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BHC Cognitive Impairment 2018

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People with ME/CFS and FM often suffer from cognitive impairment that can lead to brain fog, trouble word finding and more debilitating symptoms. In this class, you will understand the types of cognitive issues that commonly occur, possible causes, and how to implement strategies for improving cognitive function.

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Published in: Health & Medicine
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BHC Cognitive Impairment 2018

  1. 1. Important Principles of Management: FM and ME/CFS u 1) Good differential diagnosis to identify and address all aspects of illness and comorbid conditions u 2) “Pace” activity to prevent symptom escalation (preventive activity management). Avoid push/crash. u 3) Address the major aspects of illness u SLEEP: Achieve most restorative u MENTAL HEALTH/COGNITION: bolster u PAIN: control severe pain and learn to manage chronic pain u FITNESS: Achieve best fitness based on tolerance and illness relapse u ORTHOSTATIC INTOLERANCE– if applicable
  2. 2. Cognitive impairment is a common complaint of people with FM and ME/CFS. Patients report: u brain fog u trouble word finding u reduced short term memory, attention and concentration u mental/cognitive fatigue u slowed thinking... Reduced processing speed u mild confusion, disorientation, sensory overload u inability to process information u trouble multi-tasking, organizing, reduced “executive function”
  3. 3. Alternate "new" Fibromyalgia Criteria (ACR 2010) 1) Widespread PAIN index (WPI) (0-19 points—see next slide) 7+ or 3-6 2) Symptom Score (SS): 0=none, 1=mild, 2=mod, 3=severe Chronic fatigue (0-3) Unrefreshing sleep (0-3) Cognitive complaints (0-3) Multisystem complaints (0-3) Max SS = 12 5+ and 9+ FM FM > 3 months in duration and without other apparent explanation Wolf F, et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care & Research. Vol. 62, No. 5, May 2010, pp 600–610
  4. 4. ME/CFS Clinical Diagnostic Criteria: CORE criteria* required for diagnosis: 1) Impaired function related to exhaustion/fatigue/fatigability 2) PEM: post exertional malaise (illness relapse after activity) 3) Unrefreshing sleep 4) A. Cognitive impairment and/or B. Orthostatic intolerance *Must be moderate-severe and frequent (present >50% of time) Other common features of illness include: ---Pain: including overlap with FM ---Immune manifestations (allergy, inflammation, etc) ---Infections
  5. 5. Jason LA, Sunnquist M, Brown A, Evans M, Vernon S, Furst J, Simonis V. Examining case definition criteria for chronic fatigue syndrome and myalgic encephalomyelitis. Fatigue: Biomedicine, Health & Behavior. 2013b;2(1) Percentage of ME/CFS patients and healthy controls reporting neurocognitive manifestations of at least moderate severity that occurred at least half of the time during the past 6 months
  6. 6. ME/CFS and FM cognitive impairment: often difficult to measure objectively Neuropsychometric testing is expensive and not often covered by insurance. Most of the typical neurocognitive tests are within normal limits. Brain fog is not dementia. IQ intact. Slowed information processing is the best documented cognitive deficit in ME/CFS u Difficulty with timed tests u Difficulty multi-tasking (which is actually moving quickly from task to task)
  7. 7. Neuropsychometric testing 14 year old boy with ME/CFS unable to attend school or do homework Learning and Working Memory: u Verbal Learning 75th u Sound Symbol 25th u Visual learning 50th Executive/Neuropsychological Skills: u Planning 4th u Simultaneous 58th u Attention 12th u Successive 50th u Full Scale 18th Cognitive Abilities Test: u Verbal 98th percentile u Quantitative 48th u Nonverbal 65th u Composite 77th Intellectual: u Verbal Comprehension 98th u Perceptual Reasoning 61st u Working Memory 34th u Processing speed 21st u Full Scale 70th
  8. 8. Brain research in ME/CFS u Activated microglia and astrocytes (neuroinflammation) were demonstrated in the brain using PET scans in a small study of 10 patients (Nakatomi 2014) u Functional MRI and spin-echo MRI have demonstrated various changes in the brain but are not all in agreement (numerous studies) u Lactate is increased in the brain ventricles as imaged by by proton magnetic resonance spectroscopy (MRS) (Murrough 2010, Shungu 2012) u Quantitative EEG techniques can differentiate ME/CFS from controls (Duffy 2011, Zinn et al 2014, Zeineh et al 2015) u Spinal fluid of ME/CFS patients showed higher protein and altered cytokines (Spinal fluid abnormalities in patients with CFS. Natelson B, et al. Clin Diagn Lab Immunol. Jan 2005; 12(1`);52.55.) EEG spectral coherence data distinguish chronic fatigue syndrome patients from healthy controls and depressed patients-A case control study. Duffy...Komaroff. BMC Neurology 2011, 11:82
  9. 9. Microglial “glial” cells are immune cells in the brain and spinal cord. Inflammation caused by glial cells may: Ø cause or contribute to the widespread pain and fatigue of FM Ø underlie ME/CFS cognitive slowing, exhaustion, pain Ø compromise or reduce normal function in any area of the brain where inflammation occurs
