Cognitive impairment affects an estimated 40-60% of people living with multiple sclerosis (MS), yet routine cognitive monitoring is not consistently incorporated into standard MS follow-up in many practices.1,2 Clinical attention often prioritizes relapse activity, physical disability, and MRI findings, while cognitive change may be under-identified, particularly when imaging remains stable.
Part of what’s driving that shift is a growing recognition of progression independent of relapse activity, or PIRA—a pattern where patients experience real functional decline even when their imaging looks stable, and their relapse count is low. Research published in 2025 found that among patients who experienced cognitive decline, 89% met criteria for cognitive PIRA, meaning the decline was happening independent of new MRI activity.3 Establishing objective cognitive baselines and longitudinal monitoring frameworks is therefore increasingly relevant in modern MS care.
Roberto Alejandro Cruz, M.D., is a board-certified neurologist and fellowship-trained neuroimmunologist and multiple sclerosis specialist at Doctors Hospital at Renaissance (DHR Health). Based in Edinburg, Texas, DHR Health is a physician-owned health system serving patients across the Rio Grande Valley and provides a broad range of inpatient and outpatient services, including neurosciences and stroke care. The patient population is predominantly Hispanic, a demographic historically underrepresented in MS cognitive research. Dr. Cruz leads the only comprehensive MS center of the region and is the neurology medical director at DHR Health, where a team of board-certified neurologists cares for a wide variety of disorders of the central nervous system.
Comprehensive neurocognitive evaluation by a trained neuropsychologist remains an important component of cognitive assessment for selected patients with MS. However, access to neuropsychological services in the Rio Grande Valley is significantly constrained, with only a limited number of neuropsychologists specializing in neurological populations across the region, resulting in prolonged wait times and limited referral capacity. These barriers reinforce the need for a scalable clinic-based monitoring strategy.
Prior to implementing BrainCheck Assess, Dr. Cruz relied on the paper-based Symbol Digit Modalities Test (SDMT) as the primary cognitive screening tool within his practice. Several operational and interpretive limitations prompted a reassessment of this approach:
As disease-modifying therapies (DMTs) have reduced the frequency and severity of acute inflammatory events, cognitive and functional decline in some patients continues along a trajectory not captured by relapse calendars or MRI protocols. Dr. Cruz described the need to establish an objective cognitive baseline early in the disease course so that subsequent assessments can be interpreted in the context of an individual patient’s reference point rather than population norms alone.
BrainCheck Assess is now a standard part of the workflow across DHR’s neurology practice, used for patients with MS, Parkinson’s disease, and dementia, including Alzheimer’s disease.
DHR operationalized cognitive monitoring in MS according to the following protocol:
In contrast to single-domain screening instruments, BrainCheck Assess evaluates multiple cognitive domains, enabling clinicians to characterize which specific areas of function are affected when change is detected. Dr. Cruz reported that this domain-level specificity provides clinically useful information beyond what is available from composite screening scores alone—a meaningful advantage when monitoring patients with MS, where cognitive profiles vary significantly from patient to patient.
A significant aspect of Dr. Cruz’s implementation is the use of a single assessment platform across multiple neurological conditions. Dr. Cruz noted that the majority of neurologists in clinical practice are not dementia subspecialists. Access to a standardized, validated cognitive assessment tool applicable across disease states, MS, Parkinson’s disease, Alzheimer’s disease and related dementias reduces the burden of managing multiple tools for different populations and supports consistent cognitive monitoring at the practice level.
“As neurologists, we care for patients across a broad spectrum of conditions — not just MS, not just dementia. A standardized cognitive assessment allows us to monitor every patient across disease states consistently, without the overhead of managing multiple tools or workflows,” says Dr. Cruz.
Dr. Cruz’s implementation illustrates what it looks like to build cognitive monitoring into MS care in a practical, sustainable way. Key elements include: