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Carlomagno V, Mirabella M, Lucchini M. Current Status of Oral Disease-Modifying Treatment Effects on Cognitive Outcomes in Multiple Sclerosis: A Scoping Review. Bioengineering (Basel) 2023; 10:848. [PMID: 37508875 PMCID: PMC10376579 DOI: 10.3390/bioengineering10070848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/30/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Cognitive impairment represents one of the most hidden and disabling clinical aspects of multiple sclerosis (MS). In this regard, the major challenges are represented by the need for a comprehensive and standardised cognitive evaluation of each patient, both at disease onset and during follow-up, and by the lack of clear-cut data on the effects of treatments. In the present review, we summarize the current evidence on the effects of the available oral disease-modifying treatments (DMTs) on cognitive outcome measures. MATERIALS AND METHODS In this systematised review, we extract all the studies that reported longitudinally acquired cognitive outcome data on oral DMTs in MS patients. RESULTS We found 29 studies that evaluated at least one oral DMT, including observational studies, randomised controlled trials, and their extension studies. Most of the studies (n = 20) evaluated sphingosine-1-phosphate (S1P) modulators, while we found seven studies on dimethyl fumarate, six on teriflunomide, and one on cladribine. The most frequently used cognitive outcome measures were SDMT and PASAT. Most of the studies reported substantial stability or mild improvement in cognitive outcomes in a short-time follow-up (duration of most studies ≤2 years). A few studies also reported MRI measures of brain atrophy. CONCLUSION Cognitive outcomes were evaluated only in a minority of prospective studies on oral DMTs in MS patients with variable findings. More solid and numerous data are present for the S1P modulators. A standardised cognitive evaluation remains a yet unmet need to better clarify the possible positive effect of oral DMTs on cognition.
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Affiliation(s)
- Vincenzo Carlomagno
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, 00168 Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Centro di ricerca Sclerosi Multipla (CERSM), 00168 Rome, Italy
| | - Massimiliano Mirabella
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, 00168 Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Centro di ricerca Sclerosi Multipla (CERSM), 00168 Rome, Italy
| | - Matteo Lucchini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, 00168 Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Centro di ricerca Sclerosi Multipla (CERSM), 00168 Rome, Italy
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2
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De Meo E, Portaccio E, Giorgio A, Ruano L, Goretti B, Niccolai C, Patti F, Chisari CG, Gallo P, Grossi P, Ghezzi A, Roscio M, Mattioli F, Stampatori C, Simone M, Viterbo RG, Bonacchi R, Rocca MA, De Stefano N, Filippi M, Amato MP. Identifying the Distinct Cognitive Phenotypes in Multiple Sclerosis. JAMA Neurol 2021; 78:414-425. [PMID: 33393981 DOI: 10.1001/jamaneurol.2020.4920] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Cognitive impairment is a common and disabling feature of multiple sclerosis (MS), but a precise characterization of cognitive phenotypes in patients with MS is lacking. Objectives To identify cognitive phenotypes in a clinical cohort of patients with MS and to characterize their clinical and magnetic resonance imaging (MRI) features. Design, Setting, and Participants This multicenter cross-sectional study consecutively screened clinically stable patients with MS and healthy control individuals at 8 MS centers in Italy from January 1, 2010, to October 31, 2019. Patients with MS and healthy control individuals who were not using psychoactive drugs and had no history of other neurological or medical disorders, learning disability, severe head trauma, and alcohol or drug abuse were enrolled. Main Outcomes and Measures Participants underwent a neurological examination and a cognitive evaluation with the Rao Brief Repeatable Battery and Stroop Color and Word Test. A subgroup of participants also underwent a brain MRI examination. Latent profile analysis was used on cognitive test z scores to identify cognitive phenotypes. Linear regression and mixed-effects models were used to define clinical and MRI features of each phenotype. Results A total of 1212 patients with MS (mean [SD] age, 41.1 [11.1] years; 784 women [64.7%]) and 196 healthy control individuals (mean [SD] age, 40.4 [8.6] years; 130 women [66.3%]) were analyzed in this study. Five cognitive phenotypes were identified: preserved cognition (n = 235 patients [19.4%]), mild-verbal memory/semantic fluency (n = 362 patients [29.9%]), mild-multidomain (n = 236 patients [19.5%]), severe-executive/attention (n = 167 patients [13.8%]), and severe-multidomain (n = 212 patients [17.5%]) involvement. Patients with preserved cognition and mild-verbal memory/semantic fluency were younger (mean [SD] age, 36.5 [9.8] years and 38.2 [11.1] years) and had shorter disease duration (mean [SD] 8.0 [7.3] years and 8.3 [7.6] years) compared with patients with mild-multidomain (mean [SD] age, 42.6 [11.2] years; mean [SD] disease duration, 12.8 [9.6] years; P < .001), severe-executive/attention (mean [SD] age, 42.9 [11.7] years; mean [SD] disease duration, 12.2 [9.5] years; P < .001), and severe-multidomain (mean [SD] age, 44.0 [11.0] years; mean [SD] disease duration, 13.3 [10.2] years; P < .001) phenotypes. Severe cognitive phenotypes prevailed in patients with progressive MS. At MRI evaluation, compared with those with preserved cognition, patients with mild-verbal memory/semantic fluency exhibited decreased mean (SE) hippocampal volume (5.42 [0.68] mL vs 5.13 [0.68] mL; P = .04), patients with the mild-multidomain phenotype had decreased mean (SE) cortical gray matter volume (687.69 [35.40] mL vs 662.59 [35.48] mL; P = .02), patients with severe-executive/attention had higher mean (SE) T2-hyperintense lesion volume (51.33 [31.15] mL vs 99.69 [34.07] mL; P = .04), and patients with the severe-multidomain phenotype had extensive brain damage, with decreased volume in all the brain structures explored, except for nucleus pallidus, amygdala and caudate nucleus. Conclusions and Relevance This study found that by defining homogeneous and clinically meaningful phenotypes, the limitations of the traditional dichotomous classification in MS can be overcome. These phenotypes can represent a more meaningful measure of the cognitive status of patients with MS and can help define clinical disability, support clinicians in treatment choices, and tailor cognitive rehabilitation strategies.
