Perceived cognitive dysfunction and observed neuropsychological performance: longitudinal relation in persons with multiple sclerosis

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.

Association between frailty and sleep quality in people living with multiple sclerosis and obesity: An observational cross-sectional study

BACKGROUND

A majority of the people with multiple sclerosis (pwMS) experience sleep disturbances. Frailty is also common in pwMS. The geriatric literature strongly suggests that frailty is associated with worse sleep outcomes in community-dwelling older adults, but this association has yet to be explored among pwMS. This study focused on examining the association between frailty and sleep quality in pwMS.

METHODS

Seventy-six people with both MS and obesity (mean age: 47.6 ± 10.9 years, 81.6 % female, mean body mass index (BMI): 37.10 ± 5.5 kg/m2, mean Patient Determined Disease Steps (PDDS): 0.82 ± 1.20) were included in this cross-sectional secondary analysis. A comprehensive frailty index (FI) based on 41 health deficits from various health domains was calculated based on standardized procedures. Sleep quality was determined by the Pittsburgh Sleep Quality Index questionnaire (PSQI).

RESULTS

Overall, 67.1 % of the participants were identified as non-frail (FI ≤ 0.25), and 32.9 % were identified as frail (FI > 0.25). A significant correlation was observed between FI scores and global PSQI scores (ρ = 0.43, p < 0.05). Cross-tabulation analyses revealed that frail participants had worse subjective sleep quality, sleep latency, habitual sleep efficiency, sleep disturbances, daytime dysfunction, and higher use of sleep medications compared to non-frail participants (p < 0.05).

CONCLUSIONS

The current study identified a significant association between frailty and sleep quality in people with both MS and obesity with minimal disability. These findings underscore the importance of untangling the relationship between frailty and sleep quality in pwMS. These results could lead to a more targeted approach for rehabilitation interventions aiming to improve frailty in MS.

Low growth hormone secretion associated with post-acute sequelae SARS-CoV-2 infection (PASC) neurologic symptoms: A case-control pilot study

OBJECTIVE

To determine if patients that develop lingering neurologic symptoms of fatigue and "brain fog" after initial recovery from coronavirus disease 2019 (COVID-19) have persistent low growth hormone (GH) secretion as seen in other conditions with similar symptom etiology.

DESIGN

In this case-control observational pilot study, patients reporting lingering neurologic post-acute sequelae of SARS-CoV-2 (PASC, n = 10) symptoms at least 6 months after initial infection were compared to patients that recovered from COVID-19 without lingering symptoms (non-PASC, n = 13). We compared basic blood chemistry and select metabolites, lipids, hormones, inflammatory markers, and vitamins between groups. PASC and non-PASC subjects were tested for neurocognition and GH secretion, and given questionnaires to assess symptom severity. PASC subjects were also tested for glucose tolerance and adrenal function.

RESULTS

PASC subjects reported significantly worse fatigue, sleep quality, depression, quality of life, and gastrointestinal discomfort compared to non-PASC. Although PASC subjects self-reported poor mental resilience, cognitive testing did not reveal significant differences between groups. Neurologic PASC symptoms were not linked to inflammatory markers or adrenal insufficiency, but were associated with reduced growth hormone secretion.

CONCLUSIONS

Neurologic PASC symptoms are associated with gastrointestinal discomfort and persistent disruption of GH secretion following recovery from acute COVID-19. (www.

CLINICALTRIALS

gov; NCT04860869).

Cognitive impairment in people with multiple sclerosis: Perception vs. performance - factors that drive perception of impairment differ for patients and clinicians

BACKGROUND

Neurologists' perceptions of the presence of cognitive impairment (CI) in people with multiple sclerosis (PwMS) may not always align with findings of objective cognitive assessment. The accuracy of self-reported CI in PwMS can also be highly variable across individuals, and may not align with objective measurement of cognitive disturbances. Research suggests that additional factors impact perceived cognitive ability, such as depression and fatigue. Objective cognitive screening regardless of patient or neurologist perception has been recommended but still is often limited in routine care. Moreover, comprehensive neuropsychological assessment is even less routinely done.

OBJECTIVE

To explore how neurologists' perceptions of PwMS' CI compare to the perception of the patient by determining whether PwMS and their clinicians are accurate in detecting the presence and degree of CI as defined by a multi-domain validated computerized test battery in PwMS, as well as investigate what factors influence perception of CI in each group.

METHODS

PwMS completed a computerized multi-domain cognitive testing battery, and self-reported measures of disease impact (MSIS-29), fatigue (MFIS), and depression (BDI-II). Disability was assessed by the clinician using the Expanded Disability Status Scale (EDSS). Clinicians and patients also provided an estimation of cognitive deficits along a Likert scale.

RESULTS

In this cohort of PwMS (N=202, age range: 20 to 88, gender: 71% female), their level of accuracy in detecting attention deficits (k = -.028, p = .010) was low but statistically significant. In contrast, clinicians' accuracy in detecting global CI (k = -.037, p < .001) and a number of specific domain deficits was moderate. Fatigue (p < .001) and cognitive performance (p = .012) significantly predicted patient perceived cognitive deficits. Clinician perceived cognitive performance was significantly predicted by multiple factors: cognitive scores (p < .001), physical disability (p = .011), age (p = .021), and depression (p = .038).

