multiple sclerosis and neuropsychological functioning: managing cognitive deficits dr. lesley...

MULTIPLE SCLEROSIS AND NEUROPSYCHOLOGICAL FUNCTIONING:

MANAGING COGNITIVE DEFICITS

Dr. Lesley Ritchie, C.Psych.Ms. Jodie Gawryluk, B.A.

Department of Clinical Health PsychologyUniversity of Manitoba

1. Introduction to the brain2. Understanding MS3. The treatment team4. What is neuropsychology?5. Neuropsychological assessment

Cognitive domains6. Neuropsychological profile of MS7. Managing neuropsychological deficits

Specific strategies Special considerations

The brain monitors and controls nearly everything that we do from our breathing and heart beats to our senses (e.g., vision, hearing), to our movements, speech, and personality

• The brain is divided into left and right cerebral hemispheres

Left Hemisphere is important for:

Right Hemisphere is important for:

• language (thinks in words)• math• logical abilities• movement of the right side of the body

• visual information (thinks in pictures)• organization• creativity• movement of the left side of the body

• Movement• Speaking • Planning• Organizing• Reasoning• Decision making• Judgment• Personality

Frontal Lobes

• Memory• Recognition Hearing• Understanding Language• Emotions

Temporal Lobes

• Sensations • Reading and Writing• Ability to use Numbers• Spatial Reasoning• Perception

Parietal Lobes

• Seeing objects• Locating objects in space• Recognizing the things we see

Occipital Lobes

Cerebellum

• Maintaining balance• Coordination of movement• Timing of movement

Brain Stem• Connection between brain and body• Breathing• Blood pressure• Swallowing• Appetite• Body temperature• Digestion• Sleeping

Brain Anatomy The brain is made up of two types of tissue:

Grey matter (where information is processed) White matter (the highways that take information to the

processing stations)

White matter Grey matter

Functional Analogy

Multiple = more than one Sclerosis = area of stiffening/damage Autoimmune disorder Immune system attacks the CNS

Demyelination White matter tissue is white because of myelin, a fatty covering that helps information

travel to brain areas quickly

Symptom onset btwn 20 – 40 years of age

2-3x more common in women

Increased prevalence in northern latitudes

Affects brain and spinal cord Altered motor,

sensory, and cognitive functioning

Common presenting symptoms (Olek 2005)

Symptoms vary according to disease course

Symptom Frequency (%)

Sensory disturbance - limbs

30.7

Visual loss 15.9

Motor disturbance (subacute)

8.9

Diplopia 6.8

Gait disturbance 4.8

Motor (acute) 4.3

Balance problems 2.9

Sensory disturbance (face)

2.8

Disease course1. Relapsing and remitting MS (RRMS):

– Clearly defined attacks and periods of remission– Triggers: warm weather, infections, stress

2. Secondary progressive MS (SPMS):– 80% with initial RRMS show declines between attacks w/o

periods of remission; most common

3. Primary progressive MS (PPMS):– 10% who do not have period of remission following 1st

attack– Continuous decline– Older at onset

4. Progressive relapsing MS (PRMS):– steady decline with attacks

Bobholz & Gremley (2011)

GP: manages all medical concerns Neurologist: manages concerns about

MS or other brain conditions Radiologist: collects images of the brain Neuropsychologist

… is an applied science concerned with the behavioural expression of brain dysfunction (Lezak, 1995)

Normal Distribution - Test Interpretation

13.59%0.13%

Z -3 -2 -1 0 1 2 3

AVERAGELow Ave High Ave34.13%

2.14% 2.14%13.59%

34.13%

0.13%Impaired

Borderline SuperiorV. Superior

13.59%

Average

0.13%

Low average High average

X

13.59%0.13%

Z -3 -2 -1 0 1 2 3


2.14% 2.14%13.59%

34.13%

0.13%Impaired


13.59%

Average

0.13%


X X


13.59%0.13%

Z -3 -2 -1 0 1 2 3


2.14% 2.14%13.59%

34.13%

0.13%Impaired


13.59%

Average

0.13%


X X X


What neural mechanisms underlie various cognitive abilities and different emotional states?

