Symptom Management

Cognitive Deficits in Multiple Sclerosis

By By Jennie Q. Lou, MD, MSc, OTR/L,; Carolyn Tischenkel; and Lindsey DeLange

Cognition means knowing or perceiving. No matter what you are doing, your nervous system is always trying to provide you with the most complete and accurate picture of reality. Your cognitive processes create and refine this picture, and make it possible for you to use it. Your adjustment in every area of your life depends upon your cognitive abilities because they are what enables you to recognize and understand what is going on around you. You use these adjustments to come up with plans for dealing with changes, and you can come up with ways to put your plans into effect. Judging whether or not your approaches and adaptations worked, remembering them if they did, and then modifying them if they didn't are all cognitive processes. Every aspect of dealing with MS (as with everything else in your daily life) is based upon the use of your cognitive abilities, therefore it can benefit you to be aware of them.

There is another important benefit to becoming familiar with your cognitive symptoms. These symptoms tend to be extremely sensitive to changes in your level of stress, so they may serve as effective warning signals. Changes in the ways that your cognitive abilities are working may provide some useful clues that you are approaching your limits. Subtle changes in aspects of your cognitive functioning can alert you that you're in danger of exceeding your capacities. Armed with these warning signals, you may be able to slow down and re-adjust, before your established symptoms begin to appear or intensify.

The most common cognitive difficulty in people with MS is mild to moderate impairment of short-term and working memory. People who usually have good memories may find themselves forgetting things, such as appointments. Their attention span and ability to concentrate may be diminished. Sometimes they find it hard to keep track of what they were doing before they were interrupted. For example, they may have difficulty getting back on track if the phone rings while they were sorting mail. While these problems can be quite subtle, they can be extremely frustrating and upsetting.

Some people with MS experience more serious cognitive problems. They have difficulty with planning and problem-solving and tend to become overwhelmed and inflexible when a task is too complex. They may lack the flexibility to generate alternative solutions. They may even be unaware of their difficulties and have problems monitoring their own behavior. Comprehension of the effect of their behavior on others may also be overlooked.

Difficulties with the self-regulation of behavior can create problems in many different ways. Some people with MS may be unable to plan and organize purposeful activity. Sometimes the problem is in the area of initiating action. Difficulties with "getting started" may appear to others as depression or lack of motivation. Other people who have MS may have the opposite problem of being unable to stop themselves. They may be very talkative and uninhibited, blurting out comments they would have kept to themselves in the past. Because they are unresponsive to the normal social clues that let them know their behavior is inappropriate, they seem very impulsive and oblivious to the reactions of others. Furthermore, they may have a "short fuse" and experience unpredictable angry outbursts.

Cognition involves the coordinated activity of your entire brain. Your cognitive symptoms can result from problems in any part of it. The list below provides a list of some of the changes in areas of cognitive functioning that people with MS commonly report. Remember, few people have all of these symptoms, and the symptoms come and go.

Simply put, take advantage of the times when your cognitive abilities are working at their best to prepare for the times when they're not. Remember that the pattern of cognitive decline is not uniform. The more frequently impaired areas are recent memory, sustained attention, verbal fluency, conceptual reasoning, and visual-spatial perception. The less frequently impaired areas include language, immediate memory, and remote memory.


  • Problems with memory
  • Excessive drowsiness
  • Low levels of initiative or motivation
  • Emotional "numbness"
  • Poor mental acuity ("fuzzy thinking")
  • Problems with balance, body awareness, or coordination
  • Indecisiveness
  • Problems with planning or organization
  • Problems with abstract thinking, judgment, or reasoning
  • Problems understanding what you read or hear
  • Poor concentration
  • Distractibility
  • Tangentiality (your mind wanders, you can't stay on task)
  • Impulsivity or disinhibition (you can't control or restrain your impulses)
  • Preservation (you "get stuck" on a thought, or a behavior)
  • Problems processing intense, complex, or fast moving sensory input
  • Problems with recognition (for instance, you can see it, but it doesn't register)
  • Processing delays (afterimages, trails, ringing in your ears)
  • Spatial disorientation (you get lost on the way to a familiar place)
  • Poor reflective awareness (you're not aware, or conscious of yourself)
  • Poor selective attention (you can't choose what you want to think about, look at, or listen to)

