041018 Cognitive Library Image

“I must be getting old - I cannot remember anything anymore!” 

“I am always losing my keys - I think I must be losing it.”

“I used to be able to do 6 things at once but now I am lucky to do one thing at a time.”

At one time or another has any of these or similar phrases been something you said or thought about yourself? If yes, you are not alone. 

Cognitive changes are a common symptom in MS. Up to 65% of people who have a diagnosis of MS also experience cognitive changes. In some cases people may identify cognitive changes as some of the earliest symptoms of M.S they noticed. 

Cognitive changes often cause a great deal of anxiety and are often misunderstood. Many questions arise such as:

  • Are cognitive changes permanent?
  • Will my cognition continue to decline?
  • Will the cognitive changes occur rapidly?
  • How much of my memory loss is due to MS?  Old age?  Distractibility?
  • Can anything be done about these cognitive changes or are they permanent?

The good news first: Cognitive changes are generally slow to progress and respond well to cognitive rehabilitation. General intellect is not affected, nor is long term memory. 

The other news:  Cognitive changes are more likely to progress during an exacerbation.

Cognitive changes are more prevalent in progressive MS. Cognitive changes can occur at any time during MS.

But….what exactly is cognition anyway?  Is it I.Q.?  Is it thinking skills? Attention? Memory? 

The dictionary defines cognition as: 

“The mental action or process of acquiring knowledge and understanding through thought, experiences and the senses.”

We will be more specific. Cognition is comprised of several mental processes:

  • Reasoning
  • Judgement
  • Problem solving
  • Impulse control
  • Emotions
  • Numbers
  • Language
  • Processing sensory input
  • Analytical skills
  • Organizing motor output
  • Short-term memory
  • Long-term memory
  • Synthesis and attachment of emotion to memory, judgement and reasoning, language.

As stated earlier not all parts of cognition are affected by MS. Your general intellect, long-term memory and personality are not affected. 

What is affected?

  • Attention
  • Memory
  • Executive function

Attention: Tasks such as staying focused, multi-tasking and dividing attention can be affected.
Memory: Short-term memory can be affected.
Executive function: Higher level skills such as planning, prioritizing and organizing can be affected.

How Cognitive Rehabilitation Works

The goals of rehabilitation are to:

  • Enhance
  • Improve
  • Adapt

It is useful to be tested for cognitive function to determine the nature of the challenge. Often people will think they have a memory problem when it is actually a problem in attention. Diagnosing the challenge correctly leads to effective rehabilitation and effective choices in strategies.

Rehabilitation should also be eclectic, understand the client’s needs and be tailored specifically to their situation. Rehabilitation should also be goal-driven and specific. 

The idea is to empower self-sufficiency and independence in important life tasks.

In short, the hallmarks of Cognitive Rehabilitation are:

  • Determined after testing
  • Goal driven
  • Specific
  • Eclectic
  • Tailored to individual needs
  • Empowering

External Aids

What are external aids and how do you use them? External aids are items or resources that we use outside our own brain to store information or provide stimulus to train our brain.

Some examples are:

  • Smartphones
  • Tablets
  • Computers
  • Notepads
  • Shopping lists
  • Maps
  • Photographs

For instance, many busy families will use online calendars to make sure the whole families’ schedules are visible to everyone for planning purposes. Many people take photographs of important products or services to remind themselves to use or attend appointments. A smartphone can hold all your questions you wish to ask your doctor very handily. 

Voice activated software is an effective tool to use technology for people who have tremor, weakness or fine motor challenges. 

Role of Fatigue and Depression Management

This conversation would not be complete without mention of the roles of fatigue and depression on cognition. Both are common symptoms in people who have MS and directly affect our ability to think. 

Fatigue:  Unmanaged fatigue definitely worsens cognitive challenges.  Remember the last time you undertook an important project when you were tired?   It went much more smoothly after some rest, right?  In M.S there is a particular type of fatigue entitled Lassitude/Primary Fatigue. It is a direct result of the inflammation and immune response in the brain due to MS and can be severe and debilitating. It is usually characterized by a sudden onset of severe fatigue that feels capricious and unpredictable. In addition to having Primary Fatigue people who have MS also experience Secondary Fatigue which is fatigue caused by any other factor. For example, sleep deprivation, medication, over-exertion, physical de-conditioning, stress are all reasons for secondary fatigue.

Managing Fatigue: There are a number of ways to manage both primary and secondary fatigue. Occupational therapists recommend addressing the secondary sources of fatigue first to reduce or eliminate their effect. Use of planning, pacing, positioning and prioritizing or energy budget management is an effective tool for Primary Fatigue. Since those higher level executive skills are often the very cognitive skills that are challenged in MS it is important to learn how to adapt or accommodate with external aides the way to implement these strategies. Since each person is unique individual with unique needs and challenges it is often useful to use a team approach with a Speech-Language Pathologist and Occupational therapist to address specific needs. 

In Summary:

  • Identify Secondary sources of fatigue and manage them to reduce or eliminate their effect.
  • Learn about Energy Budget Management skills (Planning, Pacing, Positioning and Prioritization) to address the effect of Primary fatigue.
  • Use the expertise of both Speech-language Pathologist and Occupational Therapist to customize a plan for you that works best.

Depression:  Like fatigue, depression can be the invisible “elephant in the room”. Untreated depression can increase fatigue, pain, and cognitive challenges. If you or a loved one thinks you may have untreated depression it is imperative to receive support to improve not only your mood but your ability to function effectively in daily life. Depression, like fatigue, is not a function of a “failing” to perform but the direct effect of the MS disease process of inflammation and immune sensitivity. 

Strategies for Management:

  • Put together a healthcare team that knows about Mood and Depression.
  • Reduce stress in your daily life.
  • Exercise daily
  • Maintain social networks
  • Acknowledge and be proactive about your feelings and symptoms.

Conclusion

Cognitive challenges are a common symptom in MS (up to 65% of people), but can be overcome using a variety of approaches.

If your cognition concerns you or a loved one it is important to be proactive and seek help from a healthcare professional to address it.  There may be some very simple and practical approaches that will improve your skills to an acceptable level of independence and efficiency for you.