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March 20, 2013

Cognitive impairment differs between primary progressive and relapsing-remitting MS

Aurélie Ruet, MD, Mathilde Deloire, PhD, Julie Charré-Morin, Msc, Delphine Hamel, Msc, and Bruno Brochet, MDAuthors Info & Affiliations
April 16, 2013 issue
80 (16) 1501-1508
https://doi.org/10.1212/WNL.0b013e31828cf82f
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Abstract

Objectives:

To characterize the cognitive abilities of patients with primary progressive multiple sclerosis (PPMS) and relapsing-remitting multiple sclerosis (RRMS) compared with healthy controls (HCs) matched for age, sex, and education level while considering the different characteristics of PPMS and RRMS and to compare the cognitive patterns of these types of multiple sclerosis.

Methods:

Forty-one patients with PPMS, 60 patients with RRMS, and 415 HCs were recruited in a cross-sectional study. Controls were divided into 20 groups according to age, sex, and education level. Participants were assessed with a large battery of neuropsychological (NP) tests that included a modified version of the Brief Repeatable Battery, the Stroop test, computerized tests from the Test of Attentional Performance battery, the numerical span test, and the Rey Complex Figure.

Results:

Patients with PPMS performed worse than their matched HCs on nearly all NP tests. Patients with RRMS performed worse than matched HCs on a computerized digit-symbol substitution task and the alertness test, reaction time for visual scanning, and Paced-Auditory Serial Addition Test-3 seconds. Patients with PPMS had worse NP scores and were more impaired in cognitive domains than patients with RRMS. After controlling for Expanded Disability Status Scale score, the results remained unchanged.

Conclusion:

The patients with PPMS presented with a wide range of cognitive deficits in information processing speed, attention, working memory, executive function, and verbal episodic memory, whereas the impairments in patients with RRMS were limited to information processing speed and working memory compared with their matched HCs. Cognitive deficits were more severe in patients with PPMS than in patients with RRMS.

