Accepted Manuscript

Money Management Activities in Persons with Multiple Sclerosis

Yael Goverover, Shannon Haas, John DeLuca

PII: S0003-9993(16)30188-5
DOI: 10.1016/j.apmr.2016.05.003
Reference: YAPMR 56559

To appear in: ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 26 January 2016

Revised Date: 22 April 2016
Accepted Date: 1 May 2016

Please cite this article as: Goverover Y, Haas S, DeLuca J, Money Management Activities in Persons
with Multiple Sclerosis, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi:
10.1016/j.apmr.2016.05.003.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

Money Management Activities in Persons with Multiple Sclerosis

Yael Goverover 1,2

Shannon Haas 2

John DeLuca2,3

PT
1
New York University, Department of Occupational Therapy, New York, NY

RI
2
Kessler Foundation, West Orange, NJ
3
Rutgers University, Department of Physical Medicine and Rehabilitation, New Jersey Medical

SC
School, Newark, NJ

U
Acknowledgments
AN
The primary study (“The use of Actual RealityTM to measure everyday life functional activity in

MS”) was funded by an Investigator Initiated Grant/Trial Award from Biogen (US-MG-13-
M

10511); this secondary study did not receive direct funding from Biogen. Biogen reviewed and

provided feedback as part of a courtesy review but had no role in study design, data collection
D

and analysis, decision to publish, or preparation of the manuscript.

TE

Declaration of Interest

Drs. DeLuca and Goverover received grant funding from Biogen. Dr. DeLuca serves on an
EP

Advisory Board for Biogen. Dr. DeLuca, is a speaker for EMD Serono.

Correspondence Author:
C

Yael Goverover, PhD, OT

Department of Occupational Therapy
AC

Steinhardt School of Culture, Education, and Human Development

82 Washington Square East, 6th floor.
New York University
New York, NY 10003
Telephone: 212-998-5854
Fax: 212-998-4044
email: yg243@nyu.edu
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

1 Money Management Activities in Persons with Multiple Sclerosis

2
3

PT
RI
U SC
AN
M
D
TE
C EP
AC

1
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

4 ABSTRACT

5 Objective: To examine whether participants with multiple sclerosis (MS) have more

6 problems in managing finances compared with healthy controls (HC), and to examine the

7 variables that may contribute to these problems.

PT
8 Design: A cross-sectional study

RI
9 Setting and Participants: 30 adults with MS and 23 HC that were recruited from a

10 nonprofit rehabilitation research institution and from the community.

SC
11 Intervention: N/A

12 Main Outcome Measures: Participants were administered a battery of

13
U
neuropsychological tests, a money management survey, and a functional test to assess money
AN
14 management skills.

15 Results: Individuals with MS reported and demonstrated more problems managing

M

16 money than HC. Impaired cognitive functioning was significantly correlated with difficulties in
D

17 money management. Finally, the results revealed that self-report of functional status (Functional
TE

18 Behavior Profile) was significantly correlated with self-reported money management skills.

19 Conclusions: To our knowledge, this is the first study to examine money management in
EP

20 MS. Money management is an important activity of daily living that present problems for

21 individuals with MS. Managing one’s own requires adequate processing speed abilities as well as
C

22 executive-attentional abilities. Additional studies are needed to explore this area and understand
AC

23 the nature of the problem.

24 Keywords: Cognition, Activities of Daily Living, Quality of Life, Multiple sclerosis, Outcome
25 measurement.
26

2
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

27 Introduction

28 Multiple sclerosis (MS) is a central nervous system autoimmune disease

29 histopathologically characterized by discrete areas of myelin, oligodendrocyte, and axonal

30 loss.1,2 In addition to motor impairments, more than 50% of individuals with MS suffer from

PT
31 cognitive changes including impairments in learning and memory, attention, information

RI
32 processing speed, executive functioning, and visuo-spatial functions.3

33 MS has a significant impact on everyday life functioning including difficulties in social

SC
34 and vocational activities,4,5household activities,4 family activities and driving.6 Physical and

35 cognitive impairments lead to early retirement in 80% of MS patients.7,8 Information processing

36
U
and memory deficits are the most reported obstacles to maintaining employment .5
AN
37 Managing one’s own finances is an instrumental activity of daily living (IADL) crucial to

38 functioning independently in today’s society.9,10,11 Money management is a complex cognitively

M

39 demanding task that involves planning (to save, spend, invest, etc.), carrying out these plans,
D

40 prioritizing, avoiding impulses that contradict these plans, and being able to adjust plans in
TE

41 response to changing circumstances.12 Considering the cognitive impairments often associated

42 with MS and the complex cognitive functioning required for managing money, one could expect
EP

43 individuals with MS to report or have significant difficulties with money management. While we

44 are unaware of studies examining money management in persons with MS, such difficulties have
C

45 been reported in many other groups including patients with traumatic brain injuries,13,14,15
AC

46 schizophrenia and other mental illness,16,17,18 and elderly adults.19 These studies report significant

47 problems in managing finances due to executive dysfunctions as well as other social and

48 economic reasons.

