Identification
In advanced MS, when physical disability limits activity and confines an individual to wheelchair or bed, deficits in cognitive function can be more difficult to discern. Increased sleepiness, physical inability to hold a book to read, or not participating in family life fully make it difficult to assess attention and concentration, memory, reasoning, executive function, multitasking, or visual and spatial orientation.
The only obvious clue might be the effect of cognitive dysfunction on mood, where frustrated thinking or poor decision-making results in anger and withdrawal. Decisions must be analysed for logic, realism, and feasibility of implementation. It is not uncommon for those with advanced MS to make unhealthy and illogical decisions regarding their own care— firing a personal assistant abruptly or stopping a medication against doctor’s orders. Refusing care, or imagining care needs inappropriate to the situation, can occur.
Memory problems top the list. Forgetting names, appointments, phone numbers, movie plots, what to do next, or what goes into the favourite family recipe, are examples of memory deficits. There can also be difficulty learning new information and concentrating on a task or conversational topic.
Slowed information processing is also a frequent problem. Everything takes longer. It may be impossible to play games that are time sensitive. Response time is slowed. It may take longer to shave, bathe and dress.
Attention and concentration suffer. Inability to focus, difficulty following a conversation or remembering details from a conversation, problems relating a story, difficulty reading, concentrating, or following a movie plot are examples of attention deficits. Being easily distracted and flitting from task to task or idea to idea are examples of difficulties with concentration. The ability to multitask or shift between tasks becomes difficult or impossible.
Reasoning and problem solving difficulties, making poor decisions, and having poor judgment can be difficult to recognise and more difficult to deal with for Care Givers. Slowness to understand analogies or parables, difficulty “getting” jokes, taking things at face value, being literal or concrete, and finding it difficult to analyse complex situations, are all evidence of cognitive decline.
Executive functions such as the ability to plan and carry out a task like planning a daughter’s wedding or a holiday trip can be affected in MS. Becoming overwhelmed by a pending task can result in confusion over where to begin, and may be associated with compensatory anger and withdrawal.
Visual perceptual function and spatial orientation problems can include difficulty following directions or programming a VCR, confusion over right and left, and difficulty visualising how a certain piece of adaptive equipment could be useful, even driving.
In advanced MS, cognitive decline, like physical decline, cannot be reversed. However, cognitive disorders can be treated with medication and behavioural methods. Donepezil (Aricept®), commonly used in Alzheimer’s disease, has shown a modest effect in several small trials of memory in people with MS.
The use of ginko biloba in a small randomised controlled trial reported positive effects on attention and memory for people with MS. Symptom management of fatigue, depression, stress and pain can also have a positive impact on cognition.