Posted by: Thixia | April 29, 2008

Nature of Cognitive Dysfunction in MS 4 of 6

B.     General Strategies


There is a large and growing body of evidence to support the idea that a lifetime of exercise can result in preservation of a number of aspects of cognition. Much of this literature has focused on aerobic exercise such as walking, running, bicycling and swimming.  There are several possible mechanisms by which physical activity could affect cognitive function, including increasing blood flow to the brain, reducing the risk of heart disease and for stroke, and stimulating the growth and survival of brain cells.

In addition to exercise there are a number of other general strategies for reducing age-related cognitive decline.  These may include maintaining low blood pressure, avoiding obesity, controlling stress and depression, pursuing a life of mental stimulation, and eating a diet rich in antioxidants from fruits and vegetables.



C.     Treatment


After a careful evaluation, and once factors such as depression, or medication side effects have been addressed, other treatments may be considered.  No treatment to improve MS-related cognitive dysfunction has been shown to be effective in a definitive way.  However, there have been small studies suggesting that certain treatments may be helpful in some cases.  These interventions are reviewed below.   




Amantadine has been studied among people with MS primarily in relation to fatigue.  Indeed, amantadine has been shown to be helpful for MS-related fatigue. 


There have also been two small studies to assess whether amantadine might affect cognition in MS.  One small study was based mostly on self-reported data.  Patients taking amantadine reported improvements in concentration and problem solving.  In addition, a slight improvement on a measure of attention was also seen.  Another small study suggested that amantadine might increase speed of processing among people with MS who have fatigue.  However, a beneficial effect was not seen on clinical measures of cognitive testing.  Rather the improvement was observed through brain wave monitoring, that is, through electrophysiological monitoring with electrodes attached to the scalp.  Overall, these two studies do not provide compelling evidence that amantadine can improve cognitive function. 


Aricept (donepezil): 


Aricept, and other medications in its class, known as “acetylcholinesterase inhibitors,” are widely used among people with Alzheimer’s disease, which causes a different and much more severe form of cognitive dysfunction than is seen in MS.  Whether Aricept might also help with MS-related cognitive dysfunction has been studied in a limited way with mixed results. 

There have been several studies comparing Aricept with placebo for the treatment of cognitive dysfunction among people with MS.  One, which involved 35 patients taking Aricept and 34 patients taking placebo, showed a benefit with Aricept treatment on a memory test.  Most people did not have significant side effects during the 24-week course of the study. Another trial involving 32 people (including both the group who received Aricept and the group who received placebo) failed to find a benefit with Aricept treatment.

One additional study that involved only 17 patients with relatively severe cognitive dysfunction has also been reported.  A benefit was observed with Aricept treatment.  This study did not include a placebo group for comparison and is difficult to interpret.  We conducted a small trial of Aricept at the Rocky Mountain MS Center that involved 15 people.  No beneficial effect on treatment was observed. 


Overall, there is limited and conflicting data about whether Aricept should be used as a treatment for MS-related cognitive dysfunction.


Cognitive Assessment and Intervention:


People with MS-related cognitive problems are sometimes referred for cognitive evaluation and treatment with one of three professionals:  a neuropsychologist, a speech therapist, or an occupational therapist.  Cognitive intervention might include training in the use of diaries, calendars, notebooks and lists, as well as specific techniques such as visual memory techniques.   A recent study involving 240 patients with MS assessed whether these cognitive training techniques are useful.  Unfortunately, this study did not find any benefit with this form of cognitive therapy as compared with patients who did not receive cognitive training.  Another smaller trial of 40 patients found a benefit in only one of multiple tests.  The main conclusion of this study was that cognitive therapy may help with depression. On the other hand, a few relatively small studies have reported a favourable treatment effect related to various forms of cognitive therapy.


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