Participants:

Brian Apatoff, MD, PhD,
New York Hospital - Weill Cornell Medical College
Steven Galetta, MD,
Professor of Neurology, University of Pennsylvania School of Medicine
J. Phillips, Jr., MD, PhD,
Multiple Sclerosis Center at Texas Neurology, Baylor University Medical Center
David Thomas, ,
Fox News Channel

Medically Reviewed On: Wednesday, January 04, 2006

Webcast Transcript:

Recorded Live:Monday, September 18, 2000

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DAVID FOLK THOMAS: Hello and welcome to our webcast. I'm David Folk Thomas. For the 2.5 million people worldwide who have multiple sclerosis, the main concerns are strictly physical. During a relapse, a patient's ability to control his or her body can be seriously diminished, and treatment for MS is focused around preventing and managing these attacks. But the disease can also have a mental dimension, affecting patients' cognitive functions, like memory or the ability to complete complex tasks. Not everyone with MS will experience cognitive impairment, and for those who do, the effects are usually very subtle and perhaps caused by depression rather than the disease itself. But it is an issue of concern for many patients, and today it will be our concern as I discuss cognitive impairment from MS with a panel of experts.

Those experts are sitting to my left, starting with Dr. Brian Apatoff. He's the director of the MS Clinical Care and Research Center at New York Hospital, Weill Cornell Medical College. Sitting next to Brian is Dr. Ted Phillips. He's the director of the MS Center at Texas Neurology and Baylor University Medical Center in Dallas. On the end is Dr. Steven Galetta. He's the director of the neuroophthalmology service at the University of Pennsylvania School of Medicine in Philadelphia. Doctors -- I always like saying that -- Doctors, thank you for joining me here today.

Dr. Apatoff, what do we mean when we say "cognitive impairment"?

BRIAN APATOFF, MD: Cognitive impairment is really a very general term to describe some subtle -- and sometimes not-so-subtle -- changes in higher cortical functioning, intellectual functioning that most of us take for granted in our day-to-day activities -- things like memory, things like terms that describe executive function, our ability to take care of five different things at one time. These are controlled by the complex integration of different regions of the brain, and if you have multifocal brain injury, as can occur in multiple sclerosis, you can have some impairment of these cognitive functions.

DAVID FOLK THOMAS: Dr. Phillips, explain how somebody with MS might be cognitively impaired. What effect MS has on that.

TED PHILLIPS, MD: As Brian mentioned, sometimes it can be of a very subtle nature and actually require specialized neuropsychological testing to be able to detect it. But a patient with MS reporting those kinds of problems might say something like they're having difficulty concentrating on the work at hand or keeping track of more than one thing. Although one has to be careful to distinguish between cognitive impairment that might be MS-related versus a particularly or overly stressful life or even, as you mentioned earlier, the possibility of co-existing depression.

DAVID FOLK THOMAS: Dr. Galetta, how many MS patients, what percentage suffer cognitive impairment?

STEVEN GALETTA, MD: David, this is a big problem, and it's been under-recognized to date. It's only recently, with the various extensive testing that Ted has mentioned, that we've come to realize that this may affect about 50 percent of the MS population. In fact, as Ted has mentioned, it has a profound effect on the social and occupational function of that patient so that relationships may be broken because of this cognitive impairment. Their ability to work may also be impaired by this cognitive dysfunction, and certainly this has become a forefront issue in MS today.

DAVID FOLK THOMAS: Now, were does the cognitive part, does it come after the initial or is it simultaneously?

STEVEN GALETTA, MD: It could be the first presentation of multiple sclerosis. Again, as Ted suggested, some of it may be subtle and even unrecognized by the patient. But some of their friends or their significant others may bring it to the attention of the patient or the doctor or, in retrospect, it may come out that they've been having some problems with their thinking that actually preceded the weakness or visual loss that may also complicate multiple sclerosis.

DAVID FOLK THOMAS: Dr. Apatoff, if somebody out there who has not been diagnosed with MS, but what if their primary symptom was the cognitive part, what could be an example of -- paint a picture of what they could be doing. Would they be having trouble adding? What's going on?

BRIAN APATOFF, MD: It's usually, in early manifestations, something that relates to very complex or highly integrated cognitive functions. For example, the ability to talk on the phone, work on your computer, get paged at the same time, keep track of several other ongoing issues all simultaneously. These are things that many of us take for granted but really require a very high level of complex brain function to perform effectively.

DAVID FOLK THOMAS: Sort of like a slight chink in the armor would be enough in the complex thought process.

