About half of all people with multiple sclerosis have some degree of problem at some time with aspects of thinking - memory, attention span, planning, decision making, understanding or concentration. Cognition is the term that covers all these aspects and these symptoms are referred to as cognitive problems. Cognitive issues can arise early in the course of the condition, but the longer you have had MS the more likely problems are to occur.
For most people the symptoms are relatively mild and can fluctuate from day to day, so initially you may not recognise them as an aspect of your MS and put them down to other reasons such as stress, overwork, tiredness or just getting older. Cognitive issues can be made worse by other symptoms such as fatigue, anxiety, depression, or even some medications.
The most common cognitive problems experienced by people with MS are poor memory and trouble concentrating, which they often describe as 'brain fog' or 'fuzziness'. Research suggests that cognitive symptoms usually stay the same over several years, or only very gradually worsen, giving you time to develop strategies to compensate for any difficulties.
What causes cognitive problems?
Cognitive problems in MS are the result of inflammation and lesions in the brain interrupting the transmission of electrical messages along nerve fibres, reducing the speed and accuracy of the information. It can be helpful to think of the nervous system as a telephone exchange - if the insulation on some of the wires is damaged and other wires are broken, this results in some wrong numbers and some calls not getting through at all. This is similar to the slowed processing of information that happens in MS.
Cognitive problems can be made worse by:
- fatigue or poor sleep - which slows everything down. Key to reducing the effect of fatigue is pacing yourself and planning demanding activities for when you've got the most energy
- physical effort - if you have difficulties with your balance or your mobility you may find that you need to concentrate more when you are moving about to ensure you don't trip or fall, this means you have less capacity to concentrate on other things, such as carrying on a conversation, at the same time as walking. One way of dealing with this is to try and balance physical and cognitive activities so you only have to concentrate on one thing at a time
- emotions - stress, anxiety and depression can all impact on cognition. They can also be difficult to distinguish from other MS symptoms, for example depression can be confused with fatigue as it can make you tired and uninterested in life. Proper assessment by a psychologist may help in this situation
- infections - and other illnesses can worsen cognitive problems
- medications - including some that are commonly used to treat MS symptoms such as bladder problems, spasticity and pain. A GP or MS nurse can advise on the likely effects of all medications
- other things that generally worsens symptoms - such as heat, or tense or exciting situations. Trying to stay cool in hot weather, or using relaxation techniques can help in these situations.
What are the most common cognitive problems?
You may find that your memory isn't as good as it used to be - usually memory problems in MS revolve around difficulties remembering recent events or information and forgetting to carry out plans. Both of these situations lend themselves well to using diaries, smartphones or notice boards to record information and act as reminders or prompts. Also being organised and having set places to keep things like keys and glasses can help.
Do you feel like a word is 'on the tip of your tongue' but you can't quite recall it? This is a common problem, even for people without MS. It can be helpful to try and describe the word you are struggling with in other terms, for example 'the buidling with teachers and children' could be used to describe 'a school'.
Concentration and attention
You may find it difficult to concentrate or find your mind wanders, particularly if lots of people are talking at once. This can make it harder to follow the thread of a conversation or it can feel like 'information overload' if only some of what you are being told is relevant. Simple strategies to reduce distractions such as turning the TV off before making a phone call, or dividing large tasks into more manageable chunks can help.
This is when you experience difficulties with following a series of complex instructions, this can particularly be a problem if information is given rapidly. Again reducing distractions and avoiding interruptions can help.
This refers to the way you relate to visual information, for example accurately judging speed and distance when driving, or judging where things are in relation to the space around you so, for example, you walk through a door rather than bumping into the door frame, or being able to use a map to find your way somewhere.
Planning and problem solving
Planning and organising everyday tasks may become harder. It can also be more difficult to think through how your actions or decisions may affect you beyond the immediate future - so your decisions may not be as sound as they used to be. Being able to plan and solve problems are known as 'executive skills'. If your executive skills are affected it can be more difficult to manage your day, or even your healthcare.
Often, it is a family member or friend who picks up on this kind of issue before you recognise it yourself. In this situation it can be helpful to get another person's insight and talk through the implications before you make any important decisions.
How are cognitive symptoms managed?
Managing cognitive symptoms often involves finding strategies that work for you to minimise the effects of symptoms. Compensatory strategies might include:
- establishing a fixed routine - keeping things in the same place, or doing things in a certain order
- using verbal tricks to help you remember things - for example 'spring forward, fall back' to remember which way the clocks change by an hour in spring and autumn
- visual and verbal associations may be helpful - for example picturing 'Mr King' as 'the man with a crown on', or putting meaningful tags onto words or names such as 'Carole the lady who works in the library'
- using diaries or smartphones for reminders, planning or memory prompts
- prioritising tasks to focus on one thing at a time and removing distractions where possible, for example sitting in a quieter part of the office or turning the TV down
- breaking down longer tasks into more manageable chunks and carrying them out over a few days
- if you can, avoid doing things when you are tired or anxious so you have more chance of staying focused.
If your cognitive problems are worsened by your other MS symptoms, getting those symptoms treated can help. For example, if heat is an issue, using cooling therapies such as fans or air conditioning can be helpful. Equally, managing symptoms such as stress and anxiety can help, techniques you might want to consider include:
- guided relaxation
- breathing exercises
More severe difficulties
For some people, cognitive problems can become more serious and they may not be aware of the true extent of their difficulties and more help may be needed than the above compensatory strategies. If this is the case, referral to a neuropsychologist can be helpful. A speech and language therapist or occupational therapist may also be involved. Approaches can include a retraining approach where progressively more challenging exercises are given to help strengthen impaired function. For the most severe cases, cognitive rehabilitation may be of benefit - this is the use of a structured set of activities designed to retrain an individual's ability to use their judgement and make decisions.
There are no drugs that are specifically prescribed for the treatment of cognitive problems in MS. A small study looking at the effects of gingko biloba supplements in people with MS showed some improvements in concentration and memory, but it didn't provide enough evidence to show it has a definite effect and further research is needed.
Some of the disease modifying drugs are also being investigated for any potential effect on cognitive function, but again it is too early to draw any firm conclusions about their potential benefits.
StayingSmart is a website designed to help you find out more about how multiple sclerosis can affect thinking and build your confidence in managing cognitive problems.
Who can help?
Your GP or MS specialist nurse should be the first port of call if cognitive issues are making life difficult. They can suggest strategies that might help and if appropriate make referrals for further help from an occupational therapist, speech and language therapist, neuropsychologist or cognitive rehabilitation professional. Your neurologist can also make referrals if required.
Last updated: March 2017
Last reviewed: August 2014
This page will be reviewed within three years