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Affiliation(s)
- Ermelinda De Meo
- Neuroimaging Research Unit, Division of Neuroscience, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy.,Institute of Experimental Neurology, Vita-Salute San Raffaele University, Milan, Italy.,Section Neurosciences, Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino, University of Florence, Florence, Italy
| | - Emilio Portaccio
- Department of Neurology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.,Department of Neurorehabilitation, IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Antonio Giorgio
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Luis Ruano
- EPIUnit, Instituto de Saúde Pública de Universidade do Porto, Porto, Portugal.,Neurology Department, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Benedetta Goretti
- Section Neurosciences, Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino, University of Florence, Florence, Italy
| | - Claudia Niccolai
- Department of Neurorehabilitation, IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Francesco Patti
- Department of Neurology, University of Catania, Catania, Italy
| | | | - Paolo Gallo
- Department of Neurology, University of Padova, Padova, Italy
| | - Paola Grossi
- Neuroimmunology Center, Cardiocerebrovascular, Azienda Socio Sanitaria Territoriale (ASST) of Crema, Crema, Italy
| | | | | | - Flavia Mattioli
- Neuropsychology Unit, ASST Spedali Civili Brescia, Brescia, Italy
| | | | - Marta Simone
- Child and Adolescence Neuropsychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs University Aldo Moro Bari, Bari, Italy
| | - Rosa Gemma Viterbo
- Child and Adolescence Neuropsychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs University Aldo Moro Bari, Bari, Italy
| | - Raffaello Bonacchi
- Neuroimaging Research Unit, Division of Neuroscience, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy.,Institute of Experimental Neurology, Vita-Salute San Raffaele University, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy.,Institute of Experimental Neurology, Vita-Salute San Raffaele University, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Pia Amato
- Section Neurosciences, Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino, University of Florence, Florence, Italy.,Department of Neurorehabilitation, IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
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Zhang E, Tian X, Li R, Chen C, Li M, Ma L, Wei R, Zhou Y, Cui Y. Dalfampridine in the treatment of multiple sclerosis: a meta-analysis of randomised controlled trials. Orphanet J Rare Dis 2021; 16:87. [PMID: 33588903 PMCID: PMC7885571 DOI: 10.1186/s13023-021-01694-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background Multiple sclerosis (MS) is a chronic illness involving the central nervous system (CNS) that is characterised by inflammation, demyelination, and degenerative changes. Dalfampridine is one of the available treatments for MS symptoms and comorbidities. This meta-analysis aimed to assess the safety and benefits of dalfampridine versus placebo in MS by summarising data deriving from previously published clinical randomised controlled studies (RCTs). Results A total of 9 RCTs were included in this meta-analysis, involving 1691 participants. There were significant differences between dalfampridine and placebo in terms of decreased 12-item Multiple Sclerosis Walking Scale score (weighted mean difference [WMD] = − 3.68, 95% confidence interval [CI] [− 5.55, − 1.80], p = 0.0001), improved response to the timed 25-foot walk test (relative risk [RR] = 2.57, 95% CI [1.04, 6.33], p = 0.04), increased 6-min walk test (WMD = 18.40, 95% CI [1.30, 35.51], p = 0.03), increased 9-Hole Peg Test score (WMD = 1.33, 95% CI [0.60, 2.05], p = 0.0004), and increased Symbol Digit Modalities Test score (WMD = 4.47, 95% CI [3.91, 5.02], p < 0.00001). Significant differences in the incidence of side effects were also observed (RR = 1.12, 95% CI [1.04, 1.21], p = 0.002). Conclusion Dalfampridine exerts positive effects on walking ability, finger dexterity, and cognitive function. Treatment should be administered under the guidance of a physician or pharmacist given the higher incidence of adverse events.
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Affiliation(s)
- Enyao Zhang
- Department of Pharmacy, Peking University First Hospital, 6 Dahongluochang Street, Xicheng District, Beijing, 100034, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Xin Tian
- Department of Pharmacy, Peking University First Hospital, 6 Dahongluochang Street, Xicheng District, Beijing, 100034, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Ruoming Li
- Department of Pharmacy, Peking University First Hospital, 6 Dahongluochang Street, Xicheng District, Beijing, 100034, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Chaoyang Chen
- Department of Pharmacy, Peking University First Hospital, 6 Dahongluochang Street, Xicheng District, Beijing, 100034, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Min Li
- Department of Pharmacy, Peking University First Hospital, 6 Dahongluochang Street, Xicheng District, Beijing, 100034, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Lingyun Ma
- Department of Pharmacy, Peking University First Hospital, 6 Dahongluochang Street, Xicheng District, Beijing, 100034, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Ran Wei
- Department of Pharmacy, Peking University First Hospital, 6 Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Ying Zhou
- Department of Pharmacy, Peking University First Hospital, 6 Dahongluochang Street, Xicheng District, Beijing, 100034, China.
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, 6 Dahongluochang Street, Xicheng District, Beijing, 100034, China.
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Motavalli A, Majdi A, Hosseini L, Talebi M, Mahmoudi J, Hosseini SH, Sadigh-Eteghad S. Pharmacotherapy in multiple sclerosis-induced cognitive impairment: A systematic review and meta-analysis. Mult Scler Relat Disord 2020; 46:102478. [PMID: 32896820 DOI: 10.1016/j.msard.2020.102478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 11/19/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) commonly complicated by cognitive impairment. Unfortunately, no medical therapy has been proved to improve cognitive problems in these patients. This meta-analysis investigated the effectiveness of different categories of drugs on the minimal assessment of cognitive function in MS (MACFIMS)-related tasks outcome in MS patients. To this end, a systematic evaluation was conducted using PubMed, Google Scholar, and Scopus databases. Among a total of 128 publications, 31 studies met our inclusion criteria, and 22 included in the meta-analysis. We found that symbol digit modalities test (SDMT), paced auditory serial addition test (PASAT), controlled oral word association test (COWAT), and California verbal learning test (CVLT) were the most frequently reported tasks in included studies. The frequently reported drugs were classified into five main groups of acetylcholine esterase inhibitors, CNS stimulants, fampridine, herbal remedies, and miscellaneous. Overall heterogeneity of the studies was modest. The treatments did not affect cognitive function in any of the tasks (p>0.05). However, in subgroup analysis, we found significant improvement in SDMT task outecomes after treatment by fampridine (0.283 SMD, 95%CI, 0.015 to 0.550, p = 0.039, I2=11.7%). Our meta-analysis highlighted that the currently proposed therapeutic agents had no beneficial effects on the alleviation of MS-induced cognitive impairment.