CONCLUSION

The need to objectively screen for CI in PwMS, regardless of perception, can be aided by a better understanding of the agreement and discrepancies between the patient and clinician regarding perceived cognitive disturbances and the presence of CI defined by a multi-dimensional objective screening battery.

The effect of intravenous ketamine on cognitive functions in adults with treatment-resistant major depressive or bipolar disorders: Results from the Canadian rapid treatment center of excellence (CRTCE)

Ketamine may exert pro-cognitive effects on select measures of cognition in adults with mood disorders. We evaluated the effectiveness of intravenous (IV) ketamine on cognition in 68 adult outpatients with treatment-resistant depression (TRD) at the Canadian Rapid Treatment Center of Excellence between July 3, 2018 and April 16, 2020 (NCT04209296). Eligibility criteria for the present retrospective study included: primary diagnosis of major depressive or bipolar disorder; currently depressed; and insufficient response to two or more prior treatments. Participants received four infusions of ketamine hydrochloride (0.5-0.75 mg/kg) over 1-2 weeks. We assessed objective and subjective measures of cognition before and after two infusions, i.e., Digit Symbol Substitution Test (DSST), Trail Making Test-B (TMT-B), Patient Deficits Questionnaire, 5-item (PDQ-5-D). Ketamine significantly improved DSST (effect size [ES]=0.60), TMT-B (ES=0.84), as well as PDQ-5-D scores (ES=0.63), indicative of a moderate-to-large effect size. Improvements in DSST and PDQ-5-D with ketamine were mediated by reductions in depressive symptoms, whereas improvements in TMT-B were independent of changes in depressive symptoms. Our results support the independent, rapid-onset, pro-cognitive effects with IV ketamine in adults with TRD. Larger, randomized, controlled trials with ketamine wherein cognition is the primary outcome measure in mood and non-mood disorder samples are warranted.

Self-awareness in multiple sclerosis: Relationships with executive functions and affect

BACKGROUND AND OBJECTIVES

Deficits in self-awareness can be observed in persons with multiple sclerosis (pwMS). The present study aimed to investigate two types of self-awareness (intellectual and online) among pwMS, which will inform clinical care. Intellectual awareness refers to knowledge of one's own abilities; online awareness refers to real-time monitoring and regulation of one's performance.

METHODS

The study sample consisted of 95 pwMS and 65 healthy controls (HCs). Intellectual awareness was defined as discrepancy between participant's and informant's reports of participant's functioning. Online awareness was operationalized by change in self-assessment of performance after engaging in a functional task.

RESULTS

PwMS had significantly worse intellectual awareness than HCs regarding money management (confidence interval [CI] 0.44 to 1.99), task performance (CI -0.01 to 2.5), social interaction (CI 0.29 to 2.45), and problem solving (CI 0.87 to 2.8) abilities, but not sensory symptoms. Executive functioning was positively associated with intellectual awareness in HCs, while depressive and anxiety symptoms were negatively related to intellectual awareness in pwMS. In contrast, online awareness was not significantly different between groups; both groups were able accurately to assess their performance after engaging in a functional task.

CONCLUSIONS

Intellectual awareness, but not online awareness, is impaired in pwMS. Among pwMS, affective symptomatology may distort their perception of functional status. Persons with MS may benefit from actually performing a functional task during the assessment and treatment process, which may lead to a more accurate estimate of their own abilities.

How personality traits affect functional outcomes in patients with multiple sclerosis: A scoping review on a poorly understood topic

Personality is an important variable when explaining individual differences in disease acceptance, coping styles and psychological well-being. Personality changes, such as social inadequacy, disinhibition, apathy, emotional lability, and impulsivity, have been reported in many patients with multiple sclerosis (MS). This review sought to assess the role of personality traits in people with MS, focusing on how this may affect the patient's outcome. Studies were identified by searching on PubMed, Web Of Science and Cochrane databases. Our review shows that the personality traits commonly found in MS are often dysfunctional. In particular, it has been suggested that people with MS present with lower levels of conscientiousness, extraversion and agreeableness, as well as higher levels of neuroticism than healthy controls. These personality traits negatively affect cognitive domains, mood, and psychological well-being. As personality may affect the clinical manifestations and disabilities of patients with MS, personality assessment should be an integral part of the management of the disease, in order to achieve better functional outcomes.

On the nature of objective and perceived cognitive impairments in depressive symptoms and real-world functioning in young adults

Cognitive impairments in depression contribute to disability. According to prevailing cognitive theories, one's perception related to cognitive ability can cause and maintain depression, and related outcomes. Here, we investigate the degree to which perceived cognitive impairment predicts functional impairment above and beyond objective neurocognition. A sample of young adults (n = 123) completed a battery of tests measuring objective cognitive ability, perceived cognitive function (e.g., Perceived Deficits Questionnaire), disability (e.g., World Health Organization Disability Assessment Schedule) and depressive symptoms (Beck Depression Inventory-2). Hierarchical multiple regression analyses tested the incremental variance that perceived cognitive impairment accounts for above and beyond neuropsychological test measures and disability related to depression. Results show that perceived cognitive impairment accounts for significant incremental variance in depressive symptoms beyond neuropsychological test scores; disability measures were significantly associated with depressive symptoms, as was perceived cognitive impairment. Individuals with depression and related disorders are more likely to report cognitive impairments and experience diminished cognitive ability - relative to healthy controls - regardless of objective impairments, highlighting the importance of considering, measuring, and treating this perceived cognitive impairment, that is, Cognitive Impairment Bias (Dhillon and Zakzanis, 2019).

