Treatment Options for Cognitive Problems in Multiple Sclerosis

A majority of people with multiple sclerosis (MS) will experience some cognitive changes over the course of the disease. Even though the severity of these changes can vary from mild to quite severe, the majority of these changes are in the mild-to-moderate range.

After you've had a comprehensive cognitive evaluation, you'll work with your doctor as well as the clinician who evaluated you to decide on a treatment plan that works for you.

The treatment of cognitive symptoms falls into three categories:

  • Symptomatic treatments: Even though a variety of medications have been evaluated, none of them have been shown to be effective in large-scale clinical trials in MS.

  • Disease-modifying therapies: All of these therapies — the interferons (Avonex, Betaseron, Extavia, Rebif), Copaxone (glatiramer acetate), Gilenya (fingolimod), Tysabri (natalizumab), and Novantrone (mitoxantrone) — reduce the number and severity of attacks and reduce the number of central nervous system lesions as shown on MRI scans.

    Because there's fairly extensive evidence to show that cognitive problems are correlated with the total amount of lesion area in the brain (referred to as lesion load), and with the extent of tissue loss (referred to as atrophy) in the brain caused by damage to the neurons, it's reasonable to assume that starting a disease-modifying therapy early in the disease would be a good strategy for reducing the risk and progression of cognitive symptoms.

    So, if you don't already have reason enough to start treatment with one of the disease-modifying therapies, this could be the powerful incentive you need.

  • Cognitive remediation: This type of treatment, which is also called cognitive rehabilitation, is a practical, solution-oriented approach to managing cognitive changes. Offered by neuropsychologists, OTs, and S/LPs, cognitive rehabilitation consists of the following interventions:

    • Restorative interventions: These interventions are like physical therapy for the brain. The clinician uses your test results to identify areas of deficit and then gives you exercises that may help strengthen the impaired functions.

      The best examples of this kind of intervention are computerized exercises to improve attention and memory. Even though the research has shown that people's performance on certain types of tasks improves with these exercises, the improvements don't carry over very well to everyday life. After all, how many people live their lives in front of a computer screen with no distractions?

    • Compensatory interventions: These seem, by all accounts, to be the most useful. They consist of finding workarounds, or strategies to compensate for whatever cognitive abilities have been compromised.

    • In the same way that people use calendars to help themselves remember dates and computers to make it easier and faster to process information, the cognitive rehabilitation specialist can help you can identify tools and strategies that take advantage of your cognitive strengths to compensate for whatever problems you're having.

      Although there are an unlimited variety of workaround possibilities, the most common ones involve substituting organization for memory — for example, lists, filing systems, work and family calendars, and "tickler" mechanisms, such as alarms on your watch or computer to remind you to take a medication or go to an appointment. The remediation specialist can also recommend strategies to improve attention, reading comprehension, executive functions, and others.

Other factors like depression, anxiety, and stress also can affect cognition, so be sure to talk with your doctor if you're concerned that any of these problems may be interfering with your thinking or memory.

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