the most disabling symptoms of the disease, with devastating effects on patients' quality of life. This selective review will highlight major innovations and scientific discoveries in the areas of neuropathology, neuroimaging, diagnosis, and treatment that pertain to our understanding of the neuropsychological aspects of MS. Specifically, we focus on the recent discovery that MS produces pathogical lesions of gray matter (GM) that have consequences for cognitive functions. Methods for imaging these GM lesions in MS are discussed along with multimodal imaging studies that integrate structural and functional imaging methods to provide a better understanding of the relationship between cognitive test performance and functional reserve. Innovations in the screening and comprehensive assessment of cognitive disorders are presented along with recent research that examines cognitive dysfunction in pediatric MS. Results of innovative outcome studies in cognitive rehabilitation are discussed. Finally, we highlight trends for potential future innovations over the next decade. (JINS, 2017, 23, 832-842).

Behavioral Changes in Patients with Multiple Sclerosis

Background

Behavioral changes are common in patients with multiple sclerosis (MS), however not as readily recognized as cognitive impairments.

Objective

The aim of this study was to analyze behavioral changes and its relation to disease characteristics, disability, and cognitive impairments in patients with MS.

Method

This is a single-center cross-sectional study. A detailed neuropsychological examination, including the Frontal Systems Behavior Scale (FrSBe), the Beck depression inventory (BDI), and the Wuerzburg Fatigue Inventory for Multiple Sclerosis (WEIMuS) test, was performed. FrSBe results were correlated with disease characteristics, disability, and cognitive assessments.

Results

66 patients were enrolled (mean age: 43.4 years; disease duration: 9.3 years; Expanded Disability Status Scale: 3.0). Up to one third of patients showed behavioral changes in at least one domain or the total score of the FrSBe. Patients were mildly affected with regard to cognitive functioning. Consistent correlation was found between behavioral changes and fatigue (WEIMuS) and depressive symptoms (BDI), but not with disease characteristics, disability, or cognitive functions. There was an increase of behavioral changes on all FrSBe scales in the current status compared to the retrospectively rated status before disease onset. Self- and family ratings with regard to current behavioral changes were similar.

Conclusion

Behavioral changes are common in otherwise mildly affected MS patients with up to one third being affected. In this patient cohort, behavioral changes occur largely independent of disease characteristics, physical disability, and cognitive functioning but correlate with both fatigue and depressive symptoms. Therefore, they should be tested specifically.

Validity of the Symbol Digit Modalities Test as a cognition performance outcome measure for multiple sclerosis

Cognitive and motor performance measures are commonly employed in multiple sclerosis (MS) research, particularly when the purpose is to determine the efficacy of treatment. The increasing focus of new therapies on slowing progression or reversing neurological disability makes the utilization of sensitive, reproducible, and valid measures essential. Processing speed is a basic elemental cognitive function that likely influences downstream processes such as memory. The Multiple Sclerosis Outcome Assessments Consortium (MSOAC) includes representatives from advocacy organizations, Food and Drug Administration (FDA), European Medicines Agency (EMA), National Institute of Neurological Disorders and Stroke (NINDS), academic institutions, and industry partners along with persons living with MS. Among the MSOAC goals is acceptance and qualification by regulators of performance outcomes that are highly reliable and valid, practical, cost-effective, and meaningful to persons with MS. A critical step for these neuroperformance metrics is elucidation of clinically relevant benchmarks, well-defined degrees of disability, and gradients of change that are deemed clinically meaningful. This topical review provides an overview of research on one particular cognitive measure, the Symbol Digit Modalities Test (SDMT), recognized as being particularly sensitive to slowed processing of information that is commonly seen in MS. The research in MS clearly supports the reliability and validity of this test and recently has supported a responder definition of SDMT change approximating 4 points or 10% in magnitude.

Predictors of well-being among significant others of persons with multiple sclerosis

Objective

To examine patient and significant other characteristics as predictors of significant other well-being.

