Wednesday, 7 November 2012

Research: cognitive impairment and unemployment

Epub: Ruet et al. Cognitive impairment, health-related quality of life and vocational status at early stages of multiple sclerosis: a 7-year longitudinal study. J Neurol. 2012 Oct.

Background: The association between cognitive impairment, health-related quality of life (HRQoL) and vocational status has been studied in recent years in cross-sectional studies in MS, but longitudinal data are still lacking.

Objective: To assesses cognitive impairment in MSers followed longitudinally.


Method: This study assesses this association in a sample of 65 newly diagnosed MSers followed longitudinally. Each MSers underwent a standardised clinical assessment, cognitive tests and the HRQoL SEP-59 questionnaire six months after the MS diagnosis (baseline) and seven years later (y7).Vocational status was also established at baseline and at year 7.

Results: The HRQoL at baseline was severely reduced in MSers compared with healthy subjects. The independent predictors for HRQoL composite scores at year 7 were the baseline depression score and the memory Z-score. Accordingly, 81.5 % of MSers worked at baseline and only 54.4 % worked at year 7. Among the MSers who did not work at year 7, 72.7 % of them were cognitively impaired, while 27.3 % were unimpaired at baseline. The vocational status at year 7 was significantly associated with the baseline IPS Z-score, EDSS and age.

Conclusions: Vocational status at year 7 and its change over 7 years was significantly associated with cognitive deterioration. IPS or memory dysfunction in the early stages of MS is correlated with a decreased level in health perception, independent of fatigue, depression and physical disability. Cognitive impairment at the diagnosis of MS increases the risk of changing vocational status in MSers seven years later.




"For those of you who don't like bad news this study is just that. MS is a bad disease and leads to cognitive impairment that correlates with unemployment. The fact that almost 50% of this study population were unemployed at 7-8 years after diagnosis is in line with other studies. It is also not surprising that cognitive impairment correlates with depression and physical disability."

"How do we treat cognitive impairment in MS? We don't have any medication for this problem, i.e. no pills to pop, all we have at our disposal is behavioural therapy. In short behavioural therapy teaches you how to cope with your cognitive problems."

"On a more positive note there is some emerging evidence that DMTs may delay the development of cognitive impairment. We are also hoping that the newer agents that slow the rate of brain atrophy will do the same. My stance on this problem is as always, prevention is better than cure!"

"Big Pharma, potentially, have the drugs to help MSers with cognitive problems. Several of them are currently exploring the possibility of doing trials in this area. For those of us who attack Big Pharma, please remember they are realistically the only ones with the wares and deep enough pockets to be able to tackle this challenge. Love them, or hate them, we need them!"


Other posts on this blog in relation to unemployment:

Social consequence of MS: unemployment - Multiple Sclerosis ...

01 Mar 2012
Social consequences of multiple sclerosis (1): early pension and temporary unemployment--a historical prospective cohort study. Mult Scler. 2010 Jan;16(1):121-6. "This study confirms other data sets in the literature that MS is ...
11 Nov 2011
Methods: MS'ers and disease characteristics associated with transitions to unemployment or employment were evaluated cross-sectionally and prospectively over the course of two assessment periods (mean interval of ~18 ...

27 comments:

  1. Bad news on this blog? No way! I thought that shouldn't be allowed without something positive to say that counterbalances such an argument. Where is Sam Trucker to lift our spirits when we need him/ her?

    Prof G, it's evident that you are very pro-medicine when it comes to RRMS, and you also will go to battle to defend the interests of big Pharma even when their actions are questionable. I have no doubt that you believe in the positive powers of DMTs, but there are many, if not the majority of neurologists in Britain, that don't want to issue new DMTs until they are deemed safer, more efficacious and cost effective than current.

