Holistic Personalized Care for Patients With Multiple Sclerosis and the Importance of Cognitive Monitoring

Tom A. Fuchs, MD PhD

When we consider personalized medicine for patients with neurologic diseases, there are 3 types of tools we often use to direct our treatment: predictions, disease monitoring, and tailored treatment protocols. These 3 tools are used in concert with each other; We use predictive models and disease monitoring tools to support treatment decisions for the specific individual needs of our patients.

How can I use cognitive testing for personalized medicine with multiple sclerosis patients?

For personalized medicine in multiple sclerosis (MS), cognitive testing can be an important part of our disease monitoring toolbelt. Cognitive testing allows us to capture invisible disease progression that would otherwise go unnoticed by patients and their doctors. The results from our recent study in Multiple Sclerosis Journal¹ highlight this especially by demonstrating that the majority of cognitive decline in patients with MS occurs silently, independent of relapse and also independent of physical disability worsening.

Given that neurologists tend to detect cognitive impairment only as well as chance,² objective cognitive testing is a key ingredient to capturing this independent feature of disease progression. The Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS)³ is a short and internationally-validated tool for this purpose. With early testing, we can establish a clinical baseline which we can then use for comparison to capture cognitive decline using established cut-offs (eg, 8-point decline on the Symbol Digit Modalities Test; 7-point decline on the Brief Visuospatial Memory Test-Revised; and 11-point decline on the California Verbal Learning Test II.).¹

How can I change my medical practice with cognitive testing?

Depending on your patient, there are many ways to respond to cognitive decline. If cognitive impairment is detected early, then patients with MS are more likely to benefit from restorative cognitive telerehabilitation,^4,5 making this a good treatment option for motivated patients. If patients are more progressed and restorative rehabilitation is no longer viable, then patients can be provided with valuable compensatory strategies for use at work and at home.⁶ Perhaps most importantly, detection of cognitive impairment allows us to open conversations with patients and their families about these hard to see, though very real, neurologic changes. The neurologist is key to helping patients and their families see and understand these otherwise unrecognized symptoms that have pervasive impacts on people’s quality of life, work, and relationships.⁷

Luckily, cognitive impairment, like physical impairment, can be accommodated at home and at work as long as people know about them. For instance, to avoid unnecessary conflict a loving spouse can learn to speak more slowly and write down instructions if they know their partner has slowed cognitive processing speed and impaired verbal memory. The conversations we have with our patients and their families are therefore themselves a pivotal component of personalized and holistic care to improve our patient’s relationships.

What can I expect from future research on this topic?

In the future, we intend to research whether silent cognitive decline also occurs independent of acute inflammatory activity in the brain and to establish normative trajectories of cognitive decline. This research will help us understand the degree to which cognitive decline in multiple sclerosis occurs as an independent axis of disease progression and will also improve clinical interpretation of cognitive decline.

REFERENCES
1. Fuchs TA, Schoonheim MM, Zivadinov R, et al. Cognitive progression independent of relapse in multiple sclerosis. Mult Scler J. Published online August 28, 2024. doi:10.1177/13524585241256540
2. Romero K, Shammi P, Feinstein A. Neurologists׳ accuracy in predicting cognitive impairment in multiple sclerosis. Mult Scler Relat Dis. 2015;4(4):291-295. doi:10.1016/j.msard.2015.05.009
3. Benedict RHB, Amato MP, Boringa J, et al. Brief International Cognitive Assessment for MS (BICAMS): international standards for validation. BMC Neurology. 2012;12(1):55.
4. Fuchs TA, Ziccardi S, Dwyer MG, et al. Response heterogeneity to home-based restorative cognitive rehabilitation in multiple sclerosis: An exploratory study. Mult Scler Relat Dis. 2019;34. doi:10.1016/j.msard.2019.06.026
5. Ziccardi S, Fuchs T, Dwyer MG, et al. Cognitive phenotypes predict response to restorative cognitive rehabilitation in multiple sclerosis. Mult Scler J. Published online November 9, 2023:13524585231208331. doi:10.1177/13524585231208331
6. Chiaravalloti ND, Moore NB, Nikelshpur OM, DeLuca J. An RCT to treat learning impairment in multiple sclerosis: The MEMREHAB trial. Neurology. 2013;81(24):2066-2072. doi:10.1212/01.wnl.0000437295.97946.a8
7. Potticary H, Langdon D. A Systematic Review and Meta-Analysis of the Brief Cognitive Assessment for Multiple Sclerosis (BICAMS) International Validations. JPN J Clin Med. 2023;12(2):703. doi:10.3390/jcm12020703