Methods

A total of 74 persons with multiple sclerosis (MS) and their significant others participated. Executive functioning was measured using neuropsychological tests. Awareness of cognitive deficit was measured as the discrepancy between the patient's reports of their abilities and objective test results. Awareness of functional deficit was measured as the discrepancy between the patient's and significant other's reports of the patient's functional abilities. Patient neurobehavioral disturbance was measured using a significant-other rated questionnaire. Significant other perceived social support and well-being (ie, psychological distress, life satisfaction, and general health status) were assessed using questionnaires filled out by the significant other.

Results

Executive dysfunction, neurobehavioral disturbance, and lack of awareness of functional deficits in patients were associated with poor well-being outcomes; whereas, lack of awareness of cognitive deficits was only weakly related to well-being. Social support was associated with positive well-being outcomes.

Conclusions

Diminished insight regarding functional limitations may increase significant others’ supervisory burden as patients attempt activities independently, whereas lack of awareness of cognitive deficits may not be directly associated with behavior-relevant impairments that significant others find distressing. Social support appears to be a powerful aid in diffusing the distress among significant others of MS patients. Multiple Sclerosis 2007; 13: 238–249. http://msj.sagepub.com

Processing speed test: Validation of a self-administered, iPad®-based tool for screening cognitive dysfunction in a clinic setting

Background:

Cognitive dysfunction is common in multiple sclerosis (MS) patients and has important consequences for daily activities, yet, unlike motor function, is not routinely assessed in the clinic setting. We developed the Processing Speed Test (PST), a self-administered iPad®-based tool to measure MS-related deficits in processing speed.

Objective:

To determine whether the PST is valid for screening cognitive dysfunction by comparing it to the paper-and-pencil Symbol Digit Modalities Test (SDMT).

Methods:

We assessed PST test–retest reliability, sensitivity of PST and SDMT in discriminating MS patients from healthy controls (HC), convergent validity between PST and SDMT, correlations between T2 lesion load and PST and SDMT, and PST performance with and without technician present during administration.

Results:

PST had excellent test–retest reliability, was highly correlated with SDMT, was slightly more sensitive than SDMT in discriminating MS from HC groups, and correlated better with cerebral T2 lesion load than did SDMT. Finally, PST performance was no different with or without a technician in the testing environment.

Conclusion:

PST has advantages over SDMT because of its efficient administration, scoring, and potential for medical record or research database integration. PST is a practical tool for routine screening of processing speed deficits in the MS clinic.

Clinical correlates of memory complaints during AED treatment

OBJECTIVES

To investigate clinical correlates of memory complaints (MC) during anti-epileptic drug (AEDs) treatment in adults with epilepsy with special attention to the role of depression, using user-friendly standardized clinical instruments which can be adopted in any outpatient setting.

MATERIALS & METHODS

Data from a consecutive sample of adult outpatients with epilepsy assessed with the Neurological Disorder Depression Inventory for Epilepsy (NDDIE), the Adverse Event Profile (AEP) and the Emotional Thermometer (ET) were analysed.

RESULTS

From a total sample of 443 patients, 28.4% reported MC as 'always' a problem. These patients were less likely to be seizure free (18.3% vs 34.3%; P < 0.001), had a high number of previous AED trials (4 vs 3; P < 0.001) and high AEP total scores (49 vs 34.2; P < 0.001). There was no correlation with specific AED type or combination. Depression was the major determinant with a 2-fold increased risk (95%CI 1.15-3.86; P = 0.016). When depression was already known and under treatment, patients with MC were less likely to be in remission from depression despite antidepressant treatment (11.9% vs 1.6% P < 0.001). Among patients without depression, those reporting MC presented with significantly high scores for depression (3.3 vs 2; t = 3.07; P = 0.003), anxiety (4.5 vs 2.7; t = 4.43; P < 0.001), anger (3 vs 2; t = 2.623; P = 0.009) and distress (3.8 vs 2.2; t = 4.027; P < 0.001) than those without MC.

CONCLUSIONS

Depression has to be appropriately treated and full remission from depression should represent the ultimate goal as subthreshold or residual mood and anxiety symptoms can contribute to MC.

The Perceived Deficits Questionnaire: Perception, Deficit, or Distress?