3
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

49 The goals and the hypotheses of the current study were to examine: (a) whether persons

50 with MS report and perform more problems at managing money than healthy controls (HC); It

51 was hypothesized that MS participants will report and present more money management

52 problems, compared to healthy controls (HC), (b) whether neuropsychological tests of executive

PT
53 functioning, processing speed and memory are associated with problems managing money; It

RI
54 was hypothesized that impairments in executive functions and processing speed would have a

55 greater impact on a person’s ability to manage finances compared with problems in learning and

SC
56 memory abilities. (c) whether self-reported money management skills are associated with self-

57 report of everyday life functional status (other than money management); it was hypothesized

58
U
that reports of difficulties in financial management will be associated with other reported
AN
59 difficulties in everyday life, and (d) whether self-reported money management skills are

60 associated with errors in actual performance related to money management. It was hypothesized
M

61 that report of difficulties in financial management will not be associated with actual performance
D

62 errors of money management task.

TE

63 Method

64 Participants
EP

65 Participants consisted of 23 HC and 30 individuals with clinically definite MS20 between

66 the ages of 18 and 65 years. Participants with MS were recruited from advertisements, support
C

67 groups, word of mouth, and from the Kessler Foundation. Healthy controls were recruited from
AC

68 advertisements and by word of mouth. All recruitment and procedures were approved by the

69 Institutional Review Board and Health Insurance Portability and Accountability Act compliance

70 boards.

4
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

71 Participants were excluded if they suffered from any neurological or medical condition

72 other than MS, had an exacerbation of symptoms within the past month, had steroid treatment

73 within the past month, had insufficient visual acuity to see the test materials, and did not speak

74 English. Demographic characteristics are described in Table 1. There were no significant

PT
75 differences between HC and MS regarding years of education (F (1, 52) = .003, p = .95) and age

RI
76 (F (1, 52) = .56, p = .45). Information regarding gender, employment status and disease duration

77 are included in Table 1. The MS Functional composite score was used to reflect the clinical

SC
78 disability of MS and is described in Table 1.

79

U
80 Insert Table 1
81
AN
82 Measures

83 Learning and memory was assessed using: (a) the Selective Reminding Test (SRT),
M

84 designed to assess verbal memory and learning.21 The number of total words recalled over the six

85 learning trials and the number of words recalled after 30 minutes were used in this study. (b)
D

86 Brief Visuospatial Memory Test-Revised (BVMT-R) designed to assess visual memory.22 Total
TE

87 Recall across the three learning trials and the Delayed Recall scores served as the dependent

88 variables. (c) Memory for Intentions Test (MIST). 23 The MIST is a measure of prospective
EP

89 memory. The total correct responses of the prospective memory score was used as a dependent
C

90 variable in this study.

AC

91 Executive functions were assessed using the Delis-Kaplan Executive Function System

92 (DKEFS)24 Verbal Fluency and Color-Word Interference subtests. Raw scores were converted to

93 scaled scores and the DKEFS composite score was then created by averaging these scaled scores.

94 Processing speed and working memory were assessed using the (1) Symbol Digit

95 Modalities Test (SDMT; oral version25; correct responses was the dependent variable, higher

5
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

96 scores indicate faster processing speed); and (2) Paced Auditory Serial Addition Test

97 (PASAT).26 There are two trials of 60 numbers each. The first contains a 3-second inter-stimulus

98 interval and the second a 2-second inter-stimulus interval. Total number correct across the two

99 trials was the dependent variable.

PT
100 Depression and Anxiety were assessed using the Chicago Multi-scale Depression

RI
101 Inventory (CMDI)27 and the State and Trait Anxiety Inventory (STAI).28 Both measures are self-

102 report questionnaires that ask participants to rate their mood on a 4 or 5-point Likert scale.

