SAN DIEGO—Current practice related to screening patients with multiple sclerosis (MS) for cognitive impairment and depression may need improvement, according to a study presented at the ACTRIMS 2018 Forum. Not all patients undergo screening for these comorbidities, and patients who undergo screening are not necessarily those most likely to have cognitive impairment or depression, said the researchers. In addition, the vast majority of clinicians who perform this screening do not use validated tools.
“Education on validated screening tools, development of more accessible tools, and the sharing of best practices by MS experts may all help address these barriers,” said Guy J. Buckle, MD, MPH, Director of Neuroimaging Research at Shepherd Center in Atlanta, and colleagues. “Assisting MS clinicians in cognitive and depression screening and early referral and treatment may all positively impact outcomes for patients with MS.”
Study Included Chart Review and Survey
The National MS Society reported that as much as half of patients with MS may have cognitive impairment. A meta-analysis by Foley et al suggested that 35% of patients with MS met the criteria for clinically significant depression. Yet not all patients with MS undergo screening for these comorbidities.
Dr. Buckle and colleagues examined neurologists’ current screening practices, perceptions about screening, and barriers to screening. The investigators reviewed charts for 300 patients with MS who were seen at two large specialty clinics (150 charts per clinic). Eligible patients were 18 or older and had two or more visits during the study period. The investigators also conducted informal email interviews with 13 MS specialists recognized as leaders in research and treatment.
Dr. Buckle’s group sought to determine the extent to which screening for cognitive impairment and depression are documented in practice, as well as the extent to which clinicians use validated tools for this screening. In addition, the researchers solicited neurologists’ perceptions of the clinical value of formal screening, along with barriers to using screening tools.
Rate of Screening May Have Been Suboptimal
Participants’ median age was 52, and 76% of participants were female. Average time since diagnosis was 13 years. Fifteen patients had had one or more relapse in the previous 24 months.
Screening for cognitive impairment was documented for 52% of patients in the previous 12 months, and cognitive impairment was documented in 37% of those screened. About 2% of clinicians used a validated tool for screening, and 28% of patients were referred for more specialized care.
Screening for depression was documented for 63% of patients in the previous 12 months, and depression was documented in 42% of those screened. About 4% of clinicians used a validated tool for screening, and 25% of patients were referred for specialized care.
About 48% of patients younger than 65 were screened for cognitive impairment, compared with 73% of patients age 65 or older. Cognitive impairment was diagnosed in 69% of patients younger than 65 and in 78% of patients 65 or older. Patients younger than 65 were less likely to be screened for depression than those 65 or older (60% vs 73%), but more likely to be diagnosed with depression (71% vs 54%).
White patients were more likely to be screened for cognitive impairment than black patients (57% vs 52%), but less likely to be diagnosed with cognitive impairment (68% vs 82%). Similarly, white patients were more likely to be screened for depression (71% vs 53%), but less likely to be diagnosed with depression (65% vs 75%).
Patients who were employed were more likely to undergo cognitive screening than unemployed, retired, or disabled patients, but the latter were more likely to be diagnosed with cognitive impairment. “The analyses support previous findings suggesting links between cognitive dysfunction, patient age, and physical disability,” said Dr. Buckle and colleagues.
Specialists Cited Time as a Barrier
About 54% of the MS specialists surveyed reported that they used validated tools to assess cognitive impairment. Among the tools they named were the Symbol Digit Modalities Test, the Mini-Mental State Examination, the California Verbal Learning Test II, and the Brief International Cognitive Assessment for MS. Among the reasons the specialists gave for not using validated tools were time constraints, lack of qualified staff for administration, lack of integration of the tests into electronic medical records, and lack of reimbursement.
Approximately 46% of the MS specialists reported that they used validated tools to assess depression. The tools that they reported using included the Patient Health Questionnaire-9, the Beck Depression Inventory-II, CNS Vital Signs, and routine questions about appetite, weight loss, sleep, sexual activity, and suicidal ideation. The specialists cited time constraints, lack of compensation, cost, and inability to document results in the electronic medical record as reasons for not using validated tools.
“Integration of formal tools in clinical practice may support clinicians in appropriate and consistent identification of patient populations with these conditions,” said the investigators.