From the Speech and Language Pathology Unit, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden (CS, CG, FVE, FL) and Department of Neurology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden (CS). 

 Charlotta Saldert, PhD, Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Speech and Language Pathology Unit, Sahlgrenska Academy, University of Gothenburg, Box 452, SE-405 30 Gothenburg, Sweden; 

 The ability to communicate may be impaired in people with multiple sclerosis (MS), as both speech and language may be affected. Although word-finding difficulty is a common impairment, little is known about how this affects everyday life for people with MS.

 In this qualitative study, word-finding difficulty was explored via interviews with 18 individuals with MS. The results were reviewed via qualitative content analysis.

 In the analysis, 3 overarching themes emerged: (1) word-finding difficulty affects everyday life; (2) word-finding difficulties may be handled in various ways; and (3) there are certain factors that can facilitate or hinder word-finding. The participants described different degrees of difficulty with 
word-finding and how words may be substituted in an unpredictable way. This often affected their ability to participate in everyday communication. Despite using various strategies, for example, using other words and involving the conversation partner in the word search, many described themselves as being changed as communicators. Factors that facilitated or hindered word-finding included contextual factors, such as stressful situations and sensory processing load, and the impact of fatigue, emotions, and conversational partners’ behaviors.

 Even minor word-finding difficulty may impact an individual’s ability to participate in everyday communication. Knowing what may help or hinder communication is important for both people with MS and their communication partners.

 We thank speech-language pathologists Siri De Geer, Clara Helenius, Dr Joana Kristensson, Johanna Moreno, and Sabina Åke for their contributions to data collection as well as Professor Lena Hartelius for collecting data and for sharing her extensive knowledge.

 The authors report no conflicts of interest.

This work was supported by the Swedish Research Council for Health, Working Life and Welfare under grant 2015-00503, and by the Swedish Research Council under grants 2016-01275; 2019-02465.

The data included in this study were presented in a speech and language student seminar on April 26, 2022, at the University of Gothenburg in Sweden.

Charlotta Saldert, PhD

Clara Giocondi, CCC-SLP

Freddie Van Eijsden, CCC-SLP

Francesca Longoni, PhD

People with multiple sclerosis report that even minor word-finding difficulties, which may manifest as substitutions or prolonged pauses
for search, can impact their ability to engage in everyday communication.

Referral to a speech-language pathologist for assessment and treatment of communication disorders can be beneficial.

The context and communication partner’s behavior can both impede and facilitate communication in cases of word-finding difficulties. A calm environment and allowing sufficient time to articulate one’s thoughts, as well as explicitly offering assistance in word search, may often be helpful.

Due to disease-related impairments, people with multiple sclerosis (MS) may experience communication challenges, including difficulty speaking clearly and understanding and using language.

 In survey studies, 60% to 75% of people with MS reported some form of communicative change.

 The most reported change was word-finding, which is seemingly common even early in the disease course.

 is defined as difficulty in rapidly retrieving words from long-term memory, independent of an individual’s ability to plan and program articulatory movements or motor execution.

 In conversations, the symptoms can manifest as long pauses while searching for a word, word substitutions, and circumlocutions while attempting to describe the target word. People with MS have been shown to have difficulties with producing adequate words in both naming tests and word fluency tests.

 However, word-finding difficulties in MS are often mild and may not always be apparent in naming tests or to conversation partners. There is often a low correlation between subjective self-ratings and results from formal objective measures of word-finding and general cognition.

Much of what we know about communication in MS is based on experimental studies and survey data, and focuses on communication difficulties in general.

The communicative changes are described as negatively impacting psychological well-being, interpersonal relationships, and participation and identity in work contexts and higher academic education, although people with MS have reported being able to use different functional communicative strategies.

It is acknowledged that people with MS contribute valuable information regarding their specific conditions.

Qualitative research methods are used to understand people’s experiences, thoughts, and perceptions of different phenomena, and impaired communication has been explored in a few qualitative interview studies with people with MS.

 Besides effects from fatigue, they have described subtle language changes and how these are the source of frustration, loss of confidence, fear of the future, and difficulties in completing work tasks and maintaining employment. They also describe substantial unmet wants and needs when it comes to management of communication difficulties within the context of health care.

