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Cognition - factsheet

Date of issue: November 2007

Contents

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What is cognition?
What cognitive problems occur in MS?
Strategies for managing specific issues
  • Short-term memory problems
  • Attention and concentration
  • Verbal fluency – problems with words
  • Processing speed
  • Visuospatial problems
  • Planning and problem-solving
What causes cognitive problems?
Help for cognitive problems
Further reading
Useful organisations

1. What is cognition?

In simple terms, cognition refers to the processes involved in memory and concentration – how we think, plan and remember. A more formal definition of cognition is, 'the process of acquiring knowledge and understanding through thought, experience and the senses.'

When we speak of 'cognitive problems' in MS, we are often referring to difficulties with short-term memory and concentration skills, the most common forms of cognitive difficulty in MS. For the vast majority of people with MS, any cognitive difficulties are either non-existent or minor and easily manageable.

Some people with MS may experience cognitive problems which fluctuate like other symptoms, whereas others may develop cognitive problems quite early in their experience of MS that remain with them. Research suggests that these cognitive symptoms either stay the same over several years, or only very gradually worsen. This gives people time to develop strategies to compensate for the cognitive difficulties they experience.

Like other symptoms of MS, cognitive problems are the result of inflammation and lesions in the brain interrupting the transmission of electrical messages along nerve fibres. As with any other symptom, the impact of cognitive problems can be made worse by fatigue, poor sleep, depression or anxiety. Some medications may also increase fatigue and interrupt sleepindirectly contributing to the impact such factors have upon cognitive function. Better management of co-existing symptoms and medications may improve cognitive problems.

People with MS may be afraid to admit to cognitive difficulties because they fear other people will think that they are not the same person that they used to be. This is a very understandable concern. Sometimes, failing to remember to do tasks at work or at home can lead people to think the person with MS is unwilling to do their share, or doesn't value the relationship. Fear of admitting and talking about cognitive difficulties can be considerable, for both the person with MS and their family and friends. But this fear can be overcome. Sharing and understanding a person's experience will often reduce stress and anxiety. Adopting simple strategies and making simple changes to routines can minimise cognitive problems and are easily explained to and accepted by other people.

However, in some cases, cognitive problems become considerable, and the person with MS may not always be aware of the extent of their difficulty. This situation can be very distressing, particularly for friends and relatives of the person with MS. Professional help may be important in this situation to devise management techniques for the symptom.

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2. What cognitive problems occur in MS?

As with any MS symptom, cognitive problems are variable, and will affect different people in different ways and at different times.

MS usually affects a small range of cognitive abilities. The following is a list of the most common problems in MS, but very few people will experience all of these:

  • short-term memory
  • attention and concentration
  • verbal fluency
  • processing speed – the speed at which information makes sense
  • visuospatial abilities – processing visual information in forming an awareness of space and distance
  • problem solving and planning – known as 'executive function'

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3. Strategies for managing specific issues

Short-term memory problems
Attention and concentration
Verbal fluency – problems with words
Processing speed
Visuospatial problems
Planning and problem-solving

3.1 Short-term memory

Problems with short-term memory are very common in MS, but problems with other types of memory such as skills (eg driving, cooking), general knowledge, or remembering things about the past, are rare.

There are two types of short term memory:

  • recognition – prompted remembering, such as someone saying 'there's a party this evening'. This continues to function well in most people with MS.
  • recall – unprompted remembering such as going to the shops without a list and remembering what to buy. People with MS may experience problems with this.

The way to manage problems with recall is to devise prompts. Here are a few examples:

Being organised

  • a place for everything– using set places for keeping items like keys, wallet, spectacles
  • setting up routines – eg always brushing teeth after breakfast

Memory tricks

These vary for individuals, but can include:

  • verbal tricks to help you remember things - eg 'spring forward, fall back' for the hour change in spring and autumn
  • visual imagery – eg picturing the way from the library to the post office, rather than just directions
  • word association – putting meaningful tags onto words or names, so, for example, Dan is 'Dan the plumber'; Carole is 'Carole who works in the library'

Memory aids

Memory aids are actions or equipment that help to prompt short-term memory. Examples include:

  • keeping a notebook and writing things down
  • using a Dictaphone and playing it back
  • diary software with reminder systems on computer
  • mobile phone alerts
  • important numbers list by the telephone
  • message book by the telephone
  • calendar / desk diary / wall planner / memo board for daily reminders as well as forward planning

Doing these things can also provide a record to refer back to.

3.2 Attention and concentration

Some people with MS experience a reduction in their ability to concentrate. A reduction in attention span can make juggling the demands of daily life increasingly challenging.