The rate of neuropsychological assessments in multiple sclerosis has increased-A retrospective study in a Finnish Central Hospital

OBJECTIVE

To investigate possible changes in the rate of conducted neuropsychological assessments and rehabilitation process for patients with multiple sclerosis (pwMS) during the last two decades. The change in the rate of vocational rehabilitation process was also evaluated.

BACKGROUND

Cognitive deficits are frequent among pwMS and negatively affect patients' working ability and quality of life. Preliminary evidence suggests that neuropsychological rehabilitation positively affects cognitive symptoms. Vocational approaches are widely recommended for pwMS.

METHODS

A retrospective survey of all multiple sclerosis (MS) patients diagnosed and treated at the Department of Neurology in Kanta-Häme Central Hospital over the period 1988-2013 was conducted using hospital records. The rate of neuropsychological assessment and rehabilitation processes as well as vocational rehabilitation processes were evaluated.

RESULTS

A total of 417 pwMS were identified. A neuropsychological assessment was performed for 104 (24.9%) of these patients, of whom 21 (20.2%) were evaluated between 1988 and 1999 and 83 (79.8%) between 2000 and 2013. Of the 417 patients, eight (1.9%) received neuropsychological rehabilitation, each of these after the year 2000. Only 25 (6.0%) of the 417 pwMS received vocational rehabilitation. Fourteen (56.0%) of the 25 patients received vocational rehabilitation between 1988 and 1999 and 11 (44.0%) between 2000 and 2013.

CONCLUSIONS

Neuropsychological assessment has been a rarity in MS in Finland, but a marked increase in frequency has occurred since the year 2000. Although understanding of MS-related cognitive impairment and its impact on working ability has increased, the rate of neuropsychological and vocational rehabilitation has remained low.

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.

Cognitive Impairments and Subjective Cognitive Complaints in Fabry Disease: A Nationwide Study and Review of the Literature

Fabry disease is a rare progressive X-linked lysosomal storage disorder which leads to neuropathic pain, organ dysfunction and cerebral pathology. Few studies have investigated cognitive impairment in Fabry disease and these previous studies are difficult to compare due to heterogeneous methodological designs and small cohorts. The objective was to investigate the frequency of cognitive impairment in the Danish nationwide cohort of Fabry patients. Further, we examined if subjective cognitive complaints were associated with objective cognitive performances in this patient group. Neuropsychological tests (17 measures) and evaluation of subjective complaints with the Perceived Deficits Questionnaire (PDQ) were applied in 41 of 63 patients. According to an a priori definition, 12 patients (29.3%) were cognitively impaired. Tests tapping psychomotor speed, attention and executive functions had the highest frequency of impairment. In general, disease related variables as Mainz Severity Score Index, enzyme activity and years since onset and depression did not have a significant impact on the categorisation of patients as being cognitively impaired or non-impaired. Thus, cognitive impairment in Fabry disease does not seem to occur solely by having symptoms for many years or by having high disease burden. However, impaired neuropsychological test results were significantly more common in patients with cerebrovascular disease. Only three patients had scores in the abnormal range of the PDQ scale and subjective perceptions of cognition were not associated with cognitive performances. The levels of subjective cognitive complaints were generally very low in the studied patients demonstrating that the absence of subjective cognitive complaints does not exclude the presence of objective cognitive problems.

The state of multiple sclerosis: current insight into the patient/health care provider relationship, treatment challenges, and satisfaction

BACKGROUND

Managing multiple sclerosis (MS) treatment presents challenges for both patients and health care professionals. Effective communication between patients with MS and their neurologist is important for improving clinical outcomes and quality of life.

METHODS

A closed-ended online market research survey was used to assess the current state of MS care from the perspective of both patients with MS (≥18 years of age) and neurologists who treat MS from Europe and the US and to gain insight into perceptions of treatment expectations/goals, treatment decisions, treatment challenges, communication, and satisfaction with care, based on current clinical practice.

RESULTS

A total of 900 neurologists and 982 patients completed the survey, of whom 46% self-identified as having remitting-relapsing MS, 29% secondary progressive MS, and 11% primary progressive MS. Overall, patients felt satisfied with their disease-modifying therapy (DMT); satisfaction related to comfort in speaking with their neurologist and participation in their DMT decision-making process. Patients who self-identified as having relapsing-remitting MS were more likely to be very satisfied with their treatment. Top challenges identified by patients in managing their DMT were cost, side effects/tolerability of treatment, and uncertainty if treatment was working. Half of the patients reported skipping doses, but only 68% told their health care provider that they did so.

CONCLUSION

Several important differences in perception were identified between patients and neurologists concerning treatment selection, satisfaction, expectations, goals, and comfort discussing symptoms, as well as treatment challenges and skipped doses. The study results emphasize that patient/neurologist communication and patient input into the treatment decision-making process likely influence patient satisfaction with treatment.

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.

