“Cognitive impairment (CI) occurs in 30% to 70% of people with multiple sclerosis (MS) and has a profound influence on personal functioning, social interaction, employment, and overall quality of life,” Wan-Yu Hsu, PhD, explains. “The ability to effectively detect CI is essential to better manage further decline and help patients navigate problems related to their daily living.” Clinical cognitive assessment, she adds, currently relies on in-clinic comprehensive neuropsychological examinations. Traveling to clinics, however, may be burdensome for some patients, due to deficits in mobility or cognition. “As a result, some patients may have limited access to cognitive assessments,” Riley Bove, MD, says. “The application of digital cognitive assessments provides flexibility, as the testing can be performed in different settings, including patients’ homes, which substantially improves access for patients who may face scheduling, geographic, or economic barriers in accessing standard forms of cognitive assessment.”

Significant Performance Differences Observed

For a paper published in the Journal of Medical Internet Research, Drs. Hsu and Bove and colleagues sought to determine the feasibility and potential assessment sensitivity of EVO Monitor—an unsupervised, adaptive, digital tablet game—to assess cognition in patients with MS. A cohort of 100 people with MS (33 with CI and 67 without) and 24 adults without MS were tested with EVO Monitor and standard measures, including the written version of Symbol Digit Modalities Test (SDMT) and Timed 25-Foot Walk test (T25FW). While the EVO Monitor assessment is self-guided, a study coordinator sat in with participants to ensure they were following instructions.

When using the EVO Monitor, participants are instructed to respond to colored target stimuli by tapping an iPad screen while navigating a character along a dynamically moving road and avoiding walls and obstacles by tilting the iPad. “Patients with both MS and CI performed worse on EVO Monitor than participants without MS and worse than patients with MS without CI,” says Dr. Hsu. “Associations between performance on EVO Monitor and standard cognitive measures were also observed. These findings suggest that EVO Monitor is a potential approach to measuring cognitive performance in patients with MS.”

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Cognition in MS Linked With Physical Fitness & Balance

Previous studies have shown that cognition in MS is associated with physical fitness and balance, Dr. Bove notes. “We performed exploratory analyses to examine the association between performance on EVO Monitor and on T25FW,” she says. “We observed that a faster walking speed was associated with a better EVO Monitor performance. The association between EVO Monitor performance and the T25FW may be explained by cerebral injury causing impairment in both domains in MS (Table).”

Drs. Hsu and Bove recommend that, as new evidence is generated in the field of digital health and cognition, neurologists consider incorporating the use of digital tools for cognitive assessment in MS. “Our findings suggest that EVO Monitor could be a clinically valuable approach to capturing CI in MS,” Dr. Hsu says. “Digital cognitive assessments provide flexibility, as the testing can be performed in different settings, including in the home and where access to trained examiners is limited or costly. In addition, digital cognitive assessments can help patients effectively detect CI and allow repeated assessments to provide a more precise monitoring of longitudinal changes in cognitive performance.”

Drs. Hsu and Bove express a need for further studies evaluating the use of EVO Monitor in everyday situations across different contexts and investigating whether results would be different due to fluctuations in cognitive ability during the day. “For example, a key factor in cognitive assessment is patient fatigue,” Dr. Bove explains. “Controlling for impacts of perceived fatigue and fatigability on cognitive assessments measured by digital tools would be helpful. There is also a need for studies with multiple data points to determine the reproducibility of the observed results to conclude the test-retest reliability of EVO Monitor.”