A Guide to MS Cognitive Screenings

What is Neuropsychology?

Neuropsychology is the study of the relationship between the brain and behavior. A neuropsychological evaluation assesses how neurological disorders, brain injuries, and other health conditions can affect cognition (thinking), mood, and behaviors. People may be referred for a neuropsychological evaluation for a variety of illnesses, including stroke, dementia, neurodevelopmental disorders, and multiple sclerosis (“MS”). 

Neuropsychology and Multiple Sclerosis

Multiple sclerosis is a chronic autoimmune condition that damages the myelin sheath, a protective layer that covers nerve fibers in the brain and spinal cord. This damage disrupts communication between the brain and the rest of body, and can result in changes in cognition, emotions, and behaviors. A person with cognitive weaknesses, deficits, or impairments may experience “brain fog” and/or have trouble with attention, processing speed, memory, language skills, executive functions, visuospatial skills, and motor/coordination. 

Forty-eight to 70% of MS patients have experienced cognitive problems, and, in fact, they can be one of the first presenting symptoms. Thus, patients with MS are frequently referred for a neuropsychological evaluation at the time of diagnosis, and following any relapses or suspected changes in cognitive functioning. Fortunately, for most people with MS, cognitive problems remain mild and limited to only a couple of cognitive domains. However, for others, cognitive dysfunction can range from moderately to severely impaired. Regardless of the severity, cognitive deficits can increase disability and negatively impact one’s overall quality of life. For example, patients with cognitive concerns report decreased self-esteem and participation in social activities and more problems with interpersonal relationships. 

The presence and severity of cognitive dysfunction is associated with the number and location of MS lesions in the gray matter (where information processing occurs) of the brain. Since lesions’ characteristics determine cognitive dysfunction, there is no one consistent pattern of impairment. Additionally, there can be variability in cognitive/thinking abilities over time, with each relapse, and from one person to another. That said, there are some established facts. Disease duration and physical limitations, including reduced mobility, are not correlated with cognitive dysfunction. While cognitive decline can be seen in all subtypes of MS, it is more common in the progressive subtypes (Primary Progressive and Secondary Progressive). Lastly, although all cognitive domains can be affected in MS and research on the cognitive effects of MS have been inconsistent. People most frequently report problems in processing speed, new learning and memory, attention, and aspects of executive functioning (abstract reasoning, judgment, and problem-solving). 

Domains of Cognitive Functioning

• Processing speed is a foundation of cognition in that it can affect other areas of functioning. It describes how quickly one can process or take in, interpret, and respond to information. It is vulnerable to internal (e.g., mood) and external (e.g., noise) stimuli. For example, feeling sad can increase the time it takes to complete daily tasks or make decisions.
• Attention is another foundation of cognition thinking. It is the ability to attend to or focus on specific stimuli while ignoring anything that is irrelevant. There are several different types of attention, but divided attention (the ability to simultaneously focus on multiple tasks or stimuli) seems to be most affected in MS.
• Executive functioning is an umbrella term that describes higher level thinking skills such as problem-solving, planning and organizing, and multi-tasking. Thinking through complex topics or tasks can be difficult due to some of these problems.
• New learning and memory describe the 3 steps that occur in one’s ability to remember. First, information is learned (part 1). It is then stored in the brain (part 2) before it can be recalled (part 3). Research previously suggested that MS patients are able to learn and store new information, but have difficulties recalling the information. However, recent research has indicated that people have more difficulty and need additional time learning information but can recall information well once it is learned.
• Language is the ability to express yourself and comprehend written and spoken word. People with MS can have problems with speech production and communication. Dysarthria (caused by poor muscle coordination or weakness) can cause slurred, slowed, etc. speech and verbal fluency (ability to think of the word you want to say) deficits are often reported by MS patients.
• Visuospatial skills allow one to see, understand and interpret, and respond to objects. Optic neuritis is a vision disorder that is associated with MS and can lead to visuospatial deficits such as depth perception, navigating spaces, and recognizing objects. This could cause problems with driving, using steps, correctly seeing shapes.

