Ask the expert: Cognitive problems

21 July 2019

It's estimated that around half of people with MS will experience cognitive problems during their lifetime. Difficulties with memory, word finding, information processing, concentration and planning all fall under cognitive problems.

We spoke to neuropsychologist, Dr Eleanor Ansell to hear some of her strategies for managing these problems in everyday life.

Do you have any practical tips for dealing with memory problems?

Eleanor says: Everyday memory problems can generally be divided into two areas: remembering information and remembering to do something. There are a variety of strategies that can help with both of these areas.

Increasing strength of the memory

If you've got information you need to remember, the more you repeat it the better. Repetition will increase the connections to that memory and make it much stronger. Also if you can draw it, speak it and write it, then you've got three different pathways into that memory and that's going to make the memory trace much stronger.

Being organised

If you can organise and structure the information you need to remember it's going to be easier. For example, imagine that you have lots of shopping you need to buy. First of all writing it down is going to be helpful, but if you can structure that list into different types of shopping (e.g. fresh fruit and vegetables, meat, household goods, toiletries) by clumping them together it's going to be easier for you to recall them and think about whether you've missed anything off the list. It's also going to be easier to find them in the shop!

Other things that will help are keeping important items (like your house keys) in regular places so they're easy to find and making sure you write your appointments and other important events in your diary straightaway. This will take the strain off your memory.

Establishing a routine

Routine is a big aid in terms of your memory. If you can get in the routine of checking your diary regularly to see what you've got planned that can help you remember what you've got lined up. If you've got activities or tasks that you keep missing because you forget them, turn them into regular activities (e.g. every Thursday at 10am you go for a coffee with your friend or every Friday morning you empty the bins) and they will become much easier to remember.

Setting prompts and reminders

Using diaries, calendars, alarms, reminders and post-it notes can help take the strain off your memory. Smartphones are great because you can set reminders, make notes and dictate into them as well. Using the camera on your phone can be useful too if there's something you need to remember. You could take a picture of your appointment letters, for instance, which takes the pressure off you remembering to take the letters with you to your appointments.

My cognitive problems make me feel quite anxious when talking to people. Sometimes my mind will go blank or I can't find the right word so I start feeling embarrassed and self-conscious. How can I cope better in these situations?

Eleanor says: If you feel anxious about your memory problems in social situations the temptation is to avoid them altogether. This can make the problem worse because anxiety can start to build up and you become more fearful of those situations. You also don't get a chance to develop coping strategies.

My first recommendation is to practise. This will help you feel more at ease in these situations. We know that anxiety affects our memory so when you first start doing it it's probably going to be more difficult because you'll be anxious, but with time it will get easier.

If your mind does go blank or you've lost your train of thought, take a deep breath, give yourself time and then respond. Often you're much more aware of these difficulties than the person you're talking to, who may not even notice, so try not to worry too much about it.

What tends to happen if you're very anxious is you focus inwards, you stop paying attention to the conversation and you start feeling very self-conscious. When you notice you're becoming very introverted, try to extend your attention and focus outwards. Concentrate on what the other person's saying, what they look like, what's going on around you. That will help you normalise it and reduce the anxiety.

Do you have any tips for someone having problems finding words?

Eleanor says: Word finding difficulties are common in MS, and in the general population too. They're often made worse by stress and anxiety. The more we try to find the word, the more pressure we put on ourselves, and the more elusive the word becomes.

My advice is to take the pressure off and relax about it. You could say, "I can't think of that word at the moment, it'll come back to me". Often it'll pop back into your head later. Sometimes not getting so fixated on that word and finding another one instead that will equally do is a good technique.

Describing the word you're talking about is another option. That may help the word pop back into your head or alternatively the other person might understand what word you're looking for so you can continue the conversation.

Another technique that sometimes works is to go through the alphabet in your head whilst trying to think of the word. This can sometimes prompt you to remember the word as it acts as a distraction.

If you're finding that your word finding difficulties are impacting you significantly, then ask to be referred to a speech and language therapist. They can provide lots of really good techniques for managing word finding problems.

Will my cog fog get worse over time? Can I do anything to stop it from getting worse?

Eleanor says: It's difficult to say whether your brain fog is likely to get worse over time because everyone's MS will progress differently. However there are things that can make brain fog worse and things that can make it better; addressing these factors can be helpful.

  • Diet and exercise – Not eating healthily and not doing enough exercise can affect your cognition. Taking steps to improve your diet and increase your activity levels will help you to stay more alert and minimise your cog fog.
  • Sleep – Sleep is when we lay down our memories and consolidate them so if our sleep is disrupted that's going to affect our memory. Developing good sleep hygiene techniques can be useful, such as having a warm bath in the evening and avoiding electronic devices before bed.
  • Managing other MS symptoms – Fatigue can have a big impact on your thinking and memory skills. Make sure you're managing your fatigue by pacing yourself, allowing yourself time to relax and getting enough sleep. Pain can also affect our cognition because it can be very distracting, making it more difficult to concentrate and process information. Working with your MS team to manage your pain effectively can have a positive effect on your cog fog.
  • Alcohol – Drinking too much alcohol can affect your sleep pattern and quality. This will have a knock-on effect on your memory. Being sensible with your alcohol intake will help to minimise any impact on your cognition.