    There must be copious MSers worried beyond belief because that you repeatedly extol the essentialness of these drugs to be taken immediately if they want to avoid disability, yet they can't get them and may never will. That's irresponsible and unprofessional. MSers can't sway NICE. Talk about the need for aggressive early treatment when it becomes a reality, not now when it's still in flux and will be for many years.

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    1. Re: "....there are many, if not the majority of neurologists in Britain, that don't want to issue new DMTs until they are deemed safer, more efficacious and cost effective than current."

      Who's decision should it be to make the call that DMT x or y is too dangerous? Regulators, NICE, neurologists or MSers?

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    2. Re: ".... if they want to avoid disability..."

      That is what the trials show; or at least that is my interpretation of them. As an example; nobody expected that a 3-year delay in starting IFN-beta would have such an impact on survival at 16 and 21 years.

      http://multiple-sclerosis-research.blogspot.co.uk/2012/02/ectrims-2011-ifnbeta-and-21-yr-survival.html

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    3. Dr Dre, 12:09

      I am not sure Prof G is being irresponsible and unprofessional. All he is doing is interpreting research news for us and giving an opinion. If people don't want to hear his opinion that don't have to read the blog. They can vote with their mouse!

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    4. Spot on! In addition, I have far too many conflicts of interest for anyone to take anything I say too seriously. Saying that I know what I would do for myself if I had MS.

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    5. Prof G, the issue I have is that you continue to hammer early and aggressive treatment when a lot of the drugs you're talking about aren't available on the NHS, and will eventually be deemed too expensive. No health body is going to pay for a drug for which the benefits will only fully materialise in 15 to 20 years time, especially not and expensive drug. Health bodies want drugs that are so good that they not only stop the disease, they actually improve deficits and functions.

      Invent a drug like that and everyone and their mother will fight to have it prescribed on the NHS. The current crop you’re arguing for will never get a green light as a first line therapy because they won’t convince the powers that be that they should be given to all incipient MSers. Even if they get an NHS sanction then they’ll be given once too much damage has taken place.

      Also, please don’t argue that Pharma is a necessary evil. Their practices have been corrupt and dishonest. The money is not in a cure for MS, the money is in the medicine. Pharma doesn’t care about MSers, they care about making money out of them. They are drug dealers.`

      I have MS. I want to see the end of MS. I just don’t think the current model of doing things is working. If ever a medicine that promotes remyelination or axonal outgrowth is established then I’ll be on your side. In the meanwhile we’re talking about different things.

      On a plus point, I hate the CCSVI campaign. You and I have that in common.

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    6. A 'medicine that promotes remyelination or axonal outgrowth' will not be a cure. And it will be as much of a constant money earner for pharma.

      Something was responsible for the demyelination and axonal degeneration in the first place. Whatever that something is, it will continue to act on and destroy the newly repaired nerves.

      It will be like trying to rebuild structures that are still on fire and where new fires keep starting.

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    7. Sam Trucker, it will be more of a cure than what exists at present.

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    8. This is Anon 7.03 again. I'm not Sam Trucker

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    9. Dr Dre, you are almost as bad as VV. The only difference is that your blinkers are a different shade of grey.

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    10. Goodness me, you’re insinuating I'm as bad as VV? Why, because I have the audacity to challenge dogma?

      VV seems to be pushing his own agenda that promotes the utilisation of unproven CCSVI treatment to alleviate MS. I, on the other hand, don't believe that any current options are adequate to properly address the effects of multiple sclerosis.

      I do, however, advocate physiotherapy and good lifestyle to try and stay on top of this disease. DMTs do jack other than generate money and leave residual side effects. CCSVI just robs people of money and damn near kills them in the process.

      Giovannoni and his sidekick - MouseDoc - are good people. I genuinely believe that. Yet, their early and aggressive DMT mandate leaves much to be desired, especially when one reads about how seriously risky these drugs are. They are also seriously myopic in the sense that they ignore just how improbable such a treatment pattern on the NHS will be, especially when we consider the costs involved and that we'll have wait an entire generation to see if they are right in their assumption. No government will agree to that, ever.