There are a number of simple strategies that can help:

  • reducing the number of distractions, eg switching off the TV before talking to someone
  • avoiding interruptions, eg using an answerphone to pick up telephone calls
  • spreading out long and difficult tasks, eg form filling over several days
  • organising time to do complicated tasks at the best time of day, eg cooking a new recipe at a good time of day, not when it is time to eat

3.3 Verbal fluency – problems with words

Most people – with and without MS - are familiar with this problem. It is the feeling that a word is 'on the tip of the tongue' but is just elusive at that moment. It can also cause some people to mix up words that sound the same but mean different things, such as 'door' and 'drawer'.

Strategies for dealing with lack of verbal fluency include:

  • visual and verbal association – putting pictures to words, eg Mr King becomes a picture of a man with a crown
  • describing the concept in other words – eg 'the school' becomes 'the building with children and teachers'

3.4 Processing speed

'Information processing' is the term health professionals use to describe how people gain and make sense of new information.

Research studies have shown that people with MS tend to be slower at picking up new information than people who do not have MS. Once information is gained, people with MS show as much ability to recall and use it as anyone else. However, tests in research situations can show up very slight variations and the difference in information processing speed may not be so obvious in the real world. Examples of information processing might include:

  • making sense of instructions to assemble some flat-pack furniture
  • understanding plans for an evening out
  • understanding the rules of a new board game

If it feels as though thinking is significantly slowed, some strategies to manage this may include:

  • cutting out distractions
  • doing one thing at a time
  • trying to avoid situations where lots of information will come at once
  • breaking tasks down into very small chunks
  • allowing extra time to take in new information – ask for things to be repeated, or for written information to read later
  • multi-sense input – write down what you hear, speak what you see and so on

3.5 Visuospatial abilities

Difficulties with visuospatial abilities are less common in MS, and are believed to relate to a slowing of someone's information processing skills.

Visuospatial abilities are the way people relate visual information to the space around them. Example of visuospatial ability include:

  • driving – judging distance and speed accurately
  • walking through doorways – not into door frames – again, judging distance and speed accurately
  • using a map to get from one place to another, rather than relying on directions

Strategies for managing visuo-spatial problems are similar to those for information processing and include:

  • reducing distractions
  • breaking tasks into very small chunks

Driving can be dangerous if judging distance and speed accurately becomes problematic. If this is an issue, proper assessment will be needed, using one of the independent Mobility Centres (see the list of useful organisations).

3.6 Planning and problem-solving

A few people with MS become less able to plan and to address complex issues. This may appear to be an inability to think laterally about an issue, or perhaps simply an inability to identify the key points in a problem and plan a course of action.

This type of cognitive problem may be obvious to the person with MS if they know what they want to achieve but are baffled about where to start. An example might be planning a trip to see a family member, but not being sure what to start with. Sometimes another person's intervention is needed, to:

  • break information into manageable chunks (eg date of journey; arranging what time to meet; arranging transport there; agreeing on transport back)
  • provide prompts for each stage of the journey
  • offer concrete choices (eg train or taxi) rather than abstract ideas

However, sometimes this type of cognitive problem is only apparent to friends or relatives of the person with MS, who loses the ability to judge how their decisions might affect other people. With this type of cognitive problem, the person with MS normally has little insight. Very often a friend or family member may need to discuss the issue with someone independent and sympathetic who is then able to broach the issue with the person with MS, without breaking patient confidentiality. This type of problem may benefit from referral to a neuropsychologist, with possible access to cognitive rehabilitation (see section 5 - Help for cognitive problems).

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4. What causes cognitive problems?

It is thought most likely that the number and position of lesions, and the degree of cerebral atrophy is the cause of specific cognitive difficulties. Research in this area is ongoing.

Nevertheless, what is known is that cognitive problems can be worsened by co-existing symptoms, such as:

  • Fatigue

    Fatigue slows everything down, including mental processes. Managing fatigue through pacing, planning demanding activities at the best time of day may help these symptoms.

  • Physical effort

    If moving about or balance is becoming difficult, some people find that more cognitive input may be needed to cope with the physical effort. One way of dealing with this is to balance physical and cognitive activities by, for example, not trying to hold a conversation while walking around. It's worth noting though, that research has shown no absolute link between level of physical disability and degree of cognitive problems.

  • Emotions

    Depression, anxiety and stress all drain cognitive abilities. They can also be difficult to distinguish from other MS symptoms. For example, depression can make someone tired and uninterested in life, which can be easy to confuse with fatigue or with cognitive problems. Proper assessment from a psychologist may be most helpful in this situation (see section 5 - Help for cognitive problems)

  • Anything that generally worsens symptoms

    For example, heat or tense or exciting situations. Tips for this type of problem is simply to stay aware and plan ahead where possible. For example, trying to stay cool in hot weather or using relaxation techniques when faced with difficult situations may help.

