Mood and Cognition

Kevin N. Alschuler, Ph.D. Assistant Professor, Dept of Rehabilitation Medicine

Attending Psychologist, UW Medicine MS Center

Meghan L. Beier, Ph.D. Acting Instructor, Dept of Rehabilitation Medicine Attending Psychologist, UW Medicine MS Center

2-25-2015

Conflict of Interest Dr. Alschuler and Dr. Beier have no conflicts to disclose

Instructional Objectives

Review prevalence, impact, and screening methods for: Mood Cognition

Recognize intersection of mood and cognition

Patient C - background

56 y.o., male, dx with PPMS in 2012 Bowel, bladder, sexual functioning, gait, fatigue, pain (3/10)

Social hx: happily married, 1 child, works as engineer

Mental health hx: No MH tx, but anxious, no substance use

Referral for cognitive evaluation: Pt anxious/concerned about cognitive functioning; noticing decreased recall

Patient C – interview by psychologist Loses train of thought at work Cannot remember important information under stress Easily overwhelmed Many unfinished projects at home Feels he is getting worse, expects to perform poorly Admits to baseline anxious disposition

Cognitive impairment in MS

Present in 43-70% of patients 1

Commonly impaired: Processing speed, attention, memory (acquisition and

retrieval), executive functions, visuospatial, verbal fluency (word-finding)

Rarely impaired: General intelligence, long-term memory, recognition memory,

verbal skills

1 Chiaravalloti & DeLuca (2008)

Cognitive impairment in MS

Impact:

Decline in performance at work, cause of exiting workforce

Decreased perception of self, potentially impacting mood, self-esteem

Decreased quality of life

What is your primary method of assessing for cognitive problems? A. Self report by

interview/discussion B. Self report questionnaires C. Screening measures (MMSE,

MOCA, etc.) D. Computerized testing E. Refer to neuropsychologist F. None of above

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Rwpoll.com Session log-in: uwecho

Cognitive assessment – objective

In-clinic screening Montreal Cognitive Assessment (MOCA) Brief International Cognitive Assessment for MS (BICAMS) Processing speed, visual and verbal acquisition of information

Cognitive assessment – objective (cont’d)

“Brief” cognitive evaluation Minimal Assessment of Cognitive Functioning in MS

(MACFIMS) Attention, visual and verbal memory, processing speed, working

memory, verbal fluency Brief Repeatable Battery (BRB)

Comprehensive neuropsychological evaluation Multiple measures per domain + general intelligence and

academic achievement

Cognitive assessment – self-report

Interview

Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNQ)

How accurate? What biases perception?

Mood (vs. general population)

Major Depressive Disorder: 36-54% (vs. 16%) Anxiety: 36% (vs. 29%) Adjustment disorder: 22% (vs. 0.2-2.3%) Bipolar disorder: 13% (vs. 1-5%) Pseudobulbar affect: 7-10% (vs. N/A) Euphoria: 0-63% (vs. N/A)

Summarized in: NMSS Clinical Bulletin: Emotional Disorders in MS

Mood – causes

Biomedical Structural changes in brain Genetics Abnormalities in the hypothalamic–pituitary–adrenal (HPA)

axis

Psychosocial factors Change in circumstances, added stress, uncertainty

Feinstein, 2011

Mood

Impact: Decreased quality of life Risk factor for maladaptive behaviors (incl. suicide) Associated (bidirectionally) with worse physical symptoms Decreased adherence

…but under-diagnosed and undertreated

Mood – diagnostic challenges

Overlap of symptoms Eg, poor sleep, difficulty with concentration, fatigue

Focus on other symptoms in appointments Eg, depressed patients >2x more likely to have pain > 3/10

vs. nondepressed patients; patients with pain > 3 are 4x more likely to meet criteria for major depression vs. patients with pain < 3.

Atypical presentation and/or reluctant to mention to MD

How do you assess mood in patient visit?

A. Self-report during interview/discussion

B. Self-report questionnaire C. Both A & B D. Not at all

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Mood – screening

Depression Patient Health Questionnaire – 9 (PHQ-9) Beck Depression Inventory – II (BDI-II)

Anxiety Generalized Anxiety Disorder – 7 (GAD-7)

Depression and anxiety Hospital Anxiety and Depression Scale (HADS)

Patient C: Intersection of cognitive functioning and mood

Objective findings on cognitive evaluation: Above peers: Verbal memory (retrieval, retention,

recognition), visual memory (all), attention At peer level: processing speed and working memory

(trending to low end of normal) Below peers: acquisition of verbal information, verbal fluency

(2nd percentile) Subjective: Negative self-talk, low confidence, anxious

Patient C: Intersection of cognitive functioning and mood

Conclusions:

Self-report partially explained performance

Performed worse when “put on spot” or under pressure

Persistent negative self-talk and anxiety

Patient C: Treatment recommendations

Cognitive functioning: Cognitive rehabilitation

Mood/anxiety: Therapy and anti-anxiety medication

Employment: Rehabilitation counseling

Resources National MS Society flash drive includes publications for

clinicians and patients related to symptoms. (See: Difficult Topics booklets, which model conversations about challenging topics including cognition, sexual dysfunction, stress, family issues.)

UW MEDCON (WWAMI): 1-800-326-5300

For your Patients: MS Navigator Program 1-800-344-4867 (1-800 FIGHT MS)

Dr. John Jefferson Case 24 yo female Viral URI 2 months prior LBP 3 weeks prior RLE weakness/numbness 1 week prior – spread to BLE Urinary retention

On exam – BLE 0/5 strength, T5 sensory level UE hyperreflexia/Hoffman’s, LE hyporeflexic

12/2014 – STIR Sag Pre-gad

Extensive cord lesion, C5-6 through T4

12/2014 - FLAIR T1 Sag Post-gad

Questionable enhancement

12/2014 – FLAIR T2 Axial

“abnormal diffuse demyelination both cerebral hemispheres”

12/2014 – FLAIR T2 Sagittal

Jefferson Case (cont.) CSF 800 WBC (78% lymph), 59 RBC, pro – 147, glu – 54, negative ACE, IgG index/OCB, crypto Ag/HSV PCR/VZV

PCR/EBV PCR/CMV PCR, cytology, cultures, NMO Ab

Serology CMP, CBC, CK, CRP, TSH, B12, MMA, ANA,

Cryptococcal Ag, Copper, HIV, SPEP, NMO Ab (x2), blood cultures

Jefferson Case (cont.) Repeat CSF 10 d later – 53 WBC (94% lymph), 0 RBC,

pro – 40, glu – 49, neg IgG index/OCB, neg viral studies

IV solumedrol x 5 d – 1-3/5 strength LLE, 0/5 RLE, hyperreflexic, sensory at T8

Imaging unchanged

Jefferson Case (cont.) Plasmapharesis (PLEX) q OD x 5 (over 10 d)

Exam 1 month later – walking with front wheeled walker

Progress 3 weeks later – walking well with walker, residual subtle R foot drop

2/2015 – STIR Sag Pre-gad

“near complete interval resolution”

2/2015 – FLAIR T2 Axial

“Complete resolution”