Neurocognitive Manifestations in ME/CFS

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Neurocognitive Manifestations in ME/CFS

• Gudrun Lange, PhD
• Professor
• Department of Physical Medicine and
  Rehabilitation, Rutgers-NJMS

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Outline

• Why is it important to talk about cognitive
  function in ME/CFS?
• What is the clinical presentation?
• How can cognitive dysfunction in ME/CFS be
  understood?
• What is an effective neuropsychological battery?
• What is the research evidence?
• Final thoughts

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Brainfog Common and Disabling

• Experienced as difficulties with attention,
  concentration and multi-tasking
• Recognized as important Listed as symptom in all
  ME/CFS case definitions
• Serves as objective criterion for disability
  lack of validated physiological markers

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Clinical Presentations

• I feel like Im loosing my mind
• I feel like having the brain of an 80-year old
  in the body of a 36-year old
• I feel stupid

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Conceptualization of Cognitive Dysfunction

• Possible etiology of cognitive dysfunction
• Genetic
• Acquired
• Severity of cognitive dysfunction
• Severe
• Moderate
• Mild

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Determination of Severity of Cognitive Dysfunction

• Subjective
• Patient and family report
• Perception of degree of loss of cognitive
  function
• Objective
• Neuropsychological evaluation
• Statistical determination of degree of loss of
  cognitive function
• Behavioral observations during testing should be
  taken into consideration

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An effective neuropsychological battery for
ME/CFS patients

• Has to include standardized and normed measures
  that
• Sufficiently and repeatedly challenge complex
  information processing and multi-tasking
• reliably demonstrate areas of cognitive
  resilience
• assess mood and anxiety
• ascertain adequate effort

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Intellectual profiles in ME/CFS

• WAIS-IV profile Scores discrepant from expected
  levels
• Case 1 Case 2

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Case 1
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Case 2
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• Wisconsin Card Sorting Test (WCST)
• ? California Verbal Learning Test II (CVLT-II)
• ? Wechsler Memory Scale - Fourth Edition (WMS-IV)
• ? Boston Naming Test (BNT)
• ?Rey Osterrieth Complex Figure (ROCF)
• ? Judgment of Line Orientation Test (JOL)
• ? Hooper Visual Organization Test
• ? Hand Dynamometer
• ? Grooved Pegboard
• ? Finger Tapping Test (FTT)
• ? Validity Indicator Profile (VIP)

• Clinical Interview
• ? Wechsler Adult Intelligence Scale - Fourth
  Edition (WAIS-IV)
• ?Test of Premorbid Functioning (TOPF)
• Beck Depression Inventory II (BDI II)
• ? Spielberger State Trait Anxiety Questionnaire
  (STAI)
• ? Gordon Diagnostic Test
• ? Stroop Test
• ? DKEFS
• Trails
• Verbal Fluency Test
• Paced Auditory Serial Attention Test (PASAT)
• ?

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Findings on neuropsychological exam

• Decreased attention, concentration and slowed
  processing speed
• Problems sequencing pieces of information and
  prioritizing their use for quick decision making
• Limited working memory,
• less information available online
• Learning difficulties
• Changes in learning strategy
• Poor absorption and recall

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Neuropsychological Profile in ME/CFS

• Profile suggests mild, subtle deficits
• Evaluation of impairment relative to expected
  level of intellectual function necessary to
  uncover true deficiencies
• Profile not consistent with dementia
• Generally no frank memory problem
• Profile can be differentiated from conditions of
  a more focal nature

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Brain Abnormalities in ME/CFS

• Lange et al., 2005
• Used verbal working memory task to
• probe brain function using fMRI
• simultaneously assessing efficient information
  processing behaviorally
• Statistically controlled for age, mood, anxiety,
  self-reported mental fatigue score
• Equated on prior behavioral test performance on
  same task

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Brain Abnormalities in ME/CFS

• Controls versus ME/CFS
• No differences in brain activity during simple
  condition
• When task demands get more complex, ME/CFS
  increased involvement of
• Anterior Cingulate BA 24/32
• Left DLF BA 10/44/45/47
• Bilateral supplemental and premotor BA6/8
• Parietal regions BA 7/40

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Brain Abnormalities in ME/CFS
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Brain Abnormalities in ME/CFS

• Increased signal change was significantly
  accounted for by ME/CFS report of mental fatigue
• Perceived mental fatigue is reflected by
  increased functional recruitment of
• Left superior parietal region (BA7)
• Responsible for shifts in attention
• Bilateral supplementary and premotor regions
  (BA6/8)
• Associated with automatic information processing
• maintenance of temporal order

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Brain Abnormalities in ME/CFS

• No lack of effort accounted for the differences
  in signal change
• To achieve behavioral performance similar to
  Controls
• Brains of ME/CFS work harder when tasks are
  complex
• Require efficient and quick information
  processing
• Require effective online sequencing and
  prioritization

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Consequences of cognitive dysfunction in ME/CFS

• Automaticity of cognitive function is often lost
• Mundane tasks become effortful
• Multi-tasking often impossible
• Considered by patients as affecting every aspect
  of their lives
• Mental exertion can last for a long time

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Is there an effective cognitive screen for ME/CFS
patients?

• Dementia screens and typical brief bedside memory
  tests are not appropriate
• i.e. MMSE, Mini-Cog
• Suggestions
• Serial 7s, Digit Span Sequencing
• May work if done for at least a few minutes
• Quickly give a 6-or-7 step set of complex driving
  directions and request repetition

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Final thoughts

• If evaluation of cognitive function is needed
• Refer to Clinical Neuropsychologist knowledgeable
  about ME/CFS
• Much more work is needed to familiarize
  Neuropsychologists with ME/CFS to provide valid
  and reliable neuropsychological assessments.

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