1MULTIPLE SCLEROSIS AND NEUROPSYCHOLOGICAL FUNCTIONING: MANAGING COGNITIVE DEFICITS Dr. Lesley Ritchie, C.Psych.Ms. Jodie Gawryluk, B.A.Department of Clinical Health PsychologyUniversity of Manitoba
2Overview Introduction to the brain Understanding MS The treatment team What is neuropsychology?Neuropsychological assessmentCognitive domainsNeuropsychological profile of MSManaging neuropsychological deficitsSpecific strategiesSpecial considerations
3Overview Introduction to the brain Understanding MS The treatment team What is neuropsychology?Neuropsychological assessmentCognitive domainsNeuropsychological profile of MSManaging neuropsychological deficitsSpecific strategiesSpecial considerationsNeuropsychological rehabilitations for individuals with MS requires knowledge regarding brain function, the cognitive symptoms of MS, the impact of personal, emotional, physical, and social impacts of MS symptoms and the associated impact on cognitive functioning. We must first understand the brain and MS before selecting cognitive strategies to compensate for deficits.
4Introduction 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
5Introduction to the brain The brain is divided into left and right cerebral hemispheresLeft Hemisphereis important for:Right Hemisphereis important for:language(thinks in words)mathlogical abilitiesmovement of the rightside of the bodyvisual information(thinks in pictures)organizationcreativitymovement of the leftside of the body
6Introduction to the brain Frontal LobesMovementSpeakingPlanningOrganizingReasoningDecision makingJudgmentPersonality
7Introduction to the brain Temporal LobesMemoryRecognition HearingUnderstanding LanguageEmotions
8Introduction to the brain Parietal LobesSensationsReading and WritingAbility to use NumbersSpatial ReasoningPerception
9Occipital Lobes Locating objects in space Recognizing the Seeing objectsLocating objects inspaceRecognizing thethings we see
10Introduction to the brain CerebellumMaintaining balanceCoordination ofmovementTiming of movement
11Introduction to the brain Brain StemConnection betweenbrain and bodyBreathingBlood pressureSwallowingAppetiteBody temperatureDigestionSleeping
12Introduction to the brain Brain AnatomyThe 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)White matterGrey matter
14Overview Introduction to the brain Understanding MS The treatment team What is neuropsychology?Neuropsychological assessmentCognitive domainsNeuropsychological profile of MSManaging neuropsychological deficitsSpecific strategiesSpecial considerations
15Multiple Sclerosis Multiple = more than one Sclerosis = area of stiffening/damageAutoimmune disorderImmune system attacks the CNSDemyelinationWhite matter tissue is white because of myelin, a fatty covering that helps information travel to brain areas quicklyMost common demyelinating disorder
16Multiple Sclerosis Symptom onset btwn 20 – 40 years of age 2-3x more common in womenIncreased prevalence in northern latitudes
17Multiple Sclerosis Affects brain and spinal cord Altered motor, sensory, and cognitive functioningCommon presenting symptoms (Olek 2005)Symptoms vary according to disease courseSymptomFrequency (%)Sensory disturbance - limbs30.7Visual loss15.9Motor disturbance (subacute)8.9Diplopia6.8Gait disturbance4.8Motor (acute)4.3Balance problems2.9Sensory disturbance (face)2.8
18Multiple Sclerosis Disease course Relapsing and remitting MS (RRMS): Clearly defined attacks and periods of remissionTriggers: warm weather, infections, stressSecondary progressive MS (SPMS):80% with initial RRMS show declines between attacks w/o periods of remission; most commonPrimary progressive MS (PPMS):10% who do not have period of remission following 1st attackContinuous declineOlder at onsetProgressive relapsing MS (PRMS):steady decline with attacksBobholz & Gremley (2011)
19Overview Introduction to the brain Understanding MS The treatment team What is neuropsychology?Neuropsychological assessmentCognitive domainsNeuropsychological profile of MSManaging neuropsychological deficitsSpecific strategiesSpecial considerations
20Treatment Team GP: manages all medical concerns Neurologist: manages concerns about MS or other brain conditionsRadiologist: collects images of the brainNeuropsychologist
