MULTIPLE SCLEROSIS AND NEUROPSYCHOLOGICAL FUNCTIONING: MANAGING COGNITIVE DEFICITS

MULTIPLE SCLEROSIS AND NEUROPSYCHOLOGICAL FUNCTIONING: MANAGING COGNITIVE DEFICITS Dr. Lesley Ritchie, C.Psych. Ms. Jodie Gawryluk, B.A. Department of Clinical Health Psychology University of Manitoba

Introduction to the brain • Understanding MS • The treatment team • What is neuropsychology? • Neuropsychological assessment • Cognitive domains • Neuropsychological profile of MS • Managing neuropsychological deficits • Specific strategies • Special considerations Overview

Introduction to the brain • 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

Introduction to the brain • 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

Introduction to the brain Frontal Lobes • Movement • Speaking • Planning • Organizing • Reasoning • Decision making • Judgment • Personality

Introduction to the brain Temporal Lobes • Memory • Recognition Hearing • Understanding Language • Emotions

Introduction to the brain Parietal Lobes • Sensations • Reading and Writing • Ability to use Numbers • Spatial Reasoning • Perception

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

Introduction to the brain Cerebellum • Maintaining balance • Coordination of • movement • Timing of movement

Introduction to the brain 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) Introduction to the brain White matter Grey matter

Functional Analogy Introduction to the brain

Multiple Sclerosis • 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

Multiple Sclerosis • Symptom onset btwn 20 – 40 years of age • 2-3x more common in women • Increased prevalence in northern latitudes

Multiple Sclerosis • Affects brain and spinal cord • Altered motor, sensory, and cognitive functioning • Common presenting symptoms (Olek 2005) • Symptoms vary according to disease course

Disease course • Relapsing and remitting MS (RRMS): • Clearly defined attacks and periods of remission • Triggers: warm weather, infections, stress • Secondary progressive MS (SPMS): • 80% with initial RRMS show declines between attacks w/o periods of remission; most common • Primary progressive MS (PPMS): • 10% who do not have period of remission following 1st attack • Continuous decline • Older at onset • Progressive relapsing MS (PRMS): • steady decline with attacks Multiple Sclerosis Bobholz & Gremley (2011)

GP: manages all medical concerns Neurologist: manages concerns about MS or other brain conditions Radiologist: collects images of the brain Neuropsychologist Treatment Team

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

34.13% 34.13% Superior Borderline 2.14% 2.14% Impaired 0.13% 13.59% Normal Distribution - Test Interpretation Average AVERAGE Low average High Ave High average Low Ave V. Superior X 13.59% 13.59% 0.13% 0.13% Z -3 -2 -1 0 1 2 3

34.13% 34.13% Superior Borderline 2.14% 2.14% Impaired 0.13% 13.59% Normal Distribution - Test Interpretation Average AVERAGE Low average High Ave High average Low Ave V. Superior X X 13.59% 13.59% 0.13% 0.13% Z -3 -2 -1 0 1 2 3

34.13% 34.13% Superior Borderline 2.14% 2.14% Impaired 0.13% 13.59% Normal Distribution - Test Interpretation Average AVERAGE Low average High Ave High average Low Ave V. Superior X X X 13.59% 13.59% 0.13% 0.13% Z -3 -2 -1 0 1 2 3

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 Clinical Neuropsychology

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 Clinical Neuropsychology

All neuropsychological tests are developed through research • Administered in a standardized manner • Results are compared to normative data Clinical Neuropsychology

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 Clinical Neuropsychology

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 Neuropsychological Profile of MS

Greater deficits associated with • Progressive disease courses (PPMS, SPMS) • Duration of disease • Increased prevalence of cognitive decline in men • Quantity of MR abnormalities

Cognitive Impairment in MS • 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)

Processing Speed • 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 Attention

Information about Attention 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.

Information about Attention Sustained Attention allows you to focus on something over a long period of time For example, watching a movie or reading a book.

Information about Attention Selecting Attention allows you to pick out important information from unimportant or distracting information For example, listening to a conversation in a noisy cafeteria.

Information about Attention 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.

Information about AttentionTypes of Attention 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.

Information about Attention • 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. Memory 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

Facts about MemoryTypes of memory • Different types of memory based on time. • Short term memory, Working memory, • Recent memory, and Long term memory

Facts about MemoryShort 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

Facts about MemoryWorking memory • 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. Attention You must pay attention to what you are learning 2. Recording Your brain needs to 'take in' and record information 3. Retain The information needs to be stored in the right spot 4. Retrieve Information needs to be recalled when it is needed again Facts about Memory How are memories made? 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). Executive Functioning

Executive Functioning • 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 Executive Functioning

MULTIPLE SCLEROSIS AND NEUROPSYCHOLOGICAL FUNCTIONING: MANAGING COGNITIVE DEFICITS