  10. 10. Jarrod Younger MD PhD The use of low-dose naltrexone (LDN) as a novel anti- inflammatory treatment for chronic pain. Younger J, et al. Journal Clin Rheumatol. 2014 Apr;33(4):451-9. Epub 2014 Feb 15. The interaction of naltrexone with microglial cells results in a reduction of proinflammatory cytokines as well as neurotoxic superoxides (Wikipedia)
  11. 11. Microglia Regulation of innate immune responses in the brain. Serge Rivest. Nature Reviews Immunology 9, 429-439 (June 2009) Microglia are the innate immune cells of the CNS http://jonlieffmd.com/blog/are-microglia-the-most- intelligent-brain-cells
  12. 12. http://www.frontiersin.org/files/Articles/128434/fncel-09-00028-HTML/image_m/fncel-09-00028-g001.jpg Resting Glial Cell Activated Glial Cell Model of Neuroinflammation Healthy Brain Inflamed Brain
  13. 13. General Principles of Supportive Management: u 1) Address all other conditions (complete a good medical work-up) u i.e. anemia, thyroid, diabetes, sleep apnea, low Vit B12, polypharmacy u 2) “Pace” to prevent symptom escalation (Preventive activity management. Reduce overload) u 3) Address the major aspects of illness u PAIN: reduce severe pain u SLEEP: achieve restorative sleep u MENTAL HEALTH: insight and support u FITNESS: engage in restorative exercise u Orthostatic Intolerance PAIN SLEEP MENTAL HEALTH FITNESS
  14. 14. General Principles of Supportive Management: Possible contributors to cognitive complaints: u 1) Address all other conditions (complete a good medical work-up) u i.e. anemia, thyroid, diabetes, sleep apnea, low Vit B12, polypharmacy u 2) “Pace” to prevent symptom escalation (NOT pacing, not managing activity leads to overload or PEM) u 3) Address the major aspects of illness u PAIN: unrelenting pain is exhausting to body and brain u SLEEP: poor sleep contributes to daytime exhaustion u MENTAL HEALTH: anxiety and depression impact cognition u FITNESS: sluggish circulation reduces alertness u Orthostatic Intolerance reduced brain blood flow PAIN SLEEP MENTAL HEALTH FITNESS
  15. 15. Address potential contributors to “brain fog” and cognitive slowing u Medications for sleep, pain, anxiety, migraine u Chronic sleep disturbances u Secondary mental health conditions---depression, anxiety u Orthostatic intolerance and other causes of reduced cerebral blood flow and perfusion. “Perfusion” is the circulation or delivery of blood to every cell, bringing oxygen, glucose, everything needed for cell function… u Cognitive fatigue and fatigability u Low cellular energy production. Capacity for “function” is reduced. u PEM—the consequences of exceeding cell energy capacity
  16. 16. Address potential contributors to “brain fog” and cognitive slowing u Medications for sleep, pain, anxiety, migraine--- minimize meds when possible, especially during the daytime. u Chronic sleep disturbances ---- continue to improve restorative sleep u Secondary mental health conditions---depression, anxiety. Address mental health. u Orthostatic intolerance and other causes of reduced cerebral blood flow and perfusion. “Perfusion” is the circulation or delivery of blood to every cell, bringing oxygen, glucose, everything needed for cell function… Improve cerebral blood flow and perfusion u Cognitive fatigue and fatigability. Engage in “pacing” cognitively as well as physically u Low cellular energy production. Capacity for “function” is reduced. Pacing! u PEM—the consequences of exceeding cell energy capacity. Avoid severe/prolonged PEM
  17. 17. Medications that might help brain fog and cognitive impairment u Wellbutrin/bupropion 75-300 mg u Stimulants (examples) ---can lead to crash or PEM u methylphenidate (Ritalin) u Dexadrine (Adderall) ---can raise BP and HR u Newer drugs for daytime somnolence u Modafinil (Provigil) and armodafinil (Nuvigil) --- can disrupt sleep u Supplements (a few examples, not supported by strong evidence) u Fish oil, omega 3 fatty acids u Phosphatidyl serine 100 mg 2x or 3x daily u Curcumin (from turmeric) u B vitamins (B6, B9, B12) related to homocysteine metabolism u Vitamin E (tocopherol), Vitamin A, Vitamin C https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3311304/ Common dietary supplements for cognitive health. Aging Health. Gestuvo and Hung. 2012
  18. 18. Behavioral strategies for managing cognitive impairment Cognitive slowing: ME/CFS may recruit more brain areas to accomplish task. u Behavioral strategies for dealing with cognitive impairment: u complete cognitive tasks when more rested or at best time of day u allow more time and minimize interruptions u utilize day-timer, iphone, other recording/signaling devices u dampen or remove other sensory input to the brain uquiet room, ear plugs or sound-reducing headphones ulow or less glaring lights uReduce #people or other chaotic signaling/disruption
  19. 19. PAIN reduction Restorative SLEEP MENTAL HEALTH FITNESS ORTHOSTATIC INTOLERANCE… CHRONIC UNWELLNESS PACING and activity management

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