Relationship Between Anxiety and Cognition in Multiple Sclerosis: Implications for Treatment

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

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

Heart Rate Variability (HRV) serves as an objective correlate of distress and symptom burden in multiple sclerosis

Background

Autonomic nervous system (ANS) dysfunction is frequently seen in people living with multiple sclerosis (MS). Heart rate variability (HRV) is an easy and objective index for evaluating ANS functioning, and it has been previously used to explore the association between ANS and the experience of symptom burden in other chronic diseases. Given ANS functioning can be influenced by physical and psychological factors, this study investigated whether emotional distress and/or the presence of ANS dysfunction is associated with symptom severity in people living with MS.

Methods

Participants with MS and healthy controls (HC) with no history of cardiac conditions were recruited to self-collect HR data sampled from a chest strap HR monitor (PolarH10). Short-term HR signal was collected for five minutes, and time and frequency HRV analyses were performed and compared between groups. HRV values were then compared to self-reported distress (Kessler Psychological Distress Scale) and MS participants' self-reported measures of symptom burden (SymptoMScreen).

Results

A total of n = 23 adults with MS (51 ± 12 years, 65 % female, median Patient Determined Disease Steps [PDDS]: 3.0) and n = 23 HCs (43 ± 18 years, 40 % female) completed the study procedures. All participants were able to complete the chest strap placement and HR data capture independently. Participants with MS, compared to the HC participants, had a significantly lower parasympathetic activation as shown by lower values of the root mean square of successive differences between normal heartbeats (RMSSD: 21.86 ± 9.84 vs. 43.13 ± 20.98 ms, p = 0.002) and of high-frequency (HF) power band (HF-HRV: 32.69 ± 12.01 vs. 42.39 ± 7.96 nu, p = 0.016), indicating an overall lower HRV in the MS group. Among individuals with MS, HF-HRV was significantly correlated with the severity of self-reported MS symptoms (r = -0.548, p = 0.010). Participants with MS also reported higher levels of distress compared to HC participants (18.32 ± 6.05 vs. 15.00 ± 4.61, p = 0.050), and HRV correlated with the severity of distress in MS participants (r = -0.569, p = 0.007). A significant mediation effect was also observed, with emotional distress fully mediating the association between HRV and symptom burden.

Conclusions

These findings suggest the potential for ANS dysfunction, as measured by HRV (i.e., lower value of HF power), to be utilized as an objective marker of symptom burden in people living with MS. Moreover, it is apparent that the relationship between HRV and symptom burden is mediated by emotional distress.

Trajectories of cognitive processing speed and physical disability over 11 years following initiation of a first multiple sclerosis disease-modulating therapy

BACKGROUND

We analysed the COMparison Between All immunoTherapies for Multiple Sclerosis (NCT03193866), a Swedish nationwide observational study in relapsing-remitting multiple sclerosis (RRMS), to identify trajectories of processing speed and physical disability after disease-modulating therapy (DMT) start.

METHODS

Using a group-modelling approach, we assessed trajectories of processing speed with oral Symbol Digit Modalities Test (SDMT) and physical disability with Expanded Disability Status Scale, from first DMT start among 1645 patients with RRMS followed during 2011-2022. We investigated predictors of trajectories using group membership as a multinomial outcome and calculated conditional probabilities linking membership across the trajectories.

RESULTS

We identified 5 stable trajectories of processing speed: low SDMT scores (mean starting values=29.9; 5.4% of population), low/medium (44.3; 25.3%), medium (52.6; 37.9%), medium/high (63.1; 25.8%) and high (72.4; 5.6%). We identified 3 physical disability trajectories: no disability/stable (0.8; 26.8%), minimal disability/stable (1.6; 58.1%) and moderate disability (3.2; 15.1%), which increased to severe disability. Older patients starting interferons were more likely than younger patients starting rituximab to be on low processing speed trajectories. Older patients starting teriflunomide, with more than one comorbidity, and a history of pain treatment were more likely to belong to the moderate/severe physical disability trajectory, relative to the no disability one. There was a strong association between processing speed and physical disability trajectories.

CONCLUSIONS

In this cohort of actively treated RRMS, patients' processing speed remained stable over the years following DMT start, whereas patients with moderate physical disability deteriorated in physical function. Nevertheless, there was a strong link between processing speed and disability after DMT start.