Causes of Cognitive Impairment

There are multiple factors other than MS that can cause or worsen cognitive symptoms. Comorbid medical diagnoses (e.g., high blood pressure, high cholesterol, diabetes, thyroid disorder, etc.) can also cause cognitive deficits and must be considered during a neuropsychological evaluation. Aside from medical conditions, there are numerous non-medical factors that can impact cognitive abilities. Fatigue is one of the most common symptoms reported by MS patients and thus one of the most common factors outside of brain health that may affect cognition. Additionally, age, sleep disturbance, pain, mood and stress, and medication side effects can also have a negative effect on cognition, and will all be taken into consideration during the neuropsychological evaluation. 

The Neuropsychological Evaluation

At least once a year and/or prior to referring to neuropsychology, a medical doctor may administer a 10-minute neurocognitive screener. While screeners are useful in determining whether a person may have a major neurocognitive disorder (i.e., dementia), they do not assess all cognitive domains nor are they sensitive enough to consistently identify mild to moderate problems. A referral to neuropsychology can occur at any time but should be considered shortly after being diagnosed with MS. The referral can be used as a baseline for comparison to future evaluations so one can tell if there has been a change in functioning over time. 

What an Evaluation Entails

A neuropsychological evaluation can last between 4-8 hours depending on the referral question, medical history, and patient concerns. It includes a clinical interview, psychometric testing, and a feedback session where the results and recommendations are reviewed. During the clinical interview, the provider and patient will discuss the patient’s current concerns and medical history. Additional information from family or friends is helpful to gain a full understanding of the patient’s functioning. A clinical interview usually lasts an hour but can take longer depending on the complexity of the case. 

Psychometric testing to assess current cognitive functioning is the majority of the evaluation. Most of the tests will be question/answer style between evaluator and patient. There may also be paper/pencil or computer-based tests. The patient and their family may also be asked to complete self-report questionnaires. However, only the patient and the evaluator are allowed in the room during testing. The tests vary in difficulty level so that a pattern of strengths and weaknesses can be identified. Sometimes patients may feel tired because of the testing process or anxious or frustrated with how they think they are performing. The goal is not perfection. The best thing to do is to share any concerns with the evaluator and if necessary, ask for a break. During longer evaluations, breaks including a lunch break will likely be scheduled. 

Feedback Session

The purpose of the feedback session is to discuss the results and recommendations of the evaluation. It is a separate appointment. The patient will learn what if any cognitive weaknesses or impairments they have and whether it meets criteria for a neurocognitive disorder. Factors that may be causing or worsening any problems will be discussed. Recommendations may include follow-up testing in the future, referrals for speech therapy or cognitive rehabilitation to improve cognitive abilities, referrals for individual or group psychotherapy to manage mood concerns (e.g., anxiety, depression), and strategies to minimize sleep disturbance/fatigue, or pain. Recommendations for medication or managing safety concerns may also be considered. Following the evaluation, a neuropsychological report is produced. It is a written report of the entire evaluation and includes the results and recommendations. It can be shared with other providers, and patients are encouraged to keep a copy for their personal records. 

Final Thoughts

If you think you should have a neuropsychological evaluation, talk to your medical team. Your neurologist, primary care physician, and rehabilitation therapists may already work with a neuropsychologist or have referral information. Additionally, a referral or insurance pre-authorization may be required. Please be patient. The average wait time for a neuropsychological evaluation is several months. You can ask if they have a waitlist or periodically call to see if there are cancellations. On the day of your appointment, take an updated list of your medication as well as your eyeglasses, hearing aids, or any adaptive equipment that helps you see, speak, hear, read, or write. Although not generally preferred, if you are unable to travel to your appointment, an online neuropsychological evaluation may be possible. Ask when you call to schedule an appointment. Lastly, keep in mind that cognition is only one aspect of your health, and the best way to care for your brain is to care for yourself.