21Overview Introduction to the brain Understanding MS The treatment team What is neuropsychology?Neuropsychological assessmentCognitive domainsNeuropsychological profile of MSManaging neuropsychological deficitsSpecific strategiesSpecial considerations
22Clinical Neuropsychology … is an applied science concerned with the behavioural expression of brain dysfunction (Lezak, 1995)
23Normal Distribution - Test Interpretation 34.13%2.14%13.59%0.13%ImpairedBorderlineSuperiorAverageAVERAGELow averageLow AveHigh AveHigh averageV. Superior0.13%13.59%13.59%X0.13%Z
24Normal Distribution - Test Interpretation 34.13%2.14%13.59%0.13%ImpairedBorderlineSuperiorAverageAVERAGELow averageLow AveHigh AveHigh averageV. Superior0.13%13.59%13.59%XX0.13%Z
25Normal Distribution - Test Interpretation 34.13%2.14%13.59%0.13%ImpairedBorderlineSuperiorAverageAVERAGELow averageLow AveHigh AveHigh averageV. Superior0.13%13.59%13.59%XXX0.13%Z
26Clinical Neuropsychology 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
27Overview Introduction to the brain Understanding MS The treatment team What is neuropsychology?Neuropsychological assessmentCognitive domainsNeuropsychological profile of MSManaging neuropsychological deficitsSpecific strategiesSpecial considerations
28Clinical Neuropsychology Neuropsychological AssessmentSpecific nature of the injuryPre-injury history strengths / weaknessesSpecific situation demands of life / workSupports availablePersonality factorsEmotional response to injury & limitationsAdaptive & coping skillsBeliefs / expectations of client & familyPsychometricsThe first step in developing a rehabilitation plan is to evaluate the client’s cognitive strengths and weaknesses, and to see how these map onto his or her premorbid, current, and projected functioning.The level of functioning demonstrated by an individual with brain injury is dependent on many variables, any and all of which can influence levels of adaptive function. Some of these variables are:
29Clinical Neuropsychology All neuropsychological tests are developed through researchAdministered in a standardized mannerResults are compared to normative data
30Clinical Neuropsychology Cognitive domainsEstimated premorbid abilityGeneral Intellectual abilityAttentionSpeed of information processingSensory – motor functionLanguageVisual Perception & ConstructionExecutive functionsMemoryMood / Psychopathology / PersonalityValidity & Effort
31Overview Introduction to the brain Understanding MS The treatment team What is neuropsychology?Neuropsychological assessmentCognitive domainsNeuropsychological profile of MSManaging neuropsychological deficitsSpecific strategiesSpecial considerations
32Neuropsychological Profile of MS 45-65% of people with MS have cognitive symptoms80% of those are mildly affectedEven mild problems can interfere with everyday activitiesCognitive deficits increase with prolonged disease duration20-30% of patients develop more severe impairments, such as dementiaCognitive deficits don’t tend to fluctuate
33Greater deficits associated with Progressive disease courses (PPMS, SPMS)Duration of diseaseIncreased prevalence of cognitive decline in menQuantity of MR abnormalities
34Cognitive Impairment in MS Processing speedAttention/concentrationSustainedComplexMemory (40-60%)Episodic/recent memoryWorking memoryExecutive functioning (EF)Abstract reasoningProblem-solvingLanguageVerbal fluencyNamingVisuospatial skillsTable 20.3; Bobholz & Gremley (2011)
35Processing Speed Speed of mental activity Most common Underlying factorMemoryWorking memory
36AttentionAttention = vigilance, capacity for information, switching attention, selective attention20-25% of MS patientsDeficits in rapid and complex info processingWorking memoryAttentional switchingRapid visual scanningIntact attention span
37Information 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.
38Information about Attention Sustained Attention allows you to focus on something over a long period of timeFor example, watching a movie or reading a book.
39Information about Attention Selecting Attention allows you to pick out important information from unimportant or distracting informationFor example, listening to a conversation in a noisy cafeteria.
40Information 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.
41Information about Attention Types 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.