BACKGROUND

Cognitive dysfunction affects approximately 43% to 70% of individuals with multiple sclerosis (MS) and is an important determinant of several functional outcomes in MS and quality of life. Brief neuropsychological test batteries have been developed specifically for use in MS and are widely used to aid clinicians in assessing levels of cognitive impairment in MS. Neuropsychologists and neurologists also frequently use briefer screening measures, such as the Perceived Deficits Questionnaire (PDQ), to assist in determining whether a more extensive neuropsychological evaluation is warranted. However, despite the ease of such measures, the relationship between self-report and objective cognitive impairment has been inconsistent, at best. Moreover, factors such as depression, fatigue, anxiety, and personality have been found to be more related to reports of cognitive difficulties. The purpose of the present study was to clarify the relationship between subjective cognitive concerns and objective cognitive impairment while accounting for related symptoms.

METHODS

We examined the association of self-reported cognitive concerns on the PDQ with objective cognitive measures, as well as depression, anxiety, fatigue, and self-efficacy.

RESULTS

There was no relationship between self-reported cognitive concerns and objective performance. Rather, reports on the PDQ were more correlated with reports of depression, anxiety, fatigue, and self-efficacy.

CONCLUSIONS

Depression and poor self-efficacy can contribute to reports of cognitive difficulties. Effective treatment to improve these factors seems warranted given the impact of perceived cognitive impairment on outcomes in MS and the potential for more accurate self-reports.

The relationship among depression, subjective cognitive impairment, and neuropsychological performance in multiple sclerosis

The aim of this study was to examine, within the context of a treatment study, the relative contributions of depression and neuropsychological performance on patient ratings of cognitive functioning in a cohort of 58 moderately-depressed multiple sclerosis (MS) patients. All participants were randomized to one of three 16-week conventional treatments for depression. Assessments were conducted pre and post-treatment using: (1) Cognitive Function subscale of the Multiple Sclerosis Quality of Life-54 (MSQOL-54) to evaluate subjective cognitive impairment (SC), (2) Beck Depression Inventory (BDI), and (3) a neuropsychological index score (NP). Prior to treatment, 8% of the variance in SC was explained by NP, whereas 14% of the variance was explained by BDI, above and beyond NP. At post-treatment, patients were classified as ‘responders’ (BDI<11) and ‘nonresponders’ (BDI≥11). Among those participants classified as ‘responders’, NP accounted for 39% of the variance in SC, and BDI did not significantly predict SC. The results of this study suggest that depression may influence subjective reports of cognitive impairment, but these reports may not be reliably related to objective neuropsychological performance. Furthermore, patients may be more accurate reporters of their cognitive impairment after successful treatment for depression, suggesting that depression decreases the accuracy of patient reported cognitive impairment.

Impact of Pharmacotherapy on Cognitive Dysfunction in Patients with Multiple Sclerosis

Cognitive impairment is a common symptom of multiple sclerosis (MS), adversely impacting many spheres of daily functioning. Yet the effectiveness of pharmacological interventions for cognitive impairment in MS is unclear. Clinicians and patients alike would benefit from formal guidelines regarding effective management of cognitive symptoms. We reviewed the background on the measurement, pathophysiology and risk factors for cognitive dysfunction in MS, and then examined the published clinical trials of pharmacotherapy, including both disease-modifying treatments (DMTs) and symptom-management therapies (SMTs). Our review of DMTs revealed only a single well-designed, randomized, controlled trial where intramuscular interferon (IFN)-β1a, administered once weekly, was compared with placebo. The results showed significant benefits in terms of cognitive processing speed and memory. Less convincing but promising data have shown the potential benefits of IFN-β1b and natalizumab. The literature on SMTs is replete with placebo-controlled, single-centre studies, with a failure to replicate initially promising results. The results for SMTs such as acetylcholinesterase inhibitors and psychostimulants are mixed. Some encouraging data show promise but not to a threshold of indication for standard clinical use. Numerous methodological factors hamper research in this area. Acknowledging the lack of firm conclusions, we argue that all DMTs are likely to benefit cognition and that, if otherwise safe, SMTs with some empirical support may be attempted at the discretion of the treating clinician. We offer some guidance on the assessment and monitoring of cognitive function to inform off-license treatment of cognitive impairment in MS patients.

