“Wait, why did I walk into this room? What was it I was looking for?”
If you have rheumatoid arthritis, you might often ask yourself similar questions, or you could have trouble recalling names, appointments, birthdays or other important dates. You may even find it difficult to remember how to perform routine tasks at work, and you could have a tough time making simple decisions.
If this sounds like you, you may be suffering from cognitive impairment, or brain fog.
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“Brain fog is a widely used, nonmedical term that is often applied to describe a person’s inability to think clearly, remember things, concentrate or easily carry out day-to-day mental tasks,” says Dr. Mark Swain, who is a professor of medicine and head of the Division of Gastroenterology and Hepatology at the University of Calgary in Canada.
“People suffering from chronic inflammatory conditions, including RA, often complain of brain fog,” he says. “In one study, roughly 30 percent [of people with RA] were found to be cognitively impaired,” Swain says.
Dr. Robert G. Hylland, a rheumatologist with Mercy Health in Muskegon, Michigan, says the percentage may even be higher.
“Studies suggest that 30 to 70 percent of RA patients have cognitive impairment,” he notes.
This wide range of estimated prevalence is likely a reflection of the fact that there has been little research into the subject.
“There aren’t many [relevant, high-quality] studies on cognitive impairment in RA” says Patricia Katz, a psychologist and professor of medicine and health policy at the University of California, San Francisco. But those that have been done have “generally found that people with RA either performed more poorly at a range of cognitive assessment tasks than healthy controls, or performed at a level below age norms,” she says.
In addition, patients may not complain to their rheumatologists about memory problems and the inability to concentrate. “In my experience, [patients complaining of] cognitive deficits and brain fog are relatively uncommon,” says Hylland, who is also an assistant clinical professor of medicine at the Michigan State University College of Osteopathic Medicine. Moreover, “physicians frequently don’t ask about them, and questionnaires used to obtain patient information rarely contain such inquiries,” he adds.
According to Hylland, when patients do voice such concerns, they usually associate them with poor sleep, which is “not usually independently evaluated in the studies reporting on brain fog,” he notes. Cognitive impairment in people with RA may indeed be tied to poor sleep, which is a common complaint because pain can cause insomnia or make it difficult to get restorative sleep. Lack of good-quality sleep causes fatigue, which impairs functioning.
“There is some literature on ‘ cognitive fatigue‘ in RA,” Katz says, “which some have identified as a unique state.”
“Non-restorative sleep, chronic stress and pain independently alter cognitive function and together contribute to secondary fibromyalgia, a disorder in which brain fog is almost universal,” Hylland adds.
[See: How to Practice Yoga When You Have Arthritis or Another Chronic Condition.]
Pain and insomnia can also lead to depression, which is a known cause of cognitive impairment. According to Swain, one study found that “depression and fatigue appeared to correlate best with perceived ‘brain fog’ in a cohort of patients with RA.”
Other mechanisms may be at play as well.
Rheumatoid arthritis is an incurable, inflammatory, autoimmune disorder in which the body’s immune system mistakenly attacks its own healthy tissue for reasons that are poorly understood. RA is most closely associated with potentially disabling destruction and deformation of the joints, but it is characterized by widespread inflammation that attacks multiple organ systems throughout the body, including the heart, lungs, blood vessels, eyes and skin.
This inflammation is caused by elevated levels of several proteins, called cytokines, found in the blood, including tumor necrosis factor alpha, interleukin-1 and interleukin-6. These cytokines may also promote cognitive impairment through a variety of mechanisms.
“TNF alpha can signal the brain to cause changes in brain function, which can in turn contribute to [the development of] disease-associated symptoms, including brain fog,” Swain says.
Swain stresses that actual physical or structural changes in the brain are not typically seen in people with RA. “However, changes in how different regions and neural networks of the brain talk to each other — connectivity — appear to be altered, and this can be shown using techniques such as functional MRI,” he explains.
According to Hylland, TNF alpha and interleukin-6 have also been directly linked to the development of atherosclerosis, or hardening of the arteries, which is common in people with RA. When atherosclerosis affects the blood vessels in the brain, it restricts blood flow, which can ultimately lead to cognitive impairment.
“Patients treated with medications that block these chemicals frequently report dramatic improvement in fatigue and mental function,” Hylland says.
Other RA medications may contribute to cognitive impairment. “Moderate- to high-dose prednisone is associated with attention deficits and memory difficulties,” Hylland says. “And many patients on methotrexate (the most common disease-modifying drug in our arsenal against RA) complain of mental fog, which improves by reducing the dose or discontinuing the medication.”
One of the keys in decreasing the incidence or severity of cognitive impairment is to control disease activity.
“I do not see cognitive deficits, nor complaints of brain fog, in my patients whose disease is well-controlled, provided they are sleeping well and have no independent causes for depression,” Hylland says.
It also takes awareness and action on the part of both patients and physicians.
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“Too often patients and physicians inadequately address non-restorative sleep and depression,” Hylland stresses. “Too often patients neglect proper diet and exercise, which is possible even with active RA, and can help lift depression, [decrease] pain and reduce the anxieties [inherent in] a life-changing disease. Too often doctors fail to instruct in proper diet and exercise, and fail to enlist the expertise of our colleagues in physical and occupational therapy.”
Both patients and doctors may also be too hesitant to seek out the support of a psychotherapist, he notes, and insurance companies often restrict the number of visits.
“My advice to patients is to accurately assess their current physical and mental status and convey that information to their physician,” Hylland says. “Be proactive with requests for referral to physical and occupational therapists, psychologists, social workers and dietitians, who may help make this disease more tolerable.”
In the meantime, more research is being devoted to understanding the role of RA and other autoimmune diseases like lupus on cognitive functioning. Swain is part of a research effort in Canada studying how RA and other autoimmune diseases and various treatments impact brain functional connectivity and correlating their findings to the results of formal neurocognitive testing.
“[It] should be interesting,” Swain predicts.
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Rheumatoid Arthritis May Be Impacting Your Brain Fog originally appeared on usnews.com