Thus, although the experience of general communicative changes in people with MS has been explored, word-finding difficulties have not been studied from the patient perspective. The present study aims to investigate the subjective experience of word-finding difficulties in people with MS by asking the participants about their experiences of word-finding difficulty in everyday life, and to describe how they cope with those difficulties.

In this study, semistructured interviews were analyzed via qualitative content analysis, as described by Graneheim and Lundman.

 The study was approved by the Regional Ethical Board of Gothenburg in Sweden (reference number 506-16). All participants signed informed consent prior
to participation.

Eighteen people were included before saturation was reached, that is, when no new knowledge could be discerned from additional interviews.

The participants were a purposeful sample of people with MS in Sweden recruited via the Neurological Association and speech-language pathology clinics (

).
Inclusion criteria were: MS diagnosis documented in their medical record, no other known neurological disease or injury, Swedish as their native language, good or corrected vision and hearing, and experience with subjective word-finding difficulty.

The participants were fifteen women and 3 men with a mean age of 53.2 years (range, 30-72). Seven of them completed high school, and 11 had received more education. The sample included participants with relapsing-remitting MS (n = 8), primary progressive MS (n = 2), and secondary progressive MS (n = 8).

Six speech-language pathologists performed the interviews in quiet rooms at a clinic, a patient association facility, the local university, or in participants' homes. A semistructured interview guide was used (

), and the interviewers were instructed to give the participants open-ended questions and allow time for exhaustive answers before presenting follow-up questions. The interviewers could also provide suggestions, based on earlier research on word-finding difficulties, when needed.The interviews ranged in length from 5:45 minutes to 24:13 minutes.

The Swedish version of the Object and Action Naming Battery (OANB), including 120 pictures of high-frequency objects and actions, was given immediately after the interview.

The interviews were transcribed orthographically. Pauses, hesitations, repetitions, and nonverbal communication were included to assist the analysis.

The transcriptions were checked against the video-recorded interviews by the authors and revised if needed. Meaning units containing words, sentences, and phrases that related to the research questions were extracted from each of the transcribed interviews. This was followed by condensing each meaning unit into shorter, concentrated phrases of the core meaning. The condensed phrases were then abstracted into codes, as this could reveal new patterns.

 A single code may describe and/or be assigned to several condensations from different interviews. The coded content was then further abstracted into categories. Each meaning unit was assigned to one of the categories. The second and third authors (C.G., F.V.E.) did an initial coding and categorization of the material. Codes and categories were then discussed by all authors and sometimes altered in a consensus procedure. During the process, all authors repeatedly discussed the results, and great care was taken to preserve the context and meaning of the interpreted content.

Fourteen participants performed within normal variation for their age group on the naming ability test, but most participants endorsed that word-finding difficulties affected their everyday communication. One participant said that the word-finding difficulty did not really cause any problems in everyday life, and 3 participants said they only experienced minor communication problems despite their reported word-finding difficulties. These 4 participants were not distinguished from the others in terms of their naming ability level, age, MS type, or disease duration. There was also no relationship among the results, demographic factors, MS type, or disease duration in those who scored below normal on the naming test.

Three overarching categories, or themes, emerged in the analysis: (1) word-finding difficulty affects everyday life; (2) these word-finding difficulties may be handled in various ways; and (3) certain factors can facilitate or hinder word-finding. Within these overarching categories, 22 subcategories were identified (

We describe the categories with quotes from the interviewees. They have been translated into English, punctuation has been added, and hesitations and other signs of speech-planning have been removed to facilitate reading. Words left out within a quote are marked with brackets.

 Overarching Categories and Subcategories for Word-Finding Difficulties

Word-Finding Difficulty Affects Everyday Life

The first overarching category describes participants’ experiences of word-finding difficulties manifesting in their everyday lives.

Some participants described the word-finding process as slower or temporarily halted, although the right words would come after a while; others sometimes found the intended words totally inaccessible. “I know so well what I want to say to you, but it is difficult to formulate. I mean, it will be difficult for me to formulate the words so that it matches what I want to say”(P14). They also described how parts of the word could be available but not the whole word. “Strangely enough, I usually know what the first letter of the word is” (P17).

Both high-frequency words and more unusual words could be difficult to find, hindering participants’ use of particular words to capture the nuances of what they wanted to express. They also described word-finding difficulties as preventing them from using language in the way they used to. “…My previous [way of] speaking [was] a little more correct Swedish. I am no longer [the] word police” (P8).

Word-Finding Difficulties Are Unpredictable

Any type of word could be difficult to find, and this could occur in any type of situation. “It can be any situation, it can be a quiet, peaceful breakfast, or it can be that I enter a room and have to get ahold of a person and explain something” (P9). The difficulties could arise suddenly and at different times of the day, but were not present all the time. For some participants, this did not even occur every day. The words intended could suddenly be replaced with more or less related words, as this participant explained: “We might be talking about something we’re doing in the kitchen, cooking, and then I might say: ‘We should get a frying pan.’ But I mean a slow cooker or...now I said it wrong, or a saucepan, and I get things mixed up. I do know what they are” (P10). Sometimes a word can be involuntarily replaced by a completely unrelated word, which might be noticed by the communication partner: “It can be something that is very wrong…because I know that people have reacted to that: ‘Huh, what did you say?’” (P7). Participants also wanted a way to get rid of the involuntary word substitutions. “The thing I would most like to get rid of is the fact that totally wrong words may jump out”(P9).

Misunderstandings can occur because of word-finding difficulties. Participants described a desire for improved communication ability to avoid offending, insulting, or hurting someone because of word-finding difficulties. “I find it difficult to find words that fit, so I can be afraid that I [will] tread on someone’s toes”(P12). Participants were also worried that others would misinterpret symptoms of word-finding difficulties as attempts to say something funny and that being quiet in conversations due to word-finding difficulties could be interpreted as a lack of interest.

Searching for Words Takes a Lot of Energy

Word-finding difficulties took energy that could have been used to cope with other aspects of daily life, for example, the family. Participants also described how word-finding difficulties made work more laborious and energy-consuming. “You have to kind of stop and then you have to, yes, find the words, and it takes so much energy from what you still need to use energy to cope with, like the work and things like that” (P3).

Most of the participants had experienced changes in how they communicated and the context in which they socialized. Participants described how they expressed themselves differently than before: not with the same wit, not as spontaneous, not as quick in discussions, not with the same self-poise or rhetorical ability as before. Many felt that they had become more withdrawn. “The consequence is that you are a little more reserved, a little quieter. You’re not really so talkative or you don’t speak up in the same way” (P17). The fact that an intended word could sometimes unexpectedly be replaced by another (perhaps totally unrelated) word meant that participants chose not to make verbal jokes as much as they did before: “…because…funny or strange things [come] out of my mouth without me wanting it”(P18)

 Their wish was for a treatment that could make them more social and able to participate more.

The change in word-finding ability was described as frustrating

Several participants reported that not only did they experience frustration, but their family members did as well. A treatment for improved word-finding ability “would save a lot of time (participant laughs) most of all, and create less frustration in myself, sometimes in others, too, maybe” (P6).

Word-Finding Does Not Have to Be a Big Problem

A few participants described their word-finding difficulties as a minor concern. As one put it: “At the moment, it doesn’t bother me much not find[ing] the words” (P5).

Word-Finding Difficulties May Be Handled in Various Ways

The second overarching category concerns the different ways participants reported coping with everyday life in situations where they could not find the right words.

Some described word searching as a matter of self-esteem.“I try to muddle through because if I give up, then I think you break down as a person, or that you don’t feel good about yourself”(P10). However, several participants said they fell silent or gave up and changed the subject when they could not find the right word. Some also choose not to contribute to conversations because of word-finding difficulties. “I have a very effective way and that is to be quiet, actually, and avoid the situation” (P14). Whether some participants gave up trying to find a word also depended on the importance of what they wanted to express. “I have to, or I say: ‘Shit, whatever.’ It depends on what it is. If it’s something important, I must try” (P8).

