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Cognitive Dysfunction In Pots


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Hi All, here is an article from Dysautonomia International's blog. It was written by Dr. Amy Arnold from Vanderbilt University. (I'm not able to paste the link for some reason)

Cognitive Dysfunction and “Brain Fog” in POTS

Cognitive Dysfunction In POTS
by Amy Arnold, PhD

POTS is one of the most frequent forms of chronic orthostatic intolerance, and is a common source of disability among young adults. One of the most common symptoms reported by POTS patients is cognitive dysfunction or “brain fog.” These terms both indicate a loss of brain functioning in areas such as thinking, remembering, concentrating, and reasoning to a level that interferes with daily activities. In our center (Vanderbilt University’s Autonomic Dysfunction Clinic), approximately 80 to 90% of POTS patients report cognitive dysfunction and often describe it as: “difficulty thinking, concentrating, or paying attention; trouble remembering things; cloudy or fuzzy feeling in head; and having problems finding the right words.” This can occureven while patients are lying down or seated, which limits their ability to attend school or to work. While cognitive dysfunction is an almost universal finding in POTS patients, it is still poorly understood.

In response to our patient’s concerns, we designed a study to identify specific problem areas for cognitive function in POTS. We gave a series of standardized neuropsychological tests to POTS patients and compared their responses to healthy subjects matched for age and gender. We studied patients in the seated position, to minimize heart rate changes and related symptoms. We found clinically meaningful impairment in three areas of cognitive function in POTS patients. First, patients had impaired selective attention, or the ability to focus on specific stimuli when several stimuli are presented at the same time. For example, patients were slower and made more mistakes when asked to mark only the numbers 2 and 7 within a long series of numbers. Second, patients had impaired cognitive processing speed, indicating that it took longer to process information. Finally, patients had impaired executive function, indicating problems with planning, organizing information, and adapting to changes. There were no deficits in other areas of brain function including intelligence, memory, reaction time (psychomotor speed), and information retrieval from memory (verbal fluency). Importantly, in our study, there was no association between cognitive dysfunction and psychiatric symptoms such as mild depression or anxiety in POTS patients.

In summary, our study showed that POTS patients have deficits in specific areas of cognitive function including selective attention, processing speed, and executive function. These problems were observed even in the seated position. This may indicate that the cognitive dysfunction in POTS is not due to the increased heart rate and symptoms with standing, but rather may reflect part of the disease itself. Further studies are needed to determine the impact of standing, the underlying causes, and the optimal treatment strategies to manage this cognitive dysfunction.

Is cognitive dysfunction the same as brain fog?
There are several words that have been used to describe the cognitive dysfunction in POTS including brain fog, mental fog, mental fatigue, and mental clouding. These all refer to multiple symptoms that impair intellectual functioning to a level that interferes with daily activities. These symptoms can include difficulty thinking clearly, trouble concentrating or focusing, and mental confusion or lack of mental clarity.

What are the specific tests for cognitive function?
There is not a single test or series of tests used to diagnose cognitive dysfunction. Rather, there are numerous standardized neuropsychological tests that can provide information about different aspects of cognitive function. The basic purpose of these tests is to determine the likelihood of meaningful cognitive impairment, by comparing scores to normative values obtained from healthy subjects of similar age, gender, and education level. A potential limitation is that the tests may not have been validated in every population (such as POTS), and may have lower accuracy to detect changes in patients with mild levels of cognitive dysfunction.

Who can diagnose cognitive dysfunction?
A primary care physician can perform a general screening test for cognitive function, but this may not detect the more subtle changes that we found in POTS. In general, a neuropsychological evaluation is needed to gain a comprehensive understanding of how one’s brain is functioning. This involves a visit with a clinical neuropsychologist who will perform an interview and give a series of validated tests and questionnaires that look at a variety of brain functions such as intelligence, memory, attention, executive function, language, mood, and personality traits. The information from these tests may help in assessing brain function over time or after treatment.

What type(s) of cognitive dysfunction are common in POTS?
Our study showed problems with selective attention, cognitive processing speed, and executive function in POTS patients. Other studies have also shown problems with working memory, or the ability to hold onto and to process new and already-stored information, in POTS patients that also have chronic fatigue syndrome. This impairment in working memory may reflect the additional presence of chronic fatigue syndrome, as problems with memory and concentration have been well described in this patient population. It is important to note that there was a large variability in cognitive test scores in our study, with some POTS patients having scores within the normal range for healthy subjects. Thus, the diagnosis of cognitive dysfunction, and related treatment plans, should be considered on an individual basis.

What is the (suspected) cause of cognitive dysfunction in POTS?
The cause of cognitive dysfunction in POTS is still unknown. There have been several potential causes proposed. First, there is an association between elevated norepinephrine levels and psychiatric disorders such as depression, panic disorder, and attention deficit hyperactivity disorder. Since high levels of norepinephrine in the brain can disrupt cognitive function, it has been proposed that this mechanism could contribute to cognitive dysfunction in POTS patients with elevated norepinephrine levels (hyperadrenergic). We did not find an association between plasma norepinephrine levels and cognitive function in our study in POTS patients, but further studies are needed. Second, studies have shown that a reduction in brain blood flow may contribute to impaired memory in POTS patients with chronic fatigue syndrome. Finally, POTS patients often have other conditions including small fiber peripheral neuropathy, vasovagal syncope, immune system activation, pain, irritable bowel syndrome, and sleep disorders. These could all negatively impact cognitive function and overall mental health.

