Question
What are the cognitive impairments seen in those with multiple sclerosis? How can we intervene?
Answer
Patients with MS have been shown to have difficulty processing verbal instructions and making decisions during novel or risky and ambiguous situations (DeLuca, Barbieri-Berger, & Johnson,1994; Neuhaus, Calabrese, & Annoni, 2018). Education should be delivered in small and short segments with increased time to process. We should back up verbal information with written and visual material including videos and demonstrations. Patients should also be encouraged to trial new strategies immediately followed by a discussion of how well each strategy or technique worked. This goes for self-care techniques, transfer techniques, use of adaptive equipment, assistive equipment, energy conservation strategies, mental imagery, and rehearsing strategies. Learning and incorporating new and novel tasks into a daily routine can be difficult for patients with MS. Many patients with MS are prone to depression and have difficulty regulating their emotions. If you think back to the pathophysiology of the disease, remember that demyelination results in a deterioration of nerve signals and impulses ascending the spinal cord through the thalamus and to the areas of the brain responsible for processing and interpreting that information. When you think about that, this alone would lead to deregulated emotions and a depressive state of the central nervous system which would affect thought, behavior, and ability to adapt to occupational challenges. The slowing down of the nerve impulses because of this demyelination is going to affect the brain's ability to function as one unit.
In addition, goal discrepancy and loss of function will contribute to negative thoughts leading to depressive rumination (Watkins & Noelen-Hoeksema, 2014). Remember, there is a loss associated with this disease and a discrepancy in what the patient wishes they were able to do or wants to be able to do and what they are capable of. When you start to lose your ability to participate and perform day-to-day activities, you also lose your identity. This is how we all define who we are in social situations or what we talk about with people. What do you do for a living? What is it that you like to do? This loss of identity affects a person's emotional state leading to depressive symptoms. This then alters their decision-making, their ability to process information, and their ability to learn from past experiences to adapt. All of this can lead to anxiety, sadness, anger, and pessimism. When you meet your client with MS for the first time, do not think, "They are not motivated," or "They do not want to listen to anything I have to tell them." This is part of the disease process. We have to utilize a more therapeutic approach to engage clients to help them to identify strategies that are going to work for them.
Occupational therapy theory can guide us in our interventions for patients with MS. The Cognitive Orientation to Daily Occupational Performance, or CO-OP, is a client-centered, performance-based, problem-solving approach that uses guided discovery to enable the acquisition of skills to overcome occupational challenges and impairments. The CO-OP approach encourages individuals to identify solutions to motor problems to improve occupational performance. CO-OP improves motor acquisition, cognitive awareness, or metacognition, and skill generation so that they can be transferred to multiple situations. The therapist acts like a coach in this process whereby he or she guides the patient through the global strategy of the process, "goal-plan-do-check." You are saying to the patient, "What do you want to do? How do you want to do it? Let's try it and then let's review how it went."
In other words, you are developing goals, planning strategies to achieve the goals, implementing the strategies, and evaluating and re-evaluating the effectiveness. This sounds rather simple when you boil it down like that, but there is a method to all of this. It provides a platform for you to engage the client in the repetition of the activity so that you could find where the breakdowns are happening. As they do it more, they become more aware as to where the breakdowns are happening, and then together you can strategize activity modifications, adaptive equipment, or energy conservation techniques to improve performance. It may be a new way of doing the activity or a new thought process that helps the patient realize they have to remember a certain step as an example.
With any program, you are going to start off with an assessment. The Canadian Occupational Performance Measure (COPM) is a good assessment that you can use in the CO-OP strategy. The COPM is a semi-structured interview that helps patients identify meaningful daily activities across multiple performance domains that the patient wants to do, needs to do or is expected to do. The performance domains include self-care, productivity which would include paid work and housework, and also leisure activities. The patient then chooses the five most important activities across those performance domains and rates their performance and satisfaction each on a 10 point scale. Ten is the highest performance and satisfaction and zero is the least. The COPM provides a platform in which to develop patient-centered meaningful goals with the patient's input.