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REFERENCES

1.
Comi G, Filippi M, Martinelli V, et al. Brain magnetic resonance imaging correlates of cognitive impairment in primary and secondary progressive multiple sclerosis. J Neurol Sci 1995;132:222–227.
Crossref
PubMed
Google Scholar
2.
Camp SJ, Stevenson VL, Thompson AJ, et al. Cognitive function in primary progressive and transitional progressive multiple sclerosis: a controlled study with MRI correlates. Brain 1999;122:1341–1348.
Crossref
PubMed
Google Scholar
3.
Gaudino EA, Chiaravalloti ND, DeLuca J, Diamond BJ. A comparison of memory performance in relapsing-remitting, primary progressive and secondary progressive, multiple sclerosis. Neuropsychiatry Neuropsychol Behav Neurol 2001;14:32–44.
PubMed
Google Scholar
4.
Huijbregts SC, Kalkers NF, de Sonneville LM, de Groot V, Reuling IE, Polman CH. Differences in cognitive impairment of relapsing remitting, secondary, and primary progressive MS. Neurology 2004;63:335–339.
Crossref
PubMed
Google Scholar
5.
Poser CM, Paty DW, Scheinberg L, et al. New diagnostic criteria for multiple sclerosis: guidelines for research protocols. Ann Neurol 1983;13:227–231.
Crossref
PubMed
Google Scholar
6.
Polman CH, Reingold SC, Edan G, et al. Diagnostic criteria for multiple sclerosis: 2005 revisions to the “McDonald Criteria.” Ann Neurol 2005;58:840–846.
Crossref
PubMed
Google Scholar
7.
Brochet B. Assessing incapacity at early stages of multiple sclerosis using the EDSS. Rev Neurol 2009;165(suppl 4):S173–S179.
Crossref
PubMed
Google Scholar
8.
Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology 1983;33:1444–1452.
Crossref
PubMed
Google Scholar
9.
Rao SM; the Cognitive Function Study Group of the National Multiple Sclerosis Society. A Manual for the Brief Repeatable Battery of Neuropsychological Tests in Multiple Sclerosis. Milwaukee: Medical College of Wisconsin; 1990.
Google Scholar
10.
Bever CT, Grattan L, Panitch HS, Johnson KP. The Brief Repeatable Battery of Neuropsychological Tests for multiple sclerosis: a preliminary serial study. Mult Scler 1995;1:165–169.
Crossref
PubMed
Google Scholar
11.
Boringa JB, Lazeron RH, Reuling IE, et al. The Brief Repeatable Battery of Neuropsychological Tests: normative values allow application in multiple sclerosis clinical practice. Mult Scler 2001;7:263–267.
Crossref
PubMed
Google Scholar
12.
Ruet A, Deloire MS, Charré-Morin J, Hamel D, Brochet B. A new computerised cognitive test for the detection of information processing speed impairment in multiple sclerosis. Mult Scler Epub 2013 Mar 4.
Google Scholar
13.
Harris JG, Wagner B, Cullum CM. Symbol vs. digit substitution task performance in diverse cultural and linguistic groups. Clin Neuropsychol 2007;21:800–810.
Crossref
PubMed
Google Scholar
14.
Zimmermann P, Fimm B. 2.1 Tests d'évaluation de l'attention Würzelen: Psytest 2009.
Google Scholar
15.
Golden CJ. A group version of the Stroop Color and Word Test. J Pers Assess 1975;39:386–388.
Crossref
PubMed
Google Scholar
16.
Wechsler D. Wechsler Adult Intelligence Scale–III Administration and Scoring Manual. San Antonio: The Psychological Corporation; 1997.
Google Scholar
17.
Rey A. L'examen psychologique dans les cas d'encephalopathie traumatique. Arch Psychol 1941;28:286–340.
Google Scholar
18.
Beck AT, Brown G, Steer RA. Beck Depression Inventory II Manual. San Antonio: The Psychological Corporation; 1996.
Google Scholar
19.
Spielberger CD. Manual for the State-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press; 1983.
Google Scholar
20.
Sharrack B, Hughes RA. The Guy's Neurological Disability Scale (GNDS): a new disability measure for multiple sclerosis. Mult Scler 1999;5:223–233.
Crossref
PubMed
Google Scholar
21.
Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
Google Scholar
22.
Foong J, Rozewicz L, Chong WK, Thompson AJ, Miller DH, Ron MA. A comparison of neuropsychological deficits in primary and secondary progressive multiple sclerosis. J Neurol 2000;247:97–101.
Crossref
PubMed
Google Scholar
23.
Wachowius U, Talley M, Silver N, Heinze HJ, Sailer M. Cognitive impairment in primary and secondary progressive multiple sclerosis. J Clin Exp Neuropsychol 2005;27:65–77.
Crossref
PubMed
Google Scholar
24.
Ukkonen M, Vahvelainen T, Hämäläinen P, Dastidar P, Elovaara I. Cognitive dysfunction in primary progressive multiple sclerosis: a neuropsychological and MRI study. Mult Scler 2009;15:1055–1061.
Crossref
PubMed
Google Scholar
25.
Penny S, Khaleeli Z, Cipolotti L, Thompson A, Ron M. Early imaging predicts later cognitive impairment in primary progressive multiple sclerosis. Neurology 2010;74:545–552.
Crossref
PubMed
Google Scholar
26.
Potagas C, Giogkaraki E, Koutsis G, et al. Cognitive impairment in different MS subtypes and clinically isolated syndromes. J Neurol Sci 2008;267:100–106.
Crossref
PubMed
Google Scholar
27.
Chiaravalloti ND, DeLuca J. Cognitive impairment in multiple sclerosis. Lancet Neurol 2008;7:1139–1151.
Crossref
PubMed
Google Scholar
28.
Forn C, Belenguer A, Parcet-Ibars MA, Avila C. Information-processing speed is the primary deficit underlying the poor performance of multiple sclerosis patients in the Paced Auditory Serial Addition Test (PASAT). J Clin Exp Neuropsychol 2008;13:1–8.
Google Scholar
29.
DeLuca J, Chelune GJ, Tulsky DS, Lengenfelder J, Chiaravalloti ND. Is speed of processing or working memory the primary information processing deficit in multiple sclerosis? J Clin Exp Neuropsychol 2004;26:550–562.
Crossref
PubMed
Google Scholar
30.
De Sonneville LMJ, Boringa JB, Reuling IEW, Lazeron RHC, Adèr HJ, Polman CH. Information processing characteristics in subtypes of multiple sclerosis. Neuropsychologia 2002;40:1751–1765.
Crossref
PubMed
Google Scholar
31.
Denney DR, Lynch SG, Parmenter BA, Horne N. Cognitive impairment in relapsing and primary progressive multiple sclerosis: mostly a matter of speed. J Int Neuropsychol Soc 2004;10:948–956.
Crossref
PubMed
Google Scholar
32.
Deloire M, Salort E, Bonnet M, et al. Cognitive impairment as marker of diffuse brain abnormalities in early relapsing remitting multiple sclerosis. J Neurol Neurosurg Psychiatry 2005;76:519–526.
Crossref
PubMed
Google Scholar
33.
Kutzelnigg A, Lassmann H Cortical lesions and brain atrophy in MS. J Neurol Sci 2005;233:55–59.
Crossref
PubMed
Google Scholar

Information & Authors

Information

Published In

Neurology®
Volume 80 • Number 16 • April 16, 2013
Pages: 1501-1508
PubMed: 23516324

Copyright

© 2013 American Academy of Neurology.

