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DAVID MARKS, MD: Hi and welcome to our webcast. I'm Dr. David Marks. Today we're talking about multiple sclerosis or MS. Now most people think of MS as a physically disabling illness. It is, but it can also affect the way you think, and also the way you feel.
Here to talk to us about this aspect of MS are two of the world's experts in MS. First, we have Dr. Steve Rao. He is professor of Neurology and a Clinical Neuropsychologist at the Medical College of Wisconsin. Welcome.
STEPHEN RAO, PhD: Good to be here.
DAVID MARKS, MD: Thanks. Next to him is Dr. Rick Munschauer, Associate Professor of Neurology at the State University of New York in Buffalo.
FREDERICK MUNSCHAUER, MD: Hi, David.
DAVID MARKS, MD: Thanks for being here.
FREDERICK MUNSCHAUER, MD: Thanks.
DAVID MARKS, MD: Let's define what difficulty thinking is to begin with. What do we mean by it when we say that?
STEPHEN RAO, PhD: Cognitive really refers to thinking processes. It can be referring to attention, problem solving, memory, reasoning, an ability to use language to express ourselves.
DAVID MARKS, MD: How does a person tell if they are having these problems?
FREDERICK MUNSCHAUER, MD: It may be quit subtle at first. It may be noticed as an occasional time where somebody, oh, just forgets to do something that they normally would have done, or find that it takes them a little longer to solve a problem than it used to or that they can't solve two or three problems at a time. You might notice that and that can happen early in MS.
DAVID MARKS, MD: Which is most common? Which of these symptoms?
FREDERICK MUNSCHAUER, MD: The most common problems that people report are in memory. But they also noticed that sometimes they're a lot slower at being able to process information, to reason. This can be a problem as well.
DAVID MARKS, MD: Now does this recognition usually come from the patient or from family members who are observing their behavior?
FREDERICK MUNSCHAUER, MD: It can happen from both. Sometimes the patients are aware of it, but also sometimes the family members can notice it. It's usually the discussion of the two that brings it to the attention eventually of the physician.
FREDERICK MUNSCHAUER, MD: I just had a patient today whose wife told me that he no longer does the checkbook and he'd done the checkbook for 30 years. In fact, when you begin to ask him, he's also aware of it. He has fewer and more directed responsibilities at work, and that sort of snuck up to him and he's only 35 years old. So it can happen gradually and insidiously, but it's well worth being aware of it. It's one of the ways in which MS can affect you.
DAVID MARKS, MD: How common is it?
STEPHEN RAO, PhD: Well, approximately 50% of people with multiple sclerosis have some degree of cognitive problems when they undergo specialized neuropsychological testing. The problems sometimes is that people misattribute it. Sometimes they'll say, well, maybe it's because I'm getting older and we do know that as you get old you're cognitive abilities tend to decline. Or they may say it's because I'm feeling a bit depressed. But in fact, the cognitive problems are related to the multiple sclerosis.
DAVID MARKS, MD: Fifty percent is a very surprising statistic as I said in the intro. Most people think of it as really a physical problem. The signs must be pretty subtle for a fifty percent and then we don't think about it as being a cognitive problem.
STEPHEN RAO, PhD: For most people the problems are relatively subtle. They do have some impact on their day-to-day lives, but they can usually learn to compensate for these problems.
FREDERICK MUNSCHAUER, MD: As Steve said, it's very important to recognize that the kind of thinking abnormalities that we talk about with multiple sclerosis are not of the same degree or magnitudes, severity that we see in Alzheimer's disease. It doesn't mean they can't cause you problems. It just means that we don't think of multiple sclerosis as being a dementing disease like Alzheimer's disease. But it certainly being aware of cognitive abnormalities and measuring them can be a way in which people can achieve even more if they can receive the right treatment.
DAVID MARKS, MD: Expand on the way you can differentiate Alzheimer's from cognitive impairment in MS.
STEPHEN RAO, PhD: I think the main differences have to do with severity. In Alzheimer's disease the cognitive problems are much more severe and they progress very rapidly. On the other hand, in multiple sclerosis it's not uncommon for many people to have cognitive problems that remain stable for many, many years. In fact, over a three-year period, less than 20% of people actually get worse.
DAVID MARKS, MD: So if they have these subtle symptoms, they can learn to cope with them and adapt to them.
STEPHEN RAO, PhD: That's correct. That's correct. They can learn various strategies to help them to compensate by using, for example, memory aids or visual aids.
DAVID MARKS, MD: How about mood in people with MS?
FREDERICK MUNSCHAUER, MD: Oh, it certainly does. In fact, one of the things that I ask my patients with multiple sclerosis and their family members is, is there more lability to mood? Do they find that they laugh or cry more frequently? In fact, if you have trouble controlling your moods, that may be a sign that there is some cognitive abnormality.
I think that it's very important, as Steve was saying, to make sure also that if you think you're having trouble with your thinking and problem solving to make sure it's just not a manifestation of depression. Depression can masquerade itself as cognitive problems.
DAVID MARKS, MD: Is there an idea of how many percentage of people with MS have depression?
STEPHEN RAO, PhD: Well, the estimates vary but they can range anywhere from 20-40% of people have intermittent periods when they feel depressed. But it's important to recognize that depression is really independent of cognitive problems. In the sense that when we've looked at people who are depressed and when we look at people who are not depressed with MS, the frequency with which they have cognitive problems is about the same. So it's not the depression that is causing the cognitive problems.