Impact of the Cognitive Status on the Memory Complaints in MS Patients

Objective:

Despite the evidence of cognitive deficits in Multiple Sclerosis (MS) patients, evaluation of their cognitive integrity is often limited to the use of clinical interviews and questionnaires. However, the consensus in the literature is that these patients under- or overestimate their deficits and repercussions. The objective of this study was to clarify why some patients overestimate while others underestimate their memory deficits.

Method:

Fifty-four participants (30 MS, 24 controls) completed the Prospective and Retrospective Memory Questionnaire (PRMQ) and were tested on a battery of neuropsychological tests. Based on the test results, MS patients were categorized as having either mild or moderate/severe cognitive deficits.

Results:

The moderate/severe MS group differed from the two other groups on the Rey Auditory Verbal Learning Test (RAVLT) but did not differ from the control group on the PRMQ. Conversely, the mild MS group did not differ from the control group on the RAVLT but did report significantly more problems than this group on the PRMQ. There was no difference between the two clinical groups on the Depression Index (Beck) but there was a significant correlation (r=.409) between the depression scores and the overestimation of prospective memory problems (PRMQ).

Conclusion:

The results explain the contradiction in the literature. It is the mild group who overestimates, maybe because they are overly concerned by their deficits, whereas the cognitive impairments of the moderate/severe group lead them to underestimate and may make their self-assessment unreliable. Formal testing or information from a significant other would be advisable.

Perceived and Objective Attentional Deficits in Multiple Sclerosis

Abstract. Initially we assessed self-rated cognitive deficits, depression and quality of life in MS patients and healthy controls (n = 299) by an online survey. Secondly, attention performance of MS outpatients (n = 33) was objectively assessed by the Test battery for Attention Performance and the Symbol Digit Modalities Test. Overall, MS patients rated themselves significantly worse than controls in attentional functioning. This was reflected by a weak performance in objective tests of phasic alertness and divided attention of the MS patients compared to normative data. Subscales of subjective cognitive functioning in the online survey showed significant associations with objective measures after statistical controlling for depression (r = .370 to r = .517). Results show the differences in perceived cognitive performance between MS patients and healthy controls, and self-reported instrument are able to provide relevant information on complex attention performance and hereby on everyday functioning.

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.

Perceived cognitive difficulties and cognitive test performance as predictors of employment outcomes in people with multiple sclerosis

Perceived cognitive difficulties and cognitive impairment are important determinants of employment in people with multiple sclerosis (pwMS). However, it is not clear how they are related to adverse work outcomes and whether the relationship is influenced by depressive symptoms. Thus, this study examined perceived and actual general cognitive and prospective memory function, and cognitive appraisal accuracy, in relation to adverse work outcomes. The possible mediating and/or moderating role of depression was also examined. A cross-sectional community-based sample of 111 participants (33 males, 78 females) completed the Multiple Sclerosis Work Difficulties Questionnaire (MSWDQ), Beck Depression Inventory - Fast Screen (BDI-FS), and questions related to their current or past employment. They then underwent cognitive testing using the Screening Examination for Cognitive Impairment, Auditory Consonant Trigrams test, Zoo Map Test, and Cambridge Prospective Memory Test. Perceived general cognitive and prospective memory difficulties in the workplace and performance on the respective cognitive tests were found to predict unemployment and reduced work hours since MS diagnosis due to MS. Depression was also related to reduced work hours, but it did not explain the relationship between perceived cognitive difficulties and the work outcomes. Nor was it related to cognitive test performance. The results highlight a need to address the perceptions of cognitive difficulties together with cognitive impairment and levels of depression in vocational rehabilitation programs in pwMS.

Perceived cognitive decline in multiple sclerosis impacts quality of life independently of depression

Background/Aim. The aim of this study is to examine the effects of perceived cognitive dysfunction and of depression, on self-reported QoL, in a Greek population sample of MS patients. Methods. One hundred outpatients diagnosed with MS completed the Short-Form-36 Health Survey (SF-36), as well as the Perceived Deficits Questionnaire (PDQ) and the Depression subscale of the Mental Health Inventory (MHI), as part of a clinical evaluation which included the Expanded Disability Status Scale (EDSS) estimation. Multiple linear regression was conducted to determine the best linear combination of age, gender, education, EDSS, depression, attention/concentration, retrospective memory, prospective memory, and planning/organization, for predicting QoL scores. Results. In the multivariate regression analysis models, EDSS (P < 0.05), depression (P < 0.001), perceived planning/organization (P < 0.05), and perceived retrospective memory dysfunction (P < 0.05) independently predict quality of life scores. Age, sex, education level, and perceived attention/concentration dysfunction, as well as perceived prospective memory dysfunction, do not independently predict quality of life scores. Conclusions. Perceived planning/organization impairment and perceived retrospective memory impairment in MS patients predict QoL independently of the severity of disease and the severity of depression and therefore should be considered in the assessment of patient health status as well as in the design of treatment interventions and rehabilitation.

Tests of information processing speed: what do people with multiple sclerosis think about them?