SC
103 Everyday behavior was assessed using the Functional Behavior Profile (FBP).29 The FBP

104 is a self-reported questionnaire that assesses everyday life task performance, social interactions,

105
U
and problem-solving. Higher total scores indicate more frequent engagement in the activity.
AN
106 Instrumental Activities of Daily Living (IADL) scale10 consists of eight questions investigating

107 one’s independence in performing specific tasks such as laundry, operating the telephone and
M

108 preparing food. Total scores can range from 0 to 8, with 8 being most independent.
D

109 Money Management:

TE

110 Money management was assessed by a self-reported questionnaire9 that was designed for

111 patients with acquired brain injury. The survey consists of 10 short, concrete terminology
EP

112 questions. For example, one question asks, “Do you pay the rent late?” Never (score of 0),

113 Sometimes (score of 1), or Often (score of 2). A total score ranging from 0 and 20, with a lower
C

114 score indicating fewer problems managing money, was used. The score of each individual
AC

115 question was divided into two categories: ‘problems’ and ‘no problems’. Responses of 0

116 indicated ‘no problems’ and responses of 1 or 2 indicated ‘problems’.

117 Actual RealityTM (AR)30,31,32 is a performance-based functional test that consists of using

118 a website to accomplish a task.32 In this study, actual money management skills were assessed by

6
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

119 an AR task of purchasing a cookie bouquet, which involves specific money management skills

120 such as planning and budgeting. Participants had to choose an appropriate cookie bouquet within

121 a stated price range after considering the cost of shipping and handling. Instructions regarding

122 cookie bouquet criteria were read to the participants and specific errors were recorded. Five

PT
123 behaviors required to conduct the AR task were deemed to be goal-directed actions related with

RI
124 money management. The fives behaviors included: staying within the price range, correctly

125 using the credit card, choosing an appropriate cookie bouquet, performing the task at an efficient

SC
126 pace and correctly responding to unexpected events. A score of a 0 (no error), 1 (minor error) or

127 a 2 (major error) was given for performance of each of these goal-directed actions listed above.

128
U
The scores depended on the severity and frequency of the error/s committed during performance.
AN
129 For scoring, two types of dependent measures were used: (1) Total sum of goal-directed actions

130 (lower scores indicated better performance) and (2) The score of each individual goal-directed
M

131 action (responses of 0 indicating ‘no problems’ and responses of 1 or 2 indicating ‘problems’).
D

132 Procedure
TE

133 Upon initial telephone contact, potential participants were screened according to the

134 inclusion/exclusion criteria described above. Before study enrollment, all participants signed an
EP

135 informed consent form approved by the Institutional Review Board and were scheduled for an

136 interview and testing.

C

137 During testing, participants completed questionnaires to assess IADL, money

AC

138 management skills, quality of life, and affect symptomology. Participants then performed the AR

139 task and the neuropsychological tests (order was randomized across subjects).

140

141 Data Analysis:

7
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

142 Group differences in money management, cognitive performance, IADL reports and

143 affect symptomatology were each analyzed by one-way analysis of variance (ANOVA). For

144 each question on the money management survey, responses were divided into two groups, with

145 responses of 0 indicating ‘no problems’ and responses of 1 and 2 indicating there were

PT
146 ‘problems’. Multiple planned comparisons using the likelihood ratio were then used to examine

RI
147 the areas where individuals with MS were more likely to have problems compared to HC.

148 Additionally, this analysis was also used to examine the AR task items where individuals with

SC
149 MS were more likely to have problems than HC.

150 Pearson correlation coefficients were used to examine the association between money

151
U
management with neuropsychological test performance, self-report of functional behavior, and
AN
152 affect symptomatology.

153 Lastly, a total money management score was computed by averaging the two money
M

154 management scores (self-report as well as actual performance). A stepwise linear regression was
D

155 used to predict money management difficulties based on processing speed (SDMT), processing
TE

156 speed and working memory (PASAT) and executive functions (DKEFS).

157 Results
EP

158 Table 2 presents group comparisons between participants with MS and HC. The MS

159 group scored significantly worse on the self-reported functional activities on the IADL and FBP
C

160 questionnaires than the HC group. Regarding cognitive testing, the MS group recalled
AC

161 significantly fewer items on the SRT immediate recall test, but not on the delayed recall. The MS

162 group remembered significantly fewer items on the total BVMT-R score and on the BVMT-R

163 delayed score, and showed worse prospective memory (MIST) compared to the HC group. The

164 MS group demonstrated significantly slower processing speed (i.e., SDMT). For the DKEFS, the

8
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

165 MS group performed significantly worse than the HC group on the verbal switching and color-

166 word interference tests. MS group also performed significantly worse on the PASAT compared

167 to HC. In terms of affect symptomatology, participants with MS reported significantly more

168 depressive symptomatology but not anxiety. Participants with MS reported more money

PT
169 management problems on the money management questionnaire compared to HC and committed

RI
170 more money management errors while performing the AR functional task of shopping online.

