Cognitive assessment of Brazilian patients with multiple sclerosis: weighing the impact of disability and depressive symptoms

Andrade, Patricia Semionato; Cerqueira, Ana Cláudia Rodrigues de; Colodetti, Ana Carolina; Schmidt, Felipe da Rocha; Barreiros, José Maurício Godoy; Teixeira, Antônio Lúcio; Souza, Leonardo Cruz de

doi:10.1590/1980-5764-DN-2021-0050

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Brasil

Dementia & Neuropsychologia

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Original Article • Dement. neuropsychol. 16 (3) • jul-sep 2022 • https://doi.org/10.1590/1980-5764-DN-2021-0050 copy

Cognitive assessment of Brazilian patients with multiple sclerosis: weighing the impact of disability and depressive symptoms

Avaliação cognitiva de pacientes brasileiros com esclerose múltipla: análise do impacto da incapacidade e dos sintomas depressivos

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Multiple sclerosis (MS) is the most common demyelinating disease of the central nervous system. Cognition is not routinely assessed in patients with MS though they frequently have cognitive complaints or dysfunction.

Objective:

The aim of this study was to compare the cognitive status of patients with MS with age, sex, and schooling matched controls and to evaluate the potential influence of clinical parameters on cognition.

Methods:

A total of 35 patients with MS (mean±SD age 37.9 years±11.44, M/F: 12/23) and 33 healthy controls (mean±SD age 38.8 years±12.6, M/F: 12/21) were enrolled in this study. All subjects underwent a structured clinical assessment and the cognitive tools are as follows: Paced Auditory Serial Addition Test (PASAT), Symbol Digit Modalities Test (SDMT), Rey Auditory Verbal Learning Test (RAVLT), Digit Span, and Verbal Fluency Tests (letters F, A, and S and animal category). Psychopathology was assessed with the Mini International Neuropsychiatric Interview and the Beck Depression Inventory (BDI). The Expanded Disability Status Scale (EDSS) was used for patients.

Results:

Patients performed worse than controls in almost all tests, with approximately 70% of patients presenting cognitive impairment. The most affected cognitive domain was episodic memory (45.7%), followed by verbal fluency (42.8%) and information processing speed (22.8%). SDMT was inversely correlated with disease severity, as assessed by the EDSS. Depression did not influence cognitive performance in this cohort.

Conclusions:

Cognitive dysfunction is common among patients with MS. While motor impairment was associated with information processing speed, depression did not influence cognitive performance.

Keywords:
Multiple Sclerosis; Neuropsychological Tests; Cognition; Depression; Memory

			Controls (n=33)	Patients (n=35)	p-value
	Age (years)	Mean±SD	38.82±12.6	37.91±11.44	0.94^* * Mann-Whitney;
		(min–max)	(21–63)	(18–61)
		Median [IQR]	36 [27.5–50.5]	33 [28–49]
	Education (years)	Mean±SD	12.7±2.7	11.6±2.4	0.06^* * Mann-Whitney;
		(min–max)	(5–15)	(5–15)
		Median [IQR]	14 [11–15]	11 [11–12]
Sex (%)		Female	63.6%	65.7	0.85^ χ2; EDSS: Expanded Disability Status Scale; BDI: Beck Depression Inventory; MINI: Mini International Neuropsychiatric Interview; min: minimum value; max: maximum value; n: sample size; NA: not applicable; p: level of confidence. Significant values (p<0.05) in bold.
	EDSS	Mean±SD	NA	2.7±1.9	NA
		(min–max)		(0–6.5)
		Median [IQR]		2.5 [1–4.5]
	MS first symptoms (years)	Mean±SD	NA	29.7±10.3	NA
		(min–max)		(13–60)
		Median [IQR]		27 [24–37]
	Disease duration (years)	Mean±SD	NA	8.2±5.3	NA
		(min–max)		(1–22)
		Median [IQR]		8 [3–12]
	Medication (%)	Interferon-β	NA	57.1	NA
		Glatiramer		22.9
		Fingolimode		2.9
		Natalizumab		2.9
		Azathioprine		2.9
		No medication		11.4
Depression (MINI) (%)		Depression	0	28.6	0.001 ^ χ2; EDSS: Expanded Disability Status Scale; BDI: Beck Depression Inventory; MINI: Mini International Neuropsychiatric Interview; min: minimum value; max: maximum value; n: sample size; NA: not applicable; p: level of confidence. Significant values (p<0.05) in bold.
	BDI	Mean±SD	8±5.6	11.8±9.2	0.10^* * Mann-Whitney;
		(min–max)	(0–28)	(0–39)
		Median [IQR]	7 [6–11]	10 [6–16]

