The Neuropsychological Evaluation of Patients with MS: Room for Improvement?
During the disease course of MS, disability accrues in several domains including mobility, physical & sensory functioning, cognition (40-60% of patients) and emotional health. Whilst commonly used rating scales (specifically the Expanded Disability Status Scale, EDSS) measure mobility and physical functioning well, the impact of MS on cognition is poorly captured. Indeed, the Functional System Score designed to record impact on cerebral function within the EDSS is rudimentary, and unlikely to reflect the complex effect the pathological processes underpinning MS have on cognitive functioning. The absence of a universally accepted measure of cognitive dysfunction in MS results in the poor documentation of cognition in patients, and possibly the suboptimal recognition and management of impairments.
The MS database of patients at BHR University Hospitals NHS Trust (BHRUHT) was interrogated, to evaluate how frequently neuropsychological parameters are recorded routinely. This was compared with how often the EDSS was documented. Data on 60 patients (30 patients receiving Disease Modifying Therapies (DMTs) and 30 not on DMTs) selected randomly were scrutinised.
The database revealed that there were 122 DMT and 335 non-DMT patients. Data were therefore obtained on 24.6% and 8.9% respectively of these groups. 3/30 DMT patients and 1/30 non-DMT patients had undergone detailed neuropsychological evaluations. No documentation on cognitive functioning (including from “screening” tests) was available in any others. In contrast, 22/30 and 21/30 respectively had their EDSS documented.
Despite the predicted impact on cognitive functioning in MS, the monitoring of cognitive dysfunction in MS is poor. More patients on DMTs have evaluations, and testing takes place sporadically, or after the disclosure of cognitive dysfunction. We plan to utilise a screening tool (Brief International Cognitive Assessment for MS, BICAMS) to evaluate patients with MS in our service routinely. A more detailed evaluation (Minimal Assessment of Cognitive Functioning in MS, MACFIMS) will be carried by Neuropsychologists in subjects found to be “positive”. A repeat audit, to demonstrate a higher rate of recording of cognitive dysfunction, will be undertaken in 2020. The implications on Neuropsychology resources within BHRUHT will be evaluated.