Cognition Problems
(Thinking and Memory)

Cognition refers to acquiring, storing and retrieving information and knowledge, more informally known as thinking and memory. Cognition problems, also referred to as “brain fog”, “brain haze”, or “cog fog”, are common for people living with MS and often involve elements of decision making, focus and concentration, memory and executive function (planning and executing goals).  

You may have difficulty finding the right words to say, or trouble remembering work tasks or home routines. Some people forget appointments, take longer to solve problems, or need things repeated. Cognitive issues can arise early in the course of MS, but the longer you’ve had MS the more likely problems are to occur. 

For most people with MS, cognitive change is mild and can fluctuate. In fact, rather than recognising these symptoms as an aspect of your MS, you may link them to stress, overwork, tiredness or just getting older. For people living with MS, invisible symptoms such as cognitive issues can be frustrating, because others may not notice how you feel.

The most common cognitive problems relate to:

• Memory – difficulty remembering recent events or information or forgetting to do things.
• Word finding – when a word is ‘on the tip of your tongue’ but you can’t recall it.
• Concentration and attention – hard to concentrate, follow conversations, your mind wanders or feels overloaded.
• Information processing – hard to follow a series of complex instructions, especially if they’re rapid. 
• Visuospatial abilities – how you judge for example, distance, speed and where things are.
• Planning and problem solving – everyday tasks, thinking through implications of actions or decisions may become harder.

As we know, MS is a disease of the central nervous system that affects the brain and spinal cord. It also causes areas of inflammation and lesions on the brain. No one MS lesion causes cognition problems, but instead, they seem more associated with an increased overall number of MS lesions in the brain or the particular location of lesions.

There are also a range of other factors related to MS, which can worsen cognitive issues, often creating a vicious cycle where they make each other worse. These include: 

• Emotions – stress, anxiety and depression can all impact cognition and brain function.
• Fatigue – fatigue can slow things down and can also affect short term memory, concentration or word finding. Pacing yourself and planning demanding activities for when you’ve got the most energy can help.
• Other illnesses or infections – people living with another illness in addition to MS can experience more intense cognitive problems.
• Medications – side effects of medications, including some used to treat MS symptoms, can impact cognition. An MS Nurse or GP can advise on the likely side effects of your medications. 
• Physical Effort – if you have balance or mobility issues, you may need to concentrate more whilst moving about, to ensure you don’t trip or fall. This can lessen your capacity to concentrate on other things, such as talking whilst walking. Balancing physical and cognitive activities so you only have to concentrate on one thing at a time can help.
• Other factors – such as heat, tense or exciting situations can impact cognition. Staying cool in hot weather or using relaxation techniques can help. 

Cognitive symptoms may stay the same over several years, or only very gradually worsen, giving you time to develop strategies to compensate for any difficulties and seek the help you need.

As part of normal ageing, there is a small volume of brain volume loss as we grow older, thought to start occurring from our mid-twenties. Atrophy refers to this brain shrinkage. For people with MS, this brain volume loss is slightly more than for people without MS. This is thought to be due to the MS brain lesions becoming inflamed and later healing and shrinking, leading to loss of brain tissue over time. 

The introduction of highly sensitive MRI technology in the last decade has shifted focus to the importance of measuring this brain volume loss (atrophy) and seeing how it relates to MS progression for each person. Nowadays it is one of the key factors your neurologist will look for in examining your MRI scans. This is another reason why early reporting of any cognition issues you notice is vital – so your MS healthcare team can assess and advise on your individual situation.

If you have cognition concerns talk to your neurologist, MS Nurse or GP. Some things to think about and discuss might include:

• What you’ve noticed yourself and/or what other people have noticed?
• At what point in a conversation you can keep up with what’s being said and if you ever struggle to find the appropriate words to say.
• If you sometimes forget things, even straight after receiving information. If so, when does this happen? Are you fatigued or stressed? 
• Whether it seems you need more time to take in information or learn new things than before. 
• Whether your cognition concerns are worsened by your other MS symptoms.
• Any specific problems you may be having at work or home that are causing concern.

Some simple screening tests may be possible with your MS healthcare team to see if you might benefit from referral to a neuropsychologist for more detailed assessment. For mild symptoms, simple lifestyle adjustments can be very helpful, but for more significant issues, specific management strategies can be recommended by the neuropsychologist, tailored to your specific areas of concern.

Managing cognition problems often involves finding strategies to minimise the effects of symptoms and making some small lifestyle changes, to ensure the issues have minimal impact. 

Cognitive strategies include: 

• Starting a fixed routine – keeping things in the same place or doing things in a certain order.
• Visual and verbal associations to remember things e.g., putting meaningful tags onto words or names such as ‘Jack, the man who works in the bank’.
• Using diaries or smartphones for reminders, planning or memory prompts.
• Prioritising tasks to allow you to focus on one thing at a time and where possible, removing distractions.
• Breaking down longer tasks into smaller chunks.
• Try to avoid doing important things when you’re tired or anxious so you have more chance of staying focused.

If your cognitive problems worsen due to your other MS symptoms, having those symptoms treated can help. For example, if heat’s an issue, using cooling therapies such as fans or air conditioning can assist. Addressing stress and anxiety, using relaxation techniques, breathing exercises, meditation or yoga can also help. Paying special attention to your diet by eating nutritious foods and following the Australian dietary recommendations and exercising regularly (both resistance and cardio exercise), can also have important benefits and assist in maintaining mental health. Reporting signs of depression to your healthcare team early, can also help with managing cognition issues. 

If you’re experiencing cognitive problems, talk to your healthcare team to discuss options and to develop a tailored approach, as no two people experience MS in the same way.

There’s no magic medication to fix issues with cognition, although current research is indicating this may happen in the future. There are immediate and long-term strategies for decreasing cognition problems, or even just making it a bit more manageable. Your neurologist, MS Nurse or GP can guide you on modifiable lifestyle factors, restorative and compensatory techniques that can be developed to assist manage brain fog. You may need to try a range of options (or several at once) before you find what works best for you, and you may find the help of a neuropsychologist invaluable.

There’s growing evidence that disease modifying therapies (the drugs used in MS) can have beneficial effects on cognition, as it’s believed that some MS medications may reduce the amount of brain volume loss, in turn slowing down the progress of potential cognitive issues. This can be one of the great benefits of disease modifying therapies in addition to reducing relapses, and an important reason to stay with your medication and not miss doses.  

For some people, cognitive problems can become more serious, and you may need more help than the management strategies listed above. In this case, the neuropsychologist may take a retraining approach, by gradually introducing more challenging exercises to help strengthen impaired function. A speech pathologist or occupational therapist may also be involved. 

In many cases, cognitive training or rehabilitation can be of benefit. This involves structured activities designed to maintain or retrain someone’s ability to use their judgement and make decisions.