171 Note, that when upper extremity motor speed was controlled for, difference between HC and MS

SC
172 on AR remained significant F(2,53) = 5.8, p = .02, Eta2 = .105

173

U
Insert Table 2. Comparisons between HC and MS on functional level, cognitive performance and
affect symptomatology
AN
174
175
176 Of the 10 questions on the money management questionnaire, the likelihood of
M

177 increased problems in the MS group with operating an ATM (13.3%), owing debt for bills they
D

178 have not paid (23.3%), and needing to borrow money (30%) was significantly greater compared
TE

179 to the HC group (see Table 3).

180
EP

Insert Table 3. Percentage of participants in the MS and HC groups reporting problems in money
management on the money management survey
181
C

182 In terms of functional performance on the AR task, the MS group committed significantly
AC

183 more errors on items related to managing finances when purchasing a bouquet of cookies online

184 compared to the HC group. Results showed that the likelihood of greater problems in the MS vs

185 HC groups was observed in credit card errors and performing the task at a slower pace (see Table

186 4).

187

9
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

188
Insert Table 4. Percentage of participants in the MS and HC group who performed more errors
on the AR money management skills of the AR

189
190
191 Association between money management with cognitive skills, self-reported functional status

PT
192 As described in Table 5, AR money management errors were significantly associated

RI
193 with worse performance on all the cognitive measures scores except prospective memory.

194 Additionally, more problems managing money in both money management assessments (AR and

SC
195 money management survey) were associated with higher reported dysfunction in the IADL scale

196 and the FBP, but not with affect symptomatology. Self-reported money problems were not

197
U
significantly associated with actual money management on the AR task.
AN
198
Table 5. Correlations between money management with cognitive abilities, affective
M

symptomatology and functional status

199
200 To examine whether tests of executive functions, processing speed and memory could
D

201 predict one’s money management skills (self-report and actual), a stepwise linear regression
TE

202 analysis was performed. Three predictors were included in the analysis: 1) Executive functions

203 (DKEFS composite score), 2) SDMT and 3) PASAT for processing speed. The outcome variable
EP

204 was the total managing finances score. Using the stepwise method, processing speed was the

205 only predictor that was included in the regression model and it explains a significant amount of
C

206 the variance in managing finances (F(1, 52) = 11.1, p < .005, R2 = .18). It significantly predict
AC

207 managing finances ability (Beta = -.42, t(52) = -3.3, p < .01). The analysis excluded both the

208 PASAT score (Beta = -.15, t(52) = -.1.03, ns), and the executive functions score (Beta = -.22,

209 t(52) = -1.4, ns).

210

10
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

211 Discussion

212 The results of the present study support the hypothesis that MS participants would report

213 more problems managing money, and show problems during an actual money management task

214 compared to healthy controls. This finding is consistent with studies in persons with brain

PT
215 injuries.9,12,15,33 On the money management survey, persons with MS reported significantly more

RI
216 problems having debt for bills they have not paid, needing to borrow money, and using the ATM

217 relative to the HC group. These problems are similar to those seen in persons with brain injury.9

SC
218 On the performance-based money management task, the MS group made significantly

219 more errors related to money management on an Internet task to purchase cookies compared to

220
U
HC. Specifically, the MS group committed significantly more credit card errors and took
AN
221 significantly more time to complete the task compared to the HC group. Based on observations

222 during task performance, the MS participants often made credit card errors by omitting certain
M

223 details of the card such as the expiration date or the card verification value. Overall, based on
D

224 two methods to assess money management, one that is a performance-based (i.e. AR), and one
TE

225 that is self-report (i.e. money management survey), participants with MS clearly report and

226 perform more money management errors/problems compared to HC.

EP

227 The study’s second objective was to investigate whether neuropsychological tests of

228 processing speed, executive functioning, and memory are associated with problems managing
C

229 money. Results showed that the AR money management errors were significantly associated
AC

230 with all cognitive measures scores except prospective memory. Individuals with MS

231 demonstrated slower processing, memory impairments, impaired executive functions, and

232 committed more money management errors. This latter finding is also consistent with the MS

233 literature.30,34. Additionally, the present results show that the processing speed (SDMT) was the

11
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

234 only significant predictor of managing finances. Working memory (PASAT) and executive

235 functions (DKEFS composite score) had no significant predictive influence on managing

236 finances. This is consistent with existing literature that impaired information processing

237 efficiency significantly predicts employment status,5 and the best screen for cognitive

PT
238 impairments in MS.35 Overall, the present results are consistent with the notion that processing

RI
239 speed is crucial to the successful performance of managing finances in persons with MS.

