Easy Cognitive Assessments for People With MS

I am pleased to announce the unveiling of a free website offering the interpretation of brief and easily administered cognitive assessments for patients with multiple sclerosis (MS). Cognitive impairment is a common problem in MS, and patients frequently experience job loss and failures with activities of daily living. We hope our Brief International Cognitive Assessment for MS (BICAMS) website will make it simple and routine to identify those patients.

The BICAMS committee included a mix of neurologists and neuropsychologists, representing the United States and several European countries. All in the group are well known for international, multicenter research in MS cognition. Using psychometric criteria, the committee rated candidate tests for validity and ease of use. 

In its final form, BICAMS emphasizes three tests with high reliability and good sensitivity. The Symbol Digit Modalities Test (SDMT), a measure of cognitive processing speed, is well tolerated by patients, requires no special equipment, and can be completed in less than 5 minutes. For the domain of memory, BICAMS uses the initial learning trials of the California Verbal Learning Test 2^nd Edition (CVLT-II), which takes just 10 minutes to complete, and the Brief Visuospatial Memory Test-Revised (BVMT-R), which takes 5 minutes.

These tests can be administered by medical staff who may have no formal training in neuropsychology. But how does one interpret the results? The BICAMS website solves that problem by providing clinicians with immediate access to standard score equivalents (e.g., z-score) for the test result. There is no charge for this service; users need only agree to provide deidentified data to be kept for research purposes.

The tests themselves must be purchased from the respective publishers: SDMT is available from Western Psychological Services, CVLT-II is available from Pearson Education, and BVMT-R is available from PAR.

BICAMS is not intended to replace a full neuropsychological assessment nor to determine whether a full assessment is necessary. Instead our goal is to help clinicians monitor specific cognitive functions that are known to be compromised in many MS patients. The website facilitates use by providing immediate normalization of the test result. However, when using BICAMS, clinicians should also consider the role of comorbid neurological or medical conditions. For example, questions regarding difficulties in school performance or with reading can yield helpful information. The medical history should also include questions regarding past head trauma, cerebrovascular disease, and sleep disorders. Certain medications can adversely affect cognitive performance, such as benzodiazepines, anticonvulsants, and high doses of antispasticity agents such as baclofen. Depression is also highly prevalent in MS. BICAMS does not include a measure of depression, although such tests are available elsewhere and could be used concurrently with BICAMS. Interestingly, treatment of depression (and fatigue) improves patients’ self-report of cognitive function but may not alter their cognitive test performance.

For the website to be truly effective, normative data will be needed from many countries other than the United States. We have published an international validation protocol for BICAMS, and studies in more than a dozen other countries are completed, under way, or being planned. We envisage a day when clinicians from all over the world will monitor patients using BICAMS and, in exchange for free normalization, will share deidentified patient data with the site. In that way we will be able to improve the clinical utility of the monitoring tool. Cognitive assessment can then become a part of routine clinical MS practice.

Further details can be found in a full list of open-access, peer-reviewed publications, as well as abstracts, posters, and presentations, all of which can be downloaded from the website.

Two notable peer-reviewed publications are:

Langdon DW, Amato MP, Boringa J, Brochet B, Foley F, Fredrikson S, Hämäläinen P, Hartung HP, Krupp L, Penner IK, Reder AT, Benedict RH. Recommendations for a Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS). Mult Scler. 2012 Jun;18(6):891-8. doi: 10.1177/1352458511431076. Epub 2011 Dec 21. PMID: 22190573

Benedict RH, Amato MP, Boringa J, Brochet B, Foley F, Fredrikson S, Hamalainen P, Hartung H, Krupp L, Penner I, Reder AT, Langdon D. Brief International Cognitive Assessment for MS (BICAMS): international standards for validation. BMC Neurol. 2012 Jul 16;12:55. doi: 10.1186/1471-2377-12-55. PMID: 22799620