      If Giovannoni could design a remyelination strategy, which he can't, then that will at least stand a chance with health authorities because the positive effects can be immediately measured and quantified. That is how things work.

      I am offended that you compared me to VV. I may not be a glass half full type of 'fella but I'm not nasty. Anyway, I sense VV is more scientifically knowledgeable than what I am.

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    11. Sidekick....Maybe it is time to change my name to Robin to Prof Gs batman or should it be the other way round, as I have a batman outfit in my wardrobe.

      As to your view of treatment or lack of it, you seem share this view with Jack Osbourne, so we will need to agree to disagree. In terms of short sight I do not believe you are right about availability of active agents on the NHS.

      If prof G could design a remyelination strategy which he can't....there is info out there already....it needs work.

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    12. Dr Dre (I can't believe someone actually enquired as to whether you were a 'real doctor' - I think the answer to that question is self-evident) - It is incorrect to say DMTs "do jack". Their effects are the subject of countless trials and, in respect of RRMS at least, have proven, quantifiable impact. Do they prevent or delay time to SPMS? Maybe. That we will need more evidence of but do they reduce the anual relapse rate? Yes, we know this. Are the, also proven, side effects worth it? That's for the individual to decide. On the whole (maybe BG12 being different?) greater efficacy = greater risk. All currently licensed DMTs are available on the NHS - limited only based on the severity of your disease. Should they be more widely available? Some (including me) think so. Others, don't. Your argument is self-defeating - "they don't do anything and are really dangerous but the NHS should pay for and give them to everyone"...?!

      Anyway, my view is you are every bit as OTT in your promotion of an otherwise reasonable view (that DMTs are not yet good enough) as VV is and therefore deserve the comparison made by the earlier poster. You also fall into that camp that I hate on here (one of whom is obsessed with posting about JK Rowling's Mum and Jacqueline Du Pre as if they are representative of MS) who shouts down anyone trying to present a positive element of MS. It's like you want to be allowed to wallow in your misery and woe betide anyone not as miserable and defeatist as you.

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    13. Yeah, alright Anonymous 3:15pm (aka: SAM Trucker), no need to try and make me out to be some type of illiterate loser. Sure, I may lack the medical qualifications that constitute a proper doctor, but I make up for it in other ways. The moniker I go by seems to be wasted on the people coming here; perhaps they don’t get the irony. In fact, I’ll have you know I left school at 15 and didn’t look back. The best education is self-education.

      I am not being disingenuous. I am of the school of thought that none of my tax money should be wasted on DMTs as they do nothing of positive significance. You may think they reduce the severity of your relapses but that’s only because you’ve swallowed the propaganda peddled out by Big Pharma. If I had their marketing budgets then I’m pretty sure I could convince you these drugs are little more than expensive magic beans, but I don’t, which means you’re still going to keep on injecting yourself with that rubbish.

      Oh yeah, and MouseDoc, way to go trying to embarrass me by posting a cartoon image of a MouseBat to prove to others you’re above it all. This is a strategy to try and devalue my polemic on DMTs being poisonous junk. What a cheap thing to do.

      The real Dr Dre was put through a similar thing by the Regan Administration when they felt his lyrics were too incendiary and influential. A similar thing is happening with me on this blog. You’re trying to shut me down and paint me as a antagonist. That’s not cool. I’m speaking the truth. I’m trying to promote good living and avoid taking DMTs that give you thyroid cancer. Is that a sin?

      And, hey, if defeatism is avoiding DMTs and not dying or getting gravely ill as a result of taking lethal DMTs, as so many have done, then consider me a miserable defeatist. I’ve been called much worse in life.

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    14. Dr Dre, DMTs are certainly rubbish. But you have to ask yourself why do new rubbish drugs keep on coming around. It is not about incompetence in producing the right stuff, its about complete lack of understanding of the nature of MS.

