Cognitive Rehabilitation

Cognitive impairment affects up to two-thirds of people with MS. In most cases, it is of mild-to-moderate severity and may include problems with verbal fluency, executive functioning, attention and concentration, and information processing. Treatment options for cognitive problems associated with MS include medication and rehabilitation (sometimes also called remediation). Cognitive rehabilitation provides practical, solution-oriented interventions to manage cognitive changes and includes two types of interventions, restorative interventions and compensatory interventions.

Evaluation for cognitive problems

Cognitive rehabilitation begins with an evaluation. If you (or your doctor) think you may be developing cognitive problems, you will be referred to a rehabilitation specialist for an evaluation. The evaluation typically includes a series or battery of tests typically given by specially trained health professionals, including a neuropsychologist, occupational therapist, and speech/language pathologist. Test batteries will include paper-and-pencil items and various types of puzzles. The goal of these tests is to determine how well you are functioning at work and home. A complete evaluation can last 6 to 8 hours and is typically conducted over the course of a couple days. Because a full evaluation can be expensive, you should ask about cost early in the process and find out if your insurance will cover the expense.

Rehabilitation

Cognitive rehabilitation involves interventions designed to help improve cognitive functioning in persons who have developed impairments due to CNS disorders, including MS. These interventions are offered by a multidisciplinary team of specialists, including a neuropsychologist, occupational therapist, and speech/language pathologist. As mentioned earlier, interventions are generally categorized as restorative or compensatory.

Cognitive rehabilitation is typically offered at a center that specializes in MS care, at a rehabilitation clinic, or through individual private practices. Depending on what your evaluation reveals, one of three approaches may be adopted, including (1) a general stimulation approach, in which cognitive processing is stimulated by playing word games or listening to stories; (2) a process-specific approach, in which you carry out a series of cognitive exercises of increasing difficulty; or (3) a functional adaptation approach, in which rehabilitation tasks are performed at home or in a work environment.

Role of different specialists

In approaching cognitive rehabilitation, different rehabilitation specialists will focus on their own specialty areas. For instance, neuropsychologists will concentrate on cognitive retraining, using their special expertise in relationships between the brain and our behaviors. Speech/language pathologists will focus on problems related to communication and language. Occupational therapists will concentrate on interventions to compensate for cognitive dysfunctions, with the goal of maintaining daily functioning and independence. The type or types of specialists you work with will be determined partly by availability and partly by your individual goals and the specific problems you are encountering.

Duration of treatment

The duration and intensity of cognitive rehabilitation really depends on what problems you are experiencing and how severe they are. Therapy typically is done at least once a week and may be done on a daily basis over several months. The idea is that if therapy is done with enough intensity, it will have a greater chance of carrying over into ordinary daily functioning.

FAQs: cognitive rehabilitation

If my memory and concentration are getting progressively worse, can rehabilitation still benefit me?

Cognitive rehabilitation can help you even if your memory and concentration appear to be getting progressively worse. Cognitive rehabilitation interventions are designed to help you make the most of your cognitive functioning and compensate for the loss of function. So, learning cognitive compensatory skills early on can be especially important to maintaining cognitive abilities as your disease progresses.

Can medications help my cognitive functioning?

Symptomatic treatment for cognitive impairment is limited at present. The drug Aricept (donepezil), which is FDA approved for the treatment of Alzheimer’s disease, has been found to provide a modest benefit in some patients with MS-related memory problems. Symmetrel (amantadine), which is used to treat MS-related fatigue, may also have some benefit in terms of improving information processing. Psychostimulants (amphetamines [Adderall] and methylphenidate [Ritalin])are sometimes used to treat cognitive impairments in MS. These drugs can improve focus and attention. Disease-modifying treatments, including interferon beta drugs (Avonex, Betaseron, and Rebif), and Copaxone (glatiramer acetate), are effective both in decreasing the number and severity of exacerbations and reducing the number of CNS lesions (as confirmed by MRI results). Evidence shows that the higher the total amount of lesion area (or lesion load) in the brain, the higher the risk a person faces for developing cognitive dysfunction. Therefore, it makes sense to start a disease-modifying treatment as early as possible after diagnosis of MS, to help lower your risk for developing cognitive problems and to help keep existing problems from progressing.

Can ginkgo biloba help improve my memory?

Ginkgo biloba is made from the leaves of a tree that is common in China, Japan, and Korea, and in some American cities, as a decorative planting. There is some evidence that a dry extract made of the leaves of the tree may have some benefits in terms of concentration and memory. You can find Ginkgo biloba in many health-food and vitamin stores. However, before you take Ginkgo or any other natural remedy or supplement, you should talk to your doctor first. There is a possibility that Ginkgo may interact with other medications you are taking.

Can exercise help my memory and cognitive functioning?

Exercise is very important for a person with MS and has been shown to have benefits in a broad range of areas, including cognitive functioning. So, exercise should be a part of every person’s treatment or rehabilitation plan. Results from a recent study showed that individuals who keep themselves at a high level of cardiovascular fitness actually maintain higher brain fitness (improved maintenance of gray and white matter). Talk to your doctor or a member of your rehabilitation team about developing an exercise plan that will work for you.

Are MS-related memory problems different from Alzheimer’s disease?

There are important differences between cognitive problems related to MS and those seen in Alzheimer’s disease. In Alzheimer’s disease, there is a dramatic decrease in nerve cells (neurons) and in the volume of a part of the brain called the cortex which is comprised of gray matter or (grey matter). In MS, cognitive problems typically result from damage to white matter in the brain, as well as the optic nerve and spinal cord. Although there can be damage to the cortex and loss of neurons with MS, this type of damage is much more extensive and severe in Alzheimer’s disease. While a person with Alzheimer’s disease will eventually lose all memory function (both remote and recent) and be unable to recognize family members and friends, cognitive impairments in MS are more selective and typically just affect recent memory, the ability to process information, and executive functioning. Unlike with Alzheimer’s disease, a person with MS can use cognitive rehabilitation to maintain and improve cognitive functioning and impairments may remain relatively stable for long periods of time and only progress slowly.

Can heat affect cognitive functioning?

Heat has a negative effect on many symptoms of MS, including cognitive functioning. Whether this has to do with the tendency for heat to increase or exacerbate fatigue or whether it has a direct effect on cognition is not known. Cooling suits or cold baths may be useful in counteracting the effects of heat, but it is not known whether these interventions will directly improve cognitive functioning.

How can I talk to friends and family about my cognitive difficulties?

Talking to your friends and family about the way MS is affecting you can be difficult. It can be particularly difficult to talk about impairments in a sensitive area like cognitive functioning. However, it is important for your family and friends to understand what is going on with you, so that they can provide the support you will need. As with many symptoms of MS, it is useful to be direct and clear. Tell your friends and family that damage from MS is affecting the way your brain works and that you are having difficulties, such as loss of memory, organizational problems, or difficulty with problem solving. Also tell them that rehabilitation can help with these problems and that they can play an important role in helping you maintain and improve your cognitive abilities. If you are having great difficulty talking with your friends or family members about your cognitive symptoms, you might find it helpful to use the skills of a psychologist or social worker to have a family or caregiver meeting, during which you can discuss your problems and address concerns that your friends and family members have.