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This article discusses the importance of addressing cognitive dysfunction in ME/CFS, explores the clinical presentation and understanding of cognitive dysfunction, explores effective neuropsychological batteries, and presents research evidence. It also highlights the common and disabling nature of "brain fog" in ME/CFS.
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Neurocognitive Manifestations in ME/CFS Gudrun Lange, PhD Professor Department of Physical Medicine and Rehabilitation, Rutgers-NJMS
Outline • Why is it important to talk about cognitive function in ME/CFS? • What is the clinical presentation? • How can cognitive dysfunction in ME/CFS be understood? • What is an effective neuropsychological battery? • What is the research evidence? • Final thoughts
Brainfog: Common and Disabling • Experienced as difficulties with attention, concentration and multi-tasking • Recognized as important: Listed as symptom in all ME/CFS case definitions • Serves as objective criterion for disability: lack of validated physiological markers
Clinical Presentations • “I feel like I’m loosing my mind…” • “I feel like having the brain of an 80-year old in the body of a 36-year old…” • “I feel stupid…”
Conceptualization of Cognitive Dysfunction • Possible etiology of cognitive dysfunction • Genetic • Acquired • Severity of cognitive dysfunction • Severe • Moderate • Mild
Determination of Severity of Cognitive Dysfunction • Subjective • Patient and family report • Perception of degree of loss of cognitive function • Objective • Neuropsychological evaluation • Statistical determination of degree of loss of cognitive function • Behavioral observations during testing should be taken into consideration
An effective neuropsychological battery for ME/CFS patients • Has to include standardized and normed measures that • Sufficiently and repeatedly challenge complex information processing and multi-tasking • reliably demonstrate areas of cognitive resilience • assess mood and anxiety • ascertain adequate effort
Intellectual profiles in ME/CFS WAIS-IV profile: Scores discrepant from expected levels Case 1 Case 2
Clinical Interview • Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV) • Test of Premorbid Functioning (TOPF) • Beck Depression Inventory II (BDI II) • Spielberger State Trait Anxiety Questionnaire (STAI) • Gordon Diagnostic Test • Stroop Test • DKEFS • Trails • Verbal Fluency Test • Paced Auditory Serial Attention Test (PASAT) • Wisconsin Card Sorting Test (WCST) • California Verbal Learning Test II (CVLT-II) • Wechsler Memory Scale - Fourth Edition (WMS-IV) • Boston Naming Test (BNT) • Rey Osterrieth Complex Figure (ROCF) • Judgment of Line Orientation Test (JOL) • Hooper Visual Organization Test • Hand Dynamometer • Grooved Pegboard • Finger Tapping Test (FTT) • Validity Indicator Profile (VIP)
Findings on neuropsychological exam • Decreased attention, concentration and slowed processing speed • Problems sequencing pieces of information and prioritizing their use for quick decision making • Limited working memory, • less information available “online” • Learning difficulties: • Changes in learning strategy • Poor absorption and recall
Neuropsychological Profile in ME/CFS • Profile suggests mild, subtle deficits • Evaluation of impairment relative to expected level of intellectual function necessary to uncover true deficiencies • Profile not consistent with dementia • Generally no frank memory problem • Profile can be differentiated from conditions of a more focal nature
Brain Abnormalities in ME/CFS • Lange et al., 2005 • Used verbal working memory task to • probe brain function using fMRI • simultaneously assessing efficient information processing behaviorally • Statistically controlled for age, mood, anxiety, self-reported mental fatigue score • Equated on prior behavioral test performance on same task
Brain Abnormalities in ME/CFS • Controls versus ME/CFS: • No differences in brain activity during simple condition • When task demands get more complex, ME/CFS increased involvement of • Anterior Cingulate BA 24/32 • Left DLF BA 10/44/45/47 • Bilateral supplemental and premotor BA6/8 • Parietal regions BA 7/40
Brain Abnormalities in ME/CFS • Increased signal change was significantly accounted for by ME/CFS report of mental fatigue • Perceived mental fatigue is reflected by increased functional recruitment of • Left superior parietal region (BA7) • Responsible for shifts in attention • Bilateral supplementary and premotor regions (BA6/8) • Associated with automatic information processing • maintenance of temporal order
Brain Abnormalities in ME/CFS • No lack of effort accounted for the differences in signal change • To achieve behavioral performance similar to Controls • Brains of ME/CFS work harder when tasks are complex • Require efficient and quick information processing • Require effective online sequencing and prioritization
Consequences of cognitive dysfunction in ME/CFS • Automaticity of cognitive function is often lost • Mundane tasks become effortful • Multi-tasking often impossible • Considered by patients as affecting every aspect of their lives • Mental exertion can last for a long time
Is there an effective cognitive screen for ME/CFS patients? • Dementia screens and typical brief bedside memory tests are not appropriate • i.e. MMSE, Mini-Cog • Suggestions: • Serial 7s, Digit Span Sequencing • May work if done for at least a few minutes • Quickly give a 6-or-7 step set of complex driving directions and request repetition
Final thoughts • If evaluation of cognitive function is needed • Refer to Clinical Neuropsychologist knowledgeable about ME/CFS • Much more work is needed to familiarize Neuropsychologists with ME/CFS to provide valid and reliable neuropsychological assessments.