The paper by Anzola et al' addressed the important issue of cognitive functioning in patients suffering from MS. We appreciate their study, and share to a large degree their conclusions concerning cognition in MS patients, and we can contribute some additional information.A) The authors did not mention the exact number or the percentage of patients with deficits on neuropsychological assessment; apparently, number as well as degree of impairment allowed characterisation of the deficit as "very mild". B) The authors attributed their deviating results to their selection of ambulatory patients with relapsing-remitting course of MS. C) They considered the pattem of impairment (inferior performances in concept formation, non-verbal reasoning and verbal memory tests) as indicative of so-called subcortical disruption. We wish to confirm A, comment on B and query C.A) For counselling and management it is important to know that MS is not a sufficient or necessary condition for suffering cognitive defects, let alone dementia. Findings that are at variance with current quite high estimations of cognitive defects in MS will ultimately add to revealing the as yet insufficiently known spectrum of severity in MS.2 Our findings concur with those of Anzola et al. In a comprehensive neuropsychological study of 39 outpatients with relapsing-remitting (n = 20) and chronically progressive (n = 19) MS, who presumably were slightly more handicapped than the patients oftheir study (table), and all ofwhom were in quiescent disease stages, we also found evidence of generally adequate cognition. On a case by case basis we found signs of cognitive decline in 18% of the patients.3B) The suggestion of mild physical handicap and relapsing-remitting course of MS explaining the absence ofMS-related dementia cannot be endorsed by our findings. We studied the explanatory value of several illness variables, among which Kurtzke DSS, duration of illness, and course of MS (RR versus CP). However, using parametric and, when appropriate, nonparametric procedures, we failed to identify a significant influence ofany ofthese variables in any ofthe behavioural measures (table). The critical illness variables, apart from extensive periventricular demyelination, as stressed by the authors, remain to be identified. C) In our view, the presence of weak memory performance, poor concept formation and poor nonverbal problem solving is insufficient to result in subcortical dysfunction. The distinction between cortical and subcortical "dementia" rests on inferring the mental disorganisation underlying poor overt performances. Important variables underlying so-called cortical performance deficit should be disordered instruments of cognition. Key variables underlying so-called subcortical performance deficit should be apathy and slowness of information processing. The discrepancy between relatively adequate acquisition and poor retrieval should be taken as the distinguishing feature of so-called subcortical memory failure.' The authors present no data that may help t...
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