DAVID MARKS, MD: Hi and welcome to our webcast. I'm Dr. David Marks. Problems with thinking, concentration and memory are more common in MS patients than we used to think. So how does a person with MS know if they're having problems and what can they do about it?
Here to answer these questions are two of the world's experts in MS. First, we have Dr. Stephen Rao. He is professor of Neurology and a Clinical Neuropsychologist at the Medical College of Wisconsin. Welcome.
STEPHEN RAO, PhD: It's great to be here.
DAVID MARKS, MD: In the chair 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 a lot for being here. Now how does a person know that they're having trouble to begin with?
STEPHEN RAO, PhD: They may notice it themselves. They may notice that they're starting to have problems with their memory, being able to retrieve information that they thought they could memorize before. They may have problems with their ability to concentrate, especially when they're in very crowded environments where it's very noisy. Or they're trying to do more than one thing at a time.
They may not have the same kinds of abilities that they thought they had before. Or they may find that they're processing information at a much slower rate than they thought. Now sometimes people will observe it. Sometimes even the family members might bring it to the attention of the patient.
DAVID MARKS, MD: There are some tricks people can learn to adapt to this and since they may have it for a long time, they do learn these things.
FREDERICK MUNSCHAUER, MD: There certainly are. I had, for instance, a patient who was a dispatcher for a cab service. That person just really couldn't remember which cab was free and which wasn't. He had remembered that for years. He found he had to resort to writing lists about where each cab was and what zone it was going into. So making lists is a very important thing for people who are having trouble remembering.
If you have to do multiple tasks at a time, like virtually all of us do in our busy lives, then making a list of what tasks you have to do next and getting the satisfaction of crossing it off. Something like that may be just a simple way to sort of get your hand on some memory problems and problem solving issues.
DAVID MARKS, MD: Of course, technology can help nowadays.
STEPHEN RAO, PhD: Sure. There is low tech where you can actually keep calendars. But you can also move on to Palm Pilots. For people who have motor problems and can't use a Palm Pilot, there is always a tape recorder that they could use to record information that they have to try to remember later.
DAVID MARKS, MD: What about something that's crucial -- these are all crucial -- but taking medications when timing can be very crucial sometimes and skipping doses is not good. How do people remember how to do that if they're having memory deficits?
STEPHEN RAO, PhD: There are actually devices out there where you can actually have them beep at you every three or four hours. They allow you to remember to be able to take your medicines at a particular time.
DAVID MARKS, MD: I also know that for elderly people they have them laid out in a kind of calendar formation. Are these useful for MS patients?
FREDERICK MUNSCHAUER, MD: I think they are too and certainly knowing pill boxes that are both timed to the time of the day and to the day of the week are very helpful.
I think it's very important too for people who have noticed that they may have difficulty with memory or a little slower to solve problems to get frustrated by it. But to recognize that they can use their creativity and intelligence to try and solve the problem. I think that's very important recognizing it.
It's also very important for the significant other of somebody who's living with somebody with MS. To recognize that problems with memory, problems with problem solving can be coped with and adapted to. If you put people in a more structured environment. If you limit the number of tasks that they have to do to just a few, rather than requiring them to do three or four things simultaneously. You can improve your satisfaction with life, improve your quality of life and improve in performance by just readjusting how you get through a day.
DAVID MARKS, MD: These are things patients can do themselves.
FREDERICK MUNSCHAUER, MD: That's right. If they're creative.
DAVID MARKS, MD: One thing they can't do themselves, Steve, you're an expert on neuropsych testing. Now tell me what that is and how it's used.
STEPHEN RAO, PhD: Neuropsychological testing is conducted by a trained clinical neuropsychologist. Neuropsychology is the field of psychology which is involved in the trying to assess and measure cognitive test performance. Specifically, what is done is the person is given approximately three to five hours of testing of their attention span and memory, for example. They might be given a list of words that they have to try to remember or a short story. Or in the area of retention, they may have to recall or be able to track information as time goes along.
What we typically do as a neuropsychologist is we'll take that information, see how well the person is doing and then compare that to a healthy group of individuals who are of the same age and educational background. By doing this, we can determine whether the person is actually having some abnormalities. Because we all know, as we get older, our memories tend to decline. So it's very important that if you have a 30-year-old individual that you compare them to the test performance of somebody who is in their 30s.
DAVID MARKS, MD: Now once the diagnosis is made, we talked about some of the things a patient can do on their own, but of course, we're doctors so one of the things we do is prescribe medicines. What are the medical options for patients out there?
FREDERICK MUNSCHAUER, MD: And you know, David, that's a two-edge sword. Because there are a number of medications that are used to treat the symptoms of multiple sclerosis that may actually impair or impede our ability to think and reason. Sometimes medications for anxiety can impair cognitive kinds of thinking. It's very important, if you feel that you're having trouble with memory or judgment or thinking in any way, problem solving -- to just ask your doctor to review the medications you're on to see if any one of them may be contributing to it. Sleeping medicines are a classic one. Sometimes some of the medicines we use to treat bladder problems can slow you down thinking a little bit.
On the plus side of things, there may be some medicines that can help you out if you notice that you're having some cognitive abnormalities. Certainly since the cognitive abnormalities that we see in MS are caused by the underlying inflammation of the brain, that characterizes the illness, the first approach to treating people is to stop that inflammation. We have interferons available, and another class of drugs called Copaxone that are used to treat the underlying inflammation.
One of those, Avonex, in a large clinical trial has been shown to slow the progression of psychological difficulties in multiple sclerosis. We think that's very significant.
DAVID MARKS, MD: When I was doing residency, we used to blast them with steroids for the inflammation. Do you still do that?
FREDERICK MUNSCHAUER, MD: That is still a way of treating an acute attack of multiple sclerosis. To give corticosteroids, these are not the kinds that bodybuilders take. They are the kind that fight inflammation. They do indeed calm down the inflammation of the brain. But they've been shown not to affect the progression of multiple sclerosis. Really the only drug that's been shown to slow both the progression of disability in MS and to slow the progression of neuropsychological dysfunction in MS is beta-interferon 1A or Avonex as it is available now.
DAVID MARKS, MD: Now it's interesting because dementia is also present in Alzheimer's; it’s the hallmark of Alzheimer's and there is a drug Aricept that's used. I understand that may be helpful in MS.
FREDERICK MUNSCHAUER, MD: That's a very interesting and hot topic now. There is a large study that's going on that Steve and I are both involved with using Aricept, a drug for Alzheimer's disease (and MS is not Alzheimer's disease) in patients who have difficulties with memory, judgment and problem solving. In several small studies, it's been shown to help quite a lot -- or helped significantly. (I wouldn't say quite a lot.) But certainly it's better than placebo.
I think that it bears further study. Clinically a number of neurologists are using these medications in people with cognitive abnormalities from multiple sclerosis. We're going to see a lot more research in this area and a lot more medications that will indeed try to improve the way people function.
STEPHEN RAO, PhD: I think it's important to summarize that really there are two ways. For people who already have cognitive dysfunction, it's important to develop and systematically test drugs that will help to improve the cognitive function. But the other way to do it -- the other approach -- is to develop medicines that can prevent the development of new lesions in the brain that might cause cognitive dysfunction. I think both methods are the way we would target the problem.
DAVID MARKS, MD: The message is once the diagnosis is made, there's hope and more coming down the road hopefully.
STEPHEN RAO, PhD: Absolutely. Treat early before it's a problem.
DAVID MARKS, MD: Good. Thank you both for being here. Thank you for joining our webcast. I'm Dr. David Marks. Good-bye.
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