Reduction in information processing speed (IPS) is a key deficit in multiple sclerosis (MS). The Paced Auditory Serial Addition Test (PASAT), Symbol Digit Modalities Test (SDMT), and Computerized Test of Information Processing (CTIP) are used to measure IPS. Both the PASAT and SDMT are sensitive to deficits in IPS. The CTIP, a newer task, also shows promise. The PASAT has several limitations, and it is often perceived negatively by patients. Yet little supporting quantitative evidence of such perceptions has been presented. Therefore, in this study, subjective ratings of likeability, difficulty, and appropriateness of the PASAT, CTIP, and SDMT were obtained. Ratings were compared between MS patients and healthy controls. It was hypothesized that ratings of the PASAT would differ significantly from those of the SDMT and CTIP. The relationship between subjective ratings and objective performance was evaluated. Sixty-nine MS patients and 68 matched controls rated the three tests in terms of likeability, difficulty, and appropriateness for capturing cognitive deficits often associated with MS using a Likert scale. Both groups rated the PASAT as most difficult and least likeable. The MS group rated the PASAT and SDMT as more appropriate for measuring MS-related deficits than the CTIP. Subjects who performed better on the PASAT were more likely to rate it as easier. Ratings of the SDMT and CTIP did not vary consistently with performance. The findings lend quantitative support to the common belief that the PASAT is perceived as unpleasant. Other tests are available that are similarly sensitive to deficits in IPS and more palatable to the patient.

Structural correlates of subjective and objective memory performance in multiple sclerosis

Subjective and objective memory deficits represent a frequent and ill-understood aspect of multiple sclerosis (MS), and a significant cause of disability and quality of life reduction. The aim of the study is to verify the role of hippocampal and temporal associative fibers' damage in MS-related memory complaints. To reach this aim, 25 patients with low disability relapsing-remitting MS and 19 healthy controls were included in the study. All subjects underwent 3D T1 structural imaging and Diffusion Tensor Imaging. Additionally, MS patients underwent neuropsychological evaluation of objective (Selective Reminding Test and Spatial Recall Test) and of subjective (Perceived Deficit Questionnaire, Retrospective and Prospective Memory Subscales) memory deficits. Normalized hippocampal volume (NHV) and mean Fractional Anisotropy (FA) for the uncinate fasciculus (UF) and for the ventral division of the cingulum bundle (VCB) were calculated for all subjects. We showed that, compared to controls, MS subjects presented with reduced right NHV and with reduced mean FA bilaterally in the UF and the VCB. In the MS group, verbal memory scores correlated with left NHV, spatial memory scores correlated with right NHV, while perceived retrospective and prospective memory deficits correlated with left VCB and left UF mean FA respectively. Our data confirm an early involvement of memory-related brain structures in MS patients. Our data suggest that verbal and nonverbal memory as well as perceived retrospective and prospective memory deficits are related to alterations of discrete anatomical structures in the low-disability phase of MS.

Neuropsychiatric manifestations of multiple sclerosis

Multiple sclerosis is one of the most frequently observed neurological causes of progressive disability in early to middle adulthood. The disease is variable in its presentation and course, affects roughly 100 to 300 per 100,000 persons within the US alone and is slightly more common among females than males. Multiple sclerosis places substantial burdens on patients, families and caregivers. Its presentation includes disturbances in cognitive abilities and psychiatric functioning, as well as motor difficulties. This article reviews the current literature on the neuropsychiatric manifestations of multiple sclerosis. Cognitive domains discussed include general cognitive functioning, learning and memory ability, attention, processing speed, executive functioning, visual perceptual ability and language functioning. Attention is also given to alterations in neuropsychiatric functioning associated with disease progression and across various disease subtypes. In addition, reports are also reviewed regarding various psychiatric disturbances, affective changes, quality of life issues and fatigue and pain in individuals with multiple sclerosis. Finally, factors pertaining to pediatric populations in multiple sclerosis are addressed.

Reports of patients and relatives from the CogniCIS study about cognition in clinically isolated syndrome: what are our patients telling us?

OBJECTIVE

To assess the Multiple Sclerosis Neuropsychological Questionnaire (MSNQ) in patients with clinically isolated syndrome (CIS).

METHODS

130 European CIS patients and 60 relatives completed the MSNQ.

RESULTS

The mean (SD) MSNQ score for CIS patients was 15.5 (10.8) and for their informants 11.3 (9.6). Neither the CIS patient nor relative MSNQ report scores correlated with any of the cognitive test scores in the Brief Repeatable Battery of Neuropsychological Tests, but they were significantly related to psychosocial scales including depression.

CONCLUSIONS

In CIS, patient and relative MSNQ scores are influenced by psychosocial variables rather than actual objective cognitive status. Formal cognitive test assessment is recommended for CIS patients.

Work capacity and health-related quality of life among individuals with multiple sclerosis reduced by fatigue: a cross-sectional study

BACKGROUND

Among individuals diagnosed with the chronic neurologic disease, multiple sclerosis (MS), a majority suffers from fatigue, which strongly influences their every-day-life. The aim of this study was to investigate work capacity and health-related quality of life (HRQoL) in a group of MS patients and also to investigate if work capacity and HRQoL could be predicted by background factors, fatigue, heat sensitivity, cognitive dysfunction, emotional distress or degree of disability.