      Regarding vitamin D. You are aware that Vit.D is used by the immune system when it gets activated. MS is a chronic inflammatory disease that requires constant action by the immune system. So it is no wonder that MS patients are Vit.D deplete. It is the result of the constant immune alert against the continuous damage. It is most probably the result of MS and not part of its cause.

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    15. Wikipedia says 'a troll is someone who posts inflammatory, extraneous, or off-topic messages in an online community ... with the primary intent of provoking readers into an emotional response or of otherwise disrupting normal on-topic discussion'

      According to me Dr Dre fits this definition. So let's not get provoked

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    16. So VV is capable of some rational thought! I am surprised. Any chance the venous changes that are attributed to CCSVI are a consequence rather than a cause of MS. Less brain less blood?

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    17. It may not be accurate to talk about CCSVI as cause of MS, because there's evidence of CCSVI in healthy controls although the association is stronger in people with MS (Zivadinov's work). It might be more accurate to consider CCSVI as a promoter of MS. To consider it a consequence of MS, you have to have an explanation for how MS can cause intraluminal abnormalities in the extracranial veins as seen in Fox's autopsy work as well as Dr. Sclafani's ivus work. But there is research suggesting that CCSVI is more present in patients with advanced MS, which would lend credence to the CCSVI as consequence theory.

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    18. I do not listen to rap so the irony is lost.
      Robin took the bat down

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    19. " But there is research suggesting that CCSVI is more present in patients with advanced MS"

      This is the outcome of ultrasound studies, meaning that CCSVI is so obvious in advanced MS that even guys like Comi or Freedman can see it. This alone does not support the consequence theory, it just shows that CCSVI deteriorates with time aka it is a real biological anomaly. Dr Scholbach would support this view.

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    20. This is a strategy to try and devalue my polemic on DMTs being poisonous junk

      Nope a response to being called a sidekick

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  2. This really worries me: I am a business analyst and have already suffered the fear and embarrassment of losing words and thoughts during meetings and whilst writing documents. I hate the thought of the bl**dy MS removing promotion and job change prospects that I had before the diagnosis and I want the option of taking medicine to prevent these symptoms from occuring or getting worse. I can cope with the idea of my body letting me down more than I can the idea of my mind being lost.

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  3. This study is in line with others showing the impact of MS on employment. It is clearly 'bad news' which I agree is important to share. However, there are just a few points to be made:

    1. When looking at employment rates it needs to be remembered that some people simply don't work for non-MS reasons. Because 55% of MSers are in work, it doesn't mean the other 45% have had to stop working due to the condition. The exact numbers depend upon the age ranges etc but, for example, MS is a disease that hits a disproportionately high number of women of child-bearing age who may have been looking to give up work to look after their family in any event.

    2. In the above study, 37.5% of people changed their employment status between diagnosis and the 7 year point (either giving up or reducing to part-time). Still an awful number but nevertheless, not quite the same as the implied 50% of people have to give up work.

    3. A significant element of unemployment in MS is not disability per se but prejudice by, and ignorance of, employers who assume someone with MS can't be a valuable employee. That is one of the most important reasons it is important to promote the message that, actually, people with MS still have a huge amount to contribute to employers - even those with cognitive challenges.

    4. Equally, some with MS give up work too readily out of fear of the condition and it's likely impact when, in fact, they should be given the confidence and tools to feel able to continue for longer.

    I am not saying - and never have said - that MS is not a 'bad disease'. It clearly is. However, a significant part of its impact is the fear it causes people (like Posy above), employers & family members etc who tend to assume a prognosis that is not necessarily representative of the 'average' disease course. That anxiety itself contributes to problems with attention and concentration which becomes a vicious circle in an employment sense. The degree of cognitive impairment - even in the study above - is typically reasonably moderate and we should work to show that MSer can contibute a lot irrespective (whilst, of course, also working hard to try and come up with means of treating these and other symptoms).

