Bruce Hughes, MD: Switching a little bit on this, I think its also incumbent upon us to not just talk about disease-modifying therapy and cognitive functioning, but we do know that physicality and physical exercise ties into mental health [treatment]. If the patients mental health is out of order, their physical health is never going to be maximally in order, so treating the whole patient is important. And then identifying what youre talking about, because I think we focus more here on cognition, but kind of tying in with that is fatigue, which is so hard to identify. Educating patients on cognitive tips is very important as far as not just your disease-modifying therapy, but things that you that help minimize the effects of the cognitive decline on your health.
Robert Naismith, MD: I agree. I think your mental health plays a huge role in the disease. We see this all the time when people are under stress, when people arent able to take care of themselves, they present with worsening. Thats something you really need to dig into and assess, and we see that all the time where people are trying to juggle parents who are not doing well and who are sick, and thats putting stress on the family or family dynamics between the spouse and is not the best, and this affects the disease. So I think what you brought up with exercise is an important thing that we talk about at every visit. Doing physical therapy as a tool to show you how to do stuff for yourself at home and then doing another visit to make modifications based upon the things that youve achieved with those exercises and really stressing [that] this is something thats going to help you do better, addressing mood. People have a lot of depression [and] anxiety, [and] sleep is an issue for a lot of people. This impacts how they feel and how the disease manifests itself in the fatigue, so we use a lot of antidepressants in practice. But not everybody feels like thats going to be the best thing for them, so we also have options for counseling. We have a list of counselors. One of the nice things is [that] people are now able to do counseling by , so they dont necessarily have to go to a place to do it, so a lot of my patients choose to pick a counselor in their area. They might do some in-person visits, they might do some [telehealth] visits, so I think the access is very good for that. But thinking about the whole patient in terms of their mood, their sleep, their comorbidities, exercise program, how theyre interacting with everybody, and if theres anything within your power to help that or get them to the professional that can help them do it together with you, those are the things that Im looking for my practice. As a multidisciplinary MS [multiple sclerosis] center I want to have the tools to say, well, this isnt my expertise, but I know someone who can help you with this; we need help to treat you in every way we can.
Bruce Hughes, MD: I think thats spot-on. The referral to mental health providers is big in multiple sclerosis management because unlike many patients, MS patients tend to have very good insight into their disease process, and to me, those are the ones who do the best with cognitive therapy and counseling. At your center, do you find much benefit in referrals to speech language cognitive therapy for ongoing assessment like what you would do with physical therapy or occupational therapy, or have you not found that quite as helpful?
Robert Naismith, MD: I think it depends upon the person, but we do make the recommendation when we have the referral for neurocognitive testing, thats going to be like a 2 or 2.5-hour battery where they can go through all the different domains of executive functioning, word finding, short-term memory, reading. Theyll go through all the different domains, and theyll check their baseline level so theyre able to get a real sense of their cognitive function, and also their mood. They also check for mood disorders as well. And then well have the specialist who does the testing explain everything to the patient and document and make a report. And then well also make a referral to speech cognitive therapy so that they can use those results and gain more insight and come up with strategies to adapt to them. It may also include a referral to vocational rehab if its going to affect their work issues and if the combinations need to be made so that theyre able to perform at their best. So it depends on the person, but we always offer with that neurocognitive referral a chance to see a speech cognitive therapist and also, if they are working, vocational rehab to try to make the accommodations that are going to help them be successful in the work setting.
Bruce Hughes, MD: I think that point is very good in that sometimes were identifying [whether it is] brain volume loss in the disease process or are there confounding variables on their cognitive functioning such as depression, such as sleep disturbance, which I think is huge and really underrecognized in the multiple sclerosis population. We should be doing a lot more assessment of sleep for whatever the cause of why theyre having sleep disturbance. Its just remarkably common. How do we how do we address and improve that?
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Improving Cognitive Awareness of Patients and Caregivers in MS ... - Neurology Live
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