42Information about Attention Symptoms of Attention DifficultiesBecoming easily distractedHaving trouble keeping track of what is being said anddone or have trouble making sense of thingsHaving trouble focusing on one person, thing orconversation in crowded environmentsHaving trouble keeping track of more than one thing at a timeHaving difficulty doing more than one task at a timeHaving difficulty learning and remembering informationBecoming easily frustrated with yourself andothersFeeling confused and overwhelmedAvoiding contact with care givers, friends andfamily
43MemoryAbility to learn and recall information about previous experiences.E.g., favorite song and the look of our homeDifferent types of memory are stored in different places in the brain.Verbal information (such as words) are typically stored on the left side of the brainVisual information (such as pictures) are typically stored on the right side of the brain
44Facts about Memory Types of memory Different types of memory based on time.Short term memory, Working memory,Recent memory, and Long term memory
45Facts about Memory Short term memory This is the ability to remember something in the moment or that you only need to remember for a few minutesRemembering a phone number you have just been toldShort term memory is often impaired after a brain injury
46Facts about Memory Working memory This is the ability to remember in the moment or for a few minutes while you focus on something else or are distractedAn example is keeping a phonenumber in mind while looking for a penand paper to write it down.Working memory is often affected bybrain injury
47Facts about Memory How are memories made? 1. AttentionYou must pay attentionto what you are learning2. RecordingYour brain needs to 'take in'and record information3. RetainThe information needs tobe stored in the right spot4. RetrieveInformation needs to berecalled when it is needed againIf problems occur anywherein these steps, thenmemory difficulties willoccurThe 3 R’sof Memory
48Executive Functioning Cognitive abilities required to complete goal-directed behaviors that are not automatic, overlearned, or routine (Sohlberg & Mateer, 2001).
49Executive Functioning InitiationInhibitionSet-switchingJudgment/ReasoningGoal identificationWorking memorySpeed of processingCognitive flexibility/problem-solvingSequential processingPlanningSelf-MonitoringPerseverationPrioritizingMulti-taskingEmotional controlInsight/Awareness
50Executive Functioning 15-20% of patients with MS exhibit executive dysfunctionImpaired goal-directed behaviorVerbal disinhibitionPoor self-monitoring (e.g., tangential speech)Reduced insightDeficits in planning and prioritizingProblems with abstraction and conceptualization
51Language and Visuospatial Mild confrontation naming deficitsSpeech abnormalities (dysarthria, hypophonia)Poor verbal fluency (retrieval deficit/speed)20-25%VisuospatialAngle matchingFace recognitionimpact of changes in vision/diplopiaVisual miscalculations
52Overview Introduction to the brain Understanding MS The treatment team What is neuropsychology?Neuropsychological assessmentCognitive domainsNeuropsychological profile of MSManaging neuropsychological deficitsSpecific strategiesSpecial considerations
54Managing Neuropsychological Deficits Neuropsychological rehabilitationInterventions aiming to enhance or support cognitive abilities following brain injury, with an emphasis on achieving functional changes (Sohlberg & Mateer, 2001)Target: reductions in cognitive, emotional, psychological functioning that encumber everyday functioningGoal: increase independent functioning by means of enhanced knowledge and skill, behavior change, or implementation of compensatory strategies
55Managing Neuropsychological Deficits Foundation of cognitive interventionTx based on current level of functionBuild on strengths to support weaknessesCollaborativeGoal-orientedEducation
59Attention Orienting procedures Pacing “What am I doing?” Minimizes gaps in attentionPacingRealistic expectationsElongated performance timesMinimize frustrationVary according to time of daySchedule adequate rest
60Attention Environmental modification Work in a quiet environment Reduce clutterLimit distractionsRefer to checklists to complete tasksSet timers to prevent going overtimeWork on one task at a timeDouble/triple check work to minimize errorsHave a significant other check work
61Attention Top Ten tips to help you manage attention difficulties: PracticeCheck inModify your environmentPace yourself.Take care of yourself.Monitor your mood.Double checkBreak tasks downDo difficult tasks at your best time of day.Use your family and friends for support.
62Take care of yourself.Fatigue, hunger, and/or thirst all adversely affect your attention.Taking care of yourself will help maintain optimum attention.
64MemoryRepetition - Repeat the information over and over and over again.Looking at something one time is never enough.For example, if you are trying to learn someone’s name, repeating it over and over to yourself can help you remember it.
65Memory Multimodal learning – It helps to learn the same information in different ways.For example, to learn a new recipe, it helps to read over the steps in the recipe, listen to someone telling you the steps, and practice the recipe by doing it.See it, hear it, do it!
66MemoryBreak it down - Break up what you want to remember into smaller steps. If you have something really tough to learn, try to break it down into small bits and then learn one bit at a time.
