Cognitive Screening Tools in MS for the General Practitioner

Although cognitive impairment occurs in more than half of patients with multiple sclerosis (MS), physicians may be unable to perceive changes in cognition without specific tests. Furthermore, there is considerable variation in the degree and type of cognitive impairment among patients with MS, which makes assessment challenging.

A recent review emphasized the importance of early detection of cognitive impairment, the role of the general practitioner (GP), and the advantages and limitations of the brief cognitive screening tools currently available for detection and monitoring. According to the authors, “The GP is the ideal health professional to oversee the screening, monitoring and coordination of care of patients with MS, so cognitive screening should be a routine activity for GPs caring for people with MS in their clinics.”

It is important to detect cognitive changes early because they can indicate the need for altering therapies or increasing services. For example, mild cognitive impairment is a sign of active or progressive disease. These patients should be sent to a neurologist for a workup and initiation of disease-modifying therapies immediately. Although these therapies can slow disease progression, studies have not shown evidence to date that disease-modifying therapies prevent or slow cognitive decline.

When mild-to-moderate cognitive impairment is detected, healthy lifestyle modifications may be helpful. Guidelines suggest that these patients should also be referred for a thorough neuropsychological assessment to identify the type of cognitive deficit. The neuropsychologist may refer the patient for cognitive rehabilitation, which has been shown to benefit patients with mild-to-moderate cognitive impairment.

If more severe cognitive impairment is detected, the GP may need to help patients and caregivers find appropriate dementia-specific support services and make financial arrangements.

The consensus in the MS field is that the Symbol Digit Modalities Test and the Brief International Cognitive Assessment for MS are the most useful screening tools available. The authors described these and 3 other frequently used screening tools and their advantages, limitations, and costs.

• The Symbol Digit Modalities Test takes 3 minutes and measures processing speed impairment, which is often affected in MS. The patient should be referred to a neurologist for further assessment if they show impairment. Other types of cognitive impairments will not be detected on this test.


• The Brief International Cognitive Assessment for MS screens for different types of cognitive impairments, but it should be given by someone with training in clinical psychology.


• Other frequently used tests are less sensitive to the cognitive impairments typically found in patients with MS and therefore were not recommended. These tests include the Montreal Cognitive Assessment, the Addenbrookes Cognitive Assessment-III, and the Mini-Mental State Examination.

The need for cognitive screening may be difficult for physicians to discuss with patients. The authors also provided recommendations for how physicians could broach the subject, including to fully inform patients about the risks and benefits of screening and to start with psychological screening tools that could detect barriers patients are already experiencing. These initial steps may help patients understand the potential usefulness of cognitive screening and provide baseline scores to refer to in the future. The authors provided details for 4 psychological screening tools, each of which takes 7 minutes or less to complete:

• Multiple Sclerosis Neuropsychological Questionnaire
• Depression, Anxiety and Stress Scale-21
• Beck Depression Inventory – Fast Screen
• Multiple Sclerosis Work Difficulties Questionnaire-23

The authors concluded, “screening is clinically useful at any stage in the trajectory of cognitive change to guide GPs’ care plans related to interventions aimed at preserving brain reserve; managing the impact of cognitive impairment on everyday functioning and quality of life; and accessing effective treatments, such as cognitive rehabilitation, and relevant support services.”

Source

Longley WA, Honan C. Cognitive impairment in multiple sclerosis: the role of the general practitioner in cognitive screening and care coordination. Aust J Gen Pract. 2022;51(4):225-231.