Canaries and Coalmines: Identifying and Responding to Cognitive Impairment in Rheumatology Practice

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Although there is no indication that older adults with chronic inflammatory conditions are at higher risk for developing dementing disease, the likelihood is that mild cognitive impairment will show up in your office.

The relationship between cognitive impairment and immune-mediated and inflammatory disease is well-known and has been widely studied. That research suggests that autoimmune disease can directly result in inflammatory brain disease and cognitive deficits.1 High levels of peripheral inflammatory-cytokine, oxidative stress, and reduced brain derived neurotrophic factor levels have all been correlated with reduced cognitive ability and poorer performance on cognitive tasks. In one study, the rate of cognitive “irregularities” was around 50% among patients with lupus and 90% among patients with ankylosing spondylitis. A 2018 meta-analysis reported on the specific vulnerability of persons with rheumatoid arthritis (RA). Specifically, those authors reported that patients with RA exhibited poorer performance in the areas of verbal function, memory, and attention.2 And a 2019 study suggested that more than two-thirds of patients with RA exhibit cognitive impairment.3

Although there is no indication that older adults with chronic inflammatory conditions are at higher risk for developing dementing disease, the likelihood is that mild cognitive impairment will show up in your office. Frank dementing disease will be obvious in clinical practice and the management of those patients will be followed closely by your neurology colleagues, but mild cognitive impairment will be more subtle and pervasive. Mild cognitive impairment is defined as the stage between the expected cognitive deterioration of normal aging and the more serious deterioration of dementia involving memory, language, thinking, and judgement problems that are abnormal for the patient’s age.4 According to the US Centers for Disease Control and Prevention, more than 16 million people in the United States live with cognitive impairment. So, given the population prevalence and the unique risk for cognitive impairment among rheumatology patients, it is imperative that you know what to look for, how to assess it, and what to do about it.

Memory loss, repeating questions, changes in mood or behavior, vision problems, and failing to recognize familiar faces or places are all signs of cognitive impairment. In your daily practice, though, the manifestation of cognitive impairment may be more subtle. For example, you might notice more frequent no-shows, changes in hygiene, and general non-compliance with treatment plan. Any changes in a patient’s clinical presentation or predictability warrants attention. Mild cognitive impairment may present with general confusion or concussion-like symptoms or mood disturbance and forgetfulness.

The gold-standard for the identification of cognitive impairment, particularly, mild cognitive impairment (MCI) is the MoCA (Montreal Cognitive Assessment). There is also the MMSE (Mini-Mental State Examination), which is also used to measure cognitive impairment empirically. They both use simple cognitive tasks (eg, matching) in order to determine the level of cognitive impairment present in a patient. Both instruments are easy to deploy in clinical settings or in waiting rooms as part of the routine intake process. Tracking cognitive performance over time can give your neurology and neuropsychology colleagues a head start for diagnosis and management.

As to intervention, the best practice is to treat both the symptoms and the underlying causes of cognitive impairment. There are several case reports where the treatment of autoimmune disease remits cognitive symptoms.5 That can be true of specific conditions like Autoimmune Autonomic Ganglionopathy, for example, but also other non-specific conditions. According to the Mayo Clinic’s Neuroimmunology Research Laboratory, some patients with memory deficits may actually have an autoimmune cause for their symptoms and will respond well to immune treatments including steroids. Some researchers promote immunotherapy for adults with dementia (eg, methylprednisolone, prednisone, dexamethasone, intravenous immune globulin, and plasma exchange). In one study, 64% of all patients with dementia who were treated with immunotherapies demonstrated notable improvement in learning and memory cognitive functions. And, if treatment of the underlying autoimmune disease fails to address symptoms of cognitive impairment, you can make a referral to a neurologist for consultation, a neuropsychologist for assessment, or a mental health professional for treatment. The treatment of depression, for example, can yield an improvement in cognitive function among older adults.

Mild cognitive impairment can be managed in outpatient rheumatology practice with some lifestyle modifications and general health-promoting behavior. That includes adding vitamin B12, physical exercise, and a Mediterranean or heart- and brain-healthy diet. The deficits themselves (egABPP, memory impairments) can be managed with low-tech accommodations like written or electronic reminders, printed instructions, pill-bottle cases, or reminder calls. And support for caregivers is imperative. Consider making a referral for them as well—in clinical practice, they are the canaries in the patient’s coalmine. Keep them healthy and your patients will reap the benefits.

References:

  1. Lim L, Lippe S, Silverman E. Effect of autoimmune diseases on cognitive function. Handb Clin Neurol. 2013;112:1275-1283. doi:10.1016/B978-0-444-52910-7.00050-7
  2. Meade T, Manolios N, Cumming SR, Conaghan PG, Katz P. Cognitive Impairment in Rheumatoid Arthritis: A Systematic Review. Arthritis Care Res (Hoboken). 2018;70(1):39-52. doi:10.1002/acr.23243
  3. Vitturi BK, Nascimento BAC, Alves BR, de Campos FSC, Torigoe DY. Cognitive impairment in patients with rheumatoid arthritis. J Clin Neurosci. 2019;69:81-87. doi:10.1016/j.jocn.2019.08.027
  4. Mayo Clinic. Mild cognitive impairment. Mayo Clinic website. Updated September 2, 2020. Accessed December 4, 2020. https://www.mayoclinic.org/diseases-conditions/mild-cognitive-impairment/diagnosis-treatment/drc-20354583
  5. Devineni B, Venkatesan A, Appleby BS, Rao V. Autoimmune-mediated cognitive impairment: a case report. Psychosomatics. 2014;55(6):698-702. doi:10.1016/j.psym.2013.12.012