67MemoryWrite it down - When something is important to remember, write it down, and keep it in a safe place. Remember to check your notes regularly.Writing information down also allows for repeated exposure to the information (Hear, Write, Read – 3x exposure)CalendarDaytimerPDA or cell phoneNotebook
68Helpful Hints for Errorless Learning MemoryLearn it right the first time - New skills are easier to remember if you learn them the right way (mistakes are hard to correct later)Helpful Hints for Errorless Learning1. Break the task down into smaller steps.2. Learn each step at a time and avoid making errors that may confuse you later .3. Complete the task you are trying to learn together with someone who hasdone it before. Ask this person to talk through the steps as you learn thetask (this will help you to avoid errors)4. Use hints that will help you remember the steps (you can ask someone forhints or make up notes for yourself that guide you to the next step)5. Only try to do the new skill when you are sure you know the steps and can do it error-free
69MemoryElaboration – This is a technique that you can use to make information more meaningful and easier to remember. Information can be easier to remember if you think through all of the details. Here are some questions to help you elaborate:Can you link this with anything or anyone you know?Do you link this with any feelings?Is there anything about it that is unique or special?Can you link this with things in your daily life?How does it look?How does it feel?How does it sound?How does it smell?How does it taste?
70MemorySpace out your attempts to retrieve information - Try to recall new information several times in a row. If you can recall it correctly, then gradually increase the time (from minutes to hours) between attempts.For example, recall information the first time after 20 seconds, then space out your attempts to recall – 30 sec, 1 minute, 5 minutes, 10 minutes, 30 minutes, 1 hour, 4 hours, later that day, and the next day.Set up a Routine - Follow a daily or weekly routine to help you remember events and times to get regular tasks done each day.
71Spaced RetrievalDistributed practiceBrooke Smith
72355-2941 355-294_ 355-29_ _ 355-2_ _ _ Backward Chaining Prompts are provided and gradually faded out
74Memory External Aides (portable memory) Labels on the outside of boxes, drawers, and cupboards to help youfind things.Post-it notes to leave yourself reminders in places around your home.A notepad beside the phone to write down messages and remindersChecklists or shopping lists.Diary for storing and planningAlarm clock, or timer to help you remember when you are supposedto do somethingA calendar to keep track of appointmentsA tape recorder to leave messages for yourselfA pill reminder box to keep track of medications
75MemoryGet Organized – It is easier to remember where things are if they are kept in one place. For example, if you are constantly losing your wallet, you will find it faster if you always leave it in the same spot.Make A 'To Do' List – Making a list of things that you need to do can help you remember all that you need to get done. For example, you can make a list of chores to remind yourself of what needs to be done.
76Memory Mnemonics Richard of York gives battle in vain Consciously leanedRequire considerable effortVerbal or visualRichard of York gives battle in vainRed, orange, yellow, green, blue, indigo, violetMy very elderly mother just sat upon a new pinMercury, Venus, Earth, Mars, Jupiter, Saturn, Uranus, Neptune, Pluto
78Executive Functioning Structure and Routine!Do things that require the most initiation in the morning or after a restSet a small number of goals for each daySet up (with assistance) organizational practicesLarge family calendarOnline bill paymentUse labelsSchedulesSimplify activitiesPrioritizeChecklists
79Executive Functioning Meta-cognitive strategiesTo regulate behavior and increase goal-oriented behaviorSelf-talkTracking behaviorsSelf-monitoringTracking errors and attention lapsesGoal Management Training
80Goal Management Training Maintaining intentions in goal-directed behavior is reliant on intact executive functioningGMT based on theory of goal neglect resulting in disorganized behavior following frontal lobe injuryLevine et al. (2000).