Test		Controls (n=33)	Patients (n=35)	p-value
PASAT	Mean±SD	39.6±13.3	31.4±12.1	0.008
	(min–max)	(11–60)	(6–54)
	Median [IQR]	41 [29.5–49.5]	30 [21–41]
SDMT	Mean±SD	56.3±13.5	45±16	0.003
	(min–max)	(17–80)	(17–73)
	Median [IQR]	55 [46–67]	43 [33–57]
Direct SPAN	Mean±SD	8.1±2.7	8.2±2.3	0.69
	(min–max)	(4–14)	(4–14)
	Median [IQR]	7 [6–10]	8 [6–10]
Inverse SPAN	Mean±SD	5.4±2.9	5.1±2.1	0.30
	(min–max)	(3–11)	(0–9)
	Median [IQR]	4 [4–5]	5 [4–6]
Fluency (F)	Mean±SD	14.9±4.2	11.9±5	0.007
	(min–max)	(5–26)	(4–24)
	Median [IQR]	15 [12.5–18]	11 [7–16]
Fluency (A)	Mean±SD	13.1±4.2	10.7±4.5	0.015
	(min–max)	(3–22)	(3–21)
	Median [IQR]	14 [10.5–16]	10 [8–14]
Fluency (S)	Mean±SD	12.8±4.2	10.6±4.1	0.03
	(min–max)	(3–19)	(3–19)
	Median [IQR]	13 [10–16]	11 [7–14]
Total FAS	Mean±SD	40.8±11.1	33.2±11.6	0.008
	(min–max)	(13–63)	(15–61)
	Median [IQR]	41 [35.5–48]	33 [24–42]
Animals fluency	Mean±SD	21.9±5.9	17±4.3	0.001
	(min–max)	(12–35)	(9–28)
	Median [IQR]	21 [17.5–26.5]	17 [14–20]
RALVT – A1	Mean±SD	6.2±1.9	5.4±1.5	0.72
	(min–max)	(1–10)	(2–8)
	Median [IQR]	6 [5–7.5]	6 [4–7]
RALVT – A2	Mean±SD	9.7±2	7.9±1.9	0.001
	(min–max)	(5–13)	(4–12)
	Median [IQR]	10 [8–11]	8 [7–9]
RALVT – A3	Mean±SD	11.2±1.9	9.4±2.2	0.003
	(min–max)	(8–14)	(4–13)
	Median [IQR]	11 [10–13]	10 [8–11]
RALVT – A4	Mean±SD	12.2±1.6	10.1±2.3	0.000
	(min–max)	(9–15)	(6–15)
	Median [IQR]	12 [11–13.5]	10 [9–12]
RALVT – A5	Mean±SD	12.7±1.8	11±2.5	0.004
	(min–max)	(10–15)	(6–15)
	Median [IQR]	13 [11–14.5]	11 [9–13]
Total A1–A5	Mean±SD	52.2±7.4	44±9.1	0.000
	(min–max)	(40–65)	(25–62)
	Median [IQR]	53 [45–59]	43 [39–49]
RALVT – B1 (interference)	Mean±SD	5.9±2.2	5.1±1.6	0.20
	(min–max)	(3–12)	(1–8)
	Median [IQR]	6 [4–7]	5 [4–6]
RALVT – A6	Mean±SD	10.6±2.5	8.4±3.4	0.007
	(min–max)	(6–15)	(1–15)
	Median [IQR]	10 [8–12.5]	8 [7–11]
RALVT – A7 (late recall)	Mean±SD	10.8±2.7	7.6±3.4	0.000
	(min–max)	(6–15)	(1–14)
	Median [IQR]	11 [9–13]	8 [5–10]
RALVT (recognition)	Mean±SD	28.7±1.5	28.3±4	0.018
	(min–max)	(24–30)	(7–30)
	Median [IQR]	29 [28.5–30]	28 [27–30]

		Preserved cognition (n=11, 31.4%)	Impaired cognition (n=24, 68.6%)	p-value
Age (years)	Mean±SD	36±11	38.7±11.7	0.70^* * Mann-Whitney;
Age (years)	Median [IQR]	33 [28–47]	34.5 [28–49.7]	0.70^* * Mann-Whitney;
Education (years)	Mean±SD	11.4±1.2	11.6±2.8	0.40^* * Mann-Whitney;
Education (years)	Median [IQR]	11 [11–12]	11.5 [11–15]	0.40^* * Mann-Whitney;
EDSS	Mean±SD	2.9±2	2.7±1.9	0.84^* * Mann-Whitney;
EDSS	Median [IQR]	2.5 [1–5]	2.2 [1–3.8]	0.84^* * Mann-Whitney;
Disease duration (years)	Mean±SD	7.,1±4.9	8.6±5.4	0.50^* * Mann-Whitney;
Disease duration (years)	Median [IQR]	6 [2–13]	8.5 [3.2–11.7]	0.50^* * Mann-Whitney;
Depression (MINI) (%)	n – %	2 – 18%	8 – 33%	0.35^ χ2; EDSS: Expanded Disability Status Scale; MINI: Mini International Neuropsychiatric Interview; BDI: Beck Depression Inventory; n: sample size; p: level of confidence.
BDI	Mean±SD	12.2±8.8	11.6±9.8	0.64^* * Mann-Whitney;
BDI	Median [IQR]	10 [6–15]	9 [4–16.7]	0.64^* * Mann-Whitney;
Sex (%)	Female	8–35%	15–65%	0.55^ χ2; EDSS: Expanded Disability Status Scale; MINI: Mini International Neuropsychiatric Interview; BDI: Beck Depression Inventory; n: sample size; p: level of confidence.
Sex (%)	Male	3–25%	9–75%
Medication (%)	Interferon-β	46%	63%	0.51^ χ2; EDSS: Expanded Disability Status Scale; MINI: Mini International Neuropsychiatric Interview; BDI: Beck Depression Inventory; n: sample size; p: level of confidence.
	Glatiramer	27%	21%
	Fingolimode	9%	0%
	Natalizumab	0%	4%
	Azathioprine	0%	4%
	No medication	18%	8%

Academia Brasileira de Neurologia, Departamento de Neurologia Cognitiva e Envelhecimento R. Vergueiro, 1353 sl.1404 - Ed. Top Towers Offices, Torre Norte, São Paulo, SP, Brazil, CEP 04101-000, Tel.: +55 11 5084-9463 | +55 11 5083-3876 - São Paulo - SP - Brazil
E-mail: revistadementia@abneuro.org.br | demneuropsy@uol.com.br

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[1] Correspondence: Leonardo Cruz de Souza; Email: leocruzsouza@hotmail.com.