How do these mechanisms work ? What are the effects of brain damage on

behaviour ? Application of appropriate intervention

strategies

Neuropsychological Assessment Specific nature of the injury Pre-injury history strengths / weaknesses Specific situation demands of life / work Supports available Personality factors Emotional response to injury & limitations Adaptive & coping skills Beliefs / expectations of client & family Psychometrics

All neuropsychological tests are developed through research

Administered in a standardized manner

Results are compared to normative data

Cognitive domains Estimated premorbid ability General Intellectual ability Attention Speed of information processing Sensory – motor function Language Visual Perception & Construction Executive functions Memory Mood / Psychopathology / Personality Validity & Effort

45-65% of people with MS have cognitive symptoms

80% of those are mildly affected Even mild problems can interfere with

everyday activities Cognitive deficits increase with prolonged

disease duration 20-30% of patients develop more severe

impairments, such as dementia Cognitive deficits don’t tend to fluctuate

Greater deficits associated with Progressive disease courses (PPMS, SPMS) Duration of disease Increased prevalence of cognitive decline

in men Quantity of MR abnormalities

Processing speed Attention/

concentration Sustained Complex

Memory (40-60%)

Episodic/recent memory Working memory

Executive functioning (EF)

Abstract reasoning Problem-solving

Language Verbal fluency Naming

Visuospatial skills

Table 20.3; Bobholz & Gremley (2011)

Speed of mental activity

Most common Underlying factor

Memory Working memory

http://www.mountsinai.on.ca/care/ebffrc/ms

Attention = vigilance, capacity for information, switching attention, selective attention

20-25% of MS patients Deficits in rapid and complex info

processing Working memory Attentional switching Rapid visual scanning

Intact attention span

Focused Attention is the ability to focus on something in the moment.

For example, focused attention can be for things you see, such as watching television or for things you hear, such as listening to the radio.

Sustained Attention allows you to focus on something over a long period of time

For example, watching a movie or reading a book.

Selecting Attention allows you to pick out important information from unimportant or distracting information

For example, listening to a conversation in a noisy cafeteria.

Shifting Attention allows you to switch back and forth between two different tasks.

For example, when you are cooking you may need to shift your attention back and forth between watching for a pot boil and preparing vegetables to put in the pot.

Divided Attention allows you to work on two different tasks at the same time, and is sometimes referred to as multi-tasking.

For example, singing along to the radio while driving home.

Symptoms of Attention Difficulties• Becoming easily distracted • Having trouble keeping track of what is being said and done or have trouble making sense of things• Having trouble focusing on one person, thing or conversation in crowded environments • Having trouble keeping track of more than one thing at a time • Having difficulty doing more than one task at a time • Having difficulty learning and remembering information• Becoming easily frustrated with yourself and others• Feeling confused and overwhelmed• Avoiding contact with care givers, friends and family

Ability to learn and recall information about previous experiences. E.g., favorite song and the look of our

home Different types of memory are stored

in different places in the brain.Verbal information (such as words) are typically stored on the left side of the brain

Visual information (such as pictures) are typically stored on the right side of the brain

Different types of memory based on time. Short term memory, Working memory, Recent memory, and Long term memory

•This is the ability to remember something in the moment or that you only need to remember for a few minutes

•Remembering a phone number you have just been told

•Short term memory is often impaired after a brain injury

• This is the ability to remember in the moment or for a few minutes while you focus on something else or are distracted

• An example is keeping a phone number in mind while looking for a pen and paper to write it down.

• Working memory is often affected by brain injury

1. AttentionYou must pay attention to what you are learning

2. RecordingYour brain needs to 'take in'

and record information

3. RetainThe information needs to be stored in the right spot

4. RetrieveInformation needs to be

recalled when it is needed again

If problems occur anywhere

in these steps, then memory difficulties will

occur

The 3 R’s of Memory

Cognitive abilities required to complete goal-directed behaviors that are not automatic, overlearned, or routine (Sohlberg & Mateer, 2001).

Initiation Inhibition Set-switching Judgment/Reasoning Goal identification Working memory Speed of processing Cognitive

flexibility/problem-solving

Sequential processing Planning Self-Monitoring Perseveration Prioritizing Multi-tasking Emotional control Insight/Awareness

15-20% of patients with MS exhibit executive dysfunction Impaired goal-directed behavior Verbal disinhibition Poor self-monitoring (e.g., tangential speech) Reduced insight Deficits in planning and prioritizing Problems with abstraction and

conceptualization

Language Mild confrontation naming deficits Speech abnormalities (dysarthria,

hypophonia) Poor verbal fluency (retrieval deficit/speed)

20-25% Visuospatial

Angle matching Face recognition impact of changes in vision/diplopia Visual miscalculations

Neuropsychological rehabilitation Interventions aiming to enhance or support

cognitive abilities following brain injury, with an emphasis on achieving functional changes (Sohlberg & Mateer, 2001)

Target: reductions in cognitive, emotional, psychological functioning that encumber everyday functioning

Goal: increase independent functioning by means of enhanced knowledge and skill, behavior change, or implementation of compensatory strategies

Foundation of cognitive intervention Tx based on current level of function Build on strengths to support weaknesses Collaborative Goal-oriented Education

Processing speed Attention Memory Executive functioning Language

Complete one activity at a time

Schedule more time to complete tasks

Limit distractions Record information

for later review

Orienting procedures “What am I doing?” Minimizes gaps in attention

Pacing Realistic expectations Elongated performance times Minimize frustration Vary according to time of day Schedule adequate rest

Environmental modification Work in a quiet environment Reduce clutter Limit distractions Refer to checklists to complete tasks Set timers to prevent going overtime

Work on one task at a time Double/triple check work to minimize errors Have a significant other check work

Top Ten tips to help you manage attention difficulties:

Practice Check in Modify your environment Pace yourself. Take care of yourself. Monitor your mood. Double check Break tasks down Do difficult tasks at your best time of day. Use your family and friends for support.