What's the best way to deal with cognitive problems at work?

Eleanor says: This can be a tricky situation. It will depend on your relationship with your employer. As a rule of thumb, if you can be open about the difficulties you're having and offer up solutions, then that can open up the dialogue with your employer and give them an idea of how they can support you.

Think about how you approach the topic with your employer. Rather than saying, "I'm having memory problems, I'm struggling with work", you could approach it slightly differently by saying, "As you know I have MS, I've noticed that I'm having some memory problems. My memory's generally okay but I'm really struggling with remembering everything that's discussed during meetings. I wonder if we could make the minutes from meetings more detailed so that I can refer back to them?" This sort of approach will help because you're suggesting a solution.

Sometimes things don't go to plan and sometimes you do come across employers who are difficult. You do have rights in those situations – visit our page on the Equality Act to find out how it covers you, and our legal advice page for organisations that can help.

What cognitive problems happen in MS and why?

Research shows that between 40–65% of people with MS will experience some sort of cognitive difficulty during their lifetime. That can be quite mild, so it might be something that they're aware of and doesn't really impact them very much, to more moderate difficulties where perhaps close family and friends might be a bit more aware and they might need to use some strategies to help them, and then to more severe difficulties whereby it has quite a major impact on someone's life and they need a lot of support with it.

The reason for those difficulties varies quite a bit but generally, whilst there is often some damage to the grey matter (which is the thinking and the thought basis of the brain), most of the symptoms of cognitive difficulties are very much associated with the white matter which makes sense because if you think about the neuron, which is a nerve cell, it's the myelin sheath which MS affects. That bit of the nerve cell, which is the long axon, is the connection bit and when the myelin sheath begins to disintegrate it means that the messages don't pass down the nerve cell as well as they should and then sometimes they begin to get inhibited.

The impact of this is quite interesting. Although as things can get worse the grey matter can get affected, mostly people will experience cognitive difficulties associated with this white matter connection difficulty. This will mean that while your verbal skills are pretty good, you experience difficulties with word finding. The reason for that is you've got all that information in your brain, you know the word, but because the connections are getting fuzzy it just doesn't come to hand when you need it.

Other problems might be the speed of information processing, so you might be much more slowed up in your thinking. You might remember something but it might take ages to recall it. Again, that's because the connections are getting quite fuzzy. Other things might be attention, again for the same reason, and also planning and reasoning skills. The reason for that is we believe a lot of those higher order skills are based in the frontal lobe and that's where a lot of the connections are going because what they're doing is they're taking information from the rest of the brain and putting it together so you can plan and reason. So when your connections are going a bit fuzzy these things become a little bit more difficult as well.

Those are the main difficulties that you will find with MS and it does get a little bit more so if you get towards the more severe end but all those things can be managed with different techniques generally.

Is there anything that can make thinking and memory problems worse?

Yes, lots of things. Memory and cognition is very much affected by your mood. If you're feeling anxious or depressed, it's going to get fuzzy, it's going to get slower. If you're having a very stressful time of things or if you've had an argument with somebody and you're feeling very emotional and hurt about it, you're going to struggle to remember something. It has quite an impact in terms of your memory in that short space of time.

Sleep is when we lay down our memories and consolidate them so if our sleep is disrupted that's going to affect how our memory is and if we're not getting enough sleep again that will also have an impact. Think about some good sleep hygiene techniques if you are struggling with your sleep. Stay off the electronics just before you go to bed, think about having a nice warm bath before bed if you're struggling with going to sleep or if your mind is racing and you're struggling to focus and relax enough to go to sleep, then sometimes just getting up for a little bit and trying again can help.

If you're very fatigued generally, and obviously with MS often people are, so just being aware that if you're feeling very tired that is going to affect your cognition. So don't beat yourself up if you are feeling fatigued and then there's the knock-on effect, just be kind and actually allow yourself some time to relax and maybe get a bit more sleep and then see how things go after that.

Pain also can affect our cognition. The reason for that is we're being distracted by the pain so it's much harder to get information in, it's much harder to get information out.

Drugs and alcohol can affect cognition. If you're drinking quite heavily you're not going to be sleeping so well and your memory is not going to be so good.

Different medications can affect memory and cognitive function. A lot of recreational drugs too, for example with marijuana, can affect your short-term memory. Again, just be mindful of those side effects.

If you're not going out and getting fresh air and you're not keeping up some level of exercise, then your metabolism will slow and again that will affect your cognition because everything begins to slow a little bit.

Other conditions can also affect your cognition, for example if you've got an underactive thyroid then that can affect your memory and speed of processing too. If you're diabetic and having lots of hypos that can affect cognitive function too. Just be mindful of how all those other things might impact it as well.

Dr Eleanor Ansell is a clinical psychologist specialising in neuropsychology. She works at the West Hertfordshire Community Neuro Rehab Service.

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