This man has been waiting for eight years for an organ donor; the psychological effects of waiting are far-reaching.
“Brain fog” — the feeling of mental sluggishness that encompasses not being able to focus, being easily distracted, forgetfulness, difficulty in making decisions, mild disorientation, and feeling off-balance — is commonly referred to when people talk about their experiences of illness and medical treatment.
Those who have undergone chemotherapy treatments talk about “chemo brain” to describe such symptoms, which professionals call “cognitive dysfunction”. Research reveals that a large percentage of patients suffering chronic and end-stage kidney disease have cognitive dysfunction.
Multiple factors are associated with the genesis of brain fog in renal disease, and more and more studies are cautioning about its negative effects. Perhaps most alarming is the association with increased hospitalisation and risks of complication. Unfortunately, among the renal replacement therapies, only organ transplant is associated with clearing the fog.
The diagnosis of cognitive dysfunction is commonly made by neuropsychological tests, which are designed to assess domains of mental functioning, including memory, speech and language, the integration and organisation of visual information, attention, and the so-called “executive functions”. The latter refer essentially to problem solving, planning, controlling attention, concept formation, judgement, goal formulation and implementation.
There are no published studies on the neuropsychological or neurological assessment of cognitive functioning of large numbers of chronic and end-stage kidney disease patients in South Africa. Clinical data gathered by the author on the results of neuropsychological screening of over 100 patients with end-stage renal disease suggests that capacity for attention and concentration, integrating and organising visual information, and making judgements and decisions are areas of vulnerability.
The outcomes of assessment reveal minimal or mild dysfunction, but enough to make a difference to functioning.
Pardoxically, because renal disease usually does not affect language use, nor long-term memory, and because impairments may be minimal or mild, the effects can be elusive — just a frustrating fogginess! We could say they are sub-clinical.
Nevertheless, people do feel them. They find themselves withdrawing from their studies and work, or being in trouble at work, complaining of an underlying slowness, or for inexplicable reasons, just not coping. Some people report that their bosses don’t want them at work anymore.
Published findings of international research confirm these areas of vulnerability. For example, a 2010 study published in the American Journal of Kidney Disease, which examined 4 000 patients between the ages of 21 and 59 years in London, noted that moderate to chronic kidney disease was significantly associated with poorer performance on tasks requiring attention to visual information and on tasks that require learning and concentration.
This study is particularly relevant to South Africa in that most international studies report on older patients, while the average age of South African patients with chronic kidney disease is below 60 years. A 2013 issue of Neurology published research conducted in Nigeria, also involving younger patients, at the University College Hospital in Ibadan, which similarly confirms chronic kidney disease as a risk factor for poorer performance on tasks of executive function, attention and immediate recall of information.
There is a tendency to be flippant and even dismissive about “brain fog”; for patients and professionals it is perhaps just another burden to bear. Yet, consideration of the more serious implications gives cause for concern. Apart from the impact on quality of life and sense of self-regard, the ability to remain employed is negatively affected. Thought must be given to how poor attention and distractibility, difficulty organising visual information, and compromised decision-making affects the safety of driving and operating machinery.
Of equal concern are the potential difficulties that patients experience in understanding and remembering information and instructions about their treatment, increasing risks for complications and hospital admissions. Screening for cognitive dysfunction provides the opportunity to address treatment planning, and activities of life, in discussion with patients and their caregivers. In contrast, without due consideration, the cognitive dysfunction associated with chronic and end-stage renal disease becomes a potential additional health burden.
Written by Dr Tina Sideris