240 In contrast, self-reported money management difficulties were not significantly correlated with

SC
241 the cognitive tests scores. This is consistent with the majority of literature showing that MS

242 patient self-report is not significantly related to neuropsychological performance.30,36,37 However,

243
U
these data are not consistent with those from Hoskin and colleagues12 who reported a small to
AN
244 moderate contribution of overall self-reported money management with neuropsychological

245 assessment in TBI. Lastly, self-reported money management problems did not correlate with
M

246 actual money management performance using the Internet, which is consistent with several other
D

247 studies in MS.30 and supported the last hypothesis of this paper.
TE

248 The third study objective was to examine whether overall objective money management

249 skills are associated with self-report of functional status. The results showed that self-reported
EP

250 and actual problems managing money were both associated with greater dysfunction on the

251 IADL questionnaire and functional status questionnaire (the FBP). These results show the
C

252 importance of money management to everyday life in the study sample. As reviewed previously,
AC

253 MS often negatively affects cognitive functions including attention, memory, and executive

254 functions. As a result, an individual may have difficulty completing monetary and everyday life

255 tasks due, in part, to cognitive impairments.

256 Limitations: The present study has several limitations. First, the clinical and control

12
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

257 samples were small and are in need of replication and extension. Second, while performance-

258 based evaluations of financial skills have the advantage of objectivity, it is unclear whether the

259 AR task will generalize to other IADL’s concerning money management. For instance,

260 purchasing merchandise online requires Internet and computer experience which may not

PT
261 generalize to non-Internet based money management tasks. Additionally, the current study only

RI
262 collected participant responses. Hoskins et al.,12 suggest using proxy reports, which may lead to

263 different results. Third, variables other than those examined in the current study such as self-

SC
264 efficacy, fatigue, pain, and personality may influence money management skills, and should be

265 considered in future studies. Clearly, money management is a complex cognitive task associated

266
U
with executive-attentional, memory and processing abilities. The present results show that
AN
267 persons with MS who have cognitive impairment experience difficulty with money management

268 in daily life. Therapy targeted at money management problems may have real-life, practical
M

269 benefits to the patient. Future research should focus on identifying skills persons with MS can
D

270 use in daily life that promote productivity and well-being with regard to money management.
TE

271 Conclusions: Of note, for the last 15 years, cognitive rehabilitation has been going

272 through a gradual paradigm shift. This shift has been from addressing cognitive problems using
EP

273 artificial and a-contextual tasks (e.g. generic workbook exercises, computer tasks that `exercise’

274 the mind) to using practical, `real-world’, tasks (e.g. addressing memory problems via practical
C

275 compensatory strategies, addressing attentional problems by changing the environment).38 This
AC

276 study provides more strength and emphasis to this approach, showing the importance of not only

277 assessing cognitive impairments, but also performance of critical everyday activities.

278

13
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

279 References

1. Morrow SA, Drake A, Zivadinov R, Munschauer F, Weinstock-Guttman B, Benedict RH.

Predicting loss of employment over three years in multiple sclerosis: clinically

meaningful cognitive decline. Clin Neuropsychol. 2010 Oct;24(7):1131-45. doi:

PT
10.1080/13854046.2010.511272.

RI
2. Prineas JW, McDonald WI, Franklin RJM. Demyelinating diseases. In: GrahamDI, LantosPL,

eds. Greenfield's neuropathology. London: Arnold, 2002;471–550.

SC
3. Chiaravalloti ND and DeLuca J. (2008). Cognitive impairment in multiple sclerosis. Lancet

Neurol 2008; 7(12): 1139-1151. DOI: 10.1016/S1474-4422(08)70259-X

U
4. Goverover Y, Strober L, Chiaravalloti N, DeLuca J. Factors that moderate activity limitation
AN
and participation restriction in people with Multiple Sclerosis. Am J Occup Ther. 2015

Mar-Apr; 69(2):6902260020 p1-9. doi: 10.5014/ajot.2015.014332.

M

5. Strober L, Chiaravalloti N, Moore N, DeLuca J. Unemployment in multiple sclerosis (MS):

D

utility of the MS Functional Composite and cognitive testing. Mult Scler. 2014
TE

Jan;20(1):112-5. doi: 10.1177/1352458513488235.

6. Schultheis MT, Garay E, DeLuca J. The influence of cognitive impairment on driving

EP

performance in multiple sclerosis. Neurology. 2001 Apr 24;56(8):1089-94.

