Thinking and memory problems

Problems with thinking or memory might sound trivial, but they can have a big impact on the day-to-day experience of living with MS. It can be frustrating to find that your cognitive issues go un-noticed by those around you. Your experience might not look as bad to the outside world as it feels to you. Other people don’t see the extra, invisible effort you are putting in to get the same result.

You may need to explain your cognitive symptoms to friends, family or work colleagues in order to get understanding or appropriate support. It is worth remembering that in most cases you have not lost the skills you used to have, they just take a little longer to express. With the right support and plans in place you can continue to do things as you choose.

The longer you have had MS the more likely cognitive problems are to occur. Research suggests that cognitive symptoms usually stay the same over several years, or only very gradually worsen. You have time to develop strategies to compensate for any difficulties, or train your brain to slow down any cognitive decline.

Cognitive problems in MS are the result of nerve damage in the brain interrupting the transmission of electrical messages, 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.

Cognitive problems can be made worse by:

• fatigue or poor sleep - which slows everything down. Try to pace yourself and plan demanding activities for times 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 fall. This means you have less capacity to concentrate on other things, such as carrying on a conversation at the same time as walking. 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. 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, pharmacist or MS nurse can advise on the likely effects of all medications
• other things that generally worsen symptoms - such as heat, or tense or exciting situations. Try to stay cool in hot weather, or use relaxation techniques to cope

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. Diaries, smartphones or notice boards are useful tools to record information and act as reminders. Have a set place to keep things like your keys and glasses to make it easier to find them and stay organised.

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 building with teachers and children' could be used to describe 'a school'.

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 give you a feeling of 'information overload' if only some of what you are being told is relevant. Try to reduce distractions such as turning the TV off before making a phone call, or dividing large tasks into more manageable chunks.

This is when you experience difficulties with following a series of complex instructions. This can particularly be a problem if information is given rapidly. Reducing distractions and trying to avoid 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. It is the skill you use when you walk through a door rather than bumping into the door frame, or when you use a map to find your way somewhere. You might need to slow down and concentrate on moving around, or enlist a sat-nav to guide your journeys.

Planning and solving problems are known as 'executive skills', and these may be impaired. It can be harder to see how your actions or decisions may affect you beyond the immediate future. This means that your decisions may not be as sound as they used to be.  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. It can be helpful to get another person's insight and talk through the implications before you make any important decisions.

Managing cognitive symptoms often involves finding strategies that work for you to minimise the effects of your symptoms. You could try the following suggestions, or find more ideas in our dedicated Staying Smart website, written in conjunction with neurologists from the Royal Holloway University.

• 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
• avoiding 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. You could try these techniques:

• guided relaxation
• aromatherapy
• breathing exercises
• mindfulness
• meditation
• yoga

Cognitive reserve is the brain's ability to use its nerve pathways more efficiently or to find alternative pathways if the usual ones are damaged.

Everyone’s brain is different. Intelligence, experience and education contribute to your cognitive reserve, and people with higher cognitive reserve have more of a buffer against cognitive difficulties. The stronger and more resilient your brain, the more you will be able to cope with MS damage.

However, cognitive reserve is a moving target, not a fixed deal. You can build or maintain your cognitive reserve once diagnosed with MS. Keep your brain active and healthy as far as you can. Keep up your hobbies, even if they begin to get tricky, and find brain games, puzzles or crosswords that you enjoy. Reading, writing and physical exercise has also been shown to help reduce brain volume decline and cognitive decline.

If something is difficult, we tend to avoid doing it. This is likely to result in a decline in ability as we get out of practice at that task. Cognitive rehabilitation involves strengthening brain function and retraining neural pathways using a series of challenging exercises.

This approach used to be reserved for the most severe cases of cognitive decline. Cognitive rehabilitation is now recognised as being effective earlier on in MS as well, where previously you might have been advised to simply take the strategic approach to managing the situation. Cognitive rehabilitation works best if the exercises you do are properly tailored to match the situations you have trouble with.

Practicing well-designed cognitive exercises produces improvement, at least in test situations. Real world improvements are harder to prove, but verbal memory, working memory, information processing speed and phonetic fluency (language) can be improved with cognitive rehabilitation. Physical exercise has been shown to increase brain volume and connectivity. 

For some people, cognitive problems can become more serious. They may not be aware of the true extent of their difficulties and more help may be needed than the above 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. Rehabilitation professionals may be able 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. A recent study found positive effects of simvastatin on brain volume, brain frontal lobe function and quality of life, and further investigations are underway to see if simvastatin could be a useful treatment in SPMS.

Fingolimod and the beta interferons have been investigated to see if they protect against brain volume loss and cognitive problems in RRMS. Fingolimod appeared to have a greater effect than beta interferon, but people taking these drugs may have been at different starting points in terms of their brain health. One big difficulty with interpreting the results of studies like this is the interaction of depression and quality of life with cognitive issues.

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, a speech and language therapist, neuropsychologist or cognitive rehabilitation professional. Your neurologist can also make referrals if required.

You might also like to explore the information on our Staying Smart website, or follow some of the links at the end of this article for further insights.

• Staying Smart - Find out more about thinking problems in MS and how to deal with them
• MS Brain Health organisation - This website is about ensuring brain health is part of MS services
• Signs and symptoms of MS
• Common early symptoms of MS