Fibromyalgia, mood disorders, cognitive test results, cognitive symptoms and quality of life in systemic lupus erythematosus.

OBJECTIVES: Cognitive dysfunction, and comorbidities such as mood disorder and fibromyalgia, are common in SLE. This study aims to explore the associations between fibromyalgia, mood disorders, cognitive symptoms and cognitive dysfunction in SLE patients, and their impact on quality of life. METHODS: We tested cognition in SLE patients and healthy controls, and evaluated cognitive symptoms, mood disorder, fibromyalgia, fatigue and quality of life using patient-reported outcome measures. We examined associations of these comorbidities with both patient-reported cognitive symptoms and cognitive test performance. RESULTS: High fibromyalgia symptom score and history of depression or anxiety were associated with cognitive dysfunction. There were no significant associations between current depression, anxiety symptoms or fatigue score and objective cognitive dysfunction. In contrast, mood disorder symptoms, history of mood disorder, fibromyalgia symptoms and fatigue all had significant associations with patient-reported cognitive symptoms. There were no significant associations between patient-reported cognitive symptoms and objective cognitive dysfunction. Objective cognitive dysfunction, patient-reported cognitive symptoms, history of mood disorder and fibromyalgia symptoms all had significant associations with poorer quality of life; fibromyalgia had the biggest impact. CONCLUSIONS: Cognitive symptoms are common in SLE, but there were no associations between cognitive symptoms and objective cognitive dysfunction. Depression, anxiety and fibromyalgia were more consistently associated with patient-reported cognitive symptoms than with objective cognitive dysfunction. These factors all have a significant impact on quality of life. Understanding the discrepancy between patient-reported cognitive symptoms and cognitive test performance is essential to advance care in this area of unmet need.

Evaluation of the Montreal Cognitive Assessment as a screening tool for cognitive dysfunction in SLE.

OBJECTIVES: Cognitive dysfunction in SLE is common and associated with significant morbidity but is currently underdetected. Early detection requires the use of screening tests, as formal diagnostic cognitive testing is time-consuming. This study aims to evaluate the Montreal Cognitive Assessment (MoCA) as a screening tool for cognitive dysfunction in SLE. METHODS: Patients with SLE (n=95) and demographically matched healthy control participants (n=48) underwent cognitive testing using the 1-hour neuropsychiatric test battery recommended by the American College of Rheumatology for use in SLE and the MoCA. We used regression analyses to determine associations between MoCA and cognitive test scores. We assessed several MoCA cut-offs for predicting cognitive impairment in terms of sensitivity, specificity, positive predictive value and negative predictive value. Receiver operating curve analyses were used to determine the diagnostic accuracy of the MoCA cut-off thresholds. RESULTS: We found a significant correlation between MoCA score and 9 of the 10 cognitive endpoints studied (all p<0.001). Receiver operating curve analysis suggested that a MoCA cut-off of <27 had highest diagnostic accuracy across the cognitive impairment definitions (area under the curve 0.76-0.78). Using a screening cut-off of <28, the MoCA had sensitivity of 83%-94% and specificity of 46%-59%, depending on the impairment definition used. CONCLUSIONS: The MoCA correlates strongly with cognitive test results in SLE and has sufficient sensitivity for use as a screening tool with a cut-off of <28 as the optimal threshold. This tool can be incorporated into clinical practice for screening for cognitive dysfunction in SLE.

Qualitative assessment of medication adherence in patients with rheumatic diseases on biologic therapy.

INTRODUCTION/OBJECTIVES: Despite close management in specialized clinics, medication adherence remains a significant problem for some patients. The study aims to explore factors affecting medication adherence in patients attending a biologics clinic. METHOD: Participants completed surveys including the Compliance Questionnaire Rheumatology (CQR) to quantify adherence rates. Purposive sampling targeting poorly adherent patients was used to select individuals for qualitative evaluation. Semi-structured interviews were performed and continued until saturation was achieved. Interviews were transcribed and coded using NVivo. Principles of grounded theory were used for data analysis. RESULTS: A total of 123 patients completed the survey (72 RA, 33 PsA, 18 AS). Of which, 96 patients completed all CQR items, of these 72% were identified as adequately adherent. A major theme which emerged from patient interviews was that the presence of active symptoms significantly influenced adherence. Patients tended not to prioritize medication taking until they had a recurrence of symptoms. Despite describing biologics as "life-changing", patients expressed concern regarding potential long-term side effects of these medications which affected adherence. Patients identified their relationship with their rheumatologist as pivotal and perceived diet, exercise and stress as critical. Intentional factors were the predominant drivers for non-adherence; patients made a risk-benefit analysis based on their beliefs and chose to not take their medications as prescribed. CONCLUSIONS: Medication adherence to traditional and biological therapies was lower than expected by treating clinicians in this patient group, who are closely supported in a dedicated biologics clinic. Several of the identified themes suggest that shared decision making and enhancing patient education may improve adherence in this group. Key Points • Adherence rates are suboptimal even in supported, educated, English-speaking patients in the biologics era. • Contributing factors were 'intentional' as patients chose to be non-adherent based on their beliefs. • Emergent themes suggest that enhancing patient education could improve adherence.