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Baumstarck-Barrau et al. BMC Neurology 2011, 11:17 http://www.biomedcentral.

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RESEARCH ARTICLE

Open Access

Cognitive function and quality of life in multiple sclerosis patients: a cross-sectional study
Karine Baumstarck-Barrau1, Marie-Claude Simeoni1, Françoise Reuter2, Irina Klemina2, Valérie Aghababian3, Jean Pelletier2, Pascal Auquier1*

Abstract
Background: Nearly half of all patients diagnosed with multiple sclerosis (MS) will develop cognitive dysfunction. Studies highlighted from no/weak impact to a strong impact of cognitive impairment on quality of life (QoL). The aim of this study was to assess the impact of cognitive dysfunction on self-reported QoL in MS patients while considering key confounding factors. Methods: Design: cross-sectional study. Inclusion criteria: MS patients of any disease subtype. Data collection: sociodemographic (age, gender, marital status, education level, and occupational activity) and clinical data (MS subtype, disease duration); MS disability (Expanded Disability Status Scale, EDSS); depression (Beck Depression Inventory); fatigue (Modified Fatigue Impact Scale); QoL (SF36 and MusiQoL); and neuropsychological performance (Brief Repeatable Battery of Neuropsychological Tests, BRB-N). Statistical analysis: multiple linear regressions (forward-stepwise selection). Results: One hundred and twenty-four patients were enrolled. Performance on BRB-N subtests varied widely (6% to 70% abnormal). The BRB-N classified 37-78% of the patients as cognitively impaired, depending on the definition of cognitive impairment. No links were found between the MusiQoL index and cognitive subtests, whereas marital status, EDSS, and depression were found to be independent predictive factors. Conclusions: The present study demonstrated the weak and scarce association between cognitive impairment and QoL, when the key confounding factors were considered. These results need to be confirmed with larger samples and more accurate tests of cognitive function.

Background Multiple sclerosis (MS) is the most common demyelinating disease of the central nervous system in young adults. Cognitive impairment occurs in about 50% of patients with MS [1,2], even during the early stages of the disease [3,4]. Cognitive dysfunction may subsequently result in reduced fulfilment in work life and social life as well as in a reduction in quality of life (QoL) [5-7]. To date, few studies have reported relationships between cognitive function and patient QoL [8,9]. Existing studies have revealed contradictory results, highlighting either negligible impact [7,10-13] or a strong impact [5,14,15] of cognitive impairment on QoL. The potential weaknesses of these studies
* Correspondence: pascal.auquier@univmed.fr 1 EA3279 Self-perceived Health Assessment Research Unit and Department of Public Health, Nord University Hospital, APHM, Marseille, France Full list of author information is available at the end of the article

could lie in the cognitive or QoL evaluations. In some studies, the cognitive assessment was restricted to a single cognitive function [14,15]. In others, cognitive impairment was defined using tools recognised as insufficiently sensitive [5,12]. In still other studies, the QoL assessment was restricted to a single QoL-specific domain [11], or QoL predictors were not considered simultaneously [12,14]. Thus, it was necessary to assess the relationship between cognitive performance and QoL using a standardised neuropsychological battery and a disease-specific patient-based instrument, respectively. To our knowledge, only one previous study has reported this relationship using both a wellestablished battery of cognitive tests (Brief Repeatable Battery of Neuropsychological Tests) and a well-validated QoL measure (Multiple Sclerosis Quality of Life Inventory) [16]. However, this study focused on early MS, and depression was the only controlled variable.