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Affiliation(s)
- Ali Motavalli
- Neurosciences Research Center, Tabriz University of Medical Sciences, 5166614756, Tabriz, Iran
| | - Alireza Majdi
- Neurosciences Research Center, Tabriz University of Medical Sciences, 5166614756, Tabriz, Iran
| | - Leila Hosseini
- Neurosciences Research Center, Tabriz University of Medical Sciences, 5166614756, Tabriz, Iran
| | - Mahnaz Talebi
- Neurosciences Research Center, Tabriz University of Medical Sciences, 5166614756, Tabriz, Iran
| | - Javad Mahmoudi
- Neurosciences Research Center, Tabriz University of Medical Sciences, 5166614756, Tabriz, Iran
| | - Seyed Hojjat Hosseini
- Department of Pharmacology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran; Zanjan Metabolic Diseases Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Saeed Sadigh-Eteghad
- Neurosciences Research Center, Tabriz University of Medical Sciences, 5166614756, Tabriz, Iran; Department of Persian Medicine, Faculty of Persian Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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Lakó Á, Molnár Z, Mendonça R, Poppe L. Transaminase-mediated synthesis of enantiopure drug-like 1-(3′,4′-disubstituted phenyl)propan-2-amines. RSC Adv 2020; 10:40894-40903. [PMID: 35519186 PMCID: PMC9057730 DOI: 10.1039/d0ra08134e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/29/2020] [Indexed: 12/16/2022] Open
Abstract
Transaminases (TAs) offer an environmentally and economically attractive method for the direct synthesis of pharmaceutically relevant disubstituted 1-phenylpropan-2-amine derivatives starting from prochiral ketones. In this work, we report the application of immobilised whole-cell biocatalysts with (R)-transaminase activity for the synthesis of novel disubstituted 1-phenylpropan-2-amines. After optimisation of the asymmetric synthesis, the (R)-enantiomers could be produced with 88–89% conversion and >99% ee, while the (S)-enantiomers could be selectively obtained as the unreacted fraction of the corresponding racemic amines in kinetic resolution with >48% conversion and >95% ee. Immobilised whole-cell (R)-transaminases (TAs) enabled synthesis of either (R)- or (S)-enantiomers of drug-like amines from prochiral ketones or from racemic amines, respectively, in >95% ee.![]()
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Affiliation(s)
- Ágnes Lakó
- Department of Organic Chemistry and Technology
- Budapest University of Technology and Economics
- 1111 Budapest
- Hungary
- Hovione Farmaciência, S.A
| | - Zsófia Molnár
- Department of Organic Chemistry and Technology
- Budapest University of Technology and Economics
- 1111 Budapest
- Hungary
| | - Ricardo Mendonça
- Hovione Farmaciência, S.A
- Campus do Lumiar
- 1649-038 Lisboa
- Portugal
| | - László Poppe
- Department of Organic Chemistry and Technology
- Budapest University of Technology and Economics
- 1111 Budapest
- Hungary
- Biocatalysis and Biotransformation Research Center
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Abstract
INTRODUCTION Cognitive impairment is prevalent and debilitating among persons with multiple sclerosis (MS). While many pharmacologic treatments have shown good efficacy in reducing clinical relapses, brain lesions, and improving certain physical symptoms, their efficacy for improving cognitive function is not well understood. OBJECTIVES The current systematic review aimed to evaluate the efficacy of pharmacologic treatments for improving cognitive function among persons with MS. METHODS A literature search was conducted through the PubMed and PsycINFO databases. Two independent reviewers assessed each paper, and a third reviewer weighed in if the two reviewers could not reach a consensus. Classification of evidence was determined using the 2017 American Academy of Neurology (AAN) criteria for therapeutic trials. Standardized effect sizes (Cohen's d) were calculated to compare across studies. RESULTS Eighty-seven journal articles published between 1990 and January 2020 were included in the current review. Overall, there is insufficient evidence to support the use of pharmacologic treatments to improve cognitive function in persons with MS. There were many contradictory findings observed in this review, which may be due to possible unidentified moderating treatment response variables and/or lack of standardization in assessment procedures. There was also an overreliance on statistical significance (most papers did not provide sizes of treatment effects), which may not be clinically meaningful. CONCLUSIONS Higher-quality randomized controlled trials are needed to establish the cognitive efficacy of pharmacologic treatments for MS-related cognitive dysfunction, with cognition as the primary endpoint. Researchers are urged to use standardized criteria (such as the AAN criteria) to guide their research designs. Clinicians should consider effect sizes of studies before deciding whether to prescribe certain medications to ameliorate cognitive symptoms.
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Macías Islas MÁ, Ciampi E. Assessment and Impact of Cognitive Impairment in Multiple Sclerosis: An Overview. Biomedicines 2019; 7:E22. [PMID: 30893874 PMCID: PMC6466345 DOI: 10.3390/biomedicines7010022] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/30/2022] Open
Abstract
Cognitive impairment affects 40⁻60% of patients with multiple sclerosis. It may be present early in the course of the disease and has an impact on a patient's employability, social interactions, and quality of life. In the last three decades, an increasing interest in diagnosis and management of cognitive impairment has arisen. Neuropsychological assessment and neuroimaging studies focusing on cognitive impairment are now being incorporated as primary outcomes in clinical trials. However, there are still key uncertainties concerning the underlying mechanisms of damage, neural basis, sensitivity and validity of neuropsychological tests, and efficacy of pharmacological and non-pharmacological interventions. The present article aimed to present an overview of the assessment, neural correlates, and impact of cognitive impairment in multiple sclerosis.
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Affiliation(s)
| | - Ethel Ciampi
- Neurology, Pontificia Universidad Católica de Chile, Neurology, Hospital Dr. Sótero del Río, Santiago 8320000, Chile.
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Cognitive Deficits in Multiple Sclerosis: Recent Advances in Treatment and Neurorehabilitation. Curr Treat Options Neurol 2018; 20:53. [PMID: 30345468 DOI: 10.1007/s11940-018-0538-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW This article highlights recent progress in research on treatment and neurorehabilitation of cognitive impairment in multiple sclerosis (MS) including pharmacological interventions, physical exercise, and neuropsychological rehabilitation, both in conventional and technology-assisted settings. RECENT FINDINGS The most consistent evidence in terms of improvement or preservation of circumscribed cognitive scores in MS patients comes from moderately sampled randomized clinical trials on multimodal approaches that combine conventional or computerized neuropsychological training with psychoeducation or cognitive behavioral therapy. Disease-modifying treatments also appear to have beneficial effects in preventing or attenuating cognitive decline, whereas there is little evidence for agents such as donepezil or stimulants. Finally, physical exercise may yield some cognitive improvement in MS patients. Despite substantial and often promising research efforts, there is a lack of validated and widely accepted clinical procedures for cognitive neurorehabilitation in MS. Development of such approaches will require collaborative efforts towards the design of interventions that are fundamentally inspired by cognitive neuroscience, potentially guided by neuroimaging, and composed of conventional neuropsychological training and cognitive behavioral therapy as well as physical exercise and therapeutic video games. Subsequently, large-scale validation will be needed with meaningful outcome measures reflecting transfer to everyday cognitive function and maintenance of training effects.