METHODS

A descriptive, cross-sectional, designed survey was undertaken A questionnaire was sent to 323 individuals diagnosed with MS, aged between 20 and 65 years, with physical disability on the expanded disability status score (EDSS) in the interval 0 ≥ EDSS ≤ 6.5, living in Östergötland county in eastern Sweden. Questions on background factors, occupation and work, together with the health-related quality of life short form instrument (SF-36), the fatigue severity scale (FSS), the perceived deficit questionnaire (PDQ) and the hospital anxiety depression scale (HAD) were posed. Associations between variables were analyzed using Pearson's and Spearman's correlations. Differences between groups were tested using the Chi-square test, the Mann Whitney U-test, and the Student's t-test. Predictive factors were analyzed using multiple linear and multiple logistic regression analysis.

RESULTS

Of those who completed the questionnaire (n = 257, 79.6%), 59.8% were working. Work capacity was found significantly more among men (p < 0.005), those with a higher level of education (p < 0.001), those reporting less fatigue (p < 0.001), and those having no heat sensitivity (p = 0.004). For work capacity, significant predictors were low physical disability (EDSS), low fatigue, higher level of education, male sex and lower age. Those with work capacity showed significantly higher HRQoL than those who had no work capacity (p < 0.001). Levels of fatigue, cognition and emotional distress were found to be major contributing factors for HRQoL.

CONCLUSIONS

Work capacity and HRQoL among individuals diagnosed with MS are highly influenced by fatigue which can be considered as a key symptom. Work capacity was influenced by heat-sensitivity, cognitive difficulties and emotional distress and significant predictive factors besides fatigue, were physical disability (EDSS), age, sex, and level of education. Remaining at work also gives a better HRQoL.

Assessment of cognition using the Rao's Brief Repeatable Battery of Neuropsychological Tests on a group of Brazilian patients with multiple sclerosis

To assess the cognition of patients with multiple sclerosis (MS) using the Rao's Brief Repeatable Battery of Neuropsychological Tests (BRB-N).

METHOD

BRB-N was translated and adapted for control subjects. Subsequently, it was applied to a group of patients with relapsing-remitting (RR) MS.

RESULTS

The assessment on the healthy controls (n=47) showed that the correlation between tests on the same cognitive domain was high and that there was a five-factor solution that explained 90% of the total variance. Except for the Word List Generation subset of tests, the performance of patients with RRMS (n=39) was worse than that of the healthy controls.

CONCLUSION

BRB-N is a relatively simple method to assess cognition of patients with MS in the daily clinic. It does not take long to apply and does not require special skills or equipment.

Evaluating cognitive outcome measures for MS clinical trials: what is a clinically meaningful change?

Brief cognitive assessments are increasingly emphasized in MS treatment studies and clinical care. While much is known about the reliability of several widely-used neuropsychological tests, interpretation of the changes in individual patients is inadequate. The FDA offers guidance on the issue, as related to patient-reported outcomes. Unfortunately, cognitive ability is only weakly correlated with the frequency and severity of self-reported cognitive problems. In this review, we critically examined the psychometrics of neuropsychological testing in MS, emphasizing statistical and anchor-based approaches to interpreting clinically meaningful change. We suggest that there are two paths forward that should be currently pursued. First, to employ co-primary outcomes, including a brief cognitive test and a clinician or observer's impression on a scale of change, where successful treatment would require showing significant improvement in both measures. Secondly, to work toward showing that when reliable brief cognitive tests are employed, increments of statistically-relevant change would correlate with changes in clinically-relevant anchors (such as vocational disability or clinical relapses with cognitive impairment). The latter goal will allow a more parsimonious and scientifically efficient approach of utilizing only the brief cognitive test as a primary outcome. While some progress has been made in this direction, more research is needed. We are of the opinion that data from both the statistical and clinically meaningful approaches will be necessary to develop valid definitions of meaningful change on cognitive outcome measures, and that it would be best to pursue research using tests that already have well-established reliability and validity.

Self-assessment of cognition in Multiple Sclerosis: the role of personality and anxiety

OBJECTIVE

: To investigate the role of personality and anxiety to self-report measures of cognition in patients with multiple sclerosis (MS).

BACKGROUND

: Self-report measures of cognition have consistently been shown to correlate better with depressed mood than neuropsychological test performance in patients with MS, with few studies focusing on the role of anxiety and personality.

METHOD

: One hundred eight MS patients completed the following: (a) patient and informant report Multiple Sclerosis Neuropsychological Questionnaire (MSNQ); (b) Hospital Anxiety and Depression Scale; (c) cognitive assessment with the Brief Repeatable Battery of Neuropsychological Tests; and (d) personality assessment using the self-report NEO Five-Factor Inventory.

RESULTS

: Higher patient MSNQ (P-MSNQ) scores (greater reported cognitive dysfunction) were significantly correlated with lower scores on the Paced Auditory Serial Addition Test (PASAT; r=-0.20, P<0.05), increased depression (r=0.45, P<0.01) and anxiety (r=0.54, P<0.01), higher neuroticism (r=0.51, P<0.01), and lower conscientiousness (r=-0.35, P<0.01). After controlling for demographic variables, significant predictors of P-MSNQ scores were anxiety (ΔR=0.272, P<0.001), conscientiousness (ΔR=0.067, P=0.002), and performance on the PASAT (ΔR=0.050, P=0.005). Depression and neuroticism did not contribute significant variance in comparison to anxiety.