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2% had more than 12 years of education. no history of alcohol/drug abuse. France). and the Word List Generation test (WLG).05. The Short Form 36 (SF36) is a generic questionnaire [21] describing eight subscales (physical function. EDSS. and general health). USA). complex visual scanning.80). Associations between the QoL scores and continuous variables (fatigue. disease duration) data were recorded.3% were living in a personal home. role physical. 47. sentimental and sexual life (SSL). Cognitive impairment or deficit was defined using Camp’s normative values [24]. MS subtype. bodily pain. working memory. The MS subtypes .5% were unemployed. SRT-C.75. and he/she was considered cognitively impaired or deficient for the global battery if he/ she was cognitively impaired for at least three of the eight subtests. Depression was assessed using the self-administered Beck Depression Inventory (BDI) [19].Baumstarck-Barrau et al. Methods This study incorporated a cross-sectional design and was performed in the neurology department of a French public academic teaching hospital (Marseille. SRT-D). vitality. age. and fatigue was assessed using the 21-item Modified Fatigue Impact Scale (MFIS) [20]. To determine variables potentially predictive QoL levels. 64. All tests were two-sided. involving mental calculation. MS subtype. 11:17 http://www. The MS disability was assessed using the Expanded Disability Status Scale (EDSS). The final models incorporated the standardised beta coefficients. depression. the sexratio was 0. Two composite scores (physical and mental. EDSS. and sustained attention. which determines the speed of visual information processing.. The inclusion criteria were as follows: MS patients according to McDonald criteria [17. no history of psychiatric or neurological disease (other than MS). the two indices of the 10/36 Spatial Recall Test (SPART-T. The statistical analyses were performed using the SPSS software package version 15. Sociodemographic (age. and disease duration). a verbal learning/memory test.05 years (SD 10. The French Ethics Committee (Comité de Protection des Personnes. The independent variables with the higher standardised beta coefficients are those with a greater relative effect on QoL. relationships with friends (RFr). The subject was considered cognitively impaired or deficient for one subtest if the score was at least two SDs below the mean normative values. Statistical significance was defined as p < 0. and information processing speed. marital status. concentration. marital status.20 (MFIS-To. The Multiple Sclerosis International Quality of Life (MusiQoL) is a well-validated. a visuospatial learning and memory test. and rejection (REJ)) and yielding a global index score. psychological well-being (PWB).18]. A set of additional variables was included in the models owing to their clinical and sociodemographic relevance (gender. The battery was administered in a standardised way by the same psychologist (FR).0 (SPSS Inc. BRB-N subtests. Marseille II) approved the study. Statistical analyses Data were expressed as the means/standard deviations or the medians/ranges.30 for the BRB-N subtests. and occupational activity) and clinical (MS subtype. including any disease subtypes. education level. educational level. any disease subtype. and native French speakers. Chicago. SPART-D). BMC Neurology 2011. gender. role emotional. while considering the key sociodemographic and clinical confounding factors to report that cognitively disabled patients with MS are able to give consistent answers to self-reported questionnaires. disease duration) were analysed using Spearman’s correlation tests. coping (COP). symptoms (SPT).com/1471-2377/11/17 Page 2 of 10 We examine the relationship between cognitive dysfunction and QoL in a sample of patients with MS. who was intensively trained in test administration. The MusiQoL index and each of the MusiQoL dimensions were considered as separate dependent variables. 47. a semantic verbal fluency test. depending on the parametric or non-parametric distribution of the variable. Two QoL questionnaires were administered. the Symbol Digit Modalities Test (SDMT). living. multiple linear regressions (forward-stepwise selection) were performed. relationships with family (RFa). the Paced Auditory Serial Addition Test (PASAT-3). and patients gave their informed consent to participate. The eight subtests were selected to explore most of the cognitive functions: the three indices of the Selective Reminding Test (SRT-L. and 87. social functioning. disease-specific questionnaire [22] describing nine dimensions (activity of daily living (ADL). IL. Means-based comparisons of the MusiQoL dimensions and the indices between different sub-groups (gender. based on a threshold p-value ≤0. relationships with health care system (RHCS).2% were single. Neuropsychological performance was assessed using the Brief Repeatable Battery of Neuropsychological Tests (BRB-N) [23]. BDI) or a threshold p-value ≤0. mental health. The variables relevant to the models were selected from the univariate MusiQoL index analysis. The mean age was 45. Results One hundred and twenty-four consecutive inpatients and outpatients with MS were enrolled during a twelve-month period. marital status. age. occupational status. PCS-SF36 and MCS-SF36) can also be calculated. BRB-N cognitive function) were calculated using Mann-Whitney or Kruskal-Wallis tests.biomedcentral.