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Kalb R, Beier M, Benedict RH, Charvet L, Costello K, Feinstein A, Gingold J, Goverover Y, Halper J, Harris C, Kostich L, Krupp L, Lathi E, LaRocca N, Thrower B, DeLuca J. Recommendations for cognitive screening and management in multiple sclerosis care. Mult Scler 2018; 24:1665-1680. [PMID: 30303036 PMCID: PMC6238181 DOI: 10.1177/1352458518803785] [Citation(s) in RCA: 229] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Purpose: To promote understanding of cognitive impairment in multiple sclerosis (MS), recommend optimal screening, monitoring, and treatment strategies, and address barriers to optimal management. Methods: The National MS Society (“Society”) convened experts in cognitive dysfunction (clinicians, researchers, and lay people with MS) to review the published literature, reach consensus on optimal strategies for screening, monitoring, and treating cognitive changes, and propose strategies to address barriers to optimal care. Recommendations: Based on current evidence, the Society makes the following recommendations, endorsed by the Consortium of Multiple Sclerosis Centers and the International Multiple Sclerosis Cognition Society:
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Affiliation(s)
- Rosalind Kalb
- National Multiple Sclerosis Society, New York, NY, USA
| | - Meghan Beier
- Division of Rehabilitation Psychology and Neuropsychology, Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Leigh Charvet
- Department of Neurology, Langone Medical Center, New York University, New York, NY, USA
| | | | - Anthony Feinstein
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | | | - June Halper
- The Consortium of Multiple Sclerosis Centers and International Organization of Multiple Sclerosis Nurses, Multiple Sclerosis Nurses International Certification Board, Hackensack, NJ, USA
| | - Colleen Harris
- Multiple Sclerosis Center, University of Calgary, Calgary, AB, Canada
| | - Lori Kostich
- The Mandell Center for Multiple Sclerosis, Mount Sinai Rehabilitation Hospital, Hartford, CT, USA
| | - Lauren Krupp
- Department of Neurology, NYU Langone Health, New York University, New York, NY, USA
| | - Ellen Lathi
- The Elliot Lewis Center for Multiple Sclerosis Care, Wellesley, MA, USA
| | | | - Ben Thrower
- Emory University, Atlanta, GA, USA/Andrew C. Carlos Multiple Sclerosis Institute at Shepherd Center, Atlanta, GA, USA
| | - John DeLuca
- Department of Physical Medicine and Rehabilitation and Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, USA
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Cotter J, Muhlert N, Talwar A, Granger K. Examining the effectiveness of acetylcholinesterase inhibitors and stimulant-based medications for cognitive dysfunction in multiple sclerosis: A systematic review and meta-analysis. Neurosci Biobehav Rev 2018; 86:99-107. [DOI: 10.1016/j.neubiorev.2018.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 12/09/2017] [Accepted: 01/18/2018] [Indexed: 11/29/2022]
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Positive effects of fampridine on cognition, fatigue and depression in patients with multiple sclerosis over 2 years. J Neurol 2018; 265:1016-1025. [DOI: 10.1007/s00415-018-8796-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/12/2018] [Indexed: 11/26/2022]
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13
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Leavitt VM, Tosto G, Riley CS. Cognitive phenotypes in multiple sclerosis. J Neurol 2018; 265:562-566. [DOI: 10.1007/s00415-018-8747-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 01/22/2023]
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Kerschensteiner M. Neuroplasticity and its relevance for multiple sclerosis. Neurodegener Dis Manag 2017; 7:31-33. [DOI: 10.2217/nmt-2017-0039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Martin Kerschensteiner
- Institute of Clinical Neuroimmunology, Biomedical Center & Hospital of the Ludwig-Maximilians University, Munich, Germany
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15
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Disease modifying treatments and symptomatic drugs for cognitive impairment in multiple sclerosis: where do we stand? ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s40893-017-0025-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
OPINION STATEMENT Patients with progressive forms of multiple sclerosis have various symptoms which affect their quality of life significantly including depression, cognitive decline, sleep changes, bladder dysfunction, sexual dysfunction, and spasticity. Despite recent promising results on the effects of ocrelizumab on neurological disability in patients with PPMS, currently none of the immunomodulatory therapies are approved for progressive forms of multiple sclerosis. Therefore, clinicians currently mostly focus on management of well-recognized comorbidities of this disease phenotype in order to improve patients' quality of life. There are very few studies evaluating strategies of symptomatic management on progressive forms of multiple sclerosis and most of the data is derived from studies on relapsing forms of multiple sclerosis. Understanding of the risks, benefits, and limitations of these therapies can significantly affect patient care. In this article, we review common comorbidities associated with progressive forms of multiple sclerosis and outline important strategies for their symptomatic management.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peter Sguigna
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Olaf Stüve
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA. .,Neurology Section, VA North Texas Health Care System, Medical Service, Dallas, TX, USA.
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Roy S, Benedict RHB, Drake AS, Weinstock-Guttman B. Impact of Pharmacotherapy on Cognitive Dysfunction in Patients with Multiple Sclerosis. CNS Drugs 2016; 30:209-25. [PMID: 26884145 DOI: 10.1007/s40263-016-0319-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Shumita Roy
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York (SUNY), Buffalo, NY, USA
| | - Ralph H B Benedict
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York (SUNY), Buffalo, NY, USA.
| | - Allison S Drake
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York (SUNY), Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York (SUNY), Buffalo, NY, USA
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Feinstein A, Freeman J, Lo AC. Treatment of progressive multiple sclerosis: what works, what does not, and what is needed. Lancet Neurol 2015; 14:194-207. [PMID: 25772898 DOI: 10.1016/s1474-4422(14)70231-5] [Citation(s) in RCA: 180] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Disease-modifying drugs have mostly failed as treatments for progressive multiple sclerosis. Management of the disease therefore solely aims to minimise symptoms and, if possible, improve function. The degree to which this approach is based on empirical data derived from studies of progressive disease or whether treatment decisions are based on what is known about relapsing-remitting disease remains unclear. Symptoms rated as important by patients with multiple sclerosis include balance and mobility impairments, weakness, reduced cardiovascular fitness, ataxia, fatigue, bladder dysfunction, spasticity, pain, cognitive deficits, depression, and pseudobulbar affect; a comprehensive literature search shows a notable paucity of studies devoted solely to these symptoms in progressive multiple sclerosis, which translates to few proven therapeutic options in the clinic. A new strategy that can be used in future rehabilitation trials is therefore needed, with the adoption of approaches that look beyond single interventions to concurrent, potentially synergistic, treatments that maximise what remains of neural plasticity in patients with progressive multiple sclerosis.
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Affiliation(s)
- Anthony Feinstein
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
| | - Jenny Freeman
- Faculty of Health and Human Sciences, Plymouth University, Plymouth, UK
| | - Albert C Lo
- Departments of Neurology and Epidemiology, Brown University, Providence, RI, USA
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Sumowski JF, Rocca MA, Leavitt VM, Dackovic J, Mesaros S, Drulovic J, DeLuca J, Filippi M. Brain reserve and cognitive reserve protect against cognitive decline over 4.5 years in MS. Neurology 2014; 82:1776-83. [PMID: 24748670 DOI: 10.1212/wnl.0000000000000433] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Based on the theories of brain reserve and cognitive reserve, we investigated whether larger maximal lifetime brain growth (MLBG) and/or greater lifetime intellectual enrichment protect against cognitive decline over time. METHODS Forty patients with multiple sclerosis (MS) underwent baseline and 4.5-year follow-up evaluations of cognitive efficiency (Symbol Digit Modalities Test, Paced Auditory Serial Addition Task) and memory (Selective Reminding Test, Spatial Recall Test). Baseline and follow-up MRIs quantified disease progression: percentage brain volume change (cerebral atrophy), percentage change in T2 lesion volume. MLBG (brain reserve) was estimated with intracranial volume; intellectual enrichment (cognitive reserve) was estimated with vocabulary. We performed repeated-measures analyses of covariance to investigate whether larger MLBG and/or greater intellectual enrichment moderate/attenuate cognitive decline over time, controlling for disease progression. RESULTS Patients with MS declined in cognitive efficiency and memory (p < 0.001). MLBG moderated decline in cognitive efficiency (p = 0.031, ηp (2) = 0.122), with larger MLBG protecting against decline. MLBG did not moderate memory decline (p = 0.234, ηp (2) = 0.039). Intellectual enrichment moderated decline in cognitive efficiency (p = 0.031, ηp (2) = 0.126) and memory (p = 0.037, ηp (2) = 0.115), with greater intellectual enrichment protecting against decline. MS disease progression was more negatively associated with change in cognitive efficiency and memory among patients with lower vs higher MLBG and intellectual enrichment. CONCLUSION We provide longitudinal support for theories of brain reserve and cognitive reserve in MS. Larger MLBG protects against decline in cognitive efficiency, and greater intellectual enrichment protects against decline in cognitive efficiency and memory. Consideration of these protective factors should improve prediction of future cognitive decline in patients with MS.
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Affiliation(s)
- James F Sumowski
- From Neuropsychology and Neuroscience (J.F.S., J. DeLuca), Kessler Foundation Research Center, West Orange; Rutgers (J.F.S., J. DeLuca), New Jersey Medical School, Newark, NJ; Neuroimaging Research Unit (M.A.R., M.F.) and Department of Neurology (M.A.R., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Manhattan Memory Center (V.M.L.), New York, NY; and Clinic of Neurology (J. Dackovic, S.M., J. Drulovic), Faculty of Medicine, University of Belgrade, Serbia.
| | - Maria A Rocca
- From Neuropsychology and Neuroscience (J.F.S., J. DeLuca), Kessler Foundation Research Center, West Orange; Rutgers (J.F.S., J. DeLuca), New Jersey Medical School, Newark, NJ; Neuroimaging Research Unit (M.A.R., M.F.) and Department of Neurology (M.A.R., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Manhattan Memory Center (V.M.L.), New York, NY; and Clinic of Neurology (J. Dackovic, S.M., J. Drulovic), Faculty of Medicine, University of Belgrade, Serbia
| | - Victoria M Leavitt
- From Neuropsychology and Neuroscience (J.F.S., J. DeLuca), Kessler Foundation Research Center, West Orange; Rutgers (J.F.S., J. DeLuca), New Jersey Medical School, Newark, NJ; Neuroimaging Research Unit (M.A.R., M.F.) and Department of Neurology (M.A.R., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Manhattan Memory Center (V.M.L.), New York, NY; and Clinic of Neurology (J. Dackovic, S.M., J. Drulovic), Faculty of Medicine, University of Belgrade, Serbia
| | - Jelena Dackovic
- From Neuropsychology and Neuroscience (J.F.S., J. DeLuca), Kessler Foundation Research Center, West Orange; Rutgers (J.F.S., J. DeLuca), New Jersey Medical School, Newark, NJ; Neuroimaging Research Unit (M.A.R., M.F.) and Department of Neurology (M.A.R., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Manhattan Memory Center (V.M.L.), New York, NY; and Clinic of Neurology (J. Dackovic, S.M., J. Drulovic), Faculty of Medicine, University of Belgrade, Serbia
| | - Sarlota Mesaros
- From Neuropsychology and Neuroscience (J.F.S., J. DeLuca), Kessler Foundation Research Center, West Orange; Rutgers (J.F.S., J. DeLuca), New Jersey Medical School, Newark, NJ; Neuroimaging Research Unit (M.A.R., M.F.) and Department of Neurology (M.A.R., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Manhattan Memory Center (V.M.L.), New York, NY; and Clinic of Neurology (J. Dackovic, S.M., J. Drulovic), Faculty of Medicine, University of Belgrade, Serbia
| | - Jelena Drulovic
- From Neuropsychology and Neuroscience (J.F.S., J. DeLuca), Kessler Foundation Research Center, West Orange; Rutgers (J.F.S., J. DeLuca), New Jersey Medical School, Newark, NJ; Neuroimaging Research Unit (M.A.R., M.F.) and Department of Neurology (M.A.R., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Manhattan Memory Center (V.M.L.), New York, NY; and Clinic of Neurology (J. Dackovic, S.M., J. Drulovic), Faculty of Medicine, University of Belgrade, Serbia
| | - John DeLuca
- From Neuropsychology and Neuroscience (J.F.S., J. DeLuca), Kessler Foundation Research Center, West Orange; Rutgers (J.F.S., J. DeLuca), New Jersey Medical School, Newark, NJ; Neuroimaging Research Unit (M.A.R., M.F.) and Department of Neurology (M.A.R., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Manhattan Memory Center (V.M.L.), New York, NY; and Clinic of Neurology (J. Dackovic, S.M., J. Drulovic), Faculty of Medicine, University of Belgrade, Serbia
| | - Massimo Filippi
- From Neuropsychology and Neuroscience (J.F.S., J. DeLuca), Kessler Foundation Research Center, West Orange; Rutgers (J.F.S., J. DeLuca), New Jersey Medical School, Newark, NJ; Neuroimaging Research Unit (M.A.R., M.F.) and Department of Neurology (M.A.R., M.F.), San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Manhattan Memory Center (V.M.L.), New York, NY; and Clinic of Neurology (J. Dackovic, S.M., J. Drulovic), Faculty of Medicine, University of Belgrade, Serbia
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Erlanger DM, Kaushik T, Caruso LS, Benedict RHB, Foley FW, Wilken J, Cadavid D, Deluca J. Reliability of a cognitive endpoint for use in a multiple sclerosis pharmaceutical trial. J Neurol Sci 2014; 340:123-9. [PMID: 24656433 DOI: 10.1016/j.jns.2014.03.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 03/04/2014] [Accepted: 03/05/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Determine reliability and basic psychometric properties of a composite cognitive endpoint, MS-COG, for monitoring change in cognitive function in MS drug trials. BACKGROUND 50% of MS patients have cognitive impairment that impacts ability to work and quality of life. We selected neuropsychological tests based on sensitivity to MS cognitive impairment, availability of alternate forms, cross-cultural utility, and feasibility for multicenter trials, and assessed the reliability and validity of a composite endpoint, MS-COG. DESIGN/METHODS Administered SRT, BVMT-R, PASAT, and SDMT to 60 MS patients at 4 US centers twice over 45days, along with symptom inventories by patients and informants. RESULTS The MS-COG had test-retest reliability of 0.91. Processing Speed and Memory indices had reliabilities of 0.89 and 0.86, with modest practice effects. Reliability was high for the RR MS and SP MS subgroups as well, with correlations of .90 and .93, respectively for MS-COG. Overall, 42% of subjects obtained MS-COG scores in the impaired range, with SP MS subjects performing 0.8 SD below RR MS subjects. Impairment correlated well (r=0.37 to 0.40) with informant reports but was inconsistent with patient report, with the least reliable assessments by those with greater symptom severity. CONCLUSIONS The MS-COG is a reliable, repeatable measure of MS cognitive functioning that is sensitive to cognitive impairment in SP MS and RR MS patients and feasible for multicenter clinical trials. Further development is warranted.
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Affiliation(s)
- David M Erlanger
- Psychology Department, Rusk Institute of Rehabilitation Medicine.
| | | | | | | | - F W Foley
- Ferkauf Graduate School of Psychology, Yeshiva University
| | - Jeffrey Wilken
- Neuropsychology Associates of Fairfax, Georgetown University Department of Neurology
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He D, Zhang Y, Dong S, Wang D, Gao X, Zhou H. Pharmacological treatment for memory disorder in multiple sclerosis. Cochrane Database Syst Rev 2013:CD008876. [PMID: 24343792 DOI: 10.1002/14651858.cd008876.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This is an update of the Cochrane review "Pharmacologic treatment for memory disorder in multiple sclerosis" (first published in The Cochrane Library 2011, Issue 10).Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, demyelinating, neurodegenerative disorder of the central nervous system (CNS) and can cause both neurological and neuropsychological disability. Both demyelination and axonal and neuronal loss are believed to contribute to MS-related cognitive impairment. Memory disorder is one of the most frequent cognitive dysfunctions and presents a considerable burden to people with MS and to society due to the negative impact on function. A number of pharmacological agents have been evaluated in many existing randomised controlled trials for their efficacy on memory disorder in people with MS but the results were not consistent. OBJECTIVES To assess the absolute and comparative efficacy, tolerability and safety of pharmacological treatments for memory disorder in adults with MS. SEARCH METHODS We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Trials Register (24 July 2013), PsycINFO (January 1980 to 26 June 2013) and CBMdisc (1978 to 24 June 2013), and checked reference lists of identified articles, searched some relevant journals manually, registers of clinical trials and published abstracts of conference proceedings. SELECTION CRITERIA All double-blind, randomised controlled parallel trials on pharmacological treatment versus placebo or one or more pharmacological treatments in adults with MS who had at least mild memory impairment (at 0.5 standard deviations below age- and sex-based normative data on a validated memory scale). We placed no restrictions regarding dose, route of administration and frequency; however, we only included trials with an administration duration of 12 weeks or greater. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We discussed disagreements and resolved them by consensus among review authors. We contacted principal investigators of included studies for additional data or confirmation. MAIN RESULTS We included seven randomised controlled trials (RCTs) involving 625 people mostly with relapsing-remitting, secondary-progressive and primary-progressive MS, evaluating the absolute efficacy of donepezil, ginkgo biloba, memantine and rivastigmine versus placebo in improving memory performance with diverse assessment scales. Overall, clinical and methodological heterogeneities existed across these studies. Moreover, most of them had methodological limitations on non-specific selections of targeted sample, non-matched variables at baseline or incomplete outcome data (high attrition bias). Only the two studies on donepezil had clinical and methodological homogeneity and relatively low risks for bias. One RCT evaluating estriol versus placebo is currently ongoing.We could not carry out a meta-analysis due to the heterogeneities across studies and the high attrition bias. A subgroup analysis for donepezil versus placebo showed no treatment effects on total recall on the Selective Reminding Test (mean difference (MD) 1.68; 95% confidence interval (CI) -2.21 to 5.58), total correct scores on the 10/36 Spatial Recall Test (MD -0.93; 95% CI -3.18 to 1.32), the Symbol Digit Modalities Test (MD -1.27; 95% CI -3.15 to 0.61) and the Paced Auditory Serial Addition Test (2+3 sec) (MD 2.23; 95% CI -1.87 to 6.33). Concerning safety, the main adverse events were: diarrhoea (risk ratio (RR) 3.88; 95% CI 1.66 to 9.05), nausea (RR 1.71; 95% CI 0.93 to 3.18) and abnormal dreams (RR 2.91; 95% CI 1.38 to 6.14). However, the results in both studies were subjected to a serious imprecision resulting from the small sample sizes and the low power of test (lower than 80%), which contributed to a moderate quality of the evidence. No serious adverse events were attributed to the treatments in all experimental groups. AUTHORS' CONCLUSIONS We found no convincing evidence to support the efficacy of pharmacological symptomatic treatment for MS-associated memory disorder because most of available RCTs had a limited quality. Whether pharmacological treatment is effective for memory disorder in patients with MS remains inconclusive. However, there is moderate-quality evidence that donepezil 10 mg daily was not effective in improving memory in MS patients with mild memory impairment, but had a good tolerability. Adverse events such as nausea, diarrhoea and abnormal dreams were not frequent but were associated with treatment. Ginkgo biloba, memantine and rivastigmine were safe and well tolerated and no serious adverse effects were reported. Future large-scale RCTs with higher methodological quality are needed.
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Affiliation(s)
- Dian He
- Department of Neurology, Affiliated Hospital of Guiyang Medical College, No. 28, Gui Yi Street, Guiyang, Guizhou Province, China, 550004
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Hsieh YS, Chen PN, Yu CH, Liao JM, Kuo DY. The neuropeptide Y Y1 receptor knockdown modulates activator protein 1-involved feeding behavior in amphetamine-treated rats. Mol Brain 2013; 6:46. [PMID: 24225225 PMCID: PMC4226007 DOI: 10.1186/1756-6606-6-46] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 11/07/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hypothalamic neuropeptide Y (NPY) and two immediate early genes, c-fos and c-jun, have been found to be involved in regulating the appetite-suppressing effect of amphetamine (AMPH). The present study investigated whether cerebral catecholamine (CA) might regulate NPY and POMC expression and whether NPY Y1 receptor (Y1R) participated in activator protein-1 (AP-1)-mediated feeding. METHODS Rats were given AMPH daily for 4 days. Changes in the expression of NPY, Y1R, c-Fos, c-Jun, and AP-1 were assessed and compared. RESULTS Decreased CA could modulate NPY and melanocortin receptor 4 (MC4R) expressions. NPY and food intake decreased the most on Day 2, but Y1R, c-Fos, and c-Jun increased by approximately 350%, 280%, and 300%, respectively, on Day 2. Similarly, AP-1/DNA binding activity was increased by about 180% on Day 2. The expression patterns in Y1R, c-Fos, c-Jun, and AP-1/DNA binding were opposite to those in NPY during AMPH treatment. Y1R knockdown was found to modulate the opposite regulation between NPY and AP-1, revealing an involvement of Y1R in regulating NPY/AP-1-mediated feeding. CONCLUSIONS These results point to a molecular mechanism of CA/NPY/Y1R/AP-1 signaling in the control of AMPH-mediated anorexia and may advance the medical research of anorectic and anti-obesity drugs.