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5. Help for cognitive problems

5.1 Health professionals who can help

Generally, people with MS manage any cognitive problems successfully and develop strategies over a long period of time. As with any symptom, it may be helpful to talk over concerns about any cognitive problems, with a sympathetic listener such as a trusted health professional or friend, as keeping concerns hidden may compound the problem. Very often, discussing the issue may identify and even resolve any problems being experienced.

However, sometimes it helps to seek support from a professional, and health professionals who might be able to help are listed below. A GP, MS specialist nurse or neurologist should be able to make referrals as required. Availability of some of these services varies between areas:

  • MS specialist nurse

    An MS specialist nurse should be the first port of call if cognitive problems are making life difficult. She or he can suggest strategies and make appropriate referrals as necessary.

  • Occupational therapist

    Occupational therapists are trained to provide strategies and equipment to offer practical management techniques for many cognitive problems, particularly for memory and attention difficulties.

  • Neuropsychologist

    A neuropsychologist assesses cognitive function using a range of tests, such as quizzes and puzzles. They then suggest management techniques and strategies. Availability of neuropsychologists varies between areas.

  • Psychiatrist or neuropsychiatrist

    Psychiatrists are specialist medical professionals who assess, manage and treat mental illness. Treatment is often based around drug therapy.

  • Speech and language therapists

    Speech and language therapists specialise in speech and swallowing problems. They may be able to provide strategies and techniques for difficulties with word retrieval. Availability of speech and language therapists varies considerably.

  • Cognitive rehabilitation professionals

    Cognitive rehabilitation is the use of a structured set of activities designed to retrain an individual's ability to use judgement and make decisions. Commonly used in other neurological conditions such as brain injury, its use in MS is rare and availability is normally limited, but it can be of significant benefit to the few people more severely affected by cognitive problems.

5.2 Other treatments for cognitive problems

There are no drugs that specifically help with cognitive problems. To date, there has only been one very small study suggesting that any drug might help with cognitive issues specifically. An exploratory study randomised 39 people with MS to take either gingko biloba or a dummy placebo drug for six months. Those who received the ginkgo biloba supplements showed some improvements on measures of concentration and memory. This small study does not provide enough evidence to show that ginkgo biloba has a definite effect in MS, and further research is needed.

However, if cognitive problems are being worsened by other MS symptoms, treating those can lead to improvements in someone's cognitive ability. Some people report benefit from cooling therapies such as fans or air conditioning for fatigue, and that being less fatigued helps cognitive abilities.

Equally, managing symptoms such as stress and anxiety, which may or may not be caused by MS, can help improve MS symptoms such as cognitive problems. Techniques reported to help include:

  • guided relaxation (eg relaxation tapes)
  • aromatherapy
  • breathing exercises
  • yoga
  • meditation

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6. Further reading

  • Gingold, JN.
    Facing the cognitive challenges of multiple sclerosis.
    Demos: New York; 2006. ISBN: 1932603603
    A useful practical guide for people with MS, based on the author's personal account of managing his cognitive problems with MS.
  • LaRocca NR, Kalb R.
    Multiple sclerosis: understanding the cognitive challenges.
    Demos: New York; 2006. ISBN: 193260331X.
    This book is aimed at health professionals but gives a very good overview of all the issues involved.
  • MS Trust.
    Cognition chatroom.
    Transcript of a live webchat on 13 April 2005.
    Provides examples of real problems with cognition from people with MS together with advice from an MS specialist nurse, an MS specialist occupational therapist, a neuropsychologist and two psychiatrists with experience of MS.

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7. Useful organisations

  • AbilityNet
    Offers advice, support, assessment of needs and the supply of adapted computer equipment, for people with any sort of disability

    Tel: 0800 269545
    AbilityNet website

  • Forum of Mobility Centres
    A network of 17 independent organisations covering England, Scotland, Wales and Northern Ireland, who offer professional, high quality information, advice and assessment to individuals who have a medical condition or are recovering from an accident or injury which may affect their ability to drive, get in or get out of a motor vehicle. Although independent, the Centres are recognised by other mobility organisations including the Driver Vehicle Licensing Authority (DVLA).

    Tel: 0800 559 3636
    Forum of Mobility Centres website

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Acknowledgements

This publication has been written by the MS Trust with the help of experts - those who live with MS and those who work professionally with people with MS. We would like to thank our Readers' Panel of people with MS, together with Dr Dawn Langdon, Reader in Neuropsychology, Royal Holloway, University of London, Dr Alexander Burnfield, Psychiatrist, and Patrick Carroll, Clinical Specialist Occupational Therapist, Fareham & Gosport Primary Care Trust, for their help and advice in writing this publication.