Is cognitive dysfunction similar to attention deficit hyperactivity disorder (ADHD)? Is using ADHD medication to combat cognitive dysfunction recommended in POTS?
In a previous study, we compared the psychiatric profile of POTS patients to adult patients with ADHD (Vidya Raj and colleagues, Journal of Neurology, Neurosurgery & Psychiatry, 2009). We showed that people with both disorders have difficulty maintaining attention, but that it is more severe in ADHD. Furthermore, POTS patients developed problems with attention later in life and did not show significant hyperactivity, which is opposite to the childhood presence and the common feature of hyperactivity with ADHD. Therefore, the pattern of cognitive dysfunction appears to be different in POTS versus ADHD. The most common treatment for ADHD is the use of stimulants (such as Adderall and Ritalin) to enhance alertness, attention, and memory. There is no information on the effectiveness of ADHD medications in POTS. To address this, we are currently conducting a study examining the effects of the stimulant drug modafinil on cognitive function in POTS patients at the Vanderbilt Autonomic Dysfunction Center. Since there is concern that stimulants could worsen heart rate control in POTS, we are also examining the effect of modafinil in combination with the beta-blocker propranolol. This is the first study addressing treatment strategies to manage cognitive dysfunction in POTS.

Amy Arnold, PhD, is a Research Instructor in the Division of Clinical Pharmacology at the Vanderbilt University School of Medicine. She is also a member of the Vanderbilt Autonomic Dysfunction Center. Her clinical research program focuses on understanding the causes of autonomic nervous system disorders such as POTS and autonomic failure, as well as new treatment strategies for these conditions.

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  • 2 weeks later...

That's a great article! I actually joined Lumosity a few months back, because I was concerned about my level of cognitive functioning. It ranks different abilities by percentiles (% of your peers that you perform better than).

My current results show that my abilities are generally in the high average - highish range.

What's interesting is this.....

- I problem solve at the 96th percentile (better than 96% of my peers).

- My memory is at the 40th percentile (meaning that 60% of my peers DO BETTER than I do).

My memory is significantly lower than all of my other areas - which is what this article says (and interesting enough, I was diagnosed with ADHD in 2010).

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I thought the theory of higher NE level's associated w/ brainfog was interesting for a few reasons. Mine have been really high, so I wonder if that contributes to my fog. I have to start paying attention to a correlation between adrenaline spikes and increased fogginess. "Since high levels of norepinephrine in the brain can disrupt cognitive function, it has been proposed that this mechanism could contribute to cognitive dysfunction in POTS patients with elevated norepinephrine levels (hyperadrenergic)"

There are many POTS patients who have elevated norepinephrine levels, so I do wonder if in the future they will find link. "Postural changes in serum norepinephrine levels are much more pronounced in POTS patients" - Dr. Grubb POTS Eval & Management

Anyway, I just started Provigil 4 days ago. I am taking 100 mg. I was able to get it covered through my insurance ,so I am very pleased. They denied it initially so my doctor had to do a prior authorization.. 30 pills are $699! No side effects to report as of yet, and I am noticing improvements!

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That is great Sarah!

On a side note, I take Vyvanse for ADHD, and I notice definite improvements on it. My only productive time of the day is usually within a few hours of taking it. I'm certain that there's more to my cognitive dysfunction than just ADHD. This article makes sense.

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Thanks everybody! The Provigil seems to be working quite well. I've noticed I can't take it after 10 am though or I have more difficultly falling asleep -- And, as I've dealt with insomnia on and off for years, this is something that could be a potential issue. My POTS specialist was concerned about tachycardia, however, that's not occurred, hooray! I am able to focus on tasks for longer periods of time, can absorb information faster while having conversations and fatigue has improved.

Draven and Lily, I'm happy that you've had success as well with your medications. What symptom improvement have you noticed?

Thanks - Sarah

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Draven and Lily, I'm happy that you've had success as well with your medications. What symptom improvement have you noticed?

Thanks - Sarah

Strattera makes me feel like I have access to the full power of my intellect. All ADHD symptoms are improved. The ones that are less-improved are motivation and getting started on tasks. Coffee helps, as does listening to music. Both of these boost dopamine. POTS definitely causes a ditzy brain fog, getting my mix all worded up, and mind wandering. This is better if I do things that reduce blood pooling. The Methyldopa made it easier to get started on tasks, but it didn't help as much as I wanted with POTS. Now on Clonidine. This one really knocked down the sympathetic outflow, which was in itself distracting. I feel less "on" all the time and hence less fatigued, but I'm not sure if it is helping with ADHD.

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  • 2 weeks later...
On ‎3‎/‎3‎/‎2016 at 8:10 AM, Lily said:

Strattera makes me feel like I have access to the full power of my intellect.

