Elwick, Hannah
(2022)
Cognitive assessment in Multiple Sclerosis: towards the development of a cognitive screening pathway.
PhD thesis, University of Nottingham.
Abstract
Background
It is estimated that as many as 86% of people with Multiple Sclerosis (MS) can experience cognitive impairment, which can impact quality of life. Although the value of screening for cognitive problems is recognised, it is not routinely undertaken.
Methodology
The research comprises five studies to identify acceptable and appropriate methods of assessing cognitive impairment in people with MS. A systematic review (Study I) was conducted to determine the most frequently used cognitive assessments in MS research. Study II focused on one test, the Symbol Digit Modalities Test (SDMT), and explored the variability in scoring and interpretation in MS research. In Study III the domain structure of an MS-specific self-report measure of cognitive problems, and how it relates to an objective measure of information processing speed, was explored. Finally, two qualitative interview studies were conducted. Study VI examined stakeholders’ experience and opinions of cognitive impairment and assessments, and explored perceived barriers and facilitators to implementation in clinical practice. In Study V, people with MS completed a digital test and were asked to ‘talk through’ the process.
Results
The systematic review (Study I) extracted data from 1,526 studies, using 5,665 cognitive assessments. The SDMT emerged as the most frequently used individual test. Focusing on this, there was variability in how results of this test are interpreted for people with MS noted in Study II. Whilst the SDMT is a promising objective measure of information processing speed, the results of Study III suggest that a reduced, multidimensional questionnaire has more promise than its unidimensional version and could be used in place of an objective test. In Study IV, people with MS and clinicians reported that, despite being a prevalent symptom, cognitive impairment was not assessed routinely. Participants felt that symbol substitution tests and subjective self-reported questionnaires were acceptable and appropriate in assessment and could be completed digitally on personal mobile devices. This would also be feasible to implement in NHS clinical care. Based on these findings, a webapp was developed, and Study V identified usability problems, and barriers and facilitators to its use.
Conclusions
Future research is needed to assess the psychometric properties of the developed digital task. Normative data from non-MS control participants should also be collected to provide benchmarks for interpreting clinical data. Digitised, remote assessments can enable more people with MS to access screening, which can facilitate discussion and referral for cognitive rehabilitation. Overall, the results of this research indicate the potential of using digital, remote cognitive assessment with a symbol substitution task in MS clinical care.
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