Improving Brain Fog in Those With MS

[MUSIC PLAYING] Welcome, everyone. I'm Dr. John Whyte, the Chief Medical Officer at WebMD. Today, I want to talk a little bit about relapsing multiple sclerosis, particularly about the loss of cognitive function in patients. What we see is that over 50% of patients with MS also suffer from depression, and that the combination of depression, anxiety can severely affect a patient's memory, as well as their reasoning and what we call their activities of daily living. Depression can also be associated with a significantly increased risk of relapse.

So to help provide some insight, I'm joined by two experts. Dr. Abbey Hughes is a rehabilitation psychologist and assistant professor of Physical Medicine and rehab at Johns Hopkins Medicine. And Dr. James Sumowski, he's an associate professor of neurology at the Icahn School of Medicine at Mount Sinai. Doctors, thanks for joining me.

Let's talk about how multiple sclerosis impacts cognitive function. this concept of brain fog. So is that a component of multiple sclerosis or is that something that occurs because of the depression, the anxiety, the challenges of dealing with MS? Just cause some issues in our brain and can impact how we're able to do our daily activities. What's the latest on that, Dr. Hughes?

Sure. So what we know is that from a neurologic standpoint, lesions in the brain and atrophy of the brain, which occurs in both relapsing MS and in the progressive forms of MS can perpetuate depression, and that brain fog, slowing of speed of processing is a function of depression, and it's also a function of the damage to the brain.

We also know that perception of cognition is something that's really important for patients. That oftentimes, when they're saying I don't feel-- I feel slowed down, I feel like my mind is not as clear as it used to be. Sometimes, that perception aligns well with objective cognitive tests and sometimes it does not. And some research that our group has done and other groups have done have looked at that discrepancy between our perceptions of cognition versus our performance on objective testing.

And we find that in the presence of depression, that discrepancy widens. So our ability to accurately assess our own cognition and perceive our cognition accurately is really affected in the presence of depression. We think that we're worse than we are.

So what does that mean? Tell our viewers, what's an example of that?

So feeling slowed down, finding difficulty with the word, finding, for example, or taking longer to find the word. A lot of times, people find, they describe it as a short term memory problem, that they feel like their memory is in decline. But what is often the case is it is a learning efficiency issue. Because if we think of our neurons as these electrical cords that are insulated just like an electrical cord here that I have, when the myelin starts to get stripped, that electrical signal gets slower, it gets disrupted, it gets a little garbled at times.

And sometimes, if that myelin is damaged so much, the connection is severed altogether. And the brain is constantly trying to repair itself and to build itself. When it's trying to repair, it sometimes will go around the damaged part. And it's like a construction detour. When we go around that damage, it takes longer for the signal to get where it needs to go. And so it might not be a memory issue, the information is getting in, but it's not getting in as quickly or as efficiently because of the rate that the information is coming in. And so that processing speed is really the primary issue that we've seen within MS and cognition.

And Dr. Sumowski, in patients that don't have MS, we talk about this concept of neuroplasticity. That we're to be able to make new connections, is that not as much in play here with patients with relapsing multiple sclerosis?

So I think that as-- it's interesting because we expect that in terms of neuroplasticity, and there are two ways to think about this, one is neurogenesis, which is new neurons that you can develop in certain areas like the hippocampus, which has been linked to mood, actually, in depression. That may be at play in multiple sclerosis in that--

Meaning they're not rebuilding as many ...

Well, inflammation, systemic inflammation has been associated with reduction in how many new neurons you develop. And there are at least correlational depression. What we see is that in terms of cognition, the type of cognition that seems most related to depression and MS is attention. But really not just any attention, it's sort of your ability to inhibit distractions.

And so it's not something we measure a lot in people with MS. So usually we have batteries that people developed, and the reason they developed them is because they wanted psychologists, neuro-psychologists to be able to measure cognition quickly and uniformly across centers. And executive functioning, in terms of controlling your own thoughts and inhibition, is something that we don't evaluate very much.

What we find is that that is the most related to depression, and you can imagine how this relates to the symptoms that patients report when they're depressed. So for instance, having a thought stuck in their head and not being able to stop it, it's cycling around in the background. And the reason is they're unable to inhibit it. One of the major issues is that lots of times, there is this discrepancy between what patients report and their objective cognitive functioning. And what we find is that the reason for this is likely because things like controlling your own thoughts and inhibiting distractions are actually more important in real life.

Dr. Hughes, how do we reduce these changes in cognitive function?

So there's a few approaches. If someone is elevated on levels of depression or anxiety, there's been multiple studies that show that treating depression and treating anxiety results in both objective and perceived improvements in cognitive function. So we're tackling it from the perspective of, we know that depression, anxiety have these effects on cognition and we want to treat it at that level of that etiology.

We can also see that cognitive rehabilitation strategies are also helpful for specific types of cognitive processes. There's attention training, there's memory training. And depending on the individual patient, trying to discern what is their area of weakness, what are their areas of strengths, and this is where the rehabilitation comes into play. let's leverage someone's strengths, figure out how those work in their actual environment, not when they're in the office, in a distraction-free space and using those strategies in their workplace.

When they are a teacher surrounded by lots of noise, and smells, and things that could be distracting, how can they focus their attention and learn those skills to develop that, so that it's creating less of an impairment or less of a disruption in their functioning in daily life?

Dr. Sumowski, what does the future hold in addressing issues in anxiety, depression, cognitive dysfunction in patients with relapsing MS?

So I think the first step, and this is a hugely important step, is people in the community and in the field have to be paying attention. So we're there, I think, where people are actually measuring these things because we weren't there several years ago. So now, we're at a place where we're having this conversation, because it is in everyone's awareness now that mood and cognition are an issue.

And I think that there are two main contributors that we need to think about. One is preventing disease progression as Dr. Hughes says with disease modifying therapies. But also there are factors like depression and sleep disturbance which is prevalent forms that are affecting cognition. And I think that what we're finding is that the best treatments for both depression and cognition may actually not be outside of teaching people strategies, which is hugely important.

But teaching people strategies is actually, it's not improving the biological basis of their cognition, it's giving them tools to sort of workarounds that lower the negative impact of their cognitive issues on everyday life. That's what we want anyway, we want people to function better in the world.

We don't care how they function in our labs, we want them to function better in the world. The other piece is inflammation, systemic inflammation that may have a worse impact on MS related to things like obesity, diet, exercise, sleep. And that's the one thing we're focusing on is improving diet is a huge one and improving sleep.

Well, doctors, I want to thank you both for addressing the role of anxiety, depression, and change in cognitive function in patients with multiple sclerosis, particularly relapsing multiple sclerosis.

Thank you very much.

If you have questions for us, drop us a line. You can email me at [email protected].

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