Furthermore, many of these changes in your cognitive functioning may be evidence of depression. Emotional numbness, excessive drowsiness, poor initiative and motivation, and/or problems with mental acuity can be especially significant signs that someone is depressed. As in most cases of the onset of an illness, depression is a frequent reaction to MS. MS-related lethargy and fatigue may also be confused with depression. You should talk to your doctor or counselor if you feel that your cognitive problems may be indicative of depression. Be assured that medical and alternative treatment options are available to help cope with some difficult feelings. Counseling services are often very accessible.

It is important to remember that when your cognitive abilities are not working well, flare-ups in any of your other symptoms may be more likely. However, you can learn to manage, and reduce disruptive effects on your cognitive abilities.

As with all of your other established symptoms, stress and demand can increase the intensity and frequency of your established cognitive symptoms. You can learn how this process works and how to manage it most effectively. The goal of stress management, and of symptom management, is not to eliminate stress, but to find and maintain the right level of stress that allows you to function at your best. This will allow you to keep your established symptoms at their lowest possible levels of frequency and intensity. The ultimate goal is to prevent them from appearing in the first place.

The majority of people with MS experience intermittent cognitive symptoms and so if you are among this majority, you may be able to achieve the goal of prevention. Even if your cognitive symptoms are present all or most of the time, with the proper approaches to symptom management, you may still be able to control the intensity, and reduce the disruptive effects. The benefits of managing your cognitive symptoms can accumulate over time.

Cognitive symptoms are complex and hard to understand, and they sometimes seem to threaten your grasp of reality. But they're not fundamentally different from any of your other symptoms. Many of these symptoms can be treated very effectively once they are identified. The MS Foundation is available to provide further referrals and information.


Strategy I. Respect the Complexity of Everyday Tasks

When you look closely at the cognitive demands of any of the tasks that you perform regularly, you may notice that things are more complicated than they appear to be.

There may be a lot of separate steps, or smaller tasks, involved in performing a particular task. Each one of these steps may place demands upon several different aspects of your cognitive functioning. For example, you may have a problem with auditory comprehension. There may be times when you can't understand what people are saying to you. This could stem from problems with some of the most basic aspects of your cognitive functioning. You may not be able to focus on what the person is saying, or you might be dozing off while they are talking.

By the same token, difficulties with comprehension could be due to problems with aspects of sensory processing abilities, or memory. This would be evident when a person is talking too fast for you, or you can't remember what they have already said. Problems with higher cognitive processes could also be involved. Maybe the other person is using a lot of complicated statements, or maybe they're talking in very abstract terms.

Remember, efficient cognitive functioning depends upon the coordinated activity of your entire brain, and many, if not most, tasks place demands upon several cognitive abilities at the same time. Even everyday tasks such as cooking can present incredibly complex cognitive demands.

This suggests one of the most important general strategies for dealing with your cognitive deficits: Recognize and respect the cognitive demands of the tasks that you are trying to perform. Often, people with MS say things like: "This is so simple! I never used to have any trouble figuring this out. I must really be stupid!" But it's not so simple! Even everyday tasks can make many complicated cognitive demands, and you have to recognize and respect these demands before you can begin to look at the effects of your cognitive symptoms accurately, and begin to compensate for them.

One of the basic principles of managing all of your symptoms is that you can't take things for granted anymore. You can't look at the things you do in the old unconscious way that you used to. If you do, chances are you will feel stupid or inadequate. Having cognitive symptoms does not mean that you are stupid, but you may feel as if you are. This is especially true if you underestimate the demands of the tasks that you want to perform.