7. Baughman BC, Basso MR, Sinclair RR, Combs DR, Roper BL. Staying on the job: The
C

relationship between work performance and cognition in individuals diagnosed with

AC

multiple sclerosis. J Clin Exp Neuropsychol. 2015; 37(6): 630-40. doi:

10.1080/13803395.2015.1039963.

14
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

8. Strober LB, Christodoulou C, Benedict RH, Westervelt HJ, Melville P, Scherl WF,

Weinstock-Guttman B, Rizvi S, Goodman AD, Krupp LB. Unemployment in multiple

sclerosis: the contribution of personality and disease. Mult Scler. 2012 May;18 (5):

PT
647-53. doi: 10.1177/1352458511426735.

9. Hoskin KM, Jackson M, Crowe SF. Can neuropsychological assessment predict capacity to

RI
manage personal finances? A comparison between brain impaired individuals with and

SC
without administrators. Psychiatry, Psychology and Law. 2005; 12(1): 56-67.

10. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental

U
activities of daily living. Gerontologist. 1969; 9(3):179-86.
AN
11. Marson DC. Loss of financial competency in dementia: Conceptual and empirical

approaches. Aging Neuropsychol Cogn. 2001; 8: 164–81.

M

12. Hoskin KM, Jackson M, Crowe SF. Money management after acquired brain dysfunction:

the validity of neuropsychological assessment. Rehabil Psychol. 2005; 50(4): 355-65.

D

13. Bottari C, Gosselin N, Guillemette M, Lamoureux J, Ptito A. Independence in managing

TE

one's finances after traumatic brain injury. Brain Inj. 2011; 25(13-14): 1306-17. doi:
EP

10.3109/02699052.2011.624570.

14. Martin RC, Triebel K, Dreer LE, Novack TA, Turner C, Marson DC. Neurocognitive
C

predictors of financial capacity in traumatic brain injury. J Head Trauma Rehabil. 2012;
AC

27(6): E81-90. doi: 10.1097/HTR.0b013e318273de49.

15. McColl MA, Davies D, Carlson P, Johnston J, Harrick L, Minnes P, Shue K. Transitions to

independent living after ABI. Brain Inj. 1999;13(5) :311-30.

15
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

16. Elbogen EB, Tiegreen J, Vaughan C, Bradford DW. Money management, mental health, and

psychiatric disability: a recovery-oriented model for improving financial skills. Psychiatr

Rehabil J. 2011 Winter;34(3):223-31. doi: 10.2975/34.3.2011.223.231.

PT
17. Cook JA, Mueser KT. Economic security: an essential component of recovery. Psychiatr

Rehabil J. 2013; 36(1): 1-3. doi: 10.1037/h0094739.

RI
18 . Kurtz-Dougherty SN. Money management for the severe and persistently mentally

SC
ill. 2014 (Doctoral dissertation, Rowan University).

19. Tilse C, Setterlund D, Wilson J, Rosenman L. Minding the money: a growing responsibility

U
for informal carers. Ageing and Society, 2005; 25(02): 215-27.
AN
20. Polman CH, Reingold SC, Banwell B, Clanet M, Cohen JA, Filippi M, Fujihara K, Havrdova

E, Hutchinson M, Kappos L, Lublin FD, Montalban X, O'Connor P, Sandberg-

M

Wollheim M, Thompson AJ, Waubant E, Weinshenker B, Wolinsky JS. Diagnostic

criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Ann Neurol.
D

2011; 69(2): 292-302. doi: 10.1002/ana.22366.

TE

21. Randall KD, Kerns KA. Selective reminding test. Encyclopedia of Clinical
EP

Neuropsychology, 2011: 2235-7.

22. Benedict RH, Schretlen D, Groninger L, Dobraski M, Shpritz B. Revision of the Brief
C

Visuospatial Memory Test: studies of normal performance, reliability, and validity.

AC

Psychol Assess. 1996; 8: 145-53.

23. Woods SP, Moran LM, Dawson MS, Carey CL, Grant I; HIV Neurobehavioral Research

Center (HNRC) Group. Psychometric characteristics of the memory for intentions

16
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

screening test. Clin Neuropsychol. 2008 Sep;22(5):864-78. doi:

10.1080/13854040701595999.

24. Delis DC, Kramer JH, Kaplan E, Holdnack J. Reliability and validity of the Delis-Kaplan

PT
Executive Function System: an update. J Int Neuropsychol Soc. 2004;10(2): 301-3.

RI
25. Smith A. Symbol digits modalities test. Western Psychological Services, Los Angeles. 1982.

26. Rudick R, Antel J, Confavreux C, Cutter G, Ellison G, Fischer J, Lublin F, Miller A, Petkau

SC
J, Rao S, Reingold S, Syndulko K, Thompson A, Wallenberg J, Weinshenker B,

Willoughby E. Recommendations from the National Multiple Sclerosis Society

U
Clinical Outcomes Assessment Task Force. Ann Neurol. 1997; 42(3): 379-82.
AN
27. Nyenhuis DL, Luchetta T, Yamamoto C, Terrien A, Bernardin L, Rao SM, Garron DC. The

development, standardization, and initial validation of the Chicago Multiscale

M

Depression Inventory. J Pers Assess. 1998; 70(2): 386-401.

D

28. Spielberger C; Manual for the State-Trait Anxiety Inventory. Palo-Alto, CA: Mind Garden
TE

Publishers; 1983

29. Baum C, Edwards DF, Morrow-Howell N. Identification and measurement of productive

EP

behaviors in senile dementia of the Alzheimer type. Gerontologist 1993; 33: 403-8.

30. Goverover Y, O'Brien AR, Moore NB, DeLuca J. Actual reality: a new approach to
C

functional assessment in persons with multiple sclerosis. Arch Phys Med Rehabil.
AC

2010; 91(2): 252-60. doi: 10.1016/j.apmr.2009.09.022.

31. Goverover Y, Genova H, Griswold H, Chiaravalloti N, DeLuca J. Metacognitive knowledge

and online awareness in persons with multiple sclerosis. NeuroRehabilitation. 2014 Jan

1;35(2):315-23. doi: 10.3233/NRE-141113.

17
 ACCEPTED MANUSCRIPT
Running Head: MONEY MANAGEMENT IN MS

32. Goverover Y, DeLuca J. Actual reality: Using the Internet to assess everyday functioning

after traumatic brain injury. Brain Inj. 2015;29(6):715-21. doi:

10.3109/02699052.2015.1004744. .

PT
33. McHugh L, Wood RL. Using a temporal discounting paradigm to measure decision-making

and impulsivity following traumatic brain injury: a pilot study. Brain Inj. 2008

RI
Aug;22(9):715-21. doi: 10.1080/02699050802263027. PubMed PMID:18608202.

SC
34. Kalmar JH, Gaudino EA, Moore NB, Halper J, Deluca J. The relationship between cognitive

deficits and everyday functional activities in multiple sclerosis. Neuropsychology.

U
2008; 22(4): 442-9. doi: 10.1037/0894-4105.22.4.442..
AN
35. Parmenter BA, Weinstock-Guttman B, Garg N, Munschauer F, Benedict RH. Screening for

cognitive impairment in multiple sclerosis using the Symbol Digit Modalities Test. Mult
M

Scler. 2007 ;13(1):52-7..

36. Goverover Y, Kalmar J, Gaudino-Goering E, Shawaryn M, Moore NB, Halper J, DeLuca J.

D

The relation between subjective and objective measures of everyday life activities in
TE

persons with multiple sclerosis. Arch Phys Med Rehabil. 2005 Dec;86(12):2303-8.
EP

37. Goverover Y, Chiaravalloti N, DeLuca J. Brief International Cognitive Assessment for

Multiple Sclerosis (BICAMS) and performance of everyday life tasks: Actual Reality.
C

Mult Scler. 2015 Jul 10. pii: 1352458515593637. [Epub ahead of print] .
AC

38. van den Broek MD. Why does neurorehabilitation fail? J Head Trauma Rehabil. 2005; 20(5):

464-73. Review.

18
 ACCEPTED MANUSCRIPT

Table 1. Demographic characteristics of MS and HC

MS HC Test p
(n = 30) (n = 23)

Age 47.9 ± 10.6 50 ± 9.4 F = .56 ns

PT
Education 16.3 ± 2.0 16 ± 2.3 F = .003 ns

Disease Duration (months) 95.9 ± 53.3 N/A

RI
MSFC z-score -1.29± 2.01 .47 ± .35 F = 17.1 .00

Gender: Male 7.3% (n=3) 28.1% (n=9) χ² (1) = 2.4 ns

SC
Female 76.7% (n=23) 56.5% (n=13)

Disease Type:
Relapsing Remitting 60%
U
N/A
AN
Primary Progressive 26.7% N/A
Secondary Progressive 13.3% N/A
M

Main source of income:

D

Disability/unemployed 25 1
Part-time work 2 4
TE

Savings 0 1
Full-time work 3 17
EP

MSFC: Multiple Sclerosis Functional Composite scale

C
AC
 ACCEPTED MANUSCRIPT

Table 2. Comparisons between HC and MS on functional level, cognitive performance and affect
symptomatology
MS (n = 30) HC (n = 23) F Eta 2

Functional level
Employed (n) 3 21 x2=31.7** .70

PT
IADL score (total) 6.3 + 1.5 7.9 + .41 23.9** .32
FBP (self) 98.4 + 16.1 115.3 + 6.5 22.1** .30

RI
FBP- Task performance 33.8 + 5.7 40.9 + 2.2 31.8** .38
FBP- Social integration 35.3 + 6.3 40.2 + 3.2 11.6** .18
FBP- Problem Solving 29.3 + 5.3 34.1 + 1.8 16.9** .25

SC
Money management 1.9 + 2.2 .87 + 1.3 4.1* .08
survey

U
AR score (mean errors) 3.4 + 2.2 1.78 + 1.5 8.4** .14
AN
Cognitive
performance

SRT (total memory for 40.8 + 9.6 49.7 + 9 11.6** .18

M

6 trials)
SRT (30-minute delay) 5.7 + 2.7 6.8 + 2.6 2.2 .04
D

BVMT immediate total 20.3 + 6.9 25.1 + 5.5 7.5** .12

TE

recall
BVMT-Delayed 8.1+ 3.1 10.1 + 1.9 7.2** .12
SDMT 43.1 + 10.7 58.5 + 8.4 32.1** .38
EP

MIST- raw score 33.7 + 8.4 40.7 + 6.1 11.3** .18

DKEFS-Verbal 9.4 + 3.6 13.2 + 2.8 16.1** .24
C

category switching SS
AC

DKEFS Color word SS 8.5 + 3 12.0 + 1.8 24.1** .32

PASAT 58.0 + 26.1 88.1 + 16.3 23.2** .31

Affect
CMDI-Total t-score 54.9 + 14.6 45.6 + 8.3 7.4** .12
STAI –State 34.7 + 11.9 30.7 + 7.8 1.9 .03
STAI-Trait 36.4 + 10.5 32.7 + 8.4 1.8 .03
*p < .05; **p < .01
 ACCEPTED MANUSCRIPT

Table 3. Percentage of participants in the MS and HC groups reporting problems in money

management on the money management survey
% MS (n = % HC (n = 23) Likelihood p
30) ratio

Problems with ATM 13.3 0 4.8 .03

PT
Don’t often check change 30 17.4 1.1 .28
Pay bills or rent late 10 4.3 .63 .43

RI
Thrown out of 3.3 0 1.1 .28
accommodation

SC
Owe money for debts 23.3 4.3 4.1 .04
Spend all money within 23.3 8.7 2.1 .14
first few days
Go without essentials 10 8.7
U .02 .87
AN
Problematic impulse 13.3 8.7 .28 .59
buying
M

Spend all money on 13.3 4.3 1.3 .25

things they like
Need to borrow money 30 8.7 3.8 .04
D

Note.; ATM = automatic teller machine.

TE
C EP
AC
 ACCEPTED MANUSCRIPT

Table 4. Percentage of participants in the MS and HC groups who performed more errors on the
AR money management skills
% MS (n = 30) % HC (n = 23) Likelihood p
ratio
Going over the price range 36.3 34.8 .15 .69

PT
Credit card errors 26.6 4.3 5.2 .02
Pace 53.3 17.4 7.5 .006
Choosing the best option 63.3 43.4 2.07 .14

RI
Noticing and responding to 76.6 60.8 1.5 .25
unexpected issues

U SC
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

Table 5. Correlations between money management with cognitive abilities, affective

symptomatology and functional status.
Money management – Money management –
self-report Actual performance
Cognitive domains
SRT-total 6 trials -.05 -.26*

PT
BVMT-R Immediate recall -.008 -.43**
BVMT-R Delayed recall -.03 -.41**

RI
SDMT -.10 -.38**
MIST -.10 -.18

SC
D-KEFS-Verbal Fluency -.03 -.33**
D-KEFS – Color Word -.10 -.38**

U
PASAT -.12 -.32*
AN
Affect Symptomatology
CMDI .22 .06
Anxiety-State .12 .11
M

Anxiety-Trait .22 .09

Functional Status
D

FBP -.36** -.30*

FBP Task performance -.26* -.37**

TE

FBP Problem-solving -.50** -.26*

FBP Social -.37** -.20
EP

IADL-self-report -.31* -.28*

AR .21
C

*p < .05; **p < .01

AC