Take care of yourself.

Fatigue, hunger, and/or thirst all adversely affect your attention.

Taking care of yourself will help maintain optimum attention.

Repetition - Repeat the information over and over and over again.

•Looking at something one time is never enough.

•For example, if you are trying to learn someone’s name, repeating it over and over to yourself can help you remember it.

Multimodal learning –

It helps to learn the same information in different ways.

For example, to learn a new recipe, it helps to read over the steps in the recipe, listen to someone telling you the steps, and practice the recipe by doing it.

See it, hear it, do it!

Break it down - Break up what you want to remember into smaller steps. If you have something really tough to learn, try to break it down into small bits and then learn one bit at a time.

Write it down - When something is important to remember, write it down, and keep it in a safe place. Remember to check your notes regularly.

Writing information down also allows for repeated exposure to the information (Hear, Write, Read – 3x exposure)

• Calendar• Daytimer• PDA or cell phone• Notebook

Learn it right the first time - New skills are easier to remember if you learn them the right way (mistakes are hard to correct later)

Helpful Hints for Errorless Learning

1. Break the task down into smaller steps.

2. Learn each step at a time and avoid making errors that may confuse you later .

3. Complete the task you are trying to learn together with someone who has done it before. Ask this person to talk through the steps as you learn the task (this will help you to avoid errors)

4. Use hints that will help you remember the steps (you can ask someone for hints or make up notes for yourself that guide you to the next step)

5. Only try to do the new skill when you are sure you know the steps and can do it error-free

Elaboration – This is a technique that you can use to make information more meaningful and easier to remember. Information can be easier to remember if you think through all of the details. Here are some questions to help you elaborate:

Can you link this with anything or anyone you know? Do you link this with any feelings? Is there anything about it that is unique or special? Can you link this with things in your daily life? How does it look? How does it feel? How does it sound? How does it smell? How does it taste?

Space out your attempts to retrieve information - Try to recall new information several times in a row. If you can recall it correctly, then gradually increase the time (from minutes to hours) between attempts.For example, recall information the first time after 20 seconds, then space out your attempts to recall – 30 sec, 1 minute, 5 minutes, 10 minutes, 30 minutes, 1 hour, 4 hours, later that day, and the next day.

Set up a Routine - Follow a daily or weekly routine to help you remember events and times to get regular tasks done each day.

Brooke Smith

355-2941355-294_355-29_ _355-2_ _ _

External Aides (portable memory)• Labels on the outside of boxes, drawers, and cupboards to help you find things. • Post-it notes to leave yourself reminders in places around your home.• A notepad beside the phone to write down messages and reminders• Checklists or shopping lists.• Diary for storing and planning • Alarm clock, or timer to help you remember when you are supposed to do something • A calendar to keep track of appointments • A tape recorder to leave messages for yourself • A pill reminder box to keep track of medications

Get Organized – It is easier to remember where things are if they are kept in one place. For example, if you are constantly losing your wallet, you will find it faster if you always leave it in the same spot.

Make A 'To Do' List – Making a list of things that you need to do can help you remember all that you need to get done. For example, you can make a list of chores to remind yourself of what needs to be done.

Mnemonics Consciously leaned Require considerable effort Verbal or visual

Richard of York gives battle in vain Red, orange, yellow, green, blue, indigo, violet

My very elderly mother just sat upon a new pin Mercury, Venus, Earth, Mars, Jupiter, Saturn,

Uranus, Neptune, Pluto

Structure and Routine! Do things that require the most initiation in the morning

or after a rest Set a small number of goals for each day

Set up (with assistance) organizational practices Large family calendar Online bill payment Use labels Schedules Simplify activities Prioritize Checklists

Meta-cognitive strategies To regulate behavior and increase

goal-oriented behavior Self-talk Tracking behaviors Self-monitoring

Tracking errors and attention lapses

Goal Management Training

Levine et al. (2000).

Maintaining intentions in goal-directed behavior is reliant on intact executive functioning

GMT based on theory of goal neglect resulting in disorganized behavior following frontal lobe injury

Language Communication skills training Group interventions

Modeling and generalization Building social networks In MS, many language deficits are due to

physical changes (i.e., dysphagia) and reduced speed of processing.