72 ± 20. self-reported quality of life and cognitive functions N = 124 Disease duration in years EDSSa Depression Fatigue median [range] median [range] BDIb (0-39) BDIb classes (moderate/severe depression) MFISc Physical (0-36) MFISc Cognitive (0-40) MFISc Psychosocial (0-8) MFISc Total (0-84) SF36d Physical function (0-100) Social functioning (0-100) Role physical (0-100) Role emotional (0-100) Mental health (0-100) Vitality (0-100) Body pain (0-100) General health (0-100) Mental composite score Physical composite score MusiQoLe Activity of daily living (0-100) Psychological well-being (0-100) Relationships with friends (0-100) Symptoms (0-100) Relationships with family (0-100) Relationships with health care system (0-100) Sentimental and sexual life (0-100) Coping (0-100) Rejection (0-100) Index (0-100) BRB-N subtests f 9.42 56.44 ± 15.77 47 (70.28 ± 38.Baumstarck-Barrau et al.62 32.88 ± 26. the higher the QoL level.48 ± 19. the more severe the fatigue.97 ± 7.00] 10.07 50. 11:17 http://www.79 62. SPT.75 [1. PASAT-3 Paced Auditory Serial Addition Test 3 s. the higher the score.80 ± 26. SPART-T SPAtial Recall Test Total.00] 4. f BRB-N subtests. the higher the score.biomedcentral.17 ± 15.87 5. 36 relapsing remitting.00-8. depending on the definition of cognitive impairment.40 SRT-L g SRT-Cg SRT-Dg SPART-Tg SPART-Dg SDMTg PASAT-3g WLGg a b EDSS Expanded Disability Status Scale.68 ± 11. 20 primary progressive.83 38. SPART-D SPAtial Recall Test Delayed. and Table 1 Clinical characteristics.32 ± 8.27 18.92 34.88 ± 23.36 35.40 66.96 16.72 9. The MusiQoL index was not significantly correlated with the BRB-N subtests.com/1471-2377/11/17 Page 3 of 10 included 61 secondary progressive.48 49. and cognitive data are listed in table 1.12 45.37 ± 2.86 [0-31.24 50.31 33.09 20.81 32.64 ± 29.95 ± 30.27 40.64 ± 8. Performance on BRB-N subtests varied widely (6% to 70% abnormal). SRT-C Selective Reminding Test Consistent long-term. the higher the cognitive performance.75 55.15 ± 15.16 49. e MusiQoL Multiple Sclerosis International Quality of Life.63 ± 12.97 ± 24. c MFIS Modified Fatigue Impact Scale. BMC Neurology 2011. the higher the score.42 ± 5.21 39. the higher the score.75 ± 8. the higher the score.03 ± 15. The BRB-N classified 3778% of the patients as cognitively impaired.03 ± 24. Weakly significant correlations were identified for the ADL.89 69.49 ± 19. SRT-D Selective Reminding Test Delayed. The QoL was not strongly associated with any cognitive subtests.57 46. BDI Beck Depression Inventory.1%) 25.31 ± 23.40 ± 5.21 54. self-reported data.90 ± 17.02 25. SDMT Symbol Digit Modalities Test. The clinical features.28 32. WLG Word List Generation test.19 ± 31. the higher the score.85 72. and 7 clinically isolated syndromes.29 ± 2. the higher the QoL level.53 29. RFa.35 ± 2. d SF36 Short Form 36. the more severe the disability. the worse the depression.94 ± 21.78 50. g SRT-L Selective Reminding Test Long-term. .20 5.59 ± 9.00 ± 33.17 ± 24.

To our knowledge.18* SRT-Cc SRT-Dc SPART-Tc SPART-Dc SDMTc PASAT-3c WLGc MFIS-Phd MFIS-Cgd MFIS-Psd MFIS-Tod BDIe a -0.08 -0.03 0.13* -0.23** -0.11 0.34*** -0.32** MCSb -0.29*** -0.02 a REJ a Index -0. indicating a higher cognitive performance given a higher QoL level.24** -0. and depression were associated with the MusiQoL index. prior studies of the relationship between cognitive impairment and QoL have been contradictory.40*** -0.28*** -0. MFIS-Cg cognitive.12* -0.21* 0.20* -0.05 a SSL a COP 0. which is restricted to assessment of self-perceived cognitive difficulties [11]. Our study proposed a similar study design but included all MS subtypes and considered more key confounding factors.27** -0.15* 0. were linked to gender and marital status.02 0.03 -0.19* -0. ***p-value < 0.17* -0.17* 0.21** -0.44*** a RFr a SPT a RFa a RHCS -0.16* 0.05.61*** -0.07 0.17* -0.02 -0. SPT symptoms.56*** -0.001 0. The variables selected for the multivariate models included gender.26*** -0.21** -0. the Sickness Impact Profile [10]. respectively.06 0. RFr relationships with friends. SRT-D Selective Reminding Test Delayed.05 -0.24** -0. indicating a higher