Publication History

Received: August 3, 2012
Accepted: January 7, 2013
Published online: March 20, 2013
Published in print: April 16, 2013

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Disclosure

A. Ruet participated as a speaker for symposia organized by Biogen-Idec and Teva. She is or was an investigator for studies promoted by Novartis, Bayer Healthcare, Roche, Lilly, Peptimmune, and Merck-Serono and has received subventions for this activity. She received research support from Novartis. She is also a recipient of a fellowship-grant from Fondation pour la Recherche Médicale. M. Deloire reports no disclosures. D. Hamel received honoraria for participating on the scientific multidisciplinary advisory board for Novartis Pharma and for drafting support in this context concerning dysphagia and multiple sclerosis (Déglutition et sclérose en plaques: connaître, dépister, prendre en charge, Novartis Phrama, 2012) and received support for participation in congresses from Biogen-Idec. J. Charré-Morin received honoraria for speaking at scientific meetings supported by Merck-Serono and support for participation in congresses from Biogen-Idec. B. Brochet or his institution received honoraria for speaking at scientific meetings and serving as a member of scientific advisory boards or consultancies for Bayer Healthcare, Biogen-Idec, Merck-Serono, Genzyme, Novartis, and Teva and his institution received research grants from Bayer Healthcare, Teva, Merck-Serono, Novartis, Biogen-Idec, Sanofi-Aventis, ARSEP, and Roche. Go to Neurology.org for full disclosures.

Study Funding

The study was supported by Bayer Healthcare, France. The sponsor did not participate in any aspect of the design or performance of the study, including the data collection, management, analysis, and interpretation or the preparation, review, and approval of the manuscript.

Authors

Affiliations & Disclosures

Aurélie Ruet, MD
From the Université de Bordeaux (A.R., D.H., B.B.), INSERM U. 1049 Neuroinflammation, Imagerie et Thérapie de la Sclérose en plaques, Bordeaux; and CHU de Bordeaux (A.R., M.D., J.C.-M., B.B.), INSERM-CHU CIC-P 0005, and Service de Neurologie, Bordeaux, France.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
I report no disclosure in relation with this study. I participated as a speaker to symposia organized by Biogen-Idec and Teva.
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
I have been investigator for studies promoted by Novartis, Bayer Healthcare, Roche, Lilly, Peptimmune and Merck-Serono and received subventions for this activity.
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
I received research support from Novartis and I am a recipient of a fellowship-grant from Fondation pour la recherche médicale.
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author
Mathilde Deloire, PhD
From the Université de Bordeaux (A.R., D.H., B.B.), INSERM U. 1049 Neuroinflammation, Imagerie et Thérapie de la Sclérose en plaques, Bordeaux; and CHU de Bordeaux (A.R., M.D., J.C.-M., B.B.), INSERM-CHU CIC-P 0005, and Service de Neurologie, Bordeaux, France.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author
Julie Charré-Morin, Msc
From the Université de Bordeaux (A.R., D.H., B.B.), INSERM U. 1049 Neuroinflammation, Imagerie et Thérapie de la Sclérose en plaques, Bordeaux; and CHU de Bordeaux (A.R., M.D., J.C.-M., B.B.), INSERM-CHU CIC-P 0005, and Service de Neurologie, Bordeaux, France.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
honorarias for speaking at scientific meetings supported by merckSerono and support for participation to congresses from biogen -idec.
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author
Delphine Hamel, Msc
From the Université de Bordeaux (A.R., D.H., B.B.), INSERM U. 1049 Neuroinflammation, Imagerie et Thérapie de la Sclérose en plaques, Bordeaux; and CHU de Bordeaux (A.R., M.D., J.C.-M., B.B.), INSERM-CHU CIC-P 0005, and Service de Neurologie, Bordeaux, France.
Disclosure
Scientific Advisory Boards:
1.
Received honorarias for participating as advisor of received honorarias for participating at scientific multidisciplinary advisory board for Novartis Pharma and for drafting a support in this context about dysphagia and multiple sclérosis (“Déglutition et sclérose en plaques: connaître, dépister, prendre en charge, Novartis Phrama, 2012)
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
received support for participation to congresses from Biogen-Idec
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author
Bruno Brochet, MD
From the Université de Bordeaux (A.R., D.H., B.B.), INSERM U. 1049 Neuroinflammation, Imagerie et Thérapie de la Sclérose en plaques, Bordeaux; and CHU de Bordeaux (A.R., M.D., J.C.-M., B.B.), INSERM-CHU CIC-P 0005, and Service de Neurologie, Bordeaux, France.
Disclosure
Scientific Advisory Boards:
1.
Bayer-Healthcare, Biogen-Idec, Genzyme, Novartis, Merck-Serono, Teva
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
Received travel expenses from Bayer, Teva and Genzyme
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Bayer-Healthcare, Biogen-Idec, Genzyme, Novartis, Merck-Serono, Teva
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Bayer Healthcare, Teva, Merck Serono, Novartis, Biogen-Idec, Sanofi-Aventis, ARSEP, and Roche.
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author

Notes

Correspondence to Dr. Brochet: [email protected]
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

Dr. A. Ruet: study design, analysis and interpretation of data, wrote the original manuscript. Dr. M. Deloire: study design, acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content. J. Charré-Morin: acquisition of data, critical revision of the manuscript for important intellectual content. D. Hamel: study design, critical revision of the manuscript for important intellectual content. Prof. Brochet: study concept and design, study supervision, critical revision of the manuscript for important intellectual content.

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