Live Expert Session Replay: Cognitive Dysfunction in Lupus

Presented by Dr. Donald Thomas | Aired May 17, 2025
📍 Watch the full session below | 💬 Questions? Email info@lupusla.org

Understanding “Lupus Fog”: Cognitive Dysfunction in Lupus

Cognitive dysfunction – often referred to as “lupus fog” – is one of the most common and misunderstood symptoms of lupus. It affects memory, focus, mental clarity, and overall quality of life. In this special Lupus LA Live Expert Session, Dr. Donald Thomas, renowned rheumatologist and author of The Lupus Encyclopedia, explores the causes, contributing factors, and evidence-based strategies to manage cognitive symptoms in lupus.

With over 30 years of experience, Dr. Thomas shares the story of a long-term patient whose life was dramatically improved by targeted treatment. He walks through the science of brain inflammation, the impact of autoantibodies, and why factors like stress, sleep, and cardiovascular health all play key roles in brain function.

Key Topics Covered in the Talk:

• What cognitive dysfunction looks like in lupus patients
• How inflammation, blood flow, and antibodies affect the brain
• The role of conditions like Sjögren’s, fibromyalgia, and sleep apnea
• Common medications (like prednisone) that may impact memory
• Lifestyle strategies to support brain health, including:
  • Exercise, nutrition, and mindfulness
  • Managing stress and mental health
  • Identifying and treating co-occurring conditions
• Cognitive screening tools you can use at hom
• Tips for talking to your doctor and asking for help

Key Insights:

Dr. Thomas reminds us that while lupus fog is real and can be debilitating, there is hope. With the right support and proactive care, many patients can improve cognitive function and reclaim a higher quality of life.

Abridged Transcript:

[Dr. Thomas]
Today we’re going to talk about an incredibly important topic: lupus fog, cognitive dysfunction, and memory problems—especially because this is one of the most common problems in lupus. It’s such an important issue that affects quality of life, but there are so many things that you can do to help yourselves. That’s one of the biggest takeaways I hope you gain today: that there are things you can proactively do to help yourself.

But first, let me introduce you to a patient of mine. Let’s call him Ben. That’s not really his name, nor is this his real picture, but it kind of looks like him—just without the beard. I’ve known Ben for over 20 years.

When I first met him, he was in his 30s. He’s a rocket scientist—yes, truly! He came to me with a new diagnosis of systemic lupus erythematosus. He had polyarthritis, rashes, horrible fatigue—and one of his major concerns was memory. Memory was critical in his profession, and his issues were so severe that he had to go on disability early.

We tried everything—Methotrexate, Mycophenolate, Azathioprine, Belimumab (also called Benlysta). While these helped somewhat—his anti-dsDNA improved, his complements improved—he never reached full remission, which is always my goal.

Then in early 2022, we started him on Anifrolumab (Safnello), an IV medication that inhibits type 1 interferon. Honestly, I wasn’t very optimistic. But three months later, I walked into the room and he was smiling—a man who had looked depressed for years. He said, “Dr. Thomas, I don’t even need naps anymore. I’m doing chores around the house and I feel like myself again.” To this day, he remains in remission with normal lab markers and improved energy and memory.

We’ll come back to Ben later. But today, we’re diving into cognitive dysfunction—commonly called “lupus fog.” It involves memory, attention, concentration, and executive function (like planning, problem solving, and quick thinking).

Studies show lupus fog affects anywhere from 15% to 80% of lupus patients, depending on how it’s defined. It’s more common among patients with high blood pressure, obesity, stroke history, sedentary lifestyle, and those with antiphospholipid antibodies.

If you’ve never had your antiphospholipid antibodies tested, ask your rheumatologist. These are important, and often go hand-in-hand with vascular issues that impair blood flow to the brain.

Imaging often shows small vessel disease—hardened arteries reducing blood flow to the brain—and areas like the hippocampus and amygdala shrinking, which affects memory and mood. These changes are more common in patients with active lupus.

[Dr. Thomas]
We also need to talk about inflammation and how it impacts the brain. Autoantibodies can breach the blood-brain barrier and attack neurons. Type 1 interferon, for example, can activate microglia and cause inflammation and nerve damage. Anifrolumab targets this pathway—perhaps explaining the dramatic improvement in my patient Ben.

Other treatable causes of cognitive issues include thyroid disorders, B12 deficiency, depression, anxiety, obstructive sleep apnea, fibromyalgia, steroid use, and poor sleep. All are worth checking.

Exercise stands out as one of the most effective interventions. Studies show exercise reduces the risk of cognitive decline. Even minimal movement—like raising your arms in bed—helps. If unsure how to exercise safely, ask for a physical therapy referral.

Sleep is another crucial factor. Poor sleep contributes to cognitive dysfunction. Practice good sleep hygiene, and consider CBT-I (Cognitive Behavioral Therapy for Insomnia) if you struggle with restful sleep.

Mindfulness also matters. Studies show it may actually increase the size of the hippocampus. I encourage daily five-minute breathing exercises. YouTube is full of great resources for that.

[Dr. Thomas]
Diet is key too. We need to move away from the Standard American Diet (SAD) and toward anti-inflammatory foods. Visit my site, LupusEncyclopedia.com, to find examples and guidance.

Also: know your numbers—blood pressure, cholesterol, BMI. Keep them optimal. Ask your doctor to check your hydroxychloroquine blood level to ensure it’s in the therapeutic range.

Smoking worsens lupus and decreases the effectiveness of hydroxychloroquine. Please avoid it entirely—even secondhand smoke.

Some practical memory aids:

• Don’t multitask.
• Eliminate clutter.
• Keep everything in its place.
• Use sticky notes and notepads.
• Always bring someone with you to appointments.
• Use smartphone contacts creatively.
• Train your brain with apps like Lumosity or Elevate.

[Dr. Thomas]
Other recommendations:

• Volunteer, stay active, challenge your mind.
• Get a pet—science shows it’s good for your health!
• Learn to say no and reduce stressors.
• Consider job accommodations through askjan.org if cognitive issues are affecting your work.

Long term? We don’t fully know. Some studies show no change in cognitive function over time, but others show improvement, especially in those who exercise and manage disease activity. One study even found 50% of patients improved over 10 years.

[Moderator – Lupus LA]
Thank you, Dr. Thomas, for that incredible overview. We have some live questions coming in…

🎥 Save and share this session to revisit at any time, or catch it on our YouTube Channel.
📘 Learn more from Dr. Thomas at LupusEncyclopedia.com
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