This patient should be referred for counseling and cognitive therapy. Cognitive dysfunction is a common symptom in multiple sclerosis (MS), occurring in at least 50% of affected patients. The most common deficits involve short-term memory, processing speed, and executive function. This cognitive disability can have a significant effect on employment of patients with MS and can reduce their overall quality of life. Unfortunately no trials of pharmacologic therapy to reduce or prevent cognitive dysfunction in MS have as yet been successful. Formal neuropsychological testing, counseling, cognitive therapy, and accommodative strategies (such as creating checklists to overcome memory deficits) sometimes can be of benefit.

Amantadine is an appropriate treatment of the fatigue associated with MS but has not been shown to improve cognitive function in this disorder.

Donepezil has shown benefit for mild to moderate cognitive dysfunction due to Alzheimer disease. However, a randomized placebo-controlled trial of this medication in patients with MS who also had cognitive dysfunction showed no cognitive benefit.

The use of high-dose intravenous methylprednisolone is indicated only for acute exacerbations of MS, which the patient is not experiencing. The MRI also shows no evidence of breakthrough inflammatory activity.

Increasing the patient's fluoxetine dosage will not affect her cognition. Although depression is a common symptom in MS, and severe depression can be associated with a pseudodementia-like state, the patient did not report any worsening of depression and has a normal affect.