Importance of Identifying Cognitive Impairment in Multiple Sclerosis

This article aims to highlight the impact of cognitive impairment on outcomes and quality of life for people with multiple sclerosis (MS) and to review current evidence for the efficacy of disease-modifying therapies (DMTs) and other interventions. In addition, we provide clinical practice insights regarding screening and management of cognitive impairment in people with MS. Evidence suggests that cognitive deterioration often accompanies magnetic resonance imaging changes. Neocortical volume and deep grey matter atrophy correlate with cognitive impairment. Similarly, cognitive decline is predictive of a higher lesion burden. Cognitive impairment is an important clinical measure of disability and negatively impacts quality of life. Phase 3 studies suggest that DMTs such as natalizumab, ozanimod and fingolimod may provide long-lasting, clinically meaningful effects on cognition in people with MS. Further data are needed to support the use of adjunct cognitive behavioural and exercise interventions for people with MS who have cognitive impairment. More data are needed to define appropriate management strategies for cognitive impairment in people with MS. Baseline and periodic screening for cognitive impairment and inclusion of cognitive impairment as a clinical trial endpoint will help to inform efforts to manage this important aspect of MS.

Disorder-specific impaired neurocognitive function in major depression and generalized anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) are both highly prevalent and comorbid psychiatric disorders. Neurocognitive dysfunction has been commonly found in MDD, but the findings in GAD are inconsistent. Few studies have directly compared cognitive performance between GAD and MDD. Therefore, the present study aimed to reveal the similar and distinct cognitive impairments between both disorders.

METHODS

Three non-overlapping and non-comorbid groups were enrolled in the current study including patients with GAD (n = 37), MDD (n = 107) and healthy controls (n = 74). Levels of anxiety and depression were assessed using the Hamilton Anxiety Rating Scale (HAMA) and the Hamilton Depression Rating Scale (HAMD) respectively. The Cambridge Neuropsychological Test Automated Battery (CANTAB) was used to compare the cognitive performance, including sustained attention, visual memory, executive functions and learning.

RESULTS

Both MDD and GAD groups demonstrated common significant deficits in sustained attention, visual memory, working memory and learning when compared to healthy controls. Despite the similarities, the MDD group had significantly greater impairment in learning, particularly generalization, while the GAD group demonstrated more pronounced deficits in visual memory.

LIMITATIONS

Patients involved were medicated and the sample size for GAD was relatively small.

CONCLUSIONS

The significant differences in visual memory and learning between MDD and GAD groups might be indicators to distinguishing both disorders. These results confirm that cognitive function is of great importance as a future target for treatment in order to improve wellbeing, quality of life and functionality in both GAD and MDD.

The Complex Interplay Between Trait Fatigue and Cognition in Multiple Sclerosis

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

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

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

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

The Possible Direct Correlation between Cognitive Impairment and Fear of Catching COVID-19 among Patients with Multiple Sclerosis

Objective: The prevalence of cognitive impairment in multiple sclerosis (MS) is significant and it is estimated that 40% to 70% of patients with MS suffer from this impairment. COVID-19 is also a new infectious disease. The symptoms of this disease, which include fever, shortness of breath, and cough, can be mild to severe and can even lead to death. Due to the use of immunosuppressive drugs by Patients with MS, they might be at greater risk of catching COVID-19. Thus, patients with MS may be more afraid of catching the virus. One of the important factors is the relationship between cognitive deficit and the increase in patients' fear of COVID-19. The aim of this study was to assess the relationship between fear of catching COVID-19 and cognitive impairment in patients with MS.

Method: This cross-sectional study was conducted at the MS Clinic, Sina hospital, Tehran University of Medical Sciences, Tehran, Iran. Our participants in this project were Patients with MS who were over 18 years old and had no history of other neurological and psychiatric diseases. In addition to obtaining demographic and clinical information, we measured the fear of catching the COVID 2019 via Fear of COVID-19 Scale (FCV-19S), which is 7-item questionnaire. We also used Multiple Sclerosis Neuro Psychological Screening Questionnaire (MSNQ) to assess memory and information processing speed in Patients with MS.

Results: After adjustment for age, gender, disease duration, highest level of education, MS type, and EDSS in linear regression model, as well as the MSNQ total score and fear score of catching coronavirus, the results demonstrated a significant positive correlation with P value of 0.00 and β: 0.024.

Conclusion: The present study showed a direct relationship between cognitive disorder and level of fear regarding COVID-19. Patients with more cognitive disorders were more afraid of COVID-19.