cognitive performance given a lower QoL level.23* -0.13* 0.01 0.15* -0. SSL sentimental and sexual life. except in the case of marital status. The QoL dimensions describing physical components.25** 0.52*** -0. SDMT Symbol Digit Modalities Test. MS subtype.62*** -0.05 -0.001 -0.10 -0. age. except in the case of SPART-T with RHCS. were related to depression and fatigue.11 0. Index global score. MCS mental composite score. there has been considerable expansion of the literature that addresses cognitive issues in MS [25].09 0.02 0. RFa relationships with family. WLG Word List Generation test. While the nature of this cognitive dysfunction is relatively well described.06 -0.16* 0. No links between the MusiQoL dimensions and cognitive functions were identified.28*** -0.35*** -0. b SF36 Short Form 36.06 0.05 0.25* -0.com/1471-2377/11/17 Page 4 of 10 SSL dimensions. SPART-D SPAtial Recall Test Delayed. and the four subtests with p-value ≤0.08 0.17* 0. ADL activity of daily living.11 0. fatigue.47*** -0.08 -0.04 -0.24** 0.15* -0.26** 0. PASAT-3 Paced Auditory Serial Addition Test 3 s.05 -0. PCS physical composite score.16* 0.20** -0.01 -0.33*** 0.44*** -0.06 -0. MFIS-To.04 -0.13* 0. This work enrolled only patients with early MS.09 -0.34*** -0.30 (SRT-L.04 0. and depression MusiQoL ADL SRT-L c a a SF36b PWB -0. Lovera and colleagues did not find relationships between attention or memory impairment and scores on the Perceived Deficits Questionnaire.14* -0.07 -0.05 0.biomedcentral.57*** -0.08 -0.003 0.19* 0.09 0.02 0.07 0. QoL was weakly or negligibly related to cognitive function.27*** -0.11* 0.09 0.07 -0.02 0. SPART-T.16* 0.06 0. SRT-D. EDSS.05 0. and depression was the only controlled parameter. In Montel’s Table 2 Correlations between QoL (MusiQoL and SF36) and the BRB-N subtests.23** 0.30.08 -0.08 0. such as RFr and RFa. The link of interest (connection between visuospatial learning and the relationship with health care systems) has not been described elsewhere. c SRT-L Selective Reminding Test Long-term.12* -0. .04 -0.03 -0. Spearman rank correlation coefficients were presented.06 0.11* -0.01 0.30*** -0. e BDI Beck Depression Inventory.13* 0.Baumstarck-Barrau et al.28*** 0.03 0. Marital status.13* -0. REJ rejection. disease duration.07 -0.47*** -0. Depression and fatigue (with the exception of the physical component) were significantly linked to the MusiQoL index and the two composite scores of the SF36. and for the REJ dimension.11 0.55*** -0.18* MusiQoL Multiple Sclerosis International Quality of Life.14* 0.53*** -0.11 -0.12* 0.15* -0.08 0.58*** -0. marital status. RHCS relationships with health care system.35*** -0. All correlations are presented in table 2.06 0.17* -0.11* -0. 11:17 http://www. Discussion In the last few decades.08 -0.25** -0.06 -0. These results are summarised in table 4.13* 0. EDSS. COP coping. BMC Neurology 2011.17* -0.11 a PCSb -0. SPART-T SPAtial Recall Test Total.007 -0. No associations were found between the MusiQoL index and the cognitive subtests.22** -0.21** 0. The dimensions describing relationship aspects. respectively. Rao found only non-significant trends between cognitive impairment and QoL as assessed by a generic questionnaire. Consistent with Glanz’s study [16].17* -0. BDI. PWB psychological well-being.05 0. *p-value < 0. such as ADL and SPT.07 -0.02 -0.03 0. WLG).11* -0. This link did not seem substantial because no robust clinical hypothesis supported or denied this association.02 0.18* 0.29*** -0.23** 0.14* -0.07 0. MFIS-To total. only one recent study has described these links using both a standardised cognitive evaluation (BRB-N) and a specific self-reported QoL questionnaire [16].52*** -0.22** 0.01. single patients had lower QoL scores. SRT-C Selective Reminding Test Consistent long-term.22** 0. d MFIS-Ph Modified Fatigue Impact Scale physical. **p-value < 0.44*** -0.02 -0. Relationships between the MusiQoL dimensions and sociodemographic/clinical variables are detailed in table 3.25** -0.08 -0. MFIS-Ps psychosocial.20** 0. The MusiQoL index was not statistically linked to the sociodemographic/clinical status.

