Cognition and multiple sclerosis (MS) have become a growing focus in research and patient care. At this year’s ECTRIMS, Professor Maria Pia Amato from the University of Florence presented a comprehensive lecture on Cognitive Function and MS: Progress and Perspective.
In this blog post, I will share the key takeaways of her talk, structured for people living with MS. Cognitive changes are common, but there is also much we can do to understand, monitor, and manage them.
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1. Introduction to Cognitive Function and MS
We live in a time where early and highly effective treatments for MS are available. Early diagnosis and initiation of disease-modifying therapies (DMTs) have reduced relapses and delayed disability progression. However, silent progression (PIRA – progression independent of relapse activity) remains.
From the Global PROMS survey (Patient-Reported Outcomes in MS), the most common symptoms reported were:
Fatigue (86%)
Stress (80%)
Pain (75%)
Concentration problems (75%)
Memory problems (74%)
2. Overview of Cognitive Impairment in MS
Research into cognition in MS began in the late 20th century. Early work included:
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Stephen M. Rao (1991) – first major papers on cognitive dysfunction in MS.
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MRI studies (1989) correlating imaging with neuropsychological testing.
Prevalence of cognitive impairment in MS ranges from 30–65%, with key domains affected:
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Attention (sustained, divided, selective, processing speed)
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Learning and memory (recall, recognition, semantic, autobiographical)
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Social cognition (emotion recognition, theory of mind)
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Executive function (planning, decision making, working memory)
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Language (word finding, fluency, grammar)
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Perceptual-motor function (visual perception, visuospatial reasoning)
3. Cognitive Domains Affected by MS
Cognitive impairment starts as early as CIS (Clinically Isolated Syndrome).
Radiologically Isolated Syndrome (RIS) already shows changes in 24% of patients.
Prevalence by subtype:
RRMS: 45%
SPMS: 79%
PPMS: 91%
Overall, nearly half of all MS patients experience cognitive impairment.
4. Pediatric MS and Cognitive Challenges
Children and adolescents with MS are also affected:
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Studies (2005–2023): 18–35% show cognitive impairment.
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Emilio Portaccio studied long-term outcomes → pediatric MS impacts work and social attainment in adulthood.
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Around 20% of pediatric MS patients decline compared to 5% of controls.
5. Aging and Cognitive Decline in MS
Normal aging brings cognitive decline. In MS, this effect overlaps with disease-related decline, making the MS brain appear „older“ than expected. With 9,000 people attending the ECTRIMS lecture, awareness is growing and will hopefully impact clinical practice.
6. Progression of Cognitive Impairment in MS
Isolated cognitive relapses can occur without physical symptoms.
Tom Fuchs: study on cognitive PIRA (Progression Independent of Relapse Activity and MRI activity).
68% of patients showed cognitive decline independent of EDSS worsening.
This highlights the need for regular cognitive monitoring.
7. Importance of Cognitive Screening
Baseline screening with SDMT (Symbol Digit Modalities Test) or similar.
Annual reassessment recommended.
Screening tools:
BRB (Brief Repeatable Battery) – Stephen M. Rao, Dawn Langton, Ralph H. B. Benedict
BICAMS – Brief International Cognitive Assessment in MS
MEGFIMS – Minimal Assessment of Cognitive Function in MS
A new joint ECTRIMS–IMSCOGS guideline project is underway with 55 experts from 27 countries, including MS patients.
8. Physiopathological Mechanisms of Cognitive Impairment
Cognitive impairment in MS has multifactorial causes:
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White matter damage and lesions
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Gray matter atrophy (early predictors of impairment – Amato & DeStefano, 2004)
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Functional network dysfunction
Key research:
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Stefano Ziccardi & Massimiliano Calabrese – early gray matter atrophy predicts long-term impairment.
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Catarina Mainero & Iris Katharina Penner – functional MRI studies on attention and working memory.
9. Cognitive Reserve and Brain Health
Cognitive reserve can protect against decline. Intellectual enrichment and a brain-healthy lifestyle help:
Continuous learning
Social interaction
Mental stimulation
Lifestyle measures:
Stop smoking
Limit alcohol
Stay physically and cognitively active
Eat healthy, unprocessed foods
10. Identifying Cognitive Phenotypes in MS
Emelinda De Meo studied 1,212 MS patients, identifying five phenotypes:
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Preserved cognition (19%)
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Mild verbal memory/semantic fluency issues (30%)
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Mild multi-domain issues (19%)
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Severe attention/executive issues (14%)
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Severe multi-domain issues (18%)
Understanding phenotypes helps tailor treatment and interventions.
11. Management Approaches for Cognitive Impairment
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DMTs: small but positive effects on cognition (meta-analysis of 44 RCTs).
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Cognitive rehabilitation: proven beneficial (e.g. De Luca, Chiaravalotti, Sandroff 2020).
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Memory rehabilitation shows meaningful improvement (Taylor et al.).
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Rehabilitation-induced neuroplasticity confirmed by imaging.
Emerging approaches:
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Computerized training, VR, gamification, neurofeedback
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Mindfulness & meditation
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Combined physical and cognitive training
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Non-invasive brain stimulation (TMS, TDCS)
Referenced experts: John DeLuca, Nancy D. Chiaravalotti, Brian M. Sandroff, Anthony Feinstein (COGEx study), Leigh Charvet, Hanneke Hulst.
12. Future Directions in Cognitive Care for MS
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Make cognition visible in MS care (routine integration).
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Use digital tools for monitoring.
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Prioritize cognition in clinical trials.
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Develop evidence-based, tailored rehabilitation.
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Encourage patient participation in studies.
Acknowledged networks:
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Italian MS Centers
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Sclerosi Multipla Fondazione Italiana, Multiple Sclerosis Society of Canada, EUPeMed
13. Summary and Farewell
Cognition is becoming a central focus in MS research and care. Despite advances in treatment, cognitive challenges remain. They are crucial for work, social life, and independence. The good news: screening, rehabilitation, and lifestyle adjustments can make a difference.
A heartfelt thank you to Prof. Maria Pia Amato for her inspiring lecture at ECTRIMS.
In the next episode, I will welcome Dr. Melika Ara-Bafrani to talk about vaginal health and MS – what women should know.
Stay positive, stay active – and see you next time.
See you soon and try to make the best out of your life,
Nele
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