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Affiliation(s)
- Yih-Shou Hsieh
- Institute of Biochemistry and Biotechnology, Chung Shan Medical University and Chung Shan Medical University Hospital, Taichung City 40201, Taiwan
| | - Pei-Ni Chen
- Institute of Biochemistry and Biotechnology, Chung Shan Medical University and Chung Shan Medical University Hospital, Taichung City 40201, Taiwan
| | - Ching-Han Yu
- Department of Physiology, Chung Shan Medical University and Chung Shan Medical University Hospital, Taichung City 40201, Taiwan
| | - Jiuan-Miaw Liao
- Department of Physiology, Chung Shan Medical University and Chung Shan Medical University Hospital, Taichung City 40201, Taiwan
| | - Dong-Yih Kuo
- Department of Physiology, Chung Shan Medical University and Chung Shan Medical University Hospital, Taichung City 40201, Taiwan
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Abstract
Cognitive impairment (CI) is a serious complication of multiple sclerosis (MS), and the domains affected are well established, but new affected domains such as theory of mind are still being identified. The evidence that disease-modifying therapies (DMTs) improve and prevent the development of CI in MS is not solid. Recent studies on the prevalence of CI in MS among people treated with DMT, although not as solid as studies completed prior to DMT introduction, suggest that CI remains a problem even among people on DMTs and that CI occurs frequently even at the very earliest stages of MS. Functional MRI studies and studies using diffusion tractography show that the impact of lesions on cognition depends on the particular cortical networks affected and their plasticity. Cognitive rehabilitation and L-amphetamine appear promising symptomatic treatments for CI in MS, while, cholinesterase inhibitors and memantine have failed, and data on Ginkgo and exercise are limited. We need more work to understand better CI in MS and develop treatments for this serious complication of MS.
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Affiliation(s)
- Jesus Lovera
- Department of Neurology, Louisiana State University Health Sciences Center-New Orleans, 1542 Tulane Ave, Rm 718A, New Orleans, LA 70112, USA.
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Benedict RH, Hulst HE, Bergsland N, Schoonheim MM, Dwyer MG, Weinstock-Guttman B, Geurts JJ, Zivadinov R. Clinical significance of atrophy and white matter mean diffusivity within the thalamus of multiple sclerosis patients. Mult Scler 2013; 19:1478-84. [PMID: 23459570 DOI: 10.1177/1352458513478675] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gray-matter (GM) atrophy is strongly predictive of cognitive impairment in multiple sclerosis (MS) patients. The thalamus is the region where the atrophy/cognition correlation is most robust. However, few studies have assessed diffusion tensor imaging (DTI) metrics within the thalamus. OBJECTIVE This study was designed to determine if thalamus white matter DTI predicts cognitive impairment after accounting for the effects of volume loss. METHODS We enrolled 75 MS patients and 18 healthy controls undergoing 3T brain magnetic resonance imaging (MRI). Thalamus volumes were calculated on 3D T1 images. Voxelwise analyses of DTI metrics were performed within the thalamic white matter tracts. Neuropsychological (NP) testing, acquired using consensus standard methods, contributed measures of memory, cognitive processing speed and executive function. RESULTS All cognitive tests were significantly predicted (R (2) =0.31, p<0.001) by thalamus volume after accounting for influence of demographics. Mean diffusivity was retained in regression models predicting all cognitive tests, adding from 7-13% of additional explained variance (p<0.02) after accounting for thalamus volume. CONCLUSIONS We confirm the significant role of thalamus atrophy in MS-associated cognitive disorder, and further report that subtle thalamus pathology as detected by DTI adds incremental explained variance in predicting cognitive impairment.
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Amato MP, Langdon D, Montalban X, Benedict RHB, DeLuca J, Krupp LB, Thompson AJ, Comi G. Treatment of cognitive impairment in multiple sclerosis: position paper. J Neurol 2012. [DOI: 10.1007/s00415-012-6678-0] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tomassini V, Matthews PM, Thompson AJ, Fuglø D, Geurts JJ, Johansen-Berg H, Jones DK, Rocca MA, Wise RG, Barkhof F, Palace J. Neuroplasticity and functional recovery in multiple sclerosis. Nat Rev Neurol 2012; 8:635-46. [PMID: 22986429 PMCID: PMC3770511 DOI: 10.1038/nrneurol.2012.179] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The development of therapeutic strategies that promote functional recovery is a major goal of multiple sclerosis (MS) research. Neuroscientific and methodological advances have improved our understanding of the brain's recovery from damage, generating novel hypotheses about potential targets and modes of intervention, and laying the foundation for development of scientifically informed recovery-promoting strategies in interventional studies. This Review aims to encourage the transition from characterization of recovery mechanisms to development of strategies that promote recovery in MS. We discuss current evidence for functional reorganization that underlies recovery and its implications for development of new recovery-oriented strategies in MS. Promotion of functional recovery requires an improved understanding of recovery mechanisms that can be modulated by interventions and the development of robust measurements of therapeutic effects. As imaging methods can be used to measure functional and structural alterations associated with recovery, this Review discusses their use to obtain reliable markers of the effects of interventions.
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Bensa C, Bodiguel E, Brassat D, Laplaud D, Magy L, Ouallet JC, Zephir H, De Seze J, Blanc F. Recommendations for the detection and therapeutic management of cognitive impairment in multiple sclerosis. Rev Neurol (Paris) 2012; 168:785-94. [DOI: 10.1016/j.neurol.2012.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 02/07/2012] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
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Lovera JF, Kim E, Heriza E, Fitzpatrick M, Hunziker J, Turner AP, Adams J, Stover T, Sangeorzan A, Sloan A, Howieson D, Wild K, Haselkorn J, Bourdette D. Ginkgo biloba does not improve cognitive function in MS: a randomized placebo-controlled trial. Neurology 2012; 79:1278-84. [PMID: 22955125 PMCID: PMC3440446 DOI: 10.1212/wnl.0b013e31826aac60] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 05/01/2012] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether Ginkgo biloba extract (ginkgo) improves cognitive function in persons with multiple sclerosis (MS). METHODS Persons with MS from the Seattle and Portland VA clinics and adjacent communities who scored 1 SD or more below the mean on one of 4 neuropsychological tests (Stroop Test, California Verbal Learning Test II [CVLT-II], Controlled Oral Word Association Test [COWAT], and Paced Auditory Serial Addition Task [PASAT]) were randomly assigned to receive either one 120-mg tablet of ginkgo (EGb-761; Willmar Schwabe GmbH & Co, Germany) or one placebo tablet twice a day for 12 weeks. As the primary outcome, we compared the performance of the 2 groups on the 4 tests at exit after adjusting for baseline performance. RESULTS Fifty-nine subjects received placebo and 61 received ginkgo; 1 participant receiving placebo and 3 receiving ginkgo were lost to follow-up. Two serious adverse events (AEs) (myocardial infarction and severe depression) believed to be unrelated to the treatment occurred in the ginkgo group; otherwise, there were no significant differences in AEs. The differences (ginkgo - placebo) at exit in the z scores for the cognitive tests were as follows: PASAT -0.2 (95% confidence interval [CI] -0.5 to 0.1); Stroop Test -0.5 (95% CI -0.9 to -0.1); COWAT 0.0 (95% CI -0.2 to 0.3); and CVLT-II 0.0 (95% CI -0.3 to 0.3); none was statistically significant. CONCLUSIONS Treatment with ginkgo 120 mg twice a day did not improve cognitive performance in persons with MS. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that treatment with ginkgo 120 mg twice a day for 12 weeks does not improve cognitive performance in people with MS.