    Posy - Just one thing; when I was first diagnosed, I was very conscious of exactly the same thing. If I couldn't find the right word to type - I panicked. If I was hesistant when speaking - I panicked. I've since come to believe that this wasn't the MS at all; it was simply me being hyper-aware of everything I wrote, said, did etc and was picking up things that I would normally not even have thought about. I'm not saying that's the case for you but just be cautious of that. It is the same with physical symptoms - every twitch, pain, tingle etc becomes "oh no, it's my MS" when, actually, its just normal 'body stuff' that we've become overly aware of.

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    1. Thanks for your observations - it is good to hear about other people's experiences. I don't know any specific details about my lesions, other than that the MRI showed a couple and that my LP result showed inflammation. When I see my new neurologist I hope to get a better understanding of my condition, but the diagnosing neurologist was surprised that the MRI showed anything as apparently the symptoms I reported were not very significant and his guess before the MRI result was that I had a virus.

      Thankfully I haven't experienced any painful symptoms, just numbness, vertigo, fatigue during the episode (and I am more easily tired now I'm back to 'normal') and the cognitive problems. I am generally regarded as quite a witty person, but I regularly found that the quip I formed in my brain and started saying was ruined by the crucial word suddenly vanishing from my mind and me using a completely unrelated word in its place! It felt different from when a word is on the tip of my tongue, when I feel I can almost see the word: this felt as if there was just a void where the word used to be - I knew it should be there, but I had no idea what to even look for. The other thing was I aware of, and my family and friends noticed, was the number of completely unintentional spoonerisms I was suddenly saying and even when I realised I'd said them and tried to correct them, I would still say them the wrong way. I was frightened by that, but don't want to live in fear of what might happen nor do I want to go looking for symptoms, but at the same time, if this is a genuine symptom that can be treated, I don't want to ignore it and just hope it doesn't get worse!

      It seems that a balance needs to be struck between being aware of possible symptoms, but not automatically thinking that everything out of the normal is a symptom.

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    2. I believe this is a genuine symptom. Unfortunately it has no specific treatment.

      When the problem first started my daughter used say she has become 'de-wordified'

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  4. Incidentally, most studies show employments rates at around 20 years of c. a third (eg http://www.ncbi.nlm.nih.gov/pubmed/20802029 - 32.4% after 22.2 years; 69% in the 'benign' segmentation). Again, not great and probably compares to a population wide average of around double that but it shows that a substantial number of MSers - 1 in 3 - are able to continue working a very long time after diagnosis.

    FYI - The median time to disability retirement for an MSer in this study was 17 years post-diagnosis in RRMS; 19 years if you had >9 year education or did non-physical work and 21 years if you had viaul or sensory onset symptoms.

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  5. Prof G - I am recently diagnosed and, I'm happy to say, have no fatigue to speak of nor do I have any cognitive issues. I realise the latter can be difficult to perceive without formal testing but I'm as confident as I can be I have not developed even subtle deficits here (not really scientific but I'm currently in the 95% percentile on luminosity and did a self-administered PASAT test and scored very highly!). I also have a very challenging job and have not noticed any impact on my 'executive functioning' in that respect. I have a low lesion load - just 3 or 4 T2 lesions, no T1s, no GD+.

    My question is the extent to which that is a positive indicator for the future, specifically in terms of congition and fatigue? My neuro says that fatigue is most likely (although not proven) to be related to inflammation, which is usually at its highest earliest in the disease and therefore absence of fatigue on diagnosis is suggestive that fatigue may not be too severe ultimately (most people who have problems with fatigue, present with it initially he says). Also, the study above suggested most of those out of employment at 7 years already had deficits on diagnosis and only a few of the ones with normal baseline cognitive ability were out of employment - again, how much reliance is it safe to place on my (current) lack of cognitive difficulties? I plan to start treatment regardless but it would be good to have any thoughts you might have on the above.

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