Cognitive rehabilitation in MS

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1 14th MS Nurse International Workshop Lyon, France, October 9th 2012 Cognitive and psychological issues in MS Cognitive rehabilitation in MS Psychological Unit Neurological Department San Raffaele Hospital Milano Monica Falautano

2 What is Cognitive rehabilitation? Cognitive rehabilitation is a systematically applied set of therapeutic services designed to improve cognitive functioning and participation in activities that may be affected by difficulties in one or more cognitive domains Cognitive rehabilitation is often part of comprehensive interdisciplinary programs It s based upon sound scientific theoretical constructs Strategic approaches

3 Cognitive rehabilitation Beginning from the why Cerebral plasticity Tissue damaged by stroke Results in loss of motor function Alternative Pathway Other areas of the brain assume some function for the damaged area Neuroplasticity: The brain's ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment. A surprising consequence of neuroplasticity is that the brain activity associated with a given function can move to a different location as a consequence of normal experience or brain damage/recovery. Neuroplasticity challenges the idea that brain functions are fixed in certain locations

4 How? Theoretical models: Cognitive rehabilitation focused on improving a particular cognitive domain (Restoration): - attention - memory - executive functions used specific repetitive exercise aimed at improving performance of particular activity (Compensation): - using compensatory abilities - learning alternative strategies Accommodations: Changes in the shared environment of the individual which allow functioning in spite of disabilities

5 Why Cognitive rehabilitation Aims restore or improve damaged abilities allow functioning in spite of disabilities through specific tools and techniques and make changes in the shared environment To maximise patient participation in society To maximise patient well-being To facilitate acceptance and adjustment To minimise stress on & distress of relatives

6 How? Cognitive rehabilitation It s a part of a complex network of functional rehabilitation It s a stepwise PROCESS involving sequential and interdependent actions Assessment (observation/evaluation) Work planning Action Check

7 Cognitive rehabilitation process Speed of Processing Training Pretraining nps evaluat. Memory Training Immediate Post-Test 6/12 month Follow-up Attentive Training

8 Drugs Pharmacological therapies: Corticosteroids Immunomodulant therapies Immunosoppressive therapies Other symptomatic therapies Physical and cognitive fatigue Neuroimaging Lesions affecting strategic pathways/areas for cognition Involved of NAWM and NAGM Disconnection of associative area Cortical lesions

9 Disease s features and patient s status? Disease Neuroimaging Drugs Neurophysiopathology Damage course Age Subjects Sex Personality Cultural and social aspects Structurally identical systems may exhibit wildly different behavior M. Cini

10 How and when test the cognitive functions in MS? The premorbid subject s cognitive status (I.Q.) represents a fundamental step in the evaluation of the cognitive performance: therefore, is essential to use a specific tool which permits to quantify the cognitive reserve. The availability of an early cognitive assessment is without any doubt fundamental both to monitor the longitudinally cognitive changes of the patient and to choose the most suitable cognitive rehabilitation program. In the clinical practice, both the subject s psychological status and the damage status (remission/poussè) are milestones.

11

12 Results of O Brien, Chiaravalloti (2008) review A practical guide-line for the use of the Story Memory Technique (Chiaravalloti 2005) and a practical option for the self-generation effect (Chiaravalloti 2002; Basso 2006) can be suggested Results of Nocentini, Falautano, Grobberio, Di Vincenzo (2011) review Level B recommendation for memory deficits rehabilitation and for the meta-cognitive approach Results of Rosti-Otaljarvi and Hamalainen (2011) review Significant effects comparing cognitive training whith any other kind of intervention Results of Das Nair, Ferguson, Stark, Lincoln (2012) review Memory Rehabilitation for people with multiple sclerosis No significant effect of intervention was found, either immediately or longterm, on subjective reports of memory problems respectively

13 The nurse s contribution 1) In the stage of cognitive impairment identification: During diagnostic or rehabilitative hospitalization, the nurse can take behavioral expressions, attentive and understanding difficulty that might be a symptom of cognitive impairment 2) In the monitoring cognitive functions: During rehabilitative hospitalization, the nurse can observe, ecologically, the possible changes in the patient s cognitive functions, considering the relationship and the patient s capacity to attend or collaborate in the care activity

14 Cognitive rehabilitation Take home message Importance of the cognitive assessment neuroplasticity Restoring Compensatory Accommodatory Before and after cognitive rehabilitation Importance of the contest MS patients Disease Neuroimaging Neurophisiopatology Drugs Damage course Subjects Age Sex Personality Improve the studies about the efficacy Importance of interdisciplinarity Cultural and social aspects

15 Future directions 1. An important point is the possibility to combine the pharmacological treatment and the cognitive rehabilitative training 2. To define a precise cognitive outcome measures, training tools and training procedures 3. To start study on more homogeneous patient groups 4. Use fmri as a tool for monitoring cognitive treatment effect 5. Designed studies to identify subjects at risk and seeking interventions which may build one s cognitive reserve, or otherwise prevent cognitive decline, may be a particularly fruitful area of future research.

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