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Affiliation(s)
- Jesus F Lovera
- Department of Neurology, Louisiana State University Health Sciences Center, New Orleans, USA.
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Patti F. Treatment of cognitive impairment in patients with multiple sclerosis. Expert Opin Investig Drugs 2012; 21:1679-99. [DOI: 10.1517/13543784.2012.716036] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Benedict RHB, Walton MK. Evaluating cognitive outcome measures for MS clinical trials: what is a clinically meaningful change? Mult Scler 2012; 18:1673-9. [PMID: 22824644 DOI: 10.1177/1352458512454774] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Ralph H B Benedict
- Department of Neurology, University at Buffalo, Buffalo General Hospital, Buffalo, NY 14203, USA.
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Affiliation(s)
- Ralph H B Benedict
- Jacobs Neurological Institute, State University of New York at Buffalo, Buffalo, NY, USA (RHBB); and Department of Neurology, University of Virginia, Charlottesville, VA, USA (KF)
| | - Kathleen Fuchs
- Jacobs Neurological Institute, State University of New York at Buffalo, Buffalo, NY, USA (RHBB); and Department of Neurology, University of Virginia, Charlottesville, VA, USA (KF)
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Camarasa J, Rodrigo T, Pubill D, Escubedo E. Memory impairment induced by amphetamine derivatives in laboratory animals and in humans: a review. Biomol Concepts 2012; 3:1-12. [DOI: 10.1515/bmc.2011.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 10/04/2011] [Indexed: 11/15/2022] Open
Abstract
AbstractThe 20th century brought with it the so-called club drugs (the most notorious being amphetamine derivatives), which are used by young adults at all-night dance parties. Methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA or ecstasy) are synthetic drugs with stimulant and psychoactive properties that belong to the amphetamine family. Here, we have reviewed the literature about the cognitive impairment induced by these two amphetamine derivatives and the preclinical and clinical outcomes. Although there is controversial evidence about the effect of methamphetamine and MDMA on learning and memory in laboratory animals, results from published papers demonstrate that amphetamines cause long-term impairment of cognitive functions. A large number of pharmacological receptors have been studied and screened as targets of amphetamine-induced cognitive dysfunction, and extensive research efforts have been invested to provide evidence about the molecular mechanisms behind these cognitive deficits. In humans, there is a considerable body of evidence indicating that methamphetamine and MDMA seriously disrupt memory and learning processes. Although an association between the impairments of memory performance and a history of recreational amphetamine ingestion has also been corroborated, a number of methodological difficulties continue to hamper research in this field, the most important being the concomitant use of other illicit drugs.
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Affiliation(s)
- Jordi Camarasa
- 1Department of Pharmacology and Therapeutic Chemistry (Pharmacology Section) and Institute of Biomedicine (IBUB), Faculty of Pharmacy, University of Barcelona, E-08028 Barcelona, Spain
| | - Teresa Rodrigo
- 2Animal Experimentation Unit, Faculty of Psychology, University of Barcelona, E-08035 Barcelona, Spain
| | - David Pubill
- 1Department of Pharmacology and Therapeutic Chemistry (Pharmacology Section) and Institute of Biomedicine (IBUB), Faculty of Pharmacy, University of Barcelona, E-08028 Barcelona, Spain
| | - Elena Escubedo
- 1Department of Pharmacology and Therapeutic Chemistry (Pharmacology Section) and Institute of Biomedicine (IBUB), Faculty of Pharmacy, University of Barcelona, E-08028 Barcelona, Spain
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Benedict RHB, Smerbeck A, Parikh R, Rodgers J, Cadavid D, Erlanger D. Reliability and equivalence of alternate forms for the Symbol Digit Modalities Test: implications for multiple sclerosis clinical trials. Mult Scler 2012; 18:1320-5. [PMID: 22277740 DOI: 10.1177/1352458511435717] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cognitive impairment is common in multiple sclerosis (MS), but is seldom assessed in clinical trials investigating the effects of disease-modifying therapies. The Symbol Digit Modalities Test (SDMT) is a particularly promising tool due to its sensitivity and robust correlation with brain magnetic resonance imaging (MRI) and vocational disability. Unfortunately, there are no validated alternate SDMT forms, which are needed to mitigate practice effects. OBJECTIVE The aim of the study was to assess the reliability and equivalence of SDMT alternate forms. METHODS Twenty-five healthy participants completed each of five alternate versions of the SDMT - the standard form, two versions from the Rao Brief Repeatable Battery, and two forms specifically designed for this study. Order effects were controlled using a Latin-square research design. RESULTS All five versions of the SDMT produced mean values within 3 raw score points of one another. Three forms were very consistent, and not different by conservative statistical tests. The SDMT test-retest reliability using these forms was good to excellent, with all r values exceeding 0.80. CONCLUSIONS For the first time, we find good evidence that at least three alternate versions of the SDMT are of equivalent difficulty in healthy adults. The forms are reliable, and can be implemented in clinical trials emphasizing cognitive outcomes.
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Affiliation(s)
- Ralph H B Benedict
- SUNY Buffalo School of Medicine, Neurology, Buffalo General Hospital, Buffalo, NY 14203, USA.
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Benedict RHB, Zivadinov R. Risk factors for and management of cognitive dysfunction in multiple sclerosis. Nat Rev Neurol 2011; 7:332-42. [PMID: 21556031 DOI: 10.1038/nrneurol.2011.61] [Citation(s) in RCA: 252] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cognitive impairment is common in multiple sclerosis (MS), especially when assessed by neuropsychological tests that emphasize mental processing speed, episodic memory, and some aspects of executive function. In this Review, we question why some MS patients develop severe impairment in cognitive abilities, while cognitive ability remains intact in others. We find that the heterogeneity in neuropsychological presentation among patients with MS reflects the influence of many factors, including genetics, sex, intelligence, disease course, comorbid neuropsychiatric illness, and health behaviors. Neuropsychological deficits are also robustly correlated with brain MRI metrics. Male patients with early evidence of cerebral gray matter atrophy are most prone to impairment, whereas high premorbid intelligence improves the neuropsychological prognosis. Routine evaluation of cognition is useful for helping patients to navigate problems related to activities of daily living and work disability and, if reliable methods are employed, cognitive decline can be detected and included among the many clinical signs of disease progression or treatment failure. Pharmacological treatments for neuropsychological impairment are on the horizon, although presently no firm medical indications exist for the condition.
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Affiliation(s)
- Ralph H B Benedict
- Department of Neurology, Suite D6, Buffalo General Hospital, State University of New York at Buffalo, 100 High Street, Buffalo, NY 14203, USA.
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