DAVID MARKS, MD: Is there a correlation between the severity of the physical illness and the amount of cognitive impairment that people have?
STEPHEN RAO, PhD: That's the surprising thing. One would expect to see the severity of cognitive dysfunction being related to the amount of physical disability. But that's not the case at all. In fact, the correlation is very low.
You can have people who have a great deal of physical disability who do not have any cognitive problems at all, and vice versa.
DAVID MARKS, MD: Is it possible that people can be diagnosed initially from cognitive problems.
STEPHEN RAO, PhD: Yes. That's another thing that's very important to recognize. Sometimes cognitive problems can be some of the first manifestations of the illness. On the other hand, there are some people who have the illness for 30 years and never experience any cognitive problems.
DAVID MARKS, MD: Let's talk about tests. How does someone tell if they have cognitive problems with MS?
STEPHEN RAO, PhD: The definitive way in which cognitive problems can be diagnosed is through neuropsychological examination. Usually this is an examination that's conducted by a clinical neuropsychologist. A neuropsychologist is a specialist within clinical psychology involved in the diagnosis of people who have brain disorders or diseases that affect cognition. Usually the examination consists of various measures of attention and memory span and problem solving, all of which are designed to see if there are abnormalities.
DAVID MARKS, MD: MRIs are also being used now.
STEPHEN RAO, PhD: Well, the importance of MRI -- MRI does not diagnose cognitive problems, but what we have found is that patients who have an extensive amount of lesions in their brain, have a much higher risk of developing cognitive problems.
DAVID MARKS, MD: I think we have some video. Let's take a look and you can tell us what we're looking at.
STEPHEN RAO, PhD: Right. In this first image, you're looking at an MR scan of the brain. It's very clear the problems that you see associated with multiple sclerosis. This is the very large area that is shown in white. When we actually go ahead and measure these areas of lesions, we find that there is a very strong relationships between the amount of area of the brain that is involved and the degree of cognitive dysfunction that we see on neuropsychological testing.
DAVID MARKS, MD: We have another MRI here. You can tell us again what we're looking at -- a little bit of a different presentation. Not as large.
STEPHEN RAO, PhD: These are additional MR lesions and the numbers simply indicate the amount of area that is being involved by each of the lesions. We then quantify this and then correlate this with the severity of the cognitive dysfunction.
DAVID MARKS, MD: Now would you follow this up over time with MRI scans every six months, every year?
STEPHEN RAO, PhD: One could do that. But I think the MR scan is probably more important if a person has had a severe worsening in their cognitive status. The MR scan might actually be useful to understand whether it's related to the MS or not.
DAVID MARKS, MD: But the purpose of an MRI is to change the way you treat a patient. So do you use MRIs that way or do you just kind of track it?
STEPHEN RAO, PhD: I think I would --
FREDERICK MUNSCHAUER, MD: In general I think that the major advantage of doing an MRI is to establish the diagnosis of multiple sclerosis as accurately as we can. Then using the MRI to track the activity of the disease is one of the factors that we do use to try and come up with the appropriate treatment for an individual.
We do not as yet use repeated MRIs to track neuropsychological deficits. But I'll tell you as a clinician, if I have a patient who I see who may have -- just to be a long distance runner, let's say. I look at their MRI and there are a lot of these spots. I begin to worry that that person may have cognitive abnormalities or be at quite high risk for cognitive abnormalities.
I think, David, your point is a good one. It's that I think it's very important for people who live with people who have MS or people who have MS to communicate with their neurologist if they feel they're developing some sorts of problems with memory, problem solving, and attention. There are things that can be done. As a neurologist, we don't normally think about that and I think it's time we did.
DAVID MARKS, MD: Is cognitive impairment an inevitable part of this disease?
STEPHEN RAO, PhD: No, not at all. As a matter of fact, fifty percent of people never develop cognitive dysfunction. It's something to be aware of and it occurs quite frequently -- as we say, fifty percent. But it doesn't always happen -- occur. Most people who do experience cognitive dysfunction, most of the problems are relatively subtle.
DAVID MARKS, MD: What is the course in a person who has cognitive impairment? Is it going to be stable? Just tell me typically -- the typical average garden-variety patient?
FREDERICK MUNSCHAUER, MD: I wish we could say there is anything typical about somebody with multiple sclerosis. One of the really vexing things about this disease, particularly if you have it, is the one thing we can absolutely say for certain is establishing a firm prognosis is extremely difficult. Steve has done some good research on what happens with people with cognitive abnormalities in multiple sclerosis over time.
STEPHEN RAO, PhD: We've given people, both neuropsychological testing and MR scans separated by about three years. What we find is about 20% of those individuals experience some deterioration -- either new cognitive problems or worsening of existing cognitive problems over that three-year span. The other 80% experience no deterioration. What we also discovered is the 20% that did get worse were the individuals who experienced an increase in the number of lesions on their MR scans.
DAVID MARKS, MD: So half of the people don't get cognitive impairment. The ones that do, it's relatively subtle, not devastating, and most of those people will not worsen over time.
STEPHEN RAO, PhD: That's correct.
FREDERICK MUNSCHAUER, MD: The good news too is that there are things that we can do about cognitive abnormalities so it's important to identify it early because early treatment can help.
DAVID MARKS, MD: Well, thank you both for being with us. Thank you for joining our webcast. I'm Dr. David Marks. Good-bye.
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