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  Key Messages

  • Cognitive problems most pronounced in severe mood episodes
  • A primary symptom of bipolar disorder, not just related to mood symptoms
  • Impacted by age, medications, substance misuse, sleep problems

  Take Action

  • Watch for cognitive changes/problems; allow others to help monitor for them
  • Report changes in cognition to healthcare providers
  • Consider cognitive rehabilitation strategies if needed

  Learn more

Cognition refers to thinking skills, such as the ability to pay attention, remember, process information, solve problems and plan1. We are all born with different cognitive capabilities.    Cognitive skills can change over our lifetimes: cognitive skills may worsen with illness, injury or age; at other times, cognitive skills can become strengthened or improved.  

Why cognition is important to your quality of life

Cognition is essential for independent living and normal activities – in other words, you are using it daily! For example, to make a coffee date with a friend, you might need to a) pay attention to her on the phone, b) understand what she says, c) think about your schedule and organize a time to meet, d) remember this date and e) plan how to get there. Cognitive skills are necessary to succeed in work, school, parenting and leisure activities. They’re important in maintaining relationships -- friends and family value someone who pays attention to them, remembers things about them and follows through on plans to get together. It’s not a surprise, then, that research studies have linked cognitive function to quality of life in people living with bipolar disorder2. And we’ve now learned that cognitive problems are a primary symptom of bipolar disorder, and not just related to mood symptoms1.  

Research has shown that some people living with bipolar disorder have decreases in learning, verbal memory, planning, decision-making and/or the ability to focus their attention3. But other people with bipolar disorder may not experience any cognitive problems at all4. Cognitive problems can be most obvious during mood episodes, especially severe depression or mania5. But they can even continue afterwards when you’re not experiencing any mood symptoms.  

People of older age who are living with bipolar disorder can have more cognitive challenges than younger people6. And recreational drugs, alcohol or substance misuse can cause more cognitive problems (see the Physical section for more information).

Medications may have cognitive side effects too. It can be hard to know if cognitive symptoms are caused by your bipolar disorder or by your medications, especially as medications are often started right when the symptoms of bipolar disorder are first recognized. Side effects from different medications are not the same; some medications have cognitive side effects and others have few, if any. Some recent research studies even report cognitive protection, or improvement, with certain medications3. Cognitive side effects also may increase as the dose of your medication is increased, so it’s important to find the right dose of medication that provides the best balance for your mood with the lowest risk for side effects. As everyone responds to medications differently, this dose will be different for everyone: some people are sensitive to side effects, while others are not. Another thing to keep in mind is drug interactions (i.e., how two or more drugs act when taken together). Multiple medications taken together may interact to produce more side effects than each medication alone. So, caution may be needed, especially if you have more than one doctor prescribing medications for you, take medications differently than prescribed, or take over-the-counter medications. Additionally, sleep problems (a common symptom of bipolar disorder; see Sleep section) can lead to problems in cognition. 

How you can take action

By learning about the possible cognitive effects of bipolar disorder and your medications, you can learn to recognize cognitive symptoms and better manage your condition to improve your quality of life and ability to do your daily activities.

The first step is to pay attention to your cognitive changes or problems. Some people find it useful to track changes in memory, attention, alertness and thinking, to see how cognition may change with different medications or during different mood phases1. It can be helpful to have someone else, such as a family member or healthcare professional, also track these changes, as cognitive problems may be recognized easier by someone else.  

Report any changes in cognition that you notice to your doctor and healthcare team. This will help you work with them to see if there may be changes in medications that could help you, without destabilizing or upsetting the balance of your mood. Remember that medication changes are based on complex decisions, so be cautious about changing medications or doses without a doctor’s help. Also, be sure to share information with your healthcare team about recreational substances you may be using, other medications you are taking or changes in the way you’re taking medications-- this all may lead to drug interactions and cognitive problems.  

If, together with your healthcare team, you’ve come to the conclusion that you have cognitive challenges that have little to do with medications, you may want to try some of the following cognitive rehabilitation strategies. These are activities that help restore cognition (i.e., your thinking skills) to a healthy state. Cognitive rehabilitation includes managing cognitive problems with three different methods1: remediation techniques, compensatory strategies and adaptive approaches. Having an assessment or evaluation by a healthcare professional can help you decide which unique approach may be most helpful for you.

Remediation techniques
help improve thinking with drills and exercises that may involve computers, paper and pencil, or group activities1. It’s important to have a formal assessment and make a treatment plan specific to your own needs to guide your training. Remediation techniques don’t offer a quick fix: progress takes time and effort. Research is in its infancy for remediation techniques, but research studies are showing promising results for cognitive training in people with mood disorders, including some with bipolar disorder (but not all)7. While you may improve your results on the specific tasks you practice, it’s still uncertain how helpful this will be to your overall functioning8.  

Compensatory strategies help you come up with different ways to accomplish your goals; to help you ‘compensate’, or make up, for cognitive challenges.  For example, you can learn mnemonics (or ‘memory aids’) to help you remember things. Let’s say you need to remember three things to buy at the grocery store -- milk, eggs and butter. You can make a catchy phrase using the first letters of each item to help you remember them.  For example, ‘My ear is blue’ – a catchy phrase that makes a picture in your mind of you with a blue ear, with the first letter of each word standing for one of the things you need to buy – my – M for milk, ear – E for eggs, blue – B for butter - makes it much easier to remember what to buy when you get to the store.

Adaptive approaches try to change your environment (i.e., the world around you). You might try having a recording device to help you keep track of important information. Or you might set timers to remind you to do certain activities.  

Finally, here’s a list of useful and easy to implement tips that can help you and your supports adapt to cognitive challenges you may be experiencing:

  • Keep communication and activities simple, direct, and short
  • Keep activities to one thing at a time; try not to multi-task
  • Make sure that you rest; fatigue can make cognitive problems worse
  • Try to limit distractions
  • Try to balance activities so that you have a blend of physical, mental and social activities to keep your interest up and prevent fatigue
  • Try to keep activities and tasks structured and organized