Some participants had come to terms with the fact that they sometimes got stuck. The speakers and conversation partners mostly accepted the problems in conversation. “There’s not so much to do about it. I think most people I socialize with accept [it] a little, that you have a bit of a stammer sometimes. There’s nothing more to it, or there’s nothing to hide either, is [there]?” (P16). Being open about their difficulties was something that participants did in different ways. “If I have to talk to someone and then I realize that this is not working, then I tell them: ‘Yes, but you know, I do have MS and I have a bit of difficulty finding the words.’ And then I start over again” (P9). Others had a hard time accepting the impaired ability to express themselves.“I have trouble finding words, and I guess I put myself down more because I know I was on such a high level before”

Participants mentioned that preparation could facilitate communication during formal situations. “Before I can say that, when going to the doctor or somewhere else, I would try to remember what I should say, but nowadays…the last 10 years, I write it down beforehand on a piece of paper I can bring, so I know that I can say what I want to get across” (P5).

Involving the Conversation Partner in the Word Search

The conversation partners were often described as resources in the word search, sometimes being invited to guess or even expected to fill in the missing words. “Sometimes I ask for help, especially [with] my close ones, so to speak.Or they say it before [I do] because they know what I am looking for” (P13). On the other hand, when conversation partners completed sentences or guessed words without being invited, it was not always appreciated.

Several participants managed by using synonyms or other related words, sometimes in another language, when the intended word could not be retrieved. They also attempted to describe the missing word or use circumlocution. Less important words were also eliminated, and names were sometimes replaced with pronouns. Language was occasionally adapted in an unwanted way. “I probably back off in some way and use a more everyday word or simpler word, even though I really want to use a more difficult word, because I think it’s important to have a vocabulary. I think it’s important to use good language, but when I don’t have the energy, then I probably back off a bit, and it becomes simpler in some way, simpler words” (P3).

Participants described how they would often laugh and smooth over the problem when they needed help finding words. “Sometimes you just laugh about it, like: ‘Yeah, right, that’s it.’ So you’re always trying to find some shield, to sort of hide it” (P15). They also tried to blame something other than MS for the problems, like age or just not keeping up, to distance themselves from the negative effects of the disease.

The need for time to find the right words and different approaches to gain time were often mentioned. One participant said that he would act thoughtful or reflective to gain time in conversations, whereas another participant described using filler words: “Either there are no words, or there are a lot of ‘and’ and ‘but’ and ‘ay’ and ‘ugh’ and, I mean these words that I try to use to have time to formulate what I want to say” (P14).

Use of body language, such as gestures, was mentioned. Pointing could be used as a means of asking for something or for getting a conversation partner to fill in words. Others described using body language as a natural part of their communication but not a conscious strategy. A few participants acknowledged sometimes using drawing or writing to help with finding a word.

Certain Factors Can Facilitate or Hinder Word-Finding

The third overarching category includes factors that participants perceived as affecting their ability to find words.

Health-Related Factors and Variations During the Day

The participants in this study reported that sleeping difficulties and pain affected word-finding.The time of day could also determine how much word-finding difficulties interfered. "In general, when I’m alert, and I’m usually alert in the morning, I don’t think much about it, but…[it occurs later] during the day when I’m more tired” (P3). Word-finding was particularly difficult when participants were tired, taking longer and resulting in a more limited vocabulary.

Word-finding difficulties could become worse when participants were angry, happy, frustrated, or excited. State of mind could also affect how participants felt about word-finding difficulties. “When I’m angry or frustrated, then it is present, but not so much if I’m happy, I think. I probably don’t notice it in those cases, and if I’m happy, then I’m probably in such a state of mind that it perhaps doesn’t bother me anyway” (P8). Being keen to express something or being frustrated about not finding words could increase the difficulties

Participants found that context could influence word-finding or how the difficulties were handled. One’s own or others’ expectations could also affect the willingness to try to express oneself. “If I can’t do it the way you expect me to, then I feel that I might as well be quiet” (P17)

 Contexts where the choice of words could be critical, like discussions, were described as especially difficult.

For some participants, it did not matter whether they were talking to just 1 person or a group of people, but others felt that group conversations were really challenging. “Even though I’m good at babbling on, this situation, when you have to fight to get an opportunity to speak and feel a bit stressed that you have to get something out, to lose your words in that context [is difficult]” (P7). In group conversations, the need for more time to find words could be an issue because when the person finally found the words to contribute, the topic had already changed. Speaking with strangers was described as more stressful because people who know the person with MS well could be a resource. “Most of the time we probably find out, at least if talking to my husband, what it is I want to say” (P9). Not finding the words when the conversation partner seemed impatient was also described as stressful.

Being in situations with a lot of noise, such as cafés, was described as hampering word-finding. “If there are a lot of disruptive elements around, there can be so much noise and children screaming and so on, then I think I…then I can’t really talk anymore” (P17).

Stress and Time Limitations as Hindering Factors

When participants felt stressed, word-finding was more difficult. “Obviously, if you are stressed, then it is a bit messier so then word choice can get worse.... It is better to take it easy, or in general I think I have become a little less…the stress tolerance has changed” (P16). In general, time was described as an aggravating factor. Feeling that it took too long to express oneself or that others did not have enough time to wait were both difficult situations. A doctor’s appointment was mentioned as an example of a situation made harder due to time limitations.

The results of our study show that the participants with MS have both individual and shared experiences of how different degrees and types of word-finding difficulties affect everyday life and how they cope with these difficulties. Many described themselves as changed communicators. Negative effects on communicative participation, working life, and quality of life from changes in communication ability have been reported elsewhere, but results in the current study show these negative effects specifically from the participants’ view of their word-finding difficulties.

A pattern of intertwined factors that affect word-finding was described by participants. Health-related factors were mentioned, but temporary ill health was not reported as affecting the level of word-finding difficulty, although this has been reported elsewhere by people with neurogenic communication difficulties.

Contextual factors like sensory processing load were also mentioned, along with time limitations and the impact of the conversation partner. Communication demands and expectations and emotional impact also were reported to negatively affect word-finding. These factors may be changed to support communication, either by adapting environments—for example, by informing potential conversation partners about possible communication difficulties because of MS—or by working with people of MS to improve their self-image and acceptance of this impairment.

It has previously been recognized that people with MS may experience communication as variable and unpredictable.

In our study, participants also described word-finding difficulties manifesting in unpredictable ways. Any word could prove difficult at any time, or even suddenly be involuntarily replaced by another, sometimes totally unrelated word.

A supportive communication partner who can provide time and help to find words, was described as facilitating communication. Experiences of frustration when family and friends filled in the missing words uninvited, along with feelings of being less competent when not able to find the words themselves, have been reported by people with MS elsewhere.

As previously described in relation to communication difficulties in general, participants in the current study reported having to use circumlocution and related words to express themselves.

 They also changed their communication style by, for example, using simplified or less nuanced language.

In agreement with the findings of a study by El-Wahsh and colleagues, the findings of our study call for support and treatment for word-finding difficulties in MS.

However, people with MS are seldom referred to speech-language pathologists working with the assessment and treatment of communication disorders.

 There is also a lack of evidence-based treatment methods for word-finding difficulties in MS.

This study had several limitations. The interviewers who did the data collection did not participate in the analysis. This kept the interview guide constant throughout the study and may be a shortcoming, as new knowledge gained during the process of conducting the interviews could have prompted a revision of the interview guide.

 Another limitation is that we do not present data on the participants’ physical and cognitive health, which may affect their experiences with word-finding difficulties. Still, there was a broad range in age, time since diagnosis, type of MS, and degree of difficulty among the participants, and this diversity provided different perspectives and contributed to the rich variety of experiences related to word-finding difficulties, increasing the credibility, transferability, and validity of the study.

 Participants’ naming ability was assessed with confrontation naming via a set of picture stimuli, which is standard procedure in screening for word-finding difficulties. However, it is clear from the results of this study that such an assessment is not sensitive enough when it comes to the type of communication difficulties seen in MS. Subjective word-finding difficulties in everyday life were an inclusion criterion in the study, yet only 4 participants scored below normal on the test. Further, the few participants who experienced only minor communication problems did not necessarily perform well on the test. Although research has described impaired confrontation naming ability in people with MS, results from other studies suggest that more complex tasks involving basic cognition, such as executive function, are needed to diagnose communication difficulties in those with MS.

For people with MS, even minor word-finding difficulties may affect psychological well-being and decrease communicative participation. Evidence-based treatment methods are needed. The outcomes of training people with MS to use strategies to facilitate word-finding or teaching communication partners supportive strategies need to be assessed. The present study contributes new knowledge about the word-finding difficulties people with MS describe and highlights the importance of recognizing and managing these problems within their care.