Effects of single dose mixed amphetamine salts--extended release on processing speed in multiple sclerosis: a double blind placebo controlled study

RATIONALE

Multiple sclerosis (MS) commonly affects cognitive function, most frequently presenting as impaired processing speed (PS). There are currently no approved treatments for PS in this population, but previous studies suggest amphetamines may be beneficial.

OBJECTIVE

The objective of this study is to determine if mixed amphetamine salts, extended release (MAS-XR) has the potential to improve impaired PS in MS patients in a randomized controlled pre- and post-dose testing study.

METHODS

Fifty-two MS patients demonstrating PS impairment on either the Symbol Digit Modalities Test (SDMT) or Paced Auditory Serial Addition Test (PASAT) were randomized to a single dose of 5 mg MAS-XR (n = 18), 10 mg MAS-XR (n = 20), or placebo (n = 14). Subjects were evaluated a second time, after taking the blinded medication. ANOVA was used to compare the change on the SDMT and PASAT in each of the treatment groups compared to the placebo. Cohen's d was used to calculate effect size.

RESULTS

At baseline, the mean SDMT score was 43.3 ± 7.2 and the mean PASAT was 34.8 ± 13.4, with 47 (90.4 %) and 25 (48.1 %) categorized as impaired on the SDMT and PASAT, respectively. The change in SDMT scores from baseline to post-treatment demonstrated significant improvement for the MAS-XR 10-mg dose compared to placebo, increasing by 5.2 ± 4.5 vs. 0.6 ± 4.4 points (p = 0.043), with a medium effect size of 0.47. Change on the PASAT was not significantly different in either treatment group.

CONCLUSIONS

This study supports MAS-XR 10 mg as a potential treatment for MS patients with demonstrated PS impairment, warranting a larger longitudinal study.

Beyond depression: Predictors of self-reported cognitive function in adults living with MS

OBJECTIVE

To investigate the association between self-reported cognition and demographic/psychosocial variables in individuals with a self-reported diagnosis of multiple sclerosis (MS).

DESIGN

Secondary longitudinal analysis of mailed self-report surveys over a period of 2 years.

SETTING

Community.

PARTICIPANTS

407 community-dwelling individuals from the Pacific Northwest with a self-reported diagnosis of MS.

MAIN OUTCOME MEASURES

Subjective general cognitive concerns and subjective executive difficulties as measured by the Neuro-QOL Applied Cognition-Executive Function-Short Form (SF) and the Applied Cognition-General Concerns-SF.

RESULTS

Univariate and multiple linear regression analyses were used to identify statistically significant longitudinal predictors of perceived cognitive difficulties 2 years later. Fatigue and anxiety were statistically significant predictors of general cognitive concerns. Fatigue and perceived stress were statistically significant predictors of perceived executive difficulties. Fatigue was the strongest predictor in both models.

CONCLUSIONS

In MS, perceived cognitive impairment is frequently linked to depression without consideration of other possible contributors. This study suggests that in people with MS, fatigue is a stronger predictor of self-reported cognitive function 2 years later than depression.

Self-assessment in schizophrenia: Accuracy of evaluation of cognition and everyday functioning

OBJECTIVE

Self-assessment deficits, often referred to as impaired insight or unawareness of illness, are well established in people with schizophrenia. There are multiple levels of awareness, including awareness of symptoms, functional deficits, cognitive impairments, and the ability to monitor cognitive and functional performance in an ongoing manner. The present study aimed to evaluate the comparative predictive value of each aspect of awareness on the levels of everyday functioning in people with schizophrenia.

METHOD

We examined multiple aspects of self-assessment of functioning in 214 people with schizophrenia. We also collected information on everyday functioning rated by high contact clinicians and examined the importance of self-assessment for the prediction of real-world functional outcomes. The relative impact of performance-based measures of cognition, functional capacity, and metacognitive performance on everyday functioning was also examined.

RESULTS

Misestimation of ability emerged as the strongest predictor of real-world functioning and exceeded the influences of cognitive performance, functional capacity performance, and performance-based assessment of metacognitive monitoring. The relative contribution of the factors other than self-assessment varied according to which domain of everyday functioning was being examined, but, in all cases, accounted for less predictive variance.