CONCLUSIONS

: Overall, patient self-reports of cognition did not correspond well to neuropsychological performance. Anxiety and conscientiousness contributed significantly to patients' perceptions of their cognitive failings and thus should be taken into account when addressing these complaints.

Do subjective cognitive complaints correlate with cognitive impairment in systemic lupus erythematosus? A Danish outpatient study

This study examined the prevalence of cognitive impairment and its association with depressive symptoms and self-reported cognitive complaints in Danish outpatients with systemic lupus erythematosus (SLE). Fifty-seven consecutive female SLE-outpatients were examined with a comprehensive neuropsychological test-battery, a 20-item self-administered Perceived Deficits Questionnaire (PDQ) and a self-rated depression scale (Major Depression Inventory). Twenty-two patients (38.5%) were classified as cognitively impaired, mostly with deficits in executive functions and attention. Among cognitively impaired patients only 18.2% had significantly higher PDQ scores than the normal range. PDQ scores were highly correlated to depressive symptoms (r = 0.67, p < 0.001). Only two neuropsychological tests were significantly correlated with subjective cognitive complaints. When these variables and self-rated depression score were entered into a regression model both depression score and Symbol Digit Modalities Test performances were significantly associated with the PDQ score. In conclusion, cognitive impairments were common in this group of (mild) SLE outpatients, but the level of significant subjective cognitive complaints was low even among patients with cognitive impairment. Affective status may influence subjective experience of cognitive functions even more than cognitive functioning itself, and absence of subjective cognitive complaints did not exclude the presence of cognitive impairments.

Self-reported cognitive functioning in postmenopausal breast cancer patients before and during endocrine treatment: findings from the neuropsychological TEAM side-study

OBJECTIVE

This study aimed to evaluate self-reported cognitive functioning of postmenopausal breast cancer patients before and during endocrine treatment compared with healthy female controls, and to investigate associations between self-reported cognitive functioning, cognitive test performance and anxiety/depression, fatigue, and menopausal complaints.

METHODS

Self-reported cognitive functioning, anxiety/depression, fatigue, menopausal complaints, and cognitive tests performance were assessed before (T1) and after 1 year (T2) of adjuvant endocrine treatment in postmenopausal chemotherapy-naïve breast cancer patients. Self-reported cognitive functioning was assessed by the cognitive failures questionnaire and interview questions concerning cognitive complaints. Patients participated in the TEAM-trial, a prospective randomized study investigating tamoxifen versus exemestane as adjuvant therapy for hormone-sensitive breast cancer. Identical information was obtained from healthy postmenopausal volunteers.

RESULTS

Two measures for self-reported cognitive functioning provided the distinctive results. At T1 and T2, healthy controls reported a higher frequency of cognitive failures than patients; change over time did not differ between groups. The prevalence of cognitive complaints did not differ between the groups at T1, but change over time regarding attention/concentration complaints differed between groups, due to an increased prevalence in tamoxifen users. Self-reported cognitive functioning showed moderate associations with anxiety/depression, fatigue, and menopausal complaints. Cognitive test performance was not associated with self-reported cognitive functioning, but weakly with anxiety/depression and fatigue.

CONCLUSION

Adjuvant therapy with tamoxifen and exemestane did not influence the self-reported frequency of cognitive failures. Increased attention/concentration complaints were observed in tamoxifen users, but not in exemestane users. This latter finding should be confirmed with better validated instruments.

Parent-perceived child cognitive function: results from a sample drawn from the US general population

PURPOSES

This paper reports the development and evaluation of a perceived cognitive function (pedsPCF) item bank reported by parents of the pediatric US general population.

METHODS

Based on feedback from clinicians, parents, and children, we developed a scale sampling concerns related to children's cognitive functioning. We administered the scale to 1,409 parents of children aged 7-17 years; of them, 319 had a neurological diagnosis. Dimensionality of the pedsPCF was evaluated via factor analyses and its clinical utility studied by comparing parent ratings in patient groups and symptom cluster defined by the Child Behavior Checklist (CBCL).

RESULTS

Forty-four of 45 items met criteria for unidimensionality. The pedsPCF significantly differentiated samples defined by medication use, repeated grades, special education status, neurologic diagnosis, and relevant symptom clusters with large effect sizes (>0.8). It can predicted children symptoms with the correction rates ranging 79-89%.

CONCLUSIONS

We have provided empirical support for the unidimensionality of the pedsPCF item bank and evidence for its potential clinical utility. The pedsPCF is a promising measurement tool to screen children for further comprehensive cognitive tests.

Relationship between depression, fatigue, subjective cognitive impairment, and objective neuropsychological functioning in patients with multiple sclerosis

OBJECTIVE

This study explored the influence of depression and fatigue on subjective cognitive complaints and objective neuropsychological impairment in patients with multiple sclerosis (MS).

METHODS

Data for this study were taken from a randomized controlled trial, comparing 16 weeks of telephone-administered cognitive-behavioral therapy and telephone-administered supportive emotion focused therapy for the treatment of depression. The sample includes 127 patients with MS. The following self-report measures were collected pre- and posttreatment: Perceived Deficits Questionnaire, Beck Depression Inventory-II, and Modified Fatigue Impact Scale. Measures of objective cognitive functioning and the Hamilton Rating Scale for Depression were administered over the telephone.

