Dr Michelle Barraclough discusses what brain fog is, the ways it impacts people and how research may improve outcomes

Lupus, a long-term condition that can affect multiple parts of the body, can involve the brain too. And in some people this may lead to cognitive issues. Whilst an extensive body of research has looked into how lupus presents in the body, work with the brain is yet to catch up. Interested groups, however, are combining forces to bring about positive change in the light of new emerging research into exactly how lupus can impact the brain.

The brain

Brains are particularly difficult organs to study because unlike other systems in the body they have the blood brain barrier. The blood brain barrier can prevent damaging autoimmune and inflammatory mechanisms entering the brain during increased lupus disease activity. This means the effects of lupus on the brain, that may lead to cognitive problems, are not always seen immediately during a flare up of active disease but may be delayed.

Many different types of problems with cognition present in an array of health conditions. Memory is a common point of concern, but there are other situations around concentration, attention, verbal fluency and planning. Examples of how these manifest in the real world are:

• Forgetting to do something or words you want to use;
• Misplacing items;
• Unable to follow a conversation as well as you once did;
• Issues reading and taking in new information;
• Time management problems;
• Planning and organisational issues.

People with lupus may not be affected by any of these points, or they could be impacted by them all. For those who do experience problems, daily life is impacted and additional stress results.

Brain fog versus cognitive impairment

When clinicians talk about cognitive problems in lupus they often use terms such as “cognitive impairment” or “cognitive dysfunction”. We have tools to measure cognitive impairment in lupus and these indicate that about 40% of patients have cognitive impairment.

However, the number of patients reporting cognitive problems in the clinic is higher than this. It is also described more as a “brain fog”, a feeling of not being able to function as well as they once did, possibly more closely linked to cognitive fatigue. Recent research using a brain imaging technique may be able to shed some light onto the disconnect between brain fog and cognitive impairment.

Functional magnetic resonance imaging – which looks at blood flow in the brain – can be used to understand how the brain works when people with lupus perform cognitive tasks in a brain scanner. These cognitive tasks can test attention, memory, concentration, planning and spatial processing.

Previous work suggests that the brains of people with lupus have to work that bit harder to maintain the same level of cognitive performance as someone without lupus. This indicates that people with lupus may perform well on cognitive tests but become cognitively fatigued quicker. This cognitive fatigue may explain the feelings of brain fog reported in the clinic.

Current research

The teams I work in (see biog information below) want to explore the idea of brain fog further and whether it is associated with overuse of the brain. We also aim to understand how brain fog relates to measurable cognitive impairment.

The collaborations have brought together leading research teams who have an interest in furthering our knowledge of cognitive impairment in systemic lupus erythematosus.

In Toronto we are undertaking a functional magnetic resonance imaging study involving people with lupus and healthy volunteers. The volunteers go into a non-invasive brain imaging scanner. Whilst their brains are being scanned, they play computer games that test memory and attention. We collect data and look at how fatigued participants get during these tests.

We also collect information on health and personal details, take blood samples, give out questionnaires to look at disease activity and damage, mood, sleep problems, pain, fatigue, quality of life and cognitive performance.

Expected results

We expect to find that people with lupus use their brains differently during cognitive tasks compared to healthy volunteers. This may be linked to feelings of cognitive fatigue or brain fog and could ultimately lead onto problems with cognitive performance. We also expect to find links between cognitive performance and aspects such as pain and mood.

Why are we doing this research?

The information from this study will help us to better develop future personalised clinical trials. These clinical trials could help determine what treatments would help improve cognitive problems in people with lupus. These results may also help in studies of cognitive problems in other rheumatic conditions, such as rheumatoid arthritis.

Case study 

Roneth, a nurse from Preston in Lancashire was diagnosed with systemic lupus erythematosus in 2013, and subsequently with lupus nephritis and arthritis.

“I was on IV treatments during the first three years of my diagnosis,” she says. “However, as I am currently in remission, my lupus is controlled with immunosuppressant tablets and other maintenance medications.

“I usually suffer with body aches and pains often due to the environment of my work, but I take my prescribed painkillers to ease the pain. I also suffer with fatigue and sleep problems, and take medication to help me sleep better.

“I have regular appointments with my renal and rheumatology consultants to continue monitoring my lupus. I have cognitive problems especially when I don’t have enough sleep, am stressed and tired from working long days or generally unwell.”

 Impact of cognitive function

“I work as a nurse in surgical theatre, which requires concentration and attentiveness to maintaining safe practice, equipment sterility and keeping up with the surgeon’s pace. When I have these episodes, I become clumsier and tend to drop sterile instruments. Also, I have difficulty explaining things, or words that I say do not make sense. I also find it difficult to grasp words or instructions during a conversation which affects my work most of the time. I tend to go out less as I need to plan my rest days. Therefore, to avoid these episodes I tend to sleep early, plan my days often and take plenty of rest during my day off from work.”

Roneth recently participated in a remote research study to investigate cognitive impairment in systemic lupus erythematosus. She found the tasks in the study “challenging” but “feels that there should be more research into cognitive impairment because cognitive problems in lupus or in other autoimmune diseases are often overlooked and not considered serious.”

“Cognitive problems can vary in each lupus patient,” she explains. “This means people suffer unnoticed and the issues are not managed properly. Hopefully, in the future more research can be done to increase awareness and get more support on dealing with cognitive problems.”

What is systemic lupus erythematosus? (source NHS Choices)

Lupus is a condition that affects the immune system. It can cause problems with your skin, joints, kidneys and other organs.

Symptoms of lupus include joint and muscle pain, extreme tiredness and a rash on your face.

There’s currently no cure for lupus, but the symptoms can often be treated with medicines that reduce inflammation in your body, such as steroids.

Lupus is caused by your immune system mistakenly attacking healthy parts of your body. It’s not fully understood why this happens.

About the author: Dr Michelle Barraclough PhD works for the Schroeder Arthritis Institute, Krembil Research Institute, Toronto; the Centre for Epidemiology Versus Arthritis; and the NIHR Manchester Biomedical Research Centre, Manchester.

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