What Is APS “Brain Fog”? What Are Some Strategies to Help Manage It?

APS Program Community Q&A Series

Cognitive dysfunction (what many refer to as "brain fog") can be experienced by those who have APS or lupus, and can be confusing and frustrating. In this edition of the APS Program Community Q&A Series, Dr. Yu (Ray) Zuo discusses brain fog and what steps people can take to help manage its symptoms.

Brain fog takes many forms and affects everyone differently. One report assessed cognitive function among 143 patients with positive antiphospholipid antibodies and found cognitive dysfunction in 3% of patients with low levels of antiphospholipid antibodies, but in 12% of patients with higher levels [1]. Another study found cognitive dysfunction in 42% of APS patients compared to 11% of healthy individuals matched for age, sex, and level of education [2]. The prevalence of cognitive problems has been reported as even higher in lupus, up to 88% in some studies [3].

Symptoms vary in number and severity, and may include difficulty with word finding, inability to concentrate, trouble remembering small details, and other problems that make daily tasks more difficult. APS “brain fog” is often episodic, meaning that there can be periods of worsening (often at times of stress) before returning to relatively normal function. It should be noted that this type of cognitive dysfunction does not typically progress to severe dementia.

The cause of APS-associated cognitive dysfunction remains poorly understood. Several possible mechanisms have been suggested such as blood clots (either large strokes or multiple small blood clots in the brain), disruption of the blood-brain barrier (a semipermeable membrane that separates the blood from the brain’s fluid and in doing so prevents the passage of toxic antibodies, cells, and molecules into the brain), and psychological factors such as depression and anxiety [4]. One of the biggest challenges in the study of APS brain fog is the absence of standard definitions and approaches to diagnosis [2].Indeed, our group is actively conducting a study that aims to develop better tools to define and assess APS-associated cognitive dysfunction.

When considering a diagnosis of APS-associated cognitive dysfunction, it is important to rule out other common non-APS causes of cognitive problems such as Alzheimer’s disease, Parkinson’s disease, seizure disorder, poorly controlled chronic medical conditions (hypertension, diabetes, heart disease, etc.), and undertreated mood disorders (such as depression and anxiety) [5-7]. Targeted therapies for cognitive dysfunction in APS are not yet available.

If you experience episodes of brain fog, don’t panic, but do bring this issue to your doctor’s attention. Meanwhile, here are some strategies that may help manage your life with APS brain fog:

• Sleeping well: Not sleeping enough impairs our brain’s ability to eliminate toxic substances and is associated with cognitive decline.
• Reducing stress: Give your mind a chance to rest and relax. Set a time each day to reset yourself by meditating, listening to music, or taking a walk outside.
• Challenging your mind: Exercise your mind and keep it stimulated (such as doing crossword puzzles, reading, learning a new language, interacting with new people, etc.).
• Getting emotional support: A supportive environment is crucial for managing cognitive symptoms.
• Taking care of your body: Take on a healthy diet and exercise regularly. Avoid alcohol and tobacco.

In summary, cognitive dysfunction affects many patients with APS, but does not typically progress to severe dementia. It is likely caused by multiple factors and targeted therapy is unfortunately not yet available. Experiencing brain fog can be discouraging. It is important to take control of your life by maintaining a positive attitude, setting measurable goals, and adopting a healthy lifestyle. Do not let it undermine your confidence and sense of self.

Contributed by Yu (Ray) Zuo, MD, MSCS

References:
Erkan, D., et al., Moderate versus high-titer persistently anticardiolipin antibody positive patients: are they clinically different and does high-titer anti-beta 2-glycoprotein-I antibody positivity offer additional predictive information? Lupus, 2010. 19 (5): p. 613-9.

Tektonidou, M.G., et al., Cognitive deficits in patients with antiphospholipid syndrome: association with clinical, laboratory, and brain magnetic resonance imaging findings. Arch Intern Med, 2006. 166 (20): p. 2278-84.

Hanly, J.G., et al., Review: Nervous System Disease in Systemic Lupus Erythematosus: Current Status and Future Directions. Arthritis Rheumatol, 2019. 71 (1): p. 33-42.

Ricarte, I.F., et al., Neurologic manifestations of antiphospholipid syndrome. Lupus, 2018. 27 (9): p.1404-1414.

Norton, S., et al., Potential for primary prevention of Alzheimer's disease: an analysis of population-based data. Lancet Neurol, 2014. 13 (8): p. 788-94.

Petersen, R.C., et al., Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology, 2018. 90 (3): p. 126-135.

Langa, K.M. and D.A. Levine, The diagnosis and management of mild cognitive impairment: a clinical review. JAMA, 2014. 312 (23): p. 2551-61.

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