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Experiences of Word-Finding Difficulties in Multiple Sclerosis: A Qualitative Interview Study

From the School of Psychology (TI, LASW) and the Brain and Mind Research Institute (JDP, JAB, LASW), University of Ottawa, Ottawa, ON, Canada; Neuroscience Program, Ottawa Hospital Research Institute, Ottawa, ON (TI, JDP, MB, JAB, LASW); Department of Psychology, Carleton University, Ottawa, ON (JDP, LASW); Ottawa Hospital, Ottawa, ON (MB, RB, TP, LASW). 

 Lisa A.S. Walker, PhD, C Psych, The Ottawa Hospital – General Campus, 501 Smyth Road, Suite 7300, Ottawa, ON K1H 8L6; 

 Mental health concerns, cognitive impairment, and fatigue are prevalent among Canadians with multiple sclerosis (MS), yet many neurology clinics are not equipped to adequately address these concerns. In this quality improvement initiative, low-burden systems were implemented at an MS clinic with the aim of improving the identification of these invisible symptoms among people with MS.

 Self-report questionnaires assessing anxiety, depression, and fatigue were electronically administered to patients prior to clinic appointments. When moderate mental health symptoms were reported, clinicians were alerted by a best practice advisory and directed to provide the patient with a list of local low- and no-cost mental health services. An MS-sensitive cognitive task was also administered via a tablet upon check-in to patients meeting with the physician assistant (PA). Data were collected from appointment notes over 10 clinic days before and after implementation.

 From pre- to post implementation, the proportion of patients who received formal mental health screening increased from 0% to 54.55%, and the proportion of patients with mental health concerns who were offered resources increased from 23.53% to 47.83%. The proportion of patients who received formal fatigue screening increased from 0% to 22.46%. The rate of cognitive testing in visits with the PA increased from 33.33% to 85.11%.

 This initiative improved mental health, cognitive, and fatigue screening and established a foundation for ongoing quality improvement initiatives to better meet best practice recommendations for comprehensive MS care.

The authors declared no competing interests.

We express our gratitude to the staff of the The Ottawa Hospital MS Clinic for their invaluable dedication and support in advancing this initiative. The authors thank Novartis Pharmaceuticals Canada for the support provided to deliver CogEval.

 Preliminary analyses were presented as posters at the Canadian Psychological Association Annual National Convention from June 12 to 14, 2025, in St John’s, Newfoundland, Canada; the Behaviour Change Conference from April 2 to 3, 2025, in Lisbon, Portugal; the endMS Conference from December 3 to 6, 2023, in Toronto, Ontario, Canada; and the University of Ottawa Brain and Mind Research Institute’s Brain Health Research Day 2023 in Ontario.

This initiative was supported by the University of Ottawa Brain and Mind Research Institute.

Tamanna Islam, MSc

Jordan D. Pumphrey, MA

Marjorie Bowman, MScN, RN

Jason A. Berard, PhD

Reece Bearnes, CHE

Tammy Pham, MSc, MPAS

Lisa A.S. Walker, PhD

Electronic administration of mental health and fatigue screeners before multiple sclerosis appointments improves the detection of related concerns.

Administration of the CogEval task to patients before appointments is a feasible and suitable option for monitoring cognition.

Cognitive impairment, depression, anxiety, and fatigue contribute to quality of life for people with multiple sclerosis (MS).

 In routine care visits, it can be challenging for them to communicate these symptoms and for clinicians to detect/monitor them longitudinally.

 Results from surveys of MS care professionals by the Consortium of MS Centers found only 38% of respondents used validated measures to assess depression, and only half evaluated cognition.

 In 2019, we published results from a record review of patients followed at The Ottawa Hospital MS Clinic

 in Ontario, Canada, and reported that approximately a quarter of the reviewed records documented at least 1 cognitive, mental health (MH), or psychosocial concern despite little formal screening for these concerns. In response, we launched this quality improvement (QI) initiative. Our objective was to enhance the frequency of MH, cognitive, and fatigue (MHCF) screening, where such assessments were previously not routine. We had 4 aims: (1) screen at least 75% of patients prior to clinic visits, (2) provide community resource information to at least 75% of patients identified with an MH concern, (3) evaluate initial implementation of tablet-based cognitive screening, and (4) evaluate the initial implementation of fatigue screening. Given practical challenges regarding staff training, patient adherence, and adopting new technologies, the aim of screening 75% of patients was chosen as a pragmatic benchmark for implementation.

