An interdisciplinary approach is necessary in the treatment of cognitive decline in multiple sclerosis: Yes

Comprehensive management of cognitive decline is an interdisciplinary endeavour. Cognitive decline commonly affects people living with multiple sclerosis (MS). Cognitive limitations from MS vary between individuals (e.g. domains affected) and regardless of severity, have a large negative impact on the quality of life. In addition, cognitive impairment can impede interactions between people with MS and their health care providers. An interdisciplinary approach to treating the cognitive challenges and resulting concerns of people living with MS best addresses the functional impact of cognitive decline. Multidisciplinary care is reported as the standard of care. ¹ Furthermore, overall comprehensive management of MS (including cognition) requires interdisciplinary collaboration throughout the entirety of the disease course.

Awareness of cognitive concerns, referral options, and potential treatments is a responsibility for all members of the health care team and begins at the point of diagnosis. Although psychologists and neuropsychologists have an evident and well-established role in evaluating and characterizing cognition, access to such specialized services in the routine management of MS remains a challenge. This reinforces the need to include other members of the health care team. Cognitive challenges might be first detected or reported to other health care providers seen more regularly (e.g. family physician, nurse, neurologist). MS cognitive screening should be conducted by many different disciplines and there are easily accessible methods available (e.g. Symbol Digit Modalities Test, symptom checklists, direct observation, collateral information). Screening has many benefits including prognostic value, monitoring over the course of the illness, and early identification of those in need of intervention. ² There remains a need for tools to assist members of the health care team in increasing their confidence in the use of cognitive screening and to continue the trend of better clinical integration. ³

Once cognitive impairment has been identified, neuropsychologists can assist in determining which individuals are most likely to benefit from cognitive rehabilitation. ⁴ Another key and potentially more readily accessible rehabilitation specialist is an occupational therapist (although access varies by geographical location and type of health care system). In addition to cognitive rehabilitation and functional cognition, occupational therapists focus on patient-centred and goal-oriented approaches to maintain engagement in life activities despite cognitive impairment (e.g. driving, employment, and participation in meaningful life tasks/events). Addressing these areas of importance to people living with MS (e.g. activity limitations and participation restrictions) should be part of routine MS care and are critical to emphasizing an ‘ability’ (vs disability)-oriented approach to living with cognitive impairment. ⁵ Physiotherapists and physiatrists also play a key role in supporting people with MS with their functional cognition as it relates to safe mobility and can further address cognitive challenges, such as dual/multitask training (e.g. motor–cognitive interaction).

Throughout the disease course, there are also multiple time points when cognitive reserve can be addressed by multiple team members. How effectively cognitive reserve can be addressed to impact decline in MS remains an important research priority. Family physicians have a role in addressing healthy lifestyle as a preventive strategy. Once a diagnosis of MS has been established, rehabilitation should be initiated early to enhance cognitive reserve before declines are observed. In addition to early intervention, we must ensure that all MS symptoms (e.g. fatigue, mobility) and any social and environmental restrictions are addressed, given that these can interfere with a person’s ability to engage in cognitively enriching activities. ⁶ Optimizing physical mobility (e.g. via occupational, physical, and exercise therapists) and mood (e.g. via mental health professionals) will facilitate access to cognitively stimulating pursuits.

Engaging in meaningful activities throughout the lifespan is important for continuous enrichment. Age is a predictor of the degree of cognitive decline; as disease duration increases, the severity of cognitive impairment increases emphasizing the importance of intervention across the disease course. As cognitive dysfunction becomes more prominent, lifestyle interventions (i.e. recreation therapists, family health care team) and rehabilitation efforts can continue to optimize long-term outcomes throughout the aging process. All members of a multidisciplinary care team play a role in addressing health-related behaviours that may contribute to overall cognitive reserve (e.g. exercise, healthy diet, social connections, sleep hygiene). Collaboration with dieticians and nutritionists, recreational and vocational therapists, sleep therapists, exercise therapists, and nurse educators will continue to enhance comprehensive management of cognition. The emphasis on the importance of enhancing cognitive reserve stems from the need to preserve neural network connectivity. Interdisciplinary approaches can enhance the design and implementation of lifestyle and rehabilitation interventions targeting neural capacity, neural efficiency, and neural compensation. ⁷

Challenges remain with identifying, understanding, and addressing comorbidity (e.g. depression and anxiety) or other underlying health conditions in individuals with MS given the influence of these factors on cognitive functioning throughout the lifespan. Family physicians, neurologists, psychiatrists, and MS nurses play a critical role here, and in considering both acute and chronic confounding factors (e.g. medication, fatigue, pain). The role of social and environmental or contextual factors (e.g. family responsibilities, employment considerations, and available social assistance programmes) in cognitive decline is also understudied; social workers bring a wealth of expertise to these additional challenges. A strong social support network can assist in optimizing cognitive health in MS. ⁸

Overall, there is a positive growth seen with increasing research on cognitive interventions grounded in an interdisciplinary approach and in recognition of the importance of integrating perspectives from a multidisciplinary team. ⁹ Interdisciplinary collaboration will continue to accelerate advances in our understanding of cognitive decline in MS and in the development of effective treatment options. This collective approach will further enhance efforts to advocate for the multidisciplinary teams needed clinically to help people with MS maintain engagement in meaningful life activities despite cognitive decline. A challenge remains in accessing multidisciplinary care and implementing evidence-based recommendations. To fuel advocacy efforts for improved access, continued research in interdisciplinary approaches to cognitive concerns is needed in these areas: models of care, clinical recommendations and evolving clinical practice guidelines, and supporting implementation for frontline health care providers. ¹⁰ An interdisciplinary team will ensure a comprehensive approach to managing and ameliorating cognitive decline across the MS disease course and, in turn, can optimize outcomes.