Do You Have Brain Fog?
What to do when your brain is on the fritz 🌧️
ICYMI 👉
I recently saw a patient who came in complaining of fatigue and brain fog. A middle-aged mother of young adults, she said her concentration and short-term memory were shot. “It’s like a cloud is sitting over my brain.”
She had a number of questions for me: Is it my age? Is it menopause? Is it early dementia? Should I take supplements? An anti-inflammatory diet? Or is this my new normal?
She had seen her gynecologist who replied to her brain fog symptoms with a pamphlet about sleep and an unhelpful quip: “Welcome to middle age.” Dismissed and dismayed, my patient unsurprisingly turned to social media, friends, family, and Dr. Google for advice.
Her friends insisted she needed supplements. Her sister voiced concern about the possibility of early dementia given their family’s history of Alzheimer’s disease. A well-known wellness expert on Facebook recommended the Keto diet to anyone with brain fog, while another online holistic practitioner promised immediate results with her custom herbal supplements.
The tsunami of medical misinformation online—the sifting through gizmos and gurus—fogged up her brain even further. But brain fog, while nonspecific by definition, is real. It is a term that people commonly use to describe the combination of fatigue and difficulty with focus, concentration, and/or memory.
Here's the problem: Our medical system is failing patients. Regular people are expected to practice DIY medicine via Instagram posts and WebMD. Separating myth from fact has never been harder in our current landscape of social media, the wellness industry, and the “guru-ification” of the medical space.
In my experience seeing patients for over 20 years, complex problems usually require complex solutions. They also require asking the Why? If we don’t identify root causes for symptoms like brain fog, purveyors of health advice aren’t helping anyone but themselves. And that was exactly what was happening to my patient.
So when she and I sat down to talk, she reported not having had a menstrual period in eight months. She was experiencing hot flashes and night sweats and insomnia. Yet her gynecologist told her she wasn’t eligible for hormone replacement therapy until she went a full calendar year without a period. She was also drinking more caffeine and alcohol than usual. The caffeine provided a midday pick-me-up, however it also made her more jittery—which meant that she was relying on a glass or two of wine to wind down at the end of the day.
In addition, she was carrying the emotional weight of caring for an aging father. She admitted that feelings of guilt and grief felt overwhelming at times—so much so that she and her siblings squabbled about the minutiae of his care, and communications with her emotionally volatile sister also were weighing her down.
Last, her lab test results revealed an elevated TSH, a low free T4 and a low albumin level. She was also clearly menopausal and a perfect candidate for menopausal HRT. (We treat the patient, not the calendar.) When I asked her about her adherence to medications and her eating habits, she admitted she’d let her thyroid medication refills lapse, she often skipped lunch, and wasn’t eating enough protein.
She sighed as she began to see for herself what was going on.
It turns out that what my patient needed the most was the space to connect the dots between her medical data and the facts of her own story. Doctors are steeped in the concept of evidence-based medicine—that is, medical care that centers the highest-quality available research. But it’s easy to forget that patients themselves house a repository of data. From facts about genetics to current life circumstances, the human body is a walking dataset whose relevance cannot be dismissed.
Second, my patient needed to work on accepting things she cannot control and leaning into the areas she can change. While she couldn’t control her sister’s anxiety or her father’s failing health, she was able to get clarity on the risks and benefits of HRT and the relevance of a wonky thyroid gland plus perimenopause to her cognitive health. There wasn’t a single pill or gizmo that could solve her problems. Instead, she needed a few things at once: to start HRT, to resume her thyroid medication, to take a break from drinking alcohol, to consume more dietary protein, and to practice a little self-compassion.
No guru can fix this patient's hormonal, social-emotional and medical problems at once. In fact, I think the reason the wellness industry is so successful is because it's much easier to follow someone else’s prescription than it is to access our own medical facts, to find a trusted medical guide, to face the uncomfortable truths about our lives, and to contemplate making changes where able.
