Using Behavioral Interventions for Cognition in MS

John DeLuca, PhD, senior vice president for research, Kessler Foundation

John DeLuca, PhD

Over the years, as the armamentarium for treating multiple sclerosis (MS) has increased, physicians have the ability to address not only the course of the disease, but to turn toward the complex group of symptoms which accompany it.

One of those symptoms that have only recently begun to be addressed are the cognitive challenges which impact a disproportionate number of patients with MS. John DeLuca, PhD, senior vice president for research, Kessler Foundation, recently sat down with NeurologyLive to speak about this area of need in MS, suggesting that consistent cognitive assessments and behavioral interventions can make a real impact in beginning to put the puzzle together.

NeurologyLive: Once cognitive assessments are done in MS, what’s the next step?

John DeLuca, PhD: Of course, the big question is, if you now do the assessments, what can we do about it? That's the next big question I get all the time. You can think about it in 3 different ways. One is pharmacological, and there's some evidence and that perhaps some of these disease-modifying therapies might have, or should have, an effect on cognition. In fact, if they're decreasing brain volume loss, well then shouldn't that help cognition? Well, the literature on this is really mixed and essentially not that good, so disease-modifying therapy in and of itself is really not a treatment for cognitive problems. It might be, down the road, that some disease-modifying therapies might be better than others and that might be something that the clinician can think about. The literature, again, is not really clear on that. But that might be a way to go.

The second area, and the area where there's actually really good research is cognitive rehabilitation, these are interventions that we know can have an impact in improving aspects of their lives. We've done a lot of work in learning, in memory—patients complain of learning and memory. What we do in our work is we train patients—we go through the interventions that have been shown for decades to improve learning and memory in other populations, and in other in healthy individuals. We take those tools, put them into a program with clinical intervention and test it. What we found is if you take these tools, you can train the patients to use these tools in their everyday life to improve their learning and memory and to improve their everyday functional activity.

How do these tools—these behavioral interventions—work?

They work through neuroplasticity, through changing the functional connectivity and the functional increases in activity in the brain. We've shown, through a number of studies, that these are not just behavioral tools. These are tools which actually show changes in the brain, increased connectivity, for example, with the hippocampus and other areas of the brain from this behavioral intervention, in a randomized control trial compared to placebo.

We're training patients to utilize techniques and the more they use them, the more they were able to adapt and see that, through neuroplasticity, this is a real change in the brain for them. There's a lot of data out there that's great. There is research out there are showing really good clinical trials.

What other areas of behavioral intervention do you see potential in for cognitive issues in MS?

I see potential in exercise. Now, we know exercise is the treatment for everything, right, but it can never be a script of going to the gym and coming back to see me in 3 months. The data on exercise in cognition right now is fairly weak, fairly inconsistent, but there is some promise. The idea is we need to know what type of exercise, with what frequency, with what duration or intensity, for whom, and at what level. Do we start early in the disease? Do we wait until people actually have cognitive problems?

Exercise, ultimately down the road, is going to have an impact on cognition. We just need to get there. We're not there yet. Right now, what's available and works, and works fairly well, is cognitive rehabilitation. But in my mind, how this is going to work in the end? Some form of medication, cognitive rehabilitation, and exercise will be the ultimate treatment for cognitive problems in MS.

What do clinicians need to do for their patients with MS to keep an eye on cognition?

It's important for clinicians to be talking to their patients about cognition and about cognitive problems. It's important for clinicians to ask questions to their patients because there are going to be some patients with certain personality profiles, characteristics, that are not “I'm not going to let this MS disease get me.” They may be experiencing some changes at work, but they’re not going to let you know—they say, “I think I'm dealing okay.” And the other extreme is going to be patients who say, “Everything is going wrong.” So those are personality characteristics that have to be differentiated from emotional responses to us and differentiated from actual cognitive problems.

It's important to get that understanding, that kind of training. But I think the key right now for clinicians is to ask and talk about cognitive problems.