CONCLUSION

These results underscore the functional impact of misestimating one's current functioning and relative level of ability. These findings are consistent with the use of insight-focused treatments and compensatory strategies designed to increase self-awareness in multiple functional domains.

Cognitive impairment in multiple sclerosis: clinical, radiologic and pathologic insights

Cognitive impairment is a common and debilitating feature of multiple sclerosis (MS) that has only recent gained considerable attention. Clinical neuropsychological studies have made apparent the multifaceted nature of cognitive troubles often encountered in MS and continue to broaden our understanding of its complexity. Radiographic studies have started to decipher the neuroanatomic substrate of MS-related cognitive impairment and have shed light onto its pathogenesis. Where radiographic studies have been limited by inadequate resolution or non-specificity, pathological studies have come to the fore. This review aims to provide an overview of the nature of cognitive impairment typically seen in MS and to explore the literature on imaging and pathological studies relevant to its evolution. In particular, the relative contributions of gray (i.e., cerebral cortex, hippocampus, thalamus and basal ganglia) and white matter to MS-related cognitive impairment will be discussed and the importance of interconnectivity between structures highlighted. The pressing need for longitudinal studies combining standardized neuropsychometric, paraclinical and radiographic outcomes obtained during life with post-mortem tissue analysis after death is presented.

Relationship between subjective and objective cognitive performance in multiple sclerosis

OBJECTIVES

Self- and informant reports of patients' cognitive performance are an important source of information for clinicians to consider in neuropsychological evaluation. The aim of the study was to find out whether the relationship between subjective or informant observations of cognitive deterioration and objective cognitive performance differ in patients with relapsing and progressive multiple sclerosis (MS).

MATERIALS & METHODS

One ninety-six MS patients (relapsing-remitting n = 138; progressive n = 58) underwent neuropsychological assessment with the Brief Repeatable Battery of Neuropsychological Tests. Subjective and informant-reported cognitive symptoms, mood, impact of the disease, and quality of life were evaluated with self-reports. According to consistency of evaluations, patients and informants were classified as accurate estimators (consistent subjective and objective cognitive performance), underestimators (subjectively but not objectively cognitively impaired), or overestimators (objectively but not subjectively cognitively impaired).

RESULTS

Patients' and informants' reports on patients' cognitive performance were approximately equally appropriate, slightly over half being accurate. Mood was associated with patients' subjective cognitive complaints. The relapsing group reported more subjective cognitive symptoms than the progressive group, although the objective cognitive performance did not differ between the groups. Overestimation occurred especially among patients with more severe physical disability, progressive phenotype of the disease, more pronounced cognitive impairment, and less education.

CONCLUSIONS

Slightly over half of patient and informant observations of cognitive deterioration were appropriate. Patients with progressive phenotype were more prone to overestimation than patients with relapsing phenotype.

Cognition, functional capacity, and self-reported disability in women with posttraumatic stress disorder: examining the convergence of performance-based measures and self-reports

Individuals with posttraumatic stress disorder (PTSD) experience cognitive impairments and disability in everyday activities. In other neuropsychiatric disorders, impairments in cognition and functional capacity (i.e., the ability to perform everyday tasks) are associated with impairments in real-world functioning, independent of symptom severity. To date, no studies of functional capacity have been conducted in PTSD. Seventy-three women with moderate to severe PTSD underwent assessment with measures of cognition (MATRICS Consensus Cognitive Battery: MCCB), functional capacity (UCSD Performance-Based Skills Assessment-Brief: UPSA-B), PTSD (Clinician-Administered PTSD Scale and PTSD Symptom Scale-Self-report (PSS-SR)), and depression (Montgomery Asberg Depression Rating Scale). Patients also reported their subjective level of disability (Sheehan Disability Scale). Over-reporting of symptom severity was assessed using six validity items embedded within the PSS-SR. Results indicated that on average PTSD patients manifested mild impairments on the functional capacity measure, performing about 1/3 standard deviation below healthy norms, and similar performance on the MCCB. Both clinician-rated and self-rated PTSD symptom severity correlated with self-reported disability but not with functional capacity. Self-reported disability did not correlate with functional capacity or cognition. Greater self-reported disability, depression, and PTSD symptoms all correlated with higher scores on the PSS-SR validity scale. The divergence between objective and subjective measures of disability suggests that individuals' distress, as indexed by symptom validity measures, may be impacting self-reports of disability. Future studies of disability should incorporate objective measures in order to obtain a broad perspective on functioning.