75 (23.57 59.24) 58.63 (11.86 (19.25 (27.89 (11.29) 52.47 (23.03) 0.91 73.88) 59.36 71.46) 0.41) 0.50) 0.53) 25.77 55.41 50.00 (26.07 (29.03 (19.96 (19.41 (27.99 70.36 (25.77 (8.001 52.14 65.10 58.55 (30.02) 73.58 52.13 (18.89 (15.88 (32.62 57.85 (37.79 48.71 53.64 (28.92) 28.20 (23.25) 58.51 (30.90 (31.17 (36.18) 57.73 (34.70) 59.78 (23.72 (26. clinical characteristics.00) 67.001 54.56 (30.27) 0.61) 0.09 (26.25) 48.41) 0.59) 58.01) 0.77) 0.04) 69.61) 0.41) 0.13) 0.88 52.76) 0.54) 60.80) 0.23) 68.05 (33.01) 69.29 (28.28 (13.78 (12.19) 0.98 (22.65 (21.14) 0.65) 50.52 (19.15) 0.27) 54.70) 51.17 (27.30 (28.35) 70.33 (12.14) 0.06 51.biomedcentral.57 (25.87) 0.14) 28.39) 25.54) 0.72 (21.19) 53.80 57.40 (32.30 62.06) 50.91 (29.73) 73.47) 51.36) 31.32 (23.73 (20.83) 0.001 48.30 (19.43 (26.07) 59.77) 64.83 (33.41 (26.89 (29.35) 0.51 (18.64 (24.11 (13.35 49.28 44.65 50.33) 56.64) 50.08 (14.79 70.39 (16.64 (21.14 (21.76 65.22) 66.38 (20.90 (24.30 (19.61 (24.41) 54.20) 0.05 34.57 (10.34) 48.94) 86.07 (30.14 (22.61 (17.73) 0.81) 0.23 57.49 (21.20) 0.09) 0.43 (22.39) 0.34 (32.91) 0.17) 0.98 (16.34 52.67 (15.36 62.30 (27.56 (12.38 (26.19 53.007 47.81 (23.50 (26.99) 59.29) 0.03 71.78 (25.04 (22.36 64.96) 63.00 (30.61) 32.13 44.26 63.32 (31.80) 65.28) 73.94 (20.89 (24.33 (23.51) 0.48) 65.68 (20.50) 69.96) 73.37 (32.10 (31. and cognitive function ADLa Gender* Women Men p* Educational level* <12 years ≥ 12 years p* Marital status* Single Married/partnership p* Living* Personal home Friend/family home p* Occupational status* Working Not working p* MS subtype** RRb PPb SPb CISb p** 39. 11:17 http://www.38 (31.95) 0.91 (19.31 28.43) 0.52 56.31 31.23) 0.12) 0.37 (22.62) 0.61) 57.30) 67.49) 44.47 (24.49 (23.31 (26.20) 62.81 49.54) 53.49) 48.69) 51.80) 0.36 0.28) 0.32) 66.54) 52.88) 56.04) 0.10 (16.21) 59.20 56.48) 0.28 60.44) 59.84 (33.50 (35.44 (23.71 (14.33 (28.73 40.13 (31.84 (22.63 (21.02) 0.70) 0.36) 60.03 63.53(14.25) 51.25 (25.95) 54.04) 0.82 59.51) 61.82 (24.80 30.44) 56.28 (34.002 63.79) 59.03 (23.28) 0.29 75.65) 41.20 70.61) 79.48 (23.08 PWBa RFra SPTa RFaa RHCSa SSLa COPa REJa Indexa Page 5 of 10 .21 (31.84) 0.49) 0.83 (31.60 (24.74) 75.08 (25.84 (18.08) 0.52 (26.03 27.Baumstarck-Barrau et al.68 (19.00) 57.17) 0.97 (24.03 54.20 (24.47 (26.58 (25.93 (16.76 (13.59) 51.52 76.95) 0.91) 64.22) 0.95 (31.04) 69.91 (15.27 (32.81) 0.52 (28.com/1471-2377/11/17 Table 3 Associations between MusiQoL dimension scores and sociodemographics.33) 68.59 (10.70 53. BMC Neurology 2011.29 (21.96) 27.45 62.73 (23.76 (26.65 (32.71) 59.002 65.63 56.13) 55.59) 66.86) 0.45 65.61 48.93) 58.22 54.54) 73.76 (25.12) 70.23 (27.08) 0.09 (23.04 71.47 (24.67) 0.54) 0.88) 67.65) 0.11 (25.15 (24.53 (27.22) 35.93) 0.55 (35.02 (25.67) 19.00) 0.88 (19.46 (14.12) 64.07 68.90 (24.89 (33.

39 (30.42 0.05.55) 67.11 0.24 -0.22 (23. * mean (standard deviation).04 0.00) 0.23 0.18 0.32 0.04) 60.54 74.56 0. Page 6 of 10 .34 -0.25) 70.16) 54. d EDSS Expanded Disability Status Scale. ** mean (standard deviation). BMC Neurology 2011.37 -0.06 0. Bold values: p < 0.Baumstarck-Barrau et al.34) 50.08 0.13 0.48 0.08 0.09 0.26 (18.42 (22.37 0.25 0. c Cognitive function is defined as a deficit from BRB-N with at least three of eight impaired subtests.07 0.76 0.53) 44.12 0.45 0. SSL sentimental and sexual life.27 (22.03 0.36 -0. SPT symptoms.06 0.72 (27.15 0.14) 0.05 0.17 0.06 0.72 (20.43 -0.07 0.58 0.57 52.80 0.06 0.00 0.12 0.05 0. and cognitive function (Continued) Cognitive function* No deficit Deficit p* EDSS *** p Disease duration*** p Age*** p a 31. RHCS relationships with health care system.30 0.10 (12. PWB psychological well-being. COP coping.31 0.71 (24.03 0.71 59.12 0. CIS Clinically isolated syndrome. p: p-value Mann-Whitney test.64 -0.07 0.66 (26.07 63.20 (36. RFa relationships with family.03 (20.19 57.13) 0.30) 52.81) 0.26 (36.08) 0.04 0.05 0. PP Primary progressive. SP Secondary progressive. clinical characteristics.001 -0.08 (25. *** Spearman’s correlation coefficient.86 0.59 -0.46 67. p: p-value Spearman’s test.73) 28. REJ rejection.55 52.13 0.15 -0.40 0. b RR Relapsing remitting.45) 0.55 (29.17 61.10 0.biomedcentral. 11:17 http://www.com/1471-2377/11/17 Table 3 Associations between MusiQoL dimension scores and sociodemographics.09 0.13 0.82 (14.73 (22.53) 0.00 (32.57) 0. p: p-value Kruskal-Wallis test.10 0.68 0.65) 1.00) 50.14 (26.06 0.59 d ADL activity of daily living.16 -0.98 (28. RFr relationships with friends.97) 72.13 0.47 58.44) 0.68 0.

f SRT-L Selective Reminding Test Long-term.690 0.011 0. REJ rejection.092 -0. SPART-T SPAtial Recall Test Total.070 0.159 0.004 0.049 0.085 0.120 0.226 0.077 0.434 0.008 -0. *b: standardised beta coefficient (b represents the change of the standard deviation in QoL score resulting from a change of one standard deviation in the independent variable).135 0.670 -0.642 -0.037 0. d MFIS-To Modified Fatigue Impact Scale total.135 0.285 0.004 0.575 0.194 0.046 0.106 0.158 0.770 -0.421 0.112 0.325 -0.027 -0.738 0.030 0.946 -0.343 -0.317 -0.285 0.376 0. RFa relationships with family.142 0. study.220 0.526 0.100 0. Bold values: p < 0.214 0.078 0.416 0.056 COPa 0.011 0.449 -0.013 0.299 0.285 0.072 -0.429 0.068 0.029 0.038 -0.418 0.309 0.728 -0.368 0.272 0.117 -0.124 0. SRT-D Selective Reminding Test Delayed. SP Secondary progressive.140 0.171 0.138 -0.413 0.006 -0.023 0.209 -0.565 0.171 0.317 0. no strong correlations with cognitive status are expected or sought.795 REJa 0.449 0.010 -0.297 -0.338 0.171 0. [13].431 -0.456 0.674 -0.507 -0.196 0.965 -0.152 0. SPT symptoms.043 0.507 0. Cognitive status was not identified as a QoL predictive factor by Amato et al.329 0.360 0.044 0.208 0.152 0.357 0.324 0.977 -0.084 -0.210 0.261 0.433 0.075 0.187 0.928 0.452 -0.244 0.246 -0.886 0.276 0.304 0.284 0.864 -0.023 0.461 0.019 -0.161 0.036 0.075 0.260 0.069 -0.415 0. e BDI Beck Depression Inventory. a negative impact of cognitive impairment (defined by frontal lobe dysfunction) was identified only in the context of the mental health limitations domain of the SEP-59 questionnaire [12].182 0.200 0.185 0. RFr relationships with friends.Baumstarck-Barrau et al. PP Primary progressive.071 0.034 0.360 0.389 0. Because the MusiQoL is based on the concept of a health-related quality of life measure.852 0.363 0. p: p-value. 