BRIAN APATOFF, MD: Exactly. So if you have somebody that's a high functioning attorney or someone that works on Wall Street as an investment banker and they're used to looking at seven different television screens at the same time, they may just note some subtle inability to attend to all these details at the same time. I think it may be less obvious to someone who works in other types of occupations. If you're working in sanitation and you're not intellectually taxing yourself, these sorts of cognitive disabilities will not be as apparent. So often it's professionals that might come to a doctor early on saying, "I've noticed that I'm not quite as sharp."

DAVID FOLK THOMAS: People used to multi-tasking a lot of different things. Ted, let me ask you about somebody who has MS, and then they may be experiencing cognitive impairment. But as I mentioned in the introduction, it wouldn't necessarily be related to the MS. It could be depression or other things. Can you explain how that might work?

TED PHILLIPS, MD: Perhaps one of the more common causes, among otherwise healthy people, of inattention or difficulty concentrating or recent memory problems lots of times boils down to excessive stress in a person's life or even evidence of early depression. I guess the point is that although cognitive impairment can and does occur in, as Steve mentioned, a fairly high percentage of MS patients, one doesn't want to jump prematurely to the conclusion, especially if you are somebody with MS, that "Oh my gosh, I may have cognitive manifestations of this disease if I'm having difficulty doing these things," because the good news may be that it is evidence instead of depression, which has its own set of effective treatments. So it can be difficult sometimes to distinguish without the use of very specific, sophisticated testing.

DAVID FOLK THOMAS: Steven, do want to add something?

STEVEN GALETTA, MD: I agree with Ted. I think that it's extremely important to try to separate out depression from these cognitive problems that may complicate MS because the treatment could be different. Sometimes the depression can masquerade as thinking problems. So this battery of elaborate tests are often very helpful. For instance, in depression it's common to have problems with sleep. You sleep too much or don't get enough sleep, or your appetite --

DAVID FOLK THOMAS: So you're not thinking right --

STEVEN GALETTA, MD: So you have a lot of these what we call "constitutional symptoms" that go beyond the mere thinking problem that suggests depression. This battery of tests that Ted has been talking about is helpful in trying to separate out this very important differential between the cognitive problem and the depression, because they're treated pretty differently.

DAVID FOLK THOMAS: If you have a patient who has been diagnosed with MS but has not had any cognitive impairment, but they notice that they think something is wrong, what to do you recommend for them? What should they do next?

STEVEN GALETTA, MD: I think that obviously they need to discuss it with their doctor, and often I would like to get that formal neuropsychological testing to get an idea, at least, at the baseline what we're talking about here, to make sure that we, in fact, have cognitive dysfunction. Listen, we all forget things. I think Ted's point is well taken. You forget a name, you're not automatically going to say, "Hey, I have multiple sclerosis or this is my multiple sclerosis," because it happens to all of us. It's when it affects your ability to function socially or in your job on a consistent basis that you become aware that this may be an issue.

I think that the helpful point is that, again, the management of these conditions can be different. For instance, if you realize that you have cognitive dysfunction, it's very important to be on one of these agents. Avonex has been demonstrated, for instance, to have lessened the cognitive disability that may complicate MS. On the other hand, if you're depressed, you may be better off an antidepressant medication.

DAVID FOLK THOMAS: Steven just mentioned, Brian, about the drug treatments. What are the real treatments for the cognitive impairment of MS? And we're running out of time, so if we can --

BRIAN APATOFF, MD: Absolutely. I think controlling the underlying disease process that's contributing to that cognitive dysfunction, getting MS under control will be the best treatment for the cognitive dysfunction. There are some other sorts of experimental treatments that are under investigation. But for right now it's mainly treating the MS, excluding other factors like depression and medication side effects that might also be related to memory problems or cognitive dysfunction.

DAVID FOLK THOMAS: Is there research? And, again, we're running out of time. Ted, research that's being geared specifically to treating the cognitive impairment arm of the MS? It sounds like right now, what Brian said, that it's more like we're thinking that's a byproduct of the whole MS thing.

TED PHILLIPS, MD: I wouldn't call the cognitive issues in MS a byproduct of the disease. They're a very real part of the disease, but as Steve mentioned earlier, has traditionally been a very underrepresented facet of the disease in scholarly discussions. As our testing -- and therefore our ability to pick up cognitive impairment -- has improved, it has been increasingly recognized as a very important part of this disease, and as such a lot of relatively new research is underway looking at specific treatments that may be directed towards cognitive issues particularly.

DAVID FOLK THOMAS: All right, that's all the time we have for this webcast. We've been talking about cognitive impairment in MS. I'm David Folk Thomas. We'll see you next time.

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