Cognitive Difficulties

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Memory, planning, foresight, and judgment are part of what makes us human. This is what we call cognition. The transmission of nerve impulses from the front of the brain to the back, from side to side and back and forth, are what make for the ability to remember and communicate. This takes highly myelinated fiber tracts working at top efficiency. It should come as no surprise that impairment happens all too often in MS. It is estimated that 50 to 55% of people with MS will have some problem with cognition. About 10 to 15% have significant problems that can lead to decreased job performance and altered social skills. Because this is often a transmission problem, there may be times when it all works well and others when it falls apart. These bad times are worse with heat, stress, and fatigue. The problem is very different from that seen in Alzheimer's disease, which involves across the board memory loss. in MS the loss can be very spotty.

Occasionally a person experiences such severe cognitive difficulties that the condition is called "cerebral MS." In cerebral MS the person often has no insight that he is experiencing a problem, which makes it more difficult to help.

The key to treatment at this time is compensation. It is impossible to get the nerves to start working after they have been damaged.

Testing needs to be done to determine the strengths and weaknesses, in order to build on the strengths. The testing can be extensively done by neuropsychologists or less aggressively by speech pathologists or occupational therapists.

It is important to treat aggressively any depression that may complicate the situation, to review all medication taken for MS, and other conditions, and to assess the possible effects of each on cognition.

The brain of an adult was once thought to lack what is termed plasticity—the ability to switch function to another brain area to allow for restoration of function normally controlled by a damaged area. We now believe that the brain has a greater degree of plasticity than was once thought. How to stimulate this is a great challenge that is being worked on diligently.

A number of compensatory techniques are used to work with the cognitive problems of MS. First, those problems need to be found and their extent measured. This is done through testing, either by a speech pathologist or more formally by a neuropsy-chologist. Remember that nobody's memory is perfect. Stress, anxiety, and fatigue all decrease cognition, especially memory. Poor concentration may add to the problem. Depression must be treated. A person with MS often does not recognize his or her depression but may respond to medication and therapy. Psychologic tests may be necessary to make the diagnosis of depression.

The following strategies have been found to be helpful in managing cognitive problems:

• Make lists—shopping lists, lists of things to do, and so forth.

• Use a calendar for appointments and reminders of special days.

• Establish a memory notebook to log daily events, reminders, and messages from family and friends.

• Use a tape recorder to help remember information or make up lists.

• Organize your environment so that things remain in familiar places.

• Carry on conversations in quiet places to minimize environmental distractions.

• Ask people to keep directions simple.

• Repeat information and write down important points.

• Establish good eye contact during any discussion.

Cognitive problems may be minimized if a person with such a problem can be made aware that it exists and is willing to change her mode of operation by using compensatory techniques. Part of the difficulty is perceiving this awareness without creating antagonism. This is the age of computers, and both electronic and nonelectronic organizers may be especially helpful in organizing your life.

Cognitive rehabilitation has not been well established for MS as yet, but the beginnings are taking shape. Although cognitive rehabilitation can teach people some ways to compensate, in general it has not become a practical way to counteract the losses of brain demyeli-nation. The best strategy is to prevent the damage from occurring with aggressive earlier treatment with immune modulation.

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