RESULTS

Our results showed that changes in depression and fatigue significantly predicted changes in subjective cognitive complaints from pre- to posttreatment, with patients perceiving fewer cognitive problems at posttreatment (beta = .36, p < .001 and beta = .61, p < .001, respectively). Changes in depression and fatigue were not significantly related to changes in objective neuropsychological performance. Improvements in depression and fatigue also predicted improved accuracy in perceiving cognitive abilities from pre- to posttreatment (OR = .77, p < .001 and OR = .90, p < .001, respectively).

CONCLUSIONS

The results of this study suggest that improvements in depression and fatigue through treatment do not influence objective neuropsychological performance in MS patients, but do relate to changes in subjective impairment. Furthermore, these changes improve patients' abilities to accurately perceive their cognitive functioning.

Cognitive deficits in multiple sclerosis: a systematic review

OBJECTIVE: To present the results of prospective and retrospective studies on multiple sclerosis patients cognitive dysfunctions, as well as to discuss the batteries of neuropsy- chological tests used in these investigations. METHOD: A systematic review was performed involving 40 studies published from 1997 to 2009, in PubMed, Scopus, Ovid, ISI Web of Knowledge, Scientific Electronic Library on line (Scielo) and Latin-American and Caribbean Center of Health Sciences Informations database. Clear description of multiple sclerosis patients cognitive deficits evaluation, study design, sample size; inclusion-exclusion and discontinuation criteria; instruments for neuropsychological evaluation, diagnostic methods, evaluated functions and detailed statistical analysis had been the inclusion criteria. RESULTS: There is consensus on cognitive impairment of multiple sclerosis patients, especially on memory, speed processing, executive function, attention and concentration domains. One has identified use of 23 batteries and 74 neuropsychological tests, despite the recommendation of Consortium of Multiple Sclerosis Centers to the application of MACFIMS battery. CONSIDERATIONS: The absence of the uniformization for multiple sclerosis patients cognitive evaluation battery has precluded to achieve evidences to recommend its incorporation on diagnostic routine. Nevertheless this tendency is already outlined.

Evaluating the dimensionality of perceived cognitive function

Decrements in cognitive function are common in cancer patients and other clinical populations. As direct neuropsychological testing is often not feasible or affordable, there is potential utility in screening for deficits that may warrant a more comprehensive neuropsychological assessment. Furthermore, some evidence suggests that perceived cognitive function (PCF) is independently associated with structural and functional changes on neuroimagery, and may precede more overt deficits. To appropriately measure PCF, one must understand its components and the underlying dimensional structure. The purpose of this study was to examine the dimensionality of PCF in people with cancer. The sample included 393 cancer patients from four clinical trials who completed a questionnaire consisting of the prioritized areas of concerns identified by patients and clinicians: self-reported mental acuity, concentration, memory, verbal fluency, and functional interference. Each area contained both negatively worded (i.e., deficit) and positively worded (i.e., capability) items. Data were analyzed by using Cronbach's alpha, item-total correlations, one-factor confirmatory factor analysis, and a bi-factor analysis model. Results indicated that perceived cognitive problem items are distinct from cognitive capability items, supporting a two-factor structure of PCF. Scoring of PCF based on these two factors should lead to improved assessment of PCF for people with cancer.

Three trail making tests for use in neuropsychological assessments with brief intertest intervals

Practice effects in serial neuropsychological assessment have led to the use of alternate forms to measure change in cognitive functioning. The construct validity of three variants of the Trail Making Test was explored over a 3-week period in a sample of 158 undergraduate students. Using confirmatory factor analysis, a two-factor (sequencing-shifting) model was identified to best represent the data. Latent means structural analysis indicated the absence of order effects, lending support for the construct validity of the three tests. The study provides evidence that the three tests can be offered as potential alternative instruments in serial assessment.

Validity of performance scales for disability assessment in multiple sclerosis

Researchers increasingly use self-reported health status assessments, but these require validation. Performance Scales (PS) is a self-report measure for multiple sclerosis (MS)-associated disability, assessing mobility, bowel/bladder, fatigue, sensory, vision, cognition, spasticity and hand function. The criterion validity of the total PS score was established using the Expanded Disability Status Scale (EDSS), but the construct and criterion validity of the individual subscales have not been established. We assessed the criterion and construct validity of the PS subscales. Forty-four patients with MS completed PS, and these criterion measurements: neurological examination (EDSS), the Multiple Sclerosis Functional Composite (MSFC), contrast acuity testing, and the Multiple Sclerosis Quality of Life Inventory. We assessed criterion and construct validity with Spearman rank correlations between PS subscales and the other measurements. PS correlated with the MSFC (r=-0.58, P<0.0001). The mobility, hand, vision, fatigue and bladder subscales correlated with their criterion measures (r=0.59-0.77, P<0.0001). The sensory subscale correlated weakly with the sensory functional system score (r=0.39, P=0.01 ), and the cognitive subscale did not correlate with the PASAT (r=-0.17, P=0.26). This study supports the criterion and construct validity of PS overall, and its mobility, hand, vision, fatigue, and bladder subscales. Further assessment of the cognitive, sensory and spasticity subscales is needed.