82Language Language Communication skills training Group interventions Modeling and generalizationBuilding social networksIn MS, many language deficits are due to physical changes (i.e., dysphagia) and reduced speed of processing.Allow more time for communication
83Caveat Neuropsychological interventions should be person-specific Different presentationsAttentionProcessesExecutiveProcessesMemoryProcessesSelective AttentionDivided AttentionAlternating AttentionTask PerformanceWorking MemoryProspective MemoryAwarenessSolberg & Mateer (2001), Figure 8.3
84Special Considerations Common symptoms of MSEmotional and psychological difficultiesDepressionFatiguePain
85EMOTIONAL DIFFICULTIES Can impact neuropsychological functioning
88Depression Patients with MS have a 50% lifetime risk for depression Higher prevalence than the general population and higher than in other brain disordersDepression is treatable!Prevalence of anxiety is 25% - usually associated with diagnostic uncertainty and decreases over time
89Depression Common Symptoms Feelings of helplessness and hopelessness Loss of interest in daily activities.Appetite or weight changesSleep changesPsychomotor agitation or retardationLoss of energySelf-loathingConcentration problems
90Depression Self-management strategies Schedule in activities each day Make plans to see supportive friends/familyConsider joining a support groupTry a new hobbyTry activities that make you think (this will help with your recovery too!)Stay away from drugs/alcoholExercise (e.g., go for a short walk)Referral to a Clinical PsychologistPsychotherapy
91Depression Risk of Suicide When feelings of depression are severe, it is important for family members/friends to be aware of suicide risk.If your family member/friend talks about wanting to end their life or makes statements such as "It would have been better if I had died" he/she may be thinking about suicide.It is important not to ignore these comments and to contact a member of the healthcare team immediately.For support from the mental health crisis team (available 24 hours a day all week) Call (MANITOBA SUICIDE LINE)
92Fatigue Why does MS cause fatigue? The brain has to work harder to do the same activities it did before. Because the brain has to work so hard, it can become tired more quickly.The brain may be trying to heal as you recover from a relapse and this takes more energy than usual, which can lead to fatigue.MS can lead to problems with sleeping, which can leave you feeling exhausted.
93FatigueWhen you have fatigue, you may feel suddenly exhausted and lack the energy to do basic tasks.Mental FatigueIncreased forgetfulnessLack of motivation to plan your dayLack of interest in things you enjoyWithdrawalSlower speechGiving short answers in a quiet/dull voiceIncreased irritability or anxietySlurred speechDifficulty finding wordsPoor concentrationPhysical FatigueShortness of breathSlower movementWithdrawalCramps or weak musclesPoor coordination or balanceFallsPoor vision
94FatigueIt can help to figure out what triggers your fatigue, and how long it takes you to become fatigued.Keeping track of these factors can help you tailor coping strategies to suit you best.Once you know how fatigue affects you, there are a number of strategies that can be used to help you manage the fatigue that so often results from a brain injury.
95What makes fatigue worse? Doing too many things.Not taking breaks during the day.StressIllnessToo little exercise.Poor nutrition, such as eating junk food.Alcohol and caffeineFeeling depressed or anxious.Poor sleep.
96What are some strategies that can make fatigue better? Following a RoutineEnvironmental aidsTiming of activitiesPace YourselfSleepEat properlyExercise your bodyExercise your mindPlan aheadSeek support
97How to cope with Fatigue When should you ask for help? Talk with someone on your health care team if…..You are having trouble using strategies to cope with fatigueYour fatigue gets worse over timeYou are too fatigued to get out of bed during the dayYou have trouble sleeping and aren't functioning properlyYou feel sadness and lack of motivation along with fatigueYou are having trouble taking care of yourselfYour ability to think through daily activities is affected by fatigue
98PainLike emotional difficulties, pain can negatively impact cognitive functioning by:Stealing one’s attention/focusReducing processing speedAttention and processing speed deficits can negatively impact memoryExacerbating psychological andemotional difficulties
99Pain Coping strategies Psychotherapy Relaxation strategies Abdominal breathingImageryProgressive muscle relaxationCognitive restructuringBehavior managementPlanningPrioritizingPacingLearning how to communicate about pain
100Final Considerations Potential obstacles to successful interventions Diminished insightPoor engagement/motivation to changeSignificantly compromised cognitive functioningPoor generalizationInclude significant others in the treatment programBuild generalization into the treatment program.Collaborative relationship with the patient and familyHomeworkReal world examplesWork with patient to identify barriers to complete homeworkBring significant others on board to assist with generalizationSohlberg & Mateer (2001)
101Final Considerations Solutions Include significant others Build generalization into the treatment program.Collaborative relationship with the patient and familyHomeworkReal world examplesWork with patient to identify barriers to complete homeworkOver-learningRelapse planning and managementSohlberg & Mateer (2001)