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Could an App-Based Cognitive Assessment for Patients with Multiple Sclerosis Improve Practice?

May 8, 2020
Cognitive dysfunction is common in people with MS, yet, traditional assessments need an upgrade to be considered efficient and worthwhile. A Johns Hopkins team is close to a solution.

As many as 1 million people in the United States are affected by multiple sclerosis (MS), a chronic condition that causes the body’s immune system to attack the CNS, often leading to pain.Many individuals with MS and related pain also experience cognitive dysfunction. In fact, by some estimates, cognitive impairment affects more than half of those with the disease (including those with and without pain) during their lifetime.2

This dysfunction may include slower information processing speed, reductions in short-term memory, and problems with communication skills, among other issues. The severity and duration of these effects vary from one person to the next and, in more challenging cases, contribute to individuals leaving the workforce prematurely, which reduces quality of life.2

 

As many as 1 million people in the United States are affected by multiple sclerosis (MS), a chronic condition that causes the body’s immune system to attack the CNS, often leading to pain. Many individuals with MS and related pain also experience cognitive dysfunction. (Image: iStock)

What Clinicians Need to Know About Cognitive Dysfunction in MS

“Cognitive dysfunction that occurs in people with MS is typically related to atrophy or cell loss,” explains Meghan Beier, PhD, MA, assistant professor of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. “The disease causes lesions in the brain that can interrupt the pathway through which information travels, forcing it to take a longer route,” she said. In addition, some studies have suggested that mood, fatigue, and sleep problems - all of which can be linked to MS-related pain in MS - further contribute to these patients’ cognitive impairment.

“We know people with chronic pain have a variety of mood issues and difficulty with self-assessment. The pain can also interfere with sleep, which can reduce a person’s cognitive functioning,” Dr. Beier said. This connection makes screening for cognitive changes essential; if the chronic pain is treated but the brain changes are not, patients are left struggling. In addition, patients with chronic pain who have cognitive dysfunction may find it harder to comply with a provider’s orders to manage the pain, creating a vicious cycle.

Challenges with Current Cognitive Assessments

The current gold standard for performing cognitive screening of patients with MS is to use the Brief International Cognitive Assessment for MS (BICAMS).3 Yet, administering this test can be complicated and time-intensive, Dr. Beier said.

“A survey of neurologists in the UK a few years ago asked what they did to assess MS patients.4 Less than 8% of MS clinical providers said they were using the BICAMS. Approximately one-third of the respondents said they did something to assess their patients, but for many this was just asking if the patient was having symptoms and did not involve a formal assessment,” shared Dr. Beier. A similar study based in the United States found that 50% of MS providers had no formal procedure for cognitive screening.5

Part of the problem is that the BICAMS takes 24 minutes to screen each patient, said Dr. BEier, “which is a lot of time for a clinic visit.” This has led some clinicians to conduct only part of the assessment or to skip it entirely. Other providers may conduct the entire assessment but then do not understand how to properly interpret the results.

Putting Technology to the Test

To address these challenges, Dr. Beier and her colleagues developed a tablet-based app called iCAMS. Based on the BICAMS screening, the app consists of three separate tests (note that the test material provided through the app is not exactly the same as that in the BICAMS, but it is expected to produce similar results).

To validate its effectiveness, the scientists screened 100 adult patients from the University of Washington Medicine Multiple Sclerosis Center who had a confirmed MS diagnosis. The researchers used two assessment methods on each patient: a traditional paper assessment and the iCAMS version, delivered on a tablet. The latter contained prompts and instructions to guide staff members throughout the process.

The app version of the cognitive assessment took 40% less time to complete and score than the paper test.6 Further, the findings for both versions were consistent 93% of the time, validating the app’s effectiveness.6 Participating clinicians who administered the screening via the app reported that it was easier and less stressful to deliver than the paper version of the test and patients seemed to prefer it, as well.

Next Steps

Based on these findings, Dr. Beier plans to scale the tablet-based test to a wider audience. She noted that the app was developed for research purposes and is not being shared with the general public at this time, but the team is exploring other options that might yield similar results.

“My goal is to make what we do in the clinic to assess a patient’s cognitive ability [and address weakness if needed] more readily accessible to patients in a range of settings,” she said.

This is especially important, since in 2018, the National MS Society released a series of recommendations for clinicians on performing cognitive screening and management in multiple sclerosis care.7

When cognitive issues in MS are identified, Dr. Beier pointed that there are a number of interventions that may be employed to address them effectively, including occupational therapy to train the brain, speech and language therapy, and in some cases, medications to modify the disease course.  In addition, she said that some patients with MS may benefit from engaging in services such as BrainHQ, which offers free, scientifically validated online activities to assess cognitive ability and improve brain health. Dr. Beier pointed out that this approach has shown promise in improving cognitive function in some patients with multiple sclerosis.

Last updated on: May 11, 2020
Continue Reading:
When Pain Intrudes on Daily Function: A Study of Individuals Living with Multiple Sclerosis
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