Strategy II. Stay Conscious of How Well or Poorly You Are Functioning

If you are going to perform a task successfully, you have to be aware not only of the demands of the task, but of your capacity to meet these demands. Those basic aspects of symptom management -- observing and rating your abilities -- may be even more essential with regard to your cognitive symptoms than in any other area of your functioning. The abilities that are declining are precisely the ones that you need to recognize. Their effectiveness can change very quickly. Noticing the beginnings of decline in your functioning should emphasize the importance of observing warning signals.

In order to effectively adapt activities, you have to develop effective ways of assessing your cognitive abilities. If you wait until your cognitive abilities (the control of your thoughts and behavior, or your ability to think things through) are very weak, it may be too late to do anything about it.

Many of the unnecessary, or preventable, symptom flare-ups that people with MS experience are due to lapses in their cognitive abilities. When the abilities that allow you to recognize that you're reaching your limits aren't working well, and you have difficulty making decisions about how you should perform tasks or even if you should perform them at all, it's easy to keep going past your limits.

If you can learn to assess your cognitive abilities, you may be able to recognize when they're starting to fade, and do something to restore them to an effective level. This will allow you to keep any negative effects to a minimum.

When you can't prevent your cognitive symptoms from appearing, you have to develop ways to counter their effects. It's possible to develop techniques for enhancing your cognitive abilities, and these techniques may allow you to keep on functioning even during those periods when your cognitive symptoms are affecting you.

Strategy IV. Make the Most of Your Good Periods

A brief look at the list of general strategies and techniques on the next page suggests why it's so important to make the most of your good periods. There are a lot of things you can do to deal with your cognitive symptoms and to enhance your cognitive functioning.

Remember, it takes some thought to come up with these things, and it's an effort to put them into effect. But in doing so, your approaches in dealing with your cognitive symptoms will be there for you when you need them, and they're going to be more effective if you've worked on them in advance.

Managing your symptoms presents a number of intense intellectual challenges, so you need to do most of the work during the periods when your cognitive abilities are at their best. Analyzing your experiences and developing and rehearsing your strategies has to take place during your periods of peak functioning. This concept cannot be over emphasized.

When you're in the middle of a demanding situation, and your cognitive symptoms are actually appearing or intensifying in response to it, it's usually pretty hard to keep up with everything that's happening to you. Coming up with new and creative ways to deal with this can be difficult. It is precisely these times when you usually have more urgent priorities like damage control.

If your symptoms catch you off guard, the demands of your efforts to figure out what to do about them can actually make them more intense. This can be a vicious circle. Again, take advantage of your good periods so that you can respond to your symptoms in ways that really can help.


  • Externalize Your Cognitive Abilities
  • Use post-it notes in areas where you are likely to see them, such as mirrors, television sets, telephones, or the refrigerator
  • Use pocket calendars, palm computers, and timers
  • Arrange The Environment Where You Perform Tasks
  • Always put things back where they belong
  • Keep items of importance within reach
  • Develop And Use Task-Performance Routines
  • Make a daily list and write down things that come to mind, and refer to the list frequently during the day
  • Keep a monthly calendar so that you can remember important events such as birthdays
  • Adapt Or Modify The Ways That You Perform Tasks
  • Combine activities that you need to remember with tasks that you already perform everyday (for example, take your medication directly after you finish brushing your teeth)
  • Do activities that require going outdoors during the early morning or evening to avoid extremely warm temperatures
  • Simplify Or Reduce Task Demands
  • Prioritize and plan your week
  • Ask friends and family members to assist you
  • Use your inner dialogue
  • Talk to yourself while you are performing the task
  • Say things aloud several times to help you remember things
  • Use Feedback From Other People
  • Adjust your behavior according to the feedback from your family members or friends
  • Re-evaluate the effects that your productivity has on your work and make changes as needed
  • Use Focusing Techniques To Create An Artificial Zone Of Good Cognitive Functioning
  • Practice yoga
  • Rest and relax before you start a new task

(Last reviewed 1/2024)