Perry: I was in the Air Force for 20 years and a few months.
I did strategic nuclear war planning.
I was in a combat unit for three years,
headquarters communications,
policy and plans for communications and computers,
NATO, Joint Chiefs of Staff, DISA,
and Office of the Secretary of Defense.
Then retired.
The head of neurology, Walter Reid, reviewed my MRI,
and he put up the films,
and all of a sudden, he got quiet.
And he looked and said, "You have MS."
Dr. Dux: Often when people hear multiple sclerosis
they think about some of the physical impacts
of the disease, such as difficulty walking.
One of the things that I focus on however
is the impact of the disease on thinking skills,
sometimes referred to as cognitive functioning.
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Dr. Ryan The most commonly effected areas
of cognitive functioning
are processing speed, learning of new information,
and organization problem solving,
those kind of higher level skills that people need
in order to be able to function well in their daily lives.
Perry: I get distracted.
I can be reading my newspaper, look up,
oh, the hummingbird feeder needs to be filled.
And as I think about that,
as my eyes come back to the paper,
oh, I need to water the plants today.
I come back to the paper, where did I leave off?
Dr. Dux: So about 40 to 70% of
individuals with multiple sclerosis
have discernible cognitive impairment
on neuropsychological evaluation.
However, even more patients report subjective concerns
in their day to day function.
Dr. Lee-Wilk: Many times
individuals will be somewhat embarrassed
that they're having difficulties
and will try to hide that from people
or will come up with ways of,
maybe they'll stop going to parties
if they can't remember someone's name.
But it really does impact your quality of life.
Perry: I'm worried that my social interactions with people
will take a hit.
How will I go on a date?
How will I interact with my grandchildren?
I want to be independent.
I just hope that day never comes when I'm not.
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Dr. Dux: No two patients with MS are alike,
and that's why it's very important to have
an objective assessment of thinking skills.
Clinician: We're going to be doing a battery
of neuropsychological tests today.
And what that means is I'm going to ask you to do
a bunch of different tasks.
Dr. Lee-Wilk: The neuropsychological evaluation
includes objective tests that assess
different aspects of thinking skills,
attention, memory, problem solving,
and we look at all of that information
to better understand the inner workings of your brain
and its association with behavior.
Perry: When these tests are done, you get the results.
They're laid out in front of you.
It's you in here, it's accurate,
and it allows you to say,
okay, this is where I need to focus
to be better going forward.
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Dr. Dux: Cognitive rehabilitation is a type of intervention
or treatment to address thinking difficulties.
We are most focused on trying to understand
what's important to a patient, what their goals are,
and how cognitive symptoms are interfering
with their ability to achieve their goals.
Dr. Ryan: Cognitive rehabilitation generally comprises
two different approaches.
One of them is restorative.
In other words, you're going to try to
work on the skill that is impaired directly.
Perry: The brain needs to be exercised every day,
and it can be exercised in so many different ways.
So just like muscles,
you don't exercise them, they go flacid.
Well, certainly if you don't use your brain,
it's gonna turn to pudding.
So I do crosswords.
I periodically do math by long hand not by calculator.
I read.
I play chess.
I try to engage in serval different music instruments,
teaching myself.
Different kinds of intelligence
is working different parts of the brain.
As I exercise those, that's, I think,
how it's going to stay sharp.
Dr. Ryan: So the other aspect of cognitive rehabilitation is
learning compensatory strategies,
knowing that, okay, even if we cannot
directly modify your brain,
we can learn new ways of doing things.
Dr. Dux: There are both low tech and high tech techniques.
So starting with the low tech approach,
using a notebook, a reminder system like a calendar
to track all of your appointments can be really useful.
Perry: I have cue cards.
I made cue cards based on our conversations.
I have it for organization.
I have it for sleep hygiene.
I have it for focus.
Dr. Dux: For individuals who prefer to use technology,
we work with them to identify applications
and tools on their device, such as a smartphone,
that might assist with some of the difficulties
that they're having with thinking skills.
For example, technology can be really useful for
difficulties taking medications as prescribed.
The dosing schedules, and time,
and just sheer number of medications that they're taking
can get very complicated very quickly.
Perry: But I have the cure for that.
I put it in my iPhone.
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Dr. Dux: Cognitive symptoms and fatigue
are both symptoms of multiple sclerosis.
What we find is that when people are particularly fatigued,
that cognitive symptoms are even worse.
So we work on different strategies
sometimes referred to as sleep hygiene
to come up with a routine at night before bedtime
that works for a person.
Dr. Ryan: The last time you were here we were talking about
making some changes in your sleep habits.
How'd that go?
Perry: It was a rough week.
Dr. Ryan: Oh yeah?
Perry: Up, down, up, down, up, down.
Dr. Ryan: Depression,
in and of itself, has cognitive symptoms
not just mood symptoms.
So depression, like the word says, depresses everything.
And that has been shown to slow down people's thinking,
narrow their reasoning abilities.
So it's hard to figure out solutions to problems.
Dr. Dux: Therefore, we want to be sure to assess
for depressive symptoms
and to aggressively treat depressive symptoms.
The success of cognitive rehabilitation
hinges upon being able to take the strategies
that are practiced and identified in an office,
or treatment setting, and use them at home.
Once you've identified which strategies are useful,
it's a process of practice, practice, practice.
Dr. Lee-Wilk: There is research to show that
aspects of cognitive function
can be improved with cognitive rehabilitation,
but it's really only as useful as the patient makes it.
Perry: I schedule too many tasks.
Dr. Ryan: Mr. Loswick is someone who is really in many ways
an ideal patient because he has taken the suggestions
and strategies that we offer in cognitive rehabilitation
and really implemented them in his life.
Perry: Maybe somebody can go a week,
a couple weeks without doing their biceps,
or squats, or whatever.
The brain is a little bit different.
It needs to be exercised every day.
We're talking about the one thing in your body
that keeps everything going.
And if you let that go, and it goes to pudding,
then the rest of the body is not gonna fair well at all.
A lot of things motivate me.
I have a life.
I have goals.
I have two children.
I have three grandchildren.
And they would like me to be there for them.
But what if I have a problem
'cause I haven't been doing my exercises?
Dr. Ryan: We are here to work with people
and help them adjust, and adapt,
and find ways to live the best life that they can live.
Perry: You have to avail yourself
of the services that are there for free.
So if you're not in the VA system,
you get in the VA system.
You can then take advantage of neurology
and neuropsychology to help you deal with your MS.
You can only make yourself better.
So go.
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