The Ottawa Health Science Network Research Ethics Board determined that ethics review was not required. The initiative was implemented in 3 phases. First, MH screening was introduced. Patients who activated the MyChart option, allowing access to information from their electronic health record (EHR), received an invitation to complete MH questionnaires through the EHR prior to their appointment. The Patient Health Questionnaire-9 (PHQ-9) assessed depression symptoms, and the Generalized Anxiety Disorder 7-item assessment (GAD-7) assessed anxiety symptoms. Best practice advisories (BPAs) in the EHR alerted physicians if moderate depression or anxiety was reported (≥10 on PHQ-9 or GAD-7), prompting physicians to address the concern and provide the patient with a list of local low- and no-cost MH resources.

In the second phase, cognitive screening was implemented for all patients seen by the physician assistant (PA). At their appointment, patients completed CogEval, a tool that measures processing speed (PS). Prior to this study, the Montreal Cognitive Assessment (MoCA)

 was the sole tool used to screen for cognitive impairment. MoCA was originally developed to detect mild cognitive impairment and early signs of dementia by evaluating multiple cognitive domains.

 However, it does not assess PS, which is commonly affected in MS,

 and has not been validated in MS. The use of CogEval, a validated measure of PS in MS, was implemented, given that it is a recommended cognitive screener in MS and strengthens predictive value of the MoCA.

Fatigue screening was introduced in the third phase. The Modified Fatigue Impact Scale (MFIS), a self-report questionnaire evaluating physical, cognitive, and psychosocial aspects of fatigue, was administered prior to clinic appointments alongside MH measures in the EHR.

To evaluate these 3 phases, data were collected from the visit notes of 3 physicians over 10 clinic days before implementation of MH and fatigue questionnaires and 10 days post implementation. Data were similarly collected from PA visit notes 10 days before and after implementation of cognitive screening.

The PHQ-9 is a 9-item self-report tool that assesses depressive symptoms over the past 2 weeks, with 1 item specifically screening for suicidal ideation. It is a recommended screening tool for depressive symptoms in people with MS.

 Scores of 1 to 4 indicate “minimal depression,” 5 to 9 “mild depression,” 10 to 14 “moderate depression,” 15 to 19 “moderately severe depression,” and 20 to 27 “severe depression.”

The GAD-7is a 7-item tool that assesses the severity of generalized anxiety disorder.

 Scores of 0 to 4 indicate “minimal anxiety,” 5 to 9 “mild anxiety,” 10 to 14 “moderate anxiety,” and 15 to 21 “severe anxiety.” It is reliable and valid for screening generalized anxiety symptoms in people with MS.

CogEval is an iPad-based tool developed and validated to assess MS-related cognitive deficits, with a focus on PS.

 It is modeled after the Symbol Digit Modalities Test and evaluates PS and related cognitive domains (eg, attention, psychomotor speed, visual processing, working memory).

The MFIS is a 21-item multidimensional questionnaire assessing impact of fatigue on daily activities.

 The MS Council for Clinical Practice Guidelines recommends the MFIS to assess MS-related fatigue.

 A cutoff of 38 is commonly used to distinguish between fatigued and nonfatigued people with MS.

The 191 patients seen before implementation of MH screening were comparable to the 165 patients seen post implementation in terms of age, sex, physical disability, and disease subtypes (

). Before implementation, no visit notes recorded use of formal MH screening tools, although MH concerns were mentioned in 8.90% of patient visits. Among those with an MH concern, 23.53% received resources or referral to a specialist.

Patient Demographics From Reviewed Visits Pre- and Post Implementation of Screening Initiatives

Post implementation, 54.55% of patients completed formal MH screening (

), of which 21.22% were identified as having an MH concern based on cutoff scores. Notably, 100% of patients with an MH concern were provided resource information, as instructed by the BPA prompt. Of the 27.88% of patients identified with MH concerns post implementation, 11.52% were flagged based on PHQ-9/GAD-7 cutoffs, 16.36% were identified during regular visits, and 5.45% through both methods.

