POTS and Lyme Disease: Does Standing Worsen Brain Fog?

Patients with autoimmune disorders are at risk for POTS, along with individuals who have had a viral illness or serious infection such as Lyme disease. In fact, patients with POTS and Lyme disease often present with similar symptoms.

Key Point: Research suggests that patients with POTS may experience impaired attention and executive function when standing, which may help explain the “brain fog” often reported by patients with Lyme disease and autonomic dysfunction.

POTS patients frequently report having “brain fog,” a symptom also commonly described by Lyme disease patients. In a recent article, Miller and colleagues point out that “many patients with POTS experience subjective cognitive complaints or ‘brain fog,’ with reports ranging from 43% to 96% in the literature.”¹

Brain fog in POTS has been described as feeling “forgetful,” “cloudy,” and having difficulty focusing, thinking, and communicating. These symptoms suggest impairment in several cognitive domains including executive function, attention, and memory.

Kanjwal and colleagues describe several cases of patients with POTS following Lyme disease in their article “Postural orthostatic tachycardia syndrome following Lyme disease.”²

Another study by Wells and colleagues points out that POTS symptoms are often reported by patients with chronic fatigue syndrome and fibromyalgia. However, the authors did not discuss the potential association between POTS and Lyme disease.³

Cognitive Impairment in POTS While Standing

Investigators examined cognition in POTS patients while they were actively standing. Most previous studies had evaluated cognitive performance when patients were lying down.

“Most previous studies have reported normal cognition in POTS in the supine posture, with impairment in attention, executive function, and working memory emerging in the seated posture or during head-up tilt,” writes Miller.

The researchers recruited 87 individuals with self-reported POTS who were attending a 2018 Dysautonomia International Conference. Participants included 24 adolescents (age 14–19) and 63 adults (age 20–59). Thirty-nine healthy controls were also included.

POTS is defined by an increase in heart rate of at least 30 beats per minute in adults (or more than 40 beats per minute for ages 12–19) within 10 minutes of standing or head-up tilt. Symptoms typically include fatigue, lightheadedness, nausea, and palpitations.

Investigators measured executive function using a Stroop word-color test and attention using CogState identification tests while participants were both supine and standing.

Study Findings

The researchers found that approximately 1 in 4 POTS patients showed clinically meaningful impairment in executive function while standing.

POTS subjects also experienced impairments in cognitive function even while taking medications, with most participants demonstrating well-controlled orthostatic tachycardia.

Attention scores were worse in the standing posture compared with the supine posture. Cognitive impairment did not differ significantly between adolescents and adults.

“Overall, we found that executive function and attention are impaired in POTS during active standing when compared with healthy controls of similar age, sex, and education level,” the authors conclude.

The study was not designed to measure all aspects of cognitive function.

Clinical Insight: Because autonomic dysfunction has been reported in Lyme disease, patients with Lyme-associated POTS may experience worsening cognitive symptoms when standing during everyday activities such as work, school, or walking.

Editor’s note: These findings suggest that adolescents and adults with POTS may experience cognitive difficulties during normal upright activities, which could affect school performance, workplace functioning, and daily life.

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References

Miller AJ, Sheehan T, Bourne KM, Feeley M, Arnold AC. Attention and executive function are impaired during active standing in postural tachycardia syndrome. Auton Neurosci. 2020;227:102692.
Kanjwal K, et al. Postural orthostatic tachycardia syndrome following Lyme disease. Cardiol J. 2011;18(1):63-66.
Wells R, et al. Postural tachycardia syndrome: current perspectives. Vasc Health Risk Manag. 2018;14:1-11.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

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