Toward the use of proxy reports for estimating long-term patient-reported outcomes in multiple sclerosis

BACKGROUND

Assessment of disease impact in multiple sclerosis (MS) is usually driven by information obtained directly from patients using patient-reported outcomes. However, when patients' response in longitudinal studies is less reliable or missing, proxy respondents may be used.

OBJECTIVE

The objective of this paper is to evaluate whether long-term patient scores can be reliably estimated using scores obtained from proxies.

METHODS

Baseline, six-month and two-year data were collected from 155 patients and proxies on the physical scale of the Multiple Sclerosis Impact Scale (MSIS-29). Linear regression analyses were performed with the patient two-year scores as outcome, proxy two-year scores as predictor and other variables that could contribute to a better prediction of the patient follow-up score.

RESULTS

The patient follow-up score could be predicted rather accurately (R(2) = 0.74) using the patient baseline score and the proxy follow-up score. The correlation between observed and predicted scores was 0.86. The model performed well in different follow-up durations and even better in an external cohort.

CONCLUSION

A simple model of a constant value (intercept), the patient baseline score and the proxy follow-up score can predict patients' follow-up score on the physical impact of MS.

Treatment Optimization in MS: Canadian MS Working Group Updated Recommendations

The Canadian Multiple Sclerosis Working Group (CMSWG) developed practical recommendations in 2004 to assist clinicians in optimizing the use of disease-modifying therapies (DMT) in patients with relapsing multiple sclerosis. The CMSWG convened to review how disease activity is assessed, propose a more current approach for assessing suboptimal response, and to suggest a scheme for switching or escalating treatment. Practical criteria for relapses, Expanded Disability Status Scale (EDSS) progression and MRI were developed to classify the clinical level of concern as Low, Medium and High. The group concluded that a change in treatment may be considered in any RRMS patient if there is a high level of concern in any one domain (relapses, progression or MRI), a medium level of concern in any two domains, or a low level of concern in all three domains. These recommendations for assessing treatment response should assist clinicians in making more rational choices in their management of relapsing MS patients.

Changing definitions of euphoria in multiple sclerosis: A short report

A recent interest in euphoria in multiple sclerosis (MS) has resulted in a wealth of literature on this topic. However, a marked change in the definition of this symptom appears to have taken place since its first descriptions in the mid-19(th) century. This short report will demonstrate that the 'euphoria' being studied today may not be the same state as that originally observed and described in MS patients and some implications of this possibility are discussed.

Do patient and proxy agree? Long-term changes in multiple sclerosis physical impact and walking ability on patient-reported outcome scales

Background:

Patient-reported outcome scales (PROs) are useful in monitoring changes in multiple sclerosis (MS) over time. Although these scales are reliable and valid measures in longitudinal studies in MS patients, it is unknown what the impact is when obtaining longitudinal data from proxies.

Objective:

The objective of this paper is to compare longitudinal changes in patient and proxy responses on PROs assessing physical impact of MS and walking ability.

Methods:

In a prospective observational study, data on the Multiple Sclerosis Impact Scale (MSIS-29 physical) and Multiple Sclerosis Walking Scale (MSWS-12) were obtained from 137 patient-proxy couples at baseline and at two-year follow-up. Demographic and disease-related variables explaining agreement or disagreement between patients and proxies were investigated using linear regression analyses.

Results:

Full agreement was found in 56% (MSIS) and 62% (MSWS) of the patient-proxy couples. Complete disagreement was very rare for both scales (2% MSIS, 5% MSWS). When patients were more positive than proxies, a higher age, longer disease duration, longer patient-proxy relationship and increased levels of depression, anxiety and caregiver burden in proxies were observed.

Conclusion:

In the majority of the patient-proxy couples there was agreement. Proxies can serve as a valuable source of information, but caution remains essential when using scores from proxies.