Heck, I, too, could be dead wrong about the causes of my patient’s symptoms. While I’m fairly confident she will feel better when we meet next month, she might not be. She could also have something more serious going on—such as early dementia or sleep apnea or some other medical problem we haven’t yet identified. But that’s exactly the point. Caring for patients is like health itself—it’s a process. It’s iterative. It’s dynamic. Such that when and if my patient comes back to see me next month feeling little or no improvement in her symptoms, we will go to plan B.
Plan B will involve more coaching and accountability if she’s simply been unable to activate plan A. Or Plan B might include brain imaging, a neurology evaluation, or further testing of hormone levels if she’s not better despite regulated hormones and less alcohol, caffeine, and self-flagellation.
My point: the first step in defogging the brain is to provide people with permission to be human—plus an evidence-based, holistic way of addressing their problems.
So, what to do if you’re experiencing brain fog?
See your primary care physician to assess your medical data. This includes not only your lab tests and blood results but the immutable facts of your story. Are you perimenopausal? Do you have a family history of dementia? Are you taking your medications? Are you honest about your relationship with alcohol, sugar, and late-night social media browsing? Do you eat lunch?? Are you carrying the weight of the world on your shoulders and getting in your own way?
Limit alcohol consumption. Regardless of the root cause for your brain fog, alcohol isn’t helping. It is a neurotoxin. It impairs sleep, cognition, and attention. Especially around the time of menopause, it strips our cognitive and emotional reserves. There’s no moral prize for sobriety, but your neurons will thank you.
Limit excess sugar and processed foods. Be sure you are getting adequate dietary protein, healthy fats, complex carbohydrates, and fiber. Relative undernourishment by itself zaps attention and focus. Experiencing satiety on a regular cadence is a crucial ingredient in cognitive and emotional regulation.
Be honest about the stories you tell yourself. Recognize how they might not match reality. For example, if you convince yourself that you are responsible for other people's feelings, your brain will tire more easily. If you convince yourself that you don’t deserve to have your own needs met because others are suffering more than you, your brain will be more foggy than if you lovingly set limits with others around you. Try reframing the idea of mental energy as a bank account: you have to spend it more wisely and build reserves for moments of high emotional expenditures!
Get outside in nature. Being outside opens up brain space and declutters the mind. Regardless of your age, hormonal status, or life situation, nature has our back. Being in it is good for the body and brain.
Follow up and be patient. Nonspecific symptoms like fatigue and brain fog require an honest engagement with the facts and patience with the inherent process of figuring it out. Expecting a fast fix for a nuanced set of problems is an invitation for disappointment. If your medical provider recommends an un-sexy set of small, sustainable changes, she is probably onto something (and probably will never have her own talk show 😅 ).
Look, I love thinking outside the box. I like a prettily-packaged wellness hack like the next person. But there's still a box. Accessing facts, seeking evidence-based guidance, being honest with ourselves about how we think, feel, behave and relate to other people, and then protecting our reserves, emotionally and physically, is a critical part of being healthy.
There’s no supplement for that.
Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.
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As Sir William Osler, a famous physician once said: “Listen to the patient. They will tell you the diagnosis.”
Excellent advice Dr Mc Bride. The first thing to do, for sure, if someone complains of cognitive changes is to remove or ameliorate the multiple metabolic, neurologic and psychological factors that affect cognitive function, including the very real cognitive changes that often come with menopause and loss of estrogen. And yes, this requires careful listening and very nuanced management, over time. Even if correction to these factors does not yield a positive picture, then yes, one has to get into objective assessments, as you mentioned. I do want to throw in a reminder that, should there be reason to think there are cognitive changes underlying all these factors that have been addressed, then an experienced, qualified Speech Therapist or Speech Pathologist, (same person) often plays a key role in a) cognitive assessment b) helping an individual develop and use strategies to cope better or cope well, even with cognitive changes, in daily and prospective functioning. Since I have been involved with such cases, I have also had to meet with people just concerned about normal aging changes they are experiencing, to assess and address how they can help themselves and provide the necessary reassurance and education. Happy to talk with you further. I am based in Massachusetts.