1 men) Marital status (0 single.317 0.378 0.133 0.640 RFra -0.com/1471-2377/11/17 Page 7 of 10 Table 4 Predictive factors for MusiQoL dimensions and index: multivariate analysis (standardised beta coefficient) ADLa Gender (0 women.064 0. 1 couple) CIS (0 PP ) SPb (0 PPb) RRb (0 PPb) Age EDSSc Disease duration MFIS-Tod BDI e b b PWBa 0.085 0.182 0. SSL sentimental and sexual life.534 -0.631 -0.392 0.518 0.027 0.005 -0.908 -0.155 0. 11:17 http://www.821 -0.071 0.105 0.115 0.001 0. This result reinforces the validity and the acceptability of this questionnaire and is consistent with studies reporting that cognitively disabled patients are able to give .127 0.345 0.314 -0.052 0.919 -0. Mental and physical health composites of the MSQOL-54 were not predicted by cognitive functions in Benedict’s report [7].130 0.922 -0.902 Index 0.392 0.983 0.117 -0.068 -0.312 0.087 -0. but the latter is not a strictly cognitive assessment tool but instead includes two clinical dimensions [14].042 0.270 0.438 -0.259 0.401 0.312 RHCSa -0.413 0.295 0. Other authors have reported a more obvious association between cognitive deficits and self-reported outcomes.130 0.084 SRT-Lf SRT-Df SPART-Tf WLGf a ADL activity of daily living.018 -0.158 -0.489 SSLa -0.061 0.132 0.085 0.021 0.750 0.722 <10-3 -0.692 0.739 0.071 0. correlations between QoL (using generic questionnaires) and the Multiple Sclerosis Functional Composite were described.666 b* p* b* p* b* p* b* p* b* p* b* p* b* p* b* p* b* p* b* p* b* p* b* p* b* p* b* p* -0.203 0.318 0.107 -0.837 0. b RR Relapsing remitting.043 -0.004 -0.061 0.014 0.343 0.007 -0.184 0.025 0.121 0.552 -0.361 0.302 0.116 0. including QoL. PWB psychological well-being.057 -0.680 0.056 0.177 0.190 0.054 0.550 -0.271 0.667 0.373 0.113 0.295 0.004 0.530 -0.214 -0.05.274 0.017 0.181 0.045 0.009 0.461 0.086 0.644 0.228 0.202 0.731 -0.323 -0.044 -0.027 -0.633 0.015 0.301 SPTa -0.896 -0. Gold and colleagues identified lower QoL levels with the MS-specific Hamburg Quality of Life Questionnaire in cognitively impaired patients relative to cognitively preserved patients.035 0.087 0.890 -0.307 0.670 -0. but cognitive impairment was defined with a single attention-memory test (SDMT) [15].401 -0. WLG Word List Generation test. c EDSS Expanded Disability Status Scale.366 0.369 0.353 -0. CIS Clinically isolated syndrome.02 -0.944 -0.620 -0.250 0.155 0.500 0.130 0. In Miller’s study.005 0.biomedcentral.246 -0.429 0.571 -0.493 -0. COP coping.037 0.945 -0.654 0.482 0.938 -0. RHCS relationships with health care system.332 0.186 RFaa -0.439 -0.026 0.072 0.421 0.436 -0.167 0.563 0.077 0.732 0.416 0. BMC Neurology 2011.459 0.013 0.067 0.922 0.140 0.980 0.