Wow, Lily! What a great feeling that must be. I miss that feeling so much. I'm grateful for the doctors and researcher's who give us the chance to have that feeling once again. It's really just a terrible feeling, how it feels to  lose little pieces of yourself cognitively. I have some doctors who don't really understand the decline because they've only known me after I got sick. And it's not like this all the time, but if I'm at a party for example, I'll be standing upright and sometimes can't remember what the conversation was about. Things like that.

For the first time since I've started Provigil, I haven't had to re-count change in line 2 or 3 times,  the fatigue has improved  greatly, too. Coffee helps me as well, only one cup and just like you describe - a boost. That's pretty interesting that you mention Dopamine actually, mine have been all over the place, high, normal, but have actually not measured detectable twice. Is dopamine serum accurate though.. I mean, is it produced in the gut?

I get the same effect on Clonidine. It's a great medication for me, not only for BP control. I'm sure it's added to the fatigue which is a bummer, but not enough that it's stopped me from taking it throughout the day. I have a lot of adrenaline, so I'm sure it's doing it's job in that arena.. Clonidine has helped my anxiety as well, and it does give me a "flat" feeling. Out of all the meds that I've tried for POTS and related ailments, clonidine by far has been one of the top 3 most successful. Oh - and it's also regulated my sleeping schedule, too.

Do you use compression? That helps me a lot, too

I've always wondered about Methyldopa. Clonidine was just a better choice for me because my doctor's used it in the beginning as a PRN for hypertensive episode's.

Thanks to all who've shared in this topic!

Sarah :)

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We replaced methyldopa with clonidine.  The work on the same chain of biochemical processes, but in different ways.  Clonidine decreases sympathetic outflow, which is a great relief.  Is very distracting to the ADHD brain and feels terrible.  But I am learning today that it is not more powerful than storms.  Storm today is making POTS act up.  My heart rate was 148 while walking around the house, and decreased only to 90 after lying down a while. 

If I understand things correctly the neurotransmitters are made in the brain and in the body.  My plasma dopamine was normal and norepinepherine was sky high, even though I clearly have deficiencies of both in my brain. Neurologist says this can happen because of the way things are metabolized or something like that.

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  • 2 weeks later...
On 3/3/2016 at 11:12 PM, SarahA33 said:

Thanks everybody! The Provigil seems to be working quite well. I've noticed I can't take it after 10 am though or I have more difficultly falling asleep -- And, as I've dealt with insomnia on and off for years, this is something that could be a potential issue. My POTS specialist was concerned about tachycardia, however, that's not occurred, hooray! I am able to focus on tasks for longer periods of time, can absorb information faster while having conversations and fatigue has improved.

Draven and Lily, I'm happy that you've had success as well with your medications. What symptom improvement have you noticed?

Thanks - Sarah

Sorry for my late response.  Somehow I missed this one!

I think I have two biggest improvements on Vyvanse. One is my ability to concentrate and focus on a task.  Without it, I start something, that leads to something else, which leads something else, which leads to something else...and nothing every gets done.  And my thoughts swirl, or take on a life of their own.  I feel like Vyvanse helps my thoughts line up.  It's not quite a straight line, but better than the random, scattered order my thoughts fall into without it.  

The next biggest improvement area is organization.  Without Vyvanse I am completely unable to organize, categorize, etc. anything.  Interesting enough, I'm a secondary school teacher....I have taught Learning Strategies quite a few times, but without medication am completely unable to use the strategies myself.  I guess the old saying is true - those that can't choose to teach. ;)  

Motivation and starting on tasks is always a problem with me, on and off meds.  I am a horrible procrastinator.  Actually I think there should be another word for it with ADHD.  It's honestly more like an inability to make myself start (or to stop something when it's time to switch gears).  There has to be something insanely motivating to make me start or switch tasks (and by insanely motivating, I mean the best reward ever or worst punishment ever).  Otherwise, I stay "locked" where I am.   

I thought my ADHD had gotten really bad over the years.  Now I realize it's probably linked to whatever is going on (POTS?).  It's gotten to a point where I now live in a perpetual state of mental fog (some days a bit better than others).  Interesting enough, I went to my doctor for an ADHD med increase a couple of years ago, because I thought my ADHD had gotten so much worse.  My doctor said ADHD doesn't work that way...it's not progressive.  She increased the meds, but it did not improve my symptoms.  I realize now that the "increased symptoms" are not from ADHD.  

:)

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  • 1 year later...
  • 2 weeks later...

provigil helped me alot for over 2 years but then I developed severe headaches as the med wore off. I already had migraines so it wasn't worth it.

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I would take one in am and then half one later in the day, or half in am was enough most days and the other half later to prevent crash. But then again I was doing alot of caffiene back then too so I don't recall a crash so much as the creeping in of a headache and decrease of abilities. It does take a while to find the right time and amount and of course discuss these options with your doctor-mine gave me some lee-way. I also did not take it on my off days-only my work days back then. It seemed to work better when I did take it that way. Hope this helps

Debbie

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