Allow more time for communication

Neuropsychological interventions should be person-specific

Different presentations

AttentionProcesses

MemoryProcesses

ExecutiveProcesses

Working Memory

Prospective Memory

Awareness

Selective Attention

Divided Attention

Alternating Attention

Task Performance Solberg & Mateer (2001), Figure 8.3

Common symptoms of MS Emotional and psychological difficulties

Depression Fatigue Pain

EMOTIONAL DIFFICULTIES

Can impact neuropsychological functioning

Healthy Brain

25%

25%

50%

Nurse Cells Life Support Cognitive

Brain Injury

25%

25%

33%

17%

Nurse Cells Life SupportCognitive Brain Injury


Brain Injury + Stress/Anxiety

25%

25%22%

17%

11%

Nurse Cells Life Support Cognitive

Brain Injury Stress/Anxiety


Patients with MS have a 50% lifetime risk for depression

Higher prevalence than the general population and higher than in other brain disorders

Depression is treatable!

Prevalence of anxiety is 25% - usually associated with diagnostic uncertainty and decreases over time

Common Symptoms Feelings of helplessness and

hopelessness Loss of interest in daily activities. Appetite or weight changes Sleep changes Psychomotor agitation or retardation Loss of energy Self-loathing Concentration problems

Self-management strategies Schedule in activities each day Make plans to see supportive

friends/family Consider joining a support group Try a new hobby Try activities that make you think (this will

help with your recovery too!) Stay away from drugs/alcohol Exercise (e.g., go for a short walk)

Referral to a Clinical Psychologist Psychotherapy

When feelings of depression are severe, it is important for family members/friends to be aware of suicide risk.

If your family member/friend talks about wanting to end their life or makes statements such as "It would have been better if I had died" he/she may be thinking about suicide. It is important not to ignore these comments and to contact a member of the healthcare team immediately.

For support from the mental health crisis team (available 24 hours a day all week) Call 1-877-435-7170 (MANITOBA SUICIDE LINE)

The brain has to work harder to do the same activities it did before. Because the brain has to work so hard, it can become tired more quickly.

The brain may be trying to heal as you recover from a relapse and this takes more energy than usual, which can lead to fatigue.

MS can lead to problems with sleeping, which can leave you feeling exhausted.

When you have fatigue, you may feel suddenly exhausted and lack the energy to do basic tasks.

Mental Fatigue

Increased forgetfulness Lack of motivation to plan your day Lack of interest in things you enjoy Withdrawal Slower speech Giving short answers in a quiet/dull voice Increased irritability or anxiety Slurred speech Difficulty finding words Poor concentration

Physical Fatigue

Shortness of breath Slower movement Withdrawal Cramps or weak muscles Poor coordination or balance Falls Poor vision

It can help to figure out what triggers your fatigue, and how long it takes you to become fatigued.

Keeping track of these factors can help you tailor coping strategies to suit you best.

Once you know how fatigue affects you, there are a number of strategies that can be used to help you manage the fatigue that so often results from a brain injury.

What makes fatigue worse?

• Doing too many things.• Not taking breaks during the day.• Stress • Illness• Too little exercise.• Poor nutrition, such as eating junk food.• Alcohol and caffeine• Feeling depressed or anxious.• Poor sleep.

What are some strategies that can make fatigue better?

1. Following a Routine2. Environmental aids3. Timing of activities4. Pace Yourself5. Sleep6. Eat properly7. Exercise your body8. Exercise your mind9. Plan ahead10.Seek support

How to cope with Fatigue

When should you ask for help?

Talk with someone on your health care team if…..

You are having trouble using strategies to cope with fatigueYour fatigue gets worse over timeYou are too fatigued to get out of bed during the dayYou have trouble sleeping and aren't functioning properlyYou feel sadness and lack of motivation along with fatigueYou are having trouble taking care of yourselfYour ability to think through daily activities is affected by fatigue

Like emotional difficulties, pain can negatively impact cognitive functioning by: Stealing one’s attention/focus Reducing processing speed Attention and processing speed deficits

can negatively impact memory Exacerbating psychological and emotional difficulties

Coping strategies Psychotherapy

Relaxation strategies Abdominal breathing Imagery Progressive muscle

relaxation Cognitive restructuring Behavior management

Planning Prioritizing Pacing Learning how to

communicate about pain

Potential obstacles to successful interventions Diminished insight Poor engagement/motivation to change Significantly compromised cognitive

functioning Poor generalization

Sohlberg & Mateer (2001)

Solutions- Include significant others - Build generalization into the treatment

program. - Collaborative relationship with the patient

and family- Homework- Real world examples- Work with patient to identify barriers to

complete homework- Over-learning- Relapse planning and management

Sohlberg & Mateer (2001)

multiple sclerosis and neuropsychological functioning: managing cognitive deficits dr. lesley...

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