Neurocognitive Manifestations
in ME/CFS
Gudrun Lange, PhDProfessorDepartment of Physical Medicine and Rehabilitation, Rutgers-NJMS
Outline•Why is it important to talk about cognitive
function in ME/CFS? •What is the clinical presentation?• How can cognitive dysfunction in ME/CFS
be understood? •What is an effective neuropsychological
battery?•What is the research evidence?• Final thoughts
Brainfog: Common and Disabling
• Experienced as difficulties with attention, concentration and multi-tasking
• Recognized as important: Listed as symptom in all ME/CFS case definitions
• Serves as objective criterion for disability: lack of validated physiological markers
Clinical Presentations
• “I feel like I’m loosing my mind…”• “I feel like having the brain of an 80-year
old in the body of a 36-year old…”• “I feel stupid…”
Conceptualization of Cognitive Dysfunction
• Possible etiology of cognitive dysfunction• Genetic • Acquired
• Severity of cognitive dysfunction• Severe• Moderate• Mild
Determination of Severity of Cognitive Dysfunction• Subjective• Patient and family report• Perception of degree of loss of cognitive
function
• Objective• Neuropsychological evaluation• Statistical determination of degree of loss of
cognitive function• Behavioral observations during testing
should be taken into consideration
An effective neuropsychological battery for ME/CFS patients• Has to include standardized and normed
measures that• Sufficiently and repeatedly challenge
complex information processing and multi-tasking• reliably demonstrate areas of cognitive
resilience• assess mood and anxiety• ascertain adequate effort
Intellectual profiles in ME/CFSWAIS-IV profile: Scores discrepant from expected levels Case 1 Case 2
Case 1
Analysis
Index Level Discrepancy Comparisons
Comparison Score 1 Score 2 Difference
Critical Value .05
Significant Difference
Y / N Base Rate
Overall Sample
VCI - PRI 112 94 18 7.78 Y 9.5
VCI - WMI 112 77 35 8.31 Y 0.5
VCI - PSI 112 65 47 11.76 Y 1
PRI - WMI 94 77 17 8.81 Y 9.2
PRI - PSI 94 65 29 12.12 Y 3
WMI - PSI 77 65 12 12.47 N 20.2
Subtest Scaled Score Profile
The vertical bars represent the standard error of measurement (SEM)
Case 2
Analysis
Index Level Discrepancy Comparisons
Comparison Score 1 Score 2 Difference
Critical Value .05
Significant Difference
Y / N Base Rate
Ability Level
VCI - PRI 114 107 7 8.31 N 30.3
VCI - WMI 114 111 3 8.82 N 45.7
VCI - PSI 114 97 17 10.19 Y 19.4
PRI - WMI 107 111 -4 9.74 N 36.2
PRI - PSI 107 97 10 11 N 35.9
WMI - PSI 111 97 14 11.38 Y 23.7
• Clinical Interview• Wechsler Adult Intelligence
Scale - Fourth Edition (WAIS-IV)
• Test of Premorbid Functioning (TOPF)
• Beck Depression Inventory II (BDI II)
• Spielberger State Trait Anxiety Questionnaire (STAI)
• Gordon Diagnostic Test• Stroop Test• DKEFS• Trails• Verbal Fluency Test• Paced Auditory Serial
Attention Test (PASAT)
• Wisconsin Card Sorting Test (WCST)
• California Verbal Learning Test II (CVLT-II)
• Wechsler Memory Scale - Fourth Edition (WMS-IV)
• Boston Naming Test (BNT)• Rey Osterrieth Complex
Figure (ROCF)• Judgment of Line Orientation
Test (JOL)• Hooper Visual Organization
Test• Hand Dynamometer• Grooved Pegboard• Finger Tapping Test (FTT)• Validity Indicator Profile (VIP)
Findings on neuropsychological exam• Decreased attention, concentration and
slowed processing speed• Problems sequencing pieces of information and
prioritizing their use for quick decision making
• Limited working memory, • less information available “online”• Learning difficulties:• Changes in learning strategy• Poor absorption and recall
Neuropsychological Profile in ME/CFS• Profile suggests mild, subtle deficits• Evaluation of impairment relative to
expected level of intellectual function necessary to uncover true deficiencies
• Profile not consistent with dementia• Generally no frank memory problem
• Profile can be differentiated from conditions of a more focal nature
Brain Abnormalities in ME/CFS
• Lange et al., 2005• Used verbal working memory task to • probe brain function using fMRI• simultaneously assessing efficient information
processing behaviorally
• Statistically controlled for age, mood, anxiety, self-reported mental fatigue score• Equated on prior behavioral test performance
on same task
Brain Abnormalities in ME/CFS
• Controls versus ME/CFS:• No differences in brain activity during simple
condition• When task demands get more complex, ME/CFS
increased involvement of • Anterior Cingulate BA 24/32 • Left DLF BA 10/44/45/47• Bilateral supplemental and premotor BA6/8• Parietal regions BA 7/40
Brain Abnormalities in ME/CFS
• Increased signal change was significantly accounted for by ME/CFS report of mental fatigue• Perceived mental fatigue is reflected by increased
functional recruitment of • Left superior parietal region (BA7) • Responsible for shifts in attention
• Bilateral supplementary and premotor regions (BA6/8)• Associated with automatic information processing• maintenance of temporal order
Brain Abnormalities in ME/CFS• No lack of effort accounted for the
differences in signal change• To achieve behavioral performance similar
to Controls• Brains of ME/CFS work harder when tasks
are complex• Require efficient and quick information
processing• Require effective online sequencing and
prioritization
Consequences of cognitive dysfunction in ME/CFS• Automaticity of cognitive function is often lost• Mundane tasks become effortful•Multi-tasking often impossible• Considered by patients as affecting every
aspect of their lives
• Mental exertion can last for a long time
Is there an effective cognitive screen for ME/CFS patients? • Dementia screens and typical brief
bedside memory tests are not appropriate• i.e. MMSE, Mini-Cog• Suggestions:• Serial 7s, Digit Span Sequencing•May work if done for at least a few
minutes• Quickly give a 6-or-7 step set of complex
driving directions and request repetition
Final thoughts• If evaluation of cognitive function is
needed• Refer to Clinical Neuropsychologist
knowledgeable about ME/CFS•Much more work is needed to familiarize
Neuropsychologists with ME/CFS to provide valid and reliable neuropsychological assessments.
Top Related