1. subjects in a relationship described a higher QoL than single individuals in the MusiQoL index and in three dimensions (friends.11. they can detect. women reported worse QoL than men for dimensions such as coping and rejection.46]. and a higher QoL for relationships with friends and sentimental life. On the other hand. Age is not related to QoL. other authors have shown that women with MS reported poorer QoL than men [27]. Compared to the international and European MS populations [22.46. our patients had a higher sex-ratio (0. is questionable.35]. and a higher proportion of secondary progressive MS (21% and 36%. The proportion of cognitively impaired patients depended on these definitions. family and health care relationships).2 and 4. defined from a sample that included European populations. but the direction of this effect varied. and Spanish [43] populations. However. Finally. Finally. We chose to use the BRB-N because it was the most widely used at the beginning of this study. Our choice of European norms [24]. though this association is not always found [28]. suggesting the potential relevance of coping strategies [30]. 3) We are concerned about our neurocognitive assessment approach using BRB-N. but their version differed from the standard BRB-N in terms of the content and the number of subtests. Furthermore.com/1471-2377/11/17 Page 8 of 10 consistent answers to questionnaires [15]. BMC Neurology 2011. We are reminded of the need to use a multi-dimensional approach for QoL assessment [31].50].7] or by other clinical rating scales [29]. the strong influence of depression and fatigue as independent predictors of some aspects of QoL in MS patients was confirmed [8. Conversely. These disparities make comparisons difficult between studies. as reported elsewhere [5.37]. suggesting that women may be more vulnerable. Consistent with previous works.Baumstarck-Barrau et al. the BRB-N has several notable disadvantages: i) most studies have used a limited number of subtests from the complete set. Nevertheless. prevent. or less than the fifth percentile [49] of healthy controls.11. When we tried to identify linked factors using the multivariate approach. We note several strengths and limitations of this study: 1) The sample size was arguably too small. or even just one impaired test [45]. These disparities may partially explain the lower QoL scores reported by this population compared to others. Two neuropsychological batteries have been well-validated.41 and 0. Alternative normative values have been defined in Dutch [41]. The BRB-N and the MACFIMS [38] have comparable sensitivity among MS patients [39]. 4) There is no consensus on the definition of cognitive impairment. A patient can be considered cognitively impaired for a global battery in the case of at least three impaired tests [24. or two impaired tests [49]. respectively).12]. 2) The representativeness of our sample should be questioned. as underlined by Achiron and Barak [40]. Further studies should try to disentangle the impact of different cognitive domains on cognitive QoL on one hand and on cognitive daily functioning on the other hand. The disability level influenced a subset of QoL aspects.26]. iii) the test performance requires fine visual acuity or motor speed. a patient may be considered cognitively impaired for one test if the score is less than 2 SDs [45. revealed significantly worse QoL than those with less pronounced disabilities. the literature includes several studies with similar or smaller sample sizes [7. moderate associations may have been missed due to low statistical power. These weak and contradictory relationships between disability and QoL [8] confirm that clinical assessment does not reflect all the aspects that patients consider important in their life. Indeed. severe disability was associated with better global QoL scores and a higher score in the psychological well-being and health care relationships dimensions. respectively). defined either by EDSS [6. We found that gender was not linked to the global QoL score.biomedcentral. The existing data regarding factors that predict QoL in MS cases is somewhat contradictory.7. We were unable to confirm the impact of anxiety [36] because this data was not collected in our study. [44]. Our small sample size did not allow us to identify other factors predictive of QoL that have been reported elsewhere. Similarly. less than 1.60. These parameters may be of significant clinical value for health care workers. or manage depression or fatigue possibly impacting QoL for MS patients. 5) We did not assess thoroughly cognitive QoL nor specific cognitive dysfunction on daily functioning. and these truncated results are not readily comparable with studies that use the complete battery. . French norms were proposed by Dujardin et al.5 SDs [47. a more severe disability profile (EDSS median 3. but the literature reports contradictory results with either poorer [33] or better QoL [34] in older MS subjects. ii) the executive function evaluation is not satisfactory.22. high disability was related to poorer QoL related to activities of daily living. as already described [32]. Patients with higher disability. Italian [42]. Many studies define the cognitive impairment of a MS sample in comparison to a control group.48]. Benito-Leon’s study reported associations between lower cognitive scores (MMSE) and lower QoL levels (Functional Assessment of MS) [5]. Disease duration was poorly associated with some QoL aspects. 11:17 http://www. respectively). while other studies use available normative values.

De Sa J. 245:41-46. 11:203-212. O’Connor P. 29:108-116. cultural adaptation and preliminary psychometric evaluation. Kos D. Weiner HL: The association between cognitive impairment and quality of life in patients with early multiple sclerosis. Chronic Dis Can 2009. Mult Scler 2003. Portaccio E: Multiple sclerosis-related cognitive changes: a review of cross-sectional and longitudinal studies. measurement and effects of disease severity and treatment. Hopman WM. Falautano M. The present study. Filippi M. Malikova I. Gonzalez JM. Hôpitaux de Marseille. 3. Healy BC. Auquier P. and the sponsor was represented by Assistance Publique. Marseille. Nagyova I. 15. JP. Zivadinov R. Compston A. Jansa J: Evaluation of the Modified Fatigue Impact Scale in four different European countries. Barak Y: Cognitive impairment in probable multiple sclerosis. Benito-Leon J. Lancet Neurol 2005. 23. fatigue.Baumstarck-Barrau et al. Beiske A. Gold SM. Reuter F. Schulz KH. Baier M. JP. 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