Percentage of Patients Screened Before and After the Initiative

Forty-five patients pre–CogEval implementation were compared with 47 patients post implementation, with no significant differences in age, sex, physical disability, or disease subtype (Table). Introduction of CogEval improved frequency of cognitive screening, increasing from 33.33% preimplementation to 85.11% post implementation (Figure). Preimplementation, all patients screened for cognitive deficits were given the MoCA. Post implementation, CogEval was administered to 82.98% of patients and the MoCA was administered to 10.64%. Despite increased screening, visit notes showed a reduction in discussions regarding cognitive concerns from 33.33% to 23.40%.

A total of 166 patients were seen pre–MFIS implementation and 187 patients post implementation. The groups were comparable in age, sex, physical disability, and disease subtype (Table). Prior to implementation of the MFIS, fatigue was mentioned in 27.11% of visit notes, yet no fatigue measures were administered. Post implementation, fatigue was mentioned in 24.60% of notes, and 22.46% of patients completed the MFIS (Figure), with 45.24% of those meeting the threshold for fatigue (total MFIS score ≥ 38). Of the 31.02% of patients identified with a fatigue concern post implementation, 10.16% were identified based on MFIS cutoff, 24.60% during regular visits, and 3.74% through both.

We implemented a QI initiative to increase the frequency of MHCF screening as has been previously recommended,

 although most clinicians do not use formal tools to screen for these concerns.

 Implementation of validated screening measures led to several improvements in identifying patient concerns, although challenges remain. Importantly, screening results are now presented longitudinally in the EHR, enabling ongoing monitoring, and a procedure to inform patients about low- and no-cost MH resources was implemented.

Before implementation of MH screening, concerns were documented in only 8.90% of visits, with just 23.53% of these patients receiving resources or referrals. No validated MH assessments were administered. Post implementation, MH screening was conducted for 54.55% of patients, with the rate of resource/referral rising to 27.88%. These rates exceed those of other centers (24% receiving depression screening).

 This increase highlights the importance of standardized screening in capturing concerns given that, due to perceived stigma, patients may be reluctant to raise these issues without prompting.

 Notably, 100% of patients identified by validated questionnaires as having an MH concern received resource information. Reporting of MH concerns in notes when MH questionnaires were not completed also increased post implementation, potentially indicating heightened clinician awareness of these issues.

Implementation of cognitive screening using CogEval resulted in an increase in cognitive assessment frequency from 33.33% preimplementation to 85.11% post implementation, exceeding rates of screening in other centers (2%).

 Notably, CogEval was used more than the MoCA post implementation, representing a shift toward tools validated for use in MS. However, a decrease in discussions about cognitive concerns during visits was observed post implementation. We speculate that use of CogEval could provide assurance to the clinician and patient that cognitive concerns are being monitored sufficiently, resulting in a decrease in discussion of concerns. This change may also reflect natural fluctuations in how often cognition was discussed or documented by the physician in their notes.

Although CogEval is an effective monitoring tool, it should not replace formal conversations. Highlighting the need for conversations, patient-reported cognitive concerns correlate with declines in immediate memory and PS

and are an important part of clinical assessment. Currently, patients with significantly low PS scores on CogEval are referred for a community neuropsychological assessment if they have the financial resources. Additionally, per regulatory guidelines, the clinic will inform the Ministry of Transportation when PS deficits may pose driving safety concerns.

Volume 27, Issue Q3

Experiences of Word-Finding Difficulties in Multiple Sclerosis: A Qualitative Interview Study

Implementation of Cognition, Fatigue, and Mental Health Screening at a Canadian Multiple Sclerosis Center: A Quality Improvement Initiative

Disaster Preparation for People With Multiple Sclerosis: A Scoping Review of Resources

An Updated Assessment of Patient Knowledge in Pregnancy and Multiple Sclerosis

Tumefactive Demyelination in Older Adults: Diagnosis and Misdiagnosis

Virtual Dance Program for Multiple Sclerosis: Feasibility, Quality of Life, and Motor Imagery Outcomes

Apathy in Early Relapsing-Remitting Multiple Sclerosis: Prevalence and Predictors

Effect of a Therapeutic Patient Education Program on the Quality of Life of People With Multiple Sclerosis: A Quasi-Experimental Study