Cortical Thickness and Serum NfL Explain Cognitive Dysfunction in Newly Diagnosed Patients With Multiple Sclerosis

Background and Objectives

To determine the relative importance of global or regional MRI and blood markers of neurodegeneration and neuroaxonal injury in predicting cognitive performance for recently diagnosed patients with multiple sclerosis (MS).

Methods

Thirty-five newly diagnosed patients with relapsing-remitting MS (RRMS) and 23 healthy controls (HCs) simultaneously completed a full clinical and neuropsychological assessment, structural brain MRI, and serum neurofilament light chain (sNfL) level test. Linear regression analyses were performed to determine which global or regional measures of gray matter (GM) atrophy and cortical thickness (CT), in combination with sNfL levels and clinical scores, are most strongly related to neuropsychological impairment.

Results

Compared with HCs, patients with MS showed bilateral thalamic GM atrophy (left, p = 0.033; right, p = 0.047) and diminished CT, particularly in the right superior and transverse temporal gyri (p = 0.045; p = 0.037). Regional atrophy failed to add predictive variance, whereas anxiety symptoms, sNfL, and global CT were the best predictors (R² = 0.404; p < 0.001) of cognitive outcomes, with temporal thickness accounting for greater variance in cognitive deficits than global CT.

Discussion

Thalamic GM atrophy and thinning in temporal regions represent a distinctive MRI trait in the early stages of MS. Although sNfL levels alone do not clearly differentiate HCs and patients with RRMS, in combination with global and regional CT, sNfL levels can better explain the presence of underlying cognitive deficits. Hence, cortical thinning and sNfL increases can be considered 2 parallel neurodegenerative markers in the pathogenesis of progression in newly diagnosed patients with MS.

Predicting Neuropsychological Impairment in Relapsing Remitting Multiple Sclerosis: The Role of Clinical Measures, Treatment, and Neuropsychiatry Symptoms

OBJECTIVE

This retrospective observational study aimed to define neuropsychological impairment (NI) profiles and determine the influence of clinical, demographic, and neuropsychiatric measures in specific cognitive domains in a cohort of relapsing-remitting multiple sclerosis (RRMS) patients.

METHODS

Ninety-one RRMS patients underwent a neurological examination and a brief neuropsychological assessment. Patients were classified according to the disease-modifying therapies (DMTs) received (platform or high-efficacy). Differences between groups and multiple regression analyses were performed to determine the predictive value of the assessed measures in cognitive performance.

RESULTS

More than two-thirds of the patients showed NI. Specifically, mild to moderate NI was presented in approximately half of the participants. Paced Auditory Serial Addition Test (PASAT-3) and Symbol Digit Modalities Test (SDMT) were the most frequently impaired cognitive tests (45.3% and 41.3%, respectively) followed by phonemic verbal fluency (PVF) (27.8%). Expanded Disability Status Scale (EDSS), age, depressive symptoms, and disease duration were the best predictors of SDMT (R2 = .34; p < .01), whereas disease duration, EDSS, and anxiety-state levels predicted PASAT-3 (R2 = .33, p < .01). Educational level, age, EDSS, and depressive symptoms demonstrated the strongest association with PVF (R2 = .31, p < .01).

CONCLUSIONS

Our results indicated a significant prevalence of NI in RRMS patients that was not dependent on the DMT type. In addition to the meaningful working memory (PASAT-3) and information processing speed (SDMT) impairments found, PVF deficits may also be an important marker of cognitive impairment in RRMS patients. This study supports the relevance of standard clinical measures and reinforces the importance of quantifying clinical and neuropsychiatric symptoms to predict subsequent cognitive performance on a similar multiple sclerosis phenotype and disease stage.

Evaluation of the cognitive benefits of intrathecal baclofen pump implantation in people with intractable multiple sclerosis related spasticity

BACKGROUND

Spasticity is a common problematic symptom in Multiple Sclerosis with over one third of patients failing first line therapies. Intrathecal baclofen is a safe and efficacious option for treatment resistant spasticity. Anecdotally patients report improved concentration/cognitive performance when switching to intrathecal baclofen (ITB) from systemic medications.

AIM

To explore whether subjects who proceed with ITB pump implantation for spasticity management and reduce oral anti-spasticity agents will have improved cognitive function.

METHODS

Subjects were admitted for trial of ITB via lumbar puncture and subsequent pump implantation. Spasticity and cognitive measures before ITB trial and 3 months post implant were recorded. Paired t-test or Wilcoxon Signed Ranks test was used for within subject change and effect sizes (Cohen's d_z) were calculated. Subgroup analysis of those on ≥2, or ≤ 1 spasticity medications at baseline was performed.

RESULTS

27 subjects with MS completed per protocol. Mean age 46 years [26 - 56], disease duration 15 years [6 - 26], RRMS = 3, SPMS = 17 and PPMS=7. The majority were on multiple spasticity medications. Spasticity scores significantly improved post pump implant. Mean ITB dose at 3 months was 143 mcg / day and 19 discontinued all other treatments for spasticity. There was no deterioration on any cognitive or mood measure. An improvement of moderate effect size was found in Backwards Digit Span (d=0.41, p=0.059) and HADS - anxiety (d=0.37, p=0.097). Fatigue Severity Scale score decreased substantially (d=0.81, p=0.005). Small improvements in Symbol Digit Modalities Test score (d=0.24) and Sustained Attention to Response Task response time (d=0.23) were non-significant. Performance on other measures did not change. Effect sizes were larger in subgroup on ≥2 oral spasticity medications at baseline, compared to the group on ≤1 medication (SDMT, d=0.42 vs d=0.07; Backwards digit span 0.45 vs 0.28; HADS-anxiety 0.39 vs 0.32; HADS-depression d=0.32 vs 0.05 and FSS, d= 1.14 vs 0.42).

CONCLUSIONS

In a pilot study exploring the impact of ITB on cognition, spasticity scores improved universally and beneficial effects on some measures of fatigue, anxiety, auditory attention and verbal working memory were found. Improvement of speed of processing in those withdrawing higher doses of oral medication was also demonstrated suggesting that switching to ITB has added cognitive and psychological benefits for people with MS.

The emotional disorders associated with multiple sclerosis

Multiple sclerosis (MS) is associated with a high prevalence of emotional and mood disorders. Emotional disorders may worsen during illness progression and affect the quality of life of patients and their families. MS is often associated with depression, with an increased risk of suicide, poor adherence to treatment, decreased functional status, and quality of life. The diagnosis and treatment of emotional and mood disorders in these patients is often challenging since several symptoms of these disorders overlap with those of MS. Other prevalent emotional disorders in MS include bipolar disorder, anxiety disorders, emotional blunting (apathy), and pseudobulbar affect. Early recognition and treatment of these comorbidities could contribute to the reduction of disability and even to decreased mortality. The aim of this chapter is to provide an up-to-date review of mood and emotional disorders that are often associated with MS, focusing on their epidemiology, clinical features, pathogenesis, assessment, and treatment. The interplay between the psychosocial impact of the chronic disability and the demyelinating structural lesions of the brain in precipitating emotional and mood disorders is discussed, as well as its implications for diagnosis and treatment.

Lipid profile: causal relationship on cognitive performance in multiple sclerosis?

Although cognitive impairment (CI) is classically associated with aging, it has been proposed that neurological pathologies may increase the risk to suffer CI. Despite the evidence of an elevated prevalence of CI in patients with multiple sclerosis (MS), it is not considered among standard clinical evaluations, due the lack of specialists and time required. The aim of this study was to evaluate if lipid profile is associated with cognitive performance in persons with MS. Twenty patients with MS were evaluated. Montreal Cognitive Assessment (MoCA) was employed to determine cognitive performance. CI was observed in 85% of patients, with memory recall and language as the most affected domains. Despite biomarkers were mostly found within reference values, several correlations were observed. MoCA total score was correlated with cholesterol (r =  - 0.468, p = 0.037) and LDL (r =  - 0.453, p = 0.045). Visuospatial domain was correlated with LDL (r =  - 0.493, p = 0.027). Attention domain correlated with triglycerides (r =  - 0.455, p = 0.044) and cholesterol (r =  - 0.549, p = 0.012). When the person reaches borderline levels of triglycerides, LDL and cholesterol a decrease in cognitive performance can be observed. The mechanism underlying this association has not been established still, it has been proposed that it could be linked with neuroinflammation, alterations in synapses and in the metabolism of amyloid-β protein. This study settles the potential importance that lipid profile could have on cognitive performance in MS. Further studies are needed to establish optimal levels and implication of lipid profile in the diagnosis and monitoring of cognitive performance in Mexican people with MS.